R K Marwaha

Biomedical Informatics Centre, Chandigarh, Chandīgarh, India

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Publications (358)443.53 Total impact

  • Ravi Shah, Amita Trehan, Reena Das, R. K. Marwaha
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    ABSTRACT: Serum ferritin is a useful monitoring tool for iron overload in thalassemia major. In resource poor settings access to modalities for assessment of iron overload are limited. This study was undertaken to assess the efficiency and usefulness of serum ferritin level in thalassemia intermedia (TI) patients. This was a cross sectional observational study. Seventy seven TI patients attending the pediatric hematology clinic were included. Fasting blood sample was taken from each patient in iron free vials for iron studies. Serum ferritin was estimated by immunometric enzyme immunoassay using Orgentec GmbH kits. Mean age of patients evaluated was 10.9 ± 5.03 (3–26) years. The mean age at diagnosis was 4.21 ± 2.3 (0.8–11) years. Mean serum ferritin was 486.54 ± 640.0 ng/ml (15–4,554). Thirty two (41.5 %) patients had a ferritin value of ≥500 ng/ml. Nine patients had a serum ferritin of ≥1,000 ng/ml. Three of the subjects with a ferritin >1,000 ng/ml had never received a blood transfusion (BT) and in the other six, the number of BTs ranged from 1 to 8. Serum ferritin did not correlate with age, total number of BTs splenectomy status or BT in last one year (p > 0.05). In 41.5 % of TI patients, serum ferritin was ≥500 ng/ml. Age, BT and splenectomized status did not affect ferritin level. We postulate interplay of other biological factors like HFE gene mutation, ferroportin, etc. to contribute to ferritin level and hence iron load in TI patients. Ferritin can possibly be used as screening and monitoring tool for iron load in TI patients when other modalities to assess iron overload are not easily available.
    Indian Journal of Hematology and Blood Transfusion 12/2014; · 0.25 Impact Factor
  • Clinical Genetics 11/2014; · 4.25 Impact Factor
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    ABSTRACT: Long-term damage to the residual kidney is of concern in the survivors of Wilms tumor. Our objective was to evaluate the long-term glomerular function and size of the residual kidney in these patients. Twenty-nine survivors of Wilms tumor diagnosed between July 1999 and June 2004 were enrolled. The glomerular function was assessed by creatinine clearance, 99mTc DTPA radionuclide scintigraphy and 24-hour urinary protein. Renal size was evaluated by ultrasonography. Median age at diagnosis and at enrollment were 2.87 ± 1.8 (range: 0.5-7.5) and 7.9 ± 3.8 years (range: 2.5-18). Median duration of follow-up was 4.78 ± 2.6 years (range: 1-8.8). Evidence of renal dysfunction in the form of either function or size was identified in eight (27.6%) children. Six children had subnormal glomerular filtration rate and one had proteinuria. Subnormal size of the residual kidney was observed in one child. Age at diagnosis, stage, and duration elapsed after nephrectomy had no association with renal dysfunction (P >.05). Long-term follow up is crucial to identify clinical nephrotoxicity among survivors of Wilms tumor.
    Pediatric hematology and oncology. 09/2014;
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    ABSTRACT: Relapses of acute lymphoblastic leukemia (ALL) in unusual sites can be challenging to diagnose. We present unusual relapses occurring in children with ALL treated in a single institution over a 22-year period. Of 172 relapses, 9 (5.2%) were at unusual sites (nonmarrow, testes, central nervous system). The most common site of relapse was ocular (66%). The median symptom-to-diagnosis interval was 20 days. Two of 9 children attained second remission. A possibility of relapse should be considered when evaluating unusual symptoms in a child with underlying ALL.
