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Abstract Background Mesenchymal stem cells (MSCs) have emerged as promising candidates for immune modulation in various diseases that are associated with dysregulated immune responses like Graft-versus-Host-Disease (GVHD). MSCs are pleiotropic and the fate of MSCs following administration is a major determinant of their therapeutic efficacy. Methods Human MSCs were derived from bone marrow (BM) and Wharton’s Jelly (WJ) and preconditioned through exposure to hypoxia and induction of apoptosis, either sequentially or simultaneously. The immune programming potential of preconditioned MSCs was evaluated by assessing their effects on T cell proliferation, induction of Tregs, programming of effector T-cell towards Th2 phenotype, macrophage polarization in the direct co-culture of MSCs and aGVHD patients-derived PBMNCs. Additionally, efferocytosis of MSCs and relative change in the expression of immunomodulatory soluble factors were examined. Results Our study demonstrated that hypoxia preconditioned apoptotic MSCs (BM-MSCs, WJ-MSCs) bear more immune programming ability in a cellular model of acute Graft-versus-Host-Disease (aGVHD). Our findings revealed that WJ-MSCsHYP+APO were superior to BM-MSCsHYP+APO for immune regulation. These induced the differentiation of CD4+T-cell into Tregs, enhanced Th2 effector responses, and simultaneously mitigated Th1- and Th17 responses. Additionally, this approach led to the polarization of M1 macrophages toward an M2 phenotype. Conclusion Our study highlights the potential of WJ-MSCs conditioned with hypoxia and apoptosis concurrently, as a promising therapeutic strategy for aGVHD. It underscores the importance of considering MSC apoptosis in optimizing MSCs-based cellular therapy protocols for enhanced therapeutic efficacy in aGvHD. Graphical Abstract

Purpose T2* is the gold standard for iron quantification in liver as well as myocardium. In this study, we evaluated the diagnostic accuracy of myocardial T1 mapping for the assessment of myocardial iron overload (MIO) as compared to the T2* mapping in patients with thalassemia major (TM).

Introduction Fetal hemoglobin (HbF) levels play significant role in lowering down the morbidity and mortality in sickle cell disease (SCD) patients. Coinheritance of heme oxygenase-1 (HMOX1) rs2071746:A > T polymorphism may contribute to variable HbF levels in Indian SCD patients.

Background Immunophenotyping and enumeration of plasma cells (PCs) by flow cytometry are deemed to be prognostically significant. However, PCs enumeration by flow cytometry is challenging owing to discrepancy with morphology and PCs loss during sample processing. Enumeration and differentiation of abnormal plasma cells (APCs) and normal plasma cells (NPCs) is difficult because abnormal antigen expression can be seen in subsets of NPCs. This is particularly true when a limited panel of antibodies are relied upon.

ABSTRACTAim Hemophilia A (HA) is an inherited bleeding disorder caused by a deficiency of clotting factor VIII in the blood. In resource-limited settings like India, affordability is a significant challenge in managing patients with severe HA. This study aims to assess the cost-effectiveness of intermediate-dose prophylaxis versus on-demand factor therapy in adult and pediatric populations with moderate-to-severe congenital HA without inhibitors in India.Method We conducted a prospective cost-effectiveness analysis from a societal perspective, categorizing patients into a base state and a joint disease state (patients with Hemophilia suffering extensive bleeds leading to chronic joint disease). Using targeted literature search and primary market research, we developed a Markov model measuring the total cost of Hemophilia treatment and health outcomes, including life-years (LYs), quality-adjusted life-years (QALYs), incremental cost-utility ratio (ICUR), and incremental cost-effectiveness ratio (ICER). The model extended over a lifetime horizon of 70 years with a one-year cycle length. Sensitivity analyses assessed study robustness.Results Low-dose prophylactic therapy was cost-effective for adults (>18 years) and pediatric populations (

Introduction: Hemoglobin D Punjab is a common hemoglobin D variant, which is essentially known to cause a mild disease even in homozygous state. Heterozygous state of hemoglobin D Punjab with sickle cell is the only presentation when a severe disease may be expected. We aim to study the spectrum of clinical and haematological profile of all case of haemoglobin D, reported at an apex referral centre of the country. Material and Methods: This is a record based retrospective study of cases of hemoglobin D Punjab from hematology OPD of a apex medical care centre. The clinical and hematological findings of 30 cases with genotype/phenotype of hemoglobin D Punjab were recorded from physical records and electronic data maintained at the institute. The cases were divided into homozygous Hb D Punjab, Double heterozygous hemoglobin S and D, Hemoglobin D-β-thalassemia, and Hemoglobin D trait. Results: The reported 30 cases consisted of 3 cases of homozygous Hb D Punjab, 8 cases of co-mutation of Hb D and beta thalassemia, 6 cases of co-mutation of Hb D with sickle cell and 13 cases of Hb D trait. All three cases of Hb D disease were mild to moderately symptomatic with co-existent splenomegaly. Out of the 8 cases reported of Hb D-β-thalassemia, three cases were found to have moderate anemia and one with severe anemia. The MCV of all participants were reduced, while, MCHC of all cases was within normal range. Among the 6 cases of compound heterozygous Hb D and S Disease two had hemolytic faces and three cases had splenomegaly. Blood transfusion was required by four out of six cases at varied frequency. Conclusion: We find the spectrum of symptoms presented by the cases of hemoglobin D Punjab is varied and few cases may require blood transfusion and medical care with follow up even in absence of heterozygous hemoglobin S inheritance.

