Hematology Service Research Articles

A Multidisciplinary Quality Improvement Project to Improve Appropriate Inherited Thrombophilia Testing at VA Connecticut

Background Many guidelines and expert opinions do not recommend inherited thrombophilia testing in unselected patients with venous thromboembolism (VTE), and per American Society of Hematology Choosing Wisely Recommendations, inherited thrombophilia testing is not recommended in patients with venous thromboembolism occurring in the setting of major transient risk factors. Furthermore, non-hematologists may lack knowledge on the effect of direct oral anticoagulants on these assays. From 2019 to 2021, 75% of inherited thrombophilia testing (protein C, S and antithrombin deficiencies and Factor V Leiden and prothrombin mutations) at VA Connecticut were ordered by non-hematologists. Of these orders, 55% of tests were ordered by primary care clinicians, 29% by inpatient teams, and the remainder by non-hematology specialists. Approximately 10% of testing by non-hematologists had abnormal results, generating further hematology consults and workup. Given that testing has limited clinical utility and can result in unnecessary downstream healthcare use, there is a need to improve guideline concordant and appropriate thrombophilia testing by non-hematologists. Methods The aim of this multidisciplinary quality improvement project was to decrease the number of inherited thrombophilia tests ordered by non-hematologists at VA Connecticut by 25% six months after our intervention implementation. Quality Improvement (QI) principles were used to identify root causes, which included complexity of and confusion over appropriate patient selection for testing, a lack of awareness of potential false positives with active anticoagulant use, limitations of our electronic medical record system (EMR) to provide clinical decision support tools to triage testing or provide education, and more. After multidisciplinary stakeholder engagement and feedback from hematology, internal medicine, laboratory medicine, and clinical informatics, we established a best practice alert (BPA) for inpatient and outpatient inherited thrombophilia testing at the time of order entry. Our BPA notified the ordering clinician that inherited thrombophilia testing rarely impacts the choice or duration of anticoagulation and is not recommended for most patients. The BPA recommended that as an alternative, clinicians can consider a hematology electronic consult (e-consult) for guidance and education regarding appropriate patient selection for testing. Data was collected from our EMR seven months after intervention initiation and analyzed via Excel 365. A control chart was used to assess the outcome measure, which was the number of orders for inherited thrombophilia testing by non-hematology clinicians per month. Our balancing measure was the number of hematology e-consults for inherited thrombophilia per month. Institutional pricing was used to determine costs associated with testing and potential cost savings. Results After our BPA implementation in January 2022, the mean number of monthly inherited thrombophilia tests from January to July 2022 decreased to 7.6 tests from 13.3 tests in 2021. All 7 monthly test order numbers post-implementation were below the mean, consistent with a potential trend towards a special cause variation shift. Inpatient testing decreased from 40 total tests in 2021 to 7 tests since implementation. The average cost of testing per month decreased from $653 to $366 with an estimated $2004 saved after intervention implementation. The mean number of hematology e-consults for inherited thrombophilia related questions increased to 3.4 consults per month during the first five months of the intervention period from 2.5 consults per month in 2021. Conclusion A best practice alert in the EMR reminding clinicians about the limited role of inherited thrombophilia testing in unselected patients and the option for hematology e-consult for further specialist guidance was associated with a trend towards reduced inherited thrombophilia testing. Furthermore, there were decreased costs associated with testing without any substantial increase in workload for the hematology service. The BPA remains in place, and data collection and analysis are ongoing. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Estimative of costs of two therapeutic schemes for aplastic anemia among young individuals

Introduction: Aplastic anemia (AA) is the deficiency of the production of blood cells, with pancytopenia and hypocellular marrow as a result. Eltrombopag® (EPAG), a synthetic thrombopoietin mimic, showed improvement in bone marrow, CD34 and blood precursor cell counts. Today, it is indicated as first-line therapy, in addition to Immunosuppressive Therapy (IST) with cyclosporine and horse Antithymocyte Globulin (ATG). The aim of this study is to compare costs and results of the main current therapeutic schemes for AA among young individuals. Method: This is a study to estimate costs and results of a therapeutic scheme using EPAG associated with IST and the management of complications in comparison with standard therapy. The protocols used were those of the Ministry of Health and the scheme indicated in the literature for the EPAG. As a basis for calculation, a typical patient was simulated, who would be followed up by a pediatric hematology service in Sergipe, which works as part of the Unified Health System. Result: The cost of Cyclosporine + rabbit ATG treatment for 6 months, based on patient weight, was US$4500. The cost of Cyclosporine + rabbit GAT + EPAG treatment for 6 months was US$182,000. Conclusion: It is concluded, therefore, that drug therapy with EPAG increases the cost of treatment by 40 times. Several studies, however, point to clinical and laboratory gains and increased response rates to the proposed therapy, thus contributing to a better quality of life for a pediatric patient with AA.

