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Cryopreservation for the long-term storage of platelets (PLTs) is a useful method to overcome the limits of platelet shortage. This is an in vitro prospective study to evaluate the count, viability, and function of buffy coat-derived pooled platelet concentrates (BC-PLTs), treated with dimethyl sulphoxide (DMSO) and cryopreserved (CRY BC-PLTs) at −80 °C with a modified Valeri method. PLTs were stored in 6% DMSO with a patented kit. Overall, 49 BC-PLTs from 245 healthy volunteer donors were prepared, cryopreserved, and analysed before and after 3, 6, and 9 months of storage. In flow cytometry, a statistically significant reduction in CD 42b (92.7 ± 4.29% at T0 vs. 23.6 ± 27.5% at T3, 16.38 ± 12.54% at T6, and 17.3 ± 9.6% at T9) and PAC-1 (1.9 ± 1.34% at T0 vs. 0.62 ± 0.4% at T3, 0.63 ± 0.83% at T6, and 0.49 ± 0.48% at T9) was observed after storage. CRY BC-PLTs showed a good and stable endogenous thrombin generation potential (nM min): 529.25 ± 98.64 at T0 vs. 533.04 ± 103.15 at T9 months. CRY BC-PLTs showed a good viability in vitro, according to currently accepted criteria for cryopreserved PLTs.

Background: Cryopreservation of platelets (PLTs) at -80°C with dimethyl sulfoxide (DMSO) can extend their shelf life up to 2 years. Cryopreserved PLTs (CRY-PLTs) are reported to have a greater in vivo hemostatic effect than liquid-stored PLTs. Aims of this study were: i. to evaluate the thrombin generation potential of buffy coat derived cryopreserved PLTs (CRY- BC PLT) in comparison with fresh buffy coat derived platelets concentrates; ii. to determine the efficacy and safety of CRY-PLTs transfusion in hematological patients with severe thrombocytopenia. Materials and methods: BC PLTs were obtained from 5 buffy coats and pooled. The final PLTs concentrates were leukoreduced by filtration and transferred to a 650 mL patented cryopreservation kit (Promedical ®) which allowed mixing with DMSO 25% in a closed system and following removal of supernatant without further manipulations. BC-PLTs were washed prior freezing, suspended in homologous plasma from 1 of the 5 donors to a final concentration of 200 mL and frozen at - 80°. CRY- BC PLTs were preserved at -80°C with 6% DMSO. A system of 3 accessory bags directly connected to the mother bag was adopted for the in vitro study, to avoid repeated freezing/thawing of samples. In vitro assays were performed before freezing and at 3,6 and 9 months after thawing. Before assay, CRY-BC PLT were thawed at 37°C and diluted in plasma to adjust to 300× 109/L PLTs. Fresh BC PLTs underwent the same dilution to adjust to 300 ×109/L PLTs. Thrombin generation (TGA) was tested in CRY BC-PLTs and compared to TG potential of fresh BC PLTs. TGA was triggered by the addition of 0.5 pmol/L of recombinant human tissue factor. Endogenous thrombin potential (ETP) and peak height (PH) were determined. Flow Cytometry assays for PLTs activation markers and thromboelastography were also determined on each sample. CRY-BC PLTs, separately prepared according to the above described method for in vivo study, were infused in five hematological patients with acute leukemia (AL) and severe thrombocytopenia (PLTs Results Fourty nine BC-PLTs from 245 healthy volunteer donors (145 males and 100 females, mean age: 48.16.±18.91) were prepared, cryopreserved and analyzed up to 9 months after storage. Cryopreserved PLTs show a good thrombin generation potential that is stably maintained up to 9 months after cryopreservation [ETP (nM min): 529.25±98.64 at T0, 558.82±114.67 at T3, at 548.57±93.38 T6 and 533.04±103.15 at T9 months, respectively; PH(nM): 132.77±44.9 at T0, 103.4±44.9 at T3, 108.0±36.7 at T6 and 132.0±44.6 at T9 months, respectively]. At TGA, fresh BC-PLTs (n=35) had a mean ETP of 760.13±130.11, PH was 138.9±40.2. Thrombin generation of CRY-BC PLTs is comparable to fresh BC-PLTs, even if slightly decreased. Infusion of CRY-BC PLT (1U) was effective in controlling mucosal bleeding (epistaxis) in two patients with AL and severe thrombocytopenia. CRY-PLT were also effective when administered for prophylaxis in 3 patients with very low platelets count secondary to chemotherapy. In vivo, thrombin generation is stably maintained up to 24 hours after infusion of 1 Unit of CRY-BC PLTs, without any adverse effect (mean ETP pre-treatment was: 414.13±160.60, 24 hours after transfusion: 326.95±152.54). CRY-BC PLTs were safe and they did not determine any thrombotic event. At flow-cytometry, CRY-BC PLTs expressed higher activation markers (CD62P,CD63) than fresh BC PLTs. CRY-BC PLTs are able to significantly decrease the time to clot formation and clot strength, as measured also by thromboelastography. CRY-BCPLTs activation/deterioration is accompanied by an effective hemostatic in vivo function. Conclusions: Cryopreserved PLTs have an enhanced hemostatic activity and a good thrombin generation potential. They are effective and safe in preventing and controlling bleeding, being available in emergency/urgency settings also for patients with acute leukemia and severe thrombocytopenia. Disclosures Reina: Promedical: Consultancy.

Idiopathic thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) is a rare disease responsive to treatment with plasma exchange (PE) but with a high percentage of relapse or refractory patients. A severe deficiency of ADAMTS-13 (

We evaluated a simplified algorithm for safely postponing diagnostic imaging for pulmonary embolism (PE). At the index visit, patients were identified as being at high or low risk of PE; the former received full dosage low molecular weight heparin while the latter were left untreated until performance of diagnostic imaging (max 72 hours). During this period, no thromboembolic events occurred in low-risk patients (0/211, 0.% [upper 95% CI 0.9%]); only one event occurred in those at high-risk (1/125, 0.8% [upper 95% CI, 1.2]). Our study demonstrates that diagnostic imaging for PE can be safely deferred for up to 3 days.