Primary healthcare caters to nearly 70% of the population in India and provides treatment for approximately 80–90% of common conditions. To achieve universal health coverage (UHC), the Indian healthcare system is gearing up by initiating several schemes such as National Health Protection Scheme, Ayushman Bharat, Nutrition Supplementation Schemes, and Inderdhanush Schemes. The healthcare delivery system is facing challenges such as irrational use of medicines, over- and under-diagnosis, high out-of-pocket expenditure, lack of targeted attention to preventive and promotive health services, and poor referral mechanisms. Healthcare providers are unable to keep pace with the volume of growing new scientific evidence and rising healthcare costs as the literature is not published at the same pace. In addition, there is a lack of common standard treatment guidelines, workflows, and reference manuals from the Government of India. Indian Council of Medical Research in collaboration with the National Health Authority, Govt. of India, and the WHO India country office has developed Standard Treatment Workflows (STWs) with the objective to be utilized at various levels of healthcare starting from primary to tertiary level care. A systematic approach was adopted to formulate the STWs. An advisory committee was constituted for planning and oversight of the process. Specialty experts' group for each specialty comprised of clinicians working at government and private medical colleges and hospitals. The expert groups prioritized the topics through extensive literature searches and meeting with different stakeholders. Then, the contents of each STW were finalized in the form of single-pager infographics. These STWs were further reviewed by an editorial committee before publication. Presently, 125 STWs pertaining to 23 specialties have been developed. It needs to be ensured that STWs are implemented effectively at all levels and ensure quality healthcare at an affordable cost as part of UHC.

Introduction Acute myeloid leukemia (AML) is a heterogenous disorder consisting of clonal expansion of myeloblasts. Tumor immunity plays an important part in the pathobiology of AML. Understanding the components of tumor immunity is important for understanding tumor pathogenesis and the principles of immunotherapy. Methods We studied 41 patients with AML, for total lymphocyte, CD4 positive helper T cells, CD8 positive cytotoxic T cells, and CD16/56 positive natural killer (NK) cells proportion. Quantification was done on bone marrow aspirate sample by flowcytometry. Whenever available, post induction bone marrow was also analyzed for the lymphocyte subset. Results No significant difference was noted in the percentage of blasts among the three risk categories: favorable, intermediate, and adverse. However, there was significant difference in the total lymphocyte among the risk stratification groups, being highest in the favorable group and lowest in the adverse group. CD8 positive cytotoxic T cells were significantly less in Acute Promyelocytic Leukemia (APML) cases (p = 0.001). Total lymphocytes were, however, more numerous in APML (p = 0.005). NK cell proportion was not significantly different between APML and non-APML patients. On completion of induction chemotherapy, bone marrow samples for 12 patients could be processed for lymphocyte subset. On comparing the baseline against the post induction bone marrow, it was observed that there was significant increment in the proportion of CD4 positive T lymphocytes (p = 0.046). Conclusion There is a difference in lymphocyte subset amongst patients with AML. Larger studies including functional aspects are needed to better define the role of lymphocytes in disease pathogenesis.

Cachexia is characterized by loss of appetite, weight loss and tissue wasting, accompanied by a decrease in muscle mass and adipose tissue, affecting approximately 50% of cancer patients and contributes to decreased quality of life of patients, reduced tolerance to chemotherapy, and decreased survival. Current therapies focus on maintenance of physical function, quality of life, and reduction of distress in patients and their families rather than definitive treatment for the underlying pathophysiology. Consistent with evolving guidelines for the treatment of cachexia, current models take a multidisciplinary approach, with patients generally seeing a physician, nutritionist or dietician, and physiotherapist sequentially. This is routinely supplemented by psychosocial support, whether within the program or via referral. Early intervention and attention to nutritional status are essential in patients with anorexia-cachexia syndrome. Pharmacological interventions for neoplastic cachexia include drugs that stimulate the appetite: megestrol acetate (MA) and dronabinol; cytokine inhibitors (such as cyproheptadine, thalidomide, pentoxifylline and an eicosapentaenoic acid (EPA)); and anabolic agents such as nandrolone decanoate, oxandrolone and corticosteroids. This review will discuss about the role of supportive care in cancer cachexia with a special emphasis on nursing oncology perspective.

Background: Philadelphia chromosome (Ph): Hallmark of CML is caused by reciprocal translocation between chromosomes 9 and 22 resulting in BCR-ABL fusion protein. Most commonly associated breakpoint with CML is M-bcr in exon 13 or exon 14, producing splice variant b2a2 or b3a2 respectively. The distribution of these transcripts and their influence on clinico-hematological parameters is variable. Impact of the fusion transcripts on treatment outcome in Imatinib treated CML patients is still a matter of debate. Aims/settings and design: We conducted this study on 400 CML-CP patients to look for the distribution of fusion transcripts i.e. b3a2 and b2a2, their clinico-hematological profile and impact on treatment response in patients treated with Imatinib. Material and Methods: CML-CP was diagnosed by reverse transcriptase PCR (RT-PCR) for the BCR-ABL fusion transcript. Real-time quantitative PCR (RQ-PCR) was performed on peripheral blood every 3-6 monthly to look for treatment response. Results: The overall frequency of b3a2 transcript was observed in 288 (72%) followed by b2a2 in 104 (26%) and hybrid fusion transcript (b3a2 + b2a2) was seen in 8 (2%) cases. MMR was attained in 198/288 (68.7%) patients with b3a2 transcript and 90/288 (31.3%) patients failed to achieve MMR after 12 months of Imatinib therapy. Among the patients with b2a2 transcript, 44/104 (42.3%) patients achieved MMR and 60/104 (57.7%) patients failed to achieve MMR after 12 months of Imatinib therapy. Conclusions: In conclusion, the frequency of b3a2 transcript was more as compared to b2a2 transcript. MMR was significantly higher in patients with b3a2 transcript as compared to patients with b2a2.

