Assessment of the phenotypic severity of hemophilia A: using rotational thromboelastometry (ROTEM) and APTT-clot waveform analysis.

BACKGROUND: Hemophilia A (HA) is an X-linked inherited bleeding disorder caused by reduced factor VIII (FVIII) levels. Approximately 10-15% of patients with severe HA (SHA) do not present with the anticipated bleeding pattern. Here, we assessed the phenotypic severity of hemophilia A using rotational thromboelastometry (ROTEM) and activated partial thromboplastin time-clot waveform analysis (APTT-CWA). METHODS: Patients diagnosed with hemophilia A were enrolled. Clinical phenotype assignment was performed according to the published literature, and patients were classified into four phenotypic subgroups. The whole blood sample was first run on ROTEM in INTEM mode using platelet-poor plasma, APTT was run, and the APTT-CWA graph was simultaneously recorded. RESULTS: A total of 66 patients were recruited for this study. Statistically significant differences were observed between the four phenotypically categorized groups using ROTEM and APTT-CWA. On comparing patients with mild/moderate-to-severe phenotypes (Group II) with SHA without inhibitors (Group IV), no significant difference was found for all parameters of ROTEM or APTT-CWA. The MCF, MA30, MAXV, and Alpha angle values using ROTEM were found to be the lowest in patients with SHA with inhibitors, which helped differentiate them from those with SHA without inhibitors. However, these two groups could not be differentiated using the APTT-CWA parameters. CONCLUSION: ROTEM can be used to distinguish patients with SHA with inhibitors from those with SHA without inhibitors using a combination of parameters with high sensitivity and specificity. However, APTT-CWA cannot be used to differentiate these patient groups.

Acute panmylelosis with myelofibrosis - A rare case report with review of literature.

ABSTRACT: Acute panmyelosis with myelofibrosis (APMF) corresponds to <1% cases of acute myeloid leukemia, which could be an underestimation due to missed diagnosis. Due to its rapidly fatal course, it warrants a timely and correct diagnosis. We present a case of a 44-year male who came with a short history of fever, generalised weakness, revealed pancytopenia with occasional circulating blast in the peripheral blood smear. Bone marrow aspirate was dry tap,biopsy revealed panmyelosis with myelofibrosis with increased (22%) blasts. Flowcytometric immunophenotyping, cytogenetics and molecular tests were undertaken. Together with clinical details, immunophenotypic profile, cytogenetics and molecular studies, the diagnosis of Acute panmyelosis with myelofibrosis was made and managed accordingly. 32 The WHO 2017 describes APMF as an acute panmyeloid proliferation with increased blasts (≥20% in the bone marrow or peripheral blood) and accompanying marrow fibrosis. APMF is rare with poor prognosis thus, must be differentiated especially from Acute megakaryoblastic leukemia to arrive at the correct diagnosis which will help reduce/prevent the early mortality by providing timely chemotherapy followed by upfront hemopoietic stem cell transplantation.

Letter to editor - observation on the article titled "Vaccine-Induced Thrombotic Thrombocytopenia (VITT): first report from India".

The first case of Vaccine-Induced Thrombotic Thrombocytopenia (VITT) was reported in the letter-to-editor submission in the journal of Indian Journal of Hematology and Blood Transfusion which was published online on 29th Sep 2021. Whereas, an article published in your journal on 04th Mar 2022 has been titled as first report of VITT from India which is a very conflicting statistic. The former article under reference has been diagnosed by a confirmatory functional assay as per the recommended guidelines and is thus genuinely the first case reported in this country.

Heparin-Induced Thrombocytopenia in Hemodialysis Patients- The First Study from India.

Heparin-induced thrombocytopenia (HIT), a rare complication of heparin therapy, presents with thrombocytopenia. It leads to paradoxical thromboembolism and has high mortality if untreated. It is less recognized, especially in hemodialysis (HD) patients who are frequently exposed to heparin during dialysis because patients with renal failure may have many other causes of thrombocytopenia. We describe the clinical presentation, diagnosis, and treatment of five cases of confirmed HIT in hemodialysis (HD) patients at our center. The initial suspicion was made based on a high 4T score and positive gel card test followed by confirmation using the functional assay with heparin-induced platelet aggregation. These patients were treated according to the recent American Society of Hematology guidelines 2018 for HIT.

Patient blood management in India - Review of current practices and feasibility of applying appropriate standard of care guidelines. A position paper by an interdisciplinary expert group.

