Zimelidine is effective in the treatment of depression.' Both zimelidine and its pharmacologically active metabolite norzimelidine act by inhibiting the re-uptake of 5-hydroxytriptamine by neurones.2 In comparison with tricyclic antidepressant drugs zimelidine is fairly free of side effects.' We report two cases in which adverse effects developed during a clinical trial of the drug. Case reportsCase 1-A 34-year-old woman was prescribed zimelidine 200 mg per day for depression of three months' duration. Two weeks later she was admitted to hospital complaining of severe frontal headache and photophobia. The headache had gradually increased over three days, was exacerbated by movement and coughing, and was associated with muscular aches, vomiting, and shivering. The patient was afebrile and full systematic examination showed no abnormality. Lumbar puncture yielded normal cerebrospinal fluid. Results of liver function tests (previously normal) were disturbed, with enzyme activities of: aspartate aminotransferase 56 IU/1; alanine aminotransferase 193 IU/I; and y-glutamyltransferase 173 IU/1. Bilirubin concentration and alkaline phosphatase activity were normal. Zimelidine was withdrawn. The headaches and photophobia subsided over the next week and liver enzyme activities fell progressively to normal over 10 days. All other investigations gave normal results.Case 2-A 44-year-old man presented with one month's history of anxiety and depression. Previous history included gastric surgery seven years earlier and outpatient investigation of headache after head injury (no organic cause found) five years earlier. Two weeks after being prescribed zimelidine 200 mg per day he was admitted to hospital complaining of headache, which had gradually increased in severity over the preceding week. It was worsened by coughing and head movement and was associated with photophobia and muscular aches. He was afebrile and full systematic examination gave normal results, except for a candida throat infection. Lumbar puncture produced normal cerebrospinal fluid at a pressure of 320 mm of cerebrospinal fluid. Liver function tests (previously normal) showed: aspartate aminotransferase 131 IU/1; alanine aminotransferase 333 IU/1; y-glutamyltransferase 140 IU/l; and alkaline phosphatase 210 IU/1. Bilirubin concentration was

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Background The measurement of monoclonal free light chains is being increasingly utilized since the introduction of serum-based assays. It is important for laboratories to determine their own reference ranges in order to reflect the local population. The aim of this study was to determine if age-adjusted reference ranges for serum free light chains would have implications for demand management of further laboratory investigations including immunofixation. Methods After certain exclusions, 4293 samples from individuals seen in primary care across Oxfordshire between 2014 and 2016 were identified for analysis of patient characteristics, serum free light chain results and estimated glomerular filtration rate. Results We found age to be an independent variable when considering serum free light chain concentrations, ratio and estimated glomerular filtration rate. The reference ranges derived from our data differ markedly from the original Binding Site ranges. When the age-specific ranges are retrospectively applied to our population, there is a 38% decrease in follow-up testing with no loss of specificity. Conclusion We feel confident implementing new age-specific serum free light chain reference ranges in our laboratory. We have developed a simple algorithm for evaluating serum free light chains based on age and estimated glomerular filtration rate. We encourage laboratories to establish their own local reference ranges using large cohorts and their chosen serum free light chain assay platform.

Introduction Evaluation of minimal residual disease (MRD) in multiple myeloma (MM) by multi-parameter flow cytometry (MFC) is a biomarker for risk of relapse. Applicability of MFC in routine practice has been challenging with suboptimal marrow samples and sampling needed at multiple time points. Sensitive serological assays which can detect MRD and have prognostic utility are needed to optimize the management of MM patients. The HevyliteTM assay (The Binding Site, UK) evaluates serum heavy/light chain ratios for IgG, IgA and IgM. We hypothesised the normalisation of serological markers is a good surrogate for plasma cell reconstitution in a healthy bone marrow (BM) microenvironment. The aim of this study was to prospectively compare Hevyliteand FreeliteTM assays with MFC of BM plasma cells from patients receiving autologous stem cell transplants (ASCT). We wanted to investigate if a correlation exists between MFC MRD negativity and the serological normalisation of Hevylite plus Freelite assays. Methods Hevylite, Freelite, SPEP, IFE on serum and MFC on bone marrow were performed on 23 patients post induction therapy and at a median of 90 days post-ASCT. Serological tests were performed again in available patients at 275 days post-ASCT. The combination of Freelite and Hevylite, which measures involved (iHLCr) and uninvolved (uHLCr) heavy light chain (HLC)-pairs, allows investigation of plasma cell reconstitution and its prognostic value in transplant patients. Six-colour MFC was performed as previously published (Rawstron et al. JCO 2013). IMWG uniform response criteria were used to categorise patients. Kaplan Meier estimates of Progression Free Survival (PFS) from time of transplantation until disease progression or death (whichever came first) were calculated and log-rank test was used for comparisons across groups. Sensitivity, specificity and ROC area analysis were used to assess performance of serologic response tests against flow MRD negativity, which is considered gold standard. Results Total of 23 patients were recruited to the study, 8 female (34.8%), 15 male (65.2%), with median age 61 (46-71). Isotype and ISS distribution were as follows; 11 IgG (47.8%), 4 IgA (17.4%), 1 IgM (4.35%), 7 LC only (30.4%) and 8 ISS1 (34.8%), 6 ISS2 (26.1%), 9 ISS3 (39.1%). Median marrow PC involvement at diagnosis was 45%, (20-90%) (N=18). At diagnosis, median LDH levels 192 IU/L, (153-475), median Hb 109.5 g/l, (72-152), with renal impairment noted in 6/23 (26.1%) and abnormal skeletal survey 15/23 (65.2%). High risk MM FISH was reported in 1/23 (4.35%), unknown 11/23 (47.8%) with rest determined to have standard risk. Median time from start of induction to HDM/ASCT 8 months (6.5-20) and median number of lines of treatment before HDM/ASCT was 1. Two deaths were noted on study. Median follow-up of surviving patients from diagnosis was 31 months (10-42). VGPR or better was achieved in 18/23 (88%) patients post-transplant by IMWG criteria. Hevylite ratio (iHLCr and uHLCr) normalised in 11/23 (48%) patients, with Freelite ratio (FLCr) normalisation in 14/23 (61%). MFC MRD negativity at 3 months post-ASCT was noted in 6/23 (26%) patients, in whom the post-ASCT Hevylite ratio and FLCr were also normalised. Comparing response assessments post-ASCT using standard IMWG criteria, MFC MRD, HLCr normalisation and FLCr normalisation, we found that MFC MRD is more sensitive to pick up residual disease over other tests. MFC MRD positivity correlates with early disease progression as MRD negativity significantly improves PFS outcomes (not reached vs 21 months) p=0.01 (Figure 1a). Patients with both HCLr and FLCr normalisation have significantly better PFS outcomes (not reached vs 21 months) p=0.04 (Figure 1b). ROC curve comparison of MFC MRD negativity and HLCr and FLCr normalisation tests, shows a 100% (95% CI 54.1% - 100%) sensitivity and 82% specificity (95% CI 56.6 - 96.2%) for serological normalisation. This demonstrates that HLCr and FLCr normalisation serves as a useful surrogate marker for MFC MRD negativity in our study. Conclusions We report the first prospective study demonstrating HLCr and FLCr normalisation post-transplant is a useful surrogate marker for flow MRD negativity, which is a widely accepted gold standard. This data requires further validation in a larger cohort of post-ASCT MM patients. Disclosures Ramasamy: Celgene: Honoraria, Research Funding.