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Background and Aims: We aim to study the significance of intraoperative hyperlactatemia in reconstructive oncoplastic surgery. Material and Methods: A retrospective observational study was conducted on a cohort of patients who underwent reconstructive oncoplastic surgery with free flap for oral cancer over a 6-month period. The study population was divided into two groups based on peak lactate levels. Group N with peak lactate level less than 2 mmol/L and Group H peak lactate level more than 2 mmol/L. The various parameter studied were patient's comorbidities; intraoperative events (vasopressor requirement, blood transfusion, and duration of surgery); postoperative parameters including the need for re- exploration and duration of stay in hospital and intensive care unit. Results: The study demonstrates that intraoperative rise of lactate was not influenced by comorbidities. None of the intraoperative parameters studied influenced the lactate levels. Baseline lactate level was found to correlate with peak lactate level intraoperatively. But it was observed that there was normalization of lactate level within 24 hours postoperatively in both the groups. There was no difference in outcome parameters in the two groups. Conclusion: Intraoperative hyperlactatemia is not a significant prognostic factor for outcome in oncoplastic reconstructive surgery.

BackgroundCure rates for children with cancer in India lag behind that of high-income countries. Various disease, treatment and socio-economic related factors contribute to this gap including barriers in timely access of diagnostic and therapeutic care. This study investigated barriers to accessing care from symptom onset to beginning of treatment, from perspectives of caregivers of children with cancer in India.MethodsSemi-structured in-depth interviews were conducted with caregivers of children (ResultsThirty-nine caregivers were interviewed, where three key themes emerged from the narratives: time intervals to definitive diagnosis and treatment, the importance of social supportive care and the overall accumulative impacts of the journey. There were two phases encapsulating the experiences of the family: referral pathways taken to reach the hospital and after reaching the hospital. Most caregivers, especially those from distant geographical areas had variable and inconsistent referral pathways partly due to poor availability of specialist doctors and diagnostic facilities outside major cities, influence from family or friends, and long travel times. Upon reaching the hospital, families mostly from public hospitals faced challenges navigating the hospital facilities, finding accommodation, and comprehending the diagnosis and treatment pathway. Throughout both phases, financial constraint was a recurring issue amongst low-income families. The caregiver’s knowledge and awareness of the disease and health system, religious and social factors were also common barriers.ConclusionThis qualitative study highlights and explores some of the barriers to childhood cancer care in India. Our findings show that referral pathways are intrinsically linked to the treatment experience and there should be better recognition of the financial and emotional challenges faced by the family that occur prior to definitive diagnosis and treatment. This information would help inform various stakeholders and contribute to improved interventions addressing these barriers.

This study aims to analyse the contributions in IASLIC Bulletin –an official organ or a leading library science journal published by IASLIC. The total 97 articles were published during the period 2013 – 2017. The study covers the year-wise, institutions-wise, state-wise distribution of contributions, authorship pattern, citation analysis, length of the contributions etc. The study shows that most of the contributions of this journal are contributed by joint authors and state-wise distribution shows that most of the contributions are contributed from West Bengal. Citation analysis of 1369 citations includes finding out number of citations per volume, types of publications cited and preparing of ranked list of cited journals in contributions of this journal. The study reveals that journals are the most cited publication amongst the library and information scientists. Annals of Library and Information Studies is the most cited journal in the contributions of this journal.

Aim: One of the causes for lower cure rates in acute childhood leukemia in low- and middle- income countries (LMIC) compared to high-income countries is abandonment from treatment. The International Society of Pediatric Oncology (SIOP) defines abandonment as failure to begin treatment or an absence of 4 weeks during treatment. The aim of this study was to evaluate the extent of abandonment among patients diagnosed with acute myeloid leukemia (AML) at the pediatric ward at a low-resource cancer center in India. Methods: Medical records of all patients, aged 0–15 years, diagnosed with AML between January 1, 2014, and March 31, 2015, at the hospital were reviewed. Age, sex, date of diagnosis, and survival during the short follow-up time after completed treatment and information regarding abandonment were collected. SIOP definition of abandonment was used. Eight patients were diagnosed with AML at the hospital whereof 65 met the inclusion criteria of this study. Results: Of the included 65 patients, 6 died before treatment could be initiated and 3 were referred to palliative care upfront. Thus, 56 patients were offered curatively intended treatment. Of these patients, six refused treatment at this stage and another five abandoned during therapy. Altogether, 11 children abandoned treatment. Conclusion: In this study, the abandonment rate from treatment of childhood AML was 20%, which is in concordance from other studies conducted in India and other LMIC, stating that abandonment is a problem and hindrance when treating with a curative intent.