Background: Activated platelets release cytokines/proteins including CXCL4 (PF4), CCL5 and fibrinopeptides, which regulate infection of several pathogenic viruses such as HIV, H1N1 and HCV in human. Since platelet activation is the hallmark of Dengue virus (DV) infection, we investigated the role of platelets in DV replication and also in a closely related Japanese Encephalitis virus (JEV). Methods and findings: Microscopy and PCR analysis revealed a 4-fold increase in DV replication in primary monocytes or monocytic THP-1 cells in vitro upon incubation with either DV-activated platelets or supernatant from DV-activated platelets. The mass spectrometry based proteomic data from extra-nuclear fraction of above THP-1 lysate showed the crucial association of PF4 with enhanced DV replication. Our cytokine analysis and immunoblot assay showed significant inhibition of IFN-α production in monocytes via p38MAPK-STAT2-IRF9 axis. Blocking PF4 through antibodies or its receptor CXCR3 through inhibitor i.e. AMG487, significantly rescued production of IFN-α resulting in potent inhibition of DV replication in monocytes. Further, flow cytometry and ELISA data showed the direct correlation between elevated plasma PF4 with increased viral NS1 in circulating monocytes in febrile DV patients at day-3 of fever than day-9. Similarly, PF4 also showed direct effects in promoting the JEV replication in monocytes and microglia cells in vitro. The in vitro results were also validated in mice, where AMG487 treatment significantly improved the survival of JEV infected animals. Interpretation: Our study suggests that PF4-CXCR3-IFN axis is a potential target for developing treatment regimen against viral infections including JEV and DV. Keywords: Platelet cytokine PF4, DV and JEV replication and propagation, Monocytes and microglia cells

Background and Objective. Acquired aplastic anemia (aAA) is a bone marrow failure disorder characterized by pancytopenia and bone marrow aplasia. Bone marrow Mesenchymal Stem Cells (BM-MSCs) are an important component of BM microenvironment, associated with hematopoietic and immune homeostasis. Any alterations in BM microenvironment can disrupt the normal functioning and it needs to be assessed. Methods. In the current study, we investigated the morphological differences, proliferation capacity, population doubling time (PDT), surface marker profiling, trilineage differentiation potential, and immunosuppressive ability of BM Mesenchymal Stem Cells (BM-MSCs) from untreated aAA patients and in the same number of age- and gender-matched controls. Results. We observed similar morphology, proliferation capacity, phenotype, trilineage differentiation potential, and immunomodulatory properties of BM-MSCs in aAA patients and control subjects. Conclusion. Our results confirm that the basic and immunosuppressive properties of BM-MSCs from aAA patients do not differ from normal BM-MSCs. Our data suggest that BM-MSCs from aAA patients might not be involved in disease pathogenesis. However, owing to a smaller number of samples, it is not conclusive, and future studies with more exhaustive investigation at transcriptome level are warranted.

In the current era of COVID-19 pandemic where at least some degree of social distancing is the norm and hospitals have emerged as hotspots for acquiring the infection, it has become important for oncologists to devise methods of providing care to cancer patients while minimizing patients’ exposure to healthcare settings. In light of the on-going pandemic, it has been recommended that in-patient visits for cancer patients should be substituted by virtual visits and patients should be advised to proceed directly for infusion treatment. Telemedicine and tele-health based interventions have emerged as reasonably practical solutions to these impediments in the delivery of care to cancer patients. Technological advancements have resolved the issue of connectivity for telemedicine even to the remotest places. Teleconsultation is becoming an acceptable alternative for patients and health care providers in this era of information technology. Albeit the challenges that we are facing are diverse and therefore cannot have a singular full proof answer, telemedicine and tele-health based interventions seem to offer promise in effectively complementing our efforts in that direction. Telemedicine is beneficial for both patients and doctors in term to provide quality care without shifting to physical location.

Introduction: Outcomes in chronic myeloid leukemia (CML) have vastly improved after the introduction of tyrosine kinase inhibitors. However, patients in low and middle income countries face many challenges due to social and financial barriers. Objective: This study was conducted with the aim of understanding socio-economic hindrances and knowledge-attitudes-practices of patients of chronic phase CML who are taking imatinib. Materials and Methods: Patients of chronic phase CML, aged 15 and above, taking imatinib for 6 months or more were included in the study. A questionnaire (in Hindi language) was administered, enquiring about perceptions of nature of disease and its treatment, how imatinib was obtained, drug-taking behaviour, economic and social burden of the treatment. Results: Four hundred patients were recruited (median age 37 years, median duration on imatinib 63 months). Patients hailed from 16 different Indian states and 29.75% patients had to travel more than 500 kilometres for their hospital visit. Scheduled visits were missed by 14.75%. One third of the patients were unaware of the lifelong duration of treatment and 41.75% were unaware of the risks of discontinuing treatment. Treatment was financed by three different means- 61.75% received imatinib free of cost via the Glivec International Patient Assistance Program (GIPAP), 14.25% had treatment costs reimbursed by their employer, and 24% bore the cost of treatment themselves. Patients felt financially burdened due to cost of drugs (self-paying patients), cost of investigations, expenditure of the commute and stay for hospital visit, and loss of working days due to hospital visits. Conclusion: Cost of treatment, lack of widespread availability of hematology services and poor patient awareness are significant barriers to optimum treatment of CML in low and middle income countries.

