2021 Innovation in hematology

Marie-Christiane Vekemans, Violaine Havelange, Eric Van Den Neste, Sarah Bailly, Catherine Lambert,Nicole Straetmans, Xavier Poiré, Stefan N. Constantinescu, Cédric Hermans Published in the journal : February 2022 Category : Hematology/Oncology

The year 2021 was rich in innovations in regard to both malignant and benign hematological diseases, with the most relevant of which discussed below.

- In recent years, the prognosis of multiple myeloma has been greatly improved, yet the disease remains as yet incurable. Current strategies aim to achieve optimal disease control at diagnosis using four-drug regimens designed to delay relapse, while in relapsed patients, innovative alternatives like immunotherapy are being employed to effectively re-arm the immune system, and this represents a real hope for patients suffering from this chronic disease.

- The management of chronic myeloid leukemia is still evolving. Since 2001, tyrosine kinase inhibitors have revolutionized its prognosis, but they are also responsible for toxicities. One of the current therapeutic goals is to achieve a sufficiently deep and prolonged response, thereby enabling tyrosine kinase inhibitors to be discontinued and remission maintained.

- Myelofibrosis is a myeloproliferative neoplasm with poor prognosis. The only curative treatment available to date is peripheral stem cell allograft, which can be applied at least for some patients. New therapeutic agents are currently being investigated, which are highly promising not only on account of their efficacy on symptoms and splenomegaly, but also for their potential anti-fibrotic and reducing effect on the mutated clone. Certain agents are in clinical assays in combination with JAK2 inhibitors.

- Several recent studies have suggested that CAR-Ts were likely to emerge as the second-line treatment of choice for patients suffering from aggressive lymphomas, while secondarily reducing the number of autologous stem cell transplants.

- Patients with acute myeloid leukemia and TP53-mutated myelodysplastic syndromes still represent a challenging population to treat with low and only short-lived response rates. The advent of APR-246, which restores TP53 activity, is likely to increase the number of responders among these very high-risk patients.

- Beyond its well-known involvement in heparin thrombocytopenia, platelet factor 4 (PF4) plays a major role in the very rarely observed thrombosis with thrombocytopenia occurring in association with COVID-19 adenoviral vector vaccines. Inhibition of FXI is expected to emerge as a promising anticoagulation strategy with reduced bleeding risk, while induction of antithrombin deficiency by interfering RNA is likely to prevent bleeding in hemophilia A and B patients, either with and without inhibitors.

- Concerning the management of immune thrombocytopenic purpura, targeted therapies are currently being favored owing to their lower toxicity and individualized platelet count targets.

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Hepatology, endoscopy, and proctology: several outstanding events in 2021

Nicolas Lanthier, Bénédicte Delire, Géraldine Dahlqvist, Marie Armelle Denis, Tom Moreels Published in the journal : February 2022 Category : Hépato-Gastro-Entérologie

The year 2021 saw several developments and advances in hepato-gastroenterology, particularly in regard to the general practitioner. In 2021, several simple non-invasive methods were made available and validated by the European scientific society for the study of the liver in order to assess liver fibrosis in at-risk individuals, including patients with metabolic syndrome or excessive alcohol consumption. Moreover, the criteria for reimbursement of certain medications against hepatitis B virus were reviewed. Indeed, these criteria no longer require a systematic liver biopsy while targeting even more patients at risk. Concerning the metabolic dysfunction-associated fatty liver disease, scientific studies with different types of diets were demonstrated to induce disease regression, with their potential advantages and disadvantages described. As a result, these diets can now be proposed by general practitioners. A lesser-known field of endoscopy has also been presented using motorized spiral enteroscopy, which is currently being employed at the Cliniques universitaires Saint-Luc. This technique is likely to improve both exploration and management of small bowel disease. Lastly, for practitioners often confronted with hemorrhoidal disease, recommendations for its management were drawn up and published by a group of Belgian proctologists.

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What was new in 2021?

