MEDICAL ISSUES 01-ACQUIRED HEMOPHILIA Measurement of anti-porcine FVIII antibody titers

HERBERT GRITSCH,1 PETER WOJCIECHOWSKI,2 CHEE K O N G L A I , 2 C L A U D I A A P O S T O L 1 and P E T E R L . T U R E C E K 1 1 Baxter Innovations GmbH, Vienna, Austria; and 2Baxter BioScience, Milford, Massachusetts, USA Introduction and Objectives: OBI-1 (Baxter Healthcare) is a recombinant FVIII concentrate with porcine factor VIII sequence, which typically possesses low crossreactivity to anti-human factor VIII (FVIII) antibodies. This would make it a treatment option for patients with hemophilia A and inhibitors to FVIII or patients with acquired hemophilia. For effective treatment with OBI-1 the level of anti-porcine FVIII antibodies is relevant. Therefore in a field study, the accuracy and between laboratory precision of anti-human FVIII and anti-OBI-1 antibody assays was investigated. Materials and Methods: Samples with known anti-porcine FVIII antibody titers (approximately 3 BU/mL and 19 BU/mL respectively) and a negative control were provided to the 15 participating laboratories. Antibodies were known to have crossreactivity with human FVIII. The labs used their own Bethesda methods to analyze the anti-human FVIII antibody titers. Anti-porcine titers were analyzed with the same methods except that normal human plasma was replaced by OBI-1 pre-diluted with human FVIII-deficient plasma (“normal porcine plasma”). FVIII activities were measured with a one-stage clotting assay. Results: Fourteen sites returned acceptable results for anti-porcine FVIII antibody titers, seven sites reported acceptable anti-human FVIII data. On average the antibody titers found in the local laboratories were in the same range as found in the central laboratory, intra-laboratory coefficient of variation (CV) ranged from 30% to 57% for samples with inhibitors. The negative control was found negative in all laboratories. Conclusion: The results indicate that the degree of variability in results obtained from assays for porcine inhibitors is similar to that seen with assays for human inhibitors. Differences in assay method and standards used may affect sensitivity, accuracy, and variability of results.

Recombinant porcine sequence factor VIII (OBI-1): Results from a prospective clinical study investigating the treatment of serious bleeds in patients with acquired hemophilia A

KRUSE-JARRES R,1 ST-LOUIS J,2 GREIST A,3 SHAPIRO A,3 SMITH H,4 CHOWDARY P,5 DREBES A,5 GOMPERTS E,6 C H A P M A N M , 6 M O , M , 6 N O V A C K A 6 and F A R I N H 6 1 Louisiana Center for Bleeding and Clotting Disorders, New Orleans, LA, US; 2 Division of Hematology, H^ opital Maisonneuve-Rosemont, University of Montreal, Montreal, QC, Canada; USA; 3Hemophilia and Thrombosis Center, Indianapolis, IN, USA; 4Division of Hematology/Oncology, Tufts New England Medical Center, Boston, MA, USA; 5Royal Free Hospital, London, UK; and 6Baxter Healthcare, USA Introduction and Objectives: Acquired hemophilia A (AHA) is a rare bleeding disorder, resulting from auto-antibodies to human factor VIII (hFVIII). Currently approved therapies lack laboratory methods that allow for objective measurements of efficacy and safety, which complicates the treatment of bleeding in this typically elderly population with significant co-morbidities. A recombinant, highly pure, Bdomain deleted, porcine sequence FVIII (OBI-1) that is not generally susceptible to the inhibitory activity of anti-human FVIII antibodies affords a physician the opportunity to monitor FVIII activity levels, thus providing a reproducible and objective surrogate predictor of hemostasis. In the event of a bleeding episode, this additional monitoring capability of FVIII activity levels can be of benefit. Materials and Methods: This first prospective study in AHA is a global, prospective, multi-centre phase 2/3 open label clinical trial investigating the efficacy and safety of OBI-1 in the treatment of serious bleeds in adults with AHA. The primary efficacy endpoint was ‘hemostasis’ assessed at 24 hours after the initial infusion. Secondary efficacy outcomes were described including FVIII activity levels and by ultimate successful OBI-1 treatment. Safety was assessed by adverse events and analyses of immunogenicity profiles. Results: Subjects who have completed the study to date (N = 28) presented with a serious bleed, were all hospitalized and were treated with an initial dose of OBI-1 (200 U/kg), followed by additional doses based on the subject’s observed factor VIII activity level and clinical assessments. In all 28 subjects, a positive treatment response defined as effective/partially effective, not effective was observed at 24 hours after initial OBI-1 treatment. A positive response at 24 hours was associated with eventual successful treatment of bleeding episodes. No related serious adverse reactions occurred during the study. Some subjects demonstrated a positive anti-porcine inhibitor titer at some point after first being infused with this agent without a demonstrable effect on efficacy. Conclusion: Data from this prospective study demonstrate OBI-1 as a safe and effective treatment of bleeding episodes in patients with AHA, with the added advantage over other therapies by allowing FVIII activity to be monitored throughout the treatment and healing/recovery phase.

The economic and clinical burden of acquired hemophilia A (AHA)

V I N C E N T W . L I N , 1 A A R O N N O V A C K , 1 D E B O R A H T E S T A 2 and JOSHUA EPSTEIN1 Baxter Healthcare, Westlake Village, CA, USA; and 2Independent Consultant, Westlake Village, CA, USA


Introduction: Acquired hemophilia A (AHA) is a severe autoimmune disease characterized by the spontaneous development of autoantibodies against coagulation factor VIII (FVIII). Due to the rarity of the disease (approximately 1.5 cases million per year), the burden of AHA has not been extensively described. The goal of this study is to determine the economic and clinical burden of AHA patients treated in U.S. hospitals. Methods: A retrospective cohort study using the Premier Perspective database from January 2011 to March 2013 was conducted. This repository of hospital administrative data includes approximately one-sixth of all hospitalizations in the U.S. Hospital admissions for AHA were identified in two ways. The first was an inpatient admission with ICD-9 code 286.82 (AHA), with any record of a hemostatic agent (rFVIIa, aPCC, FVIII, or DDAVP) or an immunosuppressant (rituximab, cyclophosphamide, steroid). To capture cases with non AHA specific coding, we also identified inpatient admission with ICD-9 code 286.0 (hemophilia A), with any record of an immunosuppressant (rituximab or cyclophosphamide. Steroid use was not included due to its wide use). Total inpatient costs, hospital length of stay, thrombotic events, and mortality during the inpatient visit were assessed. Results: A total of 72 inpatient admissions were identified. The mean age of admitted patients was 64 (SD=23.4). Thirty (41.6%) admissions were male patients. The total cost for all 72 inpatient admissions was $9,543,384. Cost per inpatient admission varied widely ($22,880 to $1,392,785). The cost of hemostatic agents was the largest contributor to total inpatient cost (75.8%) for these 72 inpatient admissions. Patients treated with rFVIIa during an inpatient admission incurred the highest hemostatic agent cost (mean=$213,781, SD=$286,221, median=$96,865, min=$4,038, max= $946,492). The mean length of stay in a hospital was 11.1 days (SD=10, median 9, min=1, max=45). Five (6.9%) deaths occurred during inpatient admission after AHA treatment. Thrombotic events occurred during three (4.2%) admissions (one cerebrovascular accident, one myocardial infarction, and one deep vein thrombosis). Conclusion: The economic burden of treating bleeding episodes for patients with AHA using current therapies is high. Furthermore, AHA patients face significant risks of thrombotic events and mortality. With an aging population, these burdens are expected to increase in the future.

Thrombotic and embolic events associated with the use of FEIBA in Acquired Haemophilia: A cumulative review

ROGER BERG,1 ALESSANDRO GRINGERI,2 € L E N H A L S 1 and A R M I N J . R E I N I N G E R 2 E L I S A B E T H F UL 1 Global Pharmacovigilance, Baxter Innovations GmbH, Vienna, Austria; and 2Global Medical Affairs Haemophilia, Baxter Innovations GmbH, Vienna, Austria Introduction and Objectives: The management of bleeding episodes in acquired hemophilia often requires the use of bypassing agents such as rFVIIa or activated prothrombin complex concentrate (FEIBA - FVIII inhibitor bypassing activity; Baxter, Deerfield, IL USA). Treatment-associated thrombotic and embolic events (TEEs) have been noted for both agents with a similar incidence in a recently published registry (EACH2). The small size of observational studies in acquired hemophilia limits the capability to ascertain risk factors for FEIBA-associated TEEs. The present review provides a comprehensive overview of all TEEs associated with the use of FEIBA in acquired haemophilia documented in Baxter’s global safety database. Materials and Methods: The global safety database was reviewed for all AE reports of FEIBA received from 1975 through July 2013, addressing patient demographics, dosing regimens, and risk factors deemed relevant for the development of TEEs in association with FEIBA treatment. Results: Overall 24 TEE were reported for patients with acquired hemophilia (thereof 20 spontaneous reports), aged 53–88 years (mean 74, median 77). Of these 24 reports including one or more TEEs, 3 were reported as deep vein thrombosis and/or pulmonary embolism (DVT/PE; age 57–86, mean 70, median 66), 5 as myocardial infarction or stroke (MI; age 65–76, mean 70, median 70) and 13 as disseminated intravascular coagulation (DIC; age 56–88, mean 77, median 80). Five of 24 reports included rFVIIa as concomitant medication (2 DVT/PE, 1 MI, 2 DIC). Conclusion: The low and stable reporting rate of TEEs in acquired haemophilia over almost 40 years of use confirms the long-time safety profile of FEIBA. Moreover, the majority of TEEs occurred in the presence of additional risk factors such as age or comorbidities. The review of clinical details of all TEEs reported in association with the use of FEIBA is a valuable resource for understanding and perhaps preventing in TEEs in patients at high risk.

Pharmacokinetics of OBI-1, a recombinant porcine sequence FVIII product, in macaques and hemophilic dogs WERNER HOELLRIEGL, ALEXANDRA SCHIVIZ, C H R I S T I N A P I S K E R N I K , P E T E R L E I D E N M U E H L E R and EVA-MARIA MUCHITSCH Baxter Innovations GmbH, Vienna, Austria Introduction and Objectives: Acquired hemophilia A is a rare bleeding disorder in which subjects without a history of hemophilia develop autoantibodies against

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd




endogenous FVIII. These antibodies neutralize the circulating FVIII, creating a deficiency of FVIII procoagulant activity. OBI-1, a recombinant porcine sequence FVIII product, is being developed for the treatment and prevention of bleeding episodes in adults with acquired hemophilia A. Materials and Methods: The pharmacokinetics (PK) of OBI-1 were assessed in animal species to investigate the efficacy and safety of the compound. Hyate:C, a formerly marketed plasma-derived porcine FVIII, was used as a reference. Results: Single dose PK studies were conducted in macaques and hemophilia A dogs. Dogs received 3, 25 or 100 U/kg of OBI-1 or Hyate:C. Systemic exposure to FVIII activity increased with higher doses, but was less than dose-proportional. Exposure to OBI-1 (mean AUC0-inf: 157, 1356, 3399 U*h/dL; mean Cmax: 20.9, 125.5, 466 U/dL) was consistently higher than that to Hyate:C (mean AUC0-inf: 63.1, 315.5, 1220 U*h/ dL; mean Cmax: 8.6, 37.9, 143 U/dL). Monkeys received 49.5 or 77 U/kg OBI-1 or 100 U/kg Hyate:C. As seen in dogs, plasma exposure to OBI-1 (mean AUC0-inf: 944, 1433 U*h/dL; mean Cmax: 107, 169 U/dL) was higher than that to Hyate:C (mean AUC0-inf: 512.9 U*h/dL; mean Cmax: 78.7 U/dL) due to a lower clearance of OBI-1 (0.056 and 0.085 vs. 0.599 dL/kg/h). The higher exposure of OBI-1 compared with Hyate:C was confirmed in repeat dose toxicokinetic studies conducted in macaques: OBI-1 was administered over 4, 28 or 90 days at doses of 40-1000 U/kg, while 100 U/kg Hyate:C was administered for 4 or 90 days. On both days one and four, plasma FVIII levels were higher for OBI-1 than for Hyate:C. On days 28 and 90, plasma FVIII levels were markedly reduced in all monkeys due to the development of antiporcine FVIII inhibitor antibodies – a finding expected after multiple administrations of exogenous proteins. Conclusion: The exposure of OBI-1 was higher than that of Hyate: C in both species and at all doses tested. All authors are full-time employees of Baxter Innovations GmbH, Vienna, Austria.

Efficacy of OBI-1, a recombinant porcine sequence FVIII product, in animal models of hemophilia A ALEXANDRA SCHIVIZ, CHRISTINA PISKERNIK, P E T E R L E I D E N M U E H L E R , E V A - M A R I A M U C H I T S C H and WERNER HOELLRIEGL Baxter Innovations GmbH, Vienna, Austria Introduction and Objectives: Acquired hemophilia A is a rare bleeding disorder in which subjects without a history of hemophilia develop autoantibodies against endogenous FVIII. These antibodies neutralize the circulating FVIII, thus creating a deficiency of FVIII procoagulant activity. OBI-1, a recombinant porcine sequence FVIII product, is being developed for the treatment and prevention of bleeding episodes in adults with acquired hemophilia A. Materials and Methods: The aim of the presented studies was to determine the efficacy of OBI-1 in mice and dogs with hemophilia A. Hyate:C, a formerly marketed plasma-derived porcine FVIII, was used as a reference. Results: Six dogs were treated with each product at doses of 3, 25, or 100 U/kg in a randomized crossover cuticle bleeding time (CBT) study. OBI-1 effectively decreased CBT by an average of 6.6 min in 7 of 9 studies, correcting CBT to normal range in 5 of these 7. With Hyate:C, CBT was shortened in 3 of 9 experiments. Fourteen FVIII knock out (ko) mice were treated with varying doses of OBI-1 (10-190 U/kg) or Hyate:C (10-109 U/kg). Vehicle-treated FVIII ko mice (n = 7) served as negative controls, C57BL/6 mice (n = 7) were used as healthy controls. A tail transection mortality protocol was modified to obtain results from which the estimated dose producing 50% survival after 24 h could be established. Following a standardized tail-snip hemorrhagic insult, an estimated ED50 of 89 U/kg OBI-1 (95% CI: 65-120 U/kg) produced 50% survival. This efficacy did not differ significantly from that of Hyate:C (64 U/kg; 95% CI: 34-87 U/kg). Conclusion: Administration of OBI-1 dose-dependently reduced blood loss in hemophilic mice and dogs. The efficacy of OBI-1 was comparable to Hyate:C in mice and appeared to be more effective in correcting the in vivo hemophilic bleeding tendency in dogs. These results demonstrate that OBI-1 has a favorable preclinical efficacy profile, predictive of a comparable effect to that of the formerly licensed comparator product in humans. All authors are full-time employees of Baxter Innovations GmbH, Vienna, Austria.

Preclinical safety of OBI-1, a recombinant porcine sequence FVIII product ALEXANDRA SCHIVIZ, WERNER HOELLRIEGL, CHRISTINA PISKERNIK, PETER LEIDENMUEHLER, E V A - M A R I A M U C H I T S C H and B A R B A R A D I E T R I C H Baxter Innovations GmbH, Vienna, Austria Introduction and Objectives: Acquired hemophilia A is a rare bleeding disorder in which subjects without a history of hemophilia develop autoantibodies against endogenous FVIII. These antibodies neutralize the circulating FVIII, thus creating a deficiency of FVIII procoagulant activity. OBI-1, a recombinant porcine sequence FVIII product, is being developed for the treatment and prevention of bleeding episodes in adults with acquired hemophilia A. Materials and Methods: The potential toxicity of OBI-1 was assessed in macaques and hemophilia A dogs. Acute and subchronic studies included cardiovascular and respiratory safety pharmacology assessment (dogs only). Hyate:C, a formerly marketed plasma-derived porcine FVIII, served as reference. Results: Single dose toxicity was evaluated in hemophilia A dogs receiving doses up to 100 U/kg OBI-1 and macaques receiving up to 77 U/kg. Hyate:C was administered at 100 U/kg in both species. A single injection of OBI-1 did not induce any adverse effects. No adverse effects on the respiratory or cardiovascular systems were observed. In a 28-day dose escalation study, the tolerability and potential immunogenicity of ascending doses of up to 1000 U/kg OBI-1 in macaques (n = 2) were evaluated when injected intravenously once daily with dose levels increasing every 7 days. A pivotal 90-day repeat dose toxicity study including daily doses up to 825 U/kg was conducted in macaques (n = 12). In the latter study, 100 U/kg Hyate:C and vehicle served as a

Haemophilia (2014), 20 (Suppl. 3), 1--186

reference. Standard toxicology parameters including effect on coagulation variables, as well as safety pharmacology parameters, were assessed. No changes in the macaques’ behavior, serum chemistry, hematological or safety pharmacology parameters were observed. No test item-related changes were observed in macro- and microscopic examination of tissues. As expected after repeat administration of an exogenous protein, inhibitory antibodies against porcine FVIII developed in all groups, including Hyate:C-treated animals. Cross-reactivity with endogenous FVIII led to an increased bleeding tendency and a slight prolongation of aPTT in OBI-1-treated macaques. Conclusion: OBI-1 showed a favourable safety/toxicity profile in both animal species used. The no observed adverse effect level (NOAEL) was set to the highest dose tested in each study. All authors are full-time employees of Baxter Innovations GmbH, Vienna, Austria.

Acquired Hemophilia A with Immune Thrombocytopenia in adolescent patient

HYO SUN KIM,1 JUNG WOO HAN,1 JAE-WOO SONG,4 SEUNG MIN HAHN,1 YOON JUNG SHIN,1 SUN HEE KIM,1 M O O N K Y U K I M , 2 K U N S O O L E E 3 and C H U H L J O O L Y U 1 Department of Pediatric Hematology and Oncology, Yonsei University Health System, Seoul, Korea; 2CHA Bundang Medical Center, CHA University, Seongnam, Korea; 3Kyungpook National University School of Medicine, Daegu, Korea; and 4 Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea Introduction and Objectives: Acquired hemophilia A (AHA) is rare autoimmune disorder caused by autoantibodies which act against coagulation factor VII (FVIII) in the nonhemophilic population. The age distribution of autoantibodies is typically biphasic, with a small peak between the ages of 20 and 30 (mainly postpartum inhibitors) and a major peak in patients aged 70 to 80 years. The incidence of AHA in children is very rare. Indeed, the incidence in children under 16 years has been estimated to be 0.045 per million/year compared with 14.7 per million/year in those over 85 years of age. Also, immune thrombocytopenia is an acquired immunemediated disorder caused by increased destruction of platelets opsonized by antiplatelet autoantibodies. We experienced a case of AHA with thrombocytopenia caused by autoantibody in an 18-year-old boy. He had no previous bleeding history and presented with easy bruising on the lower extremities and was diagnosed with AHA. An initial activated partial thromboplastin time (APTT) was 136 seconds, the level of FVIII was 0.6 % and FVIII inhibitor was measured at13.1 Bethesda Units (BU). Moreover, platelet counts were low (34,000/uL), and we observed platelet-associated autoantibody. Other autoimmune diseases were ruled out. He was immediately treated with oral prednisolone (1 mg/kg/d) and one week later oral cyclophosphamide (2 mg/kg/d) was added due to elevated FVIII inhibitor (14.7 BU) levels. About seven weeks later, after treatment, FVIII inhibitor had disappeared and APTT was normalized, we started tapering off the medication. During treatment of inhibitor eradication, platelet counts were also increased and normalized. We report our experience as the first successful simultaneous antibody eradication for FVIII inhibitor and platelet-associated autoantibody in an adolescent AHA patient.

Non-clinical immunogenicity assessment of a new recombinant porcine sequence FVIII (OBI-1) PETER ALLACHER, FRANK HORLING, € L E R and C H R I S T I N A P I S K E R N I K , P E T E R L E I D E N M UH BIRGIT REIPERT Baxter BioScience, Vienna, Austria Introduction and Objectives: Acquired hemophilia A (AHA) is a rare bleeding disorder caused by circulating auto-antibodies that neutralize factor VIII (FVIII) activity. In the past, plasma derived porcine FVIII (Hyate:C) was successfully used for the treatment of patients with AHA. Since the discontinuation of the commercial production of Hyate:C in 2004, no alternative porcine FVIII has been available. A new product, recombinant porcine sequence FVIII (OBI-1) is currently in development. The objective of this study was to assess the immunogenicity of OBI-1 in comparison to Hyate:C in E16 hemophilia A mice and in Cynomolgus monkeys. Materials and Methods: E16 hemophilia A mice were pretreated with 5 intravenous (i.v.) doses of recombinant human FVIII (100 U/kg) to induce antibodies against human FVIII. Subsequently, mice received 4 weekly i.v. doses (1, 10 or 100 U/kg) of either OBI-1 or Hyate:C. Development of anti- porcine FVIII antibodies was analyzed two weeks after the last dose. Cynomolgus monkeys received either OBI-1 (40 and 100 U/kg) or Hyate:C (100 IU/kg) twice daily for 4 days. Anti-porcine FVIII antibodies were analyzed on days 8, 15, 29, 43 and 57. Total binding antibodies against porcine FVIII and human FVIII were analyzed by ELISA. Neutralizing antiporcine FVIII antibodies (inhibitors) were analyzed using a modified Bethesda assay. Results: None of the monkeys treated with 40 U/kg OBI-1, 2 of 5 monkeys treated with 100U/kg OBI-1 and 2 of 6 monkeys treated with 100 U/kg Hyate:C developed anti- porcine FVIII inhibitors. Hemophilia A mice developed inhibitors after treatment with porcine FVIII in a dose-dependent manner. The maximum response was seen at the highest dose of 100 U/kg with 81% and 94% mice developing inhibitors when given OBI-1 or Hyate:C, respectively. No significant differences in titers of antiporcine FVIII inhibitors were found. Binding antibodies against porcine FVIII, assessed in hemophilic mice, were higher in mice treated with 10 or 100 U/kg Hyate:C than in mice treated with the same doses of OBI-1. Pre-induced titers of antibodies against human FVIII did not influence the subsequent development of antibodies against porcine FVIII. Conclusion: Non-clinical immunogenicity assessment indicates that the new recombinant porcine sequence FVIII (OBI-1) expresses a similar immunogenicity profile as the porcine plasma-derived FVIII Hyate:C.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

ACQUIRED HEMOPHILIA Acquired Hemophilia A: Presentation of 5 cases

SVETLANA STANKOVIKJ,1 TATJANA SMILEVSKA,1 VIOLETA DEJANOVA,2 SANJA TRAJKOVA,1 D U S K O D U K O V S K I 1 and M A R I J A P O P O V A 1 1 University Clinic of hematology, Skopje, Macedonia; and 2Institute for transfusion medicine, Skopje, Macedonia Introduction and Objectives: Acquired hemophilia A can be defined as a bleeding disorder caused by generation of auto-antibodies towards factor VIII. In untreated patients, it often leads to a life-threatening hemorrhage. Materials and Methods: This report presents five cases with acquired hemophilia A treated at the University Clinic of Hematology, Skopje from 2006 to 2012. The menwomen ratio was 1-4 respectively. The average age of patients was 56 years (24 – 80 years). The risk factors for development of auto-antibodies included: puerperal period, lung cancer, and urolithiais. However, in two of the patients the etiology was not defined. Results: Clinical examination demonstrated extensive hematomas throughout the body and limbs in four of the patients, and hematuria in two of them. Laboratory evaluation showed initial elevation of APTT (activated partial thromboplastin time) in all patients; average 64.8sec with control 22.0 sec. The qualitative test with mixture of normal and patient-derived plasma was positive in all patients. Initially, the average value for factor VIII and the inhibitors’ titer were 1.2% and 19.7 B.E. respectively, out of which three of the patients were low responders, with inhibitor titer below 5 B.E. and two of them were high responders, with inhibitor titer over 5 B.U. The acute hemorrhage was treated with high doses of factor VIII concentrate (Coate) in two patients, fresh-frozen plasma (FFP) in one patient and activated recombinant factor VII (Novoseven) in two patients. In addition, the patients were treated with immunosuppressive therapy including corticosteroids only, or corticosteroids in combination with Cyclophosphamide and/or Rituximab. The hemorrhage was stopped and clinical remission was achieved in all patients for approximately 60 days (18 to 180). Conclusion: Acquired Hemophilia A is a very rare disease that may lead to a lifethreatening hemorrhage. However, early diagnosis and suitable treatment can prevent a fatal outcome.

Plasma derived factor VIII products induce in vitro osteoblast apoptosis

€ L E R and B E A T E E K E H R E L 2 M A R T I N F B R O D D E , A N J A M UL OxProtect GmbH, M€ unster, Germany; and 2University of M€ unster, M€ unster, Germany


Introduction and Objectives: In a previous study, blood cell proteins and complement activation have been identified in several plasma derived factor VIII (pdFVIII) products. Whether or not these impurities induce cellular stress in osteoblasts was examined by investigating their impact on osteoblast apoptosis. Methods: Primary human osteoblasts were cultured and FVIII concentrates, dissolved in sterile aqua for injection for a final FVIII concentration of up to 0,5 IU/ml. The influence of FVIII products on human osteoblasts was investigated by microscopy. Apoptosis was evaluated using the EnzChek Caspase-3 Assay 2 (Molecular Probes) adapted for flow cytometry. Phosphatidylserine exposure on osteoblasts was detected by staining with FITC conjugated Annexin V by flow cytometry. Results: After 48 h incubation with medium containing pd FVIII (0,5U/ml) many osteoblasts were dead, but all cells very healthy when incubated with rFVIII (0,5 IU/ ml) in the presence or absence of rvWf (0,5 IU/ml). Osteoblasts maintained their characteristic morphology after treatment with rFVIII. The number of apoptotic osteoblasts as shown by caspase 3 activity as by Annexin V binding, did not change by coincubation of the cells with rFVIII. In contrast, several pFVIII concentrates induced caspase 3 activity and Annexin V binding in low concentrations (0,25U/ml). Both pdFVIII and rFVIII products did not induce osteoblast necrosis as cells did not take up propidiumiodide. Conclusion: Stress to osteoblasts, leading to apoptosis by the tested pdFVIII concentrates, may lead to an enhanced destruction of bone, while the tested rFVIII concentrates do not induce osteoblast apoptosis.


10 months: the patient has a large, post -traumatic bruise on the back of the right hand , and a hematoma in the right calf requiring infusion of rVII ( Novoseven ) at 90ug/kg, in 3 injection for 2 days, with a good clinical improvement. A test for circulating antibodies found UB 32 VAC and a residual factor VIII of less than 1%. Discussion: Though a positive diagnosis is simple to conduct, Hemophilia is relatively rare and not often seen in a clinical setting. The therapeutic strategy has two components in this case: 1- Control the hemorrhagic syndrome : different hemorrhagic episodes were controlled by the rVIIa ( Novoseven ) with very good efficacy. 2 Eradicate inhibitor with either corticosteroids, cyclosporine, or more recently rituximab. Our patient was treated with corticosteroids with total eradication of the antibody, which reappeared six months later with an aetiology other than postpartum. Conclusion: Acquired hemophilia, despite its rarity, should be suspected in any postpartum bleeding issue. This is another situation where research and multidisciplinary collaboration is vital for patients.

Effect of OBI-1, a recombinant FVIII product with porcine FVIII sequence, on thrombin generation and clot structure in plasma from hemophilia A patients with inhibitors

CLAUDE NEGRIER,1 JOHANNES OLDENBURG,2 BERND POETZSCH,2 JEAN-CLAUDE BORDET,1 RAED AL DIERI,3 YESIM DARGAUD,1 COEN HEMKER,3 M A R T I N L E E 4 and P E T E R L . T U R E C E K 5 1 H^ opital Edouard Herriot, Lyon, France; 2Institute of Experimental Hematology and Transfusion Medicine, Bonn, Germany; 3Synapse BV, Maastricht, The Netherlands; 4 Inspiration Biopharmaceuticals, Laguna Niguel, CA, USA; and 5Baxter Innovations GmbH, Vienna, Austria Introduction and Objectives: Current treatment of patients with hemophilia A is replacement therapy with factor VIII (FVIII) concentrates. A major clinical complication is the development of neutralizing anti-FVIII inhibitors making factor replacement therapy ineffective due to interaction with epitopes critical for FVIII activity. OBI-1 (Baxter Healthcare) is a recombinant FVIII concentrate with porcine FVIII sequence, which may possess low cross reactivity to human FVIII inhibitors. Therefore OBI-1 might be beneficial for the treatment of patients with acquired hemophilia and in individuals with congenital hemophilia A with inhibitors. The purpose of this multicenter study was to evaluate in vitro restoration of thrombin generation (TGA) in plasma from patients with hemophilia A and inhibitors to FVIII after addition of OBI-1. Materials and Methods: From those patients with hemophilia A and inhibitors to FVIII consenting to the study, a 20 mL blood sample was obtained. Various OBI-1 concentrations (equivalent up to 400 U/kg bodyweight) were added, FVIII activity was measured with a one-stage clotting method, anti-human FVIII and anti-porcine FVIII neutralizing antibodies were analyzed with an assay based on the Nijmegen modification of the Bethesda assay. Thrombin generation was analyzed with the Calibrated Automated Thrombogram (CAT) assay. In addition, clots were observed with a scanning electron microscope (SEM), the number of fibrin fibers was counted and fibrin fiber diameter and density were determined. Results: All patients had severe hemophilia A, the inhibitor titers covered the low, mid and high titer range. After in vitro addition of various concentrations of OBI-1 a dose dependent correction of the thrombin generation parameters was observed for patients with low and mid anti-OBI-1 titers ( 32 Bethesda units / ml. A second test, in March 2013, found 200 Bethesda Units. At three months: renal colic with hematuria. 3 months: Hematoma of the forearm with difficulty bending, requiring the infusion rVII ( Novoseven ) at 90ug/kg, 3 injection for 2 days, with the introduction of corticosteroid treatment at 1 mg/kg/day for 4 weeks with gradual reduction. At the end of 6 weeks of treatment, antibody screening was negative at 0 Bethesda units.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

Acquired Factor VIII inhibitor in children: Experience in a single institute D A R I N T R S O S O T H I K U L , K O R A M I T S U P P I P A T and PANYA SEKSARN Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand Introduction and Objectives: Acquired factor VIII (FVIII) inhibitor is a rare bleeding disorder caused by an autoantibody against FVIII, with potential life-threatening complications. In this study, we report three cases of acquired FVIII inhibitor in children treated at King Chulalongkorn Memorial Hospital from 1995 to 2013. Results: Case I: A 13-year-old girl presented with fever, large bruises on both legs, and bleeding from her lip for 2 weeks. Physical examinations showed hemorrhagic blebs at left arm and flamed-shape hemorrhage at retina. An uncorrectable APTT prolongation with plasma mixing study and a deficiency in FVIII (0.95%) with presence of FVIII inhibitor (1.8 BU/ml) were found. She was treated with oral corticosteroid and FVIII inhibitor disappeared within 1 week of treatment. Case II: A 10-year-old girl, who had been diagnosed as SLE 8 months ago, came with severe epistaxis, gingival bleeding and multiple ecchymoses on both legs for 10 days. Uncorrectable APTT prolongations with plasma mixing study and deficiency in FVIII (0.25%) with presence of FVIII inhibitor (7.9 BU/ml) were found. FVIII inhibitor disappeared and bleeding stopped after 2 weeks of steroid administration. Case III: A 10-year-old girl presented with large subcutaneous hematomas of both arms and left leg for 2 days. She had history of fever with rash 1 week before this bleeding episode. Uncorrectable APTT prolongation with plasma mixing study and a deficiency of FVIII (1.1%) with presence of FVIII inhibitor (7.7 BU/ml) were found. High dose of FVIII

Haemophilia (2014), 20 (Suppl. 3), 1--186



concentrate were given due to early sign of compartment syndrome of both her arms, followed by steroid administration. Three weeks later, FVIII inhibitor disappeared and bleeding was resolved. Two of the three cases in our series are secondary to SLE and the third case is likely to be a post infectious process. Conclusion: The outcome of acquired FVIII inhibitor in children seems to be more favourable than in adults, with good responsive to corticosteroids. High dose of FVIII concentrate was required only in the third case ,due to impending compartment syndrome in her extremities.

Case Report of a rare bleeding disorder: Acquired hemophilia A and acquired FXIII deficiency

MARTIN HENDELMEIER,1 INGE SCHARRER,2 G E O R G G O L D M A N N , 1 N A T A S C H A M A R Q U A R D T 1 and JOHANNES OLDENBURG1 1 University Hospital Bonn, Institute of Experimental Hematology, Bonn, Germany; and 2University Medical Center Mainz, Department of Medicine 3, Mainz, Germany Introduction and Objectives: Acquired hemophilia A (AHA) is a rare bleeding disorder caused by the development of specific autoantibodies that are capable of inhibiting the action of naturally occurring Factor VIII (FVIII). Patients present with prominent subcutaneous hematomas as well as bleeding elsewhere. Unlike with classic hemophilia, hemarhtroses are rare. There is prolongation of the aPTT, which does not correct following in vitro addition of normal plasma. The FVIII level is reduced, but rarely to less than 2%. The Bethesda assay demonstrates an inhibitor but the degree of bleeding is often more severe than suggested by the inhibitor level. Acquired Factor XIII (FXIII) deficiency remains a doubtful entity. Coagulation factor XIII, that belongs to a family of transglutaminases, is the last enzyme to be activated in the blood coagulation pathway and functions to cross-link a- and μ-fibrin chains, resulting in a stronger clot with an increased resistance to fibrinolysis. The standard laboratory clotting tests (PT, aPTT, fibrinogen level, platelet counts, bleeding time) are normal in isolated FXIII deficiency. Materials and Methods: We report about a 76-year-old man who presented with spontaneous haematomas after operation of a inguinal hernia and in the absence of personal or family history of bleeding disorders. His past medical history included arterial hypertension, prostate cancer, and hyperlipoprotein(a). Results: Coagulation tests showed a prolonged aPTT (91sec) with normal PT and INR. aPTT was not modified after mixing tests, lupus anticoagulant was negative, FVIII was 4%, and FVIII inhibitor was 72 Bethesda Units (BU), leading to diagnosis AHA. Factor IX, factor X, factor XII and von Willebrand factor were normal. Several transfusions with packed red blood cells were required due to anemia and the persistent haemorrhagic tendency, and a recombinant factor VIIa (rFVIIa) 90 μg/kg i.v. bolus was administered, and repeated after three hours, with temporary cessation of bleeding. Prednisone was immediately started at doses of 1 mg/kg/day. Several days later, he presented again with a decrease in haemoglobin level. The patient received packed red blood cells and another rFVIIa bolus. Further investigation led to the exclusion of other malignant or autoimmune diseases. During admission, he experienced other episodes of bleeding with significant reduction of haemoglobin levels 2000 BU/ml to 7.5BU/ml(graph). A false positive for Factor IX and XI inhibitor disappeared after reduction of factor VIII inhibitor. Case-II: A 28 year-old woman with insignificant past history presented one month post-partum with multiple spontaneous bruises. She also experienced a heavy menstrual loss in her first post-partum menstrual cycle but required no treatment. On this occasion, she developed prolonged bleeding after dental extraction and was found to have a PTT of 74 sec, FVIII level 35-years-old and extracted data on cardiovascular risk factors and CVD events. Results: 294 patients were analyzed (222 hemophilia A, 72 hemophilia B) with a median age at enrolment of 48 (range 35–90). Median follow up duration was 5.86 years. The majority of the study population had non-severe hemophilia (56% mild, 19% moderate, 25% severe). Cardiovascular risk factors were common: hypertension 31.3%, diabetes mellitus 10.5%, smoking 21.8%, obesity 27.6%, dyslipidemia 22.4%, family history 8.5%, antiretroviral therapy 12.2%. Many patients had multiple risk factors with 37.4% of patients having two or more risk factors and only 24.5% having no risk factors. There were 24 CVD events with a median age at event of 63 years (range 46–83). Events consisted of coronary artery disease (CAD), 14; cerebrovascular disease, 4; and atrial fibrillation (AF) 7. All but one event occurred in patients with non-severe hemophilia. For the patients with AF, 3 were treated with ASA and 1 with a vitamin K antagonist. CAD was treated with coronary artery bypass grafting in 3 patients and percutaneous coronary intervention with stenting in 9 patients. CVD events were complicated by four bleeding events (1 minor and 3 major) occurring in three patients and none of these bleeds were fatal. Conclusion: Cardiovascular risk factors are common in PWH. Severe hemophilia may be protective against CVD events but patients with non-severe hemophilia are still at risk. PWH can be safely treated for CVD events with similar procedures as the nonPWH population with the use of factor prophylaxis, though specific protocols are not well defined.

Multivariate analysis of the occurrence of intracranial hemorrhage among adult hemophiliacs in Japan

MASASHI TAKI,1 SHINOBU TATSUNAMI,2 JUNICHI MIMAYA,3 MIEKO AKITA,4 YUTAKA NISHINA,5 JUGO HANAI,6 K A T S U M I O H I R A 7 and A K I R A S H I R A H A T A 8 1 Department of Pediatrics, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan; 2Unit of Medical Statistics, St. Marianna University School of Medicine, Kawasaki , Japan; 3Atami Public Health and Welfare Center, Atami, Japan; 4Department of Pediatrics, St. Marianna University School of Medicine, Kawasaki, Japan; 5Nishina and Fukado Law Office, Tokyo, Japan; 6 Medical Care and Human Rights Network, Osaka, Japan; 7Social Welfare Corporation Habataki Welfare Project, Tokyo, Japan; and 8Kitakyushu Yahata Higashi Hospital, Kitakyushu, Japan

Objectives: The Research Committee for the National Surveillance of Coagulation Disorders in Japan collected information on intracranial hemorrhage in the annual surveillance performed in 2012. We summarize the results of the analyses. Materials and Methods: We used data collected up to the end of May 2012. A total of 749 institutions throughout Japan participated in the research. History of intracranial hemorrhage was analyzed by multivariate logistic regression analysis using the following covariates: patients´ age, disease type and severity, presence of inhibitors against FVIII or IX, and regular replacement therapy. The following medical complications were also taken into account: diabetes, hypertension, hyperlipidemia, and HIV infection, as well as information on critical liver disease. Results: We extracted data on 1909 patients who were over 20 years of age at the end of May 2012. This included 44% of the entire number of hemophiliacs over 20 years of age at that time in Japan. The subjects comprised 1581 patients with hemophilia A (977 severe, 290 moderate, and 314 mild) and 328 with hemophilia B (180 severe, 77 moderate, and 71 mild). Among the covariates, the presence of inhibitor, and hypertension were identified as statistically significant variables (OR: 5.7, 95%CI: 1.9–16.5, p < 0.01; and OR: 2.9, 95%CI: 1.4–6.1, p < 0.01, respectively). Although statistical significance was not clearly recognized, a higher frequency of intracranial hemorrhage was found in patients with severe hemophilia compared to patients with moderate and mild hemophilia. Conclusion: A history of adult intracranial hemorrhage was associated with the presence of hypertension as well as the presence of inhibitor, but not with the other covariates. With the increasing age of the Japanese hemophiliac population, continuing research should include the monitoring of lifestyle-related diseases.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

Risk assessment for coronary heart disease in adult patients with hemophilia is influenced by hepatitis C status AFRAH S. SAIT, ANN KUO, RICKI BETTENCOURT, J A C L Y N B E R G S T R O M and A N N E T T E V O N D R Y G A L S K I University of California San Diego, San Diego, USA Introduction and Objectives: People with hemophilia (PWH) in the US have more hypertension and cardiovascular death than the general population. Therefore, we investigated coronary heart disease (CHD) risk in PWH compared to the general population. Materials and Methods: Retrospective assessment of 10-year Framingham risk (composite of systolic blood pressure [SBP], age, gender, smoking, lipids) in a single center cohort of PWH ≥ 20 years (n = 89). Levels of risk were defined as: 20% (high). Results were compared to the US representative sample provided by National Health and Nutrition Examination Survey (NHANES). Results: Mean age in both cohorts was ~ 42 years. While SBP was higher in PWH, a higher proportion of PWH were low risk compared to NHANES (77.5% versus 61.0%; p = 0.005); severe PWH were at lower risk than non-severe PWH (88.6% versus 66.7%; p = 0.02). Surprisingly, lipid profiles in PWH were better compared to NHANES, and tracked with Hepatitis C status and severe hemophilia (75% hepatitis C positive). Severe PWH tended to have lower cholesterol (165.3 mg/dL) and lower low density lipoproteins (LDL) (85.2 mg/dL) than non-severe PWH (cholesterol 180.3, p = 0.08; LDL 103, p = 0.01). Similarly, Hepatitis C positive PWH had lower cholesterol (163.7 mg/dL) and LDL (85.4 mg/dL) compared to Hepatitis C negative PWH (cholesterol 185.5; LDL 105.3; p < 0.01). All other risk factors were comparable. Those with detectable viral load had the lowest serum lipids (mean cholesterol [152 mg/dL], LDL [78 mg/dL] and triglycerides [110 mg/dL]) compared to Hepatitis C negative PWH or those with undetectable viral load (cholesterol ~190; LDL ~140; triglycerides ~105; all p < 0.001). By Hepatitis C status, the proportion of patients classified as high risk was lower for Hepatitis C positives compared to NHANES (5.7% versus 17.3%; p = 0.03), and those with detectable viral load had the highest proportion of patients at low risk (80%, NHANES 61%, p = 0.07). Conclusion: Despite hypertension, the majority of PWH were classified low CHD risk, driven by favorable lipid profiles associated with Hepatitis C. Hepatitis C is not cardioprotective and composite scores may not be appropriate to determine CHD risk in infected PWH.

Aging with hemophilia: Enhancing dialogue with our patients

GERARD DOLAN, MD,1 RUUD BOS,2 RANDALL CURTIS,3 K A R I N L I N D V A L L , 4 K A R E N W U L F F 5 and N I C H A N Z O U R I K I A N 6 1 Nottingham University Hospitals, UK; 2UMC Utrecht / Van Creveld Clinic, the National Hemophilia Center, the Netherlands; 3Factor VIII Computing, USA; 4 Department for Coagulation Disorders, University Hospital, Malm€ o, Sweden; 5 Louisiana Center for Bleeding and Clotting Disorders, Tulane University School of Medicine, USA; and 6Sainte Justine Pediatric/Adult Comprehensive Care Hemostasis and Inhibitor Center, Montreal, Canada Introduction and Objectives: With the advances in treatment of the last 30 years, people with hemophilia are living longer and experiencing health and lifestyle challenges associated with normal aging. However, as highlighted by many health care providers (HCPs) through publications and presentations, there are very few resources available on these topics for HCPs who treat and manage the care of older adults with hemophilia. To address this need, we created an online resource to support this growing part of the hemophilia community. Materials and Methods: In 2011, an international, multidisciplinary editorial board was established to develop the Above And Beyond Hemophilia program with the goal of providing information and resources to better understand and address the physical and social challenges of aging with hemophilia. Controlled exclusively by the editorial board and sponsored by Bayer HealthCare, is specifically designed to facilitate HCPs’ dialogue with their older patients on topics related to aging. Results: Since launching the website in 2012, the board has guided the creation of nearly 40 articles on topics ranging from common medical issues associated with aging such as cardiovascular disease, joint issues and sexual health, to the psychosocial impact of aging. Also available for download is the Talking About Aging booklet, which HCPs can offer to their older adult patient to help them be more proactive in preparing for and managing doctor visits. To date, has seen more than 2,000 visitors. Additional booklets and content are in development. Plans for the content to be localized in different countries are underway. Both the brochure and website have already been introduced to older adults with hemophilia at the Van Creveld Clinic in The Netherlands. The content has been well-received, many considering it to be empowering and helpful in advocating for themselves on health matters beyond, but potentially impacted by, their bleeding disorder. There are also plans to translate the brochure into Dutch. Conclusion: is a first-of-its-kind resource to inform and support HCPs in their work with this growing and challenging segment of the hemophilia community.

Haemophilia (2014), 20 (Suppl. 3), 1--186



Acute coronary syndrome in a patient with hemophilia A

MIKA MORI,1 CHIAI NAGAE,1 TOMOKO ASHIKAGA,2 ATSUKI YAMASITA,1 DAI KEINO,1 RYO OYAMA,1 M I Z U H O M O R I M O T O , 1 A K I T O S H I K I N O S H I T A 1 and MASASHI TAKI2 1 St.marianna University, Kanagawa, Japan; and 2Yokohama City Seibu Hospital, Kanagawa, Japan Case: A 64-year-old male hemophilia patient (residual factor VIII level 0.19 IU ml-1) presented to the emergency department with chest pain at rest. The patient had hypercholesterolaemia and hyperuricaemia. The echocardiographic findings (signs of myocardial ischaemia of the anterior and septal walls) prompted coronary angiography (CAG) to be performed. Subsequently, primary percutaneous coronary intervention (PCI) was performed and the anterior descending branch of the coronary artery was stented. A 3000 IU FVIII bolus was infused, aiming to achieve a clotting factor level of 1.0 IU ml-1 during the intervention. In addition, a loading dose of 5000 IU unfractionated heparin (UFH) was given before PCI, followed by continuous infusion for 48 h. During heparin treatment, 2000 IU FVIII were infused three times daily aiming to achieve a clotting factor level of 0.80 IUml-1, and the doses were then tapered. Dual antiplatelet therapy was started after PCI. On day 16, elective PCI of the right coronary artery was performed. Before PCI, 3000 IU FVIII and 7000 IU UFH were infused. During the 48 h period after PCI, 2000 IU VIII were infused twice daily. The patient was not treated with heparin after the intervention. Dual antiplatelet therapy and once-a-week FVIII prophylaxis were continued. No complications occurred, and FVIII inhibitors did not develop. Discussion: Aging hemophilia patients are increasing and being confronted with agerelated diseases, such as ischaemic heart disease (IHD). However, there are no widely accepted recommendations on how to treat IHD in hemophilia patients. It is necessary to provide independent guidelines promptly. In addition, primary preventive care for IHD is also important in hemophilia patients.

Disclosure: The project itself is supported by Bayer, however none of the authors directly or indirectly is sponsored by Bayer or any other pharmaceutical company.

Point prevalence estimates of comorbidities among people with hemophilia using a large commercial insurance database

CHRISTOPHER WALSH,1 ANISSA CYANIUK,2 DAVID L. COOPER,3 DESIREE HALL,2 DAVID UNGAR,4 C H I O M A S M I T H 3 and T A M I W I S N I E W S K I 3 1 Mount Sinai Hospital, New York, New York, USA; 2OptumInsight Life Sciences, Horsham, PA, USA; 3Novo Nordisk Inc., Plainsboro, NJ, USA; and 4Formerly of Novo Nordisk Inc., Plainsboro, NJ, USA Introduction and Objectives: Today, people with hemophilia (PWH) have near normal life expectancy. There is little understanding of the prevalence of comorbidities among aging PWH as compared to the general population (GenP). The purpose of this study is to describe differences in point prevalence estimates of chronic comorbidities in PWH versus GenP. Materials and Methods: Using Clinformatics Data Mart, a product of OptumInsight Life Sciences, a factor-treated hemophilia cohort was developed using data from Jan. 2009 – Sept. 2011. Included patients were male, had hemophilia A/B diagnosis (ICD-9 286.0-1), ≥ 1 order for factor, 1 year of continuous eligibility, and ≥ 2 claims per comorbidity. Propensity scores for age, geography, ethnicity, insurance, and primary care visit matched PWH with GenP. GenP fulfilled the same inclusion criteria except for hemophilia requirements. Fifteen common comorbidities were defined via ICD-9 codes, then by related prescription. After matching, chi-square/Fisher’s exact tests and odds ratios (OR) with 95% confidence intervals (CI) were calculated. Results: A total of 818 PWH and 40,900 GenP were identified. Mean age of PWH was 23.6 years; GenP was 23.7. When only diagnosis codes for the comorbidities were included, eight comorbidities were significantly different (see table). When a prescription for the comorbidity was also required, no significant differences were noted.

The elderly hemophilia population: A Nordic patient organization perspective

ZYGMUNT GRUSZKA,1 TROND LANGVIK,2 BENNY  AS B E R G 1 and S T E I N E R I K W E S T L I 2 1 Swedish Hemophilia Society, Sundbyberg, Sweden; and 2Norwegian Hemophilia Society, Nesoddtangen, Norway Background: The situation for the ageing hemophilia population in Scandinavia has frequently been discussed whenever the Nordic Societies get together. There is a lack of knowledge how ageing affects elderly PWH; among the PWH themselves, their relatives, as well as within the medical health care system, social services and institutions. In order to address these issues, a three year project was created in 2011 by the Swedish and Norwegian Hemophilia Societies with support from Bayer AB. Aim of the project: To identify the needs of elderly PWH in the Swedish and Norwegian hemophilia societies and to communicate these needs to members, to the medical profession and to social services. Methods: Yearly gatherings of elderly members in both countries serve as reference and work groups. A steering group in each country takes the project forward and communicates results between the two societies. The medical needs of elderly PWH are also subject to cooperation with the Nordic Hemophilia Care via an Advisory Board. The Advisory Board will, when needed, serve as medical back-up and have access to results from the project. Results So far, the project has resulted in the creation of the following material available for download from the home pages of the hemophilia societies: a short pamphlet What is important to know about elderly PWH to hand over in contacts with medical professionals and social services; checklists to be used in meetings with doctors, social services counselors and physiotherapists at the Hemophilia Centers; checklists to be used in contacts with the local health care, home service, social services, physiotherapisst, occupational therapists and retirement homes; A Patient Self-Record to be used by PWH and their relatives in contact with local and acute health care facilities. Ongoing work also includes: checklists on pain management, mental health issues, travelling and working over age 50; identifying and attending to the needs of the relatives of elderly PWH.

Haemophilia (2014), 20 (Suppl. 3), 1--186

Table. Comorbidity

Atrial Fib. Cirrhosis Hemorr. Cerebrovascular Disease Hep. C Hypertension Osteoarthritis Osteoporosis Renal Disease

PWH Estimate (%)

GenP Estimate (%)

0.2 1.0 0.1

0.0 0.0 0.0

9.1 (3.1-26.6) 23.8 (10.2-55.2) 9.1 (2.0-41.2)

8.4 1.3 3.7 0.2 1.2

0.1 0.9 0.5 0.0 0.2

163.7 (101.6-263.9) 1.5 (1.0-2.2) 8.3 (5.6-12.3) 250.5 (12.0-5221.1) 5.1 (2.6-9.7)

OR (95% CI)

Conclusion: Small sample sizes and resulting wide CIs make inferences for some comorbidity difficult. We hypothesize our cohort reflects moderate/severe PWH due to the requirement for factor prescription and arthritis. Data supports that PWH patients are at risk for hypertension and renal disease. Cirrhosis due to Hepatitis C was increased in PWH. There was no significant increase in atherosclerotic disease or cancer in PWH. Despite the limitations of this study, we believe the medical risks identified suggest that PWH be monitored prospectively. Expanded data collection through integrated systems can allow better understanding of this population’s needs.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd



03-CARRIERS AND PRENATAL ISSUES Validation of the Self-BAT (Self-administered Bleeding Assessment Tool) in hemophilia carriers: preliminary results

JANE YOUNG,1 JULIE GRABELL,1 ANGIE TUTTLE,1 MEGHAN DEFOREST,2 DAVID GOOD,1,3 NATALIA RYDZ,4,2 J O H N N Y M A H L A N G U , 5 W I L M A H O P M A N 1 , 3 and PAULA JAMES1,3 1 Queens University, Kingston, Ontario, Canada; 2University of Calgary, Calgary, Alberta, Canada; 3Kingston General Hospital, Kingston, Ontario, Canada; 4Foothills Hospital, Calgary, Alberta, Canada; and 5The National Health Laboratory Service NHLS, University of Witwatersrand, Johannesburg, South Africa

Introduction and Objectives: Approximately 30% of carriers of hemophilia (HC) manifest low FVIII or FIX levels and can have abnormal bleeding symptoms. Currently, there is no standardized tool for the assessment of bleeding symptoms in HC. The Self-administered Bleeding Assessment Tool (Self-BAT) was developed from the expert-administered International Society on Thrombosis and Haemostasis Bleeding Assessment Tool (ISTH-BAT) and optimized by studying individuals known to have Type 1 von Willebrand disease (VWD) and healthy controls. Our objectives for this study are to ensure a high degree of consistency between the Self-BAT and ISTH-BAT bleeding scores (BS) in HC and to validate the Self-BAT as a screening tool for identifying HC with low FVIII or FIX levels. Patients, Materials and Methods: This is a multi-centre, international, prospective study with participation from Queen’s University in Kingston, Canada, the University of Calgary in Calgary, Canada, and the University of Witwatersrand in Johannesburg, South Africa. Eligible subjects were female carriers of hemophilia A or B, > 18 years of age. Subjects were excluded if they had another potential cause of bleeding. Following informed consent, subjects were administered the ISTH-BAT and the SelfBAT in random order at least two weeks apart. At the first visit, a blood sample was obtained for coagulation factor testing, FVIII or FIX genotyping and ABO. Results: To date, 15 HC have been enrolled in Kingston. Of the 15, 11 have completed both BATs and 9 have had their relevant factor level determined. Data can be found in Table 1. Preliminary analysis shows that the BSs from the ISTH-BAT and Self-BAT are highly correlated, with an Intraclass Correlation Coefficient of 0.87. Additionally, a positive or abnormal Self-BAT BS (≥ 5) has a sensitivity of 100%, specificity of 50%, a positive predictive value of 0.75 and a negative predictive value of 1.0 for the identification of those with low coagulation factor levels. Conclusion: Preliminary analysis of our data suggests that the Self-BAT is a highly effective tool to incorporate into the clinical assessment of HCs. The Self-BAT allows the identification of HC who will benefit from treatment strategies aimed at controlling bleeding symptoms and will facilitate improvements in the management of these patients overall. Table 1.

Age (years) Mean(range) Factor Level (IU/mL) Mean(range) Self-BAT Bleeding Score Mean(range) ISTH-BAT Bleeding Score Mean(range)

Hemophilia A (n = 10)

Hemophilia B (n = 1)

46 (27 – 64) 0.47 (0.17 - 0.95)(n = 9) 10 (1 – 21) 9 (1 – 18)

29 0.75



Notification of hereditary issues to daughter with little knowledge of hemophilia Lack of genetic issues of hemophilia within families Negative impact of HIV on daughter’s lifestyle regarding marriage and giving a birth A variety of conflicts in the family No readiness for accepting hemophilia

Life events, support taking experiences and health readiness; psychosocial difficulties among hemophilic carriers in Japan (A pilot)

TOSHIYA KUCHII,1 AKIKO KAKINUMA,1 KAYO INOUE,2 Y U K I K O S E K I 3 and K A T S U M I O H I R A 1 Social Welfare Corporation Habataki Welfare Project, Hatataki, Japan; 2Graduate School of Humanities and Sciences, Ochanomizu University, Ochanomizu, Japan; and 3 Faculty of Education, Saitama University, Saitama, Japan


Background: Carriers of hemophilia still have a variety of psychosocial difficulties as well as insufficient social support resources (Kakinuma, WFH, 2012). Objectives: The purpose of this study was to examine explanatory empirical models among Japanese carriers of hemophilia involving difficulties in getting social support, as well as to develop a social support readiness scale including elements such as knowledge about hemophilia, support experience and potential social support needs, as a pilot study. Methods: A self-administered questionnaire was administered to 30 hemophilic carriers comprised of obligate carriers (n = 21, 70.0%) and possible carriers (n = 9, 30.0%) that had been recruited by the snowball approach. The following variables were collected: marital status, childbirth experience, age (20-39, n = 7, 23.3%), (4059, n = 7, 23.3%), (60 + , n = 16, 53.4%). The original scales were developed, which were knowledge about hemophilia (6 items, range score 6-30, Cronbach’s a=0.906), experienced social support (8 items, range score 8-40, Cronbach’s a=0.837), and social support needs (8 items, range score 8-40, Cronbach’s a=0.842). Multiple regressions were conducted to estimate the relationships among variables or scales. Results: We obtained results as follows: 1) Age-adjusted social support needs were strongly explained by the experience of childbirth. 2) The effect of childbirth experience was diminished by the addition of knowledge factor. 3) A strong effect of experienced social support was found, and the effect of knowledge factor was decreased in the full model. 4) In the full model, the explanatory model was improved. Discussion and Conclusions: The effect of knowledge and social support experience were found to be mediators. Practical values of good readiness experiences were suggested when applying a diverse of social support resources to carriers of hemophilia. Based on our study, we need to develop a planning program and multidisciplinary support for carriers of hemophilia in Japan, focusing on health literacy, disease prevention, and genetic counseling as well as emerging social support resources and networks.

4 3

How we address support needs and hereditary issues in Japanese hemophilic carriers? Narrative case study based on semi-structured interviews (a pilot)

AKIKO KAKINUMA,1 TOSHIYA KUCHII,1 KAYO INOUE,2 Y U K I K O S E K I 3 and K A T S U M I O H I R A 1 1 Social Welfare Corporation Habataki Welfare Project, Hatataki, Japan; 2Graduate School of Humanities and Sciences, Ochanomizu University, Ochanomizu, Japan; and 3 Faculty of Education, Saitama University, Saitama, Japan Background: As with other genetic disorders, hemophilia can considerably affect interpersonal relationships and disrupt patients’ family life. The situation is even more complicated due to cases of HIV contamination in the early 1980s. Our project has been dedicated to helping both Japanese HIV victims, and their families since our establishment in 1997. We have previously presented our study, addressing how to effectively support patients (Kakinuma et al, 2012 WFH congress in Paris). Objectives: Our goal is to identify the social support needs and strategies of hemophilic carriers in Japan, though a thorough analysis of their health history. Methods: Semi-structured interviews were conducted among women with carrier status or women with a family history of hemophilia. Our survey was conducted in accordance with qualitative research protocols. An analysis of each case was comprehensively investigated by researchers, focusing on objective facts. Results: Issues that were identified are as follows: Discussion and Conclusions: In a series of five interviews with family members, we obtained these findings. 1) Lack of information sharing among family members. 2) Imperfect relationships between family members and a daughter who may be a carrier. 3) Hesitant attitude by family members towards people with hemophilia. Our studies suggest that comprehensive genetic counseling is necessary for carriers.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd



The use of BclI Restriction Fragment Length Polymorphism for hemophilia A carrier detection in Sudanese families RAYAN N. YOUSIF ELSHEIKH Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan Introduction and Objectives: Hemophilia A is the most common X-linked inherited bleeding disorder caused by a deficiency in the activity of coagulation factor VIII, with an incidence of 1 in 5000 male births. The aim of this study was to investigate the usefulness of BclI restriction fragment length polymorphism (RFLP) in the linkage analysis for carrier detection in Sudanese families, in order to formulate an informative and accurate carrier diagnosis. Materials and Methods: The study included 20 families with at least one subject affected with hemophilia A, and 30 unrelated normal females as a control group. Polymerase chain reaction (PCR) and restriction enzyme analysis were used to study the polymorphism in BclI. Results: The incidence of BclI (+) allele was 78%, 39.5% and 33% in patients, female relatives and the control group, respectively. Expected heterozygosity for BclI was 0.48 in female relatives compared with 0.46 in the female control group. However, observed heterozygosity was found to be 0.54 in female relatives, compared with 0.66 in the control group. The defective X chromosome was identified in 13/20 (65%) mothers, hence this marker alone was found to be informative in 65% of the studied families. Conclusion: This study demonstrated that the PCR-based analysis of the BclI RFLP was useful in the carrier detection of hemophilia A in the Sudanese population.

Haemophilia (2014), 20 (Suppl. 3), 1--186



Non-invasive prenatal diagnosis for early detection of fetal sex in X-linked disorders

SILVIA LINARI,1 CLAUDIA GIACHINI,2 FRANCESCA GERUNDINO,2 CHIARA PESCUCCI,2 SABRINA FRUSCONI,2 FIAMMETTA SBERNINI,2 ENRICO PERITI,3 ELISABETTA PELO,2 MASSIMO MORFINI1 and F R A N C E S C A T O R R I C E L L I 2 1 Agency for Haemophilia; and 2Diagnostic Genetic Unit and 3Prenatal Diagnosis Unit, University Hospital of Florence, Italy Introduction and Objectives: The determination of fetal sex is indicated for carriers of X-linked genetic conditions (such as hemophilia A and B) and for those patients at risk of conditions associated with ambiguous development of the external genitalia. This is traditionally performed by invasive testing after the 11th week of gestation, using either chorionic villus sampling or amniocentesis. The discovery of cell-free fetal DNA (cffDNA) in maternal plasma has opened up new possibilities for noninvasive procedures in prenatal diagnosis (NIPD), with no risk of fetal loss. Materials and Methods: The aim of the study is to optimize and validate a noninvasive procedure for sex determination on a large cohort (n = 2000) of pregnant women at different gestational periods (8–11 weeks). The molecular method consists of a multiplex qRT-PCR targeting Y chromosome-specific sequences (SRY and DYS14 genes). Since a female fetus is predicted by a null result (absence of Y chromosomespecific sequences amplification), which could indicate the absence of cffDNA or the failure of the test, the simultaneous analysis of a fetal-specific DNA marker as an internal control is required to confirm the presence of cffDNA, in order to avoid false negative results. The set-up of fetal-specific (epigenetic) marker analysis – i.e. sequences that are differentially methylated in maternal blood cells and fetal placenta – represents the second aim of this study. Real-time PCR results were compared with QF-PCR/karyotype results and/or with follow up data to establish the sensitivity/ specificity of the methods, and therefore whether this test could be suitable for routine clinical settings. Results: A total of 1300 maternal plasma samples have been collected and the first set of 250 samples have been analyzed. At present, postnatal sex identification or fetal karyotype results were available for 148 samples, showing a 100% concordance between results obtained by RT-PCR and follow-up data. Sensitivity and specificity of the assay are both 100%. In this study, 5/148 samples belonged to carriers of hemophilia. Conclusions: On the basis of our preliminary data, we conclude that noninvasive fetal sex determination is highly reliable and it could be used as an early test to establish whether invasive prenatal diagnosis needs to be performed on a fetus at risk of Xlinked disorders.

A total management system of carrier diagnosis for hemophilia using gene analysis: results of 24 individuals in 15 Japanese families with hemophilia

KAGEHIRO AMANO,1,2 TAKESHI HAGIWARA,2 T A K A S H I S U Z U K I , 2 H I R O S H I I N A B A 2 and KATSUYUKI FUKUTAKE1,2 1 Department of Molecular Genetics of Coagulation Disorders; and 2Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan Introduction: Hemophilia A and B are hereditary X-linked bleeding disorders caused by gene mutations in coagulation factor VIII (FVIII) or IX (FIX) resulting in an absence or reduced activity of FVIII or FIX. Confirmation of the carrier status of women in families with a history of hemophilia is valuable for these subjects and their relatives. Until recently, carrier diagnosis has been performed by standard pedigree analysis and conventional clotting factor assays. However, because factor activity varies by X-lyonization and daily variance etc., the subjects on whom carrier diagnoses was done using a blood coagulation test have not been precisely identified. Objectives We aimed to apply gene analysis to carrier diagnosis for hemophilia and to develop a precise carrier diagnosis system in hemophilia clinics, under the approval of the ethics committee on medical research, Tokyo Medical University. Methods: A total management system from informed consent through the reporting of results was generated. Purified PCR templates from genomic DNA were directly sequenced. Analysis of Long PCR was used to detect inversion. Results: Twenty females who belonged to 13 families with a history of hemophilia A and 4 females who belonged to 2 families with a history of hemophilia B were analyzed for carrier detection by gene analysis. One obligate carrier of hemophilia A was included in the subjects. Seventeen females were diagnosed as carriers and 3 females were diagnosed as non-carriers in families with hemophilia A. Inversion of intron 22 in the heterozygous state were identified in 7 females. Six missense mutations, 3 deletions, and 1 nonsense mutation were identified in the heterozygous state. Three females were diagnosed as carriers in 2 families with hemophilia B and identified missense mutations in the heterozygous state. Results for a female from a family with a history of hemophilia B family have not yet been conducted. Conclusions: The prenatal diagnosis of hemophilia is not performed in Japan. The carrier diagnosis is important to ensure the safety of carriers and babies during delivery. Our carrier diagnosis system will play an important role in enhancing the quality of life in patients, carriers and relatives with hemophilia.

Factor IX levels in an unselected population of mothers of Haemophilia B patients

MATTIA RIZZI,1 VANESSA BOUSKILL,2 CINDY WAKEFIELD,2 A N N M A R I E S T A I N , 2 C E C I L I A M A N U E L 1 and MANUEL CARCAO1 1 Department of Paediatrics, Division of Haematology/Oncology; and 2Department of Nursing, The Hospital for Sick Children, University of Toronto, Toronto, Canada

testing is not always available and clinicians sometimes rely on women’s’ FIX levels to determine carrier status. Over the last decade, our clinic implemented a policy of genetic testing on all patients with hemophilia and determined their mothers’ carrier status. Recently, we have also been obtaining baseline FVIII/FIX levels on all carrier mothers regardless of whether they demonstrate clinical bleeding. We present the results of our evaluation of our HB mothers. Currently, 74 boys with HB are registered in our genetics database. These boys have 65 mothers (some mothers have ≥1 affected son). Of these 65 mothers, 42 (64.5%) are obligate carriers. Additionally, 15 mothers (23%; all with a negative family history of hemophilia) were proven to be carriers by genetic testing. In 7 mothers (11%), genetic testing was never performed, as these mothers were not available for testing (deceased; child adopted or family moved before mother tested). Only 1/65 mothers (1.5%) was proven not to be a carrier; her son carried an insertion mutation at n20458 (exon F) causing a frameshift at codon 160. In 29 carriers where both genetic results and FIX levels were available, the mother’s median FIX level was 68% (IQR: 51-74%; min/max, 29/122%). Only 7/ 29 mothers (24%) had FIX levels 50%, proving that FIX levels are unreliable at predicting carrier status in mothers of boys with hemophilia.

Characteristics of hemophilia carriers in clinic and testing in National Institute of Hematology and Blood Transfusion, Hanoi, Vietnam N G U Y E N H O A N G H A , N G U Y E N T H I N U , N G U Y E N T H I M A I and NGUYEN ANH TRI National Institute of Hematology and Blood Transfusion, Hanoi, Vietnam Introduction and Objectives: Carriers of hemophilia experience symptoms similar to those seen in men with mild hemophilia. They are prone to bruising under the skin, menorrhagia, prolonged bleeding after injury, surgery or after childbirth. Methods: We have implemented a study involving 72 women who were carriers of hemophilia, including 64 carriers of hemophilia A and 8 carriers of hemophilia B. Results: Average age was 35.2  9.8, (12-58 years old). Results included the following: abnormal bleeding symptoms (31.9 %); prolonged bleeding after injury, intervention (39.1 %), menorrhagia (26.1 %); other symptoms such as purpura, gum bleeding. There were no cases with musculoskeletal bleeding. Results showed 29.2 % of carriers had prolonged APTT (rAPTT from 1.25 – 1.5). The average factor VIII level of hemophilia A carriers was 51.68  20.31, and the average factor IX level of hemophilia B carriers was 55.13  18.0. Conclusions: Hemophilia carriers with prolonged APTT have a bleeding risk 3.57 times higher than those without prolonged APTT. Hemophilia carriers having factor VIII/IX ≤ 40 % in comparison with ones having factor VIII/IX > 40 % will have a risk of menorrhagia 5.65 times higher and a risk of prolonged bleeding after injury 5.7 times higher.

Thrombin generation capacity and bleeding phenotype in carriers of hemophilia A

FARIBA BAGHAEI,1 MARGARETA HELLGREN,2 € 4 and E R I K B E R N T O R P , 3 M A R G A R E T A H O L M S T R OM ANNA OLSSON1 1 Coagulation Centre, Department of Medicine/Hematology and Coagulation Disorders, Sahlgrenska University Hospital, Gothenburg, Sweden; 2Department of Obstetrics and Gynaecology, Sahlgrenska Academy, University of Gothenburg , Sweden; 3Department of Hematology and Coagulation Disorders, Sk ane University Hospital, Malm€ o, Sweden; and 4Coagulation Unit, Hematology Centre, Karolinska University Hospital, Stockholm, Sweden Introduction and Objectives: Hemophilia is an X-linked recessive genetic disorder and females who inherit the gene mutation are known as carriers of disease. Studies have suggested an increased bleeding tendency in some carriers, even when clotting factor levels are within the lower normal range. Thus, the factor levels might not be a good predictor of bleeding tendency. Previous studies have shown the ability of TG assay (TGA) to identify a milder bleeding phenotype among certain patients with hemophilia. In this study, we aimed to investigate the association between TGA outcomes and bleeding phenotype as well as clotting factor levels in carriers of hemophilia A. Materials and Methods: Carriers of severe and moderate hemophilia A, registered at the three hemophilia centres in Sweden, were eligible to participate in the study. Each female carrier suggested a female friend (with no bleeding in her own medical history or family history) as a control to evaluate bleeding tendency according to a standardised bleeding assessment tool. Venous blood for coagulation analyses and TG was collected and analysed only for carriers. TGA was performed using the calibrated automated thrombin method (CAT) on PPP (platelet poor plasma). Results: The type of data which will be submitted later on are based on TGA outcomes on the carriers and correlations with bleeding tendency given as bleeding score (BS), as well as associations between TGA and coagulation factor levels. The upcoming analysis will be performed on final results. Our intension is to submit the final updated data, including results and conclusions, before March 1, 2014.

Factor IX (FIX) levels show considerable variability in carriers of hemophilia B (HB). Genetic testing is the only reliable tool to determine carrier status. However, genetic

Haemophilia (2014), 20 (Suppl. 3), 1--186

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

CARRIERS AND PRENATAL ISSUES Influence of psychological and social factors on health-related quality of life in carriers of hemophilia C O R N E L I A W E R M E S and M A R I O V O N D E P K A P R O N D Z I N S K I Werlhof Institute, Hanover, Germany Introduction and Objectives: Hemophilia is a severe inherited x-linked bleeding disorder. About 50 per cent of female carriers have reduced factor levels and are suffering from bleeding episodes themselves. In addition, emotional and social problems could have an impact on the Quality of Life (QoL) of carriers. Materials and methods: Carriers were asked about several issues, including bleeding history, family planning, and their social life using an anonymous questionnaire. QoL has been measured by the standardized short version of the WHO-QoL-100-test (breftest), including the results of a normal female population, which served as control group. The test consists of 26 items and 5 domains including physical, emotional, social, environmental, and global aspects of QoL. A higher score means a higher QoL with a maximum of 100. Results: In this multicentre study 318 carriers with a median age of 27 years were enrolled. Of those, 80% were carriers for hemophilia A, and 70 % carried the severe form. We recorded that 78.3% lived in partnerships, and 87.7% had at least one child. The overall QoL was comparable to the normal population. Only the emotional domain showed slightly reduced values (70.24 versus 72.49). We found that 72% of carriers were suffering from bleeds like Menorrhagia, hematomas, and epistaxis and had a lower QoL. Anxiety occurred in 77%. QoL was reduced (Emotional 69.08 versus 75.34; p < 0.004; Social 70.09 versus 79.78; p < 0.0001; Global 70.82 versus 76.41; p < 0.046). Feeling of guilt in 47.8% reduced QoL (Emotional 66.93 versus 74.38, Social 68.24 versus 76.49; p < 0.0001; Environment 72.00 versus 76.01; p < 0.013). Conflicts in the family (42.5%) lead to reduced QoL (Physical 78.06 versus 82.66; Emotional 66.37 versus 73.79; Social 66.29 versus 77.07; Environment 71.11 versus 75.94; Global 68.14 versus 75.54; p < 0.008). Feelings of depression, and reduced communication about hemophilia also had a negative influence on QoL. Conclusion: Comparing carriers who are worried about their status or the hemophilia in their families, those with feelings of guilt or anxiety, carriers with conflicts in the family, or those with problems in their social environment suffer significantly more often from a reduced QoL in contrast to carriers who have not these feelings or problems.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


Profile of suspected women carriers for Haemophilia-A in a new hemophilia centre

S H R U T I K A T E , 1 S U N I T A A G G A R W A L , 2 , 3 A L P A N A S A X E N A 3 and NARESH GUPTA2,4 Tata Memorial Hospital, Mumbai, India; 2Maulana Azad Medical College, New Delhi, India; 3Lok Nayak Hospital, New Delhi, India; and 4Haemophilia Centre, Lok Nayak Hospital, New Delhi, India


Introduction and Objectives: Hemophilia A is X-linked, recessive, inherited bleeding disorder, with resultant deficiency of procoagulant factor VIII. Women are the carriers of this disease, and can be classified as obligate or possible carriers. Clinical, haemostatic and genetic profiles of suspected women carriers from families of haemophilia patients attending our hemophilia centre in New Delhi, India were studied. Materials and Methods: Amongst 25 families of hemophiliac patients attending our hemophilia centre, 61 suspected women carriers were identified and subjected to pedigree analysis, and hematological investigations including prothrombin time (PT), activated partial thromboplastin time (A PTT) and Factor VIIIc assay. Molecular genetic analysis by linkage analysis using marker bcl1 for Intron 18 was done in 31 suspected carriers. Results: Amongst the total suspected carriers, there were 47 (77%) possible carriers and 14 (23 %) obligate carriers. No bleeding history was recorded in 57 (93.45%). Hemoglobin was normal in 24 out of 61 suspected carriers (39.4%), mild (Hb 10-12) and moderately severe (Hb 7-10) anemia were found in 33 (54.1%) in 4 (6.55%) cases respectively. Abnormal APTT was seen in 6/61 (10%) of suspected carriers. Mean factor VIIIc level in these suspected carriers was 25.47  16.3%. Eighty seven percent (53/61) of carriers had abnormally low factor VIIIc level and only 8/61 had normal levels. Mean factor VIII level amongst suspected women carriers with positive family history (inherited case) was significantly lower at 22.6% 8.8% compared to 26.9% 19.1% for without positive family history (sporadic case), p value=0.04. Out of 25 families, ten families (10 confirmed patients and 31 suspected carriers) were selected for molecular genetic profiling by RFLP linkage analysis using BCL1 (Intron 18) and HINDIII (Intron 19) markers which gave non-informative results. Conclusions: Whereas the male patients with hemophilia are affected clinically, the asymptomatic females with a single mutated gene are the carriers of disease. Even a clinical and basic hematological evaluation of the suspected women carriers can be informative prior to the molecular genetic analysis to assess the carrier status.

Haemophilia (2014), 20 (Suppl. 3), 1--186



04-CLINICAL ASPECTS Thrombin generation assay in hemophilic patients with or without inhibitor undergoing orthopedic surgery MARIA ELISA MANCUSO, VEENA CHANTARANGKUL, MARIGRAZIA CLERICI, MARIA ROSARIA FASULO, LIDIA PADOVAN, ERICA SCALAMBRINO, FLORA PEYVANDI, A R M A N D O T R I P O D I and E L E N A S A N T A G O S T I N O Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy Introduction and Objectives: Laboratory monitoring of patients with hemophilia undergoing surgery is limited to the measurement of factor VIII (FVIII) levels. No routine coagulation monitoring is available for inhibitor (INH) patients treated with by-passing agents (BPA). The aims of this study were to assess if TGA is able to provide information on global coagulation activation after FVIII therapy in non-INH patients and if in INH patients it is related to the hemostatic and clinical response to BPA. Materials and Methods: TGA was assessed in platelet-rich (PRP) and platelet-poor (PPP) plasma with the addition of corn trypsin inhibitor (CTI) in 17 patients with severe hemophilia A (9 with high-responding inhibitors) aged 5-59 years (median: 39) undergoing orthopedic surgery. Four parameters of the TGA curve were evaluated: lagtime, endogenous thrombin potential (ETP), peak and time-to-peak. TGA was assessed once daily prior, and 30 minutes after, drug injection (FVIII or BPA) starting from the pre-operative bolus and for 4 post-operative days. Hemostatic treatment to cover surgical procedures was established irrespective of TGA measurements. In nonINH patients FVIII levels were measured on the same blood samples. Results: In the group of 8 non-INH patients TGA values increased after the first FVIII infusion, however during the post-operative period (FVIII trough levels >50 IU/dL) TGA was scarcely sensitive to the significant variation observed in FVIII levels prior (median: 74%) and after daily infusions (median: 155%; p < 0.001); a correlation between TGA and FVIII levels was observed only for ETP and peak in PPP+CTI. In the group of 9 INH patients TGA increased after BPA injection however TGA did not reveal different responses related to the type of BPA (rFVIIa/aPCC), the dose used and/or the occurrence of bleeding complications (n = 5). Moreover, a lack of response of the TGA curve was observed during the post-operative period irrespective of treatment regimen modifications in all INH patients. Conclusion: Our results indicate that TGA is not a suitable tool to monitor hemostatic response during surgery in hemophiliacs: in non-INH patients TGA is moderately sensitive to FVIII levels variations and does not provide additional information on coagulation activation during replacement therapy and in INH patients TGA is not able to predict either the hemostatic response to different type of BPA and/or doses used nor the risk of bleeding complications.

Non-musculoskeletal surgery in patients with hemophilia: A single centre experience

AURO VISWABANDYA,1 ABRAHAM SUNDER SINGH,1 ABY ABRAHAM,1 ABHIJEET P. GANAPULE,1 BIJU GEORGE,1 V I K R A M M A T H E W S , 1 M . J . P A U L 2 and A L O K S R I V A S T A V A 1 Departments of 1Haematology, and 2 Endocrinology Surgery, Christian Medical College, Vellore, India

Introduction and Objectives: There is limited data in the literature describing nonmusculoskeletal surgery in patients with hemophilia. There is hardly any data from developing countries. Here we describe our data on non-musculoskeletal surgery in patients with hemophilia. Materials and Methods: Data was reviewed from the medical records of all patients with hemophilia (both A and B) who were seen for surgery for non-musculoskeletal indications between 2002 and August 2013. Patients with inhibitors were excluded. For surgical hemostasis, we followed a lower dose clotting factor concentrate (CFC) infusion protocol as previously reported (Srivastava et al, Haemophilia 1998; 4; 799– 801). Results: A total of 52 patients were included in this analysis: 38 with hemophilia A (severe- 28 , moderate-5 and mild-5) and 14 with hemophilia B (severe-9; moderate-3, mild-2). The surgeries included hernia repair (12), fasciotomy and wound debridement (5), hydrocelectomy (5), circumcision, appendectomy, nephrectomy (3 each), percutaneous nephrostomy, pyloroplasty, stent for stricture urethra (2 each), atrial septal defect (ASD) closure (1), skin grafting (4), thyroidectomy (2), nasal polypectomy, parotidectomy, bilateral phaeochromocytoma excision, carpal tunnel, anoplasty, colostomy (1 each), The median age of the patients was 30 years (range: 3– 65). The median pre-procedure factor level after loading dose was 89% (range: 54– 218). The median trough factor levels on days 1, 3, 5 and 7 were 36% (range: 15-83); 35% (range: 6 – 121); 29% (range: 6–74) and 16% (3–36%), respectively. The median total dose of CFC used was 243 IU/kg (range: 122 – 658). The median duration of factor support was 8 days (range: 4–16). Seven (13%) patients had complications post-surgery: (infection and bleeding-2, haematoma-2 (however, did not require re-exploration), resuturing-1 (slipped ligature), inhibitor formation-1, expired1 (diverticulitis with intestinal perforation and intra-abdominal abscess)). Only 8% of these were clinically significant. Conclusion: Major surgery in patients with hemophilia presenting with nonmusculoskeletal indication is feasible with lower doses of CFC when resources are limited, and no major complications were seen in over 90% of patients.

A cross-sectional study of comorbidities and hypertension in patients with hemophilia A and B in Europe: Interim results from the H3 study

Cognitive disorder in adult patients with hemophilia: A clinical and MRI study

EZIO ZANON,1 RENZO MANARA,2 BARBARA BRANDOLIN,1 RODICA MARDARI,3 SANDRA ROSINI,4 DANIELA MAPELLI5 and P I E R O A M O D I O 6 Haemophilia Center and Departments of 1Cardiac, Thoracic, and Vascular Sciences, 3 Neuroradiology, Department of Neurosciences; 4CIRMANMEC; 5 General Psychology; 6 Medicine,DIMED, University of Padua, Italy; 2Neuroradiology, Department of Medicine and Surgery, University of Salerno, Italy

Introduction: Studies about the cognitive features of adult with hemophilia are lacking, despite some data showing low performance at school in children with hemophilia. Objectives: To describe the neuropsychological profile in adult patients with hemophilia and assess its relationship using brain imaging, to severity of hemophilia and its treatment. Materials and Methods: After obtaining informed consent, 49 adults (42  15 years) with hemophilia (31 severe, 18 mild), without inhibitors were enrolled. Patients underwent: i) a psychometric battery comprising 13 tests; ii) brain Magnetic Resonance Imaging (MRI). Results: Impaired overall cognitive performance was found in hemophilic patients (mean Z score of the tests=-018  0.07, 73% of the patients had altered performance on at least one test), which included a neuropsychological profile pointing to prefrontal functional impairment. Only a non-significant trend for more severe cognitive impairment in patients with severe hemophilia on-demand treatment was detectable. MRI findings, available in 44 patients, showed remarkable brain abnormalities. A trend toward more cerebral microbleeds (CmBs) was found in severe hemophilia treated on-demand; however a correlation between CmBs and age might have biased the results. CmBs were found to be correlated with the reduction of overall psychometric performance (r = 0.39 p < 0.05) and the number of cardiovascular risk factors (r = 0.33 p < 0.05). Conclusion: Minor cognitive impairment and high prevalence of minor brain abnormalities in MRI studies are detectable in adults with hemophilia; CmBs were found to be related to cognitive impairment, thus providing cues for further studies on brain damage in patients with hemophilia.

Haemophilia (2014), 20 (Suppl. 3), 1--186

P AL A N D R E H O L M E , 1 C H R I S T O P H E C O M B E S C U R E , 2 E R I K B E R N T O R P 3 and C A M P B E L L T A I T 4 Dept of Hematology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; 2 University of Geneva and University Hospitals of Geneva, Geneva, Switzerland; 3 Center for Thrombosis and hemostasis, Sk ane University Hospital, Lund University, Malmø, Sweden; and 4Department of hematology, Roal Infirmary, Glasgow, UK


Introduction and Objectives: Retrospective studies suggest hypertension is more prevalent among people with hemophilia (PWH) compared to the general population. Hematuria and consequential renal disease are also common among PWH. Renal disease is associated with hypertension in the general population. The ADVANCE Working Group, representing 20 hemophilia centres in 10 European countries, conducted a cross-sectional epidemiological study (Hematuria and Hypertension in Hemophilia; H3) to identify factors associated with hypertension in PWH. Materials and Methods: Each centre collected demographic and medical data at a single time-point per patient in around 40 consecutively recruited PWH, over 40 years of age. Descriptive analyses of the data were performed using basic summary statistics. Hematuria-specific information was summarized in a severity index. Associations between suspected factors and diagnosis of hypertension were tested in univariate analyses. Multivariate logistic regression modeling was conducted to identify independent predictors of hypertension. The predictive performance of models was assessed by ROC curve analysis. Results: We enrolled 509 patients (median age 52 years, range 35-98) with hemophilia A (n = 448, 88%) or hemophilia B (n = 61, 12%). Hemophilia was severe in 291 patients (58%), moderate in 55 (11%) and mild in 158 (31%), and 224 patients (44%) had hypertension. In multivariate analyses, age and BMI were significantly and independently associated with the risk of hypertension (OR reached 10.7, p < 0.001 in elderly patients and 11.5, p < 0.001 in patients with BMI>30). Patients with a history of coronary heart disease (5.6%, 28/498) and diabetes (48/506, 9.8%) were more at risk of hypertension (OR 3.3 p = 0.04 and 2.8 p = 0.02 respectively). A significant association between creatinine and hypertension was also found (p = 0.04). The AUC for this model was 0.80. In a second model, hypertension risk increased significantly with hematuria index (OR 1.2 per point, p = 0.03) and in patients with a family history of hypertension (OR 3.6, p < 0.001); the AUC for this model was 0.82. Conclusion: H3 represents the largest cohort of older patients with hemophilia where systematically collected information on hypertension and comorbidities is available. Established risk factors for hypertension were confirmed; further variables (e.g. hematuria) seem to have an independent influence and need to be further investigated.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

CLINICAL ASPECTS A survey on treatment and quality of life (QoL) of hemophilia A (HA) and hemophilia B (HB) children in Zhejiang Province in Southern China

WEIQUN XU,1 JIANYA YANG,1 YONGTMIN TANG,1 KOONH U N G L U K E , 2 N A N C Y L Y O N G , 3 M A N - C H I U P O O N 4 and RUNHUI WU5 1 Children’s Hospital of Zhejiang University, Zhejiang, China; 2Children’s Hospital of Eastern Ontario, Ottawa, Canada; 3School of Rural and Northern Health, Laurentian University, Sudbury, Canada; 4Departments of Medicine, Pediatrics and Oncology, University of Calgary, Foothills Hospital, Calgary, Canada; and 5Beijing Children’s Hospital and Capital Medical University, Beijing, China Objectives: The management of hemophilia in China is challenging because of economic constraints and poor availability of clotting factors. The HTC at the Children’s Hospital, Zhejiang University began the treatment and registration of hemophiliac boys in Zhejiang Province in 2008. We recently surveyed these boys on their treatment, joint and QoL status to record a baseline in order to direct their future care. Methods: We conducted (1) a retrospective chart review and telephone survey for treatment and joint status; (2) a CHO-KLAT2.0 questionnaire for boys and one of their parents. Results: (1) The 132 boys currently enrolled in the study include 115 HA, (age: 7 m17y9 m, median 7y4 m) and 17 HB (age: 11 m-17y1 m, median 7y). For episodic treatment, 78.4% patients received a decreased dose (HA: 0.05). Conclusions: 1. Prevalence of target joint is high even in mild patients. Target joints per patient increased with severity, although similar for each affected patient in all severity. 2. Target joints are more prevalent in HB than HA probably because FIX/ PCC is less available than FVIII in China. 3 QoL as assessed by both the boys and parents was poor. Contribution to the practice: These are baseline data on hemophilia boys receiving suboptimal care. Comprehensive care accompanied by full availability of clotting factors supply should improve the management of their treatment and their prognosis.


