Studies and Research

The presence of minimal residual disease (MRD) in the bone marrow (BM) of patients with acute myeloid leukemia (AML) following chemotherapy has been established by many studies to be strongly associated with relapse of leukemia. In addition, detection of MRD is the major objective of many of the newer diagnostic techniques used in malignant hematology. Because of the wide availability and conceptual straightforwardness of immunophenotyping, flow cytometry is the most accessible method for MRD detection. This review is not an overview of all MRD studies, but rather discusses the possibilities for optimizing MRD detection, the use of multiparameter flow cytometry (MFC) techniques in MRD detection, and the implications for future patient treatment. This review focuses on MRD detection in AML using MFC and discusses the reported correlations of MRD, clinical and biologic features of the disease, and outcome. In addition, it discusses the laboratory and clinical aspects of this approach.

Country-specific reference ranges for adult peripheral blood lymphocyte subsets have been established in a few countries around the world; however, there have been no specific comprehensive studies in the Gulf Cooperation Council (GCC) and Middle East, which investigated age and gender-specific reference ranges. Demographic and environmental factors may contribute to variations in these subsets around the world, and thus there is a great necessity for each country to establish its own reference ranges. Hence, the aim of this study is to establish lymphocyte subsets reference ranges for Omani healthy adults. Total, age, and gender-specific reference ranges were established using four-color flow cytometry analysis with an extensive panel of monoclonal antibodies in 50 healthy adult males and females aged between 18 and 57. Reference values were expressed as median and 95% confidence intervals for T cells-

Multiparameter flow cytometry (MFC) has been shown to be a useful approach for detection of minimal residual disease (MRD). The aim of the study was to determine the optimal threshold that can separate patients into two groups in terms of leukemic residual cells and relapse status after induction and consolidation chemotherapy. Five-color MFC and receiver operating characteristics (ROC) analysis were used to determine the optimal threshold. This study analyzed 54 acute myeloid leukemia (AML) patients. LAPs were detected in 51/54 (94%) patients. MRD was evaluated in the bone marrow (BM) in morphologic complete remission from 25 and 22 patients after induction and consolidation, respectively. The threshold discriminating MRD(-) from MRD(+) cases was set at 0.15% residual leukemic cells, a level that allowed optimal sensitivity and specificity for prediction of relapse, both at postinduction (P = 0.05) and postconsolidation (P = 0.009) time points using ROC analysis. MRD level postinduction not only influenced relapse-free survival (RFS) (P = 0.004) but also overall survival (OS) (P = 0.003). Multivariate analysis showed that MRD level postinduction was a powerful independent prognostic factor for both RFS (P = 0.037) and OS (P = 0.026). Using the ROC analysis, the threshold of 0.15% was defined as the optimal value in discriminating risk categories in AML, and postinduction MRD assessment is able to better predict disease outcome than consolidation. Therefore, MRD analysis by MFC could be used for refining the selection of therapeutic strategies and improving clinical outcome in individual patients.

Objectives: Constitutive activation of the fms-like tyrosine kinase 3 (FLT3) receptor by internal tandem duplication (ITD) of the juxtamembrane region has been described in patients with acute myeloid leukemia. FLT3/ITDs are present in about 20-30% of all acute myeloid leukemia cases. It has been shown that the mutation is correlated with worse prognosis. However, none of the previous studies investigated which FAB subtype is associated with higher percentage of FLT3/ITD, thus the reason for undertaking the current study. Methods: The prevalence and the potential prognostic impact of FLT3 mutations in 39 acute myeloid leukemia patients were analyzed by genomic polymerase chain reaction. Twelve samples with FLT3/ITDs and 27 acute myeloid leukemia samples without the mutations were compared with respect to clinical prognosis and FAB subtype. Results were correlated with cytogenetic data and the clinical response. Results: FLT3/ITD mutations were found in 31% of patients. FLT3/ITD was associated with similar clinical characteristics and was more prevalent in patients with normal karyotype (83%). Interestingly, half of the FLT3/ITD aberrations were found in patients with FAB M1 (50%), and fewer were found in patients with FAB M2 (8%), M4 (8%), and M5 (8%). Although less frequent in patients with cytogenetic aberrations, FLT3/ITDs were found in 17% of patients with t(15;17). Although the study was powered to 80%, patients with FLT3/ITD mutation did not show shorter complete remission duration or a higher relapse rate. Conclusion: The data confirm that FLT3/ITD mutations represent a common alteration in adult acute myeloid leukemia, mainly with normal karyotype (83%) and de novo acute myeloid leukemia (75%), as compared to secondary acute myeloid leukemia (25%) (p<0.001). It also showed that half of the M1-FAB subtype is FLT3/ITD positive. Therefore, FLT3/ITD is a therapeutic target, and thus inhibition of FLT3 tyrosine kinase activity may provide a new approach in the treatment of leukemia carrying these mutations.