AIM: To evaluate the predictive role of hs-CRP and fibrinogen for cardio- and cerebrovascular events in a population of patients with type 2 diabetes. METHODS: We studied 156 patients with type 2 diabetes, mean age 66+10 years, and 156 sex and age matched control subjects. Patients underwent physical examination, EKG, measurement of body mass index and blood pressure. A blood sample was drawn to evaluate glycaemia, total and HDL/LDL cholesterol, triglycerides, high sensitive C-reactive protein (hs-CRP), fibrinogen. Finally, patients underwent an ecocolordoppler examination of the common carotid arteries until the bifurcation. In a follow-up of 5+/-1.2 years we evaluated the following events: transient ischemic attack, ischemic stroke, stable or unstable angina, acute myocardial infarction, critical limb ischemia and cardiovascular death. RESULTS: During the follow-up the prevalence of fatal (p

Cancer-related disseminated intravascular coagulation (DIC) is a life-threatening condition for which no effective treatment is currently available. Protein C (PC), a modulator of coagulation as well as the inflammatory system, has been successfully tested (in its activated recombinant form [a-rPC]) in sepsis-related coagulopathy, but with an increased risk for major bleeding. Plasma-derived PC (pd-PC) is more suitable than a-rPC in patients at high risk from bleeding due to its self-limiting process. We carried out a single-arm study evaluating the role of pd-PC in adult cancer patients with overt DIC. Over a period of 3 years, we treated 19 patients with overt DIC and a PC plasma concentration

Purpose We evaluated the role of residual vein thrombosis (RVT) to assess the optimal duration of anticoagulants in patients with cancer who have deep vein thrombosis (DVT) of the lower limbs. Patients and Methods Patients with active cancer and a first episode of DVT treated with low molecular weight heparin (LMWH) for 6 months were eligible. Patients were managed according to RVT findings: those with RVT were randomly assigned to continue LMWH for an additional 6 months (group A1) or to discontinue it (group A2), and patients without RVT stopped LMWH (group B). The primary end point was recurrent venous thromboembolism (VTE) during the 1 year after disconinuation of LMWH, and the secondary end point was major bleeding. Analyses are from the time of random assignment. Results Between October 2005 and April 2010, 347 patients were enrolled. RVT was detected in 242 patients (69.7%); recurrence occurred in 22 of the 119 patients in group A1compared with 27 of 123 patients in group A2. The adjusted hazard ratio (HR) for group A2 versus A1 was 1.37 (95% CI, 0.7 to 2.5; P = .311). Three of the 105 patients in group B developed recurrent VTE; adjusted HR for group A1 versus B was 6.0 (95% CI, 1.7 to 21.2; P = .005). Three major bleeding events occurred in group A1, and two events each occurred in groups A2 and B. The HR for major bleeding in group A1 versus group A2 was 3.78 (95% CI, 0.77 to 18.58; P = .102). Overall, 42 patients (12.1%) died during follow-up as a result of cancer progression. Conclusion In patients with cancer with a first DVT, treated for 6 months with LMWH, absence of RVT identifies a population at low risk for recurrent thrombotic events. Continuation of LMWH in patients with RVT up to 1 year did not reduce recurrent VTE.

Introduction Cryopreservation for long term storage of platelets (PLTs) represents a clinical useful method for avoiding platelet shortage. Many studies have tried to define, in vitro and in vivo, the entity and weight of storage-related PLTs lesions with discordant results related to different methods. We have performed an in vitro prospective study to evaluate PLTs count, viability and function of buffy coat derived pooled platelet concentrates (BC-PLTs) treated with dimethyl-sulphoxide (DMSO) and cryopreserved at -80°C with an innovative patented system not requiring laminal flow hoods and external manipulations. Materials and methods Each BC-PLTs was obtained from 5 buffy coats and pooled according to standard procedures. The final PLTs concentrates were leukoreduced by filtration and transferred to a 650 mL cryopreservation kit (Promedical ®) which allowed mixing with DMSO 25% in a closed system and following removal of supernatant without further manipulations. BC-PLTs were washed prior freezing with removal of at least 84% supernatant solution, suspended in homologous plasma from 1 of the 5 donors to a final concentration of 200 mL and frozen at – 80°.Selection criteria to make BC-PLTs available for this study was pooled PLTs concentration > 1250 x 109/L and a blood units collection time duration shorter than 6 minutes. All the 245 donors were healthy volunteers and they did not take any medication affecting PLTs function. BC-PLTs were analyzed immediately pre-freezing (T0) and 3 months after cryopreservation ( CRY BC-PLTs). The following parameters were assayed: PLTs count (PC), mean platelet volume (MPV), pH, flow cytometry (FACS) expression of CD41a, CD42b, CD61a, CD62p, PAC-1, Annexin V PLTs surface antigens and thromboelastography (TEG). All samples were analyzed also after dilution (1:4) with homologous plasma to approximately 400 x109/L PLTs (data not shown) and for bacterial contamination (BC). CRY BC-PLTs samples were thawed in a bath at 37°C for 5 minutes and evaluated promptly. All the tests were performed according to current European recommendations. PLTs swirl was furthermore visually assessed. Results were expressed as mean +/- standard deviation (SD). Results obtained at T0 and after 3 months were compared by paired sample t-test. Differences were considered as significant at p values Results In vitro cell parameters were measured on 49 BC-PLTs and 15 CRY BC-PLTs as reported in Table1. PC was only slightly reduced in CRY BC-PLTs while MPV was significantly increased in CRY BC-PLTs. There were no differences between the 2 groups in CD41a, CD61a, CD62p and Annexin V expression while a significant reduction in CD 42b, PAC-1 for CRY BC-PLTs was observed. TEG parameters were all significantly reduced in CRY BC-PLTs samples without affecting hemostasis. PLTs swirl was observed in all samples and BC was absent. Conclusions The preliminary results of our investigation confirm the potential of a new system to overcome limits to PLTs storage. In fact, this method guarantees sterility and avoids excessive manipulations thanks to a closed system. Our method avoids PLTs apoptosis, as shown by absent expression of Annexin V. The adequate hemostasis achieved at TEG in both groups supports the hypothesis that in vitro PLTs activation/deterioration doesn’t necessarily mirror an impaired hemostatic in vivo function of CRY BC-PLTs. The next step of current study will be to evaluate the influence of the observed in vitro activation changes on PLTs recovery and survival in vivo. Disclosures: De Francisci: Promedical: Consultancy. Reina:PROMEDICAL: Consultancy. Allegro:Promedical: Employment.

