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We present a case report of a 62-year-old male, treated for kappa light chain multiple myeloma with chemotherapy followed by autologous stem cell transplant (ASCT) in 2014. He has been in complete remission for 4 years. In 2018, he was evaluated for hypercreatinemia and acute kidney injury(AKI) with a suspicion of disease relapse; he underwent evaluation with bone marrow aspiration cytology which showed no evidence of relapse. However, careful cytogenetic analyses showed IgH amplification (14q32) which probably was the cause for AKI in the absence of any structural abnormality in the kidney. Heavy chain deposition leads to AKI in multiple myeloma, and its association with IgH amplification leading to AKI is reported here. Though heavy chain deposition leading to AKI is common, IgH amplification at chromosome level is the first case observed.

Determination of the magnitude of body iron stores helps to identify individuals at risk of iron-induced organ damage in Thalassemia patients. The most direct clinical method of measuring liver iron concentration (LIC) is through chemical analysis of needle biopsy specimens. Here we present a noninvasive method for the measurement of LIC in vivo using magnetic resonance imaging (MRI). Twenty-three pediatric Thalassemia major patients undergoing bone marrow transplantation at our centre were studied. All 23 patients had MRI T2* and R2* decay time for evaluation of LIC on a 1.5 Tesla MRI system followed by liver tissue biopsy for the assessment of iron concentration using an atomic absorption spectrometry. Simultaneously, serum ferritin levels were measured by enzymatic assay. We have correlated biopsy LIC with liver T2* and serum ferritin values with liver R2*. Of the 23 patients 11 were males, the mean age was 8.3 ± 3.7 years. The study results showed a significant correlation between biopsy LIC and liver T2* MRI (r = 0.768; p

Aim: To evaluate the safety and efficacy of 10% intravenous immunoglobulin (IVIG; Flebogamma® 10% DIF) in individuals with chronic immune thrombocytopenic purpura (ITP). Patients & methods: Patients aged 3–70 years, diagnosed with chronic ITP, received 1 g/kg IVIG over two consecutive days. Results: 64 evaluable patients (51 adults, 13 children) with chronic ITP received IVIG. The primary efficacy end point (increased platelet counts from ≤20 × 109/l to ≥50 × 109/l by day 8) was achieved by 81.3% of patients; mean time to response was 1.7 days (all responders). Adverse events, mostly mild or moderate, were reported in 59 patients (92.2%). Conclusion: Flebogamma® 10% DIF administered over two consecutive days was safe and effective in adults and children with chronic ITP.

Dysregulation of BCL2 is a pathophysiology observed in haematological malignancies. For implementation of available treatment-options it is preferred to know the relative quantification of BCL2 mRNA with appropriate reference genes. For the choice of reference genes-(i) Reference Genes were selected by assessing variation of >60,000 genes from 4 RNA-seq datasets of haematological malignancies followed by filtering based on their GO biological process annotations and proximity of their chromosomal locations to known disease translocations. Selected genes were experimentally validated across various haematological malignancy samples followed by stability comparison using geNorm, NormFinder, BestKeeper and RefFinder. (ii) 43 commonly used Reference Genes were obtained from literature through extensive systematic review. Levels of BCL2 mRNA was assessed by qPCR normalized either by novel reference genes from this study or GAPDH, the most cited reference gene in literature and compared. The analysis showed PTCD2, PPP1R3B and FBXW9 to be the most unregulated genes across lymph-nodes, bone marrow and PBMC samples unlike the Reference Genes used in literature. BCL2 mRNA level shows a consistent higher expression in haematological malignancy patients when normalized by these novel Reference Genes as opposed to GAPDH, the most cited Reference Gene. These reference genes should also be applicable in qPCR platforms using Taqman probes and other model systems including cell lines and rodent models. Absence of sample from healthy-normal individual in diagnostic cases call for careful selection of Reference Genes for relative quantification of a biomarker by qPCR.BCL2 can be used as molecular diagnostics only if normalized with a set of reference genes with stable yet low levels of expression across different types of haematological malignancies.

Background: It is well known that anemia and red cell turn over affects the HbA1c value. Iron deficiency anemia increases the HbA1c and haemolytic anemia lowers it. However, the cut-off of haemoglobin (Hb) or red-cell indices when the HbA1c value becomes unreliable is not known. Aim: We sought to find out values of HbA1c and red-cell indices where there is considerable discordance between HbA1c and plasma glucose (PG) values in the diagnosis of diabetes (DM) and pre-diabetes (Pre-DM) making HbA1c values unreliable. Methods: A cross-sectional study of 237 non-diabetic subjects who attended our out-patient division of preventive health check-up clinics, between November 2016 and December 2017. Data was collected only from relatively healthy subjects who had voluntarily opted for undergoing a preventative health check-up (including a diabetes screening). Patients were classified as concordant (fasting and 2-hr post meal glucose values are in agreement with HbA1c) and discordant (values are not in agreement with HbA1c). Results: A total of 237 patients (73% males) with mean age was 47.2±9.7 years (range 25-75) were included in the study. The HbA1c definition group had more diagnosis of DM (153 vs 96) and but lesser numbers of pre-DM (66 vs 102) compared to the PG group. Out of 237 patients, 133 (56%) showed concordance and 104 (44%) were discordant. The FPG, 2h-PPBG and HbA1c are significantly higher in the concordant group. The Hb value and MCV were significantly higher (p7% (20%). While no single Hb or MCV value could predict discordance, a RDW value >17 was consistently associated with discordance across all the HbA1c strata. Conclusion: A HbA1c below 7% is significantly influenced by red-cell turn over indices and clinicians need to perform additional testing using plasma glucose levels to confirm the presence of diabetes or pre-diabetes. In patients whose RDW >17, HbA1c should be replaced by 75gm OGTT as a test of choice for diagnosis of diabetes or pre-diabetes.