    Journal of Pediatric Hematology/Oncology 08/2014; · 0.97 Impact Factor
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    ABSTRACT: Objectives Bone marrow (BM) aspiration and trephine biopsy is one of the most valuable procedures in the evaluation of hematological disorders. There is a shortage of published literature regarding the indications, procedure, and outcome of bone marrow examination (BME) in neonates and infants. The aim of the present study is to analyze the common indications of performing BME and to assess the spectrum of disorders diagnosed from BM of neonates and infants. Methods A retrospective analysis of BMEs performed in infants over a period of 5 years, between 2009 and 2013 was done. Results and discussion A total of 297 BME were performed on 285 infants, which constitutes 10.3% of pediatric BME procedures during the same period. In our institute, BME is routinely performed by trained pathologists from posterior superior iliac spine in children including infants and neonates with an overall sample adequacy of 97%. Evaluation of cytopenias and suspicion of storage disorder were the most common indications for BME procedure, while acute leukemias and storage disorders were the most common diagnoses offered in infant BM. Conclusions Posterior superior iliac spine is a good site of BME in neonates and infants. BM trephine biopsy is a difficult procedure in this age group, however remains indispensable in situations where an infiltrative pathology is suspected. BME not only helps to make specific diagnoses but should also be used as an extremely valuable, quick, and economically viable procedure to exclude major hematological disorders including certain forms of storage disorder and hematological malignancy in this age group.
    Hematology (Amsterdam, Netherlands) 08/2014; · 1.33 Impact Factor
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    ABSTRACT: There exists a general recognition of the fact that post translational modification of CYLD protein through proteolytic cleavage by MALT-1 results in sustained cellular NF-kB activity which is conspicuously found to be associated with cancer in general and hematological malignancies in particular. The present study was directed to understand the contribution of MALT-1 and deubiquitinase CYLD to the initiation of T-cell acute lymphoblastic leukemia (T-ALL). Such a study revealed for the first time that the 35kDa CYLD cleaved factor generated by MALT-1 mediated proteolytic cleavage was conspicuously present in human T- ALL subjects of pediatric age group. Further, over-expression of this 35kDa CYLD factor within normal human peripheral blood mononuclear cells had the inherent capacity to program the genome of these cells resulting in T-cell lineage ALL. Based upon these results, we propose that MALT1 inhibitors may be of crucial importance in the treatment of T-ALL subjects of pediatric age group.
    Blood Cells Molecules and Diseases 08/2014; · 2.26 Impact Factor
  • Sapna Oberoi, Amita Trehan, Ram Kumar Marwaha
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    ABSTRACT: Background Medication errors occur universally. Inappropriate administration of chemotherapy drugs can have adverse effects in cancer patients. Our objective was to assess the rate and type of medication errors in children with acute lymphoblastic leukemia (ALL) receiving oral chemotherapy in outpatient setting.ProcedurePrescription and administration of oral chemotherapy drugs in children with ALL were evaluated prospectively to determine rate and type of medication errors. Errors were defined as prescription (physician) level or administration (patient) level errors.ResultsTwo hundred eighty-nine drugs were prescribed to 121 patients. Medication errors occurred in 36 (12.5%) prescriptions; 21(7.3%) were administration errors, 13 (4.5%) were prescribing errors, and two errors occurred at both levels. Mercaptopurine (6-MP) was significantly associated with higher rates of errors (Odds ratio [OR] = 2.1, 95% CI [confidence interval] 1–4.1) whereas lapses were less with dexamethasone (OR = 0.25, 95% CI 0.09–0.67). As a result of medication errors 28 (23.1%) patients received inappropriate doses. Twenty five (21%) patients received sub-optimal doses whereas three got higher doses of chemotherapy. On univariate analysis, socioeconomic status, education status of the caregiver, 6-MP and methotrexate were significantly associated with errors (P ≤ 0.05). On multivariate analysis, ≤ primary school education of the caregiver and prescription of methotrexate were independent predictors of errors.Conclusions Medication errors affected nearly one fourth of the children receiving oral chemotherapy. Future studies are needed to look at effective interventions to avoid chemotherapy associated errors especially amongst the lower strata of society. Pediatr Blood Cancer © 2014 Wiley Periodicals, Inc.
    Pediatric Blood & Cancer 08/2014; · 2.35 Impact Factor
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    Deepti Malik, Deepak Kaul, Nalini Chauhan, Ram Kumar Marwaha
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    ABSTRACT: microRNAs (miRNAs) play both oncogenic and oncostatic roles in leukemia. However, the molecular details underlying miRNA-mediated regulation of their target genes in pediatric B- and T-cell acute lymphoblastic leukemias (ALLs) remain unclear. The present study investigated the relationship between miR-2909 and Kruppel-like factor 4 (KLF4), and its functional relevance to cell cycle progression and immortalization in patients with pediatric ALL.
    Molecular cancer. 07/2014; 13(1):175.
