Abstract Objectives Acute chest syndrome (ACS) is a life-threatening complication of sickle cell disease occurring during hospitalization for vaso-occlusive episodes (VOE). Prior studies have suggested an association between intravenous (IV) diphenhydramine and ACS. We evaluated whether IV diphenhydramine use is associated with new-onset ACS after adjusting for inpatient opioid exposure. Methods This retrospective cohort study included adults hospitalized for VOE at 3 hospitals in Bronx, NY (January 2020-January 2024). The primary endpoint was new-onset ACS defined as negative initial chest X-ray followed by subsequent radiographic consolidation and clinical symptoms. Secondary endpoints included ICU transfer and hospital length of stay (LOS). Multivariable logistic regression evaluated associations between diphenhydramine and outcomes, adjusting for daily oral morphine milliequivalents (MME). IV diphenhydramine exposure was categorized as none, 1-50 mg/day, or >50 mg/day. Results Of 477 patients, 207 patients (43%) received IV diphenhydramine and 47 patients (10%) developed ACS. Compared to no exposure, neither 1-50 mg/day (aOR 0.81, 95% CI: 0.39-1.68, P = .57) nor >50 mg/day (aOR 0.52, 95% CI: 0.18-1.49, P = .22) was associated with ACS. No significant associations were found for ICU transfer or LOS. Conversely, higher MME/day was significantly associated with both ACS (OR 1.03, P < .01) and increased LOS (OR 1.05, P < .01). Conclusion IV diphenhydramine was not associated with ACS, ICU transfer, or LOS. The correlation between higher opioid requirements and ACS suggests that opioid dose may serve as a marker for disease severity or contribute to respiratory outcomes.

ETV6-ABL1 fusion is a rare genomic rearrangement found in various hematologic neoplasms. Most cases resemble Philadelphia chromosome-negative CML or atypical CML and may transform into AML or ALL. Treatment typically involves tyrosine kinase inhibitors and bone marrow transplantation for high-risk patients. Only 52 cases have been reported, likely due to underdiagnosis and underreporting, as the rearrangement requires complex DNA breaks. Here, we present a case of ETV6-ABL1 fusion in a young ASD patient. Initial symptoms included leukocytosis, eosinophilia, and organomegaly, leading to a diagnosis of atypical CML. Treatment with Imatinib was ineffective, but Ponatinib induced remission, followed by successful stem cell transplantation. The complex rearrangement requires sophisticated diagnostic methods like FISH and next-generation sequencing. Prognosis remains uncertain due to limited data, but third-generation TKIs like Ponatinib show promise. ETV6-ABL1 fusion can lead to different malignancies across age groups, with a high risk of progression to acute leukemia. Our case demonstrates a successful treatment strategy with Ponatinib followed by transplantation, suggesting a potential curative approach, especially in younger patients. Maintenance therapy with TKIs post-transplantation may be beneficial due to the aggressive nature of the disease.