Improving the discharge medication reconciliation process for an inpatient hematologic malignancies service by utilizing a pharmacist-facilitated workflow

BackgroundThere is an opportunity for pharmacists to play a greater role during discharge medication reconciliation (MR), particularly in the oncology setting. ObjectivesThis initiative aims to decrease the number of medication discrepancies that occur during discharge MR and improve physician satisfaction with the discharge MR process for patients discharged from an inpatient adult hematologic malignancies (HM) service. Practice descriptionPatients on the HM service at Sibley Memorial Hospital, a community hospital located in Washington, DC, are co-managed by hospitalists and HM oncologists. The care team for the service also includes nursing staff and a clinical pharmacist. Practice innovationThe HM service piloted a pharmacist-facilitated workflow that involved the clinical pharmacist reconciling inpatient and outpatient medications prior to discharge, reviewing the discharge MR with the HM oncologist, and pending the discharge MR in the electronic medical record for the discharging hospitalist to review and sign. Evaluation methodsPrior to pilot implementation, discharge MRs of patients discharged from the HM service from November 2021 to December 2021 were analyzed by a pharmacist to identify medication discrepancies through retrospective chart review. This process was repeated to analyze pharmacist-facilitated discharge MRs for discrepancies for patients discharged between December 2021 to April 2022. Physician satisfaction with the process was assessed via survey pre and post-pilot. ResultsA total of 30 and 37 discharge MRs were analyzed pre- and post-pilot, respectively. There were 19 medications discrepancies identified in the pre-pilot group and 6 discrepancies noted in the post-pilot group (P=0.038). Median physician satisfaction with the process was found to be 3.3 pre-pilot, and 5 post-pilot (on a scale of 1-5, with 5 being very satisfied). ConclusionA pharmacist-facilitated workflow for discharge MR increased the accuracy of the discharge MR for patients on the HM service and improved physician satisfaction with the discharge MR process.

S2957 Cytarabine-Induced Hyperbilirubinemia in a Pregnant Patient With Acute Myeloid Leukemia

Introduction: We present a case of a 33-year-old pregnant patient with inversion 16 Acute Myeloid Leukemia (AML) that developed cytarabine-induced hyperbilirubinemia without other signs of synthetic liver dysfunction. Case Description/Methods: A 33-year-old patient, G2P1, at 19 weeks gestation with a medical history of gestational hypertension presents with a chief complaint of dyspnea on exertion over the past four days. In the emergency department, laboratory findings were notable for a white blood cell count of 86.6, hemoglobin of 5.5, and a platelet count of 18. Bone marrow biopsy was performed and confirmed the diagnosis of inversion 16, +22 AML. Once on the hematology service, maternal fetal medicine (MFM) was consulted for assistance regarding contraindications to chemotherapy. A chemotherapeutic regimen consisting of daunorubicin 60 mg/m2 and cytarabine 100 mg/m2 was chosen. On Day 5 of treatment, the patient’s total bilirubin was above 2 mg/dL for the first time and coincided with the development of jaundice. This prompted a right upper quadrant ultrasound that revealed mild non-obstructive cholestasis. The total and direct bilirubin continued to rise to a peak of 13.4 mg/dL and 8.5 mg/dL, respectively, on Day 14 (Figure 1). There were no associated rises in INR. Total and direct bilirubin continued to downtrend until discharge on day 32, after adequate recovery of neutrophils (Absolute neutrophil count > 1000) and platelets. The patient received four more maintenance cycles of high dose cyatarbine (HiDAC) at a reduced dose in the setting of hyperbilirubinemia during the induction phase. Mild elevations in total and direct bilirubin that normalized after each cycle were observed. Most recent bone marrow biopsy after maintenance cycles revealed no evidence of disease. Discussion: In this report, a pregnant patient exhibited cytarabine induced isolated hyperbilirubinemia during induction chemotherapy without any other evidence of liver dysfunction; in addition, decreasing cytarabine dosage during the consolidation phase resulted in lower elevations of bilirubin. Our findings add to the existing literature on cytarabine induced hyperbilirubinemia by highlighting its effects in pregnancy, while also showing that dose adjustments can be utilized not only to prevent high bilirubin levels but to achieve clinically significant outcomes.Figure 1.: Laboratory trends during chemotherapeutic induction phase with Cytarabine and Daunorubicin. Peak elevation in total and direct bilirubin can be seen on Day 14.

