Abstract: In utero hematopoietic cell transplantation (IUHCT) has the potential to treat patients who have hemoglobinopathies by harnessing the unique period of fetal tolerance to maternal cells, thereby enabling semiallogeneic transplantation without conditioning or immunosuppression. We conducted a phase 1 clinical trial of IUHCT in fetuses with α-thalassemia major (ATM), a diagnosis that requires serial in utero transfusions (IUT) for survival. We also analyzed outcomes in fetuses with ATM treated with IUT alone in the same time period. Six fetuses underwent transplantation with maternal CD34+ cells (1.33 × 108 ± 2.67 × 107 cells per kg + 1% T cells) at 23.1 ± 1.1 weeks’ gestation. All received serial IUT and were delivered at, or near, term. Perinatal outcomes were broadly similar to those undergoing IUT alone. Two mothers received prophylactic antibiotics because of late positive cultures of harvested cells (without fetal adverse events). Low-level maternal microchimerism was detected in all recipients; T-cell hyporeactivity to maternal antigens was detected in 2 of 6 offspring but persisted in only 1 child. Cord blood from ATM-affected pregnancies demonstrated marked expansion of host hematopoietic stem and progenitor cells compared with healthy controls, suggesting a competitive disadvantage for donor cells in this disease context. Neurodevelopmental assessments were largely reassuring, with high quality-of-life scores. Overall, this protocol was safe and feasible but demonstrates the limitations of IUHCT for ATM without concurrent bone marrow conditioning. The favorable perinatal and neurologic outcomes in most offspring underscore the benefits of prenatal transfusions and the unmet medical need for developing definitive therapies for ATM. This trial was registered at www.clinicaltrials.gov as NCT02986698.

The thalassaemia syndromes, which primarily include alpha-thalassaemia and beta-thalassaemia, are a complex group of inherited disorders affecting haemoglobin production. They are prevalent throughout the most populated parts of the world and span a wide range of severity from mild to fatal. Advances in the management of these syndromes, including blood transfusion and iron chelation, have led to substantial improvements in the life expectancy and quality of life of many patients worldwide. Nevertheless, major forms of thalassaemia are still associated with chronic comorbidities and remain an important but neglected global health burden. Prevention and advances in the treatment and management of the thalassaemia syndromes rely on the early identification of people affected, either through prenatal or premarital screening or through newborn screening or testing at later stages in life. This depends on the availability of expertise, facilities and treatment options for patients. Fast and groundbreaking developments in disease-modifying and curative gene editing therapies are promising, but not without challenges in terms of costs, accessibility and uncertainties around their long-term benefits and safety. Better awareness, patient-centred approaches and coordinated strategies are needed to reduce current inequalities.

Importance:Acute pain episodes are the leading cause of emergency department visits and hospitalizations for patients with sickle cell disease (SCD), yet US Food and Drug Administration-approved drugs for acute pain episodes are lacking. During acute pain episodes, patients develop acute arginine deficiency associated with longer time to crisis resolution and greater total parenteral opioid use. Multiple single-center, phase 2 randomized clinical trials have shown that arginine is safe, is opioid sparing, improves cardiopulmonary function, and reduces length of hospital stay. Objective:To determine the efficacy and safety of intravenous arginine for SCD acute pain episodes. Design, Setting, and Participants:Prospective, phase 3, double-blind randomized clinical trial conducted between June 21, 2021, and June 13, 2024, in 10 US children's hospitals enrolling patients aged 3 to 21 years presenting to the emergency department with SCD acute pain episodes requiring parenteral opioids. Interventions:Patients were randomized to receive intravenous arginine (200 mg/kg followed by 100 mg/kg every 8 hours until discharge; n = 129) or saline placebo (n = 142). Main Outcomes and Measures:The primary outcome was time to crisis resolution, defined as hours from initial study drug delivery to last intravenous opioid dose. Secondary outcomes included total parenteral opioid use (intravenous morphine equivalents in milligrams per kilogram from first study drug dose to last intravenous opioid dose), pain scores, and patient-reported outcomes. Results:Of 274 randomized participants, 271 received study drug; the mean age was 14.3 years (SD, 4.3 years), 51% were male, and 92% were Black. The trial was halted early for futility, as time to crisis resolution was similar in those receiving arginine vs placebo (median, 60.8 hours [IQR, 34.8-109.0 hours] vs 65.8 hours [IQR, 31.1-111.1 hours], respectively; absolute difference, 7.2 hours; 95% CI, -21.6 to 35.9 hours). No significant differences were seen in total parenteral opioid use, pain scores, patient-reported outcomes, or safety events. Conclusions and Relevance:Arginine therapy did not shorten time to crisis resolution compared with placebo among children and young adults with SCD acute pain episodes. Trial Registration:ClinicalTrials.gov Identifier: NCT04839354.

