Biclonal gammopathy in chronic lymphocytic leukemia: case report and review of the literature

Monoclonal gammopathies are frequently seen in B-cell malignancies. Monoclonal proteins are seen in a significant proportion of patients with chronic lymphocytic leukemia [CLL], which is a clonal disorder of mature B cells. The use of more sensitive laboratory methods has enabled the detection of monoclonal proteins or light chains in the serum and/or urine in the majority of these patients. The presence of some of these monoclonal proteins may explain the different autoimmune phenomena that are associated with this disease. Some reports indicate that the finding of monoclonal proteins has a negative impact on patients' survival. The presence of two different monoclonal proteins [i.e. biclonal gammopathy] is on the other hand rare. Most of the reported cases in the literature are of patients with plasma cell disorders. In this report, we describe a rare occurrence of biclonal gammopathy in a patient with CLL. Serum protein electrophoresis and immunofixation, which were negative at the time of initial diagnosis, showed biclonal immunoglobin A [IgA] kappa and IgA lambda during the course of the disease. The patient's disease showed steady progression, despite multiple treatments. Although this could just be the result of using more sensitive laboratory techniques, biclonal gammopathy in this patient likely reflects the evolution of another clone, which would explain the encountered resistance to therapy. Because of paucity of reports, the impact of biclonal gammopathies in such patients is not known and an effort to collectively report the presentation and outcome of these patients is needed to further understand the pathophysiology and clinical significance of such a finding

Knowledge and attitudes of Oman medical specialty board residents towards evidence-based medicine

This study aims to evaluate the knowledge and attitudes of Oman Medical Specialty Board [OMSB] residents towards Evidence-Based Medicine [EBM]. This cross sectional study was conducted on all OMSB residents through a self-administered online questionnaire between October 2012 and March 2013. An electronic survey was designed to identify and determine residents' knowledge and attitudes toward the use of EBM. The survey was completed by 93 [21%] OMSB residents, 76 [82%] of whom took part in continuing education courses and 50 [54%] belonged to professional practice-oriented organizations. On average, the residents were reportedly involved in patient care for approximately 70% [Standard Deviation [SD] 17%] of their time, while 14% [SD 12%] participated in research activities. The results showed that 53 respondents [57%] were competent users of medical search engines compared to 23 residents [25%] who rated their skills as neutral. Sixteen percent of the respondents strongly agreed and 46% only agreed that the facility supports the use of current research in practice. Fourteen percent strongly agreed and fifty-three percent only agreed that the foundation of EBM is part of OMSB academic preparation. On the other hand, 17% of the respondents thought that insufficient time is always a barrier against EBM, while another 27% perceived insufficient time as a usual barrier. The lack of information resources was reported to always be a barrier in 11% of the respondents while 32% thought that it usually acts as a barrier. Time constraints and skills in EBM were found to be the two major obstacles. This study was, however, limited by the low response rate of the survey; thus larger studies with a previously validated questionnaire should be conducted in the future

Non-invasive haemoglobin estimation in patients with thalassaemia major

This study aimed to validate pulse CO-oximetry-based haemoglobin [Hb] estimation in children and adults with thalassaemia major [TM] and to determine the impact of different baseline variables on the accuracy of the estimation. This observational study was conducted over a five-week period from March to April 2012. A total of 108 patients with TM attending the daycare thalassaemia centre of a tertiary care hospital in Muscat, Oman, were enrolled. Spot [Sp] Hb measurements were estimated using a Pronto-7 [Registered Sign] pulse CO-oximetry device [Masimo Corp., Irvine, California, USA]. These were compared to venous samples of Hb using the CELL-DYN Sapphire Hematology Analyzer [Abbott Diagnostics, Abbott Park, Illinois, USA] to determine the reference [Ref] Hb levels. A multivariable linear regression model was used to assess the impact of baseline variables such as age, gender, weight, height, Ref Hb and blood pressure on the Hb estimations. Of the 108 enrolled patients, there were 54 males and 54 females with a mean age of 21.6 years [standard deviation [SD] = 7.3 years; range: 2.5-38 years]. The mean Ref Hb and Sp Hb were 9.4 g/dL [SD - 0.9 g/dL; range: 7.5-12.3 g/dL] and 11.1 g/dL [SD = 1.2 g/dL; range: 7.5-14.7 g/dL], respectively. The coefficient of determination [R[2]] was 21% with a mean difference of 1.7 g/dL [SD = 1.1 g/dL; range: -0.9-4.3 g/dL]. In the multivariable model, the Ref Hb level [P = 0.001] was the only statistically significant predictor. The Pronto-7 [Registered Sign] pulse CO-oximetry device was found to overestimate Hb levels in patients with TM and therefore cannot be recommended. Further larger studies are needed to confirm these results