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S S KD, Joga R, Srivastava S, Nagpal K, Dhamija I, Grover P, Kumar S. Regulatory landscape and challenges in CAR-T cell therapy development in the US, EU, Japan, and India. Eur J Pharm Biopharm 2024; 201:114361. [PMID: 38871092 DOI: 10.1016/j.ejpb.2024.114361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 06/02/2024] [Accepted: 06/10/2024] [Indexed: 06/15/2024]
Abstract
Chimeric Antigen Receptor-T cell (CAR-T) therapy has evolved as a revolutionary cancer treatment modality, offering remarkable clinical responses by harnessing the power of a patient's immune system to target and eliminate cancer cells. However, the development and commercialization of CAR-T cell therapies are accompanied by complex regulatory requirements and challenges. This therapy falls under the regulatory category of advanced therapy medicinal products. The regulatory framework and approval tools of regenerative medicine, especially CAR-T cell therapies, vary globally. The present work comprehensively analyses the regulatory landscape and challenges in CAR-T cell therapy development in four key regions: the United States, the European Union, Japan, and India. This work explores the unique requirements and considerations for preclinical studies, clinical trial design, manufacturing standards, safety evaluation, and post-marketing surveillance in each jurisdiction. Due to their complex nature, developers and manufacturers face several challenges. In India, despite advancements in treatment protocols and government-sponsorships, there are still several difficulties regarding access to treatment for the increasing number of cancer patients. However, India's first indigenously developed CAR-T cell therapy, NexCAR19, for B-cell lymphoma or leukemia, approved and available at a low cost compared to other available CAR-T therapies, raises great hope in the battle against cancer. Several strategies are proposed to address the identified hurdles from global and Indian perspectives. It discusses the benefits of aligning regulatory requirements across regions, eventually facilitating international development and enabling access to this transformative therapy.
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Affiliation(s)
- Kirthiga Devi S S
- Department of Regulatory Affairs, National Institute of Pharmaceutical Education and Research, Hyderabad, Telangana 500037, India
| | - Ramesh Joga
- Department of Regulatory Affairs, National Institute of Pharmaceutical Education and Research, Hyderabad, Telangana 500037, India
| | - Saurabh Srivastava
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, Telangana 500037, India
| | - Kalpana Nagpal
- Amity Institute of Pharmacy, Amity University, Noida, Uttar Pradesh 201303, India
| | - Isha Dhamija
- Department of Pharmacology, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, Telangana 500037, India
| | - Parul Grover
- KIET School of Pharmacy, KIET Group of Institutions, Delhi-NCR, Ghaziabad 201206, India
| | - Sandeep Kumar
- Department of Regulatory Affairs, National Institute of Pharmaceutical Education and Research, Hyderabad, Telangana 500037, India; Department of Pharmaceutics, NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan 303121, India.
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Akram A, Gilani M, Chaudhry QUN, Iftikhar R, Ghafoor T, Khan MA, Haider M, Nisar H. Real-World Challenges of Haplo-Identical Hematopoietic Stem Cell Transplant in a Developing Country: A Single Center Experience. Cureus 2024; 16:e59744. [PMID: 38841039 PMCID: PMC11152362 DOI: 10.7759/cureus.59744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2024] [Indexed: 06/07/2024] Open
Abstract
Hematopoietic stem cell transplant (HSCT) is potentially, the sole curative option for many malignant and non-malignant hematological disorders. Finding a human leukocyte antigen (HLA) compatible donor remains one of the limiting factors, hampering the utilization of HSCT. However, the introduction of post-transplant cyclophosphamide (PTCy) has improved the outcomes of haploidentical transplants making it a suitable option for patients lacking HLA-compatible donors. We collected data from 44 patients who underwent haplo-identical allogeneic stem cell transplants at the Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant (AFBMTC/NIBMT) from the year 2015 to 2022. The diseases were divided into three categories, i.e., bone marrow failure (BMF) syndromes, hematological malignancies (HM) and miscellaneous (Misc) groups. Median age at transplant was 18 (01-39) years. Transplant indications included aplastic anemia (AA) in 21 (47.7%) cases, 15 (34.1%) HM, and eight (18.2%) cases falling in the Misc groups. A maximum number of graft failures occurred in the BMF group; primary graft failure in 07 (33.3%) cases and secondary graft failure in four (19%) cases, (p-value < 0.05). Acute graft versus host disease (aGVHD) grade II-IV occurred in nine (20.5%) cases while chronic graft versus host disease (cGVHD) occurred in 10 (22.7%) cases. Cytomegalovirus (CMV) reactivation was seen in 31 (70.5%) cases. Maximum CMV reactivation was seen in HM group 13 (86.6%) cases, (p-value < 0.05) as compared to BMF (71.4%) and Misc groups (37.5%). Post-transplant cyclophosphamide (PTCy) based regimens, early neutrophil engraftment, and patients with GVHD had better survival outcomes (p-value < 0.05) overall survival (OS), and relapse-free survival (RFS). and GVHD-free relapse-free survival (GFRS) were significantly better in cases with early neutrophil engraftment. OS of the study cohort was 50% while disease-free survival (DFS) and GFRS were 45.5% and 36.4%, respectively.