Importance Acute pain episodes are the leading cause of emergency department visits and hospitalizations for patients with sickle cell disease (SCD), yet US Food and Drug Administration–approved drugs for acute pain episodes are lacking. During acute pain episodes, patients develop acute arginine deficiency associated with longer time to crisis resolution and greater total parenteral opioid use. Multiple single-center, phase 2 randomized clinical trials have shown that arginine is safe, is opioid sparing, improves cardiopulmonary function, and reduces length of hospital stay. Objective To determine the efficacy and safety of intravenous arginine for SCD acute pain episodes. Design, Setting, and Participants Prospective, phase 3, double-blind randomized clinical trial conducted between June 21, 2021, and June 13, 2024, in 10 US children’s hospitals enrolling patients aged 3 to 21 years presenting to the emergency department with SCD acute pain episodes requiring parenteral opioids. Interventions Patients were randomized to receive intravenous arginine (200 mg/kg followed by 100 mg/kg every 8 hours until discharge; n = 129) or saline placebo (n = 142). Main Outcomes and Measures The primary outcome was time to crisis resolution, defined as hours from initial study drug delivery to last intravenous opioid dose. Secondary outcomes included total parenteral opioid use (intravenous morphine equivalents in milligrams per kilogram from first study drug dose to last intravenous opioid dose), pain scores, and patient-reported outcomes. Results Of 274 randomized participants, 271 received study drug; the mean age was 14.3 years (SD, 4.3 years), 51% were male, and 92% were Black. The trial was halted early for futility, as time to crisis resolution was similar in those receiving arginine vs placebo (median, 60.8 hours [IQR, 34.8-109.0 hours] vs 65.8 hours [IQR, 31.1-111.1 hours], respectively; absolute difference, 7.2 hours; 95% CI, −21.6 to 35.9 hours). No significant differences were seen in total parenteral opioid use, pain scores, patient-reported outcomes, or safety events. Conclusions and Relevance Arginine therapy did not shorten time to crisis resolution compared with placebo among children and young adults with SCD acute pain episodes. Trial Registration ClinicalTrials.gov Identifier: NCT04839354

The thalassaemia syndromes, which primarily include α-thalassaemia and β-thalassaemia, are a complex group of inherited disorders affecting haemoglobin production. They are prevalent throughout the most populated parts of the world and span a wide range of severity from mild to fatal. Advances in the management of these syndromes, including blood transfusion and iron chelation, have led to substantial improvements in the life expectancy and quality of life of many patients worldwide. Nevertheless, major forms of thalassaemia are still associated with chronic comorbidities and remain an important but neglected global health burden. Prevention and advances in the treatment and management of the thalassaemia syndromes rely on the early identification of people affected, either through prenatal or premarital screening or through newborn screening or testing at later stages in life. This depends on the availability of expertise, facilities and treatment options for patients. Fast and groundbreaking developments in disease-modifying and curative gene editing therapies are promising, but not without challenges in terms of costs, accessibility and uncertainties around their long-term benefits and safety. Better awareness, patient-centred approaches and coordinated strategies are needed to reduce current inequalities.

Background: Effective pain management begins with accurate pain assessment for children with sickle cell disease (SCD) experiencing a vaso-occlusive episodes (VOE). While most scales measure pain, these traditional tools do not guide therapeutic intervention directly and rely on a healthcare provider to decide what to do instead of allowing the child to direct it. The Stoplight Pain Scale (SPS) is a novel, child friendly, 3-face scale that integrates pain assessment with guidance for its management. Combining a red-yellow-green color scheme with cartoon faces and directive action phrases, SPS categorizes pain as “green” (I'm ok; I feel fine right now), “yellow” (I'm not sure; Ask me again later), and “red” (I hurt; I need something to feel better). SPS has shown early promise in assessing acute pain in children, but its validity for use in SCD-VOE, particularly for repeated measures over time, has not been previously investigated. Objective: To evaluate the validity of the SPS in children with SCD-VOE presenting to the emergency department. Methods: This prospective observational cohort study was a planned sub-study of a multicenter phase-3 randomized controlled trial evaluating the efficacy of intravenous arginine for SCD-VOE. Endorsed by the Pediatric Emergency Care Applied Research Network (PECARN) and conducted at 10 US sites from 2022-2024, the study enrolled children aged 3 to 21 years. Participants rated their pain using the SPS and verbal Numeric Rating Scale (NRS) at enrollment and daily through hospital discharge. Descriptive statistics and correlations were calculated overall and then stratified by age using cluster bootstrapped 95% confidence intervals to account for repeated measures. Pearson correlation coefficients between the two scales at the first, last, lowest, and highest recorded measures were also computed and assessed. Results: Ninety-eight participants contributed 394 assessments for up to 8 hospital days. The mean (SD) child age was 13.0 (4.6) years; 46% were male, 74% had HB-SS genotype, and 44% reported >3 hospitalizations in the prior year. At enrollment, pain severity using SPS was “green” in 17.2%, “yellow” in 37.9%, and “red” in 44.8%. Median (IQR) NRS pain score was 7 (5, 9). SPS and NRS scores were strongly correlated (r=0.77; 95% CI 0.72, 0.82), supporting convergent validity which demonstrated the degree to which these two tools that are intended to measure pain produced similar results. Correlation was strong for lowest reported values (r =0.73; p<0.001) and moderate for highest reported values (r=0.64; p=0.001). Correlation was better for children aged 6-12 years (r=0.83; 95% CI 0.77, 0.89) compared to 13–17-year-olds (r=0.70; 95% CI 0.59, 0.80) and those greater than 17 years (r=0.65; 95% CI 0.45, 0.78). Discriminant validity was supported by changes in pain scores from the first to the last recorded measure: “green” increased from 19.6% at enrollment to 62.9% at discharge, while “red” decreased from 43.3% to 13.4%. SPS demonstrated responsiveness to change by detecting meaningful changes over time, particularly in response to hospital interventions resulting in decreasing “red” and increasing “green” responses over hospitalization days; for example, “red” decreased from 50% on day 1 to 18% on day 8; and “green” increased from 17% on day 1 to 55% on day 3. Conclusion: The SPS demonstrated good convergent validity, discriminant validity and responsiveness to change in children with SCD-VOE. Overall, there is evidence that this simple, easy-to-implement SPS is a valid assessment tool for children with SCD-VOE. This holds value in the pediatric emergency department setting to rapidly indicate need for analgesia, and its applications extend into reassessments in the inpatient setting. Notably, SPS may be particularly suitable for younger children, a vulnerable group for whom reliable pain assessment is challenging. Further research is warranted to investigate the role of this tool in improving the quality and timeliness of VOE pain management for children with SCD.

