Thromboelastography-Guided versus Standard-of-Care or On-Demand Platelet Transfusion in Patients with Cirrhosis and Thrombocytopenia Undergoing Procedures: A Randomized Controlled Trial.

PURPOSE: To determine the rate of platelet transfusion in patients with cirrhosis and severe thrombocytopenia (platelet counts <50 × 109/L) undergoing high-risk invasive procedures when prescribed by thromboelastography (TEG) compared with empirical and on-demand transfusion strategies. MATERIALS AND METHODS: This was a single-center, single-blinded, randomized controlled trial. Patients with cirrhosis and severe thrombocytopenia undergoing high-risk invasive procedures were randomized into 3 groups: TEG group, transfusions based on TEG parameters; standard of care (SOC) group, 3 units of random donor platelets before procedure; and on-demand group, transfusions based on procedural adverse events/clinician's discretion. The primary outcome was periprocedural platelet transfusion in each arm. RESULTS: Eighty-seven patients were randomized (29 in each group) with no significant differences in demographics/coagulation profile/procedures. The median platelet count was 33 × 109/L (interquartile range, 26-43 × 109/L). Percutaneous liver biopsy was the most common procedure (46, 52.9%). Significantly lower number of patients in the TEG group received platelets (4 cases, 13.8%; 95% CI, 3.9-31.7) compared with SOC group (100%; 95% CI, 88.1-100; P < .001). Four patients in the on-demand group received platelets (13.8%; 95% CI, 3.9-31.7). Minor (World Health Organization [WHO] Grade 2) procedure-related bleeding occurred in 3 (10%; 95% CI, 2.2-27.4) patients in the TEG-guided transfusion group compared with 1 (3.4%; 95% CI, 0.1-17.8) patient each in the SOC and on-demand groups (P = .43), although the study was not powered for comparison of bleeding rates. No bleeding-related mortality was observed in any of the 3 groups. CONCLUSIONS: TEG-prescribed transfusion reduced prophylactic transfusions in patients with cirrhosis and severe thrombocytopenia undergoing high-risk invasive procedures.

Topical Diclofenac for Prevention of Capecitabine-Associated Hand-Foot Syndrome: A Double-Blind Randomized Controlled Trial.

PURPOSE: Hand-foot syndrome (HFS) is a dose-limiting side effect of capecitabine. Celecoxib prevents HFS by inhibiting cyclooxygenase-2 (COX-2) that is upregulated because of the underlying associated inflammation. However, systemic side effects of celecoxib have limited routine prescription. Topical diclofenac inhibits COX-2 locally with minimal risk of systemic adverse events. Therefore, we conducted this study to assess the efficacy of topical diclofenac in the prevention of capecitabine-induced HFS. METHODS: In this single-site phase III randomized double-blind trial, we enrolled patients with breast or GI cancer who were planned to receive capecitabine-based treatment. Participants were randomly assigned in a 1:1 ratio to receive topical diclofenac or placebo gel for 12 weeks or until the development of HFS, whichever occurred earlier. The primary end point was the incidence of grade 2 or 3 HFS (Common Terminology Criteria for Adverse Events version 5), which was compared between the two groups using simple logistic regression. RESULTS: In total, 264 patients were randomly assigned to receive topical diclofenac gel (n = 131) or placebo (n = 133). Grade 2 or 3 HFS was observed in 3.8% of participants in the diclofenac group compared with 15.0% in the placebo group (absolute difference, 11.2%; 95% CI, 4.3 to 18.1; P = .003). Grade 1-3 HFS was lower in the diclofenac group than in the placebo group (6.1% v 18.1%; absolute risk difference, 11.9%; 95% CI, 4.1 to 19.6). Capecitabine dose reductions because of HFS were less frequent in the diclofenac group (3.8%) than in the placebo group (13.5%; absolute risk difference, 9.7%; 95% CI, 3.0 to 16.4). CONCLUSION: Topical diclofenac prevented HFS in patients receiving capecitabine. This trial supports the use of topical diclofenac to prevent capecitabine-associated HFS.

Auer rods and faggot cells: A review of the history, significance and mimics of two morphological curiosities of enduring relevance.

Myeloid differentiation in blasts is distinguished by the presence of one or more needle-shaped crystalline structures called Auer rods. Auer rods manifest either alone or as faggot cells (containing bundles of Auer rods) in various types of acute myeloid leukemia (AML), myelodysplastic syndromes (MDS) and myelodysplastic/myeloproliferative neoplasms (MDS/MPN). Their presence largely portends a better prognosis in AML (as markers of maturation/differentiation) and upstages cases of MDS and MDS/MPN. Observation of these rods in residual blasts in treated cases of AML indicates an absence of remission. This article traces their historical discovery and examines their pathogenetic intricacies, as well as our current understanding of their relevance in myeloid neoplasms. Studies evaluating their prognostic impact in AML and MDS are catalogued. We also discuss a variety of other hematological and non-hematological neoplasms where structures potentially mistakable for Auer rods have been described. Even as the diagnostic approach to hematological malignancies has evolved from a morphology + cytochemistry + immunophenotyping-dependent one in the last century to a predominantly molecular genetics-based classification currently, and even as high-throughput sequencing and structural variation detection techniques surpass morphology in detecting clinically-relevant sub-categories of similar-appearing tumours, we review these curious microscopic structures that have withstood the test of time with respect to their diagnostic relevance.

