Iraqi Journal of Hematology

Abstract:
BACKGROUND: The onus of red blood cell transfusions in the pediatric emergency rooms (ERs) is
paramount, with no specified guidelines, and almost all current policies are based on the obtainable
adult facts.
OBJECTIVES: The aims were to study the current practice and indications of blood transfusion in
pediatric ER.
PATIENTS AND METHODS: This is a cross‑sectional study that included 50 pediatric patients
who were admitted to the ER of Children Welfare Teaching Hospital, Medical City, Baghdad, from
February to May 2017. The patients were admitted to the ER for different complaints and during their
admission, they received a blood transfusion. The decision of blood transfusion was made by the
most senior physician at different times. Patient data were tabulated and processed using Statistical
Package for the Social Sciences (SPSS) for Windows.
RESULTS: The age ranged from 15 days to 13 years, with a mean of 4.9 years. The main complaint
was pallor in 26%, followed by bleeding (14%). Hemolysis due to presumptive glucose‑6‑phosphate
dehydrogenase was the major diagnosis in 16 (32%) patients. The hemoglobin ranged from 2 to
11 g/dl, and the mean was 5.6 g/dl. The majority of decisions (28 cases, 56.0%) were made by
the third‑year resident, who is the second call on duties. Seven patients were below 4 months of
age (14%), one of them received transfusion without logical indication. Forty‑three (86%) patients
were older than 4 months of age, of whom 13 (26%) patients received transfusion without logical
scientific bases. The stay in ER ranged from 5 h to 5 days, and the mean was 26.5 h. The duration
of transfusion was ranging from 60 min to about 6 h, with a mean of 3 h.
CONCLUSIONS: The study showed major pitfalls in the management of patients with anemia. The
main obstacles to implementation are the lack of trained staff.

Abstract:
BACKGROUND: Chronic lymphocytic leukemia (CLL) is the most common type of leukemia among
adults in Western countries; however, it is relatively rare in Asia. It is characterized by abnormal
proliferation of lymphocytes in the blood, bone marrow, and lymphatic tissue. The measurement of
serum beta‑2 microglobulin (B2M) is essential for baseline workup of multiple myeloma and follicular
lymphoma patients. CD49d, an adhesion molecule mediating cell‑to‑cell and cell‑to‑extracellular
matrix interactions, represents a novel and the most reliable immunophenotypic marker regarding
prognosis and independent of other markers.
OBJECTIVES: This study aimed to assess the level of B2M and CD49d in serum CLL patients and
correlates them with treatment response.
PATIENTS AND METHODS: this is a prospective cohort study conducted on 70 patients with CLL
and 40 healthy people as a control group. Patient groups were divided into two groups: The first
group included 38 patients before receiving treatment and the second group included 32 patients
posttreatment. Diagnosis was based on lymphocyte count of >5 × 109/L and immunophenotyping.
The measurement of level B2M and CD49d in serum patients was done using enzyme‑linked
immunosorbent assay.
RESULTS: there were 53 males and 17 females, the mean age was 59.12 ± 14.23, and the most
clinical presentation was lymphadenopathy. Regarding the mean of B2M, it was 2.19 ± 0.86,
1.86 ± 0.58, and 1.41 ± 0.44 in the pre, post, and control groups, respectively, with P = 0.0001.
Regarding the mean of CD49d, it was 0.22 ± 0.15, 0.30 ± 0.44, and 0.19 ± 0.13 in the pre, post, and
control groups, respectively, with P = 0.211.
CONCLUSION: this study showed that CD49d has no clinical impact on the treatment outcome, yet
B2M has an important prognostic factor in deciding patients in advance stage.

