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Acute thrombotic thrombocytopenic purpura (TTP) is a life-threatening emergency and plasma exchange (PEX) is the initial treatment shown to reduce acute mortality.To compare current practice in the United Kingdom (UK) against the standards set out in the 2012 British Society of Haematology guideline, and to better understand the issues affecting prompt initiation of PEX.The trainee research network HaemSTAR conducted a retrospective nationwide review of adults presenting to UK hospitals with a first episode of acute TTP.Data on 148 patients treated at 80 UK hospitals between 2014 and 2019 demonstrated that 64.8% of patients received PEX within 24 h. Diagnostic uncertainty was the most commonly cited reason for delayed treatment. Conversely, a shorter time to PEX occurred in patients who had red cell fragments or severe thrombocytopenia identified on their first complete blood count. Availability of on-site PEX was associated with a greater proportion of patients receiving PEX within 8 h compared to patients transferred, but by 24 h there was no difference between the two groups and two-thirds of all patients had received their first PEX. The mortality rate for patients that received PEX was 9.2%, with 27.8% of deaths linked to delayed treatment initiation.This is the first multi-center evaluation of treatment delays in acute TTP and it will inform targeted pathways to improve prompt access to life-saving intervention.

Intravenous immunoglobulin (IVIg) is a common therapy for patients with immune thrombocytopenia (ITP). The initial response rate for IVIg is 80%[1][1] and is typically rapid, with some patients responding in 24 hours, although usually in 2–4 days.[2][2] When IVIg is used alone, the response is

Introduction Current treatment options for myelofibrosis (MF) are diverse; apart from rare patients who are eligible for allogeneic transplantation, active treatments are focused on controlling MF-related symptoms and are not disease modifying. Patients who are initially asymptomatic and those at low risk for progression are usually observed without active treatment (watch and wait) until the appearance of symptoms or progression. There are limited real-world data on the management of patients with MF in the United Kingdom (UK). The REALISM UK study documented the early management pathways for patients with MF in routine clinical practice. Method REALISM UK was a multi-centre, retrospective, non-interventional study in 15 UK secondary care centres. Eligible patients were those aged ≥18 years at diagnosis of MF, with diagnosis >6 months and ≤5 years prior to data collection and with ≥1 follow-up visit. Data on patient demographics, clinical characteristics, MF management strategies and outcomes were collected from patients' medical records; the observation period was from the date of MF diagnosis until data collection. The primary endpoint was the time from diagnosis to active treatment. Watch and wait strategies included supportive therapies (blood transfusions, erythropoiesis-stimulating agents, and steroids). Results A total of 200 