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Hepatitis C virus (HCV) is a leading cause of liver damage and has also been implicated in extrahepatic pathologies. We examined for HCV RNA paired CSF and plasma samples from 12 viremia positive patients using PCR. The CSF from 5/5 HIV-infected patients and 5/7 HIV-negative patients were HCV RNA positive. Branched DNA analysis showed that HCV loads in CSF were much lower than in plasma. Several HCV-positive CSF showed no evidence of blood contamination, impaired blood-brain barrier, or intrathecal IgG production. Comparison of HCV quasispecies in three sets of samples suggested that the virus in CSF was of plasma origin.

Over the last few years there has been increased interest in laboratory tests for thrombophilia. Testing is predominantly performed to identify asymptomatic individuals at risk for a first thrombosis or patients (pts) at risk of relapse. The results are not always concordant, and the impact on clinical practice is not yet defined, especially for heterozygous forms. We evaluated heterozygous and homozygous Factor V Leiden (FVL) and prothrombin (FII) mutations and the homozygous C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene in 98 pts with venous thrombosis distinguishing idiopathic forms from forms that are secondary to malignancy, surgery, forced immobilization or hormone treatments. FII mutation was present in 17% of idiopathic and 5.8% of secondary forms. FVL mutation was present in respectively 17% and 15.8% and MTHFR homozygous state in 31.9% and 21.5%. At least one of FII or FVL mutations was present respectively in 31.9% and 19%, at least one of the three mutations examined was present in 57.4% and 36.2%. In pts with limb venous thrombosis (n-64), the percentages for each mutation are respectively: FII-23.5% and 6.6%, FVL-20.5% and 6.6%, MTHFR 35.2% and 16.6% .At least one mutation between FII and FVL is present respectively in 42.1% and 13.3% (P = 0,028) while at least one of the three mutations is present in 61.7% and 30.5% (P = 0,022) In our pts with pulmonary thromboembolism (n-36) FII mutation was absent while FVL mutation was present in 7.6% of idiopathic and 21.7% of the secondary thrombosis, MTHFR in 30.7% and in 30.4%. At least one of the three examined mutations was present in 38.4% and 47.8%. The mutations we have studied are generally more frequent in idiopathic forms. The difference reaches statistical significance in limb venous thrombosis where they seem to have a significant relevance, although in a heterozygous state, and to promote thrombosis even in absence of other causes. In pulmonary thromboembolism (PTE) pts FII mutation was absent, FVL mutation is less frequent in pts with idiopathic thrombosis and MTHFR homozygous state is equivalent between the two subgroups. Thus, they seem to not influence PTE pathogenesis that would be likely sought in different causes. Disclosures: No relevant conflicts of interest to declare.

Chronic Graft versus Host Disease (cGvHD) is still the leading cause of late mortality in transplanted patients. Among the new drugs potentially useful in patients with steroid-refractory cGVHD (SR-cGVHD), the Tyrosine Kinase Inhibitor (TKI) Imatinib emerged as promising agent; however in our previous experiences, patient's frailty and their reduced haematological tolerance heavily limited the daily dose of Imatinib (median dose administered was 200 mg/day). Thus we planned to evaluate in the same setting a the safety and activity of a second generation TKI, such as Nilotinib (NIL), characterized by a better haematological tolerance and that could allow to treat SR-cGVHD patients with a higher relative dosage than Imatinib, thus achieving a better efficacy. Basing on this rational we designed a phase I-II study, aimed to individuate the maximum tolerated dose ( MTD) and the activity of NIL in patients with SR-cGVHD (ClinicalTrials.gov ID: [NCT01810718][1]). Primary endpoint of the phase I study was to define the dose limiting toxicity (DLT) of NIL, defined as the occurrence of any grade≥3 toxicity during at least one month of treatment. According to the Fibonacci standard 3+3 design, we started from an initial dose of 200 mg/day of NIL, up to a maximum of 600 mg/day. The drug has been supplied free of charge by Novartis Italia, Milan. In the phase II the MTD will be used to define the efficacy of NIL in SR-cGVHD patients, with similar characteristics of the previously Imatinib-treated population. Moreover all the patients enrolled in the phase I were allowed to continue NIL at the same dose, up to a cGVHD progression, if an objective improvement (OI) was documented after 3 months of treatment. We report here the preliminary results of a pre-planned interim analysis, during the phase I study, in 12 patients with SR-cGVHD who received NIL at low dose. The main characteristics of the enrolled patients are reported in table 1. Six patients received NIL 200mg/day and 6 NIL 300 mg/day. Two patients stopped NIL within 30 days: one due to cGVHD progression, the other had asymptomatic hypertransaminasemia (>5xULN) which normalized 1 month after stopping NIL; these patients received an alternative treatment. In 3 cases severe adverse events (SAE) have been reported: 1 patient had extramedullary relapse of Acute Leukemia 8 months after start of NIL, while 2 patients have been hospitalized; one due to a transient cGVHD flare, without drug interruption, the second for a late cGVHD progression; he eventually died. The most frequent extrahematological toxicities (grade 1-2 according to CTCAE) were headache, nausea, pruritus, cramps, asthenia, constipation, while the main hematological abnormalities were represented by anemia grade 1 (5/12patients), neutropenia gr.1 (1/12 patients) and lymphocyte count increase gr.2 (1/12 patients). (tab.2) With a median F-U of 10 months (range 4-20), 10 patients are alive, while two died for cGVHD progression (7 and 9 months after the enrollment). After 3 months of treatment with NIL 6 patients (50%) achieved an OI and 4 (33%) a stable disease; all the 10 patients continued Nilotinib at the same dose until ≥6 months of treatment: after 6 months we observed 5 OI, 1 stable disease and 2 mixed responses (2 lung responses with skin failure), while in 2 the response evaluation is still ongoing. These preliminary data suggest that, like Imatinib, NIL at low doses is safe and effective in SR-cGVHD patients; up to day the MTD has not been still achieved, therefore only after the end of the phase I study we will be able to fully define the NIL activity. This study is supported by GITMO (Gruppo Italiano Trapianto di Midollo Osseo). View this table: View this table: Disclosures: Off Label Use: Bendamustine. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01810718&atom=%2Fbloodjournal%2F122%2F21%2F4608.atom

