Mean White Blood Cell Count Research Articles

Immuno-hematological parameters among adult HIV patients before and after initiation of Dolutegravir based antiretroviral therapy, Addis Ababa, Ethiopia.

Immuno-hematological abnormalities are common among HIV infected individuals as well as patients with highly active antiretroviral therapy (HAART). However, the immuno-hematological outcome of Dolutegravir based antiretroviral therapy (ART) usage is not well investigated. To assess hematological and immunological parameters among adult HIV patients before and after initiation of Dolutegravir based ART regimen at St. Peter Specialized Hospital, Addis Ababa, Ethiopia. A cross-sectional study was conducted from May to July 2021 at St. Peter Specialized Hospital among adult HIV patients. A total of 422 HIV patients on Dolutegravir based ART (combination of Dolutegravir/lamivudine/tenofovir disoproxil fumarate (DTG/3TC/TDF)) for a minimum of 3 months were selected using convenient sampling methods. Socio-demographic as well as clinical data of the participants was obtained using pre-tested structured questionnaires and a review of medical records. Hematological parameters such as CBC was obtained using Beckman coulter automated hematology analyzer and immunological parameters such as CD4 count were determined using BD FACS presto. Statistical analysis of the data was done using SPSS version 21. Paired t-test was used to compare dependent variables before and after initiation of the new HAART and binary logistic regression was used to determine predictors of immuno-hematological abnormalities. P-value < 0.05 was considered as statistically significant. Of 422 adult HIV patients, about 273(64.7%) were females. The mean age of study participants was 42.2 years (±10.4SD). The mean white blood cell (WBC) count, red blood cell (RBC) count, hemoglobin (Hb), platelet distribution width (PDW), CD4 count, as well as lymphocyte percentage, neutrophil percentage, and platelet counts (PLT) were increased significantly(P<0.05) after 3 months of the Dolutegravir based therapy. While, red cell distribution width (RDW) and mean cell hemoglobin (MCH) were decreased (P<0.05) after the treatment. Other hematological parameters such as mean cell volume (MCV), hematocrit (HCT), mean cell hemoglobin concentration (MCHC), mean platelet volume (MPV) and platelet distribution width (PDW) showed no significant change. On the other hand, the most common hematological abnormalities identified after the new HAART were anemia (12.1%); followed by Leucopenia (11.3%), neutropenia (6%), and thrombocytopenia (4%). Anemia was associated with female sex (AOR = 7.8, 95% CI: 1.9-32.2, P<0.005) and WHO clinical stage III/IV (AOR = 16, 95% CI: 10.63-66.46, P<0.01). There was a significant change in certain immuno-hematological parameters such as WBC count, RBC count, PLT count, Hb, PDW, CD4 count, lymphocyte and neutrophil percentage after initiation of the Dolutegravir based therapy. Anemia was the most common hematological abnormality. Further studies are required to fully comprehend the outcome of the new treatment regimen on immuno-hematological parameters.

Children with sickle cell disease: are they protected from serious COVID-19?

COVID-19, the pandemic that hit the world in 2020, resulted in millions of deaths, with the elderly and adults succumbing to the disease more often than children. However, the presence of underlying morbidities increased the risk of death. Sickle cell disease (SCD) was previously classified as a major risk factor for severe COVID-19 disease. However, presently, there are only a limited number of studies that identify the clinical course of children with SCD and COVID-19. We conducted a retrospective observational study on children with SCD admitted due to COVID-19 at three different institutions in Saudi Arabia between March 2020 and March 2022. We studied the demographic and clinical characteristics of patients admitted to the hospital. Seventy-six patients with SCD had PCR-confirmed SARS-CoV-2 during the study period; 50.0% of our patient population were children (6-12 years old). Gender was evenly distributed, with 53.9% girls and 46.1% boys. Symptoms more commonly related to the COVID-19 infection included fever, cough, malaise, and vomiting. Chest x-ray findings revealed mild and non-specific symptoms only in approximately one-third (28) of the included children. The most common symptoms associated with SCD were vaso-occlusive crisis (47.4%) and abdominal pain (11.8%). The overall general appearance of most of the patients was reassuring. The median length of hospital stay was 4.2 ± 2.7 days. The mean white blood cell count was 11.4 ± 5.2 × 109/L, and the mean hemoglobin level was 8.3 ± 1.5 g/dl. Despite the fact that higher levels of mean D-dimer, lactate dehydrogenase, and ferritin were reported in these patients, the clinical outcome was not affected. All recruited patients received hydroxyurea as maintenance therapy. The outcome of our study was reassuring, with no significant morbidity or mortality observed among the recruited patients. Despite SCD being a chronic disease with known specific complications, there has been a claim that COVID-19 infection adds further risk. The results of this study suggest that the overall outcome of COVID-19 was favorable, with no reported mortality. Further research is needed to understand the factors that contributed to this favorable outcome. In children with SCD, it is still questionable whether hydroxyurea is one of the protective factors against severe COVID-19. Validation through large-scale research is recommended.

The role of hyperbaric oxygen treatment in the management of spondylodiscitis.

This study analysed treatment outcomes in a patient cohort diagnosed with spondylodiscitis, who received adjunct hyperbaric oxygen treatment (HBOT) in addition to antibiotic therapy at our clinic. Important considerations included the timing of HBOT initiation on treatment success, and recurrence rates. We retrospectively reviewed the records of all patients diagnosed with spondylodiscitis who received HBOT at the Underwater and Hyperbaric Medicine Clinic in Gulhane Training and Research Hospital, between 1 November 2016 and 25 October 2022. The patients received HBOT at 243.2 kPa for a total of 120 minutes per session, once daily for five days a week for a total of 30 sessions. Twenty-five patients with spondylodiscitis were evaluated before and after combination HBOT and targeted antibiotic treatment. After treatment, patients had lower median (range) visual analogue pain scores (8 [4-10] vs 3 [0-7], P < 0.001) and C-reactive protein (22.3 [4.3-79.9] mg·L⁻¹ vs 6.8 [0.1-96.0] mg·L⁻¹, P = 0.002) and lower mean (standard deviation) white blood cell counts (8.8 [3.5] x 109·L⁻¹ vs 6.1 [1.6] x 109·L⁻¹, P = 0.002). When patients were examined (median) 48 months (2-156 months) after the completion of treatment, there were no persistent cases of spondylodiscitis. Combination HBOT with targeted antibiotic therapy effectively managed our cohort of patients diagnosed with spondylodiscitis. Hyperbaric oxygen treatment was safe, with no complications experienced. Moreover, HBOT may have helped to eliminate persistence and recurrence of symptoms with long term follow-up. A randomised controlled study with a larger number of patients is needed for more definitive conclusions.

