Rh(D) immune globulin administration in pregnancy: Retrospective audit of patient safety events followed by targeted educational intervention with Bayesian analysis.

OBJECTIVES: To examine local patient safety events related to the administration of anti-Rh(D) immune globin (RhIG) during pregnancy, and to follow-up with targeted educational intervention to improve knowledge of this process. BACKGROUND: Administration RhIG is established treatment for the prevention of haemolytic disease of the foetus and newborn (HDFN). However, patient safety events in relation to its correct use continue to occur. METHODS: A retrospective audit of patient safety events related to RhIG administration during pregnancy was performed. Targeted educational intervention in the form of PowerPoint® presentation were given to nursing staff, laboratory staff and physicians and evaluated with pre- and post-tests using multiple-choice questions given immediately before and after the presentation. RESULTS: An annual incidence of 0.24% of patient safety events related to the administration of RhIG during pregnancy was found. These events were mostly in the preanalytical phase, for example mislabelled samples or samples for D-rosette/Kleihauer-Betke testing drawn from the baby, not the mother. Using Bayesian analysis, the probability of positive effect for the targeted educational intervention was 100% with a median improved score of 29%. This was compared with a control group using standard curriculum education intervention based on the current curriculum for nursing, laboratory and medical students which showed a median improved score of only 4.4%. CONCLUSIONS: Administration of RhIG during pregnancy is a multistep process involving health care professionals of several disciplines providing opportunities to enhance the curriculum for nursing, laboratory and medical students and to ensure on-going education.

Prenatally Diagnosed Infant AML.

We report the first case of a fetus with acute myeloid leukemia, without Down syndrome, diagnosed in utero. A cordocentesis sample prepared to investigate hepatomegaly led to further evaluations revealing acute myeloid leukemia, monocytic type, in the fetus. Cytogenetic analysis showed mixed lineage leukemia duplication, no gene disruption or trisomy. Planned treatment included intrauterine exchange transfusion to extend gestation, low-dose chemotherapy at birth, and full chemotherapy once stable. Before any intervention, the child was delivered emergently for maternal condition and died 2 hours later. Although it is now possible to diagnose hematologic malignancy in a fetus, there is little information to direct management.

Possible mechanisms for intravenous immunoglobulin-associated hemolysis: clues obtained from review of clinical case reports.

BACKGROUND: Intravenous immunoglobulin (IVIG) is an efficacious treatment modality for a number of conditions and is usually well tolerated with few reports of serious adverse events; however, the administration of IVIG may occasionally result in clinically significant hemolysis. STUDY DESIGN AND METHODS: The literature was reviewed for case reports and case series of IVIG-associated hemolysis. The cases were scrutinized for clues as to the possible mechanism(s) of the hemolysis. RESULTS: Review of the 129 individual cases reported in the literature identifies clinical features shared by the majority of patients. These features included non-O blood group patients and treatment with high-dose IVIG as an immune-modulating agent for an underlying inflammatory or immune-mediated disorder. Other patient factors such as secretor phenotype, soluble ABH substance, and Fcgamma receptor polymorphisms may also play a role. CONCLUSIONS: It is known that high-dose IVIG given to non-O blood group patients with underlying inflammatory and/or immune-mediated disorders is associated with increased risk of hemolysis. This review reveals additional patient characteristics in cases of IVIG-associated hemolysis, including underrepresentation of D- and group B cases, higher incidence in pediatric Kawasaki disease and unique at-risk patient groups including allogeneic stem cell transplant recipients with group A donor in a group O recipient, and patients in whom soluble AB substance is removed by plasma exchange at the same time as receiving IVIG.

Acute extravascular hemolytic transfusion reaction due to anti-Kpa antibody missed by electronic crossmatch.