Monoclonal gammopathy of undetermined significance (MGUS) occurs in 3% of people older than 50 years and up to 10% in those older than 70; it is associated with a 1%/year risk of progression to Multiple Myeloma (MM). In recent years there have been improvements in risk stratification models (involving molecular markers) of this disorder, which have led to better understanding of the biology and probability of progression of MGUS. In the context of numerous molecular events and heterogeneous risk of progression, developing individualized risk profiles for patients with MGUS represents an ongoing challenge that has to be addressed by prospective clinical monitoring and extensive correlative science. Free Lights Chains (FLC) ratio, plasma cells immunophenotype and DNA aneuplody are now important parameters of progression, in addition to the already known prognostic factors (immunoparesis, type and amount of the monoclonal component (MC). Recent data report immunoparesis and a skewed FLC ratio in 25% and 30%, respectively, of patients (pts) at diagnosis. In this study we evaluated the incidence of these two parameters in a cohort of 114 pts with MGUS, if they are associated and if their incidence is influenced by other parameters (time from diagnosis, type of Immunoglobulin (Ig) and/or light chains). The patients screened were 56 males and 58 females with a median age of 67 years (45-91). Median time from diagnosis to the time of observation was 3 years (0-21). The MC was IgA in 13 pts, IgG in 88, IgM in 13; 74 had a clonal Kappa (K) and 40 a lambda (L) light chain. K/L ratio was abnormal in 57 pts (50%). Immunoparesis was present in 60 pts (52,6%): 22 with a normal K/L ratio (38,5%) and 38 with an abnormal K/L ratio (66,6%) (p-0.004). In 18 pts two classes of Ig were involved. An association between the two parameters occurred in 39 pts (34,2%); it was more frequent in IgA MGUS (61,5%) than in IgG (31,8%) and IgM (23%); we did not observe any differences about immunoparesis between K MGUS (33,7%) and L MGUS (32,5%). The association between a skewed K/L ratio and immunoparesis was present in 25.4% of pts with time from diagnosis of less than 3 years and in 48,8% of pts with a longer time from diagnosis (p-0.04). Our new data confirm that immunoparesis is more frequent in pts with an abnormal K/L ratio. The association seems to be more frequent in case of IgA gammopathy; there are no differences between the two types of light chain. Our data also confirm that the longer is the time elapsed from diagnosis, the higher are the frequency of an abnormal K/L ratio and the incidence of immunoparesis, with a greater probability of association. We need still a larger number of pts with an adequate follow up to evaluate if the association between immunoparesis and abnormal K/L ratio has a prognostic value, although the higher frequency of association in the subset of pts with a longer time from diagnosis seems to contradict this hypothesis. Disclosures: No relevant conflicts of interest to declare.

