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BackgroundTelemedicine has revolutionized health care by significantly enhancing accessibility and convenience, yet barriers remain, such as providers’ challenges with technology use. With advancements in telemedicine technologies, understanding the viewpoints of patients and providers is crucial for an effective and acceptable telemedicine service. This study reports the findings on the usability and effectiveness of the HelixVM artificial intelligence powered platform, analyzing key aspetcs like asynchronous health care, access, time efficiency, productivity, data exchange, security, privacy, and quality of care from patient and provider perspectives. ObjectiveThis study aims to assess the usability and effectiveness of the HelixVM marketplace platform. MethodsWe recruited 102 patients and 12 providers in a mixed methods study design involving surveys and in-depth structured interviews with a subset of the providers. The survey questionnaires are a modified version of the Telehealth Usability Questionnaire. We analyzed patient data using descriptive statistics and exploratory factor analysis to identify latent demographic patterns. For provider data, we used a deductive thematic analysis approach to identify key themes from the interviews and interpreted overall sentiments of the providers as negative, neutral, or positive. We also calculated percentages of different provider responses from the survey and interviews, where applicable. ResultsOverall, 86.3% (88/102) of the patients reported satisfaction with HelixVM, and 89.2% (91/102) indicated that they would use the services again. A total of 91.1% (93/102) of the patients agreed that HelixVM improves access to health care and is an acceptable way to receive health care, and 98% (100/102) agreed it saves time. Chi-square tests demonstrated statistical significance for all survey questions (P

Abstract Background The advent of immune checkpoint inhibitors (ICIs) represented a significant breakthrough in cancer therapy. Recently, the combined use of atezolizumab and bevacizumab was approved as first‐line treatment for unresectable hepatocellular carcinoma (HCC). Exposure to a novel and diverse spectrum of immune‐related adverse events (irAEs) has increased with the growing utilization of ICIs, however, a comprehensive understanding surrounding newer agents is still lacking. The incidence of kidney toxicities is rare but rising, often underreported due to the lack of confirmatory biopsies. Here, we present a rare case of biopsy‐proven acute interstitial nephritis (AIN) following atezolizumab‐bevacizumab treatment of advanced unresectable HCC. Case An 84‐year‐old male with T4N0M0 hepatocellular carcinoma was admitted after cycle 5 of atezolizumab due to decreased urine output and dysuria with a serum creatine of 4.7 mg/dL compared to a baseline of 1.3 mg/dL. To confirm the diagnosis of possible intrinsic renal injury, an ultrasound‐guided non‐focal biopsy of the left kidney was performed, revealing AIN. Potential exacerbatory medications, such as proton‐pump inhibitors, were discontinued. The patient was discharged on oral steroids with improvement in serum creatinine. Before completing the steroid taper, the patient developed pneumocystis pneumonia and eventually transitioned to hospice care. Conclusion This case highlights the valuable role renal biopsy can play in accurately capturing irAEs and guiding appropriate management in the setting of ICI‐induced AKI. It also exemplifies important considerations for steroid treatment of irAEs in the setting of comorbidities, such as diabetes.

IntroductionFluorescence in situ hybridization (FISH) is an essential ancillary study used to identify clinically aggressive subsets of large B-cell lymphomas that have MYC, BCL2, or BCL6 rearrangements. Small-volume biopsies such as fine needle aspiration biopsy (FNAB) and core needle biopsy (CNB) are increasingly used to diagnose lymphoma and obtain material for ancillary studies such as FISH. However, the performance of FISH in small biopsies has not been thoroughly evaluated or compared to surgical biopsies.MethodsWe describe the results of MYC, BCL2, and BCL6 FISH in a series of 222 biopsy specimens, including FNAB with cell blocks, CNBs, and surgical excisional or incisional biopsies from 208 unique patients aggregated from 6 academic medical centers. A subset of patients had FNAB followed by a surgical biopsy (either CNB or excisional biopsy) obtained from the same or contiguous anatomic site as part of the same clinical workup; FISH results were compared for these paired specimens.ResultsFISH had a low hybridization failure rate of around 1% across all specimen types. FISH identified concurrent MYC and BCL2 rearrangements in 20 of 197 (10%) specimens and concurrent MYC and BCL6 rearrangements in 3 of 182 (1.6%) specimens. The paired FNAB and surgical biopsy specimens did not show any discrepancies for MYC or BCL2 FISH; of the 17 patients with 34 paired cytology and surgical specimens, only 2 of the 49 FISH probes compared (4% of all comparisons) showed any discrepancy and both were at the BCL6 locus. One discrepancy was due to necrosis of the CNB specimen causing a false negative BCL6 FISH result when compared to the FNAB cell block that demonstrated a BCL6 rearrangement.DiscussionFISH showed a similar hybridization failure rate in all biopsy types. Ultimately, MYC, BCL2, or BCL6 FISH showed 96% concordance when compared across paired cytology and surgical specimens, suggesting FNAB with cell block is equivalent to other biopsy alternatives for evaluation of DLBCL or HGBCL FISH testing.