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    ABSTRACT: Background Congenital Ichthyosis especially in darker skin types is at increased risk of developing vitamin D deficiency and rickets. The relationships between 25-hydroxyvitamin D [25(OH)D], parathyroid hormone (PTH) and bone health have not been studied previously, in ichthyosis.Objective To determine the threshold levels of 25(OH)D and PTH for impaired bone health in children with congenital IchthyosisMethods In this cross sectional study,119 children with Ichthyosis and 168 controls were recruited. Serum 25(OH)D, PTH, calcium, phosphate and alkaline phosphatase(ALP) were measured. Radiological screening for rickets was carried out only in Ichythoses children.Results47 (41%) children with ichthyosis had either clinical or radiological evidence of rickets. Correlation between serum 25(OH)D and PTH showed a serum level of 25(OH)D 8ng/mL, was associated with significant increase in PTH. Correlation between PTH and ALP showed that a serum PTH level of 75 pg/mL was associated with a significant increase in ALP levels. Of the different clinical phenotypes of ichthyosis, both autosomal recessive congenital ichthyosis (ARCI) and epidermolytic ichthyosis (EI) were found to have significantly increased PTH, ALP and radiological rickets scores as compared to common ichthyosis.Conclusions Serum levels of 25(OH)D ≤ 8 ng/mL and PTH (≥ 75 pg/mL) significantly increases the risk for development of rickets (OR = 2.8; 95% CI = 1.05 – 7.40;P = 0.04) in ichthyosis. Among the different types, ARCI (OR 4.83; 95% CI 1.74 – 13.45; p < 0.01) and EI (OR 5.71; 95% CI 1.74 – 18.79; p < 0.01) are at an increased risk of developing rickets.This article is protected by copyright. All rights reserved.
    British Journal of Dermatology 05/2014; · 3.76 Impact Factor
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    ABSTRACT: To compare parameters of insulin resistance, with special reference to McAuley index, in urban Indian adolescents, and to establish their cut-off values for defining metabolic syndrome. Cross-sectional study. Schools located in four different geographical zones of Delhi, India. 695 apparently healthy adolescents grouped as normal weight (298), overweight (205) and obese (192). Cut-off point for indices of insulin resistance was assessed by fasting insulin, insulin glucose ratio, and other methods (HOMA model, QUICKI, McAuley index) to define metabolic syndrome. The McAuley index increased progressively from normal weight to obese adolescents in both sexes. McAuley index was significantly lower in adolescents with metabolic syndrome (5.36 ± 1.28 vs. 7.05 ± 1.88; P<0.001). McAuley index had the highest area under curve of receiver operator characteristics [0.82 (0.02)] as compared to other indices of insulin resistance. McAuley index of 6.23 had the highest specificity (88%) with sensitivity of 63.3% for diagnosing metabolic syndrome, whereas insulin glucose ratio had the highest sensitivity (79.7%) but low (55.5%) specificity. McAuley index was negatively correlated with height (r= -0.257, P=<0.001), weight (r= -0.537, P=<0.001), body mass index (r= -0.579, P<0.001), waist circumference (r= -0.542, p<0.001), and waist hip ratio (r= -0.268, P<0.001). Among various parameters of insulin resistance, McAuley index had the highest specificity, and insulin glucose ratio had the highest sensitivity in diagnosing metabolic syndrome in urban Indian adolescents.
    Indian pediatrics 04/2014; 51(4):279-84. · 1.04 Impact Factor
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    ABSTRACT: IntroductionThe potential impact of concomitant iron deficiency on hemoglobin A2 (HbA2)-based identification of β-thalassemia trait (βTT) is a worrisome issue for screening laboratories. This is especially true for resource-constrained settings where iron deficiency is widespread and molecular confirmatory tests for borderline low HbA2 values may be unavailable.Methods Obligate βTT carrier individuals (n = 752) were identified during screening studies on the parents of thalassemia major patients. HbA2%, complete blood counts and serum iron, ferritin and transferrin saturation were studied. Iron-deficient individuals (n = 135) with normal range HbA2% were taken as controls.ResultsConcomitant iron deficiency (defined as ferritin ≤15 ng/mL and/or transferrin saturation ≤15%) was present in 20.7% (156/752) βTT cases, that is, 33.3% females (122/366) and 8.8% males with βTT (34/386). Mean HbA2 in iron-replete βTT was 5.4 ± 0.8 (range 3.1–7.9) and in iron-deficient βTT was 5.4 ± 0.9 (range 3.3–7.6). HbA2 < 4.0% was found in 23/752 (3.1%) βTT: 13/595 iron-replete (2.2%) and 10/157 (6.4%) iron-deficient βTT individuals. However, five of the 10 iron-deficient βTT cases carried the silent CAP+1 (A>C) β-thalassemia allele accounting for the borderline HbA2%. On a separate analysis, all five severely anemic βTT (Hb < 80 g/L) and 16/17 βTT with severe hypoferritinemia (<5 ng/mL) had HbA2 > 4.5%. The single case with serum ferritin 4.8 ng/mL and HbA2 3.3% showed a CAP+1 (A>C) mutation.Conclusions Iron deficiency was prevalent among north Indian βTT individuals, especially women. After adjusting for other causes of low HbA2 in βTT, iron deficiency, even when very severe, was very unlikely to interfere significantly with HbA2-based identification of βTT.
