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BACKGROUND: Patients with chronic liver disease (CLD) often present with an elevated International Normalized Ratio (INR). Although elevated INR reflects a higher risk of hemorrhage among warfarin users, its clinical significance in CLD patients is less clear. OBJECTIVES: We used Veterans Health Administration data to quantify the association between INR and (non-variceal) hemorrhage in patients with CLD as compared to warfarin users. METHODS: We performed a multivariate competing risk analysis to study the association between INR and hemorrhage in the two cohorts. We used an interaction term between INR and cohort (CLD/warfarin users) to test if INR had different effects on hemorrhage in the two cohorts. RESULTS: Data from 80,134 patients (14,412 with CLD and 65,722 taking warfarin) were analyzed. The effect of INR on the risk of hemorrhage differed between CLD patients and warfarin users (interaction p3.0–3.5, and 4.70 with INR > 3.5). CONCLUSIONS: The relationship between INR and risk of hemorrhage in CLD patients is different from that in warfarin users. Caution should be exercised extrapolating data from warfarin users to make clinical decisions in CLD patients.

Background We studied the effect of statins on mortality in a nationally representative sample of patients with multiple myeloma, and explored the benefit of statins in a subgroup of patients treated with novel agents. Methods Patients diagnosed with multiple myeloma between 2007 and 2013 were identified in the SEER-Medicare database using International Classification of Diseases (ICD)-03 codes. ICD-9 and Healthcare Common Procedure Coding System codes were used to identify comorbidities and treatments. We assessed the association of statins with mortality in patients with multiple myeloma using multivariate Cox proportional hazards regression analysis. For subanalysis, we used the same statistical technique to investigate the effect of statins on mortality in myeloma patients treated with novel agents. Results A total of 5922 patients were diagnosed with multiple myeloma within the study period. Use of statins was associated with 21% reduction in risk of death (adjusted hazard ratio [aHR] 0.79; 95% confidence interval [CI] 0.74-0.84) among all patients with multiple myeloma. Among the patents treated with novel agents (n = 3603), statins reduced mortality by 10% (aHR = 0.90, 95% CI 0.83-0.98). Conclusions Use of statins is likely associated with lower mortality in patients with multiple myeloma.

Background Two extracorporeal photopheresis (ECP) instruments, the CELLEX and the UVARXTS are currently being used "off-label" in the US for treatment of graft versus host disease (GVHD). Our study compared the performance of the two instruments in the setting of acute and chronic GVHD. Study design and methods We retrospectively analyzed the outcomes of patients with steroid refractory or steroid resistant GVHD undergoing ECP at Barnes Jewish Hospital. Multivariate logistic regression was used to evaluate the comparative efficacy of the two instruments with respect to steroid dose reduction (≥50% from baseline) and clinical improvement in GVHD. Chi-square/Fisher exact tests were used to compare the incidence of adverse events, while multivariate Cox regression was employed to assess a potential difference in mortality between the two instrument treatment cohorts. Results After adjusting for potential confounders, there was no significant difference in the odds of steroid dose reduction (OR = 1.41, 95% confidence interval [CI]: 0.51-3.90, p = 0.50) or clinical improvement (OR 2.0, 95% CI: 0.63-6.41, p = 0.24) between the two instrument treatment cohorts. The frequency of adverse events (CELLEX 45.4%; UVAR XTS 40.5%, p = 0.55) was also comparable between the cohorts. There was no significant difference in mortality of either acute or chronic GVHD patients when treated by the CELLEX as compared to the UVAR-XTS (aHR 0.66, 95% CI: 0.35-1.25, p = 0.20). Conclusion The efficacy and safety of the two ECP instruments, the CELLEX and the UVAR-XTS, are comparable for the treatment of acute and chronic GVHD.