patients were recruited (63% [n=126/200] with primary MF (PMF); 37% [n=74/200] with secondary MF). The median age at MF diagnosis was 69.7 years (interquartile range [IQR] 63.5-75.7) and 71% (n=141/200) had a JAK2 mutation. At diagnosis, 52% (n=104/200) of patients had International Prognostic Scoring System (IPSS) categories of intermediate-2 (Int-2) or high. Common documented features of disease at diagnosis included an enlarged spleen (47%, n=94/200), anaemia (44%, n=88/200), and constitutional symptoms (e.g. night sweats, unexplained fever, or weight loss [30%, n=60/200]). The median (IQR) time to first active treatment was 46 days (range 0-350) in the total population; patients with higher risk disease were prescribed active treatment sooner: IPSS low, 136.5 days (range 0-625; n=26); IPSS Int-1, 90 days (range 0-494; n=70); IPSS Int-2, 0 days (range 0-252; n=65); IPSS high: 0 days (0-216; n=39). The choice of first management strategy by IPSS at diagnosis is shown in Table 1. During the study period, watch and wait was the first management strategy for 54% (n=107/200) of patients, with the median (IQR) time from diagnosis to active treatment in this group being 322 (130-610) days. Constitutional symptoms were recorded in 20% (n=21/107) of patients for whom watch and wait was the first management strategy. Active treatment was started at diagnosis for 47% (n=93/200) of patients, with the most commonly used medications being hydroxycarbamide (22.5% [n=45/200]) and ruxolitinib (17.5% [n=35/200]). The median (IQR) treatment duration during the study observation window was 346 days (range 121-768) for hydroxycarbamide and 375 days (range 172-691) for ruxolitinib. In total, 5.5% (n=11/200) of patients were recorded as having undergone allogenic stem cell transplantation during the observation period. Conclusion Clinicians in the UK apply a broad range of management strategies for the treatment of patients with MF. Many patients were observed without active treatment following diagnosis, despite having symptomatic disease. The most common active treatments as first management strategies were hydroxycarbamide and ruxolitinib. Disclosures Mead: Pfizer: Consultancy; Novartis: Consultancy, Honoraria, Other: Travel/accommodation expenses, Research Funding, Speakers Bureau; Bristol Myers-Squibb: Consultancy. Somervaille:Novartis: Consultancy, Honoraria. Butt:Novartis: Consultancy, Honoraria, Speakers Bureau. Whiteway:Novartis: Consultancy, Honoraria, Speakers Bureau. Kirkpatrick:Novartis: Consultancy, Honoraria. Roughley:Novartis: Consultancy, Honoraria. Ewing:Novartis: Honoraria, Other: Meeting attendance sponsorship ; Bristol Myers-Squibb: Other: Meeting attendance sponsorship . Garg:Novartis: Consultancy, Honoraria. Harrison:Promedior: Honoraria; Shire: Speakers Bureau; Sierra Oncology: Honoraria; Celgene: Honoraria, Speakers Bureau; Roche: Honoraria; Novartis: Honoraria, Research Funding, Speakers Bureau; Incyte: Speakers Bureau; Gilead: Speakers Bureau; CTI: Speakers Bureau; AOP: Honoraria; Janssen: Speakers Bureau. Bains:Novartis: Employment. Chiu:Novartis: Employment. Hickey:OPEN VIE: Employment.

