Maharashtra University of Health Sciences Courses

D.M. (Hematology)

Course content

I. Practical Laboratory Training

• A. General Hematology
  • Proper use and care of common instruments such as light microscope, centrifuge, water baths, freezers, weighing balance, etc.
  • Blood collection samples - venepuncture and finger prick methods of sample collection, types of anticoagulants, containers and the effects of delay in processing and storage.
  • Determination of peripheral blood counts (Hemoglobin, Hematocrit, Total WBC and platelets) manually and calculation of red cell indices.
  • Use of automated blood cell counters including principles and practice. Interpretation of peripheral blood counts and abnormal flags.
  • Preparation of blood films and, staining of peripheral blood films and cytospin slides with Romanowsky and other dyes.
  • Review of normal and abnormal blood films with emphasis on morphology of red cells, white cells and platelets.
  • Performance of WBC differential counts; subjective assessment of platelet counts and diagnostic interpretation of abnormal counts.
  • Preparation and staining of thick and thin blood films for malarial parasites.
  • Measurement and significance of ESR and plasma viscosity.
  • Supravital staining of reticulocytes, counting of reticulocytes.
  • Performance of bone marrow aspiration; trephine needle biopsy, splenic aspiration.
  • Preparation of smears of bone marrow aspirates and biopsy [touch] imprints. Staining and diagnostic evaluation of bone marrow aspirates.
  • Performance of sickling and solubility tests and screening for red cell G6PD activity with interpretation of results.
• B. Laboratory evaluation of hemolytic anemias
  • Hb S solubility test
  • Screening for unstable hemoglobin, supravital staining of Hb H inclusions.
  • Principles and practice of separation and identification of normal and abnormal hemoglobins by electrophoresis and chromatography
  • Quantitation of normal and abnormal hemoglobins by densitometry and chromatography
  • Quantitation of HbF by alkali denaturation and cellular distribution of HbF by Kleihauer acid elution technique
  • Heinz body preparation
  • Screening for G6PD deficiency and quantitative estimation of G6PD and other red cell enzymes.
  • Direct and indirect Coomb’s test, warm and cold autoantibody titres
  • Miscellaneous biochemical test on red cell, plasma and urine
    • Principle and procedures for estimation of plasma bilurubin and haptoglobin; and significance of the results, screening for methaemalbumin, methaemoglobin and sulphaehemoglobin
    • Screening for cryoglobins, principles of immunoglobin estimation and immune electrophoresis
    • Estimation of urine for Hb, red cells, hemosiderin, urobilinogen and bilurubin
    • Principles of estimation of serum ferritin and iron /TIBC
    • Principles and estimation of red cell folate, serum folate and serum cobalamin.
• C. Laboratory Investigations of Bleeding Disorders
  • Platelets
    • Performance of Ivy bleeding time and platelet count; study of platelet morphology
    • Principles, practice and interpretation of platelet aggregometry tests.
    • Platelet associated immunoglobulin (PAIgG) and circulating antiplatelet antibodies.
  • Screening for coagulation factor abnormalities:
    • Prothrombin time and stypven time.
    • Activated partial thromboplastin time
    • Thrombin time and reptilase time.
    • Plasma fibrinogen.
    • Correction studies with normal plasma, adsorbed plasma, aged serum and factor deficiency plasmas.
    • FDP and D-Dimers.
    • Assays of clotting factors particularly factors VIII and IX.
    • Urea solubility test for factor XIII
    • Euglobulin Iysis time and other relevant tests of plasma fibrinolytic activity.
• D Laboratory Investigation of Thrombotic Disorders
  • Principles:
    • Assays of plasma AT III, protein C, protein S, Factor V Leiden
    • Screening for lupus anticoagulant and activated protein C resistanceprinciples of screening tests and interpretation of results.
    • Laboratory monitoring of anticoagulant (heparin and oral anticoagulants) therapy.
• E. Cytochemistry
  • Performance of the following staining procedures, Sudan Black, Myleloperoxidase, specific and non specific esterases, acid phosphatase. PAS and iron staining.
• F. Cytogenetics
  • Familiarisation with cytogenetics, understanding the principles of cytogenetics and appreciating the relevance and significance of chromosomes in diagnostic hematology, interpreting the results of chromosome preparation of hemopoietic cells.
• G. Transfusion Medicine
  • 1.
    