AIM: To evaluate the role of bone marrow-derived stem cells in the treatment of advanced dry age-related macular degeneration (AMD) using multifocal electroretinogram (mf-ERG) and fundus autofluorescence imaging. METHODS: Thirty patients (60 eyes) with bilateral central geographic atrophy (GA) were recruited. Worse eye of each patient received autologous bone marrow-derived hematopoietic stem cells (BM-HSCs) (group 1) and the fellow eye with better visual acuity served as control (group 2). The effect of stem cell therapy was determined in terms of visual acuity, amplitude and implicit time in mf-ERG and size of GA on fundus autofluorescence imaging. These tests were performed at presentation and first, third and sixth month follow up. Adverse events (if any) were also monitored. RESULTS: At 6mo follow-up there was no statistically significant improvement in median logMAR best corrected visual acuity (BCVA) in either group. Mf-ERG revealed significant improvement in amplitude and implicit time in the intervention group. A significant decrease was also noted in greatest linear dimension (GLD) of GA in the eyes receiving stem cells [6.78±2.60 mm at baseline to 6.56±2.59 mm at 6mo (P=0.021)]. However, no such improvement was noted in the control group. CONCLUSION: Electrophysiological and anatomical improvement in the intervention group sheds light on the therapeutic role of BM-HSCs. Further studies are required to determine the stage of disease at which the maximal benefit can be achieved and to standardize the dose and frequency of stem cell injection.

BACKGROUND: In India, hemoglobinopathy screening programs focus on reducing the burden of beta-thalassemia by screening the antenatal females and young adolescents. Although alpha (α)-thalassemia is common in the Mediterranean countries, alpha (α)-thalassemia screening and diagnosis are performed in a few centers in India. HbH disease is an uncommon clinical phenotype of α-thalassemia with variable clinical presentation. The hallmark feature of HbH is the presence of golf ball inclusions in the red cells demonstrated with supravital staining. PATIENTS AND METHODS: Here, we discuss an algorithmic approach to screen hemograms for thalassemic indices, followed by evaluation of reticulocyte preparation after 40 minutes (supravital stain preparation for golf ball inclusions). If golf ball inclusions were positive, Hb analysis on Hb-capillary zone electrophoresis (Hb-CZE)was done. RESULTS: We received 28,000 samples for complete hemogram and blood film examination, over a period of 8 months. Reticulocyte count was required in 11,600 samples out of which 13 cases were positive for golf ball inclusions. Of these, nine were identified as HbH disease on Hb-CZE. These patients presented with pallor and generalized weakness. On examination, jaundice (3/9 patients) and hepatosplenomegaly (4/9 patients) were relatively uncommon. The majority of them (6/9) required infrequent blood transfusions. All patients had microcytic hypochromic red cell indices with median HbA of 89% (range: 68.1%–96.9%), HbA2 of 1.4% (range: 0.8%–1.7%), and fast-moving band in zone 15 (HbH) of 5.6% (range: 1.4%–30.3%) on Hb-CZE. CONCLUSION: We emphasize a systematic screening of hemograms and peripheral smears along with a simple and cost-effective screening test for golf ball inclusions to diagnose HbH disease that often poses a clinical dilemma due to its variable clinical presentation.

Hepatosplenic T-cell lymphoma (HSTCL) is a rare extranodal T-cell lymphoma that shows preferential sinusoidal infiltration of spleen and liver. It usually shows bright expression of surface CD3 (sCD3) with restriction for γδ-T cell receptors (TCR). We present a case of a 34-year-old male who presented with hepatosplenomegaly and B symptoms. His peripheral blood and bone marrow (BM) was involved by atypical lymphoid cells that were CD2+, CD7+, CD56+, cytoplasmic CD3+, and sCD3− on immunophenotyping by flow cytometry. As sCD3 is a lineage marker for T-cell lymphomas, the loss of sCD3 posed a diagnostic dilemma. However, typical pattern of sinusoidal BM and liver involvement by CD3+ cells and TCR gene rearrangement positivity led to final diagnosis of HSTCL. The differential diagnosis, workup, and clinical course of the case are discussed. To the best of our knowledge, only one case of de novo HSTCL with negative sCD3 has been reported before in the literature.

Background: In view of the increasing burden of cancers in devel- oping countries and this study was conducted to first understand community needs and perceptions, secondly to design and im- plement evidence based preventive strategies, and lastly to test the short-term outcome of these strategies in the field. Study Design: Cross Sectional mixed methods before and after in- tervention community based study. The study had three phases. Phase I involved understanding perceptions, attitudes and prac- tices and needs assessment using qualitative and quantitative methods, gaining from the strengths of both by combining the ap- proaches. Based on the findings of Phase I, appropriate compre- hensive interventions were designed and implemented in Phase II. A repeat survey using quantitative methodology was conducted to assess the short-term impact of the intervention. The primary out- come was change in perceptions, attitudes and contextual health care seeking practices among the community. Results: Results of this study will be reported in peer-reviewed publications and in conference presentations Conclusion: This first of its kind study in India has helped in un- derstanding the determinants of perceptions, attitude and prac- tices regarding cancer in the community, which helped in formu- lating need based intervention strategies. Testing the short-term outcome of intervention showed it to be effective. The study will help in policy decision making by the planners and administrators of the state.