Abstract:
BACKGROUND: Reticulocytes are immature red blood cells that contain remnants of ribonucleic
acid. Various reticulocyte parameters can help in the proper diagnosis of different anemias. It can
be measured by manual as well as by automated method.
OBJECTIVE: The aim is to compare between the manual and automated methods of reticulocyte
count (RC) in anemia.
MATERIALS AND METHODS: It was a laboratory‑based cross‑sectional study in which the
comparison of RC by manual and automated method along with various reticulocyte parameters was
done in 300 patients with anemia and 300 control samples matched for age and sex.
RESULTS: The study cases included 146 females and 154 males. No statistically significant
difference was found between the automated and manual count among the male (P = 0.77) as well
as female patients (P = 0.61). No statistically significant difference was found in mean RC among
the infants (P = 0.71), children (P = 0.59), and adults (P = 0.66) between automated and manual
count. The difference between mean manual and automated RC was statistically significant only in
the case of males in the macrocytic anemia group (P = 0.092). Among reticulocyte indices, mean
immature reticulocyte fraction (IRF), mean reticulocyte volume (MRV), and reticulocyte hemoglobin
cellular content (RHCC) was found to be statistically significant among all types of anemia (P = 0.001,
00001 and 0.0001 respectively) while it was insignificant in case of mean corrected RC (P = 0.89).
A significant positive correlation was found between manual and automated RC method by using
Pearson’s correlation coefficient (r = 0.985, P = 0.0001).
CONCLUSION: There was no significant difference between the automated and manual methods
for reticulocyte counting. However, the manual method may be preferred as it is cost‑effective; yet,
it is laborious, time‑consuming, need efficient technique, not suitable for heavily loaded laboratories
and may be suitable for under‑resourced laboratories. However, the automated method is preferred
as it is fast, highly precise, and it is mandatory for certain diseases where reticulocyte parameters
are required as a statistically significant difference was found among the different parameters such
as IRF, MRV, and RHCC.

Abstract:
BACKGROUND: Diagnosis of α‑thalassemia can be challenging as it is clinically insignificant in
the majority of patients who are presented with one or two α‑gene deletion, it cannot be always
suspected from the red cell indices, and the confirmatory tests of α‑thalassemia are not readily
available, applied, and/or provide conclusive results. The importance of diagnosis of α‑thalassemia
is mainly to identify the patients with α0‑thalassemia, hemoglobin (Hb) H disease, Hb Bart’s hydrops
fetalis, and to identify the ameliorating effect that the coinheritance of α‑thalassemia may have on the
clinical phenotype of patients with HbS and other structural β‑globin chain variants and/or patients
with beta‑thalassemia. The aim of this study is to evaluate the presentation and diagnosis of patients
with α‑thalassemia in a cohort of Iraqi patients with hemoglobinopathies.
PATIENTS, MATERIALS, AND METHODS: This is a prospective cohort study that included
216 patients diagnosed with different types of hemoglobinopathies from June 2016 to October
2019. For each patient after reviewing the cause of presentation and family history of thalassemia,
blood samples were sent for complete blood count, including calculated absolute reticulocyte count,
peripheral blood smear, Hb H preparation, serum iron and total iron‑binding capacity, sickling test,
and if indicated Hb high‑performance liquid chromatography (HPLC) (using BioRad D10). Family
study was requested for several patients.
RESULTS: Male:female for patients with α‑thalassemia is 1:1.25. Consanguinity and family history
of α‑thalassemia are present in 85.2% and 51.9%, respectively. Out of 216 patients with different
types of hemoglobinopathies, 25% are diagnosed with isolated or copresence of α‑thalassemia. Low/
lower normal HbA2% is the most sensitive parameter for the diagnosis of α‑thalassemia.
CONCLUSIONS: The most sensitive parameter for the diagnosis of α‑thalassemia in this study is the
low/lower normal HbA2% in patient with normal iron study. Other parameters such as the presence
of golf‑ball red cells in Hb H preparation and/or presence of HbH wave in Hb HPLC can be helpful
but are only seen in smaller fraction of patients.

Abstract:
BACKGROUND: Soluble urokinase plasminogen activator receptor (suPAR) in acute myeloid
leukemia (AML) is associated with resistance to chemotherapy. The aim is to assess the effect of
remission induction on plasma level of suPAR in AML patients and to correlate between plasma levels
of suPAR with certain hematological parameters, AML subtypes, and extramedullary involvement.
MATERIALS AND METHODS: The study was conducted on 30 newly diagnosed adult AML patients
and 20 controls. The peripheral blood and bone marrow smears were examined at diagnosis and
after remission induction therapy to assess complete remission (CR). The plasma level of suPAR
was measured by enzyme immunoassay which was done at diagnosis and after remission induction
therapy.
RESULTS: Plasma suPAR level was higher in AML patients at presentation than the control
group (P < 0.001). The plasma level of suPAR revealed a significant reduction in the 37% of patients
who achieved CR or partial response (P = 0.004), whereas the differences were insignificant and
remained high in patients who did not show response (P = 0.573). Before and after treatment, there
were insignificant differences in suPAR level in patients with or without extramedullary involvement
and in various AML subgroups (P > 0.05). The suPAR levels were high before starting treatment in
both the alive and those who deceased (P = 0.984). After 5 months of follow‑up, it showed a significant
reduction among the alive group (P = 0.001). There were insignificant correlations between the level
of uPAR and hematological parameters at presentation.
CONCLUSIONS: The reduction of plasma suPAR level is associated with a better response, and
a high level is associated with a high risk of death. Before and after induction therapy, there is no
association between plasma level of suPAR in monocytic group, nonmonocytic group, and in patients
with or without extramedullary involvement. Plasma suPAR level is uncorrelated with hematological
parameters at presentation.