In a developing country like India, with limited resources and access to healthcare facilities, dealing with massive hemorrhage is a major challenge. This challenge gets compounded by pre-existing anemia, hemostatic disorders, and logistic issues of timely transfer of such patients from peripheral hospitals to centers with adequate resources and management expertise. Despite the awareness amongst healthcare providers regarding management modalities of bleeding patients, no uniform Patient Blood Management (PBM) or perioperative bleeding management protocols have been implemented in India, yet. In light of this, an interdisciplinary expert group came together, comprising of experts working in transfusion medicine, hematology, obstetrics, anesthesiology and intensive care, to review current practices in management of bleeding in Indian healthcare institutions and evaluating the feasibility of implementing uniform PBM guidelines. The specific intent was to perform a gap analysis between the ideal and the current status in terms of practices and resources. The expert group identified interdisciplinary education in PBM and bleeding management, bleeding history, viscoelastic and platelet function testing, and the implementation of validated, setting-specific bleeding management protocols (algorithms) as important tools in PBM and perioperative bleeding management. Here, trauma, major surgery, postpartum hemorrhage, cardiac and liver surgery are the most common clinical settings associated with massive blood loss. Accordingly, PBM should be implemented as a multidisciplinary and practically applicable concept in India in a timely manner in order to optimize the use the precious resource blood and to increase patients' safety.

Clinical and Laboratory Profiles of 17 Cases of Chronic Granulomatous Disease in North India.

A primary immune deficiency disorder is often suspected in children with recurrent deep seated and fungal infections and those admitted to pediatric intensive care units. Chronic granulomatous disease (CGD) is inherited disorder leading to infections caused due to defective superoxide production. Cases referred for testing for a primary immunodeficiency disorder were tested for Dihydrorhodamine 123 (DHR) assay by flow cytometry and nitroblue tetrazolium dye (NBT) slide test. The unstimulated and stimulated samples were tested for oxidative burst activity which gives bright fluorescence due to formation of Rhodamine 123 on flow cytometry and blue formazan pigment in NBT slide test. The test results were reported in real time. From a total of 330 patients screened for chronic granulomatous disease using DHR and NBT slide test, 17 patients (5.1%) were found to have CGD. These included 12 boys and 5 girls. They presented with deep seated infections, recurrent and multiple abscess, recurrent pneumonia and granulomatous lymphadenitis. The causative organisms were Mycobacteriae, Staphylococcus, Burkholderia cepacia, Pseudomonas, Aspergillus and Cytomegalovirus. In 6 out of 17 positive cases family studies were carried out. On follow up five children succumbed to disease, two patients underwent allogeneic bone marrow transplant, the chimerism status was demonstrated by repeat DHR assay at day 50 post-transplant. Rest are in follow up under prophylactic antibiotics and supportive care. As facilities for molecular testing are not easily available for primary immuno deficiency disorders, flow cytometry based clinical laboratories can help to screen for some of the frequently suspected disorders like chronic granulomatous disease. This has aided in paediatric care in our centre.

HLH Masquerading Lymphoma: Diagnostic Dilemma and Treatment Outcomes.

A case series to illustrate difficulties faced in diagnosis, management and subsequent therapeutic approach patients presenting with HLH secondary to lymphoma. A retrospective review of patients treated for HLH and lymphoma in Clinical Hematology department of a tertiary care hospital in North India, was performed from Jan 2017 to April 2019. Follow up was included till September 2019. Diagnosis of HLH was made using HLH 2004 criteria along with H score. Only patients who fulfilled HLH 2004 criteria were included. Nine patients were treated during above period, three patients with Hodgkins lymphoma, two patients had DLBCL and four patients had T-cell lymphoma. All patients presented with features of HLH and underlying lymphoma was detected on further evaluation. All patients had H score above the cut off value for diagnosis of HLH. Out of 9 patients, 6 received lymphoma directed chemotherapy and 1 was given only steroids, 1 received IVIG with steroids. 1 died early, before institution of therapy. Out of the 6 patients who received chemotherapy, all attained remission status but two patients had early relapse. In the remaining 3 patients who could not be started on chemotherapy, all died within 3 weeks of presentation. Underlying lymphoreticular malignancy should be actively searched in adult patients presenting with HLH. Early diagnosis and initiation of disease specific therapy with or without specific HLH directed treatment can improve the historical poor prognosis.

