Detecting hypodiploidy with endoreduplication and masked hypodiploidy in B-cell acute lymphoblastic leukemia using multicolor flow cytometry

BACKGROUND

Multicolor flow cytometry-based DNA-ploidy (MFC-ploidy) analysis is a simple, sensitive, and popular method for ploidy analysis in B-cell acute lymphoblastic leukemia (B-ALL). However, the utility of MFC-ploidy in the detection of B-ALL with endoreduplication or masked hypodiploidy has not been reported. Herein, we studied the patterns of MFC-ploidy assessment and its utility to detect B-ALL with hypodiploidy and endoreduplication.

METHODS

MFC-ploidy analysis was performed using FxCycle Violet-dye-based method, and cytogenetic ploidy was evaluated using chromosomal-counting and FISH analysis. A total of 20 B-ALL cases with endoreduplication were studied for the patterns of MFC-ploidy analysis and compared with 250 patients with hyperdiploidy and 11 cases with pure hypodiploidy.

RESULTS

All B-ALL with endoreduplication revealed two distinct peaks (populations) on MFC-ploidy analysis: the first (hypodiploid) peak (median-DNA-index [DI], 0.82; range, 0.6-0.95) and the second (hyperdiploid) peak with almost twice DI (median-DI, 1.53; range, 1.14-1.75). Cytogenetic findings were available in 19 cases and confirmed hypodiploidy with endoreduplication in 13/19 (68.4%) and only hypodiploidy in 3/19 cases. The remaining three cases showed hyperdiploid blasts in cytogenetic studies. Of these three, two cases had <10% blasts population with hypodiploidy. Thus, masked-hypodiploidy could be diagnosed correctly in 3/19 cases on MFC-ploidy analysis.

CONCLUSION

MFC-ploidy analysis shows a characteristic pattern of DNA-ploidy in samples with endoreduplication. It allows the distinction between samples with masked hypodiploidy from true hyperdiploidy. An integrated approach involving cytogenetic and MFC-ploidy detection is very helpful in the risk stratification of B-ALL in routine clinical practice.

Impact of plasma glucose and duration of type 2 diabetes mellitus on SYNTAX Score II in patients suffering from non ST-elevation myocardial infarction

Aim    The objective was to assess the correlation of fasting plasma glucose (FPG), HbA1c, and the duration of type 2 diabetes mellitus (T2DM) with SYNTAX score (SS) II in patients with non-ST elevation myocardial infarction (NSTEMI).Material and methods    FPG and HbA1C were measured in 398 patients presenting with NSTEMI at admission. SS II was calculated using an online calculator. Patients were stratified according to SS II (≤21.5, 21.5-30.6, and ≥30.6), defined as SS II low, mid, and high, respectively.Results    37.7 % of subjects were diabetic. Correlations of FPG (R=0.402, R2=0.162, p&lt;0.001) and HbA1c (R=0.359, R2=0.129, p&lt;0.001) with SS II were weak in the overall population. Duration of T2DM showed very strong correlation with SS II (R=0.827, R2=0.347). For the prediction of high SS II in the study population, FPG≥98.5 mg / dl demonstrated a sensitivity of 58 % and a specificity of 60 %, and HbA1c ≥6.05 demonstrated a sensitivity of 63 % and a specificity of 69 %. Duration of T2DM (adjusted odds ratio (OR): 1.182; 95 % confidence interval (CI): 1.185-2.773) and FPG (OR: 0.987; 95 % CI: 0.976-0.9959) were significantly associated with high SS II after controlling for other risk factors. Duration of T2DM (Beta=0.439) contributed strongly to variance of SS II, whereas HbA1c (Beta=0.063) contributed weakly.Conclusion    Duration of T2DM is a very important risk factor for severity of coronary artery disease.