White blood cell Indices to predict first trimester missed miscarriage.

To identify the relationship between white blood cell indices in missed miscarriage compared to ongoing pregnancy in the first trimester. The diagnostic accuracy study was conducted at the Department of Maternity, Al-Yarmouk Hospital, Baghdad, Iraq, from January to October 2021,and comprised healthy first-trimester pregnant women in group A and those with missed miscarriage after 7-13 weeks of gestation in group B. Ultrasound findings and the last menstrual period were noted for all the subjects. Total and differential leukocyte counts, neutrophil-to-lymphocyte ratio and monocyte-to-lymphocyte ratio were compared between the groups. Data was analysed using SPSS 22. Of the 167 women, 81(48.5%) were in group A and 86(51.5%) were in group B. Demographic and obstetrics data was not significantly different between the groups (p>0.05). Mean white blood cell, neutrophil and monocyte counts showed no significant difference between the groups (p>0.05), while lymphocyte count, neutrophil-tolymphocyte ratio and monocyte-to-lymphocyte ratio were significantly different between the groups (p<0.05). With respect to gestational age, neutrophil-to-lymphocyte ratio and monocyte-to-lymphocyte ratio had a fair ability to predict missed miscarriage at various time points within the first trimester (p<0.05). There was no significant correlation between WBC count and gestational age. Reduced MLR and NLR levels can be utilised to forecast miscarriages in a cost-effective manner.

Minimal Residual Disease in Pediatric Acute Lymphoblastic Leukemia

Background and ObjectiveThe detection of minimal residual disease at the end of initial therapy in Acute Lymphoblastic Leukemia to assess risk stratification is gaining clinical significance. While minimal residual disease assesses the extent of remission, remission is still defined by bone marrow morphology. The aim of this study is to determine the significance of minimal residual disease. Methods: In this cross-sectional study conducted at Zheen Oncology Center and Azadi hospital in Duhok, Iraq, data was collected from 46 patients’ records. Residual disease was detected by flow cytometry. On day 29 of induction therapy, a bone marrow sample was obtained for morphology and flow cytometry. The presence or absence of MRD was determined by using 8-color flow cytometry. Results: The median age of the study was 7 years and the male to female ratio was 1.7:1. B-cell lymphoblastic leukemia accounted for 80.43% and T-cell was 19.57%. Bloodounts at diagnosis revealed a mean white blood cell count of 74.32 x /L, mean hemoglobin level of 8.75, g/dL, and a mean platelet count of 97.84 x L. Minimal residual diease positive results were seen in 29 cases; 21 cases were of B-cell leukemia (56.75) and 8 (88.88) cases were T-cell leukemia. Minimal residual disease negative results were achieved in 17 cases; 43.24% were of B-cell origin (p value &lt;0.001), 11.11% were of T-cell origin (p value 0.008). Remission was achieved in 81.08 cases of B-cell (p value 0.103), and 66.66 of T-cell (p value 0.403). 16.21% of B-cell leukemia passed away (p value &lt;0.001) and 33.33% of T-cell leukemia (p value 0.065). Conclusion: Flow cytometry should be done in addition to bone marrow morphology.

Hematological Parameters in Patients with Pulmonary Tuberculosis and its Presentation among Favorable and Unfavorable Treatment Outcomes.

Tuberculosis (TB) management continues to be a challenge globally; weakened immunity plays a significant role in the reactivation of TB. There is limited information on hematological parameters in patients with pulmonary TB and its association with outcome. We present hematological parameters of newly diagnosed sputum-positive pulmonary TB patients enrolled in a randomized, clinical trial that assessed the efficacy and safety of 3 and 4 regimens using moxifloxacin. Blood hematological parameters at baseline, comparison of the baseline and end of treatment values, including the monocytes by lymphocytes ratio (M/L), neutrophil lymphocyte ratio (N/L), and platelet lymphocyte ratio (P/L) between the patients with favorable and unfavorable TB treatment outcome, and among different age group and sex presented in this paper. Among the total 1059 patients, 782 were males, the mean hemoglobin (HB) ± standard deviation (SD) was 11.5 g/dL ± 2.0, the mean white blood cell (WBC) count ± SD was 9800 ± 3009 and the mean platelet count (in lakhs) ± SD was 4.24 ± 1.42 cells/uL. There was an increase from baseline in the mean hemoglobin, eosinophil, and lymphocyte count and a decrease in mean neutrophil, monocyte counts to the end of treatment. There was a decrease in baseline mean total WBC count posttreatment, both in favorable (10,271 cells/uL ± 3007 SD to 6689 cells/uL ± 1837 SD, [P ≤ 0.001]), and unfavorable TB outcome patients. An increase in HB, and a decrease in WBC count, M/L, N/L, and P/L ratio is possible at the end of TB treatment and future studies to correlate blood hematology parameters with TB treatment outcome.

