• Cholesteryl ester storage disease: a rare and possibly treatable cause of premature vascular disease and cirrhosis

      Reynolds, Tim (2013-09)
      Cholesteryl ester storage disease (CESD) is an autosomal recessive lysosomal storage disorder caused by a variety of mutations of the LIPA gene. These cause reduced activity of lysosomal acid lipase, which results in accumulation of cholesteryl esters in lysosomes. If enzyme activity is very low/absent, presentation is in infancy with failure to thrive, malabsorption, hepatosplenomegaly and rapid early death (Wolman disease). With higher but still low enzyme activity, presentation is later in life with hepatic fibrosis, dyslipidaemia and early atherosclerosis.Identification of this rare disorder is difficult as it is essential to assay leucocyte acid phosphatase activity. An assay using specific inhibitors has now been developed that facilitates measurement in dried blood spots. Treatment of CESD has until now been limited to management of the dyslipidaemia, but this does not influence the liver effects. A new enzyme replacement therapy (Sebelipase) has now been developed that could change treatment options for the future.
    • Cytoplasmic PML promotes TGF-β-associated epithelial-mesenchymal transition and invasion in prostate cancer.

      Van Schalkwyk, Gerhard (2015-11)
      Epithelial-mesenchymal transition (EMT) is a key event that is involved in the invasion and dissemination of cancer cells. Although typically considered as having tumour-suppressive properties, transforming growth factor (TGF)-β signalling is altered during cancer and has been associated with the invasion of cancer cells and metastasis. In this study, we report a previously unknown role for the cytoplasmic promyelocytic leukaemia (cPML) tumour suppressor in TGF-β signalling-induced regulation of prostate cancer-associated EMT and invasion. We demonstrate that cPML promotes a mesenchymal phenotype and increases the invasiveness of prostate cancer cells. This event is associated with activation of TGF-β canonical signalling pathway through the induction of Sma and Mad related family 2 and 3 (SMAD2 and SMAD3) phosphorylation. Furthermore, the cytoplasmic localization of promyelocytic leukaemia (PML) is mediated by its nuclear export in a chromosomal maintenance 1 (CRM1)-dependent manner. This was clinically tested in prostate cancer tissue and shown that cytoplasmic PML and CRM1 co-expression correlates with reduced disease-specific survival. In summary, we provide evidence of dysfunctional TGF-β signalling occurring at an early stage in prostate cancer. We show that this disease pathway is mediated by cPML and CRM1 and results in a more aggressive cancer cell phenotype. We propose that the targeting of this pathway could be therapeutically exploited for clinical benefit.
    • Differential Diagnosis for Chronic Hypokalaemia.

      Stimson, Laura; Reynolds, Tim (2018-06)
      Doctors will often see patients with chronic hypokalaemia, frequently this is secondary to gastrointestinal losses, diuretics or renal disease. However, in this case report we review a rarer cause of chronic hypokalaemia-Gitelman syndrome (GS).GS is an uncommon genetic disorder which causes primary renal tubular hypokalaemic metabolic alkalosis with secondary hypomagnesaemia and hypocalciuria. Although rare, it is important to remember GS when considering differential diagnoses for chronic hypokalaemia. We report the case of a woman who presented to the ophthalmology department with sclerochoroidal calcification. An ophthalmologist was reviewing the medical literature, which prompted them to investigate for GS. A diagnosis was formed at that time based on the blood and urine chemistry results. However, later we were able to offer the patient genetic testing, which confirmed our provisional diagnosis.
    • Do the EULAR Sjögren's syndrome outcome measures correlate with health status in primary Sjögren's syndrome?