Background: ACS occurs in up to 20% of hospitalized patients with SCD-VOE, often prolonging and complicating hospital stay. Despite its clinical significance, variations exist in the management and outcomes of ACS across institutions. Objective: Determine prevalence of ACS in children and young adults hospitalized for SCD-VOE and describe emergency department (ED) presentation, clinical course and practice variation across institutions. Methods: Cross-sectional analysis of data collected from a PECARN-endorsed multicenter, double-blinded, randomized, placebo-controlled phase-3 trial of intravenous arginine therapy in hospitalized patients with SCD-VOE aged 3-21 (NCT04839354) at 10 pediatric EDs across the US. ACS defined by radiology-interpreted chest radiograph (CXR) positive for new infiltrate and clinical team diagnosis. ACS severity was defined a priori as mild (no oxygen (O2) use or RBC transfusion), moderate (O2 use or transfusion), or severe (bilevel positive airway pressure (BiPAP) use, intubation, or pediatric intensive care unit (PICU) transfer). Results: 271 patients enrolled (median age 15[11,18] years, 51% male; 74% HbSS/Sb°; 76% on Hydroxyurea (HU). ACS occurred in 20% (n=54; median age 13[9,16] years; 76% male; 89% HbSS/Sb°; 80% on HU); 18 diagnosed in the ED, and 36 diagnosed during their hospitalization. 72% of patients with inpatient-diagnosed ACS had a negative CXR in the ED with a mean time to diagnosis of 2.4±1.6 days. Patients with ACS at any time were significantly younger (13[9,16] vs 15[12,18] years, p=0.004), predominantly male (76% vs 45%, p<0.001), and had HbSS/Sb° (89% vs 70%, p=0.0005) vs no ACS. In the ED, ACS patients had more O2 desaturations at <94% (37% vs 12%, p<0.001), higher frequency of cough (32%vs18%, p=0.04), wheeze (15%vs6%, p=0.04), and chest pain (59%vs39%, p=0.009) vs no ACS. No significant difference in fever across groups. 83% of patients with ACS presented with a normal respiratory exam in the ED. ACS patients had lower hemoglobin (g/dL;p<0.001) and lymphocyte counts (cells/µL;p=0.02), but higher %reticulocyte (p<0.001), white blood cell counts (x109/L;p=0.001), and absolute neutrophil counts (cells/µL;p=0.02) vs no ACS. Clinical outcomes were worse in patients with ACS vs no ACS, with longer length of stay (LOS; 139[93,189] vs 71[46,113] hours, p<0.001), higher opioid utilization (2.3[0.8,3.9] vs 1.1[0.4,2.1] mg/kg, p=0.001), more transfusions (61%vs14%, p<0.001), O2 use (76%vs20%, p<0.001), BiPAP use (20%vs2%, p<0.001) and PICU transfers (15%vs1%, p<0.001). Patients with inpatient-diagnosed ACS had longer LOS vs patients with ED-diagnosed ACS (142[113,213] vs 105[52,161] hours, p=0.03). 56% of ED-diagnosed ACS was mild, with no significant difference in LOS based on severity. However, only 25% of inpatient-diagnosed ACS were mild; LOS was significantly longer in moderate/severe vs mild ACS. Viral testing was performed in 67% of ACS patients, with 36% positivity for various viral pathogens without a predominant viral isolate. Across all sites, 96% of patients received antibiotics (50% ceftriaxone, 28% ampicillin-sulbactam, 7% vancomycin, 11% other) and 82% received azithromycin. Site-level use ranged from 0-100% for ceftriaxone and 50-100% for azithromycin. 80% received albuterol, 40% received inhaled steroids, and 11% received anticoagulation. No pulmonary emboli were reported. Of the 61% of patients transfused across sites, inter-site transfusion rate varied between 0-100%. Sex, age, ED O2 saturation <94%, hemoglobin, & chest pain were independently associated with ACS in the multivariate model with an AUC=0.80. Conclusion: ACS remains common in patients with SCD-VOE (20%), with 14% of ACS diagnosed during their hospital stay. Two-thirds of subjects who developed ACS had a CXR done in the ED that was negative. ACS may have been missed in patients who did not get a CXR, and radiographic changes often lag behind symptoms. Lack of ACS-specific clinical signs and symptoms, including a normal ED respiratory exam in most patients, may delay diagnosis. Patients with inpatient-diagnosed ACS had a more severe hospital course vs those with ED-diagnosed ACS. Considerable practice variation exists in ACS management across institutions, with variable use of antibiotics and transfusion protocols. Further research on standardizing ACS treatment may be warranted. Oxygen desaturation in the ED was associated with a >3.6-fold greater risk of ACS, not included in prior ACS risk models.