Mild Moderate Severe Total

Hemophilia A with target joint

Target joint per person

6/22 (27.3%) 14/37 (37.8%) 27/56(48.2%) 47/115 (40.9%)

0.59 (13/22) 0.73 (27/37) 0.93 (52/56) 0.8 (92/115)

Usefulness of ISTH bleeding assessment tool in the prediction of bleeding disorders in suspected patients referred to a tertiary care hospital in India

A N N A M M A K U R I E N , 1 S U L O C H A N A B , 2 D I N E S H N A Y A K 3 and ASHA KAMATH4 Departments of 1Pathology and 3Paediatrics, Melaka Manipal Medical College, Manipal University, Manipal, India; 2Manipal College of Nursing, Manipal University, Manipal, India; and 4Kasturba Medical College, Manipal University, Manipal, India

Introduction and Objectives: A definitive bleeding history is a prerequisite for the diagnosis of a bleeding disorder. The ISTH- Bleeding Assessment Tool (BAT) with questionnaire and bleeding score (BS) was proposed to describe bleeding symptoms and relate them to the diagnosis of bleeding disorders. However, its clinical and diagnostic utility has not been studied extensively. It is general practice to do a battery of tests to diagnose a bleeding disorder in any suspected case. Prediction of bleeding disorders through BAT may help to make laboratory testing more cost effective. Hence, this study was done to: 1) correlate BS with the definitive diagnosis of bleeding disorders, 2) study the usefulness of the BAT in suspected patients, 3) study the utility of the BAT in suspected patients with normal screening tests. Materials and Methods: Retrospective observational study of 62 patients with suspected bleeding disorders referred to Kasturba Hospital, Manipal, Karnataka, South India were included. The ISTH BAT was administered by a trained hemophilia nurse to the study group. Patients were tested using a panel of tests which included screening tests (BT, PT, PTT, TT, Factor XIII screen, platelet count, clot retraction, direct smear) and specific tests (mixing studies, factor assays, vWF assay and platelet aggregation studies). Results: In the 62 patients with suspected bleeding disorders, 29 were found to have a bleeding problem (hemophilia- 8, vWD-10, platelet function defects-3, other factor deficiency-2, thrombocytopenia-4, acquired platelet function defect and aspirin effect2). BS in these patients was significant with 2 in 10 cases, 3 in 16 cases and 4 in 3 cases. Multiple sites of bleeding were seen in 7 cases. Screening tests were normal in 6 of these cases (21%). Also, 29 patients had normal screening tests. Of these, 23 (79%) had a significant BS of 2 (14), 3 (8) and 4 (1). The one patient with a BS of 4 had all specific tests also within normal limits. All these patients were advised to repeat the testing. Conclusion: All patients with bleeding disorders had a significant BS. In a patient with significant BS, the hemostatic work up gave a positive predictive value of 0.79 in having a bleeding disorder. In a suspected patient with normal screening tests and BAT more than 2, further testing is required to confirm a bleeding disorder.

Target joint per affected patient

2.17 1.93 1.93 1.96

Hematospermia has been experienced by one-third of hemophilia patients


(13/6) (27/14) (52/27) (92/47)

Hemophilia B with target joint

4/6 (66.7%) 4/8 (50%) 2/3 (66.7%) 10/17 (58.8%)

Target joint per person

0.83 0.75 1.33 0.88

(5/6) (6/8) (4/3) (15/17)

Target joint per affected patient

1.25 (5/4) 1.5 (6/4) 2 (4/2) 1.5 (15/10)

Iliopsoas hematoma in patients with hemophilia: a single-centre study

C H I E S A T O , 1 K A G E H I R O A M A N O , 2 Y A S U H A R U N I S H I D A 3 and KATSUYUKI FUKUTAKE2 Departments of 1Nursing and 2Laboratory Medicine, Tokyo Medical University Hospital, Tokyo, Japan; and 3Department of Infectious Diseases, National Hospital Organization Osaka National Hospital, Osaka, Japan

 SIMON,1 MIGUEL CANDELA,1,2 DANIELA NEME,1 HAYDEE B E R N A R D O R O D E , 1 , 2 L U D M I L A E L H E L O U 1 and M I G U E L 1,2 TEZANOS PINTO 1 Fundaci on de la Hemofilia, Buenos Aires, Argentina; and 2Academia Nacional de Medicina, Buenos Aires, Argentina

Introduction: Hematospermia (bloody semen) is usually a symptom of urological relevance. However, it has often been found in hemophilia patients. Generally speaking, blood in semen shows a slight possibility of cancer, especially prostate cancer,when found in men age 40 and older. Shyness and embarrassment, however, prevent the patients from informing their doctors. As a result, this condition seems to have been underdiagnosed. Consequently, there is almost no data on the incidence or recommendations treatment of hematospermia involving patients with hemophilia. Objectives and Methods: In order to evaluate the incidence of hematospermia in hemophiliacs, a survey was conducted anonymously with 317 hemophilia patients in 9 hospitals across Japan. Results: The response rate was 48%, and 148 questionnaires were analyzed. The subjects were adolescents and adults, and the average age (mean [SD]) was 40.3 (11.9). The percentage with severe hemophilia was 58%, and the rest had moderate or mild hemophilia. We recorded that 35% of them were married. Forty-seven patients (32%) out of 148 patients experienced bloody semen and the average number of hematospermia incidents was 4.6 per person. Seven of them experienced the embarrassing situation more than 10 times. The age at the initial incident ranged from 15 years to the 50s and the peak age was in the 30s. Eighty-three percent of them felt uneasy, but only 34% of them asked medical doctors or nurses for help or advice, mainly due to their embarrassment. Conclusion: The symptom of blood in semen can be frightening, but is not often serious and gradually disappears in most cases. It is surprising, however, that there is no or almost no information about hematospermia in any guidelines for hemophilia management,including the revised guidelines of the WFH, despite such frequent occurrence. Therefore, it is very important to inform caregivers and patients that hematospermia is a common bleeding symptom and that the bleeding can be properly treated.

Introduction: The hematoma of the iliopsoas muscle is a frequent complication in patients with hemophilia, is potentially fatal and is associated with significant morbidity. Its clinical appearance is characterized by lower abdominal and groin pain, thigh flexion, and symptoms of femoral nerve compression. Materials and Methods: A retrospective analysis of patients admitted in our institution with a diagnosis of iliopsoas hematoma between 2008 and 2012 was done. All data were collected during hospitalization. Results: There were 64 events in 35 patients. Only 5 patients had high responding inhibitors. None were on prophylaxis. In 11 (17%) patients the hematoma was recurrent. The mean age was 22 (9-42). In 32% of cases, hematoma was associated with trauma or physical effort. At diagnosis, all patients presented lower abdominal or groin pain, with thigh flexion. Also, 67% had sensory symptoms in the thigh (cramps/hypoesthesia). An ultrasound study was performed in 19 cases, with an average volume of 235 cc. In patients without inhibitors, replacement therapy was performed by continuous infusion for a mean of 6.6 days, with a mean dose of 1.7 IU / kg / h. Plasma factor (VIII/IX) recovery was 37% (20-97). Among the 15 cases in patients with inhibitors, 11 were treated with rFVIIa with a mean overall dose of 263 mg during hospitalization. The average hospital stay was 7 days. Of all cases, 81% achieved complete recovery (full extension of the thigh, no pain, and normal gait) at discharge. Only 3 events required red blood cell transfusion. In univariate and multivariate models, no variable was associated with probability of complete recovery. Conclusions: Among patients who are not on prophylactic treatment, the iliopsoas hematoma is a frequent event with a possibility of recurrence. Replacement treatment by continuous infusion improves case management with a higher rate of quicker and complete recovery.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

Haemophilia (2014), 20 (Suppl. 3), 1--186



Different clinical phenotypes between hemophilia B and hemophilia A: Results of global coagulation assays MARIA ROSARIA FASULO, MARIA ELISA MANCUSO,  V E E N A C H A N T A R A N G K U L , A N T O N I N O C A N N A V O, MARIGRAZIA CLERICI, LIDIA PADOVAN, ERICA SCALAMBRINO, FLORA PEYVANDI, A R M A N D O T R I P O D I and E L E N A S A N T A G O S T I N O Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy Introduction and Objectives: Hemophilia B (HB) patients may exhibit a milder bleeding tendency than seen in hemophilia A (HA). The aim of this study was to compare the phenotype of patients with severe HB (cases) and severe HA (controls) in order to ascertain whether different bleeding phenotypes exists. Materials and Methods: Coagulation tests, including thrombin generation assay (TGA) and thromboelastography (TEG) ,were performed in severe HB/HA patients (FIX/FVIII 0.05) COPD, hypertension and hyperlipidemia were all risk factors for hemophilia patients developing arterial thrombosis. The risk was increased in patients using bypassing agents. Hemophilia patients treated with factor concentrates seemed to be protected from the occurrence of arterial thrombosis. There were only 2 patients with venous thrombosis during the period. Conclusion: Compared with general population, arterial thrombosis was not increased or decreased in hemophilia patients. The risk factors for arterial thrombosis in hemophilia included COPD, hypertension, and hyperlipidemia. Patients with factor concentrate treatment and low risk of arterial thrombosis (which may suggest moderate to severe hemophilia) were protected from thrombotic events.

Clinical and genetic profile of patients with hemophilia in India

NITA RADHAKRISHNAN,1 MOHAMMED RAMZAN,1 V E R O N I Q U E D I N A N D , 1 R E N U S A X E N A 2 and ANUPAM SACHDEVA1 1 Pediatric Hematology Oncology & BMT Unit, Department of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India; and 2Department of Medical Genetics, Sir Ganga Ram Hospital, New Delhi, India Introduction: Comprehensive management of hemophilia involves a lifelong commitment from the patient and the treatment centre. Awareness of the existing facilities and shortcomings go a long way towards establishing appropriate treatment strategies. Methods: Twelve hemophilia camps were conducted across North India in 2011-2012 aided by an educational grant from NNHF. The camps were organized by a team comprising of hematologists, an orthopedician, a psychologist, physiotherapists and volunteers. The survey was aimed at assessing the quality of care available to patients of hemophilia A, B and VWD as well as to create awareness among pediatricians and physicians regarding early diagnosis and appropriate treatment. Blood samples were taken after informed consent was obtained and genetic analysis and inhibitor assay was performed at the study centre in New Delhi. Demographic and clinical data were recorded during these camps and the genetic analysis is being presented here. Results: The survey included 403 patients with a median age of 13 years (range 1.5 65 years). Hemophilia A constituted 90.3% of cases and hemophilia B 9.7% with severe, moderate, and mild in 70.5%, 22.3% and 7.2% of cases, respectively. At the time of diagnosis, 22.3% patients had received factor replacement therapy and 61% had received blood products such as fresh frozen plasma (FFP) or cryoprecipitate and 16.7% received minimal or no treatment. The most common site of bleeding was the musculoskeletal system in 247/403 (61.3%) of patients. A single target joint was involved in 215/403 (53.3%) of the cases, the knee joint was involved in 43.7%, the elbow in 7.4%, the hip in 2%, the shoulder in 1.2% and the ankle in 0.7% of cases. Two target joints were present in 28/403 (6.9%) and three target joints were present in 4/403 (1%) of the patients. Clinical joint score (Child instrument) and orthopedic joint score was calculated in these patients. Permanent disability was present in 155/ 403 (3.5%) of these patients out of which 15.1% were using crutches. Inhibitor levels had not been previously checked in the majority (>95%) of patients. Not more than 10 patients were covered by insurance or by reimbursement policy. Genetic testing was done in 316 patients. We found 35.6% of patients had intron 22 inversions whereas 1.9% had an inversion of intron 1. Conclusions: Although this survey does not cover the whole country uniformly, it gives an estimate of the health care services available to patients with hemophilia. Access to prophylaxis is limited by economic constraints.

To evaluate circumcision practices and outcomes in undiagnosed patients of factor VIII and factor IX deficiency in Pakistan

T A H I R A Z A F A R , 1 S A D D A F H I N A , 2 H U M E R A S I D D I Q 3 and NADEEM IKRAM4 1 Pak International Medical College, Peshawar; 2Holy Family Hospital, Rawalpindi, Pakistan; 3Holy Family Hospital, Rawalpindi; and 4Rawalpindi Medical College

Objective: To evaluate circumcision practices and outcomes in undiagnosed patients with hemophilia in Pakistan so as to develop a safe and efficacious local protocol. Patients and Methods: All bleeding disorder patients who were circumcised before diagnosis and then seen at the Hemophilia Treatment Centre, Rawalpindi, were evaluated to record age at circumcision, duration of bleeding, duration of healing, treatment received, and its effect on the duration of bleeding and the duration of healing and any other complications. Results: A total of 50 patients were evaluated. Among these 40 (80%) had factor VIII deficiency and 10 (20%) had factor IX deficiency. The age at circumcision ranged from 1 to 36 months with a mean age of 4.14 months. The duration of bleeding

Haemophilia (2014), 20 (Suppl. 3), 1--186



ranged between 1 to 28 days with a mean of 13 days. Healing took place between 8 to 40 days with mean duration of 20.4 days. We noted that 45 patients (90%) did not receive any hemostatic cover. Three patients had blood transfusion and 2 had FFP.These blood products were given post circumcision when prolonged bleeding was noted. One patient was given factor VIII concentrate, as his maternal uncle was known to have factor VJJJ deficiency. The durations of bleeding in patients with FFP infusion were 1 and 5 days. In patients with fresh blood transfusions, it was 5, 1, or 2 days and it was 6 hours in a patient who was given factor concentrate. Healing occurred on days 7 and 10 in FFP infusion, days 7,9,10 with blood transfusion and day 8 with factor VIII infusion. Conclusions: An outreach program to create awareness in patients, their family members and health care professionals is important in decreasing post- circumcision morbidity in patients with bleeding disorders. Hemostatic agents significantly decrease the duration of bleeding and promote early healing.

Epidemiological and clinical profile of hemophilia in Madagascar T A N T E L Y R A N D R I A M A N D R A T O and TAMBY RA ANDRIANJAFIARINOA Hospital HJRA Antananarivo Profil epidemio-clinique des hemophiles  a Madagascar Hemophilia is a recessive hereditary disease associated with abnormal sex chromosome X , and a constitutional deficiency of antihemophilic factor VIII (A) or IX ( B), and disorders in blood coagulation. Our goal is to describe the epidemiological and clinical profile of patients suffering from hemophilia in Madagascar. Materials and methods: From March 2011 to March 2013, hemophiliac patients receiving follow-up care in the Hemophilia treatment center of Antananarivo HJRA Hospital in Madagascar were studied. The following were recorded: age, age at diagnosis, circumstances of diagnosis, type of hemophilia, and clinical manifestations. Results: Forty-two hemophiliacs were registered each year. The age range was 3– 35 years. The age at diagnosis was usually between 2 and 5 years (62.5%), during circumcision (37.5 %), or after a family history of bleeding (70 %). These patients came from several areas of Madagascar: 7.5% of Mahajanga, Antsiranana 2.5% , 2.5% Toliara, Toamasina 18.75% and 68.75% Antananarivo. We recorded that 62 % had hemophilia A and 38% had hemophilia B. In terms of the severity of the disease, 35 % had levels of factor less than 1%. Hemorrhagic manifestations varied: hemarthrosis (n = 40), subcutaneous hematoma (n = 40), epistaxis (n = 12), gingival bleeding (n = 12), hematuria (n = 5), intramuscular hematoma (n = 8), gastrointestinal bleeding (n = 3), intra- abdominal hematoma (n = 3), cerebral hematoma (n = 3), hemoptysis (n = 1) , intraocular hemorrhage (n = 1). Only one in three patients had replacement therapy using concentrate antihemophilic factor. Transfusion with fresh frozen plasma is the only alternative or whole blood if there is a low level of hemoglobin. Adjuvant treatment with antifibrinolytic was established in two out of three cases. The hospital stay ranged from 1 day to 2 months. Ten children received physiotherapy.

Haemophilia (2014), 20 (Suppl. 3), 1--186

Conclusions: Haemarthrosis are the most frequent clinical manifestations of hemophilia in Madagascar, often with joint effects. The most serious bleeding is often life-threatening in these patients. Patient associations do enhanced hemophilia taking care in Madagascar.

Screening for intracranial hemorrhage following birth in neonates with severe hemophilia ELIZABETH JONES, NICOLA MACKETT, C A T H E R I N E B E N F I E L D and R U S S E L L K E E N A N Alder Hey Childrens’ NHS Foundation Trust, Liverpool, UK Introduction and Objectives: There is currently limited prospective data on the incidence and morbidity associated with intracranial hemorrhage (ICH) in neonates with inherited bleeding disorders. UK guidelines recommend screening patients at birth with cranial ultrasound. MRI is only recommended in symptomatic neonates1. Clinical features of neurological impairment may be subtle in neonates and ICH may remain undetected, having potentially significant effects. AlderHey Childrens’ NHS Foundation Trust, UK, has been undertaking screening utilizing MRI and Cranial Ultrasound to maximize detection of ICH and allow prompt treatment. MRI is recognized as a sensitive tool for detecting ICH and is becoming more readily available. Cranial ultrasound is generally accessible and enables fast detection of large bleeds. As a combination, this is proposed as an achievable way to screen for ICH in the perinatal period. Materials and Methods: This case review includes all patients following screening offered at a tertiary referral centre for pediatric bleeding disorders. Patients diagnosed with hemophilia prior to, or shortly after birth, are offered a cranial ultrasound within 24 hours, locally, and an MRI within between 48 and 72 hours at the centre to allow detection of developing bleeds. Treatment was given if a bleed was identified on either scan. Babies with an APTT of around 80 seconds had planned treatment post-delivery prior to investigation. Results: Five neonatal cases with hemophilia A & B, are included. All of the cases were neurologically asymptomatic and had normal cranial ultrasound scans within 24 hours of birth. However, 2 cases had ICH on MRI, one was a moderate bleed, and the other a very large one. Both of these patients were treated with continuing factor replacement. There have been no further neurological concerns on follow up in any of the cases. Conclusions: These cases suggest ICH can be large and asymptomatic with normal cranial ultrasound scan and may be common in this group. Combined MRI and cranial ultrasound are low-risk and allow prompt detection and management of ICH. Prospective studies are needed to ascertain incidence and morbidity of ICH in this population, to further assess screening procedures and optimize patient management.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd



05-CLINICAL ISSUES AND TRIALS Pharmacokinetics and preliminary immunogenicity of BAX 855, a PEGylated full-length recombinant factor VIII (PEG-rFVIII) with extended half-life

BARBARA KONKLE,1 OLEKSANDRA STASYSHYN,2 R A L P H G R U P P O , 3 B E T T I N A P L O D E R , 4 L I S A P A T R O N E 5 and BRIGITT ABBUEHL4 1 Puget Sound Blood Center, Seattle, WA, USA; 2Institute of Blood Pathology and Transfusion Medicine of Academy, Lviv, Ukraine; 3Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA; 4Baxter Innovations GmbH, Vienna, Austria; and 5Baxter Healthcare Corporation, Westlake Village, CA, USA Introduction and Objectives: The pharmacokinetics (PK) of BAX 855 are being assessed as part of a phase 2/3 clinical study designed to evaluate efficacy and safety in previously treated adolescent and adult patients with severe hemophilia A (FVIII < 1%). BAX 855 is a full-length recombinant factor VIII (rFVIII), modified with 20 KDa polyethylene glycol (PEG). It is based on the same original, native FVIII protein utilized in the manufacture of ADVATE, a product with a 10-year documented history of safety and effectiveness, while providing an extended half-life. Results of preclinical, structural, and functional characterizations have demonstrated that BAX 855 has an extended half-life, and comparable efficacy and safety profiles, including immunogenicity, with ADVATE. A first-in-human phase 1 clinical study demonstrated that the duration of a single infusion of BAX 855 in the circulation system is prolonged by up to 1.5 times compared to ADVATE and that BAX 855 was well tolerated. Overall, the phase 2/3 study objectives are to evaluate annualized bleeding rates, control of bleeding episodes, weight-adjusted consumption of BAX 855, immunogenicity, safety, pharmacokinetics, and patient reported outcomes. Materials and Methods: A subset of 25 patients will undergo initial PK assessments before, and repeat PK assessments after six months of prophylactic treatment with BAX 855. Each patient will initially receive a single infusion of ADVATE and then BAX 855 after an adequate washout period, and FVIII activity will be measured for up to 3 or 4 days, respectively. Results: Initial PK and preliminary immunogenicity data from periodic assessments during the course of the study will be available.

Economic impact of individualized prophylaxis approach on a severe hemophilia young adult cohort SUSANA NOBRE FERNANDES, MANUELA CARVALHO,  O M A N U E L A L O P E S and F E R N A N D O A R A UJ Center of Haemophilia, Department of Transfusion Medicine and Blood Bank, Centro Hospitalar S. Jo~ao, Porto, Portugal Background: Although prophylaxis is the treatment of choice for children with severe haemophilia, the need for continued prophylaxis in adulthood is still the subject of debate, with cost-effectiveness yet to be evaluated. There is no consensus among the hemophilia medical community on ending prophylactic treatment in adulthood, but some physicians advise individualised prophylaxis according to clinical bleeding pattern, condition of joints, pharmacokinetic profile, physical activity and type of job, with cost savings and clinical benefits. Methods: A young adult cohort of nine severe hemophilic patients (6A, 3B) with a median age of 27 years (20-33 years) and a median weight of 77 kg (60-98 kg), on standard prophylactic regimens in childhood, were evaluated and prophylaxis was adjusted to account for daily activity and bleeding pattern (dose or frequency). Patients received a lowered dose on the previous schedule of three times a week, or received the same dose only twice a week for hemophilia A patients. Hemophilia B patients received either a lowered dose on the previous schedule of twice a week, or the same dose only once a week. These were adjusted for the number of days of physical activity, sports and other major exertion that could cause bleeding. No patient wanted to stop prophylaxis and shift to on-demand treatment, as they were happy with their quality of life while complying with prophylactic regimen. Results: After 12 months of follow-up, one patient returned to their previous scheduled prophylaxis, due to breakthrough bleeds, after an evaluation at eight weeks, but the remaining patients maintained reduced prophylaxis, without an increase in bleeding rate (no spontaneous bleeding, in these 8 patients after 1 year of follow-up). This evaluation gave patients confidence that their regimen could be adjusted again, if bleeding problems occurred. Conclusions: With an individualised approach in this cohort of patients, the impact of the treatment decision resulted in savings of almost 400,000 € per year and patients were infused with a mean of 2.800 IU/kg/year of factor concentrate, instead of the previous 4.400 IU/kg/year. Resource limitations in health care are a concern for clinicians and require the search for cost-effective treatments, which maintain clinical benefits. The challenge is to find for how long we should maintain classical prophylaxis before switching to this individualised reduced-dose approach and to evaluate the clinical results of this strategy after a longer period of follow-up.

Pharmacokinetic (PK) results of two Phase III clinical studies of coagulation factor IX (Recombinant) Albumin Fusion Protein (rIX-FP) in previous treated patients with hemophilia B (PROLONG - 9FP)

ELENA SANTAGOSTINO,1 IRIS JACOBS,2 CHRISTINE VOIGT,2 A N N E T T E F E U S S N E R , 3 T H A R I N L I M S A K U N 2 and RACHAEL EASTON2 1 IRCCS Ospedale Maggiore (Centro emofilia e Trombosi), Milano, Italy; 2CSL Behring, CRD, King of Prussia, United States; and 3CSL Behring GmbH, PRD, Marburg, Germany Introduction and Objectives: A recombinant fusion protein linking coagulation FIX with human albumin (rIX-FP) has been developed to extend the half-life of FIX, thus

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

improving hemophilia B treatment by allowing less frequent dosing than the current standard of 2-3 times a week. In the completed Phase I PK study in subjects (15-58y), the mean half-life of rIX-FP was 92 hours, 5 times longer than the subjects’ previous FIX (Santagostino E, et al. Blood 2012; 120:2405-11). A Phase II study demonstrated the efficacy of weekly prophylaxis with rIX-FP, with excellent safety and an improved PK profile. Following completion of these studies, two Phase III studies are being performed in previously treated patients (1-61y) with severe hemophilia B as part of the PROLONG-9FP clinical program. The objectives of the studies are to determine long term safety and efficacy of rIX-FP, in addition to the PK of rIX-FP in all age groups. Materials and Methods: Study subjects completed 14-day rIX-FP PK evaluation, and their plasma FIX activity levels were measured prior to dosing, and at 30 minutes, 3, 24, 48, 72, 120, 168, 240 and 336 hours after 50 IU/kg rIX-FP infusion. A sub-group of the study subjects completed a PK evaluation of a marketed Factor IX product. Following the rIX-FP PK evaluation, subjects began a weekly prophylaxis regimen with rIX-FP for six months, after which some eligible subjects were switched to a 14day prophylaxis regimen for the remaining study period. Results: Subjects from 42 hemophilia treatment centres in 12 countries are participating in these studies. To date, the PROLONG-9FP clinical program encompasses over 80 hemophilia B subjects, including more than 24 children, some as young as 1-year-old, for the PK evaluation in the Phase III studies. This report will focus on PK results of rIX-FP, which demonstrates marked improvement over currently marketed FIX products. Conclusions: Prolonged half-life rIX-FP has the potential to permit 14-day routine prophylaxis. Both Phase III studies are on-going, with a promising safety and efficacy profile. Detailed PK results will be presented during the meeting.

The first step in primary prophylaxis in Algeria: An emerging country BERKOUK-REDJIMI YASMINA, BELHANI MERIEM FADELA, C H E N O U K H K A R I M A and B E N S A D O K M E R I E M CHU Beni messous Algeries Algeria In Algeria, there were 1843 hemophiliacs were in 2013, 50% of them with severe disease. The consummation of factor has increased, from 0.3 units per capita in 2005 to 2 in 2013. Primary prophylaxis treatment began in Algeria in 2008. In 2013, 51 hemophiliacs were receiving primary prophylaxis (IP) and they were followed by nine hematology or pediatric units. Of those, 14 patients were receiving a gradual dose, 5 a high dose, 14 a low dose (15UI/kgx2/w), and 18 were receiving less than 25 UI/ kgx1/w. The IP began before the age of 2 years in 20 cases, between 2-3 years in 18 cases and after 3 years in 13 cases. Only 4 of the 51 patients interrupted the IP. This was due to development of inhibitors in 2 cases, difficulties in venous access in 1 case and 1 patient loss.Therefore, 47 were followed within two years or less in 24 cases. Only 7% of patients discontinued the IP. So there is a good adherance to the IP in Algeria.But, the age at initiation was variable and different protocols were used, which mean that this group was not homogeneous and analysis was impossible. The most homogeneous group was treated at the hematology unit of Beni Messous hospital. In this group, 16 hemophiliacs receiving IP were followed, with 14 HA who were put on low dose treatment and these were the subjects of a study. The comparison of this group versus an on demand treatment (DT) group, shows an average number of bleeding episodes of 4,3 vs 21,4 (p = 0.025). There were 1,5 vs 14,8 instances of hemarthrosis (p = 0.0332) and 2,3 vs 3,7 instances of hematomas (p = 0.157). In the DT group, all patients had a target joint, that was, in most cases, the knee. Under IP, only 20% of the patients had a target joint and it was the ankle. The consumption of factors in the IP low-dose group was essentially the same (1751 IU / kg / patient / year) as in the DT group (1611 IU / kg / patient / year). Prophylaxis with low dose led to: a reduction in bleeding episodes, including hemarthrosis, an avoidance of motor disability for young patients with severe hemophilia and a better social integration.

Recombinant factor IX Fc fusion protein as episodic treatment for bleeding: Analysis from the B-LONG Study

JOHN PASI,1 MARGARET RAGNI,2 MARGARET OZELO,3 LEONARD A. VALENTINO,4 HAIYAN JIANG,5 NIGEL DODD,5 B R I A N R O B I N S O N , 5 B A I S O N G M E I 5 and G L E N N P I E R C E 5 1 Barts and the London Comprehensive Care Center, London, UK; 2Hemophilia Center of Western Pennsylvania, Pittsburgh, PA; 3Hemocentro da Unicamp, Campinas, Brazil; 4Hemophilia & Thrombophilia Center, Rush University Medical Center, Chicago, IL; and 5Biogen Idec Hemophilia, Cambridge, MA Introduction and Objectives: In the phase 3 B-LONG study, recombinant factor IX Fc fusion protein (rFIXFc) was safe and effective for control and prevention of bleeding episodes in people with severe hemophilia B and demonstrated a prolonged half-life (82 h) relative to rFIX. Here, we report detailed results for the episodic (on-demand) arm and a pharmacokinetic (PK) simulation based on FIX activity after administering a single dose of rFIXFc. Materials and Methods: B-LONG enrolled previously treated males aged ≥12 years with severe hemophilia B. In the episodic treatment arm (Arm 3), rFIXFc was dosed at 20-100 IU/kg (based on bleed severity) to target a plasma level of 20-100%. Using the median dose administered for treatment of a bleeding episode, FIX activity was simulated for a typical subject (body weight=73 kg) using a 3-compartment PK model. Results: Twenty-seven subjects were enrolled in the episodic arm; median age was 36.0 years (range, 14-64). 402 bleeds were observed. A single rFIXFc infusion resolved 93.5% of bleeding episodes, and 98.8% resolved with ≤2 infusions (median time between infusions was 48.21 hours). The median number of infusions for bleeding episode resolution was 1.0, whether first used within 8 hours or >8 hours

Haemophilia (2014), 20 (Suppl. 3), 1--186



after first sign of re-bleeding and regardless of bleeding episode type (spontaneous, traumatic, unknown) or location (joint, muscle, soft tissue, internal, skin/mucosa). For bleeding episode resolution, median dose per infusion per subject was 43.02 IU/kg (range, 19.3-84.3). The median interval from last infusion to treat bleeding, to treatment of a new episode, across all evaluable bleeding episodes was 13.4 days (range, 0.3-217.0). In a simulated FIX activity over time profile at 43.02 IU/kg (median dose per infusion per subject) based on the population PK model, FIX activity at 0.167, 12, 24, 36, 48, 72, 96, 120, and 144 hours was 41.9, 18.3, 12.8, 9.37, 7.21, 4.80, 3.55, 2.76, and 2.20 IU/dL, respectively. Conclusions: These results expand the primary B-LONG results and demonstrate the efficacy of rFIXFc for episodic treatment of bleeding episodes. PK simulation of episodic dosing showed good recovery and rapid achievement of maximum plasma concentration.

had decreased by 96% from a median of 26.5 events (range: 18-82) during the 12 months on-demand treatment to a median of 1.0 event (range: 1-6) during prophylaxis therapy. Voncentoâ was well tolerated. The AEs seen were mild-moderate and were consistent with the safety profile for this product. No inhibitor formation against VWF or FVIII was found. Conclusions: The PK profile of Voncentoâ is similar over time. Voncentoâ is efficacious and safe for treatment and prevention of bleeding episodes in VWD patients.

Efficacy, safety and pharmacokinetic results of a phase II/III, multicentre, double-blinded, randomized, cross-over study with a plasma-derived von Willebrand Factor (VWF)/factor VIII (FVIII) concentrate (Voncentoâ) in subjects with hemophilia A (the SWIFT-HA study)

AMY SHAPIRO,1 PRATIMA CHOWDARY,2 DORIS QUON,3 JUDITH LIN,4 SRIVIDYA NEELAKANTAN,5 HAIYAN JIANG,5 N I G E L D O D D , 5 A O I F E B R E N N A N , 5 G E O F F A L L E N 5 and G L E N N F. PIERCE5 1 Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany; 2The KD Haemophilia Centre and Thrombosis Unit, Royal Free Hospital, London, UK; 3Orthopaedic Hospital Hemophilia Treatment Center, Los Angeles, CA; 4Dana Farber Cancer Institute, Boston, MA; and 5Biogen Idec Hemophilia, Cambridge, MA

A. KLUKOWSKA,1 A. SKOTNICKI,2 T. LISSITCHKOV,3 V. MAMONOV,4 E. BUEVICH,5 K. KULICZKOWSKI,6 S . G O R A N O V , 7 J . K Ł O C Z K O , 8 S . S T A N K O V I C 9 and W . S E I F E R T ET AL10 1 Department of Pediatrics, Hematology and Oncology of Warsaw Medical University, Warsaw, Poland; 2Independent Public Health Care University Hospital, Krakow, Poland; 3SHAT ‘Joan Pavel’, Sofia, Bulgaria; 4Hematology scientific center RAMN, Moscow, Russian Federation; 5GOUVPO Altaysky State Medical University of Roszdrav, Barnaul, Russian Federation; 6Independent Public Clinical Hospital No. 1, Wroclaw, Poland; 7UMHAT ‘Sveti Georgi’, Plovdiv, Bulgaria; 8University Hospital, Bialystok, Poland; 9University Clinic of Hematology, Skopje, Macedonia, the Former Yugoslav Republic; and 10CSL Behring, Marburg, Germany

Introduction and Objectives: In the phase 3 A-LONG study, recombinant factor VIII Fc fusion protein (rFVIIIFc) demonstrated an approximately 1.5-fold longer half-life relative to rFVIII and safety and efficacy for control and prevention of bleeding episodes in people with hemophilia A. Here, we report results for the episodic arm and a pharmacokinetic (PK) simulation of FVIII activity based on episodic treatment. Materials and Methods: A-LONG subjects were aged ≥12 years and had severe hemophilia A. Those in the episodic arm (Arm 3) received rFVIIIFc 10-50 IU/kg, as required to treat bleeding episodes based on severity of bleed. Using the median dose administered to treat bleeding episodes, FVIII activity was simulated in a typical subject (body weight=73 kg) using a 2-compartment PK model. Results: Twenty-three subjects were enrolled in the episodic arm; median age was 34.0 years (range, 13-62). Over the course of the study, 456 bleeds were treated. One rFVIIIFc infusion was required to resolve 89.5% of bleeds, and 98.5% were resolved with 1 or 2 infusions (median interval between infusions was 36.0 hours). The median number of infusions required was 1.0 whether given within 8 hours or >8 hours after the first sign of bleeding, regardless of bleeding episode type (spontaneous, traumatic, unknown) or location (joint, muscle, soft tissue, internal, skin/mucosa). The median dose per infusion per subject was 28.38 IU/kg (range, 20.0-52.8). The median interval from last infusion to treat a bleeding episode, to treatment of a new bleeding episode, across all evaluable bleeding episodes was 6.55 days (range, 0.5-70.0). In a simulation of FVIII activity over time at 28.38 IU/kg (median dose per infusion per subject on study), the FVIII activity at 0.167, 12, 24, 36, 48, 72, and 96 hours was 56.0, 30.4, 17.3, 10.3, 6.30, 2.46, and 0.985 IU/dL, respectively. Conclusions: These results expand the primary A-LONG results and demonstrate the efficacy of rFVIIIFc for episodic treatment of bleeding episodes. PK simulation of episodic dosing with rFVIIIFc showed good recovery and rapid achievement of maximum plasma concentration, which is consistent with targets in published guidelines.

Introduction and Objectives: The Studies with von Willebrand factor/factor VIII (SWIFT) program is evaluating the PK, efficacy and safety of a low-volume, highly active, plasma-derived von Willebrand Factor (VWF)/factor VIII (FVIII) concentrate (Voncentoâ or Biostateâ, CSL Behring) that contains a large proportion of highmolecular-weight VWF multimers and a VWF:FVIII ratio of 2.4:1 in hemophilia A and VWD patients. The SWIFT-HA study aimed to investigate the PK, the hemostatic efficacy and the safety of Voncentoâ in subjects with hemophilia A (> 12 year of age) who require treatment of non-surgical bleeds (NSB) during surgical events or as prophylactic treatment. The study also assessed the bioequivalence to a previous Biostateâ manufacturing process. Methods: PK consisted of a single dose 50 IU/kg FVIII:C of either Voncentoâ or its predecessor in a double blind, cross-over design on Day 1 and 8 (n = 16). The PK of Voncentoâ was repeated on Day 180 (n = 15). The efficacy/safety component consisted of on-demand (n = 52) or prophylaxis treatment (n = 29) for a minimum of 6 months and at least 50 exposure days. Results: Bioequivalence of Voncento to the previous Biostateâ manufacturing process was demonstrated. The PK results of Voncentoâ over time were similar, indicating the absence of inhibitory antibody formation. Hemostatic efficacy was evaluated by investigators as either excellent/good in 96.4% of all bleeding events, (96.5% of spontaneous, 96.6% of traumatic and 96.9% of joint bleeds) and in 80% and 100% of major and minor surgical events at discharge. The mean number of NSB per subject was considerably lower in the prophylaxis subgroup (3.5 bleeds) than in the on-demand subgroup (10.7 bleeds). Voncentoâ was well tolerated without any troubling findings. Conclusions: The PK profile of Voncentoâ is similar over time. Bioequivalence of Voncentoâ to a previous Biostateâ manufacturing process was demonstrated. Voncentoâ is efficacious and safe for hemostatic efficacy and prophylactic treatment in hemophilia A patients.

Pharmacokinetic, efficacy and safety results of an open-label, multi-centre study with a plasma-derived von Willebrand Factor (VWF)/factor VIII (FVIII) concentrate (Voncentoâ) in subjects with von Willebrand disease (The SWIFT-VWD study)

Home treatment of hemarthrosis with recombinant activated factor VII (rFVIIa) in patients with haemophilia A or B and inhibitors: experience from developing countries

Recombinant factor VIII Fc fusion protein as episodic treatment for bleeding: Analysis from the A-LONG Study

A. KLUKOWSKA,1 T.J. LISSITCHKOV,2 E. BUEVICH,3 M. FERNANDESDE OLIVEIRA,4 K. KULICZKOWSKI,5 O . S T A S Y S H Y N , 6 C . J O C H 7 and W . S E I F E R T 7 1 Department of Pediatrics, Haematology and Oncology of Warsaw Medical University, Warsaw, Poland; 2Specialized Hospital for Active Treatment ‘Joan Pavel’, Sofia, Bulgaria; 3GOUVPO Altaysky State Medical University of Roszdrav, Barnaul, Russian Federation; 4Institute of Hematology, Rio de Janeiro, Brazil; 5Independent Public Clinical Hospital No. 1, Wroclaw, Poland; 6Institute of Pathology and Transfusion Medicine AMN, Lviv, Ukraine; and 7CSL Behring, Marburg, Germany

Introduction and Objectives: The Studies with von Willebrand factor/factor VIII (SWIFT) program is evaluating the PK, efficacy and safety of a plasma-derived von Willebrand factor (VWF)/factor VIII (FVIII) concentrate (Voncentoâ or Biostateâ, CSL Behring) in hemophilia A and VWD patients. This plasma-derived concentrate has a low-volume and contains a large proportion of high-molecular-weight VWF multimers and has a VWF:FVIII ratio of 2.4:1. The VWF profile correlates with high collagen binding activity, effective platelet adhesion, and efficient platelet aggregation. This study investigated the PK, hemostatic efficacy and safety of Voncentoâ in subjects ≥ 12 year of age with severe VWD who require treatment of non-surgical bleeding (NSB) events or as prophylactic treatment. Methods: PK consisted of a single dose of 80 IU/kg VWF:RCo on Day 1 and Day 180. Twenty subjects received Voncentoâ as on-demand therapy for 12 months. Eight subjects switched to an additional 12 month prophylactic regimen. Results: The mean VWF:RCo, VWF:Ag, and VWF:CB plasma concentrations developed similarly over time, and were similar in the repeat PK evaluation indicating the absence of inhibitory antibody formation. Excellent hemostatic efficacy after treatment with Voncentoâ was reported by the Investigator for 92.1% of the 407 NSB events with an available assessment, good hemostatic efficacy for 6.1%, and moderate hemostatic efficacy for the remaining 1.7%. A similar distribution of hemostatic efficacy outcomes was seen within bleeding event categories for type, severity, or location.The frequency of NSB reported by the 8 subjects on prophylaxis

Haemophilia (2014), 20 (Suppl. 3), 1--186

MERIEM FADILA BELHANI,1 ABDEL KAREEM AL MOMEN,2 SORAYA BENCHIKH EL FEGOUN,3 FATI HAMZY,4 NEMRA GIAD MEHALHAL,5 HABIBA HADJ KHALIFA,5 S E L M A H A M D I , 6 T A R E K O W A I D A , 7 H O S S A M A L I S A A D 8 and YASSER AHMED SOLIMAN WALI9 1 Service d’Hematologie, H^ opital Isaad Hassani, CHU Beni-Messous, Algiers, Algeria; 2 College of Medicine & King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia; 3Novo Nordisk Health Care AG, Zurich, Switzerland; 4Service d’Hematologie et d’Oncologie Pediatrique H^ opital, CHU Ibn Rochd, Casablanca, Morocco; 5Department of Haematology, Hospital of Mascara, Algeria; 6Service de pediatrie N°3, H^ opital des enfants, CHU Ibn Rochd, Casablanca, Morocco; 7King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabi; 8Novo Nordisk A/S, Dubai, United Arab Emirates; and 9Department of Child Health, Sultan Qaboos University Hospital, Muscat, Oman Introduction and Objectives: In developing countries, access to hemophilia treatment centres may be limited. Home therapy for uncomplicated mild/moderate bleeding can decrease the burden on the healthcare system, promote self-esteem, reduce complications, and provide near-normal quality of life for patients and their families. This prospective, observational study aimed to evaluate recombinant activated factor VII (rFVIIa) as a home therapy for joint bleeds in Algeria, Morocco, Oman, Saudi Arabia and the United Arab Emirates. Materials and Methods: Patients aged >2 years with severe hemophilia A or B, inhibitors, and joint bleeds were monitored for 8 months after the first bleeding episode. Hemarthrosis was treated with rFVIIa according to the physician’s usual prescription. Assessments were made by patients or caregivers with a standardised diary. Primary analyses included the number of home-managed bleeds, control of bleeding episodes, and pain relief within 9 hours after first rFVIIa injection. Secondary analyses included the evaluation of convenience, time to pain resolution, and doses given within 48 hours after bleed onset. Results: Of 27 patients enrolled, 25 completed the study, with 83 bleeds (43 spontaneous and 40 traumatic) managed at home. Of home-managed bleeds, complete

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

CLINICAL ISSUES AND TRIALS or partial hemostasis was achieved at 9 hours in 87% of spontaneous and 90% of traumatic bleeds, while complete or partial pain relief at 9 hours was achieved for 88% of spontaneous and 80% of traumatic bleeds. For all treatment settings, complete or partial hemostasis at 9 hours was achieved for 81% of spontaneous and 92% of traumatic bleeds. Complete or partial pain relief was achieved for 74% of spontaneous and 75% of traumatic bleeds. Total mean dose at 9 hours was 150.2 lg/ kg (range: 72.7–1334 lg/kg). Higher initial dosing was associated with fewer injections. Median time to complete hemostasis was 48 hours (spontaneous) and 24 hours (traumatic). Median time to complete pain relief was 24 hours for both bleed types. Satisfaction with effectiveness and convenience was high. No safety concerns were reported. Conclusions: Results from this observational study agree with previous data on the safety and efficacy of home treatment with rFVIIa, and will help to increase awareness and aggregate experience, fostering confidence in home management of patients with inhibitors in developing countries.

A clinical study in previously untreated patients with severe hemophilia A - Immunogenicity, efficacy and safety of treatment with human-cl rhFVIII

R A I N A L I E S N E R , 1 M A R T I N A J A N S E N 2 and S I G U R D K N A U B 3 Great Ormond Hospital for Children, NHS Trust Haemophilia Centre, London, United Kingdom; 2Octapharma Produktionsgesellschaft mbH, Vienna, Austria; and 3 Octapharma AG, Lachen, Switzerland


Introduction and Objectives: Human-cl rhFVIII is a human cell-line derived, Bdomain deleted recombinant FVIII concentrate for intravenous use. Due to the absence of immunogenic epitopes, as seen in recombinant FVIII concentrates from hamster cell lines, Human-cl rhFVIII is thought to be potentially less immunogenic. So far, five prospective GCP studies with Human-cl rhFVIII have been conducted in 135 previously treated adults and children with severe hemophilia A. Pharmacokinetics, efficacy and safety of the product was evaluated. The data indicate that Human-cl rhFVIII has a favorable PK profile and that it is effective in the treatment and prophylaxis of bleeding episodes. There were no product related adverse events and none of the PTPs treated with Human-cl rhFVIII developed an inhibitor. A prospective, multinational, open-label, non-controlled clinical trial is ongoing in about 45 clinical centres worldwide in order to assess the immunogenicity, efficacy and safety of Human-cl rhFVIII in previously untreated patients (PUPs). Materials and Methods: One hundred patients with severe hemophilia A without previous exposure to any FVIII concentrate or FVIII containing products will be enrolled. Inhibitor testing according to modified Bethesda method will be performed pre-treatment, every 3-4 exposure days (ED 1-20) and every 10-12 EDs (ED 21-100) but at least every three months after start of treatment. Efficacy and safety of Humancl rhFVIII during prophylactic treatment, in treating breakthrough bleeds, and in surgical prophylaxis will be assessed. The evaluation of pharmaco-economic aspects and of predictive factors for the development of inhibitors is included in the study protocol. Results: The study started in Q1 2013. Until end of October 2013, a total of 20 PUPs were screened, and 12 of them started treatment with Human-cl rhFVIII. One patient developed a transient low titer inhibitor after a total of 5 EDs. The patient continued treatment with 50 IU/kg every other day and was inhibitor negative after 6 weeks on this regime. Conclusions: A global GCP-study in PUPs is ongoing in order to investigate whether the reduced immunogenic profile of Human-cl rhFVIII will translate into a lowered inhibitor incidence.

Latest results from The PUP-GCP clinical trial: A low inhibitor rate in previously untreated patients with severe hemophilia A treated with Octanate

ANNA KLUKOWSKA,1 SIGURD KNAUB,2 VLADIMIR KOMRSKA,3 PAWEL LAGUNA,1 V L A D I M I R V D O V I N 4 and M A R T I N A J A N S E N 5 1 Warsaw Medical University, Warsaw, Poland; 2Octapharma AG, Lachen, Switzerland; 3University Hospital Motol, Prague, Czech Republic; 4Izmaylovo Children’s Hospital Haematological Centre, Moscow, Russia; and 5Octapharma Produktionsgesellschaft mbH, Vienna, Austria

Introduction and Objectives: Octanate is a highly purified, double virus-inactivated, human plasma-derived factor VIII (FVIII) concentrate with all coagulation FVIII bound to its natural stabilizer VWF in a VWF:RCo/FVIII:C ratio of approximately 0.4. Five prospective GCP studies with Octanate were conducted in 77 previously treated patients (PTPs) with severe hemophilia A. None of these 77 PTPs developed an inhibitor while treated exclusively with Octanate. A prospective clinical trial was initiated in 2000 in order to assess the immunogenicity of Octanate in previously untreated patients (PUPs). The goal was to enroll 50 PUPs with severe hemophilia A and to follow them for an observational period of 100 exposure days. Materials and Methods: Patients with severe hemophilia A and without previous exposure to FVIII or FVIII-containing products were enrolled. Efficacy and tolerability were assessed by a 4-point verbal rating scale. Inhibitor assay, according to modified Bethesda method, was tested prior to treatment every 3-4 exposure days (ED 1-20), and afterwards every 10 EDs (ED 21-100), but at minimum every three months. Results: All 50 subjects have been enrolled and two of them (4%) developed clinically relevant inhibitor titers over the course of the study. Another two displayed transient inhibitors that disappeared spontaneously without change of dose or dosing interval. All inhibitors developed under on-demand treatment and before ED 50. Of the 50 subjects, 44 currently exceed 50 EDs. Octanate was well tolerated and the adverse event profile was consistent with the population studied. The hemostatic efficacy in prophylaxis and treatment of bleeding episodes was generally rated as excellent and no complications were reported for any surgical treatment. Conclusions: Despite frequent inhibitor testing and predominant on-demand treatment, the data indicate a low overall inhibitor rate for Octanate in patients who exceeded 50 exposure days (4/44) of which only 2 (4.5%) were clinically relevant.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


S Knaub is an employee of Octapharma AG, Switzerland and M Jansen is an employee of Octapharma Pharmazeutika Produktionsges.m.b.H., Vienna. A Klukowska, V Komrska, P Laguna, and V Vdovin are investigators for Octapharma.

Factor VIII continuous infusion in El Salvador, seven years’ experience A N A R E Y E S , A R M A N D O E S T R A D A , C L A U D I A G A L D A M E Z and K E N Y G A R C IA S Hospital de Ni~ nos Benjamin Bloom, El Salvador Introduction and Objectives: With the objective of demonstrating the effectiveness and safety of continuous infusion (CI) as a replacement therapy in patients with hemophilia A in the pediatric setting, a retrospective and descriptive study was performed, reviewing the clinical files database of 1428 bleeding events that occurred in 84 patients between the ages of 0 and18 years with moderate and severe hemophilia A, from 2005 to 2012. Materials and Methods: Dilutions of recombinant or plasma derived factor VIII (FVIII) were prepared in normal saline solution to be administered over 24 hours, at velocity rates of 10.4 to 20.8 ml/hr, without heparin administration. No FVIIIc dose adjustments were performed during the CI days. For moderate bleedings, the protocol included an initial bolus (IB) administration of FVIII at 30U/kg followed by CI between 2 and 2.5 U/kg/hour. For major surgery, severe bleeding, and central nervous system (CNS) haemorrhage, the protocol performed included an initial 50 U/kg IB followed by CI at 3 U/kg/hour. Results: During this period 1113 hemarthrosis, 118 dental procedures, 14 surgeries, 15 CNS and 152 other bleeding events were managed with an average treatment duration of 5.8, 5.32, 8.78, 8.4 days, respectively. During the combined1428 bleeding events there were neither additional factor VIII usages (as IB) nor transfusions required. In terms of safety, we reported 3 cases of systemic infectious disease related to CI and 15 thrombophlebitis events. During this study, 5 patients were diagnosed with inhibitors (3 were high responders and 2 were low responders). Of these 5 patients, two had more than 50 FVIII exposure days (ED) and required high doses of factor VIII before the age of 12 months. When we compared the appearance of inhibitors in the 90 ED period of time, there were no inhibitor prevalence increases. Conclusions: FVIII CI was demonstrated to be a safe and effective treatment option for bleeding and surgery management in the pediatric setting.

EpiNine – interim analysis of a non-interventional, multicentre study in patients with hemophilia B

CHRISTOPH KOENIGS,1 ROBERT KLAMROTH,2 CORNELIA WERMES,3 VERENA WIEGERING,4 SUSAN HALIMEH,5 RONALD FISCHER,6 MANUELA KRAUSE,7 P A T R I C K S O M M E R E R 8 and C H R I S T O P H B I D L I N G M A I E R 9 1 University Hospital Frankfurt, Goethe University, Clinical and Mol Haemostasis, Frankfurt, Germany; 2Kompetenznetzwerk Haemorrhagische Diathesen Ost e.V., Berlin, Germany; 3Werlhof-Institut f€ ur Haemostaseologie GmbH, Hannover, Germany; author formerly employed by MH Hannover, Paediatric Haematology and 4 Oncology, Germany; Department of Pediatric Hematology and Oncology, University Children’s Hospital Wuerzburg, Germany; 5Medical Thrombosis and Haemophilia treatment Center, Duisburg, Germany; 6Haemostasis Center, University Hospitals Gießen and Marburg GmbH, Gießen, Germany; 7German Clinic for Diagnostic, Wiesbaden, Germany; 8CSL Behring GmbH, Marburg, Germany; and 9Dr. v. Haunersches Children’s Hospital, University Hospital Munich, Germany Introduction and Objectives: Hemophilia B is an inherited X-linked bleeding disorder caused by a deficiency of factor IX (FIX). Patients with severe hemophilia B, who present with decreased blood levels of FIX (< 1%), suffer from recurrent bleeds into joints and soft tissues. Bleeding symptoms may be different from those in hemophilia A patients. The EpiNine study is a non-interventional multicentre study. The primary objective of this on-going study is to collect data on symptoms, type of treatment, bleeding episodes and degree of arthropathy. Materials and Methods: In this study 106 patients from 19 centres were enrolled from January 2010 to August 2013. The following parameters were documented: age, diagnosis of hemophilia B, patient history, frequency/location of bleeds, type of treatment (on demand / prophylaxis), joint status, and adverse drug reactions including the development of inhibitors. Results: Data from a total of 106 patients were available for analysis. The median age was 17.4 years (range: 0.6–72 years). Of these, 68 patients suffered from severe hemophilia B. Most patients (60.4%) received prophylactic treatment. The preferred type of prophylaxis was the administration of 30 IU of FIX kg1 body weight twiceweekly. Several uncommon bleeds such as intracranial/cerebral- (7.5%), urogenital(12.3%), and gastrointestinal (17.9%) hemorrhages were documented. While most bleeds occurred after trauma, gastrointestinal bleeds typically occurred spontaneously. Joint damage was observed most often in ankles, knees and elbows. Inhibitor development was reported in six patients (5.7%). Conclusions: In contrast to earlier publications, our data support the hypothesis that hemophilia B is a different entity from hemophilia A. This is supported by the distinct bleeding patterns that were observed. The lower treatment burden is probably due to the longer half-life of FIX and not due to fewer bleeds. Hemophilia B patients might eventually exhibit a higher rate of unusual bleeds in this study. The study will be continued to evaluate the findings in a larger cohort of patients.

Haemophilia (2014), 20 (Suppl. 3), 1--186



Safety profile of IB1001, recombinant factor IX (trenonacog alfa) in the treatment of hemophilia B H U G O A S T A C I O , K A T R I N A T N I K O V , B O J A N D R O B I C and TIM BABINCHAK Cangene Corporation, Winnipeg. MB, Canada IB1001 is a next-generation recombinant FIX manufactured with a state-of-the-art process that incorporates three validated viral reduction steps and selectively purifies active forms of factor IX for the treatment of hemophilia B. The amino acid sequence is comparable to the Thr148 (MalmoA) allelic form of plasma derived factor IX. IB1001 was studied in clinical trial IB1001-01, the treatment and continuation phases of which followed 77 patients with hemophilia B (between 28 January, 2009 and 01 March, 2013). Patients were enrolled into either the prophylaxis regimen or an ondemand regimen. These subjects represent a total of 9172 documented exposure days (EDs). A total of 439 AEs were reported by 58 of the 77 subjects (75.3%). Of the 439 adverse events reported, 14 were considered serious. No deaths were reported. Of the AEs reported, 37 events were reported by 15 patients (19.5%) and were considered adverse drug reactions (ADRs). The most common ADRs included headache, pyrexia, constipation, dizziness, hyperhidrosis and palpitations. Patients who participated in the treatment and continuation phases of study IB1001-01 were also monitored for the presence of inhibitory and non-inhibitory antibodies to factor IX, as well as presence of anti-host cell protein (HCP) antibodies. No inhibitory antibodies were detected in any subject treated with IB1001. Some subjects were positive for non-inhibitory factor IX antibodies. However, the response in the majority of the subjects that tested positive was sporadic and transient and not associated with any safety signals. The study found 20 subjects (negative at screening) seroconverted to become positive for anti-HCP after receiving IB1001; none of the adverse events reported for these subjects were associated with anti-HCP reactivity, suggesting that there was no observed safety concern in these subjects. The IB1001 manufacturing process has been further modified to include a purification process to minimize host cell protein in the final drug product. Thrombogenicity, nephrotic syndrome and anaphylaxis are serious risks historically associated with factor IX replacement therapy. These events have not been observed with IB1001 administration. While these results suggest that IB1001 is well tolerated and comparable to other recombinant coagulation factor products, further evaluation is warranted.

Real-life clinical experience of 117 previously untreated patients (PUPs) treated with antihemophilic factor (recombinant), plasma/albumin free method in a Japanese post-authorization safety study

MASASHI TAKI,1 HIDEJI HANABUSA,2 KATSUYUKI FUKUTAKE,3 TADASHI MATSUSHITA,4 K E I J I N O G A M I , 5 A K I R A S H I R A H A T A 6 and A D V A T E P A S S STUDY GROUP7 1 St. Marianna University School of Medicine Yokohama City Seibu Hospital, Kanagawa, Japan; 2Ogikubo Hospital, Tokyo, Japan; 3Tokyo Medical University Hospital, Tokyo, Japan; 4Nagoya University Hospital, Aichi, Japan; 5Nara Medical University, Nara, Japan; 6Kitakyushu Yahata Higashi Hospital, Kitakyushu, Japan; and 7Baxter Japan, Medical Affairs Clinical Development, Tokyo, Japan

Introduction and Objectives: The treatment of hemophilia A patients has been improved by the availability of safe FVIII products and the adoption of routine prophylaxis, but inhibitors to FVIII remain one of the most important complications. The real-life clinical practice during the early treatment phase of hemophilia A in Japan has been documented by the ADVATE (rAHF-PFM) PUPs study since 2007 under the Japanese Good Post-Marketing Study Practice (GPSP) protocol. We investigated safety including adverse events, and namely inhibitors in PUPs. Methods: This prospective, multicentre, observational study was initiated at 63 sites in 2007 to investigate PUPs of any age and disease severity, with ≤3 exposure days (EDs) at study entry, who were prescribed rAHF-PFM. Data were collected every 6 months for over two years using an electronic data-capture system (EDC). Results: As of July 2013, data for 117 PUPs (0 ED:95, 1-3 EDs:22) of 119 enrolled patients at 63 sites were collected. Of these, 95 (81%) had undergone a greater than two-year observation period (median: 36 months, range: 0.2-67.5). During the study period, 21 dropped out within two years (adverse events: 9, lost to follow up: 5, death: 1, other: 6). The FVIII severity was recorded at 25%: 7% and >5%:12%. Forty-nine (42%) had a family history of hemophilia and 9 (8%) had a family history of inhibitors. Eighty-three (71%) had over 50 infusions (median:172). Ninety-nine (85%) started on-demand and 71 (61%) moved to prophylaxis. At the last report, 21 patients (17.95%) developed an inhibitor (8 high-, 13 low titer at inhibitor diagnosis). In 10 of 21 cases, inhibitors have disappeared. The median age of diagnosis of hemophilia A was 0.33 in subjects who developed inhibitors (Inh) and 0.67 in subjects with no inhibitor (no Inh). The median age of first bleeds was 0.53 (Inh), 0.64 (no Inh) and the median age of severe bleeds was 0.37(Inh) and 1.13 (no Inh). The median age of first exposure to rAHF-PFM was 0.68 (Inh) and 0.87 (no Inh). The adjusted odds ratio in inhibitor development was significantly higher in subjects with a family history of inhibitor. Conclusions: The safety profile of rAHF-PFM in Japanese PUPs appears consistent with previous reports with an inhibitor rate of 17.95%.

Haemophilia (2014), 20 (Suppl. 3), 1--186

Safety and effectiveness of anti-inhibitor coagulation complex (AICC) in routine clinical management: a post-authorization safety study (PASS)

AARON NOVACK,1 ROBERT P. NUMEROF,1 MANFRED PIRCK,2 SOPHIE VOISIN,3 FARIBA BAGHAEI,4 C L A U D E N E G R I E R 5 and V A D I M R O M A N O V 1 1 Baxter Healthcare Corporation, Westlake Village, CA, USA; 2Baxter Innovations GmbH, Bioscience, Vienna, Austria; 3Hemophilia Treatment Centers of Toulouse, H^ opital Rangueil, Toulouse, France; 4Sahlgrenska University Hospital, Gothenburg, Sweden; and 5Hopital Edouard Herriot, Lyon, France

Introduction and Objectives: The development of inhibitors is the most serious complication in the treatment of hemophilia and the management of inhibitors remains challenging. Activated prothrombin complex concentrate, AICC [FEIBA NF], has been a key therapeutic option for the prevention and management of bleedings in patients with inhibitors for over three decades and has been approved in more than 60 countries with a prophylaxis indication in more than 40. Launched in 2008, FEIBA NF is essentially the same as the previous formulation of FEIBA (VH) but with an additional viral removal step (35 nm nano-filtration) added during the final stages of the manufacturing process. Materials and Methods: FEIBA NF PASS was developed to prospectively monitor, in routine practice, the safety and effectiveness of FEIBA NF in the treatment of subjects with hemophilia and inhibitors. This prospective, observational surveillance program documented adverse events (AEs) and hemostatic effectiveness with FEIBA NF. An additional aim was to identify best practices in managing hemophiliacs with inhibitors on regular FEIBA prophylaxis. An electronic data collection system was utilized to monitor the safety and effectiveness of FEIBA NF in subjects for 12  2 months. Informed consent was obtained for all patients and the study was conducted according to the Declaration of Helsinki and its amendments. Results: The study was conducted in 36 sites in eight countries in Europe (EU). The last subject was added to the study in July, 2013 and database lock occurred in September, 2013. Complete data on 75 patients is available. At enrollment, 84% of patients had been diagnosed with congenital hemophilia A, 13% with acquired hemophilia A and 3% with congenital hemophilia B. At screening, 43 subjects were prescribed regular prophylaxis and 32 were prescribed on-demand treatment for bleeding episodes. Overall hemostatic efficacy rating by physicians was excellent or good for 91% of patients. Three related serious adverse events (hemarthrosis, catheter related infection, and thrombophlebitis superficial) have been reported, all associated with on demand treatment. Conclusions: FEIBA NF PASS has provided an opportunity to collect data on hemophilic patients with inhibitors during routine care, and serves as an invaluable tool for documenting the safety and effectiveness of FEIBA NF in a variety of clinical settings including prophylaxis, surgery and bleed management during ITI.

Data from a prospective post-authorization safety surveillance study in 384 hemophilia A patients in Japan with the antihemophilic factor (recombinant) plasma / albumin-free method demonstrates safety and efficacy

KATSUYUKI FUKUTAKE,1 HIDEJI HANABUSA,2 MASASHI TAKI,3 TADASHI MATSUSHITA,4 KEIJI NOGAMI,5 A K I R A S H I R A H A T A 6 and A D V A T E P A S S S T U D Y G R O U P 7 1 Tokyo Medical University, Tokyo, Japan; 2Ogikubo Hospital, Tokyo, Japan; 3St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Kanagawa, Japan; 4Nagoya University Hospital, Aichi, Japan; 5Nara Medical University, Nara, Japan; 6Kitakyushu Yahata Higashi Hospital, Fukuoka, Japan; and 7Baxter, Medical Affairs & Development Division, Tokyo, Japan Introduction and Objectives: Post-Authorization Safety Surveillance Study (PASS) is essential for the evaluation of safety in the real-life clinical settings. Data from aJapanese PASS of ADVATE [Antihemophilic Factor (Recombinant) Plasma/AlbuminFree Method: rAHF-PFM] collected under Japanese the Good Post-Marketing Study Practice (GPSP) protocol may reflect the current treatment situation of patients with hemophilia A. We reviewed data for both product safety (inhibitor development) in hemophilia A patients treated with rAHF-PFM, and for factors that affect patients’ quality of life, including on-demand and prophylaxis treatments. Methods: This prospective, multicentre, observational surveillance study was conducted at 101 sites from February 2007 to June 2012 in order to investigate hemophilia A in patients of all ages and disease severity, with ≥4 exposure days (EDs) at study entry, and who were prescribed rAHF-PFM. Data was reviewed in July, 2013. Results: Of 384 subjects receiving the rAHF-PFM more than once, 341 were observed for a period greater than two years and 43 subjects were withdrawn from the study. The severity of hemophilia varied: 5%:21 (6%). The mean age at entry was 25 years (range:0-81). EDs at study entry varied: ≤50EDs (n = 42), 51-150EDs (n = 16), to ≥151EDs (n = 326). Of 36 subjects with an inhibitor history, 30 subjects (negative status at entry) did not develop recurrent inhibitors and 1 of 6 with inhibitors had an increase in titer from 5 BU/ml to 33 BU/ ml after ITI. Three of 39 subjects with ≤50 EDs and no inhibitor history at entry developed low titer inhibitor (7.69%). No de novo inhibitor developed in 309 subjects with ≥51 ED (0%). No inhibitor was detected in subjects who switched from pd-FVIII or second generation rFVIII to rAHF-PFM. Of 228 subjects started on prophylaxis at entry, 208 subjects continued prophylaxis and their median annual bleeding rate (ABR) was 3.96. ABR in 65 (31%) was less than 2. The prophylaxis regimen of 115 of 208 subjects was 3 times per week. Eleven of 20 subjects who changed from prophylaxis to on-demand, re-started prophylaxis during the study period. Of 155 subjects, who started on-demand therapy at entry, 32 subjects switched to prophylaxis. Prophylaxis improved ABR in some patients but not others. Conclusions: This results further support the safety profile of rAHF-PFM in a large Japanese hemophilia A population and an individualized approach for treatment should be considered.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

CLINICAL ISSUES AND TRIALS Low-dose prophylaxis for Chinese hemophilia children involving maxillary hemophilic pseudotumors G U O X I A Y U , H O N G Z H U and R U N H U I W U Beijing Children’s Hospital, Capital Medical University, Beijing, China Introduction and Objectives: The incident of hemophilic pseudotumor in patients with hemophilia is estimated to be 1-2%, 5~10% among them occurring in maxilla. Patients with maxillary hemophilic pseudotumor often visit dental clinics with complaints of orofacial swelling and/or gingival bleeding and most of them were misdiagnosed as malignant tumors. Patients then underwent repeated biopsies and invasive surgeries that may be harmful to children’s craniofacial growth. Therefore, it is important to improve diagnostic accuracy and provide timely treatment. Materials and Methods: There were seven cases of maxillary hemophilic pseudotumor at our hospital during 2006~2013, with 6 cases of hemophilia A and 1 case of hemophilia B. We retrospectively analyzed patients’ medical histories, physical examination reports and laboratory and imaging information. We treated the patients with replacement therapy, and most received low-dose prophylaxis (10-20u/kg, QW).

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


In this study, six patients’ swelling and pain subsided and one patient underwent surgery without replacement therapy. We then observed the evolution of replacement treatment, including clinical and imaging observations. Results: 1) Diagnosis: Five patients who initially presented at other hospitals were misdiagnosed as having malignant tumors. Therefore, oral surgeons should be given more information on bleeding disorders and maxillary hemophilic pseudotumors in order to give correct diagnoses. 2) After short-term (3-6 months) low-dose prophylaxis, the recovery rate was 86% (assessed by clinicians and radiologists). Therefore, radiographic findings should not be used in the short-term as a standard for judging the usefulness of replacement treatment. Conclusions: Oral surgeons should be given more information on hemophilic pseudotumors. Low-dose prophylaxis may be prescribed for pediatric patients because of its clinical success, and because it is non-invasive and effective for treatment of hemophilic pseudotumors involving the maxilla.

Haemophilia (2014), 20 (Suppl. 3), 1--186



06-CLOTTING FACTOR CONCENTRATES Evaluation of the toxicology, pharmacokinetics, and local tolerance of recombinant factor IX Fc (rFIXFc) fusion protein in animals JENNIFER A. DUMONT, KEN LOVEDAY, DAVID R. LIGHT, G L E N N F . P I E R C E and H A I Y A N J I A N G Biogen Idec, Cambridge, MA, USA Recombinant factor IX Fc fusion protein (rFIXFc), under investigation for treatment of hemophilia B, utilizes the neonatal Fc receptor (FcRn) recycling pathway to extend its half-life. Here we report results from rFIXFc repeat-dose toxicology, pharmacokinetics (PK), and local tolerance studies in multiple species. Repeat dose studies in Sprague Dawley rats (4 weeks) and cynomolgus monkeys (5 and 27 weeks), investigated various doses of rFIXFc up to 1000 IU/kg administered every 4 days (rats) or once weekly (monkeys); terminal necropsy occurred 1 day after the final dose. Toxicology parameters evaluated included in-vivo observations, laboratory evaluations, immunogenicity, and post-mortem analyses. Electrocardiograms were evaluated in monkeys. Local tolerance of rFIXFc was evaluated in the repeat dose studies and a single dose study in rabbits. PK results were obtained from animals in these and additional studies (normal mice, rats, and monkeys; FIX-deficient mice and dogs). Allometric scaling was used to model the relationship of plasma clearance (CL) and steady-state volume of distribution (Vss) to body weight (BW) across animal species and hemophilia B patients. There were no effects of rFIXFc treatment on invivo observations, or in laboratory or post-mortem evaluations. As expected, rats and monkeys developed antibodies to fully human rFIXFc after repeat dosing; these antibodies did not cross-react with endogenous FIX. The no-observed-adverse-eventlevel (NOAEL) for the repeat dose studies was 1000 IU/kg, the highest dose evaluated. In the rabbit study, there were no exacerbated local reactions to rFIXFc compared with control infusion sites. There was no enhanced thrombogenic activity in any of the studies, including the Wessler Stasis Model. Allometric scaling for rFIXFc revealed more rapid elimination in small animals compared to humans; Vss was proportional to BW across species. rFIXFc was well tolerated in repeat dose studies in rats and monkeys at doses exceeding those expected for clinical use. The highest dose (1000 IU/kg) used was 10-fold greater than that anticipated for use as replacement therapy in humans with hemophilia B. rFIXFc did not cause any infusion site reactions or demonstrate increased thrombogenic risk. Allometric scaling analyses suggest PK results in animals are a good predictor of rFIXFc PK in hemophilia B patients. Disclosures: All authors are employees of and hold equity interest in Biogen Idec.

Pharmacokinetics of a new high purity factor X concentrate in subjects with severe or moderate factor X deficiency

S. AUSTIN,1 MT. ALVAREZ,2 G. AUERSWALD,3 N. BERMEJO,4 K. KAVAKLI,5 W. MITCHELL,6 A. ONER,7 S. PAVORD,8 S . M A C D O N A L D , 9 M . N O R T O N 1 0 and T . A L D W I N C K L E 1 0 1 St George’s Haemophilia Centre, London, UK; 2Hospital Universitario La Paz, Madrid, Spain; 3Klinikum Bremen-Mitte, Bremen, Germany; 4Hospital San Pedro de Alcantara, Caceres, Spain; 5Ege University, Izmir, Turkey; 6New York Presbyterian Hospital, New York, US; 7Yuzuncu Yil University, Van, Turkey; 8Leicester Haemophilia Comprehensive Care Centre, Leicester, UK; 9Addenbrooke’s Hospital, Hills Road, Cambridge, UK; and 10Bio Products Laboratory Ltd, Elstree, UK Introduction and Objectives: Hereditary factor X deficiency is commonly treated using either fresh frozen plasma or prothrombin complex concentrate. BPL has developed a high-purity factor X concentrate (BPL Factor X), and the objective of the present study was to assess the pharmacokinetics (PK) of BPL factor X in patients ≥ 12 years old with severe or moderate disease. Materials and Methods: Subjects with severe or moderate factor X deficiency ( 30 years: 31%




Hemophilia A


Male: 65% Female: 35%

Insured: 96% Uninsured: 3%

Bleeding: 85% Clotting: 15%

Severe: 51% Moderate/ Mild: 49%

HIV +: 4% HCV +: 13%

Introduction and Objectives: In order to identify outcomes requiring treatment, prevention,or research, representative databases of at-risk populations are required. Community Counts is an initiative of the Centers for Disease Control and Prevention (CDC) with the American Thrombosis and Hemostasis Network (ATHN) and the United States Hemophilia Treatment Center Network (USHTCN), consisting of 130 + clinics in 11 regions. Materials and Methods: Community Counts collects patient-level data in three parts. The HTC Population Profile records all patients seen at the USHTCN including demographics, insurance information, diagnosis, factor level, venous thromboembolism (VTE), and infections. The second component is Mortality Reporting. A Registry for Bleeding Disorders collects bleeding event data, including intracranial hemorrhage and hemarthroses, inhibitor formation, arthropathy, surgery, treatment regimens including prophylaxis, product use, mobility, pain, education, employment, genetics, family history and other medical conditions. Blood samples are collected for inhibitor and viral safety testing. Community Counts is organized nationally through ATHN with administrative and science committees, representing the USHTCN. The executive committee is formed by the chair and co-chair of the two committees, and 2 representatives each from ATHN and CDC. Results: Data collection was initiated in September,2012. As of October 21, 2013, 27383 unique patients with 32945 annual visits were entered into the population profile. Race and ethnicity mirrored US demographics. Diagnoses included: Hemophilia A,36%; von Willebrand disease, 26%; VTE, 15%; Hemophilia B, 10%; and platelet, 7%, rare bleeding, 5% and connective tissue disorders, 1%. Results are shown in Table 1. Twenty-three mortality reports have been submitted. The surveillance registry tool has been finalized; 34 centers have ethics committee approval. Conclusions: Surveillance of bleeding and clotting disorders is critical to discover complications and plan prevention. Community Counts demonstrates the network capacity to track important treatment practices and outcomes, such as product usage and inhibitor formation, prophylactic regimens and joint disease, and bleeding and mortality.

Hemophilia patient databases at the Shandong Hemophilia Centre of China YUNHAI FANG, XINSHENG ZHANG, LI AN, XUEQIN ZHANG, Y A N C H E N G and B I N T E N G Shandong Blood Center, Shandong Hemophilia Center, Jinan, China Introduction and Objectives: Shandong Hemophilia Centre is one of the six core centres in the Hemophilia Treatment Centre Collaborative Network of China (HTCCNC) and a WFH Chinese Hemophilia Training Centre. Our centre also functioned as the Shandong Hemophilia Registry Centre when the Ministry of Health of China launched the Hemophilia Data Management System Project. We collected data from hemophilia patients in Shandong Province. Materials and Methods: We registered all diagnoses of hemophilia in our centre from January, 2010 to October, 2013 in a digital format including ID number, date of birth, address, phone number, family history, F VIII:C level or FIX:C level, weight, blood group, viral infections, treatment intensity and so on. Results: A total of 1658 hemophilia patients were registered, 1425 with hemophilia A and 233 with hemophilia B. Among 1425 hemophilia A patients, 662 patients were younger than 18-years-old and 763 patients were older than 18-years-old; 702

Haemophilia (2014), 20 (Suppl. 3), 1--186

patients had a family history of hemophilia and 723 patients reported no family history. Among 233 hemophilia B patients, 110 patients were younger than 18-yearsold and 123 patients were older than 18-years-old; 111 patients had a family history of hemophilia and 122 patients reported no family history. Conclusions: A database on hemophilia patients is a powerful tool for policy-making, healthcare planning and epidemiologic research. Shandong Province has 95 million inhabitants. In 2012, factor VIII consumption was only 0.14 U per capita in Shandong Province, however, there are many patients either not yet diagnosed or undertreated, so there is still much work to be done on the hemophilia patients’ registry.

WFH annual global survey: a new integrated electronic data collection and management system A.N. TRAORE, M. BROOKER, K. GULIWALA, A. SRIVASTAVA, P H B . B O L T O N - M A G G S and O N B E H A L F O F T H E D A T A DEMOGRAPHICS COMMITTEE (DDC) OF THE WFH Introduction and Objectives: The World Federation of Hemophilia (WFH) works with 122 national member organizations (NMOs) to improve and sustain care for people with inherited bleeding disorders. The WFH has collected demographic and other data on people with hemophilia, and von Willebrand disease since 1999, and rare bleeding and inherited platelet disorders from 2004, in an Annual Global Survey (AGS). Until 2011, data were collected as text and stored in a unique database each year. This made data validation (DV), data analysis (DA), and longitudinal data comparison difficult. In 2012, WFH implemented an electronic data collection (DC) and management system to enhance AGS quality. Materials & Methods: AGS data from the first 12 years were merged into a single database and analyzed to identify discrepancies impacting quality. NMOs were surveyed. Feedback from AGS data managers (DM) and the DDC was sought and objectives identified: web-accessibility, ease of data entry, real-time DV and review capability, automated DA, flexible and longitudinal queries (by region, country, GNI, and year) and data tables formatted for the AGS report. A secure web-based DC system was implemented. Results: The new system was used for 2012 DC. Data entry is facilitated with realtime DV (missing data and discrepancy tracking). Discrepancies not resolved in realtime are flagged and reviewed with NMOs for accuracy, consistency, and completeness. With profile-based access to specific pages, one NMO used the system for the most recent (2012) AGS. Using historical data allows external DV (compare current and previous AGS). The DDC is able to review the data via purpose-built pages. The system aims to integrate data from WFH research and country-based survey activities. To reduce work involved in follow-up of incomplete data, a suitable form will be developed for the 2013 AGS that will require essential fields to be completed before submission. To securely accommodate NMOs still sending data in text format, a form that can be loaded to the system will be developed. Conclusions: The new system improves DC, DV, and DA, which will have a positive impact on the quality of data and help WFH achieve its mission. Global internet access for NMO data entry will be possible. Future success of this project requires the participation of the NMOs to provide timely, accurate data.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd



10-HEMOSTASIS TESTS AND ASSAYS Potency assignment and measurement of recombinant FIX activity in human plasma – impact of aPTT reagents on the 1-stage clotting assay HERBERT GRITSCH, STEFAN ROMEDER-FINGER, F R I E D R I C H S C H E I F L I N G E R and P E T E R L . T U R E C E K Baxter Innovations GmbH, Vienna, Austria

Introduction and Objectives: Baxter recently introduced to the US market RIXUBIS, a new recombinant Factor IX product produced from CHO cells by Baxter’s proteinfree manufacturing technology. Potency assignment for FIX products is performed with a 1-stage clotting assay based on the activated partial thromboplastin time assay (aPTT). Potency labeling should be traceable to the WHO standard for FIX concentrates. RIXUBIS and another rFIX product available on the market were analyzed for FIX potency using a panel of aPTT reagents from various manufacturers and the results were compared with the labeled potency. The impact from type and source of the aPTT reagent was investigated. Materials and Methods: The 1-stage clotting assay was run on coagulation analyzers (BCS/XP, Siemens Healthcare Diagnostics GmbH, Vienna, Austria), and FIX activities were calculated relative to a secondary in-house standard, traceable to the WHO standard for FIX concentrates. In addition, the chromogenic activity was also analyzed using test kits from two manufacturers (Biophen Factor IX, Aniara/Hyphen Biomed, Coachrom, Vienna, Austria) and Rox Factor IX (Rossix, Haemachrom Diagnostica GmbH, Essen Germany). Results: The FIX potency of both recombinant products was dependent on the type of aPTT reagent used, and discrepancies of up to 40% were found. The dependency was similar for both rFIX concentrates. For RIXUBIS, good agreement between the labeled potency and the FIX potency obtained with two different FIX chromogenic assays was found. The other product resulted in lower chromogenic activities as compared to the label. When RIXUBIS and the compared rFIX product were spiked in vitro into plasma from hemophilia B patients and the resulting FIX activity was also dependent on the type of aPTT reagent used for the 1-stage clotting assay. Conclusion: The potency of rFIX products is dependent on the aPTT reagent used for the 1-stage clotting assay. Both RIXUBIS and the compared rFIX product are affected in a similar way. For RIXUBIS, the labeled 1-stage clotting potency is in good agreement with the chromogenic activity while for the other rFIX product, lower chromogenic data were found.

Differentiation of hemostatic potency of natural, full-length recombinant FVIII molecules from B-domain deleted recombinant FVIII GERALD SCHRENK, HERBERT GRITSCH, STEFAN ROMEDERFINGER, SABINE KNAPPE, MICHAEL DOCKAL, PETER L T U R E C E K and F R I E D R I C H S C H E I F L I N G E R Baxter Innovations GmbH, Vienna, Austria Introduction and Objectives: A variety of recombinant FVIII (rFVIII) preparations that provide efficacious replacement therapy in hemophilia A patients are available. These preparations include full-length rFVIII (FL rFVIII), which is equivalent to the naturally occurring FVIII molecule, and genetically engineered B-domain deleted rFVIII (BDD rFVIII). Determination of accurate FVIII activity is crucial for manufacturing, and especially for product dosing in a clinical settings, and for testing of patient plasma. Several studies have demonstrated that assessing reliable FVIII activity for BDD rFVIII is a significant challenge due to the major discrepancy in results obtained with FVIII chromogenic and 1-stage clotting assay. Moreover, FVIII 1-stage clotting activity depends on the type of aPTT reagent used. The objective of the study was to evaluate differences in potency determination between FL rFVIII and BDD rFVIII with respect to their dependency on the type of aPTT reagent used in the 1-stage clotting assay. Materials and Methods: Potency of FVIII was measured by a FVIII chromogenic activity assay and 1-stage clotting assay, using different commercial available aPTT reagents. Both the eighth international standard for blood coagulation factor VIII concentrate (NIBSC #07/350) and human normal plasma served as assay reference standards. The performance of the two different types of rFVIII products was compared by calculating the ratios of FVIII 1-stage clotting and chromogenic activities. Results: Depending on aPTT reagent type, FVIII potencies varied within a relatively broad range, independent of which type of assay reference standard was used. The resulting ratios between FVIII 1-stage clotting and chromogenic activity showed a broader variance for the BDD rFVIII products than for FL rFVIII products.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

Conclusions: Although further investigation is required to substantiate our observation, dependence on aPTT reagent type appeared more pronounced for BDD rFVIII than for FL rFVIII. As clinical laboratories use a number of commercial aPTT reagents with different compositions, determination of the correct potency and concentration in plasma post-infusion of BDD rFVIII might be more challenging than for the natural, full-length rFVIII molecule.