Abstract:
BACKGROUND: Immune thrombocytopenia (ITP) is an immune‑mediated acquired disease
characterized by decrease of the platelet count. The majority of adult patients progress to chronic
stage with some of them failed to respond or relapsed after the second‑line therapy. Romiplostim
is a thrombopoietin receptor agonist recently approved for patients with chronic ITP, it was recently
licensed and introduced for use in Iraq. The aim of this study was to assess the efficacy and safety
of romiplostim among patients with refractory ITP.
PATIENTS AND METHODS: This prospective study was conducted between April 2017 and June
2018 in two hematology centers in Baghdad and Basra. A group of 56 adult patients with refractory
ITP enrolled in this study. The patients were evaluated before the weekly scheduled romiplostim
and followed for efficacy and safety of the treatment.
RESULTS: the median age was 39 years with a female‑to‑male ratio of 4:1. The response rate
(platelet ≥50 × 109/l) was observed in 75% of the enrolled patient. The time to initial response was
2.5 weeks, and the mean dose of romiplostim used to achieve a sustained response was 3.1 mcg/kg.
The response rate was significantly higher among splenectomized (94.4% vs. 65.8%). There was no
difference in response regarding the age and gender. The most frequent adverse effects were joint
pain (35.7%), followed by headache (32.1%) and fatigue (21.4%), resolved spontaneously within
2 days. Six patients developed thrombocytosis without any thrombotic event.
CONCLUSIONS: Romiplostim is an effective option among Iraqi patients with refractory ITP
as a long‑term treatment or as a bridge for another intervention, with a relatively safe toxicity
profile.

BACKGROUND: Blood group O is transfused as a universal blood group in emergencies. The red
cells of blood Group O possess no major ABO antigens, while the blood Group O plasma contains
naturally occurring IgM anti‑A and anti‑B and cross‑reacting IgG anti‑AB antibodies. Thus, the
transfusion of blood Group O units may cause marked destruction of the recipients’ A or B red
cells manifested as severe acute hemolytic transfusion reactions owing to potent ABO hemolytic
antibodies.
OBJECTIVES: This study was done to estimate the titers of anti‑ABO antibodies in Group O blood
donors and to suggest a possible scheme to introduce as a routine testing for high ABO antibodies’
titers in blood Group O donors in Iraqi blood transfusion centers.
SUBJECTS AND METHODS: Two hundred blood Group O Iraqi healthy blood donors (192 males
and 8 females, age range: 18–59) were chosen to evaluate the titer of ABO antibodies (IgM and
IgG) in their serums using tube test.
RESULTS: The prevalence of high‑titer anti‑A and anti‑B IgM antibody at 1:50 dilution in this study
was 98.5% and 97.5%, respectively (P < 0.05). The prevalence of high‑titer anti‑AB IgG measured by
dithiothreitol and 2‑mercaptoethanol method of at least 50 was 63% and 74%, respectively (P < 0.05).
CONCLUSIONS: There is a high prevalence of high‑titer anti‑A and anti‑B IgM and IgG antibodies
among blood Group O Iraqi donors. The detection of IgG antibodies is more practical by using
dithiothreitol method as it needs much shorter incubation time; however, 2‑ME is more sensitive.
Detection of high‑titer anti‑A IgM antibody in dangerous universal donors, by immediate spin at 1:50
dilution, can be used alone in practice, replacing the need to use all portfolio of tests of anti‑ABO
antibodies.