Introduction: Diffuse-large B cell lymphoma (DLBCL) is the most common lymphoma associated with Hepatitis C Virus (HCV) and Human Immunodeficiency Virus (HIV). During the past decades, the incidence of HIV-related lymphomas has declined; however, it still remains a major cause of morbidity and mortality in this population. Before highly effective antiretroviral therapy for HIV was introduced, individuals with HIV-related DLBCL had worse complete response and survival rates compared to their uninfected counterparts. Additionally, recent studies have shown that relapse rates are lower for DLBCL patients that achieve HCV sustained virological response (SVR). Nevertheless, outcomes in patients with active HCV infection among patients with HIV-related DLBCL have not been reported yet. This study is aimed to compare the clinical outcomes in HIV-related DLBCL among patients with and without active HCV infection. Methods: Patients with HIV infection and newly diagnosed DLBCL between 2005 and 2017 at Montefiore Medical Center/Albert Einstein College of Medicine were identified using the institutional software Clinical Looking Glass. Cases were grouped into concomitant HIV and HCV infection (HIV + HCV) or HIV alone (HIV) based on HCV antibody and viral load counts at DLBCL diagnosis. Patients with active hepatitis B infection were excluded. Data regarding demographics, laboratory parameters, HCV treatment, lymphoma treatment and clinical outcomes including complete response (CR), progression of disease (POD) and relapse were collected by manual chart review and compared among groups. SVR was defined as undetectable HCV RNA level 12 weeks after HCV treatment completion. Clinical outcomes were compared between patients with and without active HCV at the time of outcome evaluation. For this purpose, patients that achieved SVR for HCV were analyzed in the HIV group. Kaplan-Meier curves were plotted to compare 12-months relapse-free survival (RFS) among groups. Statistical analysis was performed using Stata 14.1. Results: A total of 63 patients were identified, of whom 45 (71.4%) had HIV alone (HIV) and 18 (28.6%) had concomitant active HCV and HIV infection (HIV + HCV). The median age was 49 years (IQ: 40-54), there were 39 (61.9%) males, 27 (42.9%) were Non-Hispanic Black and 27 (42.9%) were Hispanic. At DLBCL diagnosis, the majority of cases had advanced stages (stage 3: 15; 25% and stage 4: 40; 66.7%), the median CD4 count was 117 (IQ: 65-217) and 45 (72.6%) had AIDS. Baseline characteristics did not differ among groups. Of 63 patients, 53 (84.1%) were treated for DLBCL. Treatment regimens included DA-EPOCH (28; 50.9%), CHOP (22; 40%) and others (3; 9.1%). Rituximab was given to 33 cases (57.9%). Within the HIV + HCV group, only 3 (16.7%) patients received treatment for HCV; all of them were treated with ledipasvir/sofosbuvir and achieved SVR. In the full cohort, CR was achieved in 17 (32.1%) treated patients and 19 (35.9%) had POD. The CR rate was lower for patients with active HCV + HIV compared to HIV alone (7.1% vs. 41%, p=0.02) and there was no difference in POD among groups (28.6% vs. 38.5%, p=0.37). Patients with active HCV + HIV had a significantly lower 18-month RFS compared to those with HIV (62.9% vs. 87.4%, p=0.035). In a multivariate model adjusted for stage, AIDS and rituximab use; active HCV + HIV was a predictor for relapse (OR:6.36, 95% CI: 1.01 - 39.9, p=0.048). Conclusions: Despite available and effective treatment against HCV infection, only a minority of patients with DLBCL-related HIV received HCV treatment. Active HCV seems to play a role in the outcomes of patients treated for DLBCL and was found to be a predictor for relapse. Hence, HCV treatment should be considered for patients with HIV-related DLBCL. Disclosures Shah: Physicians' Education Resource: Honoraria. Friedman:Incyte pharmaceutical: Membership on an entity's Board of Directors or advisory committees, Research Funding.

Aims The bone marrow procedure (BMP) has been performed worldwide for years. Nonetheless, no generally accepted standards or guidelines for the performance of the BMP exist. Recent studies suggested that the lateral angulation technique (LAT), targeting the anterior superior iliac spine (ASIS) after penetration of the posterior superior iliac spine, yields longer biopsy cores and is safer for patients. We assessed the feasibility and safety of targeting the ASIS in the prone and lateral decubitus positions. Methods We first observed the BMP needle tracks on cadavers. Our cadaver study revealed that the LAT is feasible and safe but requires different operator techniques. Next, we studied 25 adult haematology patients undergoing elective BMP via the LAT approach. Patients returned 5 days after the BMP for a haemoglobin assessment, pain questionnaire and low-dose non-contract CT. Results 8% of patients reported persistent pain. No fall in haemoglobin and no pelvic haematomas or neurovascular injuries were detected. 88% of BMPs were successfully accomplished by targeting the ASIS. 12% required a back-up traditional angulation technique (TAT), directing the needle straight in, perpendicular to the coronal plane of the back. All three demonstrated inadvertent, but asymptomatic, penetration of the sacrum. Biopsy lengths were compared with a historical TAT control demonstrating that specimens obtained by LAT are significantly longer. Imaging studies showed that a seven-degree change in needle direction can convert a TAT to a LAT. Conclusion The LAT approach is feasible, safe and more productive than the TAT, and may be the preferred standard for training haematologists. Trial registration number NCT02524613.