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Affiliation(s)
- Ammad Akram
- Clinical Hematology, Armed Forces Bone Marrow Transplant Center, Rawalpindi, PAK
| | - Mehwish Gilani
- Chemical Pathology, Armed Forces Bone Marrow Transplant Center, Rawalpindi, PAK
| | | | - Raheel Iftikhar
- Hematology and Oncology, Armed Forces Bone Marrow Transplant Center, Rawalpindi, PAK
| | - Tariq Ghafoor
- Pediatrics, Armed Forces Bone Marrow Transplant Center, Rawalpindi, PAK
| | - Mehreen Ali Khan
- Hematology, Armed Forces Bone Marrow Transplant Center, Rawalpindi, PAK
| | - Memoona Haider
- Hematology, Armed Forces Bone Marrow Transplant Center, Rawalpindi, PAK
| | - Haider Nisar
- Clinical Hematology, Armed Forces Bone Marrow Transplant Center, Rawalpindi, PAK
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Jain A, Jandial A, Mani T, Kishore K, Singh C, Lad D, Prakash G, Khadwal A, Das R, Varma N, Varma S, Malhotra P. Comparable outcomes with low-dose and standard-dose horse anti-thymocyte globulin in the treatment of severe aplastic anemia. Blood Res 2024; 59:6. [PMID: 38485832 PMCID: PMC10903521 DOI: 10.1007/s44313-024-00003-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/10/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND The standard dose (SD) of horse anti-thymocyte globulin (hATG) ATGAM (Pfizer, USA) or its biosimilar thymogam (Bharat Serum, India) for the treatment of Aplastic Anemia (AA) is 40 mg/kg/day for 4 days in combination with cyclosporine. Data on the impact of hATG dose on long-term outcomes are limited. Here, we describe our comparative experience using 25 mg/kg/day (low-dose [LD]) hATG for 4 days with SD for the treatment of AA. METHODS We retrospectively studied patients with AA (age > 12 years) who received two doses of hATG combined with cyclosporine. Among 93 AA patients who received hATG, 62 (66.7%) and 31 (33.3%) patients received LD and SD hATG with cyclosporine, respectively. Among these,seventeen(18.2%) patients also received eltrombopag with hATG and cyclosporine. Overall response rates [complete response (CR) and partial response (PR)] of LD and SD hATG groups at 3 months (50% vs. 48.4%; p = 0.88), 6 months (63.8% vs. 71.4%; p = 0.67), and 12 months (69.6% vs. 79.2%; p = 0.167) were comparable. The mean (Standard Deviation) 5-year Kaplan-Meier estimate of overall survival and event-free survival was 82.1 (4.6)% and 70.9 (5.5)% for the study population. The mean (standard deviation) 5-year Kaplan-Meier estimate of overall survival and event-free survival of those who received LD hATG versus SD hATG dose was 82.9 (5·3)% versus 74.8 (10·3)% (P = 0·439), and 75.2 (6.2)% versus 61.4(11.2)% (P = 0·441). CONCLUSION Our study revealed that the response rates of patients with AA and LD were similar to those of patients with SD to hATG combined with cyclosporine in a real-world setting.
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Affiliation(s)
- Arihant Jain
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India
| | - Aditya Jandial
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India
| | - Thenmozhi Mani
- Department of Biostatistics, CMC, Vellore, Hematology, India
| | - Kamal Kishore
- Department of Biostatistics, PGIMER, Chandigarh, India
| | - Charanpreet Singh
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India
| | - Deepesh Lad
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India
| | - Gaurav Prakash
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India
| | - Alka Khadwal
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India
| | - Reena Das
- Department of Hematology, PGIMER, Chandigarh, India
| | - Neelam Varma
- Department of Hematology, PGIMER, Chandigarh, India
| | | | - Pankaj Malhotra
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India.