Critical Role of Flow Cytometric Immunophenotyping in the Diagnosis, Subtyping, and Staging of T-Cell/NK-Cell Non-Hodgkin's Lymphoma in Real-World Practice: A Study of 232 Cases From a Tertiary Cancer Center in India

Background

T-cell/NK-cell non-Hodgkin’s lymphoma (T/NK-NHL) is an uncommon heterogeneous group of diseases. The current classification of T/NK-NHL is mainly based on histopathology and immunohistochemistry. In practice, however, the lack of unique histopathological patterns, overlapping cytomorphology, immunophenotypic complexity, inadequate panels, and diverse clinical presentations pose a great challenge. Flow cytometric immunophenotyping (FCI) is a gold standard for the diagnosis, subtyping, and monitoring of many hematological neoplasms. However, studies emphasizing the role of FCI in the diagnosis and staging of T/NK-NHL in real-world practice are scarce.

Methods

We included T-cell non-Hodgkin’s lymphoma (T-NHL) patients evaluated for the diagnosis and/or staging of T/NK-NHL using FCI between 2014 and 2020. We studied the utility of FCI in the diagnosis and subtyping of T/NK-NHL and correlated the FCI findings with the results of histopathology/immunohistochemistry. For correlation purposes, patients were categorized under definitive diagnosis and subtyping, inadequate subtyping, inadequate diagnosis, and misdiagnosis based on the findings of each technique.

Results

A total of 232 patients were diagnosed with T/NK-NHL. FCI findings provided definitive diagnoses in 198 patients and subtyping in 187/198 (95.45%) patients. The correlation between FCI and histopathological/immunohistochemistry results (n = 150) demonstrated an agreement on the diagnosis and subtyping in 69/150 (46%) patients. Of the remaining cases, the diagnosis and subtyping were inadequate in 64/150 (42.7%), and 14/150 (9.33%) were misdiagnosed on histopathology/immunohistochemistry results. FCI provided definitive diagnosis and subtyping in 51/64 (79.7%) patients. Among these, 13 patients diagnosed with peripheral T-cell lymphoma not-otherwise-specified were reclassified (angioimmunoblastic T-cell lymphoma (AITL)-11 and prolymphocytic leukemia-2) on FCI. It corrected the diagnosis in 14 patients that were misdiagnosed (6 B-cell NHL (B-NHL), 3 Hodgkin’s lymphoma, 1 acute leukemia, and 1 subcutaneous panniculitis-like T-cell lymphoma) and misclassified (3 T-NHL) on histopathological results. AITL was the commonest T-NHL misclassified on histopathological results. FCI also confirmed the definite involvement in 7/83 (8.4%) and 27/83 (32.5%) bone marrow (BM) samples reported as suspicious and uninvolved, respectively, on histopathological evaluation.

Conclusion

AITL was the most frequently diagnosed T/NK-NHL in this study. FCI provided a distinct advantage in detecting BM involvement by T/NK-NHL, especially in patients with low-level involvement. Overall, our study concluded that FCI plays a critical role in the diagnosis, subtyping, and staging of T/NK-NHL in real-world practice.

Assessment of front-line healthcare workers' Knowledge, Attitude and Practice after several months of COVID-19 pandemic

BACKGROUND

Frontline healthcare workers (F-HCWs) are at the forefront of medical care providers against the novel coronavirus 2019 (COVID-19) pandemic which has life-threatening potentials. Inadequate knowledge and incorrect attitudes among HCWs can directly influence practices and lead to delayed diagnosis, poor infection control practices, and spread of disease.

OBJECTIVES

The aim of this study was to assess the knowledge, attitude and practice (KAP) regarding the COVID-19 pandemic among the frontline healthcare workers (F-HCWs) working at a tertiary care hospital situated in eastern Uttar Pradesh and to identify the factors significantly associated with KAP.

METHODS

A cross-sectional study was conducted among 260 health care providers across eastern Uttar Pradesh including Basti city during December 2020. Data was collected using a self-primed pretested questionnaire from the FHCWs working at a tertiary care hospital of eastern Uttar Pradesh. In this survey, a convenience sampling method was adopted. 12 items on knowledge, 10 items on attitude, and 5 items on practices related to COVID-19. The other variables consisted of 4 items on socio-demographic attributes, p-value and 95% confidence intervals (CIs) were performed to assess the attitude and practices in relation to knowledge.