SummaryAmong HIV patients treated for AIDS-related adjustment, major depressive disorders and other affective disorders, we assessed in an open study the feasibility of using a serotonergic antidepressant (fluvoxamine). Thirty-five seropositive patients with the above conditions (22 men and 13 women) were followed over a minimum period of four weeks. At the end of the treatment, a large number of patients (77%) showed marked improvement. “Nuclear” depressive and anxiety symptoms remitted, while the “somatic” ones seemed less sensitive to treatment. Treatment had to be terminated prematurely due to side effects in only two patients (6%).

Abstract 4523 Autologous Stem Cell Transplantation (ASCT) is still an option for eligible patients with Multiple Myeloma (MM). High-dose melphalan (HDM: 200mg/m∧2) is the recommended conditioning before ASCT, but synergistic effects of Bortezomib (BOR) and HDM have been reported in vitro and in vivo. PATIENTS AND METHODS: We evaluated in 56 MM fit elderly patients (median age 65 yrs), the feasibility and efficacy (also in terms of evaluation of minimal residual disease: MRD) of a strategy, combining BOR, Cyclophosfamide (CY) and dexamethasone (DEX) as induction and mobilizing therapy (CY-BOR), for ASCT, with conditioning including BOR-HD-MEL. The patients achieving at least PR after 4 CY-BOR courses, were mobilized with BOR and DEX standard schedule with CY 3g/m∧2 (day 8). The pts collecting at least 2.5×10∧6CD34+/kg underwent ASCT with HD-MEL (day-1) and BOR (1.0mg/m∧2 on -6,-3,+1,+4), followed by thalidomide consolidation until Relapse/Progression. The MRD has been prospectively evaluated both by using 4 colour flow cytometry (FC), and by using patient-specific probes, by ASO-PCR. The percentage of plasma cells (PCs) has been evaluated both in in PBSC harvested and in bone marrow, with CD38, CD45, CD56, CD138, CD19, CD27, CD28, CD117, kappa and lambda, along different steps of therapy. RESULTS: Of 44 pts evaluable for response before ASCT, 32 (73%) achieved 3PR and 30 (68%) were mobilized: 29 (66%) collected3 2.5×106CD34+/kg and 25 underwent ASCT. Median time for PMN engraftment was 11 days (range 10–13) and 14 (range12–20) for PLT>=20.000/mcl. We observed grade 3 neuropathy in 3 patients and pneumonia during induction in 2 patients. At day +180 from ASCT 23 are evaluable for response and 21 for MRD: 3 pts have progressive disease (PD), 2 pts have a PR, 4 pts have a VGPR, 10 pts a nCR and 4 pts a CR. Four colour FC, in order to detect clonal plasmacells (cPCs) along several steps of treatment, showed that 3 pts (14%) achieved MRD negativity: 1/21 pts achieved MRD negativity at day +180 (cPC CONCLUSIONS: ASCT with HDM and BOR is feasible in older patients, with very high RRs and without major toxicities. We need a longer follow up and a larger number of pts to assess if these results will translate in a benefit in terms of outcome. Disclosures: Fragasso: Mundipharma: Honoraria.

We evaluated in an open trial the safety and effectiveness of a high-potency neuroleptic (bromperidol) for the treatment of AIDS-related organic mental syndromes. Eleven (nine men and two women) seropositive patients with psychotic features were included; six were intravenous drug users (IVDU) and five were not IVDU (NON-IVDU). On the basis of the achievement of a CGI score of 1 or 2 (much improved or very much improved) at the fourth week, nine patients were considered responders, one was a partial responder and one was a non-responder. From a clinical point of view, "positive" psychotic symptoms had a significant remission, while the "negative" ones seemed to be less sensitive or insensitive to bromperidol treatment.

