Neeraj Sidharthan

Epigenetics targeted protein-vorinostat nanomedicine inducing apoptosis in heterogeneous population of primary acute myeloid leukemia cells including refractory and relapsed cases

UNLABELLED Aberrant epigenetics play a key role in the onset and progression of acute myeloid leukemia (AML). Herein we report in silico modelling based development of a novel, protein-vorinostat nanomedicine exhibiting selective and superior anti-leukemic activity against heterogeneous population of AML patient samples (n=9), including refractory and relapsed cases, and three representative cell lines expressing CD34(+)/CD38(-) stem cell phenotype (KG-1a), promyelocytic phenotype (HL-60) and FLT3-ITD mutation (MV4-11). Nano-vorinostat having ~100nm size exhibited enhanced cellular uptake rendering significantly lower IC50 in AML cell lines and patient samples, and induced enhanced HDAC inhibition, oxidative injury, cell cycle arrest and apoptosis compared to free vorinostat. Most importantly, nanomedicine showed exceptional single-agent activity against the clonogenic proliferative capability of bone marrow derived leukemic progenitors, while remaining non-toxic to healthy bone marrow cells. Collectively, this epigenetics targeted nanomedicine appears to be a promising therapeutic strategy against various French-American-British (FAB) classes of AML. FROM THE CLINICAL EDITOR Through the use of a protein-vorinostat agent, exceptional single-agent activity was demonstrated against the clonogenic proliferative capability of bone marrow derived leukemic progenitors, while remaining non-toxic to healthy bone marrow cells. The studied epigenetics targeted nanomedicine approach is a promising therapeutic strategy against various French-American-British classes of acute myeloid leukemia.

Clinical characteristics and treatment outcomes of primary autoimmune hemolytic anemia: a single center study from South India

Background Autoimmune hemolytic anemia (AIHA) is a less recognized, potentially fatal condition. There is a scarcity of data on clinicoserological characteristics and response to therapy concerning this disease from South India. Methods Data for 33 patients with primary AIHA recorded from July 2009 to June 2015 were retrospectively analyzed for clinical presentation, response to frontline therapy, durability of response, time to next treatment (TTNT), and response to second-line agents. Results The median follow-up period was 50 months. Among 33 patients, 48% of the cases were warm autoimmune hemolytic anemia (WAIHA), 46% were cold agglutinin disease (CAD), and 6% were atypical. Three-fourth of patients had severe anemia (<8 g/dL hemoglobin [Hb]) at onset; younger patients (age <40 yr) had more severe anemia. All of the patients who required treatment received oral prednisolone at 1.5 mg/kg/d as a frontline therapy, and the response rate was 90% (62% complete response [CR] and 28% partial response [PR]). The overall response to corticosteroids in WAIHA and CAD was 87% and 92%, respectively. The median corticosteroid duration was 14 months, and 50% of the patients required second-line agents. Fourteen patients received azathioprine as a second-line agent, and 11 of these patients responded well, with half of them not requiring a third agent. Four patients developed severe infections (pneumonia, sepsis, and soft tissue abscess) and two had life-threatening venous thrombosis. One case of death was recorded. Conclusion AIHA is a heterogeneous disease that requires care by physicians experienced in treating these patients.

Development and molecular characterization of polymeric micro-nanofibrous scaffold of a defined 3-D niche for in vitro chemosensitivity analysis against acute myeloid leukemia cells

Standard in vitro drug testing employs 2-D tissue culture plate systems to test anti-leukemic drugs against cell adhesion-mediated drug-resistant leukemic cells that harbor in 3-D bone marrow microenvironments. This drawback necessitates the fabrication of 3-D scaffolds that have cell adhesion-mediated drug-resistant properties similar to in vivo niches. We therefore aimed at exploiting the known property of polyurethane (PU)/poly-l-lactic acid (PLLA) in forming a micro-nanofibrous structure to fabricate unique, not presented before, as far as we are aware, 3-D micro-nanofibrous scaffold composites using a thermally induced phase separation technique. Among the different combinations of PU/PLLA composites generated, the unique PU/PLLA 60:40 composite displayed micro-nanofibrous morphology similar to decellularized bone marrow with increased protein and fibronectin adsorption. Culturing of acute myeloid leukemia (AML) KG1a cells in FN-coated PU/PLLA 60:40 shows increased cell adhesion and cell adhesion-mediated drug resistance to the drugs cytarabine and daunorubicin without changing the original CD34+/CD38−/CD33− phenotype for 168 hours compared to fibronectin tissue culture plate systems. Molecularly, as seen in vivo, increased chemoresistance is associated with the upregulation of anti-apoptotic Bcl2 and the cell cycle regulatory protein p27Kip1 leading to cell growth arrest. Abrogation of Bcl2 activity by the Bcl2-specific inhibitor ABT 737 led to cell death in the presence of both cytarabine and daunorubicin, demonstrating that the cell adhesion-mediated drug resistance induced by Bcl2 and p27Kip1 in the scaffold was similar to that seen in vivo. These results thus show the utility of a platform technology, wherein drug testing can be performed before administering to patients without the necessity for stromal cells.

