Thalidomide and Hydroxyurea in Transfusion-Dependent Thalassemia: Efficacy, Safety Profile and Impact on Quality of Life.

Transfusion-dependent thalassemia (TDT) is a major public health concern in India, requiring regular transfusions for survival. There is also significant morbidity caused by iron overload and transfusion related infections. Novel therapies targeting fetal hemoglobin induction are the need of the hour in resource-poor institutions for patients where transplant is not feasible for various reasons. This single arm, non-randomised prospective trial evaluated the efficacy and safety of a combination of low dose thalidomide and hydroxyurea in TDT along with the impact on quality of life (QoL). It included 41 TDT patients, who failed a reasonable trial of hydroxyurea. Complete response (CR) was defined as transfusion independence and partial response (PR) denoted at least a 50% reduction in transfusion requirement. The rest were defined as non-responders (NR). The mean age of the cohort was 20.78 years (range 12-45 years). There were 13 males and 28 females. Nineteen (46.3%), 7 (17.1%), and 15 (36.6%) patients achieved CR, PR, and no response respectively. The overall response rate (CR + PR) was 63.4%. There was a significant increase in hemoglobin levels with decrement in transfusion burden and ferritin levels. There were no significant adverse reactions. No significant predictors of response were found including amongst genetic modifiers. It improved the health related QoL amongst responders. The combination of thalidomide and hydroxyurea appear safe and effective in the reduction in transfusion requirement of TDT patients. The judicious use of these drugs can improve the quality of life and pave the way for patients not eligible for a stem cell transplant.

Alpha globin gene alterations modifying the phenotype of homozygous beta thalassaemia.

The phenotype of ß-thalassemia varies widely. The primary determinant is the type of beta-globin gene mutation; however, there are secondary and tertiary modifiers also as associated alpha mutations, polymorphisms, as well as coinheritance of mutations affecting other related systems. Co-inheritance of alpha thalassemia mutations is known to ameliorate the severity of HbE-ß thalassemia. However, the role of alpha globin gene alterations (deletions and triplication) is not well illustrated in homozygous ß-thalassemia. Here we evaluated the role of alpha globin gene alterations in 122 ß-thalassemia patients having IVS1-5 (G > C) homozygous mutation. ß-thalassemia mutations were detected by ARMS PCR and alpha mutations by GAP-PCR. Gene expression by qRT-PCR. Out of 122 cases, 15 patients had alpha 3.7 triplications (ααα3.7anti), 24 had alpha 3.7 kb deletion (-α3.7) mutation and three patients had 4.2 kb deletion (-α4.2). Patients were divided into two groups, requiring less than 8 units (NTDT) and more than 8 units (TDT) of blood transfusion per year (≥8U BT/year). The percentage of alpha deletion was significantly (p = 0.0042) high in NTDT (42.1%) as compared with TDT (13.2%). Conversely, the proportion of alpha triplication is high in the TDT as compared with NTDT. Even mean serum ferritin level was found to be significantly high in patients having alpha triplication as compared with those having alpha deletions (p = 0.0184) and normal alpha gene (p = 0.0003). α/ß globin ratio was highest in TDT patients with alpha triplication and lowest in NTDT patients with alpha-del. The results show that concurrent inheritance of alpha gene alterations influences the phenotypic severity of homozygous ß-thalassemia.

Cytogenetic Alterations and Correlation with Age and Gender in Patients of Multiple Myeloma: A Study from a Tertiary Care Center in Eastern India.

Karuna JhaBackground Multiple myeloma is a cytogenetically heterogeneous, evolving, and incurable disease. Differences in prevalence of myeloma already exist in Indian subcontinent as compared with Western world countries. This study attempts to investigate differences in incidence of cytogenetic abnormalities (CA) in Eastern Indian patients and study differences in incidence with respect to age and gender. Materials and Methods Interphase fluorescence in situ hybridization (FISH) was applied on purified plasma cells of 280 newly diagnosed myeloma cases using specific probes. Statistical Analysis Data was analyzed using SPSS software version 25. Results Note that 51.07% patients were FISH positive. Del13q was the most common CA. Significant association of del 13q with t(4;14), del 17p, and gain of 1q was seen. The frequencies of FISH positive and negative groups differed in the different age groups; higher number of cases in 41 to 50 years group in FISH positive group ( p < 0.05) and lower number of cases in FISH positive group in 61 to 70 years ( p < 0.05) as compared with FISH negative group. Del 17p had higher number of cases in age group 41 to 50 years and 51 to 60 years as compared with other age groups. Incidence of t(11;14) was in 5th to 7th decade while del 13q and t(4;14) had the widest range of age at presentation. Gender disparities were seen in high-risk cytogenetics like del 17p and 1q gain. Conclusion The differences in incidence rate of CAs per se in myeloma cases diagnosed in Indian subcontinent and the differences in incidence with respect to age and gender warrant further multicentric studies.