Comparison of the behavior of different factor VIII products measured with the chromogenic Factor VIII activity assay and the FVIII one-stage clotting assay

CLINTVAN DUREN,1 ROBERT POLENEWEN,1 PAUL BRONS,1 B R I T T A L A R O S , 1 R O G E R S C H U T G E N S 2 and W A A N D E R L . V A N HEERDE1 1 Radboud University medical center, Nijmegen, The Netherlands; and 2University medical center Utrecht, Utrecht, The Netherlands

Introduction and Objectives: Factor VIII levels can be measured with either a clotting assay or a chromogenic assay. The use of both assays is recommended as the FVIII one-stage clotting (FVIII:C) assay is not sensitive for factor VIII mutations affecting the stability of factor VIII. Moreover, analyzing plasma FVIII levels with the FVIIICS assay or with the FVIII:C assay calibrated with a ReFacto standard is recommended if patients are treated with ReFacto AFâ. In our study we compared the effect of different compounds after suppletion therapy as measured with both assays. Materials and Methods: The APTT based FVIII:C assay was determined with HRF deficient FVIII plasma and compared with the FVIIICS assay (Biophen FVIII:C assay, HYPHEN BioMed). One hundred twenty samples of 70 hemophilia patients treated with FVIII products or DDAVP (carrier: n = 1, mild: N = 14, moderate: N = 2, severe: N = 53) were analyzed. The slope, intercept and correlation coefficient are determined. Results: FVIII:C assay vs FVIIICS assay calibrated with normal pooled plasma Product


DDAVP (n = 3) 1.063  0.076 Aafact (n = 4) 1.018  0.117 Advate (n = 30) 0.966  0.021 Helixate (n = 25) 0.974  0.039 Haemate P (n = 1) Kogenate (n = 39) 1.019  0.016 ReFacto (n = 18) 1.101  0.044 Total group (n = 120) 0.992  0.015 Effects in Refacto-treated patients: ReFacto (One stage 1.114  0.021* with NPP and RF std. n = 18) 0.987  0.054 ReFacto (One stage with RF std. And FVIII CS with NPP n = 18)



-8.727  4.024 -1.162  5.104 0.565  0.867 -0.837  2.067 0.073  0.751 4.948  1.406* 0.900  0.685

0.997 0.987 0.993 0.982 0.996 0.987 0,986

-1.287  0.663*


6.247  1.876*


*Significant from perfect line Conclusions: The FVIIICS assay is comparable with the FVIII:C assay and is able to measure different FVIII products in patient samples. Furthermore, we showed that there is a significant difference between the FVIII:C assay and FVIIICS assay in plasma of ReFacto-treated patients. These results confirm previous reports that it is recommended to analyse Refacto suppletion with the FVIIICS assay. Similar assays are also required for the new factor VIII products with a longer half-life.

Haemophilia (2014), 20 (Suppl. 3), 1--186



11-INFECTIOUS COMPLICATIONS The Enhanced Liver Fibrosis (ELF) test compared to transient elastography in hemophilia patients with chronic hepatitis C 1


LISAVAN MANEN, DIETJE FRANSENVAN DE PUTTE, E V E L I E N M A U S E R B U N S C H O T E N , 2 K A R E L V A N E R P E C U M 3 and GREET BOLAND1 Departments of 1Medical Microbiology and 3Gastroenterology, University Hospital Utrecht, The Netherlands; and 2Van Creveldkliniek, University Hospital Utrecht, The Netherlands Introduction and Objectives: Progressive liver damage due to hepatitis C virus infection is a major cause of co-morbidity among hemophilia patients. Liver biopsies are the golden standard for determination of fibrosis. However, the most-used test to measure the stage of fibrosis is now transient elastography (TE). New biochemical markers for detection of fibrosis are upcoming. Among them is the enhanced liver fibrosis (ELF) test, combining hyaluronic acid, procollagen-III-amino terminal peptide and tissue inhibitor of metalloproteinase-1. Since liver biopsies are not desirable in hemophilia patients, the ELF test was compared with TE. Materials and Methods: We evaluated the ELF test in 55 chronically HCV-infected hemophilia patients. TE was performed using FibroScan. Univariate and multivariate analysis were performed to find determinants with impact on the ELF test. TE and ELF test were compared using the spearman rank correlation. Results: Spearman rank correlation coefficient assessing the correlation between TE and ELF was found to be significant at a 2-tailed level (r = 0.429, p-value = 0.005). ELF test and TE correlated in less than 50% when using ELF test manufacturer’s cut-off values. ELF score differences between the four levels of liver fibrosis were significant (p-value of Kruskal-Wallis test = 0.023). The increase in ELF-score was highest between stage F0-F2 and F3-F4 (p- value of Mann Whitney U test = 0.001). AST level was significantly associated with ELF score. FIB-4 and APRI showed a higher correlation with TE than ELF test (r = 0.613, p = 0.000; r = 0.644, p = 0.000, respectively). Conclusions: There was a significant, but limited correlation between TE and ELF score. There was a significant increase of ELF score between fibrosis stage F0-F2 and F3-F4. APRI and FIB-4 correlated better with TE than the ELF-score.

Analysis of the response to interferon-based therapy for hepatitis C virus infection in patients with inherited bleeding disorders between 1992 and 2012 TAKESHI HAGIWARA, YUSHI CHIKASAWA, TAKASHI MURAMATSU, IKUO SEITA, MIHOKO YOTSUMOTO, MANABU OTAKI, TAKASHI SUZUKI, YASUYUKI YAMAMOTO, K A G E H I R O A M A N O and K A T S U Y U K I F U K U T A K E Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan Introduction: Hepatitis C virus (HCV) infection is a major comorbidity in patients with inherited bleeding disorders. Antiviral treatment is administered to such patients to eradicate HCV and to prevent the development of severe liver disease. Responses to interferon (IFN)-based therapy for HCV have been improved over time by switching from monotherapy to combination therapy with ribavirin. Materials and Methods: We aimed to assess changes in the efficacy of IFN-based therapy for HCV infection in patients with inherited bleeding disorders by retrospectively investigating 147 outpatients in our hospital who received IFN therapy for HCV infection from 1992 through 2012. Results: The median age was 37 (range 8-68) years at initial IFN therapy. Subjects included 109 with hemophilia A, 24 with hemophilia B, 9 with von Willebrand disease, and 5 with other bleeding disorders; 45 patients were co-infected with HIV. The average number of courses of IFN therapy per patient was 1.83. The proportion of patients achieving sustained virological response (SVR) with initial therapy was 43% (41% in HIV-negative, 47% in HIV-positive patients). Rates of success were 26% for IFN-alpha or -beta monotherapy, 40% for IFN-alpha plus ribavirin, 33% for pegylated (PEG)-IFN-alpha monotherapy, and 54% for PEG-IFN-alpha plus ribavirin. Sixty-one patients who relapsed or did not achieve virological response after initial treatment underwent several subsequent courses of treatment. Thus, the overall rate of SVR was 61%. To achieve SVR, 23 patients were treated twice, 11 three times, 1 six times, 1 seven times, and 1 eight times. Overall, 69% (71% HIV-negative, 62% HIVpositive patients) of the 147 patients achieved SVR. Conclusions: The findings of this analysis reconfirm the efficacy of IFN-based therapy for HCV in patients with inherited bleeding disorders and suggest that for patients in whom previous anti-HCV therapy has failed, undergoing several courses of treatment can raise the rates of SVR. This is likely to lead to a decrease in the risk of liver fibrosis progression and hepatocellular carcinoma.

Long-term observation of hemophiliacs with HIV infection in Japan: Follow-up of survival and status of HCV infection

SHINOBU TATSUNAMI,1 AKIRA SHIRAHATA,2 JUNICHI MIMAYA,3 RIE KUWABARA,4 YUTAKA NISHINA,5 J U G O H A N A I , 6 K A T S U M I O H I R A 7 and M A S A S H I T A K I 8 1 Unit of Medical Statistics, St. Marianna University School of Medicine, Kawasaki, Japan; 2Kitakyushu Yahata Higashi Hospital, Kitakyushu, Japan; 3Atami Public Health and Welfare Center, Atami, Japan; 4Institute of Radioisotope Research, St. Marianna University Graduate School of Medicine, Kawasaki, Japan; 5Nishina and Fukado Law Office, Tokyo, Japan; 6Medical Care and Human Rights Network, Osaka, Japan; 7Social Welfare Corporation Habataki Welfare Project, Tokyo, Japan; and 8Department of Pediatrics, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan Introduction and Objectives: We summarize the results of survival analysis and the status of HCV infection among HIV-positive hemophiliacs in Japan.

Haemophilia (2014), 20 (Suppl. 3), 1--186

Materials and Methods: We used data collected by the Research Committee for the National Surveillance of Coagulation Disorders in Japan. The study subjects included deceased and surviving HIV-positive hemophiliacs. The total number of subjects was 1412 (hemophilia A, 1087; hemophilia B, 325). The risk of death was also computed through the kernel-smoothed time-derivative of the survival function obtained by the Kaplan-Meier method. Dropped cases were removed from the data set using the final date of follow-up. Results: The survival fraction was 49.5  1.4% and cumulative fraction of death was 50.5  1.4% at the end of May, 2012. The hazard function rose between 1983 and 1995, declined slightly between 1995 and 1996, and then decreased markedly in 1997. It remained very low until 1999 (less than 0.02/year). After a slight rise in 2000, it has been fluctuating between around 0.02 and 0.03 (/year). Coinfection with HCV was very common at an incidence of 98%. The percentage of patients with severe hepatic disease such as cirrhosis, hepatocellular carcinoma and liver failure was 10% among HIV-and-HCV-coinfected patients. Conclusions: The remarkable decrease in the annual death rate in 1997 was not caused by a reduction in the number of surviving hemophiliacs. Rather, it was attributable to the availability of protease inhibitors for therapy. The observed slight rise in risk in 2000 seems to be associated with the increased incidence of critical liver diseases noted as a cause of death in these hemophiliacs. Therapy for HCV using new and effective drugs should be prescribed in order to achieve survival benefit among this population.

Natural history of hepatitis C Virus (HCV) infection in Korean hemophiliacs H U G H K I M and S U G I J E O N Ajou University Medical Center, Suwon, Korea Introduction and Objectives: HCV infection in hemophiliacs is mostly due to exposure to contaminated coagulation factors used prior to the era of decontamination processes. The purpose of this study was to analyze the natural history of HCV infection with respect to the response to HCV treatment, and the rate of natural immunity against HCV infection in a 105 Korean hemophilic cohort. Materials and Methods : We have followed 105 Korean hemophilic patients, of whom 40 were HCVab positive (38% HCV seropositivity). The median age of HCV seropositive patients was 40 yrs with a range of 26 to 64. Results: Of 40 HCV seropositive patients, 6 (15%) were HCV rna positive and therefore, considered to be in the active stage of HCV infection and 1 of six HCVrna positive patients developed hepatoma. Of these 40 HCV seropositve patients, 34 (85%) were HCVrna negative; 24 of these were treated with interferon containing regimen, and therefore, recovered from the HCV infection. Interestingly, 10 of 40 (25%) HCV seropositive patients remained HCVrna negative despite no previous treatment for the HCV infection, and therefore, are considered to have a naturally acquired immunity against HCV. Conclusion: Our 105 patient Korean hemophilic cohort shows 38% HCV seropositivity which is somewhat lower than those of North American or European hemophilic populations. Those who were HCV infected with HCVrna (+) had favorable response to the interferon-containing regimen. In addition, a considerable number of HCV seropositive patients (25%) have acquired natural immunity to HCV infection, without treatment. This study shows that hemophilic patients who are HCV-infected, and are HCV seropsitive and HCVrna (+) should be rigorously treated in the early stage of the infection to avoid the late sequelae of HCV infection.

Prevalence and status of HCV infection among Japanese hemophiliacs

SHINOBU TATSUNAMI,1 AKIRA SHIRAHATA,2 JUNICHI MIMAYA,3 RIE KUWABARA,4 MIEKO AKITA,5 Y U T A K A N I S H I N A , 6 J U G O H A N A I , 7 K A T S U M I O H I R A 8 and MASASHI TAKI9 1 Unit of Medical Statistics, St. Marianna University School of Medicine, Kawasaki, Japan; 2Kitakyushu Yahata Higashi Hospital, Kitakyushu, Japan; 3Atami Public Health and Welfare Center, Atami, Japan; 4Institute of Radioisotope Research, St. Marianna University Graduate School of Medicine, Kawasaki, Japan; 5Department of Pediatrics, St. Marianna University School of Medicine, Kawasaki, Japan; 6Nishina and Fukado Law Office, Tokyo, Japan; 7Medical Care and Human Rights Network, Osaka, Japan; 8Social Welfare Corporation Habataki Welfare Project, Tokyo, Japan; and 9Department of Pediatrics, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan Introduction and Objectives: The Research Committee for the National Surveillance of Coagulation Disorders in Japan has been collecting information regarding HCV infection since 2001. We summarize the results using the data collected up to the end of May, 2012. Materials and Methods: The study subjects included the total number of hemophiliacs on 31 May, 2012 (hemophilia A, 4627; hemophilia B, 990). The number of patients from 2004 to 2012, for whom there was recovery with therapy for HCV infection was analyzed. Results: Among patients on whom we had information, the percentage of patients with HCV infection was 53% in HIV-negative hemophiliacs and 98% in HIV-positive hemophiliacs. Among the HCV-positive patients, the age of the HIV-negative and HIV-positive patients was 46.8  14.9 and 43.7  8.5 years, respectively. The number of patients with critical liver disease were as follows: cirrhosis 53 (3.0%), hepatocellular carcinoma 48 (2.7%), liver failure 2 (0.1%) among HIV-negative patients: and cirrhosis 53 (8.1%), hepatocellular carcinoma 11 (1.7), liver failure 1 (0.2%) among HIV-positive patients. In addition, six patients (3 HIV-negative and 3 HIV-positive) had undergone a liver transplant. The percentage of patients with

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

INFECTIOUS COMPLICATIONS critical liver disease was significantly higher among HIV-positive patients than among HIV-negative patients (P < 0.01). Regarding therapy for HCV infection, the number of patients who have recovered through therapy using interferon increased from 86 (62 in HIV-negative and 24 in HIV-positive) in 2004 to 367 (258 in HIV-negative and 109 in HIV-positive) in 2012. Conclusions: Although an interferon therapy against HCV infection is effective, the various adverse side effects deter patients from starting therapy. The present results showed that the number of patients who recovered through therapy is still small. About 20 years has passed since the termination of the possible period of infection with HCV through coagulation concentrates. A longer period since infection, especially a period longer than 20 years, is inevitably associated with a higher risk of critical liver disease onset. Therefore, an early decision to start therapy is needed.

Time for a change: People with hemophilia and hepatitis C in New Zealand CHANTAL LAUZON Haemophilia Foundation of New Zealand Inc., Christchurch, New Zealand Introduction and Objectives: Of the 189 people with bleeding disorders (PWBD) who contracted hepatitis C (HCV) in New Zealand, nearly a third continue to live with a chronic infection. For the past 4 years, an annual survey has been conducted to better understand the impact of HCV. A review of the results was undertaken to identify any trends or changes among this community in terms of their health and wellbeing. Methods: A self-completed survey was circulated to PWBD and chronic HCV in New Zealand each year from 2010 to 2013. Respondents were asked about demographic information, employment, and treatment for hepatitis C, symptoms, liver health, HCV education, their general health, activities and psychosocial functioning. Annual data was also collected on treatment and deaths. Results: An average of 31 surveys (58%) were completed and returned each year. In that time, the number of PWBD and chronic HCV patients has decreased from 66 by 19 people, 12 having died and seven having achieved a sustained viral response (SVR) to treatment. Another four were awaiting confirmation of an SVR. The majority of survey respondents were aged over 61 years (39 - 53%), with only two were aged under 30 years. A little over half (52-63%) of those aged under 61 years were in fulltime employment. Until recently, approximately half of the respondents each year reported having attempted treatment, but this increased to 68% in 2013. The percentage of respondents having undergone a FibroScan© has increased each year from 53% in 2010 to 79% in 2013. The percentage of respondents who indicated they had fibrosis has increased from 34% to 53% in 2013, perhaps due to the increased access to FibroScans. The percentage indicating they had cirrhosis has, however, remained consistent around 20%. Fatigue was reported to affect the most respondents and was the symptom that most impacted their lives. Conclusion: For the first time there has been a noticeable shift in the numbers of PWBD and chronic HCV in New Zealand. While sadly, some of the reductions have been through deaths, the opportunity to conduct trials of new direct-acting antiviral therapies has had a positive impact on the HCV status and overall wellbeing of a number of PWBD. Those that continue to live with chronic HCV, however, continue to be negatively affected by a variety of related symptoms, especially fatigue.

Antiviral treatment of HCV infected young hemophiliacs: An update after 20 years of study; New expectations for a cure for hepatitis C

K A T A L I N K O E H L E R V A J T A 1 and R E I N H A R D Z A C H O V A L 2 Pediatric Practice and Hemophilia Center, Gruenwald, Germany; and 2II Medical Clinic, Leberambulanz, Klinikum Großhadern, Munich, Germany


Introduction and Objectives: The aim of the study is the long term observation of hepatitis C infected hemophiliacs and the effectiveness of antiviral therapy in our patients. Expectations for the cure of the illness are discussed. Materials and Methods: In our study, 16 hepatitis C infected young adults were observed in our study, 6 of them were studied for more than 15 years. We report on the treatment by different therapeutic regimens and the current development of the HCV-treatment experience. All our 16 patients carried the HC-virus and are HIV negative. HCV genotype was Simmonds 1b/Okamoto II. Therapy: 1. Interferon (3 million units 3 times weekly) (1993); 2. Interferon + ribavirin (800-1200 mg/day) (1997); 3. PegIntron 1.5 lg/kg BW. once per week + ribavirin for 48 weeks (2003); 4. Triple combination therapy with protease inhibitor (2011); 5. Triple combination therapy with PegIntron, ribavirin and the nucleotid analog polymerase inhibitor sofosbuvir or double combination therapy without PegIntron (2013). Results: Two patients underwent liver transplant after unsuccessful treatment efforts with both interferon (1) and combination therapy (2). Another patient’s treatment had to be stopped after 6 months because of low response to combination therapy 2. Two patients had 48 weeks of combination therapy (3), but had a relapse after stopping the treatment. Only one patient could be successfully treated with combination therapy (3). This patient shows no relapse 11 months after the therapy. 4.: Triple combination therapy (PegIntron, ribavirin and protease inhibitors boceprevir and telaprevir), used since 2011, was not used because of the danger of virus resistance and reports of severe adverse reactions. 5.: We plan to start a new triple therapy in the next weeks with a duration of 3 months (PegIntron, ribavirin and sofosbuvir, a nucleotid analog polymerase inhibitor). Early studies show a virological response rate up to 100% in HCV infected patients. Conclusions: Since 2011, new treatments show an increasing efficacy against HCV infection, which means renewed hope for cure to HCV infection, especially for genotype 1b.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


Low risk of hepatic fibrosis in Egyptian severe hemophilia A patients with long-standing hepatitis C virus infection

M O H S E N E L A L F Y , 1 S H E R E E N A B D E L - G H A N Y 1 and MAI SHERIF2 Department of Paediatrics, Ain Shams University, Cairo, Egypt; and 2Department of Clinical Pathology, Cairo University, Cairo, Egypt 1

Introduction and Objectives: Most Hemophilia A patients in developing countries are still treated with cryoprecipitate, with a high risk of infection with hepatitis C virus and the development of hepatic fibrosis. Liver biopsy is an imperfect gold standard for assessing the severity of chronic liver disease among hemophiliacs. We aimed to assess the liver status of adolescents and young adults with severe hemophilia A patients for the degree of hepatic fibrosis after prolonged hepatitis C viral (HCV) infection in early life, left untreated for more than a decade. Materials and Methods: Twenty-six hemophilia A patients, aged 12 to 21 years, HCV-RNA positive, who contracted the infection during the first 5 years of life, were enrolled; liver transaminases and both FibroTest (FT) and liver stiffness measurement by FibroScan (FS) were assessed. Results: We found that 53.8% (14/26) of the studied hemophilia A patients had no fibrosis (F0) as determined by FT and FS, 19.2% (5/26) had minimal fibrosis (F1) as determined by FT versus 26.9% (7/26) as determined by FS, while 26.9% (7/26) and 19.2% (5/26) had mild fibrosis as determined by FT and FS respectively. A highly significant association was found between FibroTest and FibroScan with regard to the degree of fibrosis (p < 0.001). A highly significant positive correlation was also found between ALT and both FT and FS. Conclusions: None of the studied HCV-RNA positive severe hemophilia A patients showed moderate or severe liver fibrosis using FT and FS.

Prevalence and treatment response of hepatitis C in hemophilia patients

C H I N G Y E H L I N , 1 M I N G C H I N G S H E N , 1 Y U - C H U N H S U 2 and HSUAN YU LIN1 1 Hemophilia Treatment and Thrombosis Center, Changhua Christian Hospital, Changhua, Taiwan; and 2Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan

Our study was aimed at evaluating the efficacy and safety of hepatitis C treatment in hemophilia patients. Methods: From April, 2010 until now, data was collected from 11 hemophilia patients with chronic HCV infection who received HCV treatment according to guidelines of the American and European Association for the Study of the Liver. Clinical parameters including the HCV serotype, treatment course using pegylated interferon and Ribavirin combination therapy as well as adverse events were analyzed to evaluate the efficacy and safety of hepatitis C treatment in hemophilia patients. Results: The prevalence of HCV infection in our hemophiliacs was 82.5 to 89.5% in early 1990 to 2000 and decreased to 50% in 2010s. We recruited 11 hemophilia patients with abnormal transaminases and/or high HCV viral load undergoing HCV treatment, aged 32 to 73 with a mean of 47.4 years. The HCV serotype exam showed type 1b in 7 patients, and complex serotype in 3 patients. The other 2 patients showed type 1a and type 3a, respectively. Among 11 patients, early viral response (EVR) was observed in 8 patients, and 6 of 8 patients who completed HCV treatment met the criteria of sustained viral response (SVR). One patient stopped treatment after less than one month due to intolerable myalgia and general malaise, and the other 10 patients experienced a grade 2-3 hematologic adverse effect without increase of bleeding events. Conclusion: Our study demonstrated that the HCV treatment response rate in hemophilia patients is comparable to those in the general population without a higher risk of adverse events.

Safety of triple therapy with Telaprevir hemophiliacs with hepatitis C PANAGIOTA IOANNIDOU, ANNA KOURAMBA, T H E O P H A N I S A D R A K T A S , M A R I A M A N D R A K I and KATSAROU OLGA Blood Centre, National Reference Centre for Congenital Bleeding Disorders, Laiko General Hospital, Athens, Greece Introduction and Objectives: Cure rates of chronic hepatitis C patients with advanced fibrosis or cirrhosis via pegylated interferon and ribavirin are unsatisfactory, but can be increased by the addiction of protease inhibitors. Little data is available on safety and tolerability in patients receiving triple therapy. For patients with hereditary hemorrhagic disorders, like hemophiliacs, data are lacking. Preliminary safety data on triple anti- HCV therapy are reported, in hemophilia patients previously treated with double therapy. Materials and Methods: A total of 5 patients, mean age 42 years (38-51), 3 with hemophilia A (1 severe, 2 mild), 2 with hemophilia B (1 severe, 1 moderate), with genotype 1, received pegylated interferon a-2a 180 lg/week, ribavirin 1000-1200 mg daily and telaprevir 750 mg tid. Two of five patients relapsed and 3 did not respond to previous treatment. 2F3, 3F4 in Stiffness (Fibroscan). Total treatment duration was 48 weeks for those who had virological response at 4, 12, and 24 weeks. Telaprevir was administered for the first 12 weeks and then stopped. Results: Severe adverse events were not observed. All had anemia. During the triple therapy, the reduction of ribavirin-dose was a safe option. All patients completed treatment. During this period, a median decrease in hemoglobin of 3 gr/dl (2,5-4,4) was observed. No transfusions or Erythropoetin administration was added. Median PLT during therapy was 128.000 (range 72000-185000), while neutrophils ranged between 1400-4100 (median 2700). Mild general symptoms were reported including fatigue and anorexia. Two patients complained of hemorrhoids, 1 had nausea, and 1 had hyperlipidimia and low potassium. No dermatological events occurred, except mild itching after bathing. All patients responded to therapy during the first 12 weeks of therapy. After cessation of telaprevir, 3/5 were HCV-RNA negative at 24 and 48 weeks (1F3, 2F4).

Haemophilia (2014), 20 (Suppl. 3), 1--186



Conclusions: Our preliminary data with triple anti –HCV therapy in hemophiliacs is associated with the same risk of adverse events as other patients. A follow up with a higher number of patients is needed to confirm this data.

Effective HEV clearance across a FVIII manufacturing process J O A N N H O T T A and S H A R O N S M I T H Grifols Therapeutics Inc; Research Triangle Park, North Carolina, USA Introduction and Objectives: The clinical course of HEV infections can vary. Under most conditions they are acute and self-limiting but they can become chronic and more serious. Chronic infections are generally associated with genotype 3 and several cases of genotype 3 transmission by blood components have been reported. Due to the potential threat of HEV to the blood supply, it is important to ensure the safety of plasma-derived products from HEV contamination. Materials and Methods: An HEV infectivity assay was developed using the Kernow C1 strain of genotype 3 and HepG2 cells. The virus does not cause CPE in cell culture so virus detection was based on PCR of HEV RNA. The assay was used to evaluate HEV inactivation by freeze dry/dry heat treatment of a FVIII concentrate. Results: Over 4 log10 HEV reduction was achieved after drying heat treatment at 80°C for 3 days. Conclusions: HEV can be effectively inactivated by 80°C 72 h treatment of a FVIII concentrate, such as Koate, Alphanate and Fanhdi.

Patient demographics, HCV-infection and CD4 cell counts in HIVinfected hemophilia patients: data from the Bonn Hemophilia Care Centre

the life expectancy of hemophilia patients infected with human immunodeficiency virus (HIV). However, co-infection with hepatitis C virus (HCV) has significant consequences including accelerated liver disease progression and high rates of endstage liver disease. Treatment with pegylated-interferon and ribavirin is often postponed due to lower rates of sustained virologic response in co-infected patients and the fear of side effects. The current study aims to quantify HIV/HCV-coinfected patients, who should be considered for close monitoring of liver function and, ultimately, antiviral treatment. Methods: We conducted an observational, descriptive, cross-sectional study in HIVinfected hemophilia patients who were regularly treated at the Bonn Hemophilia Care Centre in 2011. Eligible patients as well as information on HCV infection status and CD4 cell counts were identified in our electronic patient database. Information related to antiviral therapies was extracted from medical records. Results: In total, 106 (15,2%) out of 689 patients with hemophilia were HIV-infected. Ninety-six (90,6%) of these patients suffered from hemophilia A and 10 (9,4%) patients had hemophilia B. HIV infection was encountered predominantly in patients with severe forms of hemophilia. The mean age of the HIV-infected patients was 47,8 years (range 32–73 years). Co-infection with HCV was present in 67 (63,2%) of patients, and 37 (34,9%) patients had cleared HCV spontaneously or following antiviral therapy. Current CD4 cell counts were available in 102 patients. From these, 59 (57,8%) had a CD4 cell count > 400/ll, 35 (34,3%) patients had a CD4 cell count of 200-400/ll and in 8 (7,8%) patients the CD4 cell count was < 200/ll. We noted that 95 (89,6%) of HIV-infected patients received cART. Conclusions: Co-infection with HCV is still present in a substantial proportion of HIV-infected hemophilia patients. With the recent advances in therapy for HCV, it is becoming increasingly important that all patients infected with HCV to be considered for treatment.

NATASCHA MARQUARDT, GEORG GOLDMANN, SILVIA HORNEFF, CLAUDIA KLEIN, V Y T A U T A S I V A S K E V I C I U S and J O H A N N E S O L D E N B U R G Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Germany Introduction and Objectives: Broad availability of virus-inactivated clotting factor concentrates and of combination antiretroviral therapy (cART) has markedly extended

Haemophilia (2014), 20 (Suppl. 3), 1--186

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd



12-INHIBITORS, PATHOGENESIS, PREVENTION AND TREATMENT Frequency of inhibitor development between 50 and 75 exposure days in severe hemophilia A; New data from the PedNet registry 1


H . M A R I J K E V A N D E N B E R G and R . L J U N G University Hospital Utrecht, The Netherlands; and 2Lund University Department of Paediatrics, Sk anes Universitetssjukhus Malm€ o, Sweden


Background: Inhibitor development occurs in 25-30% of previously undisposed patients (PUPs) with severe hemophilia A. Most inhibitors occur very early; 50% of the children with an inhibitor are diagnosed at 14-15 exposure days (ED). Most registration studies for new coagulation factor VIII products have followed children until 50 exposure days. There is limited data on the number of inhibitors that occur between 50 and 75 exposure days nor when patients can be defined as Previously Treated patients (Low risk) patient. Patients and methods: The PedNet and RODIN centers included patients with severe hemophilia A (factor VIII < 0.01 IU/ml) born between 2000 and 2009. Detailed data were collected until 75 exposure days. Primary outcome was clinically significant inhibitor development, defined as at least two positive inhibitor titers combined with a decreased in vivo factor VIII recovery. The secondary outcome was high-titer inhibitor development, defined as the occurrence of a clinically relevant inhibitor with a peak titer of at least 5 Bethesda Units per mL (BU/mL). A positive inhibitor titer was defined according to the cut-off level of the used inhibitor assay in each center’s laboratory. Results: In total 622 patients were eligible of them N = 18 had no treatment data available. From the remaining N = 604 patients; N = 5 were lost for follow-up, N = 2 died at 6 and 11 ED because of ICH and N = 14 did not yet reach 75Ed or an inhibitor. In total N = 583 (94%) could be included for analysis, all reached an inhibitor or 75 exposure days. Of these patients 188 (32.2%) developed an inhibitor, whereof 124 had a high titre inhibitor (22.4%). The median number of exposure days until inhibitor development was 14 (IQR 9-19) exposure days. From all inhibitors only 6 out of 188 (3.2%) developed between 50 and 75 exposure days. Inhibitors developed 31.4% between 1 and 10 EDs, 45.7% between 11 and 20 EDs and 19.7% between 21 and 50 EDs. Conclusions: Development of inhibitors between 50 and 75 exposure days is very rare and occurs in only 3% of PUPs. This study clearly assessed that for comparison of PUP studies 50 exposure days is sufficient. Moreover, patients can be considered as low risk (PTP) patients after 50 exposure days.

Trends in inhibitor incidence in children with severe hemophilia A born in 1990-2010; Results from the PedNet registry

H . M A R I J K E V A N D E N B E R G , 1 M O J T A B A H A S H E M I 1 and R. LJUNG2 1 University Hospital Utrecht, The Netherlands; and 2Lund University Department of Paediatrics, Sk anes Universitetssjukhus Malm€ o, Sweden Background: About 25 per cent of patients with severe hemophilia A develop inhibitory allo-antibodies towards infused factor VIII products. Over the last decades, a higher inhibitor incidence has been reported. It is unclear whether this is caused by a real increase in inhibitors or by a higher awareness and more frequent testing. Patients and Methods: The CANAL study collected data from 366 patients with severe hemophilia until 50 exposure days. Primary outcome for both studies was clinically important inhibitor development. The secondary outcome was high-titer inhibitor development, defined as the occurrence of a clinically relevant inhibitor with a peak titer of at least 5 Bethesda Units per mL (BU/mL). A positive inhibitor titer was defined according to the cut-off level of the used inhibitor assay in each centre’s laboratory. Results: In total, 926 patients were included, and 906 patients reached 50 EDs or an inhibitor. To compare different time periods, patients were divided into 4 cohorts. Cohort 1included patients born between 1990 and 1995, cohort 2 patients were born between 1995 and 2000, cohort 3 patients were born between 2000 and 2005 and cohort 4 patients were born between 2005 until 2010. In cohort 1, 144 patients were selected, of which n = 28 (19.4%) developed an inhibitor. The inhibitor incidence for high-titer patients was very similar across this large group. Only cohort 1 included 16.9% high titer patients, in the other groups it was between 19.9 and 23.0%. This was also clearly depicted in the percentage of high-titer patients included in the total inhibitor incidence in each group. As expected for cohort 1, this group showed the lowest rate at 85.7%, and the rate was 63.6% in cohort 4, due to an overrepresentation of low-titer cases. Conclusions: Over an age range of over 20 years, the inhibitor incidence for high-titer patients was not significantly different. However, significantly more low-titer inhibitors were detected.

The placement and length of XTEN moieties can impact the activity of platelet-targeted rFVIIa-XTEN proteins


Introduction and Objectives: To improve the activity and pharmacokinetic properties of rFVIIa, we have generated rFVIIa variants fused with a platelet-targeting motif (a scFv directed to platelet receptor aIIbb3) and an XTEN moiety. To maximize the

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

impact of XTEN and platelet targeting on PK and activity, respectively, we have generated three configurations of rFVIIa variants: Configuration A, the XTEN and the targeting moiety were fused to the C-terminus (CT) of the light and heavy chain of FVIIa, respectively; Configuration B, the XTEN was fused to the CT of the heavy chain while the targeting moiety was fused to the CT of the XTEN; and Configuration C, XTEN was fused to the CT of both heavy and light chain, with the targeting moiety at the CT of the heavy-chain XTEN. For each configuration, multiple XTEN lengths were tested ranging from 72 to 288 amino acids. Methods and Methods: The activities of the rFVIIa variants were measured by sTF-PT and ROTEM assays. The affinities of rFVIIa variants for aIIbb3 were measured by bio-layer interferometry. Results: Based on a platelet-independent activity assay (sTF-PT), the specific activities of these variants in all configurations were lower than that of rFVIIa. Configuration A variants displayed the highest specific activity, as high as 44% of that of rFVIIa, while placement of the XTEN at the CT of the heavy chain (Configuration B) had a higher impact on sTF-PT activity. Configuration C variants displayed the lowest activities. When tested in a platelet-dependent activity assay in whole blood by ROTEM, all configurations displayed activities greater than that of rFVIIa. Configuration A variants showed the greatest activity by this method, reaching 15-fold higher activity than rFVIIa. In general, the length of the XTEN element was inversely correlated with activity. To assess the impact of the XTEN moiety on aIIbb3 binding, its interaction with representative variants from each configuration was measured by bio-layer interferometry. These assays revealed that the affinities of the platelet-targeted FVIIaXTEN variants for aIIbb3 were inversely correlated to XTEN length. Conclusions: By combining platelet-targeting and XTEN technologies we have generated rFVIIa variants that are more potent than rFVIIa in whole-blood coagulation assays. While XTEN can improve the pharmacokinetic properties of rFVIIa, its placement and length must be optimized to maximize the impact of platelet-targeting technology.

Final data from the EPIC Study: A clinical trial to assess whether early low dose prophylaxis in the absence of immunological danger signals reduces inhibitor incidence in previously untreated patients (PUPs) with hemophilia A

G U E N T E R A U E R S W A L D , 1 K A R I N K U R N I K , 2 J A N B L A T N Y 3 and ARMIN J REININGER4 Prof. Hess Kinderklinik, Bremen, Germany; 2Dr.von Haunersches Children Hospital, Ludwig-Maximilians-University, Munich, Germany; 3University Hospital Brno, Brno, Czech Republic; and 4Baxter Innovations GmbH, Vienna, Austria


Introduction and Objectives: The EPIC study aimed to assess if a once-weekly, lowdose prophylactic regimen started before the onset of severe bleeding along with minimizing immunological danger signals could reduce inhibitor incidence in PUPs with severe and moderately severe hemophilia A (HA) to 15% or less. Materials and Methods: This was a Phase 3b, prospective, single arm, historicallycontrolled, multicentre study to assess inhibitor formation in PUPs during the first 50 exposure days (EDs) of a once-weekly, low-dose (25 IU/kg) prophylactic regimen with ADVATE. During the first 20 EDs, infusions had to be avoided within 3 to 4 days of vaccinations and in cases of fever. Main enrolment criteria were: age 0.001) and also correlated with ETP (r2 = 0.54, p = 0.04). Conclusions: The majority of patients with hemophilia A and high titer inhibitors have improved TG with combined use of fVIII and rfVIIa over rfVIIa alone. Residual fVIII activity at 15 minutes was a predictor of both peak thrombin generation and ETP. An inhibitor titer above 42 BU/ml was associated with no response.

Haemophilia (2014), 20 (Suppl. 3), 1--186

Inhibitors (N/100 yrs) (95% CI)

0.11 (0.04-0.25) 0.05 (0.00-0.29) 0.18 (0.07-0.39) 0.00 (0.00-3.11) 2.11 (0.58-5.32) 0.16 (0.03-0.47)

Inhibitor development according to concentrate in severe hemophilia A: 4-year results from the EUHASS registry

KATHELIJN FISCHER,1 RIITTA LASSILA,2 FLORA PEYVANDI,3 GABRIELE CALLIZANI,4 JERZY WINDYGA,5 A L E X A N D E R G A T T , 6 T H I E R R Y L A M B E R T 7 and MICHAEL MAKRIS8 1 Van Creveldkliniek, University Medical Centre Utrecht, The Netherlands; 2 Department of Medicine, Division of Hematology, Coagulation Disorders, Helsinki University Central Hospital, Helsinki, Finland; 3Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fonazione IRCCS Ca’ Granda- Ospedale Maggiore Policlinico, Untiversit a degli Studi di Milano and Luigi Villa Foundation, Milan, Italy; 4 Centro Nazionale Sangue, Rome, Italy; 5Department of Disorders of Haemostasis and Internal MEdicine, Institute of Haematology and Transfusion Medicine, Warsaw, Poland; 6Haematology Department, Mater Dei Hospital Malta, Tal-Qroqq, Malta; 7 Hopital Bicetre, Paris, France; and 8Royal Hallamshire Hospital, Sheffield, United Kingdom Introduction and Objectives: There is currently controversy surrounding the rates of inhibitor formation by different FVIII concentrates. Plasma-derived concentrates have been associated with reduced inhibitor development, and second generation full-length recombinant FVIII with increased inhibitor development in PUPs with severe hemophilia A. B-domain deleted products have been associated with a higher rate of inhibitor formation in PTPs. The European Haemophilia Safety Surveillance (EUHASS) registry monitors adverse events according to concentrate. Materials and Methods: EUHASS startedcollecting data on the number of patients diagnosed and treated according to concentrate on 1 October, 2008 and data was reported annually, specifying PUPs who completed 50 exposure days (EDs). Inhibitors were defined as two positive inhibitor tests according to the local laboratory. Data submitted before 31 December, 2012 was analyzed for only those centres which checked and confirmed their submitted data. Results: For PUPs, data from 56 centres, for PTPs 67 centres were analyzed. Inhibitors developed within the first 50 EDs in 108/417 (26%; CI 22-30%) PUPs. Inhibitors occurred at a median age of 1.3 years after a median of 13 EDs. Inhibitor rate in PTPs was 26/ 15838 treatment years (0.16/100 treatment years;CI 0.11-0.24). Inhibitors developed at a median age of 25 years and after 295 EDs. Comparison of inhibitor development according to concentrate in PUPs and PTPs showed no statistically significant differences between the group of plasma-derived concentrates and the different recombinant FVIII concentrates (Table). The only exception was an increased inhibitor development in a very limited number of PTPs treated with Refacto, but not with Refacto AF. Conclusions: The data from the EUHASS registry do not confirm the previously suggested differences in inhibitor development by different FVIII concentrates in patients with severe hemophilia A.

The mystery of non-pathogenic antibodies against human recombinant proteins in healthy individuals FRANK HORLING, CHRISTOPH J HOFBAUER, € L, P E T E R A L L A C H E R , B R I G I T T A B B UH F R I E D R I C H S C H E I F L I N G E R and B I R G I T M R E I P E R T Baxter BioScience, Vienna, Austria Introduction and Objectives: The origin and biological significance of non-pathogenic antibodies against self-proteins, as seen in some healthy individuals, is still a matter of debate. Cohen (J Autoimmun, 2007) suggested that auto-antibodies present in healthy individuals are biomarkers of the immunological homunculus, the body’s system to sense the current immunogenic state and to ensure immunity homeostasis. Recently, we demonstrated that some healthy individuals express low-titer antibodies which bind to human recombinant factor VIII (FVIII). Here, we extend this study and ask if healthy individuals express antibodies that bind to a variety of human recombinant proteins, including FVIII, FIX, VWF and Furin. Methods: ELISA assays for the detection of specific antibodies were established in compliance with regulatory guidelines. Plasma samples obtained from healthy individuals were screened for the presence of antibodies followed by the determination of antibody titers and the confirmation of antibody specificities. Cohorts of 480-600 healthy individuals were included for each protein. All recombinant human proteins were obtained from Baxter BioScience. Results: Our data reveal the presence of antibodies against human recombinant proteins in a number of healthy individuals, with a prevalence ranging from 1.25% to

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

INHIBITORS, PATHOGENESIS, PREVENTION AND TREATMENT 19%. Most antibodies had titers below 1:80 (1:20, 1:40), but some samples contained antibodies with titers up to 1:640. Importantly, the presence of antibodies against one protein did not predict the presence of antibodies against another protein in the same sample. Longitudinal studies indicated that antibodies against human proteins in healthy individuals could persist for the whole observation period (1-3 years). Discussion and Conclusions: Our results provide evidence for the presence of nonpathogenic antibodies against a range of human recombinant proteins in healthy individuals which resemble non-pathogenic self-reactive autoantibodies. The physiological relevance of these antibodies and the regulatory pathways which give rise to their generation are not clear. A better understanding of the nature of these antibodies might help to more easily differentiate between pathogenic and nonpathogenic antibodies, which develop in some patients following treatment with biotherapeutics.

Surgery and invasive procedure with bypassing agents in hemophilic patients with inhibitors: a single centre experience

Y O U N G S H I L P A R K 1 and H W I - J O O N G Y O O N 2 Departments of 1Pediatrics and 2Hematology-Oncology, Kyung Hee University Hospital, School of Medicine, Kyung Hee University, Seoul, Korea

Introduction and Objectives: For hemophiliacs with inhibitors, recent advances in the use of bypassing agents such as recombinant activated FVII (rFVIIa, NovoSevenâ) and activated prothrombin complex (APCC, FEIBAâ) have enabled the aggressibe management of their disease during emergency or elective surgery. This report shows an evaluation of the safety and effectiveness of bypassing agents in the treatment of peri-operative bleeding in this patient population at a single centre. Materials and Methods: We reviewed the cases of patients with hemophilia and inhibitors at a single center who underwent surgery or other invasive procedures between May, 2008 and July, 2013 and who were administered a bypassing agent. Results: Thirty procedures (21 orthopedic surgeries and 9 other surgeries and procedures) were conducted in 15 hemophilia patients with inhibitors. The median age of the patients was 30.5 years old (range 7-52). Most patients (13/15) had hemophilia A and 2 patients had hemophilia B. The median titer of inhibitors at procedures was 15 BU (range, 0.7-1900). All patients had high responding inhibitors and one of two bypassing agents was used. In all, 21 cases were covered using APCC, and nine with rFVIIa initially. The median duration of hospitalization was 14 days (range, 1-58). In most cases, bleeding stopped or was well controlled. But, in 5 cases, patients’ bleeding was controlled by sequential bypassing therapy. Four cases were performed in emergency conditions, and those were the segmental resection of small bowel, craniectomy with intracerebral hematoma removal, exploratory thoracotomy, and angiography with embolization. Efficacy of bypassing agents during various surgeries and procedures, based on final patient outcome, was 93.3% (28/30). Two deaths (6.7%) occurred during emergency procedures as a result of hypovolemic shock secondary to intracranial haemorrhage, or retroperitoneal bleeding. Conclusions: Good control of hemostasis can be achieved with bypassing agents in hemophilia patients with inhibitors undergoing invasive procedures. For surgery or procedures performed in an emergency setting, more active and aggressive management is needed. The use of bypassing agents in the peri-operative period allows for invasive procedures and surgery to be safe and successful in hemophilic patients with inhibitors.

State of immune suppression in hemophilia A with developed Factor VIII inhibitors ZHENPING CHEN, QIQI WEI, YUANYUAN LI, GANG LI, L I N G T A N G and R U N H U I W U Beijing Children’s Hospital, Capital Medical University, Beijing, China Introduction and Objectives: Hemophilia A is genetic disease, with inherited deficiencies of coagulation factor VIII. Up to now, the main treatment for hemophilia has been coagulation factor VIII replacement therapy. However, there are more and more patients with hemophilia A developed factors VIII inhibitors with the increase of coagulation factors VIII preparation use. This is the most serious complication in replacement therapy for hemophilia A. The objective of this study is to assess the roles of immune-related cytokines Th1, Th2, Tc1, Tc2, Treg and Th17 in the development of factor VIII inhibitors in hemophilia A. Materials and Methods: A total of 51 boys with moderate and severe hemophilia A and 57 age- and gender-matched normal boys were recruited in this study between July, 2013 and October, 2013 in the hemophilia centre of Beijing Children’s Hospital. Factor VIII inhibitor was detected by modified Nijmegen method. The expressed levels of intracellular cytokine, including CD3, CD4, CD8, CD25, IFN-gamma, IL-4, Th17A, Foxp3 + , were tested by flow cytometry. The cell was considered a Th1 cell if CD3 + CD4 + CD8-IFN+, a Th2 cell if CD3 + CD4 + CD8-IL4 + , a Treg if CD3 + CD4 + CD25 + Foxp3 + , a Th17 cell if CD3 + CD4 + IL17A+, a Tc1 if CD3 + CD8 + IFN+, a Tc2 cell if CD3 + CD8 + IL4 + . All of the data were analysed using the Mann-Whitney statistical test. The difference would be considered statistically significant at p < 0.05. Results: There were 11 cases of FVIII inhibitor positive results in the 51 patients with hemophilia A. Surprisingly, the group of inhibitor-positive subjects showed lower levels of Th1 (P = 0.0382) and Tc1 (P = 0.0114) than inhibitor-negative subjects in the group of 51 patients with hemophilia A (P = 0.4162). The inhibitor-positive group showed lower levels of Th1 (P = 0.0344), Treg (P = 0.0310) and Tc1 (P = 0.0096) than the group of normal boys. Moreover, the group of inhibitor-positive haemophiliacs showed a higher ratio of Treg/Th17 (P = 0.0448) and lower ratio of Th1/Th2 (P = 0.0128) than group of normal boys. Conclusion: Our current study first demonstrates a state of immune suppression in patients with hemophilia who are positive for FVIII inhibitor. The types of mutations in the FVIII gene and replacement treatment measures may bear main responsibility for the development of FVIII inhibitor in hemophilia A.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


A Phase III clinical trial of a mixture of plasma-derived factor VIIa and factor X (MC710) in hemophilia patients with inhibitors: hemostatic efficacy and safety

YUICHI SHINKODA,1 KOJI SAMESHIMA,1 KATSUYUKI FUKUTAKE,2 JUNKI TAKAMATSU,3 M I D O R I S H I M A , 4 A K I R A S H I R A H A T A 5 and H I D E H I K O S A I T O 6 1 Kagoshima City Hospital, Kagoshima, Japan; 2Tokyo Medical University, Tokyo, Japan; 3Japanese Red Cross Tokai-Hokuriku Block Blood Center, Seto, Aichi, Japan; 4 Nara Medical University, Kashihara, Nara, Japan; 5Kitakyushu Yahata-Higashi Hospital, Kitakyushu, Fukuoka, Japan; and 6National Hospital Organization Nagoya Medical Center, Nagoya, Japan Introduction and Objectives: MC710, a 1:10 protein-weight-ratio mixture of plasmaderived activated factor VII (FVIIa) and factor X (FX) is a novel bypassing agent for hemostasis in hemophilia patients with inhibitors. MC710 administers FVIIa and its substrate FX concomitantly for greater potency than FVIIa alone, and is long-acting due to the long half-life of FX. We have already clarified dose-dependency of the pharmacokinetic/ pharmacodynamic parameters of MC710, and demonstrated hemostatic efficacy in a small number of joint bleedings in hemophilia patients with inhibitors. Moreover, we confirmed the safety of MC710 up to 120 lg/kg per dose (as FVIIa dose). We evaluated the hemostatic efficacy and safety of one to two administrations of MC710 in joint, muscle, and subcutaneous bleeding episodes of Japanese male hemophilia patients with inhibitors. Materials and Methods: This trial was a multicentre, open-label, non-randomized clinical study. All subjects provided written informed consent. Subjects were administered between one and two doses of 60 or 120 lg/kg MC710 (to a maximum of 180 lg/kg), intravenously, over up to five bleeding episodes per subject. Hemostatic efficacy of MC710 was determined for each episode by investigator evaluation using changes in visual analogue scale (VAS) for pain relief, and/or knee joint or muscle circumference for swelling reduction, and range of motion (ROM) for improvement of joint mobility. Results: In 21 treatments for bleeding episodes, 19 were rated “excellent” or “effective” according to the investigator rating system 8 h after the last treatment. The VAS significantly decreased over time and the ROM significantly improved over time compared with the value before treatment. One mild adverse reaction and two serious adverse events were observed within one week after first administration with no significantly effect on safety. In the subject administered twice with MC710, although D-dimer increased approximately two-fold 24 h after first administration compared to pre-treatment, platelet count and fibrinogen levels did not change. Subjects did not develop new viral antigens or produce new antibodies following MC710 administration. Conclusion: MC710 has sufficient hemostatic efficacy and safety, and can be used as a potential bypassing agent to control bleeding in hemophilia patients with inhibitors.

The association of factor VIII genotypes and HLA DRB1*15, tumor necrosis factor -308A and interleukin -10-1082G alleles on inhibitor development in Thai patients with hemophilia A

AMPAIWAN CHUANSUMRIT,1 WERASAK SASANAKUL,1 NONGNUCH SIRACHAINAN,1 PRAGUYWAN KADEGASEM,1 P A K A W A N W O N G W E R A W A T T A N A K O O N 2 and OYTIP NATHALANG3 Departments of 1Pediatrics and 2 Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; and 3Department of Medical Technology, Faculty of Allied Health Sciences, Thammasat University, Pathumtani, Thailand Introduction: Factor VIII gene defect has a major influence on inhibitor formation. The human leukocyte antigen (HLA) class II molecules play an essential role presenting FVIII peptides to CD4-positive T-helper cells. In addition, different polymorphisms in tumor necrosis factor-a (TNF-a) and interleukin -10 (IL-10) were found to contribute to inhibitor formation. Objective: To study the association of factor VIII genotypes and HLA-DRB1*15, TNF-a -308A and IL-10-1082G alleles on inhibitor development in Thai patients with hemophilia A. Materials and Methods: 57 patients with hemophilia A (severe=42, moderate=15) and 50 normal controls were enrolled in the study. The patients’ mean age was 14.4  8.9 years. Factor VIII gene defects were identified in patients with hemophilia A and the distribution of HLA- DRB1*15, TNF-a -308A and IL-10-1082G alleles were determined. The association of the factor VIII genotypes and these alleles between patients with and without inhibitor was investigated. Results: The patients were divided into 2 groups: 26 patients without inhibitors and 31 patients with a high inhibitor ≥5 Bethesda units (BU) (n = 22) and low inhibitors (n = 9). The factor VIII gene defect was identified in 41 patients involving intron 22 inversion (n = 28), large gene deletion (n = 3), point mutation-inducing stop codon (n = 7), amino acid alteration (n = 2) and frameshift mutation (n = 1). Twenty-four out of 38 patients (63.2%) with severe gene defects of inversion, deletion and nonsense mutation exhibited inhibitor while none of the three patients with missense mutations had inhibitor. The frequencies of HLA-DRB1*15 in hemophilia patients with and without inhibitor (25.4%), and patients with inhibitor (30.6%) were significantly higher than in normal controls (13.0%) (p = 0.025 and 0.008) whereas patients with inhibitor had a higher frequency than those without inhibitor (19.2%) but the difference was not statistically significant (p = 0.198). Likewise, the frequencies of TNF-a -308A alleles among patients with inhibitor (1.6%), without inhibitor (5.8%) and normal control (8.0%) were not statistically different. Similar findings were found in the frequencies of IL-10-1082G: patients with inhibitor (3.2%), without inhibitor (7.7%) and normal controls (2.0%). Conclusions: Factor VIII genotypes and HLA-DRB1*15 showed a contribution to inhibitor development among Thai hemophilia A patients while TNF-a -308A and IL10-1082G alleles were of less importance.

Haemophilia (2014), 20 (Suppl. 3), 1--186



The results of late immune tolerance induction in children with severe hemophilia A and inhibitor in Poland

A N N A K L U K O W S K A , 1 P A W E Ł Ł A G U N A 1 and BEATA WALESZKIEWICZ-MAJEWSKA2 1 Department of Pediatrics, Hematology and Oncology, Warsaw Medical University; and 2Department of Laboratory Diagnostics and Immunology, Clinical Hospital, Warsaw Introduction and Objectives: The development of factor VIII inhibitors (FVIII) is the most serious complication in patients with hemophilia today. First-line treatment for patients with hemophilia A and inhibitors is to attempt to induce immune tolerance (ITI) by regular infusion of FVIII. The results of ITI are better when the procedure is started no later than 2 years after inhibitor detection. Complete success was noted in 72% of our young boys with hemophilia and inhibitors. The results of late immune tolerance induction (ITI) were presented in this study. Materials and Methods: From 2008 to 2012, ITI were used in 5 children with severe hemophilia A and FVIII inhibitor in Poland. Four boys were high-responders and one a low-responder but without good response for factor VIII concentrates. Inhibitors were measured according to Bethesda method in Nijmegen modification. Results: The median age of patients was 9 years (ranged from 14 months to 10 years) at the time of inhibitor detection. Median of maximal titer of FVIII inhibitors found before the start of ITI was 20 BU/ml and ranged from 2.48 to 68 BU/ml. Immune tolerance induction was started in patients with median age of 13 years (ranged from 10 to 16 years). Titers of FVIII inhibitors ranged from 0.64 to 11.2 BU/ml (median 7.12 BU/ml) at the initiation of the ITI regimen. All patients were treated with plasma derived FVIII concentrates, of medium or high-purity. In 4 children ITI was started with single daily dose of ≥100 IU/kg, and in 1 boy FVIII concentrate in a dose of 100 IU/kg was administered twice a day. Total elimination of factor VIII inhibitor was achieved in 3 patients. In the other 2 patients, the ITI failed and the ITI regimen was discontinued after 14 months and 4 years. The duration of ITI ranged from 1 to 4 years (median 16 months). In patients with positive results, the median duration of ITI was also 16 months (ranging from 12 to 18 months). In one boy Rituximab was added to the ITI procedure with transient success and finally ITI was completed after 4 years. After achievement of complete ITI, FVIII concentrates were infused 3 times a week in doses of 25 – 40 IU/kg prophylactically. Conclusion: The delayed introduction of ITI may be successful in children with severe haemophilia A. Despite better results with the early introduction of ITI, there is a chance of the total elimination of inhibitor in older children with longer-lasting inhibitors.

Concomitant therapy of a hemophilia A patient with inhibitor by using low-dose by-pass agents TURKAN PATIROGLU, MEHMET AKIF OZDEMIR, B I L G E N I S IK , E K R E M U N A L and M U S A K A R A K U K C U Erciyes University Medical School, department of pediatric hematology, KayseriTurkey Aim: F VIII or F IX inhibitors may develop in patients with hemophilia A and B for several different reasons. We present here a 14 year-old boy with haemophilia A, who had 24 BU inhibitor of F VIII, and who was given only a total of 8000 u doses of F VIII product before circumcision. Case report: The patient was admitted to our hospital because of recurrent epistaxis when he was 3 years of age. His factor VIII level was < 1%. Due to the low social and cultural status of his family, he could not come for follow-up regularly. He was hospitalized with severe bleeding after a strabismus operation at 10 years of age and was treated with factor VIII products for a week. F VIII products had not been used even though he had a few epistaxis and hematuria. Later, he had been administered a dose of 500 u F VIII product for hemarthosis on a single occaision. F VIII inhibitor was negative during this period. He was hospitalized for circumcision at the pediatric surgery clinic when he was 14 years old. Before circumcision, he was injected a dose of 1000 u F VIII concentrate after taking a blood sample for inhibitor assay. Although he had no severe bleeding during the operation or for two days after the circumcision, severe bleeding started on the third day. Surprisingly, it was discovered that he had developed an F VIII inhibitor of 24 BU. First, he was given recombinant factor VIIa (rFVIIa) at standard doses of 90 mc/kg to promote hemostasis but effective hemostasis _ could not be obtained. Concomitant infusion of low doses of rFVIIa and FEIBA was started after four days and effective hemostasis resulted within one week. After circumcision, he was given a total dose of 5500 u of FVIII product, 63 mg of rFVIIa, _ and 18000 u of FEIBA, respectively, for hemostasis. The total cost of circumcision was 66000 USD. Conclusion: In developing countries, the coordination among patient, family, and doctors may lead to problem-free operations, including circumcision, and lead to reduced costs.

Natural course of inhibitors in Korean hemophilia A patients EUN JIN CHOI Daegu Catholic University Hospital, Gyeongsan, South Korea Objectives: Inhibitor development is a major challenge in the treatment of hemophilia. Immune tolerance induction therapy (ITI) has been known as the ultimate treatment for inhibitors. Although success rate of ITI reaches 70~80%, it costs a lot. Moreover, some inhibitors may disappear spontaneously. So it is important to elucidate the natural course of inhibitors in order to determine the subjects and timing of ITI. Methods: We reviewed medical records for 1579 hemophilia A patients registered at the Korea Hemophilia Foundation from 1991 to 2013. Cut-off value of inhibitors was set at 0.6 BU/mL. Patients who had developed inhibitors at least once were regarded as inhibitor-positive. When the titers remained less than 0.6 BU/mL for at least 2 years, the patient was classified as an inhibitor-negative patient. We surveyed peak inhibitor titer, exposure days, duration of inhibitor positivity and treatment modality during inhibitor positive period.

Haemophilia (2014), 20 (Suppl. 3), 1--186

Results: Two-hundred forty-nine (15%) out of 1579 patients were identified as inhibitor-positive patients. Sixty-five patients’ inhibitor had never disappeared and 16 patients among them underwent ITI. The remaining 49 patients still had inhibitors. One-hundred eighty-four (11% with hemophilia A, 73% with inhibitors) patients’ inhibitors were transient. As for transient inhibitors, median titer was 1.2 BU/mL and lasted for 10 months. Low, median, and high titer inhibitors lasted for 9.5 months, 8 months, and 16 months, respectively (p = 0.001). Thirty of 87 high-titer, 11 of 13 moderate-titer and 144 of 149 low-titer inhibitors spontaneously disappeared without ITI. Conclusions: As ITI is very costly, it is worthwhile to wait and observe the natural course of inhibitors for at least 10 months. However, high-titer inhibitor is unlikely to disappear without ITI.

PdFVIII/VWF concentrates show significantly lower titres in the Bethesda assay than recombinant FVIII products; a kinetic in vitro inhibition study MARIA ISABEL BRAVO, BIBIANA DAROCHA-SOUTO, S A L V A D O R G R A N C H A and J U A N I G N A C I O J O R Q U E R A Instituto Grifols, S.A., Parets del Valles, Barcelona, Spain; Maria Isabel Bravo, Bibiana DaRocha-Souto, Salvador Grancha & Juan Ignacio Jorquera Introduction and Objectives: Several papers describe that the presence of VWF in FVIII concentrates makes inhibitors less reactive against FVIII, thus preserving its hemostatic clinical effect. We investigated kinetically the reactivity of inhibitors against different FVIII concentrates along different incubation times in the Bethesda assay, including normal plasma as a control. Material and Methods: Normal plasma and therapeutic concentrates (pdFVIII/VWF, full-length rFVIII, BDD-FVIII and isolated pdFVIII -separated and purified from pdFVIII/VWF by gel filtration chromatography in presence of CaCl2-) were used as FVIII source. Inhibitor human IgG was purified from a pool of hemophilic plasmas with inhibitors (Technoclone) using protein G Sepharose chromatography (GE Healthcare). To determine the inhibitor titer, a modified Bethesda assay was performed as follows: serial dilutions of inhibitor IgG were mixed with an equal volume of 2 IU/ml pdVWF and the mixtures were incubated with an equal volume of 1 IU/ml of FVIII from the different sources described above. Residual FVIII activity was determined after incubation at 37°C for different times (0, 15, 30, 60 and 120 minutes) using the Coamatic FVIII kit (Chromogenix) and the one-stage clotting method. Results: The inhibitor titer for pdFVIII/VWF was comparable to the titer for normal plasma at all time points studied. In contrast, the inhibitor titer obtained with rFVIII or BDD-FVIII was always higher (1.2 to 1.8 times, respectively, from baseline (time= 0) to 2 hours of incubation) than that obtained with normal plasma. There were no discrepancies between the chromogenic and the one-stage clotting assay results at 2 hours. The inhibitor titer obtained with isolated pdFVIII was similar to that obtained with normal plasma from 0 to 30 minutes of incubation, however after 1 and 2 hours of incubation the isolated pdFVIII concentrate behaved similarly to rFVIII or BDD rFVIII. Conclusions: The inhibitor titer of a pool of hemophilic inhibitors varies among different FVIII concentrates. pdFVIII/VWF concentrates behaves similarly to normal plasma whereas isolated pdFVIII and recombinant FVIII show lower residual FVIII activity and higher Bethesda titers. Even at time 0, the inhibitor titer is higher (from 1.2 to 1.4 times) for recombinant FVIII products in comparison with plasma and the studied plasma-derived concentrates.

Modulation of the inhibitory effect of an anti-FVIII C2 domain antibody on thrombin generation by different FVIII concentrates associated with the protective role of VWF B I B I A N A D A R O C H A - S O U T O , M A R IA I S A B E L B R A V O , S A L V A D O R G R A N C H A and J U A N I G N A C I O J O R Q U E R A Instituto Grifols, S.A., Parets del Valles, Barcelona, Spain

Introduction and Objectives: The thrombin generation assay (TGA) has been used since the 1950s to investigate hemostasis in patients with hemorrhagic diseases. Since development of anti-FVIII antibodies (inhibitors) severely affects congenital hemophilia A, the TGA has been also used to detect the ability of the inhibitors to inhibit thrombin generation, which is considered a critical point leading to coagulation. We studied the protective role of VWF in terms of thrombin generation mediated by different FVIII concentrates in the presence of an antibody against FVIII C2 domain. Material and Methods: FVIII deficient plasma (containing VWF) was spiked with FVIII concentrate (either pdFVIII/VWF, full-length rFVIII or BDD-FVIII) up to 1 IU FVIII/ml. On the other hand, FVIII deficient plasma was spiked with each FVIII concentrate already mentioned and mixed 1:1 with ESH-8 (anti-FVIII C2 domain antibody; American Diagnostica) to final concentrations of 1 IU FVIII/ml and 1 lg ESH-8/ml respectively. Additionally, 1:1 (IU) mixtures of purified pdVWF and rFVIII or BDD-FVIII were prepared in vitro to be assayed in the same manner. All samples were placed on 96-well plate and assayed by TGA. Fluorescence was read for 60 minutes. The TGA was performed at least three times for each experimental condition. Results: In the presence of pdFVIII/VWF concentrate the decreases of thrombin concentration and endogenous thrombin potential (ETP) mediated by ESH-8 were moderate (22% and 12% respectively). However, in the presence of rFVIII and BDDFVIII the decreases of thrombin concentration and ETP caused by ESH-8 were notably higher (50% and 36% for rFVIII; 40% and 26% for BDD-FVIII, respectively). Moreover, the pdFVIII/VWF product has robustly taken less time to reach the maximum peak thrombin generation (velocity). Interestingly, these differences on ESH-8 reactivity between pdFVIII/VWF and isolated rFVIII or BDDFVIII remained even when pdVWF+rFVIII and pdVWF+BDD-FVIII mixtures were prepared before measuring the thrombin generation. Conclusion: These data point to a pivotal role of VWF in the protection of FVIII activity versus antibodies directed at least against FVIII C2 domain showing that

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

INHIBITORS, PATHOGENESIS, PREVENTION AND TREATMENT pdFVIII/VWF products are more protected against inhibitory activity than recombinant products. In addition, our data suggests that VWF protection is higher in the presence of native pdFVIII/VWF complex than when FVIII and VWF are reassociated from the isolated moieties.

Selection and characterization of single-chain variable antibody fragments (scFvs) specific for anti-FVIII antibodies KERSTIN BRETTSCHNEIDER, ANJA NAUMANN, € G KAHLE, DIRK SCHWABE, S O N J A N E I M A N I S , J OR C H R I S T I N E H E L L E R , T H O M A S K L I N G E B I E L and € C H R I S T O P H K ON I G S University Hospital Frankfurt, Goethe University, Dept. of Paediatrics, Clinical and Molecular Haemostasis, Frankfurt am Main, Germany Introduction and Objectives: The development of inhibitory antibodies against coagulation factor VIII (FVIII) is currently the most serious complication for hemophilia A patients that undergo FVIII replacement therapy. In addition, nonhemophilia A patients can spontaneously develop inhibitory auto-antibodies to FVIII, which results in a condition called acquired hemophilia A. The control of the allo- or autoimmune response to FVIII apparently includes the elicitation of an anti-idiotypic immune response. In this study, the capacity of single-chain variable antibody fragments (scFvs) for the neutralization of inhibitory anti-FVIII antibodies (FVIII inhibitors) was evaluated. Materials and Methods: Phage display technology was applied to select scFvs for strongly inhibitory murine monoclonal anti-FVIII antibodies (mAbs) from synthetic libraries. As the majority of inhibitory mAbs are directed against the A2 or C2 domain of FVIII, A2- and C2-specific mAbs were used as targets. Selected scFvs were transformed in IgGs and purified scFv-IgGs were characterized in ELISA binding studies. The neutralization capacity of scFv-IgGs was additionally analyzed in the Bethesda Assay. Results: Phage display resulted in the selection of several potential anti-idiotypic scFvs. ScFv-IgGs bound specifically to mAbs and binding of mAbs to immobilized FVIII was inhibited by specific scFv-IgGs. FVIII-activity was restored, when corresponding antiidiotypic scFvs were added to plasma spiked with inhibitory mAbs. Conclusion: In conclusion, anti-idiotypic scFvs specific for anti-FVIII antibodies can be successfully selected from phage displayed libraries and efficiently neutralize FVIII inhibitors. The benefits of scFv anti-idiotypes for the development of specific immunotherapies for haemophilia A patients with inhibitors are currently under investigation.

Post authorization safety surveillance study (PASS) of hemophilia A patients switching from moroctocog alfa or other factor VIII products to moroctocog alfa albumin-free cell culture (AF-CC) in usual care settings

RAFAEL PARRA LOPEZ,1 LASZLO NEMES,2 VICTOR JIMENEZYUSTE,3 LUMINITA RUSEN,4 ANA R. CID,5 ROBERT J. CHARNIGO,6 JAMES A. BAUMANN,6 LYNNE SMITH,6 JOAN M . K O R T H - B R A D L E Y 6 and P A B L O R E N D O 6 1 University Hospital Valle d’Hebr on, Barcelona, Spain; 2National Haemophilia Center and Haemostasis Department, State Health Center, Budapest, Hungary; 3La Paz University Hospital, Madrid Spain; 4National Institute for Transfusional Hematology, Bucharest, Romania; 5Thrombosis and Haemostasis Unit, University Hospital La Fe, Valencia, Spain; and 6Pfizer Inc, Collegeville, PA Objectives: To fulfill a European Medicines Agency requirement, this PASS assessed clinically significant inhibitor development in patients (pts) with severe hemophilia A transitioning from moroctocog alfa or other factor VIII (FVIII) replacement product to reformulated moroctocog alfa (AF-CC). Methods: This nonrandomized, prospective, interventional, open-label study enrolled males ≥12y with severe hemophilia A (FVIII:C < 0.01 IU/mL), >150 exposure days to recombinant or plasma-derived FVIII products, and no detectable inhibitor at screening. Pts were assigned to cohorts based on if they were transitioning to moroctocog alfa (AF-CC) from moroctocog alfa (cohort 1) or from another recombinant or plasma-derived FVIII product (cohort 2). The primary safety end point was the proportion of pts with clinically significant FVIII inhibitor development. Secondary efficacy and safety end points included annualized bleeding rate (ABR), less-than-expected therapeutic effect (LETE), and adverse events (AEs). Results: Overall, 208 pts were enrolled (cohort 1, n = 146; cohort 2, n = 62). The mean age was 30.5y (range 12-64), with 80% of pts aged >18y. The mean number of exposure days was 94 (range 1-139). No clinically significant FVIII inhibitors were reported. Although 6 local positive FVIII inhibitors were reported in 4 pts, none were confirmed centrally, no inhibitor-related clinical manifestations were reported, and anti-FVIII antibody assays were negative. Median ABRs were 23.4 and 3.4 following on–demand (n = 52) and prophylaxis (n = 154) regimens at baseline, respectively. LETE was 0.06% during on-demand treatment and 0.19% in the prophylaxis setting. Overall, 147 (71%) pts reported ≥1 treatment-emergent AE, most commonly (>5%) nasopharyngitis (15%), arthralgia (13%), hemarthrosis (12%), headache (11%), limb injury (7%), and influenza (6%); 20 (9.6%) patients reported ≥1 serious AE, most commonly (>1%) FVIII inhibition (2%). Conclusions: Historically, there has been reluctance to change the type of factor replacement product that pts with hemophilia are using because of a perceived increase in risk of inhibitor development. During this PASS, in previously treated males aged ≥12y with severe hemophilia A transitioning from moroctocog alfa or other FVIII replacement products to moroctocog alfa (AF-CC), no clinically significant FVIII inhibitor development was noted. Efficacy and safety results were similar to previous studies.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


Immune monitoring of FVIII inhibitor development in the Hemophilia Inhibitor PUP Study (HIPS)

CHRISTOPH HOFBAUER,1 CHRISTOPH MALE,2 DEBORAH BROWN,3 ELENA SANTAGOSTINO,4 J O H A N N E S O L D E N B U R G , 5 F R I E D R I C H S C H E I F L I N G E R 1 and BIRGIT REIPERT1 1 Baxter BioScience, Vienna, Austria; 2Medical University, Vienna, Austria; 3University of Texas, Houston, USA; 4University of Milan, Italy; and 5University of Bonn, Germany Introduction and Objectives: The development of neutralizing antibodies (FVIII inhibitors) is the major complication in the treatment of patients with hemophilia A. There is a demand for biomarkers that allow early recognition of FVIII inhibitor development in previously untreated patients (PUPs) during first exposure days to FVIII. Our aim was to establish suitable technologies, which facilitate the search for early biomarkers of FVIII inhibitor development in PUPs. Materials and Methods: Specific assays were established to comprehensively characterize antibodies against FVIII in small sample volumes, including the analysis of neutralizing antibodies, the differentiation of Ig isotypes and IgG subclasses and the assessment of apparent affinities of FVIII-specific antibodies. Furthermore, FVIIIspecific CD4 + T cell signatures were analyzed after in vitro restimulation of peripheral blood cells. Results: We will present a set of proof-of-principle data that includes the prevalence and in-depth characterization of FVIII-specific antibodies (Ig isotypes, IgG subclasses and apparent affinities) found in healthy individuals and in different cohorts of severe hemophilia A patients (with and without FVIII inhibitors). High affinity FVIII-specific IgG1 and IgG4 were the predominant antibodies found in inhibitor patients, whereas low affinity FVIII-specific IgG1 and IgG3 were observed in selected healthy donors and in non-inhibitor patients. Interestingly, no FVIII-specific IgG4 was detected in healthy individuals from different geographical areas or in patients without FVIII inhibitors. In addition, our data indicate an up to 100-fold higher apparent affinity of FVIII-specific antibodies found in patients with FVIII inhibitors when compared to non-inhibitor patients and healthy individuals. The highest affinity was detected for FVIII-specific IgG4 expressed by patients with FVIII inhibitors. Furthermore, CD4 + T-cell signatures indicate a FVIII-specific up-regulation of pro-inflammatory genes in patients with FVIII inhibitors. Conclusion: We developed and validated a set of technologies that will facilitate the identification of early biomarkers associated with FVIII inhibitor development in patients with hemophilia A. Their application in the ongoing Hemophilia Inhibitor PUP Study (HIPS) has the potential to uncover new mechanisms of FVIII inhibitor development during early exposure days to FVIII.

F8 genotype specific inhibitor risks in Argentine patients with severe HA and particular risk estimation of different mutation types

LILIANA ROSSETTI,1 CLAUDIA RADIC,1 MIGUEL ABELLEYRO,1 VANINA MARCHIONE,1  SZURKALO,1 LAURA PRIMIANI,2 DANIELA NEME,2 IRUPE M I G U E L C A N D E L A , 2 , 3 M I G U E L D E T E Z A N O S P I N T O 2 , 3 and CARLOSDE BRASI1 1 Genetica Molecular de la Hemofilia, IMEX, CONICET-ANM, Buenos Aires, Argentina.; 2Fundaci on de la Hemofilia, Buenos Aires, Argentina; and 3IIHEMA, ANM, Buenos Aires, Argentina

Introduction and Objectives: About 20% of severe cases with HA from Argentina developed FVIII neutralizing antibodies (inhibitors, INH). Several studies have shown that the causative mutation is the most decisive risk factor for inhibitor formation. Our objective was to estimate locally specific risks for developing inhibitors associated with each F8 genotype in Argentine patients with severe HA (sHA). Materials and Methods: To estimate the risks for developing FVIII INH associated with each F8 mutation type/location, we considered an Argentine unbiased group of sHA patients (n = 107) showing an inhibitor prevalence (IP) of 17.6%. The comprehensive population of Argentine patients with sHA (n = 227, 84 cases and 143 controls) was considered to estimate relative inhibitor risks (OR) associated with each mutation type/F8-location. We characterized the causative mutation by application of a laboratory algorithm including inverse shifting-PCR for F8 inversions, 37 PCRamplifications for gross deletion detection, and for small-mutation screening by CSGE, and DNA-sequencing. Results: The case/control study (84/143) permitted estimation of F8 genotype–specific inhibitor risks [OR; IP (CI)] in sHA patients classifying a high-risk group including multi-exon deletions [3.66; 55% (19–100)], Inv22 [1.8; 24% (19–100)] and nonsense in FVIII-LCh [1.2; 21% (7–59)]; an average risk group including single-exon deletions, indel frameshifts and nonsense-HCh; and a low-risk group represented by missense defects [0.14; 3% (0.6–11)]. In addition, this approach allowed the performance of multiple mutation associations of more than one molecular defect, e.g.: small mutations vs INV22/1 & deletions resulted in [0.42; 10% (6.2–15)] predicting more than two times less risk of INH developing for sHA patients without large rearrangements. This analysis may be used alongside the techniques forming the traditional algorithm used in most laboratories for sHA molecular diagnosis worldwide (1st INV22/1 analysis and 2nd large deletion detection), and as it normally requires less time than small mutation screening, a rapid estimation of patient-specific INH risks is possible. Conclusion: The Argentine series of sHA patients presents similar global and mutation-specific inhibitor risks compared to the HA database and published reports. This case-specific information may be valuable in designing individualized therapies and follow-up protocols.

Haemophilia (2014), 20 (Suppl. 3), 1--186



Safety of antihemophilic factor recombinant plasma/albumin-free method [rAHF-PFM] in hemophilia A patients with low titer inhibitors or a personal history of inhibitor: A meta-analysis of ADVATE PostAuthorization Safety Studies data 1



MAURA MARCUCCI, JI CHENG, VADIM ROMANOV, L E H A N A T H A B A N E 1 , 2 and A L F O N S O I O R I O 1 Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada; 2 Biostatistics Unit, St Joseph’s Healthcare-Hamilton, Hamilton, Canada; and 3Global Medical Affairs, Baxter Healthcare Corporation, Westlake Village, California, USA


Introduction and Objectives: There is no prospective evidence on inhibitor recurrence among hemophilia A patients with low titer inhibitors or a history of inhibitors, on whether or how therapeutic choices affect the risk of recurrence. The objective of the current analysis was to synthesize safety data on rAHF-PFM (ADVATE) in patients with moderate-severe hemophilia A enrolled in the ADVATE-PASS (PostAuthorization Safety Studies) international program with low titer inhibitors or inhibitor history. Materials and Methods: Random effects meta-analysis was used to pool outcome rates across individual patients enrolled in ADVATE-PASS. Eligible patients: patients entering the studies with low titer (≤ 5 BU) inhibitors or a positive history. Patients on immune tolerance induction (ITI) at study entry were excluded. Primary outcome: any of: 1) new or recurrent inhibitor titer > 5 BU; 2) relevant treatment changes (including ITI commencement). Secondary outcome: any increase of inhibitor titer or any new inhibitor not reaching 5 BU. Results: Overall, 125 patients were included, from Europe-, United States-, Australia-, Japan-, Taiwan-, and Italy-PASS. In total, 122 (98%) patients had been previously treated for more than 50 exposure days. The table summarizes the results for the primary outcome. When any increase of inhibitor titer or the development of any new inhibitor was counted, overall 8.4% (95% CI 2.7%, 14.0%) of patients experienced that outcome. Conclusion: This is the first study reporting safety data on the routine use of a FVIII concentrate in patients with hemophilia and a low titer inhibitor or inhibitor history. This data demonstrates that ADVATE could safely and effectively be used in this population of hemophilia A patients. Table. Study population and primary outcomes(* Including ITI). Patients


Titer increase > 5 BU Events [%] (95% C.I.)

Relevant treatment change* Events [%] (95% C.I.)

Baseline low titer inhibitors Positive inhibitor history Total


0 [0] (0, 33.6)

3 [33.4] (11.4, 55.5)


0 [0] (0, 3.1)

4 [3.1] (0.0, 7.1)

Early elimination of Factor VIII inhibitor by ITI with high dose immunoglobulin in children with hemophilia A

YOKO MIZOGUCHI,1 AYA FURUE,1 IKUE CHIJIMATSU,1 MIZUKA MIKI,1 KEITA TOMIOKA,1 NAKAO KONISHI,2 ATSUSHI ONO,3 HIROSHI KAWAGUCHI,1 K A Z U H I R O N A K A M U R A 1 and M A S A O K O B A Y A S H I 1 1 Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, Hiroshima, Japan; 2Department of Pediatrics, Chugoku Rousai Hospital, Kure, Japan; and 3Department of Pediatrics, Miyoshi Central Hospital, Miyoshi, Japan Introduction and Objectives: The production of factor VIII (FVIII) inhibitory antibodies, inhibitors, is a serious problem for patients with hemophilia A. Approximately 30% of hemophilia A patients generate inhibitors against therapeutically administered FVIII, typically during the first 20 exposure days (ED), as a result of interactions between multiplegenetic and environmental factors. Immune tolerance induction (ITI) is the only strategy proven to eradicate persistent inhibitors in severe hemophilia A patients and ITI success rate commonly ranges between 60% and 80%. However, a minority of hemophilia patients will have life-long inhibitors. To eliminate the inhibitors, we designed intravenous immunoglobulin (IVIG) therapy in combination with high-dose recombinant FVIII (rFVIII) for ITI in hemophilia A children with inhibitors. Materials and Methods: Four children with hemophilia A aged from five to 15 months developed inhibitors within 25 exposures to rFVIII. The peak titers of inhibitor in patients were ranged from 3 to 12 BU/ml. All patients received ITI in combination of high dose IVIG administration. The initial dosage of rFVIII was determined based on the titer of inhibitor to neutralize. Consecutively, patients received 5 days of IVIG infusion and daily high dose of rFVIII. Results: In all patients, the administration of rFVIII with immunoglobulin eliminated the inhibitor without any anamnestic response. The inhibitor had been confirmed to be negative within a month from ITI start in all patients. The recovery of FVIII activity 30 min after infusion of rFVIII was normalized within two months after initiation of ITI. However, the recovery of rFVIII 24 hours after infusion was not completely sufficient. An additional course of IVIG treatment led to increased recovery of FVIII 24 hours after infusion in all patients. Conclusions: IVIG treatment in combination with high dose rFVIII for ITI could be effective for the early elimination of inhibitory antibodies against FVIII without anamnestic response. Accumulation of cases and further analysis are necessary to assess the efficacy of modified ITI therapy.

The development of anti-factor VIII antibodies associated with the change of serum BAFF level in hemophilia A mice

SHIN-NAN CHENG,1,2 MING-SHEN DAI,2,3 C H I E W - P E N G H U A N G 2 and Y E U - C H I N C H E N 2 , 3 Department of Pediatric, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan; 2 Hemophilia Care & Research Center, Tri-Service General Hospital, Taipei, Taiwan; and 3Division Hematology/Oncology, Tri-Service General Hospital, Taipei, Taiwan;



0 [0] (0, 2.9)

7 [5.2] (0.3, 10.1)

Bleeding phenotype and clinical management of children with severe hemophilia A and inhibitors: A follow-up cohort study

MARIA ELISA MANCUSO,1 ELENA SANTAGOSTINO,1 M A R I J K E V A N D E N B E R G 2 and C A N A L / R O D I N S T U D Y G R O U P 1 Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy; and 2Utrecht University Hospital, Utrecht, the Netherlands Introduction and Objectives: Inhibitor (INH) development is the main complication of replacement therapy in children with severe hemophilia A (HA) rendering prophylaxis unfeasible and the management of bleeding episodes difficult. Several studies have focused on the evaluation of potential risk factors of INH development taking this event as the main endpoint, however, little knowledge is available on the clinical behaviour of this patient populations especially with respect to determinants of bleeding tendency. Moreover, the recent publication of the first randomized trial on immune tolerance induction (ITI) in hemophilic children with INH has raised numerous questions about the optimization of this treatment strategy. Materials and Methods: This study was designed as a satellite study of the CANAL/ RODIN cohort studies in the frame of the European Pediatric Network (PedNet) that included previously untreated patients with severe HA who had been followed until INH development or the achievement of 75 or 50 exposure days (EDs). The patient population of this study constits of all INH children for whom a 3-yr follow-up from INH development can be evaluated. Data collection includes 3 main periods: pre-ITI, during ITI and after ITI. Data on bleeding frequency, treatment of bleeding episodes and any other treatment strategy, type and site of bleeding will be evaluated for each period. Details on ITI (regimen, dose, product) will be collected as well. Results: Demographic data are already available from 267 children, including 180 with high-responding inhibitors. The median age at INH development was 1.3 yrs (IQR: 0.9-1.7) and the median number of EDs at INH development was 14 (IQR. 919). The median INH titer at diagnosis was 2.5 BU/ml (IQR: 1-13.5) and the median historical peak 16 BU/ml (IQR: 3-70). In 86 children who started ITI during the 3-yr follow-up, the median time elapsed between INH development and ITI start was 4 months (IQR: 0.4-12), and in 49 children who completed ITI the median duration of treatment was 11 months (IQR: 5-24). Collection of data on bleeding phenotype and treatment of bleeding episodes during the follow-up is ongoing. Conclusions: The results from this large cohort study could improve the knowledge on bleeding tendency in children with severe HA and INH and will also provide valuable information on ITI performance in clinical practice which is often different from the procedures of a clinical trial.

Haemophilia (2014), 20 (Suppl. 3), 1--186

Objectives: Hemophilia A is an X-linked bleeding disorder, caused by defects in the factor VIII (FVIII) gene. FVIII antibodies provide a major challenge for replacement therapy. B cell-activating factor (BAFF) is involved in the survival and maturation of B cells and plays a critical role in most immune responses. The purpose of this study was to investigate the relationship between the emergence of anti-FVIII antibodies and BAFF level in an animal model. Methods: Hemophilia mice (C57BL/6 and 129 mix background, Exon 16 knockout) were intraperitoneally injected with 2 IU (~80 IU Kg1) of human recombinant FVIII (rFVIII) (Baxter) diluted in PBS, with/without anti-CD20 antibody treatment for 4 consecutive weeks. The mice serum and plasma were sampled before injection and after 4 consecutive weekly injections. Total anti-FVIII antibody titres and serum BAFF concentration were detected by ELISA. The difference between the groups was evaluated by one-way ANOVA using PRISM 5. Results: Four consecutive weekly intraperitoneal injection of 2 IU rFVIII successfully induced high titer of anti-FVIII antibodies (168-318 lg/mL, each group n = 3 for 3 experiments). For the group with intraperitoneal injection of 2 IU rFVIII combined with anti-CD20 antibody for 4 consecutive weeks, no apparent anti-FVIII antibodies (0.2-2.4 lg/mL) were detected but the BAFF level in the anti-CD20 antibody-treated group increased later. The BAFF level increased before high-titer anti-FVIII antibody formation in the rFVIII treated group. Conclusions: In the rFVIII treated group, high-titer anti-FVIII antibodies developed after brief BAFF surged. In the anti-CD20 antibody-treated group (B cells depleted), very low level of anti-FVIII antibodies were detected with an increase of BAFF level later on as a compensatory immune response (>23000 pg/ml). Our preliminary experiment indicated that BAFF may be responsible for the anti-FVIII inhibitor formation and therefore a BAFF targeting strategy might prevent or reduce its occurrence.