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Chichra A, Nayak L, Kothari R, Kalantri S, Bonda A, Gokarn A, Punatar S, Mirgh S, Jindal N, Bagal B, Kannan S, Mathew L, Khattry N. Fludarabine melphalan versus fludarabine treosulfan for reduced intensity conditioning regimen in allogeneic hematopoietic stem cell transplantation: a retrospective analysis. Int J Hematol 2024; 119:71-79. [PMID: 37952243 DOI: 10.1007/s12185-023-03674-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 10/02/2023] [Accepted: 10/20/2023] [Indexed: 11/14/2023]
Abstract
Various reduced-intensity conditioning (RIC) regimens are used to decrease toxicity while providing comparable outcomes to myeloablative regimens. We compared toxicity and outcomes between two RIC regimens, fludarabine with melphalan (Flu-Mel) and fludarabine with treosulfan (Flu-Treo), retrospectively over a 10-year period in two donor groups, matched related donor (MRD)/matched unrelated donor (MUD) and haploidentical (Haplo) transplants. The study included 138 patients, of which 105 received MRD/MUD (Flu-Mel: 94, Flu-Treo: 11) and 33 Haplo (Flu-Mel: 17, Flu-Treo: 16) transplants. In the MRD/MUD group, 44 (47%) of patients who received Flu-Mel had grade 3/4 oral mucositis compared to 1 (9%) who received Flu-Treo (P = 0.02). Corresponding numbers in the Haplo group were 7 (41%) and 1 (6%). Grade 3/4 diarrhoea was more frequent with Flu-Mel than Flu-Treo in the Haplo group (41% vs 6%; P = 0.039), but not the MRD/MUD group. Median follow-up time for all patients was 4.8 years. Five-year OS in the MRD/MUD group was 62% with Flu-Mel versus 53% with Flu-Treo (P = 0.0694). Similarly, 5-year OS was 41% with Flu-Mel and 28% with Flu-Treo (P = 0.770) in the Haplo group. Severe mucositis and diarrhoea were significantly less frequent with Flu-Treo than Flu-Mel. Flu-Treo provided comparable outcomes to Flu-Mel in all donor transplants.
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Affiliation(s)
- Akanksha Chichra
- Stem Cell Transplant Unit, Department of Medical Oncology, Room 211, Paymaster Shodhika, ACTREC, Tata Memorial Centre, Kharghar, Navi Mumbai, 410201, India
- Homi Bhabha National Institute (HBNI), Anushaktinagar, Mumbai, India
| | - Lingaraj Nayak
- Stem Cell Transplant Unit, Department of Medical Oncology, Room 211, Paymaster Shodhika, ACTREC, Tata Memorial Centre, Kharghar, Navi Mumbai, 410201, India
- Homi Bhabha National Institute (HBNI), Anushaktinagar, Mumbai, India
| | - Rushabh Kothari
- Stem Cell Transplant Unit, Department of Medical Oncology, Room 211, Paymaster Shodhika, ACTREC, Tata Memorial Centre, Kharghar, Navi Mumbai, 410201, India
| | - Siddhesh Kalantri
- Stem Cell Transplant Unit, Department of Medical Oncology, Room 211, Paymaster Shodhika, ACTREC, Tata Memorial Centre, Kharghar, Navi Mumbai, 410201, India
| | - Avinash Bonda
- Stem Cell Transplant Unit, Department of Medical Oncology, Room 211, Paymaster Shodhika, ACTREC, Tata Memorial Centre, Kharghar, Navi Mumbai, 410201, India
- Homi Bhabha National Institute (HBNI), Anushaktinagar, Mumbai, India
| | - Anant Gokarn
- Stem Cell Transplant Unit, Department of Medical Oncology, Room 211, Paymaster Shodhika, ACTREC, Tata Memorial Centre, Kharghar, Navi Mumbai, 410201, India
- Homi Bhabha National Institute (HBNI), Anushaktinagar, Mumbai, India
| | - Sachin Punatar
- Stem Cell Transplant Unit, Department of Medical Oncology, Room 211, Paymaster Shodhika, ACTREC, Tata Memorial Centre, Kharghar, Navi Mumbai, 410201, India
- Homi Bhabha National Institute (HBNI), Anushaktinagar, Mumbai, India
| | - Sumeet Mirgh
- Stem Cell Transplant Unit, Department of Medical Oncology, Room 211, Paymaster Shodhika, ACTREC, Tata Memorial Centre, Kharghar, Navi Mumbai, 410201, India
- Homi Bhabha National Institute (HBNI), Anushaktinagar, Mumbai, India
| | - Nishant Jindal
- Stem Cell Transplant Unit, Department of Medical Oncology, Room 211, Paymaster Shodhika, ACTREC, Tata Memorial Centre, Kharghar, Navi Mumbai, 410201, India
- Homi Bhabha National Institute (HBNI), Anushaktinagar, Mumbai, India
| | - Bhausaheb Bagal
- Stem Cell Transplant Unit, Department of Medical Oncology, Room 211, Paymaster Shodhika, ACTREC, Tata Memorial Centre, Kharghar, Navi Mumbai, 410201, India
- Homi Bhabha National Institute (HBNI), Anushaktinagar, Mumbai, India
| | - Sadhana Kannan
- Department of Biostatistics, ACTREC, Tata Memorial Centre, Navi Mumbai, India
| | - Libin Mathew
- Stem Cell Transplant Unit, Department of Medical Oncology, Room 211, Paymaster Shodhika, ACTREC, Tata Memorial Centre, Kharghar, Navi Mumbai, 410201, India
| | - Navin Khattry
- Stem Cell Transplant Unit, Department of Medical Oncology, Room 211, Paymaster Shodhika, ACTREC, Tata Memorial Centre, Kharghar, Navi Mumbai, 410201, India.
