Laboratory Diagnosis of Acute Leukemia in Kenya: The Gaps and Opportunities

Acute leukemia (AL) is a malignant disease of the bone marrow in which hematopoietic precursors are arrested in an early stage of development. The diagnosis of leukemia and lymphomas, beyond morphology, is limited in low-resource countries including Kenya. Morphological diagnosis includes Cytological and Histological assessment of blood, bone marrow aspirates and tissues on suspected Acute leukemia patients. The World Health Organization (WHO, 2016) international guidelines on Acute leukemia diagnosis recommend that cytogenetic analysis, appropriate molecular genetics, Fluorescent in situ Hybridization (FISH) testing, and flow cytometric immuno-phenotyping should be done in addition to a morphologic assessment of Acute Leukemia. In facilities where resources are relatively available, immunophenotypic and genetic features have resulted not only in providing a more accurate leukemia diagnosis but also in identifying antigens or genes that can then be targeted for therapy. This article will look at the gaps in the diagnosis of Acute leukemia in low-resource settings like Kenya and opportunities available to improve diagnosis.

Assessment Methods Used during Clinical Years of Undergraduate Medical Education at Moi University School of Medicine, Kenya

Background: Assessment is the systematic collection, review, and use of information about educational programs undertaken to improve teaching and learning. It ensures quality in training programmes, motivates, and directs students’ learning. Assessment is also used for verification of achievement of objectives of training, feedback to students, licencing, certification, and screening of students for advanced training. It is guided by several principles, including the aims of the assessment (why assess), who to assess, timing (when to assess), what to assess, methods (how to assess), and the criteria for determining the usefulness of the assessment. Objective: To describe the assessment methods used during clinical years of the undergraduate programme at Moi University School of Medicine (MUSOM) and determine the student’s perspectives concerning the comprehensiveness, relevance, objectivity of various assessment methods and challenges faced. Methodology: The study was carried out at MUSOM and a cross-sectional study design was employed. Ten study participants were studied using convenience sampling. Data were collected using an interview guide and was analyzed using content analysis. An informed consent was obtained from the study participants. Results: The methods used during clinical years at MUSOM for assessing knowledge and its applications include multiple-choice questions (MCQ), short answer questions (SAQ), modified essay questions (MEQ), long essay questions (LEQ), and oral exam. Whereas the methods for assessing clinical competence include long case, short cases, objective structured clinical examinations (OSCE), and logbook. Students felt that MCQs were comprehensive, objective, and relevant to the curriculum content. They reported that feedback was not provided after assessments. Conclusion: The assessment methods used at MUSOM during clinical years include MCQ, SAQ, MEQ, LEQ, Short cases, long cases, and OSCE. Students reported varied perceptions of the different assessment methods but favored MCQ and OSCE over other formats for assessing knowledge and clinical skills respectively.

CD34-Negative B-Lymphoblastic Leukemia/Lymphoma Presenting as Cutenous Lesions at Infancy: A Case Report

Acute lymphoblastic leukemia/lymphoma is a highly aggressive neoplasm of precursor lymphoid (blast) cells. There are 2 main subtypes based on lymphoid lineage;B lymphoblastic leukemia/lymphoma (B-ALL/LBL) and T lymphoblastic leukemia/lymphoma (T-ALL/LBL). B-ALL/LBL commonly presents with fever, fatigue, bone or joint pain, bleeding or anorexia (signs of bone marrow infiltration), lymphadenopathy, hepatosplenomegaly, involvement of skin, soft tissue and testes, with a predilection for the central nervous system. Immature cell markers, such as CD34 and TdT, can help to differentiate lymphoblasts from Burkitt lymphoma which, is considered a mature high-grade B cell lymphoma that mimics lymphoblastic lymphoma/leukemia. Unfavorable prognostic factors include: infancy and adult age of diagnosis, high white blood cell count, slow response to initial therapy, central nervous system involvement at the time of diagnosis and Minimal residual disease after therapy. We present a case report of a 4 months old infant seen at a Tertiary Hospital with a rare presentation of CD34 Negative B-lymphoblastic leukemia/lymphoma presenting as cutaneous lesions in infancy.

Bone Marrow Aspirate and Trephine Biopsy Procedure in a Teaching and Referral Hospital in Kenya

Introduction: Bone marrow aspiration and biopsies are carried out principally to permit cytological assessment of marrow. The procedure is also indicated for immunophenotypic, cytogenetic, molecular and other specialized investigations. The skill to perform bone marrow aspirate and biopsy is usually acquired by the medical personnel through apprenticeship during their training. The training includes performing the procedure, indications, contraindications, and associated hazards. Moi Teaching and Referral Hospital (MTRH) being a specialized Hospital in Western Kenya has several staff trained on performing the procedure. Objective: To assess the performance of bone marrow procedure by clinicians at a teaching and referral hospital. Materials and methods: A descriptive cross-sectional study was done involving 40 clinicians working in the hematology clinic and medical wards from June to December 2019. A structured questionnaire was used to collect the data and data analysis was done using frequency tables. Approval to carry out the study was sought from the institutional IRB. Results: Patients attended to were predominantly adults 33 (83%). The superior posterior iliac crest was the commonest site for the procedure and disposable needles were routinely used in 33 (83%) of the patients. Pain and excessive bleeding 18 (45%) were the commonest complications associated with the procedure. Conclusion: Most of the clinicians involved doing the procedure were residents/registrars. Most of the patients attended to were adults (83%) and majority of the clinicians performed the procedure on the posterior iliac site (96%) using disposable needles (83%). Local anesthesia was commonly used during the procedure (88%). The common complications associated with the bone marrow procedure were pain and excessive bleeding (45%).