Haematological screening and its correlation with sociodemographic profile among the indigenous communities in and around Puducherry.

Background: Haemoglobin disorders are unique and important health challenges for tribal populations. Hence, this study was undertaken with the aim to screen for haematological disorders, particularly anaemia and haemoglobinopathies, and to assess the sociodemographic profile in indigenous communities residing in and around Puducherry. Methods: This was a community-based cross-sectional study conducted in both urban and rural areas of Puducherry district. We included 556 participants through convenient sampling. Trained research associates visited community to enrol eligible participants and sought information on sociodemographic parameters, health status, and disease profile, using a structured questionnaire; 2-3 ml of blood was collected in ethylene diamine tetra acid anticoagulant for analysis of haematology parameters. Results: Median age of participants was 28 (17-42) years. Majority (58.8%) of the participants were female, married (52.8%). On thalassemia screening, none of the study participants had any haemoglobinopathy. The burden of anaemia among the study population was 38.7% (95% CI: 34.6-42.8%) and was higher among the female participants in both adolescent (54.5%) and adult (57.8%) age groups. The next common haematological abnormality observed was eosinophilia 21.4% (95% CI: 18-25%), more prevalent among males in the age group of 30-60 years. Conclusion: More than half of the women were anaemic. Multidimensional planning and implementation are needed to improve the socio-economic profile and overall health of this vulnerable population.

Bendamustine-Rituximab in Young CLL: Relevance in the Era of Small Molecule Inhibitors.

Purpose: Chemo-immunotherapies like Fludarabine-Cyclophosphamide-Rituximab (FCR) are used for treatment of chronic lymphocytic leukemia (CLL) in young and fit patients while Bendamustine-Rituximab (BR) is used in older patients. In a resource constrained setting, managing toxicities of FCR chemotherapy is challenging and this study explores the use of upfront BR treatment in young CLL patients (age < 65). Methods: Data of 61 CLL patients treated with the BR regimen between 2016 and 2020 was analysed. Overall-survival and progression-free-survival (OS and PFS) were compared between the two age groups (< / > 65 years) and correlated with the fluorescent-in-situ-hybridization (FISH) data, duration of illness and time to initiation of chemotherapy. Results: Out of 61 patients, 34 (85%) were below 65 years. Five patients had del 17p and were excluded from the analysis. Forty patients had indications for treatment. Twenty-four (70.5%) of the forty patients achieved overall response; 10 developed progressive disease. The median OS and PFS was 1874 days (95% CI 1617-2130 days) and 1226 days (95% CI 1021-1432 days) respectively and were non inferior between the 2 age-groups. There were no correlations with clinical, laboratory or FISH parameters. The OS and PFS were better for patients with longer time to initiation of chemotherapy as compared to those with short duration of illness and short wait-and-watch periods (p < 0.000). Conclusions: Our results show that BR chemotherapy can safely and effectively be used in upfront treatment of young CLL patients and provide durable responses.

Pattern of hemoglobinopathy among the young tribes of West Bengal: A completely different scenario from Rest of India.

Hemoglobinopathy is a major concern among the tribal population which constitutes 8.6% of the total population, and West Bengal (WB) is the home to 5.3 million tribes. The present study was conducted on 52,880 tribal school students from all the districts of WB. Written informed consent and peripheral blood were collected for complete blood count and high-performance liquid chromatography analysis. Beta trait was 5.3%, sickle trait was 2.35%, and hemoglobin (Hb) E (HbE) trait was 1.4% in this population. About 37.8% of beta trait belonged to the Santal tribe and 21.5% belonged to Oraon. HbS is mainly found in Alipurduar and Jalpaiguri districts at the prevalence of 3.69% and 5.96%, respectively. HbE trait is found at 6.06% in Alipurduar, of which 51% of cases are from Mech tribe only found in this district. Unlike central and Western parts of India, HbS trait in WB was significantly low among the tribes. A high prevalence of consanguinity among the tribes is considered responsible for the high rate of hemoglobinopathy.