BACKGROUND: Kpa antigen is a low incidence red blood cell antigen within the Kell system. Anti-Kpa alloantibody may be associated with acute and delayed hemolytic transfusion reactions. CASE STUDY: We report a case of a clinically significant acute extravascular hemolytic transfusion reaction mediated by previously unrecognized (and undetected) anti-Kpa alloantibody. This reaction occurred in a patient who met all criteria for electronic crossmatch, resulting in the transfusion of an incompatible red cell unit. RESULTS: Post-transfusion investigation showed the transfused red cell unit was crossmatch compatible at the immediate spin phase but was 3 + incompatible at the antiglobulin phase. No evidence of intravascular hemolysis was observed upon visual comparison of the pre- and post-transfusion peripheral blood plasma. Further testing showed the presence of anti-Kpa antibody. The clinical course of the patient included acute febrile and systemic reaction. CONCLUSION: Acute extravascular hemolytic transfusion reaction may occur due to undetected anti-Kpa alloantibody. Various strategies for crossmatching are discussed in the context of antibodies to low incidence antigens.

Hemolysis upon intravenous immunoglobulin transfusion.

Intravenous immunoglobulin (IVIG) is a mainstay of therapy in many disorders. An uncommon adverse side effect is IVIG-related hemolysis. Risk factors for IVIG-related hemolysis have been identified, including high dose IVIG given to non-O blood group recipients with an underlying inflammatory state. IVIG-related hemolysis has been linked to anti-A and anti-B hemagglutinins in the IVIG preparations and may involve both IgG and complement mediated hemolysis. A two-hit mechanism with threshold effect is proposed for IVIG-related hemolysis. Strategies exist to minimize or avoid IVIG-related hemolysis.

Prothrombin complex concentrate for the urgent reversal of warfarin. Assessment of a standard dosing protocol.

BACKGROUND: Octaplex®, a six factor prothrombin complex concentrate (PCC), has recently been approved for use in Canada. The optimal dose of Octaplex has yet to be established and our study was designed to monitor the efficacy of a low standard dose. STUDY DESIGN AND METHODS: Patients on warfarin treatment in need of urgent reversal for bleeding, invasive procedures or surgery were given a standard dose of 40 ml (1000 IU FIX, 14 IU/kg). We conducted a retrospective chart review of 231 patients. RESULTS: Patients given concurrent frozen plasma (FP) for reversal were eliminated from the study. Overall, 150 patients were reviewed and divided into three groups: (1) non-CNS bleeders, (2) CNS bleeders, and (3) non-bleeders. Correction of INR to 1.5 or less was achieved to the same extent in each group. Patients with active bleeding had the least successful bleeding cessation and patients with intracranial bleeding had the most dismal outcome compared to non-intracranial bleeders. CONCLUSIONS: Our data suggests that Octaplex, when given as a low standard dose is effective at INR reversal with 76% of our patients correcting to an INR of 1.5 or less. It appears that this dose is sufficient for non-bleeding patients. Bleeding patients may benefit most from a dose increase to achieve more complete reversal and patients with intracranial bleeding should achieve more complete reversal within 2h of presentation.

Practical application of mathematical calculations and statistical methods for the routine haematology laboratory.

BACKGROUND: Statistical analyses are embedded as critical functions in the routine haematology laboratory. AIM: This educational article is aimed at providing an overview of these topics and practical application examples. MATERIALS, METHODS, AND RESULTS: Topics covered include mathematical conversion between units, maintaining a quality control (QC) system, statistical methods for reagent validation, and determining uncertainty of measurement (UoM). DISCUSSION: Additional considerations may be required when a regional laboratory program is in place, such as the harmonization of INR results and determination of therapeutic reference intervals for unfractionated heparin therapy. CONCLUSION: The coauthors of this manuscript are fortunate to be part of regional network of hospital laboratories, the Eastern Ontario Regional Laboratory Association (EORLA).

Parkinson's disease-linked LRRK2 is expressed in circulating and tissue immune cells and upregulated following recognition of microbial structures.