Leukemic stem cells (LSCs) have been identified in acute myeloid leukemia (AML). Similar to haematopoietic stem cells, these LSCs are able to self-renew, differentiate, and proliferate extensively. Recent studies suggest that LSCs are critical for the initiation and maintenance of leukemia.

Strict compliance to ethical principles in conducting clinical research is mandatory to ensure safety and well-being of study participants and legal protection of researchers. Many instances of fraud and misconduct are reported in world literature that has harmed clients and also eroded the trust that society had on bioscience researchers. In the light of a review of international experience on ethical practice in clinical research, we prepared the 'Guideline for Responsible Conduct of Clinical Studies and Trials' which covers important aspects of clinical research including protection of the rights, safety, well-being, and autonomy of study participants; role and responsibilities of the researchers, supervisors, and sponsors including pharmaceutical agencies; documentation required; reporting of research findings and related issues. Clinical researchers must acquire and apply knowledge, attitude, and skill in conducting ethically sound high-quality clinical research as prescribed in this guideline. This review and our guideline will hopefully be useful resources to all researchers worldwide.

In CD34-positive acute myeloid leukaemia (AML), the leukaemia-initiating event likely takes place in the CD34+CD38- cell compartment. CD123 has been shown to be a unique marker of leukaemic stem cells within the CD34+CD38- compartment. The aim of this study was to identify the percentage of CD34+CD38-CD123+ cells in AML blasts, AML CD34+CD38- stem cells, and normal and regenerating bone marrow CD34+CD38- stem cells from non-myeloid malignancies. Thirty-eight adult de novo AML patients with intention to treat were enrolled after the application of inclusion criteria from February 2012 to February 2017. The percentage of the CD34+CD38-CD123+ phenotype in the blast population at diagnosis was determined using a CD45-gating strategy and CD34+ backgating by flow cytometry. We studied the CD34+CD38-CD123+ fraction in AML blasts at diagnosis, and its utility as a unique phenotype for minimal residual disease (MRD) of AML patients. CD123+ cells were present in 97% of AML blasts in patients ...

Reference intervals for venous blood parameters differs with age, gender, geographic region, and ethnic groups. Hence local laboratory reference intervals are important to improve the diagnostic accuracy of health assessments and diseases. However, there have been no comprehensive published reference intervals established in Oman, the Gulf Cooperation Council or Middle Eastern countries. Hence, the aim of this study was to establish reference intervals for full blood count in healthy Omani adults. Venous blood specimens were collected from 2202 healthy individuals aged 18 to 69 years from January 2012 to April 2017, and analysed by Sysmex XS-1000i and Cell-Dyn Sapphire automated haematology analysers. Results were statistically analysed and compared by gender, age, and ABO blood group. The lower and upper reference limits of the haematology reference intervals were established at the 2.5th and 97.5th percentiles respectively. Reference intervals were calculated for 17 haematology pa...

We assessed the usefulness of 5-color multiparameter flow cytometry to detect leukemiaassociated phenotypes (LAPs) in the bone marrow of patients with newly diagnosed acute myeloid leukemia (AML) and determined its usefulness for detection of minimal residual disease (MRD). Overall, 94% of patients (51/54) with AML had LAPs at diagnosis. The frequency of leukemic bone marrow/median frequency of LAPs in normal or regenerating bone marrow samples using maximum log difference statistics revealed that CD2, CD56, CD11b, CD7, and CD19 expression on AML blasts represented the most sensitive and reliable markers for detection of MRD. Serial dilutional experiments showed that the sensitivity level of immunophenotyping was between 10-4 and 10-5 and that the approach was highly reproducible. Immunophenotypic analysis using a CD45 gating strategy, 5-color staining, and an extensive panel of monoclonal antibodies allowed the identification of LAPs in 94% of AML cases, and these immunophenotypes can be used for MRD monitoring with a sensitivity limit of 10-4 to 10-5 .