COMPARISON OF DIFFERENT METHODOLOGIES FOR EXPANSION OF NATURAL KILLER CELLS FROM PERIPHERAL BLOOD AND UMBILICAL CORD BLOOD FOR IMMUNOTHERAPY APPLICATIONS

In Immunotherapy, several clinical studies with Natural Killer (NK) cells have shown promising results in the treatment of onco-hematological diseases due to their high cytotoxicity against tumor cells. There are several protocols for the expansion of these cells, but there is no consensus of a gold standard protocol that provides large numbers of functional NK cells required for conducting clinical studies. Thus, we propose the development of a protocol for the expansion of these cells with the subsequent intention of applying them as cell therapy product in the Hematology Service of the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP). Our aim was to compare different methodologies and establish a standardized protocol for the isolation and expansion of NK cells from peripheral blood (PB) and umbilical cord blood (UCB). We also characterized the expanded cells according to their functionality and cytotoxicity. The experiment was carried out at the department of Hematology and Cell Therapy of the HC-FMUSP, in the Laboratory of Medical Investigation (LIM-31), fresh PB samples were obtained from Fundação Pró-Sangue leukapheresis healthy donors and the cryopreserved UCB units were obtained from Hospital Sírio-Libanês Umbilical Cord Blood bank. Mononuclear cells were isolated by Ficoll density gradient centrifugation. The isolation and expansion of UCB-derived and PB-derived NK cells was performed with the selection of CD56+ CD3- cells by immunomagnetic separation. Cells were expanded ex vivo for 14 days in RPMI-1640 medium supplemented with different combinations of cytokines, such as interleukin IL-2 alone, IL-2 and IL-21, IL-15 and IL-18 and IL-12, co-cultured or not with CSTX002 feeder cells in a 1:2 ratio (NK:aAPC). The number of NK cells increased significantly when they were co-cultured with aAPC in comparison to conditions without feeder cells. Pre-activation conditions with IL-12, IL-15 and IL-18 for “cytokine-induced memory-like” (ML NK) cells in both PB-NK and UCB-NK expansion yielded a significantly greater fold expansion (12-fold and 8-fold) when compared to expansion with IL-2 alone or IL-2 and IL-21. Moreover, the addition of IL-21 did not have a significant impact in the expansion of CD56+ CD3- cells when compared to conditions that used IL-2 alone. Furthermore, aAPC-mediated expansion yielded a predominantly CD56bright CD16bright mature phenotype in both PB-NK and UCB-NK. To evaluate the functionality NK cells, in vitro assays against tumor target cells was performed and UCB-NK conditions with IL-2 alone or IL-2 and IL-21 showed enhanced degranulation capacity and lytic granules (Granzyme B and Perforin) and cytokine production (IFN-y and TNF-a) than PB-NK cells. ML NK cells from PB produced higher amounts of cytokines and lytic granules when compared to ML NK cells from UCB. This may be related to a lower expression of NKp46, NKG2D and CD69 activation markers in ML NK UCB, and possibly because the UCB units were cryopreserved. The results suggest that ML NK cells show good ex vivo expansion, but do not show proper functionality against tumor cells. It is possible that with the addition of IL-2, ML NK cells could improve the production of cytokines and lytic granules, as seen in the IL-2 alone and IL-2 and IL-21 conditions.