      Regan, Marian (2015-04)
      OBJECTIVE: This study sets out to investigate the relationship between health status [EuroQol five-dimensions questionnaire (EQ-5D)] in primary SS and three of the European League Against Rheumatism (EULAR) SS outcome measures-the disease activity index (ESSDAI), the patient reported index (ESSPRI) and the sicca score. In particular, the goal was to establish whether there is a relationship between the EULAR outcome measures and quality of life. METHODS: Health status was evaluated using a standardized measure developed by the EuroQol Group-the EQ5D. This permits calculation of two measures of health status: time trade-off (TTO) values and the EQ-5D visual analogue scale (VAS) scores. We used Spearman's rank correlation analysis to investigate the strength of association between health status and three EULAR measures of physician- and patient-reported disease activity in 639 patients from the UK primary SS registry (UKPSSR) cohort. RESULTS: This study demonstrates that the EULAR SS disease-specific outcome measures are significantly correlated with health outcome values (P < 0.001). Higher scores on the ESSDAI, EULAR sicca score and ESSPRI are associated with poorer health states-i.e. lower TTO values and lower VAS scores. While all three are significantly correlated with TTO values and EQ-5D VAS scores, the effect is strongest for the ESSPRI. CONCLUSION: This study provides further evidence supporting the use of ESSDAI, EULAR sicca score and ESSPRI measures in the clinic. We also discuss the need for disease-specific measures of health status and their comparison with standardized health outcome measures.
    • Eligibility for clinical trials in primary Sjögren's syndrome: lessons from the UK Primary Sjögren's Syndrome Registry.

      Regan, Marian (2016-03)
      OBJECTIVE: To identify numbers of participants in the UK Primary Sjögren's Syndrome Registry (UKPSSR) who would fulfil eligibility criteria for previous/current or potential clinical trials in primary SS (pSS) in order to optimize recruitment. METHODS: We did a retrospective analysis of UKPSSR cohort data of 688 participants who had pSS with evaluable data. RESULTS: In relation to previous/current trials, 75.2% fulfilled eligibility for the Belimumab in Subjects with Primary Sjögren's Syndrome study (Belimumab), 41.4% fulfilled eligibility for the Trial of Remicade in primary Sjögren's syndrome study (Infliximab), 35.4% for the Efficacy of Tocilizumab in Primary Sjögren's Syndrome study (Tocilizumab), 31.6% for the Tolerance and Efficacy of Rituximab in Sjögren's Disease study (Rituximab), 26.9% for the Trial of anti-B-cell therapy in pSS study (Rituximab) and 26.6% for the Efficacy and Safety of Abatacept in Patients With Primary Sjögren's Syndrome study (Abatacept). If recent measures of outcome, such as the EULAR Sjögren's Syndrome Patient Reported Index (ESSPRI) score ⩾5 (measure of patient symptoms) and the EULAR Sjögren's Syndrome Disease Activity Index (ESSDAI) score ⩾5 (measure of systemic disease activity) are incorporated into a study design, with requirements for an unstimulated salivary flow >0 and anti-Ro positivity, then the pool of eligible participants is reduced to 14.3%. CONCLUSION: The UKPSSR identified a number of options for trial design, including selection on ESSDAI ⩾5, ESSPRI ⩾5 and serological and other parameters.
    • Eltrombopag and Romiplostim: A snapshot from Derby Teaching Hospitals