Leukemic stem cells (LSCs) have been identified in acute myeloid leukemia (AML). Similar to haematopoietic stem cells, these LSCs are able to self-renew, differentiate, and proliferate extensively. Recent studies suggest that LSCs are critical for the initiation and maintenance of leukemia. This review will describe the characteristic features of LSCs in AML and the possible targets expressed on the surface of AML, the intracellular targets and the novel molecular and flow cytometry methodologies being used to particularly ablate the LSC population. Studies have shown the potential importance of ablating LSCs when treating leukemia. The unique characteristics of LSCs that differentiate them from their normal counterparts can be applied to specifically target the leukemic population. Current therapeutic strategies may not effectively ablate the LSCs, leaving the potential for disease progression or recurrence. A better understanding of LSCs and molecular biology will allow the design of more effective therapies.

Acute myeloid leukemia (AML) is a heterogeneous clonal disorder presenting with accumulation of proliferating undifferentiated blasts. Xenograft transplantation studies have demonstrated a rare population of leukemia-initiating cells called leukemic stem cells (LSCs) capable of propagating leukemia that are enriched in the CD34+/CD38- fraction. LSCs are quiescent, resistant to chemotherapy and likely responsible for relapse and therefore represent an ideal target for effective therapy. LSCs are reported to overexpress the alpha subunit of the IL-3 receptor (CD123) compared to normal CD34+/CD38- hematopoietic stem cells. It has not been demonstrated whether CD123-positive (CD34+/CD38-) subpopulation is enriched for any clonal markers of AML or any LSC properties. The aims of this study were to investigate whether FMS-like tyrosine kinase (FLT3)/internal tandem duplication (ITD) mutations are present at LSC level and whether FLT3/ITD mutation is confined to LSC as defined by CD34+/CD3...

ealth research is defined as "the process for obtaining systematic knowledge and technolog y that can be used for the improvement of the health of individual groups". 1 It provides basic information on the state of health and disease of the population; it aims to develop tools to prevent, diagnose, and cure illness and mitigate its effect; and it attempts to devise better approaches to health care for the individual and the community. 1 research improves health in three main ways. Firstly, it results in the development of new and better interventions in the form of both medical products (e.g., drugs, vaccines, diagnostics, and devices) and improved processes to strengthen health service delivery, ultimately contributing to universal coverage with essential health care. Secondly, it informs the development of effective policies and practices. Finally, it empowers people and individuals to internalize knowledge and practice health behaviors in their daily lives. Knowledge and research alone are insufficient to be a force of change without two other critical components, namely, political commitment and social movement. health research is "a broad term that covers many types of research and no attempt has been made to come up with a single system for categorizing it. Instead, it is multidimensional and can be categorized in many ways, (e.g., biomedical, clinical, public health, basic, applied, researcher driven, health system driven, quantitative, and qualitative) according to the World health Organization (WhO). 2

Globally, end-stage kidney disease (ESKD) is a huge burden on health care systems. The aims of this study were to perform a comprehensive epidemiological and etiological report of ESKD patients commencing RRT in Oman with an emphasis on genetic causes and inherited kidney disease. All newly registered Omani patients with ESKD commencing RRT from 2001 until 2015 (n = 2,922) were analysed using the RRT register in Oman. All potentially genetic or inherited causes of ESKD were reviewed. In Oman, ESKD is more prevalent in males (57.1%) than females (42.9%) with a median age of incident ESKD of 53 years. Diabetic nephropathy was the most prevalent cause of ESKD (46%), followed by hypertensive nephropathy (19%), glomerulonephritis (15%), and inherited kidney disease (5%). For patients less than 20 years of age inherited kidney disease accounted for 32.5% of cases. Of this cohort with inherited renal disease, 40.3% had autosomal dominant polycystic kidney disease, 11.5% had congenital anom...