Characteristics of inhibitors in patients with hemophilia at the National Institute of Hematology and Blood Transfusion, Hanoi, Vietnam NGUYEN THI MAI, PROF.THI NU NGUYEN, PROF. NGUYEN A N H T R I and B A C H Q U O C K H A N H National Institute of Hematology and Blood Transfusion, Hanoi, Vietnam Introduction and Objectives: The Hemophilia Centre of the National Institute of Hematology and Blood Transfusion is the largest centre in Vietnam. A study on 1000 patients with hemophilia was examined to determine prevalence and severity of inhibitor development. Materials and Methods: All patients were screened for inhibitors, using the mix test. These were carried out at diagnosis, regularly every 3 months, when there were clinical signs of poor response to treatment, or before surgery. As the mix test depends on time and temperature, patients were quantified using the Bethesda method.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

INHIBITORS, PATHOGENESIS, PREVENTION AND TREATMENT Results: The results showed that there were 56 patients with inhibitors with a prevalence of 5.6%, in which all patients were hemophilia A. There were no patients with hemophilia B. The majority of patients with inhibitors were severe (50, 89.28%), 3 patients were mild (5.36%) and 3 patients were moderate (5.36%). There were 5 patients with inhibitors that were related to surgery, including 2 patients with moderate disease. Among severe patients, there were 10 people with intron 22 inversions with ratio (25.64%). Inhibitor titer ranged from 1-72 BU. There were 15 patients (26.29%) with low titer inhibitor and 41 patients (73.21%) with high titer inhibitors. The number of patients with transient inhibitors was 15 while the remaining (41) patients had persistent inhibitors. Conclusions: In the absence of bypass agents, the control of bleeding for these patients can be difficult. Two patients died due to bleeding.

Elective orthopedic surgery in patients with hemophilia and inhibitors: Still a big challenge for haematologists?

MARIA ELISA MANCUSO,1 GIANLUIGI PASTA,2 MARIA ROSARIA FASULO,1 FLORA PEYVANDI,1 LUIGI P I E R O S O L I M E N O 2 and E L E N A S A N T A G O S T I N O 1 1 Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy; and 2Department of Orthopedics and Traumatology, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy Introduction and Objectives: Despite good efficacy rates of bypassing therapy (BPT) to treat moderate bleeds, the management of patients with hemophilia and inhibitors (INH) in the surgical setting is considered a challenge. No laboratory monitoring is available; the hemostatic response is unpredictable and may vary in the same patient. This study was aimed at evaluating the clinical outcome in a series of INH patients who underwent major elective orthopaedic surgery at a single centre. Materials and Methods: Demographic, clinical, and therapeutic data were retrospectively collected from patient files. Results: From 1997 to 2013, 41 major orthopaedic procedures (19 arthroplasties, 10 arthroscopies, 12 miscellaneous) were performed in 22 hemophilia A INH patients (20 severe; 2 mild) aged 5-71 yrs (median: 33) with a median of 2 surgeries/patient (range: 1-4). Seven children (median age: 10 yrs, range: 5-13) underwent 14 surgeries and 3 underwent 2 concomitant procedures (ankle arthroscopy plus sinus tarsi endorthesis). Eighteen patients were high-responders (82%) and the median INH titer at surgery was 20 BU/ml (IQR: 3-75). Patients were hospitalized for a median of 8 days (range: 2-101). BPT and FVIII were used for 33 and 8 procedures in 17 and 6 patients (median INH titer: 42 and 2 BU/ml) respectively. Hemostatic therapy was given by boluses in 30 and by continuous infusion in 11 procedures (FVIII in 7; rFVIIa in 4). Overall, median product consumption was 139 IU/kg/day of FVIII, 0.74 mg/kg/day of rFVIIa and 179 IU/kg/day of aPCC. Tranexamic acid was associated with FVIII or rFVIIa in 19 procedures. Overall, 7 patients bled (32%); bleeding occurred after 11/33 procedures with BPT (33%) and 1/8 procedures with FVIII (12%). Bleeding was successfully managed by continuing the same drug at increased doses in 6 cases and by using rFVIIa and aPCC combined as a rescue treatment in the other 6 procedures. Bleeding was more frequent when surgery was performed without tourniquet (71 vs 14%, p < 0.001). Red blood cells were transfused after 22 procedures (56%) in 14 patients and the median drop in hemoglobin level was 4.1 g/dl (range: 2-7). No deaths nor thrombotic complications occurred. Conclusions: Major elective orthopedic surgery is feasible and should be considered in patients with INH who need it, however it can be complicated by bleeding and careful clinical monitoring is warranted in order to properly adjust hemostatic therapy.

Effect of first vaccinations on inhibitor development in patients with severe hemophilia A: first results of the PedNet Registry

M O J T A B A H A S H E M I , 1 K A T H E L I J N F I S C H E R 2 and MARIJKEVAN DEN BERG1 1 Julius Center, UMC Utrecht, Utrecht, The Netherlands; and 2Van Creveldkliniek, UMC Utrecht, Utrecht, The Netherlands Introduction and Objectives: Many risk factors for inhibitor development in previously untreated patients (PUPs) with severe hemophilia A have been identified. However, the effect of pediatric vaccinations in combination with exposure to FVIII on inhibitor development has never been determined. The objective of this study is to evaluate the association of vaccinations with inhibitor development in PUPs with severe hemophilia A. Materials and Methods: In total, 194 PUPs with severe hemophilia A (FVIII 80 ED of pdFVIII developed inhibitor, while a low-titer inhibitor occured after 21 ED of rFVIII in 1 patient, who switched for rFVIII after 4 initial exposures to pdFVIII. Eight of a total 9 inhibitor patients underwent immunotolerance induction (ITI) employing FVIII/vWF concentrate. Success was achieved in 3/3 low responders treated with a Dutch protocol and in 4/5 high responders treated with a high-dose Bonn protocol. One high responder achieved partial success and the ITI is still ongoing. Conclusions: Cumulative incidence of inhibitors in PUPs treated with pdFVIII in our two centres was 11.4% (high titer-inhibitors 6.8%), much lower than that reported by Gouw et al. (2013). The ITI with FVIII/vWF concentrates resulted in a high rate of ITI success.

Prospective ADVATE Immune Tolerance Induction Registry (PAIR) interim results: Success rates continue to support published literature

AMY SHAPIRO,1 KATE KHAIR,2 JERRY TEITEL,3 ILIANA LEONY-LASSO,4 KATHARINA STEINITZ,5 A L E S S A N D R O G R I N G E R I 5 and G E R A L D S P O T T S 4 1 Indiana Hemophilia and Thrombosis Center, Indianapolis, USA; 2Great Ormond Street Hospital for Children, London, United Kingdom; 3St. Michael’s Hospital, Toronto, Canada; 4Baxter Healthcare Corporation, Westlake Village, USA; and 5 Baxter Innovations GmbH, Vienna, Austria Introduction and Objectives: The PAIR Registry is an ongoing, global, noninterventional, post-authorization safety surveillance designed to collect information on ADVATE safety and effectiveness in ITI therapy. Materials and Methods: From July, 2007 to April, 2011, 44 hemophilia A patients with inhibitor were enrolled in 10 countries. The primary objective was to assess the incidence of adverse events (AEs) related to ADVATE during ITI therapy. Secondary objectives were to assess the incidence of central venous access device (CVAD)-related complications and the success rates of ITI therapy. The maximum observation period for ITI is 33 months plus a 12-month follow-up. Results: As of 14 June, 2013, 34 of 44 patients (77.3%) completed ITI therapy and 26 of those completed the 12-month follow-up. Six patients withdrew prior to completing ITI therapy. Dosing regimens were: ≥200 IU/kg/day (n = 4, 9.1%); 131199 IU/kg/day (n = 2, 4.5%); 90-130 IU/kg/day (n = 27, 61.4%) and 5ED) were screened within 6 weeks. In patients receiving FVIII concentrate with a high-risk F8 mutation, 14% (12/88) of treatment episodes were screened within 6 weeks. In patients with a standard-risk F8 mutation treated in the first year of the study with 1 year of follow-up, 47% (107/229) of episodes were screened within one year, with a median time to screening of 104 days (range 1–353). Three de-novo inhibitors were detected. Conclusions: Our data suggests that current timing of inhibitor screening is opportunistic and may underestimate the occurrence of FVIII antibodies in non-severe hemophilia A. We believe these patients require more focused timing of inhibitor screening to optimize inhibitor detection and future management. The relevance of this will need to be determined in a multicentre prospective clinical trial.

Devastating tongue bleeding due to self-bite after dental extraction in hemophilia patient with inhibitor BARBAROS KARAGUN, ILGEN SASMAZ, BULENT ANTMEN, Y U R D A N U R K I L I N C , S E R K A N G U L E C , V O L K A N C I F T C I and  N M U H A R R E M D O GA Cukurova University, Adana, Turkey Introduction and Objectives: Inhibitors are the most serious complication of hemophilia therapy. There is also an increased risk of bleeding complications after surgical procedures. In this study, we report life-threatening bleeding in the tongue, which then spread to the neck and caused respiratory distress and hypoxia in a hemophilia A patient with high responding inhibitors after dental extraction, and the management of this severe case. Materials and Methods: A 16-year-old male severe hemophilia A patient with high responding inhibitors presented with a constant toothache and sensitivity. After oral examination, a tooth extraction was planned due to non-restorable carrier’s destruction using by-passing agents. Results: Prior to dental extraction, aPCC (FEIBA) was given to the patient at a dose of 75 U/kg. No hemorrhage was seen after 6 hours of extraction and the patient was discharged after receiving a second aPCC dose of 75 U/kg. Home treatment was given. Ten hours after hospital discharge, the patient bit his tongue due to hypokinesia and anesthesia which resulted in bleeding of the tongue. A huge swelling developed on the tongue because of hematoma and then bleeding spread to the neck and caused respiratory distress. The patient was admitted to the pediatric intensive care unit. Over a short period of time, the patient’s bruised tongue protruded from the mouth, and progressive hematoma was noted over the entire tongue. Emergency tracheotomy was considered. In the meantime, aPCC treatment was started with 50 U/kg/dose every 6 hours. The huge neck and tongue hematomas began to regress along with an improvement in respiratory status. Conclusions: Surgical procedures in hemophilia patients with inhibitors can present a challenge because of the increased risk for bleeding complications and the potential difficulty in controlling bleeding during and after surgery. Thus, even a simple dental extraction operation can be life-threatening situation despite appropriate by-pass agent therapy in hemophiliac patients with inhibitors, and an experienced dentist and hematologist.

Uptake and timing of inhibitor screening in non-severe hemophilia A: results of a pan-London evaluation

PAUL BATTY,1 SAVITA RANGARAJAN,2 STEVE AUSTIN,3 € PEL,1 K A T E K H A I R , 4 C A R O L Y N M I L L A R , 5 J A N - P H I L L I P S T UM M U R U G A I Y A N T H A N I G A I K U M A R , 6 T H Y N N T H Y N N Y E E 7 and DAN HART1 1 The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, QMUL, London, UK; 2Centre for Haemostasis & Thrombosis, Guy’s & St Thomas’ NHS Foundation Trust, London, UK; 3St George’s Healthcare NHS Trust, London, UK; 4Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; 5Imperial College London, London, UK; 6 Lewisham Hospital Haemophilia Centre, University Hospital Lewisham, London, UK; and 7The Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free Hospital NHS Foundation Trust, London, UK Introduction and Objectives: The most important complication in the management of non-severe hemophilia A is the occurrence of inhibitory antibodies to factor VIII (FVIII). Given the predominance of on-demand treatment in this group, timing of inhibitor screening after FVIII exposure may be crucial in the detection of an immune response. Little data exists to support the optimal timing of inhibitor screening in

Haemophilia (2014), 20 (Suppl. 3), 1--186

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

INHIBITORS, PATHOGENESIS, PREVENTION AND TREATMENT Inhibitors increase the burden of disease in nonsevere haemophilia A patients - treatment strategies to obtain hemostasis

ALICE S.VAN VELZEN,1 CORIEN L. ECKHARDT,1 NINA STREEFKERK,1 MARJOLEIN PETERS,1 JAN ASTERMARK,2 PAUL P. BRONS,3 GIANCARLO CASTAMAN,4 MARJON H. CNOSSEN,5 NATASJA DORS,6 CARMEN ESCURIOLA-ETTINGSHAUSEN,7 KARLY HAMULYAK,8 DANIEL P. HART,9 CHARLES R.M. HAY,10 SATURNINO HAYA,11 WAANDER L.VAN HEERDE,3 CEDRIC HERMANS,12 € ,13 VICTOR JIMENEZ-YUSTE,14 M A R G A R E T H A H O L M S T R OM RUSSELL D. KEENAN,15 ROBERT KLAMROTH,16 BRITTA A. P. 3 LAROS VAN GORKOM, FRANK W.G. LEEBEEK,5 € IPERNAA,18 CHRISTOPH MALE,19 R I L I E S N E R , 1 7 A N N E M AK EVELINE MAUSER-BUNSCHOTEN,20 MARIA 21 G. MAZZUCCONI, SIMON MCRAE,22 KARINA MEIJER,23 MASSIMO MORFINI,24 MARTEN NIJZIEL,25 JOHANNES OLDENBURG,26 KATHELIJNE PEERLINCK,27 PIA PETRINI,13 HELEN PLATOKOUKI,28 SAVITA RANGARAJAN,29 SYLVIA E. REITTER-PFOERTNER,19 ELENA SANTAGOSTINO,30 PIERCARLA SCHINCO,31 FRANS J. SMIERS,32 BERTHOLD SIEGMUND,33 ANNARITA TAGLIAFERRI,34 THYNN T. YEE,35 PIETER WILLEM KAMPHUISEN,23 JOHANNA G. VAN DER BOM32,36 and KARIN FIJNVANDRAAT1 FOR THE INSIGHT STUDY GROUP 1 Academic Medical Center, Amsterdam, the Netherlands; 2Sk ane University Hospital, Malm€ o, Sweden; 3Radboud University Medical Center, Nijmegen, the Netherlands; 4 5 San Bortolo Hospital, Vicenza, Italy; Erasmus University Medical Center, Rotterdam, the Netherlands; 6Catharina Hospital, Eindhoven, the Netherlands; 7 Haemophilia Centre Rhein-Main, Darmstadt, Germany; 8Maastricht University Medical Center, Maastricht, the Netherlands; 9Royal London Hospital, Barts and The London School of Medicine and Dentistry, London, the United Kingdom; 10 Manchester Royal Infirmary, Manchester, the United Kingdom; 11University Hospital la Fe, Valencia, Spain; 12St-Luc University Hospital, Brussels, Belgium; 13 Karolinska University Hospital, Stockholm, Sweden; 14University Hospital La Paz and Autonoma University, Madrid, Spain; 15Alderhey Childrens Hospital, Liverpool, the United Kingdom; 16Vivantes Klinikum im Friedrichshain, Berlin, Germany; 17 Great Ormond Street NHS Trust, London, the United Kingdom; 18Children0 s Hospital, Helsinki University Central Hospital, Helsinki, Finland; 19Medical University of Vienna, Vienna, Austria; 20University Medical Center Utrecht, Utrecht, the Netherlands; 21Sapienza University of Rome, Rome, Italy; 22Royal Adelaide Hospital, Adelaide, Australia; 23University Medical Center Groningen, Groningen, the Netherlands; 24Azienda University Hospital Careggi, Florence, Italy; 25Maxima Medical Center, Eindhoven/Veldhoven, the Netherlands; 26 University Clinic of Bonn, Bonn, Germany; 27University of Leuven, Leuven, Belgium; 28Aghia Sofia Children’s Hospital, Athens, Greece; 29Guy’s and St. Thomas’ NHS Foundation Trust, London, the United Kingdom 30Ospedale Maggiore Policlinico, Fondazione IRCCS Ca’ Granda, Milan, Italy; 31San Giovanni Battista “Molinette” Hospital, Turin, Italy; 32 Leiden University Hospital, Leiden, the Netherlands; 33Raphaelsklinik, Munster, Germany; 34University Hospital of Parma, Parma, Italy; 35Royal Free Hospital, London, the United Kingdom; and 36Sanquin Research, Leiden, the Netherlands Introduction and Objectives: Neutralizing antibodies (inhibitors) directed against the FVIII protein may increase the bleeding frequency and compromise the management of bleeding episodes in nonsevere haemophilia A patients. The median annual bleeding frequency in patients without inhibitors is described to be 0 (IQR 0-3) for mild haemophilia and 1 (IQR 0-13) for moderate haemophilia. The aim of this study was to evaluate the burden of bleeding and to describe the treatment strategies that are used for bleeding episodes in a large group of unselected inhibitor patients with nonsevere haemophilia A. Materials and Methods: We included all inhibitor patients from the INSIGHT study, an international multicentre cohort study including all 2709 nonsevere HA patients (FVIII:C 2–4 IU/dL) that received at least 1 exposure to FVIII concentrate between 1980-2011. Data of the 1st inhibitor period were analyzed. Results: We included 107 nonsevere HA inhibitor patients (median baseline FVIII:C 9 IU/dL (IQR 6-16); median age of 38 years (IQR 15-61)). A high titre inhibitor (> 5 BU/mL) was present in 57 (53%) patients. In 30 (28%) patients the FVIII:C level was decreased ≤1 IU/dL. Eighty-nine patients (83%) received treatment for bleeding episodes. Most patients had spontaneous bleeds (n = 49, 46%); a higher proportion of high titre patients had spontaneous bleeds compared to low titre patients (83% vs. 53%, relative risk (RR) 2.7, 95% confidence interval (CI) 1.3-5.8). The median number of bleeding episodes per inhibitor year was 2 (IQR 1-5); this did not differ between patients with FVIII:C ≤ 1 IU/dL and those with measurable FVIII levels (p = 0.5), patients with low titre and high titre inhibitors (p = 0.5) and patients receiving eradication treatment or not (p = 0.7). In order to treat bleedings, FVIII concentrate was used in 59 patients (55%), FVIII bypassing agents in 50 (47%) and desmopressin in 18 patients (17%). Desmopressin was used more often in patients with remaining circulating FVIII:C levels compared to patients with a FVIII:C ≤ 1 IU/dL and in patients without eradication treatment compared to patients with eradication treatment (25% vs. 3%; RR 7.4, CI 1.0-53.5 and 25% vs. 0%; RR 14.0, CI 0.9 – 224.6, respectively). Conclusion: Inhibitor development in nonsevere HA patients aggravates the burden of bleeding with the majority (83%) of the patients needing treatment for bleeding episodes, at a median of 2 bleeding episodes per year.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


Impact of HLA I/II genotypes on the risk of inhibitor development in Korean patients with severe hemophilia A

JIN-HEE CHO,1 HEE-JUNG KIM,1 HAE-SUN CHUNG,1 KI-O LEE,2 SOO-YOUNG JUNG,3 KI-YOUNG YOO,3 Y O N G - M O O K C H O I 3 and H E E - J I N K I M 1 1 Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 2Samsung Biomedical Research Institute, Samsung Medical Center, Seoul, Korea; and 3Korea Hemophilia Foundation, Seoul, Korea Introduction and Objectives: The development of inhibitor is the most serious complication of factor replacement therapy in hemophilia. Several studies have suggested that HLA genotypes have an impact on the risk of inhibitor development. In this study, we investigated the association of HLA genotypes with inhibitor formation in Korean patients with severe hemophilia A, stratified according to the F8 mutation types. Materials and Methods: The study subjects were 100 Korean patients with genetically confirmed severe hemophilia A, including 27 patients with inhibitor to factor VIII. The HLA class I (A, B and C) and class II (DRB1, DQB1 and DPB1) genotypes were determined by using Allele SEQR HLA PCR/SBT kit (Abbott Diagnositics). The differences in allele frequencies were statistically compared between inhibitor-carrying and non-inhibitor patients. Results: HLA class I alleles were not associated with the inhibitor status. In HLA Class II, DRB1*15 [n = 100, odds ratio (OR) 0.217, 95% CI: 0.049-0.955, P = 0.028] and DPB1*05:01 [OR: 0.461, 95% CI: 0.231-0.920, P = 0.026] were found to be negatively associated with the formation of the inhibitors. In a subgroup of patients with intron 22 inversion, C*07:02 was positively associated with inhibitor formation [n = 30, OR: 5.500, 95% CI: 1.136-26.633, P = 0.043], whereas the statistical significances for DRB1*15 and DPB1*05:01 were not consistent. In subgroups of patients lacking intron 22 inversion, the negative association between DPB1*05:01 allele and inhibitor formation was reinforced [n = 70, OR: 0.327, 95% CI: 0.137-0.780, P = 0.010], and the DRB1*13:02 and DPB1*04:01 alleles showed a positive association with inhibitor formation [OR: 3.059, 95% CI: 1.030-9.081, P = 0.037 in both alleles]. The previously reported risk alleles were not consistently associated with inhibitor formation in our series. Conclusion: This study demonstrated that HLA alleles associated with inhibitor risk in severe hemophilia A vary by ethnicity and depend on the mutation types and subpopulations of patients.

Prevalence of inhibitors in Indian hemophilia patients SHRIMATI SHETTY, KANJAKSHA GHOSH, PATRICIA PINTO, TEJASHREE SHELAR, VIDHYA NAWADKAR, D A R S H A N A M I R G A L and A L F I Y A M U K A D D A M National Institute of Immunohaematology, Mumbai, India Introduction and Objectives: The mechanism of inhibitor development in patients with bleeding disorders is multi-factorial and cannot be predicted, but a prompt and accurate diagnosis is critical as early therapy can be life-saving. The aim of this study was to diagnose patients with bleeding disorders in India and screen them for inhibitors, and subsequently to analyse and compare the prevalence of inhibitors in different regions in India. Methods and material: Patient details were recorded; samples from 3332 patients in different cities in India were collected in sodium citrate vacutainers, after informed consent. Coagulation and inhibitor screening, and Bethesda assays (quantification of inhibitor titre) were performed. Results: Of the 3332 samples screened, 2694 were hemophilia A patients (181 FVIII Inhibitor positive), 430 hemophilia B patients (3 FIX inhibitor positive), 37 patients had rare bleeding disorders (without inhibitors), and 117 were von Willebrand Disease (vWD) patients. Conclusion: The state-wise highest incidence of FVIII:C Inhibitors was seen among the Pondicherry samples (11.94%), followed by Jammu & Kashmir (9.90%), Tamil Nadu (9.09%), and Maharashtra (8.46%). Other regions showed an inhibitor incidence < 8%. The overall FVIII:C inhibitor incidence in the samples studied was 6.72% 181/ 2694). FIX:C inhibitors were detected in samples from Maharashtra (1.10%), Kerala (1.37%), and Uttar Pradesh (3.13%). The overall incidence of FIX:C inhibitors was 0.70% (3/430). This study may have implications for the therapeutic management of these patients.

Multifactorial etiology of high-titer inhibitor development in 309 children with hemophilia A < 5%.

SUSAN HALIMEH,1 GILI KENET,2 CHRISTINE HELLER,3 SVEN GUTSCHE,4 CHRISOPH BIDLINGMAIER,5 € TL7 V E R E N A L I M P E R G E R 6 and U L R I K E N O W A K - G OT 1 Coagulation Centre Rhine-Ruhr, Duisburg, Germany; 2Sheba Medical Center, TelHashomer, Israel; 3Universit€ atsklinikums Frankfurt am Main, Ambulanz f€ ur Gerinnungs- und Immundefekte, Frankfurt, Germany; 4Medical practice for children, 5 Kiel-Lubbock, Germay; Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, P€ adiatrisches H€ amophiliezentrum, Universit€ at M€ unchen, Germany; 6 Universit€ atsklinikum Schleswig Holstein, Germany; and 7Department of pediatric Hematology/Oncology, UK M€ unster, Germany

Objectives: Among discussed risk factors for high-titer inhibitor [HRI] development in children with hemophilia A [HA] are high dose FVIII replacement therapy, presence of risk gene mutations [RGM: i.e. large deletions, nonsense mutations and intron inversion 22] and peak treatment moments [PTM]. In contrast, the preference of recombinant FVIII concentrates [r] over plasmatic FVIII [pd] products seems not to be relevant any more. The aim of the present cohort study was to evaluate the aforementioned risk factors for HRI development in children with hemophilia A < 5%. Material and methods: In all, 309 consecutively ascertained Caucasian PUPs [Israel & Germany] not previously enrolled into the CANAL or RODIN study, were followed

Haemophilia (2014), 20 (Suppl. 3), 1--186



after initial HA diagnosis over 200 exposure days. The study endpoint was HRI development. Inhibitor-free survival, hazard ratios [HR] and 95% confidence intervals [CIs] were calculated. Adjustment was performed for early FVIII administration before the age of three months, presence of RGM, median single FVIII dose administered over the first three months of treatment, presence of PTM, “year of birth” (proxy for different treatment periods) and the use of rFVIII concentrates. Results: HRI occurred in 78/309 children [25.2%]. In multivariate analysis, early FVIII administration [HR/CI: 2.13/1.17-3.91], underlying RGM [HR/CI: 2.02/1.213.38] and the individual FVIII dose measured per one IU increase per kgbw [HR/CI: 1.06/1.04-1.08] showed a significant impact on HRI development. Apart from the aforementioned associations the risk of HRI was not influenced by the presence of PTM [HR/CI: 1.13/0.53-2.39] or the use of rFVIII products [HR/CI: 1.12/0.61-2.02]. No difference was found between Israeli and German patients with HA. Conclusions: Children at risk should be treated with carefully calculated lower-dose regimens, adapted to individual bleeding situations.

Thrombotic and embolic events associated with the use of FEIBA in congenital hemophilia: A cumulative review over four decades

ROGER BERG,1 ALESSANDRO GRINGERI,2 € L E N H A L S 1 and A R M I N J . R E I N I N G E R 2 E L I S A B E T H F UL Global Pharmacovigilance, Baxter Innovations GmbH, Vienna, Austria; and 2Global Medical Affairs Haemophilia, Baxter Innovations GmbH, Vienna, Austria


Introduction and Objectives: In 1975 activated prothrombin complex concentrate (FEIBA - FVIII inhibitor bypassing activity; Baxter, Deerfield, IL USA) became commercially available. The use of this bypassing agent has steadily increased since its introduction and contributes to the better management of the treatment of persons with hemophilia (PWH) and inhibitors. While bypassing therapy has been proven effective, it introduced the risk of treatment-associated thrombotic and embolic events (TEEs) – a risk otherwise significantly lower in PWH than in the general population. The small size of clinical trials and post- authorization surveillance studies in PWH with inhibitors limits the capability to ascertain risk factors for FEIBA-associated TEEs. The present review provides a comprehensive overview of all TEEs associated with the use of FEIBA in congenital hemophilia documented in Baxter’s global safety database. Materials and Methods: The global safety database was reviewed for all AE reports of FEIBA received from 1975 through July, 2013, addressing patient demographics, dosing regimens, and risk factors deemed relevant for the development of TEEs in association with FEIBA treatment. Results: More than 4.8 billion units of FEIBA were distributed during the review period. Overall, 70 reports including one or more thromboembolic events were received for PWH (including 50 spontaneous reports), in patients aged 0-73 years (mean 33, median 22). Of these 70 TEEs, 12 were reported as deep vein thrombosis and/or pulmonary embolism (DVT/PE; age 3-22, mean 12, median 11), 24 as myocardial infarction or stroke (MI; age 3-73, mean 37, median 34) and 18 as disseminated intravascular coagulation (DIC; age 0-71, mean 42, median 49). It is interesting to note that 25 TEEs were reported with rFVIIa as a concomitant medication (7 DVT/PE, 4 MI/stroke, 9 DIC, 5 others). Conclusions: The low and stable reporting rate of TEEs in PWH over almost 40 years of use confirms the long-time safety profile of FEIBA. Moreover, the majority of TEEs occurred in the presence of additional risk factors such as concomitant medications. The review of clinical details of all TEEs reported in association with the use of FEIBA is a valuable resource for their understanding and perhaps prevention in patients at high risk.

Rituximab as first-line treatment for the management of adult non-severe hemophilia A patients with inhibitors: A single-centre experience B R E N D A N I E L S E N , N I G E L S K E Y and A L I C E M A University of North Carolina, Chapel Hill, USA Introduction and Objectives: Rituximab use in the management of patients with congenital hemophilia and inhibitors has been limited to case reports and case series. In most reports, rituximab was used as second- or third-line treatment following failure of conventional immune tolerance induction (ITI), and more commonly in pediatric patients. The objective of this study is to describe our experience with rituximab as a first-line treatment for the eradication of factor VIII (FVIII) inhibitors in adult non-severe hemophilia A patients in a single US institution. Methods: We retrospectively reviewed the medical records of adult non-severe hemophilia A patients with a diagnosis of FVIII inhibitor treated with rituximab (375 mg/m2 weekly x 4) as first-line treatment at our Hemophilia Center from 2000 to 2013. Results: We identified 12 hemophilia A patients (moderate, n = 6; mild, n = 6) with a median age of 57 years (range: 24-77) at the time of inhibitor development. One patient was female with mild hemophilia A (FVIII:c = 24 IU/dL). Three patients had peak inhibitor titers of 200 BU/ mL), high (HT; 5-200 BU/mL) and low (LT; < 5BU/mL). Results: Data from 17 centres from 14 countries were analysed. Of the 134 patients with current inhibitors at time of the survey, 26 were ITI failures, 75 had never been on ITI and 33 had on-going ITI. The current treatments for HT inhibitors wer, in 46% of cases, a high-dose regimen with up to 200 IE/kg/d, compared to 36% in the period from 2002 to 2012. In 32% of the cases with VHT, inhibitors immunosuppression (IS) was added. From 2002 to 2012, low-dose ITI with < 50 IU/ kg/d was used in 42% of LT inhibitor patients and 28% of HT inhibitor patients, whereas 82% of VHT patients were treated with >200 IU/kg/d and/or additional IS. Compared to the survey from 2006, no major difference could be seen between the two surveys. Success rates were highest in LT inhibitors (85%) and lowest (28%) in poor-risk patients with VHT inhibitors. Of the 8 patients with mild haemophilia A, 2 were treated with IS alone, 3 with factor and IS, and 2 with factor alone; 5 achieved complete remission. Three of 6 patients with hemophilia B achieved complete remission, 2 of whom were treated with IS. Conclusions: There may be a trend towards more usage of a high-dose regimen in patients with high titers. The combined use of IS is considered in some centres, in particular in mild hemophilia A, poor-risk patients and in hemophilia B. Multicentre studies and/or prospective international registries exploring of any type of consensus on treatment are needed.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

INHIBITORS, PATHOGENESIS, PREVENTION AND TREATMENT Continues ITI versus prophylaxis with NovoSeven; An immune tolerance induction failure cost analysis model

CHRIS BARNES,1 JULIE CURTIN,2 SCOTT DUNKLEY,3 S I M O N B R O W N , 4 M E L I S S A H A R D Y , 5 P A T R I C I A F I S K E N 6 and JOHN WLODARCZYK7 1 Royal Children’s Hospital, Melbourne, Australia; 2Westmead Children’s Hospital, Sydney, Australia; 3Prince Alfred Hospital, Sydney, Australia; 4Royal Children’s Hospital, Brisbane, Australia; 5Two Ripples Pty Ltd Australia; 6Novo Nordisk, Australia; and 7The Lead Group

Introduction and Objectives: The development of inhibitors to factor VIII in patients with hemophilia A is the most important complication of modern treatment management. Immune tolerance induction (ITI) remains the cornerstone of care management for these patients and is successful in approximately 70% of patients. Failure of ITI is difficult to accurately define with some evidence of improvement in bleeding frequency in patients who continue on ITI despite the continuing presence of an inhibitor and/or impaired pharmacokinetics of factor VIII. Patients with inhibitors, however, may also be managed using prophylaxis with bypassing agents to reduce bleeding episodes. The decision to use or continue ITI or to commence a patient on prophylaxis with bypassing agents is difficult and presents significant economic challenges. Materials and Methods: An ITI costing model was developed using assumptions based on typical demographic, clinical and laboratory inputs from real patient examples. The model was designed to compare the costs of ITI with theoretical costs of managing the same patient with prophylaxis using recombinant VIIa (NovoSeven). The model provides the ability to vary clinical inputs to accommodate a variety of realistic clinical scenarios by altering inputs and by doing so, can be used to model the costs involved in managing patients using different management regimens. The model is currently in a semi-validation phase using additional real-life patient examples. Results: Data will be analyzed and communicated as a descriptive summary of statistics, providing details of the model after appropriate validation. A variety of clinical scenarios will be presented to challenge the model and provide an analysis of costs involved in the difficult scenario of managing patients with hemophilia A and inhibitors to factor VIII. The upcoming analysis will be performed and available by January 31, 2014. Conclusion: N/A – as per Late-Breaking Abstract Specifications.

Does a once-weekly prophylaxis with low-dose factor VIII in PUPs with hemophilia A decrease the risk of inhibitor development? Results of a survey in centres of the Competence Network Hemorrhagic Diatheses East

RALF KNOEFLER,1 SUSANNE HOLZHAUER,2 ROSEMARIE SCHOBESS,3 LARS FISCHER,4  HOFMANN,6 VOLKER AUMANN,5 ANDRE KARIM KENTOUCHE,7 AXEL SAUERBREY,8 ANTJE NIMTZ9 T A L A S K A and R O B E R T K L A M R O T H 1 0 1 University Hospital, Dept. of Pediatric Hemostaseology, Dresden, Germany; 2Charite University Hospital, Dept. of Pediatric Hematology/Oncology, Berlin, Germany; 3 Outpatient Clinic for Coagulation Disorders, Leipzig, Germany; 4University Hospital, Dept. of Pediatric Hematology/Oncology and Hemostaseology, Leipzig, Germany; 5University Hospital, Dept. of Pediatric Hematology/Oncology, Magdeburg, Germany; 6Municipal Hospital, Dept. of Pediatric Hematology/ Oncology, Chemnitz, Germany; 7University Hospital, Dept. of Pediatric Hematology/ Oncology, Jena, Germany; 8Helios Hospital, Dept. of Pediatrics, Erfurt, Germany; 9 Pediatric Outpatient Clinic, Frankfurt/Oder, Germany; and 10Vivantes Hospital Friedrichshain, Dept. of Internal Medicine, Angiology and Hemostaseology, Berlin, Germany Introduction and Objectives: The development of an inhibitor against factor VIII (FVIII) is the most serious complication of replacement therapy with FVIII concentrates in patients (pts) with severe hemophilia A (HA). Recently published data suggest that an early start of prophylaxis with a once-weekly application of 25 IU FVIII/kg decreases the risk of inhibitor development. Patients and Methods: We performed a retrospective survey in all pediatric network centres and collected the following data from PUPs with HA treated between 2006 and 2013: age at diagnosis and at start of prophylaxis, mutation type, dose and frequency of FVIII administration, number of exposure days (ED), danger signals, details of immune tolerance induction (ITI). Results: All 12 centres treating children with HA participated in this survey. Data from 91 PUPs (severe HA: n = 49, moderate HA: 6, mild HA: 23, sub-HA: 13) were included. Forty-four (90%) out of 49 patients (pts) with severe HA (sHA) had more than 50 ED. In sHA an inhibitor was detected in 30% (9/30) of pts receiving prophylaxis once weekly with 25 IU FVIII/kg (median), in 20% (3/15) of pts with two to three times weekly 30 IU /kg and in 25% with on-demand treatment. Eleven (44%) out of 25 pts receiving prophylaxis with recombinant FVIII (rFVIII) developed an inhibitor. In contrast, in only 1 (5%) out of 20 pt treated prophylactically with plasma derived FVIII (pdFVIII) was an inhibitor detected. ITI was performed in 7 out of 8 patients with a high titer inhibitor and was successful in 5. For ITI, mainly pdFVIII products were used (5/7); 3 pts were switched during ITI from rFVIII to a von Willebrand factor-containing pdFVIII product. Conclusions: Our retrospective data did not confirm a lower inhibitor rate in PUPs with severe HA starting prophylaxis once weekly with low-dose FVIII. Prospective

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


data are needed for a clear assessment of potential benefits of this new prophylaxis regimen.

Allergic reaction mediated by IgE in hemophilia A patient using plasmaderived factor VIII concentrate is not acting against factor VIII protein ~ , ALINE TUCUNDUVA, S I L M A R A M O N T A L V AO A N D R E A S A M B O , S A M U E L M E D I N A and M A R G A R E T H O Z E L O Hemophilia Unit “Cl audio L. P. Correa” – INCT do Sangue Hemocentro UNICAMP, University of Campinas –Campinas, SP, Brazil

Introduction and Objectives: Anaphylactic reactions have rarely been reported in hemophilia A (HA) patients treated with plasma-derived (pdFVIII) or recombinant factor VIII (rFVIII) concentrate products. The IgE isotype is responsible for mediation of type I reactions, resulting in a potentially life-threatening situation. Among HA patients, a single case of allergic reaction mediated by IgE to rFVIII was previous reported by Kadar in 2007. The objective of this study was to evaluate immunoglobulins (Ig) in HA patients that presented allergic reaction to pdFVIII followed in a single reference centre. Materials and Methods: Blood samples from HA patients that presented with allergic reactions were collected on the same day as the event and were compared to previous samples (when available), and samples taken over the following weeks. IgG1, IgG4 subclasses and IgE anti-FVIII were performed by ELISA using HRP-conjugated mouse monoclonal antibody, antihuman-IgG1, IgG4 and IgE (Southern Biothechnology). The plates were coated with (1) pdFVIII (Hemofil-M, Baxter) and (2) rFVIII (Advate, Baxter). Plasma samples were diluted to between 1:10 and 1:1280. Samples from 20 healthy individuals and 20 HA patients without inhibitor were also analyzed as controls. Results: Three of 296 HA patients (1%) presented with allergic reaction after exposure exclusively to pdFVIII during the past five years in our centre. Patient 1 with severe HA and high-responding inhibitor, presented with IgG1 and IgG4 anti-FVIII when the plates were coated with both, pdFVIII, and rFVIII. IgE anti-FVIII was negative in all analysis. Patient 2 with severe HA without inhibitor, had IgE and IgG4 anti-pdFVIII on the same day as the allergic reaction with peak titer after 15 days. Any Ig was detected when rFVIII was used. Patient 3, with moderate HA without inhibitor, showed only low titer IgG1 anti-pdFVIII. The results observed in patient 1 can be related to the presence of inhibitor. Conclusions: The allergic reaction mediated by IgE observed in patient 2 seems to be associated with other proteins present in pdFVIII product, since no reaction to rFVIII was observed. The mechanism of allergic reaction for FVIII products is uncommon and unclear and in some patients could be mediated by IgE without specificity to FVIII, when plasma-derived products are used.

Recurrence of inhibitors after immune tolerance induction: A retrospective single-centre study

MARICEL MIGUELINO,1 JONATHAN DUCORE,2 K I M S C H A F E R 1 and J E R R Y P O W E L L 1 Departments of 1Internal Medicine and 2 Pediatrics, Division of HematologyOncology, University of California, Davis, USA Introduction and Objectives: Development of neutralizing anti-FVIII antibodies is the most common complication in persons with hemophilia (PWH) A who use exogenous factor products. Age of exposure, hemophilia type, genetic mutation and type of factor (plasma derived or recombinant) treatment has been reported to play a role in immunogenicity. The clinically proven management strategy to achieve antigen-specific tolerance is immune tolerance induction (ITI) in which high-dose factor VIII (FVIII) is administered to eradicate the inhibitor. PWH with no anamnestic response can continue to use FVIII products. With the development of long-acting FVIII proteins, PWH will have the option of using these products. However, prior inhibitor formation in PWH is an exclusion criterion from clinical trials for FVIII products with an extended half-life. Therefore, no data exist on the recurrence of FVIII inhibitor after exposure to long-acting FVIII products. Our objective is to conduct a retrospective analysis on recurrence of inhibitor formation in PWH who have resumed use of FVIII products after successful ITI. Materials and Methods: Medical records from the Hemophilia Treatment Center database of severe PWH (5 Bethesda U/ ml were analyzed. We identified 14 PWH who had developed alloantibodies during their first 50 exposure days, received ITI and continued use of FVIII products after successful ITI. Select demographic, therapeutic and comorbid parameters were analyzed. Results: None of the 14 severe PWH identified in this study who received ITI after initial development of high-titer neutralizing inhibitory antibodies developed a recurrence of the inhibitor after continued use of FVIII products. Conclusion: Our study suggests that PWH who developed high-titer inhibitors, underwent successful ITI, and resumed use of FVIII products developed an anamnestic response. Since the protein structure of the long-acting FVIII products is identical to current FVIII products, it is reasonable to expect that after successful ITI, PWH will not experience recurrence of their inhibitor after exposure to long-acting FVIII products. urther investigation using a larger patient population and with the inclusion of patients in appropriate clinical trials is warranted to provide reliable clinical data for future use of long-acting FVIII in this patient population.

Haemophilia (2014), 20 (Suppl. 3), 1--186



13-LABORATORY ISSUES Thrombin generation assay in patients with hemophilia undergoing total knee replacement: a reliable monitoring tool for replacement therapy? 1


MARIA ELISA MANCUSO, MARIA ROSARIA FASULO, MARIGRAZIA CLERICI,1 GIANLUIGI PASTA,2  1 LUIGI PIERO SOLIMENO,2 A N T O N I N O C A N N A V O, F L O R A P E Y V A N D I , 1 A R M A N D O T R I P O D I 1 and ELENA SANTAGOSTINO1 1 Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy; and 2Department of Orthopedics and Traumatology, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy Introduction and ObjectivesGlobal coagulation tests are increasingly used in the assessment of bleeding disorders. FVIII activity measurement is the mainstay of laboratory monitoring during surgery in hemophilia A (HA). The aim of this study was to evaluate if TGA may add information on clotting activation during surgery in HA patients. Materials and Methods: Adult patients with severe HA (FVIII %66) in one; in the other one inhibitor became negative after about one year but during the recovery test there was a partial response (39.6%) and ITI is on-going. In five patients who were receiving on-demand treatment with aPCC or rFVII and on prophylaxis with aPCC, on follow up when inhibitor became negative, a recovery test was performed. Although inhibitors were negative, half-life of plasma FVIII level was not adequate for us to say that inhibitor was negative. Conclusion: In the follow up of inhibitor-positive patients with hemophilia, inhibitor can be negative in laboratory tests. Although inhibitor is negative, it can not be assessed by FVIII or FIX levels, it must be confirmed with recovery test and half-life of FVIII/FIX.

Cut-off value of the Bethesda assay and detection of low-titer inhibitors in previously untreated children with severe hemophilia A

HELEN PLATOKOUKI,1 JOHANNES OLDENBURG,2 ROLF LJUNG,3 ELENA SANTAGOSTINO,4 H. MARIJKE VAN D E N B E R G , 5 O N B E H A L F O F T H E P E D N E T and R O D I N STUDY GROUP 1 Haemophilia Centre and Haemostasis Unit, “Aghia Sophia” Children’s Hospital, Athens, Greece; 2Institute of Experimental Haematology and Transfusion Medicine University Clinic Bonn, Germany; 3Lund University, Department of Paediatrics, Sk€ane University Hospital, Malm€ o, Sweden; 4A. Bianchi Bonomi Haemophilia Centre, Ca Granda Foundation, Maggiore Hospital Policlinico, Milan, Italy; and 5Julius Centre for Health Sciences and Primary Care, University Medical Centre, Utrecht, The Netherlands Introduction and Objectives: About one third of patients with severe hemophilia A (sHA) develop inhibitors towards infused FVIII. The inhibitor risk depends on genetic and non-genetic factors. After the introduction of recombinant FVIII products, the reported inhibitor incidences have increased. It is still unclear whether this is caused by higher intrinsic immunogenicity, by more frequent testing, higher awareness in reporting low titer inhibitors or higher sensitivity of the performed tests with a lower cut-off. Aim: to describe the impact of the cut-off value of the Bethesda assay on the overall inhibitor outcome in previously untreated (PUPs) children with sHA. Patients and Methods: The RODIN Study (Research of Determinants of Inhibitor development) included PUPs with sHA for the first 75 exposure days (ED). Uniform prospective data and well-defined outcomes were collected from this patient cohort which was regularly tested for inhibitors in 29 hemophilia centres in Europe, Israel and Canada. The investigators are members of the European Paediatric Network for Haemophilia Management (PedNet) and/or the RODIN Study group. The centres, which all used the Nijmegen modification of the Bethesda assay, were asked to report on the cut-off value used during the study period (2000-2010) and on the frequency of testing during the first 20 ED and between 20 –75 ED. Results: Inhibitory antibodies were detected in 188 (30%) out of 621 eligible patients. Of all inhibitor patients, 124 (66%) developed a high titer (>5 BU) and 64 (34%) a low titer. Inhibitors were developed after a median of 15 ED. During the first 20 ED, patients were tested every 3-5 ED. After 20 ED, the frequency of testing was unchanged (6 centres) or reduced. Low cut-off values (0.3 and 0.4 BU/ml) were used in 10 centres and high cut-off values (0.5 and 0.6 BU/ml, the latter being the highest cut-off value for positivity) in 19. Centres that used the lowest cut-off values followed 203 PUPs (32.7%); centres that used the highest followed 418 (67.3%). The inhibitor incidence was 27.5% and 31.6%, respectively. In both groups, 66% of the inhibitors were diagnosed with a high and 34% with a low titre. Conclusions: A lower cut-off value did not influence the detection rate of inhibitors. Also, the frequency of low- versus high-titre inhibitor patients was similar for both cut-off values.

Under-filled blood samples: An important source of error and improved detection using an automated sample volume check on Sysmex CS Analysers A N I T A W O O L L E Y , P E T E R B R O W N and S T E V E K I T C H E N Dept of Coagulation, Royal Hallamshire Hospital, Sheffield, UK Introduction and Objectives: The preanalytical phase is the source of the majority of errors in laboratory medicine. If the ratio of blood to anticoagulant is altered, there may be an effect on the results of clotting tests. Filling of tubes has most often been verified by visual scrutiny. Automated sample volume checking is now available on the Sysmex CS series. We decided to assess the impact of introducing automated detection and to assess the effects of under-filling on routine coagulation tests. Materials and Methods: Under-filled samples (n = 45) (Vacutainer Plus), which contained less than 80% of the target fill volume were retained and analysed alongside matched samples from the same patients which contained 90–100% of the target fill volume and which were received within 4 hours of the under-filled sample. We determined PT (Innovin), APTT (Actin FS), Clauss fibrinogen (Siemens), and Thrombin time (Thromboclottin) using Sysmex CS series analysers. Results: Approximately 0.6% of 120 000 samples were detected as under-filled by visual scrutiny (mean fill 71%, range 53–79%). This increased to approximately 1%

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


of samples after introduction of automated sample volume check. Mean results for full and under-filled sample tubes are shown below.

Full Under-filled Max. difference

PT (sec)

APTT (sec)

Fib (g/l)

TT (sec)

14.1 16.8 20.4

29.3 33.6 21.7

3.9 3.7 1.6

15.9 17.9 5.8

PT/APTT/TT were all significantly longer in under-filled samples (p < 0.001). There was a significant negative correlation between the per cent fill of samples and the difference in PT and APTT test results in full and under-filled tubes – thus the lower the per cent fill the greater was the prolongation of PT and APTT. Approximately 20% of under-filled samples had falsely elevated APTTs. Conclusion: We conclude that blood samples (from subjects with normal hematocrits) collected into 3 ml Vacutainer plus tubes should not be accepted for analysis if 50 IU/dL) or not complete (FVIII:C ≤ 50 IU/dL). Data were first analyzed by binary logistic regression analysis. Next, the predictive value of the combined determinants for a CR was used to construct a receiver operator curve (ROC). The area under the ROC curve (AUC) reflects the predictive value of the combined determinants as it represents the proportion of patients with correctly predicted CRs. AUC >80% is considered good, 70–80% fair, and 60–70% poor. Results: We included 850 non-severe hemophilia A patients; median age at time of DDAVP administration was 20 years (IQR 8-40), median baseline FVIII:C, VWF:Ag and VWF:Act levels were 17 IU/dL (IQR 10-25), 95 IU/dL (IQR 72-118), and 86 IU/ dL (IQR 67-111), respectively. A CR was present in 64% of the patients. In the total population, the predictive value for CR was 74% (fair). F8 genotype was known in 508 patients (60%), displaying 136 different missense mutations. Most prevalent were Asn618Ser (n = 105, CR in 84%), Arg593Cys (n = 91, CR in 62%), and Arg2150His (n = 17, CR in 59%). The predictive value of the combined determinants for a CR in the Arg593Cys group was 76% (fair), but was poor in the Asn618Ser group and the Arg2150His group (AUC = 62%, and 67%, respectively). Conclusions: The predictive value of the known determinants of DDAVP response is fair in the complete study group. However, it varies among different mutation groups between fair and poor. This suggests yet unidentified determinants of the response to DDAVP.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

Clinical presentation of inhibitor development in non-severe hemophilia A: half of patients have high titer inhibitors and present with bleeding complications

CORIEN L. ECKHARDT,1 JANNEKE I. LOOMANS,1 ALICE S.VAN VELZEN,1 MARJOLEIN PETERS,1 JAN ASTERMARK,2 PAUL P. BRONS,3 GIANCARLO CASTAMAN,4 MARJON H. CNOSSEN,5 NATASJA DORS,6 CARMEN ESCURIOLAETTINGSHAUSEN,7 KARLY HAMULYAK,8 DANIEL P. HART,9 CHARLES R.M. HAY,10 SATURNINO HAYA,11 WAANDER L.VAN HEERDE,3 CEDRIC HERMANS,12 € ,13 VICTOR JIMENEZ-YUSTE,14 M A R G A R E T H A H O L M S T R OM RUSSELL D. KEENAN,15 ROBERT KLAMROTH,16 BRITTA A.P.VAN LAROS-GORKOM,3 FRANK W.G. LEEBEEK,5 € IPERNAA,18 CHRISTOPH MALE,19 R I L I E S N E R , 1 7 A N N E M AK EVELINE MAUSER-BUNSCHOTEN,20 MARIA G. MAZZUCCONI,21 SIMON MCRAE,22 KARINA MEIJER,23 MICHAEL MITCHELL,24 MASSIMO MORFINI,25 MARTEN NIJZIEL,26 JOHANNES OLDENBURG,27 KATHELIJNE PEERLINCK,28 PIA PETRINI,13 HELEN PLATOKOUKI,29 SAVITA RANGARAJAN,24 SYLVIA E. REITTER-PFOERTNER,19 ELENA SANTAGOSTINO,30 PIERCARLA SCHINCO,31 FRANS J. SMIERS,32 BERTHOLD SIEGMUND,33 ANNARITA TAGLIAFERRI,34 THYNN T. YEE,35 PIETER WILLEM KAMPHUISEN,23 JOHANNA G. VAN DER BOM33,36 and KARIN FIJNVANDRAAT1 FOR THE INSIGHT STUDY GROUP 1 Academic Medical Center, Amsterdam, the Netherlands; 2Sk ane University Hospital, Malm€ o, Sweden; 3Radboud University Medical Center, Nijmegen, the Netherlands; 4 San Bortolo Hospital, Vicenza, Italy; 5Erasmus University Medical Center, Rotterdam, the Netherlands; 6Catharina Hospital, Eindhoven, the Netherlands; 7 Haemophilia Centre Rhein-Main, Darmstadt, Germany; 8Maastricht University Medical Center, Maastricht, the Netherlands; 9Royal London Hospital, Barts and The London School of Medicine and Dentistry, London, the United Kingdom; 10 Manchester Royal Infirmary, Manchester, the United Kingdom; 11University Hospital la Fe, Valencia, Spain; 12St-Luc University Hospital, Brussels, Belgium; 13 Karolinska University Hospital, Stockholm, Sweden; 14University Hospital La Paz and Autonoma University, Madrid, Spain; 15Alderhey Childrens Hospital, Liverpool, the United Kingdom; 16Vivantes Klinikum im Friedrichshain, Berlin, Germany; 17 Great Ormond Street NHS Trust, London, the United Kingdom; 18Children0 s Hospital, Helsinki University Central Hospital, Helsinki, Finland; 19Medical University of Vienna, Vienna, Austria; 20University Medical Center Utrecht, Utrecht, the Netherlands; 21Sapienza University of Rome, Rome, Italy; 22Royal Adelaide Hospital, Adelaide, Australia; 23University Medical Center Groningen, Groningen, the Netherlands; 24Guy’s and St. Thomas’ NHS Foundation Trust, London, the United Kingdom; 25Azienda University Hospital Careggi, Florence, Italy; 26Maxima Medical Center, Eindhoven/Veldhoven, the Netherlands; 27University Clinic of Bonn, Bonn, Germany; 28University of Leuven, Leuven, Belgium; 29Aghia Sofia Children’s Hospital, Athens, Greece; 30Ospedale Maggiore Policlinico, Fondazione IRCCS Ca’ Granda, Milan, Italy; 31San Giovanni Battista “Molinette” Hospital, Turin, Italy; 32 Leiden University Hospital, Leiden, the Netherlands; 33Raphaelsklinik, Munster, Germany; 34University Hospital of Parma, Parma, Italy; 35Royal Free Hospital, London, the United Kingdom; and 36Sanquin Research, Leiden, the Netherlands Introduction and Objectives: Inhibitor development in nonsevere haemophilia A patients (FVIII:C, 2–40 IU/dL) has a heterogeneous clinical phenotype, ranging from irrelevant transient inhibitors to high titre neutralizing antibodies with severe bleeding complications. Data on inhibitor presentation are scarce and selected, favouring those with severe complications. The aim of current study was to describe the presenting symptoms of inhibitors in a large unselected cohort of nonsevere haemophilia patients. Materials and Methods: Clinical data were collected of 107 inhibitor patients derived from a source population of 2,709 nonsevere haemophilia A patients that were treated between 1980 and 2011 in 34 European and Australian centers (the INSIGHT consortium). Patients were subdivided according to age and calendar period at time of inhibitor development (10-year groups), aiming to search for age-related trends and trends over time. Results: Age at inhibitor detection varied widely between 1 and 85 years with a median age of 38 years (IQR, 15–61). Most inhibitors developed in the period of 2000-2010 (n = 64, 60%). Inhibitors developed after a median of 28 exposure days (IQR, 14–66), which was comparable between all age groups. Fifty-seven patients (56%) had high titre inhibitors (>5 BU/mL). About half of the high titre inhibitors developed in patients older than 40 years (n = 30, 53%) and 60% after the year 2000 (n = 34). In 13 (12%) inhibitor patients the inhibitor was detected during routine laboratory screening and no clinical signs of the inhibitor were present. More than half of the patients (n = 61) had an increased bleeding tendency at presentation with inhibitor. In 80 patients (80%) endogenous FVIII:C was decreased to below 5 IU/dL (including 33/44 patients with low titer inhibitors), of whom FVIII:C fell below ≤ 0.01 IU/mL in 49 patients (46%). Conclusion: Half of the patients with nonsevere haemophilia A and inhibitors developed high titre inhibitors; these were more common in the last decennium. More than half of the patients presented with bleeding complications and 46% had changed to a severe phenotype. These results stress the importance of close follow-up after exposure to therapeutic factor VIII concentrates in nonsevere haemophilia A patients.

Haemophilia (2014), 20 (Suppl. 3), 1--186



The incidence of arthropathy in patients with mild and moderate hemophilia

TOMOKO ASHIKAGA,1 CHIAI NAGAE,2 MIKA MORI,2 A T S U K I Y A M A S H I T A 2 and M A S A S H I T A K I 1 St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan; and 2St. Marianna University School of Medicine, Kawasaki, Japan


Introduction and Objectives: It was formerly thought that, compared with severe hemophilia patients, the prevalence of arthropathy would be lower in those with mild to moderate hemophilia, but the details were unknown. Therefore, we evaluated the prevalence of arthropathy in patients with mild to moderate hemophilia in our hospital. Materials and Methods: We evaluated 53 hemophilia cases including 21 moderate (15 A, 6 B) and 32 mild (25 A, 7 B) cases. Results: The average and median ages were 25.6 years and 21.0 years, respectively. The prevalence of arthropathy was 16.9% (9 cases). The joints affected by arthropathy were knees in 5, ankles in 4, elbows in 3 and hips in 1 case. According to age brackets, the incidence of arthropathy was 8.7% in the teens, 18.1% in the 20s, 22.2% in the 30s, and 30.0% in those 40 and older. There were no cases requiring orthopedic surgery. The rate of self-infusion was 62.2% (33 cases). All of these patients carried out on-demand therapy and/or prophylactic infusion before exercise or difficult activities. The rate of regular replacement therapy at least once a week was 9.4% (5 cases). A rate of prophylaxis of at least once a week was 9.4% (5 cases). Two cases had moderate hemophilia A, 2 had moderate hemophilia B and 1 had mild hemophilia A. Conclusions: The prevalence of arthropathy in cases with mild and moderate hemophilia was constant, in definite proportions. The prevalence of arthropathy rose with advancing age. Therefore, even with mild or moderate hemophilia, the introduction of regular replacement therapy should be considered and patients must be educated regarding the importance of early treatment for bleeding episodes, especially hemophilia patients with numerous bleeding episodes.

Von Willebrand Factor antigen and age explain variation in baseline FVIII:C among nonsevere hemophilia A patients with the same F8 genotype (Arg593Cys and Asn618Ser)


Haemophilia (2014), 20 (Suppl. 3), 1--186

1 Academic Medical Center, Amsterdam, the Netherlands; 2Sk ane University Hospital, Malm€ o, Sweden; 3Radboud University Medical Center, Nijmegen, the Netherlands; 4 San Bortolo Hospital, Vicenza, Italy; 5Erasmus University Medical Center, Rotterdam, the Netherlands; 6Catharina Hospital, Eindhoven, the Netherlands; 7 Haemophilia Centre Rhein-Main, Darmstadt, Germany; 8Maastricht University Medical Center, Maastricht, the Netherlands; 9Royal London Hospital, Barts and The London School of Medicine and Dentistry, London, the United Kingdom; 10 Manchester Royal Infirmary, Manchester, the United Kingdom; 11University Hospital la Fe, Valencia, Spain; 12St-Luc University Hospital, Brussels, Belgium; 13 Karolinska University Hospital, Stockholm, Sweden; 14University Hospital La Paz and Autonoma University, Madrid, Spain; 15Alderhey Childrens Hospital, Liverpool, the United Kingdom; 16Vivantes Klinikum im Friedrichshain, Berlin, Germany; 17 Great Ormond Street NHS Trust, London, the United Kingdom; 18Children0 s Hospital, Helsinki University Central Hospital, Helsinki, Finland; 19Medical University of Vienna, Vienna, Austria; 20University Medical Center Utrecht, Utrecht, the Netherlands; 21Sapienza University of Rome, Rome, Italy; 22Royal Adelaide Hospital, Adelaide, Australia; 23University Medical Center Groningen, Groningen, the Netherlands; 24Guy’s and St. Thomas’ NHS Foundation Trust, London, the United Kingdom; 25Azienda University Hospital Careggi, Florence, Italy; 26Maxima Medical Center, Eindhoven/Veldhoven, the Netherlands; 27University Clinic of Bonn, Bonn, Germany; 28University of Leuven, Leuven, Belgium; 29Aghia Sofia Children’s Hospital, Athens, Greece; 30Ospedale Maggiore Policlinico, Fondazione IRCCS Ca’ Granda, Milan, Italy; 31San Giovanni Battista “Molinette” Hospital, Turin, Italy; 32 Leiden University Hospital, Leiden, the Netherlands; 33Raphaelsklinik, Munster, Germany; 34University Hospital of Parma, Parma, Italy; 35Royal Free Hospital, London, the United Kingdom; 36Sanquin Research, Leiden, the Netherlands; and 37 JW Goethe University Hospital, Frankfurt, Germany.

Introduction and Objectives: Non-severe hemophilia A (baseline FVIII:C, 2-40 IU/dL) is caused by a mutation in the F8 gene. There is limited knowledge on the factors determining the variation in baseline FVIII:C. The aim is to identify the determinants of baseline FVIII:C in non-severe hemophilia A patients. Materials and Methods: We analyzed clinical data for non-severe hemophilia A patients, treated between 1980–2013, in European Haemophilia Treatment Centers (HTCs) participating in the INSIGHT/RISE project. We performed analyses on mutations that were present in ≥10 patients. Age (at FVIII:C measurement), F8 gene mutation, VWF:Ag, VWF:Act and HTC were analyzed as potential determinants by multivariate regression analyses. Results: We identified nine missense mutations present in ≥10 patients in 321 individuals, median age 23 years (IQR 7-47). From these individuals we had data on 667 FVIII:C measurements in 5 HTCs. Median baseline FVIII:C, VWF:Ag and VWF: Act were 17 IU/dL (IQR 11-22), 98 IU/dL (IQR 78-128) and 91 IU/dL (70-115) respectively. Baseline FVIII:C, VWF:Ag and VWF:Act all increased with age, both in the total population and within the two largest mutation groups (Asn618Ser, 113 patients; Arg593Cys, 107 patients). VWF:Ag, age and F8 mutation were significant predictors of baseline FVIII:C (p < 0.0001-0.024). In mutations that were present in ≥10 patients the determinants age, F8 mutation, VWF:Ag and HTC together explained 61% of the variation in baseline FVIII:C. Within the specific mutation group Asn618Ser only 21% of the variance in baseline FVIII:C was explained by the combined potential determinants, with VWF:Ag and HTC as significant predictors (p = 0.008 and 0.013 respectively). Among individuals with the Arg593Cys F8 genotype the determinants age, VWF:Ag and HTC were significant predictors (p < 0.0001 for age and VWF:Ag and p = 0.04 for HTC), together explaining 34% of the variance in baseline FVIII:C. Conclusion: In non-severe hemophilia A patients carrying the same F8 mutation the determinants age, VWF:Ag and HTC contribute to baseline FVIII:C to variable extends. With the studied determinants we can only explain 61% of the variance in baseline FVIII:C. This suggests that yet unknown factors influence FVIII:C in nonsevere hemophilia A.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd



15-MOLECULAR GENETICS Expression of a gain of function factor IX variant from adeno-associated virus (AAV) serotype 8 in a human clinical trial of gene therapy 1



PAUL E. MONAHAN, JUNJIANG SUN, GENLIN HU, CARMEN J BOOTH,2 CHRISTOPHER E. WALSH,3 SCOTT W . M C P H E E 4 and R . J U D E S A M U L S K I 1 1 University of North Carolina at Chapel Hill, Chapel Hill, NC USA; 2Yale University School of Medicine, New Haven, CT USA; 3Mount Sinai School of Medicine, New York, NY USA; and 4Asklepios Biopharmaceutical, Chapel Hill, NC USA Introduction and Objectives: Clotting factor replacement is standard care for hemophilia in resource-rich countries but has significant limitations, in particular if avoiding joint bleeding altogether requires sustained trough levels of 10-15% (den Uijl et al. Haemophilia., 2011). Gene therapy may provide a sustainable supply of pathogen-free clotting protein and sustained factor levels without repeated i.v. injections. Although factor IX (FIX) activity of 2-7% has been achieved in a clinical trial using an AAV.FIX vector (Nathwani et al. N Engl J Med 2011), FIX expression in that range was associated with a dose-dependent immune response toward the vector and hepatic inflammation. We have conducted preclinical and clinical development of a novel gene therapy AAV.FIX-R338L (BAX335/AskBio009), which utilizes a recombinant AAV vector to deliver the gain of function variant FIX-R338L. Methods and Results: In FIX-/- animals the AAV.FIX-R338L vector mediated expression of FIX protein with specific activity 4-8X higher than the equivalent AAV.FIX vector expressing wild type FIX. A joint hemarthrosis challenge in FIX-/mice indicated AAV.FIX-R338L protected against synovitis in a dose-responsive fashion and at doses that were ineffective using wild-type FIX vector. Safety testing, including observations for thrombotic and inhibitor complications, indicated that AAV.FIX-R338L was well tolerated, supporting initiation of an ongoing Phase 1/2 human clinical trial ( Identifier NCT01687608). The lowest dose cohort, which has completed enrollment, received a vector dose 10-fold lower than the dose associated with hepatic inflammation in two prior trials. At this dose (2 x 1011 vg/kg) there were no drug-related safety concerns. Sustained FIX expression has been observed at >4 months after dosing. Specifically, no hepatitis, AAV capsiddirected T cell response or immunologic recognition of factor IX have been observed. Conclusions: These results supported a recent 5-fold dose escalation to the 2nd planned dose; trial progress regarding safety and expression results at each dose will be presented. The trial seeks to establish a vector dose that achieves 10-40% factor IX expression without the associated need to treat hepatic inflammation.

Quantitative and qualitative mRNA analysis in a severe hemophilia A patient with high F8 expression and no active FVIII protein BEHNAZ PEZESHKPOOR, NICOLE ZIMMER, J O H A N N E S O L D E N B U R G and O S M A N E L - M A A R R I Institute of Experimental Haematology and Transfusion Medicine, University of Bonn, Bonn, Germany Introduction and Objectives: Hemophilia A (HA) is caused by a wide spectrum of mutations in the F8 gene, leading to a decreased or total loss of FVIII activity. In the current study, we investigated the causative mutation in a severe HA patient with no mutation in F8 exons and its adjacent intronic regions. Materials and Methods: The patient is a severe HA case with FVIII:C100 fold) in several regions in comparison to healthy individuals. Moreover, all exon-exon boundaries of F8 were analyzed using 25 qRT probes. The analysis showed an association between the duplication/triplication pattern on DNA level and the F8 mRNA expression level when compared to 20 healthy individuals. Conclusions: In conclusion, we report a duplication/triplication pattern comprising most genomic region of F8 locus leading to a severe HA phenotype in combination with relative high F8 mRNA expression level. The authors declare no conflict of interest.

stage assay. The amount of FIX protein circulating in patient plasma (FIX:Ag) was measured by enzyme-linked immuno-assay (ELISA). FIX inhibitor titers were quantified using the Nijmegen modification of Bethesda assay. Polymerase chain reaction (PCR) amplification and direct sequencing of all exons and flanking sequences of F9 was performed. Multiplex ligation-dependent probe amplification (MLPA) was employed in patients in whom no mutation was found after full F9 gene sequencing. Results: Among these patients, 16 had severe HB, 8 had moderate HB, 12 of them were classified as Type I and the others as Type II. No FIX inhibitors were detected in any of the patients whoparticipate in this study. Overall,19 different mutations were identified, which included 14 point mutations composed of 12 missense and two nonsense, two small deletions, one large deletion, one duplication, and one splice site mutation. In particular, we identified five novel mutations. Of the two nonsense mutations, three small/large deletions and one duplication were identified. All of the eight patients had severe HB. As to the one splicing mutations, one was seen in moderate HB. Both novel in-frame deletion and duplication result in type II, one large deletion, two nonsense mutations, one single base deletion causing premature stop codon and one splicing mutation all lead to type I. The missense mutations were distributed among both severe and moderate types of HB. In the twelve missense mutations, it was seen that seven cause type II and five cause type I. The five type I mutations all lead to moderate phenotype, reversely, out of the seven type II mutations, six caused severe phenotype. Conclusions: The F9 mutations were heterogenous and the outcome of this study will enable us to give an accurate diagnosis in 100 per cent of affected families by direct sequencing and MLPA.

Carrier investigation in females with low FVIII or FIX and no family history of hemophilia

GIUSEPPE TAGARIELLO,1 DONATA BELVINI,1 ROBERTA SALVIATO,1 ANNARITA TAGLIAFERRI,2 MARIA MESSINA,3 SILVIA LINARI,4 E M A N U E L A M A R C H E S I N I , 5 F L O R A P E Y V A N D I 6 and PAOLO RADOSSI1 1 Regional Centre for Blood Disease and Haemophilia, Castelfranco Veneto, Italy; 2 Regional Centre for Blood Disease and Haemophilia, University Hospital of Parma, Parma, Italy; 3Pediatric Regional Centre for Blood Disease and Haemophilia, M. OIRM Sant’Anna Torino Italy; 4Department of Hematology Azienda Ospedaliera Careggi, Firenze Italy; 5Haemophilia Centre University Hospital of Perugia Italy; and 6 Angelo Bianchi Bonomi” Hemophilia and Thrombosis Center, University of Milan and IRCCS Maggiore Hospital, Mangiagalli and Regina Elena Foundation, Milan, Italy Hemophilia is an X-linked recessive disease caused by factor VIII (hemophilia A) or factor IX (hemophilia B) deficiency usually known as bleeding disorder in males, owing to hemizygosity for X genes. A wide range of factor VIII (FVIII) and factor IX (FIX) levels are observed in heterozygous carriers of hemophilia as well as in noncarriers. Females might rarely have FVIII or FIX levels below normal range in the absence of clinical symptoms or sometimes with clinical manifestation of the disease. If they belong to a family with a history of hemophilia, carrier status is commonly assessed, as they are involved in genetic counselling usually associated with an affected male. The low clotting factor levels in carriers could be due to rare homozygosity for mutated gene, structural X abnormalities in chromosomes or skewed inactivation of the normal X chromosome (extreme lyonization). We describe genetic analysis in 4 and 7 females with decreased FVIII and FIX level, respectively (FVIII:C ranging from 5 to 23% and FIX:C ranging from 1 to 55%). In some cases hemorrhagic symptoms were observed, in others factor defect was detected by chance. No history of hemophilia on either parental lineages has been observed. Conformation sensitive gel electrophoresis (CSGE), sequencing of the F8 or F9 gene and multiplex ligation-dependent probe amplification (MLPA) were performed. All females with FVIII defect were found to be heterozygous for mutation:1 intron, 22 inversion, and 3 diverse point mutations, 2 already reported in HA international database. Four females with F9 defects showed point mutations, all already reported in the international HB mutation database. A few cases of HB females have been explained by the presence of cytogenetically detectable aberrations, which can’t be excluded in our patients since no cytogenetic studies has been done. Both sensitivity of screening methods and mutations mapping outside the investigated fragments could explain the 3 undetectable mutations. Our findings suggest that cytogenetic and molecular studies should be conducted in females with low clotting factor levels even in absence of family history of hemophilia, since if they are carriers of a mutated gene they can transmit the defect to their children. These females could be misdiagnosed unless medical staff suspects a carrier condition and offers them genetic investigation of F8 or F9 genes.

Molecular characterization of 22 hemophilia B families in Shanxi, China: identification of five novel mutations ZHIPING GU, LINHUA YANG, XIUYU QIN, XIUE LIU, Y A O F A N G Z H A N G and J I A N F A N G C H E N Department of Hematology, the Second Hospital of Shanxi Medical University, Taiyuan, China Introduction and Objectives: Hemophilia B (HB) is an X-linked recessive inherited hemorrhagic disorder caused by heterogeneous mutations in the factor IX gene (F9). Molecular characterization of F9 mutations may be indispensable for precise genetic counseling in carriers. The present study was undertaken with an aim to characterize the molecular defects of the F9 in HB families at the Shanxi hemophilia centre in China. Materials and Methods: In total, 24 Chinese HB patients from 22 families were enrolled. FIX clotting activity (FIX:C) was measured using citrated blood by a one-

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

Genetic basis of vitamin K-dependent clotting factor deficiency in the Pakistani population

ARSHI NAZ,1 MATTHIAS WATZKA,2 JOHANNES OLDENBURG,2 INGA KRISTIN,2 ALI M. WARYAH,3 N I S A R A H M E D 4 4 and T A H I R S . S H A M S I 1 1 National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan; 2Institute of Experimental Haematology and Transfusion Medicine, University of Bonn Germany; 3Liaquat University of Medical Sciences, Jamshoro, Pakistan; and 4Children Hospital, Lahore, Pakistan Introduction: Vitamin K-dependent coagulation factors (VKD), i.e. factor II, VII, IX, and X, play an important role in the human clotting cascade. Defects in any of these

Haemophilia (2014), 20 (Suppl. 3), 1--186



factors or vitamin K deficiency will lead to bleeding disorders of variable intensity. Furthermore, mutations in enzymes responsible for vitamin K metabolism and activation of VKD proteins have been known to cause deficiency of all VKD clotting factor (VKCFD) (g-glutammyl-carboxylase fpr VKCFD1 and vitamin K epoxide reductase for VKCFD2). Objective: To investigate the biochemical, hemostatic, and genetic basis of vitamin Kdependent factor deficiency in Pakistani subjects. Method: For this purpose, 7 subjects, (6 males and 1 female) with age ranging from 7 months to 13 years who had a history of bleeding disorder and low levels of all VKD clotting factors were included in the study. BT,PT,APTT, factors II, VII, IX, platelet count and fasted serum bile acids were analysed for exclusion of thromobocytopenia which cause bleeding and bile acid for cholestatic liver disease, respectively. DNA sequencing was performed for the GCCX and VKORC1 gene to understand the etiology at molecular level. Results: Platelet counts of all the subjects were normal. In only one case it was mildly low 100x103/ul. MeanS.E.M value of platelet was 440x10367. Factor II, VII, IX and X mean levels were 12.7%, 6.9%, 11.2%, 7.1%, respectively. Out of eight subjects, the mean bile acid levels were increased in two patients (>20 lmol/l) while 2 had low levels (1.2 lmole/l). In all patients, the VKORC1 gene showed no alteration. In the GGCX gene, we were able to identify three novel mutations in two patients (Gly215Asp, His235Asn, Ala533Glu). Conclusion: Out of seven patients, only two had mutations that were identified in GCCX while VKORC1 showed the wild-type sequence. In one patient cholestasis might be the trigger for the observed VKCFD. Therefore, in four patients the cause of the apparent bleeding disorder was not identified and further diagnosis/research is necessary.

Identification of novel mutations in fibrinogen alpha chain gene of congenital afibrinogenemia patients

ARSHI NAZ,1 MARGUERITE NEERMAN-ARBEZ,2 PHILIPPEDE MOERLOOSE,2 SHEHLA TARIQ,3 NAZISH SAQLAIN,4 N I S A R A H M E D 4 and T A H I R S . S H A M S I 1 1 National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan; 2University of Geneva, Geneva, Switzerland; 3Chugtai’s Lab Lahore, Pakistan; and 4Children Hospital Lahore, Lahore, Pakistan Introduction: Fibrinogen is a hexameric soluble plasma protein consisting of three pairs of polypeptides; two a, two b and two c. It is located on chromosome 4q and encoded by three sets of genes which are FGA, FGB and FGG. Inherited fibrinogen defects include quantitative (type I) and qualitative (type II) defects. Out of 61 mutations of fibrinogen, the majority of mutations have been reported in FGA. Objective: This study focuses on genetic and hemostatic abnormalities in afibrinogenemia patients which are manifested by mutation in any of the three genes. Material And Methods: This descriptive and cross-sectional study was carried out at the NIBD, Karachi, and the Children’s Hospital and Chughtai’s Lab, Lahore. Subjects were included if they had inherited bleeding tendency in the absence of any acquired cause of hemostatic defect. Afibrinogenemia was labelled after analysis of PT, APTT, fibrinogen levels and fibrinogen antigens. Genomic DNA of 3 patients were extracted from whole blood by QiAamp DNA Blood mini kit (Qiagen). Primer sequences (provided on request) were designed on the basis of known sequences of the three fibrinogen genes and intergenic regions (GenBank accession numbers M64982, M64983, M10014, U36478, and AF229198). The amplified fragments were purified by ammonium acetate precipitation and directly sequenced on both strands using the Big Dye Terminator Cycle Sequencing Kit (Applied Biosystems, Foster City, CA, USA). Sequencing reactions were analysed on an ABI-3100 multicapillary automated DNA sequencer (Applied Biosystems). Factura and Sequence navigator software (Applied Biosystems) were used for mutation detection. Results: Three patients were diagnosed to have inherited fibrinogen deficiency. Out of these, 2 were males and 1 female. Three patient’s mutations were found: one had a known non-sense mutation in FGA exon 4: c.385C>T and two had novel homozygous non-sense and frame-shift mutations in FGA exon 1 & 2 leading to premature truncation. Conclusion: FGA gene mutations are found in our study population, which were not reported earlier. Further study of these mutations are required to validate the findings.

An int22h-related deletion combined with unbalanced X-chromosome results in severe hemophilia A in a female B E H N A Z P E Z E S H K P O O R , A N N A P A V L O V A and JOHANNES OLDENBURG Institute of Experimental Haematology and Transfusion Medicine, University of Bonn, Bonn, Germany Introduction and Objectives: Hemophilia A (HA) is caused by a wide spectrum of mutations in the factor 8 (F8) gene. Being an X-linked recessive disorder, females are generally not affected, although they can be carriers of the disorder. Here, we report severe HA in a female due to del22-type1 inversion and skewed lyonization. Materials and Methods: The index patient is a one-year old girl with FVIII:CG, p.Tyr443Cys) was found in the F7 gene. One patient was identified with a homozygous nonsense mutation (c.1042C>T, p.Arg306X) in the PROC gene, inducing a premature stop codon. Conclusion: Our study indicates the presence of genetic abnormalities in patients suspected to be affected by RHDs, including RBDs. Our genotypic approach confirmed our phenotypic suspicion, based on FXII, FXI, FVII, FXIII, Fg and ProteinC levels. The homozygous protein-C patient had a severe clinical phenotype, due to thrombosis whereas the other heterozygous family members had a mild clinical phenotype.

Genotyping of a cohort of 12 HA families from Suriname

SELENE SCHOORMANS,1 SHELDON SIMSON,2 SANDY KROUWEL,1 JOHN TJONG TJIN JOE,3 JOOST MEIJERS,4 JIMMY ROOSBLAD,2 J. F. CODRINGTON,2 M A R J O L E I N P E T E R S , 5 L I E S H O E F S L O O T 6 and W A A N D E R V A N HEERDE1 1 Laboratory for Haematology Radboud University Medical Centre, Nijmegen, the Netherlands; 2Laboratory of Academic Hospital, Paramaribo, Suriname; 3Department of Exp. Vascular Medicine AMC, Amsterdam, the Netherlands; 4Department of Exp.Vascular Medicine AMC, Amsterdam, the Netherlands; 5Department of pediatrichematology EKZ/AMC, Amsterdam, the Netherlands; and 6Department of human genetics Radboud University Medica lCentre, Nijmegen, the Netherlands Introduction and Objectives: Hemophilia A (HA) is a recessive X-linked bleeding disorder caused by a deficiency or abnormality in the procoagulant activity of factor VIII (FVIII). The prevalence is 1:5000 male births. HA can be divided in three different subclasses: severe (FVIII activity < 1%), moderate (1-5%), and mild (630%). The objective is to genotype a cohort of 12 families with 52 family members from Suriname, suspected to be affected by HA. All family members were screened for mutations in the F8 gene. This information is important for proper genetic counseling. Moreover, analysis of F8 gene variations is important to understand the patient’s clinical phenotype. Materials and Methods: DNA of patients suffering HA was analyzed by Sanger sequencing. All coding regions including the intron-exon boundaries of the F8 gene were sequenced. Intron 22 inversions were analyzed using inverse-PCR described by Rossetti et al. (Clinical Chemistry, 2005). The F8 intron 1 breaking inversion was analyzed using a PCR method as described by Bagnall et al. (Blood, 2002). Results: Up to October, 2013, 42 family members were analyzed. In total, 21 family members had a genetic abnormality. So far, 2 nonsense mutations (patient number n=4), 2 missense mutations (n=2), 1 small deletion (n=3), 2 splice site mutations (n=8) and 2 polymorphisms (n=12) were identified. No mutations were found in 21 family members. Of all mutations detected, 6 mutations were reported previously (n=14) and 1 deletion was novel (n=3). The novel deletion (c.180delC, p.Asn41fs) induces a frameshift leading to a premature stop codon. Polymorphism D1241E was found in 8 family members and polymorphism M2238V was found in 4 family members. Both polymorphisms were reported previously. Conclusion: Our genotypic approach confirmed our phenotypic suspicion, based on FVIII levels, of HA in 12 families from Suriname. So far, 11 HA carriers hav been identified. In one family a novel deletion (c.180delC, p.Asn41fs (n=3)) was found. This deletion leads to severe HA. Finally, the D1241E polymorphism leads to a mild decrease in FVIII activity as reported previously (Viel e.a., Blood, 2007) which may have a clinical impact.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

MOLECULAR GENETICS Molecular pathology of hemophilia A in patients from Western India K A N J A K S H A G H O S H , P R E E T H I N A I R and S H R I M A T I S H E T T Y National Institute of Immunohaematology, Mumbai, India Introduction and Objectives: Despite increased awareness and diagnostic facilities, about 70-80% of HA patients still remain undiagnosed. India, with a huge population (1.27 billion), is genetically heterogeneous due to several thousands of years of migration, colonization and genetic mixing. Hence, studies on prevalent mutations on HA from this country will be informative. The majority of hemophilia A (HA) cases in India go undiagnosed and although restriction fragment length polymorphism is a feasible method, it has many limitations. Mutation screening adds to the existing diagnostic methods to give more accurate results. The present study was undertaken to detect causative mutations. Materials and Methods: Intron 1 and 22 inversion -negative HA patients with severe to mild/moderate clinical manifestations were included in the present study. Conformation-sensitive gel electrophoresis and DNA sequencing techniques were incorporated for mutation detection. Results: In a cohort of 109 inversion-negative cases, we identified causative mutations in 96 cases (14 familial and 84 unrelated). In total, 67 individual mutations comprised of 27 novel and 40 previously seen mutations were observed. Of these, 39 were missense, 8 nonsense, 12 deletions, 6 insertions and 1 splice-site mutation. Double mutation was also identified which shows the importance of scanning the entire gene for better diagnosis. Mutations known to predispose towards CRM positive and inhibitor formation were also identified. Genetic diagnoses were successfully offered to 10 families affected by HA, using this data. Conclusion: A sizeable number of novel mutations, a few double mutations and recurrent mutations were detected. Overall, 6% of mutations were CRM positive and 1.2% of patients treatment was complicated by the development of inhibitors. In spite of the low prevalence of inhibitors observed, probably due to less aggressive prophylactic treatment, few predisposing mutations were identified.

Factor VIII gene (F8) mutations in a pediatric population with severe hemophilia A

ANNA PAVLOVA,1 JOHANNES OLDENBURG,1 E R I C A N D E R S E N 2 and I R I N A M A T Y T S I N A 3 1 Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany; 2Clinical Reporting Haemophilia, Novo Nordisk A/S, Søborg, Denmark; and 3Hemophilia Medical & Science, Novo Nordisk A/S, Søborg, Denmark Introduction and Objectives: Turoctocog alfa is a new recombinant FVIII (rFVIII) with a truncated B-domain for treatment of hemophilia A. Sixty-three (63) children aged 0-11 years who had previously been treated with FVIII products were included in a pediatric trial (guardianTM3) investigating the safety and efficacy of turoctocog alfa. Fifty-two (52) had their F8 gene mutation analysed. Here we present the results of the genetic analyses. Materials and Methods: The DNA analyses of the F8 were conducted by sequencing of all 26 exons and exon/intron boundaries, reverse polymerase chain reaction (PCR) for intron 22 inversion and multiplex ligation-dependent probe amplification (MLPA) for large deletions/duplications detection. Results: In 51 of the 52 patients (98%), the genetic defect was identified. The mutation profile showed the following distribution: intron 22 inversion, 20 (38%); intron 1 inversion, 2 (4%): missense mutations, 7 (13%); nonsense mutations, 8 (15%); small deletions, 7 (13%); small insertions/duplications, 3 (6%); splice-site, 4 (8%). Although all patients had severe hemophilia A, no large deletions were identified. Fifteen (29%) novel mutations were characterized. In total, 87% of all genetic defects were null mutations. Interestingly, when we excluded cases with intron 22/1 inversions, 55% of all other mutations were localized in exons 13 and 14. All found genetic alterations in exon 14 belonged to the group of null mutations, which was causative for severe hemophilia. One of the patients with intron 1 inversion showed an atypical pattern in the applied intron 1 diagnosing method allowing us to propose a larger genetic rearrangement including the region of intron 1. Conclusions: The mutations profile in our cohort of severe hemophilia A patients represents a normal prevalence of each mutation type, which is in concordance with general mutation distribution for severe hemophilia A.