In a recent work, we have described the kinetics among the monocyte subsets in the peripheral blood of hemolytic patients including paroxysmal nocturnal hemoglobinuria (PNH) and sickle cell disease (SCD). After engulfing Hb-activated platelets, classical monocytes (CD14+CD16-) significantly transformed into highly inflammatory (CD14+CD16hi) subsets in vitro. An estimated 40% of total circulating monocytes in PNH and 70% in SCD patients existed as CD14+CD16hi subsets. In this study, we show that the nonclassical (CD14dimCD16+) monocyte subsets are nearly absent in patients with PNH or SCD, compared to 10-12% cells in healthy individuals. In mechanism, we have described the unique role of both free Hb and nitric oxide (NO) in reducing number of nonclassical subsets more than classical monocytes. After engulfing Hb-activated platelets, the monocytes including nonclassical subsets acquired rapid cell death within 12 h in vitro. Further, the treatment to monocytes either with the secretome of Hb-activated platelets containing NO and free Hb or purified free Hb along with GSNO (a physiological NO donor) enhanced rapid cell death. Besides, our data from both PNH and SCD patients exhibited a direct correlation between intracellular NO and cell death marker 7AAD in monocytes from the peripheral blood. Our data together suggest that due to the immune surveillance nature, the nonclassical or patrolling monocytes are encountered frequently by Hb-activated platelets, free Hb, and NO in the circulation of hemolytic patients and are predisposed to die rapidly.

Multiple sclerosis (MS) is a chronic inflammatory disease of central nervous system (CNS), which is disabling and majorly involves younger population. Various available treatments in forms of immunomodulation are not very effective; however, stem cell transplantation seems to be promising in recent literature. The current case report is a novel evidence for autologous hematopoietic stem cell transplantation (HSCT) in progressive MS. Case Summary: A 33 year old male with secondary progressive MS (SPMS), after being failed and/or intolerance to standard approved interferon (IFN) and mitoxantrone therapy, autologous HSCT was administered. At 2years of post-stem cell transplantation follow-up, he has remained stable with some improvement in functional status (Expanded Disability Status Scale (EDSS) reduced by 1.5), with no relapse, no treatment related complications, and no fresh magnetic resonance imaging (MRI) lesions. Conclusion: Autologous stem cell transplantation may be beneficial in progressive forms of MS, but needs to be tested in well-designed randomized trial.

Introduction: There is a significant difference in the Reactive Oxygen Species (ROS) levels of Chronic Myeloid Leukaemia (CML) patients before and during treatment with Tyrosine Kinase Inhibitors (TKIs). This is because high ROS levels support oncogenic phenotype of CML by inducing proliferation pathway and accumulation of further genetic mutations. Often the measurement is done on WBC or serum for ascertaining one type of ROS species, but measurement of global ROS in fresh whole blood will give more accurate estimation of ROS. Aim: To measure global ROS in peripheral blood of CML patients. Materials and Methods: A case control study was undertaken to measure ROS in peripheral blood of CML patients from Northern India. CML patients on TKIs (n=40 on imatinib herein called treated) and untreated (n=17, who were not on any TKIs or alternative medicine, called as treatment naive) and 52 healthy controls were also enrolled. Chemiluminescent assay was carried out using luminol as signal enhancer in 400 µl of blood to measure ROS. The chemiluminescence was measured as Relative Light Units (RLU)/sec/104 WBC. Data was presented in terms of mean±SE or geometric mean (95% Confidence Interval) for continuous variables and percentage for categorical variables. Groups were compared using two sample t-test for continuous variables and chi-square test for categorical variables. Results: The WBC profile and ROS levels of patients taking TKIs were quite similar and showed no significant difference (p

Background : There is substantial evidence that adult stem cell populations exist in human endometrium, and hence it is suggested that either endogenous endometrial stem/progenitor cells can be activated or bone marrow derived stem cells can be transplanted in the uterine cavity for endometrial regeneration in Asherman′s syndrome (AS). Aims and Objectives : The objective was to evaluate the role of sub-endometrial autologous stem cell implantation in women with refractory AS in attaining menstruation and fertility. Setting : Tertiary care referral center. DESIGN: Prospective case series. Materials and Methods : Six cases of refractory AS with failed standard treatment option of hysteroscopic adhesiolysis in the past were included. Mononuclear stem cells (MNCs) were implanted in sub-endometrial zone followed by exogenous oral estrogen therapy. Endometrial thickness (ET) was assessed at 3, 6, and 9 months. RESULTS: Descriptive statistics and statistical analysis of study variables was carried out using STATA version 9.0. The mean MNC count was 103.3 × 106 (±20.45) with mean CD34+ count being 203,642 (±269,274). Mean of ET (mm) at 3 months (4.05 ± 1.40), 6 months (5.46 ± 1.36) and 9 months (5.48 ± 1.14) were significantly (P < 0.05) increased from pretreatment level (1.38 ± 0.39). Five out of six patients resumed menstruation. Conclusion : The autologous stem cell implantation leads to endometrial regeneration reflected by restoration of menstruation in five out of six cases. Autologous stem cell implantation is a promising novel cell based therapy for refractory AS.