Oman is located in the southeast of Arabian Peninsula with a relatively young population of about 3 831 553 people. The Ministry of Health, which is the healthcare provider, is facing a challenge with the increased levels of noncommunicable diseases including chronic kidney disease. A growing number of patients progress to end-stage kidney disease (ESKD), demanding renal replacement therapy. In 2014, there were 1339 of ESKD patients receiving dialysis and almost 1400 patients received kidney transplants. The estimated annual incidence of ESKD is 120 patients per million population. Diabetes mellitus and hypertensive nephropathy are the commonly identified causes of ESKD. Many patients with glomerulonephritis, systemic lupus erythematosus, nephrolithiasis, and inherited kidney disease present with advanced chronic kidney disease. This article reviews the current status of kidney disease in Oman and addresses the present and future needs, through a systematic-review of all related pap...

To address the demands of worldwide demographic and epidemiologic changes and globalization, as well as their effects on population health, the Ministry of Health in Oman developed a long-term plan for its health system called Health Vision 2050. The plan was shaped by international consultants, who sought to augment the vision with up-to-date evidence and achieve alignment with international standards. The Health Vision 2050 main document was anchored by 24 separate strategic studies covering different dimensions and pillars of the health system, one of which was the strategic study of medical equipment and healthcare technology (MEHT). This study analyzed the current status of MEHT, highlighted the achievements and bottlenecks, anticipated future challenges, and determined the future vision through pragmatic, contextualized, and actionable objectives and strategies that will provide a platform for comprehensive MEHT planning. Of note, pharmacological technologies, pharmaceutical d...

Fibroblast growth factor 23 is induced by an activated reninangiotensin-aldosterone system in cardiac myocytes and promotes the pro-fibrotic crosstalk between cardiac myocytes and fibroblasts. Nephrol Dial Transplant. 2018;33: 1722-1734. 8. Tranaeus Lindblad Y, Olauson H, Vavilis G, et al. The FGF23-Klotho axis and cardiac tissue Doppler imaging in pediatric chronic kidney disease-a prospective cohort study. Pediatr Nephrol. 2018;33:147-157. 9. Okamoto Y, Fujita S, Morita H, et al. Association between circulating FGF23, alpha-Klotho, and left ventricular diastolic dysfunction among patients with preserved ejection fraction.

Background Sickle cell disease (SCD) is a genetic blood disorder that increases the risk for recurrent painful episodes. Parents’ knowledge regarding SCD management is poor, leading to poor symptom management and lower Health Related Quality of Life (HRQOL) in children with SCD. The purpose of this study was to examine the effects of a parent educational intervention program ( PEIP ) on the parental knowledge, self-efficacy and perception of the HRQOL of their children with SCD.Methods Two groups of Omani parents of children with SCD were randomly assigned to either an experimental group (n=37) receiving PEIP accessed on a smartphone + weekly phone reinforcement for four weeks, or a control group (n=35) receiving Standard Educational Program (SEP) as part of standard of care. Outcome measures were knowledge, self-efficacy and HRQOL of children with SCD. Knowledge Questionnaire, Self-Efficacy Scale, and HRQOL-SCD + HRQOL-GENERIC were administered twice (at enrollment, and 4 weeks aft...

Objective: This concept paper aims to portray the steps and strategies followed in setting the health research priorities in Sultanate of Oman. Methods: This exercise was developed based on COHRED management process to priority setting for planning a high-quality health research priority setting exercise at national and sub national levels. Ranking for the diseases and risk factors in Oman was based on the estimates obtained from the Global Burden of Disease (GBD) 2016 study by the Institute for Health Metrics and Evaluation (IHME). The most important topics were generated from a panel of experts to tackle the above ranked problems, which was supported with a feasibility score to plan for conducting research. Results: A list of top 30 diseases and 10 risk factors based on DALYs estimates was ranked and listed. Sub-research topics were listed under each category. Feasibility scores were obtained from all the sub-national levels based on available human resources, infrastructure, fina...