The safest duration of anticoagulation after idiopathic deep vein thrombosis (DVT) is unknown. We conducted a prospective study to assess the optimal duration of vitamin K antagonist (VKA) therapy considering the risk of recurrence of thrombosis according to residual vein thrombosis (RVT). Patients with a first unprovoked DVT were evaluated for the presence of RVT after 3 months of VKA administration; those without RVT suspended VKA, while those with RVT continued oral anticoagulation for up to 2 years. Recurrent thrombosis and/or bleeding events were recorded during treatment (RVT group) and 1 year after VKA withdrawal (both groups). Among 409 patients evaluated for unprovoked DVT, 33.2% (136 of 409 patients) did not have RVT and VKA was stopped. The remaining 273 (66.8%) patients with RVT received anticoagulants for an additional 21 months; during this period of treatment, recurrent venous thromboembolism and major bleeding occurred in 4.7% and 1.1% of patients, respectively. After VKA suspension, the rates of recurrent thrombotic events were 1.4% and 10.4% in the no-RVT and RVT groups, respectively (relative risk = 7.4; 95% confidence interval = 4.9-9.9). These results indicate that in patients without RVT, a short period of treatment with a VKA is sufficient; in those with persistent RVT, treatment extended to 2 years substantially reduces, but does not eliminate, the risk of recurrent thrombosis.

Idiopathic thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) is a rare disease responsive to treatment with plasma exchange (PE) but with a high percentage of relapse or refractory patients. A severe deficiency of ADAMTS-13 (5% of normal activity), congenital or caused by an autoantibody, may be specific for TTP and it has been proposed that severe ADAMTS-13 deficiency now defines TTP. B cells play a key role in both the development and the perpetuation of autoimmunity, suggesting that B-cell depletion could be a valuable treatment approach for patients with idiopathic TTP-HUS. This review of the literature focuses on the role of rituximab, a chimeric monoclonal antibody directed against CD20 antigen expressed by B lymphocytes, in patients with relapsing or refractory TTP-HUS with or without ADAMTS-13 deficiency, suggesting that rituximab may produce clinical remission in a significant proportion of patients. Rituximab therapy reduces plasma requirement and avoids complications related to salvage-immunosuppressive therapy. In conclusion, rituximab provides an effective, well-tolerated, and safe treatment option for patients with idiopathic TTP-HUS, thus giving an alternative approach to the current treatment based on PE.

Introduction: We tested the efficacy and safety of fixed doses of Low-Molecular Weight Heparin (LMWH) in patients requiring interruption of Vitamin-k Antagonist (VKA) because of invasive procedures Methodology: Pre-operatively, patients discontinued VKA 5 +/- 1days; in those at low-risk for thrombosis, LMWH was given at a prophylactic dosage of 3.800 U.I. (nadroparin) or 4.000 U.I. (enoxaparin) anti-FXa once daily the night before the procedure. In patients at high-risk for thrombosis, LMWH was started early after VKA cessation and given at fixed sub-therapeutic doses (3.800 or 4.000 UI anti-FXa twice daily) until surgery. Post-operatively, LMWH was reinitiated 12 hours after procedure while VKA the day after. Heparin was continued until a therapeutic INR value was reached. The primary efficacy endpoints were the incidence of thromboembolism and major bleeding from VKA suspension (because of surgery) to 30 +/- 2 days post-procedure. Results: A total of 328 patients (55.4% at low-risk and 44.6% at high-risk for thrombosis) were enrolled; 103 (31.4%) underwent major surgery and 225 (68.6%) non major invasive procedures. Overall, thromboembolic events occurred in 6 patients (1.8%, 95% confidence intervals 0.4 to 3.2), 5 belonging to high-risk and 1 to low-risk group. Overall, major bleeding occurred in 7 patients (2.1%, 95 CI 0.6 to 3.6), 6 patients belonged to high-risk and 1 to low-risk group; most of events occurred in high-risk group during major surgery. Conclusion: LMWH given at fixed sub-therapeutic doses appears to be a feasible and safe approach for bridging therapy in chronic anticoagulated patients. Summary. Introduction: We tested the efficacy and safety of fixed doses of low-molecular-weight heparin (LMWH) in patients requiring interruption of vitamin-K antagonist (VKA) because of invasive procedures. Methodology: Preoperatively, patients discontinued VKA for 5 +/- 1 days; in those at low risk for thrombosis, LMWH was given at a prophylactic dosage of 3800 UI (nadroparin) or 4000 UI (enoxaparin) anti-factor (F) Xa once daily the night before the procedure. In patients at high risk for thrombosis, LMWH was started early after VKA cessation and given at fixed sub-therapeutic doses (3800 or 4000 UI anti-FXa twice daily) until surgery. Postoperatively, LMWH was reinitiated 12 h after procedure while VKA was reinitiated the day after. Heparin was continued until a therapeutic INR value was reached. The primary efficacy endpoints were the incidence of thromboembolism and major bleeding from VKA suspension (because of surgery) up to 30 +/- 2 days postprocedure. Results: A total of 328 patients (55.4% at low risk and 44.6% at high risk for thrombosis) were enrolled; 103 (31.4%) underwent major surgery and 225 (68.6%) non-major invasive procedures. Overall, thromboembolic events occurred in six patients (1.8%, 95% confidence interval 0.4-3.2), five belonging to the high-risk group and one belonging to the low-risk group. Overall, major bleeding occurred in seven patients (2.1%, 95 confidence interval 0.6-3.6), six patients belonged to the high-risk group and one belonged to the low-risk group; most of the events occurred in the high-risk group during major surgery. Conclusion: LMWH given at fixed sub-therapeutic doses appears to be a feasible and safe approach for bridging therapy in chronic anticoagulated patients