Background/Methods: STArT (NCT04839354) was a phase-3 double-blind, randomized placebo-controlled trial of intravenous (IV) arginine therapy in participants aged 3-21 years with sickle cell disease (SCD) and vasoocclusive episode (VOE) pain requiring IV opioids. STaRT was conducted at 10 US sites utilizing the Pediatric Emergency Care Applied Research Network (PECARN). Enrolled participants were randomized 1:1 to receive either study drug or placebo within 12 hours of receiving their first dose of IV opioid. The primary outcome was time-to-crisis- resolution defined as the time in hours from study drug delivery to the last dose of IV opioid. Secondary outcomes included total parenteral opioid & patient reported outcomes (PROMIS) at admission, discharge, and 7-12 days post-discharge. Participants were classified at enrollment as having chronic pain (CP) if they experienced pain on ‘15 or more days of the month’ or ‘atleast half the days of the month’ for the last 6 months. Methods: We compared demographic and clinical characteristics and change in pain score (enrollment-discharge) by CP group. We then examined pain intensity trajectories of the highest daily pain score (0-10) during hospitalization in study participants by CP status at enrollment; to do so, we included CP status as a main effect and CP status X follow-up day as an interaction term in linear mixed models. Similar models were also examined with sex as a main effect. Finally, a four-level sex-CP variable as a main effect and sex-CP X follow-up day as an interaction were assessed. Unadjusted models were examined, as were models adjusted for total opioid received in IV morphine milligram equivalent/kilogram body weight. Results: Two hundred and seventy-one participants were randomized and received study drug (129-arginine, 142-placebo), and data on presence of CP was available for 268 participants. The median age of participants was 15.1 years (IQR 11.2-17.7), 71.3% (n=191) of participants were age 12 and older, and 51.9 %, (n=139) were male. Most had Hemoglobin SS genotype (70.1%, n=188). Most participants were prescribed HU (75.7%, n= 203) and 21.1% (n=54) received chronic transfusion therapy. About half (51%) reported that they experienced CP, and 77.2% (n=207) experienced 3 or more healthcare visits for pain in the 12 months prior to enrollment. Almost all reported a pain score of 6 or higher at arrival to the Emergency Department. Clinical characteristics at enrollment were similar across CP groups, except that the CP group was more likely to have a history of acute chest syndrome (p=0.013) and asthma (p=0.026). Participants in the CP group were also more likely to report 3 or more healthcare visits for pain in the 12 months prior to enrollment (p<0.001). We found a significantly lower change in pain score (enrollment-discharge) in the CP group (mean 3.9, SD 3.2) compared to the non-CP group (mean 4.8, SD 3.4, p=0.018). Participants with CP were more likely to return to the ED within 28-days. The mean number of follow-up number of days with pain score assessments was 3.82 days (SD 1.99 days). Examining trends in highest pain intensity score during hospitalization, we found a significant decrease in pain score for the entire cohort (p<0.001), with an average 0.18-point decrease (slope estimate -0.18, 95% CI: -0.28, -0.08) in highest pain score for every day of measurement. There was no difference in decrease in pain score by sex. The interaction between CP X follow-up day was significant (p<0.001), indicating a difference in trends by CP status; the CP group had a slower decrease in pain (slope estimate -0.05, 95% CI -0.19, 0.08) as compared to non-CP group (slope estimate -0.42, 95% CI -0.58, -0.26). The interaction between follow-up day and sex-CP was significant (p=0.007), indicating that pain trajectories over time differ by sex-CP level. Both male and female participants with CP experienced a significantly smaller decline in daily high pain scores over time compared to those without CP. Conclusion: About half of children and young adults hospitalized with SCD VOE have CP. Children and young adults with CP, compared to those without CP, experience a smaller magnitude of change in pain score and a slower decline in pain during hospitalization. These findings should be considered in the study design and selection of study outcomes for future SCD acute pain clinical trials.

ABSTRACT Background Children with transfusion‐dependent thalassemia (TDT), also known as thalassemia major, require monthly blood transfusions and regular iron chelation therapy for long‐term survival. While the burden of caring for these children is recognized, little has been done to address the parents’ experience. Procedure A 38‐item parent self‐report was included in the previously designed disease‐specific tool, the transfusion‐dependent quality‐of‐life questionnaire (TranQol), to identify the issues they may be facing. We wanted to ensure that the self‐report was reliable and valid. Questionnaires were given to parents during their children's routine clinic visits as part of a multi‐center North American study of the TranQol. Construct validity was assessed using Pearson's correlation with the Pediatric Quality of Life (PedsQL) Family Impact Module (FIM) (hypothesis: correlation of 0.4–0.6). Results Sixty‐seven parents completed both the TranQol and PedsQL Family Impact Module questionnaires at baseline. There was substantial correlation ( r = 0.76) between TranQol parent self‐report scores (median 63, interquartile range [IQR]: 53–76) and PedsQL Family Impact Module scores (median 77, IQR: 59–89). Conclusions The median PedsQL FIM score was similar to previously reported scores for parents of children with sickle cell disease. The TranQol parental burden tool demonstrated construct validity was internally reliable (Cronbach's α = 0.94) and had acceptable test–retest reliability (intraclass correlation coefficient [ICC] = 0.81), for future research into TDT. In addition, this tool could also be used to help clinicians assess the impact of the disease on parents to potentially target appropriate support and care that is required.