The impact of ABO mismatch has been studied on various hematopoietic cell transplant (HCT) outcomes, including neutrophil and platelet engraftment, pure red cell aplasia, acute and chronic graft-versus-host disease (GVHD), nonrelapse mortality (NRM), and overall survival (OS). Yet conflicting results have been reported. However, the impact of ABO mismatch on transplant outcomes with various graft types has not been carefully investigated. We analyzed the impact of various graft sources and type of ABO mismatch on transplant outcomes for 1502 patients who underwent HCT at the University of Minnesota between 2000 and 2014: 312 receiving marrow (BM), 475 filgrastim-mobilized blood (peripheral blood stem cell [PBSC]), and 715 umbilical cord blood (UCB) grafts. Neutrophil engraftment by day 28 was marginally less frequent in the bidirectional ABO mismatched transplants receiving UCB, whereas ABO matching had no influence on engraftment in the BM or PBSC cohorts. ABO mismatch led to no significant differences in platelet engraftment irrespective of stem cell source. We observed a modest but not significantly lower incidence of grades II/IV acute GVHD in the bidirectional ABO mismatched transplants in the UCB and the PBSC cohorts but not in the BM group. We found a higher incidence of chronic GVHD in the PBSC group, but it was not significantly lower in the minor ABO mismatched transplants. The incidence of chronic GVHD was similar in the major ABO mismatched transplants receiving BM. We found no significant difference in the OS and NRM between ABO matched and ABO mismatched transplants within each of the 3 graft source groups. Multivariable analysis adjusting for other relevant factors confirmed that ABO match status did not significantly influence the outcomes of either engraftment, acute or chronic GVHD or NRM. We conclude that ABO mismatch does not influence the outcomes of allogeneic HCT, regardless of stem cell source.

Introduction Multiple myeloma (MM) is a malignancy involving terminally differentiated plasma cells. Its incidence in India is about 0.7/1,00,000 population amounting to about 6,800 new cases a year A number of genomic aberrations are associated with MM, most of which confer prognostic significance. Cytogenetic abnormalities are a part of R-ISS score for prognostication which stratifies presence of del(17p), t(4;14) or t(14;16) as stage 3, mSMART is another risk stratification tool which divides MM into high risk and standard risk groups based on genetic aberrations. Hence it is evident that determining the genetic abnormality in MM is important. however, due to limited resources genetic testing is not routinely done and the data in the Indian population is limited. Objective: To estimate the prevalence of molecular cytogenetic abnormalities by Fluorescent in situ hybridization (FISH) analysis in patients with MM and to assess the co-relation with response to induction chemotherapy, relapse and overall survival. Material and Methods: 64 patients were included from January 2016 to December 2019 and followed up till June 2020. Interphase FISH study was performed either at diagnosis or at relapse, on bone marrow aspirate with panel of probes consisting of CKS1B (1q21-22), CDKN2C (1p32.3), D13S319 (13q14.2/13q34), IGH (14q32.33), p53 (17p13.1) and trisomy (5p15/9q22/15q22) (trisomies are considered as hyperdiploidy in this study). Plasma cell purification techniques were not applied prior to FISH analysis. Patients were divided into 2 risk groups; 1) high risk group with presence of del17p, del13q, amplification 1q, del1p and two or more aberrations with either of these and 2) standard risk group with presence of hyperdiploidy or no genetic abnormality. There was no difference in chemotherapy regimen between the 2 groups; 46 (71.8%) received bortezomib-thalidomide-dexamethasone, 10 (15.6%) received bortezomib-cyclophosphamide-dexamethasone, 2(3.1%) received bortezomib-lenalidomide-dexamethasone, 1(1.5%) received daratumumab-bortezomib-dexamethasone and 5(7.8%) received 2 drug chemotherapy. Patients who did not complete minimum follow up of 6 months either due to death or lost to follow up were excluded from the study. Institutional Ethics Committee's approval was taken. Results: Mean age of the population was 60.33 years and male to female ratio was 1.65. 46.87%, 28.13% and 25% of the study population were in the age group of ≤ 60, 61 - 65 and ≥66 years respectively. 12.3%, 43.8% and 43.8% were in R ISS stage 1, 2 and 3 respectively. FISH analysis was done on 61 out of 64 patients (remaining 3 were excluded due to hemodilute bone marrow sample). 22 (36.1%) patients had abnormal genetic aberration on FISH analysis with 10 (16.39%) having two or more abnormalities. The frequency of genetic aberrations was as follows; amplification 1q (13/61, 21.31%), del13q (9/61, 14.75%), hyperdiploidy (7/61, 11.47%), del17p (4/61, 6.55%), IgH rearrangement (3/61, 4.91%), and del1p (1/61, 1.6%). All 3 patients with IgH rearrangement had associated one or more high-risk genetic aberration and hence were included in high risk group. 31.1% of the patients were high risk and 68.9% were standard risk. The response to induction chemotherapy, incidence of relapse, time to 1st relapse and total number of relapses are shown in (table;1) and there was no significant difference between high risk and standard risk group. Overall survival in standard risk group at 2 and 5 years was 89.6% ± 5.8% and 78.6% ± 13.9% and in high risk group was 60.7% ± 13.2% and 29.5% ± 23.1% respectively (p value: 0.762). Overall survival was significantly lower in age group ≥66 years as compared to age group ≤ 60 years and 61 - 65 years (p value 0.001) and it was also significantly lower in R ISS stage 3 as compared to R ISS stage 1 and 2 (p value 0.006). Conclusion: More than one third patients of MM (36.1%) showed genetic abnormality, amplification 1q being the most frequent. Overall survival was significantly lower in older age group and R ISS stage 3 patients. Response to induction chemotherapy and relapse rate were similar in high and standard risk groups. Although overall survival was lower in high risk group, it was statistically not significant. This study highlights the importance of FISH analysis for disease stratification and prognostication which should be routinely practiced. Disclosures No relevant conflicts of interest to declare.