Evaluation of Epidemiological Risk Features and Hematological Parameters in the Lymphoma Patients in the Larkana Region

Background: Hodgkin lymphoma (HL) is a type of lymphatic cancer that is distinctly characterized and classified into various subtypes, with varying prognoses based on the stage at diagnosis and treatment modalities. Despite advances in treatment, the specific demographic and clinical factors influencing treatment outcomes and the incidence of side effects, such as chemotherapy-induced anemia and neutropenia, remain under-explored, particularly in diverse regional settings. Objective: This study aims to evaluate the epidemiological risk features and hematological parameters of lymphoma patients in the Larkana region, with a focus on the impact of chemotherapy on these parameters. Methods: A case-control study was conducted over twelve months at Linar Hospital in Larkana, involving 40 participants aged between 10 and 70 years. Informed consent was obtained, aligning with ethical standards akin to the Declaration of Helsinki. Two types of blood samples were collected pre- and post-chemotherapy for hematological analysis including total leukocyte count, hemoglobin, and platelet levels, which were assessed using Complete Blood Count (CBC) containers with EDTA. Statistical analysis was performed using Microsoft Excel 2010 and SPSS Version 23, utilizing descriptive statistics and the Student's t-test. Results: The study documented a decrease in mean hemoglobin levels from 11.42 ± 1.74 g/dL before chemotherapy to 10.65 ± 1.55 g/dL after (p = 0.001), mean white blood cell count from 7.30 ± 2.6 × 10^3/uL to 5.71 ± 2.1 × 10^3/uL (p = 0.003), and platelet count from 297.52 ± 116.2 × 10^3/uL to 230.2 ± 72.6 × 10^3/uL (p = 0.001). These findings indicate a significant hematological impact associated with chemotherapy. Conclusion: The significant reduction in critical hematological parameters among lymphoma patients’ post-chemotherapy highlights the need for rigorous monitoring and tailored management strategies to mitigate treatment side effects. The findings emphasize the importance of comprehensive patient care and support in improving treatment outcomes in lymphoma.

The Outcome of Patients with Leukemia Presenting with Hyperleukocytosis Requiring Leukapheresis. The Experience of King Fahad Specialist Hospital in Dammam, Saudi Arabia

Background: Patients with acute and chronic leukemia presenting with hyperleukocytosis are at risk of developing leukostasis which has serious and life-threatening complications. Leukapheresis is usually performed to reduce the complications of leukostasis in patients presenting with hyperleukocytosis and clinical manifestations compatible with leukostasis. Methods and materials: A retrospective study of patients with acute and chronic leukemia who received leukapheresis for hyperleukocytosis between the 1st of January 2013 and the 31st of December 2023 at King Fahad Specialist Hospital (KFSH) in Dammam, Saudi Arabia was performed. Results: Over a period of 11 years, a total of 50 patients with acute and chronic leukemia presenting with hyperleukocytosis and clinical manifestations of leukostasis; 32 patients with acute leukemia (AL) and 18 patients with chronic myeloid leukemia (CML); received leukapheresis at our institution. Among the 32 patients with AL who received leukapheresis, 24 patients (75%) had acute myeloid leukemia (AML), 7 patients (21.88%) had acute lymphoblastic leukemia (ALL) and 1 patient (3.13%) had bilineage acute leukemia (BAL). At presentation of their AL: 3 patients (9.38%) had fever, 9 patients (28.13%) had infections, 4 patients (12.5%) had palpable spleen or liver, 6 patients (18.75%) had palpable external lymph nodes, and 9 patients (28.13%) had extramedullary disease (EMD). After receiving induction and consolidation cycles of chemotherapy, 11 patients (34.38%) of AL patients received allogeneic hematopoietic stem cell transplantation (HSCT). At the end of the follow-up, 17 patients (53.1%) with AL were alive while 15 patients (46.9%) were dead. The 8-year overall survival (OS) for all patients with AL subjected to leukapheresis was 47%. The 5 years OS for patients with AL who subsequently received HSCT and those who did not receive allogeneic HSCT were 70% and 40% respectively. The mean white blood cell (WBC) count of CML patients subjected to leukapheresis was 465.5 × 109/L, 11 patients (61.11%) had clear signs of leukostasis, and 8 patients (44.44%) had splenomegaly at presentation. Regarding the disease stage at presentation, 14 CML patients (77.78%) had chronic phase (CP), 2 patients (11.11%) had accelerated phase (AP) and 2 patients (11.11%) had blast phase (BP). Regarding the fate of CML patients at the end of the study were: 15 (83.33%) were alive, 1 (5.56%) dead, and 2 (11.11%) were unknown as they lost follow-up. However, the 10-year OS of patients with CML subjected to leukapheresis was 90%. Conclusion: Patients with acute or chronic leukemia presenting with hyperleukocytosis and either ongoing or impending leukostasis should have urgent cytoreductive chemotherapy and leukapheresis to prevent life-threatening complications. Although the outcome of AL patients presenting with leukostasis is generally poor, prompt cytoreductive therapy and leukapheresis, followed by induction chemotherapy and allogeneic HSCT may improve the outcome. Also, urgent cytoreduction including leukapheresis improves the outcome of patients with CML presenting with hyperleukocytosis and leukostasis.

Myocarditis-A Helpful Algorithm to Overcome Diagnostic Challenges in the Pediatric Population.

This study was designed to investigate clinical differences between pediatric patients who presented with chest pain, tachycardia, and/or tachypnea who subsequently were or were not diagnosed with myocarditis. The results were used to develop a decision tree to aid in rapid diagnosis of pediatric myocarditis. A retrospective case-control study was performed using the electronic medical records of children aged 0 to 18 years between the years 2003 and 2020 with a complaint of chest pain, tachycardia, and/or tachypnea. Patients included in the study were those diagnosed with myocarditis and those with suspected myocarditis, which was ultimately ruled out. Demographic and clinical differences between the research groups were analyzed. A decision tree was rendered using the rpart (Recursive Partitioning and Regression Trees) package. Four thousand one hundred twenty-five patients were screened for eligibility. Seventy-three myocarditis patients and 292 nonmyocarditis patients were included. Compared with the control group, the study group was found to have a higher mean respiratory rate (37 ± 23 vs 23 ± 7 breaths per minute) and mean heart rate (121 ± 44 vs 97 ± 25 beats per minute) and lower mean systolic and diastolic blood pressure (102 ± 27/56 ± 17 mm Hg vs 114 ± 14/67 ± 10 mm Hg). The mean white blood cell count was greater in the case group (13 ± 6 vs 10 ± 5 × 10 3 /μL). A decision tree was rendered using simple demographic and clinical variables. The accuracy of the algorithm was 85.2%, with 100% accuracy in patients aged 0 to 2.5 years and 69% in patients aged 2.5 to 18 years. The clinical and laboratory characteristics described in this study were similar to what is described in the literature. The decision tree may aid in the diagnosis of myocarditis in patients 2.5 years and younger. In the population aged 2.5 to 18 years, the decision tree did not constitute an adequate tool for detecting myocarditis.