      Khan, I; Lala, J; Smith, A; Millar, C; Addada, Jo (2018-04)
      Severe Idiopathic Thrombocytopenic Purpura (ITP) is a relatively common disorder with a small but definite associated mortality. For many years, first line therapy has consisted of steroid or Intravenous Immunoglobulin. A plethora of second line treatment options have traditionally included splenectomy, Rituximab, Mycophenolate, other immunosupressants & Danazol. Each has had its own risks and uncertain efficacy and treatment sequencing for refractory patients has always been very much at the discretion of individual clinicians. Recently the Thrombopoietin Receptor Agonists (TPO-RA) Romi-plostim and Eltrombopag have been available in the UK (NICE approved in 2011 and 2013 respectively). Both are regarded as highly effective but costly treatments. We present here our recent experience of using TPO-RA in a large clinical unit serving a population of 600,000. We audited patients on TPO-RA between March 2016 and April 2017. TPO-RAs were used in 34 episodes (30 patients, 4 patients required switching from one to other). Eltrombopag was used in 25 episodes and Romi-plostim in 9 episodes. Patient demographics were as follows: 21 females, 9 males; Age range 28-91 (median 65.4). 26 out of 30 patients were treated in accordance with NICE guidance. These patients were refractory to other standard treatment for ITP and/or had severe disease and a high risk of bleeding requiring frequent rescue therapy. Splenectomy was considered inappropriate in 20 out of 26 (76.9%) patients. 6 out of 26 (23%) patients were post splenectomy and had refractory ITP. 4 out of 30 patients were treated with TPO (Eltrombopag) out with NICE guidance. Splenectomised patients had a median of 5.5 previous treatment lines compared with non-splenectomised patients (1.36). Eltrombopag doses ranged from 25-75 mg/day. Romiplostim doses ranged from 2-10 mcg/kg/week. 4 patients switched between Romiplostim and Eltrombopag due to loss/failure of response. Doses were individualized to maintain platelet counts in a safe range. All patients showed a positive response to one or the other agent (defined as greater than 50 x 10/l) In general both treatments were well tolerated and no drug needed discontinuation due to side effects. Main side effects with Eltrombopag were fatigue (2 patients), headache (2) and grade 1 diarrhoea (1). Side effects experienced with Romiplastim were dyspepsia (1) and occasional mild headache (1). In our experience TPO-RA treatments are well tolerated and all patients audited showed an effective response. Furthermore, we also noticed that our clinicians do not consider splenectomy to be a favoured second line treatment in the era of TPO-RAs. This suggests that the current treatment paradigm should be reviewed.
    • Experience of romiplostin use in the management of ITP in a district general hospital setting-can fixed doses be used during stable phase to reduce wastage?

      Van Staden, Bernhard; Ahmad, Humayun (2014-05)
      The thrombopoetin receptor agonist, Romiplostim is indicated in chronic ITP patients with refractory ITP. We reviewed and analysed the data from two refractory ITP patients managed with Romiplostim. Using current manufacturer guidelines, we started with weekly dosing adjustments aiming for the recommended baseline platelet count of at least 50 9 109. Guidelines recommend an initiating dose of 1mcg/kg per week with increase in 1mcg increments to a maximum of 10 mcg/kg weekly until platelet count is stabilized above mentioned baseline. Hereafter, monthly blood tests are recommended and readjustment made if platelet count exceeds 200 x 109. Our patients commenced on 1mcg/kg, though once the platelet count was consistently above baseline, after a few dose adjustments, we found in both patients that during the stable phase, 250 mcg hence between 3 and 4 mcg/kg per patient respectively was an ideal maintenance dose that consistently kept the platelet count above 50 x 109 without requiring need for regular dose adjustment. Therefore these two patients have now been continued on this fixed dose and have shown an excellent response. Though our experience is limited, we have found a standard dose of 250 mcg to be an effective in maintenance of safe platelet counts. Also, as Romiplostim is available only in 250 and 500 mcg vials, variable doses will invariably lead to some wastage of this expensive drug. Given the economic climate and to simplify self-administration we propose further studies are required to assess whether a fixed dose of Romiplostim can be established for stable phase management of chronic ITP.
    • Health Assessment Questionnaire disability progression in early rheumatoid arthritis: systematic review and analysis of two inception cohorts.