    International journal of laboratory hematology 04/2014; · 1.30 Impact Factor
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    ABSTRACT: Prevalence data of herpes simplex virus (HSV) in oral mucositis in children on treatment for cancer is limited. Quantitative polymerase chain reaction (PCR) has been seldom utilized for detection of HSV-1/2 in oral mucosa. Children on treatment for cancer with oral mucositis were enrolled as cases and healthy children as controls. An oral swab from the lesion in cases and mucosal scraping in controls were obtained. Both qualitative and real-time quantitative PCR for HSV-1/2 were performed. Serum ELISA-IgG/IgM for HSV-1/2 antibodies (NovaLisa™-Dietzenbach-Germany) were measured. Thirty-two cases (Age, 6.3 ± 3.4 years) and 30 controls were enrolled. Majority (69 %) of cases had ALL. All patients had febrile neutropenia, except two. ELISA-IgM-HSV-1/2 was not positive in any case or control. ELISA-IgG-HSV-1/2 was positive in 11 (34 %) cases and nine (30 %) controls (p = 1.0). Qualitative PCR for HSV-1 detected the virus in eight (25 %) cases and nil controls (p = 0.009). HSV-2 was not detected in any case/control by qualitative PCR. Quantitative PCR detected HSV-1 in 21 (66 %) and HSV-2 in 22 (69 %) cases. In controls, quantitative PCR detected HSV-1 in three (10 %) and HSV-2 in none. In patients, the mean viral load of HSV-1 (5,500 ± 15,987 × 10(4) copies/nanogram DNA) was more than HSV-2 (4.03 ± 8.5 × 10(4)) (p = 0.11). There was no correlation of HSV-1/2 with grading of mucositis. Both HSV-1/2 are commonly shed from oral mucosal lesions in children receiving chemotherapy. In a novel finding, real-time PCR detected copies of HSV-2 in 69 % cases, all missed by conventional PCR. Implication for morbidity, if any, or treatment needs to be determined.
    Supportive Care in Cancer 02/2014; · 2.09 Impact Factor
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    ABSTRACT: To describe profile of 82 children with hereditary spherocytosis diagnosed over a period of 27 years (1985-2011) from a single center. Retrospective analyses of case records. The mean (SD) age at diagnosis was 6.7 (2.8) years; 7 (8.5%) were diagnosed in infancy. Pallor (100%), icterus (67%), undocumented fever (28%), splenomegaly (96%) and hepatomegaly (73%) were the most frequent findings. Cholelithiasis was observed in 26%. Twenty-six (32%) underwent splenectomy and were followed for a median duration of 4.5 years. Two (7.7%) children developed post-splenectomy sepsis. Anemia, hepato-splenomegaly and jaundice are commonest clinical features of hereditary spherocytosis. Post-splenectomy sepsis is uncommon.
