Thrombotic Thrombocytopenic Purpura: our clinical experience

Objectives: To assess clinical presentation and outcome of patients with thrombotic thrombocytopenic purpura [TTP] in our setup

Study Design: Descriptive study

Place and Duration of Study: Combined Military Hospital [CMH] Peshawar, from Feb 2016 to Aug 2017

Patients and Methods: In a prospective design, patients diagnosed to be suffering from TTP, were included in this study. Detailed history along with physical examination and thorough investigation of all cases was carried out and collected on proformas. The diagnosis of TTP in our study was done by demonstration of significant schistocytes [more than 1 percent] on peripheral blood film. The patients were treated with steroids and plasma pheresis and in some cases with weekly Rituximab for 4 weeks. The patients were followed up in outdoor clinic on monthly basis

Results: Being a very rare disease, only 11 patients suffering from TTP reported during the study period. They were followed prospectively with a mean duration of follow-up of 11.23 months [ +/- SD 5.57]. All patients [100 percent] had anaemia, thrombocytopenia and acute kidney injury. Fever was seen in 54.4 percent patients and 63.6 percent patients had neurological involvement. A likely secondary cause of precipitation of TTP was found in 54.5 percent cases. The mortality rate was 18.2 percent

Conclusion: TTP is a challenging disease for intensive care specialists and can be fatal without effective treatment. A high index of suspicion followed by early diagnosis and prompt treatment can save life. Documentation of deficiency of plasma ADAMTS13 activity is not essential for the diagnosis of TTP and plasmapheresis is the treatment of choice

Bone marrow infiltration and patterns in previously diagnosed patients of non hodgkin lymphoma [a single centre study]

Objective: The objective of this study was to determine the frequency of bone marrow infiltration along with various histological patterns of bone marrow infiltration in previously diagnosed patients of Non Hodgkin Lymphoma

Study Design: Cross sectional study

Place and Duration of Study: Department of Haematology, Armed Forces Institute of Pathology Rawalpindi. Six months, from Nov 2013 to May 2014

Material and Methods: This study involved 70 patients diagnosed of Non-Hodgkin Lymphoma

Results: The mean age of the patients was 51.40 +/- 16.50 years and 78.6% of the patients were males and 21.4% were females. Diffuse Large B-Cell lymphoma was the most frequently observed variant [DLBCL, 60%], followed by Follicular [22.9%] and small lymphocytic lymphoma [SLL, 14.3%]. Most of the patients were suffering from Stage-IV disease [51.4%], followed by Stage-III [25.7%] and Stage-II disease [22.9%]. Bone marrow infiltration was observed in 51.4% patients. The most common pattern of infiltration was recorded as diffuse, observed in 33.3% of patients. The second most common pattern was interstitial which was recorded in 25% cases followed by mix [22.2%] and focal [16.7%] patterns. The frequency of bone marrow infiltration was unaffected by age [p=0.497], gender [p=0.868] and type of the disease [p=0.486]

Conclusion: The most common pattern of diffuse large B-cell Non Hodgkin lymphoma infiltration was bone marrow followed by interstitial tissue

Comparative analysis of fluorescence in situ hybridization and real time polymerase chain reaction in diagnosis of chronic myeloid leukemia

Objective: To compare the sensitivity and specificity of fluorescence in situ hybridization [FISH] with real time polymerase chain reaction [RT-PCR] in the diagnosis of Chronic Myeloid Leukemia [CML]

Study Design: A cross-sectional, analytical study

Place and Duration of Study: Haematology Department, Armed Forces Institute of Pathology, Rawalpindi, from January 2012 to February 2014

Methodology: A total number of 87 patients of CML were studied. The diagnosis was made on the basis of clinical history, peripheral blood and bone marrow aspiration. These patients were tested for the presence of BCR-ABL1 fusion gene by RT-PCR and FISH. About 5 ml of venous blood was collected, half was taken in heparin for FISH and half in ethylenediamine tetra-acetic acid [EDTA] for CBC and PCR. For FISH, cells were cultured for 24 hours in RPMI 1640 medium and evaluated using BX51 fluorescence microscope for dual fusion signal of yellow colour. Samples having 20 or more interphases positive for dual fusion signals were taken as positive. For PCR, RNA extraction was done by Tri-Reagent LS [MRC, USA] and cDNA was synthesized using reverse transcriptase and gene specific primer. RT-PCR was done on ABI-7500. The positive samples were identified when fluorescence exceeded threshold limit. Results of RT-PCR and FISH were compared