The energy demand of the hotel sector of an Italian region is here utilized for hierarchizing, by means of an empirical method, efficient measures devoted to energy saving and reduction of CO2 emissions. Due to the large number of consumers present in the selected territorial area and the lack in detailed data, the energy demand assessment is here carried out by the analysis of a sample of representative consumers. A short set of indexes, referring to energy and environmental performances, are defined and calculated for different clusters of hotels, grouped on the basis of site characteristics, opening periods, number of beds, and building age. Such indexes are utilized to establish lists of actions with assigned priorities stemming from energy, environmental and economics issues. Energy planners and decision makers can easily use this approach for defining, implementing and monitoring energy efficiency as well as sustainability policies in the tourist sector of a given geographical area, starting from a limited set of data. The method has been proposed by authors within the assessment of the Sicilian Energy Masterplan.

Abstract 3999 Poster Board III-935 Background Clinical advantage of extensive screening for occult cancer in patients with idiopathic Deep Vein Thrombosis (DVT) is unknown. We have demonstrated that the Residual Vein Thrombosis (RVT)-based screening for occult cancer improves early detection as well as cancer-related mortality (Siragusa S et al. Blood 2007;110(699):OC). Here we report on final analysis of 537 patients over a period of 8 years. Objective of the study We conducted a prospective study evaluating whether a RVT-based screening for cancer is sensitive and influences cancer-related mortality. Study design Prospective with two cohorts of DVT patients: the first cohort was monitored for clinical overt cancer only (Group A), while the second (Group B) received complete screening for occult neoplasm and subsequent surveillance. Materials and methods Consecutive patients with a first episode of DVT who presented RVT after 3 month of anticoagulation and without signs and/or symptoms for overt cancer. Screening for occult cancer was based on: ultrasound and/or CT scan of the abdomen and pelvis, gastroscopy, colonoscopy or sigmoidoscopy, hemoccult, sputum cytology and tumor markers. These tests were extended with mammography and Pap smear for women and ultrasound of the prostate and total specific prostatic antigen (PSA) for men. All investigations had to be completed within four-weeks from the assessment of RVT. All patients were followed-up for at least 2 years. Incidence and cancer-related mortality was compared between the two groups by survival curves (Kaplan-Mayer) and related Breslow test for statistics. Results Over a period of 8 years, 537 patients were included in the analysis: first cohort included 346 patients (Group A), second cohort 191 (Group B). Clinical characteristics between groups were homogenous. During the follow-up, 8.3% of patients developed overt cancer in group A; in group B, 7.8% of patients had diagnosed cancer at the moment of extensive screening while 2 new cases (0.7%) occurred during the follow-up (Table). The sensitivity of this approach was 92.1% (95% confidence intervals 75.2-104.2). Cancer-related mortality was 7.5% in group A and 3.6% in group B (p< 0.001). Conclusions The RVT-based screening for occult cancer is highly effective for improving early detection as well as cancer-related mortality in a cohort of 537 patient with DVT of the lower limbs. Disclosures: Off Label Use: Hydroxyurea use in myelofibrosis.

Hemostatic disorders can often complicate transplantation procedures. Moreover, antihemmorhagic drugs may not efficiently control bleeding that occurs in such cases. We report on a patient who underwent kidney transplantation complicated by bone marrow aplasia and gastric bleeding who was succesfully treated with recombinant activated FVII (Novoseven). In May 2005, a 53-year-old man affected by chronic renal insufficiency underwent kidney transplantation. At the beginning of June, laboratory tests showed progressive reduction in the blood cell count with anemia, granulocytopenia, and thrombocytopenia related to the development of marrow insufficiency. We commenced transfusion therapy and administered hematologic growth factors. On June 3, 2005, the patient underwent surgical procedure to repair the abdominal wall. Two days thereafter, the postsurgical period was complicated by an episode of melena. The patient received additional treatment with packed red cells, platelets, and fresh-frozen plasma. The gastrointestinal bleeding continued until June 9, 2005, when therapy with recombinant activated FVII (Novoseven) was commenced at an initial dose of 90 μgr/kg. The first bolus did not significantly reduce the blood loss; it was therefore administered as a successive bolus at the same dosage that was able to stop bleeding. Endoscopic examination performed the day after showed the absence of the hemorrhagic lesion in the gastric mucosa. In the subsequent days, the need for transfusion was dramatically reduced with no episode of bleeding. At the same time, the laboratory and clinical findings of marrow insufficiency disappeared. Our case report showed that the use of a global antihemorrhagic factor, such as Novoseven, can successfully control gastrointestinal bleeding even in complicated patients despite failure of traditional antihemostatic therapy.