RESULTS

Of the total 260 study population, 228 were interviewed online, 32 were self-administered. Knowledge and attitude of the nursing staff were highest but practice score was best for residents. Among different age groups knowledge, attitude and practices scores were highest for 35-45, 45-60 and 25-35 age groups respectively. Respondents having 5-10 years of experience had the best knowledge and the attitude score was highest for HCWs having 10-20 years' experience but the practice score was higher for HCWs having more than 20 years' work experience. Overall knowledge score of respondents having strong correlation with attitude (p<0.05) and to the practice (p<0.05).

CONCLUSION

In this survey many F-HCWs reported adequate overall knowledge with a positive attitude and adopted appropriate practices. The F-HCWs with a higher level of education and more years of experience in health care facilities had better KAP towards COVID-19.

Comprehensive immune cell profiling depicts an early immune response associated with severe coronavirus disease 2019 in cancer patients

Recent studies have highlighted multiple immune perturbations related to severe acute respiratory syndrome coronavirus 2 infection-associated respiratory disease [coronavirus disease 2019 (COVID-19)]. Some of them were associated with immunopathogenesis of severe COVID-19. However, reports on immunological indicators of severe COVID-19 in the early phase of infection in patients with comorbidities such as cancer are scarce. We prospectively studied about 200 immune response parameters, including a comprehensive immune-cell profile, inflammatory cytokines and other parameters, in 95 patients with COVID-19 (37 cancer patients without active disease and intensive chemo/immunotherapy, 58 patients without cancer) and 21 healthy donors. Of 95 patients, 41 had severe disease, and the remaining 54 were categorized as having a nonsevere disease. We evaluated the association of immune response parameters with severe COVID-19. By principal component analysis, three immune signatures defining characteristic immune responses in COVID-19 patients were found. Immune cell perturbations, in particular, decreased levels of circulating dendritic cells (DCs) along with reduced levels of CD4 T-cell subsets such as regulatory T cells (T_regs ), type 1 T helper (Th1) and Th9; additionally, relative expansion of effector natural killer (NK) cells were significantly associated with severe COVID-19. Compared with patients without cancer, the levels of terminal effector CD4 T cells, T_regs , Th9, effector NK cells, B cells, intermediate-type monocytes and myeloid DCs were significantly lower in cancer patients with mild and severe COVID-19. We concluded that severely depleted circulating myeloid DCs and helper T subsets in the initial phase of infection were strongly associated with severe COVID-19 independent of age, type of comorbidity and other parameters. Thus, our study describes the early immune response associated with severe COVID-19 in cancer patients without intensive chemo/immunotherapy.

Imaging of cochlear implants

Aim : To evaluate the role of various imaging modalities in pre and post operative evaluation of cochlear implant candidates. Materials and methods : 30 patients were evaluated by HRCT and 15 of these subsequently underwent MRI temporal bones prior to cochlear implant device insertion. All implanted patients were subjected to post operative radiography to assess position of implant. Results : Both modalities provided critical information on abnormalities of the otic capsule, pneumatisation of the mastoid, middle ear abnormalities, cochlear ducts patency and vascular abnormalities- thus helping to assess the suitability of the ear for implantation, determine the side to be implanted and to find any associated abnormality which could adversely influence the surgery or post op period. HRCT missed two cases of luminal ossification and MRI was more reliable in detecting early luminal obstruction. Conclusion : Based on our findings, we offer a realistic and practical protocol for imaging in cochlear implants in the Indian setting. HRCT is recommended in all patients for pre implant analysis of the temporal bone morphology due to its reliability and easy availability. MRI is recommended in all cases of post meningitic deafness and in others with doubtful CT findings.