Background: Autoantibodies are commonly used as biomarkers in autoimmune diseases, but there are limitations. For example, autoantibody biomarkers have poor sensitivity or specificity in systemic lupus erythematosus and do not exist in the spondyloarthropathies, impairing diagnosis and treatment. While autoantibodies suitable for strong biomarkers may not exist in these conditions, another possibility is that technology has limited their discovery. The purpose of this study was to use a novel high-density peptide array that enables the evaluation of IgG binding to every possible linear antigen in the entire human peptidome, as well as a novel machine learning approach that incorporates ELISA validation predictability in order to discover autoantibodies that could be developed into sensitive and specific markers of lupus or spondyloarthropathy. Methods: We used a peptide array containing the human peptidome, several viral peptidomes, and key post-translational modifications (6 million peptides) to quantify IgG binding in lupus, spondyloarthropathy, rheumatoid arthritis, Sjögren’s disease, and control sera. Using ELISA data for 70 peptides, we performed a random forest analysis that evaluated multiple array features to predict which peptides might be good biomarkers, as confirmed by ELISA. We validated the peptide prediction methodology in rheumatoid arthritis and COVID-19, conditions for which the antibody repertoire is well-understood, and then evaluated IgG binding by ELISA to peptides that we predicted would be highly bound specifically in lupus or spondyloarthropathy. Results: Our methodology performed well in validation studies, but peptides predicted to be highly and specifically bound in lupus or spondyloarthropathy could not be confirmed by ELISA. Conclusions: In a comprehensive evaluation of the entire human peptidome, highly sensitive and specific IgG autoantibodies were not identified in lupus or spondyloarthropathy. Thus, the pathogenesis of lupus and spondyloarthropathy may not depend upon unique autoantigens, and other types of molecules should be sought as optimal biomarkers in these conditions.

Background and Aims: The incidence of ulnar nerve sparing has declined with the corner-pocket approach of the supraclavicular block (SCB), however, it continues to persist. A recent technique of SCB, the intertruncal approach, separately blocks each trunk of the brachial plexus. Thus, we hypothesised that the intertruncal approach results in a complete ulnar nerve blockade. Methods: Eighty-eight patients were randomised to undergo SCB using an ultrasound (USG)-guided corner-pocket or intertruncal approach and were compared primarily regarding the complete sensory and motor blockade of the ulnar nerve and all four nerves (ulnar, radial, median and musculocutaneous nerves) at 15 min. Secondary objectives included time required for block performance, patient discomfort score, time to readiness for surgery and duration of sensory blockade of the ulnar nerve. Continous data were compared using an independent t-test, and categorical data were compared using the Chi-square test. Results: The proportion of participants with complete sensory (30/44 vs. 14/44, P < 0.001) and complete motor (22/44 vs. 7/44, P < 0.001) blocks in the ulnar nerve and all four nerves at 15 min was significantly higher in the intertruncal group. Block performance time and patient discomfort score were higher in the intertruncal group (P < 0.001). The total duration of sensory blockade in the ulnar nerve was more in the corner-pocket group (P < 0.001). Conclusion: USG-guided intertruncal approach is superior to the corner-pocket approach of SCB regarding a complete ulnar nerve blockade.

Single atom catalysts have exhibited high selectivity for hydrogenation, yet improved selectively is often accompanied by loss of activity. Here the authors report that synergistic interactions of neighboring Pd single atoms lead to both high activity and selectivity for hydrodehalogenation catalysis.