Identification of 13 previously unreported F9 gene mutations in hemophilia B subjects genotyped in the B-LONG clinical trial of rFIXFc

EKTA SETH CHHABRA,1 BARBARA A. KONKLE,2 NEIL C. JOSEPHSON,2 SHELLEY N. FLETCHER,2 JURG SOMMER1 and G L E N N F . P I E R C E 1 1 Biogen Idec Hemophilia, Cambridge, MA, USA; and 2Puget Sound Blood Center, Seattle, WA, USA

Introduction: Hemophilia B (HemB) is an X-linked bleeding disorder caused by the deficiency of factor IX. Human Factor IX (FIX) is a 461 amino acid serine protease, which plays an essential role in the clotting cascade. The F9 gene is located on the X chromosome (Xq27.1-q27.2), is approximately 34 kb long and consists of 8 exons and 7 introns, which encode a 2.8 kb mRNA. Mutations in the F9 gene can lead to quantitative and qualitative deficiencies of FIX, resulting in HemB. The majority of HemB (~ 85%) is due to a point mutation in the F9 gene. Objective: To determine the genotypes of HemB subjects enrolled in the B-LONG trial of rFIXFc. Method and Subjects: Severe and moderately severe HemB subjects (≤ 2 IU/dL endogenous FIX activity) who enrolled in the rFIXFc trial were genotyped in this study by sequencing the FIX coding region, intron-exon boundaries and 5’ and 3’ untranslated regions using the Sanger method. The King’s College London Hemophilia B database and NCBI human F9 sequence (Ref Seq NM_000133.3) were used as references for the analysis. Results: In the rFIXFc B-LONG trial, 123 HemB subjects from 50 different centres (spanning 17 countries) were screened and enrolled; out of 123 subjects, 114 were

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


genotyped. The F9 gene was studied to determine the exact mutation in these subjects. Similar to previous reports, we found that 86% (98 /114) of the subjects had some form of point mutation. Approximately 12% (14/114) of the subjects had deletions in the F9 gene (4 large deletions ≥ 50bp; 10 small deletions) and nearly 2% (2/114) had insertions. The most important outcome of this genotyping initiative was the identification of 13 previously unreported FIX mutations, which included 10 substitutions (7 missense, 2 nonsense and 1 splice site change), 1 deletion (c.1074_1075del2) and 2 insertions (c.823_824insA and c.1175_1176insA). In this group of 114 subjects, about 34% of the mutations were located in exon 8, which encodes the FIX catalytic domain. Conclusions: In this study, we identified 13 novel mutations in the F9 gene of HemB subjects genotyped as part of the B-LONG clinical trial. Knowing these mutations will help the prenatal diagnosis and identification of carrier status. Additionally, this study will further contribute to the improvement of the hemophilia B mutation database and will help us to better understand the relationship between the genotype and pathophysiology.

Identification of 23 previously unreported FVIII mutations in severe hemophilia A subjects genotyped during the clinical trial of rFVIIIFc (ALONG)

EKTA SETH CHHABRA,1 BARBARA A. KONKLE,2 NEIL C. JOSEPHSON,2 SHELLEY N. FLETCHER,2 JURG SOMMER1 and G L E N N F P I E R C E 1 1 Biogen Idec Hemophilia, Cambridge, MA, USA; and 2Puget Sound Blood Center, Seattle, WA, USA

Introduction: Human Factor VIII (FVIII) is a 265 kDa protein which on activation acts as a co-factor for FIX during coagulation. The F8 gene is located on Xchromosome (Xq28), is 186 kb in length, has 26 exons and 25 introns which encode a 9 kb mRNA. Mutations in the F8 gene result in the X-linked bleeding disorder hemophilia A (HemA). Objective: To determine the genotypes of HemA subjects screened during the phase III clinical study of rFVIIIFc (A-LONG trial). Method and Subjects: Severe HemA subjects from 60 different centres across 19 countries were genotyped. HAMSTeRS (Hemophilia A Mutation, Structure, Test and Resource Site) and CHAMP (CDC Hemophilia A Mutation Project) databases along with NCBI human FVIII sequence (Ref Seq NM_000132.3) were used as references for the analysis. Results: F8 genotyping of 170 severe HemA subjects was performed during the screening process of rFVIIIFc clinical trial. Subjects’ DNA was first screened for the presence of inversions in intron 22 (Int22inv) and intron 1 (Int1inv) by inverse shifting and long distance PCR. If an inversion mutation was not detected then the FVIII coding, intron-exon boundaries, 5’ and 3’ untranslated regions were sequenced by the Sanger method. We found an Int22inv in 36% (61/170) of subjects, nucleotide substitutions in 39%, frameshift mutations in 21% (due to either a deletion or insertion), Int1inv in 3% and an in frame duplication in 1 patient. We found that 24 subjects had previously unreported mutations, with 2 non-family subjects having the same mutation. Thus, we identified 23 novel mutations (14% of screened subjects). These new mutations included frameshift, missense and splice site changes. The baseline FVIII protein level (FVIII:Ag) was also measured in 170 subjects. The majority of subjects had FVIII:Ag below the detection limit (≤ ~ 3 IU/dL), and only 22% of subjects had FVIII:Ag above the detection limit, ranging up to 33 IU/dL. Conclusions: In this study, we identified 23 previously unreported mutations causing a severe phenotype in HemA subjects screened during the A-LONG trial. Identifying new HemA mutations will allow better prenatal diagnosis and identification of carrier status. This study will lead to further enhancement of HemA databases and will assist in better understanding of the relationship between the genotype and phenotype in individuals with hemophilia.

Sustained FVIII Expression in Human Mesenchymal Stem Cells Derived from Chorionic Villus Sampling

MARICEL MIGUELINO, M. D,1 AIJUN WANG PH.D, L E E L A N K F O R D M . A and J E R R Y P O W E L L M . D Departments of 1Internal Medicine, Division of Hematology-Oncology and 2Surgery, University of California, Davis, USA Introduction and Objectives: Hemophilia A (HA), the most common inherited deficiency of coagulation, is caused by a genetic mutation of the Factor VIII (FVIII) gene. Chorionic Villus Sampling (CVS) is a widely used prenatal screening tool for hemophilia in which a small amount of chorionic villi from the placenta is obtained for DNA analysis. Apart from diagnostic use of CVS, human chorionic villus derived mesenchymal stem cells (C-MSC) have multi-potent characteristics analogous to mesenchymal cells from the bone marrow (BM-MSC). BM-MSCs have been reported to contribute to endogenous FVIII production and to phenotypically correct HA in morphology mice and sheep. However, the techniques for harvesting BM-MSCs have low quantitative yield and cannot be performed in utero or early post-natal. Herein, we demonstrate that C-MSCs may contribute to exogenous production of FVIII after ex vivo transduction and ectopically express FVIII. The aim of this study is to engineer C-MSCs as a cell delivery vehicle for sustained FVIII expression. Materials and Methods: C-MSCs were isolated and characterized via flow cytometry. Osteogenic, adipogenic, and chondrogenic differentiation was assessed in lineagespecific induction media. Lentiviral vector transduction of the C-MSCs with B-domain deleted FVIII tagged with green fluorescent protein (GFP) was performed. At 72 hours after transduction, transgene FVIII expression was examined via immunofluorescence imaging. Identification of FVIII was conducted through immunocytochemistry. Results: Isolated C-MSCs showed spindle shape after 5-7 days in culture. Flow cytometry showed that the majority of C-MSCs were mesenchymal in origin. Adipogenic differentiation was characterized by microscopic observation of intracellular lipid droplets by Oil Red O staining. Osteogenic differentiation potential was confirmed by Alizarin red staining. Intense Alcian blue staining confirmed

Haemophilia (2014), 20 (Suppl. 3), 1--186



presence of proteoglycans in chondrogenic differentiation. Immunocytochemistry was positive for FVIII after lentiviral transduction with 80-90% of the cells GFP positive. These FVIII-expressing C-MSCs will be implanted into appropriate animal models. Conclusion: Our data suggest that human C-MSCs exhibit stem cell markers, multilineage differentiation, and following ex vivo transduction express FVIII. Human CMSCs may provide an autologous cell source and a novel technique for early postnatal or in utero correction of hemophilia.

Detection of intron 22 and intron 1 inversions of coagulant factor VIII gene in a large cohort of severe Chinese hemophilia A patients L I N H U A Y A N G , Z H I P I N G G U O , X I U Y U Q I N , X I U E L I U and YAOFANG ZHANG Department of Hematology, the Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China Introduction and Objectives: Hemophilia A is an X-linked bleeding disorder caused by a heterogeneous spectrum of mutations in the factor VIII gene. The identification of pathogenic mutations is important for genetic counseling, the assessment of clinical manifestations, and the risk estimation of inhibitor formation. It has been reported that about 50% of severe hemophilia A cases are the result of an inversion in the factor VIII gene. The aim of this study was to report the frequency of intron 22 inversion (Inv22) and intron 1 inversion (Inv1) in the large cohort of severe HA patients in the Shanxi province of China, assess the carrier status for HA, and explore the origin of inversion in families with an isolated patient. Materials and Methods: Peripheral blood samples were collected from 189 unrelated severe HA patients. The Bethesda method was used to detect F VIII inhibitor. They

Haemophilia (2014), 20 (Suppl. 3), 1--186

were screened for Inv22 using long-distance PCR (LD-PCR) at first, then Inv1 was tested by duplex multiplex PCR in the Inv22 negative severe HA patients. Pedigree investigation was conducted for 4 involved HA families, and two of them were sporadic. A female carrier resulting from her Inv22 positive father was phenotyped as the only female HA patient and was screened by direct DNA sequencing. Results: Among 189 severe HA subjects, 5.82%(11/189) were detected with F VIII inhibitor, 47.1% (89/189) were found to be Inv22 positive, the frequency of Inv1 is 2.64% in all severe HA patients and 5% if we only considered patients who were negative for intron 22 rearrangement. In all, 4.49% (4/89) of the patients with Inv22 and one Inv1 positive severe HA patient developed F VIII inhibitor. Overall, 4 females were diagnosed as Inv22 carriers from 3 Inv22 positive HA families. The mother of the sporadic Inv22-positive patient was found to be a carrier while the inversion was not present in either maternal grandparent. A non-carrier mother had an affected son who was positive for Inv1. An Inv22 in heterozygous state was detected in the only female with the phenotype of severe HA and no other mutation was detected after F VIII gene sequencing. No other mutation was detected in the female with Inv22 in heterozygous state after DNA sequencing. Conclusion: We found that 49.7% of severe HA patients in our study resulted from Inv22 and Inv1, which can be used to evaluate carrier mosaicisms. Inversion probably occurred in grandpaternal or maternal germ cells. Inv22 and Inv1 cannot be induced as a risk factor for F VIII inhibitor development. Non- random inactivation of a normal X-chromosome is probably the cause of female hemophilia with Inv22 in the heterozygous state.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd



16-MUSCULOSKELETAL ISSUES 44 years later: Is hemophilia still an orthopedics disease? MARVIN GILBERT Orthopaedics, Mount Sinai Hospital, New York, USA Is an orthopedic surgeon in the hemophilia clinic an anachronism? “Anachronism” implies that the thing is behind the times, antiquated, outworn, and useless. If not, is he or she just an appendage, just the carpenter? Hemophilia is still a musculoskeletal disorder and that every clinic needs musculoskeletal specialist, perhaps an orthopedic surgeon, perhaps a rheumatologist, perhaps a physiatrist, perhaps a physical therapist. The role of this specialist is to evaluate the PWH regularly, obtain appropriate but not excessive diagnostic studies, document loss of function and institute appropriate treatment. This may include augmented factor replacement, activity modification, antiinflammatory medications, physical therapy, orthosis and surgery. Orthopedic surgery is now so specialized that no one person may be able to perform all the indicated procedures, but a dedicated specialist must be in the clinic on a regular basis. There are certain principals this specialist must follow: 1)We do not need diagnostic imaging to insist on prophylactics, “the best orthopedic procedure”; 2)Treat the patient, not just the joint or limb; 3)Do not order a diagnostic study unless you are considering modifying treatment on the basis of the results; 4:Consider which imaging study will most easily give you the information you need. Perhaps a sonogram instead of an xray; 5) Remember that all “standard” orthopedic interventions may not be indicated in the PWH.

Hemophilia 101: A hematologist’s perspective ALISON STREET* The Alfred Hospital, Melbourne, Australia *The author is retired from this affiliation at time of writing The links between the bleeding symptoms of hemophilia and their musculoskeletal consequences were not appreciated until the late nineteenth century. Hematologists now accept that hemophilia should be recognised as a muscle and joint disease and that their professional role is in diagnosis, active and preventative treatment of bleeding and in support and audit of multi-disciplinary programs for the care of persons with hereditary bleeding disorders. An accurate and precise diagnosis depends on clinical awareness and quality laboratory support. It is important to correlate laboratory results with clinical bleeding expression as “basic” testing may be misleading as to the true level of factor deficiency. The addition of molecular testing permits accurate carrier detection and pre-natal diagnosis. There are many examples worldwide of pilot and routine genetic testing which requires simultaneous development of integrated education, laboratory testing and counselling programs. The hematologist’s ongoing responsibility is to prescribe and review the efficacy and safety of a patient’s treatment with regard to prevention or reduction of bleeding. Inhibitors remain a major problem. There is little data to help predict their onset, so regular testing is required for their detection. The global availability of more product and novel product technologies herald an exciting time in haemophilia care but bring their own issues. Programs such as EUHASS, which collect and analyse registry data on product use and safety in large numbers of patients with bleeding disorders, provide invaluable information to clinicians, patients and funders.

Pathogenesis of haemophilic arthropathy – back to basics

LIZEVAN VULPEN,1,2 GORIS ROOSENDAAL,1 S I M O N C . M A S T B E R G E N , 2 F L O R I S P . J . G . L A F E B E R 2 and ROGER E.G. SCHUTGENS1 1 Van Creveldkliniek, University Medical Center Utrecht, The Netherlands; and 2 Rheumatology & Clinical Immunology, University Medical Center Utrecht, The Netherlands Joint damage due to recurrent joint bleeds remains the most common complication in haemophilia. Synovial tissue is highly vascularized and in haemophilia even minimal forces could lead to haemarthroses. Blood filling the joint space leads to an influx of inflammatory cells into the synovial tissue. During natural evacuation of blood from the joint cavity, iron accumulates as haemosiderin deposits in the synovium and in addition to the inflammatory response, this leads to an irregular thickening of the synovial membrane called villous hypertrophy. Moreover, new, brittle blood vessels underneath the hypertrophied synovium are formed, which increases the risk of subsequent bleeds. Over time, a chronic synovitis develops and the synovial tissue becomes fibrotic. In addition, haemarthroses induce cartilage damage. This is caused both by tissue destructive enzymes and pro-inflammatory cytokines produced by the inflamed synovium, as well as by the direct harmful effects of blood itself on cartilage. Iron catalyses the production of toxic hydroxyl radicals, a process enhanced by the pro-inflammatory cytokine interleukin-1. The formation of these hydroxyl radicals in the vicinity of chondrocytes results in chondrocyte apoptosis. As human cartilage consists ofabundant extracellular matrix with only a limited number of chondrocytes that hardly proliferate, this blood-induced apoptosis leads to further long-lasting cartilage damage. Finally, subchondral bone changes occur as haemophilic arthropathy progresses. Typical changes are loss of bone mineral density, increased bone sclerosis, formation of osteophytes and subchondral cysts, and eventually fusion of the bones. Concluding, a combined cascade of inflammatory as well as degenerative processes initiated by recurrent joint bleeds leads to haemophilic arthropathy.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

The Role of MRI in Clinical Decision Making for Treatment of Arthropathy in Persons with Hemophilia: Critical to Orthopedic Management ANDREA S. DORIA The Hospital for Sick Children, Department of Diagnostic Imaging, Toronto, Canada Round Table (“cross-fire”): Is MRI a must or an expensive luxury in diagnosing hemophilic arthropathy? Two speakers will describe pro’s and con’s and give arguments to convince the other speaker and the audience of his/her point of view. Primary objective: To respond the question “Is MRI a must or an expensive luxury in diagnosing hemophilic arthropathy?” outlining “pros” and “cons” for the use of MRI as a clinical tool for assessment of hemophilic arthropathy in patients under prophylaxis from a developed country perspective. Background: Clinicians and scientists are aware that X-rays, the current standard practice tool for assessment of hemophilic arthropathy, accurately depict bone changes, however, these changes occur at a late stage of hemophilic arthropathy at a time where changes in prophylactic management are unlikely to produce reversibility of joint damage. MRI, on the other hand, being more sensitive than radiography, is suitable for early identification of joint changes, prompting the initiation of long-term prophylaxis or adjustment of individual schemes for patients already on prophylaxis regimens. Advantages for the use of MRI for joint assessment include its capability of direct visualization of the cartilage (which is not feasible with conventional radiography), and equipoise high sensitivity for assessment of both soft and osteochondral tissues. With regard to soft tissue changes, whereas both MRI and ultrasound are able to characterize and quantify joint effusion, synovial hypertrophy and hemosiderin deposition, x-rays cannot discriminate such joint components. Concerning osteochondral changes (erosions, subchondral cysts or cartilage loss) an ultrasound is unable to visualize the central aspect of the joint resulting in false-negative results for central osteochondral abnormalities. Xrays enable the assessment of the entire joint; however important findings may be superimposed by other anatomic structures making their identification difficult. Despite challenges for the use of unenhanced MRI in the assessment of hemophilic joints such as the need for sedation/general anesthesia in younger children, and limited access in clinical practice, the previous long scanning time of joints has been benefited from the implementation of recent MRI technologies including faster parallel imaging software’s and modern hardware. Although access to MRI scanners is still problematic in health care systems there has been an overall dramatic increase in number of MRI scanners per person across the world in the last 10 years, most notably in developed countries. The lack of evidence at the present time on the predictive value of early joint changes such as minimal hemosiderin deposition and early cartilage damage on progression of arthropathy does not preclude the widespread use of unenhanced MRI in children who do not require sedation / anesthesia in health care systems that support this type of technology. Recommendations: For identification, characterization and quantification of early structural joint damage at a given timepoint MRI is the current reference standard tool. Appropriate diagnostic approaches should be tailored to the patient’s age (regarding sedation/anesthesia) and to the health care system infra-structure to accommodate regular imaging examinations for diagnosis and follow-up of hemophilic patients. Disclosures: Dr. Doria is the project lead of on-going studies funded by the Canadian Hemophilia Society, and Baxter Healthcare Inc. and is a consultant of Baxter Healthcare Inc.

The Role of MRI in clinical decision making for treatment of Arthropathy in PWH (Patient with Hemophilia): a luxury N I N G N I N G Z H A N G , Y U N P E N G and R U N H U I W U Beijing Children’s Hospital, Imaging Centre, Beijing, China Primary Objective: To formulate MRI examination is a luxury approach for patients with hemophilia. Relatively to MRI, the application of combining x-ray and the high frequency ultrasound is a more feasible pathway for evaluating the joint changes of hemophiliac arthropathy(HA) in children. Background: HA is caused by recurrent episodes of hemorrhage into the joint, and if left untreated can lead to permanent functional disability. For most developing countries, we face a contradicting question: the cost constraint in medicine and a large patient population. As illustrated in China, many boys with hemophilia (approximately 100,000) are suffering from severe joint diseases. A study at Beijing Children’s Hospital (BCH) in 2010 showed that 90 per cent of severe and moderate boys with hemophilia had joint disease by six years of age and 57 per cent involved two or more joints. It is an urgent challenge to develop and provide compatible and affordable imaging diagnosis and care to prevent future joint disabilities. Summary: While MRI has been instrumental in the diagnosis of hemophilia, in recent years the values of both x-ray and ultrasound have been investigated. X-ray can show moderate and severe changes in bones. Findings from HA demonstrated on plain radiographs include osteoporosis, osteonecrosis, epiphyseal overgrowth, widening of the epichondral notch of the knee, bone cysts, joint-space irregularity and narrowing, angulation of the knee and ankle and bony fusion. Softtissue swelling can be suggested, but is often not clearly delineated. As a non-invasive examination, the implementation of high-frequency transducers and colour Doppler capabilities have provided new insights for clinical applications of ultrasound in the assessment of haemophilic arthropathy. In spite of the technical challenges of this imaging modality such as operator-dependency, ultrasound has advantages over MRI for its ability of differentiating synovium hypertrophy and hemosiderin deposition, which is not possible with MRI given the presence of susceptibility artefacts from extracellular hemosiderin on gradient-echo MR images. Recommendations: In conclusion, based on the current development trend of imaging and our practical experience, we can demonstrate that the combination of x-Ray and ultrasound could be an innovative approach for evaluation of haemophilic joints compared to the use of MRI alone. But further ongoing studies are required to confirm this theory.

Haemophilia (2014), 20 (Suppl. 3), 1--186



Wound repair with autologous adipose graft in patients with coagulation disorders

M A R IA L A N D R O , 1 E D U A R D O G A L L O , 1 A N A D O U G L A S P R I C E , 1 D A N I E L A N E M E , 2 M I G U E L C A N D E L A 2 and HORACIO CAVIGLIA1,2 1 Hospital General de Agudos Juan A. Fern andez, Ciudad Aut onoma de Buenos Aires, Argentina; and 2Fundaci on de la Hemofilia, Ciudad Aut onoma de Buenos Aires, Argentina Introduction and Objectives: Wound repair is a complex and dynamic process. Tissue reconstruction in patients with loss of substance of mesenchymal origin like fat, bone and muscle due to trauma, tumor resection or vascular damage, represents a clinical problem of difficult solution. In these cases, the use of autologous tissue, such as adipose, to reconstruct soft parts is of great importance. Adipose stem cell (ASCs) can be obtained from liposuction aspirates or excised fat, are multipotent, and can differentiate into ectodermal, mesodermal and endodermal lineages. They are immunocompatible due to their autologous nature and their use does not involve ethical issues. One gram of adipose tissue yields approximately 5,000 stem cells. The aim of this work is to demonstrate a minimally invasive technique that involves the use of autologous adipose graft cells obtained from subcutaneous abdominal tissue by liposuction aspirates, without complications for wound repair in patients with coagulation disorders. Materials and Methods: Four patients were under this treatment, aged 37, 42, 43 and 62 years, 3 with severe hemophilia A, and 1 with severe von Willebrand disease,. The skin lesions were located as follows: one inguinal, two in the knee, one in the gluteus region, with more than one year of evolution. Eighty autologous adipose grafts were obtained from subcutaneous abdominal tissue by liposuction aspirates with a 3-mm blunt cannula connected to a 60 ml syringe with vacuum locks. After centrifugation, the recovered cells were applied in the periphery of the lesion. Results: No intraoperative or postoperative complications were present in any of the four patients with coagulation disorders. Wound repair occurred approximately four weeks after application of the adipose graft. Conclusions: Repair of soft tissues in patients with coagulation disorders by autologous adipose graft is a simple, uncomplicated, short, and low-cost treatment.

Treatment with botulinum toxin type A for flexed knee in patients with hemophilia

CARLA DAFFUNCHIO,1,2 ANA DOUGLAS PRICE,1 J O R G E N A S S I F , 1 D A N I E L A N E M E 2 and H O R A C I O C A V I G L I A 1 , 2 Hospital General de Agudos Juan A. Fern andez, Ciudad Aut onoma de Buenos Aires, Argentina; and 2Fundaci on de la Hemofilia, Ciudad Aut onoma de Buenos Aires, Argentina


Introduction: Knee flexes remains a common disease in children and young adults with hemophilia, mainly in developing countries where many patients do not have access to replacement therapy. If flexed knee is not treated properly, it produces disability, postural alterations and gait abnormalities, and avoiding ambulation in severe cases. Botulinum toxin type A causes a blockage in the release of acetylcholine at the neuromuscular junction, producing a reversible chemical denervation of the muscle fiber. This reduction in muscle contracture facilitates extension and rehabilitation. Objectives: Our goal was to evaluate the effectiveness of conservative treatment of knee flexes with botulinum toxin type A in PWH. Methods: Seventeen patients were treated, with 21 affected knees. Of these, 15 patients had severe hemophilia A, 2 of them had high response inhibitor and 2 were B severe. Mean age was 26 years (9-52). The mean follow up was 11 months (6-12 m). We evaluated flexion and flexion contracture pre-injection of botulinum toxin and after 15 days, a month, 3 months, 6 months, and a year. Botox application was done in hamstring and calf muscles. The average doses was 60 U (50-100 U) According to the degree of flexion contracture patients were divided in 3 groups: Group I - 10 to -30 (n = 10), Group II of 31 to 45 (n = 6) Group III, > 45 ° (n = 5). The rehabilitation started the same day of injection. Results: The average pre-application flexion was 114° and post-application was 119°. The improvement was 5º (p < 0,113). The average flexion contracture improved from - 38 ° to -24 °. The improvement was 15° (p < 0.001). By group, the average flexion contracture improvement was 9º in group I, 17 º in group II and 23º in group III The difference was statistically significant in all the groups (p < 0.001). Conclusions: This is a low cost and easy treatment with very good results in our experience. It is the first use of Botulinum toxin type A for flexed knee in PWH.

Long term follow-up for total joint replacement in patients with inhibitors: a single-centre experience

PAOLO RADOSSI,1 ALBERTO RICCIARDI,2 F R A N C O W I L L I A M S F U L L O N E , 2 L A U R A C A N D I O T T O 1 and GIUSEPPE TAGARIELLO1 1 Transfusion Service, Regional Centre for Blood Diseases and Haemophilia Centre and 2Orthopaedic Department, Castelfranco Veneto General Hospital, Veneto Region, Italy Introduction: In patients with hemophilia and inhibitors the possibility of planning major surgery was, until a few years ago nearly prohibitted; so, the long-term outcome of total joint replacement (TJR) is still unknown. Methods: From 1997 to 2011, we performed a total of 11 primary arthroplasties in 8 patients affected by severe hemophilia A with inhibitors: 5 had total knee replacement (TKR) and 6 total hip replacements (THR). The median age at the time of surgery was 36 years (range 32 to 59 years). A total of 4 TKR and 5 THR were performed in 6 patients affected by HR inhibitors, 1 TKR and 1 THR were performed in 2 LR patients. In 2 LR and 2 of the HR patients we waited for decline of inhibitor level to less than 5 BU to use FVIII plasma-derived concentrates until possible. In case the titer was more than 5 BU (either at the beginning or following booster dose), patients received rFVIIa. One HR patient underwent two procedures (TKR and THR) during the same session. Results: The mean follow-up period was 9 years (range 2 to 16 years): these procedures may be considered successful for pain relief of pain and improvement of

Haemophilia (2014), 20 (Suppl. 3), 1--186

QoL. Some TJR were characterized by complications: in 1 HR patient one-stage revision was performed to treat infection after 2 years from the primary TKR. The result can be considered successful after 9 years of follow-up. One HR developed late infection of TKR 10 years after the primary procedure; he’s waiting for removal of prosthetic component. In 1 patient a mayor bleed occurred the site of wound with a prosthetic infection. Conclusions: In our view, the presence of inhibitors has not represented a limitation for surgery as hemostasis was under control in all patients. All of our patients underwent surgery by using rFVIIa by continuous infusion: this option represents an advantage in terms of cost-savings. Two patients developed late infections (one E. C coli and one Serratia mercescens). The incidence of infections does not seem higher than infections in not inhibitors patients. In one patient, one stage-removal was performed to decrease morbidity and lower cost with good results at 9 years follow-up.

Further evidence of the very low risk of subclinical deep venous thrombosis among patients with hemophilia undergoing major orthopedic surgery

 ASTIEN LOBET1 C E D R I C H E R M A N S , 1 F R A N K H A M M E R , 2 S EB and C A T H E R I N E L A M B E R T 1 1 2 Divisions of Haematology, and Radiology, Cliniques universitaires Saint-Luc, Universite catholique de Louvain, Brussels, Belgium

Introduction and Objectives: Deep venous thrombosis (DVT) is a common postoperative complication in patients undergoing major orthopedic surgery of the lower limbs, such as total hip replacement (THR), total knee replacement (TKR), or hip fracture surgery (HFS). In the absence of thromboprophylaxis, subclinical venous thrombosis rates as high as 60% have been reported when using systematic bilateral phlebography after orthopedic surgery. As a result, routine pharmacological thromboprophylaxis with low-molecular-weight heparin (LMWH) or a new oral anticoagulant agent is strongly recommended in patients undergoing these procedures. With the availability of efficient and safe clotting factor concentrates, THR, TKR, as well as ankle arthrodesis are frequently performed in subjects with hemophilia suffering from chronic hemophilic arthropathy. Yet, pharmacological prophylaxis of venous thromboembolism (VTE) in this patient group remains controversial. With the exception of retrospective case reports and small series, the incidence of VTE disease in hemophilic patients after major orthopedic surgery is still unclear. Materials and Methods: In 2002, we initiated a prospective study in order to evaluate by systematic US-Doppler imaging the incidence of subclinical deep venous thrombosis (DVT) in consecutive hemophilic patients referred to our centre for major orthopedic surgery. In 2010, we reported that three out of 22 patients undergoing 29 major orthopedic surgeries developed subclinical distal DVT. The overall incidence of DVT of 10% found in our study was significantly lower than that reported in nonhemophilic patients. The study has been prospectively continued and has until September, 2013 included 36 different patients (32 HA, 4HB) undergoing 47 major orthopedic procedures of the lower limbs. Most were treated with continuous infusion of clotting concentrates and all did not receive antithrombotic pharmacological prophylaxis. Results: This follow-up study did not reveal any new case of clinical and subclinical of DVT screened by bilateral US-doppler of the lower limbs. The overall incidence of DVT recalculated on the whole population is 6%. Conclusions: These data provide additional evidence that the risk of DVT following major orthopedic surgery among patients with hemophilia is very low and that systematic pharmacological thromboprophylaxis in this specific population is, for most patients, not required.

Total knee replacement in hemophilic patients and management of bone loss LUIGI PIERO SOLIMENO, ENRICA CRISTINI, T I Z I A N O D O N Z E L L I , P A O L O G O Z Z I N I , P I E R O T E C C H I O and GIANLUIGI PASTA Department of Orthopedic Surgery and Traumatology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy Introduction: Bone loss around the knee in the setting of total knee arthroplasty remains a difficult and challenging problem for orthopedic surgeons. There are a number of options for dealing with smaller and contained bone loss; however, with massive segmental bone loss there are fewer options. Objectives: The objective of this retrospective study was to evaluate the surgical treatment options for bone defect and their clinical and radiological outcomes, in hemophilic patients treated with total knee replacement (TKR). Methods: Data on primary and revision TKR performed in patients with hemophilia A or B and inhibitors at a single centre were reviewed. Bone loss treatment was registered. Orthopedic outcome of TKR was evaluated clinically using the hospital for special surgery knee-rating scale (HSS) and radiologically. Moreover, to better define the functional outcome of prostheses, data on knee flexion contracture and range of motion (ROM) were also analyzed. All these measurements were performed preoperatively and at last follow-up visit. Results: From January 1995 to November 2013 we performed 192 primary total knee replacements and 31 revision surgeries in hemophilic patients. At the end of follow-up period (median duration: 9.1 years), the 93% of implants are still in place, the median HSS is 92, median flexion contracture is 0° and a median ROM of 85°. Small contained defects were treated with cement, morselized autograft/allograft, or metal augments. In case of massive bone loss, allograft was used. Conclusions: Not all bone defects are equal. The surgeon must assess the degree of complexity and have a broad armamentarium available. Principles to consider in bone loss management are defect size and location and patient demographics. For younger or higher-demand patients, the use of allograft is a good option as it provides a durable construct with high rates of union.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

MUSCULOSKELETAL ISSUES Osteopontin as a biomarker for early stages of blood-induced joint disease in hemophilia patients

NARINE HAKOBYAN,1 CANDACE ENOCKSON,2 M I C H A E L M A N C O - J O H N S O N 2 and L E O N A R D A V A L E N T I N O 1 1 Rush University Medical Center, Chicago, USA; and 2University of Colorado Health Sciences Center, Aurora, USA Introduction and Objectives: Development of sensitive, non-invasive biomarkers predictive of early stage joint disease is vital in identifying at-risk patients so that aggressive strategies can be employed to prevent synovitis and arthropathy. Our previous animal studies suggested that osteopontin (OPN), a multifunctional extracellular matrix protein that plays an essential role in the pathogenesis of rheumatoid arthritis and many other diseases, may be a marker of hemarthrosis and hemophilic synovitis. The goal of this study was to analyze the relationship between human plasma OPN and chronic synovitis and hemophilic arthropathy as evaluated by magnetic resonance imaging (MRI). Materials and Methods: Seventy-four subjects with severe hemophilia A or B (ages 2 to 63 years) were included in the study. Plasma OPN concentration of subjects with and without joint disease (diagnosed clinically) was measured by enzyme-linked immunosorbent assay. MRI was performed on a subset of thirty-five subjects with clinically evident synovitis. Images were evaluated and MRI scores assigned for soft tissue (ST) and osteochondral (OC) involvement. Results: The OPN concentration in plasma of immature hemophilia subjects (≤16 years) with clinically diagnosed synovitis was significantly greater compared to age-matched hemophilia subjects without synovitis (202.6  9.505 ng/mL vs. 171.8  6.270 ng/mL, P = 0.0070) and to a reference population of age-matched healthy controls without hemophilia (165.5  6.319 ng/mL, P = 0.0016). Analysis of the relationship between plasma OPN concentration and total MRI score (ST+OC) in subjects with hemophilia showed a statistically significant positive correlation (p = 0.037) in immature but not in mature subjects. Among the immature subjects, the ST component contributed 81% of the total score while among the mature subjects the ST component contributed only 49%. These data are supported by those from animal experiments correlating plasma OPN concentrations and histological changes in the knee joint of mice during early stages of the development of hemophilic arthropathy. Conclusions: Plasma OPN concentration is increased in young hemophilia patients with clinical and radiographic evidence of synovitis and may serve as a biomarker of synovitis, an early manifestation of blood induced joint disease.


From sitting to walking: bilateral total knee replacements for a hemophilia patient with inhibitor, a case study RACHEL TIKTINSKY Sheba Medical Center, Tel Hashomer, Israel Introduction: I.L., a 30-year-old severe hemophilia A patient with high-titer inhibitor presented with advanced arthropathy of both knees. In 2006, the patient had undergone a total hip arthroplasty of the left hip. The hip and knees remained painful and the patient began using a wheelchair on a regular basis. Range of motion of both knee showed flexion contractures of 60 degrees. Both hips showed flexion contractures of 30 degrees. The patient could move independently, but could not stand or walk even with ambulatory aids. In December, 2011, he underwent bilateral total knee replacements. Surgery was performed under therapy with FVIII, rFVIIa and application of fibrin glue. The post operative course was complicated by inhibitor increase, requiring rFVIIa administration prior to any strenuous physical therapy during the rehabilitation period. Objectives: 1. Regain full range of motion in both knees 2. Improve muscle strength in the muscles of the pelvis, hip and lower extremities 3. Regain independent standing and ambulation 4. Improve cardiovascular endurance. Methods: 1. Post op, full range of motion was regained in both knees, although both were unstable for full weight bearing. Lower extremities were casted in plaster longleg cylinder casts for two weeks. The patient stood for a few minutes aided with a walker and two physiotherapists. 2. Two weeks post op, the plaster casts were replaced with fiberglass. Strengthening UE, isometric strengthening the quadriceps, continued standing and commencing ambulation. 3. Four weeks post op, the casts were opened to allow active knee flexion and extension. 4. Six weeks post op, improved ambulation, knee braces were worn during all activities. 5. Hydrotherapy and ambulation using the anti-gravity walker. 6. Increasing strength using sling systems and weights. 7. Ten weeks post op, ambulation with Canadian crutches improving distances and improving hip extension. Results: Currently, 2 years post op, the patient has full knee range of motion and he has -15 degrees to extension bilaterally in hip range of motion. There is an improvement in cardiovascular endurance as the patient can ambulate 1.2 km. The patient is fully independent in all ADL including ambulation, driving, chores in the home and working as an assistant paramedic. Conclusions: Whereas, in the past, there were no options for patients with inhibitors, now there are various solutions to difficulties otherwise encountered. The progress in hemophilia treatment has helped this patient overcome huge obstacles and achieve his goals of independence.

Bilateral total knee arthroplasty in patients with hemophilia: a safe and cost-effective procedure SM JAVAD MORTAZAVI Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran Introduction and Objectives: The benefits and risks of simultaneous bilateral total knee arthroplasty (TKA) in the general population remain controversial. The major risk of bilateral procedure relates to patients comorbidities and may lead to increase risk of mortality and morbidity. However, in the general population, TKA is usually perform in elderly patients with several comorbidities. Patients with hemophilia frequently have bilateral knee involvement and do not have any comorbidities other than bleeding diathesis. It is our purpose of to see if simultaneous bilateral TKA in patients with hemophilia is safe and cost-effective. Materials and Methods: We did 6 bilateral simultaneous TKA in 6 patients with hemophilia between January, 2010 and 2012. We then matched them, based on age at the time surgery, to a group of patients who underwent staged bilateral TKA at an earlier time. We compared operative time, length of stay, amount of factor used, functional scores and patients’ satisfaction in both groups. Results: At the latest follow up, which was after 18 months for patients and 46 months for controls, there was no significant difference in knee society and functional scores. The mean operative time for patients and controls were 130 minutes and 155 minute, respectively. The amount of factor concentrates used was significantly higher in control groups (more than twice). There were no significant complications in both groups. Lengths of hospital stay were 7.5 days in patients and 8.5 days in controls for each admission. There was no difference in patients’ satisfaction in both groups. Staged bilateral cases utilized resources simultaneous to a bilateral ones. Conclusions: Our study, with its acknowledged limitations, showed that bilateral simultaneous TKA in patients with severe hemophilia is a safe and rewarding procedure. It is of utmost importance if we consider the fact that most of these population are younger patients with multiple joint involvement in developing countries with limited resources, therefore, a 50% decrease in the cost of the procedure makes it cost-effective.

Joint outcome evaluation by magnetic resonance imaging: results at the 3-year evaluation in the SPINART study

W A L T E R H O N G , 1 D A V I D R A U N I G 2 and B J O R N L U N D I N 3 Bayer HealthCare Pharmaceuticals, Whippany, USA; 2ICON Medical Imaging, Warrington, USA; and 3Lund University and Sk ane University Hospital, Lund, Sweden


Introduction and Objectives: The benefits of prophylaxis in preventing joint damage in pediatric patients with hemophilia A are well established. Long-term prospective data are lacking on the effects of routine prophylaxis on joint outcomes in adults with hemophilia A. Joint status was assessed as part of the 3-year SPINART study, which compared routine prophylaxis vs on-demand treatment in adults with severe hemophilia A. Results from the first year of SPINART have been published (MancoJohnson et al. J Thromb Haemost. 2013;11:1119–1127). Here, we report SPINART joint outcome results at year 3, obtained using magnetic resonance imaging (MRI). Methods: Patients were eligible for inclusion in the open-label, randomized, controlled, parallel-group, multinational SPINART study if they were males aged 12– 50 years with severe hemophilia A and had ≥150 exposure days with any factor VIII (FVIII) product, no inhibitors, no prophylaxis for >12 consecutive months in the past 5 years, and 6–24 documented bleeding events or treatments in the previous 6 months. All patients were treated with sucrose-formulated recombinant FVIII (rFVIII-FS), either on demand or as prophylaxis (25 IU/kg 3 times weekly, with dose escalation by 5 IU/kg permitted once per year). MRI was performed at baseline and year 3 (study end) to evaluate the structure of 6 index joints (elbows, knees, ankles). Each joint MRI was read by 3 radiologists blinded to treatment assignment who independently completed the extended MRI scale. The final change score for each of the 45 items in the scale was the median response level of the 3 readers when comparing the MRIs from the different time points. Between-group comparisons of mean change from baseline in total score of the extended MRI scale (prespecified secondary endpoint) using final (3-year) data will be presented.

3-year joint outcomes in the SPINART trial: results using the Colorado adult joint assessment scale Endovascular embolization of the knees and elbows arteries as a therapy of hemarthrosis in hemophilic patients E D U A R D O G A L L I , N O E M I M O R E T T I and H O R A C I O C A V I G L I A Fundacion de la Hemofilia, Buenos Aires, Argentina Introduction and Objectives: It is well known that intrarticular blood produces progressive hemosiderin deposition with synoviocyte hypertrophy and neovascularization of the synovium, which is the basis for the chronic arthropathy seen in people with hemophilia. Selective embolization of the knee and elbow arteries can prevent bleeding episodes and potentially slow down the progression of arthropathy. To evaluate the long-term efficacy of these procedures, we assessed the outcomes of 57 procedures from our centre. Materials and Methods: We performed 57 procedures in 50 hemophilic patients, including 44 knee, and 13 elbow procedures. To evaluate the efficacy of selective embolization of knee and elbow arteries in people with hemophilia, we analyzed the number of bleeding episodes during 12 months before the procedure, compared with the number of episodes that occurred 3, 6, and 12 months after embolization.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

W A L T E R H O N G , 1 D A V I D R A U N I G 2 and S H A R O N F U N K 3 Bayer HealthCare Pharmaceuticals, Whippany, USA; 2ICON Medical Imaging, Warrington, USA; and 3University of Colorado Denver, Aurora, USA


Introduction and Objectives: The benefits of prophylaxis in preventing joint damage in pediatric patients with hemophilia A are well established. Long-term prospective data are lacking on the effects of routine prophylaxis on joint outcomes in adults with hemophilia A. Joint status was assessed as part of the 3-year SPINART study, which compared routine prophylaxis vs on-demand treatment in adults with severe hemophilia A. Results from the first year of SPINART have been published (Manco-Johnson, et al. J Thromb Haemost. 2013;11:1119–1127). Here, we report SPINART joint outcome results obtained using the Colorado adult joint assessment scale (CAJAS), a tool designed to measure the functional status of the 6 main index joints in adults. Methods: Patients were eligible for inclusion in the open-label, randomized, controlled, parallel-group, multinational SPINART study if they were males aged 12– 50 years with severe hemophilia A and had ≥150 exposure days with any factor VIII (FVIII) product, no inhibitors, no prophylaxis for >12 consecutive months in the past 5 years, and 6–24 documented bleeding events or treatments in the previous

Haemophilia (2014), 20 (Suppl. 3), 1--186



6 months. All patients were treated with sucrose-formulated recombinant FVIII (rFVIII-FS), either on demand or as prophylaxis (25 IU/kg 3 times weekly, with a dose escalation of 5 IU/kg permitted once per year). CAJAS assessments were performed at baseline, year 1, year 2, and year 3 (study end). The physiotherapists performing CAJAS assessments were blinded to patients’ treatment assignment, bleeding history, and previous joint assessment data. Between-group comparisons will be performed for mean change in CAJAS scores from baseline to year 3 or last observation carried forward for the mean of the joints with the lower scores at baseline for each joint type (1 elbow, 1 knee, 1 ankle); these comparisons were a prespecified secondary endpoint. Final analyses of (3-year) data will be presented.

The role of biomarkers of joint damage in monitoring the efficacy of different prophylaxis regimens for severe hemophilia

IRENA DJUNIC,1 VIOLETA DOPSAJ,2 ALEKSANDAR LESIC,3,4 PREDRAG MILJIC,1,4 BILJANA MIHALJEVIC,1,4 NADA SUVAJDZIC-VUKOVIC,1,4 DRAGICA TOMIN,1,4 A L E K S A N D R A N O V K O V I C 5 and I V O E L E Z O V I C 1 , 4 1 Clinic for Hematology, Clinical Center of Serbia, Belgrade; 2Institute for Medical Biochemistry, Pharmacy Faculty of Belgrade University, Serbia; 3Clinic for Orthopaedic Surgery and Traumatology, Clinical Center of Serbia, Belgrade; 4Medical Faculty of Belgrade University, Serbia; and 5Clinical Hospital Center “Zemun”, Belgrade, Serbia Introduction and Objectives: The aims of this study were to detect correlations between serum and urine concentrations of biomarkers of joint cartilage degradation and the radiological score for hemophilic arthropathy, as well as to estimate whether measurement of these biomarkers could be useful in monitoring the efficacy of different (secondary) prophylaxis regimens for severe hemophilia. Materials and Methods: This single-centre study included 20 adult males with severe hemophilia, without inhibitor. Five patients with hemophilia A were received prophylaxis with factor VIII (FVIII) concentrate in standard dose 20 IU/kg three times per week, five patients with hemophilia A were received intermediate dose of FVIII concentrate as prophylaxis, 10-15 IU/kg three times per week. Seven patients with hemophilia A and 3 with hemophilia B, were received FVIII/IX concentrate only on demand. The following joint cartilage degradation products were measured: serum cartilage oligomeric matrix protein (COMP) and urinary C-terminal telopeptide of type II collagen (CTX-II). Blood and urine samples were collected initially, before the start of treatment (marked as COMP-1 and CTX-II-1) and after 3 months follow-up (marked as COMP-2 and CTX-II-2). Radiological evaluation of hemophilic arthropathy was estimated initially according to the Pettersson score. Results: The results showed significant positive correlations between the number of points in the Pettersson score and both COMP level (r = 0.602, p = 0.006) and CTXII level (r = 0.580, p = 0.009). In the group of patients given standard dose prophylaxis, the mean value for COMP-2 was significantly lower than that for COMP-1 (p = 0.043). Likewise, in the group of patients treated with standard dose prophylaxis, the mean value for CTX-II-2 was significantly lower than that for CTXII-1 (p = 0.014). Moreover, the mean value of CTX-II-2 was also significantly decreased compared to that for CTX-II-1 (p = 0.028) in the group receiving intermediate dose prophylaxis. Conclusions: Joint cartilage degradation products, such as the biomarkers serum COMP and urinary CTX-II, can provide an estimation of the amount of joint damage in patients with hemophilia. Measurement of serum/urinary biomarker levels is useful for monitoring the efficacy of the applied doses of FVIII in different treatment approaches towards these patients.

Radiological evaluation of patellofemoral joint in hemophilic arthropathy

E L C I L K A Y A B I C E R , 1 S E M I H A Y D O G D U , 1 K A A N K A V A K L I, 2 C A N B A L K A N 2 and H A K K I S U R 1 Departments of 1Orthopaedics and Traumatology and 2Pediatric Hematology, Faculty of Medicine, Ege University, Izmir, Turkey Introduction and Objectives: Recurrent bleeding episodes affect the patellofemoral compartment as well as the tibiofemoral compartment of the knee joint. During the course of the hemophilic arthropathy chronic, progressive, and irreversible changes develop inevitably in the distal femur and patella. The aim of this study was to evaluate quantitatively the radiological changes of the patellofemoral joint with respect to the severity of joint involvement. Materials and Methods: Thirty-three knees of 24 male patients with a mean age of 30.30  12.67 (range, 13 to 57) were included in this retrospective study. To assess the severity of joint involvement, Pettersson scores (PS) of 32 knees were determined on conventional knee radiographs, zero being the best and 14 being the worst score. The knees were grouped into two as mild-moderate with PS equal to and less than seven (14 knees, group I), and severe with PS greater than seven (18 knees, group II). The dimensions of patella (mediolateral length and anteroposterior width) and distal femur (length of transepicondylar axis (TEA), and sulcus (S)) were measured on axial MRI or CT sections and the results were adjusted with respect to the magnification ratios. Statistical analyses were performed utilizing SPSS v16. Statistical significance was set at 0.05. Results: The mean length and width of patella was 40.31  9.32 and 18.04  6.73 in group I, and 43.98  6.56 and 20.19  7.14 in group II, respectively. Despite being insignificant in group II, patella was found to be larger and longer (p = 0.393 and 0.201, respectively); the distal femur widened with an increase in length of TEA (p = 0.583). The length of sulcus and ratio of S over TEA increased in group II. Patellofemoral synostosis was observed in one patient. When patients were grouped according to their ages (below and above 25), the ratio of length of patella over TEA was significantly greater in the older group (p = 0.041. Conclusions: The typical morphological changes in the patellofemoral joint develop in accordance with the progression of hemophilic arthropathy, though the difference in the findings of cases with advanced and mild involvement are not statistically significant.

Haemophilia (2014), 20 (Suppl. 3), 1--186

Radioisotope synovectomy in patients with hemophilia: single-centre experience

TURKAN PATIROGLU,1 EKREM UNAL,1 MEHMET € KAN MUTLU,1 MUSTAFA KULA,2 A K I F O Z D E M I R , 1 F A T M A T UR  N A Y 4 and M U S A K A R A K U K C U 1 € E Y , 3 S E L I M D O GA A H M E T G UN Departments of 1Pediatric Hematology; 2Nuclear Medicine; 3Orthopedia; and 4 Pediatric Radiology, Erciyes University Medical School, Kayseri, Turkey Aim: Hemophilic arthropathy represents the most common clinical manifestation of hemophilia, related to recurrent hemarthoses and chronic synovitis. Hemophilic arthropathy is radiologically characterized by destructed articulation, bone deformities, complete closure of intra-articular spaces. Surgical synovectomies are not cost-effective procedures whereas radioisotope synovectomy (RS) is both a less invasive and inexpensive procedure. It is accepted that RS is the gold-standard of therapy before surgical synovectomy. We aimed to investigate the efficacy and complications of RS in patients with hemophilia. Material and Methods: Twenty-five RS were performed over the past five years in 12 patients with hemophilia A and B, age range 6-21, mean (11 years) at the time of RS. We preferred to use Yttrium 90 (Y90) for knees and ankles, and Erbium 169 (Er169) for elbows. Radioisotopes such as Y90 and Er169 were injected intra-articularly for treating target joints and chronical synovitis. Results: We have evaluated our experience for knees (n:12), for ankles (n:9) and for elbows (n:4) in a total of 25 RS procedures for 12 patients. Afterward, RS joint bleedings were decreased for all patients. Radioisotop injections were repeated three times in the right ankle of one patient. We observed local hematoma after RS in three patients. For elbows, RS with Er 169 seems to be a safe treatment method. Conclusions: We observed that RS was a safe and efficient therapeutic strategy.

Long-term evaluation of synovectomy and synoviorthesis on the evolution of joint damage: what’s happened after 30 years of follow up? NICOLA GHIDELLI, CHIARA AMBAGLIO, FABIO LODO, A L I C E T R I N C H E R O , F E D E R I C A Z A N E , N A D I A M O N T A N I and GABRIELLA GAMBA Universit a degli studi di Pavia, Pavia, Italy; IRCCS Policlinico San Matteo, Hemophilia Centre, Pavia, Italy Background: During 70s new therapeutic approaches were introduced for the treatment of hemophilic hemarthrosis. Eliminating the site of intra-articular bleeding synovectomy and chemical synoviorthesis (CS) could resolve recurrent bleedings and possibly prevent the development of chronic arthropathy. Objectives: Our aim was to evaluate, through 30 years of follow-up, the progression of hemophilic arthropathy and the frequency of total joint replacement (TJR) in patients previously treated with synovectomy or CS with osmic acid for recurrent hemarthrosis in knee or ankle. Patients: We assessed 14 patients affected by hemophilia A or B, 12 with severe disease and 2 with moderate disease, aged between 42 and 68 yrs (mean age 55 yrs). In total, 8 pts were treated exclusively with synovectomy (of these, 7 treated before age 20, and 1 after), 3 pts exclusively with CS (1 treated before age 20 and 2 after), and 3 pts with both treatments before age 20. Results: At the time of observation, all the patients have developed severe hemophilic arthropathy. Seven patients were treated with TJR of knee and 5 of these needed a bilateral knee TJR. Three patients have refused TJR although there were clinical indications. Two patients died of causes unrelated to hemophilia. All the joints replaced have been previously treated with synovectomy or CS. All the patients not subjected to TJR identified as target joint of chronic arthropathy those joints treated with synovectomy or CS. Conclusions: Although synovectomy and CS are still considered in development countries as efficient hemostatic techniques due to their ability to reduce number of bleedings in short-term follow up, they are not able in long term to prevent the development of hemophilic arthropathy and the need of TJR.

A combined ultrasonographic and simple radiographic study for hemophilic arthropathy

JAE HYUNG KIM,1 CHUR WOO YOU,2 KANG JAE JUNG,1 DO W O N H W A N G 1 and J U N G H W A N K I M 1 Departments of 1Physical Medicine and Rehabilitation and 2Pediatrics, Eulji University Hospital, Eulji University College of Medicine, Daejeon, Korea Introduction and Objectives: The evaluation of hemophilic joint conditions is very important not only for staging the joint damage but also for the follow-up of prophylaxis and for providing a proper rehabilitative approach. Hemophilic joint disease can be diagnosed by various imaging studies. However, with X-ray it is difficult to find early joint pathology and adjacent soft tissue structures, and ultrasonography has limitations in evaluating internal bony structures. The MRI provides more complete information. However, it is too expensive, and may be cumbersome in young children who require sedation. We assessed whether a combination ultrasonography and simple radiography could be used as a cost-effective imaging tool for the evaluation of hemophilic joints and adjacent structures and reflect the functional status in hemophilic patients. Materials and Methods: Thirty-six males (mean age 16.89  12.58 years, severe 34, mild 2) with hemophilia were recruited. We used the modified ultrasonographic score (US) for hemophilic arthropathy. The joints were consecutively evaluated and scored for effusion, cartilage damage, synovial hypertrophy, hemosiderin, hemarthrosis, and fibrotic septa with ultrasonography in all patients on the knee, ankle joints. We evaluated the severity of hemophilic arthropathy on the X-ray was determined using the Petterson scale (PS). Hemophilic joint function was assessed using the Gilbert scale and hemophilic joint health score (HJHS). We assessed functional independence score in hemophilia (FISH) and hemophilia activities list (HAL) for the functional level of ADL. We performed a correlation analysis between the imaging score and the joint impairment scores as well as the functional scores.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

MUSCULOSKELETAL ISSUES Results: 1) The mean score of modified US was 4.97  3.99 points and the mean score of PS was 2.85  2.91 points, then a combination score was 7.83  6.31 points. 2) HJHS was 2.97  5.09 and Gilbert score was 3.53  5.45. 3) HAL score was 89.80  15.11 and FISH score was 30.29  3.22. 4) The combination score (PS+modified US) showed a significant correlation with HJHS (p = 0.006) and Gilbert score (p = 0.019) as well as with HAL score (p = 0.002). Conclusions: A combination of simple radiological and ultrasongraphic evaluation might ultimately impact on the optimal evaluation of joint impairment and functional status in hemophilic patients.

Use of knee mega-endoprosthesis in the treatment of massive hemophilic pseudotumor YOSHVIN SUNNASSEE, WEIBIN ZHANG, JIANQIANG XU, R O N G W A N and Y U H U I S H E N Ruijin Hospital, Shanghai, China Introduction and Objectives: Massive hemophilic pseudotumors (MHP) in the distal femur region are rare and difficult to treat. They can cause severe bone reabsorption, loss of soft tissue, massive swellings and complete loss of motion and in the knee and inability to bear weight. The only treatment currently available is amputation. Two such patients were treated with a knee mega-endoprosthesis and we aimed to study the viability of this treatment and compare the post-operative results with total knee arthroplasty (TKA) for hemarthrosis. Materials and Methods: Two type A hemophiliacs were treated with a two-stage surgical protocol. In the first stage, a medial approach to the femur was used to incise and drain the MHP. All bleedings were cauterized or ligated, the hard outer lining of the pseudotumor was resected and a bone cement spacer was placed to form a pseudo knee joint with the tibia. Following rehabilitation, the patient regained satisfactory muscle strength around the knee and recurrence of the pseudotumor was closely monitored. When the condition of surrounding soft tissue was good for prosthesis implantation, the spacer was replaced with a knee mega-endoprosthesis one year after the initial surgery. Results: The mean age of the two patients at time of admission was 17-years-old and the mean follow-up time was 18 months. One patient was successfully implanted with prosthesis and his range of motion was then from 2o to 91o. The functional knee society score value increased from 0 to 85. The patient reached 90 o flexion 3 months after the second stage and X-rays showed no signs of loosening. The second patient witnessed a recurrence of the hemophilic pseudotumor after the first stage and his knee had to be amputated. Conclusions: Use of mega-endoprosthesis for MHPs is a new and viable treatment protocol. Early post-operative results are on par with those obtained with TKA posterior-stabilized implants. Achieving success depends on the ability to prevent hematoma recurrence. Therefore, staging of the surgery and careful management of deficient coagulation factors are of prime importance in achieving good post-operative results and preventing complications. More cases are needed to improve the surgical technique and post-operative results.

Ankle impingement: arthroscopic treatment of anterior osteophyte in patients with hemophilia

ANA DOUGLAS PRICE,1 GUILLERMO CAMBIAGGI,1 A L E X I S E L J A T I B , 1 D A N I E L A N E M E , 2 M I G U E L C A N D E L A 2 and HORACIO CAVIGLIA1,2 1 Hospital General de Agudos Juan A. Fern andez, Ciudad Aut onoma de Buenos Aires, Argentina; and 2Fundaci on de la Hemofilia, Ciudad Aut onoma de Buenos Aires, Argentina Introduction and Objectives: The hemophilic joint is prone to bleed with trauma. A spontaneous bleed could occur in severe hemophilic patients (< 1% activity coagulation factors). Anterior impingement is made when there are clinical symptoms and signs of pain and dorsiflextion limitation in the anterior ankle region. Imaging studies, such as as Rx and MRI, have to be performed. This pathology can lead to important disability in patients with hemophilia.The aim of this work is to evaluate the arthroscopic treatment of painful ankle arthropathy with movement limitation and anterior osteophyte. Material and Method: Twelve ankles in 11 patients underwent surgery, all of them with ankle anterior osteophyte, with pain and movement limitation. The mean age was 24  8. There were 5 (41.7%) patients with hemophilia A, moderate, 6 (50%) with hemophilia A severe, and 1 (8.3%) with hemophilia B, severe. AOFA (American Orthopaedic Foot and Ankle Society) score was taken before surgery. Imaging studies were performed to demonstrated the lesion. Ankle arthroscopy with anterior osteophyte resection was performed in all patients. All of them have 6 weeks without weight bearing. Mean follow-up was 18.5 months (5-37 months). Six months after surgery AOFAS score was taken again to evaluate progress. Results: According to the AOFAS score, significant differences between 44 preoperative patients and 78 postoperative patients 78 were found (p < 0.001). There was an improvement in the patients’ clinical results, in all patients there was decreased pain and patients were able to resume their daily activities. Conclusions: Arthroscopic treatment a shorter surgery time than open surgery, and this is a benefit to hemophilic patients. Arthroscopic treatment shows significant improvement based on AOFAS score, and improves the quality of life of patients.

Fractures in patients with hemophilia: our experience over 27 years

HORACIO CAVIGLIA,1,2 GUSTAVO GALATRO,1,2 CARLA DAFFUNCHIO,1,2 NOEMI MORETTI,2 D A N I E L A N E M E , 2 A N A D O U G L A S P R I C E 1 and M A R IA L A N D R O 1 1 Hospital General de Agudos Juan A. Fern andez, Ciudad Aut onoma de Buenos Aires, Argentina; and 2Fundaci on de la Hemofilia, Ciudad Aut onoma de Buenos Aires, Argentina Introduction and Objectives: Hemophilia is a very old disease; before the advent of factor concentrates the expected median survival time in a person with severe

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


hemophilia was close to 30 years. When safe products became generally available during the late 1980s and especially with the advent of recombinant products in the earl’s 1990s, physicians could focus on effective replacement therapy. Fractures in patients with hemophilia have changed with the advances in replacement therapy. No publications on the epidemiology of replacement therapy are available. The purpose of this paper is to show the epidemiological analysis of our experience over the past 27 years, treating patients with hemophilia who suffered fractures. Materials and Methods: In this work we present our experience at the Buenos Aires Hemophilia Center over the last 27 years (1986-2013). We treated 151 fractures in 140 patients with hemophilia. For this analysis we divided the patients into 5 groups according to the period when the fracture occurred: 1986-1990, 1991-1995, 19962001, 2002-2007, and 2008-2013, and classified the fractures in the lower limb (LL) and upper limb (UL). Results: The incidence of presentation of fractures of the UL and LL has varied through the years, During the first period analyzed (1986/90) it was 76.2% in LL and 23.8% in UL, and in the last period analyzed (2008/2013) was 37% in LL and 63% in UL. This result shows a significant difference. Also, we can see a decrease in the mean age of patients over the years. Conclusions: Fractures in patients with hemophilia have changed with advances in replacement therapy; fractures are more common in young patients and more frequent in upper limbs. This change may be due patients’ active lifestyles and the advent of new, efficacious and accessible treatments for this disease.

Hemophilic pseudotumors treatment in patients with inhibitors

HORACIO CAVIGLIA,1,2 GALATRO GUSTAVO,1,2 MIGUEL CANDELA,2 NOEMI MORETTI,2 DANIELA NEME,2 A N A D O U G L A S P R I C E 1 and M A R IA L A N D R O 1 1 Hospital General de Agudos Juan A. Fern andez, Ciudad Aut onoma de Buenos Aires, Argentina; Fundaci on de la Hemofilia, Ciudad Aut onoma de Buenos Aires, Argentina; 2 and Fundaci on de la Hemofilia, Ciudad Aut onoma de Buenos Aires, Argentina Introduction: The hemophilic pseudotumor is a serious complication in patients with hemophilia that can lead to disability and even death. The new mini-invasive treatments have reduced the number of amputations and disabilities. The development of inhibitors against factor VIII (FVIII) or IX (FIX) is the most serious complication of replacement therapy in patients with hemophilia. The purpose of this study is to show our experience in the treatment of 9 pseudotumors in 7 patients with inhibitors treated by the same multidisciplinary team. Methods: Seven patients had 9 pseudotumors. Seven pseudotumors had bone location: 2 in femur, 2 in tibia, 2 in calcaneus and 1 in cuboid.Two were found in soft tissues, one in the arm and another, in the thigh. All patients underwent radiography and magnetic resonance imaging (MRI) at baseline to assess the size and content of the lesion. The patients received the Buenos Aires protocol as conservative treatment of their pseudotumors for 6 weeks. After 6 weeks of treatment, the patients underwent a new MRI of each pseudotumor to assess the response to treatment. Results: Of the 7 patients with 9 pseudo tumors, only one responded to conservative treatment. In the other 6 patients, the pseudotumor was reduced by less than 50% of its original size, and surgery was performed. All procedures were performed by the same multidisciplinary team. Conclusions: The only effective treatment to prevent pseudotumors is the timely treatment of bleedings in the musculoskeletal system. Given the proper hemostatic coverage, and by applying new and adequate surgical techniques, pseudotumor surgery in inhibitor patients with hemophilia is possible, improving the quality of life of these patients.

Chemical synovectomy with rifampicin for hemophilic arthropathy in Korea

KI-YOUNG YOO,1 JI-YOUNG LEE,2 DON-KYU KIM,2 T A I - J U H W A N G , 1 K Y U N G - M O O K S E O 2 and S I - H Y U N K A N G 2 1 Korea Hemophilia Foundation, Seoul, Korea; and 2Chung-Ang University, Seoul, Korea Objectives: The aim of this study is to evaluate the effectiveness of chemical synovectomy using rifampicin in Korean hemophilic patients. Methods: From January, 2012, we performed chemical synovectomy using rifampicin at 30 joints of 28 hemophilic patients with a diagnosis of hemophilic arthropathy stage I-III (based on Fernandez-Palazzi clinical classification); 9 elbows, 9 knees, 12 ankles. Radiographic staging using Arnold- Hilgartner radiographic scale was also checked. All patients were males and mean age was 18.28 years (range, 5-40 years). Patients were covered with factor concentrate up to 50% before intra-articular injection. The dosage of rifampicin (Rifaldinâ, Aventis Pharma, Madrid) used for the knee was 500 mg with 7-10 ml normal saline. Intra-articular injection of rifampicin was done every two weeks consecutively with total number of injections ranging from four to six. For elbow and ankle, the dosage of rifampicin was 250 mg with 3-5 ml normal saline. All the procedure was done under the guidance of ultrasonography. During follow-up, both clinical assessment, including bleeding frequency, pain, joint physical status, and radiological staging were evaluated as part of the WFH scoring system. Physical status evaluation included swelling, muscle atrophy, axial deformity, range of motion, etc. The WFH pain score was used to describe patients’ subjective joint pain as follows: grade 0 (no pain) to grade 3 (severe). Patients were asked to score their satisfaction on a scale from 1 (not satisfied) to 10 (completely satisfied). Overall outcome was derived from post-injection functional status and clinical features, according to the following scale; excellent, good, fair, and poor. Results: According to the WFH system, mean frequency of hemarthrosis was reduced from 2.02  0.76 per month to 0.3  0.43 per month (p < 0.01). The mean pain score decreased from 2.13  0.63 to 0.67  0.71 (p < 0.01). The mean joint physical score was reduced from 5.6  2.60 to 3.5  3.13 (p < 0.01). The mean subjective satisfaction score improved from 2.5  1.04 to 7.23  1.55 (p < 0.01). After treatment, the radiographic stage was unchanged in most joints (p > 0.05).

Haemophilia (2014), 20 (Suppl. 3), 1--186



Conclusions: Chemical synovectomy using rifampicin appeared to be effective in stabilizing chronic hemophilic athropathy, reducing the bleeding frequency and degree of pain. Chemical synovectomy using rifampicin is a cost-effective, simple, and practical method in the management of hemophilic arthropathy.

Elective major surgery in hemophiliacs: Istanbul experience

GULEN TUYSUZ,1 BULENT ZULFIKAR,2,6 ONDER KILICOGLU,3 FATIH DIKICI,3 BASAK KOC,2 € O G L U 5 and F I K R E T B E Z G A L , 6 N E C D E T A R A S , 4 R E C E P G UL OMER TASER4 1 2 Departments of Pediatric Hematology and Oncology Institute Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey; Departments of 3Orthopedics and Traumatology; 4Urology and 5Emergency, Istanbul University, Istanbul, Turkey; and 6 The Hemophilia Society of Turkey Objective: To review the perioperative management and outcome of elective major surgical procedures in severe and moderate type hemophiliacs. Methods: Data pertaining to major surgeries from 1996 to 2013 at our centre were retrospectively analysed. All operations were elective and a plan for management of hemostasis was prepared for each patient. Results: During this period, 114 major surgeries were performed on 81 hemophiliacs (72 with hemophilia A and 9 with hemophilia B). Their median age was 25 years and range was 3 months-72 years. Four of these patients had high responding inhibitors against FVIII during their surgical procedures. Fifty seven of 72 hemophilia A and 6 of 9 hemophilia B patients had severe disease (factor level 45 ° (n = 5). Results: There is a correlation between post-treatment flexion contracture and total score of the survey (R = 0, 73). When group membership was included in the analysis, results were higher (R = 0, 77). Conclusions: Group I patients had a better functional outcome.

The importance of joint ultrasound to improve adherence to treatment in children and adolescents with hemophilia M A R T A M I L A N , F A B I O D A L L A V A L L E , E M I L I A N O D E B O N and EZIO ZANON Hemophilia Center, Internal Medicine, University of Padua, Padua, Italy Introduction and Objectives: Prophylaxis with FVIII or FIX concentrates is the first therapeutic option for preventing hemophilic arthropathy in hemophilia A or B patients. It is established that joint damage occurs before symptomatic hemarthrosis, and subclinical detection of joint modifications could lead to therapeutic changes. Joint ultrasound (US) examination is a low-cost, readily available, operator-dependent technique and may be helpful in detecting subclinical damage, in evaluating the efficacy of treatment regimen and improving adherence to therapy as well as monitoring the effectiveness of therapeutic changes.

Haemophilia (2014), 20 (Suppl. 3), 1--186

Materials and Methods: We performed US evaluation of the knee, elbow and ankle in 20 people with hemophilia aged under fourteen: 18 with hemophilia A, and 2 with moderate hemophilia B. In total, 17 patients were on prophylaxis (15 on standard regimen) and 3 on demand. The severity of joint damage was assessed by US score with a value >5 used as a cut-off for joint damage and as a decision-making tool to change therapeutic regimen. In patients undergoing a therapeutic switch, US joint examination was repeated after six months to evaluate whether there was any improvement in US score. Results: A total of 150 joint US scans were performed. Average US score at time zero was: 1.9  2.4. In 5 children (3 on prophylaxis, 2 on demand) US results led to modifying the existing treatment regimen. As expected, a statistically significant difference in joint damage severity was found in patients receiving on-demand or modified scheme prophylaxis (4/5) compared to patients receiving standard prophylaxis (1/15) p = 0.007 (OR 8.12 95% CI 1.83-86.8). US examination at six months showed statistically improved state of joints in all 5 patients (average US score time zero 5.8  0.84 points vs 4  1 points at six months, p = 0.016). An improvement in synovial hypertrophy was detected at six-month examination and no sign of intra-articular activity or joint effusion was found in any of the patients. Conclusions: Joint ultrasound could become an indispensable tool to evaluate efficacy of therapeutic strategy and improve adherence to treatment in patients with hemophilia.

Outcome after total knee arthroplasty in hemophilic patients with stiff knees

ANDREAS C. STRAUSS,1 MARTIN WESSLING,1 € LLER,1 G E O R G G O L D M A N N , 2 M A R C U S C . M UL RICHARD PLACZEK,1 AXEL SEUSER,3 J O H A N N E S O L D E N B U R G , 2 D I E T E R C . W I R T Z 1 and PETER H. PENNEKAMP1 1 Department of Orthopedics and Trauma Surgery, University of Bonn, Germany; 2 Institute for Experimental Haematology and Transfusion Medicine, University of Bonn, Germany; and 3Centre for Orthopedics, Rehabilitation and Prevention, Bonn, Germany Introduction and Objectives: Outcomes after total knee arthroplasty (TKA) in stiff knees are considered to be inferior compared to those with better preoperative range of motion (ROM). There is only very limited data on the results of primary TKA in hemophilic patients with stiff knees. The purpose of this retrospective study was to evaluate the clinical outcome after TKA performed in hemophilic patients with stiff knees. Materials and Methods: In total, 21 consecutive patients with end-stage hemophilic arthropathy of the knee with a preoperative range of motion of 50° or less were included. All but one patient was positive for either HIV or hepatitis C. Mean followup was 6.6 years (range, 1-24 years). Clinical assessment included range of motion (ROM), flexion contracture, and complication rate. Functional evaluation and pain status were evaluated using the knee society scoring system. Results: Mean ROM improved from 27.1° (range, 10°-50°) preoperatively to 75.2° (range, 40°-105°) after the operation. Mean preoperative flexion contracture decreased from 21.9° (range, 0°-45°) to 7.6° (range, 0°-20°). Mean knee society score increased from 23.7 points (range, 12-45) to 72.9 points (range, 49-86). These differences were statistically significant (p < 0.05). The overall complication rate was 14.2% including one deep periprosthetic infection leading to implant removal, and two hematomas requiring surgical decompression. Conclusions: TKA for stiff knees in patients with hemophilia provides substantial improvement of knee function and quality of live. Complications may be attributed to the extended surgical exposure and the high rate of concomitant virus infections in this cohort of hemophilic patients.

How to evaluate the state and the progress of hemophilic joints with no or only mild hemarthropathy in routine and research AXEL SEUSER,1 CLAUDE NEGRIER,2 C L A U D I A D J A M B A S K H A Y A T 3 and L I L Y H E I J N E N 4 Center for Prevention, Rehabilitation and Orthopeadics, Bonn, Germany; 2 Hematology Department, Edouard Herriot University Hospital, Lyon, France; 3 H^ otelDieu de France Hospital, Beirut, Lebanon; and 4Van CreveldKliniek UMC Utrecht, The Netherlands


Introduction and Objectives: We need a tool or combination of tools that are useful in detecting early alterations. Materials and Methods: Assessment of clinimetric tools was done by clinical relevance, disease specificity, feasibility, content validity, and sensitivity to change. To get a more functional, joint-specific and therapy-focused impact,, we decided to add the integrative model of joint function and evaluate the power of the tools on describing structure (form closure), force closure, motor control and neural control. As we wanted to figure out an early input of the tools we integrated their use in children (3y) into our evaluation system. The general basis of evaluation should be the concept of the motion pattern generator, thus adding the brain-muscle-joint axis and the concept of neural motor processing to the evaluation. As for assessment, we used the literature data and if not available we gathered expert opinion. We tried to figure out how useful the tools are at different stages of hemarthropathy: low level, medium level, and high level of hemarthropathy. Then we scored 0 for none, 1 for low, 2 for medium and 3 for high impact of the different clinimetric tools on the different items. Results: There is not a single tool that fits all clinimetric needs. We have to combine different tools for a high percentage of coverage. All PWH start their lives with healthy joints. We could not find scores or QoL measures strong enough or sensitive enough to differentiate early changes in joints. Most of the common tools cover the medium to highly-damaged joint. The only tools to detect early changes in the locomotive system and which are suitable for prevention are examination for silent symptoms, thermography, MRI, ultrasound, superficial kinetic EMG and 3D motion

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd



analysis. Complex therapy interventions are only individualised using skEMG and 3DMA. Conclusions: The new insights into the pathology of hemarthropathy makes it necessary to use more sensitive clinimetric tools that describe very early changes that are related to silent bleeds and with the possibility of individual therapy intervention. We might need different measurement kits for different age groups, stages of illness, or which are suitable for children. Very simple tools like the goniometer or tools for measuring circumference, lack validity and should only be used as additional acute phase instruments. We need a study to determine whether early physiotherapy will change joint evolution.

Conclusions: Once arthropathy begins, it worsens according to its natural course despite maintained or increased physical activity levels. However, a significant reduction in the incidence of synovitis might play a role in reducing the need for medications, minimize or delay the onset of joint injury and encourage physical activity.

Acute hemarthrosis in hemophilic mice results in expansion of mesenchymal progenitor cells: a novel mechanism of arthropathy

Introduction and Objectives: Repeated hemarthroses result in destructive arthropathy in hemophilia patients. The aim of the study was to assess the correlation between ultrasonographic (USG) score and clinical evaluations in hemophilic knee and ankle arthropathy. Materials and Methods: A total of 56 hemophilia patients who had been followed at our hemophilia centre, without major knee or ankle surgery were studied. We collected clinical information including age, hemophilia type, disease severity, factor inhibitor and SF-36. Bilateral knees and ankles were evaluated in terms of range of motion (ROM), visual analogue pain scale (VAS), Pettersson score by X-ray and USG score by ultrasound on the same day. Correlations were assessed by the Spearman’s correlation coefficient. Results: Fifty-five hemophilia A and 1 hemophilia B patients were enrolled. The mean age was 29.59  14.1 years (range, 18 to 63 years). The USG abnormalities were found in 86/112 ankles (76.8%) and 69/112 knees (61.6%). As determined by X-ray evaluations, 61/112 ankles (54.5%) and 44/112 knees (39.3%) had hemophilic arthropathy. There was a strong correlation between USG score and Pettersson score (r = 0.894, p < 0.001). Significant correlations were also noted between USG score and age (r = 0.684, p < 0.001), hemophilia severity (r = 0.351, p = 0.008), ROM (r = -0.862, p < 0.001), VAS (r = 0.502, p < 0.01), SF-36 (r = -0.430, p = 0.001). Conclusions: Our findings suggest that USG score is a useful tool to evaluate hemophilic knee and ankle arthropathy and even detected abnormalities in the joints that radiography shows to be normal. USG score also correlates with many clinical variables of hemophilic knee and ankle arthropathy. We believe that USG score is an optimal assessment tool for early detection and follow-up monitoring of hemophilic arthropathy.

A N N E T T E V O N D R Y G A L S K I , 1 , 2 M E R I S S A O L M E R 2 and MARTIN LOTZ2 1 University of California, San Diego, USA; and 2The Scripps Research Institute, La Jolla, USA Introduction and Objectives: The sequence of pathophysiological tissue changes after hemophilic joint bleeding is incompletely understood. To address this, we studied the time course of histopathological and molecular changes in response to acute hemarthrosis in a joint injury model in FVIII-deficient mice. The objective was to improve our understanding of hemophilic arthropathy as a prerequisite for novel intervention strategies in hemophilia. Materials and Methods: FVIII-deficient mice were subjected to frontal subpatellar right knee needle injury. Bleed induction was ascertained by visual inspection and hematocrit measurements. Histopathological changes were studied 4, 7, 14, 30, and 75 days after injury (n = 5 per group for each time point) and compared to changes in the uninjured left knee. Alterations of cartilage, synovium and vascularity were determined by semi-quantitative scoring systems after staining with Safranin-O-fastgreen. Cell proliferation index and phenotypic characterization of cells were performed by immunohistochemistry using proliferating cell nuclear antigen (PCNA), mesenchymal progenitor (a-smooth muscle actin, Stro-1, CD105) and leukocyte (CD45) markers. Results: Joint bleeding post-injury was significant in all mice. Mean hematocrit decreased from 47% at baseline to 31% on day 2 (p < 0.001). Erythrocytes were present in all injured joints until 14 days post-injury with hemosiderin depositions in adjacent tissues thereafter. Compared to the uninjured knee, significant synovial and stromal hyperplasia with maximum scores was already present at day 4 and persisted through day 14. On day 14, the number of vessels had increased ~3-fold, and the percentage of large vessels ≥ 20 lm (normal 10 lm) ~2-fold (p < 0.03 for both). The reaction subsided thereafter, with only some mild tissue changes present 75 days postinjury. The tissue reaction was accompanied by strong PCNA staining, bright expression of mesenchymal progenitor markers in the majority of cells in the hyperplastic synovium, and negative staining for CD45. Cartilage changes consisted of transient glycosaminoglycan loss. Conclusions: In a mouse model of hemophilia, acute joint bleeding induces transient strong synovial hyperplasia with neovascularization. Absence of leukocyte infiltration and the presence of many mesenchymal progenitor cells suggest that these are responsible for the rapid tissue reaction. This may be a unique mechanism for prevention of tissue damage.

Four years of experience in a population of patients with hemophilia: a comprehensive musculoskeletal approach H E R M E S A B R E O and M A R I A O R O Z C O Integral IPS, Medellin, Colombia Introduction and Objectives: Therapeutic advances for patients with hemophilia have reduced bleeding, but musculoskeletal conditions (joint and muscle bleeds, arthropathy and synovitis) have occur most commonly. To prevent these conditions impairing the patient’s independence and quality of life, a multidisciplinary approach was taken on the prevention and treatment of these conditions involving orthopedic professionals, physiatrists and physical and occupational therapists. Our objective was to evaluate the incidence of hemophilic arthropathy and synovitis in patients receiving comprehensive treatment and understand its relationship with physical activity. Materials and Methods: From June, 2009 to September, 2013, a group of 48 patients with hemophilia A was periodically evaluated for bleeding episodes, presence of arthropathy and synovitis, and their functional status. Physical therapy, routine home exercises and guidelines for sports were provided. Results: Our forty-eight hemophilia A patients were between 3 – 69-years-old (mean 26). They completed five appointments/patient/year. The table summarizes the evolution of arthropathy and synovitis.

Arthropathy Synovitis



Changes% var

187 22

222 14

+18.7% -36.4%

At the beginning, the maximum number of joints with synovitis per person was four, with greater occurrence in those around 9 years, while the group with no synovitis (average 29 years) showed an inverse relationship between age and synovitis. At the end, there were no more than two affected joints per persons. Arthropathy, however, showed a progressive trend over time. Patients with average age of 54 exhibited up to ten joints affected, the worst being the elbows and ankles. All patients performed weekly physiotherapy 1.31 times at the clinic and 0.9 times at home. On follow-up, this ratio was 1 and 1.13, respectively. At the start, 20 patients were practicing sports (swimming, cycling, gym), which increased to 65% to 33 by the end.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

Correlation between ultrasonographic score and clinical variables in hemophilic knee and ankle arthropathy TSUNG-YING LI, LIANG-CHENG CHEN, SHIN-NAN CHENG, R U - Y U P A N and Y E U - C H I N C H E N Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan

Role of orthopedic care in hemophiliac arthropathy: experience with 101 procedures

RADOVAN KUBE S, 1 P A V E L D U N G L 1 and P E T R S A L A J 2 Municipal Hospital Bulovka, Orthopaedic Clinic 1st. Medical Faculty, Charles University, Prague, Czech Republic; and 2Institute of Hematology and Blood Transfusion (IHBT), Prague, Czech Republic


Introduction and Objectives: In the entire population of the Czech Republic (10 million inhabitants), there are about 800 registered hemophiliac patients and orthopedic care for these patients is concentrated in our clinic. Materials and Methods: Each year we regularily examine 156 registered patients at our centre. This means that we have continuous retrospective results. During each evaluation we take an X-ray of operated and targeted joints and also conduct a physical examination. Results: From 1994 till end of 2013, we implanted 72 total-knee joint replacements in 41 patients with an average age of 41.3 years. Preoperative ROM was between 15 – 65 degrees of flexion, postoperative ROM was between 6 – 78 degrees on average, clinical score acc. Insall was improved from 28 to 72 points and functional score was improved from 37 to 70 points on average. We also implanted 21 total hip replacements in 17 patients with an average age of 52.3 years. Preoperative ROM was between 2–60 degrees of flexion, postoperative ROM was between 0 – 82 degrees of flexion on average, Harris hip score was improved from 23 to 70 points on average. We also performed one redressement force of the knee joint with good results, 4 ORIF, and 1 spine surgery case. We had no early septic complications, but we had 5% late infections. We had to revise knee replacements 8 times, and one patient died postoperatively due to chronic renal insufficiency related to diabetes. Conclusions: Objective results are, unfortunately, not comparable to “the general arthritic population, but patients are very happy with each functional improvement. We can guarantee patients no bleeding in replaced joints and promise them about 50% improvement in range of motion and functional score, but with the risk of early aseptic or septic loosening. For us, joint replacement the a final option and patients must be realistically instructed. We are strongly against preventive joint replacements.

Total ankle replacement in hemophilia: a single-centre, Seven years of experience

GIANLUIGI PASTA,1 ENRICA CRISTINI,1 MARIA E L I S A M A N C U S O , 2 E L E N A S A N T A G O S T I N O 2 and L U I G I PIERO SOLIMENO1 1 Department of Orthopedic Surgery and Traumatology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy; and 2Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy Introduction: The fusion of the ankle joint has represented the standard treatment for end-stage arthropathy of the ankle in patients with hemophilia. The option of total ankle replacement is still controversial because of limited and poor long-term results. Objectives: This retrospective study was designed to evaluate the mid-term outcome of patients with hemophilia who underwent total ankle replacement by using unconstrained three-component ankle implant.

Haemophilia (2014), 20 (Suppl. 3), 1--186



Methods: Twenty-four total ankle replacements were performed in 23 patients (20 with hemophilia A and 3 with hemophilia B) at a median age of 42 years (range: 1860). Patients were followed up for a median of 36 months (range: 6-72). Outcome measures included clinical (AOFAS-hindfoot score, visual analogue scale for pain) and radiological assessments; QoL was also investigated by using SF-36. All measurements were performed pre-operatively and at least at the last follow-up visit. Finally, a selfassessment questionnaire was administered at the last follow-up visit to evaluate patient satisfaction. Results: No bleeding or other complications occurred in all but 2 surgeries (lateral malleolus fractures). The AOFAS-hindfoot-score increased from a median of 34 (range 8-42) preoperatively to 83 (range 71-93) postoperatively. Twenty-one patients had no more pain after the intervention and pain scoring decreased from a median value of 8 (range 7-9) preoperatively to 0 (range 0-3) postoperatively. The SF-36 scoring system showed relevant improvements in all investigated domains of quality of life in all patients but 1. The vast majority of patients (21/23, 91%) were fully satisfied with the outcome of the procedure. In one patient, the ankle replacement had to be removed for aseptic loosening after 20 months of follow-up and an open arthrodesis was performed. Conclusions: For patients with chronic hemophilic arthropathy of the ankle joint, total ankle replacement is a valuable alternative treatment to ankle fusion.