e18762 Background: Prognostication of patients with myelodysplastic syndromes (MDS) using IPSS-R is not possible in administrative database analysis. In 2014, a claims-based prognostic scoring system, the SEER-Medicare MDS Risk Score (SMMRS) was developed to risk-stratify MDS patients for overall survival using ICD9 codes {Uno, 2014}. In 2015, ICD9 codes were replaced by ICD10 codes. In this study, we updated SMMRS with inclusion of both ICD-9 and -10 codes, and studied its predictive value for overall survival, leukemia-free survival and initiation of treatment among MDS patients. Methods: Patients with MDS were identified through ICD-O-03 codes in the SEER-Medicare database between 2007 and 2017. SMMRS was calculated using MDS subtype, age, comorbidities, cytopenias, transfusion-dependence, and recent hospital admissions. We analyzed the association of SMMRS with overall survival, leukemia-free survival (time from MDS diagnosis to leukemia), and initiation of treatment (hypomethylating agents /stem cell transplant) in Cox proportional hazards models while adjusting for potential confounders. Results: Patients with MDS (N = 12,710) had a median age of 80 years, half were males, and most were Caucasians. SMMRS stratified patients into low-risk (n = 3155), intermediate-1 risk (n = 3255), intermediate-2 risk (n = 3121), and-high risk (n = 3209) categories at diagnosis. The overall survival, leukemia-free survival and treatment initiation for patients in each SMMRS category is summarized in Table. The 5-year overall survival for the entire cohort was 20%. At 5 years, 10% of the MDS patients had transformed to leukemia, and 1/3rd had started MDS treatment. Conclusions: SMMRS based on ICD-9 and -10 codes predicts overall survival, leukemia-free survival and MDS treatment initiation by stratifying MDS patients into 4 risk-categories. It can be utilized to design/analyze future observational studies.[Table: see text]

e19063 Background: Statins can inhibit cholesterol synthesis through inhibition of mevalonic acid synthesis, and reduce prenylation of proteins involved in tumor growth. Their anti-neoplastic potential has been explored for many malignancies (e.g., multiple myeloma) with improvement in progression free- and overall- survival. Preclinical data support anti-neoplastic activity of statins for myeloid malignancies. In this study, we examined the effect of statins on mortality of patients with myelodysplastic syndromes (MDS) in this nationwide retrospective cohort study. Methods: We identified patients diagnosed with MDS through ICD-O-03 codes in the SEER-Medicare database between 2007 and 2017. Statins users were required to have at least one claim for a statin prescription within 6 months prior to MDS diagnosis. Propensity score matching was done to identify non-statin users with a similar cardiovascular risk profile. We analyzed the effect of statins on mortality (from any cause) in a Cox proportional hazards model that adjusted for demographics, SEER-Medicare MDS Risk Score ( SMMRS comprises of age, comorbidities, MDS histological subtype, cytopenias, transfusion-dependence and hospital admissions), treatments for lower risk MDS (growth factors or lenalidomide), and higher risk MDS (hypomethylating agents/stem cell transplant). Results: Our cohort of 6878 MDS patients (3439 statin users and 3439 non-statin users) had a median age of 80 years at diagnosis, and most were Caucasians. Non-statin users were more likely to have higher risk MDS (by SMMRS) at diagnosis. Statins users had a 33% {95% Confidence Interval (CI) 25%-40%; p

Background In multiple myeloma, venous thromboembolism (VTE) is common, and treatments for myeloma, such as lenalidomide, increase the risk of thrombosis while improving survival. The association between VTE and survival is not well known. Objectives To determine the association between VTE and survival in multiple myeloma (MM) while adjusting for known confounders that affect risk of thrombosis and survival, including patient characteristics and treatment in a retrospective cohort of US veterans. Patients/Methods A cohort of patients with newly diagnosed MM treated within Veterans Health Administration between September 1, 1999, and June 30, 2014, was created to assess the association between VTE and mortality using Cox proportional hazards regression modeling while accounting for known prognostic factors and treatments. Results The cohort comprised 4446 patients with myeloma, including 2837 patients diagnosed after lenalidomide approval in July 2006. VTE occurred in 327 (7.4%) patients within 1 year and occurred at a median of 77 days (interquartile range, 37‐153) after starting therapy for MM. In all patients, VTE was associated with increased mortality at 6 months (adjusted hazard ratio [aHR], 1.67; 95% confidence interval [CI], 1.18‐2.37). Patients in the post‐lenalidomide cohort with VTE had an increased mortality at both 6 months (aHR, 2.31; 95% CI, 1.52‐3.51) and 12 months (aHR, 1.66; 95% CI, 1.19‐2.33) after treatment initiation. Discussion This study shows that VTE during the first 6‐12 months of therapy is associated with increased mortality in patients with MM. Studies evaluating thromboprophylaxis in patients at high risk of thrombosis are needed.