Mast cell differentiation of leukemic blasts in diverse myeloid neoplasms: A potential pre-myelomastocytic leukemia condition

INTRODUCTION

Myeloid neoplasm with blasts showing mast cell (MC)-differentiation and MC-component less than 10% of all nucleated cells but not fulfilling the criteria for systemic mastocytosis with associated hematological neoplasm (SM-AHN) or myelomastocytic leukemia (MML) has not been described in the literature. Herein, we report a study of diverse myeloid malignancies with blasts showing MC-differentiation but not meeting the criteria for SM-AHN or MML. We also evaluated the utility of flow-cytometric immunophenotyping (FCI) in the characterization of immature-MCs (iMCs).

METHODS

We identified nine patients of myeloid neoplasms and studied their morphological, FCI, immunohistochemistry, cytogenetic and molecular characteristics. We also compared the immunophenotypic features of MCs from patient samples with control samples.

RESULTS

The study included patients with newly-diagnosed acute myeloid leukemia (n = 4), chronic myelomonocytic leukemia (n = 1), and chronic myeloid leukemia on follow-up (n = 4) showing MC differentiation in leukemic-blasts. These patients had mildly increased MCs (range, 0.5%-3%) in bone-marrow morphology, including immature-forms and did not meet the criteria for either SM-AHN or MML. On FCI, iMCs were positive for bright-CD117, heterogeneous-CD34, dim-to-negative-HLADR, and moderate-CD203c expression. Expression-levels of CD123 and CD38 were higher (p < 0.001) but CD33 and CD45 were lower in iMCs compared to mature-MC from control samples (p = 0.019 and p = 0.0037).

CONCLUSION

We reported a rare finding of MC differentiation of leukemic blasts in diverse myeloid neoplasms and proposed it as a potential pre-myelomastocytic leukemia condition. We described the distinct immunophenotypic signature of immature-MCs using commonly used markers and highlighted the utility of FCI for the diagnosis of this entity.

Expression of CD304/neuropilin-1 in adult b-cell lymphoblastic leukemia/lymphoma and its utility for the measurable residual disease assessment

INTRODUCTION

Many new markers are being evaluated to increase the sensitivity and applicability of multicolor flow cytometry (MFC)-based measurable residual disease (MRD) monitoring. However, most of the studies are limited to childhood B-cell lymphoblastic leukemia/lymphoma (B-ALL), and reports in adult B-ALL are extremely scarce and limited to small cohorts. We studied the expression of CD304/neuropilin-1 in a large cohort of adult B-ALL patients and evaluated its practical utility in MFC-based MRD analysis.

METHODS

CD304 was studied in blasts from adult B-ALL patients and normal precursor B cells (NPBC) from non-B-ALL bone marrow samples using MFC. CD304 expression intensity and pattern were studied with normalized-mean fluorescent intensity (nMFI) and coefficient of variation of immunofluorescence (CVIF), respectively. MFC-based MRD was performed at end of induction (EOI; day-35), end of consolidation (EOC; day 78-80), and subsequent follow-up (SFU) time points.

RESULTS

CD304 was positive in 120/214(56.07%) and was significantly associated with BCR-ABL1 fusion (P = .001). EOI-MRD and EOC-MRD were positive in 129/214(60.3%) and 50/81(61.72%), respectively. CD304 was positive in a significant percentage of EOI (48%, 62/129) and EOC (52%, 26/50) MRD-positive B-ALL samples. Its expression was retained, lost, and gained in 73.7%, 26.3%, and 11.3% of EOI-MRD and 85.7%, 14.3%, and none of EOC-MRD samples, respectively. Low-level MRD (<0.01%) was detectable in 34 of all (EOI + EOC + SFU = 189) MRD-positive samples, and CD304 was found useful in 50% of these samples.

CONCLUSION

CD304 is commonly expressed in adult B-ALL and clearly distinguish B-ALL blasts from normal precursor B cells. It is a stable MRD marker and distinctly useful in the detection of MFC-based MRD monitoring, especially in high-sensitivity MRD assay.