Introduction: Bone marrow aspirate and biopsy (BMP) is the most common procedure used by the hematologist to evaluate benign and malignant conditions. During the last decade, several factors associated with this procedure such as higher rates of CT-guidance use, nurse practitioners trained on this skill and the use of drills has increased. It is unclear whether any of these factors have an impact on the quality of the BMP specimens. Hence, we undertook a retrospective study among patients that underwent BMPs in a large academic hospital to evaluate the factors associated with optimal samples.

Pathologists and haematologists generally agree that the length of the biopsy core is a good surrogate for the diagnostic quality of the bone marrow. Previous studies suggested that the angulation of the biopsy needle from the posterior superior iliac spine (PSIS) could influence the length of the biopsy cores, targeting the anterior superior iliac spine (ASIS) from the PSIS would yield longer specimens than the traditional angulation technique (TAT), where the biopsy needle is directed straight in, perpendicular to the plane of the back. Twenty five adult haematology patients were prospectively recruited by haematologists-in-training (HITs), who were trained to target the ASIS using a lateral angulationtechnique (LAT). The mean length of biopsy cores was 16 mm and that was significantly longer (p=0.003) than a comparable group of bone marrow biopsies previously obtained by HITs using the TAT approach. These results support the LAT as a new standard of haematology practice. Trial registration number NCT 02524613

Hemin and hemodialysis had an additive effect in decreasing ALA and PBG in our patient with acute intermittent porphyria and renal failure.The time course of ALA and PBG reaccumulation after hemodialysis is not known.