Results: Out of the 87 patients, 85 [97.7%] were PCR positive and 2 [2.3%] were PCR negative, whereas in FISH 83 [95.4%] were positive and 4 [4.5%] were negative. Sensitivity and specificity of FISH was 97.6% and 100%, respectively

Conclusion: FISH is a reliable supplementary method to PCR for detection of BCR-ABL1 fusion gene in the diagnosis of CML

Effect of iron deficiency on the phenotype of beta-thalassaemia trait

The objective of this study was to determine the effect of iron deficiency on Hb-A2 level in beta-thalassaemia trait and to determine the frequency of individuals with beta-thalassaemia trait who could be missed due to concomitant iron deficiency. A total of 120 patients were studied, out of which 23 were iron deficient [serum ferritin < 20 ng/ml]. Mean Hb-A2 in the iron deficient individuals was 4.1 +/- 0.47% as compared to 5.1 +/- 0.58% in the remaining 97 individuals without iron deficiency [p < 0.001]. In the 120 individuals with beta-thalassaemia trait, mean Hb-A2 was 5.8% with range 3 - 6.8% and confidence interval was 95%. In 2 individuals with beta-thalassaemia trait, Iron deficiency was observed and showed Hb-A2 less than 3.5%. These could have been missed while screening by Hb-A2 estimation alone. Co-existence of Iron deficiency and beta-thalassaemia trait may mask the diagnosis of beta thalassaemia trait and such individuals can be missed during screening by Hb-A2 estimation alone

Early diagnosis of dengue virus infection in clinically suspected cases

Objective: Comparison of real time reverse transcriptase polymerase chain reaction [RTPCR] and immunoglobulin M [IgM] capture enzyme linked immunosorbent assay [ELISA] for diagnosis of dengue virus infection in first week of illness in clinically suspected patients of dengue fever

Study Design: Cross sectional study

Place and Duration of Study: Department of haematology, Armed Forces Institute of Pathology [AFIP] Rawalpindi from Jan 2013 to Nov 2013

Material and Methods: A cross sectional study including 68 clinically suspected patients of dengue fever according to the World Health Organization [WHO] criteria. IgM capture ELISA and RT PCR for dengue virus ribonucleic acid [RNA] was performed on samples collected from patients having fever for 1 to 7 days. These were divided into two groups. Patients in group 1 presented with fever of 4 days or less, patients in group 2 had fever of 5 to 7 days duration

Results: In group 1, 72% of the patients were positive by RT PCR while 31% were positive by IgM capture ELISA. In group 2, 43% of the patients were positive by RT PCR while 97% were positive by ELISA

Conclusion: RT PCR can be used for early detection of dengue virus infection in the first few days of fever while IgM ELISA is diagnostic afterwards

Frequency of Gc-globin promoter 158 [C>T] XmnI polymorphism in patients with homozygous/compound heterozygous beta thalassaemia

BACKGROUND: Response to hydroxyurea therapy in homozygous or compound heterozygous beta thalassaemia [BT] has been reported as more favourable in the presence of XmnI polymorphism. The prevalence of XmnI polymorphism may vary with BT phenotypes and genotypes, and differs geographically in distribution. Prevalence of XmnI polymorphism is not known in northern Pakistan. Objective: To determine the frequency of Gc-globin promoter 158 [C>T] XmnI polymorphism [XmnI polymorphism] in patients with homozygous or compound heterozygous beta thalassaemia. MATERIALS: Polymerase chain reaction [PCR] for common beta thalassaemia mutations and Gc-globin promoter 158 [C>T] XmnI polymorphism was performed on 107 blood samples of transfusion dependent beta thalassaemia [BT] patients in Pakistan. One hundred samples of unrelated BT traits and 94 samples of healthy subjects as controls were also analysed for BT mutations and XmnI polymorphism. Results: Out of 301 DNA samples, XmnI polymorphism was detected in 71[24%]; in normal controls, XmnI polymorphism was detected in 34/94 [36%] subjects; while in homozygous/compound heterozygous BT, it was detected in 14/107[13%] patients [Fisher's exact test, p =. 0002]. In heterozygous BT group, XmnI polymorphism was detected in 23/100 subjects [Fisher's exact test, p =. 03 with normal controls, and p =. 049 with homozygous/compound heterozygous BT]. The most common BT genotype was Frame Shift [Fr] 8–9/Fr 8–9, and none of the patients with this genotype had XmnI polymorphism. The second most common genotype was IVSI-5/IVSI-5; 4/26 [15%]. Cases with this genotype had XmnI polymorphism. Conclusion: XmnI polymorphism in homozygous/compound heterozygous BT group is 13%. The most common genotype associated with XmnI polymorphism was IVSI-5/IVSI-5