Bleeding per rectum during induction chemotherapy: Looking beyond the leukaemia - 2 case reports and review of literature.

Synchronous malignancies involving acute leukemia and a solid organ are rare. Bleeding per rectum is a common manifestation of acute leukemia during induction chemotherapy and might mask the presence of synchronous colorectal adenocarcinoma (CRC). Here we present two rare cases of acute leukemia with synchronous CRC. We also review previously reported synchronous malignancies to investigate demographics, diagnosis, and treatment modalities. Management of these cases requires a multispecialty approach.

Prenatal Screening and Diagnosis of ß-Thalassemia in India: Is ARMS-PCR Enough?

Accurate and timely prenatal diagnosis of thalassemia is cornerstone to the success of thalassemia control; currently parents are screened for ß-thalassemia mutations by ARMS-PCR and subsequently chorionic villus sampling is done. We did an audit to ascertain whether the present design is adequate and determined the role of sequencing for pre-natal diagnosis of beta-thalassemia. This was a retrospective analysis of prenatal testing data collected over 10 years, (2010-2019). ARMS-PCR was done to identify the beta-globin mutation followed by CVS wherever indicated. Data was classified into 3 groups:-5 most commonly occurring mutations (group 1), less common mutations (group 2) and mutations not detected (group 3). Total number of cases studied were 2128. Mean age of the cohort was 29.30 years (range 18-48 years). Approximately 90% individuals had one of the 5 common mutations in decreasing order of frequency: IVS 1-5 G>C (1297/2128); Codon 26G>A/HbE (451/2128); codon 30G>C (69/2128); codon 15G>A (61/2128); FS 41-42-CTTT (48/2128). Undetected mutations amounted to 7.3% (156/2128). Mean haemoglobin was highest in the group 2 (12.46 g/dl) followed by the group 1 (11.20 g/dl) and least in group 3 (10.99 g/dl). MCV, MCH and MCHC showed similar trends. ANOVA on all these parameters, except RDW, within groups and for individual mutations, were statistically significant (p < 0.001). The hemogram-HPLC-ARMS-PCR-CVS approach is a cost-effective and established method but tends to miss out a considerable number of thalassemia mutations (~7%), emphasizing the role of sequencing in difficult cases. This needs to be addressed while formulating guidelines for thalassemia screening in future.

Innate Immune Invisible Ultrasmall Gold Nanoparticles-Framework for Synthesis and Evaluation.

Nanomedicine is seen as a potential central player in the delivery of personalized medicine. Biocompatibility issues of nanoparticles have largely been resolved over the past decade. Despite their tremendous progress, less than 1% of applied nanosystems can hit their intended target location, such as a solid tumor, and this remains an obstacle to their full ability and potential with a high translational value. Therefore, achieving immune-tolerable, blood-compatible, and biofriendly nanoparticles remains an unmet need. The translational success of nanoformulations from bench to bedside involves a thorough assessment of their design, compatibility beyond cytotoxicity such as immune toxicity, blood compatibility, and immune-mediated destruction/rejection/clearance profile. Here, we report a one-pot process-engineered synthesis of ultrasmall gold nanoparticles (uGNPs) suitable for better body and renal clearance delivery of their payloads. We have obtained uGNP sizes of as low as 3 nm and have engineered the synthesis to allow them to be accurately sized (almost nanometer by nanometer). The synthesized uGNPs are biocompatible and can easily be functionalized to carry drugs, peptides, antibodies, and other therapeutic molecules. We have performed in vitro cell viability assays, immunotoxicity assays, inflammatory cytokine analysis, a complement activation study, and blood coagulation studies with the uGNPs to confirm their safety. These can help to set up a long-term safety-benefit framework of experimentation to reveal whether any designed nanoparticles are immune-tolerable and can be used as payload carriers for next-generation vaccines, chemotherapeutic drugs, and theranostic agents with better body clearance ability and deep tissue penetration.

Analysis of blood stream infections, antibiograms and clinical outcomes in haematological patients with febrile neutropenia: data from a tertiary care haematology institute in India.