BACKGROUND: Acute myeloid leukemia (AML) is a clonal proliferation of hemopoietic cells.
Interleukin‑35 (IL‑35) is a pro‑inflammatory cytokine expressed in T regulatory (Treg) and B regulatory
cells. IL‑35 promotes the proliferation of AML blasts and lessens apoptosis. Hence, IL‑35‑derived
from Tregs promotes the growth of adult AML blasts, suggesting that IL‑35 has an important role
in the pathogenesis of AML. IL‑10 is anti‑inflammatory cytokines with immune‑stimulatory activities
and is formed by CD4 and CD8 T‑cells and activated B‑lymphocytes.
OBJECTIVES: The aim of th study was to estimate the levels of IL‑10 and IL‑35 in the sera of patients
with AML before and after chemotherapy induction and to correlate levels with blast cells percentage
and other hematological parameters.
PATIENTS, MATERIALS AND METHODS: This study was conducted on thirty newly diagnosed (ND),
de novo adult AML patients, 15 males and 15 females with a age range between 19 and 75 years for
a period from September 20, 2017, to March 15, 2018. It included 18 healthy (9 males and 9 females)
individuals who were taken as a control group. Diagnosis of AML was established according to the
morphology, cytochemistry and flow cytometry study of both peripheral blood and bone marrow
aspiration as well as biopsy reports. ILs‑35 and 10 levels were measured at diagnosis and after
induction chemotherapy when achieving complete remission based on Cheson et al. definition.
RESULTS: Serum IL‑35 and IL‑10 were significantly higher in ND AML patients than controls and were
reduced after induction chemotherapy (P < 0.001). In patients with remission, IL‑10 was significantly
reduced compared with non‑remission group, while the reduction in IL‑35 level in remitted compared
to nonremitted patients did not reach the level of significance (P > 0.001). No correlations were found
between hemoglobin, platelet counts, white cell count, and blast percentage with IL‑35 and 10 levels
in de novo AML patients.
CONCLUSIONS: Both ILs‑35 and 10 levels were elevated in de novo AML patients and lowered
following induction chemotherapy. Both ILs have no correlation with hemoglobin level, platelet count,
white blood cell count, and blast percentage.

Abstract:
BACKGROUND: Iron‑deficiency anemia (IDA) is a common hematological disorder. Anemia of
chronic disease (ACD) is mild‑to‑moderately severe anemia associated with chronic diseases.
Growth‑differentiation factor‑15 (GDF‑15) is a member of the transforming growth factor‑, produced by
late‑stage erythroid precursors in the bone marrow; it suppresses hepcidin expression during ineffective
erythropoiesis. The aim of this study was to measure the level of the GDF‑15 level in ACD and IDA and to
evaluate its ability to differentiate between ACD and ACD with coexisting iron deficiency (mixed anemia).
PATIENTS, MATERIALS AND METHODS: The present study including 87 persons “30 with IDA, 30
with ACD, and 27 controls.” The following investigations were done: complete blood count, erythrocyte
sedimentation rate, iron profile (serum iron and total iron‑binding capacity), C‑reactive protein, ferritin,
hepcidin, and GDF‑15, depending on the results of these investigations, some patients of ACD group
appear to be ACD with co‑existing iron deficiency. The analysis of data was carried out using the
Statistical Packages for the Social Sciences software version 24.
RESULTS: The serum hepcidin was significantly lower in IDA, whereas the serum GDF‑15 is
comparable to that of the control group. The serum hepcidin and serum GDF‑15 were significantly
higher in (ACD and mixed anemia) group compared to the control group.
CONCLUSION: GDF‑15 is high in ACD group and comparable to the control in iron‑deficiency group,
and it is not a useful marker to differentiate between ACD and ACD with coexisting iron deficiency.

BACKGROUND: Health‑related quality of life (HRQoL) in multiple myeloma (MM) gained increasing
importance to ensure that the improved survival is associated with improved life quality.
OBJECTIVES: The aim of this study was to assess the HRQoL in a cohort of myeloma patients
from Kurdistan region in Iraq.
MATERIALS AND METHODS: This observational, cross‑sectional, multi-center study enrolled
138 patients with symptomatic MM patients. The patients’ records were retrieved and they were
also clinically assessed and appropriately investigated at the time of enrolment. HRQoL was
assessed using the European Organization for Research and Treatment of Cancer Quality of Life
Questionnaire‑Multiple Myeloma module (EROTC QLQ‑MY20.
RESULTS: The 138 patients included had a mean age of 60.4 years and included 83 males and
55 females. Significant predictors of worse HRQoL disease symptoms and side effects of treatment
domains included increasing age, female sex, and increase number of treatment courses. Other
predictors associated with worse disease symptom domain include presence of bone lesions and
nonsecretory myeloma versus light chain myeloma. Basic parameters including the concentration
of monoclonal band, hemoglobin, serum creatinine, calcium, and albumin were not significant
associated with scores in any of the domain while serum LDH was associated with worse side effects
of treatment scores. Furthermore, it was noted that patients who had underwent autologous stem
cell transplants had better HRQoL in all domains compared to other modalities of therapy, though
this did not reach significance.
CONCLUSIONS: HRQoL in MM treated in Iraqi Kurdistan is not much different from their Western
counterparts and several predictors of worse QoL were identified in this cohort of patients.

