Introduction: The rates of request and use of blood concentrates are still poorly reported in the literature. This study aimed to analyze the rates of requests for blood concentrates and their use in patients undergoing emergency surgery in a teaching hospital. Methods: A retrospective, quantitative and descriptive study was conducted in 359 medical records of patients in urgent surgery scheduled with a request for a reserve of blood concentrate. The ratios between crossmatched and transfused units (C/T), transfusion index (TI), and probability (TP) were calculated, and the times between request and delivery at the transfusion agency (TA) and patient admission to the surgical center (SC). Results: The mean age was 58.5 (22.2) years, with the majority being male (53.1%). There was an average of 27.5 monthly requests (min 12, max 44). Ninety-seven units of blood concentrates were transfused into 44 patients (C/T ratio 7.59; TI 0.27; TP 12.3%). Only seven patients had their requests made after admission to the OR. The median time between the request and arrival at the TA was 1h15min, while that between the request and the patient's arrival at the SC was 5h23min. There was greater transfusion in major surgery (major 37, 14.8% vs. medium 7, 6.5%; p = 0.027) and non-orthopedic surgery (orthopedic 9, 4.0% vs. non-orthopedic 35, 26.9%; p < 0.001). Conclusion: there was a significant discrepancy between the number of requests for blood reservation and its real use and an increased time between reservation requests and their arrival at the TA.

Introduction: Hemolytic Uremic Syndrome (HUS) is a rare thrombotic microangiopathic disease characterized by hemolytic anemia, thrombocytopenia, and acute renal failure occurring after infection with a Shiga-like toxin producing bacteria. Patients without evidence of infection with such kind of bacteria are described as having atypical HUS (aHUS). aHUS can be classified as sporadic or familial, and both conditions are associated with complement abnormalities, more specifically with dysregulation of the alternative complement pathway. Familial aHUS is caused, most of the times, by either gain of function mutations in activators of complement or loss of function mutations in complement regulators. Among others, the genes commonly mutated in a HUS are CFH, C3, CFB, MCP and etc. Here we describe a novel mutation in C3 present in a patient with familial aHUS, and the successful treatment of this patient with the complement inhibitor Eculizumab. Report: A 40-year-old female presented at the emergency room with headache and anasarca. Physical exam was consistent with hypertension, pale skin and mucous membranes. Blood tests revealed renal insufficiency, anemia and low platelet counts. She had no history of infections. The first diagnostic hypothesis was thrombotic thrombocytopenic purpura and she was started on plasmapheresis and hemodialysis. She was discharged 40 days later with clinical improvement. One week after discharge she was admitted at our hospital with recurrence of the clinical picture. Blood tests at admission showed hemoglobin = 7,8 g/dL, platelet counts = 70.000 / uL, LDH = 1024 U/L, Creatinine = 4, 19 mg/dl, ADAMTS13 activity = 79%, C3 = 29,5 mg/dL, C4 = 16.2 mg/dL and factor H = 212 µg/mL. The patient informed that her mother and five aunts, died around 40 to 50 years of age due to renal insufficiency. Plasmapheresis and hemodialysis were resumed and she was started on Rituximab 375 mg/m² weekly. After an initial clinical response, but soon anemia, low platelets and high LDH recurred. At that point we made a hypothesis of aHUS, ordered a C3 sequencing and started a therapeutic trial with Eculizumab. She received 900 mg of eculizumab during four weeks, and maintenance of 1200 mg every two weeks. She showed a continuous improvement after the first dose and was discharged after the third dose, without the need for hemodialysis, with a serum creatinine = 2.1 mg/dl, hemoglobin = 711 g/dL, platelet counts = 262.000 / uL and LDH = 1024 U/L. Now, 6 months after discharge she remains in remission of her disease, with normal blood counts and serum creatinine of is 1.6 mg/dL with Eculizumab maintenance at dose of 1200 mg twice a month. The C3 sequencing revealed the following heterozygous mutations in the 6thexon, c.640C>T (p.Pro214Ser). Since this variant has not been previously described in the medical literature, we performed an in silico analysis using Polyphen2 software and the result was probably pathogenic. Discussion: We have presented a patient with aHUS harboring a novel heterozygous mutation in C3. At least 47 C3 mutations have been described at the FH aHUS database (http://www.fh-hus.org/) spanning almost the entire sequence of the gene (from Lys65 to Val1658). The mutation described here is novel and functional studies to characterize its consequences are needed. But the very strong family history, coupled with the clinical evolution of the patient, the in silico protein analysis and the complete response to eculizumab strongly suggests that this variant is pathogenic and may be used in the future as a predictor of response to Eculizumab. Disclosures No relevant conflicts of interest to declare.