Investigating the clinical, hematological and cytogenetic profile of endoreduplicated hypodiploids in BCP-ALL

Ploidy, besides known translocations in lymphoblasts, is a strong predictor of prognosis in B- cell progenitor acute lymphoblastic leukemia (BCP-ALL). While hyperdiploidy with >50 chromosomes shows a favourable outcome, hypodiploidy with <45 chromosomes have a dismal clinical outcome. However, there exists a small subset where both the hypodiploid and hyperdiploid clones are apparent either by cytogenetics or flow cytometry and are defined partially masked hypodiploids or mosaics based on the percentage of clonal population. These patients are essentially hypodiploids, and show the hyperdiploid clone as a consequence of endoreduplication of the primary hypodiploid clone- A phenomenon of successive replication of genome without mitosis (cytokinesis) resulting in increased ploidy. In the current study, we present the complete clinical, hematological and cytogenetic profile of 11 such newly diagnosed mosaics or partially masked hypodiploid BCP-ALL cases.

No longer a historical ailment: two cases of childhood scurvy with recommendations for bone health providers

PURPOSE

Scurvy, due to vitamin C deficiency, is commonly referenced as a "forgotten" or "historical" disease. A growing number of case reports challenge this notion. Bone health providers are often consulted early in the presentation of scurvy to evaluate musculoskeletal complaints resulting from impaired collagen production and disrupted endochondral bone formation. In this report, we describe two cases of childhood scurvy. Our objective is to summarize the key features of scurvy for bone health providers, with the goal of raising awareness and facilitating diagnosis in future cases.

CASE DESCRIPTIONS

Case one occurred in a 12-year-old non-verbal, non-ambulatory female on a ketogenic diet for refractory epilepsy. Clinical findings included hemarthrosis, transfusion dependent anemia, elevated inflammatory markers, and epiphysiolysis. Magnetic resonance imaging (MRI) revealed multi-focal bone marrow signal abnormalities and physeal irregularities. Case two occurred in a typically developing 5-year-old male presenting with limp and knee pain. Symptoms progressed despite casting and immobilization. Mild anemia, elevated inflammatory markers, and multi-focal marrow and physeal MRI abnormalities were identified. Subsequent dietary history revealed total absence of fruit or vegetable consumption. The diagnosis of scurvy was confirmed in both cases by undetectable plasma vitamin C concentrations. Treatment with vitamin C led to rapid clinical improvement.

CONCLUSION

Scurvy can no longer be considered a historical diagnosis and should not be forgotten when evaluating children with musculoskeletal ailments. Early recognition of the signs, symptoms, and imaging findings of scurvy can reduce the clinical burden of this disease with the timely initiation of vitamin C therapy.

Profiling Autoantibodies against Salivary Proteins in Sicca Conditions

Salivary gland dysfunction occurs in several autoimmune and immune-related conditions, including Sjögren syndrome (SS); immune checkpoint inhibitor-induced sicca (ICIS) that develops in some cancer patients and is characterized by severe, sudden-onset dry mouth; and autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED). Although subjects with these conditions present with oral dryness and often exhibit inflammatory infiltration of the salivary gland, little is known about the B-cell humoral responses directed against salivary gland protein targets. In this study, autoantibodies were evaluated against Ro52, Ro60, and La, as well as against a panel of 22 proteins derived from the salivary proteome. The tested cohort included healthy volunteers and subjects with SS, ICIS, and APECED without and with sicca. As expected, a high percentage of autoantibody seropositivity was detected against Ro52, Ro60, and La in SS, but only a few ICIS patients were seropositive for these autoantigens. A few APECED subjects also harbored autoantibodies to Ro52 and La, but only Ro60 autoantibodies were weakly associated with a small subset of APECED patients with sicca. Additional testing of the salivary panel failed to detect seropositive autoantibodies against any of the salivary-enriched proteins in the SS and ICIS subjects. However, APECED subjects selectively demonstrated seropositivity against BPI fold containing family A member 1 (BPIFA1), BPI fold containing family A member 2 (BPIFA2)/parotid salivary protein (PSP), and lactoperoxidase, 3 salivary-enriched proteins. Moreover, high levels of serum autoantibodies against BPIFA1 and BPIFA2/PSP occurred in 30% and 67% of the APECED patients with sicca symptoms, respectively, and were associated with an earlier age onset of oral dryness (P = 0.001). These findings highlight the complexity of humoral responses in different sicca diseases and provide new insights and biomarkers for APECED-associated sicca (ClinicalTrials.gov: NCT00001196; NCT00001390; NCT01425892; NCT01386437).

