Degree of blood safety of voluntary non-remunerated versus replacement blood donations: A multi-centre study of the large cohort of blood donors from two provinces of Pakistan.

BACKGROUND AND OBJECTIVES: Voluntary non-remunerated blood donors (VNRBDs) are recognized as being crucial for the safety and sustainability of national blood supplies. Systems based on replacement donors (RDs) pose high risks of transfusion transmissible infections (TTIs). Currently, only 10%-13% of blood donations are voluntary in Pakistan. No large-scale studies have been conducted to objectively evaluate the impact of the mode of donation on the frequency of TTIs, a gap this study aimed to fill. MATERIALS AND METHODS: The study was conducted at the Indus Hospital, Karachi. Data from a total of 591,820 blood donations were included from 1 October 2017 to 30 May 2021 and evaluated for type of donations and results of TTI testing, primarily performed on Architect i2000SR (Abbott). The TTIs tested include hepatitis B virus, hepatitis C virus, human immunodeficiency virus, syphilis and malaria. RESULTS: A total of 477,938 (80.7%) RDs and 113,882 (19.3%) VNRBDs were screened. Among these, 53,590 (9.06%) were positive for TTIs. There were 10.2% positive RDs (10.08-10.25 95% confidence interval [CI]) while 4.4% in VNRBDs (4.29-4.53 95% CI). Co-infections were observed in 2367 (0.4%) RDs, while 159 (0.02%) in VNRBDs. Geographically, the highest frequency of TTIs was observed in semi-urban areas of Sindh (11.2%) and Punjab (9.6%). A site-wise comparison of TTIs in RD versus VNRBD showed significant differences (p-value 0.00). CONCLUSION: RDs are associated with higher frequencies of TTIs, compared with VNRBD. However, the study was unable to assess whether the significant difference was related to individual risk or repeat/first time status of the donors. Other important variables affecting frequency are the catchment area of the blood donors in Pakistan. Urban areas have less prevalence than semi-urban areas.

Cytogenetic Profiling In Paediatric Acute Leukaemia; A Report On 746 Newly Diagnosed Paediatric Cases Analyzing The Spectrum Of Recurring Chromosomal Rearrangements In B Cell Lymphoblastic And Acute Myeloid Leukaemia.

Background: Cytogenetics is evolving and different molecular mechanisms we know now have proved to be of diagnostic and prognostic significance in both acute lymphoid (ALL) and myeloid leukaemia (AML). This study aims to find out and compare the occurrence of different cytogenetics in paediatric acute leukaemia. Methods: This is a cross-sectional study of diagnosed B-ALL and AML patients presenting at The Indus Hospital. We studied FISH and karyotype in BALL and FISH in AML patients. FISH analysis shows a total of 69 (12.8%) of B ALL patients had cytogenetic abnormalities. BCR-ABL1 was positive in 5.1%, ETV6/RUNX1T1 in 8.6% and KMT2A in 2.3% individuals. Karyotype reveals hyper diploidy in 24.3%, Monosomy in 1.94%, and t (1:19) and t (17:19) were observed in 5.8% and 0.24% cases respectively. FISH analysis in AML cases reveal positivity of t (8:21) in 26.4%, INV (16) in 6.1% while PML-RARA t(15:17) was done on morphological suspicion in 17 cases; all of which showed positivity; making 7.9% of the total AMLs. The study demonstrated a wide spectrum of heterogeneity in paediatric acute leukaemia. Conclusion: Hyperdiploidy was the most common cytogenetic abnormality. We report a lower incidence of t (12:21), compared to the world. We showed a higher prevalence of RUNX1/RUNX1T1 in young children. The prevalence of core binding factor AML was 32.5%.

Monocyte Distribution Width, a Novel Biomarker for Early Sepsis Screening and Comparison with Procalcitonin and C-Reactive Protein.