    • ABO blood grouping (forward and backward); Rh typing (phenotypes and genotypes), screening of antibody in sera of donors and recipients, antibody identification following elution by various techniques.
    • Blood group compatibility (crossmatching) testing.
    • Investigation of ABO, Rh and other immunohaemolytic diseases of the newborn.
    • Practical aspects in the selection of blood for neonatal exchange transfusion.
  • Donor evaluation & recruitment.
  • Clinical evaluation and laboratory screening of donors to phlebotomy.
  • Phlebotomy of donors.
  • Blood component preparation and storage.
  • Practical and administrative procedures involved in issuing and transfusing blood.
  • Principles of the mechanics of the cell separator and its use for blood component preparation and therapeutic apheresis.
  • Practical steps in the laboratory investigation of transfusion reactions.
  • Quality control
• H. Flow Cytometery
  • working knowledge of the principle and practice of flowcytometery and interpretation of the clinical significance of common leukocyte immunophenotypes.
  • I Laboratory Equipment and Organization
  • working knowledge of the mechanics of the various laboratory instruments including their operation, calibration and basic maintenance, is desirable.
    • Laboratory space distribution; ordering, siting and installation of laboratory equipment; workflow procedures and handling of samples.
    • Staffing – technical and non-technical.
    • Use of computers and generation of laboratory statistics.
    • Health and Safety measures.[Physical/Chemical/Biological/Radiation]
    • Waste disposal.
    • Quality Assurance (Internal and External) measures.
    • Budgeting
  • II. Histopathology Module
    
  • Practical laboratory training and related theory should cover the following areas:
    • General processing of tissues, especially Lymph Node Biopsy, Bone Marrow trephine biopsy, F.N.A.C and other tissues with special emphasis on leukemic deposits of lymphomatous involvement.
    • Techniques of cytology including cytospins in relation to body fluid of patients with hematological disorders.
    • Immunocytochemistry relevant to Hematology.
    • Electron microscopy of hemopoietic cells.
  • III Biochemistry Module
  • A. Laboratory Techniques :
  • Practical “hands –on” experience and related theoretical background in the following:-
    • Separation procedures – electrophoretic techniques, chromatography
    • Immunochemical methods.
    • Radioimmunoassays.
  • IV HLA Module
  • Demonstration and understanding the principles of:-
    • Separation of lymphocytes using density gradient and centrifugation.
    • The microlymphocytoxicity test and its application in HLA typing, crossmatching and antibody screening.
    • The mixed lymphocyte reaction: one way and two-way cultures.
    • Miscellaneous investigations (on request) including mitogen and antigen induced lymphocyte transformation and neutrophil function assays.
  • V. Molecular Biology Module
  • Understanding the principles involved in the molecular diagnosis of hematological disorders.
    • DNA separation
    • PCR
    • RFLP and Southern Blotting.