Objectives: The objective of this study to comprehensively analyze bone marrow (BM) infiltration by nonhematological round cell tumors. Materials and Methods: A total of 206 diagnosed cases of small round blue cell tumors (excluding lymphomas) during a period of 2½ years, referred for BM examination were included in the study. Clinical details were obtained from medical records. BM aspiration (BMA) and BM biopsies (BMBx) were performed under local anesthesia for staging workup. BMBx were studied for cellularity, presence of infiltration by round cells (nonhematopoietic), histologic patterns (island/nests and diffuse sheets), fibrosis, necrosis and other secondary changes. Immunohistochemistry panel was used depending on the morphology. Results: The cases included age range from 45 days to 25 years with a median age of 12 years. There was a male predominance with male:female 1.5:1. Among these, 37/206 cases (17.9%) were positive for BM involvement (BMI) on BMBx. Of these, 24 cases were neuroblastoma (64.8%), 9 cases Ewing’s sarcoma/primitive neuroectodermal tumor (24.3%), and 4 Rhabdomyosarcoma (10.8). BMBx was done in all the 206 cases. Among these, 37/206 cases were positive for BMI on BMBx while 35/206 cases were positive on BM imprints and 33/206 cases were positive on BMA. Conclusion: Detection of metastasis in the BM has both therapeutic and prognostic significance. BMBx are complementary in the diagnosis of small round cell tumor.

Aim: Childhood cancer patients are subjected to recurring painful medical procedures. In low- and middle-income countries (LMIC), where the majority of the world’s childhood cancer patients live, pain management is often unsatisfactory due to limited resources. This study aimed to evaluate the possibility of conducting a preprocedural preparation for lumbar punctures (LPs) at a pediatric oncology unit in a LMIC and to assess whether this intervention would decrease procedural pain and fear. Methods: Patients aged 5–18 who underwent LPs between February 25, 2017, and April 12, 2017, were eligible and invited to participate. Included patients were interviewed to assess the procedural pain and fear in conjunction with the LP and the patients’ understanding of why an LP was done. Closest caregivers and the medical staff were interviewed to compare the perceptions of pain. The study was conducted in two separate phases; patients included in the period of February 25–March 9 underwent LP according to routines without preparation while patients included in the period of March 10–April 12 received procedural preparation with information. Results from the interviews from the two study groups were compared. Results: Out of 79 patients who met the inclusion criteria, 76 were included and preparation was successfully implemented for 25 of them. The pain decreased significantly (P = 0.022) after preparation. The physicians underestimated the patients’ pain (P < 0.0001). The understanding of the reason for the LP increased significantly among patients (P = 0.0081) and their caregivers (P < 0.0001). Conclusions: Preparation by preprocedural information, created to fit the situation at a state-run hospital in a LMIC, is feasible and efficient.