Inherited hemorrhagic telangiectasia (HHT or Osler–Weber–Rendu syndrome) is a hereditary
condition characterized by malformations of multiple blood vessels (vascular dysplasia), which may
lead to bleeding (hemorrhaging). Chronic nosebleeds are often the first warning, and malformations
in various blood vessels can lead to abnormalities in the lungs, brain, spinal cord, and liver. There
are a number of therapies available for various aspects of HHT to improve the quality of life and
avoid life‑threatening complications. Individuals with HHT have an almost average life expectancy.
HHT is inherited as a dominant autosomal trait. We have done this review to enlighten the scientific
fraternity about HHT. In this review, we have tried to explain about HHT and its related management.

Abstract:
BACKGROUND: The impact of the different ABO blood phenotypes has not been extensively
investigated on high‑density lipoprotein (HDL) functionality. Therefore, the aim of this study was to
assess HDL‑related serum paraoxonase 1 (PON1), ApolipoproteinA‑1 (ApoA‑I) and also oxidized
low‑density lipoprotein (OxLDL) in relation to ABO blood groups.
SUBJECTS AND METHODS: ABO blood types represent part of the genetic phenotype.
Therefore, we assume that ABO blood phenotypes are associated with many diseases. This
cross‑sectional study involved 169 apparently healthy male medical staff with different ABO
blood phenotypes.
RESULTS: The most important of the findings in this study is that the amount of PON1, which is one
of the valuable markers of HDL function, was statistically significantly lower in people with AB blood
group than in other blood groups. Furthermore, one notable important findings of this study are the
lowest serum ApoA‑I levels of individuals in AB blood phenotype. On the contrary, serum OxLDL
levels in the subjects with AB blood phenotype are increased.
CONCLUSION: There is no doubt that it is necessary to examine in more detail the molecular changes
in HDL metabolism linked to the ABO blood group phenotype. What is really interesting is that the
AB blood phenotype in many Mediterranean countries has the lowest rate of distribution. According
to the findings from this study, the A and B blood group phenotypes may be more effective than
expected in disease susceptibility.

Abstract:
BACKGROUND: Hodgkin’s lymphoma (HL) is a malignant lymphoma that accounts for approximately
7% of childhood cancers. The incidence of HL in childhood varies by age; it is the most common
childhood cancer in the age group of 15–19 years.
OBJECTIVE: The objective of the study is to determine the clinical presentation and outcome of HL
among children under 15 years of age.
PATIENTS AND METHODS: A retrospective study carried out at the hemato‑oncology department of
child’s central teaching hospital included 46 HL patients under 15 years of age who were diagnosed
over 6 years from January 2010 to December 2015. Demographic characteristics, histopathological
and clinical features, treatment modalities, response to treatment, and outcome were obtained from
the records files of the patients.
RESULTS: Among a total of 46 children with HL, there were 33 (71.7%) males and 13 (28.3%) females;
the male‑to‑female ratio was 2.1:1; the mean age of this study was 8.3 years. Lymphadenopathy was
the most common sign, with cervical lymph node being the most common primary site of involvement.
47.8% of the atients present with Stage II, and the mixed cellularity histopathological subtypes were the
common recognized subtype. Event‑free survival (EFS) is 78.3%, and overall survival (OS) was 95.5%.
CONCLUSION: Two‑year OS (95.5%) and EFS (78.3%) of the HL patients were accepted as
compared to other studies.

Abstract:
Imported malaria is defined as an infection acquired in a malaria‑endemic area but diagnosed in a
nonendemic country after the development of clinical symptoms. The fatality rate of malaria in the
nonendemic area was 60 times higher than that in endemic areas, mainly because of the late diagnosis
and treatment. Here, we report a 23‑year‑old Bangladesh male worker in a cleaning company was
admitted to the Al Nuaman Teaching Hospital on May 22, 2018, with high‑grade fever and abdominal
pain of 2 days duration. In medical history, he had been diagnosed with malaria since childhood.
The case report is presented with a review of the literature. Microscopy remains the gold standard
diagnostic tool of malaria, thick and thin smears ± rapid diagnostic tests should be performed on all
febrile returned travelers from risk areas.