Bone marrow biopsy and aspiration are frequently performed to diagnose hematologic and oncologic diseases. The bone marrow procedure (BMP) is generally considered to be a low risk procedure, albeit briefly painful. The safety data of the procedure is largely based on retrospective surveys of British hematologists between 1995 and 2006, with reported major complication rate ranging from 0.05% to 0.12%. Hemorrhage was the most commonly reported adverse event. Anaphylactic reactions, persistent pain and pelvic fractures were also seen.1, 2 The majority of BMPs in adults in the US are performed on the posterior superior iliac spine (PSIS). Over the last 50 years, there have been many case reports and small series of neurovascular injuries, postprocedure hemorrhage, arteriovenous fistula formation, gluteal compartment syndrome, and pseudoaneurysm formation following BMPs.3 A cadaver study at our institution showed that advancement of the biopsy needle perpendicular to the body's coronal plane was associated with increased likelihood of neurovascular injuries.4 We conducted a prospective study of adult patients undergoing an elective diagnostic BMP to visualize the bone marrow biopsy needle track with use of low dose, noncontrast computer tomography (CT) scan performed 5 days after the BMP. Patients 40 years of age and older, undergoing an elective BMP, were recruited for participation in this study. All BMPs were performed by first or second year hematology-oncology fellows using a Jamshidi needle with a Snarecoil device (Ranfac Corp. Avon, MA). All procedures were supervised by an attending investigator. Prior to performing the BMP, fellows were trained on localization of the PSIS and were instructed to advance the biopsy needle towards the anterior superior iliac spine (ASIS) after needle penetrated the PSIS, and to obtain at least a 2 cm biopsy core (also known as the lateral angulation technique). All patients underwent a low dose, noncontrast pelvic CT scan 5 days after the BMP. Two radiologists independently reviewed all CT scans to report the visualized needle track as well as any complications. Study protocol was approved by institutional review board. The average age of the 25 study patients was 64 years, 56% were male, and the average BMI was 25.7 kg/m2. All patients had successful BMP's under local anesthesia. In 3 (12%) patients, the needle track traversed the ilium and penetrated the sacro-iliac joint and the sacrum (Figure 1). The needle track in these cases was at approximately 90 degrees to the coronal plane of the body. None of the 3 patients with sacral penetration reported significant pain or neurological symptoms. In 6 cases, the needle tracks were visualized at various angles in the ilium. In 16 scans, no needle track was seen. Of the 25 CT scans, none revealed a significant hematoma or other vascular complication. The lengths of the biopsy cores have been reported elsewhere.5 (A) A needle track (arrow) is seen entering the PSIS and traversing the left sacroiliac joint and the hemi-sacrum. (B) A needle track is seen penetrating the PSIS (arrow), the needle track is seen crossing the left sacroiliac joint and penetrating the left hemi-sacrum. (C) A needle track is seen penetrating the PSIS (Arrow). It penetrates the inner table of the ilium entering the right sacroiliac joint There is little data available on the safest techniques for the BMP. In a study on cadavers, Konda et al demonstrated that advancement of the biopsy needle perpendicular to the body's coronal plane was associated with increased risk of injury to the iliac and iliolumbar arteries, femoral and obturator nerves, and the sacro-iliac joint, if penetration of the inner table of the ilium occurred. Retroperitoneal hemorrhage following a BMP, although uncommon, likely occurs due to traversal of the ilium by the needle. In contrast, penetration of the inner iliac cortex while advancing the biopsy needle laterally towards the ASIS is significantly less likely to result in neurovascular damage or trauma to the sacroiliac joint. It seems reasonable to conclude that fewer neurovascular injuries will occur by targeting the ASIS.4, 6 In our study, 3 patients (12%) had penetration of the inner table of the ilium through the sacro-iliac joint and into the sacrum. Analysis of CT scans shows that a 9 degree change in needle angulation can lead to penetration of the sacrum (Figure 1). No adverse consequences of inadvertent penetration of the sacrum were noted in this small series. Study limitations include the relatively small sample size and lack of control for objectively comparing the technique and tools used. Despite these limitations, this study presents novel information about real-world visualization of needle tracks after a blind BMP. Further studies are needed to determine the safest and most efficacious technique for the BMP. None of the authors have any conflict of interest to report.

Background:Phlebotomy is integral to the clinical management of patients with PV; however, it may be inconvenient and/or poorly tolerated. Frequent and long-term phlebotomies may cause iron deficiency, increased symptom burden, and lost productivity. This analysis from the Prospective Observational Study of Patients With PV in US Clinical Practices (REVEAL) describes the patient-reported burden of phlebotomies at enrollment and ≤6 months post-enrollment.