Low-dose prophylaxis for children with haemophilia in a resource-limited setting in south India—A clinical audit report

dosing scheme; guiding dose frequency in older patients switching from on demand to prophylaxis; and assessing the clinical efficacy of new molecules. The scoring method we propose is a relatively simple approach to determining bleeding phenotype. A potential next step might be to test the usefulness of our scoring system prospectively in welldefined cohorts. Until fully validated, this scoring system should be applied selectively to avoid the consequences of bleeding. Possible situations might include a PWH desiring a lower frequency of injections or one who wants to try newer agents, such as extended halflife products.

Methotrexate Induced Lung Toxicity- A Case Report

Methotrexate (MTX) belongs to a class of antimetabolites. It may cause serious side effects like lung problems, lung infections. Methotrexate-induced lung disease, as well as acute or chronic interstitial pneumonitis, is a potentially risky sore, which can happen intensely whenever, amid treatment and has been accounted for at low doses. The diagnosis of drug-induced pulmonary toxicity is generally settled in light of clinical discoveries. The present report describes a case of methotrexate-induced lung toxicity. Biopsy that had done reported as relapsed lymphoma. Then he got admitted for high dose methotrexate and rituximab followed by folinic acid rescue. He tolerated 2 chemotherapies well, without any major complications. He developed fever, cough with expectoration and breathlessness. In view of persisting high grade fever, associated with cough and breathing difficulty, pulmonology consultation was sought and CT done. In medication-induced lung toxicity, the radiologic patterns seen are exceeding factor and rely upon the kind of unfavorable response the patient is experiencing. One possibility in the clinical setting is methotrexate induced lung changes. Differential diagnosis (DD) is alveolitis due to infection. In view of suspected methotrexate induced lung toxicity, planned to withhold next dose of Methotrexate. He was started on high dose steroids. The patient symptomatically improved, fever subsided, counts improved. Prompt diagnosis is vital in light of the fact that early medication actuated lung harm will regularly relapse with cessation of treatment. It was found that the severity of the methotrexate induced lung toxicity is a probable adverse drug reaction (ADR) with Naranjo score of 7.

Cerebral venous thrombosis in refractory idiopathic thrombocytopenia treated with eltrombopag.

1. Indian Epilepsy Society: Guidelines for the Management of Epilepsy in India. Available from: http://www.epilepsyindia.org/ ies/GUIDELINES/Gemind_Combine.pdf. [Last accessed on 2016 Apr 17]. 2. Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and Management of Epilepsy in Adults. (SIGN Publication No. 143). Edinburgh: SIGN; 2015. Available from: http://www. sign.ac.uk. [Last accessed on 2016 Apr 17]. It is not clear why clobazam is the most commonly prescribed anticonvulsant in this part of rural India. However, its prescription may be now causing problems for this group of patients for two reasons: first, it is likely to be associated with more seizures than the guideline-indicated treatment of maximum dose of a first-line anticonvulsant followed if necessary by another first-line anticonvulsant, alone or in combination; second, its costs must be borne by the patient from earnings which are often meager; 10 mg each day costs Rs. 282 each month. A dose of 800 mg daily of carbamazepine costs slightly less than this and most epilepsy specialists would reckon that a better deal.

Salmonella Typhimurium pneumonia in a patient with multiple myeloma.

Pneumonia due to non-typhoidal Salmonella is a rarely reported entity. A fatal case of Salmonella pneumonia is reported here where Salmonella Typhimurium was isolated from the endotracheal aspirate and blood culture.

Carbimazole-induced agranulocytosis.

A 47 year old lady with hyperthyroidism for past 1½ years was initially on Carbimazole 20 mg orally then changed to 30 mg (during Hysterectomy) but was taking 10 mg for last 1 year. She had intermittent fever with severe B/L bifrontal headache since 3 weeks. Routine investigations showed anaemia, neutropenia, leucopenia and CRP elevation. Peripheral smear showed normocytic normochromic anaemia with Rouleaux formation, leucopenia with 2% atypical cells and mild thrombocytosis. Widal test, RA factor (Rheumatoid factor) test, Ig M (Immunoglobulin M) dengue, Ig M Lepto, TORCH infections (Toxoplasmosis, Other (Syphilis, varicella-zoster, parvovirus B19), Cytomegalovirus and Herpes infections), ANA (Antinuclear antibody) screen cANCA (Cytoplasmic antineutrophil cytoplasmic antibodies) and pANCA (Perinuclear Anti-Neutrophil Cytoplasmic Antibodies) tests were negative. Bone marrow aspiration showed normo to hypercellular marrow with 15% atypical cells and plasma cells. Multiple myeloma workup was done. Carbimazole was withheld. Conclusion: Drug induced agranulocytosis occurs with in 1-2 months of taking the antithyroid medication but onset delayed by 1½ year. De-challenge resulted normalization of blood parameters.