Effect of Antibiotic Administration Before Joint Aspiration on Synovial Fluid White Blood Cell Count in Native Joint Septic Arthritis.

This study was performed to assess the impact of preaspiration antibiotics on synovial fluid analysis and timing of operative treatment in native-joint septic arthritis. We performed a retrospective record review of adult patients from an urban level 1 trauma center with native joint septic arthritis in 2015-2019, identified by means of codes from the International Classification of Diseases (Ninth Revision and Tenth Revision). Univariate and multivariate analyses were performed to determine whether antibiotics were associated with lower synovial fluid white blood cell counts (WBCs), the percentage of polymorphonuclear neutrophil (PMNs), and rate of culture positivity. Secondary analysis included time elapsed from aspiration to surgery. Of the 126 patients with septic joints included, nearly two-thirds (n = 80 [63.5%]) received antibiotics before joint aspiration. The synovial fluid WBC count, percentage of PMNs, and rate of culture positivity were significantly lower in patients who received preaspiration antibiotics than in those who did not (mean WBC count, 51 379.1/μL [standard deviation, 52 576.3/μL] vs 92 162.7/μL [59 330.6/μL], respectively [P < .001]; PMN percentage, 83.6% [20.5%] vs 91.9% [6.0%; P = .01]; and culture positivity, 32.5% vs 59.1% [P = .008]). Multivariable analyses revealed that these associations remained after controlling for potential confounders (change in PMNs, -42 784.60/μL [95% confidence interval, -65 355/μL to -20 213.90/μL [P < .001]; change in PMNs, -7.8% [-13.7% to -1.8%] [P = .01]; odds ratio, 0.39 [.18-.87; P = .02). Patients with a synovial fluid WBC count ≤50 000/μL experienced significant delay in time from joint aspiration to operative intervention (mean [standard deviation], 10.5 [11.3] vs 17.9 [17.2] hours; P = .02). The administration of antibiotics before joint aspiration for suspected septic arthritis appears to decrease the synovial fluid WBC count, the percentage of PMNs, and the rate of culture positivity. Efforts to limit antibiotic administration before joint aspiration are important to minimize diagnostic dilemmas and circumvent treatment delays.

Brucellar arthritis and sacroiliitis: an 8-year retrospective comparative analysis of demographic, clinical, and paraclinical features.

Brucellosis is a common global zoonotic disease with a wide range of complex and nonspecific clinical manifestations that may lead to misdiagnosis and delayed treatment. Osteoarticular involvement is the most common complaint in brucellosis. This present study aims to describe the clinical and laboratory characteristics and treatment of brucellosis patients with arthritis and sacroiliitis. This retrospective descriptive study was performed on patients presenting to a teaching hospital in Kermanshah, Iran with a diagnosis of brucellosis from 2011 to 2019. The demographic and clinical characteristics, complications, laboratory findings, and treatment were recorded during the study period. Then, the difference in the collected data was investigated between brucellosis patients with and without arthritis or sacroiliitis. Of 425 patients studied, 130 (30.58%) had osteoarticular involvement. Among them, 41 (9.64%) and 58 (13.6%) patients were diagnosed with arthritis and sacroiliitis, respectively. There were no significant demographic differences between patients with and without brucellar arthritis or sacroiliitis (p > 0.05). The patients with Brucella arthritis had a significantly higher frequency of arthralgia and radiculopathy (p ⩽ 0.05). Sacroiliitis was significantly more common in patients with arthralgia, neck pain, and low back pain, positive flexion-abduction-external rotation (FABER) test, radiculopathy, and vertebral tenderness compared to patients without sacroiliitis (p ⩽ 0.05), while fever and headache were significantly more common in patients without sacroiliitis (p ⩽ 0.05). The median Wright and 2-Mercapto Ethanol titers were higher in brucellosis patients with arthritis or sacroiliitis versus patients without arthritis or sacroiliitis, but the difference was not significant (p > 0.05). Synovial fluid had been analyzed in 20 cases. The mean white blood cell count, glucose, and protein level were 3461 ± 2.70 cells/mm3, 58.54 ± 31.43 mg/dL, and 8.6 ± 11.85 g/dL, respectively. In 80% of the subjects, neutrophil cells were predominant. There were no significant laboratory differences between patients with and without brucellar arthritis or sacroiliitis, except for a higher median platelet count in patients with arthritis and higher median levels of aspartate aminotransferase (AST) and alkaline phosphatase (ALP) in patients with sacroiliitis. Most cases of arthritis and sacroiliitis were diagnosed with ultrasound (31.8%) and FABER test (79.3%), respectively. Arthritis and sacroiliitis were the two most important and common manifestations of brucellar osteoarthritis with a frequency of 9.64% and 13.6%, respectively. Any complaints of low back pain and radiculopathy as well as the presence of spondylitis in patients should raise suspicion of sacroiliitis. High levels of AST and ALP and a high platelet count may be associated with brucellar sacroiliitis and arthritis, respectively. The use of imaging methods such as MRI and bone scan seems necessary for the diagnosis of sacroiliitis.

The effect of neutrophil lymphocyte ratio and other biochemical parameters on mortality in cancer patients admitted to the emergency department

Aims: To investigate the effectiveness of the neutrophil/lymphocyte ratio and other biochemical parameters in predicting mortality in oncology patients with cancer admitted to the emergency department. Methods: This was a retrospective, observational, single-center study. The study period included a two-year period from January 2014 to December 2015. Demographic data, cancer history and blood tests, emergency department diagnoses, blood parameters evaluated in the emergency department, discharge, and mortality status of the patients were recorded in the data form. The APACHE 2 and SOFA scores of all patients were also calculated. Patients whose data could not be reached were excluded from the study. p&lt;0.05 was considered statistically significant. Results: A total of 180 patients were included in the study. The mean age of the survivor group was 66.4±10.752 years, while the mean age of the non-survivor group was 65.18±13 years. The mean neutrophil/lymphocyte (NLR) ratio of the non-survivor group was 1.0288±11.3, while the NLR of the survivor group was 4.400±3.563. (p&lt;0.05) The mean lactate ratio of the non-survivor group was 2.60±3.384, while the mean lactate ratio of the survivor group was 1.36±1. 090. (p&lt;0.05) When survivor and non-survivor patient groups were compared, a statistically significant difference was observed in mean white blood cell count, neutrophil count, hemoglobin, hematocrit, and blood urea nitrogen (BUN) values. (p&lt;0.05) Conclusion: According to the results of this study, NLR, elevated white blood cell and neutrophil values, decreased hemoglobin and hematocrit, and elevated BUN and lactate levels seem to be predictors of mortality during emergency admissions in cancer patients.

Observation of Clinical Profile of Different Types of Meningitis in a Tertiary Care Hospital

Background: Meningitis, an inflammation of the membranes surrounding the brain and spinal cord, presents significant diagnostic challenges due to its varied etiologies and overlapping clinical symptoms. This study aims to observe and document the clinical and laboratory characteristics of viral, bacterial, and tubercular meningitis in a tertiary care hospital setting. Methods: This descriptive observational study was conducted at the Department of Neuromedicine, Cumilla Medical College Hospital, Bangladesh, from January 2020 to December 2020. We enrolled 159 patients diagnosed with meningitis based on clinical, biochemical, and investigative criteria. Detailed demographic data, clinical examination findings, and relevant investigations, including cerebrospinal fluid (CSF) studies, were recorded. Data analysis was performed using SPSS software version 20 and MS-Excel 2016. Results: Among the 159 participants, 36.7% were diagnosed with bacterial meningitis, 32.5% with viral meningitis, and 24.9% with tubercular meningitis. Fever was a universal symptom, while headache was reported by 87.3% of viral, 87.1% of bacterial, and 95.2% of tubercular meningitis patients. Vomiting was more prevalent in tubercular (57.1%) and bacterial (50%) meningitis. Laboratory findings showed the highest mean white blood cell count in bacterial meningitis (11803.18±2905.55 cells/cmm). C-reactive protein levels were also highest in bacterial meningitis (21.23±16.20 mg/dl). Elevated adenosine deaminase levels were a distinguishing feature of tubercular meningitis (14.18±10.60 Unit/L). Conclusion: This study highlights the distinct clinical and laboratory profiles associated with different types of meningitis. The findings emphasize the importance of comprehensive evaluations for accurate diagnosis and effective management of meningitis. Further research should aim to refine diagnostic criteria and explore advanced diagnostic tools to improve patient outcomes. , , , , , ,

Microbiological Profile and Clinical Features of Septic Arthritis of the Shoulder: A 10-Year Cohort Single-Centre Study.

Introduction Septic arthritis (SA) constitutes a pressing orthopedic emergency characterized by acute, non-traumatic joint pain. Timely diagnosis and intervention are imperative to avert complications such as chondrolysis and systemic sepsis. The etiology is predominantly hematogenous, necessitating an integrated approach involving surgical and microbiological modalities. Shoulder aspiration and microbiological analysis play pivotal roles in guiding treatment, especially when positive findings prompt more aggressive therapeutic strategies. This study aims to elucidate the nuanced clinical and epidemiological characteristics of septic arthritis in both native and prosthetic joints within a singular institutional cohort over a decade. Methods This retrospective case series analysis spanned a 10-year period, focusing on non-prosthetic shoulder joints from January 2012 to July 2021. In this timeframe, only 183 aspirations were performed and sent to the microbiology department for analysis, including cultures, microscopy, and antibiotic sensitivity tests for positive cultures. The study delved into the microbiological profile of infections, encompassing gram stain, culture positivity rates, identification of microorganisms, and antibiotic susceptibility patterns. Additionally, the incidence of primary joint infections with resistant strains, particularly methicillin-resistant Staphylococcus aureus(MRSA), was scrutinized. Statistical analysis utilized the SPSS program version 20.0 (IBM Inc., Armonk, New York), with a significance level set at 5%. The project, registered with the trust's clinical audit department (Reg #5372), adhered to the Declaration of Helsinki and good clinical practice guidelines. Data collection involved extracting non-identifiable patient modifiers from the laboratory database bank into Excel spreadsheets. Results The study included 183 patients, with 108 (59%) females and 75 (41%) males. The average age was 76.2±16.5 years. Among them, 138 (75.4%) reported pain, and 15 (8.2%) had a body temperature over 37.8°C. Lab results showed a mean white blood cell count of 11.6±4.5 and an average C-reactive protein level of 121.7±102.1. Leucocytosis (>11,000 WBC) was seen in 82 (44.8%) cases. Elevated C-reactive protein (CRP; >10 mg/dl) was found in 136 (74.3%) patients. Synovial fluid analysis revealed no crystals in 91.3% of cases. Microbial resistance analysis showed 19 strains resistant to co-trimoxazole and 11 to erythromycin. Among co-trimoxazole-resistant strains, 73.7% were Staphylococcus aureus, a statistically significant association (p<0.001). Conclusion The evolving sensitivity patterns of microbes in septic arthritis underscore the necessity to reassess empirical antibiotic therapy. Subsequent joint damage resulting from infection can result in substantial disability.

Mean platelet volume and total white blood cells as diagnostic biomarkers for acute appendicitis at Omdurman military hospital: a cross-sectional study − 2021

BackgroundAcute appendicitis (AA) is among the most common nontraumatic indications for emergent abdominal surgical procedures. However, accurately diagnosing all cases can be challenging, physical examination, biochemical markers, and imaging techniques can sometimes be insufficient. This study aimed to (a) compare the mean platelet volume (MPV) and total white blood cell count (TWBCs) in patients with or without histological evidence of an inflamed appendix and (b) determine the positive predictive value, negative predictive value, sensitivity, and specificity of both MPV and TWBCs as diagnostic biomarkers in the diagnosis of AA. We conducted this research at Omdurman Military Hospital, focusing on patients who presented with symptoms suggestive of AA.Materials and methodsAn analytical cross-sectional study conducted at Omdurman Military Hospital from December 2020 - December 2021. The study population was patients who presented to our emergency department with symptoms and signs suggestive of AA. Participants were patients operated on as cases of AA. Data variables included sociodemographic characteristics, clinical presentations, intraoperative appendix macroscopic findings, preoperative MPV and total white blood cell count (TWBCs), and postoperative histopathological findings.ResultsA total of 106 patients were included in this study, with 75 (68.2%) males; half were 10–19 years old. Sixty-three patients (57.3%) had low (< 7.5 fL) MPV, whereas 47 (42.7%) had normal values. Comparing MPV to total white blood cells (TWBCs) revealed that MPV was more sensitive (84.6%) and specific (90%) than TWBCs during the first 24 h of inflammation. However, the TWBCs were more sensitive (97.2%) but less specific (94.7% vs. 100%) after 24 h of onset.ConclusionIn this study, MPV was lower in patients with AA, while there was an increase in TWBCs. The high sensitivity and specificity of TWBCs and MPV indicated that they form a promising diagnostic marker for AA.

Progression to Myelofibrosis in Patients with Essential Thrombocythemia: A Real-World Analysis from the Prospective MOST Study

Background: Essential thrombocythemia (ET) is a myeloproliferative neoplasm (MPN) characterized by clonal blood cell proliferation, excessive platelet production, constitutional symptoms, and increased risk of vascular complications, as well as a risk of progression to myelofibrosis (MF). Previous prognostic studies of patients with ET have largely been based on retrospective analyses, and limited prospective data exist regarding disease progression. The prospective Myelofibrosis and Essential Thrombocythemia Observational Study (MOST) collected real-world data from patients with ET. This analysis evaluates disease progression in patients with ET enrolled in MOST. Methods: MOST (NCT02953704) enrolled patients with ET aged ≥60 years, or with a history of thromboembolic events, or who were receiving ET-directed therapy (excluding aspirin only). Baseline clinical characteristics data were collected as previously described (Yacoub A. CLML. 2021). For this analysis, progression from ET to MF was defined as meeting 1 or more of the following criteria during the study period: 1) Bone marrow biopsy with fibrosis grade ≥2 or pathologic diagnosis of MF; 2) death owing to MF/myelodysplastic syndrome/acute myeloid leukemia; 3) circulating blasts &amp;gt;1% and new/worsening splenomegaly (SPM); 4)new/worsening SPM and ≥2 of white blood cell (WBC) count &amp;gt;11×10 9/L, hemoglobin (Hb) &amp;lt;10 g/dL, and platelet count &amp;lt;100×10 9/L. Median (range) follow-up was 57.3 months (42-70). Results: Of the 1237 patients with ET enrolled in MOST; 53 (4.3%) met criteria for progression to MF. Among patients with progression, most had progressed due to fibrosis (criteria 1, 56.6%); 15.1%, 11.3%, and 28.3% of patients progressed due to criteria 2, 3, and 4, respectively. Notably, only 176 patients (14.2%) enrolled in the study had bone marrow data available. Comparison of the enrollment characteristics of patients with and without progression identified no differences in age at enrollment or diagnosis (Table 1). However, time from diagnosis to enrollment and from diagnosis to end of study were significantly longer in patients with progression than those without (median 7.9 vs 4.2 years, median 12.7 vs 9.0 years, respectively; both P=0.001). Of all enrolled patients with vs without progression tested for known driver mutations, a higher percentage with progression were JAK2-positive vs those without progression (80.6% [29/36] vs 69.7% [598/858]). At enrollment, the percentages of patients with vs without progression receiving ET-directed therapies were similar (94.3% vs 94.8%). Among patients with vs without progression, mean baseline Hb was significantly lower (12.5 g/dL vs 13.1 g/dL; P=0.026), mean WBC counts were significantly higher (10.4×10 9/L vs 7.4×10 9/L; P&amp;lt;0.001), and mean platelet counts were comparable (418.6×10 9/L vs 455.0×10 9/L; P=0.466). MPN-SAF TSS was similar for patients with vs without progression at baseline. Fewer patients with vs without progression had ≥1 thrombotic events (1.9% [1/53] vs 3.7% [44/1184]) during the study, whereas a higher percentage of patients had ≥1 hemorrhagic events (7.5% [4/53] vs 1.3% [15/1184]). Conclusions: This real-world analysis of data from MOST showed that 4.3% of patients with ET progressed to MF during the study period. Compared with patients without progression, patients with ET to MF progression had longer duration of disease, higher WBC count, and lower Hb at enrollment; symptom burden at enrollment was similar between the 2 groups. One limitation of this study is the lack of bone marrow data for the majority of patients, suggesting a possible underestimation of progression to MF. These findings and further analysis of MOST data will add insight into disease progression in patients with ET and facilitate clinical management of this patient population.

Picalm::MLLT10 can Identify a New Subgroup of Acute Leukemias of Ambiguous Lineage with Unique Extramedullary Disease and Treatment Response

Background: Mixed-phenotype acute leukemias (MPAL), which is included in acute leukemias of ambiguous lineage (ALAL), can be classified as four different subtypes based on recurring genetic alterations including BCR::ABL, KMT2A and ZNF384 gene rearrangement as well as BCL11B activation. The 2022 WHO classification has already mentioned PICALM::MLLT10 fusions are also enriched in MPAL but need more data. In 2022 ELN classification, PICALM::MLLT10 was identified as acute myeloid leukemia (AML) with other rare recurring translocations but not ALAL. In addition, there is no separate classification for PICALM::MLLT10 in the new ICC classification. Therefore, it is still confused whether PICALM::MLLT10 corresponds to AML or acute lymphoblastic leukemia (ALL) or ALAL. Methods: Fourteen PICALM::MLLT10 positive patients of 390 AL patients (14/390, 3.6%) were identified by RNA sequencing (RNA-seq) in our center from 2020-2022, including 8 female and 6 male, with a median age of 33 years (16-50 years). These patients were newly diagnosed AL according to bone marrow morphology and immunology including 5 ALAL, 5 T-ALL [ 4 early T-cell precursor ALL (ETP-ALL), 1 cortical T-ALL], 2 AML, 1 B-ALL with aberrant expression of myeloid antigen, and 1 B/T MPAL. Results: The mean white blood cell counts of these patients was 8.25×10 9/L (2.34-51×10 9/L) and platelet counts was 168.5×10 12/L (39-429×10 12/L) individually. It should be mentioned that extramedullary disease (EMD) was found in 7 cases (7/14), including mediastinum, tonsil, and skin. In terms of immunotyping, CD7 was identified in all patients (14/14) and CD33 in 71.4% (10/14) patients. The major concurrence mutations were PHF6 mutation (8/14), JAK3 mutation (5/14), and SUZ12 mutation (4/14). Characteristic cytogenetic abnormality t(10;11)(p12.3;q14.2) was only found in three cases (3/14) (Table 1). The PICALM breakpoints are mainly concentrated in exon 17 (n=6) and exon 19 (n=8). Exon 4 (n=8), exon 6 (n=2), exon 9 (n=2) and exon 10 (n=2) are the most commonbreakpointsof MLLT10. To our knowledge, this is the first report about the breakpoints and fusion gene forms of PICALM::MLLT10. For initial treatment, these patients individually received standard ALL induction chemotherapy (VDPCP, vincristine, idarubicin, pegaspargase, cyclophosphamide, prednisone) and AML induction chemotherapy (3+7 IA regimen including idarubicin, cytarabine). The initial complete remission (CR) rate was only 35.7% (5/14), and 9 patients showing no remission (NR). These NR patients subsequently received salvage chemotherapy. It is worth mentioning that 6 of them received combined chemotherapy regimen including low doses of cytarabine (LDAC), granulocyte colony-stimulating factor (G-CSF) and anthracyclines such as aclarubicin or idarubicin or homoharringtonine (CAG or IAG or HAG), and 2 of 6 patients also further received combination therapy with venetoclax (CAG or IAG +VEN). Finally, 5 of them dramatically achieved CR (5/6). In the other 3 patients, 1 patient who was failure to initial Hyper-CVAD A/B regimen also dramatically achieved CR after the more Hyper-CVAD A regimen combined with venetoclax, and 1 patient achieved CR while another still NR with both receiving CLAG (cladribine, cytarabine, G-CSF) regimen. Subsequently 11 patients (9 CR, 2 with refractory disease) received allogenic hematopoietic stem cell transplantation (allo-HSCT), and all the CR patients survived well after HSCT (follow up 3-24 months, median 15 months) without relapse, while 2 NR patients died soon after transplantation because of severe complications (Table 2). Conclusions: Our data suggested PICALM::MLLT10 positive AL should be more appropriately recognized as an independent ALAL entity and may benefit from LDAC, G-CSF and anthracyclines combination chemotherapy as well as venetoclax. Sequential HSCT after chemotherapy combined with venetoclax may further improve long-term survival in AL patients with CR even MRD positive.

Stump Appendicitis: A Rare Late Complication of Appendectomy, a Retrospective Analysis of 9082 Appendectomy Cases

Objective: Appendectomy for appendicitis is one of the most common surgical procedures performed worldwide. The remnant of the appendix stump after the first appendectomy carries the risk of developing stump appendicitis. Stump appendicitis is a rare late complication of appendectomy; inflammation occurs in the remaining appendicular stump. Delayed diagnosis of this condition can cause serious complications. Stump appendicitis is indeed a recognized clinical picture, but is often overlooked when evaluating patients with right lower quadrant abdominal pain, especially those with a history of appendectomy. It remains a clinical challenge because of its often delayed diagnosis and effective treatment, and possible accompanying morbidity or mortality. Material and Methods: Materials and Methods: We retrospectively screened the patients who were hospitalized in our general surgery clinic and diagnosed with stump appendicitis in the hospital for 12 years. There were 11 patients between January 2011 and 2023 Results: The mean age of all 11 patients described was 55 years (range: 20 to 66). 72% of the patients were male (8/11 males and 3/11 females). 63% of the patients had their first operations open, and 36% of them were laparoscopic. The mean white blood cell count on presentation of all reported 11 cases was 11,996 cells/mm3 (range: 5930 to 18,740), the mean fever was 37.82°C (range: 36.8 to 38.6), and the mean CRP count on presentation of all cases was 36.7 (range: 0.4 to 142.91). The most commonly performed radiographic examination used to diagnose stump appendicitis is the abdominal computerized tomography (CT) scan. It was used in 100% (11 cases). Ultrasound was also used in 100% (11 cases). Conclusion: The appendicular base must be accessed prior to undertaking an appendectomy, irrespective of the chosen strategy or technique. It is noteworthy that, apart from open or laparoscopic appendectomy, antibiotic therapy should also be considered as part of the treatment regimen, as documented in the literature series.

Comparing Cairo Bishop and Howard Criteria for Identifying Clinically Meaningful Tumor Lysis Syndrome Among Acute Myeloid Leukemia Patients Treated with Venetoclax and Hypomethylating Agents: A Single Center Experience

Introduction Venetoclax (ven) in combination with hypomethylating agents (HMA) is the standard of care for the treatment of acute myeloid leukemia (AML) in patients (pts) who are ineligible for intensive chemotherapy. The most serious complication of ven is tumor lysis syndrome (TLS). The phase 1b trial of ven and HMA in AML pts included strict prophylactic measures to prevent TLS. Reported rates of TLS in real world cohorts vary widely and prophylactic measures are not standardized. Methods Here we describe TLS prophylaxis (ppx) and incidence in a cohort of 100 consecutive pts age ≥18 years at the University of Pennsylvania who received inpatient or outpatient ven and HMA for up front treatment of AML between 1/2017-8/2022. TLS ppx was at the discretion of the treating team. TLS was retrospectively defined by Cairo Bishop and Howard Criteria (table 1). Howard TLS (H-TLS) criteria differs from Cairo Bishop TLS (CB-TLS) in that it requires two lab abnormalities be present in the same 24-hour period, uses calcium corrected for albumin and does not include ≥25% changes from baseline lab values. Results 92 pts had a white blood cell count (WBC) &amp;lt;25,000 cells/μL on the first day of treatment (table 1). 34 pts developed laboratory (lab) CB-TLS; 8 of these pts met criteria for clinical CB-TLS due to acute kidney injury (AKI). 13 pts developed CB-TLS prior to starting ven. While the original phase 1b trial mandated frequent lab monitoring as well as starting allopurinol ≥72 hours prior to ven and suggested a target of 2L of intravenous (IV) fluid per day starting the night prior to ven, TLS ppx was variable in our pts. 56 pts received allopurinol ≥72 hours prior to starting ven, 21 received ≥2L of IV fluid per day starting at least the day prior to ven, and 56 had TLS labs measured every 8-12 hours during the first 3 days following ven initiation. CB-TLS was associated with a higher ECOG score and baseline lactate dehydrogenase as well as FLT3 and NPM1 mutations. The CB-TLS group had a higher mean WBC count but there was no difference in the proportion of pts with WBC counts ≥25,000 cells/μL. There was a trend towards increased CB-TLS in pts with WBC counts ≥15,000 cells/μL; this reached statistical significance when comparing the percent of pts with non-spontaneous CB-TLS with WBC count ≥15,000 cells/μL to the rest of the cohort (33% vs 13%, p=0.034). To characterize TLS severity, we categorized the pts with CB-TLS into three groups: insignificant TLS, significant TLS, and those whose lab abnormalities were explained by a different pathology. We defined significant TLS as pts who required hospitalization (if started treatment outpatient) or ICU transfer, received rasburicase, developed AKI, or had treatment held due to TLS. 17 pts had insignificant TLS, 14 had significant TLS, and 3 were ultimately felt not to have TLS (table 2). We also compared pts who developed CB-TLS with those who met criteria for H-TLS. Of the 34 pts who met lab CB-TLS criteria, only 6 also met Howard criteria. All 6 of these pts had significant TLS. Of the 8 pts with significant TLS who only met Cairo Bishop criteria, 6 developed spontaneous TLS &amp;gt;3 days prior to starting treatment with ven that would have met H-TLS criteria at onset. Their lab abnormalities were not as severe by ≤3 days prior to ven start when the formal time frame for defining TLS begins. Discussion Other studies have shown lab TLS rates of 0-40% in AML pts receiving ven with HMA, with the majority reporting rates &amp;lt;10%. Our data show a higher rate of lab CB-TLS than other published cohorts. However, our data also show that most pts do not develop significant TLS despite less aggressive ppx than was used in the original ven trial and suggest that less aggressive ppx is appropriate for most pts. There was a high rate of spontaneous TLS in our cohort. Debate exists over the most appropriate WBC threshold for ven initiation; our data suggest an association of WBC count &amp;lt;15,000 cells/μL with lower TLS risk. Of the pts who developed significant TLS, a majority had spontaneous TLS; only 5 pts had significant TLS occur after starting ven. We also found that the Howard criteria for TLS better identify pts who will have adverse outcomes from TLS and may be a more clinically meaningful set of criteria to use in future studies.

Gastrointestinal symptoms, diagnostic evaluations, and abdominal pathology in children with sickle cell disease.

Children with sickle cell disease (SCD) frequently present with acute pain. The abdomen, a common site of acute SCD-related pain, may be present in a variety of gastrointestinal (GI) pathologies. Limited data exist on prevalence and workup of abdominal pain in patients with SCD during acute pain events. Determine prevalence of GI symptoms, GI-specific evaluation and risks of hospitalization in children with SCD presenting to the emergency department (ED) or hospitalized with abdominal pain. Retrospective study of children less than 21years presenting to the ED or hospitalized with pain in our center over 2years. Descriptive statistics were used to report clinical characteristics, frequency of GI symptoms, workup by age (<5 vs. ≥5years), and genotype (sickle cell anemia [SCA] vs. non-SCA). Logistic regression models were used to identify risks associated with hospitalization. A total of 1279 encounters in 378 patients were analyzed; 23% (n=291) encounters were associated with abdominal pain. More abdominal pain-associated hospitalizations occurred in older children, SCA, children with lower mean hemoglobin (8.7±1.9 vs. 9.6±1.6g/dL, p<.001) and higher mean white blood cell (WBC) count (14.9±6.6 vs. 13.2±5.3×103 /μL, p=.02). We identified that less than 50% of patients presenting to the ED with abdominal pain received a GI-specific evaluation. Children with SCD frequently present with abdominal pain and other GI symptoms, with limited GI evaluations performed. GI-specific evaluation may increase diagnosis of GI pathologies, rule out GI pathologies, and contribute to the limited knowledge of the abdomen as a primary site of SCD pain.