Abstract 4394 Therapy-related acute myeloid leukemia (AML) and myelodysplastic syndrome (t-AML/MDS) are common after alkylating agents. t-AML/MDS related to alkylating agents are associated with monosomies or deletions of the long arm of chromosomes 5 and 7. Among patients with chronic lymphocytic leukemia (CLL), the potential for disease transformation to diffuse aggressive non-Hodgkin's lymphoma (Richter's syndrome) or the evolution to prolymphocytic leukemia is well known. However, the development of therapy related myelodysplastic syndrome (t-MDS) or t-AML is uncommon. In most trials, an incidence rate of 1% has been reported. We describe here a patient who developed t-AML twentyone years after treatment with chlorambucil and fludarabine for CLL, carrying a typical CLL-associated Chromosomal abnormality (CA), associated with a typical AML-related CA. In 1988 a 42-year-old man was found to have B-cell CLL (Binet stage B). Examination of the marrow showed infiltration by small lymphoid cells that expressed CD5, CD19, CD23, and weak surface immunoglobulin with lambda light chain restriction. The residual hematopoiesis was otherwise normal in morphology. During subsequent years he received courses of therapy with chlorambucil and fludarabine which resulted in partial remission. In June 2009 he developed pancytopenia (WBC 11.4×10e9/L, PMN 0.1×10e9/L, Hgb 7.7g/dL, PLT 26×10e9/L). Physical examination showed small, diffuse lymphadenopaties and splenomegaly. Peripheral blood film examination and immunophenotype were consistent with diagnosis of CLL. Bone marrow examination showed trilineage myelodisplasia with 25% blasts and 62% lymphocytes that expressed CD5, CD19, CD23 and sIg lambda, confirming the diagnosis of concurrent AML with multilineage dysplasia and CLL. Cytogenetic analysis showed a hyperdiploid karyotype with a number of chromosomes comprised between 47 and 55. FISH analysis of bone marrow showed del 5q in 50% of nuclei and biallelic deletion of 13q14 in 70% of nuclei. FISH analysis on peripheral blood confirmed deletion 13q14 in 80% of nuclei, and del 5q in 10% of nuclei; trisomy of 18 in 50% of nuclei was also present. Although patients with CLL have an increased risk for the development of second malignancies, solid tumors are most common. With regard to second hematologic malignancies, the risk of multiple myeloma in patients with CLL is increased 10-fold over the incidence of myeloma in the general population. However, AML develops in 1% or fewer of patients with CLL, despite the frequent and long-term use of alkylating agents for therapy, the older age of many of these patients, and their relatively long survival with this disease process. In a retrospective review by Robertson et al of 1,374 CLL patients who received care at the M.D. Anderson Cancer Center from 1972 to 1992, only three cases of MDS or AML were found. Seventy-two percent of these patients had received prior alkylator therapy. Anecdotal cases of myelodysplasia or AML occurring in untreated patients with CLL have been reported, as have cases of concomitant diagnoses of CLL and AML, although these are quite uncommon. These cases of secondary leukemia were generally refractory to therapy, with a median survival after diagnosis of approximately 1 month. Lenalidomide (Revlimid) is an immunomodulatory drug that yields a high frequency of erythroid, pathologic, and cytogenetic response in patients with myelodysplastic syndromes (MDS) with an interstitial deletion of the long arm of chromosome 5 (del 5q). Responses of AML with del 5q are also reported. Whether both the diseases will respond to this drug it is matter to prospectively investigate in these cases. Disclosures: No relevant conflicts of interest to declare.

A retrospective analysis of renal vein renin results has been done in 96 patients with renal artery stenosis and hypertension studied in two Italian centers (Sassari and Pisa) with respect to the outcome of either surgery or percutaneous transluminal angioplasty (PTA). In all patients the renal vein renin ratio and the V-A/A ratios for the affected and unaffected kidney were calculated. Each patient underwent surgery (75) of PTA (21): 71 subjects were cured, 17 improved whereas the arterial pressure did not vary after revascularisation procedure in 8 patients. In the Pisa series all 54 patients showed a lateralisation with contralateral renin suppression and 95% of them benefitted from surgery. In the Sassari series 42 patients were submitted to PTA or surgery, not only on the basis of a positive renal vein renin study but taking into account a complete clinical evaluation: 8 of them were cured or improved in spite of negative renal vein renin criteria. In the two series, the better predictive index appeared to be the suppression of the renin secretion from the contralateral kidney while the high/low renin ratio showed a consistent amount of false-positive and false-negative results. Our retrospective study demonstrates that the renal vein test in hypertensive patients with renal artery stenosis is highly predictive of the curability of the disease, particularly when contralateral suppression of renin secretion is present. On the other hand, since patients with negative renin indexes can also take benefit from surgery of PTA, the renin parameters cannot be adopted as the sole criterion in making the decision to operate.