Long-term functional outcome of primary total knee replacement and arthroscopic procedures in patients with hemophilia and inhibitors: a single-centre study

LUIGI PIERO SOLIMENO,1 MARIA ELISA MANCUSO,2 E L E N A S A N T A G O S T I N O 2 and G I A N L U I G I P A S T A 1 1 Department of Orthopedic Surgery and Traumatology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy; and 2Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy Introduction: The availability of safe and effective bypass therapy (BPT) with either recombinant activated factor VII (rFVIIa) or activated prothrombin complex concentrate (aPCC), has meant that elective orthopedic surgery (EOS) has become a feasible option for patients with hemophilia and inhibitors. Objectives: This retrospective study was designed to assess the long-term functional outcome of primary total knee replacement and arthroscopic procedures in patients with hemophilia and inhibitors. Methods: Data on major orthopedic procedures, such as total knee replacement (TKR) and arthroscopic procedures performed in patients with hemophilia A and inhibitors at a single centre were reviewed. The outcome of TKR was clinically evaluated using the hospital for special surgery knee-rating scale (HSS), and radiologically. In addition, to better define the functional outcome of prostheses, data on knee flexion contracture and range of motion (ROM) were also analyzed. The outcome of arthroscopic procedures was evaluated by measuring ROM, pain (as quantified by the visual analogue scale, VAS), bleeding frequency and the need for additional surgical procedures. All measurements were performed pre-operatively and at least at the last follow-up visit. Results: From January, 1997 to September, 2013, 12 TKRs were performed in 11 patients. The median duration of follow-up per implant was 29 months (range: 7162); 4 implants were removed due to infection (n = 3) or aseptic loosening (n = 1). At the last follow-up visit, the median HSS was 92 (vs 28 pre-operatively) the median flexion contracture 0° (vs 15° pre-operatively) and the median ROM 85° (vs 35° preoperatively). Eleven arthroscopic procedures (8 knees, and 3 ankles) were performed in 10 patients. The median duration of follow-up per procedure was 48 months (range: 1-142). Nine patients showed a post-operative reduction of annual bleeding frequency in the operated joint (median 1 vs 6 episodes/yr) and of pain (median VAS 0 vs 6) and an improved ROM (median 90° vs 50° for the knee, and 60° vs 50° for the ankle). In 2 patients no improvements were registered and further surgery was performed within 1 year. Conclusions: EOS in patients with hemophilia and inhibitors is feasible and can be safely performed with satisfying long-term outcomes.

Surgical treatment of flat foot in Glanzmann thrombasthenia patient ENRICA CRISTINI, ANDREA ARTONI, PAOLO GOZZINI, P I E R O T E C C H I O and T I Z I A N O D O N Z E L L I Department of Orthopedic Surgery and Traumatology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy Introduction and Objectives: Glanzmann Thrombasthenia is a severe congenital platelet disorder caused by GpIIbIIIa deficiency characterized by absent platelet aggregation. Patients have a lifelong mucocutaneous bleeding diathesis; surgery can be complicated by excessive bleeding and life threatening hemorrhages. We described surgical approach in this setting. Materials and Methods: Data collection, including age at surgery, indication for surgery, was augmented by examination of clinic and hospital charts, bleeding calendars, and operative reports in patients with Glanzmann thrombasthenia who underwent orthopaedic surgery. Results: We performed 4 surgical procedures in 2 patients. 2 minimally invasive surgical corrections of flat foot, 1 minimally invasive surgical correction of flat foot and opening of calcaneus-navicular sinostosis, and 1 removal of screw. The median age at surgery was 11.75 years. A single pool of platelets was infused to each patient half an hour before the beginning of invasive procedures; antifibrinolitic drugs (tranexamic acid) at the dose of 12,5 mg/kg i.v. every 8 hours was administered to every patient starting one hour before surgery: intraoperative bleeding was in normal range. All surgical procedures were perfomed with tourniquet. At the end of surgical procedure we used a local hemostatic agent. Hemostasis was excellent in every patient. No blood transfusion was required in the subsequent days and hemoglobin levels were only slightly reduced. Median follow up after surgery was 31 months,

Haemophilia (2014), 20 (Suppl. 3), 1--186

median arc of motion of ankle was improved after surgery. Tranexamic acid was stopped after 48 hours. A post-operative rehabilitation program was performed. Conclusion: We report that surgery aimed to improve quality of life can be performed in Glanzmann thrombasthenia patients safely and without excessive bleeding under the supervision of a qualified team of orthopedics and hematologists.

Radioisotope synovectomy in severe hemophiliac patients with chronic synovitis in target joints: Six years of experience at Cukurova University by the medical faculty hemophilia team BULENT ANTMEN, ILGEN SASMAZ, CENK OZKAN, ERKAN KOZANOGLU, BARBAROS KARAGUN, B I R O L G U V E N C , K E N A N B IC A K C I, A Y G U L P O L A T , M U S T A F A K I B A R and Y U R D A N U R K IL IN C Cukurova University, Adana, Turkey Introduction and Objectives: The most common sites of bleeding in a person with hemophilia are the joints and muscles of the extremities. Once a joint develops target joints because of recurrent bleeding episodes in hemophiliac patients, chronic changes occur in this target joint. Options for synovectomy include chemical or radioisotopic synoviorthesis and arthroscopic or open surgical synovectomy. Non-surgical synovectomy should be the procedure of choice for treating chronic hemophilic synovitis. Clearly, radioisotopic synovectomy using a pure beta emitter (phosphorus32 or yttrium-90) is the most effective and less invasive choice. Materials and Methods: In this study, we present 80 radioisotope synovectomy (RS) in 40 hemophiliac patients, with age ranging from 6 to 33 years and an average of 13 years seen at C ß ukurova University by the hemophilia team of the medical faculty in Adana, Turkey. All patients, except one patient with won Willebrand disease, had severe hemophilia A and B. Two patients (4 joints) had high-responder inhibitor. Of 80 target joints, 46 were knees, 25 were elbows, 9 were ankles. A second RS procedure was performed in four patients with hemophilia. All patients and target joints were evaluated by the hemophilia team, which included hematologists, a radiologist, orthopedics, physiotherapists, nuclear medicine specialists, and sports physiologists. Results: During the procedures, no complications were seen except in one patient. In this patient; skin hyperemia and pain occurred at the injection site of the joint and bleeding developed into joint after a procedure in four joints. All patients and their parents were satisfied with the outcome of RS. However, after two years, four patients needed a second RS procedure after evaluation of their target joints. Conclusions: RS seems to be a simple, safe and effective treatment procedure for chronic synovitis in hemophiliac patients.

Long-term results of radiosynovectomy in the treatment of hemophilic synovitis: experience in Istanbul

BULENT ZULFIKAR,1,5 CUNEYT TURKMEN,2 O N D E R K IL IC O G L U , 3 F . B E T U L C A K IR , 4 B A S A K K O C , 1 FATIH DIKICI,3 FIKRET BEZGAL,5 AHMET KIZIR,6 R E M Z I T O Z U N 3 and O M E R T A S E R 3 1 _ Istanbul University, Cerrahpasßa Medical Faculty and Oncology Institute, Istanbul; Departments of 2Nucleer Medicine and 3Orthopedics and Traumatology, Istanbul 4 University, Istanbul Medical Faculty Istanbul, Turkey; Bezmi-Alem University, Department of Pediatric Haematology/Oncology, Istanbul, Turkey; 5The Hemophilia Society of Turkey; and 6Department of Radiation Oncology, Oncology Institute, Istanbul University, Istanbul, Turkey Introduction: Despite recent advances, including new therapeutic options and availability of primary prophylaxis in hemophiliacs, hemophilic synovitis is still a major clinical problem in a significant number of patients, worldwide. Objectives: We retrospectively reviewed our ten years of experience with radiosynovectomy to determine the long-term results in the target joints of patients with hemophilic synovitis. Methods: The patients were referred from the Hemophilia Society of Turkey and evaluated by the Institutional Hemophilic Arthropathy Council. The indication for radiosynovectomy was clinical diagnosis of synovitis and the presence of 3 or more hemorrhages into the same joint within the last 6 months. Radiosynovectomy was performed using Y-90 citrate in 82 knee joints and Re-186 sulfide colloid in 81 elbow, 8 shoulder, 74 ankle and 2 hip joints of 156 patients (median age 18.0  7.5 yrs; 136 hemophilia A, 17 hemophilia B and 3 vWD). All patients were boys, except three girls who had von Willebrand disease. Eighteen patients had high-responder inhibitors. The mean follow-up period was 47.6  25.6 months (range: 12 to 120 months). Rebleeding after radiosynovectomy was used as an end point in patient time to progression (TTP) analysis. Results: The median TTP was calculated as 72 months for knee and elbow joints, and 67 months for ankle joints in Kaplan-Meier analysis. There were no TTP differences between the joint groups (p:0.22). Longer TTP was evident in patients who had a greater reduction in bleeding frequency within 6 months after radiosynovectomy. No relation was found between the TTP and the following variables: age, type and severity of hemophilia, the presence or absence of inhibitor, the radiological score, range of motion (ROM) of joints and the pre-treatment bleeding frequency. Conclusions: Radiosynovectomy in target joints represents an important resource for the treatment of hemophilic synovitis, markedly reducing joint bleeding and long-term durability, irrespective of the radiographic stage and inhibitor status.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

MUSCULOSKELETAL ISSUES Surgical treatment of knee arthropathy in hemophilic children: 20 years experience

GIANLUIGI PASTA,1 ENRICA CRISTINI,1 PAOLO GOZZINI,1 MARIA ELISA MANCUSO,2 ANTONIO NICOLINI,3 E L E N A S A N T A G O S T I N O 2 and L U I G I P I E R O S O L I M E N O 1 1 Department of Orthopedic Surgery and Traumatology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy; 2Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy; and 3Interventional Radiology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy

Introduction and Objectives: Hemophilic arthropathy is often associated with arthrofibrosis and loss of range of motion. Progressive fibrosis of synovium leads to pain, spasm and shortening of muscles, resulting in joint contractures and restriction of joint motion. It is possible to see even young children with severe loss of motion in the knees. We conducted this study in order to assess the safety and efficacy of the available surgical options (arthroscopic synovectomy, temporary epiphysiodesis, femoral osteotomy, and angiographic embolization). Materials and Methods: Data on major orthopedic procedures performed to treat knee arthropathy in children with hemophilia A or B and inhibitors were reviewed. Orthopedic outcomes of the procedures were evaluated by comparing pre- and postoperative bleeding frequency, ROM, pain (according to VAS) and the need for additional surgical procedures. A joint radiological evaluation according Pettersson score was performed. All these measurements were performed pre-operatively and at last follow-up visit. Results: From January, 1993 to September, 2013, 30 surgical procedures (24 arthroscopic procedures, 2 temporary epiphysiodesis, 2 femoral osteotomy, 2 angiographic embolization) were performed in 27 patients (22 HA and 5 HB; 5 with inhibitors). The median duration of follow-up per procedure was 60 months (range: 1-216) and 3 peri-operative complications were observed in inhibitors patients. In total, 25 patients had a reduced bleeding frequency after the procedure (median: 1 bleed/yr vs 6 pre-operatively), median pain level decreased from 5 (range: 4-7) to 0 (range: 0-3) and an improved median ROM (100° vs 50° pre-operatively). In 3 patients no improvements were registered and more than 1 procedure was needed. At last follow-up visit median Pettersson score was 7 vs 5 pre-operatively. Conclusions: Management of hemophilic knee arthropathy in children is still a challenge, especially with inhibitors. Different surgical options should be considered in order to achieve reduction of bleeding frequency and ROM improvement.

Surgical treatment of hemophilic ankle arthropathy in a pediatric population: long-term results

ENRICA CRISTINI,1 GIANLUIGI PASTA,1 TIZIANO DONZELLI,1 MARIA ELISA MANCUSO,2 E L E N A S A N T A G O S T I N O 2 and L U I G I P I E R O S O L I M E N O 1 1 Department of Orthopedic Surgery and Traumatology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy; and 2Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy Introduction and Objectives: Nowadays, the ankle is considered the most frequently involved joint in hemophilic patients. Hemarthroses causing a progressive joint’s damage lead to chronic arthropathy associated with pain, axial deviations and reduced function. Flat foot can be associated with an increased incidence of ankle bleedings. In the last decade, despite prophylaxis, surgical indications in children increased. Materials and Methods: Data on major orthopedic procedures performed to treat ankle arthropathy in children with hemophilia A or B and inhibitors were reviewed. Orthopedic outcome of the procedures was evaluated by comparing pre- and postoperative bleeding frequency, ROM, pain (according VAS) and the need for additional surgical procedures. A joint radiological evaluation according Pettersson score was performed. All these measurements were performed pre-operatively and at last followup visit. Results: From January, 1993, to September, 2013, 49 surgical procedures (24 arthroscopic synovectomies, 16 minimally invasive surgical correction of flat foot, 9 arthroscopic synovectomies + minimally invasive surgical correction of flat foot) were performed in 38 patients. For minimally invasive surgical correction of flat foot, the median age at surgery was 10 years, median follow up was 40 months, median arc of motion of ankle was stable or improved after surgery. Complications were rare. For the 24 arthroscopic synovectomies, the median age at surgery was 14, median followup was 60 months, median arc of motion of ankle was stable or improved after surgery. Complications were rare. For the 9 minimally invasive surgical correction of flat foot and arthroscopic synoviectomy, the median age was 9.7 years, median follow-up was 24, median arc of motion of ankle was stable or improved after surgery. Complications were rare. Radiographic scores worsened slightly. Conclusions: The described surgical procedures can be performed safely on an outpatient basis, but an experienced treatment team is of utmost importance in obtaining a good outcome, in order to reduce tibio-talar bleedings, improve range of motion and axial load, and prevent subtalar arthropathy.

A review of changing pain management strategies over the last decade in an adult Australian hemophilia centre ANNE POWELL Ronald Sawers Haemophilia Centre, Australia Pain management strategies have changed in the general population over the last decade. Strategies appear to differ between hemophilia centres depending on different experiences and access to care. With an ageing population, it is necessary to work on sustainable pain management strategies. We looked at all consecutive patients seen in our adult hemophilia musculoskeletal clinic in 2003 and 2013 to analyse our current and past strategies.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


Materials and Methods: We conducted a retrospective chart review of consecutive patients seen in the musculoskeletal hemophilia clinic in 2003 and 2013. Paracetamol, NSAID use, opiate class medication and other pain modulator therapy usage were described. In addition to this, physiotherapy intervention, cortisone injections for pain management and yttrium synovectomy was described and compared between the two time periods. Results and Conclusions: When compared to 10 years ago, we are using more conservative non-medication-type strategies with a dedicated physiotherapist. The use of yttrium synovectomy has remained relatively stable, but access to cortisone injections for pain management has increased. The use of chronic daily opiate use has dramatically decreased compared to 10 years ago. This is likely a reaction to the emergence of adverse literature on prolonged opiate. The use of other pain modulators such as pregabalin and gabapentin that were not previously being used is now in routine clinical practice as they become more affordable and experience with their use increases. Staffing has changed significantly over the last 10 years with a dedicated rheumatologist, physiotherapist and pain physician having joined the hemophilia centre and this is likely responsible for much of the change noted. It is important for adult hemophilia centres to be up to date with the changes in pain management strategies over the last decade.

Could hip resurfacing arthroplasty (HRA) be an alternative for hip function restoration in hemophilic hip arthropathy M Y U N G C H U L Y O O , Y O O N J A E C H O , Y O U N G S O O C H U N and SANG HOON LEE Hemophilia Surgery Center, Department of Orthopedic Surgery, KyungHee University Hospital at Gangdong, Seoul, Korea Introduction and Objectives: Total hip arthroplasty (THA) has so far been the treatment of choice for severe hemophilic hip arthroplasty, but it is still a challenging issue. The rate of survival with THA for hemophilic arthropathy is not as good as that of THA for other causes. hip resurfacing arthroplasty (HRA) is currently a major emerging evolution of hip arthroplasty. A large diameter of the femoral head provides a wider range of hip motion. By deep engagement of the femoral head, and enhancing jump distance, incidence of dislocation is low, and impingement is much less. This means that rehabilitation can be started earlier, and patient can return to their original activities faster. The purpose of this study was to evaluate the HRA effects in severe hemophilic hip arthropathy. Materials and Methods: Authors have experienced eight HRA in seven severe hemophilic arthropathy (one bilateral) patients from January, 2008 to February, 2011. Mean age was 37.1 years (range, 30 – 53 years). Six were male patients, and one was female. Mean follow up period was five years and 4 months (range, 2 years 7 months – 6 years). Four patients had hemophilia A, two patients had hemophilia B, and one was factor VII deficient. All HRA used in this study was Conserve RZ (Wright co. USA). Results: Preoperative average HHS improved significantly from 38.3 (range, 33 – 47) to 94.3 (range, 70 – 100) postoperatively, and all seven hips had more than 90, except one. There was no bleeding episode in the hip resurfacing joints postoperatively. No radiographic loosening or osteolysis were found around the acetabular cups and femoral heads in any of the cases. No adverse tissue reactions related to metal ions were found. All patients showed significant improvement in pain and function (especially range of motion). Patient satisfaction was excellent in all cases. These mid-term HRA results in severe hemophilic hip arthropathy are very promising. In conclusion, HRA could be a good alternative for hip function restoration in hemophilic hip arthropathy. However, more long term follow-up is needed to verify metallosis-related complications.

Factors influencing the range of motion for total knee arthropathy in hemophilic patients

KEITA OKADA,1 MINORU KUBOTA,2 JUNYA KINKAWA,2 M E G U M I N O G U C H I 2 and H I D E Y U K I T A K E D A N I 2 1 The University of Tokyo Hospital, Tokyo, Japan; and 2Research Hospital of The Institute of Medical Science, The University of Tokyo, Tokyo, Japan Introduction and Objectives: Recurrent hemoarthrosis causes arthropathy in many hemophilic patients, leading to stiff painful joints. Knees and ankles are the major target joints,which start to show symptoms of arthropathy as early as the third decade of life. Currently the only established treatment for severe knee arthropathy is total knee arthroplasty (TKA). However, it is well known amongst surgeons that TKAs in hemophilic patients result in less mobility compared to that in TKA with osteoarthritis. Here, we analyzed data to determine factors affecting the surgical outcome focusing on postoperative range of motion. Materials and Methods: Nineteen hemophilic patients (hemophilia A = 16; hemophilia B = 3; all male) who received 20 TKAs, and who were followed for more than 6 months were included. The grading used was severe=3; moderate=2; mild=2, and 5 had inhibitors. The mean ageSD was 44.0  10.8 and mean BMISD was 22.9  2.9. Range of motion was analyzed thoroughly and the outcome was defined as good when all three, fair when two, poor when one or fewer of the following conditions were satisfied: (1) Flexion≧100°, (2) Flexion contracture ≦10°, (3) active range of motion (ROM) ≧80°. We also assessed preoperative ADL i.e. walking with or without assistive devices, perioperative data (operation time, blood loss, gap balance), quadricep and hamstring muscle strength, ambulatory function (80 m test), duration of hospital admission, to evaluate the influence on ROM. Gap balance was measured using Strykerâ JDK-mini system. Wilcoxon rank sum test, Fisher’s exact test, and Spearman’s rank correlation were used appropriately to evaluate statistical significance. Results: The final outcome was good=12; fair=3; poor=5. The average gain in active ROM was 29.3°30.7°. Overall, 16 knees showed a gain in ROM post-operatively. Factors affecting the outcome were preoperative ADL, pre- and intra-operative ROM, and extensor lag on hospital discharge. Hospital stay was significantly shorter for those with better ROM. Neither the gap balance nor muscle strength had any correlation with the final outcome.

Haemophilia (2014), 20 (Suppl. 3), 1--186



Conclusions: The study findings show that the mobility of the patient, and pre- and intra-operative ROM are important factors in determining outcome, which gives us suggestions on the timing of TKAs for hemophilic patients. Operations should be carried out while the patients and their knees are mobile.

Application of local air cryotherapy (LAC) in the complex treatment of acute hemarthrosis in hemophilia patients K A T E K A B A E V A , V L A D I M I R Z M A C H I N S K Y and DZMITRY TSVIRKO Belorussian Academy of postgraduate study, Minsk, Belalus Objetives: Our goal was to estimate the efficacy of magnetotherapy and LAC in the complex treatment of acute hemarthrosis in hemophilia patients. Patients and methods: We assessed 133 episodes of hemarthrosis in 29 patients with a median age of 30.3 (19-48). All patients received replacement therapy by concentrates of FVIII/IX in a dose of 20 ED/kg and were divided into 3 groups (g.) according to the method of physiotherapy. Group 1 received (n = 51) magnetotherapy №10, for 15 min and local air cryotherapy (Crio-air-1000) on a joint by a labile technique, for 20 min, №8. Group 2 received (n = 37) magnetotherapy, № 5, for 15 min. Group 3 (control group, n = 45) didn’t receive any physiotherapy. Results: In group 1 showed: increases in the range of motion (ROM,% from N) by 19.5%, from 45.8  17.5% to 65.3  17.7%; reduction of the total joint score (TJS) by 1.0 point from 8.9  2.0 to 7.9  1.8 points; decrease in pain on a visualanalogue scale (VASc) by 2.3 points, from 6.7  1.0 to 4.4  1.0 points; decrease in quantity of an intra-articulate liquid (IL,mm) by ultrasonic data, from 10.6  3.1to 6.7  3.4 after one course (p < 0.0001). The quality of life test SF-36 increased from 29.8  12.5 to 49.7  12 points. The dose of NAID (nimesulid) decreased from 300  25 mg/day to 75  22 mg/day. The same results were shown in group 2, but to a lesser degree: ROM increased by 6.1%, from 51.6  10.1% to 51.5  10.1%, (p < 0.001); the VAS decreased by 1.0 point, from 6.4  1.8 to 5.4  1.8 points; TJS decreased from 9.5  1.4 to 9.0  1.4 points; SF-36 increased from 30.1  15.2 to 38.6  14.4 points; the dose of NAID decreased from 180  20 to 100  20 mg/ days; IL by ultrasonic data decreased from 11.6  2.3 to 10.1  2.3 mm (p < 0.05). In group 3 (CG) ROM increased by 4.1%, from 55.6  11.6% to 59.7  11.3%; pain, as measured by VAS decreased by 0.8 points from 6.1  1.1 to 5.3  1.0; TJS decreased by 0.4 points from 7.2  1.9 to 6.8  1.9; IL by US data decreased by 0.7 mm, from 14.9  1.2 to 14.2  1.2 mm; test SF-36 has increased by 0.3 points, from 46.3  11.3 to 46.6  11.6 (p < 0.18). Conclusions: In the group 1 data, ROM, TJS, pain (VAS), quantity of ILby US data, test SF-36 have improved in comparison with group 2 (p < 0.001) and group 3 (p < 0.005). These results show a high degree of reliability.

Bone mineral density and bone turnover markers in children with hemophilia A

PANAGIOTA XAFAKI,1 HELEN PERGANTOU,1 A R T E M I S D O U L G E R A K I , 2 H E L E N A T H A N A S O P O U L O U 2 and HELEN PLATOKOUKI1 1 Haemophilia Centre/Haemostasis Unit and 2Institute of Child Health, “Aghia Sophia” Children’s Hospital, Athens, Greece Recurrent hemarthroses, prolonged immobilization and limited physical activity may predispose people with hemophilia to low bone mineral density. Fifty-one children with hemophilia A (severe 41, all on prophylaxis), mean age: 11.7  3.6 years, were evaluated for bone mineral density (BMD) and bone turnover markers. Dual-energy X-ray absorptiometry (DXA) of total body (TB) and/or lumbar spine (LS) was applied for BMD measurement and expressed as z-score (normal value: ≥-1). Bone reabsorption [urinary deoxypyridinoline/cretinine (uDPD/uCr), urinary excretion of calcium (uCa/uCr), tartrate-resistant acid phosphatase (Trap)] and bone formation markers [serum total and bone specific alkaline phosphatase (ALP, bALP), osteocalcin (OC) and carboxy-terminal propeptides of type I collagen (PICP)], as well as vitamin D (25OHD), parathormone (PTH), serum Ca and urinary excretion of phosphorus (uP/uCr), were measured. Results: The mean z-score for LS BMD was -0.51  0.98 [4/40 (10%) had a z-score ≤ -2 and 8/40 (20%) had z-score between -1 and -2)]. Mean z-score for TB BMD was 0.18  0.85 [(0/44 (0%) had a z-score ≤ -2 and 4/44 (9.1%) had a z-score between -1 and -2)]. Octeocalcin levels were significantly decreased in these patients compared to a standard control group (19.06  5.8 vs 22  10, p < 0.05), whereas, other bone formation markers were within normal range. Moreover, OC was positively correlated with LS and TB z-scores (r = 0.337 and r = 0.313 respectively, p < 0.05). Thirty-eight out of 49 children (77.6%) had increased uDPD/uCr (mean value 32.35  14.6). This bone reabsorption marker inversely correlated with LS BMD (r = -0.677) and TB BMD (r = -0.569), p < 0.01. Furthermore, the patients with abnormal levels of uDPD/uCr had lower LS z-scores (mean -0.82  0.85 vs -0.20  0.97, p < 0.05) and TB z-scores (mean -0.08  0.69 vs -0.37  0.91). No significant differences were detected in uCa/uCr and bone Trap. Decreased vitamin D levels (mean 27.9  19.33, normal values >20 ng/ml) were found in 18/49 children (36.7%). No differences were observed in z-scores between children with adequate or inadequate vitamin D levels. Conclusions: In our study, 30% of children with hemophilia A had low LS BMD for chronological age,, unrelated to vitamin D levels. Almost 80% of our study group had increased uDPD/uCr (bone reabsorption marker), without parallel increase of bone formation markers. Hemophilic children are prone to develop bone metabolic disturbances; thus, close monitoring of bone status seems to be beneficial for longterm outcomes.

Haemophilia (2014), 20 (Suppl. 3), 1--186

Effects of hemophilic arthropathy and age on subjective physical performance in people with severe hemophilia

€ B E R , 1 D OR € TE CZEPA,1 F R A N Z I S K A S T AU € LER,1 A L E X A N D E R B R U N N E R , 1 S A N D R A G OH 1 € ER, MAREIKE WENDEL,2 AXEL SEUSER,2 UDO S T E F F E N K R UG F R A N K W E H M E I E R 1 and T H O M A S H I L B E R G 1 1 Department of Sports Medicine, University of Wuppertal, Germany; and 2Institute of Motion Analysis and Quality Control of the Locomotive System, Bonn, Germany Introduction and Objectives: Adult people with severe hemophilia (PWH) suffer from intra-articular bleeding predominantly in large synovial joints, inducing hemophilic arthropathy (HA). HA leads to joint destruction, which is accompanied by significant pain with consequences for physical performance. A previous study has shown that HA increases with age. However, less is known about the subjective physical performance (SPP) and its correlation with HA and age in PWH. Materials and Methods: 240 adults (40  12 years) with severe hemophilia (A or B) had undergone an orthopedic examination (knees, ankles, elbows). HA was classified by applying the WFH physical joint examination instrument and pain scales (total WFH score). SPP was assessed by HEP-Test-Q questionnaire, consisting of the domains: mobility, strength & coordination, endurance and body perception. Results: The total WFH score of PWH was 23  12 (range: 3-63) and the total HEPTest-Q was 58  22 (range: 0-100, higher values are better). A significant relationship was found between total WFH score and total HEP-Test-Q (rs=-0.63, p < 0.001), whereby the highest negative correlation existed for the HEP-Test-Q domain: strength & coordination (rs=-0.72, p < 0.001). In contrast, the other domains showed only moderate negative correlations with the total WFH score (mobility: rs=-0.57, endurance: rs=-0.50; body perception: rs=-0.37, p < 0.001). An inverse relationship was detected between age and strength & coordination (rs=-0.61, p < 0.001), but only moderate relationships were found between age and all other HEP-Test-Q domains (mobility: rs=-0.38, endurance: rs=-0.42; body perception: rs=-0.28, p < 0.001). Conclusions: Our data indicates that HA obviously affects SPP more than age. Furthermore, this study provides evidence that worsening of joint status and increasing age were most clearly associated with impairment of strength and coordination. Therefore, the improvement of strength and coordination by sports therapy should be given special attention in PWH. ( - in cooperation with HaemArthroGroup).

Circulating biochemical markers of acute joint bleeding in a mouse hemarthrosis model NARINE HAKOBYA, XIANGQIAN SONG, C A N D A C E E N O C K S O N , L I N C O N G and L E O N A R D A VALENTINO Rush University Medical Center, Chicago, USA Introduction and Objectives: Joint bleeding, the most common serious hemorrhage in patients with severe hemophilia, results in a chronic arthritis characterized by synovial inflammation and vascularization as well as cartilage and bone destruction. Early detection of joint bleeding can increase the ability to prevent further hemarthrosis and the ensuing destructive changes. In addition to existing clinical and imaging evaluations, identifying circulating biochemical markers would greatly enhance the assessment of early joint bleeding. Our goal was to identify measurable plasma biomarkers of inflammatory and vascular changes for early detection of blood in the joint and to verify joint-specificity of candidate markers by comparison with gene expression signatures of affected joint tissue. Materials and Methods: Joint bleeding was induced in F8-/- mice; animals with similar bleeding were selected for further analyses. Mice were euthanized, synovial tissue and plasma collected 1, 2 or 3 days following hemarthrosis, and compared with those from non-bleeding mice. Plasma was analyzed for 32 inflammatory and 27 angiogenesis-associated soluble factors using quantitative multiplex magnetic beadbased immunoassay (Luminex). Joint tissue was examined by real-time PCR array for expression of 83 genes in inflammatory (SABioscience) and 41 genes in angiogenesis (Life Technologies) associated pathways. Results: This study identified significant changes in a number of soluble factors in plasma, which strongly correlated with gene expression in synovial tissue of affected joints. Conclusions: Once verified in human subjects, the pattern of cytokine expression identified in this study can provide a biomarker signature to detect early or even subclinical joint bleeding, the utility of which will augment the ability to provide earlier treatment.

A tissue engineering approach to the treatment of early focal lesions in hemophilic arthropathy

PAOLO RADOSSI,1 ELENA STOCCO,2 ROSA DI LIDDO,2 DANIELE DALZOPPO,2 SILVANO LORA,3 PIER PAOLO PARNIGOTTO,3 CLAUDIO GRANDI,2 ROSA D I G A E T A N O , 1 R O B E R T A S A L V I A T O 1 and GIUSEPPE TAGARIELLO1 1 Regional Centre for Blood Disease and Haemophilia, Castelfranco Veneto, Italy; 2 Dept Pharmaceutical Sciences, University Padua; and 3TES Foundation Padua

In hemophilic patients, joints are the main target of bleeding episodes. Even a small number of joint hemorrhages can cause irreversible alterations leading to severe arthropathy characterized by inflammation and degenerative damage. Factor prophylaxis, debridement, synoviectomy or intra-articular injections of hyaluronic-acid can only slow the progression of joint damage; none promotes cartilage restoration. Considering that hemophilic arthropathy (HA) remains one of the most disabling complications of hemophilia, identifying a method able to sustain cartilage defect restoration is an interesting objective, especially because of the limited selfregenerative property of this tissue. Our aim is to suggest a tissue engineering

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

MUSCULOSKELETAL ISSUES approach that could allow for the recovery of early joint focal lesions, preventing the development of HA. Moreover, using autologous cells it will eliminate the risk of transplant rejection in the case of an in vivo implant. Chondrocytes, from the articular cartilage of normal, osteoarthritic and hemophilic patients were isolated and cultivated in monolayer. All cell sources were expanded and characterized by FACS analysis to compare expression of surface markers; RT-PCR analysis was than performed to access if hemophilic chondrocytes maintain their characteristic phenotype, even in vitro. The behaviour of isolated chondrocytes was than studied in 3D conditions, seeding them on a composite scaffold made of polyvinyl alcohol (PVA) hydrogel combined with a-specific umbilical cord derived matrix obtained from decellularization of Wharton’s jelly. A MTT test was performed to measure the proliferation activity of cells cultured in 3D conditions. Hemophilic chondrocytes revealed the same surface marker expression profile of osteoarthritic ones and RTPCR analysis showed that all cell types have the ability to synthetize extracellular proteins typical of cartilage matrix in vitro. MTT test showed a satisfying cell metabolic activity capacity by all chondrocytes types seeded on the composite scaffolds. From these results, we can assume that hemophilic chondrocytes could be employed in autologous transplantation in the treatment of early focal lesions, preventing the progression of joint degenerative damage without risk of post-implant rejection. Moreover, a PVA composite scaffold combined with Wharton’s jelly could be an interesting model able to sustain cartilage restoration in vivo.

Results of ankle prosthesis in patients with severe hemophilic arthropathy: a follow-up

MANUELA KRAUSE,1 MARKUS PREIS,2 DANIELE PILLITTERI,1 ANN-KATHRIN PILGRIMM-THORP,1 CARL M. KIRCHMAIER,1 R O G E R S C H O L Z 3 and U T E S C H O L Z 4 1 Deutsche Klinik f€ ur Diagnostik, Wiesbaden, Germany; 2Aukammklinik - Department of Orthopaedics, Wiesbaden Germany; 3University Leipzig - Department of Orthopaedics, Leipzig, Germany; and 4Practice and Laboratory for Diagnostic and Therapy of Coagulation Disorders, Leipzig, Germany Introduction: Arthrodesis is predominantly used in cases of hemophilic arthropathy of the ankle joint. The prosthetic replacement surgery can offer a new therapeutic option for ankle arthropathy, and is a well-established operation in patients with rheumatoid arthritis and in post-traumatic arthritis. Few cases have been published on ankle replacement in hemophilic arthropathy. The aim was to evaluate the efficacy of ankle prosthesis in patients with severe hemophilic arthropathy. Patients and Methods: Five patients with hemophilia A (severe: 4, mild: 1; 3044 years), 1 female with von Willebrand disease type 3 (vWD) (45 years) and 1 patient with a severe deficiency of factor V showed an advanced state of joint destruction of the ankle as evaluated by MRI/ X-rays. The presence of severe pain, radiological joint damage (MRI score/Pettersson score) and a sufficient residual condition of mobility were the main indications for ankle replacement therapy. Surgical interventions were performed under FVIII or FVIII/VWF replacement therapy and the daily monitoring of the substitution. Results: No complications (infection, intra-articular ankle bleeding) or side effects were documented in any patient. Typical lymphatic oedema was resolved after 6 months. Three years after ankle replacement, the patient with vWD required revision surgery due to a progressive decrease in mobility. After follow-up of 1 – 7 years, all prostheses were still in place and did not show any signs of loosening. Clinical scores showed a good (n = 2) to excellent (n = 4) result in the patients. Conclusions: The ankle prosthetic replacement surgery represents a therapeutic option in patients with hemophilic arthropathy. Prospective studies are needed to confirm the efficacy of ankle replacement compared with that of ankle fusion.

Interleukin-1beta is essential for blood-induced cartilage damage in vitro

L.F.D.VAN VULPEN,1 G. ROOSENDAAL,2 F.P.J.G. LAFEBER,3 R . E . G . S C H U T G E N S 2 and S . C . M A S T B E R G E N 3 1 Hematology and Van Creveldkliniek; Rheumatology & Clinical Immunology, University Medical Center Utrecht, The Netherlands; 2Hematology and Van Creveldkliniek, University Medical Center Utrecht, The Netherlands; and 3 Rheumatology & Clinical Immunology, University Medical Center Utrecht, The Netherlands

Introduction and Objectives: The combination of interleukin (IL)4 and IL10 is shown to limit blood-induced cartilage damage. This effect seems to be dependent on an inhibition of the production of pro-inflammatory cytokines IL1, TNF and IL6. The aim of this study is to investigate whether direct blocking of IL1 specifically prevents blood-induced cartilage damage in vitro. Materials and Methods: Full thickness healthy human articular cartilage explants, obtained post-mortem, were cultured for 4 days in presence or absence of 50% v/v blood. A recombinant human IL1 monoclonal antibody (IL1mAb) was only added during blood exposure in a concentration of 0, 1, 2, 10, 30, or 100 ng/mL. Cartilage matrix proteoglycan turnover was determined 12 days later to analyse long-term effects. Moreover, to investigate the direct effects of IL1mAb on cartilage, explants were cultured for 4 days in the presence of 10 ng/mL IL1mAb in the absence of blood. Results: Exposure to blood decreased the proteoglycan-synthesis rate (-62%) and proteoglycan content (-19%), and increased the proteoglycan release (+191%, all p < 0.05). Adding IL1mAb resulted in a dose-dependent increase of the proteoglycan synthesis rate leading to normalisation at higher concentrations. Moreover, proteoglycan release was statistically significantly decreased from a concentration of 3 ng/mL and above (see Figure B). Similarly, the proteoglycan content increased to a statistically significant level upon addition of the IL1mAb (3 ng/mL and above; all p < 0.05). In the absence of blood, IL1mAb did not have direct beneficial effects on cartilage proteoglycan turnover (p = 0.51). Conclusions: This study demonstrates that IL1 is a crucial factor in the development of blood-induced cartilage damage in vitro. Blocking this pro-inflammatory cytokine with a monoclonal antibody protects cartilage from the damaging effects of blood

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


exposure. Further research is warranted to investigate the in vivo capacity of IL1mAb in prevention and its position as a treatment of hemophilic arthropathy.

Radiosynoviortesis with Cuban chromic phosphate [32p] suspension

AYMARA BAGANET COBAS,1 TERESA FUNDORASARRAFF,1  EZ,1 ENRIQUE D U N I A C A S T I L L O G O N Z AL G A R C IA R O D R IG U E Z , 2 J O R G E C R U Z A R E N C I B I A , 3  CHEZ,1 YAMILE   P A D R ON K A L I A L A V A U T S AN MIRABAL,1  D E Z R E Y E S 1 and J O S E  M O R IN Z O R R I L L A 3 L A S E R H E R N AN 1 2 Instituto de Hematologıa e Inmunologıa; Hospital General Docente “Enrique Cabrera”; and 3Centro de Is otopos CENTIS. La Habana, Cuba Intra-articular hemorrhage is common in hemophilia. If joint bleeding is not adequately treated, it tends to recur and causes tchronic synovitis, inflammatory arthritis, and progressive arthropathy. Therefore, an aggressive management of hemarthrosis is very important for the successful prevention of hemophilic arthropathy. If chronic synovitis develops, radiosynoviorthesis should be undertaken in order to decrease the progression of the hemophilic arthropathy and to prevent the development of arthropathy. The aim of this study was to assess the safety and efficacy of the application of our locally-produced chromic phosphate suspension (CENTIS, Havana, Cuba) in the radiosynoviorthesis of joints in hemophilic patients suffering from chronic synovitis. Eligibility requirements included a diagnosis of hemophilia, history of more than three hemorrhages into a joint within a month and evidence of synovitis by objective imaging. Patients’ informed consent was obtained, and 1.0 mCi of chromic phosphate suspension was injected into the affected joints. Safety was monitored by external beta-scanning, routine blood tests and chromosomal analysis. Efficacy was determined by analysis of the change in joint hemorrhage frequency, twelve months after the injection and clinical evaluation (state of joint involvement, pain, motility, requirements of antihemophilic factors) and recorded in follow-up charts. One injection was given in the joints of nine patients. The joints injected were the knee. One joint required reinjection. There were neither local nor systemic effects, nor leakage during chromic phosphate suspension treatment. All patients showed a significant decrease in joint hemorrhage frequency rate (P < 0.0001). The follow-up evaluation demonstrated decreased pain, increases in joint motion, and less requirement for and frequency of the use of antihemophilic factors. Chromosome aberrations have not found. Radiosynovectomy with Cuban chromic phosphate suspension is a safe and effective procedure in limiting the frequency of joint hemorrhage, decreasing pain and improving function in hemophilic patients with chronic synovitis.

Validation of the HEP-Test-Q for the assessment of subjective physical performance in English-speaking hemophilia patients

€ TE CZEPA,2 KATE KHAIR,3 S Y L V I A V O N M A C K E N S E N , 1 D OR L E O N A R D A . V A L E N T I N O 4 and T H O M A S H I L B E R G 2 Institute of Medical Psychology, University Medical Centre, Hamburg, Germany; 2 Department of Sports Medicine, University of Wuppertal, Germany; 33 Haemophilia Centre, Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH, UK; and 4RUSH Hemophilia and Thrombophilia Center, RUSH University Medical Center, Chicago, IL USA


Introduction and Objectives: Hemophilia patients mainly bleed into joints or muscles. The most frequent complication of recurrent bleeding into joints is arthropathy and disability leading to pain in people with hemophilia (PWH). The assessment of orthopedic joint score (OJS) and physical functioning with objective and so-called patient-rated outcome (PRO) measures in PWH is essential. The HEP-Test-Q is a PRO assessing subjective physical performance and was originally developed and validated in Germany. The aim of this study was to linguistically validate and psychometrically test the English version of the HEP-Test-Q in English-speaking PWH from the UK and US. Material and Methods: The HEP-Test-Q consists of 25 items pertaining to four subscales ‘mobility’, ‘strength & coordination’, ‘endurance’ and ‘body perception’ (high scores indicating good physical performance). A version for adult and one for paediatric patients is available, which differs only in the wording of the items. The English versions of the HEP-Test-Q were administered to adult and pediatric patients from the UK and US. In addition, clinical data were collected by hemophilia specialists. Results: So far, 38 PWH (9 adults and 28 children) with a median age of 14 years (range 4-48) with hemophilia A (89.5%) or B (10.5%) completed the questionnaire. In this study, 81.6% were severely affected and most PWH received prophylaxis (81.1%). PWH had 6.4  14.1 bleeding events in the previous 12 months and 2.8  5.6 hemarthroses respectively; PWH had an OJS of 4.3  7. 44.4% of PWH reported about pain and 26.5% about limitations in mobility. Psychometric characteristics of the HEP-Test-Q showed good values for internal consistency, Cronbach’s alpha ranging from a=.703 to a=.893. Known groups validity revealed that PWH with a high OJS (≥3) and those with limitations in their mobility reported a significantly worse subjective physical performance (p < .001). PWH reported a good subjective physical performance, with the highest impairments in the dimension ‘endurance’ (67.1  16.9). Conclusions: The English version of the HEP-Test-Q has proven to be a reliable and valid instrument for the assessment of subjective physical performance for use in English-speaking PWH. The HEP-Test-Q can be included in observational and clinical trials, but in routine care as well due to its short completion time.

Haemophilia (2014), 20 (Suppl. 3), 1--186



Total knee and hip replacement in hemophilia and related bleeding disorders

ANGELIKA BATOROVA,1 BORIS STENO,2 D E N I S A J A N K O V I C O V A , 1 T A T I A N A P R I G A N C O V A 1 and ANNA MORONGOVA1 1 National Hemophilia Center, Dept. of Hematology and Blood Transfusion Medicine, University Hospital, Bratislava, Slovakia; and 2Dept. of Traumatology and Orthopedy, University Hospital, Bratislava, Slovakia Introduction and Objectives: Total knee/hip replacement (TKR/THR) represents a common orthopedic surgery in patients with congenital bleeding disorders if the normal hemostasis is ensured by adequate replacement therapy. However, the success of surgery depends on a surgeon0 s skill and his knowledge of the specifics of bleeding disorders as well as on a comprehensive management of hemostatic therapy under the supervision of hemophilia centre. Material and Methods: We report on the management and outcomes of joint replacement performed at our centre in patients with congenital bleeding disorders between 1993 and 2013. Results: A total of 56 operations (22 TKR and 34 THR) were performed in 39 patients,. Out of these, 36 procedures were performed in 25 hemophilia A (HA) patients, 2 in 2 hemophilia B (HB), 13 in 7 factor VII deficiency (FVIIdef), and 5 in 5 v.Willebrand disease (vWD) patients. Median age at time of operation was 50 yrs (3063). Hemostatic management included intensive pre- and postoperative factor replacement (10-16 days), with continuous infusion employed in 15 severe HA patients, and enhanced 3-5 weeks prophylaxis for postoperative physiotherapy. Postoperative thromboprophylaxis was used in 5/56 procedures (2 HA, 1 FVIIdef and 2 vWD type 1). No thrombotic nor inflammatory complications were observed, however 3 HA and 2 FVIIdef patients developed postoperative hematoma despite sufficient hemostasis. Median follow up was 6 yrs (0.5-20). TKR performed in 22 patients (18 HA, 1 HB, 2 FVIIdef and 1 vWD) resulted in a disappearance of pain. The ROM improvement 3 months postoperatively was expressed by a decrease in the deficit of extension (from 21.5  6.6º to 3.8  5.5º) but only a slight increase in the flexion (from 80.3  34.8º to 90.0  20.0º). The long-term follow-up showed a mean ROM of 88.0  15.6º. All of the 34 THR patients (18 HA, 1HB, 11 FVIIdef, and 4 vWd) reported a disappearance of pain and the ROM was improved in 29/34 (85%) patients. Only two aseptic loosenings requiring revision occurred, 7 and 6 years after the first THR in 1 HA and 1 FVIIdef patient, respectively. Conclusions: Our results show that joint replacement is a safe and effective procedure in hemophilia and related bleeding disorders if performed by a highly experienced surgeon, cooperating well with the team from a comprehensive hemophilia centre.

Successful treatment of pseudotumor in a patient with moderate hemophilia

 C  Sˇ A L E K , 1 A N A B O B A N , 1 S I L V A Z U P A N CI  R O B E R T , 2 D R A ZE  N PULANIC  1 and K O L U N D Zˇ I C 1 DAMIR NEMET 1 Department of hematology, Division for haemostasis and thrombosis, University Hospital Center Zagreb; and 2Clinical Center ‘ Sestre Milosrdnice’, Department for traumatology, Zagreb, Croatia Introduction and Objectives: Pseudotumors are rare conditions that occur in patients with hemophilia as the result of inadequately treated bleeds into soft tissues, frequently muscles adjacent to the bone. They can be asymptomatic, although symptoms often occur as the pseudotumor grows and compresses the surrounding tissues, causing neurovascular damage and pathologic bone fractures. Diagnosis is usually made easily by physical examination, and confirmed by imaging methods, but the treatment can be challenging. Depending on localization, growth rate, and size of pseudotumor, as well as its association with surrounding tissues, treatment may be conservative or require surgical excision. Here we present a case of successfullytreated pseudotumor of the left femur in a patient with mild hemophilia. Case Report: A 62-years old patient was diagnosed as having hemophilia at the age of 7. The patient had a mild clinical presentation of disease and experienced major bleedings only following trauma. In 2004, after a fall from a height that caused a fracture of the left femur, a tumor mass started to grow at the site of the muscle bleed. Within years it significantly increased in size, causing pain and walking difficulties. After verification of the diagnosis, the patient agreed to surgical excision of the pseudotumor. In addition to tumor removal, placement of total knee endoprothesis was needed. The multidisciplinary team included a hematologist, an orthopedic surgeon and specialist in plastic and vascular surgery, a cardiologist, and a physiotherapist. The procedure was complicated by infection, necrosis, removal and re-implantation of endoprothesis. After a vigorous physiotherapy the patient is now fully recovered and able to walk without help. Conclusions: This case demonstrates that pseudotumors can complicate an otherwise benign course of moderate hemophilia and emphasizes the importance of a multidisciplinary approach in managing this rare condition.

Joint damage and bleeding assessment in the hip by ultrasonography

SILVIA LINARI,1 MASSIMO MORFINI,1 MARCO M A T U C C I C E R I N I C 2 and D A N I E L A M E L C H I O R R E 2 1 Agency for Haemophilia, University Hospital of Florence, Italy; and 21Department of Clinical and Experimental Medicine, University Hospital of Florence, Italy Introduction and Objectives: The hip is not a frequent target joint in hemophilic arthropathy (HA). Patients with hemophilia can suffer from hip pain without obvious signs of joint involvement and hematoma or bursitis are very often diagnosed. The aim of this study was to investigate the role of ultrasonography (US) to detect bleeding and joint damage in HA of the hip. Materials and Methods: In 30 patients with hemophilia and monolateral hip pain, the iliopsoas and its bursa, the greater trochanteric bursae, and the joint were studied by US. The 30 joints were evaluated and scored (scores ranging from 0 to 21) for effusion, bone remodelling, cartilage damage, synovial hypertrophy, hemosiderin,

Haemophilia (2014), 20 (Suppl. 3), 1--186

osteophytes, hemarthrosis, erosion and fibrotic septa. The World Federation of Hemophilia orthopedic joint scale (WFH score) was evaluated in all patients. Power Doppler US (PDUS) was performed in all studied hip joints. Results: US showed effusion in 20 hip joints, bone remodelling in 18, cartilage damage in 10, synovial hypertrophy in 12, hemosiderin in 4, osteophytes in 7, hemarthrosis in 10 with PDUS activity, erosion in 0 and fibrotic septa in 0. In hemophiliacs, 15 out of 30 joints showed US score ≤5, and 15 showed US score >5. In 8 patients was present hematoma of iliopsoas; in two patients great trocanteric bursitis was diagnosed. Conclusions: US detected bone and cartilage alterations and synovitis in the hip. Indeed PDUS identified the bleeding in the joints and was able to show hemarthrosis. US may be useful to evaluate joint modifications in HA and also in non target joints.

Gait analysis comparison of adolescents with moderate and severe hemophilia using the Zebris interactive FDM-T treadmill system RACHEL TIKTINSKY National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel Introduction and Objectives: Twenty adolescents with moderate and severe hemophilia have had joint hemarthroses both in the ankle and knee joints. These hemarthroses have led to painful joints and deviations of gait. Evaluation of the stance and gait parameters of these adolescents, combined with assessment of additional physical measurements, may be able to provide the best possible treatment plan for these patients. The Interactive FDM-T Treadmill System from the Zebris Medical Company consists of a treadmill with over 5,000 force sensors integrated underneath the treading surface and a large screen on which a virtual running environment is depicted, for example, in the form of a path running through the forest. The runner sees his own footprints live on the screen and gains direct feedback on his movements. Obstacles then occur such as puddles that have to be jumped over, or avoided. An evaluation system awards points according to how successfully this is achieved. Participants: Participants were twenty adolescents with hemophilia A and B, with moderate or severe hemophilia. Methods: Range of motion and lower limb muscle testing was performed on each of the patients. Each participant first stood on the platform of the treadmill. He then practiced the use of the treadmill. The first activity was walking at a comfortable speed, the second was walking at an increased speed, and the third walking at an increased speed with an increased incline. Results: The main differences found were in foot rotation, step width, step length, and stride length, with the moderate group having an improved gait of between 10-20%, when compared to the severe group. The differences between the two groups increased with increasing speed and incline. Differences of between 20-50% in weight distribution were found both between the moderate and severe hemophilia participants. Kinetic and kinematic differences were also found to be significant. Conclusions: Hemarthroses affect the stance and gait patterns of even young hemophilia patients. Due to the changes seen in gait characteristics, a different approach should be considered in treatment and education. This should include a more intense and active exercise and stretching program, and possibly more properly fitting insoles and shoes.

Arthroscopic synovectomy for hemophilic arthropathy of hemophiliacs in Taiwan

CHIA-YAU CHANG,1 CHIAN-HER LEE,2 HSIEN-TSUNG LU,2 J I U N N - H O R N G K A N G , 3 C H E N - H U A T S A I 4 and G E N G CHANG YEH1 Departments of 1Pediatrics, Division of Pediatric Hematology/Oncology; 2 Orthopedics; and 3Rehabilitation, Hemophilia Center, Taipei Medical University Hospital, Taipei, Taiwan; and 4Department of Hematology/Oncology, Cheng Hsin General Hospital; Hemophilia Center, Taipei Medical University Hospital, Taipei, Taiwan

Introduction: Hemophilic arthropathy is a common complication resulting from recurrent hemarthrosis in hemophiliacs. Arthroscopic synovectomy is a relatively simple, less traumatic procedure for hemophilic arthropathy. However, reports on arthroscopic synovectomy for hemophilic arthropathy in Asian countries are relatively limited compared to those from the West. Materials and methods: From August, 2011 to August, 2013, there were 10 severetype Taiwanese hemophiliacs (8 hemophilia A, 2 hemophilia B) receiving arthroscopic synovectomy and enrolled in this study, who had recurrent bleeding with chronic synovitis that did not respond to secondary prophylactic factor replacement, and physiotherapy. Following their operation, all patients received prophylaxis with factor replacement and physiotherapy. Outcome data including joint pain, the frequency of bleeding and factor injection, and range of motion (ROM) were analyzed. Results: The average age was 23.6 years old, ranging from 15 to 28. A total of 12 joints (4 knees, 4 elbows, 3 ankles, one shoulder) received surgery. With all the joints there was a reduction of joint pain, frequency of bleeding and factor injection, and improvement of ROM after operation. No complications were found. Six joints got significant pain relief (3 knees, one elbow, one ankle, one shoulder). With another 6 joints, there was partial pain relief with residual pain at a different location (3 elbows, 2 ankles, one knee). Residual pain from concurrent early arthritis was confirmed on 3 elbows and 1 ankle. Residual pain from residual reactive synovitis was identified on 1 knee and 1 ankle. Conclusions: This is the first report of Taiwanese hemophiliacs receiving arthroscopic synovectomy for hemophilic arthropathy. The effects of arthroscopic synovectomy included reduced joint pain, frequency of bleeding and factor use, and improvement of ROM. Concurrent early arthritis is the most common cause of post-synovectomy joint pain. We suggest that synovectomy should be performed earlier before concurrent early arthritis develops.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

MUSCULOSKELETAL ISSUES Spectrum of involvement and quantitative limitations in the four commonly affected joints in 478 hemophilia patients in Northern India

N A R E S H G U P T A 1 , 2 and M O N I K A S H A R M A 2 1 Maulana Azad Medical College, New Delhi, India; and 2Haemophilia Centre, Lok Nayak Hospital, New Delhi, India Introduction and Objectives: Musculoskeletal morbidities in hemophilia are common in developing countries due to inadequate patient management. This paper presents a spectrum of joint involvement and active ROM (range of motion) in knee, elbow, ankle and hip joints in patients at baseline. Method: Our hemophilia centre in New Delhi, India has 1620 patients who also undergo subjective and objective assessment for musculoskeletal disabilities. Data from an initial 478 consecutive hemophilia patients assessed during 2009 to 2013 for active ROM in four major joints (i.e. hip, knee, ankle and elbow) prior to our interventions are presented. Movements tested included flexion, extension, abduction and adduction and were measured in degrees using standard goniometer by a single observer. Patients with active bleeds were excluded. Observation and results: Mean age was 19.30  10.37 years, range 1-63, in the study group of 478 hemophilia patients comprising 416 (87%) hemophilia A,and 62 (13%) hemophilia B. Hemophilia A was severe in 177 (42.54%) cases and moderate in 112 (26.92%), whereas for hemophilia B it was 40 (64.51%) and 11 (17.74%), respectively. Factor levels were missing in 115. The total numbers of joints affected in these 478 patients was 747, an average 1.6 joints per hemophilic patient. The knee was the most commonly affected joint (over 80%), followed by the elbow (around 40%). Hip joint was more frequently affected than ankle in our study, which was unusual. Quantitative limitation in active ROM was maximal (40-45%) in the ankle flexion, hip flexion and abduction whereas disabilities in knees and elbows were limited to around 10-15%. No difference was observed between the sides of joint involved. Conclusions: The Spectrum and extent of joint damage can be vast with grave limitations in active ROM when treatment facilities are inadequate; knees are the most frequently affected joints, accounting for over 80% of arthropathies; the hip is affected more frequently than the ankle in our subjects; the less commonly affected ankle joint has the largest limitation in active ROM; such frequent and large involvements have adverse effects on physical activity and QoL and highlight the importance of physiotherapy as part of treatment in hemophilia.

An evaluation of whether the ankle is now the dominant site of chronic hemophilic arthropathy in young adults with severe hemophilia

SHANNON JACKSON,1,2 MING YANG,1 LEN MINUK,3 JEAN ST-LOUIS,4 MICHELLE SHOLZBERG,5 ROBERT CARD,6 A L F O N S O I O R I O 7 and M A N - C H I U P O O N 8 1 Hemophilia Program of British Columbia - Adult Division, 2St. Paul’s Hospital, Vancouver, Canada; Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC; 3Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON; 4CHU-Sainte-Justine and Department of Medicine, University of Montreal, Montreal, QC; 5St Michael’s Hospital, Toronto, ON; 6Division of Hematology, Department of Medicine, University of Saskatchewan, Saskatoon, SK; 7Clinical Epidemiology & Biostatistics and Medicine, McMaster University, Hamilton, ON; and 8Division of Hematology and Hematologic Malignancies, Department of Medicine, University of Calgary, AB Introduction and Objectives: A significant proportion of young adults with severe hemophilia in Canada have been exposed to prophylaxis and are expected to have better overall joint outcomes than age-comparable peers had in the past. Anecdotally, chronic hemophilic arthropathy of the ankles continues to be seen among young adults, who are presenting with pain and limitation in activity, and arthropathy involving other joints is less common. Confirmation of this finding on a large population is necessary to determine the scope of the problem and to form the basis of future preventative strategies. Materials and Methods: The number and type of joints affected with chronic hemophilic arthropathy in a Canadian cohort of subjects with severe hemophilia A and B and the proportion of subjects with unilateral or bilateral arthropathy will be compared between older (≥ 40 years of age), intermediate (30-39 years), young (2429) and very young (18-23) age groups. Calculations to determine the proportion of subjects with isolated ankle, knee or elbow joint arthropathy and combined arthropathies in each age group, and the relative change between each age group will be performed. Factors such as body weight and duration of prior prophylaxis exposure will be examined for correlation with the presence of ankle arthropathy. The analysis will be adjusted for hip and knee surgical replacements and ankle fusions. A sample of approximately 290 subjects will be analyzed and described over the age spectrum. Results: NA as per late breaking abstract specifications. Conclusions: NA as per late breaking abstract specifications.

Long term MRI assessment of arthropathies in Japanese hemophiliac children


Materials and Methods: From 2006 to 2012, 10 patients aged 3 to 19 years old (7 hemophilia A and 3 hemophilia B) were enrolled this study. Of 10 patients, one had been treated with primary prophylaxis, 5 with secondary prophylaxis, 4 with ondemand therapy, respectively. No patients were suffering from hepatitis C virus infections or inhibitors. None has clinical manifestations of persisting joint damage. Every joint was evaluated with MRI findings annually. We studied changes in the long-term MRI assessment of 40 joints, (4 joints consisted of bilateral knees and ankles for every patient). Every MRI assessment was scored by the compatible MRI scoring system (Haemophilia, 2005, 11, 116 – 122). Results: At the first evaluation of this study, of the 40 joints we found 5 at the stage of severe damage, 6 at the moderate stage, 21 at the mild stage, and 8 with no damage, respectively. At the last assessment, after 6 years of treatment with supplement s of FVIII concentrates, 34 joints were evaluated as having the same score for damage status, three joints were evaluated with a reduced score, and 5 were scored as showing a progression of joint damage. The decreased score case was a moderate hemophilia B patients treated with prophylaxis. The progressive case was a child with severe hemophilia A and treated with on-demand therapy. Conclusions: We consider that MRI assessment of joints could identify the very early changes of hemophilic arthropathy. Also, prophylaxis might have some role in preventing the progression of joint damage from bleedings. However, this study consists of a small number of joints and the observation period is considered insufficient. Further studies are needed to confirm this information.

Surgical treatment of pseudotumor in the right thigh with the destruction of the proximal femur in a patient with severe hemophilia A V . Z O R E N K , M . S A M P I E V , E . K A R P O V , G . M I S H I N and T. POLYANSKAYA National Research Scientific Center of Hematology, Moscow, Russian Federation The most complicated and difficult manifestation of hemophilia is hemophilic pseudotumor. Currently, patients with this type of lesion are rare. This paper presents the experience of treating a patient with severe hemophilia A and pseudotumor in the right thigh, with the destruction of the proximal femur. Patient T., 32-years-old sufferred from severe hemophilia A. The disease mainly occurs in lesions of the musculoskeletal system. In 2005, the patient fell and fractured the right femur. Conservative treatment was conducted (spica cast for 6 months). After removal of the cast, the formation of a tumor was observed in the upper third of the right femur, which subsequently increases in volume. There was a shortening of the right leg by 11 cm, which was not bearing weight. In our department, after conducting clinical and laboratory examinations and preoperative care, the patient underwent extirpation of pseudotumor with a total hip replacement and replacement of the proximal femur. Modular endoprosthesis MATI-CITO was used. The limb was lengthened by 5 cm and the weight-bearing function was restored. The operation was conducted with substitution therapy with factor VIII standard scheme. Total intraoperative blood loss was 2600 ml. Of 1900 ml (73%) collected in «Orto-Pat», 650 ml were returned as red cells. After 1 week active vacuum aspiration of cavity wounds was done. Activity of the patient started on the 5th day. As a result of limb lengthening by 5 cm, and the return of weight-bearing function the quality of life of the patient was improved.

Illeopsoas bleeds: challenges in a developing country

T A H I R A Z A F A R , 1 H U M E R A S I D D I Q , 2 N A D E E M I K R A M 3 and ASIF ZAFAR3 1 Pak International Medical College, Peshawar; 2Holy Family Hospital, Rawalpindi, Pakistan; and 3Rawalpindi Medical College Objective: To study clinical spectrum, treatment, complications, and outcome of illeopsoas bleeds in patients with inherited bleeding disorders in Pakistan. Patients and Methods: All patients who presented to the Rawalpindi Haemophilia Treatment Centre with symptoms of illeopsoas bleeds, and which were confirmed by ultrasound, were evaluated. Their age, diagnosis, symptoms, inhibitor status, time to centre, examination findings, any previous episodes, treatments and treatment responses were documented over a 2-year period. Results: In total, 12 patients reported to the centre. Five had previous episodes of a similar nature. Eleven patients were of severe F VIII deficiency and 1 had von Williebrand’s disease (vWD). The age range was 13 to 45 years with a mean of 22.3 years. Seven patients had left-side and 5 right-side bleeds. Four patients who presented early (within 12 hours) reported abdominal pain and numbness of the thigh only. Flexion at the hip joint was seen in patients who reported late (after more than 12 hours), and where Factor VIII concentrates, vWD concentrates and FFP were used. The response was good in all hemophilia patients. The vWD patient had an evacuation of his hematoma prior to arriving at the centre. He required treatment for 4 weeks. Conclusions: Illeopsoas bleeds are not uncommon. Early and adequate treatment results in early resolution of hematoma. Patients, their families, and health care professionals need to be aware of bleeding at this site so that it can be treated early and effectively. Surgical intervention is best avoided.

A K I R A I S H I G U R O , K I M I K A Z U M A T S U M O T O and HISAYA NAKADATE Department of Hematology, National Center for Child Health and Development, Japan Objective: Arthropathy is one of the major problems for patients with hemophilia. To prevent progression of arthropathy, we started prophylactic therapy for hemophilia in Japan fifteen years ago. X-ray findings of bone joints, which are the standard evaluation technique for advanced joint damage, were considered less useful for detecting early changes of hemophilic joints. Magnetic resonance imaging (MRI) had been considered to accurately evaluate early changes of these joint damages. This study shows 6 years of experience using sequential MRI assessment of arthropathy in Japan.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

Haemophilia (2014), 20 (Suppl. 3), 1--186



Periprosthetic joint infection with brucella following total knee arthroplasty in a patient with severe hemophilia S M J A V A D M O R T A Z A V I , M O H A M M A D R E Z A S O B H A N and HAMED MAZOOCHY Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran Introduction and Objectives: Periprosthetic joint infection (PJI) with brucella species is a very rare condition with few case reports. However, we are not aware of any previous report of brucellosis in a prosthetic joint in a patient with hemophilia. Materials and Methods: A 28-year-old man presented with swelling in his right knee four years after total knee arthroplasty. A thorough work up for infection was performed. Initial culture was negative for aerobic and nonaerobic microorganisms. Considering the indolent and chronic course of disease and a history of consumption of non-pasteurized dairy products, serologic test for brucellosis were done. Results: High titer of brucellosis standard tube agglutination (STA) test result (1/1280) strongly suggested brucellosis, and brucella-PCR of synovial fluid confirmed the diagnosis. Brucella was isolated on the 14th day of incubation in Bac-Tec media. A negative TB-PCR test ruled out tuberculosis. Fungal culture after one week of incubation and BK culture after two months of incubation were negative as well. Antibiotic therapy for several months failed to eradicate infection, therefore, a twostage excision and a re-implantation were performed. The patient was infection free for three years after surgery. Conclusions: Painful TKA in patients with hemophilia may occur as a result of PJI. Infections of a chronic nature, especially brucellosis and tuberculosis should be considered in differential diagnosis and appropriately assessed, especially in endemic areas.

Extended factor IX activity improves joint healing in hemophilia B mice

JUNJIANG SUN,1 BAOLAI HUA,2,1 ERIC W. LIVINGSTON,3 ANTHONY G. LAU,3 TED A. BATEMAN,3 MIRELLA EZBAN,4 M A U R E A N E H O F F M A N 5 and P A U L E . M O N A H A N 6 1 Gene Therapy Center, University of North Carolina, Chapel Hill, NC, USA; 2 Department of Hematology, Peking Union Medical College Hospital, Peking, China; 3 Department of Biomedical Engineering and Radiation Oncology, University of North Carolina, Chapel Hill, NC, USA; 4Haemostasis Biology, Novo Nordisk A/S, M aløv, Denmark; 5Department of Pathology, Duke University, Durham, NC USA; and 6 Gene Therapy Center and Department of Pediatrics, University of North Carolina at Chapel Hill, NC USA Objective: Healing in skin wounds of hemophilia B mice is delayed when compared to hemostatically normal wild-type WT) mice, and is characterized by persistence of iron deposition, inflammation, and neovascularity. In this study we observed healing following hemarthrosis in WT and factor IX (FIX) knockout mice, examining the same parameters previously studied in the dermal wound model. We also examined whether extended FIX activity, achieved by glycopegylation of FIX (N9-GP, Novo Nordisk) when compared to unmodified recombinant factor IX (rFIX), improves defects in a joint bleeding model. Methods: FIX-/- or WT mice received unilateral needle puncture of the knee joint capsule to induce hemarthrosis. An additional group of WT mice received intraarticular injection of autologous blood. Following wounding, FIX knockout mice were treated intravenously with either normal saline, with single dose N9-GP 250 U/kg, or with rFIX 250 U/kg as a single dose or multiple doses. Joints were examined two weeks following hemarthrosis. Results: Hemarthrosis resulted in severe synovitis in untreated hemophilic mice (Valentino synovitis grade 5.9 on scale of 0-10) compared to WT mice (0.87 of 10). When compared to joints of WT mice that received the identical joint puncture either with or without blood injected into the joint – histology of the hemophilic joint included chronic iron deposition and exaggerated, persistent macrophage residence and neovascularity. One dose of rFIX minimally protected the joint (mean synovitis grade 3.7) compared to N9-GP (synovitis grade 1.8), whereas rFIX given on days 0, 1, and 3 after hemarthrosis reduced the synovitis grade to 2.5. Pathologic iron, macrophages and neovessels were reduced by N9-GP when compared to unmodified rFIX. Conclusions: The impaired features of wound healing observed in cutaneous wounds have close parallels in the mouse hemarthrosis model. Compared to single-dose unmodified rFIX, extending FIX activity following the time of wounding significantly improves wound healing in hemophilia B mice, as achieved using an equivalent dose of N9-GP. These results suggest that treating joint bleeding only until hemostasis is obtained may not result in optimal joint healing, which requires extended FIX activity.

The hemophilia joint health score (HJHS) in children with hemophilia during prophylaxis in Colombia: Experiences at two centres

DORIS VALENCIA,1 ADRIANA LINARES,2 I S A B E L S A R M I E N T O , 3 A N G I E U B A Q U E 3 and YADIRA VALDERRAMA4 1 Hospital La Misericordia, Universidad Nacional De Colombia; Bogota Colombia; 2 Hospital La Misericordia, Clinica Infantil Colsubsidio, Universidad Nacional De Colombia; Bogota Colombia; 3Hospital La Misericordia; Bogota Colombia; and 4 Clinica Infantil Colsubsidio; Bogota Colombia Introduction and Objectives: The HJHS is a scoring tool for assessing joint impairment in children, it is a clinical measure of joint structure and function. Our goal was to determine the HJHS in a cohort of patients during prophylaxis in two pediatric hemophilia treatments centres and describe the correlation of the physician’s global score of joint damage with hemophilia severity and type of prophylaxis. Materials and Methods: We conducted a retrospective evaluation of 25 patients under prophylaxis for at least 12 months. The HJHS tool was applied by a pediatric rehabilitation specialist with experience using the test. In all the cases we conducted a complete medical history that included prophylaxis details, and bleedings.

Haemophilia (2014), 20 (Suppl. 3), 1--186

Results: The main findings of the population are on Table 1. N


Primary prophylaxis/secondary HA/HB Hemophilia severe / moderate Average age years (SD) Months on prophylaxis average (SD) HJHS mean score Score 0 Score 8-15 Score >16 Joint disease Yes No Elbow Ankle Knee Hip

5/20 19/6 23/2 10 (5.1) 58.7 7 (IQR 0 - 25) 8 3 4 17 8 17 12 7 1

The median score of HJHS for all patients was 7 (IQR 0 – 25), for patients on primary prophylaxis it was 0 (0-7) and for patients on secondary prophylaxis it was 7 (1-27,5) (p = 0,004). The score was higher in severe hemophiliac patients. Conclusions: HJHS score are higher in patients on secondary prophylaxis. The HJHS score is a useful tool for an objective assessment of joint disease progression in hemophiliac children. We consider HJHS to be an important measurement instrument for the evaluation of patients with hemophilia and also to assess the functional impact of implemented treatment.

Factor VIII deficient mice have reduced bone mass: Chronic effects of factory deficiency without injury and acute bone loss in injured joints

TED A. BATEMAN,1 WILLIAM B. HANNA,2 ERIC W. LIVINGSTON,3 JUNJIANG SUN,2 SHEILA RAO-DAYTON,3 D O M I N I Q U E H E Y M A N N 4 and P A U L E . M O N A H A N 5 1 Departments of Biomedical Engineering and Radiation Oncology, University of North Carolina, Chapel Hill, NC USA; 2Gene Therapy Center, University of North Carolina, Chapel Hill, NC, USA; 3Department of Biomedical Engineering, University of North Carolina, Chapel Hill, NC USA; 4INSERM U957, Universite de Nantes, Nantes, France; and 5Gene Therapy Center and Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA Objectives: While joint damage is the primary co-morbidity of hemophilia, osteoporosis is also observed. This study investigates bone loss of the knee joint in skeletally mature FVIII-/- mice. The goal was to understand the relative contribution of both chronic factor deficiency and acute joint injury on bone mass and bone turnover. Changes in bone mass were examined by DXA and microCT. Bone turnover was assessed by serum levels of osteocalcin (formation) and TRAP5b (reabsorption). Methods: This study consisted of 4 groups: 1) Uninjured (UINJ) WT, 2) Injured (INJ) WT, 3) UINJ FVIII-/-, and 4) INJ FVIII-/-. Injured mice were subjected to a unilateral joint hemorrhage of the left knee at 22-weeks of age. All mice were euthanized at 24weeks of age. DXA scans were performed at 16-, 22-, and 24- weeks with bone mineral content (BMC) analyzed. Serum was collected at 22-and 24- weeks for ELISA analysis of osteocalcin and TRAP5b. Hind limbs were processed for microCT; surface roughness ratio (SRR), and BMD are reported. Results: UINJ FVIII-/- had lower whole body BMC than UINJ WT mice at all time points: 16-weeks -5.32% (p < 0.05), 22-weeks -4.25% (p < 0.05), 24-weeks -5.47% (p = 0.19) compared to UINJ WT mice. There was greater statistical power at 16and 22-weeks as all mice were UINJ. INJ caused additional whole body bone loss in the 24-week old FVIII-/- mice with BMC declining -8.36% (p = 0.001) compared to INJ WT mice. Quantitative analysis of distal femur SRR demonstrates a change for only the left INJ FVIII-/- limb compared to the limb. MicroCT analysis of trabecular bone at the proximal tibia show a significantly lower BMD (-28%) for UINJ FVIII-/compared to UINJ WT mice. Joint injury caused a further loss of BMD (-30%) for the left INJ FVIII-/- limb compared to the uninjured limb. There were no changes in serum levels of either osteocalcin or TRAP5b for injured or uninjured mice. Conclusions: This study suggests that hemophilia A results in a skeletal phenotype that is compromised of both genotype and joint injury. By 16-weeks of age, FVIII-/mice have reduced whole body BMC that is exacerbated by joint injury. When combined with lower pre-injury bone mass, injured FVIII-/- mice cumulatively have half the trabecular BMD of uninjured WT mice. The absence of changes in both osteocalcin and TRAP5b suggest that developmental and injury-induced bone loss occurs earlier than the time points examined.

Multimodalities for pseudotumor treatment in a severe hemophilia B patient with inhibitors

RAUL BORDONE,1 MARIA WILLIAMS,1 MARIANA GIL,1 V E R O N I C A A R R I E T A 1 and V I C T O R I A A L L E N D E 2 1 Centro de Tratamiento de Hemofilia Cordoba, Argentina; and 2Sanatorio Allende Cordoba, Argentina Pseudotumor is serious but rare complication in hemophilia and has been observed in 1-2% of cases with severe hemophilia A and B. It consist of encapsulated blood collection, which appears in soft tissue, perosteum and bone tissues, and grows due to recurrent hemorrhage and the consequent pressure in its interior. Most of the

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

MUSCULOSKELETAL ISSUES literature agrees on excision as the only curative treatment. We report a case of a 17year-old patient with severe B hemophilia with inhibitors, who suffered, in 2006, a left little finger pseodotumor. The bone defect was treated with Tisucolâ and oral calcium D vitamin with success. In 2010, present proximal tibial diaphisis pseudotumor was diagnosed by MRI. Surgical excision and filling with calciumphosphate cement granules was done. In 2013, MRI showed increasing bony erosion of tibial bone. The patient underwent daily external radiotherapy with 2 Gy per treatment for 15 days for total 30 Gy on a Linera Accelerator using 6 mV photons in

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


an attempt to induce endarteritis, fibrosis and calcification. All the treatments were done in combination with FVII ar replacement without hemorrhage complication. At present, the patient is on prophylaxis with FVII ar three times a week. There is no standard approach to the treatment of pseudotumors. The modality in each patient depends on the size of pseudotumor, site of involvement and the presence of inhibitors.

Haemophilia (2014), 20 (Suppl. 3), 1--186



17-NOVEL THERAPEUTICS Preventive effect of a humanized bispecific antibody to factors IXa and X (ACE910) on spontaneous joint bleeding in a non-human primate model of hemophilia A

ATSUSHI MUTO,1 KAZUTAKA YOSHIHASHI,1 MINAKO TAKEDA,1 TAKEHISA KITAZAWA,1 TETSUHIRO SOEDA,1 TOMOYUKI IGAWA,1 Y O S H I K I K A W A B E , 1 K E I J I N O G A M I , 2 M I D O R I S H I M A 2 and KUNIHIRO HATTORI1 1 Research Division, Chugai Pharmaceutical Co., Ltd., Gotemba, Japan; and 2 Department of Pediatrics, Nara Medical University, Kashihara, Japan

Introduction and Objectives: Clinical issues in hemophilia A treatment are the development of factor VIII (FVIII) inhibitors and the frequent intravenous (IV) injections of therapeutic agents. ACE910 is a FVIII-function mimetic IgG antibody that may overcome these issues. We previously reported that an i.v. dose of ACE910 exerts hemostatic activity against artificial ongoing bleeds in an acquired-hemophilia A short-term (4-day) monkey model. Because a hallmark of hemophilia A is spontaneous joint bleeding, we aimed to establish an acquired-hemophilia A long-term (8-week) monkey model with spontaneous bleeding episodes, especially joint bleeding, and to evaluate the preventive effect of weekly subcutaneous (SC) doses of ACE910 on these bleeding symptoms. Materials and Methods: For 8 weeks, cynomolgus monkeys received weekly IV doses of a mouse-monkey chimeric anti-primate FVIII neutralizing antibody, which had a mouse variable region and a monkey constant region of IgG to reduce its antigenicity in monkeys. In efficacy testing (n = 4 each), ACE910 was administered at 3.97 mg kg1 SC on Day 0 and thereafter at 1 mg kg1 SC a week to achieve plasma concentration over 30 lg mL1. The same regimen of vehicle was administered as a control. Bleeding symptoms were monitored until Day 56. Results: In the control group, continuous FVIII neutralization was shown by APTT increase, and bleeding symptoms (bruises, hematuria, decreased blood hemoglobin level, and the abnormal behavior of a leg joint known as claudication) were observed; especially, claudication was noted on average for about 60% of the observation time, and intra-articular hemorrhage was detected in 2.0  0.8 (mean  SD) joints per animal at necropsy. In the ACE910 group, these bleeding symptoms were significantly prevented; notably, claudication and intra-articular hemorrhage at necropsy were not observed at all. A plasma concentration of ACE910 above 30 lg mL1 was confirmed. Conclusions: A monkey model of hemophilia A was established to evaluate spontaneous bleeding including joint bleeds. Weekly SC doses of ACE910 significantly prevented them. ACE910, which has a user-friendly prophylactic regimen, is expected to prevent joint bleeding in hemophilia A patients. Conflict of Interest Disclosure: Atsushi Muto, Kazutaka Yoshihashi, Minako Takeda, Takehisa Kitazawa, Tetsuhiro Soeda, Tomoyuki Igawa, Yoshiki Kawabe, and Kunihiro Hattori are employees of Chugai Pharmaceutical Co., Ltd. Keiji Nogami receives research support paid to his institution from Chugai Pharmaceutical Co., Ltd. Midori Shima receives consulting honoraria and research support paid to his institution from Chugai Pharmaceutical Co., Ltd.

The safety, tolerability, pharmacokinetic, and pharmacodynamic profiles of ACE910, a humanized bispecific antibody mimicking the FVIII cofactor function, demonstrated in healthy adults

MIDORI SHIMA,1 NAOKI UCHIDA,2 TAKEHIKO SANBE,2 KOICHIRO YONEYAMA,3 HIROKO MIWA,3 N A O K I F U K A Z A W A , 3 T A K E H I K O K A W A N I S H I 3 and SHINICHI KOBAYASHI2 1 Department of Pediatrics, Nara Medical University, Kashihara, Japan; 2Showa University Clinical Research Center for Clinical Pharmacology & Therapeutics, Tokyo, Japan; and 3Clinical Development Division, Chugai Pharmaceutical Co., Ltd., Tokyo, Japan Introduction and Objectives: To overcome the laborious prophylactic intravenous interventions with FVIII agents given to hemophilia A patients, and to establish a novel prophylactic therapy, ACE910, a humanized bispecific antibody against both FIXa and FX mimicking the cofactor function of FVIII, was successfully generated. Here, we will present the phase I study data on ACE910 conducted in both Japanese and Caucasian healthy adults. Methods: The safety, tolerability, pharmacokinetic, and pharmacodynamic profiles of ACE910, and their racial differences were comparatively investigated in 64 subjects with a maximum observation period of 24 weeks. Japanese healthy adults received ACE910 subcutaneously at each respective dose of 0.001, 0.01, 0.1, 0.3 and 1 mg/ kg1, or placebo, where six for the ACE910- and two for the placebo-groups were included at each of dose employed. Doses of 0.1, 0.3 and 1 mg kg1 of ACE910, or placebo, on the other hand, were given to Caucasian adults. Results: Both Cmax and AUCinf increased in a dose-proportional manner over dose ranges between 0.01 and 1 mg kg1. Cmax given at a dose of 1 mg/kg1 was found to be approximately 6 lg/mL1. Tmax were found to be ranging from 7 to 14 days, and t1/2 was found to be about 4 weeks. While no apparent changes were observed for APTT or any thrombin generation(TG) parameters before or after administration, when artificial FVIII-deficient plasma samples spiked with two anti-FVIII antibodies cocktail were used, both the shortenings of APTT and the increasing of TG were observed in a dose-dependent manner. No apparent racial differences were observed in each of the pharmacodynamic parameter investigated. The adverse events observed in 14 subjects (ACE910-group) were all non-serious. Conclusions: These data suggest the medically acceptable safety and tolerability profiles of ACE910 given up to 1 mg/kg1. In addition, a long plasma t1/2 of approximately 4 weeks was observed. Furthermore, APTT was shortened and TG was increased in both Japanese and Caucasian when artificial FVIII-deficient plasma

Haemophilia (2014), 20 (Suppl. 3), 1--186

samples spiked with two anti-FVIII antibodies cocktail were used. Altogether, ACE910 is expected to establish a novel prophylactic treatment for hemophilia A patients either with or without FVIII inhibitors, which enables care-givers as well as patients to overcome laborious prophylactic interventions. Conflict of Interest Disclosure: The study is sponsored by Chugai Pharmaceutical Co., Ltd., Midori Shima receives consulting honoraria and research support paid to his institution from Chugai Pharmaceutical Co., Ltd., Koichiro Yoneyama, Hiroko Miwa, Naoki Fukazawa and Takehiko Kawanishi are employees of Chugai Pharmaceutical Co., Ltd.

Prolonged efficacy in hemophilia A mouse bleeding models of a recombinant FVIII-XTEN/D’D3 heterodimer with four-fold extended half-life in circulation

TONGYAO LIU,1 EKTA SETH CHHABRA,1 JOHN KULMAN,1 SUSANNAH PATARROYO-WHITE,1 DOUGLAS DRAGER,1 BRAD JOHNSON,1 GLENN PIERCE,1 V O L K E R S C H E L L E N B E R G E R , 2 R O B E R T P E T E R S 1 and HAIYAN JIANG1 1 Biogen Idec Hemophilia, Cambridge, USA; and 2Amunix Operating Inc., Mountain View, USA Introduction: Prophylaxis has demonstrated clear benefit over episodic treatment in hemophilia A (HemA) patients but its usage is impeded by the frequent dosing due to the short half-life of Factor VIII (FVIII). Despite different technologies that have been applied, the half-life extension of all current long-lasting FVIII molecules under development is limited to 1.5-fold. This limitation is attributed to the interaction of FVIII and circulating von Willebrand Factor (VWF). To overcome this problem, we have engineered a heterodimer of rFVIII and the D’D3 region of VWF, with its clearance decoupled from that of the endogenous VWF. The half-life of rFVIII/D’D3 is further extended by the insertions of XTEN, a non-structured polypeptide. Here we evaluated the pharmacokinetics (PK) and pharmacodynamics of rFVIII-XTEN/D’D3 in HemA mice. Methods: rFVIII-XTEN/D’D3 was produced recombinantly and composed of a FVIIIXTEN-Fc chain covalently associated with a 2nd D’D3-XTEN-Fc chain via the two Fc-domains. The heterodimer’s PK profile was evaluated in HemA mice; its prolonged and acute efficacies were evaluated in HemA mouse tail vein transection (TVT) and tail clip bleeding models. Results: In HemA mice, the half-life of the heterodimer was found to be more than 30 hrs, representing a 4-fold longer half-life than that of rFVIII. In addition, the AUCinf (area under the curve) and clearance were consistently improved by 3-fold. Correlated to the improved PK profile, rFVIII-XTEN/D’D3 provided a 3-fold longer protection against venous injury than rFVIII, as demonstrated by the comparable survival rate in mice treated with rFVIII-XTEN/D’D3 at 72 hrs prior to TVT or rFVIII at 24 hrs before TVT at same dose level. Furthermore, at the therapeutic equivalent doses, both rFVIII and rFVIII-XTEN/D’D3 reduced the blood loss to a similar degree following the tail clip injury in HemA mice, indicating that the heterodimer is also efficacious in treating acute bleeds. Conclusions: The rFVIII-XTEN/D’D3 heterodimer is the first engineered FVIII to date that has overcome VWF-imposed limitation on FVIII half-life. With 4-fold half-life extension and 3-fold prolonged prophylactic efficacy, rFVIII-XETN/D’D3 could potentially improve FVIII prophylaxis with longer dosing frequency and/or higher target trough, which may significantly advance the clinical management of hemophilia A.