Frequency of pyruvate kinase [PK] deficiency in neonates with haemolytic anaemia

Objective: To determine the frequency of pyruvate kinase deficiency in neonates presenting with haemolytic anaemia

Study Design: Cross sectional descriptive study

Place and Duration of Study: Haematology department, Armed Forces Institute of Pathology, Rawalpindi [AFIP] from Jan 2011 to Jan 2012

Material and Methods: Study was done in collaboration with neonatology department of Military Hospital. Informed consent from parents of neonates was obtained. Two hundred and twenty five neonates with haemolytic anaemia based on low haemoglobin [<14g/dl], raised reticulocyte counts [>5%] and indirect hyper bilirubinaemia [as per CDC nomogram for evaluation of hyper bilirubinaemia in term neonates] were selected. Qualitative pyruvate kinase enzyme assay was done using Bio vision PK assay kit. Estimation of enzyme was based on generation of pyruvate by addition of substrate with change in optical density [OD] of sample in presence of enzyme. Dilution of standard as recommended by manufacturer was made and standard graph was plotted. The OD was measured using wave length of 570 nm at two points [start and at 25 min]. Cut off limit of less than 25% activity was considered positive for pyruvate kinase deficiency. Confirmation was done by running in parallel negative and positive controls [provided]

Results: Seven [3.1%Confidence Interval: +/- 3.33] out of 225 patients were found deficient. Among these 4 were male and 3 were female neonates. The age range was between 1 to 3 weeks. The mean age of presentation was 1.89 +/- [0.832] weeks

Conclusion: We conclude that pyruvate kinase deficiency is not uncommon in our setup and all patients with congenital non-spherocytic haemolytic anaemia where cause cannot be established should be screened for pyruvate kinase deficiency

Haematological manifestations and frequency of FAB subtypes in patients of acute meyoloid leukaemia: a single center study

To determine the clinical/haematological manifestations and frequency of different subtypes of Acute Myeloid Leukaemia [AML] according to the French-American-British [FAB] classification. Descriptive study. The study was carried out at haematology department of Armed Forces Institute of Pathology [AFIP], Rawalpindi from January 2011 to September 2012. Retrospective review of documents of patient diagnosed to have acute myeloid leukaemia on bone marrow aspiration was done. Patient's age, gender, major signs and symptoms at time of presentation and haematological parameters of peripheral blood and bone marrow were noted. The subtype of AML according to FAB classification was also documented. Data was entered and analyzed in SPSS 16.0. During the selected study duration acute myeloid leukaemia was diagnosed in 173 patients on bone marrow examination. Out of these 123 [71.1%] were males and 50 [28.9%] were females. Thirty [17.3%] of the patients fell in paediatric age group [< 15 years] while the remaining 143 [82.7%] were in adult age category [> 15 years]. The mean age of presentation was 9 years among paediatric patients and 44.5 years among adults. The overall mean age of both these two groups was 38.4 years [3-84 years]. Fever [71.6%], generalized weakness [34.1%] and pallor [23.7%] were the three main complaints of the patients, followed by splenomegaly and lymphadenopathy. The mean total leukocyte count, haemoglobin and platelet count were 57.4 x 10[9]/L, 7.9 g/dL and 54 x 10[9]/L respectively. AML-M[2] was found to be the most frequent FAB AML subtype among 72 [41.6%] paediatric and adult patients. The main signs and symptoms of the patients of AML presenting to our centre were fever, generalized weakness and pallor. AML-M[2] was found to be the most common FAB subtype among AML in children and adults