      Deighton, Chris (2014-10)
      OBJECTIVE: The Health Assessment Questionnaire is widely used for patients with inflammatory polyarthritis (IP) and its subset, rheumatoid arthritis (RA). In this study, we evaluated the progression of HAQ scores in RA (i) by systematically reviewing the published literature on the methods used to assess changes in functional disability over time and (ii) to study in detail HAQ progression in two large prospective observational studies from the UK. METHODS: Data from two large inception cohorts, ERAS and NOAR, were studied to determine trajectories of HAQ progression over time by applying latent class growth models (LCGMs) to each dataset separately. Age, sex, baseline DAS28, symptom duration, rheumatoid factor, fulfilment of the 1987 ACR criteria and socio-economic status (SES) were included as potential predictors of HAQ trajectory subgroup membership. RESULTS: The literature search identified 49 studies showing that HAQ progression has mainly been based on average changes in the total study population. In the HAQ progression study, a LCGM with four HAQ trajectory subgroups was selected as providing the best fit in both cohorts. In both the cohorts, older age, female sex, longer symptom duration, fulfilment of the 1987 ACR criteria, higher DAS28 and lower SES were associated with increased likelihood of membership of subgroups with worse HAQ progression. CONCLUSION: Four distinct HAQ trajectory subgroups were derived from the ERAS and NOAR cohorts. The fact that the subgroups identified were nearly identical supports their validity. Identifying distinct groups of patients who are at risk of poor functional outcome may help to target therapy to those who are most likely to benefit.
    • Hepatitis C virus-infected patients with a persistently normal alanine aminotransferase: do they exist and is this really a group with mild disease?

      Lawson, A (2010-01)
      Opinion varies on whether or not hepatitis C virus (HCV) infected patients with persistently normal aminotransferase (PNALT) levels represent a group with mild disease. To evaluate the risk of ALT flare and fibrosis progression in patients with PNALT followed up as part of the Trent HCV cohort. Treatment-naïve patients with an elevated ALT (n = 1140) or PNALT, the latter defined as either an ALT < or = 30 IU/L (n = 43) or an ALT < or = 40 IU/L (n = 87) on > or =2 occasions in the 6 months following diagnosis, and no ALT > 40 U/L were included. The likelihood of maintaining a PNALT < or = 30 IU/L was 42.2% and PNALT < or = 40 IU/L 41.7% at 3 years. The Ishak fibrosis score was > or =3 in 3.7%, 8.3% and 29.6% of patients with PNALT < or = 30 IU/L, PNALT < or = 40 IU/L and elevated ALT, respectively. Fibrosis progression between paired biopsies was similar for patients with PNALT < or = 30 IU/L (0.33 +/- 0.94 Ishak fibrosis points/year), PNALT < or = 40 IU/L (0.35 +/- 0.82) and elevated ALT (0.19 +/- 0.48). The majority of those defined as PNALT subsequently have an abnormal ALT. They have a similar risk of disease progression to other HCV infected patients and, therefore, warrant the same consideration with regard to treatment.
    • Histopathological evidence for macrophage activation driving post-transfusion hyperhaemolysis syndrome.

      Hebballi, S; McKernan, A; Hamilton, R; Robinson, Ivan (2019-04)
      Post-transfusion hyperhaemolysis syndrome (PTHS) is a rare life-threatening transfusion complication reported mainly in sickle cell patients. Its pathogenesis is poorly understood. Antibody-mediated haemolysis and bystander effect have been proposed as putative mechanisms, but in half of cases, red cell antibodies are undetectable, and PTHS develops despite transfusion of cross-matched compatible RBC. An alternate hypothesis proposes activated macrophages as the main drivers of red cell destruction through direct phagocytosis. We report the histopathological findings of two patients with PTHS showing extensive macrophage expansion and erythrophagocytosis, supportive of macrophage activation driving PTHS. This supports a possible role for novel therapies that target macrophage activation.Pre. 12 Month embargo on post
    • Identification of rare diseases by screening a population selected on the basis of routine pathology results-the PATHFINDER project: lysosomal acid lipase/cholesteryl ester storage disease substudy