Bone marrow (BM) examination is an essential tool in evaluation and staging of non-Hodgkin lymphoma (NHL). The aim of this study is to overview the approach to the use of unilateral versus bilateral BM sampling in lymphoproliferative disorders for diagnosis and staging. All cases diagnosed as lymphoproliferative disorders from January 2014 to January 2017 were studied. Bilateral trephine biopsy and aspiration of 414 cases were assessed for involvement patterns and presence/absence of background changes. Bone marrow involvement (BMI) was seen in 109 (26.3%) cases. The cases ranged from 2 to 80 years. BMI was more frequent in B-cell lymphomas than T-cell lymphomas as was the incidence (B-NHL= 87/109 [79.8%]; T-NHL=21/109 [19.1%]). Among B-cell lymphomas, BMI was most frequent in chronic lymphocytic lymphoma followed by B-lymphoblastic lymphoma (BLL) and mantle cell lymphoma. Among T-cell lymphomas, BMI was most frequent in T-lymphoblastic lymphoma (TLL). A single case of anaplastic large cell lymphoma (ALCL) had BMI. Bone marrow aspiration (BMA) and bone marrow trephine (BMT) agreed in 97% of cases (401 of 414: 308 both negative, 93 both positive). Additional 13 cases were diagnosed on BMT whereas BMA was negative for these cases. Background changes (fibrosis and necrosis) were common in TLL followed by BLL. Of the 109 positive cases, 4 were missed by unilateral BMT. Peripheral spill of lymphoma was seen in 14 of 109 cases. BMT involvement by lymphoma is more commonly seen in lymphoblastic lymphoma. Bilateral trephine biopsy remains gold standard to determine the marrow involvement and staging and assess the remission.

Aim: This study aimed to compare the quality of life (QoL) of cancer patients, with an Eastern Cooperative Oncology Group (ECOG) performance of 3–4, in contact with or without contact, with a specialized palliative care unit (PCU) at a low-resource governmental cancer hospital, as well as studying the impact of this contact on the QoL in their caregivers. Materials and Methods: Hospitalized patients with an ECOG performance of 3 or 4 and their primary caregiver were asked to participate in this observational study. Patients in contact with the specialized PCU and their closest caregivers formed Group A, while patients and families without this contact formed Group B. Contact was mainly one consultation. The patients were asked to complete the Palliative Care Outcome Scale (POS), and the caregivers were asked to complete the Hospital Anxiety and Depression Scale (HADS) and the distress thermometer (DT). Results: There was no statistically significant difference between the median POS values of the patient groups, neither regarding the total sum nor per any item. There were also no statistically significant differences between the median HADS values and median DT values when comparing the caregivers to Group A and B. Conclusion: Consultation with a specialized PCU at this tertiary referral center did not alter the QoL of patients with an ECOG performance of 3–4 nor did it affect the psychological well-being of their caregivers. We argue that monitoring prescribed treatment and follow-up is a necessary component of PC.

Purpose of the study: Deregulated DNA repair is one of the hallmarks of cancers including Acute Myeloid Leukemia (AML), as it results in genomic instability. ATM gene functions as a sensor, activates cascade of events leading to stimulation of multiple DNA damage- responsive signaling pathways. Principal DNA repair mechanism activated in the hematopoietic stem cells is the Non Homologous End Joining (NHEJ) pathway. However, this pathway was shown to be error prone. Functional SNPs in the genes involved in DNA repair might influence the gene expression leading to altered DNA repair which might confer the risk to AML. Materials & Methods: This hospital-based case-control study included 225 AML patients and 326 cancer-free controls from South Indian population. Six polymorphisms of XRCC5, XRCC6, XRCC7 and ATM were genotyped using polymerase chain reaction (PCR)-Restriction Fragment Length Polymorphism (PCR- RFLP) method. Statistical analyses were performed by using SPSS (version20v) and SNPSTAT online tool. Protein-Protein Interaction (PPI) analysis was also done to see the relationship between these genes. Results: We found that there was an elevated risk of AML associated with the XRCC5 VNTR 0R repeat and A allele of 2408G>A polymorphism (p-0.04 and pG and T allele (p-0.003) of ATM -5144A>T polymorphisms were also significantly increased in AML cases. Further, analyses of the variant genotypes with epidemiological and clinical variables revealed a significant association of the risk genotypes with development and progression of AML. Conclusion: The XRCC5 0R repeat, 2408G>A, XRCC6 -1310 C>G and ATM- 5144A>T polymorphisms, but not XRCC6 -61C>G and XRCC7 6721G>T polymorphisms, play an important role in the pathogenesis of AML. Figure Disclosures No relevant conflicts of interest to declare.