- Homi Bhabha National Institute (HBNI), Anushaktinagar, Mumbai, India.
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Kumar R, Kapoor R, Sharma S, Pramanik SK, Yanamandra U, Mishra K, Khera S, Sharma A, Das S, Verma T, Singh J, Nair V. Bone marrow transplant: A two-decade single centre hematology experience. Med J Armed Forces India 2023; 79:657-664. [PMID: 37981920 PMCID: PMC10654354 DOI: 10.1016/j.mjafi.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 09/05/2023] [Indexed: 11/21/2023] Open
Abstract
Background Bone Marrow Transplant (BMT) is a curative form of therapy for many hematological disorders in both the adult and pediatric patients. The availability of BMT in the AFMS at AHRR for the last 02 decades has been a game changer for the patients. Methods We reviewed our BMT data since the inception of the program till Feb 2023. Results Over 700 patients with more than 23 different types of hematological disorders have undergone this procedure 58%% patients underwent an Autologous BMT and 42% an allogenic BMT. Autologous BMT for Multiple Myeloma and Allogenic BMT for Aplastic Anemia and Acute Leukemias have been the most common indications. 73% patients were adults, and 27% patients were of the pediatric age group. The male: female ratio was 2:1. The spectrum of allogenic Hematopoietic Stem Cell Transplant (HSCT) has expanded from Matched Sibling Donor (MSD) transplants to Matched Unrelated Donor (MUD) Transplants and Haploidentical Donor Transplants. 93% of our Allogenic BMT patients underwent a MSD BMT, 1% MUD BMT and 06% Haploidentical BMT. Today no patient with a malignant hematological disorder requiring a BMT is denied the procedure due to the lack of an HLA donor due to the availability of haploidentical BMT. Conclusion The evolution of a BMT program has a long learning curve and the expanded pool of eligible donors has led to a situation of "transplant for all". Haploidentical HSCT for nonmalignant hematological disorders is an unmet need. CART cell therapy and Cellular therapies need to be prioritized for future inclusion.
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Affiliation(s)
- Rajiv Kumar
- Senior Advisor (Medicine) & Clinical Hematologist, Army Hospital (R&R), New Delhi, India
| | - Rajan Kapoor
- Consultant (Medicine) & Clinical Hematologist, Army Hospital (R&R), New Delhi, India
| | | | | | - Uday Yanamandra
- Professor (Medicine) & Clinical Hematologist, Armed Forces Medical College, Pune, India
| | - Kundan Mishra
- Senior Advisor (Medicine) & Clinical Hematologist, Command Hospital (CC), Lucknow, India
| | - Sanjeev Khera
- Classified Specialist (Pediatrics) & Pediatric Hematoncologist, Army Hospital (R&R), New Delhi, India
| | - Ajay Sharma
- Consultant (Medicine) & Clinical Hematologist, Paras Hospital, Panchkula, India
| | - S. Das
- Consultant (Medicine) & Clinical Hematologist, Jaypee Hospital, Noida, India
| | - Tarun Verma
- Consultant (Medicine) & Clinical Hematologist, Yashoda Hospital, Ghaziabad, India
| | - Jasjit Singh
- Consultant (Medicine) & Clinical Hematologist, Sir Ganga Ram Hospital, New Delhi, India
| | - Velu Nair
- Group Head Medical Services, Chief Consultant – Hemato -Oncology & Bone Marrow Transplant, Apollo-CBCC, Ahmedabad, India
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Singh P, Shaikh S, Parmar S, Gupta R. Current Status of β-Thalassemic Burden in India. Hemoglobin 2023; 47:181-190. [PMID: 37947120 DOI: 10.1080/03630269.2023.2269837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/07/2023] [Indexed: 11/12/2023]
Abstract
Thalassemia is a major public health concern in India. The thalassemic burden in India is high, with an estimated 100,000 patients diagnosed with β-thalassemia syndrome. However, the exact number is unknown because of the absence of National Registries for patients. India alone contributes to approximately 25% of the global β-thalassemia burden. A possible option to control this burden is to endorse education and awareness programs, compulsory prenatal screening, and develop suitable facilities for genetic counseling, and availability of cost-effective diagnostic tests in India, especially in rural areas. In addition to the various clinical complications associated with thalassemia, lifelong intervention creates mental and physical trauma in patients and their relatives. Government and nongovernment organizations have initiated screening programs to prevent thalassemia. However, prenatal screening is not mandatory, and the reachability of screening programs in rural areas is yet to begin. This review article will discuss the progress in thalassemia research in India, including its prevalence, spectrum of β-thalassemia mutations, preventive and therapeutic measures, and awareness programs. More importantly, we will discuss the need and roadmap to strengthen prevention programs in India.