Intravascular hemolysis increases the risk of thrombosis in hemolytic disorders. Our previous study showed that the binding of adult hemoglobin (HbA) to glycoprotein (GP) 1bα induced the activation of platelets. The elevated plasma Hb or platelet surface bound Hb positively correlated with platelet activation in patients with paroxysmal nocturnal hemoglobinuria (PNH). Furthermore, this study shows that the sickle Hb [HbS, occurs due to single nucleotide polymorphism at A>T of β-globin gene of Hb and causes sickle cell disease (SCD)] also bound to GP1bα and activated platelets in a concentration-dependent manner. The HbS bound to glycocalicin (extramembranous part of GP1bα) with KD ~ 10.46 ± 3 μM. HbS induced phosphorylation of signaling adapter proteins, such as Lyn, PI3K, Akt and ERK in platelets, and also increased the surface expression of platelet activation markers such as P-selectin (10.7 fold) and PAC1 binding (10.4 fold) in platelet surface in a concentration-dependent manner. HbS also increased the platelet microparticle-generation (4.7 fold) and thrombus-formation (4.3 fold) in a concentration-dependent manner. An elevated level of extracellular Hb in plasma correlated directly with platelet activation markers such as P-selectin (r = 0.7947), PAC1 binding (r = 0.5914) on platelet surface and plasma levels of platelet-derived microparticles (r = 0.7834) in patients with SCD. Our study therefore suggests that the HbS-induced platelet activation may play a crucial role in intravascular clot formation observed in SCD patients characterized by high propensity to vascular occlusion and hypercoagulable states.

OBJECTIVE: The aim of this study was to assess the antibody response to combined passive-active immunization versus active immunization against hepatitis B in 71 patients with acute leukemia with negative hepatitis B virus serology at presentation. METHODS: The first group (n=28) received a double dose of hepatitis B vaccine at 0, 1, 2 and 6 months and immunoglobin (HBIG) at 0 and 1 month concurrently with vaccine but at a different intramuscular site. The second group (n=43) received double dose of hepatitis B vaccine at 0, 1, 2, and 6 months. HBsAg and anti-HBs titers were determined one month after the 1st, 2nd, 3rd and 4th doses of vaccine. RESULTS: In the vaccine-only group, 2.56%, 8.33%, 14.28% and 34.29% of patients developed anti-HBs titer ≥10 IU/L after the 1st, 2nd, 3rd and 4th doses of vaccine, respectively. In the HBIG group, 91.30%, 91.30%, 69.56% and 73.91% of patients developed anti-HBs titer ≥10 IU/L after the 1st, 2nd, 3rd and 4th doses of vaccine, respectively. Those in the vaccine-HBIG group maintained their anti-HBs titer ≥10 IU/L from the 1st to the 4th doses. In the vaccine-only group, 34.29% of patients gained protective antibody titer after receiving the 4th dose of vaccine. Subgroup analysis of age (pediatric vs adult) and disease (acute lymphoblastic leukemia vs acute myeloid leukemia) groups showed no effect of either on the development of protective antibody titer. The incidence of HBsAg positivity one month after the 4th dose of vaccine was 8.62%. No patient became positive for anti-HCV or HIV antibody before or after chemo therapy. CONCLUSION: Combined HBIG and vaccine may protect acute leukemia patients during the intensive chemotherapy period.

Intravascular hemolysis increases the risk of hypercoagulation and thrombosis in hemolytic disorders. Our study shows a novel mechanism by which extracellular hemoglobin directly affects platelet activation. The binding of Hb to glycoprotein1bα activates platelets. Lower concentrations of Hb (0.37–3 μM) significantly increase the phosphorylation of signaling adapter proteins, such as Lyn, PI3K, AKT, and ERK, and promote platelet aggregation in vitro. Higher concentrations of Hb (3–6 μM) activate the pro-apoptotic proteins Bak, Bax, cytochrome c, caspase-9 and caspase-3, and increase platelet clot formation. Increased plasma Hb activates platelets and promotes their apoptosis, and plays a crucial role in the pathogenesis of aggregation and development of the procoagulant state in hemolytic disorders. Furthermore, we show that in patients with paroxysmal nocturnal hemoglobinuria, a chronic hemolytic disease characterized by recurrent events of intravascular thrombosis and thromboembolism, it is the elevated plasma Hb or platelet surface bound Hb that positively correlates with platelet activation.

IntroductionCases with microcytosis not responding adequately to iron supplementation are diagnostic dilemma and have been reported to harbor alpha (α) thalassemia mutations. The aim of this study was to identify and determine the common α globin gene deletions in cases with microcytic anemia. Methods Fifty four patients selected (22 females and 32 males) had microcytic anemia (MCV < 80 fl, Hemoglobin Hb 5M/mm3) but normal HbHPLC. They had either low or normal Transferrin Saturation (TS). Gap-PCR for four common a-gene deletions (-a3.7, -a4.2, - -aSA and --aSEA) was done. Results Out of the total fifty four microcytic anemia cases nineteen (35.2%) were found to have a gene mutations; Three homozygous and sixteen heterozygous cases of chiefly -a3.7 deletions, a single case of -- a SA were noted ; but no -a4.2 and –SEA mutations were found. Conclusion In India a gene mutations may be much more than what has been documented and its presence should be considered as a causes of relentless microcytic anemia not responding to iron. It can confound iron deficiency anemia hence its coexistence should be sought even in the face of low iron stores in subjects who respond incompletely to iron supplementation. Since no RBC indices or a discriminant function can identify its presence only molecular studies commonly using Gap PCR for common α thalassemia deletions mutation including – α SA need to be done for their detection.