Machine learning (ML) is vital to many application-driven fields, such as image and signal classification, cyber-security, and health sciences. Unfortunately, many of these fields can easily have their training data tampered with by an adversary to thwart an ML algorithm’s objective. Further, the adversary can impact any stage in an ML pipeline (e.g., preprocessing, learning, and classification). Recent work has shown that many models can be attacked by poisoning the training data, and the impact of the poisoned data can be quite significant. Prior works on adversarial feature selection have shown that the attacks can damage feature selection (FS). Filter FS algorithms, a type of FS, are widely used for their ability to model nonlinear relationships, classifier independence and lower computational requirements. One important question from the security perspective of these widely used approaches is, whether filter FS algorithms are robust against other FS attacks. In this work, we focus on the task of information-theoretic filter FS such MIM, MIFS, and mRMR, and the impact that gradient-based attack can have on these selections. The experiments on five benchmark datasets demonstrate that the stability of different information-theoretic algorithms can be significantly degraded by injecting poisonous data into the training dataset.

Objective: Epidemic methicillin-resistant Staphylococcus aureus (MRSA) clones have been described in Ghana, but so far, no typical livestock-associated MRSA isolates (CC398) have been found. In this study we provide baseline information on antimicrobial resistance, population structure, and virulence gene content of S. aureus isolates from livestock and farm attendants. Methods: Nasal samples were collected from cattle, pigs, goats, sheep, and farm attendants from three farms. Staphylococcus aureus was identified by matrix-assisted laser desorption/ionisation time-of-flight and antimicrobial susceptibility testing was performed using VITEK II (Biomerieux, Marcy l'Etoile, France) and interpreted according to EUCAST guidelines. Whole-genome sequencing was performed using the Illumina, San Diego, CA, USA MiSeq Platform. Results: In total, 401 nasal swab samples were obtained from 57 farm attendants, 208 pigs, 30 goats, 26 sheep, and 80 cattle. The S. aureus isolates (n = 25) recovered (farm attendants: n = 10; pigs: n = 8; and goats: n = 7) were frequently resistant to penicillin (68%), tetracycline (44%), and ciprofloxacin (32%); two human isolates were MRSA. Twelve isolates (48%) were multidrug resistant (MDR) (>3 classes). Genome sequencing of the isolates revealed ST152-t355, ST9-t1430, and ST133-t8662 as dominant clones among farm attendants, pigs, and goats, respectively. The two MRSA isolates detected belonged to ST8-t334 and ST152-t355. The scn and sak genes associated with human-adaption were detected in 10 isolates; 9 from humans and 1 from a goat. Typing results provided evidence of a single potential transmission event (t861, PVL-, scn+). Conclusion: No MRSA was detected among livestock, perhaps because of low intensive farming; however, the relatively high prevalence of MDR isolates may be a result of inappropriate antibiotic usage in Ghanaian livestock production.

Abstract The therapeutic options for disease modification in relapsing-remitting multiple sclerosis (RRMS) have expanded remarkably in the last 15 years. Although intravenous immunoglobulins (IVIg) have shown some therapeutic effects in multiple sclerosis, reducing global supplies, restriction of treatment to essential indications and availability of effective alternative treatments for MS currently exclude IVIg from being an accepted therapy for MS, other than for some exceptional considerations. We report the case of a female patient with RRMS who was diagnosed with Ehlers-Danlos syndrome (EDS) and Muir-Torre syndrome (MTS) soon after the diagnosis of active RRMS was made. The coexisting conditions precluded the use of available disease-modifying treatments. She benefited from monthly and then bi-monthly IVIg, with a single mild relapse over 10 years. Discontinuation of IVIg due to reduced availability with a brief aborted course of subcutaneous PEGylated interferon-beta was followed by significant relapses. Five months after the first ocrelizumab infusion, she developed caecal cancer requiring colectomy. Reinstitution of IVIg is contemplated.

Shotgun metagenomics is a powerful tool to identify antimicrobial resistance (AMR) genes in microbiomes but has the limitation that extrachromosomal DNA, such as plasmids, cannot be linked with the host bacterial chromosome. Here we present a comprehensive laboratory and bioinformatics pipeline HAM-ART (Hi-C Assisted Metagenomics for Antimicrobial Resistance Tracking) optimised for the generation of metagenome-assembled genomes including both chromosomal and extrachromosomal AMR genes. We demonstrate the performance of the pipeline in a study comparing 100 pig faecal microbiomes from low- and high-antimicrobial use pig farms (organic and conventional farms). We found significant differences in the distribution of AMR genes between low- and high-antimicrobial use farms including a plasmid-borne lincosamide resistance gene exclusive to high-antimicrobial use farms in three species of Lactobacilli. The bioinformatics pipeline code is available at https://github.com/lkalmar/HAM-ART.