Clinical Utility of Staging Laparoscopy for Advanced Obstructing Rectal Adenocarcinoma: Emerging Tool

The multimodal treatment for advanced rectal adenocarcinoma mandates accurate preoperative staging with contrast-enhanced computed tomography (CECT) of the thorax, abdomen, and pelvis, and magnetic resonance imaging (MRI) of the pelvis. Unlike gastric cancer, the role of staging laparoscopy (SL) in advanced colorectal cancer has not been evaluated. This study aims to evaluate the clinical value of SL in treatment decision-making for advanced rectal cancer (RC) with near or complete obstructing tumors. Observational review of colorectal database at Tata Memorial Hospital from January 2013 to December 2016 identified 562 patients diagnosed and treated for advanced RC. Of the 562 cases, 48.7% (274) were clinically and radiologically diagnosed of near or complete obstructing advanced RC. Medical records of 34% (94/274) who underwent SL with diversion stoma (DS) were analyzed. In the absence of ascites, extensive peritoneal deposits, and unresectable liver metastases on SL, a curative treatment was offered, which entailed neoadjuvant chemoradiation (NACTRT), whereas the cohort of patients with extensive peritoneal disease received palliative therapy. Of the 94 patients with advanced RC, conventional imaging studies staged 73.5% (69/94) cohort as non-metastatic locally advanced and 26.5% (25/94) had potentially resectable metastatic RC. Pre-therapeutic SL upstaged the disease by 26% (18/69) and 8% (2/25) in locally advanced and potentially resectable metastatic RC cohorts, respectively. Treatment decision changed in 21.2% (20/94) of the patients, and midline laparotomy was thus avoided. In our observational study, SL was found to be a safe and effective staging modality in RC; it detected occult peritoneal disease and prevented midline laparotomy in 21.2% of the cohort, which was of value to determine treatment strategy in patients with advanced RC before initiating NACTRT. SL and laparoscopic-assisted de-functioning stoma were associated with minimal morbidity and led to early initiation of NACTRT.

Diagnostic use of intramedullary reaming biopsy in metastatic long bone disease

INTRODUCTION Bone is the third most common site of metastasis. A histological diagnosis is important in guiding therapy and prognosis. In up to 15% of cases of metastatic disease, the primary tumour remains unknown. This emphasises the importance of adequate, reliable and accurate sampling when performing any type of biopsy. Reaming biopsy is commonly performed during intramedullary nailing of metastatic long-bone disease but there is little published evidence on the diagnostic use and reliability of this technique. AIMS AND METHODS We reviewed 49 cases of confirmed metastatic bone disease to determine adequacy for analysis, diagnostic accuracy and factors affecting reliability. RESULTS Adequate tissue for histopathological analysis was obtained in 96% of cases but metastasis was confirmed in only 51% of cases. The presence of a pathological fracture had no effect on accuracy of the results but metastasis was more likely to be missed in the presence of tissue crushing and or necrosis (P = 0.015). DISCUSSION This study determines the use and accuracy of bone reaming biopsy in metastatic disease and, to the best of our knowledge, is the only study determining the effect of additional factors such as the presence of a pathological fracture and tissue necrosis or crushing on the diagnostic accuracy of this technique. CONCLUSIONS In spite of adequate tissue sampling, the diagnostic accuracy and, hence, reliability of intramedullary reaming biopsy in metastatic bone disease is less than optimal. A reaming histopathology report suggesting no evident metastasis should always be taken in clinical context.