Background: Elevated INR values are common among patients with chronic liver disease (CLD), and signify a decrease in the synthesis of clotting factors II, V, VII, IX and X. Preclinical evidence suggests that the decrease in these factors is balanced by a decrease in anticoagulant factors (e.g. antithrombin, protein C) and an increase in factor VIII {Tripodi 2009, Tipodi 2010}, establishing a rebalanced hemostasis in CLD {Tripodi 2011}. The proposed rebalanced hemostasis has been observed in vitro by rate of thrombin generation being similar to that of individuals with normal hepatic function {Tripodi 2005, Tripodi 2006}. There is however, a lack of in vivo data supporting rebalanced hemostasis in CLD patients. Whether an elevated INR protects against thrombosis among these patients is therefore controversial. We studied the INR-specific rate of non-portal venous thromboembolism (VTE) in a large cohort of United States Veterans with CLD. Methods: Study Population: We identified patients diagnosed with CLD in the Veterans Health Administration database between January 2001 and December 2016 using International Classification of Diseases (ICD) 9/10 codes. To improve the positive predictive value of CLD diagnosis, we followed a previously validated algorithm where patients were required to have an additional ICD9/10 code for one of the common clinical presentations of CLD (e.g., esophageal varices). We identified a control cohort of patients with atrial fibrillation using ICD9/10 codes that had a prescription for warfarin for at least 30 days. Patients with artificial valves, history of VTE within 5 years prior to diagnosis and malignancy were excluded from both cohorts. Patients on warfarin were excluded from the CLD cohort, and those on other anticoagulants were excluded from the control cohort unless anticoagulation was started after a thrombotic event. Patients were followed retrospectively until December 2016. Measurement of Outcomes: Non-portal VTE was identified using ICD9/10 codes plus the presence of a current procedural terminology code for relevant diagnostic imaging (e.g. Doppler ultrasound or computerized tomography scan). Statistical Analysis: To account for the competing risk of non-VTE related death, we analyzed the association between INR and non-portal VTE in a competing risk analysis by the methods of Fine and Gray. For atrial fibrillation patients with newly prescribed warfarin, time 0 started 15-days after their 1st warfarin prescription. For patients with CLD, time 0 was the time of first INR measurement, at least 15 days after CLD diagnosis. We used the natural logarithm of INR as a time-dependent continuous variable in the analysis, and adjusted for the following confounders: age, gender, race, body mass index (BMI), concomitant antiplatelet therapy, surgery, fracture, trauma, presence of central venous line, estimated glomerular filtration rate (GFR), and Charlson comorbidity index (excluding liver disease and chronic kidney disease). The primary test of our hypothesis (that INR values had a different risk among patients with CLD than warfarin users) was an interaction term between CLD (Yes/No) and INR. Results: A total of 15,930 patients with CLD, and 81,415 atrial fibrillation patients on warfarin were included in the study. During the 12-month follow-up, 164 CLD patients and 1,347 warfarin users developed VTE. African American race, low serum albumin, low eGFR, central-line placement, surgery, fracture and trauma increased the risk of VTE. The interaction between INR and CLD was significant (p < 0.01) i.e., the effect of INR values on the incidence of VTE differed between CLD patients and warfarin users. Each unit-increase in INR decreased the risk of VTE in warfarin users by 33% [adjusted hazards ratio (aHR)= 0.67 , 95% Confidence Interval (CI)=0.56 to 0.80]); it however, did not affect the risk of VTE in CLD patients (aHR=1.45, 95% CI=0.82 to 2.59) Conclusion: In this study of 97,345 Veterans, elevated INR values did not decrease the risk of VTE in CLD patients. Thus, healthcare providers should not rely solely on INR values to inform decisions regarding primary and secondary thromboprophylaxis in this patient population. Disclosures Sanfilippo: Bayer HealthCare Pharamceuticals: Membership on an entity's Board of Directors or advisory committees; AstraZeneca: Other: Travel Support for Investigator Meeting; Pfizer: Membership on an entity's Board of Directors or advisory committees; Covington & Burling LLP: Consultancy; Luther & Associates: Consultancy; Health Services Advisory Group: Consultancy; Amgen: Other: Trasfer of Value (food) during discussion of research.

