Background Hydroxyurea (HU) induces dose-dependent increased fetal hemoglobin (HbF) for sickle cell disease (SCD). Large deviation from historical personal best (PBest) HbF, a clinic-based version of maximum dose, may identify a subset with suboptimal HU adherence over time. Procedure Retrospective clinical data from youth ages 10–18 years prescribed HU at two centers were extracted from medical records at three time points: pre-HU initiation, PBest and a recent assessment. Decrease from PBest HbF of 20% or more at recent assessment despite stable dosing was designated as high deviation from PBest. Acute hospital use was compared between 1-year periods, pre-HU and ±6 months for PBest and recent assessment. Groups were compared using descriptive and bivariate nonparametric statistics. Results Seventy-five youth, mean HU duration 5.9 years, met eligibility criteria. Mean ages of HU initiation, PBest and recent assessment were 8.0, 10.9 and 13.9 years, respectively. Despite stable dosing, average HbF of 19.5% at PBest overall declined by 31.8% at recent assessment. PBest HbF declined by 11.7 and 40.1% in two groups, the latter comprised 70.7% of the sample, had lower pre-HU and recent HbF and higher dosing. They experienced more urgent hospital use during the year framing recent assessment than during PBest; these findings were supported by sensitivity analysis. Conclusions Decline from PBest HbF is a novel approach to assess HU effectiveness, is common among youth and may represent suboptimal adherence. Larger prospective studies using additional adherence measures are needed to confirm our approach of tracking HbF deviation over time and to define an appropriate cutoff.

SummaryUnrecognised dural punctures are difficult to diagnose early. Failure of recognition may lead to sinister consequences. A case of unrecognised dural puncture in a young female leading to the development of subdural hygroma and cortical vein thrombosis is presented. The dilemma in the diagnosis of headache in such patients along with the significance of follow‐up of all, including attempted, epidurals is also discussed.

Hematopoietic stem cells (HSCs) have extensive regenerative capacity to replace all blood cell types, an ability that is harnessed in the clinic for bone marrow transplantation. Finding appropriate donors remains a major limitation to more extensive usage of HSC‐based therapies. Derivation of patient‐specific HSCs from pluripotent stem cells offers great promise to remedy this problem if scientists could crack the code on how to make robust, transplantable HSCs in a dish. Studies delving into the native origins of HSC production during embryonic development should supply the necessary playbook. This review presents recent discoveries from animal models, with a focus on zebrafish, and discusses the implications of these new advances in the context of prior knowledge. The focus is on the latest research exploring the role of epigenetic regulation, signaling pathways, and niche components needed for proper HSC formation. These studies provide new directions that should be explored for de novo generation and expansion of HSCs for regenerative therapies. Stem Cells Translational Medicine 2017;6:60–67

Despite advancements in the diagnosis and treatment of acute lymphoblastic leukemia (ALL), a need for improved strategies to decrease morbidity and improve cure rates in relapsed/refractory ALL still exists. Such approaches include the identification and implementation of novel targeted combination regimens, and more precise upfront patient risk stratification to guide therapy. New curative strategies rely on an understanding of the pathobiology that derives from systematically dissecting each cancer’s genetic and molecular landscape. Zebrafish models provide a powerful system to simulate human diseases, including leukemias and ALL specifically. They are also an invaluable tool for genetic manipulation, in vivo studies, and drug discovery. Here, we highlight and summarize contributions made by several zebrafish T-ALL models and newer zebrafish B-ALL models in translating the underlying genetic and molecular mechanisms operative in ALL, and also highlight their potential utility for drug discovery. These models have laid the groundwork for increasing our understanding of the molecular basis of ALL to further translational and clinical research endeavors that seek to improve outcomes in this important cancer.

Hemophagocytic lymphohistiocytosis (HLH) is a clinical syndrome that can be inherited or acquired. Herein, we report a case of HLH and pulmonary alveolar proteinosis (PAP) in the setting of lysinuric protein intolerance (LPI) in a male toddler who presented with prolonged fever, respiratory distress, and failure to thrive. On histologic examination, hemophagocytosis was observed in lymph node, bone marrow sections and aspirates. Lung wedge resection was consistent with PAP. LPI was confirmed with genetic sequencing which revealed compound heterozygous mutations in the SLC7A7 gene. LPI is a rare inborn error of metabolism and is not widely known beyond the pediatric group. Though the association of LPI with HLH has been previously described, we believe this is the first reported case of HLH and PAP associated LPI with histopathological correlation. Early recognition of HLH is critical to successful treatment and LPI should be considered in any young infant who presents with HLHand PAP-related symptoms.