Background: Patients with lower-risk MDS (LR-MDS) are prone to iron toxicity due to long-term iron accumulation either caused by RBC transfusions or ineffective erythropoiesis. Nontransferrin bound iron (NTBI), including labile plasma iron (LPI), are toxic iron species that may mediate cellular damage via oxidative stress. The EUMDS registry collects prospective observational data on newly diagnosed LR-MDS patients from 145 centers in 17 countries since 2008. Methods: We analyzed serum from 247 LR-MDS patients collected at six-month intervals for ferritin, transferrin saturation (TSAT), hepcidin-25, soluble transferin receptor (sTfR) and toxic iron species (NTBI and LPI) in order to evaluate temporal changes in iron metabolism, the presence of potentially toxic forms of iron and their impact on survival, and quality of life. In addition, we measured the impact of iron chelation on the iron species levels and its impact on the outcome parameters. Results: The median age was 73 years (range: 37 to 95 years) and 66% were males. WHO2001 MDS-subtypes were RCMD (45%), RARS (22%), RA (18%), RAEB-1 (7%), 5q-syndrome (4%) and RCMD-RS (4%). The IPSS-R categories were: (very) low risk: 66%; intermediate risk: 11%; (very) high risk: 2% and unknown: 20%. The median EQ5D index score was 0.80 (p10 to p90: 0.52 to 1.00). The table shows iron parameters at registration, 1 and 2 years follow-up both in transfusion-dependent (TD) and transfusion-independent (TI) patients and according to: MDS-RS (RARS/RCMD-RS) or MDS Other (RA/RCMD/RAEB/5q-syndrome). Mean serum ferritin levels were increased in TD patients, compared to TI patients (Table). Increase of ferritin levels over time was high in both TD groups, but the increase was more pronounced in the RS subgroup. Elevated CRP levels (> 10mg/L) were observed in TD nonRS patients, especially during the first year after diagnosis. Markedly increased mean TSAT levels (>75%) occurred in the subgroup of TD-RS patients throughout the observation period. Hepcidin levels were most markedly elevated in TD nonRS patients at registration and remained elevated during follow-up (Table). Hepcidin levels were low in MDS-RS TI patients at all time points compared to nonRS MDS patients and decreased over time as a result of an increased (ineffective) erythropoiesis (Table). This is supported by the highest levels of STfR also noted in this patient category (data not shown). The highest NTBI and LPI levels were observed in TD-RS patients compared to the other 3 subgroups (Table). Both NTBI and LPI levels had a strong correlation (p 80%) occurred almost exclusively in patients with MDS-RS and/or previous transfusions. Both the EQ5D index score and EQ-VAS showed a negative correlation (r) with LPI levels with r = -0.09 (p = 0.028) and r = -0.07 (p=0.046) respectively. This negative effect of elevated LPI levels was most pronounced in the TD RS subgroup with a negative correlation of -0.17 for the EQ5D index score and -0.2 for the VAS score. In total 16 patients received iron chelation during the sample collection period (11 patients deferasirox, 4 patients desferioxamine and 1 patient unknown). LPI levels were normal in 14 out of the 17 samples collected during deferasirox treatment and in 2 out of 5 samples collected during desferoxamine treatment. The Kaplan-Meier curves (Figure) demonstrate the prognostic impact of elevated LPI levels by transfusion status as a time dependent variable; once a subject had an elevated LPI level, they remained in this group. Patients were censored at time of starting iron chelation (16 patients). In a multivariate analysis comparing elevated LPI levels and transfusion dependency to the control group with undetectable LPI and no transfusion showed a significantly decreased survival in all 3 risk groups after adjustment for age at diagnosis, baseline IPSS-R category and ESA treatment status; for details, see supplementary table. Conclusion: This study illustrates labile plasma iron species as a clinically relevant assay for identification of the toxic fraction of overt iron overload and its negative impact on HRQoL and overall survival in transfusion dependent and transfusion independent patients. Table. Table. Disclosures Culligan: Merck Sharp & Dohme (MSD): Honoraria; Abbvie: Other: Support to attend conferences; Takeda: Honoraria, Other: Support to attend conferences; Pfizer: Honoraria; Celgene: Other: Support to attend conferences; JAZZ: Honoraria; Daiichi-Sankyo: Other: Support to attend conferences. Garelius:novartis: Honoraria. de Witte:Celgene: Honoraria, Research Funding; Novartis: Research Funding; Amgen: Consultancy, Research Funding.