Introduction Pancreatic cancer is a thrombogenic malignancy with nearly half of venous thrombotic events occurring in the splanchnic circulation. The effect of splanchnic vein thrombosis on mortality in pancreatic cancer is unknown. We studied the effect of splanchnic vein thrombosis on mortality in veterans with advanced pancreatic adenocarcinoma, and explored the association of anticoagulant therapy on mortality and hemorrhage. Methods Using International Classification of Diseases (ICD) codes, we identified eligible patients and outcomes in the Veterans Health Administration database. Using Cox proportional hazards regression, we analyzed the association between splanchnic vein thrombosis and mortality among patients with advanced pancreatic cancer. We used propensity score inverse probability-of-treatment weighting to balance the groups who did and did not receive anticoagulation. To understand the role of anticoagulant therapy, we used Cox proportional hazards regression to analyze mortality and competing risk analysis to assess the risk of hemorrhage. Results Of the patients with advanced pancreatic cancer (N = 6164), 122 developed splanchnic vein thrombosis. Splanchnic vein thrombosis was associated with a two-fold increase in mortality, aHR 2.02, 95% CI 1.65–2.47. The finding held true after restricting the analysis to patients undergoing treatment for pancreatic cancer, and after adjusting for immortal time bias by a 30-day landmark analysis. Anticoagulant therapy did not affect mortality (aHR 0.99, 95% CI 0.65–1.51), and increased the risk of hemorrhage (aHR 2.7, 95% CI 1.02–7.07). Conclusion Splanchnic vein thrombosis predicts worse survival in patients with advanced pancreatic adenocarcinoma. Anticoagulant therapy may not mitigate this increased mortality, and increases the risk of hemorrhage.

Hematopoietic stem and progenitor cells (HSPCs) can acquire age-dependent somatic mutations that result in clonal expansion, a process termed clonal hematopoiesis, presumably as a consequence of a competitive fitness advantage in the setting of an aging HSPC pool. Genetic analyses of large population cohorts have demonstrated consistently that clonal hematopoiesis is detectable in the blood of subjects without a clinically apparent myeloid neoplasm. The prevalence of clonal hematopoiesis increases with age and genes that are commonly mutated in clonal hematopoiesis and are also recurrently mutated in myeloid malignancies. The presence of clonal hematopoiesis is associated with an increased risk of developing a hematologic malignancy, increased risk of cardiovascular disease, and a higher all-cause mortality rate. However, only a fraction of individuals with age-dependent clonal hematopoiesis develop a myeloid malignancy; thus, the term “clonal hematopoiesis of indeterminate potential” (CHIP) has been suggested to describe the acquisition of somatic mutations associated with clonal expansion without evidence of hematologic disease. Mutations in the epigenetic modifiers DNMT3A, TET2, and ASXL1 account for the majority of age-dependent clonal hematopoiesis. Individuals with clonal hematopoiesis and the presence of a cytopenia are at a particularly increased risk of developing a subsequent hematologic malignancy. However, the size of a CHIP clone can remain stable over time, and most individuals harboring mutations do not progress to a myeloid neoplasm. This suggests that clonal evolution through the acquisition of cooperating mutations and/or selection of mutant HSPCs by stressors that promote the expansion of cells with a fitness advantage is required for progression. Clonal hematopoiesis can occur after treatment with cytotoxic chemotherapy and is associated with TP53 mutations and an increased risk of developing a therapy-related myeloid neoplasm. Future studies of the natural history of CHIP and strategies to identify at-risk individuals, coupled with an intervention strategy to prevent subsequent development of hematologic malignancies, are needed.

The prognosis for patients with Philadelphia chromosome (Ph)-negative myeloproliferative neoplasms (MPNs) is highly variable. All Ph-negative MPNs carry an increased risk for thrombotic complications, bleeding, and leukemic transformation. Several clinical, biological, and molecular prognostic factors have been identified in recent years, which provide important information in guiding management of patients with Ph-negative MPNs. In this review, we critically evaluate the recent published literature and discuss important new developments in clinical and molecular factors that impact survival, disease transformation, and thrombosis in patients with polycythemia vera, essential thrombocythemia, and primary myelofibrosis. Recent studies have identified several clinical factors and non-driver mutations to have prognostic impact on Ph-negative MPNs independent of conventional risk stratification and prognostic models. In polycythemia vera (PV), leukocytosis, abnormal karyotype, phlebotomy requirement on hydroxyurea, increased bone marrow fibrosis, and mutations in ASXL1, SRSF2, and IDH2 were identified as additional adverse prognostic factors. In essential thrombocythemia (ET), JAK2 V617F mutation, splenomegaly, and mutations in SH2B3, SF3B1, U2AF1, TP53, IDH2, and EZH2 were found to be additional negative prognostic factors. Bone marrow fibrosis and mutations in ASXL1, SRSF2, EZH2, and IDH1/2 have been found to be additional prognostic factors in primary myelofibrosis (PMF). CALR mutations appear to be a favorable prognostic factor in PMF, which has not been clearly demonstrated in ET. The prognosis for patients with PV, ET, and PMF is dependent upon the presence or absence of several clinical, biological, and molecular risk factors. The significance of additional risk factors identified in these recent studies will need further validation in prospective studies to determine how they may be best utilized in the management of these disorders.