A TIME- AND COST-EFFECTIVE REMOTE ONCO-HEMATOLOGY DIAGNOSTIC STRATEGY IN BRAZIL: ALGORITHMS AND REFLEX TESTS

Brazil is a country with >200 M habitants, where high-complexity diagnostic services are provided almost exclusively by expensive private companies and university hospitals in metropolitan areas. Yet, early, fast, and accurate hematology diagnosis is crucial for the successes rate of any subsequent treatment, independent from where the patient resides within Brazil. We have evaluated the effectiveness of our remote onco-hematology laboratory and our decision-making algorithm (DMA) as a diagnostic facility for the Hospital Estadual Nossa Senhora das Graças , a institution for children with cancer. Covering the period of the last 4 years (2018 to 2021), we have evaluated 300 new hematology patients (average age: 7-8 years) for triage and DMA evaluation (samples were submitted for flow cytometry, molecular and cytogenetic analysis, and reflex tests were performed after obtaining the flow-cytometry results). Furthermore, we performed 598 minimal residual disease investigations. Flow cytometry was performed using Beckman Coulter Life Science platform (Navios, DxFLEX and Kaluza) based on Harmonemia concept and results were released within 24 h; reflex tests were conducted only when appropriate. Among 300 submitted cases, 147 (49%) were classified as negative and 153 (51%) were classified as new cases for hematology disorders as follows. B-ALL: 104 (67,9%), T-ALL: 9 (5,9%), Burkitt: 4 (2,6%), AML/MDS: 30 (19,6%), PNH: 2 (1,3%), Aplasia: 2 (1,3%), and T-cell lymphoma: 2 (1,3%). The DMA triggered 304 molecular reflex tests (BCRABL: 100; ETV6-RUNXB: 87; KMT2A-AFF1: 88; FLT3: 15; NPM1: 14) and 125 cytogenetic analyses. Using a high-complexity, remote, onco-hematology facility, we were able to reduce diagnosis turn-round-time (TAT) to 24 h, compared to the 72 h commonly required by reference labs, while target-driven molecular and cytogenetic analyses were only required for 50% of the submitted samples. This strategy thus drastically reduces the number of tests, operational costs, sample recollections, and the TAT for the molecular tests/cytogenetic analyses. In Brazil, DMA and reflex test strategies are currently exclusively performed as part of high-complexity hematology services; usually, they are not offered by reference laboratories, not routinely used in hospitals, and not covered by health-insurance plans. The present strategy is proof of concept that distance, economics, or payment models are not necessarily a barrier to provide precision medicine while reducing costs.

UTERINE GRANULOCYTIC SARCOMA AS AN EXTRAMEDULLARY RELAPSE OF ACUTE MYELOID LEUKAEMIA IN AN ALLOGENEIC HEMATOPOIETIC STEM CELL TRANSPLANTATION RECIPIENT

Myeloid Sarcoma (MS) is a common condition characterized by proliferation of immature myeloid cells in extramedullary sites. It most often develops in patients with Acute Myelogenous Leukaemia (AML), myeloproliferative neoplasms or myelodysplastic syndromes. MS in AML may precede the disease, appear during the onset or as a relapse, especially in patients after bone marrow transplantation (BMT). Although MS can present in various parts of the body, the most common sites are lymph nodes, central nervous system, bones and soft tissues. MS of the gynaecologic tract is rare, especially in the cervix and uterus. We report an unusual case of EM relapse in the uterus without evidence of a bone marrow (BM) recurrence, two years after an allogeneic BMT. A nulliparous female 32 years old patient was currently attending the hematologic service at a quaternary Brazilian Naval Hospital since 2018, due to AML. She had no specific molecular mutation in the diagnosis. The patient was submitted to an unrelated BMT after her second complete remission in 2020 and had a relapse nine months after, with loss of variable number of tandem repeats (VNTR) from the donor and minimum residual disease (MRD) positive. Donor's Lymphocytes were infused twice and chemotherapy with a hypomethylating agent and BCL-2 inhibitor Venetoclax was established. The patient achieved her third complete remission and was in follow-up until she presented herself with complains of neuropathic and acute abdominal pain. Clinical examination revealed several soft tissue tumorations resembling MS. During the investigation, an abdominal pelvic magnetic resonance imaging (MRI) peculiarly demonstrated a large uterine mass with compression of the right ureter and pyelocalyceal dilation. Gynaecological clinical exam showed a large violaceus mass about four cm with anterior and right vaginal wall infiltration. The first diagnostic hypothesis was primary cervical cancer stage IV. The biopsy revealed a massive infiltration of immature myeloid cells with the expression of anti-ERG and myeloperoxidase antibodies, confirming MS. The immunophenotypical analysis of the bone marrow aspirates showed the patient still had a complete remission with MRD negative and a VNTR with full donor chimerism. The patient started systemic chemoterapy with a hypomethylating agent and BCL-2 inhibitor Venetoclax. Decision making on the treatment of cervical MS is challenging due to the absence of gynaecological classification guidelines. In patients in this age group with no offspring, the choice of therapy should consider the fertility issue, covering from hysterectomy to radiation, with or without a second BMT. Finally, MS should be a differential diagnosis in a patient with a uterine mass and a previous medical history of AML and BMT.

