Hairy Cell Leukemia in a Filipino Male during the COVID-19 Pandemic - Report of a Rare Case

Hairy cell leukemia (HCL) is a rare, chronic, mature B-cell lymphoproliferative disorder accounting for 2% of all leukemias. In this paper, we would like to present our experience in the management of HCL in a financially limited setting where other diagnostic tests and chemotherapy are unavailable. The case report aims to emphasize the recognition of the distinctive morphology of hairy cells in the peripheral blood in the consideration of the initial diagnosis. A 60-year-old Filipino male was incidentally found to have anemia, thrombocytopenia and an absolute neutrophilic count below 1,000 in a pre-operative clearance for elective herniorrhaphy. Blood smear revealed atypical lymphocytes with hair like cytoplasmic projections. CT-scan of the abdomen showed splenomegaly and prominent paraaortic nodes. Flow cytometry of the bone marrow aspirate was consistent with an involvement of a Mature B cell neoplasm markers CD19, CD20, CD22 and surface immunoglobulin lambda and hairy cell leukemia markers CD11c, CD103 and CD25. He responded to six-weekly sessions of Cladribine with remission of the bone marrow and hematologic parameters. HCL is a rare type of a mature B cell neoplasm characterized by pancytopenia, splenomegaly, bone marrow fibrosis and the presence of atypical lymphoid cells with hairy projections in blood, bone marrow and spleen. Immunophenotyping express CD11c, CD103, CD123, and CD25. BRAF V600E mutation is the disease defining genetic event. Cladribine and Pentostatin are the first line of treatment. Cases of leukemia can be easily overlooked because of the mild derangement in the complete blood count. A meticulous differential review of the atypical lymphocyte, is the first step in the diagnosis of this rare disease.Copyright © 2022, Philippine College of Physicians. All rights reserved.

Radical popular education today: Popular education in populist times

Popular education is more needed than ever. The Covid 19 pandemic has been highlighting the challenges of widening inequalities, increasing exploitation and oppression, along with persistent xenophobia and violence against women and minority communities. Yet popular education faces threats of its own, and resources have been on the decline, precisely when they have become so urgently required in the contemporary context. Whilst acknowledging these threats, the article goes on to focus on some of the ways in which popular education initiatives have continued to be promoted despite these wider challenges. 'The World Transformed' (TWT) has provided evidence of just such initiatives in Britain. The conclusions of TWT's research resonate with Paulo Freire's own reflections in the final section of 'The Pedagogy of Hope'. Despite the challenges he continued to look forward to the future with hope. © 2023, Linkoping University Electronic Press. All rights reserved.

INCREASING USE OF AGE-ADJUSTED D-DIMER

SESSION TITLE: Quality Improvement SESSION TYPE: Original Investigations PRESENTED ON: 10/17/22 1:30 pm - 2:30 pm PURPOSE: Age adjusted D-dimer is a well validated method by which to rule out pulmonary embolism in patients with low to intermediate pretest probability. The specificity of the traditional D-dimer cutoff (500 mcg/L) decreases with age and leads to false-positive results and unnecessary imaging tests. When an age-adjusted cutoff is used (age x 10 mcg/L), specificity improves, and excessive testing is avoided. METHODS: We began by collecting retrospective data for all patients who underwent D-dimer testing over the course of a 29-month period (from October 2017 through February 2020) within our 400 bed community hospital. We determined how many of these patients underwent further imaging with either a CT angiogram (CTA) or ventilation-perfusion (VQ) scan. We then implemented a messaging system within the hospital’s electronic medical record (EMR) with the purpose of reminding providers to consider age-adjusted D-dimer values prior to ordering imaging. Post-intervention data was collected over a period of six months (August 2021 – January 2022). Patients who tested COVID positive were excluded from analysis. RESULTS: A total of 1054 patients were included in the pre-intervention group, while 371 patients were included in the post-intervention group. There was no significant difference in age between the two groups (p = 0.241). A total of 13.6% (n = 143) of the patients in the pre-intervention group underwent CTA or VQ scan despite having a D-dimer below the age-adjusted cutoff, indicating that the patient did not require any imaging. Post-intervention, a total of 9.2% (n = 34) of patients underwent CTA or VQ scan despite having D-dimer values below the age-adjusted cutoff. Using a chi-square test for association, there was a statistically significant decrease in unnecessary testing (χ2(1) = 5.343, p = 0.021). CONCLUSIONS: Despite high quality evidence that suggests the use of age-adjusted D-dimer is safe and effective for ruling out pulmonary embolism, many imaging tests are ordered based upon standard cutoff values. Implementing a reminder message within our hospital’s EMR system produced a significant reduction in inappropriate imaging. This ultimately resulted in less radiation for patients, as well as an estimated cost savings of $33,758 over a six-month period. Although statistically significant improvement was seen, further interventions, such as automatically adjusting D-dimer cutoff values within the EMR, may further reduce unnecessary imaging and avoid pop-up message fatigue. CLINICAL IMPLICATIONS: Built-in EMR reminders to use age-adjusted D-dimer cutoff values may decrease unnecessary CTAs and VQ scans. This may translate into reduced patient irradiation and decreased overall healthcare costs without sacrificing patient care. DISCLOSURES: No relevant relationships by Naren Bhupatiraju No relevant relationships by Meagan Mayo No relevant relationships by Katherine Reano