Abstract Background The introduction of rotavirus A vaccination across the developing world has not proved to be as efficacious as first hoped. One cause of vaccine failure may be infection by zoonotic rotaviruses that are very variable antigenically from the vaccine strain. However, there is a lack of genomic information about the circulating rotavirus A strains in farm animals in the developing world that may be a source of infection for humans. We therefore screened farms close to Accra, Ghana for animals sub-clinically infected with rotavirus A and then sequenced the virus found in one of these samples. Results 6.1% of clinically normal cows and pigs tested were found to be Rotavirus A virus antigen positive in the faeces. A subset of these (33.3%) were also positive for virus RNA. The most consistently positive pig sample was taken forward for metagenomic sequencing. This gave full sequence for all open reading frames except segment 5 (NSP1), which is missing a single base at the 5′ end. The virus infecting this pig had genome constellation G5-P[7]-I5-R1-C1-M1-A8-N1-T7-E1-H1, a known porcine genotype constellation. Conclusions Farm animals carry rotavirus A infection sub-clinically at low frequency. Although the rotavirus A genotype discovered here has a pig-like genome constellation, a number of the segments most closely resembled those isolated from humans in suspected cases of zoonotic transmission. Therefore, such viruses may be a source of variable gene segments for re-assortment with other viruses to cause vaccine breakdown. It is recommended that further human and pig strains are characterized in West Africa, to better understand this dynamic.

Smart city infrastructures enable the routine interleaving and integration of diverse activities, including new ways to play, to be playful, and to participate. We discuss three examples: (1) citizen-based water quality monitoring, which combines outdoor exercise and social interaction with safeguarding public water supplies, (2) a digital scavenger hunt, which combines the experiences of a community arts festival with shared reflections about significant community places and events, and (3) public thanking, which encourages people to acknowledge neighbors and local groups that serve and strengthen the community. Each of these interaction possibilities in itself alters lived experience modestly. We argue that lightweight and playful meaning making activities can be prosocial fun, that is to say, they can simultaneously be playful and fun, but also substantive contributions to the coherence and richness of a community.

Abstract Campylobacter is the most common cause of foodborne bacterial illness worldwide. Faecal contamination of meat, especially chicken, during processing represents a key route of transmission to humans. There is a lack of insight into the mechanisms driving C. jejuni growth and survival within hosts and the environment. Here, we report a detailed analysis of C. jejuni fitness across models reflecting stages in its life cycle. Transposon (Tn) gene-inactivation libraries were generated in three C. jejuni strains and the impact on fitness during chicken colonisation, survival in houseflies and under nutrient-rich and –poor conditions at 4 °C and infection of human gut epithelial cells was assessed by Tn-insertion site sequencing (Tn-seq). A total of 331 homologous gene clusters were essential for fitness during in vitro growth in three C. jejuni strains, revealing that a large part of its genome is dedicated to growth. We report novel C. jejuni factors essential throughout its life cycle. Importantly, we identified genes that fulfil important roles across multiple conditions. Our comprehensive screens showed which flagella elements are essential for growth and which are vital to the interaction with host organisms. Future efforts should focus on how to exploit this knowledge to effectively control infections caused by C. jejuni.

Campylobacter spp. are a leading cause of bacterial enteritis worldwide, including countries in Africa, and have been identified by the World Health Organisation (WHO) as one of the high priority antimicrobial resistant pathogens. However, at present there is little knowledge on the prevalence, molecular epidemiology or antimicrobial susceptibility of Campylobacter spp. isolates in Botswana, both in patients and in the zoonotic context. Some data indicate that ~14% of diarrhoeal disease cases in a paediatric setting can be ascribed to Campylobacter spp., urging the need for the magnitude of Campylobacter-associated diarrhoea to be established. In this survey, we have characterised the genomic diversity of Campylobacter spp. circulating in Botswana isolated from cases of diarrhoeal disease in humans (n = 20) and from those that colonised commercial broiler (n = 35) and free-range (n = 35) chickens. Phylogeny showed that the Campylobacter spp. isolated from the different poultry and human sources were highly related, suggesting that zoonotic transmission has likely occurred. We found that for Campylobacter spp. isolated from humans, broilers and free-range chickens, 52% was positive for tetO, 47% for gyrA-T86I, 72% for blaOXA-61, with 27% carrying all three resistance determinants. No 23S mutations conferring macrolide resistance were detected in this survey. In summary, our study provides insight into Campylobacter spp. in poultry reservoirs and in diarrhoeal patients, and the relevance for treatment regimens in Botswana.