Background Allogenic hematopoietic stem cell transplantation (allo-HSCT) is one of the best therapies for acute myeloid leukemia (AML) and a proven post-remission therapy for intermediate and high-risk AML. The best HSCT source seems to be a matched sibling donor (MSD), but in the absence of one, a readily available haplo-identical donor provides an equally high cure rate. This is of relevance in a developing country like India as the cost of an unrelated donor is usually unaffordable. We present our experience from a single centre. Methods We analysed retrospective data of 122 AML patients who have undergone HSCT between Jan-2012 to Jun-2019 at our centre. Fludarabine + Busulfan or Fludarabine + Melphalan based conditioning regimen were used in MSD transplant and John Hopkins's protocol was followed in haploidentical HSCT. Cyclosporine + methotrexate was used as GVHD prophylaxis in MSD and unrelated donor group and cyclophosphamide + tacrolimus + mycophenolate was used for haploidentical post-transplant. Day 100 Survival, overall survival, incidence of GVHD and CMV reactivation was computed. Results Out of 122 patients, 69 (56.6%) were males, the mean age was 29.05±20.13 (range, 1 -74) years. Peripheral blood stem cell (99%) was the predominant graft source with majority of matched sibling donor (MSD; 54.1%) compared to Haplo-identical donors (30%). Figure 1 shows the demographic and clinical details of the study patients. The incidence of acute GVHD (40.9% vs 32.6%; p=0.372) and chronic GVHD (16.7% vs 15.2%; p=0.837) are similar in MSD and Haplo transplantation. There were 25 (38%) deaths in MSD and 23 (50%) deaths haplo-identical transplantation (p=0.245). The day-100 survival and overall survival function is significantly better in MSD transplantation (p Conclusion Our study showed comparable outcomes in MSD and Haplo-identical transplant with respect to incidence of GVHD and mortality. However, the survival function is better with MSD transplantation. Haplo-identical transplant is a feasible option in case of non-availability of MSD, due to ease of donor availability and strong motivation from the family donor to donate the stem cells.

Background Hematopoietic stem cell transplant (HSCT) is widely used as a gene replacement therapy in Thalassemia patients for decades. Survival probabilities after HSCT have increased considerably with advancements in graft versus host disease (GVHD) preventive strategies and conditioning regimens. Here we report our HSCT experience in patients with Thalassemia major, with different graft sources, in terms of transplant outcomes such as neutrophil and platelet engraftment, acute and chronic graft versus host disease (GVHD), thalassemia free survival and overall survival. Methods We analysed the data of 164 Thalassemia patients who have undergone HSCT between Jan-2012 to Jun-2019 at our centre. We evaluated the demographic and clinical characteristics of patients, graft source on the HSCT outcomes, such as engraftment, graft versus host disease, day-100 survival, thalassemia-free survival and overall survival. Results Out of 164 patients, 100 (61%) were males, the mean age was 9.47±4.41 (range, 1 -24) years. Peripheral blood stem cell (50%) and bone marrow (47%) are the respective graft sources with predominant matched sibling donor transplants (60.4%). One third of the patients received Fludarabine/Busulfan/Cyclophosphamide based conditioning regimen. Twenty-eight percent of the patients developed acute GVHD (grades I-IV) and 7.3% developed chronic GVHD. The average time to neutrophil engraftment was 14 (range, 8-24) days and platelet engraftment was 18 (range, 8-72) days. The average time to neutrophil engraftment and platelets engraftment did not significantly differ between the HLA-donor type (Figure 1). There were 26 deaths (15.9%) and 7 (4.3%) graft rejections during the follow-up. Infections are the major cause of deaths. The day 100 survival was 89%, the overall survival was 84% and the thalassemia free survival was 74.4%. Conclusion HSCT with various preparative regimens, GVHD preventive strategies, and varied graft sources is certainly a unique curative option for the Thalassemia major patients in the developing world. The survival after HSCT in Thalassemia patients are similar regardless of stem cell source, donor-HLA type (Figure 2) and GVHD (Figure 3). However, the incidence of GVHD is more with matched unrelated donors.

We performed a prospective multi-centre observational study to understand the incidence of IFI in patients with AML in India with use of anti-fungal prophylaxis. All patients with AML receiving either induction chemotherapy or salvage chemotherapy between November 2014 and February 2016 were included in this prospective observational study from 10 Indian centres. IFI was defined as per the revised EORTC-MSG criteria. Data on type of chemotherapy used, type of anti-fungal prophylaxis used, time to neutrophil recovery, incidence of IFI and survival were collected. Two hundred patients (118 male and 82 females) with a median age of 35 years (range: 2–66) were recruited. One hundred and eighty-six (93%) had newly diagnosed acute myeloid leukemia (AML) while 14 (7%) had relapsed disease. IFI occurred in 53 patients (26.5%) with proven or probable IFI occurring in 17 (8.5%). Use of posaconazole prophylaxis (p = 0.027) was the only factor found to be associated with a reduced incidence of IFI. The overall survival (OS) at 6 weeks and 3 months respectively was similar among patients who had IFI (83.0 ± 5.2%; 81.0 ± 5.4%) as compared to those without IFI (84.4 + 3.0%; 81.4 ± 3.2%). This prospective study reveals a high incidence of IFI in patients undergoing chemotherapy for AML in India. The use of posaconazole prophylaxis was associated with a significantly lower incidence of IFI. Optimal strategies to prevent IFI need to be studied.