Introduction: The number of patients with sickle cell disease (SCD) approaches 100,000 in US after adjusting for early mortality (Hassell Am J Prev Med 2010). Management of SCD and its complications require frequent access to healthcare system lifelong, thus impacting patients' quality of life and cost of healthcare. Chronic pain inducing illnesses are known to increase susceptibility to mental health disorders (Rayner Pain 2016). Psychosocial disorders are common in this population and impact the course of hospitalization, however we have limited published data in this area. Hence, we performed a large retrospective study utilizing the National Inpatient Sample (NIS) data to evaluate the prevalence of mental health disorders in hospitalized sickle cell patients, and their influence on length of hospitalization. Methods: We identified hospitalized sickle cell patients using ICD 9 codes (282.5,282.6X -282.6X ) in the National Inpatient Sample (NIS) database. Similarly, ICD-9 codes were used to identify patients with mental health disorders of interest. The demographics and length of hospital stay of patients with and without mental health disorders were then compared. Surveyfreq was used to calculate proportions and surveymeans was used to calculate median length of stay and hospital charges. Cochran-Armitage test was used for analyzing trends. We used chi-square for categorical data frequency, P value of < 0.05 was considered statistically significant. All analysis was performed using SAS 9.4. Results: We identified a total of 1,349,701 hospitalizations for sickle cell patients between 2003-2014, of which 221,279 (16%) had associated mental health disorders. Mood disorders were most common (40%), followed by substance abuse (28%) and anxiety disorder (16%) (Table 1). Over the timeline of our study, we found a longitudinal trend towards higher prevalence of mental health disorders in hospitalized sickle cell patients (Figure 1). There was higher prevalence of mental health disorders among patients aged between 21-40 years (24%). No difference in the rate of mental health disorders was noted in patients admitted with or without acute sickle cell pain episode. Median length of hospital stay (LOS) was 4 days in patients with mental health disorders (95% CI 4.04-4.12) compared to 3 days in those without (95% CI 3.17-3.20). Conclusion: The prevalence of mental health disorders in hospitalized sickle cell patients has been gradually increasing from 2003 to 2014 and approaches 16% overall. The length of hospital stay is longer for the individuals with these disorders than those without hence, increasing the cost of health care and reducing patient satisfaction. Therefore, early recognition and intervention for mental health disorders is paramount to promote quality of life and reduce health care costs. This demands for a multidisciplinary approach to provide better access to mental health resources to this population in the outpatient setting. Disclosures No relevant conflicts of interest to declare.

BACKGROUND: The incidence of venous thromboembolism in pancreatic cancer is high. Pancreatic cancer patients who develop deep venous thrombosis (DVT) or pulmonary embolism (PE) have increased mortality compared to those without. Pharmacological anticoagulation mitigates the increased mortality in these patients thus providing rationale for treatment. The incidence of splanchnic vein thrombosis (SVT) in pancreatic cancer is also high ~8% (Pachon JCO 2015, Sogaard Blood 2015). However, the correlation between SVT and mortality in pancreatic cancer is not well established. Current guidelines recommend anticoagulation for SVT on a case-to-case basis, assessing the risk-benefit of treatment and patient prognosis (Khorana J Thromb Thrombolysis 2016). Hence, we conducted the largest study to date to evaluate the impact of SVT on mortality in a cohort of United States Veterans with advanced pancreatic cancer. METHODS: Study Population: We identified patients in the Veterans Administration Central Cancer Registry (VACCR) diagnosed with unresectable or metastatic pancreatic cancer (stage II, III, IV) between October 1st, 1998 and December 31st, 2014 using ICD-O3 codes. We then identified the pancreatic cancer patients who developed SVT using ICD-9/10 codes and the CPT codes for relevant diagnostic imaging. Patients with DVT, PE and atrial fibrillation were excluded. Statistical Analyses: We compared baseline patient characteristics between pancreatic cancer patients with SVT and those without using Chi-square and Cochrane-Mantel-Haenszel tests for categorical variables, and unpaired Student's t-tests for continuous variables. Using Cox proportional hazard models, we assessed the association between SVT and overall survival in patients with pancreatic cancer while adjusting for significant prognostic indicators including: age, gender, body mass index (BMI), Charlson comorbidity index, stage of cancer (stage IV vs. stage II/III), white blood cell count (WBC), estimated glomerular filtration rate (eGFR), use of radiation or chemotherapy. A two-tailed alpha significance level of 0.05 was used for all analyses. Statistical analyses were performed using SAS version 9.2 (SAS Institute, Cary, NC). RESULTS: We identified 6296 patients with unresectable or metastatic pancreatic cancer within the VACCR, of whom 170 were diagnosed with SVT. Baseline demographics of patients with and without SVT are shown in Table 1. The median OS of the patients with SVT was 140 days as compared to 92 days for those without SVT, Figure 1. After adjusting for potential confounders, patients with SVT had a 16% reduction in mortality compared to those without (HR 0.84, p = 0.03). In addition, increasing age, male gender, BMI < 18.5, increasing comorbidities, eGFR < 45 mL/min, WBC > 10 x 109/L, metastatic disease (stage IV) were associated with increased risk of death, while receipt of chemo or radiation therapy and BMI ≥ 25 were associated with a reduced risk of death. DISCUSSION/CONCLUSION: In this large retrospective study of patients with advanced pancreatic cancer, we found no association between SVT and increased mortality in patients with pancreatic cancer. A significant number of SVTs are detected incidentally on surveillance scans, and are thus asymptomatic at diagnosis. Anticoagulation is associated with an increased risk of hemorrhage which can be fatal in some cases. Given the lack of association between SVT and death in pancreatic cancer, future studies should assess the impact of anticoagulation on outcomes in this population with consideration given to observation only to reduce the risk of hemorrhage. Disclosures Sanfilippo: BMS/Pfizer: Speakers Bureau.