Histoplasmosis is a systemic mycosis which has a worldwide distribution.Though common in immunocompromised patients, disseminated histoplasmosis has rarely been reported in patients with aplastic anemia. We report here a case of very severe aplastic anemia who developed disseminated histoplasmosis in the form of hepatic involvement, which proved fatal due to lack of cell mediated immunity.

A 45 years old male, known case of T-cell Acute Lymphoblastic Leukemia on maintenance therapy presented with painless progressive dimunition of vision in both eyes. Evaluation revealed Cytomegalovirus retinitis with low CD4 counts. CMV retinitis is usually seen in HIV disease or in post allogenic stem cell transplant recipietn patients. CMV retinitis occuring in ALL maintenance phase is very rare. The patient showed some improvement with intra-vitreal and intra-venous Gancyclovir injections.

Primary Hepatic lymphoma (PHL) is a very rare malignancy representing approximately 0.016% of all cases of Non Hodgkin Lymphoma (NHL). It oftens presents in elderly persons with signs and symptoms of hepatitis, primary liver cancer or metastatic tumor. In this case report, we present a 58 year old lady with poor performance status who presented with obstructive jaundice, epigastric pain and bilious vomiting. Abdominal imaging revealed a large hepatic mass that was pathologically confirmed primary hepatic diffuse large B cell lymphoma without bone marrow involvement. Because of severe jaundice, she was managed with Rituximab, cyclophosphamide and prednisolone based therapy, but succumbed to neutropenic fever following chemotherapy.

Mantle cell lymphoma (MCL) is a distinct type of non-Hodgkin’s lymphoma that commonly affects extra nodal sites. The most commonly affected sites are bone marrow, gastrointestinal tract and Waldeyer’s ring, however, skin is rarely involved. We report a case of 56 year-old patient with MCL, exhibiting multiple large maculopapular skin rashes and skin ulcers. Histopathological examination demonstrated dilated and congested vessels in the dermis without any atypical cells. Our patient showed significant improvement of skin lesions with a combination chemotherapy and debridement. Awareness of skin manifestations of MCL is essential to establish the diagnosis and for timely administration of appropriate treatment.

Introduction Janus kinase2 (JAK2) V617F mutation in myeloid cells has been reported from the majority of patients with Polycythemia vera (PV). Materials & Methods A cross sectional study was conducted to review clinical records of 93 cases of erythrocytosis who were evaluated for JAK2V617F mutation by Amplification Refractory Mutation System polymerase chain reaction at our institution. The significance of this mutation in the context of clinical & hematological features in cases that fulfilled World Health Organisation 2008 diagnostic criteria for PV was investigated. Results 66(71%) patients fulfilled the WHO diagnostic criteria for PV. Erythrocytosis could be attributed to secondary causes in 20(21.5%) cases and in seven (7.5%) cases, erythrocytosis was idiopathic. The JAK2V617F mutant allele was detected in 61 of the 66 patients (92.4%) with 19(31.1%) showing homozygosity. A comparison between JAK2V617F mutation positive and JAK2V617F wild type PV patients at presentation revealed that the JAK2V617F mutation positive patients were older(P=0.05), with significantly lesser mean values of hemoglobin (P= 0.02). Compared with heterozygote counterparts, JAK2V617F homozygotes showed significantly higher hemoglobin (P=0.03), incidence of thrombosis(P=0.04) and transformation to myelofibrosis(P=0.02). Conclusions This is the largest Indian study correlating JAK2V617F mutation status with clinicohematologic characteristics in PV patients and reveals that prevalence of JAK2V617F mutational status is 92.4% in PV patients with 31.1% homozygosity. JAK2V617F homozygosity is associated with significantly higher hemoglobin values, and, confers higher risk of thrombosis and progression to myelofibrosis.

Pulmohary complications are a major cause of morbidity and mortality post-transplant and are the major risk factor governing the outcome in the early post-transplant period. Management depends upon the etiology. Both infective and non-infective etiologies can involve the lung. Since infective etiologies are now being better managed, non-infective causes of severe pulmonary damage remain a serious concern. Diffuse alveolar hemorrhage is one of such a cause which carries a high mortality.

Managing hematological disorders in a tropical country presents several unique diagnostic and management problems. Apart from the disease process, we need to be aware of infections that can exacerbate or mimic serious hematological problems. We present here a series of five patients with pre-existing hematological diseases who were infected by dengue virus. These cases highlight the need to keep a strong suspicion of common endemic diseases in tropical countries before considering extensive workup for the basic hematological disease. There was no mortality and all patients recovered without any significant impact on their pre-existing hematological condition inspite of their low baseline blood counts. There was no excessive bleeding, prolonged stay in the hospital or relapse of underlying hematological disease in these patients and the only major concern was the increased anxiety among both the patient and treating physician regarding the relapse of pre-existing hematological disease.