B-cell lymphoma 2 (BCL2) and BCL2-associated X protein (BAX) proteins are anti-apoptotic and pro-apoptotic determinants of mitochondrial-mediated apoptosis, and their relative expression determines the cell fate. The promoter polymorphisms in these genes were shown to alter the protein function or expression and exert an impact on apoptosis regulation. Deregulation in the expression of any of these genes leads to disruption of cellular homeostasis and malignant transformation. The present study was aimed to determine the association of BCL2-938C>A and BAX-248G>A promoter polymorphisms with origin and progression of acute myeloid leukemia (AML). We also have performed combined genotype analysis to evaluate the cumulative effect of risk genotypes in the AML development. These polymorphisms were genotyped by polymerase chain reaction- restriction fragment length polymorphism (PCR-RFLP) in 221 AML patients and 305 age- and sex-matched healthy controls. Our study revealed that BCL2-938CA (p = 0.018) and BAX-248GG (0.043) genotypes were significantly associated with increased risk for AML occurrence. BAX-248A allele had shown decreased risk for AML. The combined analysis had shown that BCL2-938CA+AA-BAX-248GG group had a 1.63-fold (95 % CI: 1.08-2.45, p = 0.02) increased risk for AML. None of the clinical variables had shown any significant association with both polymorphisms. With respect to complete remission (CR) rate, BAX-248GG genotype (p = 0.002) and G allele (p = 0.009) had conferred significant risk for complete remission failure. Although the log rank test was not significant, survival analysis had shown a trend where BCL2-938CA genotype, and BAX-248GG had reduced median disease-free survival (DFS) of 9 and 10 months, respectively. In conclusion, BCL2-938C>A and BAX-248G>A gene polymorphisms might contribute to the origin of AML. Moreover, influence of BAX-248GG genotype on CR and DFS rate suggests that the BAX-248G>A polymorphism can serve as marker for poor prognosis in AML.

Endobronchial spillage of fungal material into normal lung can infect it and the spillage of fungal material should be prevented during surgery. We report our experience of a patient who presented for right upper lobectomy with bronchiectasis, tubercular destruction and subsequent aspergilloma. A 4F Fogarty catheter was introduced through the tracheal lumen of the left sided endobronchial double lumen tube (DLT) to occlude the bronchus intermedius to prevent spillage of aspergilloma into the non-infected lower and middle lobes of the right lung. The Fogarty catheter was pulled into the trachea just before stapling the bronchus; thereafter, right upper lobectomy was completed successfully. The patient was extubated uneventfully and transferred to post-operative recovery ward. The endobronchial blockage of the intermediate bronchus of the operative lung by the Fogarty catheter and isolation of the left lung by the DLT prevented spillage of aspergilloma in both the operative right lung and the left lung.

The human homologue of the mouse double minute 2 (MDM2) gene is a negative regulator of Tp53. MDM2-309TG a functional promoter polymorphism was found to be associated with overexpression thereby attenuation of Tp53 stress response and increased cancer susceptibility. We have planned to evaluate the possible role of MDM2-309TG polymorphism with risk and response to chemotherapy in AML.A total of 223 de novo AML cases and 304 age and sex matched healthy controls were genotyped for the MDM2-309TG polymorphism through the tetra-primer amplification refractory mutation system (ARMS)-PCR method. In order to assess the functional relationship of -309TG SNP with MDM2 expression level, we quantified MDM2 mRNA in 30 primary AML blood samples through quantitative RT-PCR. Both the (-309TG) genotypes and the MDM2 expression were correlated with disease free survival (DFS) rates among patients who have achieved complete remission (CR) after first induction chemotherapy.MDM2-309TG polymorphism was significantly associated with AML development (p0.0001). The presence of either GG genotype or G allele at MDM2-309 confered 1.79 (95% CI: 1.12-2.86; p0.001) and 1.46 fold (95%CI: 1.14-1.86; p=0.003) increased AML risk. Survival analysis revealed that CR+ve cases with GG genotype had significantly increased DFS rates (16months, p=0.05) compared to CR+ve TT (11 months) and TG (9 months) genotype groups. Further, MDM2 expression was also found to be significantly elevated in GG genotype patients (p=0.0039) and among CR+ve cases (p=0.0036).The MDM2-309TG polymorphism might be involved in AML development and also serve as a good prognostic indicator.