Background: Sickle cell disease (SCD) is a common hemoglobinopathy, characterized by vaso-occlusive crises and affects over 100,000 people in United States. It afflicts long-lasting organ damage with a spectrum of clinical severity. Median survival for SCD is shortened to the 6th decade of life despite advances in medical care (Elmariah et al Am J Hematol 2014). Allogeneic stem cell transplant (SCT) is a potentially curative option and is increasingly considered in patients with severe symptomatic SCD. The use of SCT is limited by donor availability and treatment related complications. Several advancements in conditioning regimen and use of alternate donor source have favorably impacted the feasibility of this approach. We identified SCT performed for sickle cell disease in the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) from 2002-2014 in an attempt to identify hospitalization outcomes, factors affecting length of stay and healthcare utilization. Methods: HCUP-NIS is a 20% stratified sample of all discharges from hospitals across 46 states in the United States and incorporates weighting algorithms to predict nationwide estimates. We used International Classification of Diseases, Ninth Revision (ICD-9) procedure codes to identify HCT hospitalizations {Bone marrow (BM):41.02, 41.03, Peripheral blood (PB): 41.05, 41.08 and Cord blood (CB): 41.06} for sickle cell disease (282.5,282.6X -282.6X). We excluded patients who underwent SCT for indications other than SCD. Surveyfreq was used to calculate proportions and surveymeans was used to calculate median length of stay and hospital charges. Kruskal-Wallis test was used for non-parametric data. Chi-square for categorical data frequency, P value of < 0.05 was statistically significant. All analysis was performed using SAS 9.4. Results: Outcomes were analyzed from a total of 742 hospitalizations for SCT from 2002-2014 (table 1). Median age for stem cell transplant was 9 years. GVHD occurred in 14% of stem cell transplants. Overall, in-hospital mortality was low at 2.6% while mortality in patients who developed GVHD was 14%. Bacterial infections (including C.difficile) occurred more commonly than viral or fungal infections (table 2). Patients who developed graft vs host disease (GVHD) were also more likely to have bacterial, viral and fungal infections than those without. Pain crisis was noted in 9% of total admissions while stroke occurred in 6%. Median length of stay (LOS) was 35 days and median charges were $359,646. If GVHD developed, median LOS increased to 54 days while median charges increased to $712,324. Similarly, bacterial sepsis was associated with a longer median LOS of 63 days while median charges increased to $626,986 (table 3). Conclusions: The rate of inpatient mortality with SCT in sickle cell disease is lower than the overall inpatient mortality rate for allogeneic SCT (7%; Godara et al bbmt 2018), indicating a favorable outcome for these patients. Infections do occur commonly during the course of hospitalization, especially in association with GVHD. Length of stay is adversely impacted by occurrence of GVHD, bacterial sepsis, C.difficile infection and viral infections. While we are limited by duration of follow up in our study, these patterns suggest some essential modifiers for inpatient morbidity and mortality, therefore require validation in a large prospective study. Disclosures No relevant conflicts of interest to declare.