act:
BACKGROUND: Chronic immune thrombocytopenic purpura (ITP) is an immune‑mediated bleeding
disorder, in which platelets are opsonized by autoantibodies directed against platelet surface
membrane glycoproteins, and prematurely cleared and destructed by Fc‑receptors on the surface
of macrophages in the reticuloendothelial system.
OBJECTIVES: This work is designed to show the contribution of lymphocyte subsets and platelet
destruction in adult chronic ITP and role of infection.
MATERIALS AND METHODS: Transforming growth factor‑β1 (TGF‑β1) was measured using ELISA,
and the frequency of regulatory T‑cell (Treg) profile (CD4+CD25+CD127−) was investigated by FCM
in blood samples of 50 Iraqi ITP patients (35 on‑treatment ITP patients and 15 newly diagnosed) along
with 20 age‑matched healthy people that act as controls, as well as all patients were breath tested
for detecting Helicobacter pylori using urea breath test. The study was carried out in the National
Center of Hematology, Mustansiriyah University.
RESULTS: The results showed that although there was a significant reduction in Treg number in
ITP patients compared with the control individuals (P < 0.001), the effect of treatment has shown
a restored count of Tregs in comparison to the newly diagnosed ones (P = 0.002), while the
assessment of cytokine serum level revealed that TGF‑β1 was significantly increased (P = 0.001)
in the on‑treatment group of patients (TGF‑β1 = 3.24 ± 0.3 ng/μl) in comparison with the nontreated
group of patients (TGF‑β1 = 1.75 ± 0.2 ng/μl). However, it was still significantly (P < 0.001) less
than their values in the apparently healthy individuals (TGF‑β1 = 9.0 ± 0.2 ng/μ). Moreover, 25 out
of 50 (50%) showed positive results for the presence of H. pylori.
CONCLUSION: The present study revealed that Treg and its cytokines may play a fundamental role in
the pathophysiology of adult chronic ITP since they contribute to the maintenance of peripheral immune
tolerance. However, a causal link between H. pylori infection and ITP diseases is considerable.

Abstract:
BACKGROUND: Multiple myeloma (MM) is a plasma cell malignancy in the bone marrow (BM),
where imaging is an essential tool in its management.
OBJECTIVE: The aim of this study was to compare the sensitivity of radiological skeletal survey (RSS)
with magnetic resonance imaging (MRI) of the lumbosacral spine (LSS) in advanced MM patients.
PATIENTS AND METHODS: We retrospectively reviewed the RSS and MRI of the LSS for 33 patients
with a new diagnosis of symptomatic MM. Chi‑squire test was used for comparing the results.
RESULTS: Of 33 patients, 20 (60%) were male and 13 (40%) female, with a mean age of 61 years.
Characteristic findings on RSS were osteopenia (86%), compression fractures (60.5%), multiple
lytic lesions (39.5%), solitary focal lesion (6.06%), and normal findings (9.3%), The commonest
findings on the MRI were combined diffuse and focal lesions (27.27%), multiple focal lesions of
macronodular pattern (18.2%) and variegated (micronodular) pattern (15.15%), The other finding
on MRI were diffuse homogeneous infiltration with SI> adjacent disc (12.12%) while SI ≤ adjacent
disc (6.06%), solitary focal lesions (6.06%), and normal findings (15.15%). A majority (58.1%) of
patients presented with an advanced stage and the pathological compression fracture found in 60%
of cases. Focal lesions were detected in five patients (15.15%) whose radiographs were negative,
and more lesions were detected in 11 patients (33.33%) with positive radiographs. Diffuse infiltration
pattern was found in eight cases (24%) on MRI imaging when radiographs showed only osteopenia
and in one patient (3%) in whom radiographs were normal.
CONCLUSIONS: MRI had higher sensitivity in the detection of diffuse BM involvement and discovery
of focal spinal lesions compared to conventional radiographs with a positive P value.

Abstract:
BACKGROUND: Chronic myelogenous leukemia (CML) is a hematological stem cell disorder that
associates with mutations in BCR‑ABL. Although mutations identified in more than 30 different
amino acids, the highest degree of resistance was associated with single‑point mutation T315I of
the ABL gene.
OBJECTIVES: This study aims to identify the prevalence of T315I mutation among CML patients
who lost their Major molecular response to second‑generation tyrosine kinase inhibitor (TKI) at the
time of the study and its relation to failure response.
SUBJECTS AND METHODS: A prospective cross‑sectional study included 50 adult patients
diagnosed with CML. We have used the Sanger sequencing polymerase chain reaction based
methods for detection of T315I mutation.
RESULTS: Out of 50 patients, 28 were female (56%). Patients’ age was ranged between 23 and
63 years with a mean age of 42.8 ± 11.46 years. There was no expression of T315I mutation
in any of 50 CML patients, however, there was another mutation have been detected which is
rs2070997 (response to drug) and was positive in 18 patients. There were 8 (16%) patients that have
rs2070997 mutation have primary failure on first‑generation TKIs, while the other 10 (20%) patients
were those who started second‑generation TKIs directly.
CONCLUSIONS: T315I mutation was not common in patients with CML‑chronic phase.
Other (BCR‑ABL dependent or independent) mechanism could be responsible of TKIs resistance.