Context: Nurses in India often practice in resource-constrained settings and care for cancer patients with high symptom burden yet receive little oncology or palliative care training. Aim: The aim of this study is to explore challenges encountered by nurses in India and offer recommendations to improve the delivery of oncology and palliative care. Methods: Qualitative ethnography. Setting: The study was conducted at a government cancer hospital in urban South India. Sample: Thirty-seven oncology/palliative care nurses and 22 others (physicians, social workers, pharmacists, patients/family members) who interact closely with nurses were included in the study. Data Collection: Data were collected over 9 months (September 2011– June 2012). Key data sources included over 400 hours of participant observation and 54 audio-recorded semi-structured interviews. Analysis: Systematic qualitative analysis of field notes and interview transcripts identified key themes and patterns. Results: Key concerns of nurses included safety related to chemotherapy administration, workload and clerical responsibilities, patients who died on the wards, monitoring family attendants, and lack of supplies. Many participants verbalized distress that they received no formal oncology training. Conclusions: Recommendations to support nurses in India include: prioritize safety, optimize role of the nurse and explore innovative models of care delivery, empower staff nurses, strengthen nurse leadership, offer relevant educational programs, enhance teamwork, improve cancer pain management, and engage in research and quality improvement projects. Strong institutional commitment and leadership are required to implement interventions to support nurses. Successful interventions must account for existing cultural and professional norms and first address safety needs of nurses. Positive aspects from existing models of care delivery can be adapted and integrated into general nursing practice.

The objective of study was to determine the frequency of prediabetes and observe the influence of various risk factors on the development of prediabetes at Liaquat University Hospital, Hyderabad. Descriptive case series. Medical outpatient department Liaquat University Hospital, Hyderabad. From 01-03-2007 to 31-03-2008. Total 500 subjects with BMI>25 and aged either 45 year and above or BMI>25, with an additional risk factor were enrolled for the study.All diagnosed patients of diabetes were excluded from study. A well designed proforma included demographic information, history regarding first degree relative with diabetes, gestational diabetes, delivery of large baby and related investigations. Fasting blood glucose (FBG)≥100 mg/dl but

Background: Patients with recurrent and metastatic head and neck Squamous Cell Cancer (HNSCC) have poor prognosis with limited treatment options. In view of decimal prognosis, the treatment decision should include quality of life (QOL) issues, cost-effectiveness besides the response rates and survival. Aim: Present retrospective analysis was conducted to evaluate efficacy (disease-free survival), pharmacoeconomics, and toxicity profile of four (4) different regimens, viz. gefitinib alone, gefitinib with methotrexate, methotrexate alone, or 5-FU with cisplatin. Materials and Methods: Case records between 2007 September and 2008 September were analyzed, 68 patients were found suitable for analysis. Patients received gefitinib (250 mg/day), methotrexate as 50 mg intramuscular weekly or a combination of the same or 5-FU 750 mg/m 2 /day for 4 days along with cisplatin 75 mg/m 2 /day on day 1 in 21-day cycle. Results: A total of 68 patients received therapy. Fifty-one patients have clinically meaningful response (stable disease + complete + partial responses) (75%) and had symptomatic improvement. The median progression-free survival was significantly superior in responders (those who achieved partial or complete response) (8.4 months vs. 3.1 months, P=0.001). Methotrexate with gefitinib had maximum median survival and better overall QOL compared to the other treatment regimens. Weekly methotrexate is relatively cost-effective followed by methotrexate with gefitinib and gefitinib alone. 5-FU with cisplatin in our experience does not appear so attractive in view of high complication rates (when given in full doses) and prolonged hospital stay. Conclusion: Based on the results of this retrospective analysis, methotrexate weekly as single agent or in combination with gefitinib appears as an attractive alternative regimen for patients with metastatic HNSCC including those having poor performance status. A prospective study was planned and submitted to the local ethics committee based on above results to validate these results and compare methotrexate and gefitinib arm with 5-FU + cisplatin.