Outpatient treatment of deep vein thrombosis (DVT) has become a common practice in uncomplicated patients. Few data are still present in patients with comorbidity (such as cancer) or concomitant symptomatic pulmonary embolism. Cancer patients with DVT are often excluded from home treatment because they have a higher risk of both bleeding and recurrent DVT. We tested the feasibility and safety of the Home Treatment (HT) program for acute DVT a PE in cancer patients. Patients were treated as outpatients unless they required admission for other medical problems, were actively bleeding or had pain that requires parenteral narcotics. Outpatient treatment was with low molecular weight heparin (LMWH) followed by warfarin or with LMWH alone. An educational program for patients was implemented. Two-hundred and seven patients with cancer were evaluated, 36 (17.4%) of whom had metastatic disease. Treatment with LMWH and warfarin was prescribed to 106 (51.2%) and LMWH alone to 102 (48.8%). One hundred and twenty-seven patients (61.3%) were entirely treated at home. There were no differences between patients treated at home and hospitalized patients with regard to gender, mean age, site of cancer, presence of metastases, and treatment. After 6 months, recurrent thrombo-embolism occurred in 8.7% of patients treated at home and in 5.6% of hospitalized patients (P=0.58); major bleeding in 2.0% and 1.5%, respectively (P=0.06). Twenty-seven patients (33%) in the hospitalized, and 33 (26%) in the home-treatment group, died after a follow-up of 6 months. These results indicate that, regarding cancer patients with acute DVT and/or PE, there is no difference between hospitalised and home-treated patients in terms of major outcomes.

Background. We have recently demonstrated that the presence of Residual Vein Thrombosis (RVT), UltraSonography (US)-detected at the 3rd month after an episode of Deep Vein Thrombosis (DVT) of the lower limbs, is an independent risk factor for developing recurrent Venous Thromboembolism (VTE). The management of DVT patients by detection of RVT may, therefore, represent a simple and reproducible method for establishing the individual risk of recurrence and for tailoring the optimal duration of Oral Anticoagulants (OA) (Siragusa S et al. Blood 2003;102(11):OC183a). At the present, it is unknown whether RVT may also identify patients at increased risk for cancer and/or cardiovascular disease (CD). Objective of the study. In patients with DVT of the lower limbs, we conducted a prospective study for evaluating the correlation between RVT and the risk of new overt cancer and/or CD. Materials and methods. Consecutive patients, with an episode of idiopathic or provoked DVT, were evaluated after 3 months from the index DVT; presence/absence of RVT was detected and patients managed consequently (table). The incidence of VTE recurrence, overt cancer and new CD was evaluated over a period of 3 years after the index DVT. Survival curves (Kaplan-Mayer) and related Breslow test have been used for statistics. Results. Three-hundred fourty-five patients were included in the analysis. The results are listed in the table and figures. The incidence of recurrent VTE and new overt cancer was statistically lower in patients without RVT than in those with RVT; no significant differences were found in the incidence of new CD. These data are applicable in patients with idiopathic or provoked index DVT. In patients with RVT, the advantage of prolonging anticoagulation for 12 months was lost at the end of the treatment. Conclusions. This is the first study evaluating the relationship between US-detected RVT and the risk of developing cancer and CD; RVT presence, at 3rd month from the index DVT, is an independent risk factor for recurrent VTE and indicates patients at risk for new overt cancer. This risk remains over a period of 3 years, independently whether index DVT was idiopathic or provoked. In these patients, the advantage of indefinite anticoagulation should be assessed in properly designed study. | Group | Number of patients | Presence of RVT at the 3rd months of OA from the index DVT | Duration of OA from the index DVT | Incidence of recurrent VTE | Incidence of new cancer | Incidence of new CD | |:----------------------------------------------------------------------------------:| ------------------ | ---------------------------------------------------------- | --------------------------------- | -------------------------- | ----------------------- | ------------------- | | *Part of these patients were originally randomized to receive 3 or 12 months of OA | | Group *A1 | 142 | yes | 12 months | 11 (7.7%) | 8 (5.6%) | 7 (4.9%) | | Group *A2 | 91 | yes | 3 months | 16 (17.5%) | 9 (9.9%) | 7 (7.7%) | | Group B | 112 | no | 3 months | 1 (0.9%) | 3 (2.6%) | 4 (3.5%) | Incidence of events over a period of 3 years accordingly to RVT findings ![Figure 1: ][1] Figure 1: Relationship between RVT and subsequent Cancer ![Figure 2: ][1] Figure 2: Relationship between RVT and subsequent Cardiovascular Event [1]: pending:yes

