Adherence to imatinib(IM) is of utmost importance in patients with chronic myeloid leukemia (CML) to maximise treatment effectiveness. The main objective is to measure adherence to IM by evaluating individual patient characteristics, personal behaviour and, treatment related psychological factors influencing adherence behaviour. Hundred patients receiving IM were analysed for adherence behaviour using 9 item Morisky Medication Adherence Scale (9-MMAS). Various factors were assessed for their impact on adherence behaviour. These factors were age, gender, duration of treatment, frequency and dosing of treatment, use of tobacco and alcohol, educational qualification, employment status, monthly income, side effects, financial assistance in treatment, social support, knowledge about medicine and disease, concomitant drug burden, polypharmacy, physician patient interaction, patient educational sessions and prevalence of depression. Seventy five percent of patients were found to be adherent. On univariate analysis, prevalence of depression (p<0.000001), moderate severe depression (p<0.000001), concomitant drug burden (p=0.036) and monthly income (p=0.015) were found to be significantly influencing adherence. The final multivariate model retained prevalence of depression with OR= 10.367 (95% CI, 3.112–34.538) as independent predictor of adherence to therapy. This study suggests that identification and treatment of depression among CML patients may further enhance adherence to IM therapy.

Majority of patients obtained CR/VGPR post-ASCT. Longer PFS was seen with patients who were transplanted in first remission.

Peptic perforation is a serious complication of peptic ulcer disease. The defect in the intestinal wall usually does not present a difficult technical problem of surgical management, in most cases perforation can be closed primarily. On rare occasions an extremely large defect (giant peptic perforation – defined as any perforation greater than 2.5 cm in size) cannot be closed by these simple techniques. Modalities of treatment advocated for such an ulcer over the years are: free omental plug in the form of a mushroom; serosal patch technique; jejunal pedicle graft, partial gastrectomy, and finally the possible addition of proximal gastrojejunostomy. The omental plug is a simple procedure which does not require expertise and can even be performed in a very short time by a trainee general surgeon in a seriously ill patient in emergency. We review 7 cases of giant peptic perforations closed by a free omental plug.

TB should be suspected in patients with unexplained fever post alloSCT. Active GVHD and ongoing immunosuppression/steroids are possible risk factors. Early diagnosis and treatment can salvage most patients. Hepatotoxicity following ATT is a potential concern.