BACKGROUND: Anemia occurs frequently in critically ill patients and it can impact on long‑term
outcome more so after a critical illness. Very little data are available about anemia in pediatric critical
care survivors. Recent randomized control trials in children support the use of restrictive transfusion
strategy in critically ill children.
OBJECTIVES: This study aims to estimate the prevalence of anemia in pediatric critical care survivors,
its causative factors and impact of restrictive transfusion strategy on its resolution.
PATIENTS AND METHODS: In this retrospective observational study, patients who got discharged
from pediatric intensive care unit (PICU), their clinical course, serial hemoglobin (Hb) level, and
transfusion history were collected. Patients were divided into two groups according to transfusion
strategy (restrictive and liberal group). Patients with anemia were followed up and persistence of
anemia was noted monthly.
RESULTS: In 54 cases enrolled in the study, 35 children had anemia (prevalence 35/54 = 64.8%).
Statically significant difference between anemic and nonanemic groups was found in terms of duration
of PICU stay and development of infection and no significant difference in age, gender, diagnosis, and
requirement of mechanical ventilation. Among the 35 anemic children, restrictive transfusion strategy
was followed in 21 and in 14 children liberal transfusion strategy was followed. Ten children were
lost to follow‑up. Anemia got resolved in 18 children (18/25 = 72%) and 7 children (7/25 = 20%) had
persistent anemia. Among 25 children, 4 children in restrictive group (4/15 = 26.6%) and 3 children
in liberal group (3/10 = 30%) had persistent anemia (statistically not significant; P > 0.05).
CONCLUSIONS: A large proportion of PICU survivor children is anemic at discharge, this could be due
to long duration PICU stay or acquired infection during hospital stay or following restrictive transfusion
strategy but on a long‑term follow‑up no statistically significant difference was noted between two groups.

Abstract:
BACKGROUND: The use of BCR‑ABL tyrosine kinase inhibitor imatinib mesylate improved outcomes
for patients with chronic myeloid leukemia (CML). Hypophosphatemia is found to be associated with
imatinib mesylate use; the exact mechanism of this is not clear yet but mostly related to a drug‑induced
proximal renal tubular defect.
OBJECTIVE: The objective was to measure the renal phosphate loss in CML patients treated by
imatinib mesylate.
PATIENTS AND METHODS: A cross‑sectional study included 40 patients (25 females) who were
already diagnosed cases and treated with imatinib mesylate (400 mg/day). The mean age was
40.2 ± 7.8 years. The study was conducted at the medical city teaching hospital, Baghdad, hematology
outpatient clinic from July 2016 to December 2016. Serum and random urine samples were measured
phosphate and creatinine in serum and urine, respectively. Serum and urine phosphate were
measured using the colorimetric method, whereas serum and urine creatinine were calculated by the
kinetic method. Fractional excretion of phosphate and tubular maximum of phosphate reabsorption
were calculated. After the completion of the study, we tested ten newly diagnosed patients at 0‑ and
3 months of treatment.
RESULTS: Sixteen patients (40%) developed hypophosphatemia. The fractional excretion of phosphate
increased (FEPO4 = 21.1%) with a comparable reduction in tubular reabsorption of phosphate to the
glomerular filtration rate (Tmpi/GFR = 2.3 mg/dl). There was a significant direct correlation between
SPO4 level and white blood cell count (R = 0.451; P = 0.001). The mean intact parathyroid hormone
and Vitamin D levels were normal for the study group. All ten newly diagnosed cases developed
hypophosphatemia at 3 months. This was statistically significant (P = 0.002). There increase in FEPO4
and decrease in Tmpi/GFR was statistically significant (P < 0.001 and 0.002), respectively.
CONCLUSION: Hypophosphatemia while using imatinib mesylate is due to increased urinary
phosphate excretion.