Background. Management of patients with suspected Pulmonary Embolism (PE) is problematic if diagnostic imaging is not available. Pretest Clinical Probability (PCP) and D-dimer (D-d) assessment were shown to be useful to identify those high risk patients for whom empirical, protective anticoagulation is indicated (Siragusa S et al. Arch Intern Med2004;164:2477–82). Objective of the study. In consecutive patients with suspected PE, we evaluated whether PCP and D-d assessment, together with the use of low molecular weight heparins (LMWHs), allow objective appraisal of PE to be deferred for up to 72 hours. Methods. In case of deferment of diagnostic imaging for PE, patients identified at high-risk (those with high PCP and those with moderate PCP and a positive D-d), received a protective full-dose treatment of LMWH; the remaining patients were discharged without anticoagulants. All patients were scheduled to undergo objective tests for PE (ventilation/perfusion lung scanning or computed tomography lung scan) within 72 hours from the index visit (figure). Standard antithrombotic therapy was then administered when diagnostic tests confirmed Venous ThromboEmbolism (VTE). Results. 336 patients with suspected PE were included in this study. The prevalence of VTE was 6.1% (95% CI 2.7–9.3) in the “low-risk group” and 50.4% (95% CI 41.7–59.1) in the “high-risk group”. In total, VTE was confirmed in 76 (22.6%) of 336 patients (95% CI 18.2–27). Patients’ characteristics, median time for deferral test and for LMWH administration are listed in table 1. Events at the short-term (72 hours) and long-term follow-up are listed in table 2. None of the patients had major bleeding events during the follow-ups. Conclusions. When objective diagnostic assessment of PE is not immediately available, management of symptomatic PE patients can prove highly unsatisfactory. This study demonstrates that a simple and reproducible approach allows a safe deferral of diagnostic imaging for PE for up to 72 hours. patients’ characteristics Baseline features Low risk group (n. 211) High-risk group (n. 125) p value n.s.: not significant Age in years (range) 59.3 (22–91) 60.3 (23–91) n.s. Sex (F/M) 98/113 59/66 n.s. Time since onset of symptoms (days) 1.7 1.5 n.s. Co-morbidity and 16 (7.5) 25 (19.2) 0.03 Median time of deferral test (hours) 49.5 42.5 n.s. Median time of protective anticoagulation (hours) not applicable 35.5 not applicable Outcome of Short- and Long-term FU Categories of patients (n) Events at the short-term FU Events at the long -term FU* FU indicates follow-up; CI indicates Confidence Intervals. *This refers to patients in whom Pulmonary Embolism has been previously ruled out (n. 260). “Low-risk group” (211) 0 (0%) [95% CI 1.4] 0 (0%) [95% CI 1.4] “High-risk group” (125) 1 (0.8%) [95% CI 2.3] 3 (2.4%) [95% CI 3.2] Patients clinically suspected of PE without immediate availability of diagnostic tests Patients clinically suspected of PE without immediate availability of diagnostic tests

Background. Prothrombin time is a benchmark for functional assessment in cirrhosis and Factor VII levels (FVII), crucial in determining the prothrombin time, are genetically determined. Methods. We have evaluated the prothrombin time, a number of haemostatic variables synthesised by the liver (FII, FV, FVII and activated FVII, AT and fibrinogen) and two polymorphisms of the FVII gene (5′F7 and 353R/Q) in: (a) patients with liver cirrhosis ( n = 118), (b) patients with chronic hepatitis ( n = 102) and (c) controls ( n = 100). Results. By one-way analyses of variance, the prothrombin time and the mean levels of the FII, FV, FVIIc, FVIIa, and AT were statistically different between cirrhotics, chronic hepatitis patients and controls. The allele frequency of the FVII polymorphisms did not differ between the three groups. Those rare patients (4.6%) who were homozygous for the type 2 alleles had markedly reduced FVIIc and FVIIa levels. The analysis carried out taking into account Child class versus FVII genotype showed that the mean FVIIc levels were comparable for different genotypes within each Child's class, with the exception of the patients homozygous for the type 1 allele. Conclusion. Our findings help to explain the not infrequent finding of a severely prolonged prothrombin time in patients who are otherwise in a good functional class.

Stroke incidence rates in the Mediterranean area are higher compared to northern European countries. In this study, we present the 8-year prospective data from a small rural Sicilian town. This population, consisting of 1351 subjects (622 males and 729 females), is homogeneous for ethnic background with traditional healthy dietary habits and shows low cholesterol mean levels. We found that the risk of stroke was significantly associated with the record of at least one previous neurological symptom (PNS), such as lack of strength, loss of vision or speech or possible drop attacks, and high hematocrit in males, and to high body mass index (BMI) and waist-hip ratio (WHR), diabetes, hypertension, high leukocyte count in females. We also documented age-related differences: stroke was associated in younger subjects (age < 65 years) with diabetes, high BMI, high uric acid levels and in older patients (age ≥ 65 years) with high WHR, hypertension, diabetes, PNS, leukocyte count and hematocrit above the 95th percentile. Multivariate analysis demonstrated an independent association between stroke and age, diabetes, leukocyte count, hypertension and PNS. In conclusion, in this rural Sicilian population, the incidence rate of stroke is 1.72 cases per 1000/year in the subjects between 40 and 75 years of age. The risk factors associated with stroke are different in younger and older subjects. Leukocyte count, as an expression of an undergoing inflammatory process, may have a relevant role at least in the elderly. © 2001 Elsevier Science Ireland Ltd.

Background. Clinical advantages of extensive screening for occult cancer in patients with idiopathic Deep Vein Thrombosis (DVT) is still debated since this approach improves early detection of cancer but not cancer-related mortality. Recently, we have demonstrated that patients with Residual Vein Thrombosis (RVT), 3 months after DVT, have a high risk for cancer in the subsequent 2 years (Siragusa S et al. Blood2005;106(11):OC262). At the present it is unknown whether RVT assessment may be used to select patients, with idiopathic DVT, who require screening for occult cancer. Objective of the study. We conducted a prospective study evaluating whether a RVT-based screening for cancer is sensitive and influences cancer-related mortality. Study design. Prospective with two cohorts of DVT patients: the first cohort was monitored for clinical overt cancer only (Group A), while the second (Group B) received complete screening for occult neoplasm and subsequent surveillance. Materials and methods. Consecutive patients with a first episode of DVT who presented RVT after 3 month of anticoagulation and without signs and/or symptoms for overt cancer. Screening for occult cancer was based on: ultrasound and/or CT scan of the abdomen and pelvis, gastroscopy, colonoscopy or sigmoidoscopy, hemoccult, sputum cytology and tumor markers. These tests were extended with mammography and Pap smear for women and ultrasound of the prostate and total specific prostatic antigen (PSA) for men. All investigations had to be completed within four-weeks from the assessment of RVT. All patients were followed-up for at least 2 years. Incidence and cancer-related mortality was compared between the two groups by survival curves (Kaplan-Mayer) and related Breslow test for statistics. Results. Over a period of 6 years, 345 patients were included in the analysis: first cohort included 213 patients (Group A), second cohort 132 (Group B). Clinical characteristics between groups were homogenous. During the follow-up, 8.4% of patients developed overt cancer in group A; in group B, 8.3% of patients had diagnosed cancer at the moment of extensive screening while one new case (0.7%) occurred during the follow-up (Table). The sensitivity of this approach was 91.6% (95% confidence intervals 74.7–108.5). Cancer-related mortality was 6.5% in group A and 3.0% in group B (p< 0.001) (Figure). Conclusions. Our study demonstrates that RVT-based screening for occult cancer improves early detection as well as cancer-related mortality. Cancer events during surveillance Characteristic Group A (n= 213) Group B (N= 132) *4+0.5 months. **At least 24 months Cancer, No (%) at screening time* - - **10 (8.3) Cancer, No (%) during clinical surveillance** 18 (8.4) 1 (0.7) Density incidence (cases x 1000 p/y) 41.9 40.3 Mean time cancer diagnosis (months ±SD) 6.9 (1.3) 3.6 (0.7) Cancer-related mortality, No (%) 14 (6.5) 4 (3.0) Cancer-related mortality, mean time (months ±SD) 19 (3.4) 18 (2.8) Figure: Cancer - related mortality Figure: Cancer - related mortality