Improve stroke prevention in atrial fibrillation (AF) patients. AF patients on warfarin who visited Bradford Anticoagulation Clinic between January and December 2013 were listed randomly, then the first 200 patients were selected. Time in therapeutic range (TTR) over that year was calculated for each patient using the Rosendaal method. Exclusion criteria: 1. Patients recently started on warfarin (within 6 weeks). 2. Patients with a target international normalised ratio (INR) range other than 2.0–3.0. …

Aicardi-Goutieres syndrome is an inflammatory disease occurring due to mutations in any of TREX1, RNASEH2A, RNASEH2B, RNASEH2C, SAMHD1, ADAR or IFIH1. We report on 374 patients from 299 families with mutations in these seven genes. Most patients conformed to one of two fairly stereotyped clinical profiles; either exhibiting an in utero disease-onset (74 patients; 22.8% of all patients where data were available), or a post-natal presentation, usually within the first year of life (223 patients; 68.6%), characterized by a sub-acute encephalopathy and a loss of previously acquired skills. Other clinically distinct phenotypes were also observed; particularly, bilateral striatal necrosis (13 patients; 3.6%) and non-syndromic spastic paraparesis (12 patients; 3.4%). We recorded 69 deaths (19.3% of patients with follow-up data). Of 285 patients for whom data were available, 210 (73.7%) were profoundly disabled, with no useful motor, speech and intellectual function. Chilblains, glaucoma, hypothyroidism, cardiomyopathy, intracerebral vasculitis, peripheral neuropathy, bowel inflammation and systemic lupus erythematosus were seen frequently enough to be confirmed as real associations with the Aicardi-Goutieres syndrome phenotype. We observed a robust relationship between mutations in all seven genes with increased type I interferon activity in cerebrospinal fluid and serum, and the increased expression of interferon-stimulated gene transcripts in peripheral blood. We recorded a positive correlation between the level of cerebrospinal fluid interferon activity assayed within one year of disease presentation and the degree of subsequent disability. Interferon-stimulated gene transcripts remained high in most patients, indicating an ongoing disease process. On the basis of substantial morbidity and mortality, our data highlight the urgent need to define coherent treatment strategies for the phenotypes associated with mutations in the Aicardi-Goutieres syndrome-related genes. Our findings also make it clear that a window of therapeutic opportunity exists relevant to the majority of affected patients and indicate that the assessment of type I interferon activity might serve as a useful biomarker in future clinical trials. (c) 2015 Wiley Periodicals, Inc

PB 2.54-1. Bauduer, F., Guichandut, J.P. & Ducout, L. (2004) Successful use of fresh frozen plasma and desmopressin for transurethral prostatectomy in a French Basque with combined factors V + VIII deficiency. Journal of Thrombosis and Haemosta

SAMHD1 is a deoxynucleoside triphosphate triphosphohydrolase and a nuclease that restricts HIV-1 in noncycling cells. Germ-line mutations in SAMHD1 have been described in patients with Aicardi-Goutières syndrome (AGS), a congenital autoimmune disease. In a previous longitudinal whole genome sequencing study of chronic lymphocytic leukemia (CLL), we revealed a SAMHD1 mutation as a potential founding event. Here, we describe an AGS patient carrying a pathogenic germ-line SAMHD1 mutation who developed CLL at 24 years of age. Using clinical trial samples, we show that acquired SAMHD1 mutations are associated with high variant allele frequency and reduced SAMHD1 expression and occur in 11% of relapsed/refractory CLL patients. We provide evidence that SAMHD1 regulates cell proliferation and survival and engages in specific protein interactions in response to DNA damage. We propose that SAMHD1 may have a function in DNA repair and that the presence of SAMHD1 mutations in CLL promotes leukemia development.

Comparatively little is known of the cytogenetics of Waldenstrom macroglobulinemia (WM). This is primarily due to the low proliferation of the clonal B cells, which precludes conventional karyotyping in many cases. Translocations involving the immunoglobulin heavy chain (IGH) gene at 14q32 are characteristic of many B-cell lymphomas and myelomas. Initial reports suggested that the t(9;14) was characteristic of lymphoplasmacytic lymphoma (the underlying pathological diagnosis in WM), but subsequent studies have failed to confirm the uniqueness of the translocation. To clarify this, we examined 69 cases of WM with interphase fluorescence in situ hybridization and failed to demonstrate an IgH translocation in 67 (97%). We conclude that IGH translocations are not a feature of WM, and the implications of this finding are discussed.