Aims SARS-CoV-2, an infectious agent behind the ongoing COVID-19 pandemic, induces high levels of cytokines such as IL-1, IL-2, IL-4, IL-6, IL-10, TNF-α, IFN-γ etc in infected individuals that play a role in the underlying patho-physiology. Nonetheless, exact association and contribution of every cytokine towards COVID-19 pathology remains poorly understood. Delineation of the roles of cytokines during COVID-19 holds the key to efficient patient management in clinics. This study performed a comprehensive meta-analysis to establish association between induced cytokines and COVID-19 disease severity to help in prognosis and clinical care. Main methods Scientific literature was searched to identify 13 cytokines (IL-1β, IL-2, IL-2R, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12, IL-17, TNF-α and IFN-γ) from 18 clinical studies. Standardized mean difference (SMD) for selected 6 cytokines IL-2, IL-4, IL-6, IL-10, TNF-α and IFN-γ between severe and non-severe COVID-19 patient groups were summarized using random effects model. A classifier was built using logistic regression model with cytokines having significant SMD as covariates. Key findings Out of the 13 cytokines, IL-6 and IL-10 showed statistically significant SMD across studies synthesized. Classifier with mean values of both IL-6 and IL-10 as covariates performed well with accuracy of ~92% that was significantly higher than accuracy reported in literature with IL-6 and IL-10 as individual covariates. Significance Simple panel proposed by us with only two cytokine markers can be used as predictors for fast diagnosis of patients with higher risk of COVID-19 disease deterioration and thus can be managed well for a favourable prognosis., COVID-19, Meta-Analysis, Cytokines, Logistic Models.

BACKGROUND : Clinical Phenotype and outcomes of patients with Acute myeloid leukemia (AML) in the Indian subcontinent differs from published literature. A younger age at diagnosis and higher induction mortality complicate AML management in India(1). Metaphase Karyotyping represents the backbone of prognostication and risk stratification in AML. Optimal treatment strategies for the cohort of Cytogenetically normal AML are still under evaluation. Applications of Next generation Sequencing (NGS) techniques in AML have unravelled the genetic heterogeneity of this disease. Whole genome sequencing has identified many novel mutations leading to tremendous improvements in diagnosis and risk stratification. Development of therapies targeting these genetic alterations is enabling a gradual shift from non-specific approaches to personalised therapy tailored to an individual patient's genome. This will undoubtedly translate to better clinical outcomes for this disease, with otherwise poor prognosis. Whole genome sequencing is still in a nascent stage in Indian settings with no published literature on genomics in AML till date. We aimed to study the genomic landscape of AML in the Indian population and to co-relate this with clinical outcomes over the course of 1 year. METHODS: We recruited 34 newly diagnosed patients with AML who presented to our Centre (Mazumdar Shaw Medical Centre, Narayana Health City, Bangalore, India) between November 2017 and May 2018. Clinical and laboratory details of all patients were recorded. Bone marrow and paired peripheral blood samples were drawn before initiating therapy. Whole genome sequencing and Exome capture was done for each sample using Ilumina HiSeq platform. Patients were risk stratified as per ELN 2017 and treated as per NCCN guidelines. Patients were followed up prospectively for one year from initial diagnosis. Genetic results were stratified according to gene function and analysed with respect to predefined clinical outcomes (remission status post induction, relapse rates, progression free and overall survival). RESULTS: Amongst the 34 study participants, 5 patients failed QC during sequencing and were de-recruited. Hence 29 patients were available for final analysis. Median age of patients was 42 years with 13 patients (44.8%) less than 40 years of age.18 patients (60%) had normal cytogenetics at baseline.17 patients (58%) were classified as intermediate risk and 6 patients each as Standard and high risk, as per ELN 2017. 22 patients (79.3%) patients received standard Induction chemotherapy (3+7 regimen) while 6 patients received hypomethylating agents. Overall CR rate following induction at Day 28 was 50% and Induction mortality was 21.42%. 6 patients underwent an Allogenic Stem cell transplant. A total of 96 mutations (47 driver and 49 VUS mutations) in 123 genes were identified. The average number of Driver mutations was 1.48 per patient. IDH genes were the most frequently mutated Driver genes followed by FLT3 mutations. Frequency of NPM1 mutations was significantly low (17.25%). Highest frequency of VUS mutations was seen in the ETV6, ATM and CBLC genes. Highest frequency of somatic mutations were identified in the genes encoding for myeloid transcription factors and DNA methylation. Average driver mutations showed significant co-relation to Age (> 60 years) and high burden of Bone marrow blasts (>30%). An updated risk stratification incorporating mutation analysis findings resulted in re-stratification of 8 intermediate risk patients into high risk. 2 patients with detectable FLT3 ITD mutation by NGS were negative by PCR. Choice of consolidation therapy and Driver mutation status were found to show statistically significant association with both Event free survival and Overall survival at 1 year. Increased driver mutation burden was associated with increased refractoriness to chemotherapy and poor EFS and OS. Mutations in Tumour suppressor genes, were associated with suboptimal treatment outcomes and poor survival. CONCLUSIONS Genomic landscape of AML in Indian patients shows significant differences from published literature. This may hold clues to the differing biological characteristics of AML seen in this population. Genome based risk stratification and tailored therapy needs to be adapted into the management of AML. This data provides valuable insights into developing therapeutic strategies for Indian patients. Disclosures No relevant conflicts of interest to declare.