Laurence de Montjoye, Axel De Greef, Alexia Degraeuwe, Evelyne Harkemanne, Romane Thirion, Laura Nobile, Pierre-Dominique Ghislain, Marie Baeck Published in the journal : February 2022 Category : Dermatology

Several innovations in dermatology in 2021 should be mentioned, particularly in the field of inflammatory and immunological diseases, such as atopic dermatitis, chronic urticaria, alopecia areata or Behçet's disease, but also in oncodermatology.

For the past few years, advances have been made in atopic dermatitis leading to a better understanding of the pathogenesis, identification of comorbidities, and emergence of new biological treatments.

In the course of the year 2021, international guidelines for chronic urticaria clarified the classification and therapeutic management of this disease.

Treatment of patients with alopecia areata became more promising through the advent of Janus kinases inhibitors, leading to encouraging results.

Apremilast became a new treatment option being reimbursed for oral ulcers in Behçet's disease.

In onco-dermatology, several new developments in both diagnosis and management were made:

- Reflectance confocal microscopy is a non-invasive optical imaging technique that was made available for managing patients with suspected malignant skin lesions;

- Chlormethine, a local chemotherapy gel, was shown to be effective and is thus being reimbursed for treating cutaneous T-cell lymphoma mycosis fungoides type in adult patients;

- Simulated daylight-mediated photodynamic therapy is a new technique, which was made available for the therapeutic arsenal designed to manage transplant patients with actinic keratoses.

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Medical treatment of chronic heart failure

Agnès Pasquet, Anne Catherine Pouleur Published in the journal : February 2022 Category : Cardiology

During the year 2021, the European Society of Cardiology published new recommendations for the management of patients with chronic heart failure (1). Classically, patients with heart failure have previously been categorized according to the left ventricular ejection fraction (LVEF). Three different groups are currently recognized:

- Patients with reduced LVEF defined as LVEF ≤40%, which is referred to as heart failure with reduced Ejection Fraction).

- Patients with LVEF between 41% and 49%, i.e,. slightly reduced, which is referred to as heart failure with mildly reduced ejection fraction or HFrEF.

- Patients with signs or symptoms of heart failure with structural or functional cardiac abnormalities or elevated natriuretic peptides and an LVEF >50%, which is referred to as heart failure with preserved ejection fraction or HFpEF.

This article has reviewed the principles of pharmacological treatment pertaining to these three groups.

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A rebuilt and revitalized team

Véronique Deneys, Bénédicte Brichard*, Alice Brochier, Julien Cabo, Katherine Carkeek*, Virginie Chapelle, Corentin Deckers, Anabelle Decottignies*, Jean-Philippe Defour*, Antoine Froidure*, Thibaut Gervais, Claudine Guerrieri, Salwa Hamdash, Sarah Peerae Published in the journal : February 2022 Category : Biologie Hématologique

In 2021, a new wind of creativity and dynamism blew through the department owing to the arrival of two new medical staff members. In the special hematology laboratory, the diagnostic protocols in morphology and flow cytometry were reviewed, with the recommendations for the research and interpretation of schistocytes updated accordingly. The search for short telomere syndromes based on the Flow-Fish technique has taken off, with increasingly numerous clinical indications, including pulmonary fibrosis, bone marrow aplasia, and several others. The research outcomes are critical for both optimally managing patients and genetic counseling of families.

High-throughput sequencing (NGS) has been revolutionizing routine medical practice in hemato-oncology for several years now. This targeted sequencing has enabled the search for markers with diagnostic, prognostic, or therapeutic value, thereby opening the way to a more personalized medicine. The hematology molecular biology laboratory has kept on developing this technology. As a result, NGS can now be carried out there for all the hematological-oncological pathologies provided for in the RIZIV-INAMI agreement. Efforts are also being focused on further developing the RNA sequencing technique recommended since 1/1/2022 for two onco-hematological pathologies.