    Indian pediatrics 02/2014; 51(2):139-41. · 1.04 Impact Factor
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    ABSTRACT: The aim of this study is to evaluate the role of (68)Ga-DOTATATE positron emission tomography/computed tomography (PET/CT) scan for the detection of bone metastases in pediatric neuroendocrine tumors (NETs) and to compare it with CT scan. A total of 30 patients (18 were males and 12 were females; age range: 1-18 years; mean age 7.6 years) with histologically confirmed NETs referred to our department were retrospectively analyzed. All patients underwent (68)Ga-DOTATATE PET/CT scan at the time of diagnosis for primary staging. Contrast enhanced CT (CECT) performed at the time of PET scan acquisition was used for comparison with PET data. Imaging results were analyzed on a per-patient and on a per-lesion basis. Clinical follow-up of all patients and repeat PET/CT imaging (n = 10) was taken as the reference standard. Out of the 30 patients, 17 had no evidence of bone metastases on any imaging modality or on clinical follow-up while the rest of 13 patients showed evidence of bone metastases (nine showing positivity both on (68)Ga-DOTATATE PET and CT scan while four showing positivity only on (68)Ga-DOTATATE PET). Compared with CT scan, (68)Ga-DOTATATE PET detected bone metastases at a significantly higher rate (P = 0.0039). On a per lesion analysis, out of a total of 225 lesions detected by (68)Ga-DOTATATE PET, only 84 lesions could be detected by CT scan. (68)Ga-DOTATATE PET/CT scan is more useful than CECT scan for the early detection of bone metastases in pediatric NETs.
    Indian journal of nuclear medicine : IJNM : the official journal of the Society of Nuclear Medicine, India. 01/2014; 29(1):13-7.
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    ABSTRACT: High prevalence of vitamin D deficiency (VDD) has been reported throughout the India for all age groups. Increased awareness about VDD among treating physicians has led to increased prescriptions of vitamin D preparations. Based on our experience of varied clinical and radiological response with different vitamin D formulations, we decided to assess cholecalciferol content of commonly available vitamin D formulations. We measured cholecalciferol content of 14 commercial preparations (two in the form of tablets and 12 as sachet) available in Indian market. Lab analysis was carried out in Shriram Institute for Industrial Research by high-performance liquid chromatography. Of the total 14 samples analyzed only 4 (28.57%) were found to be within the acceptable ranges from -90 to +125% as defined by Indian Pharmacopia while 5 (35.7%) had higher and 5 (35.7%) had lower than the acceptable range. The percentage variation in cholecalciferol content as observed from the printed ranged widely from -91% to +65%. Our study shows a high degree of variability in cholecalciferol content of commercial preparations available in the Indian pharmaceutical market. This variation has many clinical implications as it may lead both, under treatment as well as vitamin D toxicity.
    Indian journal of endocrinology and metabolism. 11/2013; 17(6):1100-3.
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    ABSTRACT: Compound heterozygous HbSD-Punjab is an uncommon hemoglobinopathy encountered in Indians. Limited literature is available about its clinical course. The aim of this study was to describe the clinical and hematological profile of HbSD-Punjab patients from North India. HbSD-Punjab patients diagnosed in the hematology clinics between year 2000 and 2010 were reviewed retrospectively. The diagnosis was established using high-performance liquid chromatography, molecular analysis, and family screening. Clinical details, laboratory parameters, and therapy details were recorded from case records. Ten patients were identified. Median age at onset of symptoms was 3.5 years (interquartile range [IQR], 1.9 to 7.2). Clinical presentation included: anemia in 3, painful vaso-occlusive crisis in 2, acute chest syndrome in 2, and 3 were diagnosed incidentally. All had moderate to severe anemia (mean hemoglobin [Hb]: 6.8±1.2 g/dL). Eight required red cell transfusions (median: 3 [IQR, 2 to 8]). On high-performance liquid chromatography, median HbF, HbD, and HbS were 12.1% (IQR, 9 to 18.3), 39.7% (IQR, 35 to 42), and 38.5% (IQR, 29 to 43). Five patients received hydroxyurea (HDU), median dose: 20 mg/kg/d (IQR, 18 to 23) with median duration of 7 months (IQR; 6, 45). Increment in Hb and reduction in painful crisis was observed in response to HDU. HbSD-Punjab has a heterogeneous clinical presentation. Anemia and sickle crises are quite common. HDU may be considered for those presenting with severe phenotype.
    Journal of Pediatric Hematology/Oncology 10/2013; · 0.97 Impact Factor
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    ABSTRACT: Abstract We present a 2-month-old male affected by Zellweger syndrome, a rare peroxisomal disorder. The diagnosis was supported by clinical and radiological findings and established by biochemical tests. The characteristic radiological features included anomalous ossification (epiphyseal stippling). We also discuss main differential diagnoses of epiphyseal stippling and a brief literature review.