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Affiliation(s)
- Pratik Singh
- Centre of Research for Development, Parul University, Vadodara, India
| | - Samir Shaikh
- Centre of Research for Development, Parul University, Vadodara, India
| | - Sagar Parmar
- Centre of Research for Development, Parul University, Vadodara, India
| | - Reeshu Gupta
- Centre of Research for Development, Parul University, Vadodara, India
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Vaid A, Rastogi N, Doherty TM, San Martin P, Chugh Y. Review of the unmet medical need for vaccination in adults with immunocompromising conditions: An Indian perspective. Hum Vaccin Immunother 2023; 19:2224186. [PMID: 37402477 DOI: 10.1080/21645515.2023.2224186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/01/2023] [Accepted: 06/08/2023] [Indexed: 07/06/2023] Open
Abstract
Immunocompromised (IC) populations are at increased risk of vaccine-preventable diseases (VPDs). In India, the concern of VPDs in IC populations is particularly acute due to the prevalence of crowded living situations, poor sanitation and variable access to healthcare services. We present a narrative review of IC-related disease and economic burden, risk of VPDs and vaccination guidelines, based on global and India-specific literature (2000-2022). IC conditions considered were cancer, diabetes mellitus, chronic kidney disease, respiratory disorders, disorders treated with immunosuppressive therapy, and human immune deficiency virus (HIV). The burden of IC populations in India is comparable to the global population, except for cancer and HIV, which have lower prevalence compared with the global average. Regional and socioeconomic inequalities exist in IC prevalence; VPDs add to the burden of IC conditions, especially in lower income strata. Adult vaccination programs could improve health and reduce the economic impact of VPDs in IC populations.
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Affiliation(s)
- Ashok Vaid
- Medical Oncology and Hematology, Medanta Cancer Institute, Gurugram, India
| | - Neha Rastogi
- Pediatric Hematology, Oncology and BMT, Medanta Cancer Institute, Gurugram, India
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Uchil A, Muranjan M, Gogtay NJ. Economic burden of beta-thalassaemia major receiving hypertransfusion therapy at a public hospital in Mumbai. THE NATIONAL MEDICAL JOURNAL OF INDIA 2023; 36:11-16. [PMID: 37615146 DOI: 10.25259/nmji_580_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
Background Treating beta-thalassaemia major may entail high costs with considerable out-of-pocket expenditure. Therefore, determination and valuation of the economic costs of a common haemoglobinopathy such as beta-thalassaemia major in India may provide insights to evolve policies for reduction or elimination of the disease. We estimated economic burden of beta-thalassaemia major in Mumbai in terms of cost to the family and the healthcare system. Methods This single-centre, prospective, cross-sectional, non-interventional study included children <12 years of age treated at the thalassaemia day care centre of a public hospital in Mumbai. The demographic data and treatment-related information was recorded. Cost of illness was studied from a societal perspective by the prevalence-based approach. Direct (medical and non-medical), indirect (loss of wages and loss of school days) and intangible costs (closed-ended iterative bidding) were calculated for each patient by interview. Results The total annual cost of treating 130 children with beta-thalassaemia major in Mumbai was ₹86 72 412 (US$ 127 535) or ₹66 710 (US$ 981) per patient per year and ₹12 82 30 412 (US$ 1 885 741) including intangible costs. Direct costs contributed to 94% of the cost of illness with chelation therapy (23%) and blood investigations (21%) being major contributors. Direct and indirect costs correlated significantly with duration of blood transfusion (p<0.05 and p=0.006, respectively), whereas indirect costs correlated with socioeconomic status (rho=0.25). Conclusion The majority (94%) of costs incurred by families for treatment of beta-thalassaemia major are direct costs, especially expenses for chelation and blood investigations. Even at subsidized rates, financial burden to the families from lower socioeconomic strata is likely to be considerable as these are out-of-pocket expenses. In consideration of the economic impact of treating beta-thalassaemia major in individual families, the healthcare system and society, it is prudent to promote and pursue long-term and short-term measures with urgent emphasis on prevention as a public health activity at the national level in India.