High prevalence of protein C, protein S, antithrombin deficiency, and factor V Leiden mutation as a cause of hereditary thrombophilia in patients of venous thromboembolism and cerebrovascular accident

To determine the frequency of Protein C, Protein S [PC and PS], antithrombin deficiency [AT III] and Factor V Leiden mutation [FVL] as a cause of thrombophilia in the patients with venous thromboembolism [VTE] and cerebrovascular accident [CVA]. It was an observational study conducted at Department of Haematology, Armed Forces Institute of Pathology [AFIP], Rawalpindi, Pakistan. All patients referred for thrombophilia screening from July 2009 to June 2012 were screened. Patients with evidence of VTE or CVA were screened for PC and PS, AT III deficiency, and FVL. Total 404 patients of age between 1-71 years mean 33 +/- 14 with male to female ratio of 2.4:1 had evidence of thrombophilia. Two hundred eighteen [54%] patients presented with CVA, 116 [29%] with deep vein thrombosis [DVT], 42 [10.5%] with pulmonary embolism [PE], and 28 [7.5%] with portal or mesenteric vein thrombosis [PV]. Protein C and S deficiency was detected in 35/404 [8.7%], AT III in 9/404 [2%], and FVL in 25/173 patients [14.5%]. The findings were suggestive of a significant association of FVL mutation for developing DVT [OR=11.0, 95% C I 4.6-26.3], CVA [OR=5.7, 95% C I 2.1-15.1], and PV [OR=5.4, 95% C I 1.3-21.9]. PC and PS deficiency was a significant risk factor for developing PE [OR=3, 95% C I 0.8-11.4]. FVL mutation and Protein C and S are the leading causes of thrombophilia with strong association of Factor V Leiden mutation as risk for developing DVT

Molecular and serological assessment of chronic HBV carriers and additional burden of applying updated guidelines in Pakistan

To assess the additional burden of the patients eligible for treatment, based on recommendations on viral load, in the light of 2009 version of AASLD guidelines, as compared to 2004 guidelines and to determine the frequency of HBeAg in chronic HBV carriers. Descriptive cross-sectional study. Virology Department, Armed Forces Institute of Pathology, Rawalpindi, from November 2010 to January 2012. Persons with chronic HBV infection, reporting for HBV DNA PCR test, were included in the study and blood samples were collected. HBV DNA load was determined by Real Time PCR. HBsAg and HBeAg were tested by ELISA. Out of the 801 subjects positive for HBsAg, 74 [9.24%] were positive for HBeAg. Out of them, 113 [14.1%] had HBV DNA load > 100,000 copies/ml and were eligible for treatment according to AASLD 2004 guidelines. Forty one [5.1%] had HBV load between 10,000 and 100,000 copies/ml, and were additionally eligible for treatment as per AASLD 2009 guidelines. The 5.1% of 4.5 million estimated HBV carries in Pakistan comes to 229500. There was a low HBeAg positivity and HBV DNA positivity in our chronic HBV infected persons. Moreover, there is an increase of 229500 potential candidates for HBV treatment in Pakistan based on viral load testing, according to the AASLD 2009 guidelines when compared with 2004 guidelines. The increase in the number of candidates for treatment may require an additional expenditure of tens of billions of rupees