Wider perspectives: It's a changing world-The use of ABO-incompatible plasma for resuscitating massively bleeding patients.

Wider perspectives: It's a changing world-The use of ABO-incompatible plasma for resuscitating massively bleeding patients.

Administration of chemotherapy in patients admitted to a haematology service: a best practice implementation project.

To promote evidence-based practices related to the prevention of adverse events associated with medication administration (only chemotherapy) in a hospital service. The medication management process in a hospital setting is highly complex, going through multiple stages from drug selection, procurement and storage, to prescription, validation, dispensing, preparation, administration and monitoring. An evidence implementation project based on an audit and feedback approach was conducted from December 2019 to April 2021 using the JBI Practical Application of Clinical Evidence System and Getting Research into Practice. The results of the baseline audit showed that the 10 audit criteria were mostly met; however, two of the criteria (criterion 6: the expiry date of medication is checked before use and criterion 7: the nurse who prepares the medication administers the medication to the patient) had low compliance (respectively, 0 and 67.9%). After identifying the barriers and implementing strategies to deal with the identified barriers, we verified a significant improvement in compliance with best practices (criterion 6 improved to 64.3% and criterion 7 to 78.6%). This implementation project was a success, achieving a great improvement of the implementation of evidence-based guidelines concerning the prevention of adverse events associated with medication administration in a hospital in central Portugal. More such projects should be planned to sustain the implementation of evidence-based methods to improve health outcomes, patient safety, costs and health systems.

Gynaecological management of women with inherited bleeding disorders. A UK Haemophilia Centres Doctors' Organisation Guideline.

Women with inherited bleeding disorders (IBDs) may present to healthcare professionals in a variety of ways and commonly will be encountered by either haematology or gynaecology services. Heavy menstrual bleeding is very often the first manifestation of an IBD. There is a wide variation in severity of bleeding for women with IBD and diagnosis and subsequent management of their condition requires multidisciplinary specialised care which is tailored to the individual and includes excellent cross-specialty communication between gynaecology and haematology teams. This guideline is intended for both haematologists and gynaecologists who are involved in the diagnosis and management of women with bleeding disorders. It sets out recommendations about how to investigate heavy menstrual bleeding (HMB), the commonest presentation for women with IBD to hospital services, to guide physicians about how to diagnose an IBD and covers the management of women with known IBD and HMB. The second section sets out recommendations for patients known to have IBD and covers management of patients with IBD in the setting of gynaecological surgery and management for all other non-surgical gynaecological situations.

PRIMARY DIFFUSE LARGE B-CELL LYMPHOMA SUBCUTANOUS IN FACE: CASE REPOR

A 62-year-old female patient presenting asymmetry in the right malar region with a 3-month evolution sought dental care. An intraoral swelling was also observed on the same side. Magnetic resonance imaging revealed an oval lesion with undefined margins, presenting hypersignal during the use of contrast, located in the subcutaneous space, and extending to the maxillary sinus. The hypotheses of reaction to the filling material or soft tissue neoplasia were considered. We proceeded with the incisional biopsy of the intraoral lesion, and the evaluated specimen revealed a lymphoproliferative lesion with areas of neural invasion. Immunomarking for BCL-6, CD-10, CD-20, Ki-67 (40%-50%), PAX-5, and c-MYC was evidenced in the immunohistochemical evaluation, defining the diagnosis of diffuse large B-cell lymphoma. The patient was referred to the hematology service and, after the end of chemotherapy, no hypermetabolic lesions were detected by PET-CT. There are no signs of lesion recurrence after 8 months of follow-up.