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Affiliation(s)
- Ashwija Uchil
- Department of Paediatrics, Seth GS Medical College and KEM Hospital, Parel, Mumbai 400012, Maharashtra, India
| | - Mamta Muranjan
- Department of Paediatrics, Seth GS Medical College and KEM Hospital, Parel, Mumbai 400012, Maharashtra, India
| | - Nithya J Gogtay
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Parel, Mumbai 400012, Maharashtra, India
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Nakka T, Bhattacherjee A, Krishnamoorthi N, Tumathy DB, Dahagama S, Dubashi B, Ganesan P, Kayal S. Outcomes of Allogeneic Stem Cell Transplant in Chronic Myeloid Leukemia - Blast Phase: A Single-center Experience from South India. Indian J Med Paediatr Oncol 2022. [DOI: 10.1055/s-0042-1743508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AbstractThe blast phase (BP) is challenging to treat and leads to inferior survival in chronic myeloid leukemia (CML). Allogeneic hematopoietic stem cell transplant (AlloSCT) is the only curative option for CML-BP. We are sharing our experience of AlloSCT in seven patients with CML-BP who underwent transplants during the period from January 2017 to December 2019. Three patients each had myeloid-BP, lymphoid-BP, and one patient had mixed phenotypic BP. Donors were matched siblings in four, mismatched siblings in one, and haploidentical in two. All patients received peripheral blood stem cell grafts. The median CD34+ dose was 7.6 (range: 6.6–8.9) × 106 cells/kg. Neutrophil engraftment was observed at a median of 15 (10–20) days and platelet engraftment at 19 days (10–22). At a median follow-up of 24 months, the 2-year leukemia-free survival (LFS) and overall survival (OS) were 43% and 57%, respectively. Transplant-related, non-relapse mortality was observed in three patients. AlloSCT results in promising survival for carefully selected patients of CML-BP, especially with a matched sibling donor.
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Affiliation(s)
- Thejeswar Nakka
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Arnab Bhattacherjee
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Narendran Krishnamoorthi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Divya Bala Tumathy
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sindhu Dahagama
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Smita Kayal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Goel V, Arora P, Malhotra P, Gupta AK. Cost of HSCT in a Tertiary Care Public Sector Hospital in India. Indian J Hematol Blood Transfus 2022; 38:78-83. [PMID: 35125714 PMCID: PMC8804029 DOI: 10.1007/s12288-021-01421-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 02/24/2021] [Indexed: 01/03/2023] Open
Abstract
India harbours a significant burden of hematological diseases including cancers for which Hematopoietic Cell Transplant (HCT) is a definitive life-saving procedure. Very few studies in India have carried out the costing of the important procedure, hence we undertook a study to ascertain the cost of auto HCT in our tertiary care teaching hospital. We did a prospective study using Top-down and Bottom-up approach to arrive at the cost of autologous HCT which came out to be INR 699,200 ($10,282) out of which hospital bears 34% of the cost. The major share of the hospital cost is on account of expenditure on Human Resources. The rest 66% is Out of Pocket Expenditure (OOPE) for the patients. We also calculated the cost which is borne by patient attendants over & above the cost of procedure while caring for the patient, which on an average came to be INR 88,598. This is approximately 19% of the cost borne by the patient for the procedure itself. The cost is usually not factored in while contemplating the procedure and is not covered by any insurance scheme. The overall cost, OOPE & attendant cost can all lead to a substantial financial hardship. Hence, steps need to be taken to make HCT an affordable and accessible procedure.
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Affiliation(s)
- Vinay Goel
- grid.414546.60000 0004 1759 4765Deputy Medical Superintendent, Civil Hospital, Ambala (Cantt), Haryana India
| | - Pankaj Arora
- grid.415131.30000 0004 1767 2903Department of Hospital Administration, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Pankaj Malhotra
- grid.415131.30000 0004 1767 2903Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anil Kumar Gupta
- grid.415131.30000 0004 1767 2903Department of Hospital Administration, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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11
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Colah RB, Seth T. Thalassemia in India. Hemoglobin 2022; 46:20-26. [PMID: 35950587 DOI: 10.1080/03630269.2021.2008958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Management and control of hemoglobinopathies are a challenge in India where 67.0% of people reside in rural regions. The GDP spent on health is one of the lowest (1.3%) resulting in high out-of-pocket expenses. The β-thalassemias are prevalent with an estimated 7500-12000 new births each year. Hb S (HBB: c.20A>T) and Hb E (HBB: c.79G>A) are also common regionally. Over 80 β-thalassemia (β-thal) mutations have been characterized in Indians. The δ gene mutations are increasingly being described and their coinheritance in β-thal carriers leads to a reduction in Hb A2 levels and a misdiagnosis of carriers. Around 15-20 centers offer prenatal diagnosis (PND) mainly in urban regions. The projected annual cost of care of β-thal patients over a decade (2016-2026) will increase from INR30,000 (US$448) million to INR55,000 (US$820) million if all patients are adequately treated. Cost comparisons are difficult to make with other international studies as the standard of care, cost of medicines and other services vary in different countries. Several centers provide hematopoietic stem cell transplants (HSCTs) for thalassemias, however, only around 250 HSCTs are done annually. Although the cost is high, financial assistance is available for a few patients. There are disparities in the quality of care and to address this a National Policy has been proposed for the management and prevention of hemoglobinopathies that will embark on a comprehensive program, providing adequate care and augmenting the existing public health care services. It will also include training, genetic counseling and easier access to preventive options and a National Registry.