BACKGROUND: Acute promyelocytic leukemia (APL) is a biologically and clinically distinct subtype
of acute myeloid leukemia (AML) Etiological and seasonal factors that play a role in APL still unclear.
OBJECTIVES: The aim of the study was to retrospectively evaluate the available data to assess the
impact of seasonal variations on incidence of APL over a period of 6 years.
PATIENTS AND METHODS: A retrospective, observational study based on APL record of a
Hematology Nasiriyah Center from January 2014 to January 2020 was processed. The collected
data of diagnosed (APL) patients at this center for 6 years was analyzed, and APL presenting in
each month of the year was also assessed for any evidence of seasonality.
RESULTS: Fifty‑eight cases of APL were included in this study: there were 22 males (37.93%) and
36 females (62.07%). The mean age was 31.1 ± 14.4 years (minimum 15 and maximum 67). We
found a pronounced peak of APL occurrence in March (within winter and early spring months) and
decline in summer to zero point in August, which was repeated periodical all studied 6 years.
CONCLUSIONS: Seasonal pattern of APL was observed. Investigation of specific seasonal risk
factors would be informative in explaining the etiology behind the observed variation.

Abstract:
BACKGROUND: Vascular E‑ and P‑selectins play important roles in sickle cell anemia (SCA),
vaso‑occlusive crises (VOC); however, the extent to which they determine VOC has not been studied.
OBJECTIVES: The aims of the study were to assess vascular selectin levels and the extent to which
they determine VOC among SCA patients.
SUBJECTS AND METHODS: This was a cross‑sectional comparative study conducted among
patients with SCA in a tertiary hospital, Northwestern Nigeria. Eighty‑eight participants were enrolled
(44 each in VOC and steady state). Soluble E (sE) and P (sP) selectin levels were assessed using
enzyme‑linked immunosorbent assay technique. The frequency of blood transfusion and bone pains
was collated.
RESULTS: Patients with VOC compared to those in steady state had higher levels of
sP‑selectin (5.5 ± 4.6 ng/ml vs. 3.2 ± 0.8 ng/ml, P = 0.001) and mean rank sE‑selectin (53.2 vs.
35.8, P = 0.001). The odds ratio (OR) for sE‑selectin levels and VOC was 1.135 (P = 0.009), while
that of sP‑selectin was 2.693 (P = 0.002). The adjusted ORs for sE‑selectin and sP‑selectin were
1.184 (95% confidence interval [CI]: 1.021, 1.373) and 3.748 (95% CI: 1.475, 9.524), respectively.
CONCLUSIONS: Patients in VOC have elevated sP‑and E‑selectin levels. sP‑selectin level is a
better predictor of VOC compared to sE‑selectin.

BACKGROUND: Coronavirus disease 2019 (COVID‑19) is a novel infectious disease that is caused
by SARS‑CoV‑2, a newly emergent coronavirus, was first recognized in Wuhan, China, in December
2019. Genetic sequencing of the virus suggests that it is a betacoronavirus closely linked to the
SARS virus. COVID‑19 disease associated with hematological parameter changes like changes
in complete blood picture and coagulopathy. Numerous observational studies have suggested that
the neutrophil‑to‑lymphocyte ratio (NLR) and lymphocyte proportion and the platelet‑to‑lymphocyte
ratio (PLR) are inflammatory markers.
OBJECTIVES: The aim was to study the changes in hematological parameters in patients with
COVID‑19 in relation to the severity and outcome of the disease.
PATIENTS AND METHODS: A prospective study had been done during the period of 3 months
that extends from March to May 2020. From 543 patients admitted to the Basra Teaching Hospital
COVID‑19 wards, 112 medical reports of patients had been randomly selected. The demographic
and blood test results for each patient were collected and followed the patient disease severity and
the outcome. None of the selected patients had chronic disease or chronic use of medicine (s) that
might affect the blood indices. Further analysis and statistics were done by SPSS software.
RESULTS: The study showed that females were more than males 56.25% and 43.75%n respectively.
Severity categorization showed that majority of cases were mild (88, 78.58%). Furthermore, the
study reveals that 11 (9.82%) had leukocytosis, 6 (5.4%) of patients with leukopenia, 6 (5.36%) of
patients with lymphopenia, and 16 (14.28%) of patients with neutrophilia. Seven patients (6.25%) had
thrombocytosis while 6 patients (5.36%) presented with thrombocytopenia. Neutrophil/lymphocyte
ratio in this study showed 28/112 (25%) patients with N/L ratio ≥3.1. Of those patients with high
N/L, 39.29% were aged ≥65 years. All the patients with severe disease had high N/L (P = 0.000).
The study showed that PLR ≥ 626 was found in 13.39% (15/112) of the studied patients, all of
them had either severe (73.3%) or moderate (26.67%) disease which was highly significant when
compared to low ratio (P=0.000).
CONCLUSION: The study showed that the severity of COVID19 was associated with lymphopenia,
monocytosis, and elevated NLR and PLR values. On the other hand, both values (NLR and PLR) could
be used as hematological predictors for disease severity and the outcome of patients with COVID‑19.