Effect of green coffee extract on rheological, physico-sensory and antioxidant properties of bread

Green coffee extract, GCE (Coffee canephora) was used at 1.0, 1.5 and 2.0% levels for making bioactive rich bread. The processed GCE from the green coffee beans had 21.42% gallic acid equivalents (GAE) total polyphenols (TPP), 37.28% chlorogenic acid (CGA) and 92.73% radical scavenging activity (RSA), at 100 ppm concentration of GCE and caffeine content (1.75%). Rheological, physico-sensory and antioxidant properties of GCE incorporated breads were analysed and compared with control bread. The results revealed not much significant change in the rheological characteristics of dough up to 1.5% level; an increase in bread volume; greenness of bread crumb and mostly unchanged textural characteristics of the bread with increased addition of GCE from 0 to 2.0%. Sensory evaluation showed that maximum level of incorporation of GCE without adverse effect on the overall quality of bread (especially taste) was at 1.5% level. The contents of TPP, RSA and CGA increased by 12, 6 and 42 times when compared to control bread and had the highest amount of 4-5 caffeoylquinic acid.

Acute myeloid leukemia derived from lympho-myeloid clonal hematopoiesis

We studied acute myeloid leukemia (AML) patients with lympho-myeloid clonal hematopoiesis (LM-CH), defined by the presence of DNA methyltransferase 3A (DNMT3A) mutations in both the myeloid and lymphoid T-cell compartment. Diagnostic, complete remission (CR) and relapse samples were sequenced for 34 leukemia-related genes in 171 DNMT3A mutated adult AML patients. AML with LM-CH was found in 40 patients (23%) and was associated with clonal hematopoiesis of indeterminate potential years before AML, older age, secondary AML and more frequent MDS-type co-mutations (TET2, RUNX1 and EZH2). In 82% of AML patients with LM-CH, the preleukemic clone was refractory to chemotherapy and was the founding clone for relapse. Both LM-CH and non-LM-CH MRD-positive AML patients who achieved CR had a high risk of relapse after 10 years (75% and 75%, respectively) compared with patients without clonal hematopoiesis in CR with negative MRD (27% relapse rate). Long-term survival of patients with LM-CH was only seen after allogeneic hematopoietic stem cell transplantation (HSCT). We define AML patients with LM-CH as a distinct high-risk group of AML patients that can be identified at diagnosis through mutation analysis in T cells and should be considered for HSCT.

An unusual case of lipoma arborescens

Introduction Lipoma arborescens is a rare condition of the synovial lining. It is particularly uncommon in the bicipitoradial bursae of the elbow. Case Report A 68-year-old woman presented with a 5-month history of anterior elbow pain and swelling causing discomfort. Radiography demonstrated reactive changes of radial tuberosity and magnetic resonance imaging confirmed lipoma arborescens of the bicipitoradial bursa with distal biceps tendinopathy. A bicipital bursa bursectomy and lipoma excision was performed. Gross pathology and histology was consistent with lipoma arborescens. Three months postoperatively, our patient had full range of motion and good strength. Conclusions To our knowledge, this is the first published case report of lipoma arborescens affecting the elbow. Recognising the differential diagnoses of anterior elbow pain and the characteristic imaging is essential for accurate diagnosis.

Chronic Recurrent Multifocal Osteomyelitis: A Diagnostic Dilemma: A Case Report and Review of the Literature

CASE

Chronic recurrent multifocal osteomyelitis, a misnomer in itself, is a rare disorder that presents infrequently to orthopaedic units. The differential diagnosis is wide, including neoplastic lesions and infection, which may lead to unnecessary interventional and surgical procedures. We present a case that exhibited the hallmark features of this condition-recurrent, multifocal, aseptic osteitis in a 9-year-old girl-and our rationalized management including imaging, nonsteroidal anti-inflammatory drugs, and bisphosphonates.

