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Over the past 40 years, the introduction and refinement of hydroxyurea therapy has led to remarkable progress for the care of individuals with sickle cell anemia (SCA). From initial small proof-of-principle studies to multi-center Phase 3 controlled clinical trials and then numerous open-label studies, the consistent benefits of once-daily oral hydroxyurea have been demonstrated across the lifespan. Elevated fetal hemoglobin (HbF) serves as the most important treatment response, as HbF delays sickle hemoglobin polymerization and reduces erythrocyte sickling. Increased amounts of HbF, especially when distributed across the majority of erythrocytes, improve clinical outcomes by reducing hemolytic anemia and preventing vasoocclusion, thereby ameliorating both acute and chronic-and overt and covert-complications. Additional benefits of hydroxyurea beyond HbF induction include lower neutrophil and platelet counts, reduced inflammation, and improved rheology. Toxicities of hydroxyurea in SCA are typically mild and predictable; modest cytopenia is expected and actually therapeutic, while occasional gastrointestinal and cutaneous manifestations are well-tolerated. Long-term risks of hydroxyurea for SCA are mainly theoretical but require ongoing surveillance. Accordingly, hydroxyurea should be initiated as part of standard-of-care, ideally in the first year of life. Proper dosing of hydroxyurea is critical, aiming through stepwise dose escalation to achieve modest but safe myelosuppression, with periodic adjustments for weight gain. Precision dosing using pharmacokinetics may facilitate optimal dosing without frequent dose adjustments. Although transformative and even curative therapies for SCA are emerging, hydroxyurea is the only available and accessible disease-modifying treatment that can address the global burden of disease, especially in low-resource settings within sub-Saharan Africa.

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Von Willebrand factor (VWF) plays a critical role in hemostasis, and emerging evidence suggests its involvement in inflammation. Our study aimed to investigate the interaction between circulating plasma VWF and neutrophils (polymorphonuclear cells, PMNs), elucidate the fate of VWF after binding, and explore its impact on neutrophil behavior. Neutrophils were isolated from the whole blood of healthy volunteers, and their interaction with plasma VWF was examined ex vivo. Immunofluorescence imaging revealed an enhanced binding of VWF to neutrophils following stimulation with inflammatory agents (PMA, TNFα, and IL-8) and exposure to shear forces, highlighting a previously unknown interaction. Furthermore, immunofluorescence images demonstrated increased co-localization of VWF with the early endosome marker EEA1 and the late endosome marker Rab7 over time, indicating the uptake of VWF by neutrophils subsequent to the binding. This was supported by a significant decrease in VWF antigen levels in the supernatant of cells after stimulation. Moreover, stimulated neutrophils exposed to purified plasma-derived VWF exhibited elevated expression of neutrophil surface markers CD45 and CD66b, indicative of altered neutrophil function related to cell adhesion, migration, and phagocytosis. These findings suggest that VWF binding can modulate neutrophil function, potentially influencing their role in immune responses and inflammation. In summary, our study provides novel insights into the complex interplay between VWF and neutrophils, shedding light on the multifaceted roles of VWF in inflammation. Importantly, we have identified neutrophils as potential cellular mediators involved in the clearance of VWF from circulation, introducing a novel mechanism for VWF removal.

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While outcomes for pediatric acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LBL) have improved dramatically in recent decades, relapsed and refractory disease remain a significant therapeutic challenge. This is particularly true for patients with T-cell ALL and LBL, where survival for patients with relapsed/refractory disease remains dismal. Recent efforts to comprehensively profile the genomics of T-ALL/LBL to improve understanding of disease biology have enhanced our ability to identify high-risk patients at diagnosis who are more likely to relapse and have also identified novel targets for precision medicines. Novel immunotherapies have transformed the treatment landscape for patients with B-cell ALL (B-ALL). Many immunotherapies are under investigation in clinical trials for patients with T-ALL/LBL and early results are very promising. Given these insights into disease biology and the development of targeted and immune-based treatments, it is reasonable to hope for improved patient outcomes, although challenges still exist. In this review, we summarize the present state of understanding of the risk factors for relapse of T-ALL/LBL, established treatment regimens, and the promising small molecule inhibitors and immunotherapies with the potential to revolutionize the treatment of relapsed/refractory T-ALL/LBL.

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