Heparin-induced thrombocytopenia (HIT) is a drug-induced thrombocytopenia that results in thrombotic complications rather than bleeding.In many countries like India, the availability of functional assay for diagnosing HIT is unavailable. But with the utility of scoring systems the probability of HIT can be assessed and can guide the intervention required. Presently there are two well characterised and easily calculated scoring systems, which are the commonly used 4T scoring system and newly designed HEP score, to overcome some of the limitations of 4T`s scoring system. The 4Ts score has a negative predictive value (NPV) approaching 100%, but is limited by modest positive predictive value (PPV) and significant inter-observer variability.In this study we are comparing the two scoring systems and their relevance in the Indian scenario in patients undergoing cardiac intervention, receiving heparin. METHODS: - We recruited 100 patients with suspected HIT, for whom antibody testing was orderedat our centre (Narayana Health City, Bangalore, India) between November 2017 and May 2018. - Data were collected at baseline diagnosis in the form of clinical and laboratory data. 4T`s score and the HEP score was calculated based on the above details before the availability of antibody test. - HIT antibody testing was done using ID-PaGIA Heparin/pF4 Antibody Test Kit with control. In this 10 millilitre of serum is pippeted into the upper chamber of the appropriate microtube. Incubate the ID card at room temperature for 5mins at room temperature (18-25oc). Later centrifuge the ID-card for 10mins in the ID-centrifuge then read and records the results. - Patients were followed up daily till the discharge and complete blood picture including WBC count, development of any adverse effects including renal failure, sepsis, intra-arterial device insertion, bleeding was noted. - Area under the curve (AUC) for the receiver operating curve (ROC) of HEP and 4T scores was calculated and p value was obtained based on these curves. RESULTS: - 37 patients were HIT antibody positive out of 100 patients with suspected HIT from a patient population of 26430, who received heparin. The overall incidence of HIT in our institute is 0.14% (37/26430). - Out of the 100 suspected patients 37 were proven to have HIT by using ID-PaGIA Heparin/PF4 rapid gel agglutination assay. In this series, 91% patients had undergone cardiothoracic surgery forming the majority. Two-thirds of the study population was in the age group (41-70years). Males (61%) are more in the study than females (39%).The percentage of HIT positivity was more in females (43.5) than males (32.7%). - In 87 patients who received UFH, who presented with thrombocytopenia during their perioperative period, 30 were proven to have HIT (34.4%).We also observed during that the total leucocyte count at the nadir of platelet was higher in thr HIT positive group. However, it was not statistically significant (p-0.283) - Out of 100 patients with suspected HIT 49% expired. Of the 37 cases proven to have HIT 20 patients expired (54%). There was no statistically significant association between the occurrence of HIT and mortality ( p-value =0.438). - In this study, the areas under the curve for predicting HIT by 4T score was more than HEP score (0.754 and 0.66) with P value-0.093. As the HEP score was not superior to 4T score we have evaluated 2 subgroup analysis. - Among 36 subjects with the intra-arterial device (included in HEP score), 12 were positive for HIT (33.3%). Area under the Curve for the 4T score (0.698) was higher than that for HEP score (0.599) although the difference was not statistically significant(p-0.3906) - In this study, the incidence of renal replacement therapy (not included in HEP score)was 43%. In this patient population, 46% (n=20) are HIT positive. Among subjects on RRT, 4T score (814) had higher Area under the curve compared to HEP score (0.607) in the diagnosis of HIT positivity and the difference was statistically significant (p value 0.035). CONCLUSION The newly diagnosed HEP scoring system, which includes additional causes of thrombocytopenia was not superior to the 4T's score in this study. The inclusion of intra-arterial device in the HEP score did not make a difference in prediction of HIT. Conversely the 4T score was superior to HEP score in the evaluation of the subset of patients on renal replacement therapy, a significant cause of thrombocytopenia, which was not included in the scoring system. Disclosures No relevant conflicts of interest to declare.

Management of acute myeloid leukemia (AML) in India remains a challenge. A major constraint is the cost of therapy. In a predominantly self paying system the majority of patients will not have the resources to manage a subsequent relapse. Hence, the choice of consolidation therapy has to be carefully considered to balance cost and efficacy. An allogeneic SCT (alloSCT) with a reduced intensity conditioning regimen (RIC) in first remission (CR1) is an attractive option to fulfill these requirements of relatively low cost without compromising efficacy. The need for consolidation chemotherapy prior to offering a RIC alloSCT for AML CR1 remains controversial. To evaluate these aspects we undertook a retrospective analysis of patients with AML CR1 who received a RIC alloSCT from multiple centers in India. Conventional criteria were used for definition of conditioning regimens to be considered RIC (CIBMTR). Data from 8 centers in India was collected between 2005 and 2013. A total of 138 patients fulfilled the criteria of AML CR1 having received an alloSCT with a RIC regimen. The median age was 34 years (range: 2 – 63) and 60% were males. The median time from diagnosis of AML to transplant was 99 days (range: 41 – 504). 123 (89%) were HLA matched related donors, 3 (2.1%) were MUD transplants and the rest were HLA mismatched related donors. The majority by cytogenetics (n=115) were intermediate risk (76%) followed by high risk (23%). 70 (51%) received chemotherapy consolidation prior to transplant, 61 (44%) did not and data was not available in 7 (5%). 68% of those that received consolidation received intermediate or low dose cytosine based regimens. 129 (94%) were CMV serology positive pre-transplant. Fludarabine with melphalan (140mg/m2) (128{93%}) was the most commonly used regimen and cyclosporine with short course low dose methotrexate (126{91%}) the most commonly used GVHD prophylaxis regime. All patients received a PBSC graft with a median CD34 cell dose of 9.1x106/kg (range: 1.3 – 43). With the exception of one, all patients engrafted. The median time to ANC >500/mm3 was 13 days (range: 7 – 22) and platelet count of >20,000/mm3 was 15 days (range: 0-33). Of those that engrafted, 97% achieved complete chimerism at one month post transplant (data not available in 4). Post transplant CMV reactivation was seen in 32% and a fungal infection (possible, probable or definitive) in 13%. Acute GVHD Grade 2-4 was seen in 29% and of patients evaluated 62% had chronic GVHD, the majority of these being limited (61%). The 100 day treatment related mortality (TRM) was 7.5% and the one year TRM was 25.6%. At a median follow up of 24 months the 5 year EFS and OS was 64.0±5.07 (Figure 1A) and 71.1±4.0 respectively. The 5 year cumulative incidence of relapse was 21.8% (Figure 1A). The baseline characteristics as mentioned above were not significantly different between the group that received consolidation and the group that did not. The use of consolidation therapy prior to alloSCT did not have a significant impact on EFS or OS (Figure 1B). On univariate analysis the factors that adversely impacted EFS were mismatched non sibling family donor (RR 8.1; P-value 0.001), CMV reactivation (RR 2.6; P-value 0.001), fungal infection post transplant (RR 6.8; P-value 0.000) and acute GVHD (RR 2.1; P-value 0.02). On a forward stepwise multivariate analysis adjusting for these and other conventional risk factors only CMV reactivation (RR 2.0; 95% CI 1.03-3.87; P-value 0.042) and fungal infection (RR 7.1; 95%CI 3.154-16.12; P-value 0.000) retained their adverse impact. There was no correlation between CMV reactivation and relapse of disease post transplant. The mean costs of induction chemotherapy for these patients was US$ 9239±3596 (n=74), for consolidation chemotherapy it was 5007±3490 (n=21) and for alloSCT it was 18138±13826 (n=118; costing up to 1 year post transplant). Induction chemotherapy followed by HLA matched RIC alloSCT is likely to be a cost effective and affordable treatment option for young adults with AML in CR1in an Indian context. With an average gross net income in India of US$3500/year (http://indiabudget.nic.in) the limitation still remains the cost of treatment and number of centers that can offer this therapy. Figure 1 Figure 1. Disclosures Srivastava: Octapharma: Consultancy, Other. Off Label Use: Bortezomib in the treatment of acute promyelocytic leukemia.