Sequence variants at or near the leucine-rich repeat kinase 2 (LRRK2) locus have been associated with susceptibility to three human conditions: Parkinson's disease (PD), Crohn's disease and leprosy. As all three disorders represent complex diseases with evidence of inflammation, we hypothesized a role for LRRK2 in immune cell functions. Here, we report that full-length Lrrk2 is a relatively common constituent of human peripheral blood mononuclear cells (PBMC) including affinity isolated, CD14(+) monocytes, CD19(+) B cells, and CD4(+) as well as CD8(+) T cells. Up to 26% of PBMC from healthy donors and up to 43% of CD14(+) monocytes were stained by anti-Lrrk2 antibodies using cell sorting. PBMC lysates contained full-length (>260 kDa) and higher molecular weight Lrrk2 species. The expression of LRRK2 in circulating leukocytes was confirmed by microscopy of human blood smears and in sections from normal midbrain and distal ileum. Lrrk2 reactivity was also detected in mesenteric lymph nodes and spleen (including in dendritic cells), but was absent in splenic mononuclear cells from lrrk2-null mice, as expected. In cultured bone marrow-derived macrophages from mice we made three observations: (i) a predominance of higher molecular weight lrrk2; (ii) the reduction of autophagy marker LC3-II in (R1441C)lrrk2-mutant cells (<31%); and (iii) a significant up-regulation of lrrk2 mRNA (>fourfold) and protein after exposure to several microbial structures including bacterial lipopolysaccharide and lentiviral particles. We conclude that Lrrk2 is a constituent of many cell types in the immune system. Following the recognition of microbial structures, stimulated macrophages respond with altered lrrk2 gene expression. In the same cells, lrrk2 appears to co-regulate autophagy. A pattern recognition receptor-type function for LRRK2 could explain its locus' association with Crohn's disease and leprosy risk. We speculate that the role of Lrrk2 in immune cells may also be relevant to the susceptibility of developing PD or its progression.

HLA-DR(negative), CD34(negative) hypergranular acute myeloid leukemia with trisomy 6 and del(5)(q22q33): case report and review of the literature.

We report a unique pediatric case of hypergranular acute myeloid leukemia with myelodysplasia-related changes. The patient presented with moderate leukocytosis with neutrophilia with left-shift maturation and dysplasia, anemia, and multiple sclerotic bone lesions. The bone marrow was hypercellular with a predominance of myeloblast cells and/or abnormal promyelocytes with hypergranular cytoplasm. Flow cytometric immunophenotyping showed that the leukemic cells were positive for CD13, CD33, and myeloperoxidase, and negative for HLA-DR and CD34. Morphology and immunophenotyping were highly suggestive of acute promyelocytic leukemia. The classic t(15;17) or other RARα rearrangements were not detected by cytogenetic or molecular assays, ruling out acute promyelocytic leukemia. Standard cytogenetic analysis showed that the karyotype of the predominant clone was 47,XY,+6 with evidence of clonal evolution to 47,XY,+6,del(5)(q22q33). A literature and database review showed that trisomy 6 is a rare occurrence in hematological malignancies and, to our knowledge, has never been reported in association with del(5)(q22q33) in a child presenting with hypergranular acute myeloid leukemia with myelodysplasia-related changes. We present a current review of the literature and summarize the clinical features of 57 cases of trisomy 6 as the primary chromosomal abnormality in hematological disease.

Osteogenesis with hematopoiesis simulating infection in a hydroxyapatite orbital implant.

A 28-year-old woman underwent secondary orbital implant surgery with placement of a hydroxyapatite implant. Over the next 7 years she underwent 3 drilling procedures. She began having copious discharge 1 year after the last drilling procedure. She was seen on numerous occasions with socket discharge, unresponsive to a variety of topical and oral antibiotics. Clinically, with the conjunctiva diffusely inflamed, the implant tender to touch, and the presence of a pyogenic granuloma, implant infection was suspected and the implant subsequently removed. Histopathologic assessment revealed widespread lamellar bone formation, including focal areas of marrow with active extramedullary hematopoiesis. There was no evidence of an inflammatory process or infection. Postoperatively the patient's symptoms and signs resolved. Extramedullary hematopoiesis within hydroxyapatite implants is rare. Porous orbital implant infection is also rare. Osteogenesis with extramedullary hematopoiesis simulating implant infection has not previously been reported.

Disseminated cryptococcal infection in a patient with treatment-naïve chronic lymphocytic leukemia (CLL).

We report a case of disseminated cryptococcosis in a treatment-naïve chronic lymphocytic leukemia (CLL) patient. A 60-year-old man presented with a two-week history of intermittent fevers, frontal headaches, night sweats, weight loss and multiple pink papules on hands and face. Cryptococcemia was found by blood culture unexpectedly. Further investigation confirmed cryptococcal meningitis and skin disease. He responded to two week amphotericin B and flucytosine followed by four-week amphotericin B and fluconazole, three-month high dose fluconazole (800 mg/day), and maintenance fluconazole (400 mg/day) thereafter. CSF pleocytosis persisted until day 203 while cryptococcal antigen in the CSF persisted at day 334 of treatment.

