Early Prediction of Coagulopathy in Acquired Bleeding Disorders - Revisited Using Rotational Thromboelastometry

Introduction: Acquired bleeding disorders are a major causeof mortality, both in the developed and developing countries.An acute haemorrhage should be managed immediately withblood products, factor concentrates or anti-fibrinolytics.Investigations to detect coagulopathies typically includebaseline screening tests like prothrombin time, activatedpartial thromboplastin time, platelet count and fibrinogenlevel. These tests have a long turn around time whichfrequently lead to a blinded approach towards blood productsupport leading to under or over transfusion. In contrast,rotational thromboelastometry (ROTEM) which assesseshaemostasis from the start of clot formation to fibrinolysisgives earliest results within ten minutes. This study wasdone to establish a correlation between ROTEM parametersand standard coagulation profile in the context of acquiredbleeding disorders.Material and Methods: A total of 138 subjects - 70 patientswho presented with acquired bleeding disorders and 68 subjectsdiagnosed to be normal on the basis of a complete coagulationwork up were included as the cases and controls respectively.All samples were subjected to standard coagulation profileand ROTEM analysis which included Clotting Time, ClotFormation Time, Alpha Angle, Maximum Clot Firmness andMaximum Lysis.Results: The Maximum Clot Firmness had a very goodco relation with serum fibrinogen levels (k value - 0.807;p<0.000; Sensitivity - 88%; Specificity - 92%), and goodcorrelation with platelet count (k value - 0.793; p< 0.000;Sensitivity - 86%, Specificity-92%), whereas Clot FormationTime showed moderate correlation with aPTT. Clotting timehad a poor correlation with prothrombin time and activatedpartial thromboplastin time.Conclusion: The achievement of haemostasis is a crucialfactor for determining patient outcomes in acquired bleedingdisorders. The gold standard test to diagnose coagulopathy is thestandard coagulation profile. Rotational thromboelastometrycorrelates well with standard coagulation parameters. Thistest which is performed on whole blood showed interpretableresults within 10 minutes, whereas standard coagulationprofile required an average of 45 – 75 minutes. In view of thegood correlation to the standard coagulation profile, it appearsthat Rotational Thromboelastometry results can be safely usedto implement early transfusion therapy for haemorrhage.

Mean reticulocyte volume enhances the utility of red cell mean sphered cell volume in differentiating peripheral blood spherocytes of hereditary spherocytosis from other causes.

Context: Mean sphered cell volume (MSCV) and mean reticulocyte volume (MRV) are additional reticulocyte parameters generated while processing the blood samples on Beckman coulter LH 755 in the reticulocyte mode using the volume, conductivity and scatter technology. It has been observed that the difference between mean corpuscular volume (MCV) and MSCV is higher in the cases of hereditary spherocytosis (HS) and this difference is increasingly being utilized as a screening tool for spherocytes. In addition now there have been new observations that reticulocyte volume in cases of HS is less as compared to normal reticulocyte. Aims: Our aim was to test the usefulness of reticulocyte parameters like MSCV and MRV in distinguishing cases of HS and autoimmune hemolytic anemia (AIHA). Materials and Methods: This is a retrospective and partly prospective study where peripheral blood ethylenediaminetetraacetic acid samples from cases of HS (n = 57) and AIHA (n = 29) were processed on LH 755 in both the differential and the reticulocyte mode. The data generated were analyzed and compared with data from normal healthy donors (n = 46). Results: Using an algorithm of MCV — MSCV >10 and MRV — MSCV <25, a sensitivity of 84.2% and specifi city of 94.7% was observed in cases of HS. Conclusions: With the reticulocyte analysis, we may now have a simple and cheap additional tool for screening of HS.

V-raf murine sarcoma viral oncogene homolog B (BRAF) mutations in hairy cell leukaemia.

Introduction: Hairy cell leukemia (HCL) is a B-cell non-Hodgkin lymphoma with distinct clinical, morphological and immunophenotypic features; however, there are many other B-cell lymphomas, which closely mimic HCL. Accurate diagnosis of HCL is important as treatment with 2-chloro-2’-deoxyadenosine (cladribine) is associated with >80% chance of complete cure. The recent description of BRAF p.V600E mutations in almost all HCL cases in various studies has not only improved the pathogenetic understanding of this entity but also increased the diagnostic accuracy of this disorder. Aim: The aim of the study was to standardize a molecular test for diagnosis of HCL and compare with standard established morphological, cytochemical and immunophenotypic parameters for HCL diagnosis. Materials and Methods: The incidence of this mutation was sought in 20 patients with either classical HCL or HCL variant (HCLv) by Sanger sequencing and allele-specifi c polymerase chain reaction. BRAF p.V600E mutation was present in all HCL cases and absent in the only HCLv case. Results: A high degree of correlation was noted between the presence of BRAF p.V600E and established diagnostic criteria in 20/20 patients with HCL/ HCLv. Our data supports the observation that this mutation is present in all cases of HCL and is absent in HCLv. Hence, detection of the BRAF p. V600E mutation can be a useful adjunct in the diagnostic algorithm.