The HLA system plays a central role in human immunity, whereas it also constitutes a major obstacle to organ transplantation. The involvement of anti-HLA antibodies in early and late rejection is currently indisputable. Given this context, the leuko-platelet immunology laboratory implemented a new test for identifying clinically more relevant anti-HLA antibodies in order to facilitate graft allocation.

COVID-19 has not spared the hematological biology department, playing spoilsport at the Blood Bank. Indeed, not only were the transfusion needs of certain Sars-CoV-2-infected patients rather substantial, but the erythrocyte immunology laboratory was confronted with detecting virus-induced anti-erythrocyte autoantibodies, thereby interfering with routine tests while rendering the search for compatible blood at times even more complex.

One of the Transfusion Committee’s objectives in 2021 was to further develop "Patient Blood Management" (PBM) within the various departments at Cliniques universitaires Saint-Luc. The neonatology department was chosen to be the pilot department, with the intention to work on the second PBM pillar, meaning to minimize blood loss by reducing blood sampling in infants. A decision-making flowchart was established and presented to the pediatric medical and nursing teams prior to being implemented.

These different initiatives have been made possible only through the work of the different departmental teams, at all times seeking to fully respect the patient while offering them optimal care.

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Fibroblast Growth Factor 23 is a powerful biomarker of cardiovascular disease

Damien Gruson Published in the journal : February 2022 Category : Biochimie

Cardiovascular diseases are associated with significant morbidity and mortality, markedly impacting healthcare budgets. Biomarkers play an essential role in the diagnosis and prognosis of cardiovascular diseases. Fibroblast Growth Factor 23 is a hormone regulating phospho-calcium metabolism, which is increasingly emerging as a powerful biomarker of cardiovascular risk.

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Semaglutide (Rybelsus®) – first GLP-1 receptor agonist available as oral formulation

Michel P. Hermans Published in the journal : January 2022 Category : Actualité thérapeutique

Oral semaglutide (Rybelsus®) is a new formulation of semaglutide for oral administration of this GLP-1 receptor agonist (GLP1-RA). Oral semaglutide, recently marketed in Belgium, is indicated for the treatment of hyperglycemia in poorly controlled adult Type 2 diabetics (T2DM) (HbA1c >7.5%) while taking metformin, with or without insulin. Phase 3 studies with active comparators or placebo demonstrated oral semaglutide’s sustained efficacy in reducing HbA1c and body weight in diabetic patients that were representative of the natural T2DM history, requiring the progressive stepping-up of glucose-lowering therapies. A prospective cardiovascular outcome trial recently confirmed the safety of this new semaglutide formulation.

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Storm on O negative blood: “collateral damage” of patient blood management?

Véronique Deneys, Louisiane Courcelles, Christine Pirlet, Corentin Streel Published in the journal : January 2022 Category : Immunohématologie

Patient blood management is a multidisciplinary approach that aims to personalize and optimize transfusion. In addition to the obvious benefit to the patient, applying this methodology reduces the overall consumption of blood components. A collateral effect observed is a disproportionate reduction in all blood components according to blood type, with a negligible reduction effect on O-Rh-negative red cell concentrates, thereby unbalancing the supply chain. This could herald a chronic shortage of these products. As a result, is appears essential to rebalance blood component needs and resources by working on three levers of action, which involve reducing demand, reducing waste, and optimizing supply.

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Published in the journal : January 2022 Category : Ama Contacts Read more

What to do about hyperferritinemia?

Géraldine Verstraete Published in the journal : January 2022 Category : Hematology/Oncology

Regularly dosed upon routine biological work-ups, ferritin is revealed increased in a certain proportion of the population. At times, detection of hyperferritinemia leads to exhaustive and useless work-up, often including HFE genotyping. Although hemochromatosis is the most common genetic disease, this condition is not the primary cause of hyperferritinemia. In Western countries, metabolic syndrome and consumption of alcoholic beverages are the first etiologies to be considered. In general, a complete diagnostic approach, including complete medical history, clinical examination, and biology with a complete martial assessment, allows for identifying, without any specialized consultation required.

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