Background: The bone marrow biopsy procedure (BMP) is a frequently performed diagnostic procedure. The majority of BMP's in adults in the United States are performed on the posterior superior iliac spine (PSIS). Patients are generally assured that the BMP is a low-risk procedure, albeit momentarily painful. Major complications, include hemorrhage and hematomas, persistent pain, anesthesia reactions, pseudoaneurysms and fractures at the biopsy site. The reportedly low incidence of complications derive from retrospective surveys and case reports, but no prospective studies have been previously reported. The goal of this study was to delineate the actual patient risks of BMP, via the PSIS, when performed by Hematologists-in-Training (HIT's). Methods: Twenty five adult patients, 40 years of age and older, who were undergoing an elective BMP, were recruited and consented for this study. Exclusion criteria included lack of ability to consent, psychiatric issues, alcohol or drug abuse, bleeding disorders, pregnancy and lactation. All BMP's were performed, via the PSIS, by HIT's under the supervision of attending investigators. Based on prior safety studies, all biopsies targeted the anterior superior iliac spine (ASIS). 4-5 days after the BMP, all patients returned for a non-contrast pelvic CT, a questionnaire on pain and neurologic symptoms and hemoglobin/hematocrit (Hb/Hct) determination. Results: The average age of the 25 patients was 64 years, 44% were female and the average BMI was 25.7. By prespecified criteria, radiographic evidence of needle penetration outside the iliac bone was designated an adverse event. This was observed in 3 of 25 pelvic CT's (12%) where the needle track penetrated the posterior cortex of the ilium, into the sacro-iliac joint and the sacrum (Figures 1a, 1b and 1c). None of the 3 cases had excessive pain or evidence or unusual bleeding, and the pathology of the marrow did not differ between the sacral and the iliac biopsy specimens in terms of length, cellularity or fat content. CT analysis revealed that only a 9 degree deviation from the ASIS target could lead to sacral penetration (figure 1). Needle tracks were detected in the ilium in 5 additional patients. In 17 pelvic CT's, needle tracks were not identified. 2 of 25 patients reported prolonged moderate pain requiring analgesia after the BMP. Needle tracks were not visualized in either patient. No patient developed a significant hematoma or had an unexplained fall in Hb/Hct. Conclusions: The success and safety of the BMP depend upon correct identification of physical landmarks and correct angulation of the biopsy needle. A cadaver study at this institution showed that biopsy needle angulation towards the ASIS (Lateral Angulation Technique-LAT) was safer than the Traditional Angulation Technique where the needle is directed straight into the PSIS, perpendicular to the plane of the back. The present prospective study of the risks of BMP's by HIT's, supervised by attending investigators, revealed that 8% of the patients had prolonged pain requiring analgesia. Pelvic CT's 5 days after the BMP revealed that 12% of patients had penetration of the sacrum, although none had significant pain or blood loss and the pathology specimen was adequate. Analysis of CT's showed that only a 9 degree change in needle angulation can lead to penetration of the sacrum. We conclude that targeting the ASIS by the LAT approach, avoids inadvertent penetration of the sacrum. The LAT approach is probably safer for patients and may be a new standard of care for hematology training and practice. The high incidence of adverse events (20%) after BMP by HIT's calls for further research and consideration. Download : Download high-res image (178KB) Download : Download full-size image Disclosures No relevant conflicts of interest to declare.

Although absolute neutrophil counts (ANC) below 1.5x103/uL are used to define neutropenia as a marker of increased susceptibility to infections, their relationship with survival has not been examined. Since low counts trigger extensive investigations, determining prognostic cutoffs especially for different ethnicities and races is critical. A multiethnic cohort of 27,760 subjects, 65 years old and above, was utilized to evaluate the association of neutropenia with overall survival in different ethnicities and races. The mean ANC was 4.6±1.51x103/uL in non-Hispanic whites, 3.6±1.57x103/uL in non-Hispanic blacks and 4.3±1.54x103/uL in Hispanics (p<0.001). An ANC below 1.5x103/uL was associated with significantly shorter overall survival among whites (HR 1.74; 95% CI 1.18 - 2.58; p<0.001), but not in blacks (HR 0.89; 95% CI 0.86 - 1.17; p=0.40) or Hispanics (HR 1.04; 95% CI 0.76 - 1.46; p=0.82), after adjustment for age, sex, comorbidities, anemia and thrombocytopenia. Using Cox regression multivariable models, an ANC below 1.1x103/uL in blacks was found to be associated with increased mortality (HR 1.86; 95%CI 1.21 - 2.87; p<0.01). We found no association between neutropenia and mortality at any ANC cutoff in elderly Hispanics. In conclusion, neutropenia was found to be an independent prognostic variable in the elderly, when determined in race-specific manner. Most importantly, a cutoff of 1.1x103 neutrophils/uL may be a more prognostically relevant marker in elderly blacks and could serve as a novel threshold for further evaluation and intervention in this population.

Tyrosine kinase inhibitors (TKIs) have become the first-line treatment of choice for chronic myelogenous leukemia (CML) after imatinib was shown to offer improved and durable responses.[1,2] Second...