Malignant changes in polyostotic fibrous dysplasia are very rare. Most common malignancies reported are osteosarcoma and fibrosarcoma, chondrosarcoma and malignant fibrous histiocytoma. Here, we report a previously diagnosed case of fibrous dysplasia who has developed leiomyosarcoma; diagnosis of which was delayed for about one year despite repeated fine needle aspiration and open biopsy.

We report a case of 41-year-old lady who presented with chronic headache of 6-month duration and a sellar mass with a suprasellar extension on imaging, which was interpreted as pituitary macroadenoma. She had normal pituitary function and visual perimetry. On clinical examination and imaging it was provisionally diagnosed as pituitary incidentaloma due to hypophysitis and she was advised steroid therapy, but underwent transnasal resection of the tumor against suggestion. Histopathological examination revealed combined granulomatous and lymphocytic hypophysitis most likely of autoimmune in origin. Definitive diagnosis of hypophysitis can be made only on histopathological examination. As most cases of autoimmune hypophysitis are surgically treated, patients should be assessed on individual basis for requirement of steroids in postoperative period.

Germination of dormant spores of Bacillus species is initiated when nutrient germinants bind to germinant receptors in spores' inner membrane and this interaction triggers the release of dipicolinic acid and cations from the spore core and their replacement by water. Bacillus subtilis spores contain three functional germinant receptors encoded by the gerA, gerB, and gerK operons. The GerA germinant receptor alone triggers germination with L-valine or L-alanine, and the GerB and GerK germinant receptors together trigger germination with a mixture of L-asparagine, D-glucose, D-fructose and KCl (AGFK). Recently, it was reported that the B. subtilis gerW gene is expressed only during sporulation in developing spores, and that GerW is essential for L-alanine germination of B. subtilis spores but not for germination with AGFK. However, we now find that loss of the B. subtilis gerW gene had no significant effects on: i) rates of spore germination with L-alanine; ii) spores' levels of germination proteins including GerA germinant receptor subunits; iii) AGFK germination; iv) spore germination by germinant receptor-independent pathways; and v) outgrowth of germinated spores. Studies in Bacillus megaterium did find that gerW was expressed in the developing spore during sporulation, and in a temperature-dependent manner. However, disruption of gerW again had no effect on the germination of B. megaterium spores, whether germination was triggered via germinant receptor-dependent or germinant receptor-independent pathways.

Fanconi’s Anemia is primarily an autosomal recessive genetic disorder characterized by congenital abnormalities, defective haematopoiesis leading to bone marrow failure and increased risk of development of Myelodysplastic syndrome,acute myeloid leukemia and solid tumours.Chromosomal instability can be demonstrated by breakage caused by alkylating agents and forms the basis of diagnosis.Our patient presented with structural deformities associated with features of bone marrow failure in form of pancytopenia. Bone marrow analysis and flow cytometry done on aspirate was suggestive of MDS.He subsequently progressed to frank acute myeloid leukemia and succumbed to the illness.The case is being reported for its rarity especially, Fanconi’s Anemia associated with two chromosomal abnormality i.e monosomy 7 and trisomy21.

Introduction AML and ALL differ substantially in response to therapy and course, and accurate differentiation of the two is fundamental to therapeutic decisions. Immunophenotyping helps in accurate differentiation between the two and various guidelines have been proposed regarding minimal screening antibody panel. Material and methods Eighty two cases of consecutive acute leukemias reporting to this hospital over a period of two years were included in the study. Peripheral blood smear, bone marrow aspirate and bone marrow biopsy were studied using morphology, cytochemical stains and relevant immunohistochemistry stains on selected biopsy specimens. FCM analysis was done on peripheral blood or bone marrow aspirate using Indian consensus screening panel and our proposed minimal screening panel for comparison. Result Out of 82 cases of acute leukemias, by morphology alone 75.6% and by combined morphology and cytochemistry 93.90% of cases were classified correctly into lymphoid and myeloid lineage. By immunophenotyping using proposed minimal screening panel 95.12% and Indian consensus minimal screening panel 93.90% of cases were classified into myeloid and lymphoid lineage. Conclusion Proposed minimal screening panel can be used as a substitute for Indian consensus minimal screening panel as it includes lineage specific cytoplasmic antibodies and a lesser number of monoclonal antibodies(mAbS).