Real time polymerase chain reaction in diagnosis of chronic myeloid leukemia

To compare the sensitivity and specificity of Real Time Polymerase Chain Reaction [RT-PCR] with conventional cytogenetics in diagnosis of chronic myeloid leukemia. A cross-sectional, analytical study. The Armed Forces Institute of Pathology [AFIP], Rawalpindi, from December 2010 to January 2012. A total number of 40 patients were studied, in which all were diagnosed as CML on peripheral blood and bone marrow aspiration. The subjects were tested for the presence of Philadelphia [Ph] chromosome by cytogenetics and BCR-ABL fusion gene by RT-PCR. 2-3 ml of venous blood was collected, half in sodium heparin [anti-coagulant] for cytogenetics and half in EDTA for PCR. For cytogenetics, cells were cultured for 72 hours in RPMI 1640 medium and examined by arresting in metaphase using Colchicine to identify Philadelphia chromosome. For PCR, RNA extraction was done by Tri Reagent LS [MRC, USA] and cDNA was synthesized using reverse transcriptase and gene specific primer. RT- PCR was done on ABI-7500. The positive samples were identified when fluorescence exceeded threshold limit. Results of cytogenetics and RT PCR were compared. Out of the 40 patients, PCR showed 37 [92.5%] were positive and 3 [7.5%] were negative for BCR-ABL fusion gene, whereas in cytogenetics 28 [70%] were positive for Ph chromosome and 12 [30%] were negative for Ph chromosome. Sensitivity and specificity of cytogenetics was 75.6% and 100% respectively. Real time PCR as compared to cytogenetics is less tedious, gives quick results, does not require multiple sampling due to culture failure and can be done on peripheral blood

Role of genetic counselling in prenatal diagnosis of p-thalassaemia in Pakistan

To compare the response towards prenatal diagnosis [PND] of [3-thalassaemia, in individuals who had not received genetic counselling and a genetically counselled population. Cross-sectional survey. Department of Haematology, Armed Forces Institute of Pathology [AFIP], Rawalpindi, from March 2009 to December 2010. Using non-probability consecutive sampling, a total of 176 individuals having thalassaemic children, were interviewed regarding PND of thalassaemia, by using a structured questionnaire. Forty two individuals were taken as controls as they had received genetic counselling for PND, whereas the remaining 134 were taken as cases. Responses towards PND were compared using chi-square test. Odds ratio was also calculated for subsequent PND utilization. Seventy [52.2%] cases and 42 [100%] controls were aware of the availability of PND in Pakistan. This difference in awareness was statistically significant [p < 0.001]. In the controls, 40 [95.3%] individuals were aware of the appropriate timing of the test, in contrast to 52 [39%] cases [p < 0.001]. PND was used in subsequent pregnancies by 50 [37.3%] cases and 32 [80%] controls [p < 0.001]. The calculated odds ratio for subsequent PND utilization was 5.37. The study reflects a very positive attitude of genetically counselled thalassaemia affected families towards PND. For better utilization of PND, genetic counselling services should be available at all health strata

Frequency of Janus associated kinase 2 [JAK2] mutation in patients of BCR-ABL negative myeloproliferative neoplasms

To determine the frequency of Janus associated kinase 2 mutation in the patients of BCR-ABL negative classical myeloproliferative neoplasms. Cross-sectional descriptive study. Molecular Department of Haematology, Armed Forces Institute of Pathology [AFIP], Rawalpindi from Jul 2011 to Jul 2012. Ninety three consecutive patients of Polycythaemia vera [PV], Essential thrombocythaemia [ET] and Idiopathic myelofibrosis [IMF] diagnosed by the conventional haematological criteria were included in the study. All patients were screened for G-T point mutation [V617F] in the JAK2 gene on chromosome 9 by an allele specific PCR. Out of the 93 myeloproliferative neoplasm [MPN] patients, 33[35%] had polycythaemia vera, 36[39%] had essential thrombocythaemia and 24[26%] had idiopathic myelofibrosis. JAK2 mutation was seen in 64/93 [69%] patients including 33/33[100%] in PV, 19/36[52.6%] in ET and 12/24[50%] in IMF. Classical myeloproliferative neoplasms are an important group of heamatological disorder in our country. JAK2 gene mutation is seen in significant proportion of these disorders [69%]. JAK2 mutation analysis can be used to differentiate between polycythemia vera and secondary polycythemia in most cases with near certainty, where it was found in 100% of the cases