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Affiliation(s)
- Roshan B Colah
- Department of Haematogenetics, Indian Council of Medical Research, National Institute of Immunohaematology, King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Tulika Seth
- Department of Haematology, All India Institute of Medical Sciences, New Delhi, India
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12
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Shanbhag SS, Basu S. Commentary: Ocular graft versus host disease: Need for multidisciplinary care. Indian J Ophthalmol 2021; 69:1051. [PMID: 33913830 PMCID: PMC8186641 DOI: 10.4103/ijo.ijo_772_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Swapna S Shanbhag
- The Cornea Institute, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Sayan Basu
- The Cornea Institute; Brien Holden Eye Research Centre (BHERC), L V Prasad Eye Institute, Hyderabad, Telangana, India
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13
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Arora S, Pushpam D, Tiwari A, Choudhary P, Chopra A, Gupta R, Kumar R, Bakhshi S. Allogeneic hematopoietic stem cell transplant in pediatric acute myeloid leukemia: Lessons learnt from a tertiary care center in India. Pediatr Transplant 2021; 25:e13918. [PMID: 33142026 DOI: 10.1111/petr.13918] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/09/2020] [Accepted: 10/18/2020] [Indexed: 01/10/2023]
Abstract
There is paucity of data on outcomes of MSD-HSCT in children with relapsed or high-risk AML from developing countries, which have unique challenges including adverse host factors and resource constraints. We retrospectively reviewed records of children (age ≤ 18 years) who underwent MSD-HSCT for AML at our center from 2009 to 2019 to evaluate clinical outcome and its predictors using Cox proportional hazards model. There were 46 children (36 boys and 10 girls) with mean age 10.7 ± 4.8 years. Indication for HSCT was relapsed AML in CR2 (n = 37), primary refractory (n = 3), or relapsed refractory disease (n = 3); high-risk (n = 1) or secondary (n = 2) AML in CR1. Five-year EFS and OS were 33.3 ± 7.2% and 36.3 ± 7.6%, respectively. On multivariate analysis, CR1 duration less than 12 months, presence of active disease at transplant, and use of bone marrow stem cell graft were associated with poorer EFS and OS. There was one (2.2%) TRM, while disease relapse occurred in 20/40 patients who underwent HSCT in remission. Though the 5-year EFS and OS were inferior to results reported from high-income countries, relapse (and not TRM) was the major cause of treatment failure. A well-sustained CR1, achievement of disease remission, and use of peripheral blood allograft seem imperative to a successful transplant. Targeted therapy along with HSCT may be the option for those with early relapse.
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Affiliation(s)
- Shalabh Arora
- Department of Medical Oncology, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Deepam Pushpam
- Department of Medical Oncology, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Akash Tiwari
- Department of Medical Oncology, Dr. BRAIRCH, AIIMS, New Delhi, India
| | | | - Anita Chopra
- Unit of Laboratory Oncology, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Ritu Gupta
- Unit of Laboratory Oncology, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Rajive Kumar
- Unit of Laboratory Oncology, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Sameer Bakhshi
- Department of Medical Oncology, Dr. BRAIRCH, AIIMS, New Delhi, India
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14
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Batra A, Perumal Kalaiyarasi J, Kannan K, Mehra N, Ganesan P, Karunakaran P, Dhanushkodi M, Selvarajan G, Rajan AK, Kesana S, Ganesan T, Sagar TG, Radhakrishnan V. Haploidentical Hematopoietic Stem Cell Transplantation in Leukemia's: Experience from a Cancer Center in India. Indian J Hematol Blood Transfus 2020; 37:463-471. [PMID: 34267468 DOI: 10.1007/s12288-020-01374-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/23/2020] [Indexed: 12/16/2022] Open
Abstract
There has been a surge in haploidentical hematopoietic stem cell transplantation (HSCT) in India recently. However, there is a paucity of data on haploidentical HSCT from India. The report is an analysis of data of haploidentical HSCT performed at our center. Analysis of patients with acute leukemia or chronic myeloid leukemia who underwent haploidentical HSCT during 2014-2019 was performed. The graft versus host disease (GVHD) prophylaxis was post-transplant Cyclophosphamide with Mycophenolate-mofetil and Cyclosporine. All patients were transfused peripheral blood stem cells from donors. Overall survival (OS) was calculated using the Kaplan-Meier method. Twenty-one patients underwent haploidentical HSCT. Fourteen-patients were males. The median age of patients was 15 years. Fludarabine with total body irradiation was the most common conditioning regimen (n = 15, 71.4%). The median duration for neutrophil and platelet engraftment was 14 days. Cumulative incidence of acute and chronic GVHD was 19%, and 38% respectively. The median follow-up was 26 months and the two-year OS was 38%. Twelve (57%) patients died during the study period, 8 patients (38%) died from transplant-related mortality (TRM), and 4 from disease relapse. Sepsis was the cause of death in six of the eight TRM. Nine out of 21 patients (42.8%) are leukemia-free on follow-up. Haploidentical HSCT is a promising modality of treatment in patients who have no suitable matched donors. Though the TRM remains high, good disease control was achieved in 42.8% of patients. Multi-drug resistant bacterial infection remains a challenge in performing haploidentical HSCT in developing countries.