Improving pharmacokinetic properties of the platelet-targeted coagulation factor VIIa by an unstructured polypeptide XTEN


Introduction and Objectives: Development of activated factor VII (FVIIa) muteins to improve therapeutic potency is hampered by mutation-related immunogenicity. To circumvent this problem, we have fused wild-type FVIIa with two classes of moieties: a single chain antibody against human integrin aIIbb3 (scFv) to direct FVIIa to platelets and an unstructured polypeptide (XTEN) to increase the hydrodynamic radius. The scFv–mediated platelet targeting has been shown to increase the hemostatic activity. Here, we engineered XTEN to enhance the pharmacokinetics (PK) of platelet-targeted FVIIa. Materials and Methods: Effects of the size and placement of XTEN on PK were investigated using strategies that employed either a single XTEN or two smaller XTENs. PK of the activity in plasma was assessed in hemophilia A (hemA) mice, and the PK of the protein on platelets was evaluated in humanized aIIb transgenic mice where platelet-bound protein was quantified by flow cytometry using a fluorescently labeled antibody to FVII. Results: For the strategy of using a single XTEN, the 288 amino acid XTEN (XTEN288) was found to be optimal. To evaluate the positional effect of XTEN288 on the PK of platelet-targeted FVIIa, two configurations that displayed hemostatic activity equal to or better than FVIIa were investigated: 1) FVII-scFv-XTENHC, where XTEN288 was fused to the heavy chain and the scFv was further linked to XTEN288, and 2) FVII-scFv-XTENLC, where the scFv was fused to the heavy chain and XTEN288 to the light chain. FVII-scFv-XTENHC cleared slower on platelets in circulation than that of FVII-scFv-XTENLC in aIIb mice. When compared to rFVIIa,

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

NOVEL THERAPEUTICS plasma activity PK in HemA mice of FVII-scFv-XTENHC indicated about 7-fold reduction in clearance and 6-fold increase in exposure (AUC, area under the curve). For the strategy of using two smaller XTENs, we found that attaching two XTEN72, one to the heavy and one to the light chain, improved the PK of platelet-bound FVIIa in aIIb mice and the PK of FVIIa activity in plasma in HemA mice similarly to that of FVII-scFv-XTENHC. Conclusions: By XTEN engineering and platelet targeting, we have generated multiple long lasting and more potent rFVIIa variants without altering the FVIIa coding sequence, which may improve both on-demand and prophylactic treatment of hemophilia patients with inhibitors.

In vitro characterization of ACE910, a humanized bispecific antibody to factors IXa and X

TETSUHIRO SOEDA,1 TAKEHISA KITAZAWA,1 ATSUSHI MUTO,1 TOMOYUKI IGAWA,1 ZENJIRO SAMPEI,1 MASAHIRO TAKEYAMA,2 YOSHIKI KAWABE,1 K E I J I N O G A M I , 2 M I D O R I S H I M A 2 and K U N I H I R O H A T T O R I 1 1 Research Division, Chugai Pharmaceutical Co., Ltd., Gotemba, Japan; and 2 Department of Pediatrics, Nara Medical University, Kashihara, Japan

Introduction and Objectives: ACE910 is a humanized factor (F) VIII-function mimetic bispecific antibody for the treatment of hemophilia A. It recognizes FIXa and its precursor form, FIX, with one arm and FX and its activated form, FXa, with the other arm, and places FIXa and FX into specially appropriate positions to mimic the cofactor function of FVIIIa. Its in vitro characteristics, however, have not been fully analyzed. Here, we present the in vitro functions and activity of ACE910. Materials and Methods: We performed a chromogenic FX activation assay using purified coagulation factors to elucidate the nature of ACE910’s cofactor activity, including its phospholipid (PL) dependency and effect on catalytic efficiency. We also determined ACE910’s affinity to FXa by surface plasmon resonance (SPR) analysis to address the possible release of FXa from ACE910 and performed plasma-based assays to validate the results. Results: In the chromogenic FX activation assay in the presence or absence of FIXa, ACE910 promoted FX activation only in the presence of FIXa, indicating that ACE910 functions as a cofactor. Also, ACE910 cofactor activity was shown to be PL dependent, suggesting that ACE910 should work specifically at hemostatic sites. In a kinetic analysis of the FIXa-catalyzed FX activation to quantify the cofactor activity, ACE910 increased kcat, decreased Km, and dramatically improved kcat/Km by tens of thousands-fold. These results indicated that ACE910 was capable of functioning as a FVIIIa-mimetic cofactor. Next, we tried to address whether ACE910 could release FXa to facilitate the formation of prothrombinase complex. By SPR analysis, ACE910 affinity to FXa was found to be low (KD=1 lM) and was comparable to FVIIIa’s affinity to FX (KD=1–3 lM), which supports the possibility of FXa being released from ACE910 in the coagulation cascade. Actually, ACE910 was capable of shortening APTT and of promoting thrombin generation (TG) in FVIII-deficient plasma. In terms of TG peak height, ACE910 exerted activity up to 10 U dL1 of FVIII at a concentration of 300–1000 nM. Conclusions: ACE910 functions as a FVIIIa-mimetic cofactor that can work in the coagulation cascade.

Improvement of coagulation by inhibition of cellular tissue factor pathway inhibitor

ROBERT PACHLINGER,1 ANGELINA BALDIN-STOYANOVA,1 FABIAN KNOFL,1 NADJA ULLRICH,1 M. CHRISTELLA L.G.D. THOMASSEN,2 ALEXANDRA HEINZMANN,2 RUDOLF HARTMANN,1 JAN ROSING,2 F R I E D R I C H S C H E I F L I N G E R 1 and M I C H A E L D O C K A L 1 1 Baxter Innovations GmbH, Vienna, Austria; and 2Department of Biochemistry, Maastricht University, Maastricht, The Netherlands Tissue factor pathway inhibitor (TFPI) is a Kunitz-type protease inhibitor that inhibits both FXa and TF-FVIIa and is an important physiological inhibitor of the extrinsic coagulation pathway. Full-length TFPI released by endothelial cells and by activated platelets into plasma is a physiologically important soluble form of TFPI. The main portion (~80%) of TFPI in humans is reportedly associated with endothelial cells. Targeting all forms of TFPI by an inhibitory peptide might mitigate bleeding complications and therefore become an important approach in hemophilia treatment. We analyzed the TFPI inhibitory activity of a fusion peptide, consisting of two peptides targeting two different binding epitopes on TFPI, on soluble platelet released and cell surface associated forms of TFPI. Binding studies of an inhibitory fusion peptide to TFPI alpha as well as to TFPI beta on living human umbilical vein endothelial cells (HUVECs) were performed using fluorescence activated cell sorting (FACS) and fluorescence microscopy. Inhibition of cell surface TFPI was analyzed in a FX activation assay performed on living cells. Inhibition of platelet TFPI, isolated after activation by convulxin, and plasmatic TFPI were compared in model systems including FXa and TF-FVIIa-catalyzed FX activation and in plasma-based TFtriggered thrombin generation. Detailed kinetic analysis showed that platelet-derived TFPI and recombinant TFPI were equally potent inhibitors of TF-FVIIa-catalyzed FX activation in model systems. The TFPI antagonistic fusion peptide blocked the anticoagulant activity of plasma- and platelet TFPI with similar IC50 values in the low nM range. The fusion peptide also enhanced thrombin generation in TFPIdepleted plasma reconstituted with platelets, indicating specific inhibition of platelet TFPI. We also showed that the fusion peptide binds cell surface TFPI alpha as well as TFPI beta and inhibits all forms of cell surface TFPI. In summary, a fusion peptide was shown to efficiently inhibit endothelial cell surface TFPI as well as plasmatic and platelet derived TFPI, implying that it targets all cellular forms of TFPI. These results support the notion that targeting TFPI with TFPI inhibitors is a promising novel strategy to diminish the bleeding risk in hemophilia patients.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


Design of an efficient inhibitor of TFPI by molecular fusion of two inhibitory peptides improves coagulation in hemophilia

RUDOLF HARTMANN,1 THOMAS POLAKOWSKI,2 HANS BRANDSTETTER,3 WILLIBALD KAMMLANDER,1 ERWIN PANHOLZER,1 CHRISTOPH REDL,1 F R A N K O S T E R K A M P , 2 F R I E D R I C H S C H E I F L I N G E R 1 and MICHAEL DOCKAL1 1 Baxter Innovations GmbH, Vienna, Austria; 23B Pharmaceuticals, Berlin, Germany; and 3Department of Molecular Biology, University of Salzburg, Salzburg, Austria TFPI is an important physiological inhibitor of the extrinsic coagulation pathway as it inhibits FXa and TF-FVIIa. Inhibition of TFPI with blocking antibodies, aptamers, or peptide inhibitors improves hemostasis and may become an option to treat hemophilia. Two TFPI inhibitory peptides, JBT-A7 and JBT-B5, were shown by crystallography to bind to two distinct sites on TFPI: K1 and K1-K2, respectively. The structure of the ternary complex K1-K2/JBT-B5/JBT-A7 revealed a close proximity of the termini of both peptides and provided atomic details for linking the two peptides to generate a fusion peptide that efficiently blocks TFPI activities. A fusion peptide with a 10-serine-linker showed highly improved dissociation in Biacore experiments, and most efficiently inhibited TFPI in model assays and global hemostatic assays using hemophilia plasma. To model situations of increased TFPI concentration, all assays were carried out at flTFPI concentrations up to 10 nM, which is 40-50-fold higher than the physiological flTFPI plasma concentration. Although a mixture of the single peptides showed an improved response over each monomeric peptide, both of which are partial inhibitors of TFPI, it did not reach the effect of the fusion peptide. Such increased TFPI levels may occur upon platelet activation or be induced by TFPI inhibiting compounds as seen for the TFPI inhibiting aptamer BAX 499 by affecting its clearance. We assessed the interference of this fusion peptide with low density lipoprotein receptor-related protein 1 and asialoglycoprotein receptor, two TFPI clearance receptors. Human flTFPI and hflTFPI in complex with the fusion peptide interacted efficiently via its K3-C-terminus region with both receptors. Unchanged association and dissociation kinetics with and without the peptide corroborates that binding of hflTFPI to the clearance receptors is unaffected. The fusion peptide, binding to different epitopes on TFPI, inhibits the interaction of TFPI with both FXa and FVIIa, resulting in full inhibition of TFPI activity even at highly elevated TFPI, as it occurs during platelet activation. Furthermore, our data suggest minimal effects on flTFPI plasma level after administration. Thus, the fusion peptide can be useful to prevent bleeding in hemophilia patients, and provides a FVIII- and FIX-independent approach for non-i.v. treatment.

Reversal of anticoagulants directly inhibiting FXa or thrombin (NOAC) by FEIBA can be monitored by thrombin generation assay GERALD SCHRENK, MICHAELA SCHAEDLER, SYLVIA PEYRER-HEIMSTAETT, H A N S P E T E R R O T T E N S T E I N E R , P E T E R L T U R E C E K and FRIEDRICH SCHEIFLINGER Baxter Innovations GmbH, Vienna, Austria Introduction and Objectives: Rivaroxaban and dabigatran, direct inhibitors of factor Xa and factor IIa (thrombin), respectively, are new oral anticoagulants (NOACs) used in a large number of patients to prevent thromboembolic disease following orthopedic surgery and non-valvular atrial fibrillation. In the event of a major bleed, however, there is no specific way to reverse their anticoagulant effect. We evaluated the effect of rivaroxaban and dabigatran on the thrombin generation (TG) potential of human normal plasma and determined the potential of FEIBA, a marketed and clinically used activated prothrombin complex concentrate, to reverse the anticoagulant effect of these NOACs. Materials and Methods: The effect of rivaroxaban and dabigatran on the TG of human normal plasma was assessed using the Technothrombin TG assay. Plasma was spiked with up to 1900 ng/mL of NOACs and TG determined with or without addition of a concentration series of FEIBA. Prothromplex total, a marketed and clinically used 4-factor PCC (prothrombin complex concentrate), and Prothromplex, a marketed and clinically used 3-factor PCC, served as active control items. Results: Both NOACs inhibited TG in a concentration-dependent manner. In contrast to dabigatran, which mainly delayed the initiation phase (lag time), rivaroxaban inhibited TG with respect to lag time and peak thrombin level. FEIBA corrected the impaired TG parameters induced by both NOACs to the level of normal human plasma while this was less pronounced for Prothromplex and nonexistent for Prothromplex total. This lack of efficacy turned out to be associated with the presence of heparin in the formulation buffer of these drugs. While FEIBA showed a concentration-dependent increase of TG in human normal plasma, Prothromplex had no effect and Prothromplex total even had an anticoagulant effect on TG. Neutralization of heparin in Prothromplex total increased TG to a level similar to that obtained with FEIBA when added to human normal plasma. Conclusions: Thrombin generation assay was demonstrated to be suitable for monitoring the effect of NOACs and determining the potential of FEIBA as a reversal agent. By contrast, other coagulation factor complex concentrates containing heparin were not effective, and occasionally showed an anticoagulant effect.

Interaction of BAX 855, a PEGylated full-length recombinant FVIII, with the FVIII clearance receptor LRP GERALD SCHRENK, MANFRED BILLWEIN, M I C H A E L A S C H A E D L E R , P E T E R L T U R E C E K and FRIEDRICH SCHEIFLINGER Baxter Innovations GmbH, Vienna, Austria Introduction and Objectives: Baxter and Nektar have developed a longer-acting recombinant FVIII (BAX 855), which is manufactured by stably coupling PEG using Nektar technology to Baxter’s full-length rFVIII bulk drug substance from its protein-

Haemophilia (2014), 20 (Suppl. 3), 1--186



free rFVIII manufacturing process. The low-density lipoprotein-receptor-related protein-1 (LRP, also known as a2- macrogobulin receptor or CD91) is considered to be a relevant determinant in the clearance of FVIII. We investigated the interaction properties of BAX 855 to LRP in different experimental approaches and compared them with those of unmodified, recombinant (r) rFVIII. Materials and Methods: Binding kinetics between BAX 855 and LRP was determined using surface plasmon resonance technology (SPR, Biacore). A defined amount of LRP was immobilized onto the flow cells of a CM4 sensor chip surface. A series of dilutions (10 to 100 lg/mL) of BAX 855 was then injected and association was allowed to occur for 10 minutes. Four kinetic parameters, including the equilibrium dissociation constant KD, were calculated. The effect of von Willebrand factor (VWF) on the FVIII/LRP interaction was studied using an ELISA based assay, where the binding of BAX 855 alone or in a preformed complex with rVWF to surface immobilized LRP was measured. Results: Both unmodified rFVIII and BAX 855 showed a FVIII-concentration dependent interaction with chip-immobilized LRP. Mean KD values were 58.2 nM for unmodified rFVIII and in the range between 68.6 and 185 nM for BAX 855, indicating a similar or slightly decreased binding affinity. In contrast, binding capacity, which was determined from the binding signals (response units), was approximately reduced by 50% for BAX 855 compared to unmodified rFVIII. The reduced binding of BAX 855 to LRP was confirmed using the ELISA-based assay. The addition of rVWF interfered with the binding of FVIII to LRP in a VWFconcentration dependent manner, with no relevant differences between BAX 855 and unmodified rFVIII. The effective inhibition of BAX 855/LRP interaction by rVWF also indicates a fully preserved binding of BAX 855 to rVWF. Conclusions: These results show that PEGylation of rFVIII reduces its interaction with an important clearance receptor for FVIII, which might be one determinant for the increased circulation time of BAX 855.

Structural and functional characterization of BAX 855, a PEGylated recombinant FVIII GERALD SCHRENK, MICHAEL GRANINGER, HERBERT GRITSCH, PETER MATTHIESSEN, HANSPETER ROTTENSTEINER, MARTIN KALIWODA, PETER L . T U R E C E K and F R I E D R I C H S C H E I F L I N G E R Baxter Innovations GmbH, Vienna, Austria Introduction and Objectives: Baxter and Nektar have developed a longer acting recombinant FVIII (BAX 855), which is manufactured by stably coupling PEG using Nektar technology to Baxter’s full-length rFVIII bulk drug substance from its proteinfree rFVIII manufacturing process. To corroborate the controlled production process of BAX 855, batches from clinical Phase 1 and Phase 2/3 production were characterized with respect to their structural and functional properties. Materials and Methods: Structural characterization included analysis of the primary structure, composition of the N-linked oligosaccharides, hydrodynamic diameter, secondary structure using Fourier-transformed infrared spectroscopy (FTIR) and twodimensional electrophoresis (2-D DIGE). PEGylation site distribution and detailed analysis of the consistency of PEGylation was investigated by activating BAX 855 with thrombin. The resulting PEGylated and non-PEGylated fragments were separated using RP-HPLC and the bound PEG was measured for each thrombin fragment. Assays to functionally characterize BAX 855 included FIXa cofactor activity, time course of thrombin-mediated activation and inactivation, thrombin generation capacity and susceptibility to activated protein C. Finally, the binding affinity and capacity of BAX 855 to VWF and the clearance receptor LRP were determined. Results: Tryptic peptide mapping of BAX 855 resulted in a sequence coverage of 94% with high consistency between batches. BAX 855 batches from clinical Phase 1 and Phase 2/3 production showed comparable distribution and extent of PEGylation. Two-dimensional electrophoresis confirmed high similarity of the spot and band patterns of clinical Phase 1 and 2/3 batches, indicative of high consistency of the manufacturing process. The mean hydrodynamic diameter of BAX 855 was between 35 and 38 nm; several BAX 855 batches showed almost overlapping FTIR absorbance spectra. Functional characterization of BAX 855 revealed characteristics similar to those of unmodified rFVIII in all assays used. Binding affinity and capacity to VWF was similar between BAX 855 and rFVIII. Interaction with the clearance receptor LRP was altered by PEGylation of rFVIII, shown by a decreased binding capacity. Conclusions: BAX 855, a PEGylated rFVIII development product, can be manufactured reproducibly without changes to the protein structure and retaining its functional activities.

Correlation between in vitro activity of human recombinant ADAMTS13 obtained with FRETS-VWF73 assay and assays using full-length VWF as substrate GERALD SCHRENK, HERBERT GRITSCH, JUTTA SCHREINER, BARBARA PLAIMAUER, PETER L. TURECEK, H A N S P E T E R R O T T E N S T E I N E R and F R I E D R I C H S C H E I F L I N G E R Baxter Innovations GmbH, Vienna, Austria Introduction and Objectives: Baxter has developed a human recombinant (r) ADAMTS13 to treat patients with hereditary thrombotic thrombocytopenic purpura. The potency of ADAMTS13 is usually determined by FRETS-VWF73 assay, which is based on fluorescence resonance energy transfer (FRET) using a fluorogenic version of the VWF73 substrate, containing the minimal VWF amino acid sequence required to be recognized and cleaved by ADAMTS13. We analyzed and compared the correlation of in vitro activity of rADAMTS13 measured by FRETS-VWF73 assay with that measured by alternative assays using full-length VWF as substrate. Materials and Methods: Human full-length rVWF was incubated with defined concentrations of two different rADAMTS13 preparations in the presence of a denaturing agent (1.5 M urea). Thereafter, the partially degraded rVWF was quantified by VWF:collagen binding (CB) and VWF:Ristocetin cofactor (RCo) activity assay as well as VWF multimer height analysis. The activities of the samples obtained

Haemophilia (2014), 20 (Suppl. 3), 1--186

with the full-length substrate assays were taken to recalculate their FRETS-VWF73 activities using an in-house standard preparation with an assigned FRETS-VWF73 activity as reference. Results: Incubation of rVWF with rADAMTS13 resulted in a dose-dependent decrease of VWF:CB activity. At the highest concentration used (70 mU), VWF:CB activity was reduced to about 30%. The mean value obtained from six independent test units for each concentration and sample showed relative standard deviation (RSD) in a range between 2.2 and 10.2%. Similar results were obtained when VWF:RCo activity was measured (RSD between 4.4 and 9.8%), indicating that also this assay yielded data in a reproducible manner. Low resolution VWF multimer analysis revealed a rADAMTS13 concentration-dependent disappearance of high molecular weight VWF multimers. Here, the calculated mean showed RSD values in a range between 1.9 and 10.8%. The relative deviation between the measured and re-calculated FRETS-VWF73 activities was 2-3% for the VWF:CB assay, 2-14% for VWF:RCo assay and 13-20% for the VWF relative multimer height analysis. Conclusions: The results confirmed the reliability of the FRETS-VWF73 assay for determining the activity of human rADAMTS13, as a good correlation could be demonstrated between the activities measured with the FRETS-VWF73 assay and alternative assays using full-length VWF as substrate.

Discrepancy in inhibitor assessment for two acquired TTP patients using a static and a flow-based assay RANA GRILLBERGER, BERNADETTE GRUBER, SUSANNA SKALICKY, BARBARA PLAIMAUER, PETER L . T U R E C E K , F R I E D R I C H S C H E I F L I N G E R and HANSPETER ROTTENSTEINER Baxter Innovations GmbH, Vienna, Austria Introduction and Objectives: Acquired (a) TTP is usually caused by inhibitory autoantibodies against ADAMTS13. Several Bethesda-type methods under static conditions are currently used to determine ADAMTS13 inhibitors. The neutralizing activity of such antibodies has not yet been evaluated under the more physiological condition of flow. We sought to establish a flow-based assay to measure ADAMTS13 activity in the presence of platelets and full length VWF. We also assessed whether the inhibitor titers of different anti-ADAMTS13 antibody preparations determined with FRETS-VWF73 assay correlate with the neutralizing activity obtained with this flowbased assay. Materials and Methods: For the flow-based activity assay, microcapillaries were coated with collagen and rVWF and transfused with a reconstituted blood cell suspension containing fluorescent labeled-platelets, red blood cells, and rVWF, as well as rADAMTS13. The surface area covered by the platelet aggregates was calculated, and its decrease upon addition of increasing amounts of rADAMTS13 used to build a standard curve for ADAMTS13 activity. A polyclonal goat anti-ADAMTS13 IgG antibody was used to establish the flow-based inhibitor assay. Recovery of ADAMTS13 activity was investigated in the presence of predefined FRETS-VWF73 based-inhibitor titers. To assess clinical relevance, affinity purified IgG autoantibodies isolated from two patients with aTTP were studied. Results: The flow-based assay showed a consistent and ADAMTS13 FRETS-VWF73 activity-dependent decrease in surface coverage of platelet aggregates. The assay was also suitable for demonstrating the inhibitory effect of anti-ADAMTS13 IgG antibodies. Interestingly, for two purified anti-ADAMTS13 antibody preparations from aTTP patients, different FRETS-based inhibitor titers (2 and 9 BU mL1) were required to achieve the same increase in surface coverage at a constant concentration of ADAMTS13. Conclusions: We present a novel flow-based ADAMTS13 activity assay that shows a good correlation with the FRETS-VWF73 activity assay. When measuring inhibitor titers of aTTP samples, however, an unexpected difference was observed between the two assays, suggesting that inhibitor titers determined by FRETS-VWF73 assay may not always be predictive of their actual in vivo inhibiting function.

Functional characterization of BAX930, a human recombinant ADAMTS13 drug candidate HANSPETER ROTTENSTEINER, BARBARA PLAIMAUER, GERALD SCHRENK, HERBERT GRITSCH, MICHAELA SCHMIDT, BERNADETTE GRUBER, J U T T A S C H R E I N E R , P E T E R L . T U R E C E K and FRIEDRICH SCHEIFLINGER Baxter Innovations GmbH, Vienna, Austria Introduction and Objectives: Baxter has developed a human recombinant (r) ADAMTS13 to treat patients with hereditary thrombotic thrombocytopenic purpura. We report on the characterization of preclinical and clinical lots of rADAMTS13 with respect to their functional properties. Materials and Methods: The ability of rADAMTS13 to degrade human full-length rVWF under moderate denaturing conditions was analyzed using two functional assays (VWF:CB and VWF:RCo activity) and gel electrophoresis (multimer analysis and immunoblot analysis). In all assays, the extent of rVWF degradation served as a direct measure for ADAMTS13 activity. The activity of rADAMTS13 was also tested in two flow-based assays. A VenaFlux-based assay determined the rADAMTS13 concentration-dependent decrease of the surface coverage of fluorescently-labeled platelets that had been perfused with red blood cells and rVWF over an adhesive surface. The other assay measured the extent of VWF cleavage product generation after subjecting a reaction mixture consisting of multimeric rVWF, lyophilized platelets, and rADAMTS13 to fluid shear stress on a vortex mixer. Results: VWF:CB activity of rVWF decreased upon incubation with rADAMTS13, with only minimal differences between the individual batches. VWF:RCo activity of rVWF also decreased after exposure to rADAMTS13, with no relevant differences between rADAMTS13 batches. Likewise, VWF multimer analysis demonstrated the disappearance of high molecular weight multimers upon incubation with rADAMTS13. Non-reducing SDS-PAGE followed by immunostaining using a

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

NOVEL THERAPEUTICS polyclonal anti-human VWF antibody clearly showed C-terminal and N-terminal VWF fragments, with no visible differences in the intensity of these bands between preclinical and clinical Phase I rADAMTS13 batches. Proteolytic activity of rADAMTS13 towards its multimeric VWF substrate was confirmed in two flow-based assays. Both assays revealed a high comparability between preclinical and clinical batches. Conclusions: All assays demonstrated consistency between rADAMTS13 batches over different production stages. Importantly, comparability was also shown between the ADAMTS13 activity measured by the assays using full-length VWF as substrate and FRETS-VWF73 assay used for potency assignment of rADAMTS13.

Nanobody-based TAFIa stabilization stabilizes hemophilia A clots and reduces the bleeding tendency in mice

M A A R T E N L V H E N D R I C K X , 1 , 2 P A U L J D E C L E R C K 1 and LAURENT MOSNIER2 1 KU Leuven, Leuven, Belgium; and 2The Scripps Research Institute, La Jolla, USA Introduction and Objectives: Activated thrombin-activatable fibrinolysis inhibitor (TAFIa) is a very powerful antifibrinolytic enzyme. However, TAFIa is very unstable (half-life = 8 min at 37°C), therefore stabilization of TAFIa is a promising novel approach for the treatment of patients with hemophilia. Materials and Methods: Stabilization of purified TAFIa by nanobody VHH-TAFIa428 was evaluated by a chromogenic assay. In vitro clot lysis assays were performed in the presence of VHH-TAFI-a428 in normal and hemophilia A plasma. Furthermore, VHH-TAFI-a428 was evaluated in an in vivo tail bleeding model in hemophilia A mice. Results: A detailed description on the TAFIa stabilizion by VHH-TAFI-a428 was done. Clot lysis times of normal plasma and hemophilia A plasma in the presence and absence of VHH-TAFI-a428 were measured. Blood loss in the in vivo mouse bleeding model in the presence and absence of VHH-TAFI-a428 was measured.

A novel semisynthetic activatable factor VII comprising an optimal synthetic thrombin cleavage site and a self-immolative linker VU HONG, JOE SALAS, ELENA KISTANOVA, M A R I S O L A C O S T A , B O B P A P E , A D A M M E Z O and ROBERT PETERS Biogen Idec Hemophilia, Cambridge, USA Introduction and Objectives: We previously reported recombinant thrombinactivatable factor VII variants that are resistant to ATIII inhibition and display FVIIa activity following activation by thrombin. However, they have low activity in in vitro coagulation assays due to slow activation by thrombin of the known sites composed of naturally occurring amino acids. An additional reason for the slow cleavage kinetics is that the sterically demanding isoleucine 153 residue, which is C-terminal of the cleavage site, is essential for the activity of FVIIa but not preferred by thrombin. We aimed to develop a novel semisynthetic thrombin-activatable FVII (ssTA-FVII) that allows the incorporation of a synthetic thrombin cleavage site and overcomes the limitation of the isoleucine 153 residue. Materials and Methods: Model peptides, which comprise a thrombin substrate and the first 6 N-terminal amino acids of the FVIIa heavy chain were screened. A selfimmolative PABC linker (p-aminobenzylcarbamate), which hydrolytically decomposes upon cleavage, was also inserted between these components to alleviate the steric

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


effect imposed by isoleucine. The ssTA-FVII variant was generated by native chemical ligation between a thioester peptide containing the optimized thrombin substrate and the first 6 N-terminal amino acids Ile153 to Val158 of the FVIIa heavy chain and a recombinantly produced FVIIFc fragment having an N-terminal cysteine residue 159 on the catalytic domain. Amidolytic and FXa generation activities after thrombin cleavage were evaluated with chromogenic substrates. Results: We identified DPhe-Pip-Arg-PABC-IVGGKV (pip: pipecolic acid) as the optimal candidate, and after optimizing the reactions conditions, we generated the ssTA-FVII. Although only a small fraction of the ssTA-FVII was converted into the desired zymogen, after proteolytic cleavage of the thrombin substrate (DPhe-Pip-Arg) and 1,6 spontaneous fragmentation of the PABC linker, the natural sequence of FVIIa was indeed restored. Furthermore, the ssTA-FVII enhanced zymogen displayed amidolytic and FXa generation activities following thrombin activation. Conclusions: We successfully generated the desired ssTA-FVII variant which displayed FVIIa activity after thrombin cleavage. This novel approach lays the foundations for the generation of protease variants that are not feasible by recombinant technology alone.

In vivo efficacy of human recombinant Factor IX produced by the hepatoma cell line HuH-7 NATHALIE ENJOLRAS, YESIM DARGAUD, ELOISE PEROT, J O N A T H A N G I R A R D , A L I C E I N D A L E C I O and CLAUDE NEGRIER1 Unite Hemostase, Inflammation & Sepsis, Faculte de Medecine, Lyon, France For hemophilia B treatment, a strong need exists for a new recombinant FIX (rFIX) preparation which could be administered in lower dosage than conventional rFIX from CHO cells for obtaining the same in vivo recovery than observed with plasmaderived FIX. This is accompanied by the desire to improve cell lines in order to achieve higher titers and a better product quality. Our previous studies described a methodology for obtaining a highly efficient cellular clone from a human hepatomacell line Huh-7 secreting FIX. This rFIX (HIX) has been described having better posttranslational modification (PTM) profile than rFIX produced by CHO cells. To verify the effect of improved PTM on in vivo recovery, HIX has been produced in a bioreactor and then purified from supernatant via anion-exchange and heparinaffinity chromatographies. Benefixâ, Mononineâ and HIX were then formulated in the same buffer. To study the biochemistry and clotting function of HIX, activation courses of HIX by FXIa and FVIIa-TF complex appear normal as did activation of Benefixâ, Mononineâ. Activation of FX by FIXa/Factor VIIIa/phospholipid (Intrinsic Tenase Complex) was also studied. The three molecules were then administrated (i.v.) to FIX-knockout mice at a dosage of 10 lg/20 g body weight. Two minutes after injection, blood samples were collected and subjected to human FIX-specific-ELISA and thrombin generation tests (TGT). Circulating HIX did not present any significant difference in term of antigen value with Benefixâ. Intriguingly, TGT were clearly exhibiting a better velocity for HIX than Benefixâ and Mononineâ. These data suggested that HIX may improve in vivo coagulant efficacy in comparison with the two commercial FIX injected at the same dose. In conclusion, HuH-7 cells could represent an effective cellular system for production of rFIX. If enhancement of in vivo recovery was not demonstrated for HIX versus Benefixâ, this rFIX from human hepatoma cell clone could be used in vivo at the same concentration than Benefixâ.

Haemophilia (2014), 20 (Suppl. 3), 1--186



18-OTHER Population pharmacokinetics of plasma-derived factor IX

€ S S O N , 2 E L I S A B E T I N I E L S E N 2 and K I R S T E N J E N S E N , 1 S I V J ON ERIK BERNTORP1 1 Centre for Thrombosis Haemostasis, Lund University, Sweden; and 2Dept. of Pharmaceutical Biosciences, Uppsala University, Sweden Introduction and Objectives: Optimization of factor IX (FIX) dosage in the prophylactic treatment of haemophilia B requires information about FIX pharmacokinetics (PK) in the individual. However, due to the high degree of interindividual variability (IIV), the relative complexity of FIX PK (versus factor VIII PK), and biases arising from insufficient sampling schedules, reported studies of FIX PK have failed to produce congruous results. In the present study we aim to develop a population PK (popPK) model of plasma-derived FIX (pdFIX) including characterization of the inter- and intra-individual variability, with the aim to facilitate PK-based dosing. Materials and Methods: Data from five previously published studies, each encompassing blood sampling for at least 72 hours post-infusion, was used for this analysis. The dataset included 34 patients with a median age of 26 years (range 13.7 58.5), being sampled on 1 to 6 study occasions. In total, data following 179 infusions comprising 1736 plasma level observations were used. Modeling was performed with NONMEM, and a previously published model of pdFIX popPK (Bj€ orkman, Haemophilia, 2012) was used as the starting point. Considered covariates were age and weight. Results: Application of the previously published model to the data revealed a reasonable fit. Estimation of model parameters based on the new data resulted in a similar estimate of pdFIX clearance. Conclusion: A popPK model for pdFIX was developed, demonstrating that the existing model remained a good fit for new data. However, the high degree of variability in individual PK parameters cannot be fully explained by patient characteristics, indicating that individual PK assessments are required for dose optimization. The application of full PK assessments in the clinical setting is not a realistic goal; therefore our ongoing research will consider the possibility of sparse sampling for determination of individual PK.

Genetic background and risk of postpartum hemorrhage: results from an Italian cohort of 3219 women

EUGENIA BIGUZZI,1 FRANCA FRANCHI,1 BARBARA ACAIA,2 WALLY OSSOLA,2 UGO NAVA,2 ELVEZIA M A R I A T I R A B O S C H I , 3 R O S A N N A A S S E L T A 3 and FLORA PEYVANDI1 1 A. Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Fondazione C a Granda Policlinico, University of Milan, Italy; 2Department of Obstetrics and Gynecology, IRCCS Fondazione C a Granda Policlinico, University of Milan, Italy; and 3Department of Medical Biotechnologies and Translational Medicine - University of Milan, Italy Introduction and Objectives: Postpartum hemorrhage (PPH) is a leading cause of maternal mortality, particularly in developing countries, and of severe maternal morbidity worldwide. The aim of the present study was to investigate the impact of genetic influences on postpartum hemorrhage, in association with maternal and intrapartum risk factors, using a candidate gene approach. Materials and Methods: All women (n = 6,694) who underwent a vaginal delivery at the Obstetric Unit of a large University hospital in Milan (Italy) between July, 2007 and September, 2009 were enrolled. The first consecutive 3219 women entered the genetic study. Postpartum hemorrhage was defined as ≥ 500 mL blood loss. Eight functional polymorphisms in seven candidate genes were chosen because of their potential role in predisposing/protecting to/from hemorrhagic conditions: tissue factor (F3), factor V (F5), tissue factor pathway inhibitor (TFPI), platelet glycoprotein Ia/IIa (ITGA2), prothrombin (F2), platelet glycoproteins Iba (GP1BA), and angiotensinconverting enzyme (ACE). Results: After correction for the already known PPH risk factors, only the promoter polymorphism of the tissue factor gene (F3 -603A>G) showed a significant association with PPH, the G allele exerting a protective effect (p = 0.00099; OR = 0.80, 95% CI = 0.70-0.91). Conclusions: This finding is biologically plausible since the G allele is associated with an increased protein expression and this protein is strongly represented in the placenta at term, particularly in decidual cells of maternal origin. A genetic background predisposing to PPH could help explain recurrent PPH in women not affected by bleeding disorders.

Circumcision and complications in adolescent and adult patients with hemophilia in southern Turkey: Cukurova experience BULENT ANTMEN, ILGEN SASMAZ, BIROL GUVENC, GOKSEL LEBLEBISATAN, BARBAROS KARAGUN, Y U R D A N U R K IL IN C , R E C E P T U N C E R and A T I L A A R I D O G A N Cukurova University, Adana, Turkey Introduction and Objectives: Circumcision is the oldest and most frequent surgical procedure for hemophiliac patients in the world. This is the case in Turkey, as in the other Islamic countries, because of religious and traditional pressures. The World Health Organization defines an adolescent as any person between ages 10 and 19. The social pressures are very strong in adolescent and adult hemophiliac patients in our country. In this study, we aim to report on the experience of circumcision at C ß ukurova University in a total of 36 adolescent and adult patients with hemophilia between 1994 and 2013.

Haemophilia (2014), 20 (Suppl. 3), 1--186

Materials and Methods: We retrospectively reviewed medical records for 33 hemophiliac patients without inhibitors and 3 hemophiliac patients with inhibitors who had been circumcised. Before the year 2000, factor concentrates were given before and after circumcision for 6-7 days. After 2000, we used fibrin glue together with factor concentrates for only 3 days. By-passing agents were used for circumcision in hemophiliac patients with inhibitors. Results: In total, 36 patients with hemophilia were circumcised in our centre under general anesthesia except for 3 patients who were given local anesthesia. Eight of 33 hemophilia patients (24,2%) without inhibitors had 5 mild, and 3 moderate bleeding complications. A few patients had significant bleeding despite adequate factor replacement. Two of three hemophilia patients with inhibitors had mild bleeding complications. Conclusions: Our experience showed that circumcision for patients with hemophilia should be carefully performed by surgeons together with a hematologist under appropriate conditions in hemophilia centres.

Circumcision in hemophilia patients in eastern Algeria: a single centre experience

AMINA KRIM,1 FAIZA MEZHOUD,1 NAOUEL SALHI,1 FAIC ßA L B O U A B E L L O U , 1 N O U R E D D I N E S I D I M A N S O U R , 1 M O U N A K H E L L A F 2 and L O T F I M E S K A L D J I 2 1 CHU IBN BADIS,Constantine, Algeria; and 2EHS Mansourah, Constantine, Algeria Introduction and Objectives: Circumcision is a traditional and religious ceremony in Algeria as in other Muslim countries. It is one of the most frequent surgical procedure but no Algerian guidelines have been established for its management. The aim of this study was to analyse outcomes of circumcision and to provide guidelines for its management. Materials and Methods: We retrospectively reviewed medical records of nine patients who had been circumcised between 2009-2013. Factor concentrates were given before and after circumcision for 10 days (for circumcision done before 2011) and 5 days (for circumcision done after 2011); the doses had been adjusted according to the severity of hemophilia and bleeding phenotype. Results: We studied nine patients (Hemophilia A = 5, Hemophilia B = 4). In five patients factor activities were < 1%, 3/9 were between 1 and 5% and 1/9 was >5%. The ages of circumcision ranged from 2 to 18 years (median 8 years). All indications for circumcision were parental request. The patients with hemophilia < 15 years were circumcised in the pediatric surgery department with the collaboration of surgeons, anesthesiologists and hematologists. All circumcisions were done under general anesthesia. Two patients had mild bleeding. Transfusion was not needed. Thrombotic events were not observed and antibody occurrence was not detected in these patients. Conclusion: Our experience showed that circumcision should be performed under appropriate conditions by a multidisciplinary team in a specialized centre. It allowed us to reduce the consumption of clotting factor concentrate and to establish a protocol to manage circumcision but the number of patients is small and we should apply our protocol on a larger patient sample to have convincing conclusions, and in order to provide Algerian guidelines for the management of circumcision.

Desmopressin does not lead to early hypertension N A N D A U I T S L A G E R and R O G E R E G S C H U T G E N S Van Creveldkliniek, University Medical Center Utrecht, The Netherlands Introduction: The Dutch guidelines Diagnostic and treatment of hemophilia and other hemostasis disorders state that high blood pressure is a contra-indication for the use of desmopressin. Patients with mild hemophilia A or von Willebrand Disease (vWD) have a life expectancy comparable to the rest of the population. As aging is associated with an increased risk in rising systolic and diastolic pressure, the aging patient group is treated with clotting factor instead of desmopressin. However, treatment with clotting factor increases the risk of developing an inhibitor and the associated financial implications, and the burden on patients is significantly higher. Objectives: To evaluate the effect of desmopressin use on blood pressure in adult patients with mild hemophilia A or vWD. Methods: From November, 2010 until November, 2013, 48 patients received desmopressin (0,3 microg/kg). Blood pressure was measured at the same arm before, 1 hour (h) and 4 hours after the infusion. ANOVA was used to compare means in the subjects at different time points. Results: Mean systolic value before desmopressin was 131.7 mmHg; after 1 and 4 h it was 126.0 and 126.6, respectively (p = 0.19). Mean diastolic readings before were 76.0 and descended to 70.7 and 70.8 at 1 and 4 h, respectively (p = 0.04). Post-hoc testing with Bonferroni correction showed a trend for lower diastolic values after desmopressin infusion. Sub-analysis in 13 patients with hypertension (systolic >140 mmHg or diastolic >90 mmHg) showed a mean systolic pressure before of 154.4 mmHg; after 1 and 4 h it was 140.0 and 140.3, respectively (p = 0.02). Mean diastolic value was initially 87.7 and descended to 77.5 and 82.5 at 1 and 4 h respectively (p = 0.12). Conclusion: Desmopressin does not lead to higher blood pressure within 4 hours of desmopressin infusion in patients with mild hemophilia A or vWD. In contrast, diastolic blood pressure was decreased 1 h after infusion and remained stable after 4 h. The group with initial hypertension showed a significant decrease in systolic pressure after the treatment with a desmopressin infusion. Based on these results, hypertension does not seem to be strictly contra-indicated to the use of desmopressin.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

OTHER IgG autoantibodies in plasma of acquired TTP patients and healthy individuals share common linear epitopes on ADAMTS13

RANA GRILLBERGER,1 VERONICA C. CASINA,2 PETER L. TURECEK,1 X. LONG ZHENG,2 H A N S P E T E R R O T T E N S T E I N E R 1 and FRIEDRICH SCHEIFLINGER1 1 Baxter Innovations GmbH, Vienna, Austria; and 2Children’s Hospital of Philadelphia, Philadelphia, USA

Introduction and Objectives: Anti-ADAMTS13 autoantibodies are found in plasma of patients with acquired (a) TTP, but also in about 5% of healthy individuals. Antibodies from aTTP patients have previously been studied using epitope mapping, whereas ADAMTS13-specific autoantibodies from healthy individuals remain illdefined and their binding specificities are unknown. To identify which binding sites are recognized by anti-ADAMTS13 antibodies from healthy individuals, we affinitypurified IgG anti-ADAMTS13 autoantibodies from a plasma pool of healthy donors (HD), and as reference, from plasma samples of three aTTP patients, and studied these preparations using epitope mapping. Materials and Methods: Anti-ADAMTS13 antibodies were purified by specific immuno-adsorption on an ADAMTS13 affinity matrix followed by protein G. The antibodies’ binding sites were mapped by immunoprecipitation using full-length

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


rADAMTS13 and a series of truncated variants. Epitopes were further mapped using peptide microarrays containing the protein sequence of ADAMTS13 translated into 13mer peptides. Results: ADAMTS13-specific IgGs were recovered not only from the TTP patients but also from the HD plasma pool. The latter antibody preparation showed low affinity towards ADAMTS13 and was non-neutralizing in ADAMTS13 activity assays. The purified IgGs from all three aTTP patients interacted with full-length ADAMTS13, the N-terminal fragments up to the spacer domain and only weakly with the C-terminal fragments. The HD antibody preparation gave rise to a similar profile. Incubation of ADAMTS13 peptide arrays with the affinity-purified antibodies revealed multiple hits with peptide recognition patterns that were remarkably similar for the HD pool and aTTP patients. Conclusions: Based on our data, it is tempting to suggest that anti-ADAMTS13 IgG autoantibodies in healthy individuals provide the template for the emergence of high affinity and pathogenic IgG autoantibodies in aTTP. Further studies should address whether the presence of anti-ADAMTS13 antibodies precedes clinical disease onset in aTTP, as this may improve our understanding of the pathophysiology of aTTP and help to identify biomarkers for early diagnosis and possible therapeutic intervention.

Haemophilia (2014), 20 (Suppl. 3), 1--186



19-OTHER TREATMENT MODALITIES Thrombin generation is restored in transient haemophilic rabbits after administration of concizumab, a monoclonal, tissue factor pathway inhibitor antibody E M I L Y K . W A T E R S , I D A H I L D E N , B R I T B . S Ø R E N S E N and BRIAN LAURITZEN Novo Nordisk A/S, M aløv, Denmark Introduction and Objectives: Tissue factor pathway inhibitor (TFPI) is the primary regulator of the initiation of coagulation. It binds to and inhibits the complex of tissue factor (TF) and factor VIIa (FVIIa) as well as factor Xa (FXa). Inhibition of TFPI may be an effective treatment for hemophilia, by allowing enough thrombin to be generated through the TF:FVIIa:FXa complex to overcome the deficit in either factor VIII (FVIII) or factor IX (FIX) present in hemophilia A or B, respectively. Concizumab (mAb 2021) is a high affinity, monoclonal, humanized IgG4 antibody targeting the kunitz-2 domain of human TFPI. Concizumab was previously reported to reduce cuticle blood loss in transient hemophilic rabbits in a dose-dependent manner. In the present study, we analysed the plasma samples from the cuticle-bleed rabbit study for thrombin generation to look for correlation to the bleeding response. Materials and Methods: Rabbits were made transiently hemophilic by i.v. administration of a monoclonal human FVIII antibody, followed by administration of concizumab (from 0.125 to 1.0 mg/kg) or an isotype control antibody. Platelet-poor plasma was acquired at various time-points and analysed for thrombin generation using the calibrated automated thrombogram system with 1 pM TF. Results: Thrombin generation was reduced greatly after administration of the FVIII antibody. After administration of concizumab, all rabbits demonstrated restored thrombin generation, while rabbits receiving the isotype-control antibody showed no improvement in thrombin generation. There was a slight dose response to concizumab, with the lowest dose (0.125 mg/kg) resulting in the lowest velocity index (rate of thrombin generation), and the highest dose (1.0 mg/kg) resulting in the highest velocity index. Conclusions: Concizumab was able to restore thrombin generation in rabbits previously treated with a FVIII antibody, at all tested concentrations. This differs from the cuticle bleeding results at the low doses where 0.375 mg/kg was needed to reach maximum effect. This discrepancy may potentially be due to involvement of different pools of TFPI (eg. platelet) in vivo compared to the in vitro thrombin generation assay.

ALN-AT3: an RNAi therapeutic targeting antithrombin for the treatment of hemophilia

ALFICA SEHGAL,1 JUNE QIN,1 TIM RACIE,1 SCOTT BARROS,1 BENNY SORENSEN,1 LACRAMIOARA IVANCIU,2 RODNEY CAMIRE,2 YESIM DARGAUD,3 CLAUDE NEGRIER3 and A K I N A K I N C 1 1 Alnylam Pharmaceuticals, Cambridge, USA; 2Children’s Hospital of Philadelphia, Philadelphia, USA; and 3Hopital Edouard Herriot, Lyon, France

Introduction and Objectives: The hemostatic system balances the need to control blood loss with the need to prevent thrombosis. In hemophilia, a deficiency in procoagulant factors VIII or IX (in the case of hemophilia A or B, respectively) results in an imbalance of the hemostatic system toward a bleeding phenotype. We are currently investigating the use of RNA interference (RNAi) to target the natural anticoagulant antithrombin (AT) as strategy to rebalance the hemostatic system and improve thrombin generation, and therefore hemostasis, in hemophilia. ALN-AT3, a subcutaneously administered RNAi therapeutic targeting AT, is currently being developed for the treatment of hemophilia. Materials and Methods: In this study we investigated the ability of ALN-AT3 to silence AT, and consequently, increase thrombin generation in a dose-dependent manner in hemophilia mouse and non-human primate models. In addition, we explored the impact of AT reduction in the human coagulation system using human hemophilia A and B plasma samples. Thrombin generation was measured using a calibrated automated thrombinoscope (CAT). Functional hemostatic effect of ALNAT3 was assessed using rodent models. Results: ALN-AT3 treatment in both hemophilia A and B genetic mouse models, as well as in an induced hemophilia A non-human primate model (mimicking hemophilia with inhibitors), led to improved thrombin generation. Dose-dependent increases in platelet accumulation and fibrin deposition were observed in a laser injury model of the microvasculature of the cremaster muscle and were found to compare favourably with results obtained with replacement factor therapy. Depletion of AT from human hemophilia plasma samples led to increased thrombin generation in an AT-dose dependent manner. Further, a novel clotting time-based assay was developed with increased sensitivity to AT levels in human plasma. Using this assay, shortening of clotting time in hemophilia A and B plasmas was demonstrated with AT depletion. Conclusions: Collectively, these data suggest that the use of a novel RNAi therapeutic targeting AT is a promising approach for the treatment of hemophilia, and potentially, other bleeding disorders. Furthermore, the subcutaneous route of administration, infrequent dosing, and applicability to persons with hemophilia who have inhibitors, make this a particularly encouraging potential therapy.

Biochemical characterization of rVIIa-FP, a novel recombinant FVIIa albumin fusion protein PHILIPP CLAAR, THOMAS WEIMER, GERHARD DICKNEITE and S T E F A N S C H U L T E CSL Behring GmbH, Marburg, Germany Introduction and Objectives: Antibodies to factor VIII (FVIII) or factor IX (FIX) impact coagulation therapy of affected patients. A recombinant factor VIIa (rFVIIa) is

Haemophilia (2014), 20 (Suppl. 3), 1--186

available as a therapeutic option to control bleeding episodes with a good balance of safety and efficacy. A novel recombinant fusion protein linking coagulation factor VIIa with albumin (rVIIa-FP) with a 3-4 fold increase in half-life (Golor et al., JTH 2013) has been described. A prophylactic management could be possible due to the extended half-life and could improve quality of life for haemophilia patients with inhibitors. Materials and Methods: Several biochemical characteristics of rVIIa-FP were compared to a commercially available recombinant FVIIa molecule (rFVIIa). The cleavage of FIX and FX by different FVIIa products was investigated in vitro by SDSPAGE. The FVIIa products cleaved both substrates in a comparable manner with a band pattern as described in literature. A tissue factor (TF) binding assay was performed in vitro using a cell culture based assay with TF bearing cells. The detection of FVIIa products bound to TF on the cell surface was performed using a fluorescence labelled anti-FVII antibody and the mean fluorescence as a function of concentration was analysed in a flow cytometer. Results: Comparable binding behaviour of the tested FVIIa products to TF was measured. In a similar cell based assay inhibition of binding of different FVIIa products to TF by tissue factor pathway inhibitor (TFPI) was found to be comparable. Conclusions: A comparable binding to TF and the comparability of cleavage patterns of FIX and FX indicates a comparable functionality of the tested FVIIa products, while being comparably inhibitable by TFPI, which indicates comparable low thrombogenic risk.

Reversal of the effects of new oral anticoagulants by treatment with FEIBA ALEXANDRA SCHIVIZ, GERALD SCHRENK, BARBARA DIETRICH, PETER L TURECEK, F R I E D R I C H S C H E I F L I N G E R , E V A - M A R I A M U C H I T S C H and WERNER HOELLRIEG Baxter Innovations GmbH, Vienna, Austria Introduction and Objectives: Rivaroxaban and dabigatran are new oral anticoagulants (NOACs) often used to prevent thromboembolism after orthopedic surgery and nonvalvular atrial fibrillation. The presented study evaluated the potential of FEIBA, a licensed activated prothrombin complex concentrate, to reverse their anticoagulant effect in the event of a major bleed. Materials and Methods: Six male NZW rabbits per group were intravenously dosed with 25, 50, or 100 IU/kg FEIBA, or saline as a negative control item. Efficacy was defined as a correction of the animals’ thrombelastogram (R-time) compared with saline-treated controls. Results: After baseline coagulation parameters were assessed, animals received 1.2 mg/ kg of the respective NOAC. Buffer was used as a negative control item to validate the model. After 10 minutes, coagulation was assessed followed by intravenous administration of test or control. Another 5 min and 1 day later, coagulation was assessed again. Administration of NOACs increased median R-time (from 21.5-35.5 to 67.3-120.0 min), aPTT, PT and reduced thrombin generation in all groups; saline showed no effect on coagulation parameters. Treatment with 25, 50, or 100U/kg FEIBA led to a dose-dependent correction of the prolonged R-time (28.6, 24.9 and 12.6 min with rivaroxaban; 46.5, 42.0 and 33.8 min with dabigatran). R-time on day 1 was similar to baseline values. FEIBA’s procoagulant effect was also evident in other coagulation variables: treatment with 25, 50 or 100U/kg FEIBA led to a correction of the prolonged PT (9.15, 8.3 and 9.1sec with rivaroxaban; 9.90, 7.70 and 6.80 sec with dabigatran) and dosedependent increase in thrombin generation (56.0, 81.1 and 103.6 nM with rivaroxaban; 77.5, 167.5 and 406.7 nM with dabigatran) 5 min after administration. Administration of FEIBA also corrected aPTT after pretreatment with rivaroxaban (39.55, 38.80 and 40.40 sec). After pretreatment with dabigatran, however, aPTT remained above baseline 5 min after treatment with FEIBA (56.40, 62.90 and 62.00sec). Conclusions: These results show that FEIBA effectively and quickly corrected the anticoagulant effect of NOACs, and thus may be a suitable candidate to further investigate as an antidote for bleeding complications after treatment with NOACs. All authors are full-time employees of Baxter Innovations GmbH, Vienna, Austria.

The TFPI antibody, Concizumab, improves thrombin generation in plasma from patients with hemophilia A, hemophilia B or inhibitors

EMILY K. WATERS,1 IDA HILDEN,1 SUPREET DHILLON,2 C A T H E R I N E J . R E A 2 and B R I T B . S Ø R E N S E N 1 Novo Nordisk A/S, M aløv, Denmark; and 2Haemotasis Research Unit, Centre for Thrombosis and Haemostasis, Guy’s and St Thomas’ NHS Foundation Trust, London, UK


Introduction and Objectives: Tissue factor pathway inhibitor (TFPI) is the primary regulator of the initiation of coagulation, inhibiting the tissue factor (TF): factor VIIa (FVIIa) complex, and factor Xa (FXa). Inhibiting TFPI may be an effective treatment for hemophilia, allowing the generation of sufficient thrombin by TF:FVIIa:FXa to overcome the deficiency in either factor VIII (FVIII) or factor IX (FIX) present in hemophilia A or B, respectively. Concizumab (mAb 2021) is a monoclonal IgG4 antibody targeting the kunitz-2 domain of human TFPI. In the present study we analysed the ability of concizumab to improve thrombin generation when added to plasma from hemophilia patients. Materials and Methods: Blood was collected from 19 patients with hemophilia (n = 10 with severe hemophilia A, n = 3 with severe hemophilia B, and n = 6 with inhibitors) in tubes with 3.2% trisodium citrate. Platelet-poor plasma was spiked with increasing concentrations of concizumab (0.001 to 500 nM). Plasma samples were

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

OTHER TREATMENT MODALITIES analysed for thrombin generation using the calibrated automated thrombogram system with 1 pM TF and 4 lM phospholipids. Results: Concizumab consistently improved thrombin generation when added to the plasma of all patients, regardless of patient diagnosis. The most robust parameters were peak thrombin and endogenous thrombin potential, with concentrationdependent improvements for > 1 nM concizumab and close to maximum effect for > 10 nM, reaching levels nearly equivalent to normal controls. Conclusions: This study marks the first time concizumab was tested ex vivo in patient plasma. Concizumab successfully restored thrombin generation in plasma from patients who have severe hemophilia A, severe hemophilia B, or inhibitors. These results indicate that concizumab could be an effective therapeutic in hemophilia.


deviations (RSD) were ≤ 20% with ≥ 0.4% rFIX or N9-GP. With TF, RSD values were ≥ 20% at most concentrations tested. Conclusions: N9-GP had similar activity as rFIX when FXIa triggered the reaction. This contrasts the TF-triggered reaction, where N9-GP is activated more slowly than rFIX. Sensitivity and variability with FXIa as trigger were improved compared to the TF-triggered experiments. These differences highlight the importance of the contact pathway in FIX activation. Further analysis with clinical samples is needed to confirm these observations.

Serratiopeptidase in treating hematomas without surgical drainage in hemophilia: three successful cases

Efficacy and safety of concomitantly administered activated prothrombin complex concentrate and recombinant activated factor VII in hemophilic mice MICHAEL DOCKAL, ALEXANDRA SCHIVIZ, PETER LEIDENMUEHLER, SABINE KNAPPE, CHRISTINA PISKERNIK, SYLVIA TIPPL, ALEXANDER BAUER, B A R B A R A D I E T R I C H , F R I E D R I C H S C H E I F L I N G E R and E V A MARIA MUCHITSCH Baxter Innovations GmbH, Vienna, Austria Acute bleeds in FVIII inhibitor patients are treated with FVIII bypassing agents: activated prothrombin complex concentrate (APCC, FEIBA) or recombinant factor FVIIa (rFVIIa). In cases where patients are non-responsive to monotherapy, concomitant combined bypass therapy (CCBT) with rFVIIa and APCC is a possible option to arrest bleeding. Using a translational in vitro-to-in vivo approach, we studied the combined effect of APCC and rFVIIa (BAX 817) in a global hemostasis assay, and the efficacy and toxicity of CCBT in a hemophilia A mouse model. The in vitro hemostatic effect of rFVIIa/APCC was assessed by thrombin generation in FVIIIinhibited human plasma. Several combinations reached the target activity of 1 U/mL APCC. Plasma concentrations of 0.2 U/mL APCC + 0.88 lg/mL rFVIIa were translated to doses for the mouse tail clip model. FVIII knockout (ko) mice received a single i.v. injection of 200-2700 lg/kg rFVIIa, 60-250 U/kg APCC, combinations of 60 U/kg APCC and 200-2000 lg/kg rFVIIa, or buffer. Blood loss after tail clip was measured over 60 min. The minimally effective doses were 2000 lg/kg rFVIIa, 250 U/ kg APCC, and 1200 lg/kg rFVIIa + 60 U/kg APCC for the combination therapy. Thus, low doses of rFVIIa and APCC in combination are effective in correcting a bleeding phenotype. Safety and thrombogenicity were evaluated in an acute toxicity study. FVIII ko mice were dosed with the minimally effective rFVIIa/APCC combination, a high-dose combination (2000 lg/kg rFVIIa + 270 U/kg APCC), or buffers only. No clinical signs or changes in blood chemistry were observed. In addition, tissue samples of potential target organs were examined for microscopic abnormalities. Treatment with the high-dose combination caused microscopic changes at the injection site, heart, and lung. Administration of the minimally effective rFVIIa/ APCC combination, however, did not result in any thrombotic organ damage. To our knowledge, these are the first in vivo studies assessing CCBT with low doses of rFVIIa and APCC in a hemophilia animal model. We show that combined doses of rFVIIa/ APCC, inefficacious as a stand-alone treatment, reduce blood loss after tail clip and appear to be non-thrombogenic. Interestingly, the minimally effective combination dose in mice translates to human doses of 40 lg/kg rFVIIa + 20 U/kg APCC which falls within the clinically applied dose ranges of CCBT.

Comparison of recombinant factor IX and a glycoPEGylated factor IX (N9-GP) in thrombin generation initiated by either tissue factor or Factor XIa EMILY K. WATERS, IDA HILDEN, BRIT B. SØRENSEN, M I R E L L A E Z B A N and P E R N I L L E K . H O L M Novo Nordisk A/S, M aløv, Denmark Introduction and Objectives: The thrombin generation assay (TGA) has gained attention as a possible method for monitoring hemophilia treatments. A glycoPEGylated derivative of recombinant FIX (N9-GP) currently in clinical development has a 5-fold prolonged half-life and has shown in a phase 3 trial to be effective in both the prophylaxis and treatment of bleeding episodes. Previously published in vitro data showed N9-GP is activated by FXIa to the same extent as recombinant FIX (rFIX) but more slowly by the TF:FVIIa complex compared to rFIX. The current study compares N9-GP and rFIX with both TF and FXIa as triggers in the TGA. Materials and Methods: Commercially available plasma from patients with severe hemophilia B was spiked with rFIX or N9-GP (0.13% to 130%). The calibrated automated thrombogram assay was used with 1 pM TF or 0.05 U/mL FXIa as the trigger. The activity of the two molecules, assay sensitivity, and variability were compared when either trigger was used. Results: With FXIa as the trigger, rFIX and N9-GP had nearly identical activity. Peak thrombin values were 323  16 nM and 327  19 nM with 33% rFIX or N9-GP, respectively. As expected, N9-GP had lower activity than rFIX with TF as the trigger. Here, peak thrombin values were 64  12 nM (rFIX) and 44  14 nM (N9-GP) when tested at 33%. The sensitivity with FXIa was higher than with TF: 0.1% rFIX or N9-GP was distinguishable from hemophilia B plasma alone, compared to 0.4% with the TF trigger. Variability was lower with FXIa as the trigger: relative standard

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

CESAR NOLASCO CANCINO,1,3 MATILDE CECILIA H E R N A N D E Z T R E J O , 2 E U G E N I O Q U E V E D O R A M O S 3 and ARIOSTO BASTAR ACOSTA1,3 1 Hospital Regional de Alta Especialidad Juan Graham Casasus, Villahermosa, Mexico; 2UNEME Secretaria de Salud, Villahermosa, Mexico; and 3Tabasque~ na de Hemofilia A. C., Villahermosa, Mexico Introduction and Objectives: Hematomas generate complications like pseudotumors in many sites (CNS, abdomen, thorax, soft tissues). The drainage of the hematoma limits the chronic inflammatory damage, but this is not always possible because of resource constraints or the patient0 s rejection of a surgical procedure. By using fibrinolitic drugs, hematoma can be absorbed through the lymphatics, once the vascular damage has been healed, around the tenth day of injury, after the proliferative phase of cicatrization. Materials and Methods: Three patients were treated with factor VIII concentrates according to the WFH guidelines, but surgical drainage was impossible. On the tenth day of treatment, the enzyme serratiopeptidase (Takeda Chemical Industries) was started with the purpose of pain relief and functional improvement. One patient had a hematoma in the left eyelid measuring 6 x 4 x 2 cm, blocking the eye opening. A second patient had a chronic iliopsoas hematoma with an initial volume of 980 cm3 measured by CT scan, besides intense pain. The third patient had a frontotemporal subgaleal hematoma with an initial volume of 150 cm3. Results: After two weeks of treatment with serratiopeptidase, the first patient decreased his hematoma by 80% of the initial volume, the iliopsoas hematoma decreased 66%, controlling the abdominal discomfort and pain, recovering mobility. The third patient reached 100% absortion. None of them presented with new hemorrhagic episodes. Conclusions: Serratiopeptidase has been used in respiratory diseases to dissolve inflammatory exudates and in cosmetic surgery to reabsorb residual hematomas minimizing the size of scars. This enzyme can be used in major hematomas like the hemophiliac pseudotumors to avoid or minimize the chronic damage such the progressive arthropathy, muscular atrophy or seizures in case of intracranial hematoma. This has a good potential to improve the quality of life of patients. This work has the intention to stimulate the development of appropriate studies to assess the therapeutic effects of using fibrinolitic strategy in the management of hematomas.

Endoscopic treatment of bleeding esophageal varices in hemophilia patients

ANDRZEJ B. SZCZEPANIK,1 ANDRZEJ MISIAK,1 SLAWOMIR HUSZCZA,1 ANNA M. SZCZEPANIK,2 K O N R A D P I E L A C I N S K I 1 and W O J C I E C H P . D A B R O W S K I 1 1 Department of General and Hematological Surgery, Institute of Hematology and Transfusion Medicine, Warsaw, Poland; and 2Department of Gastroenterology, Medical University of Warsaw, Warsaw, Poland Introduction and Objectives: In hemophilia patients with liver cirrhosis, bleeding from esophageal varices is a serious clinical condition due to congenital deficiency of clotting factors VIII or IX, decreased clotting factor synthesis in the course of chronic liver disease and hipersplenic thrombocytopenia. The aim of the study was to evaluate the effectiveness of emergency endoscopic treatment of bleeding esophageal varices in hemophilia patients. Materials and Methods: From 2001 to 2012, all hemophilia patients admitted with endoscopically documented hemorrhage from esophageal varices were enrolled into the study. The group included 21 hemophilia A patients (11 severe, 2 severe with low - titer inhibitor, 5 mild) and 3 hemophilia B patients (severe), aged 23-59 (mean age 41.4). All were cirrhotic; 11- A, 4 - B and 6 - C according to Child-Pugh classification. In all patients emergency endoscopy was performed. Diagnosis of esophageal variceal bleeding was based on commonly accepted criteria. When diagnosis was established, esophageal band ligation with multiband ligator, or injection sclerotherapy with 5% ethanolamine oleate was performed. All patients received a three-day replacement therapy to secure each sclerotherapy or ligation procedure; factor VIII/IX activity was maintained at level of 80-100%. Results: We performed variceal ligation in 3 patients and injection sclerotherapy in 18. As a result of the endoscopic procedure, variceal bleeding was arrested in 20 patients (95%). One patient died due to uncontrolled bleeding and liver insufficiency. Recurrent bleeding was observed in 3 patients (14%); all were successfully treated with repeated endoscopic procedures. Complications were observed in two patients (9.5%); deep esophageal ulcer in one and exudative pleuritis in one. Two deaths occurred (hospital mortality 9.5%), both in C child group. Conclusions: Emergency endoscopic ligation and sclerotherapy are both effective, firstline methods in emergency management of bleeding esophageal varices in patients suffering from hemophilia.

Haemophilia (2014), 20 (Suppl. 3), 1--186



20-OUTCOME ASSESSMENTS Validation of the International Society on Thrombosis and Haemostasis Bleeding Assessment Tool (ISTH-BAT) in Hemophilia Carriers J O H N N Y M A H L A N G U and P A U L A J A M E S on behalf of the Global Hemophilia Panel (GEHEP) Background: Since its publication in 2010, The International Society on Thrombosis and Haemostasis Bleeding Assessment Tool (ISTH-BAT) has increasingly become widely accepted as a standardized, quantitative tool to assess bleeding symptoms. However, the ISTH –BAT has not been validated in hemophilia carriers. The aim of this study was therefore to validate the expert-administered ISTH-BAT as a screening tool in hemophilia carriers for the identification of those with low factor VIII or IX levels due to skewed X-inactivation. We will present preliminary results of this ongoing study. Patients and methods: This is a multinational, prospective, observational, cross sectional study in hemophilia A or B carriers who are 18 years or older, able to give informed consent, with documented FVIII or FIX, with or without bleeding symptoms. The ISTH-BAT was administered to all carriers. Psychometric reliability of the ISTH-BAT (test retest and inter-observer reliability) was conducted in subset of carriers. Results: This study is ongoing. So far, 13 carriers have been recruited (10 hemophilia A, three hemophilia B) with mean age of 46 years (range 27-64). Nine have positive bleeding score of which six have low factor levels. The calculated sensitivity therefore is 100%, Specificity 57%, PPV 0.67, and NPV 1.0. The ICC for Test/re test (same observer) was 0.64 and ICC for test/re-test (inter-observer) was 0.97. Conclusion: Preliminary results of this ongoing study suggest that the ISTH-BAT may be a useful tool in the evaluation of bleeding symptoms in hemophilia carriers.

Validation of the Self-BAT (Self-administered Bleeding Assessment Tool) in Hemophilia Carriers: Preliminary Results

JANE YOUNG,1 JULIE GRABELL,2 ANGIE TUTTLE,1 MEGHAN DEFOREST,3 NATALIA RYDZ,4 J O H N N Y M A H L A N G U , 5 W I L M A H O P M A N 6 and PAULA JAMES1,2 1 Department of Pathology & Molecular Medicine, Queen’s University; 2Department of Medicine, Queen’s University; 3Department of Orthopedics, University of Calgary; 4 Department of Medicine, University of Calgary; 5Department of Hematology, University of Witwatersrand; and 6Public Health Sciences, Queen’s University Hemophilia A and B are X-linked deficiencies of Factor VIII (FVIII) and IX (FIX) respectively. Males are affected, while females are carriers of the disease. However, 30% of hemophilia Carriers (HC) manifest low FVIII or FIX levels due to extreme lionization. Additionally, HC can manifest abnormal bleeding symptoms. The objective for this study is to validate the Self-BAT as a screening tool for identifying HC with low FVIII or FIX levels. This is a multi-centre, prospective observational study with participation from two Canadian centers and one in South Africa. Eligible subjects are female carriers of hemophilia A or B, > 18 years of age. Subjects are excluded if they have another potential cause of bleeding. A blood sample was obtained for coagulation factor testing, FVIII or FIX genotyping and ABO. To date, 10 HC have been enrolled (Eight hemophilia A, two hemophilia B) with an average age of 45 years (range 27 – 64). Eight had a positive or abnormal BS (≥5) and of those six had low FVIII or FIX levels. Therefore, preliminary analysis shows that a positive or abnormal Self-BAT BS has a sensitivity of 100%, specificity of 50%, a positive predictive value of 0.75 and a negative predictive value of 1.0. In summary, our data suggests that the Self-BAT is a highly effective tool to incorporate into the clinical assessment of HCs because it identifies those who will benefit from treatment strategies aimed at controlling bleeding symptoms. Recruiting of additional subjects is ongoing. Disclosures for Paula James: Research Support – Bayer, CSL Behring.

iPad-based PedHAL app is intuitive and acceptable to boys with hemophilia

KATE KHAIR,1 NICOLA HUBERT,1 ALPHA BARRIE,1 J U L I A S P I R E S , 1 A N J A G R I F F I O E N 1 and M I K E H O L L A N D 2 1 Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom; and 2Haemnet Ltd, UK Department of Health, UK Introduction and Objectives: PedHAL (the Paediatric Haemophilia Activities List) is a disease-specific self-reported functional outcome questionnaire which measures the impact of hemophilia on activities of daily living in clinical and research settings. PedHAL is currently completed (though often not fully) in the clinic on paper; the 7page questionnaire takes boys about 15 minutes to complete. This then requires calculation of the results by a data analyst. We have developed an attractively designed PedHAL iPad app that gives real-time results to patients and clinicians, and have tested its acceptability to boys with hemophilia. Materials and Methods: Over a two-week period in October, 2013, 14 boys with severe hemophilia aged 6-17 years attended routine clinic appointments and were invited to complete the PedHAL on an iPad app, and were subsequently asked to answer a short feedback questionnaire on paper. All had previously completed the PedHAL on paper between October, 2012 and April, 2013. Results: Three boys answered more questions on the iPad than they had answered on the paper version; none answered fewer questions. In feedback responses: 6/14 boys said the iPad questionnaire took 10 mg/dL VWF reached maximal levels (mean VWF-Act 236%96; mean VWF-Ag 223% 85). The strongest confounder was CRP followed by age and BMI. Blood group had the weakest impact. Conclusion: Diagnosis of VWD can only be done reliably if several modifiers of VWF are taken into account. If modifiers co-occur, adjusted VWF reference ranges are necessary to minimise the risk of misdiagnosis.

Validity of the bleeding score in vWD patients with hereditary thrombophilia MARIOVON DEPKA, CORNELIA WERMES, FLORIAN BRASSEL, A L I N A F U R S A and C A R S T E N D E T E R I N G Werlhof Institute, Hannover, Germany Introduction: Diagnosis of VWD can be difficult as VWF shows a large variability in bleeding frequency and severity. The diagnosis is based on both clinical and laboratory criteria. A bleeding score can help to quantify the number and severity of bleeding symptoms, thus, to improve the reliability of the diagnosis. However, hereditary thrombophilia is present in a considerable percentage among the healthy population as well as among VWD patients. Here we analyse the validity of the bleeding score by TOSETTO ET. AL. in patients with VWD who are carriers of at least one risk factor of hereditary thrombophilia. Patients and Methods: We included 96 patients with VWD type 1 (86; 89.6%), and type 2A (10, 10.4%) for evaluating the validity of the bleeding score. Patients with type 3 were excluded. Hereditary thrombophilia was present in 62 patients (64.6%, PAI1-4G, FV-Leiden, Lp(a) elevation, or PTG20210A). 34 patients (35.4%) did not suffer from thrombophilia. Results: Age range of the total group was 2 to 73 with a mean of 34.1 years. Seventy female (72.9%) and 26 male patients (27.1%) were included. Mean age of patients without concomitant thrombophilia was 37.5 years  15.6 and in the group with concomitant hereditary thrombophilia 27.79 years  16.2. Mean levels of VWFactivity (VWF:Act) was 41.74%  7.4, VWF-antigen (VWF:AG) 56.95  13.1 and of FVIII-activity (FVIII:Act) 74.92%  20.3 in the total group. Among patients with thrombophilia mean level of VWF:Act was 42.35  6.0, mean VWF:AG 58.58  13.4 and mean FVIII:Act was 78.48  20.76. The group without concomitant thrombophilia showed lower levels (VWF:Act: 40.62  9.4, VWF:AG: 53.97  12.1 and FVIII:Act: 68.41  18.4). Among patients with VWD and thrombophilia mean bleeding score was 1.97 ( 2.72; range -1 to 11) compared to 3.79 ( 3.12; range -1 to 12) in those without thrombophilia (p < .005). Conclusion: In patients with VWD and concomitant hereditary thrombophilia bleeding score may not represent an appropriate tool to improve the reliability of VWD diagnosis. As the bleeding history is considered the hallmark of VWD the development of reliable tools to assess bleeding symptoms is warranted.


Haemostatic management of von Willebrand disease type 3 in surgery using low doses of FVIII-VWF or VWF concentrates

MERIEM BENSADOK,1 MOHAMED ADJALI,2 D J A F A R H A N T A L A , 3 Z O H R A K A C I , 4 S A L I M N E K K A L 4 and MERIEM FADILA BELHANI1 Departments of 1Hematology & Blood Banking, 2Gynecology/Obstetrics, and 3 Pediatric Surgery,University Hospital of Beni Messous, Algiers, Algeria

Introduction and Objectives: Surgery in von Willebrand disease (VWD) is still a challenge in developing countries because the required substitution factor concentrates are not always available; therefore fresh frozen plasma & cryoprecipitate were mostly used. The use of FVIII-VWF & recently, VWF concentrates, is a new experience for us. We report 2 cases of haemostatic management in surgery for patients with VWD type 3 using low doses of factor concentrates. Materials and Methods: The first patient, a 27 years old woman was operated in emergency for suspicion of extra uterine pregnancy. The only available substitution treatment was fresh frozen plasma that she received before & after surgery. She had a life threatening hemorrhage immediately after the operation. She was then infused with FVIII-VWF concentrate (usually used for hemophilia A) at a dose of 50 IU FVIII/ kg, 25 IU VWF/kg twice a day for 3 days & then once a day until wound healing. The second case, a 6 years old boy, had an appendectomy & circumcision. VWF concentrate was available at that moment. He received a first dose 50 IU/kg of VWF concentrate & 30 IU/kg of FVIII before surgery. He had 2 daily infusions of VWF for 3 days, then once a day for 2 days & received FVIII-VWF concentrate for the last 3 days. In both cases, infusing low doses of factor concentrates was not a choice but a question of availability of the products. We followed daily the plasmatic levels of VWF:RCo & FVIII all the duration of the substitution. Results: The bleeding was progressively controlled for the first patient, the VWF plasmatic level was from 50 to 96% & FVIII increased to more than 200%. No hemorrhage occurred for the second patient, VWF plasmatic level was from 63 to 124%; FVIII was up to 100% when VWF was infused & reached 200% when FVIIIVWF concentrate was used. The important elevation of FVIII plasmatic levels during the substitution with FVIII-VWF concentrate raises the risk of thrombosis. No thrombotic event occurred. Conclusion: The pharmacokinetic profile of FVIII-VWF & VWF concentrates plays a key role in the dosing of patients with VWD: although the infused doses in both cases were lower than those proposed in the literature, haemostatic plasma concentrations of VWF were observed, the bleeding stopped in the first case & did not occur in the second one & it was not necessary to increase the doses.

Repair of a bicuspid aortic valve resolved the acquired von Willebrand syndrome in a 17 year-old boy: Bleeding was the only indication for surgery

MARIA LAURA AVILA,1 VANESSA BOUSKILL,1 M A R G A R E T R A N D , 2 P A U L A J A M E S 3 and M A N U E L C A R C A O 1 Thrombosis and Haemostasis Service, The Hospital for Sick Children, Toronto, Canada; 2Dept. of Laboratory Medicine & Pathobiology, The Hospital for Sick Children, Toronto, Canada; and 3Departments of Medicine and Pathology & Molecular Medicine, Queen’s University Kingston, Canada


Introduction/Objectives: Acquired von Willebrand Syndrome (AVWS) is a rare bleeding disorder that can occur in patients with high flow-high shear cardiac lesions. We aim to describe the challenges in the diagnosis of a case of AVWS. Materials/Methods: An 11 yr-old Caucasian boy was referred for recurrent epistaxis and excessive bruising that started at 7 yrs of age. Epistaxis occurred from either nostril, 2–3 times/month, lasting 20 min-4 hrs. He had undergone circumcision without bleeding as a newborn and at 5 yrs of age was diagnosed with a bicuspid aortic valve with mild stenosis. There was no family history of bleeding. Laboratory results showed normal hematocrit and platelet count; VWF:Ag, 1.03 IU/mL; VWF:RCo, 0.61 IU/mL; VWF:RCo/Ag ratio, 58%; normal VWF multimer (VWFm) distribution. PFA closure times (CTs) were prolonged (collagen/epinephrine, >300 sec; collagen/ADP, 153 sec). Platelet aggregation testing and morphology by electron microscopy were normal. Given his cardiac condition, absence of a family history of bleeding and normal platelet aggregation studies, AVWS was suspected. Over the following years, his VWF panel did not change significantly and PFA CTs remained prolonged. He experienced a traumaassociated right-knee hemarthrosis, continued to have recurrent epistaxis and experienced a gastrointestinal bleed. Upper gastrointestinal endoscopy failed to show angiodysplasia. At 17 yrs of age, he had a severe episode of epistaxis, which was unresponsive to DDAVP and balloon packing, requiring hospitalization, administration of VWF concentrate, red cell transfusion and tranexamic acid. It was felt that surgical intervention was warranted solely on the basis of bleeding symptomatology. He successfully underwent a Ross procedure with hemostatic coverage (VWF concentrate). Immediately pre-surgery, prior to receiving VWF concentrate, high molecular weight VWFm were slightly reduced (76% of control plasma). Three weeks after the procedure, his PFA CTs were normal (collagen/epinephrine 158 sec); VWF:RCo/Ag ratio was 82%. Conclusion: The finding of abnormal VWFm has been proposed as the gold standard for laboratory diagnosis of AVWS of cardiac origin. However VWFm testing can be challenging. PFA testing is readily available and CTs seem very sensitive to this condition. Our case highlights the complexity of AVWS in the context of cardiac conditions.

Acquired von Willebrand Disease – To treat or not to treat the inhibitor?

SUSAN CUROE,1 SURBHI SHAH,1 SHIVANI SHINDE,2 R A J I V P R U T H I , 2 A N E E L A S H R A N I 2 and M A R K R E D I N G 1 1 University of Minnesota, Minneapolis, United States; and 2Mayo Clinic, Rochester, United States

Introduction: Acquired von Willebrand disease (vWD) is characterized by mucocutaneous bleeding presenting with no prior personal or family history of bleeding tendency. We describe our experience managing this rare bleeding disorder.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

Haemophilia (2014), 20 (Suppl. 3), 1--186



Methods: Retrospective chart review was conducted in 2 large academic medical centers. Results Results: We identified 24 patients with acquired vWD, excluding those with valvular heart disease or mechanical cardiac assist devices. Median age was 59.5 years (range 0-87). Males and females were equally affected. 17 of 24 patients (71%) had an underlying myelo/lymphoproliferative disorder. Most presented with mucocutneous bleeding (bruising, epistaxis, GI or GU tract bleeding). 4 patients presented with post procedural bleeding and 2 presented with intracranial hemorrhage. At diagnosis, the median ristocetin cofactor activity was 3 times/week (Roth 2001 and Lambert 2007; actual) and 1 to 2 times/week (Korth-Bradley 2011 and Windyga 2012; protocol-specified). The mean ABR for rFIXFc was 3.07, and the pooled mean ABR estimate for rFIX was 3.84 (I2 = 57.5%, DABR=0.77; P = 0.23). Analysis of hypothetical changes in compliance

Haemophilia (2014), 20 (Suppl. 3), 1--186



showed improvements in compliance with rFIXFc of ≥9-14 percentage points over values reported in the literature (58.8%-75.7%) could result in a statistically significant improvement in mean ABR. Conclusions: Based on an unadjusted indirect comparison of rFIXFc and other rFIX products and a model of the potential impact of differences in compliance, the prospect of less burdensome dosing with rFIXFc may lead to improved real-world effectiveness.

Max, the frog: an educative tool for toddlers with hemophilia

FRANC ß O I S E D E L A C O L L E T T E , 1 L A M B E R T L E E N D E R S 2 and CORINNE MORIS3 CHR, Citadelle Liege, Belgium; 2Hemato-Oncology Unit, University Children Hospital Queen Fabiola HUDERF, Brussels, Belgium; and 3Bayer Belgium, Brussels, Belgium


Introduction and Objectives: As part of their prophylactic treatment, children with severe hemophilia are exposed very early to frequent injections, but do they know the benefits? This tool aims to teach young children with hemophilia about one of the most important aspects of their illness, namely the importance of regular treatment and compliance. The illustrated story of Max, The Frog allows the child to connect with the reality of his illness. This tool enables HCP, after reading, to begin a structured discussion with the child in order to make the connection between storytelling and his real life. The questions asked after reading will give to the child the opportunity to freely express his thoughts and perceptions. The goal is to translate the benefits of regular treatment tp a fantasy world. The child understands that his treatment is positive and that he has to put it into practice in his daily life. Materials and Methods: Max, The Frog is an illustrated short story intended for children aged between 4-6 years and on prophylaxis treatment. The story tries to make the link between Max’s difficulty jumping and the bleeding problems of children with hemophilia. The story explains that Max, a frog who cannot jump, is not able to participate at the annual competition of the biggest jump. Thanks to his parents, he can drink a specific magic potion in order to jump again. This drink has a really bad taste but thanks to the drink he won the competition and can now play with his friends. Now he takes it regularly and is very happy. Conclusions: Some children don’t make the connection with their own experience after the first reading. That is why it is important to stimulate discussion with targeted questions proposed with the story. It is advisable to conduct this interview with a HCP. The workbook provided with the book is a very good reminder to continue education at home or at school, and is fun to use. Some parents remarked that the book makes it easier for them to discuss hemophilia with their child.

Drug facility for support in the treatment of patients with hematological disorders NATALIA VALENZUELA Integral IPS, Medellin, Colombia Introduction and Objectives: The Granada Consensus defines pharmacotherapy follow-up as the professional practice in which a pharmacist is responsible for the patient’s drug-related needs. For this, we are constantly detecting drug-related problems (DRP) and preventing and resolving negative outcomes associated with medication (NOM). Pharmacy services conduct several activities, unrelated to drug dispensation, to ensure technical conditions, but also in the ongoing education of patients, to achieve safe drug management and treatment efficacy. In this abstract, we measure the safety, effectiveness, and compliance of treatment, through pharmacy service monitoring in a group of patients from an IPS. Materials and Methods: We conducted a cross-sectional study. Results: Monitoring hemophilia A patients, we found that 93% had no drug-related problems (DRP) and 4% reported mild adverse reactions, which did not require drug withdrawal. In terms of compliance, 2% miss a dose of their complementary pharmacological therapy, but more than 50% of the patients commit to the therapeutic indications and self-care. While plasma derivatives are used, we have no new HIV- or hepatitis C-infected patients. The highest percentage (89%) of interventions with these patients is aimed at monitoring and contributing to the permanent education of patients. For hemophilia B patients, there were no DRP. Overall, 85% of them are motivated and responsible in compliance related to their condition. Their evolution is stable and they usually meet the terms of therapeutic indications and self-care. The products we use are plasma derivatives. We have no new HIV or hepatitis infections. In addition, there are two patients with inhibitors. Conclusions: As noted, the treatment provided to patients with hemophilia A and B is safe, and patient adherence is verified, thanks to the constant monitoring by pharmacy services, not only in the medical centre but also, when it is used by patients under optimal conditions using the standards of the World Federation of Hemophilia. Therefore, we are contributing to the health and safety of the patient, by ensuring treatment efficacy.

Using closed loop reporting to change patient behaviour: a case report R O B Y N S H O E M A R K 1 and Z I R K E W I I D 2 The Children’s Hospital, Westmead, Australia; and 2Pfizer Australia, West Ryde, Australia


Introduction and Objectives: Treatment adherence is a widely reported challenge for patients with chronic health conditions. Adherence is often reported to be worse in teenagers who struggle with the impact of adolescence in addition to the limitations that treatment regimens may impose on their lives. In Australia, clinicians at hemophilia treatment centres (HTCs) have access to a hemophilia telemonitoring tool, pfusion, that allows real-time reporting of bleeds and factor usage by patients. This case report demonstrates the effectiveness of using patient-reported bleed and factor usage information to improve adherence through education in an adolescent patient. Case report: A 12-year-old male patient with severe hemophilia A reported 2 to 4 bleeds per month during three consecutive months, with some bleeds requiring up to 5

Haemophilia (2014), 20 (Suppl. 3), 1--186

infusions. Patient-reported bleed and factor usage information suggested that poor adherence with the prescribed twice weekly prophylaxis regimen was contributing to the bleeding pattern and that factor replacement was generally administered ondemand to treat bleeds. Data was used in graphic format by the clinician to educate the patient about the association between bleeds and infusions. The number of infusions administered each month on demand to treat bleeds was similar to the number of infusions prescribed as part of the prophylaxis regimen. The patient realised that by administering the same number of infusions prophylactically at regular intervals instead of on-demand, the pain and discomfort associated with bleeds could be minimised or avoided. In the 9-month period following the patient education session, prophylactic factor replacement was administered more frequently and only one bleed occurred. Conclusions: This case illustrates how closed-loop reporting can be used to educate patients and improve patients’ insights about the impact of poor adherence. With the necessary education and guidance from clinicians, patients are able to use the reported information to their advantage to minimise the impact of the condition on their daily activities. The report is consistent with published literature that suggests teenagers are able to understand and make complex treatment decisions about treatment schedules that offer protection from bleeds and facilitate participation in normal daily activities.