Introduction Sickle cell disease (SCD) is a recessive blood disease affecting about 300,000 newborns every year. SCD causes polymerization of deoxygenated hemoglobin resulting in tissue hypoxia and reperfusion injury leading to inflammation that contributes to pain crises and organ damage. Uric acid is the most abundant and potent plasma antioxidant. Epidemiologic, physiological, and animal studies suggest a protective effect of this antioxidant. Murine sickle cell models of hemolysis support his hypothesis. Too low uric acid levels are associated with multiple sclerosis, poor innate immunity, and inflammation. Chronic kidney disease (CKD) is a leading cause of death and morbidity in about 50% of adult sickle cell patients. Prior associative studies have led to the belief that an increase in uric acid concentrations may cause this decline in renal function. However, given its antioxidant properties, it is not known whether this increase in serum uric acid with kidney disease in SCD is a cause or an effect and may even be protective. To examine this question, we employed statistical models that account for the effects of a rise in uric acid concentrations on renal function over time. This study utilized the ASH Research Collaborative (ASH RC) Data Hub. Methods After IRB approval, the ASH RC Data Hub was queried for basic demographics, sickle cell genotypes, uric acid measurements, and renal parameters. Time-Varying Effect Modeling (TVEM) estimated how the association between time-varying uric acid levels and renal markers (serum creatinine, estimated glomerular filtration rate (eGFR)) changed flexibly over the study period. Distributed Lag Non-Linear Models (DLNM) characterized lead-lag patterns between uric acid fluctuations and kidney outcomes to identify critical exposure windows where uric acid levels exerted their strongest influence. The earliest available serum uric acid and creatinine levels within 30 days of each other was used as the baseline pairs for these analyses. Severe disease was defined as SS or S Bthal0 genotypes. The CKD-EPI creatinine equation (2021) was used to calculate eGFR. Both models controlled for age, sex, and severe disease. Model selection was guided by evaluation of competing specifications using information criteria (e.g., AIC, BIC) to ensure optimal fit and interpretability. Analyses were performed using SAS version 9.4. Results Querying the ASH RC Data Hub found 12,773 attested SCD patients and their genotypes. We excluded labs within 14 days of emergency room visits or hospital stays, patients with no data after 1/1/2015, and patients with no uric acid values. There were 581 patients included for analysis, with 46% of these having two or more creatinine and uric acid paired values. Mean age was 36.8 years old, with 88.5% ≥18 years old. The sexes were nearly 50% each. The genotypes were 74.5% SS, 15.8% SC, and 1.9% Sthal0. Those with severe disease were 76.4%. Of those with less severe disease, 67 % were SC. Mean uric acid level was 6.3 (SD 2.31). TVEM modeling found that after three years, the effect of uric acid on eGFR suggested an increasingly protective trend. The confidence intervals (CIs), however, crossed zero precluding statistical significance in later years, possibly from smaller numbers of subjects, dropping from 84 subjects at year four to just 2 at year nine. The DLNM found a statistically significant protective uric acid range of 4.5 – 6.5 mg/d, with CIs not crossing zero. Uric acid levels over 9 mg/dl were associated with worsening eGFR. There was no difference between sexes or between severe vs non-severe disease. Conclusions This study highlighted the importance of the ASH RC Data Hub for sickle cell research. Future work will examine other renal outcomes such as proteinuria, while controlling for additional variables such as hemolysis, red cell turnover, medications such as hydroxyurea and NSAIDs, and hospitalizations. In this pilot study of the time effect of changes in uric acid on renal function, DLNM analysis found a potentially protective range of uric acid levels on renal function. The TVEM analysis, although not reaching statistical significance, showed a steadily increasing trend for benefit of higher uric acid levels on renal function up to a value of about 9 mg/dL. Despite being limited by small numbers, these results, given uric acid's known functional role as a potent antioxidant, warrant further study.

Alpha thalassemia major (ATM) is the most severe form of α-thalassemia, with thousands of cases annually throughout the world. It was historically incompatible with life, with almost all affected individuals dying at or before birth. Recent advances utilizing early, serial intrauterine transfusions have resulted in improved outcomes, including improved neurocognitive functioning and less congenital anomalies. At-risk families should be identified pre-conceptually for counseling and options such as preimplantation genetic testing. ATM, when diagnosed prenatally, requires counseling about termination options and transfusion therapy. Postnatally, aggressive transfusion, in contrast to standard thalassemia transfusion protocols, suppresses ineffective erythropoiesis and hemoglobin Barts formation. These advances have changed the course of ATM in utero and postnatally. Preliminary results suggest iron chelation may be safely administered after one year of age with monitoring, including quantitative liver iron measurements. Patients with ATM can now survive on chronic transfusion therapy and potentially be cured by hematopoietic cell transplantation (HCT). New therapies continue to emerge, including in-utero stem cell transplantation using maternal stem cells and Phase 1 gene therapy trials evaluating reactivation of the embryonic α-globin (zeta) gene and encoding the α-globin gene. Globally, an international working group has been formed to address ATM, which should lead to advances worldwide.