To confirm the safety and efficacy of an indigenous equine antithymocyte globulin (eATG) along with cyclosporine in Indian subjects with acquired aplastic anaemia. Subjects >2 years old with acquired aplastic anaemia were enrolled at six hospitals between April 2011 and February 2013, after approval from respective Ethics Committees. Equine ATG at a dose of 40 mg/kg/day was infused for 4 days. Efficacy analysis defined a priori, was in subjects, who had completed eATG treatment and followed-up on day 90 and/or 180. Complete response (CR) was defined as—transfusion independent, haemoglobin ≥11 g/dL, absolute neutrophil count (ANC) >1.5 109/L and platelet ≥150 109/L; partial response (PR) was transfusion independent, haemoglobin ≥8 g/dL, ANC >0.5 109/L and platelet ≥20 109/L; non responders were transfusion dependent. Lymphocyte subsets (CD 2, 3, 4 and 8) in the blood were tested on days 0 (pre eATG infusion), 3, 5, 7, 14 and 21 after eATG. Of the 30 subjects (two children

Acquired haemophilia is a very rare condition, occurring in less than 2 per million populations. This condition is caused commonly by acquired antibodies against factor VIII and rarely by antibodies against factor IX. Here we describe an extremely rare presentation of idiopathic acquired haemophilia in an otherwise healthy male patient, caused by simultaneous occurrence of circulating antibodies against both factor VIII and IX.

INTRODUCTION EGFR (epidermal growth factor receptor) is important for the proliferation of stem cells across the body including the hematopoietic niche. However, the role of EGFR in aplastic anemia and subsequent responses to standard-of-care therapy is unknown.TWIST is a basic helix-loop-helix transcription factor recently found to regulate the hematopoietic stem cell (HSC) niche. The HSC niche is important for treatment of aplastic anemia. Telomerase and associated gene mutations have been reported in aplastic anemia, but these mutations are not present in all subjects and hence the cellular mechanisms of therapeutic responses observed is not explained by deregulated telomerase or associated genes. OBJECTIVE: To investigate the utility of measuring gene expression levels of EGFR and TWIST on the clinical response to immunosuppressive therapy in acquired Aplastic anemia patients without mutations in telomerase gene. METHODS: This was a single institution analysis of patients with acquired Aplastic anemia, in the age group of 16 to 60 years, who were treated with immunosuppressive therapy between June 2014 to December 2015. 15 patients who did not have homozygous TERT (telomerase catalytic subunit) or DKC (Dyskeratosiscongenita) mutations as determined by sequencing were included in this study. Diagnosis of Aplastic anemia was established with bone marrow aspiration and biopsy with normal cytogenetics. PNH was ruled out in all patients. 7 patients had very severe aplasticanemia (VSAA) and 8 had severe aplastic anemia. There were 11 males and 4 females.Following informed consent, we performed RT-PCR analysis on harvested RNA from each patient and measured levels of TWIST and EGFR expression compared to that of normal samples (n=6).15 patients underwent immunosuppressive therapy with horse ATG at 40mg/kg/day for 4 days followed by oral cyclosporine for at least 3 months. Clinical response was assessed at 3 months and 6 months post ATG administration. Total RNA from healthy donors (6) were used to establish normal baseline gene expression values. RESULTS: Out of the 15 patients that received ATG infusion, 10 patients (66%) had an 8-fold reduced expression of EGFR and TWIST compared to normal control. We grouped the study subjectsintoEGFR/TWIST-low (C1) and EGFR/TWIST-normal(C2). C1 subjects were younger in age (average age 29) compared with C2 (average age 40) andwere more likely to be diagnosed with a more severe form of the disease (VSAA). In the C1 group, all patients responded well to treatment with 4 (80%) patients achieving CR and 1 patient achieving a partial response. In C2, 8 (80%) patients showed no response, with 2 patients showing a partial response at the end of 6 months. CONCLUSION: Our data suggests that EGFR and TWIST may have significant impact on the ability of the hematopoietic stem cell niche to respond to immunosuppressive therapy in aplastic anemia, particularly in the absence of telomerase mutations. Therefore, low expression levels of EGFR/TWIST at diagnosis in may be useful in predicting response to immunosupressive therapy and thereby influence treatment decisions in aplastic anemia patients. Disclosures No relevant conflicts of interest to declare.