Abstract 713 Chronic lymphocytic leukaemia (CLL) has a highly variable clinical course. Recent whole genome sequencing (WGS) data reflects this heterogeneity revealing low level recurrent somatic mutations (Puente Nature 2011, Quesada Nat Gen 2011, Wang NEJM 2011, Schuh Blood 2012). Our WGS study of sequential samples from 3 patients revealed candidate founder mutations that were present in all cells at all time-points. We focus on one of the genes affected by founder mutations; SAMHD1. SAMHD1 has been identified as an anti-viral restriction factor that targets HIV-1 by blocking reverse transcription of viral RNA (Laguette Nature 2011, Hrecka Nature 2011). The recently elucidated triphosphohydrolase activity of SAMHD1 leads to depletion of deoxynucleotide triphosphates (dNTP) during reverse transcription, thus interrupting the viral replication cycle before integration into the genome (Goldstone Nature 2011). In constitutional disease, recessive mutations in SAMHD1 have been implicated in deregulation of the innate immune response and development of a congenital autoimmune encephalopathy, Aicardi–Gouti ères syndrome (AGS) (Crow Hum Mol Gen 2009). In our single institutional cohort of 100 1st line and relapsed CLL patients we identified 8 patients with acquired mutations in SAMHD1, of which 6 were chemorefractory (Table 1). This is much higher than the expected frequency of 25% chemorefractory patients in this cohort (Knight Leukemia 2012), implying a correlation between SAMHD1 mutations and poor outcome. In order to precisely establish the incidence of SAMHD1 mutations in patients requiring 1st line treatment, we sequenced 200 samples from patients recruited into first line UK clinical trials. We determined a mutation frequency of 3% (Table 1). Whole genome SNP arrays on our SAMHD1 mutated patients reveals monoalleleic deletions or copy neutral loss of heterozygosity at the SAMHD1 locus in 14 of 15 samples. TABLE 1: SAMHD1 mutated patients Sample Age IgHV mutation TP53 disruption Clinical Status Mutation 1 72 U Neg Pre Treatment c.-166G>T 2 72 M Neg Refractory M1K K523X 3 NK U Neg Refractory Y155C 4 65 U Neg Refractory R145X 5 NK NK NK Pre Treatment R145Q 6 63 U Neg Pre Treatment I136T 7 77 M Neg Refractory E355K 8 68 U Neg Refractory L431S 9 72 U Neg Refractory F545L 10 NK NK NK Pre Treatment W572X 11 69 NK NK Pre Treatment N/A 12 66 M Pos Refractory T365P 13 NK NK Neg Pre Treatment R371H 14 77 M Neg Refractory N/A 15 25 NK Neg AGS N/A U=Unmutated, M=Mutated. Next, we questioned whether patients with congenital SAMHD1 mutations are more susceptible to developing B-cell malignancies. We reviewed 20 patients with AGS and homozygous SAMHD1 mutations. Intriguingly, 2 of these patients have developed a B-cell malignancy. One of these patients presented at 1 month of age with features typical of AGS and has been subsequently diagnosed with CLL at the age of 25. Sequencing the SAMHD1 locus of both germline and CLL cells from this patient confirmed the homozygous 1609-1G4C mutation. We screened the patient's CLL cells for acquired mutations recently found to be recurrent in CLL. None of these genes were mutated suggesting the SAMHD1 germline mutation was sufficient to cause CLL. In addition, whole exome analysis is in progress for a more complete view of acquired mutations potentially contributing to CLL pathogenesis. To evaluate the interplay of recurrent somatic mutations in CLL in the context of our SAMHD1 mutations, we used a custom designed targeted sequencing panel (TruSeq Custom Amplicon, Illumina). SAMHD1 mutations were found exclusively in SF3B1 negative patients. Only one SAMHD1 patient had a TP53 mutation. To begin to functionally define the role of SAMHD1 mutations in CLL, we examined the impact of SAMHD1 mutations on SAMHD1 mRNA gene expression by quantitative PCR analysis of purified CLL cells and normal B cell controls. Expression in the mutated CLL cells was significantly lower compared to normal B cells. From this, we hypothesise that CLL cells with SAMHD1 mutations might show an increase in intracellular dNTP levels. We are currently evaluating the levels of dNTPs using a custom designed qPCR to measure dNTP incorporation onto template DNA. In conclusion, we provide the first evidence that the lentiviral restriction factor and dNTP triphosphohydrolase SAMHD1 acts as a tumour suppressor in human B cells. We propose that deregulation of the dNTP pool in B cells caused by mutations in SAMHD1 might contribute to lymphomagenesis. Disclosures: Ross: Illumina: Employment. Bentley:Illumina: Employment. Hillmen:Alexion Pharmaceuticals, Inc: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees.