BACKGROUND: Graft versus host disease (GVHD) is a significant contributor to non-relapse mortality after allogeneic stem cell transplant (SCT). Steroids are first line therapy and extracorporeal photopheresis (ECP) is used as second line therapy for steroid refractory or intolerant patients. ECP has immunomodulatory effects rather than immunosuppressive effect which decreases the risk of infection, and may decreases the risk of disease relapse. There are two ECP instruments approved in the US for the treatment of Cutaneous T Cell Lymphoma (CTLC), however both have been used "off-label" to prevent or treat solid organ transplant rejection, acute and chronic GVHD, and other autoimmune diseases. Until recently the UVAR-XTS instrument has been the most commonly used closed system in the US until the CELLEX was approved in 2009. The CELLEX and the UVAR-XTS procedures are similar in that buffy coat is collected, exposed to methoxsalen (UVADEX®) ex vivo and then UVA light before returning the treated cells back to the patient in a closed looped system. The instruments differ in the collection of the buffy coat; collection is continuous by the CELLEX, and it is intermittent by UVAR-XTS. In addition CELLEX has been shown to be more efficient in collecting mononuclear cells when compared to the UVAR -XTS. Little clinical data is available comparing the clinical efficacy of the two instruments in the setting of GVHD. We designed a single institution retrospective study to compare the efficacy and safety of the two instruments. The primary outcomes analyzed were >/=50% reduction of steroid dose between the initial and final dose during the study period, and the number and type of adverse events that occurred during the ECP procedures. METHODS: Study Population: We reviewed charts of allogeneic stem cell transplant patients who received ECP for the treatment of acute or chronic GVHD between 1/2009 and 12/2015. The patients were divided into two groups based on the type of ECP instrument that was used. One group was exclusively treated with UVAR-XTS while the second group with CELLEX. Patients who received treatments with both instruments were excluded. The frequency of steroid dose reduction by >/=50%, and toxicity was compared between the two instruments while adjusting for age, gender, GVHD severity, number of organs involved by GVHD, type of allogeneic stem cell transplant, conditioning regimen, number of other immunosuppressants, type of anticoagulants (ACDA vs heparin), type of access line, and baseline blood counts. Statistical Analysis: The baseline characteristics of the patients in the two groups were compared using Chi square, Fischer's exact test for categorical variables and one-way analysis of variance (ANOVA) for continuous variables. Chi square analysis was used to determine the difference in frequency of >/=50% steroid dose reduction and adverse events between the two groups. Logistic multivariate regression was used to evaluate the potential interactions of all significant covariates. A p value of less than 0.05 was considered to be statistically significant. Statistical analyses were performed using STATA14 software (StataCorp, College Station, TX). RESULTS: We identified 242 allogeneic SCT recipients who received ECP for acute or chronic GVHD in the study period, 146 of whom met the selection criteria. 69 patients had all procedure performed with UVAR-XTS and 77 patients had all procedures performed with CELLEX. There was no significant difference in age, gender, percent of acute GVHD, anticoagulant used, type of transplant, number of organs involved, number of immunosuppressants, vascular access and baseline blood counts between the two treatment cohorts as shown in table 1. Although year of transplant and conditioning regimen were different between the two cohorts, neither of these covariates influenced the impact of instrument on the primary outcome. In multivariate analysis, the patients who underwent ECP with CELLEX were 3 times more likely to have >/=50% steroid dose reduction (p =0.01). The total number of adverse events was similar between the instruments (p = 0.73). (Table 2) CONCLUSION: More than twice as many patients with GVHD treated with the CELLEX had a steroid dose reduction by >/=50% reflecting clinical improvement when compared to the patients treated with the UVAR-XTS. Similar safety profile was observed between the two instruments based on a similar number of adverse events. Disclosures No relevant conflicts of interest to declare.