Granulocytic sarcoma in a patient with acute promyelocytic leukemia (APML) has been described often in the relapse setting, however primary presentation of APML as granulocytic sarcoma is rare. We present a case of a 29 year old male who was evaluated for thrombocytopenia with haematochezia and a diagnosis of acute promyelocytic leukemia was established after the colonic biopsy was reported as a granulocytic sarcoma.

Introduction: Allogeneic stem cell transplantation (SCT) is the only curative therapy currently available for patients with thalassemia major (TM). In developing countries, the significant delay that often occurs between diagnosis and SCT for a variety of reasons and the inadequate transfusion-chelation that most patients can access, leads to greater liver damage and advanced risk status for SCT in most of these patients. This study was therefore aimed at evaluating the outcome of SCT among a large cohort of these patients in India. Methodology: Data on the clinical profile and outcome after allogeneic SCT carried out for patients with TM was collected from the participating centers. All patients transplanted between January 2000 and June 2014 with matched related (MRD) or unrelated donors (MUD) were included in the analysis. Conditioning regimen was based on Bu/Cy (busulfan and cyclophosphamide, ± ATG) or Treo/Thio/Flu (treosulfan, thiotepa and fludarabine) in the vast majority of patients. Graft versus host disease (GVHD) prophylaxis consisted predominantly of cyclosporine and short course methotrexate. Data was collected from prospectively maintained standardized institutional individual medical records and analyzed with the SPSS software version 16.0 Results: Five hundred and ninety six patients [356 males and 240 females] with a median age of 7 years (range: 1 - 25) underwent allogeneic SCT during the study period. There were 560 (94.0%) children aged ≤ 15 years, while 36 (6.0%) were aged >15 years at the time of SCT. Majority of the patients belonged to Pesaro class 3 (n=310; 52.0%), while 219 to class 2 (36.7%) and 67 to class 1 (11.2%). Among the 226/310 patients in Class 3, 126 (55.8%) belonged to the Vellore high risk category (age >7 years and liver size >5cms). Conditioning regimen was based on Bu/Cy (±ATG) in 315 patients (52.9%) while in 278 (46.6%) patients it was based on Treo/Thio/Flu. There was a MRD for 564 patients (94.6%) while 32 (5.4%) received the graft from MUDs. Of the total of 596 patients, 568 (95.3%) engrafted by day +28. 22 patients (3.6%) had early mortality by day +15, 23 (3.9%) more by day +28, and another 50 (8.4%) by day +100. Graft rejection was noted in a total of 38 patients (6.4%), 6 of whom were before day +28. The overall incidence of acute GVHD was 195/568 (34.3%) with grade II-IV in 25.2% (n=143) and grade III-IV was seen in 9.2% (n=52). Chronic GVHD, which was limited in most patients, was seen in 91/501 patients (18.2%) of evaluable patients. At a mean follow up of 11 years (range: 0 -14 years), the overall survival (OS) and event free survival (EFS) for the entire group are 78.9%±1.9% and 72.8%±2.1%. A total of 119 (19.9%) of patients expired - 58 (48.7%) of whom were due to infections while regimen related toxicity lead to death in 23 (19.3%), GVHD in 10 (8.4%) and 28 (23.5%) died due to other causes. The OS and EFS for the different risk categories were the following: class 1 (95.5%±2.5%, 92.5%±3.2%), class 2 (82.0%±2.6%, 75.9%±2.9%) and class 3 (72.5%±3.6%, 65.6%±3.6%), (p=0.001 and p=0.000, respectively). The OS and EFS among those with grade II to IV GVHD was 76.1%±3.6 and 75.4±3.6% while among those with grade III/IV GVHD was 40.4%±6.8, respectively. We compared the outcome in patients who received Bu/Cy based conditioning (n=315; 52.9%) with those receiving Treo/Thio/Flu based conditioning (n=278; 46.6%). In terms of their baseline characteristics, there were greater number of older and class 3 patients in the latter group. (Table 1) While the OS was comparable in the two groups, the EFS was higher among those receiving Treo/Thio/Flu with Class 3 disease (72.3±3.2% vs 58.8±4.9%; p=0.045). (Fig.1) This result was more pronounced among those with Vellore high risk class 3 disease (70.6%±5.0% vs 46.3±7.6%; p=0.010). (Fig.2) Conclusion: The majority of patients with thalassemia major undergoing SCT in India are in the higher risk categories. The overall outcome of SCT among these patients is comparable with those reported in the literature. Treosulfan based conditioning regimen has improved outcome significantly among the high risk patients. Table 1. Bu/Cy(n=315)N (%) Treo/Thio/Flu(n=278)N (%) P value Age 15 309 (98.1)6 (1.9) 248 (89.2)30 (10.8) 0.000 Risk groupClass 1Class 2Class 3 35 (11.1)164 (52.1)116 (36.8) 32 (11.5)54 (19.4)192 (69.1) 0.000 Class 3 HRClass 3 LR 43 (57.3)32 (42.7) 82 (54.7)68 (45.3) 0.776 Disclosures No relevant conflicts of interest to declare.