Timely administration of appropriate empirical antibiotics in febrile neutropenia is crucial for favourable patient outcomes. There are guidelines in place recommending such antibiotics. However, regional variations and local epidemiological data must be evaluated to tailor the antibiotics for best possible and rational use. In this study, we audited the clinical and microbiological data of febrile neutropenic episodes occurring at a tertiary care haematology institution. Three hundred and ninety-three febrile neutropenic episodes occurring in 123 patients over a 1-year period were analysed for microbial profile, sensitivity and resistance patterns, and finally clinical outcomes. Gram-negative bacilli (GNB) blood stream infections (46.9%) were more prevalent as compared to gram-positive infections (41.9%). Overall mortality due to complicated neutropenic sepsis was 19.5% (24/123 patients). Increased resistance to carbapenems, beta-lactam beta-lactamase inhibitor combinations, aminoglycosides, fluoroquinolones, and cephalosporins were observed. Cefepime and tigecycline resistance were seen in 20% and 15% GNB isolates, respectively. Chest was the most frequent focus of infection, and acute myeloid leukaemia (AML) was the most common underlying disorder which correlated with the likelihood of death (p < 0.01). Multidrug-resistant GNB (esp. Klebsiella sp.) are still most worrisome isolates in neutropenic patients. Single-agent cefepime or piperacillin-tazobactam/tigecycline combination may be considered empirical agents. Chest infections and AML were independent predictors of poor clinical outcome in neutropenic patients. Regular audit of infections and antibiotic susceptibility data is needed to improve clinical outcomes in patients with febrile neutropenia.

Turoctocog alfa is safe for the treatment of Indian patients with hemophilia A: Guardian 10 trial results.

BACKGROUND: Hemophilia A is an X chromosome-linked bleeding disorder caused by the deficiency of coagulation factor VIII (FVIII). The majority of the Indian population with hemophilia A use plasma-derived clotting factors and, in some instances, fresh frozen plasma and cryoprecipitate. Safer and more efficient treatment options are needed for this group of patients. OBJECTIVES: To assess the safety of turoctocog alfa, a third-generation recombinant FVIII molecule, for the treatment and prophylaxis of bleeding episodes in previously treated Indian patients with moderate or severe hemophilia A. PATIENTS/METHODS: This single-country, multicenter, open-label, nonrandomized trial enrolled 60 patients who received prophylactic treatment with turoctocog alfa for 8 weeks, which corresponded to a minimum of 20 exposure days. Confirmed development of FVIII inhibitors during the 8-week treatment period was evaluated. Other assessments included frequencies of adverse drug reactions (ARs), serious adverse reactions, drug-related allergic reactions, and infusion reactions during the 12-week period after the first treatment; hemostatic effect of turoctocog alfa for the treatment of bleeding episodes; and total annualized dose of turoctocog alfa administered during the 8-week treatment period. RESULTS: No incidence of FVIII inhibitors was detected. No safety concerns such as ARs, serious ARs, or drug-related allergic reactions were noted. The hemostatic success rate for the treatment of bleeding episodes with turoctocog alfa was 81.6%. CONCLUSIONS: The trial results demonstrated that turoctocog alfa is a safe treatment option for the prophylaxis and treatment of bleeding episodes in previously treated adolescent and adult patients with hemophilia A in the Indian population.

Interfacial energy driven distinctive pattern formation during the drying of blood droplets.

HYPOTHESIS: Dried blood droplet morphology may potentially serve as an alternative biomarker for several patho-physiological conditions. The deviant properties of the red blood cells and the abnormal composition of diseased samples are hypothesized to manifest through unique cell-cell and cell-substrate interactions leading to different morphological patterns. Identifying distinctive morphological trait from a large sample size and proposing confirmatory explanations are necessary to establish the signatory pattern as a potential biomarker to differentiate healthy and diseased samples. EXPERIMENTS: Comprehensive experimental investigation was undertaken to identify the signatory dried blood droplet patterns. The corresponding image based analysis was in turn used to differentiate the blood samples with a specific haematological disorder "Thalassaemia" from healthy ones. Relevant theoretical analysis explored the role of cell-surface and cell-cell interactions pertinent to the formation of the distinct dried patterns. FINDINGS: The differences observed in the dried blood patterns, specifically the radial crack lengths, were found to eventuate from the differences in the overall interaction energies of the system. A first-generation theoretical analysis, with the mean field approximation, also confirmed similar outcome and justified the role of the different physico-chemical properties of red blood cells in diseased samples resulting in shorter radial cracks.