      Reynolds, Tim; Mewies, Clare (2018-01)
      AIMSLysosomal acid lipase deficiency (LALD) is an autosomal recessive disorder of cholesterol ester storage associated with hepatic disease, cirrhosis and accelerated atherosclerosis. Its prevalence in the general population, patients with dyslipidaemia and raised transaminases is unclear. This study attempted to identify the prevalence of LALD from patients with abnormal results in laboratory databases.METHODSElectronic laboratory databases were interrogated to identify from clinical biochemistry records patients with a phenotype of low high-density lipoprotein-cholesterol (≤0.85 mmol/L; 33 mg/dL) and with elevated alanine or aspartate transaminases (≥60 IU/L) on one occasion or more over a 3-year time interval. Patients were recalled, and a dried blood spot sample was collected for lysosomal acid lipase determination by a fluorimetric enzyme assay. Histopathology databases of liver biopsies were interrogated for patients with features of 'microvesicular cirrhosis' or 'cryptogenic cirrhosis' in the report. Histological blocks were sampled, and samples were analysed by next-generation sequencing for the presence of mutations in the LAL gene.RESULTSSamples were obtained from 1825 patients with dyslipidaemia and elevated transaminases. No cases of LALD were identified. Liver biopsies were obtained from six patients. DNA extraction was successful from four patients. Two patients were homozygous for the LAL c.46A>C;p.Thr16Pro unclassified variant in exon 2.CONCLUSIONSPathology databases hold routine information that can be used to identify patients with specific patterns of results or those who had biopsies to allow targeted testing for possible causes of disease. Biochemical screening suggests that the gene frequency of LAL deficiency in adults is less than 1 in 100.
    • Identification of rare diseases by screening a population selected on the basis of routine pathology results-the PATHFINDER project: lysosomal acid lipase/cholesteryl ester storage disease substudy.

      Reynolds, Tim; Mewies, Clare (2018-07)
      AIMS: Lysosomal acid lipase deficiency (LALD) is an autosomal recessive disorder of cholesterol ester storage associated with hepatic disease, cirrhosis and accelerated atherosclerosis. Its prevalence in the general population, patients with dyslipidaemia and raised transaminases is unclear. This study attempted to identify the prevalence of LALD from patients with abnormal results in laboratory databases. METHODS: Electronic laboratory databases were interrogated to identify from clinical biochemistry records patients with a phenotype of low high-density lipoprotein-cholesterol (≤0.85 mmol/L; 33 mg/dL) and with elevated alanine or aspartate transaminases (≥60 IU/L) on one occasion or more over a 3-year time interval. Patients were recalled, and a dried blood spot sample was collected for lysosomal acid lipase determination by a fluorimetric enzyme assay. Histopathology databases of liver biopsies were interrogated for patients with features of 'microvesicular cirrhosis' or 'cryptogenic cirrhosis' in the report. Histological blocks were sampled, and samples were analysed by next-generation sequencing for the presence of mutations in the LAL gene. RESULTS: Samples were obtained from 1825 patients with dyslipidaemia and elevated transaminases. No cases of LALD were identified. Liver biopsies were obtained from six patients. DNA extraction was successful from four patients. Two patients were homozygous for the LAL c.46A>C;p.Thr16Pro unclassified variant in exon 2. CONCLUSIONS: Pathology databases hold routine information that can be used to identify patients with specific patterns of results or those who had biopsies to allow targeted testing for possible causes of disease. Biochemical screening suggests that the gene frequency of LAL deficiency in adults is less than 1 in 100.
    • Identifying patients with non-valvular atrial fibrillation & poorly controlled INR on warfarin who are suitable to be switched to NOACs