The importance of community-based learning

This chapter starts by examining definitions of community-based learning, focusing on the theoretical case for popular education, building proactive support for alternative futures from the bottom up and working towards shared agendas for solidarity and social justice. Community-based learning can enable communities to develop shared understandings of the underlying causes of their problems. This can provide the basis for developing strategies for collaborating across differences and divisions, tackling discriminatory attitudes and behaviours rather than blaming ‘the other’, building democratic alliances and movements for social change, and responding to climatechange challenges. Such understandings have particular relevance in the current context, with increasing pressures from austerity policies along with divisive messages from Far Right populists, exacerbated by the effects of the COVID-19 pandemic. These pressures have been having the most severe impact on those who have been among the most disadvantaged already, particularly people from Black and minority ethnic communities, exacerbating tensions and prejudices, and posing major challenges for the future. Community-based learning can contribute to the development of more hopeful alternatives, it will be suggested in this chapter, without in any way implying that deep-rooted inequalities can be resolved by communities on their own, without wider structural changes. This is absolutely not about promoting ‘resilience’ as a backward-looking strategy for communities to turn inwards, as they attempt to pull themselves up by their own bootstraps - rather the reverse. This is about enabling communities to support each other inclusively rather than exclusively, as part of wider strategies for social justice. © Bristol University Press 2021.

Bleeding in critically ill patients with COVID-19

Background : COVID-19 is a prothrombotic infection but there is limited data on bleeding risks. Aims : This study aims to identify bleeding and thrombosis rates in relationship to anticoagulants in ventilated COVID-19 patients at a community hospital from March 1, 2020 until Feb 1, 2021. Methods : This study was approved by the Institutional Review Board. All ventilated COVID-19 patients were included. Data was gathered by electronic medical record review. Bleed events were classified by ISTH criteria. Thrombosis events included venous thrombosis/arterial thrombosis/MI/stroke. Anticoagulant/antiplatelet agents at the time of the bleed/thrombosis event, and percent of hospitalization spent on full anticoagulation were recorded. Bleeding/thrombosis rates according to duration/degree/type of anticoagulant were calculated. Results : Of 145 pts analyzed, bleeds occurred in 40/145 (28%), (25/145 (17%) major, 15/145 (10%) minor) with 10/40 (25%) bleeds contributing to cause of death. Of 73 patients who received full dose anticoagulation at some point during their hospitalization, 31/73 (44%) had a bleeding event. Of patients who received full dose anticoagulants for 75-100% of their hospitalization: 8/21 (38%) bled, 50-74%: 7/15 (46%) bled, 25-49%: 8/14 (53%) bled, 1-24%: 9/23 (39%) bled. All patients who bled were on full anticoagulation at the time of the bleed. Of the 72 patients who never received full dose anticoagulation, 9/72 (12%) bled. Multiple anticoagulants were involved in bleeding events (Figure 1). Of patients who bled, 14/40 (35%) were also on antiplatelet agents. Site of bleed was predominantly pulmonary/ tracheal (Figure 2). Indications for full anticoagulation were predominantly atrial fibrillation (14/31 (45%) and pulmonary emboli (6/31 (19%)). Thrombosis rates were 15%, with 16/21 (76%) on prophylactic and 5/21 (24%) on full anticoagulation. Conclusions : Ventilated COVID-19 patients had rates of thromboses consistent with other critically ill patients, but bleed rates were extremely high with significant mortality. Pulmonary bleeds predominated. Bleeds occurred regardless of type of full anticoagulant. Bleeding was highly correlated with use but not duration of full dose anticoagulation. Anticoagulant decisions for COVID-19 patients remain challenging.