CONCLUSION

With increased awareness by orthopaedic surgeons, patients may be diagnosed and managed appropriately, enabling a benign course and limiting morbidity.

Constitutive IRF8 expression inhibits AML by activation of repressed immune response signaling

Myeloid differentiation is blocked in acute myeloid leukemia (AML), but the molecular mechanisms are not well characterized. Meningioma 1 (MN1) is overexpressed in AML patients and confers resistance to all-trans retinoic acid-induced differentiation. To understand the role of MN1 as a transcriptional regulator in myeloid differentiation, we fused transcriptional activation (VP16) or repression (M33) domains with MN1 and characterized these cells in vivo. Transcriptional activation of MN1 target genes induced myeloproliferative disease with long latency and differentiation potential to mature neutrophils. A large proportion of differentially expressed genes between leukemic MN1 and differentiation-permissive MN1VP16 cells belonged to the immune response pathway like interferon-response factor (Irf) 8 and Ccl9. As MN1 is a cofactor of MEIS1 and retinoic acid receptor alpha (RARA), we compared chromatin occupancy between these genes. Immune response genes that were upregulated in MN1VP16 cells were co-targeted by MN1 and MEIS1, but not RARA, suggesting that myeloid differentiation is blocked through transcriptional repression of shared target genes of MN1 and MEIS1. Constitutive expression of Irf8 or its target gene Ccl9 identified these genes as potent inhibitors of murine and human leukemias in vivo. Our data show that MN1 prevents activation of the immune response pathway, and suggest restoration of IRF8 signaling as therapeutic target in AML.

Effect of gabapentin premedication on preoperative anxiety and postoperative pain

Background: In addition to chronic pain and anxiety disorders, few studies have found promising role of gabapentin in relieving acute postoperative pain as well as acute anxiety too. Objectives: To evaluate the effect of gabapentin premedication on preoperative anxiety and postoperative pain in patients undergoing elective open cholecystectomy. Methods: A prospective, randomized, double blind and placebo controlled study. Eighty adult patients of ASA I and II were divided into 2 groups of 40 each. Patients in group 1 and group 2 received capsules Gabapentin (1200mg) or identical placebo capsules 2 hours prior to surgery respectively. Preoperative anxiety and 12 hours postoperative pain was assessed using Anxiety and Pain VAS score respectively along with the observation of side effects. Postoperatively, intravenous pethidine 0.5 mg/kg was given when pain VAS > 40mm and time to first pethidine injection and total pethidine consumption in 12 hours was recorded. Results: Anxiety VAS scores after one hour of drug intake (35.75±20.11 versus 46.63±12.73) and just before induction of anaesthesia (45.75±30.27versus 68.13±29.84) along with postoperative Pain VAS scores were significantly lower in gabapentin group. Time to the first pethidine demand was significantly longer (145.34±194.54 min versus 26.30±51.02min) and cumulative pethidine consumption throughout study period was also significantly lower (35.91 ± 16.61 versus 57.84 ± 20.72mg) in gabapentin group. Conclusions: 1200 mg gabapentin premedication in open cholecystectomy patients significantly reduced preoperative anxiety, postoperative pain and total pethidine consumption with negligible side effects. DOI: http://dx.doi.org/10.3126/hren.v11i3.9642 Health Renaissance 2013;11(3):254-259

Locked-in syndrome during stellate ganglion block

Intra-arterial injection of a local anaesthetic during stellate ganglion blockade may cause life-threatening complications. The usual complications are apnoea, unconsciousness and seizures. However, occasionally an unusual complication, ‘locked-in’ syndrome, has also been reported. In this syndrome the patients remain conscious despite their inability to move, breathe or speak. Here we describe a patient who developed features akin to the locked-in syndrome along with severe hypotension and bradycardia, after an injection of only 2 ml of lignocaine during a stellate ganglion block.