Evaluation of multiparametric flow cytometry in diagnosis & prognosis of myelodysplastic syndrome in India.

Background & objectives: Diagnosis of myelodysplastic syndromes (MDS) is subjective in low-grade cases with <5 per cent blasts or <15 per cent ring sideroblasts. Flow cytometry (FCM) has been used to diagnose MDS; but, it still has only an adjunctive role. This study was conducted to evaluate the role of FCM to diagnose MDS and correlate the number of aberrancies with revised international prognostic scoring system (R-IPSS). Methods: This study included 44 consecutive clinically suspected cases of MDS with refractory cytopenia(s) and 10 controls. Patients were divided into two groups: (i) proven MDS cases (n=26), and (ii) suspected MDS (n=18). Ogata quantitative approach, pattern analysis and aberrant antigen expression were studied. Results: Ogata score ≥2 correctly diagnosed 80.7 per cent (21/26) while aberrant antigen and pattern analysis with flow score of ≥3 could diagnose 92.3 per cent (24/26) patients with proven MDS. Combination of both with flow score ≥3 could diagnose 100 per cent patients. Eight patients in suspected MDS group with persistent cytopenia on follow up were labelled as probable MDS. Ogata score ≥2 was present in 5 of 8 and pattern analysis score ≥3 was present in six probable MDS patients. Combination of both with flow score ≥3 was present in seven of eight patients. Spearman's correlation between Ogata score and R-IPSS, pattern analysis and R-IPSS and combination of both scores and R-IPSS showed significant positive correlation in proven MDS as well as when proven and probable MDS patients were combined. Interpretation & conclusions: Our results showed that combined Ogata approach and pattern analysis, demonstration of ≥3 aberrancies in >1 cell compartment could diagnose most MDS patients. Patients with high flow scores had high R-IPSS scores. Patient with flow score ≥3 and borderline cytomorphology should be observed closely for the development of MDS.

Predictive models of COVID-19 in India: A rapid review.

BACKGROUND: The mathematical modelling of coronavirus disease-19 (COVID-19) pandemic has been attempted by a wide range of researchers from the very beginning of cases in India. Initial analysis of available models revealed large variations in scope, assumptions, predictions, course, effect of interventions, effect on health-care services, and so on. Thus, a rapid review was conducted for narrative synthesis and to assess correlation between predicted and actual values of cases in India. METHODS: A comprehensive, two-step search strategy was adopted, wherein the databases such as Medline, google scholar, MedRxiv, and BioRxiv were searched. Later, hand searching for the articles and contacting known modelers for unpublished models was resorted. The data from the included studies were extracted by the two investigators independently and checked by third researcher. RESULTS: Based on the literature search, 30 articles were included in this review. As narrative synthesis, data from the studies were summarized in terms of assumptions, model used, predictions, main recommendations, and findings. The Pearson's correlation coefficient (r) between predicted and actual values (n = 20) was 0.7 (p = 0.002) with R2 = 0.49. For Susceptible, Infected, Recovered (SIR) and its variant models (n = 16) 'r' was 0.65 (p = 0.02). The correlation for long-term predictions could not be assessed due to paucity of information. CONCLUSION: Review has shown the importance of assumptions and strong correlation between short-term projections but uncertainties for long-term predictions. Thus, short-term predictions may be revised as more and more data become available. The assumptions too need to expand and firm up as the pandemic evolves.

A Prospective, Cross Sectional Study of PNH Clone in MDS Patients Using High Sensitivity Flowcytometry: A Single Center Experience.

Subclinical PNH can be present in patients with bone marrow failure like aplastic anemia and myelodysplastic syndrome (MDS). Such clone may have prognostic and therapeutic implications. In literature around 1-10% MDS cases have shown a PNH clone, however, data from India is relatively scarce. A high sensitivity PNH assay was employed using a single tube combination of FLAER, CD157, CD64, CD15 and CD45 antibodies in adult patients of MDS at presentation. A clone size of  > 0.01% was taken as significant. A total of 30 patients were included. PNH clone was present in 30% cases. Correlation done between PNH clone size and LDH values showed moderately positive correlation (r = 0.735, p = 0.001, r2 = 0.541). As per this study a LDH cut off of 247 IU is likely to predict a PNH clone (> 1%) with moderate sensitivity and specificity. High sensitivity PNH assay is able to detect small PNH clone. Calculating the cut-off of LDH to predict PNH positivity can help us judiciously prescribe this test in MDS patients in resource constrained settings.