ORAL PLASMABLASTIC LYMPHOMA DIAGNOSIS AND TREATMENT FOLLOW-UP: CASE REPORT

Plasmablastic lymphoma (PBL) is a rare variant of large diffuse B-cell non–Hodgkin lymphoma with predilection for extranodal localization in the oral cavity. A 43-year-old HIV-positive female patient attended a stomatology service for evaluation of a painful oral mass with 6 months of duration. At the extraoral examination, swelling in the left hemiface and facial increased lymph nodes were present. Intraorally, a purplish red exophytic sessile nodule presenting indefinite borders and an ulcerated surface was found. Areas of necrosis were observed at the upper alveolar ridge, palate, and left buccal mucosa, and adjacent teeth were mobile. The clinical impression was a malignant neoplasm, and the patient was submitted to an incisional biopsy. The histopathologic and immunohistochemistry were consistent with a PBL. The patient was referred to the hematologic service and submitted to DA-EPOCH chemotherapy. After 3 months of follow-up consultations, partial remission of the lesion without considerable systemic or oral intercurrences was observed.

An evaluation of the content of hematology and medical oncology fellowship websites

IntroductionThe growing demand for Hematology and Oncology services has greatly piqued the interest of potential residents towards this specialty. Since the programs' official websites are now becoming the primary source of information that potential residents turn to, we aimed to analyze program websites’ content and availability across parameters that have been used by evaluators of websites. Methods& Materials: A list of 181 fellowship programs were identified using The Fellowship and Residency Electronic and Interactive Database (FRIEDA). 160/181 were accessed via a hyperlink or Google search. Content of these websites was evaluated on a 40-point criteria system in 10 distinct domains. Websites without accessible links were excluded from the search. ResultsThe 160 programs were divided based on the region with the North-East having the most programs (32.5%) and the West having the least programs (12.4%). Exactly 3/4th of the websites had been updated with the latest available information. “Program overview” (89%) was the most common domain present on the websites while “Alumni” was the least common, present on only (25%) of the websites. ConclusionWhen compared with previous similar research, there have been a few significant improvements across the programs' websites, however many still lack important information regarding certain domains. The content and availability of the program's website can encourage or deter an applicant, in their decision to apply to the program, hence making it necessary for programs to augment their websites.

P1586: IN-HOSPITAL MORTALITY AND POOR PROGNOSIS FACTORS ASSESSMENT IN PATIENTS WITH ACUTE LYMPHOBLASTIC LEUKEMIA AND COVID-19.

Background: Acute lymphoblastic leukemia (ALL) belongs to a heterogeneous, highly aggressive group of hematologic malignancies. In the context of the epidemic of a new coronavirus infection (COVID-19), patients with hemoblastoses have a more severe course of the viral infection and high mortality rate due to COVID-19. The management protocols of patients with ALL in the context of the COVID-19 pandemic has not been developed, and approaches to both the treatment of a new coronavirus infection and the antitumor treatment of ALL in patients with COVID-19 have not been defined. Aims: To analyze in-hospital overall survival of patients with acute lymphoblastic leukemia and coronavirus infection, to assess the impact of poor prognostic factors on the outcome of the disease, and to determine the therapeutic tactics for ALL and COVID-19. Methods: From April 21, 2020 to November 30, 2021 46 patients with ALL (24 men, 22 women) with a median age of 44.5 (18-74) years were observed on the basis of the hematological service of the City Clinical Hospital No. 52 (Moscow). According to the immunophenotypic variant of ALL, 27 (59%) were patients with B-ALL, of which Ph-positive ALL was diagnosed in 8 (30%), Ph-negative - in 19 (70%); T-ALL - 16 (35%), biphenotypic - 2 (4%). Patients with newly diagnosed ALL (20%) underwent induction antitumor therapy, 67% - convalescents and PCR positive for SARS-CoV-2 infection. To determine the factors of hospital mortality, a statistical analysis was performed, including: age, hematological disease status, degree of lung tissue damage according to computer tomography (CT), stay in the intensive care unit due to severe respiratory failure requiring mechanical ventilation (ALV), the presence of neutropenia of the IV degree, transfer from another hospital, the formation of an antiviral immune response after a coronavirus infection. Results: Hospital mortality in ALL patients was 30%. Statistically significant factors for poor prognosis were: age (>40 years), p=0.033, hematological disease status (newly diagnosed ALL, progression/relapse), p=0.004, high (≥50%) degree of lung tissue damage according to CT (p =0.003), neutropenia IV degree (p=0.004), their transfer to another hospital, stay in the intensive care unit and mechanical ventilation (p=0.004). Summary/Conclusion: The main adverse factors affecting hospital mortality were the absence of ALL remission and the presence of severe infectious complications. Carrying out antitumor therapy allows to stabilize the status of ALL and is an important aspect in the simultaneous course of coronavirus infection. In patients with ALL and confirmed coronavirus infection, the decision to conduct induction therapy should be discussed on an individual basis, depending on ALL status, the activity of coronavirus infection and comorbidity status.