Abstract 1244 Introduction. We tested the efficacy and safety of fixed doses of Low-Molecular Weight Heparin (LMWH) in cancer patients requiring interruption of Vitamin-k Antagonist (VKA) because of invasive procedures (defined as major and non major surgery) or chemotherapy inducing platelets depletion. Methodology. Cancer patients were defined to be at high (atrial fibrillation [AF] with previous stroke, prosthetic mitralic valves and venous thromboembolism [VTE] lasting < 3months) or low risk of thrombosis (AF without previous stroke, VTE lasted > 3 months, and prosthetic aortic valves). They discontinued VKA 5 + 1days before surgery or chemotherapy; in those at low-risk for thrombosis, LMWH was given at a prophylactic dosage of 3.800 U.I. (nadroparin) or 4.000 U.I. (enoxaparin) anti-FXa once daily the night before the procedure or the beginning of chemotherapy. In patients at high-risk for thrombosis, LMWH was started early after VKA cessation (when an INR < 1.5) and given at fixed sub-therapeutic doses (3.800 or 4.000 UI anti-FXa twice daily) until procedure or beginning of chemotherapy. In patients undergoing procedures, LMWH was reinitiated 12 hours after procedure while VKA the day after; in patients receiving chemotherapy, LMWH was reinitiated 12 h after a stable platelet count > 30.000 mmc3 and VKA 12 h after a stable platelet count > 50.000 mmc3. Heparin was continued until a therapeutic INR value was reached. The primary efficacy endpoints were the incidence of thromboembolism and major bleeding from VKA suspension to 30 + 2 days post-procedure or next chemotherapy. Results. A total of 156 patients (68, 53.9% at low-risk and 58, 46.1% at high-risk for thrombosis) were enrolled (Table 1); 44 (28.2%) underwent major surgery, 53 (33.9%) non-major surgery and 29 (18.5%) chemotherapy. Overall, thromboembolic events occurred in 5 patients (3.2%, 95% confidence intervals 0.5–5.9), 4 belonging to high-risk and 1 to low-risk group. Overall, major bleeding occurred in 5 patients (3.2%, 95 CI 0.5–5.9), all belonging to high-risk group (3 during major surgery and 2 during chemotherapy). The mean time of anticoagulation with LMWH was 7.5 days in patients underwent procedures and 13.2 days in those who received chemotherapy. Conclusion. LMWH given at fixed sub-therapeutic doses appears to be a feasible and relatively safe approach for bridging therapy in chronic anticoagulated cancer patients requiring VKA interruption. Disclosures: No relevant conflicts of interest to declare.

Abstract 190 Type and duration of anticoagulation is still matter of debate in cancer patients with acute Deep Vein Thrombosis (DVT) of the lower limbs. Residual Vein Thrombosis (RVT) has been proven to be effective for assessing the optimal duration of oral anticoagulants in non cancer patients (Siragusa S et al Blood 2008:112:511-5). In the present study we evaluate the role of a RVT-based management of anticoagulation with Low-Molecular Weight Heparin in cancer patients with acute DVT. Materials and Methods. Patients with active cancer and a first episode of DVT were treated with LMWH for 6 months (the first month at full dosage followed by dose reduction of 25% in the next 5 months). At the end of treatment, they were managed according to RVT findings: those with RVT were randomized to continue anticoagulants for 6 additional months (Group A1) or to stop it (Group A2), while patients without RVT stopped LMWH (Group B). Outcomes were recurrent venous thromboembolism and/or major bleeding; patients were followed up for one year after LMWH discontinuation. Results. Over a period of 36 months, 409 patients were evaluated; 62 were excluded (refusal, need for continuing anticoagulation, etc). In total, 347 were included in the study (Table 1). RVT was detected in 242 (69.7%) patients; recurrent events occurred in 21.9% of those randomized to discontinue and 14.2% of those who continued LMWH. In patients without RVT (105, 30.3%), recurrent events occurred in 3 cases (2.8%) (Table 2 and Figure 1). The adjusted Hazard Ratio (HR) for age and sex between RVT groups (Group A2 vs A1) was 1.58 (95% confidence interval [CI], 0.85–2.93; P=.145). The adjusted HR between group A1 versus RVT-negative group (B) was 4.54 (CI 2.3–6.66; P =.028). Five major bleeding events occurred in Group A1 and two events both in Group A2 and B (Table 2). Overall, 89 (25.6%) patients died due to cancer progression after a median follow-up of 10.2 months after heparin withdrawn. Conclusions. The Cancer DACUS is the first ever study evaluating an individual marker for assessing duration of anticoagulation in active cancer population. Final results of the study show that absence of RVT identifies a group of patients at low risk for recurrent thrombosis who can safely stop LMWH after 6 months. Disclosures: No relevant conflicts of interest to declare.