    Journal of pediatric endocrinology & metabolism: JPEM 09/2013; · 0.75 Impact Factor
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    ABSTRACT: The aim was to study risk-factors for vascular thrombosis and incidence of pulmonary artery hypertension (PAH) in splenectomized children with hereditary spherocytosis (HS) at a single center. Pre- and post-splenectomy hemoglobin and platelet counts were recorded. Post-splenectomy lipid-profile, fibrinogen, D-dimer, CRP and anti-coagulant-protein levels were compared to established controls. Echo-Doppler was performed for PAH. Twenty-six children with HS had undergone splenectomy; the mean age at surgery was 7.9 ± 3.7 years. Nineteen of the 26 were prospectively investigated at a median duration of 4.5 years (range: 4 months to 19 years) following splenectomy. Thrombocytosis was observed in 19 (73%), whereas no patient had erythrocytosis at the last follow-up visit. Total cholesterol, LDL-C, HDL-C, and triglyceride levels were not deranged (P ≥ 0.3). Mean CRP levels (males: 2.8 ± 0.5; females: 2.1 ± 0.5 mg/L) were significantly higher than described for normal children (P < 0.001). Six (23%) patients had a positive D-dimer assay. Protein S, anti-thrombin-III and fibrinogen were in range. A single patient had a borderline low protein C activity. Lupus anticoagulant and anti-cardiolipin antibody assays were negative. The mean tricuspid regurgitant jet velocity (TRJV) was 1.8 ± 0.55 meter per second (range: 0-2.4). None had a TRJV ≥2.5 meter per second to suggest PAH. There was no evidence of PAH, dyslipidemia, elevation of fibrinogen or a reduction in anti-coagulant proteins, at a median follow-up duration of 4.5 years following splenectomy in children with HS. However, elevated CRP level (42%), persistent thrombocytosis (73%) and elevated D-dimer levels (23%) were observed. These have been recognized as risk factors for cerebrovascular and coronary heart disease. Pediatr Blood Cancer © 2013 Wiley Periodicals, Inc.
    Pediatric Blood & Cancer 09/2013; · 2.35 Impact Factor
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    ABSTRACT: Severe childhood infections can occasionally be accompanied by bone marrow suppression. It is unusual for infection induced marrow aplasia to evolve into acute leukemia. We share our experience in managing four children with severe sepsis and pancytopenia which in due course evolved into acute leukemia. This report emphasizes that sepsis related pancytopenia can be a harbinger of evolving hematopoietic disorders.
    Indian Journal of Hematology and Blood Transfusion 09/2013; 29(3). · 0.25 Impact Factor
  • Ketan P Kulkarni, Ram K Marwaha
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    ABSTRACT: Acute lymphoblastic leukemia has a wide variety of presentations. There is paucity of any data addressing pancytopenia at presentation in acute lymphoblastic leukemia. In this study we assessed 84 patients with pancytopenia at presentation. They had a significantly lower incidence of bulky disease at presentation. A significantly higher fraction of these patients (n=66, 78.57%) opted for therapy (P=0.005) as compared with the rest. The estimated mean survival in patients presenting with pancytopenia (67.2±17.2 mo) was significantly higher (P=0.031, log-rank test) as compared with that of other patients (47.2±7.4 mo). Pancytopenia was an independent predictor of better survival (P=0.043) in multivariate analysis.
    Journal of Pediatric Hematology/Oncology 08/2013; · 0.97 Impact Factor

Publication Stats

2k Citations
443.53 Total Impact Points

Institutions

  • 1984–2014
    • Biomedical Informatics Centre
      Chandigarh, Chandīgarh, India
  • 1983–2014
    • Postgraduate Institute of Medical Education and Research
      • • Department of Cytology and Gynaecological Pathology
      • • Department of Histopathology
      • • Department of Haematology
      • • Department of Paediatrics
      Chandigarh, Chandīgarh, India
  • 2011–2013
    • Stollery Children's Hospital
      Edmonton, Alberta, Canada
  • 2010
    • Sanjay Gandhi Post Graduate Institute of Medical Sciences
      • Department of Endocrinology
      Lucknow, Uttar Pradesh, India
  • 1981–2009
    • All India Institute of Medical Sciences
      • • Department of Biostatistics
      • • Department of Pathology
      New Dilli, NCT, India
  • 2003
    • B.P. Koirala Institute of Health Sciences
      Dharan, Eastern Region, Nepal