Bone marrow biopsy is generally a safe procedure. However, infrequently the procedure is associated with serious injuries that are attributed to inadvertent needle penetration of the iliac bone's inner cortex. An evidence-based approach to needle orientation during iliac crest biopsy does not exist. In our study, the posterior to anterior path of the bone marrow needle from the posterior superior iliac spine (PSIS) was studied in human cadavers in two orientations: (1) perpendicularly to the coronal plane (the perpendicular approach) and (2) laterally toward the ipsilateral anterior superior iliac spine (ASIS) (the lateral approach). The biopsy needle was deliberately advanced through the inner ilial cortex in both approaches. Dissections and imaging studies were done to identify the relationship of the penetrating needle to internal structures. Both approaches begin with a perpendicular puncture of the outer cortex at the PSIS. The perpendicular approach proceeds anteriorly whereas in the lateral approach the needle is reoriented toward the ipsilateral ASIS before advancing. The lateral approach caused less damage to neurovascular structures and avoided the sacroiliac joint compared to the perpendicular approach. This procedure is best done in the lateral decubitus position. Proper use of the lateral approach should obviate many of the complications reported in the literature.

Introduction : Recent approval of second generation tyrosine kinase inhibitors (TKI) in chronic myelogenous leukemia (CML) has raised issues about their efficacy and pharmaco-economic utility in front line therapy of CML. We aimed to study these issues as well as reasons for switching TKIs in a real world setting of inner-city, multi-ethnic, underserved patient populations. Methods : We conducted an analysis of CML treatment and outcomes in an inner city cohort in the Bronx, NY. We identified 149 confirmed cases of CML that were treated over the last 17 years. All chart review was conducted by one of the study authors and discrepancies were reviewed by at least two of the authors. Data were analyzed using Chi-squared, t-testing for unpaired samples, and analysis of variance (ANOVA) to determine significance. Mortality was analyzed using Kaplan-Meir curves. Results: Demographics and Presentation: The mean age at time of presentation was 50 years (range 10 - 89 years, n=124). Average follow-up time was 5.1 (± 3.9) years. The cohort was minority rich and included 38.9% Hispanic, 32.9% African American, 18.8% Caucasian, 6.7% Asian and 2.7% multi-ethnic. The majority of the patients had private insurance or Medicare (62.4%), followed by Medicaid (30.9%) and emergency Medicaid (6.7%). The majority of evaluable patients presented in chronic phase (96.1%). Treatment Patterns: Front-line therapy was a 1 st generation TKI (imatinib) in the majority of evaluable patients (83.9%) followed by a 2 nd generation TKI (dasatinib or nilotinib) (11%). Rates of imatinib use as first line therapy were similar for both Private/Medicare (82.1%) and Medicare (88.1%) patients. Interestingly, a higher percentage of patients with Emergency Medicaid were started on a 2 nd generation TKI (22.2%) as opposed to Private/Medicare and Medicaid (9.0% and 11.9% respectively). This was due to the availability of patient assistance programs to pay for TKIs. After the approval of dasatinib and nilotinib in 2008, there was increased use of the 2 nd generation TKIs as first line though a majority of patients were still treated with imatinib as first line (72.2%, 80.0%, and 66.7% for Private/Medicare, Medicaid and Emergency Medicaid respectively). Outcomes: At the time of conclusion of the study, a total of 31 patients had expired. Twenty patients were evaluable for therapy at the time of death, percentages of patients on 1 st , 2 nd and 3 rd line therapy were 10%, 50%, and 25% respectively. Allogeneic stem cell transplant was performed in 15% of expired patients. Of evaluable live patients (n=109), 45.9% were receiving the original front line therapy, whereas 37.6% and 16.5% were receiving second and third line therapies respectively. Regarding reasons for switch from a one TKI to another, we noted 34 patients who had been switched from a 1 st to a 2 nd generation TKI. Progression of disease was the cause in 53.0% of cases, followed by lack of response (17.6%), adverse events (14.7%), cytopenias (8.8%) and intolerance (5.9%). Two patients were switched from a 2 nd generation TKI to a 1 st generation, and both cases were due to intolerance. Overall survival of the cohort at 2 and 5 years was 94% and 82% respectively. No differences in survival were detected between different ethnicities, gender and age groups. Emergency Medicaid patients had a poorer overall survival compared to other insurance types though this did not reach statistical significance (p=0.0928). Interestingly, overall survival was similar for patients treated with 1 st of 2 nd generation TKIs as first line therapy (Median survival not reached, Log rank P value =0.4). Discussion: We analyzed CML outcomes and treatment patterns in a large inner city underserved multiethnic cohort in the Bronx. The CML population reflected the ethnic composition of the borough which is predominantly Hispanic and African American. The majority of patients presented in chronic phase CML which is in agreement with other studies. Majority of patients were started on imatinib as first line therapy and had similar overall survival to those that were started on Dasatinib or Nilotinib. The majority of patients who were switched from a first generation TKI to a second generation TKI were due to relapse or lack of adequate response. Our results suggest that TKIs are successfully used in real world populations and are leading to high overall survival even with use of imatinib as first line therapy. Disclosures No relevant conflicts of interest to declare.