Introduction: Allogeneic stem cell transplantation (SCT) is the best form of therapy for a young patient (< 50 years) with severe aplastic anaemia. In developing countries, there is a big time interval between diagnosis and SCT leading to increased transfusions and increased risk of infections, both of which adversely affects transplant outcome. This retrospective analysis is aimed at studying the outcomes of SCT among Indian patients with aplastic anaemia. Methodology: The Indian Stem cell transplant registry (ISCTR) is a group of transplant physicians representing about 30 active transplant centres in India. This retrospective analysis was done on data reported on 634 patients by 20 centres who reported outcomes of SCT for aplastic anaemia. Data was collected from individual medical records and databases. Analysis was done using SPSS software version 16.0 Results: Six hundred and thirty four patients [445 males and 189 females] with a median age of 21 years (range: 2 - 65) underwent allogeneic SCT between 1990 and March 2015. There were 209 children (age < 15 years). The median time from diagnosis to SCT was 5 months (range: 1 - 120) while the median number of transfusions was 20 (range: 1 - 150). All donors were HLA identical sibling or family donors; matched unrelated and haplo-identical donor transplants were excluded from this analysis. Conditioning regimen was Cyclophosphamide based (Cy/ Cy+ ATG/ Cy+ TBI/TLI) in 78 patients (12.3%) while majority received Fludarabine with Cyclophosphamide (n = 481; 75.8%) and 75 received other conditioning regimens (Flu/TBI, Flu/Bu, Bu/Cy etc). Graft source was bone marrow [BM] in 124 (19.5%) and peripheral blood stem cells in 510 patients (80.5%). Graft versus host disease (GVHD) prophylaxis predominantly consisted of Cyclosporine and methotrexate in 543 patients (85.6%). Engraftment was seen in 572 patients (90.4%) while 19 (2.9%) had primary graft failure and 43 (6.7%) expired prior to engraftment due to infection or bleeding. The median time to neutrophil engraftment was 13 days (range: 8 - 21) while platelet engraftment occurred at 13 days (range: 5 - 37). Grade II - IV acute GVHD occurred in 29.3% while grade III-IV was seen in 14.1%. Chronic GVHD was seen in 41% of evaluable patients which was limited in most patients. At a median follow up of 43 months (range: 1 - 264), 431 patients are alive. The 5 yr OS for the entire group is 66.3 + 2.0%. The OS was higher in children compared to adults (73.4 + 3.3% vs 62.8 + 2.5%; p = 0.006), better for Flu/Cy compared to Cy based conditioning (69.8 + 2.2% vs 57.8 + 5.6%; p = 0.002) and better for PBSC compared to BM (68.9 + 2.2% vs 56.1 + 4.8%; p = 0.020). There has been significant improvement in outcomes over the past 15 years [3 yr OS of 41.9 + 1.3% for 1984-1995, 40.9 + 1.2% for 1996-2000, 70.6 + 5.0% for 2001 -2005, 70.3 + 3.1% for 2006-2010 and 68.8 + 3.0% from 2011 onwards]. Conclusion: Outcomes of patients with aplastic anaemia are improving and patients have a 70% chance of getting cured with a HLA identical sibling donor transplant. The use of PBSC as graft source is not associated with inferior outcomes. Disclosures No relevant conflicts of interest to declare.

Data on 90 patients (55 adults and 35 children) with chronic idiopathic thrombocytopenic purpura (ITP) and a platelet count of

Introduction: The thalassemias are the most common of the inherited abnormalities of hemoglobin, typically characterized by a quantitative defect in the synthesis of either the alpha or beta globin chain, resulting in reduced or absent synthesis of either of the globin chains followed by ineffective erythropoiesis with hemolysis. Beta thalassemia is prevalent in the populations of the Mediterranean region, the Middle East, India, Pakistan, and Southeast Asia. Patients are treated with red blood cell transfusions and iron chelation to prevent organ iron overload. Currently, the only cure for thalassemia is allogeneic bone marrow transplantation which corrects the genetic defect in the hematopoietic system by the use of allogeneic stem cells. Methods: We retrospectively and prospectively analyzed the outcomes in transfusion dependant beta Thalassemia patients, who underwent allogeneic HSCT between June 2004 and June 2014. The patients were classified into Class 1, 2 and 3 as per the Pesaro criteria. Results: Sixty seven patients (Males n=40; females n=27) with a median age of 7 years (range 2 to 22 years) underwent HSCT during this time. Fifty seven patients were classified as Class 2, 8 as Class 3 and 2 as Class 1. The conditioning regimens used consisted of Bu-Cy-ATG (n=30), Bu-Cy (n=2), Flu-Bu-Cy-ATG (n=23), Treo-Flu-Thio (n=8), Treo-Flu-Thio-ATG(n=3) and Flu-Bu-Cy-Thio-ATG(n=1) with cyclosporine and methotrexate as GVHD prophylaxis. Stem cell source was marrow, peripheral stem cells and cord in 50, 17 and 1 patients respectively. Sixty four patients had matched sibling transplant and three non-sibling donors (one unrelated cord, one matched unrelated and one haplo-identical ). One patient received both both marrow as well as peripheral stem cells. The median TC cell dose was 6.4x108/kg (range 3 to 16.3 x108/kg) and median CD34 cell dose of 2.4 x106/kg (range 0.6 to 19.6 x106/kg). Hematological recovery was seen in all patients except three patients, who died before engraftment. Neutrophil and platelet engraftment occurred at a median of 14 days (range, 10-22 days) and 22 days (range, 10-35 days), respectively. Twenty four patients developed veno-occlusive disease, 20 patients developed Gr II-IV acute graft-versus-host disease (GVHD), and 3 patients had chronic GVHD. At day +28, thirty five patients showed more than 90% donor chimersim and rest had mixed chimerism. Four patients experienced graft rejection. Treatment-related mortality (TRM) for the whole cohort was 10.4% at 100 days and 14.9% at 6 months post transplant. TRM was 12.28% and 37.5% for Class 2 and class 3 patients respectively. At a median follow up of 416 days, overall survival and thalassemia free survival are 82.1%, and 74.6% respectively. Conclusion: Similar outcomes have been reported from developed countries. Outcome of Class 3 patients still continues to be poor and VOD rates are high in this patient group. Disclosures No relevant conflicts of interest to declare.