INTRODUCTION: Cancer patients with venous thromboembolism (VTE) have threefold increase in all cause hospitalization and days of hospitalization than cancer patients without VTE. Hospitalization with VTE is also associated with higher overall all cause inpatient cost (PMID 23430767). We hypothesized that a centralized cancer-associated thrombosis clinic instituted at the Cleveland Clinic in August 2014 would reduce hospital admissions for this indication and impact the cost of healthcare. METHODS: The study population comprised two cohorts: cancer patients admitted with a new diagnosis of VTE to the Cleveland Clinic Main Campus between August 1 and December 31 in 2013 before initiation of the cancer-associated thrombosis (CAT) clinic and between August 1 and December 31 in 2014 after initiation of CAT clinic. Patients who were accepted as transfers from outside hospitals were excluded from the study. RESULTS: In the pre CAT clinic study period, there were 101 admissions. Of these, 51 (50%) were admitted primarily for a thromboembolic event whereas the rest had VTE as a secondary diagnosis. In the post CAT clinic study period, there were 94 admissions. Of these, 42 (44.7%) were admitted primarily for a thromboembolic event. The baseline characteristics of the two study groups are detailed in table 1. There was a reduction in hospital admissions for VTE by 9 admissions in the post CAT clinic period (RR 0.89, RRR 11%, p 0.252). The median length of hospital stay per patient was 3 days, reducing the total days of hospitalization by 27 days in post CAT clinic period. Figure 1 CONCLUSION : We demonstrated that a centralized CAT clinic can reduce but not eliminate admissions for VTE. Larger health care systems should consider the development of such a service for the management of VTE in cancer patients as it can lead to significant cost savings and reduce unnecessary exposure of this vulnerable patient population to hospital environment | Characteristic | Pre CAT clinic period (N) | Post CAT clinic period (N) | | ----------------------------------------------- | --------------------------------- | ----------------------------------- | | Patients admitted with VTE as primary diagnosis | 51 | 42 | | Median age (years) | 62.41±12.85 | 61.6±13.4 | | Female patients | 22 (44%) | 26 (39%) | | Solid tumor diagnosis | 42 (82.4%) | 36 (70.6%) | | Hematological malignancy | 9 (17.6%) | 6 (11.8%) | | DVT | 16 (31.4%) | 12 (28.6%) | | PE | 35 (68.6%) | 30 (71.4%) | | PE patients with high PESI score (Class III/IV) | 33 (94%) | 28 (93%) | | Median length of hospital stay (days) | 3 (1-27) | 2.5(1-16) | Table 1. ![Figure 1.][1] Figure 1. Disclosures Khorana: Pfizer: Consultancy, Honoraria; sanofi: Consultancy, Honoraria; Leo Pharma: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Boehringer-Ingelheim: Consultancy, Honoraria; Daiichi Sankyo: Consultancy, Honoraria. McCrae: Janssen Scientific Affairs: Membership on an entity's Board of Directors or advisory committees. [1]: pending:yes

Background: Induction chemotherapy (IC) in Acute Myeloid Leukemia (AML) leads to significant bone marrow suppression. The standard clinical practice to prevent or manage cytopenia related complications, namely anemia or bleeding, has been red blood cell (RBC) and platelet (PLT) transfusion. Accumulating evidence suggests no advantage to patients (pts) managed with liberal transfusion strategies compared to a restrictive approach. However, prior studies excluded patients with bone marrow failure conditions such as AML; hence it remains unclear whether a similar approach can be extrapolated for AML pts. We undertook this study to evaluate the effects of transfusions on treatment outcomes and complications in AML. Methods: Adult pts diagnosed with AML (excluding acute promyelocytic leukemia) at the Cleveland Clinic from 01/2008 - 12/2012 who underwent IC with 7+3 (full dose of cytarabine and anthracycline) and had complete adverse event data were included. Variables including demographics, preexisting comorbidities, AML disease characteristics, organ dysfunction (neurologic, cardiac, pulmonary, renal, hepatic, bleeding and thromboembolic events), infections (bloodstream infection, pneumonia and clostridium difficile associated diarrhea) and treatment response [complete remission (CR), incomplete remission (CRi), persistent disease (PD) and 30-day mortality] were assessed. The outcome of interest was any correlation between the total number of PLT and/or RBC transfusions and (i) organ impairment, (ii) infections, and (iii) treatment outcomes during the induction period. Culture confirmed bloodstream infections included vancomycin resistant enterococcus (VRE), gram-positive bacteria (except VRE), gram-negative bacilli and fungemia. Univariable and multivariable logistic regression models adjusted for potential confounders were performed for each outcome category. Odds ratio (OR) with 95% confidence intervals (CI) are reported. Results: Of 192 pts, 48% (n=93) were female, 85% (n=163) were Caucasian, 54% (n=103) were In univariable analysis a higher number of RBC and PLT transfusions was associated with an increased risk of bloodstream infections (OR=1.03; CI,1.01-1.05; p=0.001). In multivariable analysis increased number of transfused RBCs and PLTs was associated with lower CR rates (OR=0.94; CI,0.91-0.97; p Conclusion: In multivariable analysis the number of RBC and PLT transfusions during AML IC is associated with a slightly increased risk for cardiac, pulmonary and some infectious complications. Higher numbers of transfusions also appear to be associated with lower CR rates. These data can inform future prospective studies designed to determine the benefits and risks of a restrictive transfusion policy in the AML population. Figure 1. Figure 1. Figure 2. Figure 2. Disclosures Sekeres: TetraLogic: Membership on an entity's Board of Directors or advisory committees; Celgene Corporation: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees.