Hematology Section Research Articles

Bone marrow disease profile in geriatric patients: An institutional study

For the diagnosis and treatment of numerous hematological and non-hematological disorders in patients of all ages, a bone marrow examination is a crucial investigation. Due to the growing elderly population and the paucity of published studies on bone marrow disorders that only affect the elderly, age-related health conditions are becoming more prevalent. In our study, we enrolled elderly patients >60 years old who had a bone marrow examination at GMC Jammu's pathology department.: To study the profile of various hematological and non-hematological lesions diagnosed on Bone Marrow aspiration and/or Trephine biopsy in Geriatric age group 2. To summarize an approach for evaluation of anemia in elderly patients for better management.: The study was conducted in two parts; a Retrospective study for 4 years and a prospective study of 1 year. It included all the patients >60 years of age who had undergone Bone marrow examination in the hematology section of the Department of Pathology.: 200 bone marrow aspirations and 40 trephine biopsies, as well as peripheral blood smears and biopsy imprint smears, were all examined. Aplastic anemia, Megaloblastic anemia, Iron deficiency anemia, chronic disease-related anemia, and ITP were among the non-malignant hematological disorders that affected 50.5% (n=101) of the patients; various hematological malignancies affected 40.5% (n=81) of the patients; and non-hematological malignancies affected 1% (n=2) of the patients. 1% (n=2) of the cases were insufficient, and 7% (n=14) of the cases in which BMA and/or BMB were used for lymphoma staging and follow-up did not show any signs of marrow infiltration. With the growing elderly population in India, it is important to pay more attention to diagnosing and treating easily treatable conditions like anemia as well as enhancing the general health of geriatric patients the elderly, bone marrow aspiration.

The particularities of SARS-CoV-2 infection on onco-hematological diseases in children

The particularities of SARS-CoV-2 infection on onco-hematological diseases in children. Introduction: Cancer in childrenis a rare disease among the pediatric population, representing approximately 0.5%- 1% of the total number of cancers. In the Republic of Moldova, anually, approximately 90 children are diagnosed with malignant tumors. The survival rate of children with cancer has improved considerably over time, but it remains a significant cause of morbidity and mortality among children. In oncological pathology, viral and bacterial infections acquired in the community can lead to a delay in chemotherapy treatment, which increases the risk of disease recurrence and resistance, thus increasing mortality. Children with hematologic malignancies generally have a more favorable prognosis for COVID-19 infection than adults with the same pathologies, but their risks of hospitalization, and death are much higher compared to the general pediatric populationThe purpose of the study: Determination of the infection rate of children with hemoblastosis with SARS Cov 2 infection, evolution and survival rate. Materials and methods: Thisis a retrospective study carried out in the Oncological Institute, hematology section for children, carried out during the SARS-CoV-2 pandemic March 2020-March 2022. Results: Among all patients hospitalized and treated in theOncological Institute, the children’s hematology section (125 patients) - 33 (26.4%) patients suffered SARS COV 2 infection, of which 3 had endured covid 2 times. The majority of patients - 26 patients (78.78%) had acute lymphoblastic leukemia, 1 (3.03%) Hodgkin’s lymphoma and 2 (6.06%) with Burkitt’s lymphomas, and non-Hodgkin’s lymphoma. Among the clinical symptoms, most children presented with 11 patients (30.5%), and fever> 38-10 patients (27.7%), 12 children (33.3%) did not present any symptoms, only the positive COVID-19 test. Among children diagnosed with COVID-19 infection, 10 (27%) cases of COVID were registered in children before or simultaneously with the basic hematological diagnosis, 25% (9 patients) were in the period of intermediate maintenance and we had one case ( 2.7%) in reinduction therapy and refractory therapy respectively. Analyzing the paraclinical data, a slight prevalence of the absolute number of lymphocytes compared to that of neutrophils was observed in patients who presented radiological signs of viral pneumonia. According to the imaging data, we had 7 confirmed cases of bilateral viral pneumonia, Rx1, 1 case of severe bilateral viral pneumonia-Rx4, which resulted in death, and one case of bilateral viral pneumonia due to leukemoid infiltration which also led to death, the child being decompensated approximately 2 months before the diagnosis of COVID-19. Conclusions: For most pediatric patients with hematologic malignancies, infection with COVID-19 does not result in severe progression. But this infection leads to the discontinuation of specific therapy, but the long-term consequences are notyet sufficiently studied.

To Determine the Incidence of Various Subtypes of VWD with Specified VWF:RCof/ VWF:Ag Ratio’s In Pediatric Patients

Background: VWD is the most common inherited bleeding disorder characterized by defects in the concentration, structure, or function VWF. There are three main types of VWD that differ according to the degree of disease severity and inheritance pattern (Type 1, Type 2A, 2B, 2M, 2N and Type 3). Methodology: This is 05 years study (Feb 2016–Jan 2021) conducted in hematology section. In present study, amongst total inherited bleeding disorders, Incidence of VWD is 27%, Hemophilia (50%), inherited platelet disorders (14%) and remainder are undiagnosed. Amongst VWD, Type 1 VWD is the most common subtype studied, comprising 66% of total cases. Type 2 & 3 VWD comprised 23% and 10% of total cases showing good correlation with the literature and other studies. Discussion: The European cross-sectional study yielded a population-based estimate of 0.05 per 100,000 for type 3 VWD. Estimates by VWD type from Europe and Western Pacific reported higher prevalence estimates for type 1 disease than type 2 or type 3: 2.7–7.2 per 100,000 for type 1 VWD, 0.8–2.5 per 100,000 for type 2, and 0.1–0.3 per 100,000 for type 3. Conclusion: VWD usually presents with mild bleeding symptoms (except in type 3 VWD) the diagnosis is often delayed. Prompt diagnosis and management can help to avoid potentially life-threatening bleeding events and unnecessary exposure to blood products.

Assessment of Artificial Intelligence Language Models and Information Retrieval Strategies for QA in Hematology

Introduction Large language models (LLMs) have gained popularity due to their natural language generation and interpretation capabilities. Integrating these models in medicine enables multiple tasks like summarizing medical histories, synthesizing literature, and suggesting diagnoses. Models like ChatGPT, GPT-4, and Med-PaLM2 (Singhal et al., 2023) have demonstrated their proficiency by achieving high scores in medical tests like the United States Medical Licensing Examination (USMLE) (Kung et al., 2023). However, LLMs may sometimes be inaccurate, providing unverified and erroneous information. In this study, we investigate the potential uses of LLMs in hematology, assessing their knowledge through hematology questions from the USMLE. Additionally, we propose augmenting LLMs with retrieval capabilities for medical guidelines in order to eliminate incorrect information. By extracting relevant information from specified medical documents, this approach holds the potential to streamline decision-making processes. Methods For comparative purposes, all experiments were conducted using both GPT 3.5-turbo and GPT-4 models. In a first step, we evaluated the general knowledge and performance of LLM in the field of hematology by testing it in a collected dataset of 127 question-answer pairs from the hematology section (covering various aspects of the field) of the USMLE. In a second step, we evaluated the proposed information retrieval framework using a set of 120 multiple-choice questions. These questions were specifically focused on the 4th revision of the World Health Organization classification of myeloid neoplasms and acute leukemia guidelines (subsequently called WHO 2017). By testing the framework on this domain-specific dataset, we aimed to assess its ability to extract specific clinical context and relevant information from complex clinical guidelines. Each question from the WHO 2017 guideline dataset was subjected to a comprehensive evaluation using two techniques. First, the questions were assessed using a zero-shot approach (the question together with the different options are directly posed to the model) to assess the LLM's capability to respond based on its own knowledge. Second, we employed our proposed retrieval information approach, enabling the system to conduct in-depth searches throughout the external documents (WHO 2017 guideline) to identify relevant (and similar) extracts about each question. Subsequently, the system provided answers based on the retrieved contexts from the document, thus facilitating more accurate and contextually informed responses. To achieve this, we created an embedding space containing the document's content and conducted a cosine-similarity search between a given question and all the content extracts from the document. The top three relevant extracts, based on similarity to the given question, were used as context for the LLM. Results In the evaluation of 127 hematology questions from the USMLE, GPT-3.5 in zero-shot mode achieved 63% accuracy, while GPT-4 demonstrated a higher accuracy rate of 82%. The evaluation of the WHO 2017 questions dataset revealed that the zero-shot approach achieved accuracy rates of 51% for GPT-3.5 and 71% for GPT-4. Incorporating information retrieval, retrieving the three most relevant extracts from the guidelines, substantially improved performance, with GPT-3.5 achieving 86% accuracy and GPT-4 demonstrating 97% accuracy. Conclusions LLMs have great potential, with current models showcasing substantial knowledge in hematology. However, ensuring their consistency and safety in responses is critical for their reliable application in medical settings (Thirunavukarasu et al., 2023). To address this, we demonstrated the benefits of information retrieval for question-answering in the field of hematology, significantly improving response reliability and accuracy by empowering LLMs to deliver more informed and contextually appropriate answers. The concept was effectively validated using the WHO 2017 guideline, and it can be effortlessly adapted to answer questions based on any set of hematology-related documents. Leveraging LLMs has the potential to significantly enhance the efficiency and effectiveness of clinical, educational, and research work in hematology.

The Effect of Ferritin Level on Respiratory Functions in Patients with β-Thalassemia Major

Introduction-Purpose β-thalassemia major (β-TM) is an autosomal recessive disorder caused by mutations in the β-globin gene of hemoglobin. The disease is characterized by splenomegaly due to ineffective erythropoiesis, iron accumulation signs in tissues as a result of increased iron absorption, bone expansion due to increased erythropoietic activity, and decreased tissue oxygenation. One of the effected organ can be the lungs due to excessive iron deposition in these patients. The current study aimed to investigate the effect of serum ferritin level, which is known as a marker of iron accumulation in tissues, on pulmonary function tests (PFT) in patients with β-TM. Methods and Materials Patients aged ≥6 years who were regularly followed in the pediatric hematology section of Mersin City Research and Training Hospital with a diagnosis of β-TM were included. All patients received regular blood transfusion and iron chelation therapy. Study participants underwent PFT prior to blood transfusion in the pediatric pulmonology section Results A total of 43 patients with β-TM were studied. Included patients were divided into two groups according to the mean annual ferritin level; low ferritin group if below 2000 ml/ng and high ferritin group if above 2000 ml/ng. The low ferritin group was consisted of 19 patients and the high ferritin group was consisted of 24 patients. The characteristics of these two groups are shown in Table 1. There were no statistical significance in age, gender, body mass index, age at diagnosis, mean annual hemoglobin, splenectomy, cardiac involvement and oxygen saturation among both groups, but the number of annual transfusion was significantly higher in the high ferritin group than lower ferritin group. When PFT parameters of both groups were compared, FVC (forced vital capacity) was statistically lower in the high ferritin group compared to the low ferritin group. Other parameters included FEV 1 (forced expiratory volume in 1 second), FEV 1/FVC ratio, PEF (peak expiratory flow) and FEF 25-75 (forced expiratory flow between 25% and 75% of vital capacity) were similar among groups. (Table 2) Discussion Patients with β-TM may accumulate iron in the interstitial area of the lungs which can lead fibrosis and impaired lung function over time. There are several studies investigated lung dysfunction and its etiology in these patients. Although the results of the studies are varied, the majority of them reported a restrictive pattern of respiratory dysfunction in thalassemia patients. Additionally, some studies showed the presence of mild or moderate obstruction in small airways and decrease in diffusion capacity with the increase of alveolar-capillary membrane thickness at advanced ages. In the present study, we found that patients with β-TM who had high ferritin level showed restrictive type lung function compared to those with low ferritin level. There were no difference among the groups in obstructive parameters (i.e. FEV 1, FEV 1/FVC, FEF 25-75) of PFT. In the literature, studies investigating PFT in patients with high ferritin levels had variable results, impaired or no change, in pulmonary status. In conclusion, loss of respiratory function and impaired tissue oxygenation in patients with β-TM may develop over time due to iron deposition in the interstitial area. PFT assessment of these patients is essential and recommended for the detection of early lung disease. Routine PFT follow in patients with β-TM of high ferritin values is highly important.

A Narrative Review on the Preanalytical Sample Errors in the Hematology Section of Clinical Laboratory

A Narrative Review on the Preanalytical Sample Errors in the Hematology Section of Clinical Laboratory

Diagnostic Interpretation and further evaluation of Extreme Hyperferritinemia (>10,000 microg/L) with reduced % Tsat (<50%) in pediatric patients in Tertiary care Hospital

Background: Ferritin is a soluble protein which provides intracellular storage of bioavailable iron. It is found primarily in Liver, bone marrow macrophages, spleen. Ferritin is measured by ELISA, RIA and Mass spectrometry. The main aim of this study is to etiologically categorise extreme hyperferritinemia (serum ferritin > 10000 microg/L). Methodology and Results: This is 05 years retrospective study (July -2018 to June 2023), conducted in hematology section, MMCH, KSA. Out of 34 cases of extreme hyperferritinemia, viral infection was the most common cause comprising 41% of all cases. Amongst the infectious etiology, 6 cases of EBV, 3 cases of ALF of suspected viral etiology, 2 cases of PIDS with secondary infection, 1 case each of Hepatitis A virus and CMV noted. 10 cases presented as Macrophage Activating syndrome comprising 29% of total cases of which 70 were Systemic Juvenile Idiopathic arthritis and remaining 30% includes SLE and juvenile rheumatoid arthritis. Discussion: Study conducted by Dondu et al., indicate that the most common causes of hyperferritinemia are rheumatologic diseases and infections, which were identified in 59.1 and 27.3%, respectively. Present study showed infective etiology as the most common cause of extreme hyperferritinemia. Reasons for differences in results are because other studies were conducted in Adult patients and in Rheumatologic department. Conclusion: Our study formulated a systematic investigating pathway for raised serum ferritin. If the laboratory screening tests, BMA and other sophisticated tests are done in systematic way, then challenging cases can be diagnosed easily.

Analysis of the Six Sigma Principle in Pre-analytical Quality for Hematological Specimens.

Introduction Blood tests are essential for detecting and treating hospitalized individuals with diseases. Laboratory blood tests provide doctors with critical information required to treat their patient's illnesses. The most common sources of error in clinical laboratories are pre-analytical errors. Although quality control measures can remediate analytical errors, there is a requirement for stringentquality checks in the pre-analytical sector as these activities are performed outside of the laboratory. Pre-analytical errors when combined with the sigma value can reflect a better pictureas the sigma value represents the laboratory's performance. Aim In this study, six sigma and the Pareto principle were utilizedto assess pre-analytical quality indicators for evaluating the performance of a clinical hematologylaboratory. Methodology This is a retrospective observational study conducted from 2015 to 2023 (for a period of eight years). Information about the frequency of pre-analyticalerrorswas retrieved from the hematology section of the central diagnostic researchlaboratory information system and the data was entered into an MS Excel sheet and datawas evaluated utilizingSPSS version 23(IBM Corp., Armonk, NY). Results In the current research, total of 15 pre-analytical errors were noted. Out of the total 15 pre-analytical errors studied, 55.4% of pre-analytical errors were notedamong which80% errors were due to lack of mention of sample type or received timeand20% of errorswere attributedto no mention of diagnosis in requisition forms. The next most common errors noted were insufficient samples (8.26%) followed by absence of physician's signature (7%), incomplete request form (5.4%), age (4.2%), unique hospital identification (UHID) number (3.7%), clotted samples and transportation of the samples (3.6%), date and incorrect vials (2.6%). Gender (0.95%), hemolysed(0.85%), and lipemic samples (0.45%).Hemolysed andlipemic samples hada sigma value of 4.4 and 4.6, respectively, whereas gender and age had a sigma value of 4.3 and 3.8, inadequate sample for testing and an incorrect anticoagulant to blood ratio had a sigma value of 3.6, indicating that sample collection has to beimproved as the inverse relationship is noted between sigma value and laboratory performance. Conclusion Pareto chart and sigma value can help recognize most common pre-analytical errors, which consequently will help to prevent further recurrence of pre-analytical errors. Adequate training with regard to best practices in phlebotomy for interns, clinicians and technicians must be provided to decrease quantitative errors, which will further enhancetotal quality management in the laboratory.

Myelodysplastic Syndromes/Neoplasms-Insights Into Pathogenesis Leading to Improved Classification, Risk Stratification, and Treatments.

From the ∗VA Connecticut Cancer Center, West Haven †Section of Hematology, Department of Internal Medicine, Yale School of Medicine and Yale Comprehensive Cancer Center, New Haven, CT. Conflicts of Interest and Source of Funding: A.M.Z. is a Leukemia and Lymphoma Society Scholar in Clinical Research. A.M.Z. received research funding (institutional) from Celgene/BMS, Abbvie, Astex, Pfizer, Medimmune/AstraZeneca, Boehringer-Ingelheim, Cardiff oncology, Incyte, Takeda, Novartis, Shattuck Labs, Geron, Aprea, and ADC Therapeutics. A.M.Z. participated in advisory boards and/or had a consultancy with and received honoraria from AbbVie, Pfizer, Celgene/BMS, Jazz, Incyte, Agios, Servier, Boehringer-Ingelheim, Novartis, Astellas, Daiichi Sankyo, Geron, Taiho, Seattle Genetics, BeyondSpring, Takeda, Ionis, Amgen, Janssen, Genentech, Epizyme, Syndax, Gilead, Kura, Chiesi, ALX Oncology, BioCryst, Notable, Orum, Mendus, Foran, Syros, and Tyme. A.M.Z. served on clinical trial committees for Novartis, Abbvie, Gilead, Syros, BioCryst, Abbvie, ALX Oncology, Geron, and Celgene/BMS. For M.G.R., none were declared. Reprints: Michal G. Rose, MD, VA Connecticut Cancer Center, 950 Campbell Avenue (III-d), West Haven, CT 06516. E-mail: [email protected].

ACCURACY OF AUTOMATED CELL ENUMERATION METHOD FOR VARYING CONCENTRATION OF WBCS FOR VARIOUS BODY FLUID SAMPLES

Background: Body fluids (BF) including peritoneal, pericardial, pleural, synovial and cerebrospinal fluids are now being analyzed by fully automated methods that are replacing the manual methods. The aim of this study is to assess the accuracy of automated instrument at varying concentrations of WBCs of various body fluid samples. Material and Methods: This cross-sectional study was conducted at the section of Hematology, Department of Pathology and Laboratory Medicine, the Aga Khan University, Karachi, Pakistan from November 2020 to April 2021. Forty body fluid samples with suspicion of infection including peritoneal, pericardial, pleural, synovial and cerebrospinal fluids (CSF) were analyzed to verify accuracy of white blood cells counts on fully automated XN-1000TM hematology analyzer (Sysmex Corporation, Kobe, Japan) against Neubauer chamber method (a manual method of differentiating WBCs via microscopy). The culture results of the body fluid samples were also analyzed. EP Evaluator version 10.3.0.556 (Data Innovations, LLC, VT, US) was used for statistical analysis with other supporting statistics such as Correlation Coefficient (R), Bias, Mean and Standard Deviation were included. Results: Eleven (n=11) of forty (n=40) body fluid samples showed high WBC count above the normal range. Samples with normal WBC (n=29) were also included in accuracy study to assess instrument performance at varying concentration of analyte. An average Error Index of -0.27 (-0.99 to 0.74) for WBC was obtained. Microbiological cultures grew Escherichia. Coli in 1 and Acinetobacter species in 1 CSF samples and Staphylococcus Aureus in 1 pleural sample. Conclusion: The study verified accuracy of varying concentration of WBC counting by fully automated Sysmex XN-1000 analyzer for various body fluid samples. Keywords: Body fluids, Validation, Automated analyzer, Performance specifications, Accuracy verifications, High white blood count, Infectious.

Correlation of automated cell counter RBC histograms and peripheral smear in anemia typing

Background: Red blood cell (RBC) indices and histogram obtained from automated hematology gives an idea about the morphological changes in anemia and therefore forms the fundamental process for diagnosis of anemia. Along with the peripheral smear, they can be used for anemia typing and to interpret the cause of anemia. Aims and Objectives: (1) Interpretation of histograms in normal persons and patients with different types of anemia. (2) Anemia typing based on RBC histograms complemented with Peripheral smear examination. Materials and Methods: The present prospective study is conducted in Haematology section of Department of Pathology, Shyam Shah Medical College and Sanjay Gandhi Medical Hospital Rewa, Madhya Pradesh. A total of 1000 patients blood sample is collected for complete blood count and anemia typing irrespective of age and gender and examined over a period of 1 year from August 2021 to July 2022. The patient’s blood sample is collected in EDTA vacutainer and analyzed on the basis of histogram obtained and peripheral smear slide prepared. Results: In the present study, we noted that the predominant age group affected was 20–30 years. Peripheral smear finding shows normocytic normochromic anemia was seen in 6% cases (60/1000), microcytic hypochromic anemia seen in 24.2% cases (242/1000), macrocytic anemia seen in 14% cases (140/1000), dimorphic anemia seen in 50.2% cases (502/1000), and hemolytic anemia seen in 5.6% cases (56/1000). This peripheral smear finding shows well correlation with findings of histogram pattern and RBC indices, where normocytic normochromic seen in 6.4% of cases (64/1000), microcytic hypochromic anemia seen in 24.4% of cases (244/1000), macrocytic anemia seen in 13.8% of cases (138/1000), dimorphic anemia seen in 49.5% of cases (495/1000), and hemolytic anemia seen in 5.9% of cases (59/1000). The most common anemia is dimorphic anemia (combined nutritional deficiency) in 49.5% cases followed by microcytic hypochromic anemia in 24.4% of cases based on histogram findings along with RBC indices. Conclusion: Histogram guides a technologist about the cases that need actual detailed peripheral smear examination by experts. Our study shows a well correlation in findings of automated hematology analyzer with the microscopic examination. Histogram alone could be used as screening method and when combined with peripheral blood smear findings, they act as useful supplement and by correlating findings of both methods, we could diagnose majority of anemia.

Diagnosis of Disseminated Intravascular Coagulation in Patients Suffering from Sepsis using the Modified International Society of Thrombosis and Haemostasis Criteria and Japanese Association of Acute Medicine Criteria