PB1870: COVID - 19 IN PATIENTS WITH CHRONIC LYMPHOCYTIC LEUKEMIA: HOSPITAL MORALITY PREDICTORS

Background: Patients with chronic lymphocytic leukemia (CLL), as the disease progresses and the tumor load increases, are characterized by high susceptibility and severe course of viral infections. The depth of immune dysfunction can be influenced by factors such as age, comorbidity, disease status and previous treatment. The detection of SARS-COV2 in this cohort of patients made it possible to analyze the course of COVID-19, as well as to develop a strategy for the disease management of these patients. Aims: To assess the risk factors for the severe course of COVID-19, as well as to identify predictors of hospital mortality. Methods: 179 patients with verified CLL and COVID-19 were followed up by the hematology service of Moscow City Clinical Hospital No.52 (Moscow) from April 21, 2020 to November 31, 2021. Anthropometric, anamnestic, clinical and laboratory data were evaluated, treatment tactics of both CLL and COVID-19 were analyzed in 179 patients (69 women and 110 men, median age - 66 years). A statistical multivariate analysis of hospital mortality, factors of unfavorable prognosis of COVID-19 (complications, humoral response, hospital mortality) was carried out. Results: Age was a significant adverse factor for men: the age of a man from 73 years and more, increases the risk of death of the patient by 3.0 times (p<0.05). For women, age was not a significant adverse factor. Assessment of the effect of comorbidity: patients with 6 or more comorbidity scores according to Charlson have 2.2 times greater risk of death; the presence of cardiovascular diseases increases the risk of death of the patient by 2.3 times. The presence of 1 or more lines of chemotherapy in the anamnesis increased the risk of hospital mortality by 1.5 times. Patients who had previously undergone chemotherapy were treated until the moment of discharge statistically significantly longer than patients who had not undergone antitumor therapy. Relapse/progression of the disease was a factor of unfavorable prognosis for the survival of patients with CLL (mortality was 47% compared to 14.7% in patients in remission). A significant unfavorable prognosis is also the Binnet stage C (p<0.05). A valid factor in the failure of COVID-19 (p<0.05) was ICU therapy and the development of secondary bacterial complications (the use of 2nd-line antibacterial therapy). The assessment of the humoral response in 59 patients shows the presence of an increase in IgG on the 10th-14th days of the disease in 44% of patients, among whom no deaths were detected, 1/3 were vaccinated patients. The absence of a humoral response was a statistically significant adverse outcome factor in 25% of patients (p<0.05). Summary/Conclusion: Progression/recurrence of chronic lymphocytic leukemia is a factor in the severe course of COVID-19, and, as a result, increases the risk of hospital mortality. The absence of a humoral response determines the persistent course of COVID-19 and increases the risk of death by 25%. The study of the course of COVID-19 in patients with CLL allows us to identify key aspects affecting the choice of management tactics for this category of patients: additional booster vaccination (stimulation of the humoral response), early detection (screening) of SARS-COV2 for virus-neutralizing antibodies therapy, timely hospitalization of patients.