Abstract Background Acute chest syndrome (ACS) is a leading cause of morbidity and mortality in children with sickle cell disease (SCD), often developing during vaso-occlusive episodes (VOE) with minimal early signs. Most children present with a normal lung exam, making early detection challenging. sPLA2, a potent inflammatory mediator, rises before ACS onset and may help predict its development and severity. We aimed to assess sPLA2 as a marker for ACS risk and severity in SCD-VOE Methods Cross-sectional analysis of a multicenter, double-blind, phase-3 randomized controlled trial evaluating IV arginine therapy in patients aged 3–21 years with SCD-VOE at 10 US EDs, with 9 in the Pediatric Emergency Care Applied Research Network. sPLA2 levels at ED presentation, day 2, and discharge (DC) were analyzed by enzyme-linked immunosorbent assay. Levels ≥48 ng/mL were considered elevated. ACS severity was classified as mild (no oxygen/transfusion), moderate (oxygen/transfusion), or severe (BIPAP, intubation, PICU admission). Results Of 271 enrolled, 251 had sufficient samples for sPLA2 analysis. Demographics are shown in Table 1. Mean sPLA2 at ED presentation was 116±131 ng/mL; 60% had elevated levels. ACS occurred in 21%, with 18 diagnosed in the ED and 34 during hospitalization. Despite normal lung exam in 85%, 71% had elevated sPLA2. Patients diagnosed with ACS at any point had significantly higher sPLA2 at presentation compared to patients without ACS (152±146 vs 106±125 ng/mL, p = 0.01), and higher peak levels (263±169 vs164±164 ng/mL, p < 0.001). The sPLA2≥48 ng/mL cutoff yielded a sensitivity=85%, specificity=33%, NPV=89% and PPV=25% in predicting ACS. Mean sPLA2 at presentation was highest in those with ACS and positive chest x-ray (CXR) (198±182 ng/mL), followed by those with negative initial CXR who later developed ACS (128±120 ng/mL); both significantly higher than no ACS (106±125 ng/mL; p = 0.02). Levels rose further by Day 2 and remained elevated at DC (p < 0.001). Among ACS cases, 36% were mild, 46% moderate, and 17% severe with stepwise rise by severity. (severe 192±200 vs mild 122±140 ng/mL). Peak sPLA2 was higher in febrile vs afebrile patients (254±19 vs 120±10 ng/mL, p < 0.0001). ED sPLA2 correlated positively with heart rate (r = 0.42, p < 0.001), respiratory rate (r = 0.14, p = 0.02), white blood cells (r = 0.48, p < 0.001) and neutrophils (r = 0.40, p < 0.001), and negatively with lymphocytes (r=-0.42, p < 0.001) and hemoglobin/hematocrit (r=-0.26, p < 0.001). Conclusions sPLA2 is a promising biomarker for ACS risk and correlates with severity in children with SCD, with potential to enhance early diagnosis and guide management.

Background: Vaso-occlusive pain episodes (VOE) are the leading cause of emergency department (ED) visits and hospitalizations for patients with sickle cell disease (SCD). Yet, FDA-approved drugs for SCD-VOE are lacking. During SCD-VOE, patients develop an acute arginine (Arg) deficiency that is associated with adverse clinical outcomes including longer time-to-crisis-resolution (TCR), and greater total parenteral opioid use (TPO) during hospitalization. Multiple RCTs in the US, Brazil, Nigeria, and Egypt have established that supplementation with Arg is safe, has opioid-sparing effects, improves pain scores, blood pressure, and cardiopulmonary function and decreases length of hospital stay. We and others have shown that Arg increases nitric oxide production, improves mitochondrial function, and decreases both oxidative stress and biomarkers of hemolysis and inflammation. A phase-3 RCT was needed. Objective: To determine the efficacy and safety of intravenous (IV) Arg for SCD-VOE. Methods: We conducted a multicenter, double-blind, phase-3 RCT of IV Arg therapy in subjects aged 3-21 years with SCD-VOE receiving IV opioids at 10 US sites utilizing the Pediatric Emergency Care Applied Research Network (PECARN). Enrollment began in 2021 with a sample size goal of 360 patients. Within 12 hours of receiving their first dose of IV opioids, enrolled participants were randomized 1:1 to receive either 1) a one-time loading dose of IV Arg (200 mg/kg with a max of 20g) followed by a standard dose of 100 mg/kg (max 10g three times/day) or 2) placebo (normal saline) at equivalent volumes/duration as the study drug. Participants, research staff, and investigators were blinded to the patient's randomization. The primary outcome was TCR defined as the time in hours from study drug delivery to the last dose of IV opioid delivery. Secondary outcomes included TPO, defined as total IV morphine equivalents in mg/kg from study drug delivery to last parenteral opioid) and patient reported outcomes (PROMIS) at admission, discharge, and 7-12 days post-discharge. This protocol utilized FDA-IND#66943, registered with ClinicalTrials.gov (NCT04839354).Results: The STArT trial was halted early for futility to achieve the primary outcome of TCR. A total of 2,629 patients were screened, 1034 were eligible, 741 were approached, 293 consented, and 271 randomized who received study drug (129-Arg, 142-placebo) with enrollment milestones nearly a year ahead of schedule. Mean age ±standard deviation (SD) was 14±4 years, 51% were male, 71% had Hb-SS, 76% on hydroxyurea, and 41% had chronic pain (SCD-pain ≥15 days/month for the last 6 months). Demographics were similar across study arms. TCR was similar in the Arg arm vs placebo (82±80 vs. 89±152 hours, p=0.98). TPO was also similar across both arms (2.6±4.5 vs 1.9±2.8mg/kg, p=0.33). No differences in safety outcomes, adverse events, pain scores, PROMIS Pain Interference, Behavior or Fatigue were noted. 54 subjects had or developed acute chest syndrome (ACS). Among participants with ACS, there was a mean 76-hour difference in TCR in those treated with Arg vs placebo (108±98, n=29 vs. 184±327, n=25; p=0.16; median difference of 34 hours) that was not statistically significant. Larger than expected site variation, outliers and SD occurred; sample size recalculation based on STArT data would require randomization of over 900 subjects. Conclusion: All phase-3 RCTs for SCD-VOE to date have failed to meet their primary outcomes after promising phase-2 RCTs. The PECARN STArT trial is the latest addition to this list, stopped early for futility to achieve the primary outcome of TCR. There were no safety concerns. Ultimately, RCTs evaluating orphan drugs for SCD-VOE face significant challenges due to shorter hospital lengths of stay over the last 20 years, and extensive interpatient variability in TCR that could confound RCT outcome measures. Larger than expected SD and outliers occurred. Clinically relevant differences in TCR among patients with VOE-ACS treated with Arg similar to a prior RCT (Morris et al, Am J Hematol 2025) requires further study with a larger sample size. Dialogue between the FDA, ASH, SCD researchers and patients is needed to identify more ideal outcome measures beyond TCR, currently FDA-preferred for orphan drug approval.