II. Clinical Haematology Training

• With appropriate guidance and under supervision, the post graduate trainee will be responsible primarily for the acquisition of knowledge in all areas of hematology and Transfusion Medicine. Such knowledge will be acquired and demonstrated through seminars, case presentations, journal clubs, tutorials and proper use of library for suggested reading and formal reviews of major selected topics. Faculty staff should be present at these various exercises so as to provide the appropriate inputs. When necessary faculty staff may be required to review certain subjects in form of formal lectures. Clinical experience will be acquired by the trainee by day to day management of all patients admitted to the hematology service. Faculty will also be involved in teaching of trainees in the ward-rounds and outpatient clinics.
• I. Red Cell Disorders
  • Clinical evaluation of a patient with anemia: history, physical examination, appropriate laboratory investigations and management. Comparative epidemiologic significance of ‘nutritional’ and other anemias in the population and the national programme for control.
    • Iron Deficiency Anemia Epidemiology, iron deficiency as a community health problem, causes in the population, control strategies in the population. Evaluation of the individual patient, interpretation of serum iron, TIBC, transferrin. Indications for and interpretation of ferrokinetic studies, management including iron replacement.
    • Megaloblastic Anemia Clinical and laboratory evaluation, clinical recognition, evaluation and management of complications of vitamin B12 deficiency investigation of etiology and management. Understanding the role of vitamin B12 and folate in cellular metabolism and the interaction of disease and drugs with the metabolism of folate.
    • Hemolytic anemia
    • a. Evaluation of a patient with hemolysis and investigations of its causes.
      • Thalassemia: principles of control of the thalassemia syndromes in the population, screening strategies, antenatal diagnosis, genetic counseling, clinical and laboratory diagnosis of alpha and beta thalassemia syndromes. Management of thalassemia intermedia and majortransfusion regimes chelation, role of splenectomy and bone marrow transplantation. Comprehensive thalassemia care center, its functions, role of the staff, social workers and paramedics, etc.
      • Sickle cell disease: Evaluation, management of the steady state, management of painful and anemic crisis, management of chronic complications, clinical and hematological features of the various sickle cell diseases, clinical and hematological effects of the interaction of thalassemia with sickle cell anemia, therapeutic role of bone marrow transplantation.
      • Inherited enzymopathies (Red Cell G6PD deficiency): Evaluation and management of acute hemolytic crisis.
      • Acquired hemolytic disorder: Immune hemolytic anemia management with immunosuppression, role of intravenous immunoglobulin, plasmapheresis, and splenectomy. Clinical and laboratory evaluation etiological diagnosis) of patients suffering from acquired intravascular hemolysis.
  • 4. Aplastic Anemia Etiology, evaluation and management including immunosuppression (Antilymphocyte globulin, etc) and supportive therapy. Role of bone marrow transplantation in treatment of the individual patient; preparation for bone marrow transplantation.
  • 5. Pure red cell anemia Diagnostic evaluation and treatment of congenital and acquired forms. Transient erythroid aplasia including the pathogenic role and biology of the human B19 parvovirus.
• II. White cell disorders
  • Neutropenia
    
    • Clinical evaluation of a neutropenic patient, role of surveillance microbiology, antimicrobial therapy in neutropenia, role of growth factors, principles in providing a sterile environment for the neutropenic patient.
  • Functional Disorders of neutrophils
    
    • Neutrophil function, laboratory tests foe evaluation and management of patient with chronic neutrophil dysfunction, role of growth factors and bone marrow transplantation.
  • Leukemia
    
    • Clinical evaluation, diagnostic confirmation by morphology, immunophenotyping, special stains, cytogenetics and electron microscopy. The trainee must be familiar with the principles of leukemia management and the various protocols available. He/she should be familiar with the statistical tools used to evaluate therapy protocols, survival curves etc. He /she should also be familiar with the pharmacology of antimitotic drugs and their toxicity and well versed in the supportive management of patients with all types of leukemia.
  • Myeloproliferative disorders
    • Classification, systemic diagnostic evaluation of erythrocytosis, including polycythemia vera; interpretation of blood volume studies; with radionuclides, familiarity with current management strategies of MPD including the use of interferon.
  • Lymphoma
    • Classification of lymphomas, principles of staging and management of different types of lymphomas
  • Immune Deficiency Disorders
    • Trainees must be able to order systematically the appropriate investigative scheme for a patient with congenital or acquired immunodeficiency they must understand the principles of management with immunoglobulin replacement, interferon, and bone marrow transplantation and be familiar with the hematological manifestations and their therapy of AIDS.
  • Multiple Myeloma and other Paraprotein anemias
    • Clinical and laboratory evaluation of a patient with a monoclonal gammopathy. Interpretation of quantitative immunoglobulin levels, serum protein electrophoretic strips and immunoelectrophoresis patterns, concept of monoclonal gammopathy of undetermined significance (MGUS); management of Myeloma and Waldenstrom’s macroglobulinaemia.
  • Miscellaneous disorders like Histiocytosis, Splenic disorders and systemic diseases affecting the haemopoietic system, etc.
• III. Hemostasis
• Trainees should be thoroughly grounded in the general clinical (history and physical signs) approach to the patient with a bleeding tendency.
  • Thrombocytopenia
    • Thorough understanding of platelet kinetics and evaluation with radionuclides. Evaluation and investigation of the etiology of thrombocytopenia. The student should be conversant with the spectrum  of management including immunosuppression, intravenous immunoglobulin, plasmapheresis and immunoadsorption.
  • Inherited platelet function disorders
    