Anterior segment infiltration of acute lymphoblastic leukemia: case report and systematic review.

Acute lymphoblastic leukemia (ALL) relapse implies a poor prognosis and demands emergency treatment. Leukemic infiltration of the anterior segment can masquerade as intraocular inflammation; a high index of suspicion for this complication is essential. We describe a case of ocular relapse in a 2-year-old male on maintenance therapy for ALL. A systematic review of all known cases of similar leukemic infiltration of the anterior segment of the eye in ALL was performed. A total of 106 patients in 43 reports described leukemic infiltration of the eye as an initial presentation of ALL or relapse. Ocular relapse may be the first visible manifestation of systemic disease, with concurrent disease in the CNS, bone marrow, or testes. Prognosis for ALL patients with ocular relapse is poor, with death after initial presentation reported as early as 16 days. Patients with a history of ALL presenting with any sign of ocular inflammation should be assessed for relapse and leukemic infiltration. As soon as a diagnosis of relapse has been confirmed, appropriate leukemia therapy should be initiated.

Guidance for quality control practices and precision goals for CBCs based on IQMH patterns-of-practice survey.

INTRODUCTION: Effective medical laboratory quality management systems ensure confidence in analyzing and reporting accurate and reliable patient results. To guarantee quality assurance, each laboratory needs appropriate internal quality control (IQC) procedures to monitor their test systems. The Institute for Quality Management in Healthcare (IQMH) Centre for Proficiency Testing conducted a survey on quality control (QC) practices in routine hematology. METHODS: An online survey was sent to 184 Ontario laboratories performing complete blood counts (CBC) and leukocyte differentials. RESULTS: All participants used three levels of commercial QC for test system monitoring. Eighty percent of laboratories supplement with in-house patient QC. The frequency of QC analysis was variable based on: Manufacturer recommendations (80%) Parameter stability (25%) Clinical impact of incorrect results (21%) Number of samples potentially requiring retesting if there is a QC failure (11%). All laboratories used established QC rules and limits to monitor results. They utilized various methods in establishing limits including: Standard deviation of QC results (60%) Manufacturer precision goals (55%) Published precision goals (24%) IQMH allowable performance limits (APLs) (37%). CONCLUSION: Considerable variation in QC practices of Ontario laboratories was identified, and consensus practice recommendations and precision goals were developed to guide and standardize QC practice.

Characteristics of Lymphoproliferative Disorders with More Than One Aberrant Cell Population as Detected by 10-Color Flow Cytometry.

BACKGROUND: We have evaluated the frequency of lymphoproliferative disorders with more than one aberrant population of monotypic B-cells detected during routine hematopathological diagnostics. MATERIALS AND METHODS: 2600 samples peripheral (blood, bone marrow, fine-needle aspirate, lymph node, and pleural fluid cell suspensions) were analyzed using a 10-color B-cell panel and a 10-color T-cell panel. A 10-color plasma cell/lymphoplasmacytic panel was performed when appropriate. RESULTS: 790/2600 samples (30%) showed at least one aberrant B-cell population and 27(1%) showed an aberrant T-cell population. 41/790 samples (5.1%) showed two aberrant B-cell populations. Thirteen patients had two B-cell populations with different surface immunoglobulin restriction (one kappa+ and one lambda+), most with B-cell chronic lymphocytic leukemia-related phenotype. Five cases showed two B-cell populations with the same light chain restriction but distinctly different immunophenotypes. In 23 cases, two populations had the same light chain restriction and differed by expression of one or 2 markers, thus, a possibility of intraclonal differentiation could not be excluded. Cases with possible intraclonal differentiation had a significantly higher proportion of aberrant B-cells than those with two coexisting aberrant B-cell populations (49.9% vs. 27.7%, p = 0.008). In only one sample one population of clonal B-cell and one clonal T-cell population with large granular lymphocyte related phenotype were found. CONCLUSION: Using our panels 5.1% of cases with lymphoproliferative disorder-associated aberrant findings show two aberrant (clonal) lymphoid and/or plasma cell populations. © 2016 International Clinical Cytometry Society.