Analysis of the placebo cohort in the STArT trial shows that patient characteristics and hospital site strongly influence time-to-crisis-resolution and total opioid use in children and young adults with sickle cell disease, highlighting the need to account for these factors in the design of future clinical trials.

Background: Patient engagement is critical to the success of clinical trials. Community Advisory Boards (CABs) provide a vital feedback loop between individuals with lived experience and researchers, ensuring patient-centered outcomes. The American Society of Hematology Research Collaborative® (ASH RC) established local and national CABs affiliated with its SCD Research Network to deepen engagement in SCD research. However, a gap often exists in the practical research literacy of stakeholders. This study was designed to test whether experiential learning enhances clinical trial literacy among CAB members by guiding them through running their own clinical trial. Methods: Protocol Development: We first conducted pre-implementation listening sessions with the ASH RC National CAB (n=32) and Principal Investigators (PIs) (n=46) to refine the study protocol using a participatory approach. Intervention Design: The intervention is a “study within a study” where CAB members are the research team that designs and implements their clinical trial. Over six months, participants guided the entire research lifecycle of an educational intervention to reduce SCD stigma among providers, from finalizing the research question and study protocol to overseeing data collection and planning dissemination. Baseline Assessment: To establish a baseline before the intervention, we conducted two virtual focus groups with local CAB members (N=18) from site A (n=10) and site B (n=8). Participants were asked about their understanding of the research process, experiences with clinical trials, and methods for receiving research information. An abductive content analysis was used to identify emerging themes regarding participants’ perceptions of clinical research. Results: Protocol Development Findings: Feedback from the National CAB and PIs was positive. Key suggestions for protocol revision addressed patient-centered concerns (e.g., time requirements, baseline knowledge) and clinical concerns (e.g., institutional constraints, increased staff workload, and consistency across sites). PIs noted the unique value of CAB input on an active study rather than a theoretical proposal. Baseline Participant Data: Among local CAB participants (N=21), 40% reported prior research participation, and 30% had served as co-investigators or stakeholders. Thematic analysis revealed that participants with prior experience demonstrated a clearer understanding of research processes. Participants commonly associated research with seeking cures, testing new medications, and gathering information. Trust in healthcare providers was a key facilitator for participation, while concerns included trial risks, potential side effects, and impact on family responsibilities. A strong, articulated desire to increase personal research literacy to better advocate for their community was a dominant theme. Conclusions: Baseline data confirm a gap in practical research literacy even among engaged CAB members and a strong motivation to learn. These findings validate the need for our novel, experiential learning model. By empowering CAB members to lead their own research project from concept to conclusion, we hypothesize that we can build more robust and practical trial literacy than traditional didactic methods. Post-intervention focus groups will be crucial to evaluating this empowerment-based educational strategy and its impact on fostering equitable research partnerships in SCD.