Management of mandibular fracture in paediatric patients at L.U.H Hyderabad

The study was conducted to analyze the different treatment options practiced in pediatric mandibular fracture patients at L.U.H Hyderabad. Maxillofacial fractures are infrequent in the pediatric population, and their treatment is unique due to the psychological, physiological, developmental and anatomical characteristics of children. Besides this it is difficult to examine child both clinically and radiographically. Retrospective Study This study was carried out in Department of oral and maxillofacial surgery L.U.H Hyderabad for a period of two years i.e. from June 2010 to June 2012. Gender distribution Total 180 patients, 118 patients [65.6%] were males and 62 patients [34.4%] were females. Most common site involved was parasymphysis, involved in 85 [47%], in other sites angle in 43 [23%], condyle 25 [13%]cases, symphysis 15 [8%], body 10 [5%] and ramus in 2[1%]. Most of the patients were treated with IMF with arch bar i.e 75 [41%]. Clearer understanding of paediatric pattern of mandibular fractures will help out health care providers as they plan and manage the treatment of mandible fractures in children. The most common site involved in these patients is mandibular parasymphysis. Clearer understanding of pediatric pattern of mandible fractures will help out oral maxillofacial surgeon as they plan and manage the treatment of mandible fractures in children

Comparison of analgesic effects of oral carbamezapine with pregablin in idiopathic trigeminal neuralgia

Idiopathic trigeminal neuralgia, a form of neuropathic pain, caused by not well defined etiology, is a formidable therapeutic challenge to clinicians because it does not respond well to traditional drug therapies. Anticonvulsant drugs are regarded as useful treatment for neuropathic pain. Carbamazepine, the first anticonvulsant studied in clinical trials, probably alleviates pain by decreasing conductance in Na[+] channels and inhibiting ectopic discharges. Pregabalin has the most clearly demonstrated analgesic effect for the treatment of neuropathic pain. The role of anticonvulsant drugs in the treatment of Idiopathic trigeminal neuralgia is evolving and has been clearly demonstrated with Pregabalin and carbamazepine. The aim of this study was to investigate comparison of analgesic effects of oral carbamezapine with pregablin in idiopathic trigeminal neuralgia. Interventional study. Oral and Maxillofacial surgery department, LUMHS. Jan 2012 to DEC 2012 . 30 patients with well defined history and diagnostic clinical symptoms of idiopathic trigeminal neuralgia were selected, divided into two groups of 15 individuals with similar gender and age difference. Clinical trial were conducted with group 1 with carbamazepine and group 2 with Pregabalin for 4 weeks. Subjective pain level of both groups was recorded before intervention [pre treatment recording] and after intervention [1[st], 2[nd], 3[rd] and 4[th]] on weekly basis by using 0-10 visual analogue scale [zero represent no pain 10 represent pain that could not be worse]. Following intervention, both groups were evaluated for pain score in 1[st] and 2[nd] week, there was no significant difference observed between the two groups. [P value 0.44 and 0.456], but after 3[rd] and 4[th] weeks it was observed that, there is significant difference, [p value 0.000 and 0.009] on visual analogue scale. It was observed that there was a significant difference between pretreatment and fourth week mean pain score in group 2, [8.9 and 1.07]. Similarly marginally significant difference with [r = .640] was seen in 1[st] week of group 2 receiving Pregablin, the mean value was [2.53, 1.60] respectively. Based on these results that are in line with the recommendations made by other studies, the 1[st] line medical therapy is Carbamazepine but this should be changed to other drug therapy if there is no pain relief or adverse effect

Mixed donor chimerism in non-malignant haematological diseases after allogeneic bone marrow transplantation

To determine the frequency of mixed donor chimerism in patients of non-malignant haematological diseases after allogeneic bone marrow transplant. A cross-sectional, observational study. Department of Haematology, Armed Forces Institute of Pathology [AFIP], Rawalpindi, from July 2010 to June 2011. Methodology: Donor chimerism was assessed in patients of aplastic anaemia and beta-thalassaemia major who underwent allogeneic bone marrow transplantation [BMT]. Peripheral blood samples were used to assess chimerism status by analysis of short tandem repeats [STR]. In patients where pre-transplant blood sample was not available, swab of buccal mucosa was used for pre-transplant STR profile. A standard set of primers for STR markers were used and the amplified DNA was resolved by gel electrophoresis and stained with silver nitrate. The percentage of donor origin DNA was estimated by densitometer. Out of 84 patients, 52 [62%] were males, while 32 [38%] were females. In patients of beta-thalassaemia major, 31 [62%] developed mixed donor chimerism [MC], 13 [26%] developed complete donor chimerism [CC] and 6 [12%] had graft failure. In aplastic anaemia, 17 patients [50%] achieved MC, 13 [38.2%] had CC and 4 [11.8%] developed graft failure. The combined frequency of mixed donor chimerism for both the diseases was 58.3%. D3S1358 was the most informative STR marker in these patients. Majority of the studied patients developed mixed donor chimerism following bone marrow transplantation, whereas only a minor percentage of the patients had graft failure. Analysis of D3S1358 was the most informative in assessing donor chimerism in patients who underwent BMT