Background: One of the most distressing complications of head and neck cancer patients on chemoradiotherapy is mucositis. There is no proper tool to predict its occurrence in these patients. Aim: This study was conducted to develop a risk-scoring system to predict probable incidence and severity of mucositis in head and neck cancer patients on chemoradiotherapy. Materials and Methods: This is a retrospective analysis conducted at a tertiary care cancer center with approximately 2,000 new cases of head and neck cancer patients annually. We Hypothesized were age, comorbid conditions, leukocyte count, nutritional status, oral hygiene, tobacco use, erythrocyte sedimentation rate (ESR); Eastern cooperative oncology group (ECOG) performance status (PS) and TNM (tumor, node, metastasis) stage as possible risk factors. Receiver operating characteristic (ROC) curves were drawn to predict the cutoff values for risk factors, and a final scoring system was developed with sensitivity and specificity data. Results: A total of 218 patients on chemoradiation receiving cisplatin 40 mg/m 2 /week along with local radiation of 60-70 Gy depending on primary site were analyzed. Based on ROC analysis, the following cutoff values were selected: age > 40 years, ECOG PS > 2, WBC < 3000/μL, elevated ESR, albumin < 3 gm/dL and > stage III disease. The remaining factors were indicated as present or absent. A score of 1 was assigned for the above risk factors. For patients, the final score of 3 or less there is 17% probability of developing grade 3 or 4 mucositis, while patients having score of 6 or more have 76% probability. Conclusion: The current tool is fairly accurate in predicting development of mucositis in head and neck caner patients on chemoradiotherapy. This will further help clinicians to adopt preventive strategies as well as better counseling.

Health-related quality of life (HRQL) experienced by children with cancer is more important than ever before as survival rates are increasing. The aim of this study was to assess the HRQL of children with cancer in a developing country, using physician proxy assessments.The Health Utilities Index (HUI) was chosen as the measurement tool and physicians' assessments were obtained using an HUI proxy-respondent interview-administered questionnaire.A total of 45 patients and their physicians (n=6) were recruited from 2 hospitals in Andhra Pradesh, India. Most of the children had acute lymphoblastic leukaemia. There were no differences in patterns observed between cancer types for the child's HRQL, but there was wide variation in the total HRQL scores among the children. This variation was more evident in certain aspects of children's life such as emotion and pain.This study has shown that HRQL as determined by physician proxy assessments in children with cancer in India is compromised, matching results in similar populations elsewhere.

Background: Apoptosis plays a pivotal role in maintaining cellular homeostasis mainly in rapidly proliferating tissue like hematopoietic tissue. Defective apoptosis is one of the hallmarks of cancer as it plays a crucial role in malignant transformation through disruption of homeostasis mechanism resulting in acquired chemo-resistance. Aim: The functional single nucleotide polymorphisms (SNPs) in apoptotic genes can influence the gene expression leading to altered apoptosis that may promote malignancy. Moreover, these SNPs might also influence the treatment outcome, since most of the chemotherapeutic drugs being used are aimed to induce apoptosis of malignant cells. The present study mainly aims to evaluate the role of SNPs in BCL2 (-938C>A (rs2279115); BAX (-248G>A (rs4645878), CASP9 [-1263A>G (rs4645978); -712C>T (rs4645981); -293del (rs4645982); Ex5+32G>A (rs1052576)] with development of acute myeloid leukemia (AML) and treatment outcome in terms of disease free survival (DFS) among patients who have achieved complete remission(CR) rates after first induction chemotherapy. Methods: The study includes 225 AML cases and 307 age-gender matched controls for case-control comparison. The study was approved by ethical committee of Osmania University. Before collecting 5ml of blood sample, each participant had provided written informed consent. Baseline line clinical characteristics and follow-up data were collected from the tumor registries with the help of oncologist. Genomic DNA was extracted and SNPs were genotyped using PCR, RFLP, Tetra primer techniques. The genotype data was subjected to various statistical analyses to correlate with disease occurrence and treatment outcome in terms of CR and DFS rates using SPSS Software. We have also performed non parametric analysis to know gene-gene interaction through Multi Dimensionality Reduction (MDR). Results: The single SNP analysis had revealed that BCL2 (rs2279115), BAX (rs4645878), CASP9 (rs4645978) and CASP9 (rs4645982) were significantly associated with the origin of AML. Survival analysis had shown that minor alleles of both CASP9 (rs4645978 and rs4645982) SNPs were associated with reduced DFS rates (log rank p = 0.02). Further, cox regression analysis had also confirmed these observations where CASP9 rs4645978 (HR = 1.91; 95%CI = 1.19-3.07; p = 0.008) and rs4645982 (HR = 1.88; 95%CI = 1.06-3.35; p = 0.03) had elevated risk for relapse and shorter DFS rates. The MDR analysis had revealed that CASP9 (rs4645981) is the highest predicting variable. The best interaction model was found to be CASP9 (-1263A>G (rs4645978); -712C>T (rs4645981); and BCL2 (rs2279115) with CVC = 8/10 and TAB = 0.604. Conclusion: Our results suggest that CASP9 (rs4645978 and rs4645982) SNPs might influence the AML development and DFS rates after first induction chemotherapy. Citation Format: Anuradha Cingeetham, Sugunakar Vuree, Nageswara Rao Dunna, Manjula Gorre, Raghunadharao Digumarti, Sudha Sinha, Vishnupriya Satti. Influence of intrinsic apoptotic pathway gene polymorphisms on the development and progression of acute myeloid leukemia: Case-control study. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4625. doi:10.1158/1538-7445.AM2015-4625