We evaluated the acute blood pressure lowering effect of enalapril in terms of dose-response curve and compared this effect with that on humoral parameters. Eleven renovascular patients with acute angiotensin-converting enzyme (ACE) inhibition received (according to a randomized double-blind cross-over design) placebo, 10, 20, and 40 mg of enalapril with a 72-hour interval between each dose. Seated blood pressure and heart rate were measured every hour for 6 hours and then again at the twelfth and twenty-fourth hour, while venous blood samples for plasma renin activity, plasma aldosterone and serum ACE measurements were obtained at the fourth and twenty-fourth hour after receiving the placebo or drug. Blood pressure was significantly reduced by all three doses of enalapril at hour 4, while at hour 24 it was reduced only by the 20- and 40-mg doses. A significant correlation (r = 0.68; P less than 0.001) was found between percentage decrements of mean blood pressure and the log of the doses at hour 4 with a similar (although not significant) trend at hour 24. Plasma renin activity was significantly and to a similar extent increased by the three doses of enalapril at hour 4, while at hour 24 it was significantly increased only by the 40-mg dose. Serum ACE and plasma aldosterone were significantly reduced both at hours 4 and 24 without any difference between doses. No correlation was found between mean blood pressure changes and those of humoral factors.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiotensin-converting enzyme (ACE) inhibitors are a new class of drugs, whose main indications are the treatment of hypertension and of heart failure. Data obtained with captopril, the first orally active ACE inhibitor, affords an understanding of the rationale of their therapeutic use based on the knowledge of their mechanisms of action, efficacy, contraindications and precautions, dosage and frequency of administration, side-effects, interactions and advantages. ACE inhibitors appear to exert their haemodynamic effect mainly by inhibiting the renin-angiotensin-aldosterone system, but also by modulating sympathetic nervous system activity and by increasing prostaglandin synthesis. Therefore they act both on vasoconstrictor and volume factors, since they cause vasodilation (the main effect) and mild natriuresis without affecting the heart rate and contractility and, probably, favourably influencing renal, coronary and cerebral circulation. So far it appears that ACE inhibitors can be usefully employed in the treatment of heart failure, in which they reduce both pre- and after-load, and mainly of hypertension. In the past captopril has been used to treat only severe and or resistant hypertension and some secondary forms, like renal parenchymal and renovascular hypertension, but now it seems that captopril is useful also to treat mild to moderate essential hypertension. Their efficacy in reducing blood pressure is similar to that of thiazide diuretics and of beta-blockers, the two drugs now considered of first choice and they exert their hypotensive action without the development of pseudotolerance or tolerance. ACE inhibitors seem, at the moment, contraindicated in pregnancy and in hyperkalaemic syndromes and must be used with caution in patients with collagen disease (mainly associated with renal failure), with severe bilateral renal artery stenosis (and with severe artery stenosis of a solitary kidney) and with severe sodium depletion. It is now established that captopril has a flat dose response curve and that it must be given (twice daily) at a dose not exceeding 150 mg/day. The same pharmacological approach must be used with future ACE inhibitors in order to establish the right posology and the frequency of administration. In this respect enalapril seems to be a promising ACE inhibitor with a prolonged action (at least 24 hours). The exact posology of ACE inhibitors might be crucial, since it has been shown that the side-effects of captopril (skin rashes, fever, taste disturbances, proteinuria and neutropenia) are dose dependent.(ABSTRACT TRUNCATED AT 400 WORDS)

To test the hypothesis that acute angiotensin-converting enzyme (ACE) inhibition might predict the postoperative blood pressure outcome, a single oral dose of captopril ranging from 12.5 to 100 mg, was given to 26 patients with renovascular disease and its hypotensive effect was compared with that of surgery (21 patients) or of percutaneous transluminal angioplasty (PTA) (5 patients). Both systolic and diastolic blood pressure fell significantly (p less than 0.001) from 179.9 +/- 5.4/114.1 +/- 2.1 to 148.4 +/- 3.8/94.1 +/- 1.9 after captopril and to 141.1 +/- 3.7/88.9 +/- 2.0 at least 3 months after operation. Postoperative pressure values were directly related to those after captopril (SBP: r = 0.65, p less than 0.001; DBP: r = 0.45, p less than 0.05) as were their absolute decrements (SBP: r = 0.70, p less than 0.001; DBP: r = 0.64, p less than 0.001). However, after captopril, individual pressure tended to be higher (and their decrements to be lower) than after operation. 12 out of 19 patients cured by surgery were considered cured by captopril, while 5 out of the remaining 7 were improved and 2 not cured. The 6 patients improved by surgery or PTA were also improved by captopril and the only patient not cured by surgery was not cured by captopril. Therefore, if we consider both cure and improvement as a positive result, the captopril test gave 23 true-positive, 1 true-negative and 2 false-negative responses. Taken together, these data suggest that acute ACE inhibition may be an useful tool in predicting postoperative blood pressure of patients with renovascular disease.