Introduction: Diamond Blackfan anemia (DBA) is a rare congenital hypoplastic anemia that usually presents early in infancy. Methods: All consecutive children of DBA attending the Department of Hematology OPD, AIIMS were included in the study. This is a retrospective study, with few cases enrolled prospectively, over the last 3 years. Aim: To study the clinical profile & treatment response of Diamond Blackfan anemia patients at our center. Results: 10 patients were included in the study; male: female ratio was 9:1. Median age was 2.5 yrs, ranging from 4 months to 8 yrs. Anemia requiring frequent blood transfusions was the predominant complaint since infancy. Two children were siblings.Abnormal phenotypic features were observed in 60%. The craniofacial abnormalities seen included triangular facies with DBA phenotype 50 % (5), microcephaly 10 %( 1), low set ears 10 %( 1), low hairline 10 %( 1), wide spaced teeth 10%( 1), malar prominence 10 %( 1), wide spaced toes 10 %( 1), growth failure 30%( 3) and wide spaced nipple10 % (1). Out of 10 patients, 5(50%) are transfusion independent on steroids, 4 patients had partial response with steroids and 1 had partial response on cyclosporine with occasional transfusions and the other 3 are transfusion dependent and on iron chelation. Conclusion: DBA is a rare congenital hypoplastic anemia. About 50% of patients have a good response to steroids.

Mantle cell lymphoma (MCL) is a distinct type of non-Hodgkin’s lymphoma that commonly affects extra nodal sites. The most commonly affected sites are bone marrow, gastrointestinal tract and Waldeyer’s ring, however, skin is rarely involved. We report a case of 56 year-old gentleman with MCL; exhibiting multiple large maculopapular skin rashes and skin ulcers. Histopathological examination had not shown direct infiltration by any atypical cells. He had significant improvement of skin lesions with combination chemotherapy and debridement. Awareness of skin manifestations of MCL is essential for dermatologists and haematologists to establish the early diagnosis and timely administration of appropriate treatment.

Introduction: Inherited bleeding disorders are characterized by the absence or reduced level of clotting factors, and the clinical manifestations vary according to the type and magnitude of the deficient factor. Aim: To study the clinical presentation of these rare inherited coagulation factor disorders in a tertiary care hospital and to compare the data from those reported in other populations. Methods: Sixty-seven patients, who presented to the Department of Hematology, All India Institute of Medical Sciences, New Delhi, were evaluated retrospectively from 2005 to 2011. The tests performed included platelet count, prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time (TT), factors assay and clot solubility test in 5 M urea. Factors VIII, IX and XI assays were aPTT based while factors II, V, VII and X assays were PT based. Results: Male to female ratio was 2:1. The median age of onset of the first episode of bleeding was at 6 months (range, from birth to 20 years) whereas the median age of presentation to our hospital was 9 years (range, 2 months to 54 years). The most common deficient factor was factor X (43.28%), followed by factor XIII deficiency (26.86%) and factor VII (10.4%). Conclusion: There is a wide gap between the initial manifestation of the bleeding disorder and first presentation to the tertiary care hospital for assessment and treatment. Factor X deficiency is the most common among these rare coagulation disorders in our population, whereas factor VII deficiency is more common in Iranian and North American population.

Suppression of T cell response is thought to be involved in the pathogenesis of visceral leishmaniasis (VL). Regulatory T cell (Treg) mediated immune-suppression is reported in animal models of Leishmania infection. However, their precise role among human patients still requires pathologic validation. The present study is aimed at understanding the frequency dynamics and function of Treg cells in the blood and bone marrow (BM) of VL patients. The study included 42 parasitologically confirmed patients, 17 healthy contact and 9 normal bone marrow specimens (NBM). We show i) the selective accumulation of Treg cells at one of the disease inflicted site(s), the BM, ii) their in vitro expansion in response to LD antigen and iii) persistence after successful chemotherapy. Results indicate that the Treg cells isolated from BM produces IL-10 and may inhibit T cell activation in IL-10 dependent manner. Moreover, we observed significantly higher levels of IL-10 among drug unresponsive patients, suggesting their critical role in suppression of immunity among VL patients. Our results suggest that IL-10 plays an important role in suppression of host immunity in human VL and possibly determines the efficacy of chemotherapy.

Abstract Patients post allogenic stem cell trasplantation are at increased risk of infection owing to immunocompromised state. Other than bacterial and viral infections, patients are at increased risk of fungal and mycobacterial infections. Infection with mucormycosis is rare but dreaded infection and requires aggressive management. Tubercular infection can also complicate post transplant period and risk of infection is high in endemic countries. We report a case of aplastic anemia who following allogenic stem cell transplantation developed combined infection with both tuberculosis and mucormycosis. Isolated infections by tuberculosis and mucormycosis have been reported in transplant recipients but simultaneous infection with both mucormycosis and tuberculosis in transplant recipient has not yet been reported. Anti-tubercular drugs cause interaction with immunosuppressive and anti-fungal drugs and management of such patients is a therapeutic challenge, paticularly in areas where tuberculosis is endemic.

Managing hematological disorders in a tropical country presents several unique diagnostic and management problems. Apart from the disease process, we need to be aware of infections that can exacerbate or mimic serious hematological problems. We present here a series of five patients with pre-existing hematological diseases who were infected by dengue virus. These cases highlight the need to keep a strong suspicion of common endemic diseases in tropical countries before considering extensive workup for the basic hematological disease. There was no mortality and all patients recovered without any significant impact on their pre-existing hematological condition inspite of their low baseline blood counts. There was no excessive bleeding, prolonged stay in the hospital or relapse of underlying hematological disease in these patients and the only major concern was the increased anxiety among both the patient and treating physician regarding the relapse/progression of pre-existing hematological disease.