Therapy of lymphoproliferative diseases in the era of COVID-19: challenges and solutions

On January 20,2022, the symposium "Therapy of lymphoproliferative diseases in the era of COVID-19: difficulties and solutions" was held. It was organized by the Russian Society of Oncohematologists. At the symposium, the experience of the hematology service of City Clinical Hospital №52 of Moscow was discussed, as well as changes in international clinical guidelines for managing patients in conditions of COVID-19 based on a review conducted by the European Hematology Association (EPICOVIDEHA).

Telemedicine for rural and regional patient access to haematology services during the COVID-19 pandemic in Australia

Australia is a vast country encompassing major cities along with smaller rural and remote communities often separated by substantial distance. Approximately 28% of the Australian population live in rural and remote areas, defined as regions outside of major cities. Smaller local hospitals in these areas can provide general medical services; however, certain outpatient subspeciality care, including haematology, is often provided by so-called fly-in fly-out specialists running outreach clinics, or requires travel to more urban areas for appointments.

Guillain-Barré Syndrome after Hematopoietic Transplantation

The Hematology Service at the University Hospital of Federal University of Juiz de Fora (HU-UFJF)/Brazil carried out a research project focused on assessing the toxicity and effectiveness of progressive Lomustine doses in association with Etoposide and Cyclophosphamide in the Autologous Hematopoietic Stem Cell Transplantation (AHSCT) conditioning regimen adopted for lymphoma patients. During the follow-up, a 31-year-old woman belonging to the 400 mg/m2 Lomustine cohort evolved with neuromuscular complications 6 months after AHSCT. Initially, she experienced diffuse pain, mainly proximal weakness in the lower limbs; however, it got worse 10 days after vaccine protocol application. She evolved with rapidly ascending motor worsening, decreased ability to walk, foot paresthesia, binocular diplopia, areflexia, bulbar and dysautonomic symptoms such as sweating, tachycardia and postural hypotension. She experienced syncope episodes 72 h before being referred to intensive care unit at HU-UFJF.

History taking in patients with suspected haematological disease.

This is the first article in a two-part series. The fundamental skill of advanced nursing practice is the ability to undertake concise history taking and examinations to aid differential diagnosis and appropriate referral to specialist services. This article aims to discuss and highlight specific consultation questions and required clinical assessments of a patient with a potential haematological diagnosis. The complexity of a haematological diagnosis may be become clear with the exploration of constitutional symptoms, which include fever, drenching night sweats, loss of appetite or weight. The rapidity of onset of symptoms is pivotal to diagnosis and may influence speed of referral, if required, to specialist haematology teams. Physical symptoms may include shortness of breath, easy bruising, fatigue or palpable enlarged lymph glands. The relevance of these symptoms and what consitutes a haematological emergency will be explored. This article will discuss clinical findings pertinent to haematological diseases, when it is appropriate to refer to specialist haematological services and current national guidance. The second article in this series will examine how critical thinking aids in the diagnosis of blood disorders.

Right portal vein thrombosis from idiopathic cause: case report

The aim of this study was to describe the case report of a 33-year-old girl with portal vein thrombosis. J.S.D.F., 33 years old, female, previously healthy, with a personal and family history negative for thromboembolic phenomena, without comorbidities, started with severe abdominal pain in the mesogastric region, radiating to HCD and back, associated with vomiting. Smoking active for about 20 years and using OC for 2 years. In view of the symptoms, she sought emergency services, where the first suspicion would be pancreatitis. Initial tests plagued leukocytosis. GUS of the total abdomen with doppler and CT of the abdomen showed the presence of thrombus in the right portal vein, with no other alterations. Rocefin® and metronidazole as an initial measure in the service began in addition to full coagulation with Clexane®. It showed clinical and laboratory improvement, with a reduction of leukocytes. The patient remained hospitalized in a hospital for 22 days to investigate the etiological cause. After of hospitalization, the patient was released with medical discharge, with guidelines for seeking the hematology service. During the investigation consultations, the results of the requested tests were negative for the diagnostic suspicions of nocturnal paroxysmal hemoglobinuria and chronic myeloproliferative disease. After 6 months of follow-up, she was discharged from the hematology service because she did not present a suspected disease and classified the cause of thrombolytic event as idiopathic associated with the combined use of OC and smoking.