The association between Polycythemia Vera (PV) and thrombosis is multi-factorial involving the complex interaction between activated leukocytes, platelets and endothelium. Recent reports have postulated that PV patients may over express adhesive molecules on red cell surface, likely by JAK2 mutation (Wautier M et al. Blood.2007;110(3):894–901). This process activates endothelium with production of vascular growth factors and other mechanisms leading to atherosclerosis. Aortic Stenosis (AS) is the commonest valvular heart disease in western countries; its pathogenesis is mainly related to a degenerative process sharing many characteristics with atherosclerosis. At the present is not known whether patients with PV are at high risk of developing AS. Objective of the study. We perform a case-control study for evaluating rate of AS and its correlation with blood cells count and mutational status in patients with PV. Materials and methods. Prevalence of AS among PV patients have been compared with control patients matched for age, cardiovascular risk factors (hypertension, hyperlipidemia, diabetes, smoke and alcohol abuse) and coexisting cardiac diseases (i.e. heart failure). Diagnosis of PV has been posted accordingly to PVSG criteria. Diagnosis and severity of AS has been posted by echocardiography: stenosis with a valve area Results. Over a period of 18 months we recruited 43 PV patients (28 males and 15 females) and 74 controls. No differences were found in regard of the above cited characteristics; median age was 66.7 among PV patients and 68.2 among controls. The average duration of PV was 5.7 years with an average follow-up of 2.5 years. Most of the PV patients were on antiplatelet/anticoagulant therapy (27/43, 62.7%) and have been treated with cytoreductive therapy. Twelve (27.9%) had a thrombotic event before PV diagnosis; 4 (9.3%) developed thrombosis during the follow-up (median 1.3 years). A moderate/severe AS was found in 11 PV patients (25.6%) in comparison to 4 (5.4%) in control group (P= 0.023), thus giving a Relative Risk of 4.7. Among PV patients, the multivariate analysis did not show any correlation regarding JAK2 V617F mutational status, duration of disease, previous thrombosis, cytoreductive therapy and other common cardiovascular factors. Comparison of laboratory findings is reported in Table 1; a not significant trend was demonstrated in favor of patients with elevated hematocrit (>55%). Conclusions. Our study clearly shows that PV patients carry a fourfold risk of developing AS, without a clear association with blood cell alterations or previous thrombosis. Whether high prevalence of AS may be related to expression of adhesive molecules on red cells or altered share stress is currently under investigation. Table 1. Comparison of laboratory findings between PV patients with and without AS Laboratory parameter* PV patients with AS (11) PV patients without AS (32) Relative Risk P value *At diagnosis Legend: PV (Polycythemia Vera), AS (Aortic Stenosis) White blood cell×109/L (mean± SD) 9520 ± 1230 12.900 ± 2120 0.73 .078 Hemoglobin, g/dL (mean ± SD) 17.5 ± 1.3 17.1 ± 1.2 1.02 .088 Hematocrit, % (mean ± SD) 56.2 ± 0.6 51.1 ± 0.8 1.1 0.06 Platelets × 109/L(mean ± SD) 415.9 ± 43 353 ± 55 1.1 0.76 JAK2 V617F, n/N (%) 11/11 (100%) 31/32 (97%) -

Background. The optimal duration of Oral Anticoagulant Therapy (OAT) for Deep Vein Thrombosis (DVT) can be tailored by Residual Vein Thrombosis (RVT) (Siragusa S et al. Blood2003;102(11):OC183), a marker able to assess the individual risk for recurrent thrombosis. However, in patients with idiopathic DVT the safety of early interruption of OAT, because of absence of RVT, is still debated. Objective of the study. In the present study, we evaluated the safety of withholding OAT, in patients with idiopathic DVT and without RVT, three months after the index thrombotic episode. Study design. Prospective controlled study with two groups: patients without RVT stopped OAT after 3 months while those with RVT continued for additional 3 months. Materials and Methods. Consecutive patients with a first episode of idiopathic DVT of the lower limbs; patients with cancer or known thrombophilia were excluded. At the third months of OAT, RVT was assessed as previously described; briefly, RVT was considered absent when a clot occupying less than 40% of the vein lumen was detected by compression ultrasonography. Events, classified as recurrent DVT and/or Pulmonary Embolism (PE) and/or major and minor bleeding were evaluated; all patients were followed-up for at least 12 months after OAT discontinuation. Results. During the period 1999–2006, 518 patients were included in the study. In 206 (39.7%) RVT was considered absent (RVT negative group) and they stopped OAT; the remaining 312 patients continued anticoagulants for additional 3 months (RVT positive group). Total duration of follow-up (FU) was 184.7 years for RVT negative group (with a mean FU of 3.0 ± 0.83 years) and 191.3 years for RVT positive group (with a mean FU of 3.1 ± 0.89 years). The rate and type of events during FU is reported in table and figure. Conclusions. This investigation shows that in patients without RVT, three months of OAT are safe even after an episode of idiopathic DVT. This hold for at least 30% of the entire DVT population and has an important clinical impact; in fact, it is possible to select a group of patients with a very low risk for recurrences over a period of 3 years. This approach carries also a negligible risk for bleeding. Events between RVT Negative and Positive Groups Outcomes RVT Neg. group (206) RVT Pos. group (312) "p" value *After OAT discontinuation, **During OAT Recurrences, n/total (%)* 2/206 (0.9) 63/312 (20.2)