Key Determinants of Phenotypic Heterogeneity of Hb E/ß Thalassemia: A Comparative Study from Eastern India.

HbE Beta thalassemia is phenotypically very diverse disease. We aim to study role of various genetic factors in determining severity of this disease. 243 diagnosed cases of HbE Beta thalassemia were included in this study. Patients were divided in two arms-transfusion dependent and non-transfusion dependent arms. Various factors (percentage of haemoglobin F, hemoglobin E, type of Beta mutation, Xmn1 polymorphism, alpha deletion, HPFH mutation) were evaluated in these patients. Xmn1 polymorphism (homozygous and heterozygous), presence of HPFH mutation and alpha deletion were more prevalent in NTDT arm versus TDT arm (p value < 0.001). Higher prevelance of severe beta mutation IVS 1-5 (G → C) mutation {64(61.54%) vs 38(27.34); p value < 0.001} was found in TDT arm when above factors were excluded from analysis. Higher mean haemoglobin F and mean Hemoglobin E percentage was associated with NTDT arm (p value < 0.001). Various factors (hemoglobin F and E percentage, Xmn1 polymorphism, HPFH mutation, alpha deletion and IVS 1-5 Beta mutation) were identified to affect severity of this cohort.

Alpha Globin Gene Mutation: A Major Determinant of Hydroxyurea Response in Transfusion-Dependent HbE-ß-Thalassaemia.

Thalassaemias are the most common inherited autosomal recessive single gene disorders characterised by chronic hereditary haemolytic anaemia due to absence or reduced synthesis of one or more of the globin chains. Haemoglobin E (HbE)-ß-thalassaemia is the genotype responsible for approximately one-half of all cases of severe ß-thalassaemia worldwide. This study proposes to evaluate response of hydroxyurea in reducing transfusion requirements of severe HbE-ß-thalassaemia patients, and its correlation with foetal haemoglobin (HbF) level and α-mutation. Hydroxyurea was started at a baseline dose in 82 transfusion-dependent HbE-ß-thalassaemia patients. HbF levels and %F-cells were measured. ß-Thalassaemia mutations and α-globin gene deletions and triplications were detected by amplification refractory mutation system (ARMS)-polymerase chain reaction (PCR) and Gap-PCR, respectively. Patients were categorised as good (41.5%), moderate (31.7%), and poor responders (26.8%) based on their decrease in transfusion requirements. Nine patients were excellent responders who became transfusion independent. The mean increase in HbF levels and %F-cells after therapy was correlated with decrease in transfusion requirements. Patients having a deletion of the α-globin gene were better responders. The response was proportional to the number of α-globin gene deletions. We conclude that hydroxyurea treatment decreases transfusion requirements, and the response correlates with α-globin gene deletions.

Association of alpha hemoglobin-stabilizing protein (AHSP) gene mutation and disease severity among HbE-beta thalassemia patients.

In this study, we aimed to investigate the pattern and association of genetic mutations occurring within the alpha hemoglobin-stabilizing protein (AHSP) gene among HbE beta thalassemia patients with varying phenotypic expressions. Fifty-four diagnosed cases of HbE beta thalassemia (transfusion dependent and independent) were included in the study. Among them, 38 patients with similar genotypes (IVS 1-5, alpha gene deletion and triplication, Xmn polymorphism) were selected for further analysis. AHSP gene sequencing was done for these 38 samples to study associated mutations in AHSP gene. HbE beta thalassemia patients with similar genotypes but different phenotypic expressions were found to have mutations in the AHSP gene. There were five mutations found most prevalent among the samples analyzed for AHSP gene sequencing. Among these, two mutations were from intron 1 region of AHSP and three mutations were found in exon 3. The most prevalent mutation was found at the Oct binding site at intron 1 of AHSP. The mutations in exon 3 were more prevalent among the TDT groups. A mutation in exon 3 changing the amino acid (33rd) from serine to phenylalanine was found to be associated with only TDT group. This study documents that among the HbE beta thalassemia patients with varying severity, an exon mutation in AHSP is significantly prevalent only among the TDT group. Further understanding of the mechanism will shed light upon the impact of AHSP in modifying the disease severity in thalassemia.