Introduction: The international task force defines sepsis as ‘life- threatening organ dysfunction caused by a dysregulated host response to infection’. Disseminated Intravascular Coagulation (DIC) is a coagulopathy syndrome that causes microvascular and macrovascular thrombosis and increases the risk of bleeding due to consumptive coagulopathy. Sepsis causes dysfunction in coagulation due to release of inflammatory markers which leads to inappropriate deposition of intravascular fibrin. In order to facilitate the diagnostic process for detecting DIC, the scoring system recommended by International Society of Thrombosis and Haemostasis (ISTH) and Japanese Association of Acute Medicine (JAAM) were used which are based on the global coagulation tests such as the platelet count, Prothrombin time, International Normalised Ratio (INR) and Fibrin Degradation Products (FDPs)/D-dimer. Aim: To determine the prevalence and outcome of DIC in patients suffering from sepsis using ISTH criteria and JAAM criteria. Materials and Methods: A prospective cohort was carried out from January 2021 to July 2022 in the haematology section of pathology department of Government Medical College and Hospital, Aurangabad, Maharashtra, India. Hundred patients suffering from clinically suspected sepsis were included in the study. Venous blood was collected from patients in Ethylene Diamine Tetra-acetic Acid (EDTA) and Citrate bulbs. The tests performed were Complete Blood Count (CBC), Prothrombin Time (PT), INR and D-Dimer. CBC was performed on Fully automated three part cell counter. PT, INR, D-Dimer testing was done on fully automated coagulometer. The above test results were used to diagnose DIC in patients suffering from sepsis using the modified ISTH and JAAM criterias. The results were analysed using Microsoft excel 2019 i.e., chi-square test was applied for p-value calculation. Results: Out of 100 patients with clinically suspected sepsis 35 patients (35%) suffered from Overt DIC using ISTH criteria and 58 patients (58%) suffered from DIC using JAAM criteria. The total mortality in patients with sepsis in the present study was 40%. The mortality in patients with DIC in sepsis using the ISTH criteria was 26 patients (74.28%) and 37 patients (63.79%) using the JAAM criteria. Conclusion: Coagulation abnormalities are widely prevalent in patients with sepsis and are likely to play a key role in multi- organ dysfunction. Both ISTH and JAAM criteria are good predictors of mortality.

PLATELET INDICES IN LEUKEMIAS: - A CROSS SECTIONAL STUDY

Objective: To evaluate the pattern of changes in the platelet indices in different Leukemias. Material and method: This descriptive cross-sectional study was conducted in the Pathology Department of Khyber Teaching Hospital from January 2021 to December 2021 (1-year duration). Diagnosed acute and chronic leukemia cases were included while those receiving therapeutic chemotherapy were excluded. The platelet count was analyzed as a part of complete blood counts by the Sysmex Hematology analyzer in the Hematology section of the Pathology department. The changes observed in the platelet counts in different types of leukemia were recorded in a proforma. Mean, standard deviation, frequency and percentages were used to compute variables. Results: The age range of the 100 included cases of leukemia was 01 - 50 years. The mean age of the study population was 30 ± 10 SD years. Platelet count was low in acute Leukemias and chronic lymphocytic leukemia. Only in chronic myeloid leukemia, raised platelet count was seen (in 62% of cases). Mean platelet volume and platelet distribution width were decreased in all leukemias. Conclusion: Platelet indices are decreased in Leukemias, with the exception of chronic myeloid leukemia where platelet count is raised. Keywords: Platelet count, Acute lymphoid leukemia, Acute myelogenous leukemia, Chronic lymphocytic leukemia, Chronic myelogenous leukemia.

Demographic features and hematological profile in patients of chronic lymphocytic leukemia in southern Punjab Pakistan.

Objective: To generate data regarding clinicohematological findings of CLL in patients of Southern Punjab Pakistan. Study Design: Descriptive Cross-sectional study. Setting: Hematology Section Pathology Department, Nishtar Medical University, Multan. Period: January 2016 to September 2019. Material & Methods: A total of 44 patients of all age groups diagnosed as CLL were enrolled. Diagnosis was made on morphology and immunohistochemistry of bone marrow trephine biopsies and cases without immunohistochemical panel were excluded from the study. Clinical features and baseline tests were evaluated in all cases. The data was analyzed using SPSS Version 23.0. Results: Out of 44 patients, majority were males (70.5%). Mean age was 51±12.6 years. B symptoms were present in 71% patients. Lymph nodes were enlarged in 44%. Splenic and hepatic enlargement was seen in 32% and 15.9% respectively. Anemia was seen in 45.5% and thrombocytopenia in 34.1%. Bone marrow was infiltrated in 100% patients and the most common pattern of infiltration was diffuse (65%). CD20 and CD5 were positive in all of the cases (100%) and CD23 in 96%. Seropositivity for both anti HCV and HBsAg was present in 2.3%. Conclusion: The clinicohematological features of CLL in our patients show some differences to the cited literature with a greater majority presenting at younger age with diffuse bone marrow involvement having lower positivity for HBsAg, anti HCV and less hepatosplenomegaly.