Medical postgraduate (MD) program in Laboratory Medicine in India: The Past, Present and Future.

A medical postgraduate course in the field of Laboratory Medicine for the Bachelor of Medicine and Bachelor of Surgery (MBBS) degree holders has existed for more than two decades in India, initiated and offered by the All India Institute of Medical Sciences, New Delhi, which was created under the special Act of Parliament of India 1956. This course has recently been included in the draft of National Medical Commission's Post Graduate Regulation 2021 list of medical courses, and the foundation guidelines have been laid for other medical colleges and teaching hospitals across the country to start this course. This article, written purely in academic interest, describes the past, present and future of this postgraduate training program in India with an aim to answer several doubts regarding this unique and holistic course with a view to providing a direction to those who are willing to become a laboratory physician through this post-graduation.

Acquired Bernard-Soulier syndrome and hypodysfibrinogenaemia because of multiple myeloma.

We describe a case of a patient with multiple myeloma with initial presentation simulating a bleeding disorder. Detailed coagulation work-up showed hypodysfibrinogenaemia along with a platelet function defect consistent with acquired Bernard-Soulier syndrome (BSS). Multiple plasma exchanges led to significant improvement in his bleeding symptoms. To the best of our knowledge, this is the first described case of simultaneous presentation of hypodysfibrinogenaemia and BSS secondary to multiple myeloma.

Abnormal Chromatin Clumping in Myeloblasts Mimicking Chronic Lymphocytic Leukaemia: A Diagnostic Pitfall.

Abnormal chromatin clumping (ACC) in cells of myeloid lineage is a distinct morphological entity. It has been described mainly in polymorphs in haematological neoplasms involving myelodysplasia or myeloproliferation. We here describe a rare case of ACC in myeloblasts in an elderly man that mimicked chronic lymphocytic leukaemia. Flow cytometry played a crucial role in characterizing the myeloid lineage of the blasts, thus avoiding a misdiagnosis. To the best of our knowledge, this is the third time such a case has been reported in the literature.

Stodtmeister Cells (Polymorphs with Pelger-Huët Anomaly) Showing "Faggots" in Mixed Phenotypic Acute Leukemia (T/Myeloid).

"Faggot" cells, named for the resemblance of multiple Auer rods to a bundle of sticks, are often considered sine qua non for acute promyelocytic leukemia. However, blasts in other acute myeloid leukemias rarely also show faggot cells. This case demonstrates faggot cells in stodtmeister cells in mixed phenotypic acute leukemia. In addition to being uncommon, this case also highlights the importance of immunophenotyping and genetic analysis in avoiding misdiagnosis and inappropriate therapy.

Membranoproliferative Glomerulonephritis Secondary to a Low-Grade Lymphoproliferative Disorder: A Rare Cause of Renal Dysfunction.

Chronic lymphocytic leukemia is a B-cell neoplasm with an indolent clinical course. Most patients are asymptomatic and are diagnosed incidentally on a routine blood count. The malignant cells of this low-grade neoplasm infiltrate various organs and tissues. However, the resultant end organ damage is a rare phenomenon. Here we describe a case of chronic lymphocytic leukemia that presented with an unusual cause of acute renal dysfunction. The patient had deranged renal parameters with a nephrotic range proteinuria. The uncommon cause for his renal problem was membranoproliferative glomerulonephritis diagnosed by performing a kidney biopsy. Moreover, the acute renal dysfunction in this patient mandated an appropriate treatment and as of now there are no well-established treatment protocols for chronic lymphocytic leukemia with nephrotic syndrome. The patient was successfully treated with rituximab and bendamustine based on the expertise and judgement of the clinician.

Pancytopenia and isolated bone marrow recurrence in a case of previously resected gastric carcinoma: a rare finding.

Recurrences in resected cases of gastric carcinomas are well known. However isolated involvement of bone marrow is a rare presentation. We present a previously treated case of gastric carcinoma-signet-ring cell type who had a progressive shortness of breath since 1 month. A hemogram done at this occasion showed pancytopenia and leucoerythroblastic picture. Bone marrow examination revealed infiltration by signet-ring cells. All such patients who presents with unexplained pancytopenia should prompt us to suspect a bone marrow recurrence.

Synchronous occurrence of prostate carcinoma and multiple myeloma: a case report.

We describe a rare case of metastatic prostate cancer to bone marrow and synchronous multiple myeloma as the second malignant disease. Various diagnostic procedures, including cytomorphology and immunohistochemistry analyses together contributed to the detection of metastasis of prostate cancer and synchronous plasma cell proliferation in the bone marrow. The association between these two disorders is poorly understood however, some studies show that bone marrow microenvironment may play a crucial role. The need for further research in this regard is required to unfold this fascinating association.