Fibroscore for the non-invasive assessment of liver fibrosis in chronic viral hepatitis

To evaluate the predictive value of a set of laboratory markers for the assessment of liver fibrosis in chronic viral hepatitis patients. Cross-sectional study. Baqai Medical University, Combined Military Hospital, Malir, Karachi, from November 2006 to May 2008. Twenty laboratory parameters were measured in 100 treatment-na‹ve chronic viral hepatitis patients who also had liver biopsy performed. Descriptive statistics, areas under the ROC's curves, and multivariate logistic regression analysis identified a fibrosis panel, a set of five most useful markers, for the assessment of stages of fibrosis, stage 0 to stage 4. The fibrosis index, FibroScore, consisted of bilirubin, Gamma glutamyl transferase, Hyaluronic acid, alpha 2 macroglobulin, and platelets evaluation. A score of>0.5 predicted stages 2, 3 and 4, with a sensitivity of 82%, and specificity of 92%. A score>0.5 for stages 3 and 4 had a sensitivity of 85%, and specificity of 89%. At a score of>0.80, for stages 3 and 4, the sensitivity was 70%, specificity was 97%, and PPV 87% [there was>85% possibility of presence of stage 3 or 4]. A score of<0.20 predicted the absence of stages 2, 3, and 4 with a sensitivity of 91%, specificity of 86%, and NPV of 96%. Scores from 0.00 to 0.10 almost certainly ruled out the presence of stages 2-4 [NPV=98%]. The areas under the ROC curve were: 0.808 for stage 2; 0.938 for stage 3; and 0.959 for stage 4. A combination of 5 markers is very useful in predicting various stages of liver fibrosis, and is helpful in the non-invasive assessment of liver fibrosis in chronic viral hepatitis patients

Real time polymerase chain reaction for the detection of malarial parasite

To evaluate the sensitivity and specificity of real time polymerase chain reaction [PCR] for the detection of Malarial parasite. Descriptive cross-sectional study. The Armed Forces Institute of Pathology [AFIP], Rawalpindi, from April to June 2010. A total of 60 Leishman stained blood films with clinical suspicion of malaria were studied by light microscopy for detection of malaria parasite [MP]. The samples were also subjected to real time PCR for the small subunit [SSU] rRNA gene of MP found in all the four subspecies of Plasmodium. Real time PCR was done by the Taqman probe method. One sample positive for MP was serially diluted with ABO compatible blood, and light microscopy and real time PCR were performed on all dilutions. Results of light microscopy and real time PCR were compared. Sensitivity and specificity were calculated using PCR as the gold standard. PCR detected MP in 33 samples with sensitivity and specificity of 100% whereas light microscopy could detect MP in 30 samples. Sensitivity and specificity of light microscopy was 90.9% and 100% respectively. In the serially diluted blood sample, MP was visible at 1/16 dilution whereas the PCR showed positive results even at 1/512 dilution. Real time PCR is more sensitive than light microscopy for the detection of malarial parasite

Philadelphia chromosome in a patient of T cell acute lymphoblastic leukaemia

T-cell acute lymphoblastic leukemia [ALL] arises from blasts committed to T cell lineage at varying stages of maturation. It mostly occurs in later part of childhood, adolescent and in young adults. Patient usually presents to clinician with cytopenias, lymphadenopathy and organomegaly. Common symptoms and signs include, fatigue, generalized weakness, recurrent infections, bruising, bleeding complaints, pleural effusion, mediastinal mass, central nervous system, testicular, skin and bone involvement. The incidence of Philadelphia chromosome in T lineage ALL is less than 1%. We present a case of T cell ALL in which Philadelphia chromosome was detected. Morphology and immunophenotyping were also consistent with T cell ALL.