Even though alterations in platelet counts are presumed to be detrimental, their impact on the survival of patients has not been studied in large cohorts. The prevalence of thrombocytopenia and thrombocytosis was examined in a large inner city outpatient population of 36,262 individuals aged ≥65 years old. A significant association with shorter overall survival was found for both thrombocytopenia (HR=1.45; 95% CI: 1.36-1.56) and thrombocytosis (HR=1.75; 95% CI: 1.56-1.97) when compared to the survival of patients with normal platelet counts. This effect persisted across all ethnic groups. However, African-Americans (non-Hispanic Blacks) with either thrombocytopenia or thrombocytosis were at significantly lower risk compared to non-Hispanic Caucasians (HR=0.82; 95% CI: 0.69-0.96 and HR=0.70; 95% CI: 0.53-0.94, respectively). Furthermore, Hispanics with thrombocytosis were found to have a lower mortality risk compared to non-Hispanic Caucasians with thrombocytosis (HR=0.60; 95% CI: 0.44-0.81). A value of <125,000 platelets per microliter was a better prognostic marker for non-Hispanic Blacks and these subjects with this platelet count had similar overall survival to that of Caucasians with a value of <150,000 per microliter. In conclusion, thrombocytosis and thrombocytopenia are independently associated with shorter overall survival in elderly subjects and this effect is modified by ethnicity. Using different thresholds to define the association of thrombocytopenia and thrombocytosis with overall mortality risk among non-Hispanic Blacks may, therefore, be warranted.

Background: A neutrophil count of 1500 cells per microliter has been traditionally used as the cutoff for neutropenia and has been considered a marker of increased susceptibility to infections and adverse prognosis. Despite conventional use of this definition, there are no large studies that have examined the direct relationship of low neutrophil counts with overall survival, especially in relation to different ethnicities. Thus, the aim of this study was to examine the prevalence of neutropenia and its prognostic impact among the various ethnicities.

Little is known about the epidemiology of MDS in minority populations. The IPSS and newly released IPSS-R are important clinical tools in prognostication of patients with MDS. Therefore, we conducted a retrospective epidemiological analysis of MDS in an ethnically diverse cohort of patients. Demographics, disease characteristics, and survival were determined in 161 patients seen at Montefiore Medical Center from 1997 to 2011. We observed that Hispanics presented at a younger age than blacks and whites (68 vs. 73.7 vs. 75.6 years); this difference was significant (p = 0.01). A trend towards greater prevalence of thrombocytopenia in Hispanics was observed, but this was not significant (p = 0.08). No other differences between the groups were observed. Overall median survival after diagnosis was the highest among Hispanics (8.6 years) followed by blacks (6.2 years) and Caucasians (3.7). Adjusted hazard ratios however did not show significant differences in risk of death between the groups. The IPSS-R showed slightly better discrimination when compared to the IPSS in this cohort (Somers Dxy 0.39 vs. 0.35, respectively) but observed survival more was more closely approximated by IPSS than by IPSS-R. Our study highlights the possibility of ethnic differences in the presentation of MDS and raises questions regarding which prognostic system is more predictive in this population.