    • Clinical evaluation, laboratory diagnostic strategies and management.
  • Inherited coagulation factor deficiencies
    • Laboratory diagnosis of hemophilia genetics and antenatal diagnosis. Principles of factor replacement; factor replacement schedule in a patient with hemophilia who needs surgery; management of complications. Principles of management of patients with inhibitors. Organization of hemophilia care center and training.
  • Acquired bleeding disorders
    • Vitamin K deficiency and supplementation; DIC its causes and management, management of haemorrhagic complications of liver disease and renal failure, after cardiothoracic surgery.
  • Thrombotic Disorders
    • Classification and laboratory diagnosis of inherited thrombotic disorders; evaluation of hemostasis in the acquired thrombotic disorders, clinical use and monitoring of anticoagulants.
• IV Transfusion Medicine
  • Blood component preparation and their clinical use
    • Collection of blood, correct techniques of venepuncture, plastic systems, anticoagulants and additives, and their effect of storage stability, centrifugation, preparation of platelets, fresh frozen plasma and cryoprecipitate, storage of components, principles of fractionation. Quality control. A thorough understanding of the clinical indications for proper use of specific blood components.
  • Diagnosis & Management of Transfusion related complications
    • Febrile transfusion reactions- laboratory investigations, diagnosis, management and prevention. Diagnosis and management of hemolytic transfusion reactions. Infections transmitted by transfusion, physical and clinical complications of transfusion.
  • Cell separation principles
    • The trainee must be able to perform cell separation and apheresis. Principles of cell separators; continuous versus intermittent flow techniques, replacement fluids for plasmapheresis, current status and indications in various diseases should be known and understood.
  • Techniques of leuco-depletion
    • Problems related to white cells in donor blood and techniques of removal. Principles of filter design and use.
  • Irradiation of blood and components
    • Biology of irradiation of blood and components, transfusion graft versus host disease [GVHD] Indications for irradiation of blood and protocols. Use of equipment.
  • Management of alloimmunization in relation to transfusion
    • Techniques for prevention of alloimmunization, role of ultraviolet radiation and photosensitizers, management of patients with red cell and platelet alloantibodies.
  • Management in relation to Blood Transfusion, at the time of Disaster or natural calamities.
• V. Bone Marrow Transplantation
• The student must be familiar with current indications and results of bone marrow transplantation in various diseases.
  • Donor selection
    • HLA typing and MLR in bone marrow transplantation, screening of Donor
  • Conditioning regimens
    • the trainee must be familiar with the different conditioning regimens, principles of their use in different disorders and complications
  • Harvesting and manipulation of the bone marrow
    • Bone marrow collection, red cell or plasma reduction, peripheral blood stem cell mobilization and collection, cryopreservation, Transfusion of marrow. Purging of marrow –T cell depletion.
  • Transplantation immunology
    • Histocompatibility, graft versus host disease – diagnosis and management. Immune reconstitution following transplantation.
  • Management of post transplant patient
• VI. Haematological Oncology
  • Cell cycle – cell kinetics
  • Principles of chemotherapy
  • Oncogenesis
  • Cytogenetics in relation to hematological malignancies
  • Use of growth factors
  • Principles of development of clinical algorithems, etc.
• VII. Consultation Haematology Services
  • Hematological complications of pregnancy and the interaction of the pregnant state with disorders of the haemopoietic system.
  • Hematological complications of systemic disease.
  • Hematological problems in Intensive Care Unit patients.
  • Hematological management of neonatal sepsis, hemolytic disease of new born[HDN], alloimmune thrombocytopenia, etc
• VIII. Research Methodology and Data Base
  • Clinical Trial Protocol designing.
  • Statistical evaluation & Kaplan-Meyer plot, etc.
  • Bioethics.