myeloma. The role of surgery in addition to radiotherapy for the management of MSCC continues to be debated [2,3]. The most persuasive evidence for the benefit of surgery in addition to radiotherapy for the management of MSCC came in 2005 from a randomised trial of 101 patients that showed improved functional outcomes and survival for MSCC managed by decompressive surgery followed by radiotherapy compared with radiotherapy alone [4]. However, this study was limited to highly selected patients recruited over 10 years and has been criticised on several methodological grounds [2]. Importantly in the context of myeloma, the trial excluded patients with haematological malignancies. Rades et al. [3] carried out a retrospective review of the outcome of 521 patients with less than three vertebral metastases with MSCC managed with radiotherapy alone. This series included 63 patients with myeloma/lymphoma (grouped together for analysis); 76% of the myeloma/ lymphoma patients experienced an improvement in motor function, 2% deteriorated and local control (defined as the absence of recurrence or progression of motor defects) was achievedin98%at1year.Onmultivariateanalysis,myeloma/ lymphoma was a highly significant factor predicting a favourable functional outcome. The authors highlighted myeloma/lymphoma patients as a group that should be managed with radiotherapy alone. These results are supported by a subsequent retrospective matched pair analysis of 324 patients with MSCC [2]; in this series the outcomes (motor function, ambulatory status, regaining ambulation, local control and survival) after radiotherapy alone were similar to those after surgery and radiotherapy. In the 48 patients in the series with myeloma/lymphoma, motor function improved in 63% and deteriorated in 2% of patients, with a high local control rate of 95% at 1 year of follow-up. The optimal radiotherapy dose fractionation schedule is uncertain in MSCC. In a retrospective multinational study of 172 myeloma patients with MSCC, a functional improvement after radiotherapy alone was observed in 52% of patients and 47% of non-ambulatory patients regained the ability to walk at 4 months [5]. A functional improvement was more common after long-course than short-course radiotherapy (76 versus 40% at 12 months, P¼0.003). The authors concluded that a schedule of 30 Gy in 10 fractions over 2 weeks was appropriate for myeloma MSCC. In summary, we believe that the current evidence does not support the use of surgical decompression in myeloma patients with MSCC; these patients are adequately managed with radiotherapy. Exceptions include patients with spinal instabilityand/orbonycompression(uncommoninmyeloma). Vertebroplasty and kyphoplasty remain useful options after radiotherapy if pain control has not been achieved.

A 60-year-old woman was admitted with dysarthria, unsteady gait and limb weakness. She had been diagnosed 5 years previously with symptomatic IgG k multiple myeloma and had been treated with ABCM [adriamycin, BCNU (carmustine), cyclophosphamide, melphalan], melphalan autograft, alphainterferon maintenance and a combination of cyclophosphamide with dexamethasone for relapsed disease. At this presentation she was transfusion-dependent despite erythropoietin/granulocyte colony-stimulating factor support and her general health was deteriorating. On examination she had dysarthria and an ataxic gait. Investigations showed a stable IgG paraprotein of 22 g/l. Preand post-contrast head computed tomography was normal. A magnetic resonance imaging scan of her head demonstrated marked meningeal enhancement, particularly in the posterior fossa, consistent with leptomeningitis (left image, post gadolinium contrast). A lumbar puncture was performed and showed a low glucose (0AE5 mmol/l), a high protein (2AE3 g/l) and a high white cell count. The cerebrospinal fluid cytology showed a large number of plasma cells, all with a neoplastic phenotype CD19–56+/) (right image). Treatment options were discussed and she was treated palliatively with dexamethasone and died peacefully 12 d after this presentation.