Objectives Monocyte distribution width (MDW) can be used for the early recognition of sepsis. The study compared the diagnostic accuracy of the MDW with two well-known sepsis biomarkers, procalcitonin (PCT) and C-reactive protein (CRP). Materials and Methods A study was conducted from July 2021 to October 2021, on 111 patients admitted to the Indus Hospital and Health Network. Patients from the ages of 1 to 90 years were enrolled if hospitalized for more than 24 hours for suspected sepsis to avoid inclusion of patients who had short-term stay in the emergency department. According to the Sequential Organ Failure Assessment score, the clinical team did the characterization of cases as with sepsis or without sepsis. SPSS version 24 was used, and the diagnostic accuracy of MDW was assessed and compared using the area under the curves (AUCs) acquired from receiver operating characteristic curves. Pearson's chi-square/Fisher's exact test (as per need) was applied to determine the association. A p -value of less than 0.05 was considered significant. Results Among 111 patients, 81 (73%) patients were labeled with sepsis and 30 (27%) were without sepsis. We have reported significantly higher MDW, PCT, and CRP levels in septic patients ( p < 0.001). The AUC of MDW was comparable with PCT (0.794). Significant cutoff value for the MDW was greater than 20.24 U with 86% sensitivity and 73% specificity. Conclusion MDW may have a predictive ability similar to PCT and CRP in terms of sepsis and, thus, can be used as a standard parameter for the timely diagnosis of sepsis.

Mixed-phenotype acute leukemia, T/megakaryoblastic: does it really exist?

Mixed-phenotype acute leukemias (MPAL) account for < 4% of all cases of acute leukemias. These are a heterogeneous group of leukemias grouped together by the WHO classification as "rare subtypes." The diagnosis and treatment of MPAL is extremely challenging particularly for low middle income countries. Of these, B/myeloid and T/myeloid combinations are relatively common subtypes. However, megakaryoblastic and erythroid lineages in combination with other lineages are still rare enough to not even be addressed in the WHO classification. To date, there have been only a few reports of mixed B or T cell and megakaryocytic or mixed B or T cell and erythroid leukemias. We report the clinical presentation, diagnostic profile, and disease course of MPAL cases with a biphenotypic pattern consistent with T/megakaryoblastic lineage which is not yet defined in WHO classification. These cases were phenotyped using 8-color flow cytometry (BD FACS CANTO-II) using an extensive panel of markers. Interphase fluorescence in situ hybridization (FISH) was done using dual color dual fusion probes for BCR::ABL1, RUNX1::RUNX1T1, and ETV6::RUNX1, while MLL and CBFB gene rearrangement was tested by break-apart probes. Karyotyping was performed using the conventional GTG-banding technique. Both FISH and karyotyping were analyzed by the automated cell imaging system Leica Biosystems, using Cytovision MB8. The cases presented here satisfy the criteria for both T-lineage assignment (cyCD3 intensity reaches that of normal T-lymphocytes) and acute megakaryoblastic leukemia (≥ 1 megakaryocytic marker in > 50% blasts) and thus represent the first documented examples of this unusual entity from Pakistan. It is crucial to report these cases to gather more data about clinical presentation, diagnostic profile, and disease course. Additionally, the reported cases highlight the limitations of existing classifications which do not address rare subtypes. More importantly, T/megakaryoblastic MPAL needs to be included in the WHO classification as a separate entity.

Spectrum of hemoglobinopathies with hematological and biochemical profile: A five year experience from a tertiary care hospital.

Background & Objective: Determination of hemoglobinopathies is significant for epidemiological studies. There is a need to identify burden of hemoglobinopathies at national level to lay down the foundation of appropriate screening and prevention programs. The present study aimed to evaluate the spectrum of hemoglobinopathies along with hematological and biochemical parameters in a tertiary care hospital. Methods: This retrospective study included results of high performance liquid chromatography (HPLC) test from July 2015 - May 2020 in the department of Hematology, Indus Hospital and Health Network, Karachi, Pakistan. Data of all patients collected for red blood cell (RBC) indices, serum iron profile, and vitamin B12 and red cell folate levels. Diagnosis of hemoglobinopathies was done by an automatic analyzer ADAMS A1C Model No. HA-8180T Arkray/Japan. Results: Among 2422 participants, hemoglobinopathy observed in 14.5% (n=352). Beta thalassemia trait is observed as the most common hemoglobinopathy (6.4%). Severe anemia (Hb=5.1-5.5 g/dl) found in beta thalassemia major (BTM) and HbE disease. Red cell parameters showed significant association with different types of hemoglobinopathies. Mean ferritin level was high in E-beta thalassemia (687.8±591.9) followed by sickle cell disease (615.7±543.5). Conclusion: Apparently, overall frequency is static however, results of this study are not applicable to general population due to sample bias. Moreover, true figures are difficult to identify due to high incidence of iron deficiency anemia that masks the diagnosis by conventional techniques. Molecular characterization by DNA analysis is the most reliable tool of diagnosis. However, this method is not widely available in our country due to lack of expertise and cost issues.