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Affiliation(s)
- Ankit Batra
- Department of Medical and Pediatric Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu India
| | | | - Krishnarathinam Kannan
- Department of Medical and Pediatric Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu India
| | - Nikita Mehra
- Department of Medical and Pediatric Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu India
| | - Prasanth Ganesan
- Department of Medical and Pediatric Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu India
| | - Parathan Karunakaran
- Department of Medical and Pediatric Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu India
| | - Manikandan Dhanushkodi
- Department of Medical and Pediatric Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu India
| | - Gangothri Selvarajan
- Department of Medical and Pediatric Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu India
| | - Arun Kumar Rajan
- Department of Medical and Pediatric Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu India
| | - Sivasree Kesana
- Department of Medical and Pediatric Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu India
| | - Trivadi Ganesan
- Department of Medical and Pediatric Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu India
| | - Tenali G Sagar
- Department of Medical and Pediatric Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu India
| | - Venkatraman Radhakrishnan
- Department of Medical and Pediatric Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu India
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15
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Mtenga J, Orf K, Zheng J, Chamba C, Chuwa H, Luoga F, Malangahe SW, Iversen PO, Makani J. Haematopoietic stem cell transplantation in Tanzania. Br J Haematol 2020; 192:17-21. [PMID: 32976624 DOI: 10.1111/bjh.17106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 08/20/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Janeth Mtenga
- Department of Haematology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Kate Orf
- Department of Haematology, University College London Hospital, London, UK
| | - Jiexin Zheng
- Department of Haematology, University College London Hospital, London, UK
| | - Clara Chamba
- Department of Haematology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Harrison Chuwa
- Department of Haematology, Aga Khan Hospital, Dar es Salaam, Tanzania
| | - Frederick Luoga
- Department of Haematology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,Sickle Cell Programme, Department of Haematology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Per Ole Iversen
- Department of Haematology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,Department of Haematology, University of Oslo, Oslo, Norway.,Department of Nutrition, University of Oslo, Oslo, Norway
| | - Julie Makani
- Department of Haematology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,Sickle Cell Programme, Department of Haematology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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16
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Garg A, Ganguly S, Vishnubhatla S, Chopra A, Bakhshi S. Outpatient ADE (cytarabine, daunorubicin, and etoposide) is feasible and effective for the first relapse of pediatric acute myeloid leukemia: A prospective, phase II study. Pediatr Blood Cancer 2020; 67:e28404. [PMID: 32672904 DOI: 10.1002/pbc.28404] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 04/26/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Approximately 40% children with acute myeloid leukemia (AML) invariably relapse, after attaining the first complete remission (CR), with dismal long-term outcome. There is little consensus regarding choice of optimal induction chemotherapy regimen for relapsed pediatric AML. PROCEDURE A prospective single arm phase II study (CTRI/2017/02/007757) was carried out at our center to evaluate the safety and efficacy of outpatient cytarabine, daunorubicin, and etoposide (ADE) regimen in pediatric AML (≤18 years) at the first relapse. Response evaluation was done by bone marrow aspiration morphology along with minimal residual disease (MRD) assessment. All adverse events including need and duration of hospitalization, transfusion support, and antimicrobial use were recorded. RESULTS Total 45 patients were included with median age of 12 years. The CR rate of the cohort was 66% and 54% of patients were MRD negative. The estimated 2-year event-free survival (EFS) and overall survival (OS) were 29% (±7%) and 34% (±7%), respectively. The presence of fever at relapse was associated with inferior CR rate (P = .001), positive MRD (P = .01), and inferior EFS (P = .02), while not achieving nadir absolute neutrophil count of zero during induction was associated with inferior CR rate (P = .03) and inferior OS (P = .04). Approximately all patients developed ≥Grade 3 cytopenia and febrile neutropenia. Twenty-six (59%) patients required hospitalization for management of toxicity and there were four (9%) deaths attributed to infection. CONCLUSION ADE is an effective induction regimen for pediatric AML patients at the first relapse with reasonable toxicity profile. Outpatient administration of the regimen is feasible in the presence of proper support structure and rigorous follow up.
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Affiliation(s)
- Arun Garg
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Shuvadeep Ganguly
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | | | - Anita Chopra
- Department of Laboratory Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sameer Bakhshi
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
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17
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Development of a clinical hematology and stem cell transplantation program to provide state-of-the-art and cost-effective treatment to patients: a successful collaboration between a medical college in India and a leading medical university in the United States. Blood Adv 2019; 3:23-26. [PMID: 31809544 DOI: 10.1182/bloodadvances.2019gs121428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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18
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Affiliation(s)
- Reinhold Munker
- Department of Internal Medicine, Division of Hematology & BMT, University of Kentucky, Lexington, KY 40536, USA
| | - Gregory Monohan
- Department of Internal Medicine, Division of Hematology & BMT, University of Kentucky, Lexington, KY 40536, USA
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