      Ahmad, Humayun; Van Staden, Bernhard (2014-05)
      There are quite a significant number of patients of non valvular Atrial Fibrillation (AF) who are on Warfarin for stroke prevention but fail to achieve stable INR control and hence remain at risk. In recent years at least three different New Oral Anticoagulants (NOACs) have been shown to be effective as well as non inferior to Warfarin for stroke prevention in AF. These drugs despite not having effective antidotes yet are considered to have lesser risk of serious bleeding than Warfarin. Although work may be in progress, no clear guidelines have yet been established to decide which patients require switching to NOACs and when. We decided to address this in the form of an audit of Percent time in therapeutic INR range (TTR) amongst AF patients attending our Warfarin Dosing Service. Using our electronic patient records a total of 797 patients were identified as non-valvular AF patients on Warfarin at our dosing service. We found that 79% of these patients had a TTR of more than 60% and 53% above 70%. The 21% patients who did not meet the TTR target were arguably still at a higher risk of stroke. Moreover the fluctuation in their INRs also put them at a higher risk of bleeding. We went on to check the records for abnormalities of renal (eGFR) and liver blood tests (LFTs) in this cohort. Our results showed that 94% of these patients had normal LFTs, 97% had eGFRs of >30 and 59% had eGFRs of >60. Thus majority of the patients in this cohort were eligible for switching to NOACs. Although our data is limited to a single center, it suggests that approximately 20% of the AF patients on Warfarin may require switching to a NOAC due to poor INR control.
    • IQC trending with unity software and evaluation of the bio-rad EQAS blood typing system

      Harden, Trevor (2016-09)
      Derby Teaching Hospitals NHS Foundation Trust provides both acute hospital and community based health services, serving a population of over 600,000 people in and around Southern Derbyshire. The Royal Derby Hospital, which incorporates the Derbyshire Children's Hospital, and is a busy acute teaching hospital. The Trust treats a million patients each year and more than 6,000 babies are born in its maternity unit annually. 72,000 elective operations take place every year in the hospital's suite of 35 modern operating theatres, an average of more than 280 operations per day. The hospital has a total of 1,100 beds. Pathology at the Royal Derby Hospital consists of three departments, Blood Sciences (Incorporating Haematology, Biochemistry, Immunology and Blood Transfusion), Cellular Pathology and Microbiology. The Blood Transfusion Laboratory is CPA Accredited, MHRA compliant, meets current BCSH Guidelines and participates in all relevant Quality Assurance schemes. The department processes around 60,000 blood group and antibody screens annually utilising two Biorad IH-1000 analysers and Biorad column technology. Routine Internal quality assurance is performed daily using the Biorad Basic QC package. Other tests performed are Antibody identification, Compatibility testing including serological crossmatch and electronic issue, Neonatal sample testing, Kleihauer testing and Direct Antiglobulin testing is undertaken. The department provides an Antenatal Screening Service and a routine Antenatal Anti-D prophylaxis (RAADP) programme. In January 2016 Bio-Rad installed a software package called Unity onto the Bio-Rad analysers for evaluation. Unity can be utilised to provide trend analysis/monitoring of sensitivity of the internal quality control material being processed routinely on the analysers. It is a requirement of the International Standard ISO 15189:2012 (E), 5.6.2.3 that: 'Quality control data shall be reviewed at regular intervals to detect trends in examination performance that may indicate problems in the examination system'. Initial results show that the Basic QC 1 & 2 cell samples in routine use on both the analysers appear to be stable throughout the period they are used maintaining consistent strengths of reaction for both grouping and antibody screening. Reports can be generated from the Unity software as PDF documents which are reviewed at local Quality meetings. Remote access for managers to the results on Unity via the hospital network is also a useful feature. In addition to evaluating the Unity software for IQC we were also involved in trialling the new Bio-Rad EQAS blood typing system. In February 2016 we received the first cycle of EQAS material which consisted of four blind samples, three samples suitable for Blood Grouping, phenotyping, antibody screening and antibody identification plus a further sample to act as a donor sample for compatibility testing. The samples were run routinely on the IH-1000 analysers and the results subsequently submitted before the closing date on the dedicated EQAS online portal via the Bio- Rad QCnet website. An EQAS online account was set up for the Derby Blood Transfusion Laboratory, which allowed us access to the portal to set up the instrument requirements (IH- 1000) and test requirements. Once the system was configured we could then enter the results for each test performed and submit the results accordingly. The report being made available 48 h later, which provided a comparison with other EQAS users using similar and alternative technologies. Further evaluation of the EQAS blood typing system will take place in Cycles 2 and 3 available in June and October 2016. (Table Presented).