Distribution of subtypes and immunophenotypic characterization of 1379 cases of paediatric acute leukaemia.

OBJECTIVES: Acute leukaemia is the most common and highly curable childhood malignancy; subtyping and identification of antigens via immunophenotyping helps in treatment plan as well as minimal residual disease monitoring. METHODS: This retrospective study was conducted at the Haematology section of the clinical laboratories of Ziauddin University Hospital and The Indus Hospital, Karachi conducted at January 1st, 2012 to December 31st, 2017. The study included 1379 cases of de novo acute leukemia from 2012 to 2017. Among these, 80% were diagnosed by using four color flowcytometry (FACS Calibur), 9% and 11% via immunohistochemistry on bone marrow trephine biopsy samples and morphological examination respectively. RESULTS: The mean age of patients was 7.4 ± 4.3 years while male to female ratio was 1.75:1. Lymphoblastic leukaemia accounted for 77.2% and myeloid leukaemia 21.2%. Amongst lymphoblastic lineage, B-ALL was 80.4% while T-ALL was 19.6%. Among the phenotypic expression of B-ALL, CD79a (99.8%) had the highest positivity. In B-ALL, CD13 (29.8%) was the most common aberrant myeloid marker. Aberrant expression of CD79a observed in 11.1% of T-ALL cases. In non APL AML, aberrant expression of CD79a and CD19 was observed in 6.6% and 5.5% of cases respectively. CONCLUSION: Overall immunophenotypic profile, expression of aberrant phenotypes and subtype distribution in our patients was similar to international literature except for a relatively high frequency of T-ALL which was discordant from the western data.

Burkitt Lymphoma With Aberrant Immunophenotype Imposing Diagnostic Challenge.

BACKGROUND: Burkitt lymphoma (BL) exhibits a characteristic immunophenotype that is positive for pan-B-cell antigens and germinal center markers while negative for immature markers. A deviation from classic immunophenotype can cause diagnostic confusion and might result in false exclusion of BL. In some cases, overlapping clinical, morphological and immunophenotypic features of BL and B lymphoblastic lymphoma (B-LL) can be of diagnostic challenge. However, definitive delineation is of paramount importance due to difference in treatment. We describe a case of BL in a child with atypical features including absence of L3 morphology in diagnostic tissue and aberrant expression of CD34, CD99 and BCL2 on immunohistochemistry. These findings led to the interpretation of B-LL which was later on excluded by detection of t (8;14). This unorthodox case not only highlights the importance of cytogenetic testing but also emphasizes the correlation of all the diagnostic tools before making a definitive diagnosis. Therefore, reporting this case will help in eliciting the high index of suspicion among pathologists for this exceptionally unusual immunophenotype.

Minimal residual disease in childhood B Lymphoblastic Leukemia and its correlation with other risk factors.

OBJECTIVE: To determine frequency of post induction and post consolidation minimal residual disease (MRD) in pediatric B-lymphoblastic leukemia (B-ALL) patients and its association with clinical risk factors. METHODS: This is a retrospective, cross sectional study carried out at the Indus Hospital on paediatric patients (1-17 years) was performed from May 2015 to January 2018. On day 35, MRD testing was done on bone marrow aspirate using four color flow cytometer with 0.01% cut off. Positive cases were retested at post consolidation. Data was collected for demographics, total leukocyte count (TLC), central nervous system status (CNS), Cytogenetics for BCR-ABL, MLL, TEL-AML by FISH and prophase response then analyzed in association to MRD status. RESULTS: Out of 362 patients, 133 (37%) were post induction MRD positive, with no statistically significant association to age, gender, TLC, CNS status, prophase response, BCR-ABL and TEL-AML1. However, MLL showed closely significant association (p-value=0.05). Post consolidation, 49 (44%) were MRD positive; age, National cancer institute (NCI) risk groups and CNS status showed statistical significance (p-value <0.05). CONCLUSION: Despite high frequency of MRD positivity, significant association is not observed between post induction MRD and risk factors. However, post consolidation MRD has a significant association with NCI risk groups, age and CNS status.