Context: Acute promyelocytic leukemia (APL), an AML subtype, is characterized morphologically by abnormal promyelocytes. Cytogenetically, PML-RAR? fusion gene shows 3 possible bcr isoforms. This study undertakes analysis of PML-RAR? bcr isoforms and their correlation with hematological parameters and response to treatment in Indian patients. Aims: To study different bcr isoforms in Indian patients and to find any correlation with various hematological parameters and response to treatment Settings and Design: Patients diagnosed as APL on morphology or flowcytometry and confirmed by RQ PCR were included in the study. Treated APL patients or patients with relapse and on follow up were excluded from the study. Methods and Material: Twenty patients over thirty one months period were included. The clinical, hematological & morphological features were analysed, the latter using routine & special cytochemical stains on blood and bone marrow . Flow cytometric evaluation using 4-color Beckman Coulter FC 500 and molecular studies using RT PCR FusionQuant® kits for bcr-1, bcr-2 and bcr-3 on the instrument Rotor Gene™ 3000 were also performed . Statistical analysis used: Student t test was applied to correlate different bcr isoforms with various haematological parameters and response to treatment. Results: In our study , M:F ratio was 1.5:1 with median age 42 years, Hb - 8.0 g/dl, TLC-7900/?l, and platelet – 35000/ ?l and varied clinical presentation. Four patients were microgranular variants and rest hypergranular . MPO and CAE positivity was 100% and 33.33% for NSE. Molecular analysis revealed bcr1 in 42.85% , bcr2 in 14.28% and bcr 3 in 38.09 % patients. No correlation was found between bcr isoforms , different hematological parameters and response to treatment . Conclusions: Higher incidence of bcr-1 was found in Indian APL patients with no significant correlation between different hematological parameters and response to treatment.

Context: Acute promyelocytic leukemia (APL), an AML subtype, is characterized morphologically by abnormal promyelocytes. Molecular studies show three possible bcr isoforms of PML- RARα fusion gene . This study undertakes analysis of PML-RARα bcr isoforms and their correlation with hematological parameters and response to treatment in Indian patients. Aims: To study different bcr isoforms in Indian patients and to find any correlation with various hematological parameters and response to treatment Settings and Design: Patients diagnosed as APL on morphology or flowcytometry and confirmed by RQ PCR were included in the study. Treated APL patients or patients with relapse and on follow up were excluded from the study. Methods and Material: Twenty patients over thirty one months period were included. The clinical, hematological & morphological features were analysed, the latter using routine & special cytochemical stains on blood and bone marrow . Flow cytometric evaluation using 4-color Beckman Coulter FC 500 and molecular studies using RT PCR FusionQuant® kits for bcr-1, bcr-2 and bcr-3 on the instrument Rotor Gene™ 3000 were performed . Statistical analysis used: Student t test was applied to correlate different bcr isoforms with various haematological parameters and response to treatment. Results: In our study , M:F ratio was 1.5:1 with median age 42 years, Hb - 8.0 g/dl, TLC-7900/μl, and platelet – 35000/ μl and varied clinical presentation. Four patients were microgranular variants and rest hypergranular . MPO and CAE positivity was 100% and 33.33% for NSE. Molecular analysis revealed bcr1 in 42.85% , bcr2 in 14.28% and bcr 3 in 38.09 % patients. No correlation was found between bcr isoforms , different hematological parameters and response to treatment. Conclusions: Higher incidence of bcr-1 was found in Indian APL patients with no significant correlation between different hematological parameters and response to treatment.

One case of acute panmyelosis with myelofibrosis (APMF) is being reported. A 45 year old male presented with abrupt onset of rapidly progressing low backache, weakness and pancytopenia. On examination there was no organomegaly. Peripheral blood examination revealed normocytic normochromic red blood cells with 10% circulating blasts. Flowcytometric examination of peripheral blood revealed blasts which were positive for CD 34 ,HLA- DR and myeloid associated antigens (i.e. CD13 and CD33).Blasts were negative for anti MPO. Bone marrow aspirate resulted in a dry tap. Bone marrow biopsy revealed panmyeloid proliferation with scattered blasts which were CD 34 positive on imunohistochemistry and negative for anti MPO. Reticulin stain showed grade III myelofibrosis (WHO). Differential diagnosis considered included AML-M7, MDS-RAEB II and AML with myelodysplasia . He was started on chemotherapy [idarubicin and cytarabine; 3+7 induction regimen followed by three cycles of HIDAC (High dose cytosine arabinoside)] after which patient was in complete morphological remission with markedly reduced bone marrow fibrosis. He is now being worked up for allogeneic stem cell transplantation. Patient is asymptomatic at eight months of diagnosis. In conclusion these patients should be managed aggressively with AML therapy and this case report reaffirms the fact that APMF is subtype of AML.