The widespread use of “routine” automated blood testing in primary care practice appears to have increased the demand for consultative services by hematologists. To explore this hypothesis, we tracked consecutive first-time referrals to our university hospital hematology clinic retrospectively between July 2002 and June 2003 and prospectively from July 2003 to May 2004. Findings were similar in both time intervals and thus are combined for reporting. Of 557 consultative referrals, 326 patients (58.5 %) were referred for abnormalities of the peripheral blood counts, 209 (64%) of which were detected as incidental findings in asymptomatic patients. 144 (26%) of all referrals were for anemia and 79 (55%) of those proved to have primary medical conditions including active alcoholism, medication effects, chronic renal failure, iron deficiency, chronic inflammatory diseases or advanced liver disease. The rest had hematological disorders including, myelodysplastic syndromes, hemoglobinopathies, hemolytic anemias, and others. 66 (12%) of all referrals were for abnormalities of the white blood cell count and only 24 (36%) turned out to have a primary hematological disorder (e.g. CLL, CML or benign chronic leukopenia). The other 42 (64%) had primary medical disorders including leukocytosis of smoking or pregnancy, allergies, anti-convulsant-related leukopenia, etc. 50 patients were referred for thrombocytopenia or thrombocytosis, of which 29 (58%) had primary medical disorders including iron deficiency or inflammatory states, gestational thrombocytopenia, known hypersplenism, medication-related thrombocytopenia, or alcoholism. Similarly 20 of the 40 patients referred for bi- or pancytopenias had primary hematological disorders and 20 had medical disorders that included hypersplenism, drugs, or mild disorders that resolved by the time of referral. The remaining 231 patients (41.5%) included 69 who were referred for evaluation of, and counseling for, hypercoagulable disorders, 39 referred for presumed bleeding disorders (4 had senile purpura; 9 had storage pool disorders), 9 with hereditary hemochromatosis, 51 with hematological malignancies, 12 with unexplained lymphadenopathy (8 with infectious mononucleosis or other reactive lymphadenopathy, 1 with enlarged tonsils, 1 CLL, 1 T-cell lymphoma, 1 Kimura’s disease) and 9 patients with polyclonal hyperglobulinemia. Overall, only 45 % of the patients referred for consultation turned out to have a primary hematological disorder. The rest had conditions that are traditionally considered to be in the realm of internal medicine or primary care. Most consults were initiated based on incidental abnormalities of the CBC that were not, or could not be, worked up by the referring physician. Thus primary care practitioners are relying on hematologists to explain routine findings in often-asymptomatic patients with fortuitous abnormalities of the peripheral blood counts. Medical surveillance of asymptomatic patients is likely to result in progressively early detection of subtle changes in the CBC that internists and others will rely on hematologists to explain. Thus the hematologist’s role as consultant continues to expand.