Introduction There is no standard of care for patients with elderly Acute Myeloid Leukemia (AML), and in those unfit for Intensive Chemotherapy. When treated with intensive chemotherapy, elderly AML patients achieve 45% CR/CRi (incomplete Complete Remission) rates, however, at the cost of high induction mortality of 29%.On the other hand, patients treated with Hypomethylating agents (HMAs) alone have low response rates, median time to best response of 3-4 months and a median OS of <1 year. Relapse or refractoriness to myeloid malignancies has been attributed to quiescent leukemic stem cells (LSCs) that are resistant to conventional chemotherapy. BCL2 inhibitors like venetoclax (VEN) target oxidative phosphorylation and selectively eradicate these LSCs. In pre-clinical studies, VEN in combination with HMAs, has been shown to deplete ATP in LSCs. Interestingly, Azacytidine has not only been reported to be synergistic in combination with VEN, but also reverse the resistance associated with it. VEN monotherapy and combination therapy have been reported, both in relapsed/refractory (R/R) AML and treatment naïve elderly patients from western world. VEN in combination with HMAs/LDAC (low dose Ara-C) was recently approved in November 2018 for patients >=75 years / those with co-morbidities precluding use of intensive chemotherapy. In view of paucity of real-world data, we aim to report the remission rates and safety of VEN in combination with HMAs from India. Methods All treatment naïve and R/R elderly (Age >= 65years) or patients deemed unfit for intensive chemotherapy [ECOG PS 3-4, non-resolving infections after atleast 7 days of supportive therapy] who received HMAs (Azacytidine/Decitabine) + VEN during September 2018 to May 2019, with a minimum follow-up period of 90 days were retrospectively reviewed. All patients received either Azacytidine 75mg/m2 SC daily for 7 days or Decitabine 20mg/m2 IV daily for 5 days along with ramp up of VEN from day1 (50mg OD X 2 ays, 100mg OD X 2 days, 200mg OD X 2 days, 400mg OD till day 21/28).Maximum dose of VEN was 200mg, if on concomitant voriconazole. Antifungal prophylaxis (Azoles/Amphotericin B) and TLS prophylaxis (Rasburicase) were administered as per institutional protocol. On achievement of CR, patients were either continued on the respective HMA with VEN [400mg OD till day7/14], every 4 weekly, or received standard consolidation (High dose Ara-C or allogeneic stem cell transplant), as per fitness. Results Twenty patients with a median age of 60 (Range:31-75) years were treated for AML (89.4%;n=18), BPDCN (Blastic Plasmacytoid Dendritic Cell Neoplasm) (5.3%;n=1) and MDS-EB-1 (5.3%;n=1). Amongst AML patients, 12 were newly diagnosed, 5 were relapsed cases [3 post HSCT relapses], while 1 was refractory. As per ELN classification, majority of our patients with AML were intermediate risk (n=9), followed by high (n=5) and low (n=3) risk. Patient with BPDCN belonged to the high risk group, while another patient with MDS-EB-1 belonged to Very High IPSS-R risk group at diagnosis. Prior to receiving VEN + HMA combination, 15 patients had infections (fungal=10,bacterial=7,viral=1), out of which 9 (47.36%) patients had persistent infection prior to commencing chemotherapy. In our cohort, CR/CRi was seen in 60% (n=12) patients. 67% (n=8) of newly diagnosed AML, 40% (n=2) of relapsed AML, and one patient with BPDCN and MDS-EB-1 achieved CR/CRi. Median number of VEN+ HMA cycles received were 3 (1-10) cycles, while most patients achieved CR in one cycle [Median-1,Range:1-4]. Amongst patients who achieved CR (n=12), only one relapsed after a duration of 72 days. Induction mortality was observed in 15%(n=3) patients. At a median follow-up of 5.13 months (95% C.I. 5.02-5.24), 70% of patients were alive. Estimated 9 month OS was 60±13% [Figure 1]. Overall 20 patients received 74 cycles. Adverse events are enlisted as in tTble 1. Conclusions : Azacytidine and VEN combination is an effective regimen than HMAs alone, with CR rates of 60%, and better tolerated than intensive chemotherapy. This novel combination regimen produced responses even in high risk patients, including those with poor risk cytogenetics, AML with myelodysplasia related changes, and post-transplant relapse. In our experience, reducing the duration of VEN to 21 days in Induction lessens the duration of grade 4 myelosuppression, lesser febrile neutropenia, with similar response rates which needs to be validated. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: Venetoclax has been approved in combination with Hypomethylating agents for patients >=75 years and those elderly unfit for intensive chemotherapy. We used Venetoclax + hypomethylating agents in elderly, as well as in adults who were unfit for intensive chemotherapy due to poor ECOG PS [PS 3-4]or due to non-resolving infections

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Context Nilotinib is a second-generation BCR-ABL1 tyrosine kinase inhibitor used in the treatment of chronic myeloid leukemia (CML). Aims We aim to evaluate the responses and safety of upfront Nilotinib therapy in Indian CML patients. Setting and Design We retrospectively reviewed the medical records of CML patients who received Nilotinib as an upfront treatment at our center between January 1, 2011 and October 15, 2019.The follow-up was taken till March 31, 2020. Results Forty One patients (n = 36 chronic phase and five accelerated-phase CML) received frontline Nilotinib. Median age was 39 years (21–63) with male-to-female ratio of 1.1: 1. At 3 months, 96.9% patients achieved BCR-ABL of ≤10% at international scale. By the end of 12 months, 71.5% patients achieved major molecular response (BCR-ABL ≤0.1%) and 91.4% patients achieved complete cytogenetic response assessed by BCR-ABL polymerase chain reaction of ≤1%. Common toxicities observed were weight gain, thrombocytopenia, corrected QT prolongation, and elevated serum amylase in 14 (34.1%), 7(17.07%), 4(9.7%), and 4(9.7%) patients, respectively. Overall, five patients had loss of response with further progression and death in three patients. At a median of 43.7 months, 38 patients survived with estimated 3 year event-free survival and overall survival of 65 ± 9 and 93 ± 5%. Conclusion This study showed remarkable good response with upfront Nilotinib in Indian patients with CML.

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