Economics in Medicine- a Study on Price Transparency in Hematology

Introduction: In early 2022, a study was done to assess the knowledge of Internal Medicine (IM) residents on healthcare charges in North Alabama Medical Center (NAMC). This study revealed a significant knowledge gap among residents, identifying a potential area that needs academic advancement to empower future physicians with vital information to make cost-conscious decisions for their patients. A curriculum was started as part of the Systems-Based Practice core competency to educate IM residents at NAMC about healthcare costs and price transparency to serve this purpose. As an extension, we performed this study to create awareness among hematologists-in-training and practicing hematologists regarding price transparency in hematology. Methods: This study used data from the ZeaMed Health hospital pricing database. ZeaMed Health is a pricing analytics company that downloaded hospital information across the United States from the Centres for Medicare and Medicaid (CMS) database. As part of the CMS Hospital price transparency rule, the hospitals publish data of the chargemaster and 300 shoppable services in a machine-readable format on hospital websites. ZeaMed Health collected hospital pricing data posted on the hospital websites. The data collection period was from January to June 2022. The information compiled included charge master data (i.e., standard gross prices, discounted cash prices, de-identified minimum negotiated charges, and de-identified maximum negotiated charges). The individual insurance negotiation rates were excluded since the minimum, and maximum negotiated rates exist. The following 12 unique Diagnosis Related Groups (DRGs) are related to the hematology section (799, 800, 801, 808, 809, 810, 811, 812, 813, 814, 815, 816). DRG 811, Red blood cell disorders with major complications or comorbidity (MCC), and DRG 812, Red blood cell disorders without MCC, were chosen to make it easy for the audience to comprehend. It is found that not all hospitals have provided all four standard charges on pricing data. Some hospitals provided only minimum and maximum negotiated prices, and others provided all four charges. Those hospitals' data that have all four standard prices are retained. Eight hundred forty-two out of the total 3115 DRG files were identified as 811 and 812 DRGs. Of 842 files, 332 were excluded because they did not provide all four standard charges. Of the remaining 510 files, 31 only mentioned anesthesia charges, making the total file count 479 (which includes both DRGs 811 and 812). Of the 479 files, 210 files belong to DRG 811, and 269 files belong to DRG 812. Any four standard prices below $1000 were excluded to remove the outliers. After excluding them, the final count was 204 for DRG 811 and 253 for DRG 812. The data does not include the professional fee. Results: The Red Blood Cell Disorders with MCC (DRG 811) and Red Blood Cell Disorders without MCC (DRG 812) were studied. For the 204 hospitals with DRG 811, the average standard gross price is $58,000, the average cash price is $30000, the average minimum negotiated price is $11000, and the average maximum negotiated price is $32000. For the 253 hospitals with DRG 812, the average standard gross price is $35000, the average cash price is $18000, the average minimum negotiated price is $6000, and the average maximum negotiated price is $22000. In both the DRGs, the average discounted cash price is lower than the average maximum negotiated price and higher than the average minimum negotiated price. This information is helpful for patients who are either uninsured or underinsured. This average data gives the power to the patient to negotiate for the lower price, that is, the minimum negotiated price. Without this information, the patient would otherwise pay the discounted cash price, which is $19000 higher on DRG -811 and $12000 higher on DRG-812. Conclusion: As hematologists in training and in practice, we have a duty to our patients to educate them on the economics of medicine and to provide cost-effective care. Our study serves to encourage other clinical educators to consider incorporating this curriculum into their resident's and fellow training. Our program serves as a model for this and has already taken the initiative of incorporating this curriculum in resident didactic with lectures delivered by the senior author and senior investigator of this study, who is also the founding designated institutional official (DIO) of the program. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Editorial introductions.

Editorial introductions.

Diagnostic Accuracy of Positron Emission Tomography-Computed Tomography (PET-CT Scan) In Detecting Bone Marrow Involvement in Patients with Diffuse Large B cell Lymphoma

Objective: To evaluate the diagnostic accuracy of positron emission tomography combined with CT scan (PET-CT Scan) in detecting bone marrow involvement in patients with diffuse large B-cell lymphoma, keeping bone marrow biopsy as gold standard. Methodology: From November 2017 to May 2018, a cross sectional validation study was carried out at the Aga Khan University in Karachi Department of Oncology's Section of Clinical Hematology. The study comprised a total of 112 patients who were identified as having diffuse large B cell lymphoma after a lymph node was implicated was histopathologically examined. All patients had a PET-CT scan and bone marrow biopsy technique as part of the staging workup. With bone marrow biopsy acting as the gold standard, the diagnostic efficacy of a PET-CT scan for identifying bone marrow involvement was evaluated. Results: Of 112 patients, there were 71(63.39%) males and 41(36.61%) females. The mean age was 45.09±17.36 years. The mean duration of diagnosis was 17.19±6.02 days. Through biopsy, bone marrow involvement was identified in 40 (35.7%) cases. Through a PET-CT scan, bone marrow involvement was identified in 47 (41.9%) cases. The PET- CT scan in comparison with bone marrow biopsy for detecting bone marrow involvement in patients with DLBCL had a sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of 95%, 87.7%, 80.85%, 96.92% and 90.18% respectively. Conclusion: PET-CT scan can accurately detect bone marrow involvement in patients with DLBCL so it can be used in most patients instead of invasive bone marrow biopsy procedure for staging of DLBCL patients.