Abstract Introduction Bone marrow examination is an essential and commonly performed bedside procedure in diagnosis and staging of hematological malignancies and benign hematological disorders. Although when performed on the posterior superior iliac spine(PSIS), it is considered a safe procedure with minimal complications, cases of excessive bleeding , hematoma formation, injury to neurovascular structures, retroperitoneal and intraperitoneal hemorrhage, pseudo aneurysm formation and gluteal compartment syndrome have been reported. Cases of retroperitoneal hemorrhage are presumed to occur due to penetration of the needle through the iliac crest indicating that accurate placement and angulation of the biopsy needle is critical to avoid iatrogenic complications. Bone marrow biopsy has been described in various publications and text books. However, standardized technique for positioning the biopsy needle and its penetration orientation are lacking. Various authors have described the correct needle placement and orientation as perpendicular to the bone or pointing towards the anterior superior iliac spine (ASIS) but most of the studies do not specify angulation of the needle. These methods appear to be extrapolated from personal experience and, to date, an evidence based approach for needle angulation has not been described. We present a comparison of different described approaches to perform bone marrow biopsy relative to injury to critical structures should the needle penetrate the inner bone cortex. This study compares the two most commonly used PSIS biopsy approaches that advance the needle towards: 1. The Umbilicus (Medial Approach) 2. Ipsilateral ASIS (Lateral Approach). Methods The study was done on cadavers in the dissection laboratory at the Albert Einstein College of Medicine. The procedure was performed by Attendings and Fellows in Hematology Division who are experienced in performing bone marrow biopsy. Manual Jamshidi needles or powered bone marrow device were used. Anatomy professors helped identify the landmarks and performed dissections after biopsy procedures. The Radiology Department assisted with performing and reading the CT scans of the pelvises. The first phase of study involved placing two dissected cadavers with intact pelvises in prone and lateral positions. Bone marrow needle was placed perpendicular to the PSIS and, during penetration, the direction was changed toward the umbilicus for the Medial Approach and towards the ASIS during the Lateral Approach. A bone marrow biopsy was obtained. Subsequently, using the same needle track, the needle was deliberately pushed through the inner ilial cortex to assess the resultant potential for injury. Keeping the needles in situ, metal wire probes were inserted via the needle for better visualization. The cadavers were further dissected to identify injury to neurovascular bundles and adjacent structures. In the second phase, bone marrow biopsy was performed on two intact cadavers. The needles with inserted probes were left in situ to mark different angulations. The cadavers were then scanned and dissected to identify penetrated structures and closely related neurovascular bundles that were at risk had the orientation varied slightly. Results Dissections and CT scan imaging showed that Lateral Approach was less likely to cause injury to significant neurovascular structures and penetrate the sacroiliac joint in comparison to the Medial Approach. Using the Medial Approach, in the event of penetration of inner cortex, we documented injury to the sacro-iliac joint, femoral nerve, common iliac vessels and mesentery of the sigmoid colon. The needle was observed in close proximity to the iliolumbar vein and artery and the lumbosacral trunk. Using the Lateral Approach, the structures adjacent to the needle were limited to the iliacus muscle and the lateral cutaneous branch of femoral nerve. The lateral approach had the added benefit of more consistent orientation since the relationship of the ASIS to the PSIS is both consistent and palpable whereas the location of the umbilicus may vary. We suggest that the safest way to perform a bone marrow biopsy is to advance the needle in a perpendicular direction to reach the PSIS. Once the needle penetrates the outer cortex of the bone, the direction should be changed pointing towards the ipsilateral ASIS. We believe that this procedure will obviate complications reported in the literature. Disclosures: No relevant conflicts of interest to declare.