Introduction Hemoglobinopathies are a heterogenous group of disorders comprised of variants in α-globin (HBA), β-globin (HBB) genes or both. Newborn screening (NBS) is aimed to identify clinically significant hemoglobin disorders and facilitate early delivery of specialized care and education before the onset of clinical symptoms. The rapid growth in Asian and Middle Eastern segments in the US population has resulted in higher frequency of non-sickling thalassemia disorders and has affected NBS practices in some states; In California, due to such demographic changes, NBS for α thalassemia (Hb H disease) is mandated. In many other states the reporting for α thalassemia is of a presumptive diagnosis, mostly due to the complexity and expense of such testing, causing delays in diagnosing clinically significant forms of α thalassemia. Our ‘Hb Reference Lab’ (https://hemoglobinlab.ucsf.edu) performs confirmatory testing following primary screening by HPLC (California NBS Program). The diagnostic approach targets the most common mutations or deletions (e.g., allele specific PCR) or analyzes the entire HBB and/or the HBA genes to identify the gene/s responsible for a Hb disorder (e.g. Sanger direct sequencing). Thus, different molecular techniques, in a sequential workflow, which cannot simultaneously assess both α and β genes, are required. It is therefore time consuming, a costly process and results in an extended turn-around time. Next-generation sequencing (NGS) has a wide application in detecting disease-causing variants in genetic disorders; while not widely adopted for Hb disorders due to cost and technical challenges, NGS has proven helpful in carrier screening and diagnosing complex cases. We sought to assess the effectiveness of targeted NGS for confirmatory diagnosis of hemoglobinopathies in newborns. Methods Genomic DNA was extracted from peripheral blood and based on initial protein chemistry analysis (HPLC, IEF) molecular essays for HBA, HBB or both were performed and hemoglobinopathy determined. 98 samples with a known genotype were then analyzed by amplicon based NGS (Devyser Thalassemia NGS) which detects variants in HBA1, HBA2 and HBB genes. Results NGS successfully identified both deletions and point mutations including compound heterozygous conditions: HBB gene; Hb SS, SC, S/ β +, SE, S/β variant, S trait, E / β variants, homozygous β 0, Hb EE, β traits, β variants; E, D carriers. HBA genes; deletional or non-deletional Hb H disease, a case of 4 alpha gene deletion and several benign α-variants. Previously unknown genotypes detected by NGS: A large β deletion making the diagnosis S/β0 thalassemia (instead of presumed Hb SS)3 cases of HPFH or a delta/beta deletion in patients with Hb SS9 homozygous and 26 heterozygous Xmn1 polymorphisms13 of 28 case of SCD had one alpha gene deletion (α3.7)3 cases of an α mutation carrier: Constant Spring (CS) and Hb Pakse. Genotypes not detected by NGS: We could not specify if α variants were located on HbA1 or HBA2. However, unique mutation to HBA2, such as CS and Pakse were correctly identified.A case a coinheritance of α -4.2 deletion and α2 triplication was not identified (as they balance out each other) Discussion The use of NGS Thalassemia assay accurately detected mutations and deletions and provided a comprehensive hemoglobin profile for all NB samples flagged during initial screening. The essay also revealed variants that were not identified through our standard approach. This capability is particularly advantageous in regions with a high prevalence of thalassemia, where traditional methods may not detect these important genetic variants, in particular of α thalassemia. The ability to simultaneously analyze the HBA and HBB genes, is a significant benefit in reducing laborious processes of multiple essays and extended turn-around time. Additionally, it can limit or eliminate the need to analyze parents' samples (currently done on an elective basis for abnormal NBS results). Beyond diagnosis of important NB hemoglobinopathies, the findings add clinically relevant data, such as presence of HPFH and a β deletion in patients diagnosed with Hb SS, which are therefore expected to have a milder phenotype, or knowledge of XMN1 status for considerations of hydroxyurea treatment. Some limitations exist due to a high degree of homology between HBA1 and HBA2 but have a limited impact on the accurate diagnosis of the expected clinical phenotype.

BackgroundDue to the risk of cerebral vascular injury, children and adolescents with high-risk sickle cell disease (SCD) experience neurocognitive decline over time. Haploidentical stem cell transplantation (HISCT) from human leukocyte antigen-matched sibling donors may slow or stop progression of neurocognitive changes.ObjectivesThe study is to determine if HISCT can ameliorate SCD-associated neurocognitive changes and prevent neurocognitive progression, determine which specific areas of neurocognitive functioning are particularly vulnerable to SCD, and determine if there are age-related differences in neurocognitive functioning over time.MethodsWe performed neurocognitive and neuroimaging in SCD recipients following HISCT. Children and adolescents with high-risk SCD who received parental HISCT utilizing CD34+ enrichment and mononuclear cell (T-cell) addback following myeloimmunoablative conditioning received cognitive evaluations and neuroimaging at three time points: pre-transplant, 1 and 2 years post-transplant.ResultsNineteen participants (13.1 ± 1.2 years [3.3–20.0]) received HISCT. At 2 years post-transplant, neuroimaging and cognitive function were stable. Regarding age-related differences pre-transplantation, older children (≥13 years) had already experienced significant decreases in language functioning (p < 0.023), verbal intelligence quotient (p < 0.05), non-verbal intelligence quotient (p < 0.006), and processing speed (p < 0.05), but normalized post-HISCT in all categories.ConclusionThus, HISCT has the potential to ameliorate SCD-associated neurocognitive changes and prevent neurocognitive progression. Further studies are required to determine if neurocognitive performance remains stable beyond 2 years post-HISCT.Clinical trial registration: The study was conducted under an investigator IND (14359) (MSC) and registered at clinicaltrials.gov (NCT01461837).

Alpha-thalassemia is an inherited blood disorder caused by impaired α-globin chain production, leading to anemia and other complications. Hemoglobin H (HbH) disease is caused by a combination of mutations generally affecting the expression of three of four α-globin alleles; disease severity is highly heterogeneous, largely driven by genotype. Notably, non-deletional mutations cause a greater degree of ineffective erythropoiesis and hemolysis, higher transfusion burden, and increased complication risks versus deletional mutations. There are limited treatment options for HbH disease, and effective therapies are needed. This review discusses the pathophysiology of HbH disease, current management strategies, unmet needs, and emerging treatment options.