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Introduction: The treatment of human hematologic malignancies has rapidly advanced through the application of genomic platforms that have identified drug-able targets and companion diagnostics (e.g. BCR-ABL, IDH-1) and added new classes of targeted agents to the established compendium of cytotoxics. Despite these advances, the complexity, redundancy and promiscuity of cellular transformation remain incompletely understood at the molecular level. This has led to a renewed interest in whole cell experimental models for drug discovery. Laboratory platforms that measure cellular response to cytotoxic insult at the phenotypic level have been shown to correlate significantly with clinical response, and have the capacity to provide insights into chemotherapy selection and drug development. The Ex Vivo Analysis of Programmed Cell Death (EVA/PCD) uses metabolic and morphologic features of drug induced cell death to measure both cytotoxic and targeted drug effects in human primary cultures. We applied EVA/PCD in 20 heavily pre-treated, drug refractory patients from the Hospital Israelita Albert Einstein (HIAE) in Sao Paulo - Brazil. Methods: Peripheral blood, node biopsy or bone marrow aspirates were submitted by overnight courier. Cells isolated by density centrifugation were evaluated by dose response curves that were interpolated to provide LC50 values for comparison with our databases by Z-score. Patients with Acute Lymphoblastic Leukemia (ALL, N=5) , Acute Myeloid Leukemia (AML, N=6), Non-Hodgkin Lymphoma (NHL, N=4) or Multiple Myeloma (MM, N=4) had received a mean of 5, median of 4 (range 1-8) prior therapies, 7 with prior bone marrow transplantation (BMT). Results: of 20 specimens, 16 (80%) provided viable tumor for EVA/PCD. A mean of 8, median of 7(range 3-22) cytotoxics and a mean 7, median of 5(range 1-20) targeted agents were evaluated. Findings were reported by day 7. Nine of 16 patients were treatment candidates, with 5 lost to follow up, 3 dying of sepsis before evaluation and 1 achieving complete remission (CR) with radiation plus Rituximab. Of 7 patients who received assay directed therapy there were 3 CR (43%), 2 partial responses (PR: 28%) and 2 progressive disease (PD: 29%) for an overall response rate of 71%. Conclusion: These results establish the feasibility of laboratory directed therapy in heavily pre-treated patients, with 80% of submitted samples providing actionable results. Although the extremely advanced state of these patients limited the capacity to undergo treatment in some cases, the achievement of CR's and PR's in this drug refractory cohort is of interest. Clinical responses by disease, treatment history and drugs received will be reported. Studies correlating molecular profiles with phenotypic analyses are currently under development. Disclosures Evans: Rational Therapeutics: Employment. Nagourney:Rational Therapeutics: Employment.

Introduction: Hemophagocytic lymphohistiocytosis (HLH) corresponds to a wide array of potentially fatal hyper-inflammatory diseases involving pathologic immune activation and engulfment of hematopoietic cells by activated macrophages. These disorders have common clinical and laboratorial features, such as severe cytopenias, fever, hepatosplenomegaly and hyperferritinemia, leading to a dismal prognosis when treatment is delayed. Secondary hemophagocytic syndromes may develop as a result of strong immunological activation of the mononuclear phagocyte system by underlying conditions, such as infection, autoimmune diseases, malignancies and metabolic disorders. Mortality rates are high, even with proper treatments, and can reach up to 50%, usually within the first two months of the diagnosis. Diagnosis of this condition is difficult and requires a high degree of suspicion, since the diagnostic criteria are non-specific. Up to 30% of patients with confirmed hemophagocytic syndrome do not show this morphologic aspect in bone marrow examination. We report the data of our institution, regarding the clinical aspects, treatment and outcome of patients with confirmed hemophagocytosis in bone marrow aspiration analysis. Objective: To determine clinical aspects underlying the development of secondary hemophagocytosis and the outcome of patients with this condition. Methods: We retrospectively reviewed all bone marrow aspirations conducted from January, 2012 until December, 2013, regardless of diagnosis. A total of 1682 examinations were performed during this period and reevaluated by three specialists. We found 45 patients with cytological evidence of hemophagocytosis. The medical charts of these patients were reviewed and the following data was retrieved: age, gender, presence of fever and hepatosplenomegaly, underlying disease, past medical history, known underlying immunosuppression, treatment and outcome. Laboratory data was evaluated in the day of the bone marrow aspiration or in the two preceding or following days and included: hemoglobin, leucocytes and platelets counts; ferritin; triglycerides; fibrinogen, lactate dehydrogenase. Diagnosis criteria were defined accordingly to the guidelines of the Hemophagocytic Lymphohistiocytosis Study Group, published in 2004, excluding the soluble CD25 and NK cell activity assays that were unavailable. Results: Median age was 52 years old (range <1 year-72 years) and 58% were male. Twenty-six (57%) had a diagnosis of neoplasia (21 hematological and 5 solid organ malignancies), and 3 patients had recently underwent bone marrow transplantation. Eighteen patients (40%) were receiving immunosuppressive therapy. Evidence of ongoing infection was identified in 34 cases (75.5%), and in 61.8% the agent was identified. Viral infections were commonly associated (26%), and in our case series, cytomegalovirus was the most implicated agent (5 cases). Other virus found were Parvovirus B19, H1N1, Parainfluenza, Herpes-Virus 6 and Epstein-Barr Virus. Bacterial and fungal infections were each responsible for 28,8% of the cases, and in 13 cases (38,2%) the agent was not identified. Among the patients who had complete laboratory evaluation (27 patients), we found that only 37% presented with all diagnostic criteria. Mortality rate was 35.5%, and median survival was 23 months (95% CI 22-60), with most deaths taking place in the first two months. None of the patients received specific treatment, being treated exclusively for the underlying conditions. Conclusion: Secondary hemophagocytic syndrome is a rare yet severe condition, usually associated with a high mortality rate. In most cases, the diagnosis is not suspected and proper treatment not applied. Diagnosis criteria lack specificity and are more useful to the diagnosis of familial forms of HLH. The most common underlying conditions appear to be malignancies, infections and transplant-related immunosuppression. Treatment of the underlying conditions alone still retains large failure rates, and efforts must be made to achieve early diagnosis and employment of therapy. Disclosures No relevant conflicts of interest to declare.