Superoxide Dismutase and Vitamin E Levels in Serum as Indicators in Patients with Acute and Chronic Leukemia

Oxidative stress has been linked to the development of a variety of malignancies, including leukemia. Furthermore, the incidence of leukemia increases with age due to an increase in the number of free radicals reacting with age and a lower ability of the immune system to detoxify those free radicals. This study aims to investigate the levels of antioxidant activity and their relationship with various types of leukemia. The current study was carried out in the Hematology section of Baghdad Teaching Hospital/Medical City from November 2020 to January 2021. Patients with leukemia (n = 60) were divided into four groups based on their leukemia type: Acute lymphoid leukemia (ALL), acute myeloid leukemia (AML), chronic lymphoid leukemia (CLL), and chronic myeloid leukemia (CML). These groups were compared to 30 healthy subjects. In this study, serum levels of superoxide dismutase (SOD) and vitamin E were measured using an enzyme-linked immunosorbent assay. The findings revealed that (Mean±SE) SOD levels were observed to be raised with age, but (Mean±SE) vitamin E levels decreased with age in leukemia patients. There were no statistically significant differences in gender (males and females). Compared with healthy subjects, the results showed a significant increase in SOD levels in ALL, AML, CLL, and CML (P < 0.01). There were no statistically significant differences observed in vitamin E levels in ALL, AML, and CML except for the CLL group, which showed a significant decrease compared to the healthy subjects. Positive correlations were found between SOD and age (r = 0.367 P < 0.01). These results suggest that SOD and vitamin E levels play a critical role as an indicator of acute and chronic leukemia.

A study of critical value analysis at hematology and biochemistry sections of laboratory in a multispeciality hospital

The issue of laboratory critical value (CV) reporting has gained importance in the recent times due to the national focus on patient safety. Critical value notification (CVN) has become an essential part of accreditation procedures for medical laboratories, including the universally accepted International Organization for Standardization (ISO) 15189: 2012. Our study aimedto analyze the critical value data in hematology and biochemistry sections of the laboratory, to compare the frequencies of critical values for different parameters and to suggest measures for improving the effectiveness and operational efficiency of the critical value notification process.Our study was a retrospective, cross-sectional, descriptive study done over a period of one year six months (January 2020 to June 2021). The parameters chosen for CVN included platelets, hemoglobin and International Normalized Ratio (INR) from hematology section and creatinine, glucose, sodium, potassium and calcium from the biochemistry section. A test result that was significantly outside the normal range and that required immediate communication was considered as a “critical value (CV)”. Both verbal (through telephone) and non-verbal [through short message service (SMS)] communication processes for CVN were implemented in our lab. We also followed the practice of CV “read-back” by the person who was informed over the phone. A total of 2199 critical values were reported. A maximum of 1224 (55.7%) critical values were recorded from the emergency department. CVs were highest from biochemistry (1898, 86.3%) section. Analyte most commonly notified was creatinine (1151, 52.3%). CVNs were maximum in the morning shifts (1378, 62.7%).Implementation of the critical alert short message service (SMS) send outs has greatly helped us in reducing the CV turn around time (TAT). Our study has successfully demonstrated the importance of both verbal and non-verbal communication processes for notification of CVs.

Role of bone marrow aspiration and biopsy in evaluation of leucoerythroblastic blood picture

Leucoerythroblastosis was considered as a circulating expression of haematological and non-haematological malignancies. However many benign conditions are also associated with leucoerythroblastosis such as hemolytic anaemia, marked infections and congestive cardiac failure, etc. So the study was performed to determine the various causes of leucoerythroblastic blood picture on bone marrow examination. The current retrospective diagnostic analytical study was performed in the hematology section of post graduate department of pathology over a period of one year. 80 patients with leucoerythroblastic picture on peripheral blood film (PBF), who were subjected to bone marrow aspiration and/or biopsy were included in the study. The findings were documented on a predefined performa and results tabulated.Majority of cases were seen in 21-30 years age group (25%) with male to female ratio of 1.1:1. Non-neoplastic disorders accounted for majority of cases (65%) while neoplastic lesions were seen in 35% cases. Megaloblastic anaemia was the commonest neo-neoplastic etiology while acute leukemia was the commonest neoplastic disorder in the present study.Leucoerythroblastosis represents disordered marrow function and is reflected in PBF. Bone marrow aspiration and biopsy help in establishing early diagnosis and management of the underlying condition.