Five years of comprehensive care: applying the World Federation of Hemophilia recommendations MONICA COLONIA Integral IPS, Medellin, Colombia Introduction and Objectives: Within the comprehensive treatment of hemophilia patients, nursing care is an essential component.The ntursing team develops educational, guidance and support activities, emphasizes the importance of following clotting factor concentrate regimens, highlights the importance of self-care, empowerment, and self-treatment. Materials and Methods: The most frequent nursing diagnoses in our patients are the risk of bleeding, impaired physical mobility, and loss of locomotion ability related to the deficit of VIII or IX clotting factor, which are administered according to NANDA nursing diagnoses (North American Nursing Diagnosis Association). Results: Nursing activities have generated a satisfactory evolution in 70% of patients with hemophilia A and hemophilia B, who have shown a noticeable decrease in the incidence of spontaneous bleeding episodes, due to their educational efforts. This percentage corresponds to that of patients attending nursing consultation, in terms of adherence. This aspect demonstrates that motivation regarding treatment, and a positive attitude, lead to positive self-care behaviours, taking responsibility for and proper management of their disease. Conclusions: It is satisfying for us to see that our work with hemophilia patients has made great progress; our commitment to improve their quality of life is further reflected in their success in leading a normal life. We have a duty to continue our team’s work, and to reach a point where 100% of patients show evidence of excellent progress in empowerment, care, and management of their disease.

Perspectives of patients with hemophilia on adherence to prophylaxis: a grounded theory approach

LIESBETH SCHRIJVERS,1 MARIJKE KARS,2 MARLENE BEIJLEVELT -VAN DER ZANDE,3 MARJOLEIN PETERS,3 M A R I E K E S C H U U R M A N S 4 and K A T H E L I J N F I S C H E R 1 , 2 1 Van Creveldkliniek, University Medical Centre Utrecht, Utrecht, the Netherlands; 2Julius Center for Health Sciences and Primary Care, University Medical Centre, Utrecht, the Netherlands; 3Academical Medical Centre Amsterdam, Amsterdam, the Netherlands; and 4 Nursing Science, Faculty of Health Care, University of Applied Science, Utrecht, the Netherlands, University Medical Centre Utrecht, Utrecht, the Netherlands Introduction and objectives: To prevent bleeding effectively, a lifelong high level of adherence to prophylactic replacement therapy is needed. The aim of this study is to explain and clarify the factors underlying adherence to prophylaxis from the patients’ perspective. Material and methods: A grounded theory study was undertaken involving one-time individual in-depth interviews to unravel experiences, perceptions and beliefs concerning adherence to prophylaxis. In total, 19/21 adults with severe hemophilia who were prescribed prophylaxis with low and high adherence levels were selected from two Dutch treatment centres. Results: These 19 patients revealed that ‘the position of prophylaxis in patients’ life’ was the core concept for taking prophylaxis as prescribed. The perceptions on prophylaxis were divided into four basic positions according to adherence to prophylaxis and degree of awareness ((un)intentional) (Fig. 1). Patients who integrated the treatment into their life were mostly intentional-adherent, had high selfmanagement skills and a positive perception about their hemophilia. Patients who were following doctors’ advice, were struggling with situations requiring extra treatment (low self-management skills). The non-adherent patients had difficulties acceptating their illness (SW) or difficulty with self-management skills (SE). Conclusions: This concept provides a framework for the main reason for being treatment compliance. The position taken towards prophylaxis and its determinants clarify patients’ adherence behaviour. Contribution to the findings: These findings help individualize interventions to promote adherence. Each group needs a specific intervention, focused on selfmanagement to improve skills (SE and NE) or a psychological intervention to improve illness acceptance (SW).

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

ADHERENCE Hemophilia patient user preference analysis of the human interface of devices used for factor reconstitution ZACH MARKS West Pharmaceutical Services Introduction and Objectives: All replacement factors today are lyophilized products requiring patient or caregiver reconstitution prior to administration. This market research study will evaluate user preference in determining the feature drivers for current systems as well as design of a next generation system. Materials and Methods: We plan to conduct a market research study with hemophilia patients to understand current devices and evaluate future devices. Results: Study will be conducted in the first quarter of 2014. Conclusions: To be determined.

Patient and caregiver satisfaction with BAXJECT III, a next-generation reconstitution system for AHF-rFVIII (ADVATEâ) M I C H E L L E W I T K O P , 1 J E N N I F E R M A A H S , 2 D I A N E I T O 3 and JOSH EPSTEIN3 Northern Regional Bleeding Disorders Center, Traverse City, Michigan, USA; 2 Indiana Hemophilia & Thrombosis Center, Indianapolis, USA; and 3Baxter Healthcare Corporation, West Village, USA


Introduction and Objectives: BAXJECT III is an all-in-one, next-generation reconstitution system currently being developed for reconstituting antihemophilic factor (recombinant), plasma/albumin-free method (ADVATE). The primary advancement of BAXJECT III is that it does not require users to cleanse and attach the FVIII and sterile water vials to the reconstitution system, which allows for faster reconstitution and reduction of potential physical contamination. This analysis evaluated patient satisfaction and preferences for BAXJECT III and assessed the potential for improved adherence using this new system. Materials and Methods: Hemophilia patients and caregivers of pediatric hemophilia patients were recruited to participate in an evaluation of the usability/safety of BAXJECT III. A paper-based survey was administered to all participants to assess satisfaction with and preference for BAXJECT II and BAXJECT III, and the potential for improved adherence to their treatment regimen with BAXJECT III. Results: Overall, there were 25 adult hemophilia patients (48%) or caregivers of pediatric patients (52%) who completed the survey. Of these, 22 (88%) respondents reported that it was ‘very easy’ to learn to use BAXJECT III and felt comfortable with it after a median of 2 minutes. Of the 18 participants who provided satisfaction ratings for both BAXJECTII and BAXJECTIII, the majority indicated being ‘very satisfied’ with various attributes of BAXJECT III compared to BAXJECT II, including, the number of steps involved (83% v 6%), time to reconstitute (72% v 17%), total time to prepare infusions (78% v 6%), ease-of-use (78% v 11%), safety/sterility (89% v 22%), portability of the kit (44% v 17%) and overall satisfaction (89% v 11%) (all p < 0.05). Additionally, there was a positive trend in increased satisfaction regarding the size of the kit (44% v 17%) for BAXJECT III compared to BAXJECT II (p = 0.059). Overall, 24 participants (96%) preferred BAXJECT III over BAXJECT II. While approximately 30% indicated being ‘somewhat’ or ‘not adherent’ to their current treatment regimen, the majority (78%) indicated that BAXJECT III may help improve their adherence to treatment. Conclusions: Hemophilia patients/caregivers were highly satisfied with BAXJECT III, preferring it over BAXJECT II, with most feeling that it may help improve patient adherence to their treatment regimen.

An indirect comparison of the efficacy of prophylactic use of rFVIIIFc and other rFVIII products and model of the effect of compliance

ALFONSO IORIO,1 SANGEETA KRISHNAN,2 LYNN HUYNH,3 P A U L K A R N E R , 3 M E I S H E N G D U H 3 and S A N D E R Y E R M A K O V 3 1 McMaster University, Hamilton, Ontario, Canada; 2Biogen Idec, Cambridge, MA, USA; and 3Analysis Group, Boston, MA, USA Introduction and Objectives: Current prophylactic treatment for hemophilia A with factor VIII requires infusions 3 times/week or every other day. The heavy burden of such infusions can lead to poor compliance with therapy. Drugs requiring less frequent infusions could improve compliance and outcomes. In the absence of direct

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


comparative evidence, this analysis indirectly compared the efficacy of the first recombinant factor VIII Fc fusion protein (rFVIIIFc) and current rFVIII products in the routine prophylactic treatment of previously treated subjects with hemophilia A based on published clinical study results, and explored the potential impact of differences in compliance. Materials and Methods: A literature search was conducted to identify clinical studies of routine prophylactic use of rFVIII products in previously treated subjects. Efficacy was compared using reported differences in mean annualized bleed rates (ABRs) between rFVIIIFc (A-LONG study, individualized arm) and rFVIII. Comparisons were conducted for individual and pooled results using meta-analysis with random effects. For studies that did not report standard deviation (SD) of ABR, SD was estimated assuming a Poisson distribution and adjusted for over-dispersion. A model examining the effect of improvement in prophylaxis compliance on mean ABRs was developed. Results: Results from A-LONG (rFVIIIFc) in severe hemophilia and those from 4 published studies of rFVIII in moderate and severe hemophilia (Advateâ: Tarantino 2004, Shapiro 2003, and Valentino 2012; Xynthaâ: Recht 2009) were analyzed. Infusion frequencies were 1.4 to 2.4 (median 2.0) times/week for rFVIIIFc (actual) and 2.3 to 4 times/week for rFVIII (protocol-specified). The mean ABR for rFVIIIFc was 2.9 and the pooled mean ABR estimate for rFVIII was 4.8 (I2 =44.2%, DABR=1.8; P = 0.003). Analysis of hypothetical changes in compliance suggested that improvements in compliance with rFVIIIFc of ≥6-12 percentage points over values reported in the literature (58.8%–75.7%) could result in a statistically significant improvement in mean ABR. Conclusions: Unadjusted indirect comparison of clinical study results suggests that the efficacy of routine prophylactic treatment with rFVIIIFc may be greater than that of other rFVIII products examined in this study. Potential improvements in compliance with products requiring less burdensome dosing may lead to higher effectiveness.

Identification of socio-cognitive determinants of adherence to treatment in children and adolescent with severe hemophilia  UBE  S, RIVARD G., ZOURICHIAN N, PRIVE  S, B ER A M E S S E C . and S U L T A N S Sainte-Justine UHC, Montreal, Canada

Introduction and Objectives: Hemophilia can be medically managed with a lifelong prophylactic or on-demand treatment. The treatment plan also includes recommendations regarding physical activities and nutrition. Throughout adolescence, children’s quality of life decreases and adherence to treatment is reduced remarkably. It is thus necessary to assess levels of patient education and the perceptions they have regarding their illness during this transition to adult treatment. The objectives of this study are (1) To identify illness perceptions and determinants of core precautionary behaviours in exercise and medical treatment. Based on the theory of planned behaviour, predictors are beliefs about social norms, barriers, attitudes, intentions, self-efficacy and control (2) To relate these predictors to parent-child relationships, as assessed by characteristics of parenting and differences in illness perception between parents and children. Materials and Methods: Questionnaires assessing illness perceptions, predictors of adherence and behaviour were completed by 25 hemophilia A (88%) and B (12%) patients, aged 6-18, receiving care at Sainte-Justine UHC in Montreal, Canada, and their parents: these included the brief illness perception questionnaire (Brief IPQ), VERITAS-Pro, VERITAS-PRN, and a questionnaire assessing socio-cognitive determinants. In children, we also used the self-care inventory (SCI) and in parents, the parenting sense of competence scale (PSOC) and the parenting stress index, short form (PSI-SF). Results: Data collection is being completed (60%). Preliminary analyses suggest that attitudes towards medical treatment and unrecommended exercise is highly associated with social norms. Treatment adherence is moderately associated with positive attitude. At-risk behaviour is related to greater difference in illness perceptions between parents and children. Multivariate analyses will explore the contribution of each predictor on behaviour. Conclusions: In order to propose preventive interventions to avoid at-risk behaviors, identifying determinants is central. The results suggest that social norms together with positive attitudes are core factors in adherence. Further socio-cognitive interventions could address these factors.

Haemophilia (2014), 20 (Suppl. 3), 1--186



26-APPROACHES TO INHIBITORS Nursing: challenges and top tips in managing tolerisation in children CHRIS GUELCHER Center for Cancer and Blood Disorders, Children’s National Medical Center, Washington, DC USA Primary Objective: Review of the latest proposed strategies for prevention, management and eradication of inhibitors and the challenges that inhibitors pose for patients and families. Background: Hemophilia is a rare deficiency of a factor protein. Approximately 25– 30% of patients with hemophilia develop antibodies to the factor replacement products. Inhibitors may present with anaphylactoid reactions at the time of factor infusion, as failure to respond to factor replacement, with breakthrough bleeding while on prophylaxis, or be identified by routine screening. Once inhibitors develop, patients may not respond to standard factor replacement. Approximately 70% of patients with inhibitors can be tolerized, but tolerization can take months or years. Development of an inhibitor poses additional challenges that further increase the burden on the patient/family and has a significant impact on quality of life. Summary: A case study will highlight some of the challenges and management strategies. The emphasis of the presentation will focus on ways to increase the likelihood of success and optimal outcomes. Recommendations: Providers and caregivers must work together to determine the best course of action with the goal of providing the best possible outcome. Disclosure: This presentation will review the current literature related to inhibitors in hemophilia. The speaker is on several advisory boards (Novo Nordisk, Baxter), is on a speaker’s bureau (Solution Sight) and sits on several Boards (Mid-Atlantic Region III Executive Committee, American Thrombosis and Hemostasis Network (ATHN) and Thrombosis and Hemostasis Societies of North America (THSNA) Steering Committee).

Physiotherapy: breaking the cycle of bleeding and rehabilitating bleeding episodes for children with inhibitors IAN D’YOUNG Haemophilia Physiotherapy, Auckland DHB Haemophilia Centre, Auckland, New Zealand The musculoskeletal management of children with inhibitors can present significant challenges for physiotherapists. Minimising maladaptive biomechanical changes that occur following a single bleeding episode is essential for breaking the cycle of bleeding and reducing the risk of accelerated blood-induced arthropathy. The primary objective of this session will be to raise the awareness of the importance of good musculoskeletal management in the paediatric inhibitor population. Specific case studies will be highlighted to explore some of the different challenges to physiotherapy rehabilitation that a child with an inhibitor can present. Ian will also report on the New Zealand experience in tolerising children using interventions such as retuximab. Recommendations will be made for patients, parents and musculoskeletal clinicians.

Psychosocial issues and coping strategies for patients and families dealing with an inhibitor SUSAN CUTTER Hospital of the University of Pennsylvania, Philadelphia, USA Inhibitors are considered to be the most significant and challenging complication in the management of hemophilia (Coppola, et al). Persons with hemophilia (PWH) face many psychosocial issues which potentially impact their well-being; these issues are often intensified for those with an inhibitor. Literature specific to the psychosocial impact of inhibitors on PWH and their families is limited. There is a need for increased attention to and assessment of the psychosocial and educational needs of PWH with inhibitors (Salek, et al). There is also a need for targeted psychosocial interventions to enhance their utilization of effective coping mechanisms. Quality of life studies on PWH with inhibitors have been conducted on national and multinational levels and, more recently on a global level. Using validated health-related quality of life, self-assessment instruments such as the Medical Outcome Survey Short Form (SF-36), EuroQol (EQ-5D), and the Hemophilia Well-Being Index, the majority of the studies have focused on adults. Quality of life in PWH with an inhibitor has been found to be most impaired in the physical functioning domain (Gringeri, et al; Morfini, et al; Hoots, et al). As psychosocial workers it is important for us to assess and understand the quality of life issues for the full range of ages of PWH with inhibitors, including children newly diagnosed with an inhibitor to older adults whose inhibitor was never able to be eradicated. Individualized targeted psychosocial interventions, developed in conjunction with PWH with inhibitors and their families, can strengthen coping strategies and help to enhance quality of life.

An exome-sequencing analysis: functional variants of the protein-coding area of the genome associated with the development of inhibitors

ISABELLA GARAGIOLA,1 LUCA A. LOTTA,1 MARCO FORNILI,2 FEDERICO AMBROGI,2 ELISA MANCUSO,1 ELENA SANTAGOSTINO,1 SABRINA SEREGNI,1 RICHARD A . G I B B S , 3 E L I A B I G A N Z O L I 2 and F L O R A P E Y V A N D I 1 1 Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Universit a degli Studi di Milano and Fondazione Luigi Villa, Milan, Italy; 2Unit of Medical Statistics, Biometry and Bioinformatics, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; and 3Human Genome Sequencing Center, Baylor College of Medicine, Houston TX, USA Introduction and Objectives: The major complication of FVIII replacement therapy is inhibitor development, occurring in up to 30% of hemophilia A (HA) patients. Inhibitors impair efficacy of replacement therapy, rendering management of bleeds difficult and prophylaxis unfeasible. The predisposition to the development of inhibitors is highly heritable, but the genes and the DNA sequences that cause this predisposition are largely unknown. We designed an exome sequencing study with the goal of assessing the role of rare, functional variants of the exome in inhibitor development. Materials and Methods: A total of 28 Italian HA patients with/without inhibitor underwent sequencing of the exome on Illumina HiSeq 2000 platforms. Inclusion criteria were diagnosis of severe HA and presence of intron 22 or intron 1 inversion of F8. We restricted our analysis to rare (minor allele frequency 25% of normal FVIII levels. The activity was dependent upon a free N-terminus of the procoagulant peptide. In addition to stabilizing the monomeric population of BH48, the Fc fusion construct improved the pharmacokinetic properties in hemophilia A mice. Conclusion: Selected procoagulant peptide Fc fusions significantly improved the physical properties of the overall constructs relative to those of the corresponding unconjugated peptides, and monomeric BH48 was found to have prolonged half-life in hemophilia A mice compared to the parental peptide. We are currently investigating this compound class as an alternative bypass therapy for hemophilia A patients with the potential for subcutaneous delivery.

Surveillance for hemophilia inhibitors in the United States J . M I C H A E L S O U C I E and C O N N I E H . M I L L E R Centers for Disease Control and Prevention, USA Introduction: Hemophilia inhibitors have been identified as a serious public health problem for people with hemophilia (PWH) in the United States. Surveillance and public health research are needed to inform efforts to develop prevention strategies.

Haemophilia (2014), 20 (Suppl. 3), 1--186

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

APPROACHES TO INHIBITORS Method: We describe here progress in the development of a comprehensive surveillance system to address this issue. From January 2006 to June 2012 the U.S. Centers for Disease Control and Prevention (CDC) conducted a study designed to assess the feasibility of national surveillance for inhibitors. 1,163 PWH were prospectively followed for a total of 3,329 person years. Methods were developed and evaluated for sample shipping and storage, specimen preparation and high throughput testing. A total of 3,048 inhibitor tests were performed and reproducible cutoff values for abnormal results were established. An expert panel was convened in March 2012 to review the results and make recommendations. Results: By early 2014, the approximately 18,000 PWH receiving care in one of the more than 130 federally supported U.S. hemophilia treatment centers will be invited to participate in a surveillance program that includes annual collection of a core set of data elements along with donation of a blood specimen to be tested for an inhibitor in a central laboratory at CDC using a modified Nijmegen Bethesda assay. Data

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


collected will include any previous history of inhibitors, the most recent and highest locally obtained titers and any history of inhibitor treatment. Conclusion: PWH with no previous history and confirmed inhibitor test results that exceed established thresholds will have additional data collected including family history of inhibitors, allergies and recent surgeries or procedures. In addition, information on historical exposure days and details of all factor exposures including product switches in the previous 4 months will be obtained. Surveillance for inhibitors in a large population of PWH using a standardized approach and centralized testing will provide valid and representative data with which to evaluate inhibitor incidence and prevalence, monitor trends in occurrence rates, and identify potential inhibitor outbreaks associated with products.

Haemophilia (2014), 20 (Suppl. 3), 1--186



27-CAPACITY BUILDING Data on Education and Employment WERNER KALNINS German Hemophilia Society DHG, Hamburg, Germany Primary Objective: Showing data on education and employment of people with bleeding disorders; comparing the situation in different countries and of different age groups; illustrating tendencies and developments. Background: To collect data on this topic we have conducted different surveys and evaluated different studies: a) Survey of young hemophiliacs / parents of young hemophiliacs among the members of the German Hemophilia Society, b) survey of patients with von-Willebrand-disease among the members of the German Hemophilia Society, c) HERO international study: results about education and employment issues of people with hemophilia, d) study about the living conditions of hemophiliacs in Germany, e) data from several national studies which we received from other European NMOs. Summary: To have a profound education and a good job is an important factor for a high quality of life. Due to absence of work caused by illness, people with bleeding disorders have a higher risk of occupational disability than other people. We experience that young hemophiliacs, when choosing a job, partly tend to overestimate their own physical capabilities while others suffer from total uncertainty. Choosing an adequate job is the precondition for not becoming incapable of work in a higher age. Therefore a realistic self-assessment as well as an effective counseling are essential for young hemophiliacs. Recommendations: As a good state of health correlates with a successful working life a high quality of treatment has a great impact on employment – an argument which can also be very useful when discussing the costs of treatment with politicians or representatives of health insurances.

The Contribution of the Non-Governmental Organizations into the Recruitment Process of the People with Bleeding Disorders; Applications & Evaluations € FIKAR H A L U K Z UL Istanbul University, Faculty of Economics; Hemophilia Society of Turkey, Istanbul, Turkey

Objectives: While approaching as a process to employment status of individuals with bleeding disorders –PWH and VWD-, and examining Hemophilia Society of Turkey (TRHD) approach, application and initiatives with the methodological perspective into the process, conducting a systematic behavior pattern alternative for NMO’s have been aimed by the study. Within this scope, individuals with PWH and VWD are examined in three categories as follows: 1. Evaluations Related to Labor Supply; 2. Evaluations Related to Labor Demand; 3. Evaluations Related to Intermediary Service in Labor Market. In the study, the first two categories are broadly examined whereas the final category is examined in larger detail. Under this category, the quality and relevant competencies of the labour force supplied to the market place by PWH and VWD individuals and its particular relevance to the current and probable demand from within the marketplace are analysed. By doing this, the process of finding out the right type of intermediary services for employment creation is tackled. In the study, the concerned intermediary services such as a) Non-governmental organisations, b) Individuals with PWH and VWD, c) Within the scope of TRHD, are examined only as a type of support services. Method: The applications within the course of this study have been realized on 3 subpopulations by using “Qualitative Research Techniques and Strategic Analyses” Conclusion: It was analysed that the necessary endeavours for employment creation and converting it into a permanent and systematic process, can be analysed in 4 main headings: 1) Data analysis and efficient data management, 2) solution-oriented education and training programs, 3) accurate internal and external communication and 4) rational administrative-legal and financial activities. Accordingly, it was observed that all are specifically significant in terms of solution finding.

Importance of joint efforts in advocacy of health authorities and the National Hemophilia Committee ARAFAT AWAJAN Jordan Thalessmia and Hemophilia Society, Amman, Jordan Primary Objective: To highlight the importance of building strong alliance between hemophilia societies, health authorities (HA) and national hemophilia committees (NHC) for improving the hemophilia care and the quality of life of people with hemophilia (PWH). Background: Building strong coalition with HA and NHC is vital to promoting access, and improving and maintaining hemophilia care. It has very positive impacts helping PWH and their families to cope with their condition. The main objective should be to deal with the complex and growing challenges facing PWH including the availability of product, shortcomings in the healthcare delivery system, and securing government commitment and support to a national hemophilia program. This presentation presents the main results of implementing the World Federation of Hemophilia (WFH) Advocacy in Action program in Jordan. Several actions were conducted in the last two years. These activities include meeting with the decision makers at different levels and organizing awareness meeting for the health professionals. These activities were aimed at approaching the national HA to convince them enforcing the national registry, elaborating national strategy for the hemophilia care and implementing comprehensive care in the country. The outcomes were very positive. A national strategy for hemophilia was adopted, a guideline for hemophilia care was published, and the availability of product was increased. Summary: By implementing active advocacy programs, the quality of hemophilia care is improved and health authorities’ engagement is guaranteed. Recommendations: Implementing successful hemophilia care needs close collaboration between HA, NHC and the NMO.

Importance of Joint Work in Planning and Executing Outreach Campaigns MOHAMMAD NURUL ISLAM Hemophilia Society of Bangladesh HSB, Bangladesh Primary Objective: The importance of collaboration in planning and executing outreach campaigns, to improve the quality of health care for the bleeding disorder community. Background: In many developing countries, people with bleeding disorders living in rural areas are suffering due to lack of knowledge, living conditions, lack of treatment facilities and non-availability of treatment products. Before the outreach campaign, there was a lack of understanding amongst healthcare professionals. Those in the bleeding orders community were also not aware of where to receive treatment which resulted in them travelling to Dhaka. HSB (NMO) took initiatives to bring all the stakeholders concerning hemophilia care in Bangladesh to establish treatment facilities in two key regional areas (Chittagong & Jessore). Summary: Whilst planning, HSB identified the nature and scope for the target location and employed two local representatives. Then a relationship building and maintenance phase was implemented focusing on local hospitals and health officials. This was a vital part because the local healthcare officials were reluctant and not eager to help at first. An emotional approach was used and motivation for training was given from NMO. Finally the workshops commenced. The successful execution of the Chittagong workshop inspired the formulation of Jessore workshop. The outcome of the workshops resulted in better coordination of departments within government hospitals, improved relationships with people with hemophilia and healthcare professionals and identifying new patients. It also helped in closing the gap between urban and rural areas in terms of overall awareness and knowledge. Recommendations: To inspire and coordinate the joint workshop, there needs to be support from the NMO and other healthcare professionals. Communication and empathy is required to avoid crisis and run the venture smoothly. Disclosure: This outreach campaign was supported by grants from the World Federation of Hemophilia.

Collaboration is Powerful PAMELA WILTON CRE, London, Canada Primary objective: To increase awareness of the benefits of hemophilia organizations (World Federation of Hemophilia/national member organizations) working together, as a community, along with our medical professionals to achieve our goals. Background: There is a long, rather unique history of hemophilia organizations working closely with their health care providers to improve advocacy, to increase knowledge and understanding, to secure health care resources, to facilitate access to care, to support one another and to find ways to provide care around the globe. People with bleeding disorders can share their first hand experiences of living with a chronic disease. Volunteers can bring skills related to communication, fundraising, governance, advocacy, public policy, business, education, parenting, finance, technology, law, ethics and so much more. Health care providers can share their knowledge and expertise; help to establish best practices; seek answers to questions; mentor others; inform decisions and help to open doors to those we need. Collaboration is powerful. Strategy: Governments in North America and Europe have encouraged patients to contribute to the development of health services for several decades. Research supports the concept that patient involvement has contributed to changes in the provision of care and services across a broad range of settings. The South Western Ontario region model will be highlighted. Summary: The World Federation of Hemophilia, national member organizations and regional/local chapters have been extremely effective in facilitating collaboration, achieving many successes.

Haemophilia (2014), 20 (Suppl. 3), 1--186

Co-operation in establishing a Medical and Scientific Advisory Committee (MASAC) BRADLEY RAYNER South African Haemophilia Foundation, Johannesburg, South Africa Primary objective: Share the benefits of having or establishing a MASAC and how the close co-operation by NMOs and MASAC can maximize outcomes and successes of the hemophilia healthcare system. Background: Comprehensive teams are critical to the success of hemophilia healthcare. These professionals are best organized in a MASAC. Partnerships beyond MASAC are also critical and an integral part to achieve and improve standards of care. Ethical principles governing healthcare delivery:Health care is a human right; Care of individuals is at the centre of healthcare delivery; Responsibilities of the healthcare delivery system include the prevention of illness and the alleviation of disability; Co-operation between those served or being served is imperative; Individuals and groups involved in health care have a responsibility to help improve the quality of care. Strategy: Critical to the success is defining and building a strong partnership and working relationship based on respect, trust and transparency to an agreed outcome driven plan. Identifying what is essential to the partnership, what is already in place and can be improved with minimal effort, what the weaknesses are, where partnering achieves the biggest impact and how the partnership can execute to achieve the goals. Example will be shared.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

CAPACITY BUILDING Summary: The responsibility of NMO and MASAC therefore exists to organize themselves to exploit the opportunity for closer co-operation in order to maximize results and improve the standard of care.

Screening tool on identification of suspected cases with bleeding disorders SULOCHAN B,1 ANNAMMA KURIEN,2 DINESH M NAYAK,3 V E E N A G K A M A T H 4 and A S H A K A M A T H 5 Departments of 1Medical Surgical Nursing; 2Pathology; 3Pediatrics; 4Community Medicine; and 5Statistics, Manipal University, Manipal, India

Introduction: The aim of the study is to identify suspected cases of bleeding disorders through Accredited Social Health Activists (ASHAs). ASHA’s are government health workers who work as an interface between the community and the health sector. They routinely visit the families and are well placed to screen families for bleeding disorders. Objectives: 1. To train the ASHA workers with a designed training manual and screening tool to help identify suspected cases of bleeding disorders. 2. To prepare a tool to screen the general community for bleeding disorders. Methods: The training manual consisting of six sections namely - Basic elements of blood, Blood clotting process, Bleeding disorders and their types, Screening persons with bleeding symptoms, Management for bleeding disorders and role and responsibility of health care workers, was prepared. The screening tool was focused on family history and bleeding symptoms. A survey record book and an educational material pamphlet on hemophilia and other bleeding disorders were provided to ASHAs. Instruction was given on conducting of door-to-door surveys to identify people with symptoms of a bleeding disorder. Results: A total of 586 ASHAs were trained by a hemophilia nurse at the community health centre and out of that, 52 ASHAs reported identifying families for further testing. Conclusion: A total of 586 ASHAs have been trained to screen for people with a bleeding disorders. By developing and then using the screening tool during routine community visits, 51 people were found to have a possible bleeding disorder and referred to Kasturba Hospital HTC for further investigation. Of these, six have been diagnosed with a bleeding disorder, 46 no diagnosed bleeding disorder, 15 had some other hematology diseases like sickle cell anemia, leukemia and dysfunctional uterine bleeding and 31 cases had very trivial presentation where no definitive diagnosis could be identified. ASHA health care workers to carry out this screen as part of their routine health visits and it has created awareness amongst the community on the early detection of bleeding disorders resulting in several new diagnoses being made. This screening tool has proven to be useful in the community setting to help in identifying people who potentially may have a bleeding disorder, who can then be tested and diagnosed correctly.

Patients’ perspective of care at the US federally funded hemophilia treatment centres

ANN FORSBERG,1 REGINA BUTLER,2 DIANE ASCHMAN,1 S U S A N C U T T E R , 3 R A N D A L L C U R T I S 4 and A L L E N C H E A D L E 5 American Hemostasis and Thrombosis Network, Chicago, IL; 2Children’s Hospital of Philadelphia, Philadelphia, PA; 3Hospital of the University of Pennsylvania, Philadelphia, PA; 4Factor VIII Computing, Berkeley, CA; and 5Center for Community Health and Education, Seattle, WA


Introduction and Objectives: To conduct the first national needs assessment survey of hemophilia patients to determine from the patients’ perspective whether they receive the services they require and how well these services meet their needs. Materials and Methods: In September 2013, 135 federally funded hemophilia treatment centres (HTCs) mailed a four-page questionnaire in English and Spanish to 30,000 households of patients with hemophilia, von Willebrand (VWD) and other inherited coagulation disorders. These patients had significant contact with their HTC during 2012. The questionnaire was anonymous and linked only to the patient’s treatment centre. Analysis of the data included one-way frequencies, cross-tabulations and regression analysis using Stata v.12.0. Results: The survey is still in the field so final response rates and results are not yet available. Preliminary analysis of 2840 questionnaires returned to date (an estimated 75% of the total anticipated response) showed that respondents were representative of the total HTC population compared to the existing US Hemophilia Data Set in gender, type and severity of hemophilia. Whites and older patients were over represented; individuals with type 1 VWD and age 17 to 21 years were under represented. A small number of patients (1-2%) reported not receiving a range of services when needed (e.g., hematologist: 82% received vs. 83% needed; hemophilia nurse: 77% received vs. 78% needed). Virtually all patients said the services met their needs well or very well (e.g., 98% for hematologist, 98% for hemophilia nurse, 95% for pharmacist, 93% for social worker, 93% for physical therapist, 88% for dental care, and 85% for orthopedist). Variation in needs based on race, ethnicity, disease severity, region and other variables is underway; and will be used for priority setting. Conclusion: The overwhelming majority of patients responded with a positive view of the services provided by the US federally funded HTCs and indicated high levels of satisfaction that the services provided were meeting their needs.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


Including volunteers from across France in the work of the French Hemophilia Society (AFH): methodology and assessment after one year’s work THOMAS SANNI, MICHEL DU LAURENTDE LA BARRE, JEAN-CHRISTOPHE BOSQ, JEAN-MARC DIEN,  E P I ET  U , E M M A N U E L P I O T , N A D EG  E PRADINES, G E N E V I EV L U D O V I C R O B I N and M A R I O N B E R T H O N French Hemophilia Society AFH, Paris, France Introduction and objectives: The AFH wishes to include the skills of its volunteers in the work of the seven members of the Executive Committee in order to serve the AFH project. Seven specialised working groups (WG) have been set up, composed of five to eight volunteers. The goals include; enabling the AFH to benefit from the skills of its members spread throughout France; supporting the work of the members of the Executive Committee by constituting a team; improving the quality of documents presented to the Board; and promoting the involvement of the volunteers in the daily work of the AFH. Material and Method: The WGs have a 1h30 conference call meeting every four to six weeks. Each member of the Executive Committee chairs his/her WG assisted by a paid member of staff. The Chairman and CEO of the AFH take part in the meetings. In total, 7 WGs have been set up: 1) Research, 2) Therapeutic patient education (TPE), 3) International action, 4) Communication, 5) Members-volunteers and chapters, 6) Human resources and finance and 7) Public health. Each member of the WG is chosen for his/her skill in the particular field. At least one member is an elected member of the Board. A guide on conducting WG meetings has been written. A volunteer supervises the conference call meetings. After one year, a self-assessment operation was conducted. Results: The self-assessment operation was carried out between July and September 2013 and involved all the members of the WGs. The response rate was 80% (fig 1). The participants assessed 8 skill fields and allotted a mark from 0 to 7 (fig 2). Almost 2/3 of the marks were six or seven and more than 95 per cent were higher or equal to four (fig 3). The highest marks concerned the mutual respect of members towards each other and the value of the subjects under review, the areas for improvement concerned timing of the Executive meetings and the setting up of genuine collective work. All the documents produced by the WGs have been submitted to the Board and have been approved unanimously. Conclusion: The results show strong volunteer support for this method of work and validate it. The method enables more than 40 volunteers to be regularly involved in conducting the work of the AFH.

Judicial recognition for obtaining treatment DANIEL ADOLFO LUNA Fundaci on de la Hemofilia de Salta, Salta, Argentina Introduction: The Hemophilia Foundation of Salta is an organization based in Salta, Argentina. The Foundation is tackling the attitude of apathy and rejection of the health systems (public or private) towards patients with Hemophilia or von Willebrand disease. When the health systems fail to meet their legal obligations, the Foundation can file a legal request in court. This is a legal action that fits all cases that do not have specific legislation. This action only serves to protect the rights of the person who asks, and is not valid not for other people who are in the same situation. However, the positive judgment sets a precedent, called jurisprudence. This legal action, called Amparo may be accompanied by a precautionary measure, which implies that the health system (public or private), is obliged to deliver the medication for the entire duration of the trial and until sentencing. Objectives: Achieving judicial recognition of a right established by law for patients with these diseases and thus gains access to appropriate treatment for each and every one of the Foundation’s patients. Method: The legal tool used is the writ of Amparo. Result: The Foundation has so far achieved a 100% success rate in the nine Amparo action lawsuits filed in the Justice Court of the Province of Salta. Conclusion: With the legal action of Amparo, the patient is assured that their health system will provide coverage of treatment, during their affiliation to their health system. Before the Foundation was established, patients were unprotected and often times ignored by the health systems. Patients currently are slowly becoming aware of the legal options and the power of this tool. The Foundation’s legal work is allowing patients to demand their rights and the patients are overcoming fear of legally suing those who have the obligation to provide treatment.

Speaking as one voice: Uniting and educating advocates

VAL BIAS,1 PAUL BRAYSHAW,2 YASUHARU NISHIDA, MD, P H D , 3 B R I A N O ’ M A H O N Y 4 and M A R K S K I N N E R 5 National Hemophilia Foundation, USA; 2Factor Support Network Pharmacy, USA; 3 National Hemophilia Network of Japan, Japan; 4Irish Haemophilia Society, Ireland; and 5Institute for Policy Advancement, Ltd., USA


Introduction and Objectives: Patient advocates have a unique and direct insight into the needs and challenges of the hemophilia community. They often serve as their voice on key issues, so it is critical for them to have the tools and experience to effectively advocate for their constituents. To help support the efforts of this important community, we created a platform for them to come together to discuss the issues they face and empower them to affect change in their local communities. Materials and Methods: In 2011, an international advocacy board, Hemophilia Advocacy Advisors Board, was established to help identify unmet advocacy needs in the community and create programs that would galvanize advocates and help them drive impact in their communities. One of the immediate areas of need recognized by the Hemophilia Advocacy Advisors Board was the importance of educating and uniting the community. To help address this need, the Hemophilia Advocacy Advisors Board – sponsored by Hemophilia Solutions by Bayer – created the Global

Haemophilia (2014), 20 (Suppl. 3), 1--186



Haemophilia Advocacy Leadership Summit, a gathering of top hemophilia advocates from across the globe to discuss issues critical to the advocacy community. Results: The inaugural event attracted 30 advocates from 17 countries – including the UK, Brazil, South Africa, Italy, Canada, Mexico, and the US and covered the topics of economics in advocacy, government relations and communications. The Summit offered participants an opportunity to learn from leading experts and from each other through presentations, case studies, discussions, workshops, and networking opportunities. Due to the success of the first event, the Hemophilia Advocacy Advisors Board will host a second Summit in December 2013, which will focus on the evolving communications landscape – from traditional to social media – and how it affects advocacy in the hemophilia community. Currently, thirty-two participants representing 18 countries, including Australia, Taiwan, Saudi Arabia, Korea, Venezuela, Colombia, Ireland, are confirmed to attend. Conclusion: The Global Haemophilia Advocacy Leadership Summit is an educational platform for advocates interested in learning the tools and strategies they will need to create change in their own communities.

Growing an organization is easy, cutting it down costs blood

maintained a very professional (and maybe even spoiled) organization due to a lot of financial and moral support from the Danish government. Up to eight people have been employed in the organization, we have had a lot of projects going on, and actually we have never been worried about the future for the organization. However time changes, and when the financial crisis hit the world, the Danish Hemophilia Society was not exempt. Suddenly the politicians in Denmark seemed to have ‘forgotten’ the Danish Hemophilia Society, and the ‘positive’ awareness we had some years ago because of the HIV-tragedy, was suddenly gone. Therefore our budget was reduced with more than 300.000 euros, and we had to fire almost all of the staff. How does a patient organization survive that? Materials and Methods: In the following we will present how we have moved on by going back to our roots. The crisis was a wakeup call, and for the last two years we have worked within our role as patient-speaker; focus and motivation of volunteers; better fundraising; and better communication with the members. Results: We have managed to develop our organization, get new ideas and involve our patients in a new way, even though we had a huge financial setback. Conclusion: When you have your back against the wall, then you are forced to think in a new way. We have survived by simplifying our organization and going ‘back to the roots’. That’s a good story and perhaps it can inspire other organizations that also have economic problems.

JACOB BECH ANDERSEN Danish Hemophilia Society, Copenhagen, Denmark Introduction and objectives: To show how an organization survives and even grows, when finances are reduced. For a long time The Danish Hemophilia Society has

Haemophilia (2014), 20 (Suppl. 3), 1--186

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd



28-CARE DELIVERY Hemophilia management in development countries is a big challenge

YACOUBA DIALLO,1 ABDOUL AZIZ DIAKITE,2 BOUBACARY ALI TOURE,3 MADANI LY,4 MOUNIROU BABY,5 N A D I N E A J Z E N B E R G 6 and D A P A A L Y D I A L L O 4 1 Service d’hematologie et d’oncologie medicale, CHU du Point ‘‘G’’, Bamako, Mali, 01 BP106; 2Service de Pediatrie, CHU Gabriel TOURE, Bamako, Mali; 3Centre de Recherche et de Lutte contre la Drepanocytose, Bamako, Mali; 4Service d’hematologie et d’oncologie medicale, CHU du Point ‘‘G’’, Bamako, Mali; 5Centre National de Transfusion Sanguine, Bamako, Mali; and 6Service d’Hematologie et d’Immunologie Biologiques, H^ opital Bichat, Paris, France Introduction: Hemophilia is a bleeding disorder characterized by a tendency to bleed. Best management needs firstly to diagnose the biological abnormality and specify treatment. In the world, it is estimated to affect to 1 per 5.000 in the male population. To date no epidemiological data exist in Mali. We report some routine difficulties in hemophilia management in Mali illustrated by two cases. The aim of our report is to create an international network to improve hemophilia management in Mali. Cases: An 11 year old Malian boy is suffering from recurrent knee bleeding. He lives in Yelimane, 759 km far from Bamako estimated to be 11 hours (directly) by car. We could not estimate the exact number of bleeding events. A familial history of bleeding has been reported in his brothers and sisters. Because his family could not pay for medical fees, no coagulation test, nor radiological evaluation of his hemarthrosis could have been done. The second case is a nine year old Malian boy who lives with his parents in Koutiala located to 495 km from Bamako, six hours by car. This boy has a bleeding history. About one month prior to the report he had a hematoma of left buttock. Ten days later, he received three fresh plasma units in our hematology department in Bamako with good efficacy. He is also probably suffering from hemophilia but no biological test has been performed. These two cases gave us cause for reflection: On the possibilities to diagnose hemophilia: Severe Hemophilia is clinically suspected by a past history of recurrent bleeding events (hemarthrosis, posttraumatic bleeding, etc. . .) in male and confirmed by biological analysis. aPTT is prolonged and PT is in the normal range and specific dosage of coagulation factor VIII (FVIII) for (hemophilia ‘‘A’’) or IX for (hemophilia ‘‘B’’) is required. In Mali, only aPTT test is available. On the accessibility to Treatment: Access to medical care is a big challenge in Mali. Only two clinical units are able to care for hemophilic patients. These units are exclusively located in Bamako, not easy to reach for most of the patients and their families. The small cohort of 20 hemophilic patients followed in our Department of Hematology mostly live far from Bamako, as represented by our two cases. Fresh plasma is the sole possibility to manage acute bleeding event, no concentrate of coagulation factor is available in Mali. Research perspectives: To date hemophilia is a big research domain which needs an international network to collaborate with Mali to help improve diagnosis, treatment and research.

Hemophilia in developing countries: an analysis of the first data in Cameroon

CLAUDE TAYOU TAGNY,1 SYLVIE MOUDOUROU,2 A N N I C K N D O U M B A 3 and D O R A M B A N Y A 1 Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Cameroon; 2 Chantal Biya International research Center, Yaounde, Cameroon; and 3University Teaching Hospital, Yaounde, Cameroon


Introduction and Objectives: In sub-Saharan Africa, hemophilia remains a huge problem mainly because of a lack of knowledge of the disease, limited screening capabilities and access to treatment. A strategic plan for managing hemophilia should start with the mastery of local characteristics of the disease. This review aims to discuss the characteristics of Cameroonian patients living with hemophilia. Materials and Methods: A retrospective study has been done on the data of four main reported studies between 1972 and 2010 at the Faculty of Medicine and Biomedical Sciences, University of Yaounde I. Epidemiological, clinical and biological features of people living with hemophilia in Cameroon has been analyzed. Results: The mean age of the 103 patients was between 14 and 16.2 years. All hemophiliacs reported by the studies were male. For most patients, the frequency of bleeding episodes ranged from 2–15 bleeds per year. Chronic joint complications were found in almost all patients in the 2010 study. Hemophilia A was more common than B, representing 88.4% and 87.5% in 2008 and 2010 respectively. All the 37 patients reported in the study of 2010 were tested negative for HIV in spite of history of transfusions. Conclusion: Some features of hemophilia in Cameroon are different from those of other African countries. However, as in many countries, the biggest challenge in the long term is the constant availability of clotting factors concentrates for patients.

Increasing cohesion in a province with nine hemophilia treatment centres through a central coordinator SARAH CRYMBLE BA St. Michael’s Hospital, Ontario, Canada Introduction and Objectives: Canada has 26 hemophilia Treatment centres (HTC) across the country. Of these 26 HTCs, nine are located in the province of Ontario. The nine HTCs are responsible for > 3300 patients with inherited bleeding disorders whom are registered with one of the HTCs. Materials and Methods: To deal with the large number of HTCs in one province, the position of the Hemophilia Provincial Coordinator (HPC) was created in 2005. The

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

primary role of the HPC is to support and sustain the programs, facilitate the sharing of information among them and to create then maintain the national standards of care for people with inherited bleeding disorders. The HPC works directly with a steering committee that consists of a medical delegate from each of the nine HTCs. Multiple HTCs in one province could lead to silos of care that is in direct opposition to the Canadian vision of a standard of care. The HPC position ensures all HTCs have equal access to achieving best practice; an advocate to assist in lobbying for adequate resources to deliver the identified standards and the opportunity to review the standards biannually. Results: The HPC has been successful in: (1) Managing clotting factor concentrates (CFC) resulting in savings of over CDN $ 4,000,000, (2) Standardizing the approach to product ordering for the >450 home care patients in Ontario in conjunction with >150 Transfusion Medicine Services, (3) Optimizing provincial utilization of CFC, and (4) Identifying common priorities and program development needs. Conclusion: The HPC role has facilitated the building of trust and credibility within the HTCs, various levels of the Hemophilia Society, and the Ministry of Health and Long Term Care. The HPC is a central contact for inquiries from all these stakeholders, resulting in a streamlined approach to data gathering and problemsolving.

An evaluation of a Canadian transition program: From pediatrics to adult care

GEORGINA FLOROS,1 ALANA KAPLAN,2 DIANA COTTINGHAM,3 JORDAN LEWIS,1 CINDY D W A K E F I E L D , 3 S A R A H C R Y M B L E 1 and V A N E S S A N BOUSKILL3,1 1 St. Michael’s Hospital, Toronto, Canada; 2University of Toronto, Canada; and 3The Hospital for Sick Children, Toronto, Canada

Introduction and Objectives: Transitioning from the pediatric to the adult Comprehensive Care Bleeding Disorders Centre in Toronto, Canada has been occurring for the last three decades. An established transition program was developed 10 years ago and was implemented as an organized gathering integrating both health care professionals and transitioning patients and their families. The desired outcome of the gathering was to address the transitioning needs of this complex patient population. Despite the initial success of this program, in recent years attendance at this gathering fell dramatically and the number of patients who did not transition to adult care began to increase. Materials and Methods: A questionnaire was developed by both centres to elicit respondents’ feedback on the current transition program and suggestions to improve the process. At the pediatric centre, questionnaires were disseminated to individuals seen at their routine clinic visit who were due to transfer to adult care within the next 36 months. Twenty questionnaires were completed by 16 patients and 4 caregivers. At the adult centre, all patients transitioned within the last 12 months were mailed a questionnaire to complete. Of 28 questionnaires disseminated, five responses were obtained. Results: The common theme that emerged from the pediatric respondent feedback was anxiety around unfamiliarity of the adult hospital and treatment team; caregiver responses focused on the perceived lack of involvement in their child’s care as the focus of care moves from family-centre to patient-centre. The adult respondents indicated retrospectively that the transition was smooth and not anxiety-provoking. Conclusion: Interestingly, the initial concerns around transition previously identified remained consistent with current findings. Therefore, given the lack of participation at the previously-offered program, a different approach to address the needs of transitioning patients was necessary. A standardized process for transition from pediatric to adult care has been formalized. The process includes: 1) Quarterly clinics designated for transition at the pediatric facility attended by adult care team members and 2) Implementation of a transition checklist. The success of the modified transition process will be evaluated by monitoring the overall satisfaction of patients and the number of patients that remain lost to adult transition.

A comprehensive review of current hemophilia care and outcomes in Singapore

HENG JOO NG,1 JOYCE LAM,2 PEI LING KOH,3 LILLIE HO,1 CHIEW YING LIM,2 MUFEEDHA AKBAR ALI,1 DAWN MYA,1 L I A M P O C K H O , 1 L A I H E N G L E E 1 and S I M L E N G T I E N 1 1 Department of Haematology, Singapore General Hospital, Singapore; 2Department of Paediatrics, Kandang Kerbau Women’s and Children’s Hospital, Singapore; and 3 Department of Paediatrics, National University Hospital, Singapore Introduction and Objectives: As a small island nation, hemophilia care in Singapore is delivered by a modern and easily accessible state-funded health care system with a component of co-payment by patients. On-demand therapy has been the standard of care especially in our adult patients. We surveyed a representative section of our patients to determine how they have fared with this model of health care. Materials and Methods: Hemophilia A and B patients of all severity registered with the National Haemophilia Registryand attending the three main treatment centres, were invited to participate by contributing their demographic and clinical data and attend a clinic visit where their joint status could be assessed with the Hemophilia Joint Health Score(HJHS). Results: Singapore has 195 hemophilia A and 37 hemophilia B patients among a resident population of 3.8 million. A total of 103 patients consented for this study (45 severe, 43 moderate and 15 mild). Among pediatric patients with severe hemophilia, more than 70% of our patients are now on regular prophylaxis. In contrast, only 40% of our adult patients with severe hemophilia were receiving prophylaxis with

Haemophilia (2014), 20 (Suppl. 3), 1--186



most started only in recent years for frequent bleeds. Plasma-derived factor VIII was the predominant concentrate used although recombinant clotting factors are increasingly being given to pediatric patients. Inhibitor rate (both transient and persistent) was detected in 17.6% of patients. Hepatitis C infection rate was about 50% among the adult population who were more likely to be exposed to cryoprecipitate previously. We have no HIV infected patients. The average HJHS scores for the different severity categories were: severe 19.75 (range 0-38), moderate 14.32 (0-77), mild (0-8). Sixteen pediatric patients with moderate to severe disease below the age of 10 had scores of 0-32 (median 0), while another 20 patients between the ages of 10-19 had scores of 0-18 (median 4). The median HJHS scores of older patients group by decades from 20-70 years of age were 7, 20, 23, 18.5 and 32, reflecting increasing joint burden with age. Conclusion: Prophylaxis therapy is becoming the standard of care among our younger hemophiliacs. The joint scores, while reflective of on demand therapy, were lower than we expected, which may be due to easy access of our patients to factor replacement therapy during bleeding episodes.

A universal outcome measurement system for improving care in hemophilia RICHARD LITTLEWOOD Applied Strategic, London, United Kingdom Introduction and Objectives: Outcome measures are increasingly important in health care. Currently, it is difficult to compare performance and results in hemophilia care in different settings. Significant questions on the economic value of, and approach to treatment in, hemophilia are outstanding. A system with universal acceptance by patients, clinical and payer teams is needed. Materials and Methods: Development of a multifactorial tool for the hemophilia outcomes measurement and move towards the consensus for its acceptance and use has been pointed out. The proposed tool will facilitate the measurement of effectiveness of delivery of hemophilia care. This will drive improvement in care through outcomes-based decisions. Various existing approaches may not collect sufficient data, or may not produce results allowing comparison with other performance assessments. Results: Understanding the effectiveness or success achieved by a particular model, or centre for, hemophilia care service can be measured with the proposed Haemophilia Success Scorecard (HSS). The aim is to create a simple measurement system using existing data. A scorecard made up of four main groups of measurement: care, wellbeing, service and cost is proposed. There is one lead and a small number of supporting measurements per group. This is based on experience of hemophilia care and existing systems of measurement. Performance is scored based on a weighted ranking of results for each metric against a panel of other centres. Group

Description of Lead Measurement


Average, estimated trough levels of factor VIII for all patients under the care service with severe hemophilia A, and an estimation of care efficiency Population assessment, quality of life score, average across population under treatment Percentage of listed service functions for hemophilia care, available under care model and focus on staff Efficiency of care and unit cost: per patient, average of all costs to provide all aspects of hemophilia care

Wellbeing Service Cost

Haemophilia (2014), 20 (Suppl. 3), 1--186

Conclusions: The HSS offers an approach to develop consensus on the measurement of effectiveness of haemophilia care in different models and settings. This could improve care in emophilia. The proposed scorecard should be piloted in a number of care settings and developed into a formally agreed approach.

Continuous quality improvement for continuous factor infusion G E O R G I N A F L O R O S , R A C H E L H E and M O N I Q U E A N D E R S O N St. Michael’s Hospital, Toronto, Canada Introduction and Objectives: At the adult hemophilia treatment centre (HTC) in Toronto 13 surgeries were performed over the last three years using continuous infusion of clotting factor concentrates. This method of administration of factor VIII and IX concentrate can be very effective in achieving stable factor levels and minimizing the risks for post-operative bleeding. However, because this is not done very often, careful attention to every step of the process is required. In an effort to continually improve care at our institution, nurses in the HTC and transfusion medicine technologists are constantly evaluating the process. The goal is to ensure that the practice of continuous factor infusions leads to the safest and most controlled factor coverage possible while optimizing the use and ensuring no wastage of this precious resource. Given the number of nurses responsible for providing in patient care to patients with hemophilia, our strategy focused on creating resources and a process to limit the chance for errors. Materials and Methods: The HTC nurses regularly meet with nurses on the inpatient floors when patients are receiving continuous factor infusions, checking to make sure the process is well understood and the care seamless. In response to concerns raised, a number of resources were created to improve the knowledge and understanding of nurses responsible for infusing and maintaining the continuous factor infusion. Current practice includes the use of special labels on the factor issued from transfusion medicine, an information sheet included with the issued factor and an education package created for each patient chart. Results: We acknowledge that patients play a vital role as their own advocate ensuring that the factor infusion remains continuous. That being said, since the implementation of a number of quality improvement resources, the process for continuous factor infusions at our institution has improved. This has resulted in an overall improvement in the management of post-operative patients with hemophilia. Conclusion: Infusing factor concentrate by continuous infusion can be a great asset to patient care but requires carefully orchestrated team work. Maintaining a practice that continually evaluates the quality of care provided at an institution should be forefront in our minds. Small changes to practice can have huge impact on patient care.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd



29-DENTAL ISSUES Minimal factor use for Oral Surgery at The Alfred Hospital IAN D HEWSON The Alfred Hospital, Melbourne, Australia

First meeting on dental care in hemophilia and von Willebrand patients

M A R IA S O L C R U Z , 1 E U G E N I A R E Y N O S O , 2 L A U R A F O R Z A N I 3 and X I M E N A R A M O S 4 Fundaci on de la Hemofilia de Salta, Salta, Argentina; 2Fundaci on de la Hemofilia de Tucum an, Tucum an, Argentina; 3Programa Provincial de Odontologıa de Salta, Salta, Argentina; and 4Hospital Nuevo Materno-infantil de Salta, Salta, Argentina


Primary Objective: To reduce the amount of factor support provided during oral surgery procedures for inherited bleeding disorder patients. Background: Using a protocol we developed for warfarinised patients, over 180 consecutive inherited bleeding disorder patients from the Alfred Hospital underwent oral surgery with no additional factor support; patients on prophylactic factors continued this cover. The protocol involves the use of careful surgical technique, oral and topical tranexamic acid, placement of surgical into the socket(s) and careful suturing. Summary: Over 180 consecutive inherited bleeding disorder patients have been treated at the Alfred Hospital, of the total number of patients treated 3.9% returned for some form of post-operative bleeding management, of the severe patients 6.7% returned for some form of post-operative bleeding management. None of the VWD patients returned for any bleeding problems. 117 inferior dental nerve blocks were administered with no evidence of hematoma associated with this procedure. Conclusions: Oral surgery can be carried out with minimal factor support for inherited bleeding disorder patients using careful surgical technique and a protocol of tranexamic acid, surgical in the socket(s) and careful suturing. Inferior dental nerve blocks can be safely administered without factor cover.

Assessment of management of early caries management programs in children and adolescents with hereditary coagulation disorders KIRSTEN FITZGERALD Dept of Paediatric Dentistry, Our Lady’s Children’s Hospital, Dublin, Ireland Aim: a) to evaluate the state of the art of the management of dental caries in children and adolescents with hereditary coagulation disorders, b) to share our experiences and techniques with our international colleagues , and c) to propose potential areas for further research related to these inter-linked conditions. Dental caries in children and adolescents has a high prevalence worldwide. It is the most common chronic condition of childhood in the developed world. Despite this, current risk assessment and preventive and management protocols for dental caries lack a compelling evidence base. Similarly, the hematological aspect of management of children with hereditary coagulation disorders undergoing dental treatment lacks evidence and global consensus. Current available evidence-based strategies related to dental caries will be presented, and the audience will be invited to participate in their appraisal. Available strategies for management of bleeding in dental treatment will be examined and the audience will be invited to discuss their experiences, techniques, and the advantages and limitations thereof with the group. Topics for further research in these spheres will be developed.

Incorporating patient expertise in the design of a disease specific mobile dental application to promote oral health for people with hemophilia

G R A E M E T I N G , 1 D E C L A N N O O N E , 2 P E T E R L . E V E R Y 3 and ALISON J. DOUGALL4 1 Special Care Dentistry, University of Malaya, Kuala Lumpar, Malaysia; 2Irish Haemophilia Society Dublin, Ireland; 3Coputing Department, Coventry University, Coventry, United Kingdom; and 4Dublin University Dental Hospital,Trinity College, Dublin Contemporary hemophilia care aims to empower patients to self-manage and monitor their own condition: supported by optimal treatment regimes, expert medical teams and strong patients organisations. Access to oral healthcare continues to be a challenge for people with hemophilia (PWH), with poor oral health impacting on their quality of life, general health and self esteem. Barriers to the maintenance of good oral health for PWH include reduced access to general dental care in their communities, the fear of dental interventions - by patients and dentists alike, and multiple inconsistencies in knowledge about the relative risks of different types of dental treatment held by PWH and the teams that treat them. This presentation will describe a patient centred design methodology employed to develop a mobile application with the potential to assist PWH to manage and optimise their oral health care while also supporting their safe and effective decision making. The application incorporates information content and evidence based decision trees which assist in the self-management of common problems such as toothache, dental abscess and bleeding gums. The application aims to provide essential information for dentists by using algorithms which embed well-established guidelines to determine the relative risk of dental procedures in all domains of dentistry including surgery, prosthodontics, periodontology, orthodontics, and pain and anxiety management. Results will outline the ways in which problems related to the technical execution, clinical efficacy and usability of the application were resolved using a collaborative interdisciplinary team including clinicians, patients, user-experience designers and programmers. Initial analysis of qualitative and quantitative data will explore the effectiveness and usability of the application in relation to specific tasks and scenarios in the domain of dentistry and hemophilia. Discussion will centre on the potential value of app technology, the necessity of patient centred design, and planned multi-centre usability testing.

Objective: To train the dentists in the Province Salta, Argentina, in order to guarantee a greater involvement of hemophilia and von Willebrand patients in dental care. Introduction: Given the need of dental care shown by patients with coagulation disorders, a meeting on theoretical and practical training for dentists was organized by the Provincial Dentistry Program and the Salta Hemophilia Foundation in order to achieve greater and better care for these patients, which consequently would allow them a better quality of life. Methodology: A theoretical and practical workshop with patients suffering from hemophilia and von Willebrand disease was offered. For extractions, local infiltration anesthesia was used; bismuth subgallate combined with anesthesia (filler consistency) was placed as an alveolar pack; silk stitches 4-0 were used. In severe hemophilic patients, the factor was increased by 50%, and in VWD patients tablets of tranexamic acid were used. For endodontics, in patient with VWD type 2B disease, the factor was increased by 50% plus VWD concentrates. Dental surgeries and fluoride topications were conventionally done. Supragingival scalings were (manually) done; bleedings were restrained using cotton balls slightly soaked with trichloroacetic acid. Results: We trained 148 dentists. Nineteen patients were seen: Eight with severe Hemophilia A; one with severe Hemophilia B; three with von Willebrand type 2B; four with von Willebrand type 1 refractory to desmopressin; andthree with von Willebrand type 1. Panoramic X-rays were obtained from these 19 patients. Following procedures were performed: Extraction of permanent teeth, 18; extraction of temporary teeth, 2; operative extractions, 3; fluoride topication, 2, endodontics, 1; tartrectomy, 5. Conclusion: A good exchange of knowledge was achieved among dentists and the professional staff of the Salta Hemophilia Foundation. Doubts were resolved and a knowledge-based reduction of professional fears was intended. A final goal of the Salta Hemophilia Foundation and the dentistry program is to prepare the dental management guidelines for hemophilia and von Willebrand patients in the province salta.

An experience of dental surgical operative interventions in 84 patients with hemophilia from a large hemophilia centre in Northern India

G I T A M E H R O T R A , 1 S A R T A J A L I 2 and N A R E S H G U P T A 3 Maulana Azad Institute of Dental Sciences, New Delhi, India; 2Haemophilia Centre, Lok Nayak Hospital, New Delhi, India; and 3Maulana Azad Medical College, New Delhi, India; Haemophilia Centre, Lok Nayak Hospital, New Delhi, India


Introduction and Objectives: Dental problems are common, albeit commonly neglected problems in hemophilia and have logistics issue in managing those developing countries like India. A review of our experience with surgical dental interventions in hemophilia patients from our hemophilia centre in New Delhi are presented in this paper. Materials and Methods: Data from the charts of consecutive cases requiring dental intervention for their dental problems and hemostasis management during 2009-2013 CE are presented in this paper. Results: The study had a total of 86 cases with hemophilia, mean age 21.29 years, range 6- 69, comprising of 77 hemophilia A and nine with hemophilia B. Majority were severe (39/86) or moderate (35/86) hemophilia in functional severity. Carious broken teeth accounted for 38.4% whereas mobile or retained deciduous teeth were the cause in 37.2% and 5.8% respectively. Other less frequent diagnosis were periapical abscess, impacted 3rd molar, imparted tooth permanent, scaling, chronic hypertrophic pulpitis, mobile tissue fibroma, gingivitis and fractured tooth. A total 84 surgeries were performed. All dental operative interventions/ procedure were performed under local anesthesia. Hemostasis was achieved with anti-hemophilic factor (AHF) infused 45-50 minutes prior to surgical intervention. Patients were kept under observation in the centre for minimum two hours post-surgery. All but three cases achieved good hemostasis with a single dose of AHF, mean 20.17 IU/kg, with 83% receiving under 30 IU/kg AHF. Only one case required 57 IU/kg. Additionally, local anti-fibrinolytic agent, tranexamic acid was applied besides good local pressure and general hemostatic measures. Successful hemostasis was achieved in all cases except three who demonstrated gum bleed post-operatively. These three patients required AHF for next 2 days, and the cause of bleeding was attributed to local pathogenic/ procedure-related aetiology. Conclusions: Dental problems in hemophilia often get neglected and are a constant source of ill health and poor nutrition. Addressing them is pretty easy, safe and rewarding.

A local hemostatic method for tooth extraction using fibrin glue + polyglycolic acid sheets for hemophilia and von Willebrand disease patients YUICHIRO IMAI, SATOSHI FUKUTSUJI, MORIHIKO TAKASHIMA, NOBUHIRO UEDA, H A J I M E Y O S H I O K A , Y A S U T S U G U Y A M A N A K A and TADAAKI KIRITA Department of Oral and Maxillofacial Surgery, Nara Medical University, Nara, Japan Introduction and Objectives: Replacement therapy is performed for hemostasis of intraoral hemorrhage in hemophilia and von Willebrand disease (VWD) patients, but simultaneous local hemostasis is also necessary, and no sufficient hemostatic control

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

Haemophilia (2014), 20 (Suppl. 3), 1--186



can be obtained lacking either one of these. However, there have been only a few reports on local hemostasis methods. The combined application of a polyglycolic acid (PGA) sheet and fibrin glue to cover mucosal defects in patients treated with oral surgery has recently been occasionally reported. In this study, we applied a PGA sheet and fibrin glue on tooth extraction in 10 hemophilia and vWD patients, and investigated the usefulness. Materials and Methods: The subjects were 10 patients with hemophilia and VWD without inhibitors who underwent tooth extraction at our department between June 2010 and May 2012. Tooth extraction was performed under treatment with blood coagulation factors or vasopressin. The extraction socket was filled with a mixture of gelatin sponge and fibrin glue for local hemostasis and then covered with a PGA sheet, and the wound surface was protected with a protective plate. Results: There were 8 hemophilia A and two VWD patients aged 17-70 years, with nine males and one female. The mean number of extracted teeth was 2.12, and the mean durations of coagulation factor and vasopressin administration, protective plate attachment, and analgesic administration were 2.42, 3.66, and 3.25 days, respectively. No postoperative hemorrhage occurred in any patient, and the healing course was favourable. Conclusion: Suture was unnecessary for local hemostasis on applying fibrin glue and a PGA sheet after tooth extraction in hemophilia and VWD patients with no inhibitor, blood product and DDAVP administration was unnecessary at suture removal, and the duration of protective plate attachment and analgesic administration could be shortened. This method may contribute to reduce the incidence of postoperative complications and improve the QOL.

Dental surgery and preventing complications: It is more than factor

K . A . M C I N T O S H B S N 1 and S . P U R C E L L R N 2 Hemophilia Program of British Columbia: Adult Division; and 2South Eastern Ontario Regional Inherited Bleeding Disorders Program


Introduction and Objectives: Traumatic dental bleeding complications in the lifetime of people with inherited bleeding disorders are overwhelmingly common. There was a scarcity of practical guidelines to promote oral health and managing oral surgery in Canada. The objective was to develop a booklet in French & English promoting oral health and guidelines to prevent oral surgery complications for people with bleeding disorders. Materials and Methods: The Canadian hemophilia nurses created a dental booklet which includes basic guidelines on how to recognize and cope with dental problems. The Canadian Dental Association has clear post-op guidelines to control bruising, bleeding, swelling and pain. These guidelines were adapted for people with a bleeding disorders. The booklet was reviewed by two Dentists; a person with hemophilia in his last year of dental school; a dental hygienist instructor and a medical director of hemophilia. In collaboration with the Canadian Hemophilia Society, the booklet was published in 2012. The booklet observes it is normal to bleed for one to two hours after oral surgery. The clot forms as bleeding is controlled by gently and firmly biting down on a gauze pad soaked in tranexamic acid mouthwash. If bleeding persists after one hour of constant pressure, add a second gauze pad onto the first while biting down for a second hour. Elevating the head six inches above the heart during rest slows down the flow of blood to the wound site. Cold compresses applied every 10 minutes on then 10 minutes off for the first 24 hours can reduce swelling. The booklet also includes personalized planning with the oral health care team with discussions on suture type, gum disease and platelet levels. Results: This 2012 booklet Dental Care For People With Bleeding Disorders was distributed to 27 hemophilia treatment centres in Canada. In 2013, three of the 28 British Columbia oral surgery patients with bleeding disorders overlooked following the dental booklet’s recommendations resulting in emergency room visits and excessive factor usage. Conclusion: Prolonged bleeding, bruising and delayed bleeding are traumatizing complications that could be averted by using measurable guidelines and personalized planning.

Multi-disciplinary risk assessment for the dental management of patients with inherited bleeding disorders LAKSHMI RASARATNAM, PRATIMA CHOWDARY, D E B R A P O L L A R D and U L P E E D A R B A R Katharine Dormandy Haemophilia Centre & Thrombosis Unit, London, United Kingdom Background: For most patients, detection of dental disease begins in childhood. However, for patients with inherited bleeding disorders (IBD), there have often been barriers to accessing regular dental care; with delayed diagnosis and dental management a consequence. Objectives: This study aimed to identify the barriers to dental access for patients with IBD, present the results of a retrospective audit assessing a local clinical protocol and introduce a risk-assessment tool for the appropriate haematological and dental management of these patients. Materials and Methods: A retrospective audit of 30 patients with IBD undergoing 200 dental procedures was reviewed. History of dental attendance pattern, type of bleeding disorder, prevalence of untreated primary dental disease, dental preventative measures, dental procedures carried out, anaesthesia used, haemostasis management plan and any post-operative complications were recorded and analysed. Clinical practice was compared to current guidelines. A local, evidence based clinical protocol and risk assessment tool was created in collaboration to standardise care of these patients Results: 86.7% of patients seen were either not enrolled with a dentist or were pain related dental attendees. 90.0% presented with at least one carious tooth and 73.3% had Chronic Periodontitis. Altogether, 200 dental procedures were undertaken including 55 supra and sub-gingival debridements (deep cleaning), 64 fillings, 14 root canal treatments and 32 dental extractions using local anaesthetic infiltrations or inferior alveolar nerve blocks.

Haemophilia (2014), 20 (Suppl. 3), 1--186

Conclusion: This study shows that adults with IBD’s have had minimal previous dental care due to difficulty with dental access. They presented with high levels of untreated primary dental disease, requiring more complex treatment including extractions and multiple restorations. Contribution to clinical practice: The introduction of the clinical protocol was effective in managing the needs of patients included in the audit. Furthermore, the implementation of a risk assessment tool enabled the standardisation of management for these patients that could be used on a large population scale

Oral health in children and young adults with hemophilia in Serbia

SANJA VUJKOV,1 BRANISLAV BAJKIN,1 DUSKA BLAGOJEVIC,1 BOJAN PETROVIC,1 NADA KONSTANTINIDIS,2 N E B O J S A R A J I C , 3 I S I D O R A N E S K O V I C 1 and I V A N K A S A V I C 3 1 Dental Clinic, 2Institute for Child and Youth Health Care; and 3Clinic of Hematology, Clinical Center of Vojvodina, Faculty of Medicine Novi Sad, University of Novi Sad, Serbia Introduction and Objectives: Gingivitis and periodontal diseases are frequently associated with bleeding in patients with hemophilia. Advanced tooth decay and disease of periodontal tissues are common indications for teeth extractions that require factor replacement therapy. According to collected data, oral health in patients with hemophilia differs throughout the world. Oral health is influenced not only by hemophilia itself, but also by the degree of preventive dentistry care, collaboration between dentist and hematologist and the presence of comprehensive hemophilia care centres which should include dentists. Data on the oral health status in these patients in Serbia have not yet been fully evaluated. The aim of this study was to evaluate oral health status and distribution of oral diseases: gingivitis and caries in children and young adults with hemophilia, and to compare these findings with results in healthy controls. Materials and Methods: The study group included 33 patients, aged 10-25 years, with hemophilia, and control group comprised 40 healthy subjects of the same age range. Data were collected using a modified WHO questionnaire for oral health assessment. Results: Gingival index score (GI) of the children with hemophilia (1.57  0.77) was statistically higher than in control (0.12  0.35) (p < 0.05). No statistical difference was found in decay-missing-filled index (DMF) in study group (4.21  4.14) compared to control (4.45  4.19) (p > 0.05), while decay score (D) of study group (2.26  2.86) was significantly higher than the control (1.47  2.16) (p < 0.05). The difference in oral hygiene index score (OHI) between study (1.54  0.70) and control group (0.28  0.48) was statistically significant (p < 0.05). Conclusion: The results of our study revealed that children with hemophilia represent a special group regarding dental care. Oral health in patients with hemophilia points to the need to implement additional preventive measures and schedule more frequent check-ups. Treatment of oral diseases in initial stages could prevent further development of diseases, and decrease the complications rate whose management requires factor replacement therapy.

Management of dental procedure in patients with hemophilia: 10 years’ experience in Nara Medical University

FUKUTSUJI SATOSHI,1 IMAI YUICHIRO,2 TAKASHIMA MORIHIKO,2 UEDA NOBUHIRO,2 Y O S H I O K A H A J I M E 2 and K I R I T A T A D A A K I 2 1 Department of Oral and Maxillofacial Surgery, Nara Medical University, Nara, Japan; and 2Department of Oral and Maxillofacial Surgery, Takita Hospital, Nara, Japan

Introduction and Objectives: Hemophilia is an X chromosome-linked recessive hereditary blood disease. Its incidence is high among congenital coagulation disorders, and the disease is often encountered in the practice of dental procedures. Systemic hemostatic management is necessary for invasive treatment, such as tooth extraction. We have performed dental management in cooperation with pediatric and hematology departments. The aim of this study was to investigate the management of dental procedure in patients with hemophilia. Materials and Methods: Of 135 hemophilia patients treated at our department between 2000 and 2009, 27 patients received invasive treatment. The background, factor VIII and IX activity levels, invasive treatment, replacement therapy, and frequency of postoperative hemorrhage were surveyed in these patients. Results: There were 24 hemophilia A and three hemophilia B patients. Tooth extraction, local hemostatic treatment, and surgical treatment other than tooth extraction were performed in 34, 10, and 9, respectively. The coagulation factor activity level at the time of treatment was 79% in impacted tooth extraction, 77% in normal tooth extraction, 78.3% in surgical treatment other than tooth extraction, and 60.2% in local hemostatic treatment. Post-treatment hemorrhage occurred in nine, and two of them were accompanied by inhibitors. A protective plate was applied in 46: a simple type in 31 and combination type in 15. Oral surgical treatment was performed setting the target plasma level based on the severity, content of treatment, and grade of invasiveness. Conclusion: It was suggested that the frequency of post-treatment hemorrhage can be reduced regardless of the content of treatment when a sufficient coagulation factor activity level is established. Using a combination-type protective plate for local hemostasis, post-treatment intraoral discomfort can be reduced and the QOL may be improved.

Oral health situation of a group of Chinese hemophilic preschool children J I M E I S U , X I A O Y U N Q I A N , X I A O L I N G J I A and L E I X U Department of Stomatology, Children Hospital, School of Medicine, Zhejiang University, Hangzhou, China Introduction and Objectives: Children with hemophilia in China have received minimal dental intervention and their oral health situation needs an essential assessment. The purpose of this study was to investigate dental and other aspects of

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

DENTAL ISSUES oral health status of preschool patients with hemophilia and the cognition degree of knowledge about oral health compared with controls. Materials and Methods: DMFS-dmfs (Decayed, Missed, Filled Tooth Surfaces in permanent and primary tooth), Simplified oral hygiene index (OHI-S) and occlusion of 27 hemophilic children at age 3–7 years and 27 of other healthy children as control are compared, and the cognition degree of knowledge about oral healthcare were also investigated. Data were analysed by Mann-Whitney U test, Kruskal-Wallis H test and t-test. Results: The results showed that the dmft and dmfs of hemophilic children (2.92  3.82, 5.00  8.02) were higher than those of non-hemophilic children (2.19  2.86, 4.48  6.06) in China, but the difference was not significant (P > 0.05), and that the decayed component represented most of the index values. The mean value of the OHI-S of hemophilia group and control group was 0.52  0.63 and 0.59  0.71, respectively, the difference was not significant (P > 0.05), and the main component of the OHI-S in both groups was DI-S not the CI-S. There was a history of oral bleeding in 18(66.7%) of 27 hemophilic patients, mainly because of trauma induced bleeding, especially in the tongue region, followed by during the time of eruption/exfoliation of primary teeth. The investigation of cognitive degree of knowledge about oral health showed that the hemophilic patients, or the control group patients, had enough knowledge about oral health care, 82.7% of all children did not know how to brush the teeth, and only 10.3% children brushed their teeth twice a day. Conclusion: We found no evidence that oral health in children with hemophilia is worse or better than that in healthy children; however, larger studies are needed. And we should give them more professional introduction to oral health care to improve their oral health status.

Dental anxiety and pain among children with hemophilia

_ G E N SßA SßM A Z , 2 I F F E T Y A Z I C I O G L U , 1 M . C E M D O G A N , 1 IL B U L E N T A N T M E N , 2 B U S E S E R I N 1 and C E R E N D E V E C I 1 Departments of 1Pediatric Dentistry; and 2Pediatric Hematology, Adana, Turkey Introduction and Objectives: Dental interventions have the potential to be overwhelming for children with hemophilia; the study was designed to assess the levels of dental anxiety related to the first dental intervention for children with hemophilia. Materials and Methods: 56 boys with severe hemophilia A and B and 56 healthy peers living in C ß ukurova region of Turkey between the ages of 7-12 who needed primary dental extraction were chosen for this study. Facial Analog Scale and Visual Analog Scale were applied to all participants. Results: No significant differences among the groups were detected by dental anxiety scores (FIS) and pain scores (VAS). The FIS scores of children who had experienced dental pain before the treatment were significantly higher regardless of the group they were part of (p = 0.001). Conclusion: Children with hemophilia are not at an increased risk of dental anxiety using special precautions and with the help of adequate treatment regimes. Pain is a predictor for dental fear and anxiety on dental chair both for children with hemophilia and healthy children.

Dental health and its determinants in Lithuanian hemophilia patients – a case control study

RUTA ZALIUNIENE,1 VYTAUTE PECIULIENE,1 J O L A N T A A L E K S E J U N I E N E 2 and V I L M A B R U K I E N E 1 University of Vilnius, Vilnius, Lithuania; and 2University of British Columbia, Vancouver BC, Canada


Introduction and Objectives: To compare the dental health of hemophiliacs with matched healthy subjects and to examine if hemophiliacs have a higher risk for dental caries when it is controlled for known risk determinants. Materials and Methods: Census sampling was used to invite patients with hemophilia and a cluster random sampling was used to recruit healthy controls. The cases and controls were matched on gender, age and place of residence. An overall response rate for hemophiliacs was 76.6% and there were 27 child and 49 adult patients with hemophilia. The control group comprised 30 children and 49 adults. The dental health-related outcomes were: overall caries experience, dental treatment experience, unmet dental treatment need and functional dental health. The following risk determinants were tested: levels of dental plaque, socio-economic status, salivary biological functions and lifestyle factors. Independent sample t-test was used to compare cases and controls regarding dental health outcomes and regression was employed to study the risk for caries where multiple risk determinants were considered. Results: The overall caries experience, i.e. the number of decayed and filled deciduous teeth (P = 0.003) and unmet treatment need in deciduous dentition i.e. the number of decayed teeth (P = 0.036) differed between the hemophilia patients and healthy controls. Regression analysis showed that overall caries experience was lower for young children with haemophilia and the only statistically significant consistent predictor for higher caries experience was lower salivary buffer capacity even when it was controlled for other risks. Conclusion: Better dental health in deciduous dentitions was observed in children with hemophilia. No differences were observed when permanent dentitions were compared between the hemophiliacs and controls. None of the linear multiple regression models confirmed hemophilia to be an additional caries risk when it was controlled for other caries determinants.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


Case report documenting the challenges of managing mild chronic periodontitis in two patients with Glanzmanns Disease

L O C H A N A N A N A Y A K K A R A 1 and D A N P H A R T 1 , 2 The Royal London Dental Hospital, Bartshealth NHS Trust, London, UK; and 2 Barts and the London School of Medicine and Dentistry, QMUL, London, UK


Introduction and Objectives: Gingivitis and periodontitis present as bleeding on brushing or dental probing. In patients with inherited bleeding disorders, achieving hemostasis in these situations can be difficult, resulting in their reluctance to comply with good oral hygiene practices and active periodontal therapy. This report highlights the benefit of managing periodontal inflammatory disease in two patients with a severe primary hemostatic defect and the need to consider alternate therapeutic strategies in the face of poor hygiene compliance or complications not amenable to standard treatment (eg orthodontics or strategic extractions to alleviate crowding). Materials and Methods: Two individuals with Glanzmanns disease presented with early chronic periodontitis. Both individuals suffered spontaneous intra oral bleeding, reporting blood on the pillow on waking and regular taste of blood. Both received initial hygiene therapy including oral hygiene instructions and scaling and polishing with prophylaxis paste. Both were covered with HLA matched platelets and Tranexamic acid for the scaling procedure. Crowding was an additional local risk factor in Case two, but orthodontic therapy was contraindicated due to the risk of soft tissue trauma from wires and brackets and poor levels of plaque control. She did not consent to strategic extractions to relieve the crowding. A low level diode laser was used to facilitate healing and inflammation resolution. Results: Case one was compliant with improved oral hygiene practices, responded to hygiene therapy, and reported an improvement in symptoms. Case two had complicating crowding, was less compliant with hygiene measures and experienced persistent symptoms. The use of a low-level laser diode has shown a positive early response. Conclusion: These cases highlight the need to actively manage periodontitis in the context of severe bleeding disorders. Low level diode laser therapy to help reduce the inflammation in the tissues, thus decreasing the post treatment bleeding experience may have a more extended role beyond just those with additional complications. A clinical trial is needed to establish this as an adjunctive therapy for managing postoperative bleeding and promote soft tissue healing in these patients.

Er: YAG laser on dental emergencies patients with hemophilia as an alternative for hemostasis and reducing the use of factor VIII concentrate. Case Report

M A R C O A N T O N I O R U E D A V E N T U R A 1 and L A U R A B E A T R I Z  2 I S I D R O O L AN Ministry of Health; Children’s Hospital, Tabasco Mexico; Hemophilia Association of Tabasco Juarez Autonomous University of Tabasco; and 2Juarez Autonomous University of Tabasco; Hemophilia Association of Tabasco


Introduction and Objectives: Hemophilia is a hereditary disease, where the coagulation system is affected by the reduction of one of the coagulating factors, in this case factor VIII. Objective: To optimize the use of factor VIII in emergencies and dental treatment through the use of Er: YAG laser. Materials and Methods: It covered 5 patients with age range 4-11 years who had different types of emergency oral bleeding (extractions, lip laceration and pulp polyp removal) for which we used the laser emission Er: YAG in order to achieve hemostasis and optimize the use of factor VIII. In extractions´ cases (3) was used single initial dose of 25 IU / kg / body weight in two patients and the other of 50 IU / kg / body weight, in the cases of labial laceration and pulp polyp factor was not used. Results: In all cases, after the first application of the Er: YAG laser was achieved hemostasis and allowed observation for a second application of Er: YAG, if necessary, only a second application was done in one case. Conclusion: In all cases the use of the factor was reduced between 60-80%, and also this reduces the ability to develop inhibitors.

Gingival- periodontal and emergency treatment in patients with Glanzmann disease: A report of 2 cases

MARIANO VASSALLO,1 PARREIRA MIRYAM,2 EDUARDO REY1 and T E Z A N O S P I N T O S 1 1 Academia Nacional de Medicina, Buenos Aires, Argentina; and 2Fundacion de la Hemofilia, Buenos Aires, Argentina Glanzmann disease is a congenital thrombocytopathy due to a platelet membrane defect. It is a rare, recessive autosomal disorder characterized by a normal platelet count, normal PT and PTT, prolonged bleeding time, abnormal clot retraction and lack of platelet aggregation. Clinically, the manifestations are cutaneous-mucosal hemorrhages starting from early infancy to childhood, and characterized by purpura, epistaxis, gingival hemorrhage, and menorrhagia. Bleeding in the oral cavity is difficult to manage in these patients because the severity of the bleeds is unpredictable. Historically, patients with Glanzmann disease have posed a professional challenge to those providing oral care, both because of the disease characteristics and the difficulty to control post-surgical bleeding. We report our experience and care protocol, presenting two clinical cases which help us exemplify at what point it will be necessary to use systemic support such as platelet transfusions (prescribed by the hematologist) in addition to local hemostatics, and when the use of systemic support can be stopped and management carried out solely with local hemostatics. The objective pursued by presenting these two very different cases (one patient had gingivitis and the treatment was uneventful and straightforward; the other patient had severe periodontitis, which proved very challenging) is to analyse the manifestations and clinical-dental management of these patients in order to present our care protocol.

Haemophilia (2014), 20 (Suppl. 3), 1--186



Pseudotumour of the mandible complicated by an odontogenic cyst in a young hemophilia A child with inhibitor NORAINI YUNUS Department of Paediatric Dentistry, Institute of Paediatrics, Kuala Lumpur Hospital, Malaysia Background: Pseudotumour is a complication in patients with bleeding diathesis resulting from recurrent hemorrhage in tissues. Pseudotumours have been reported in the oral regions and pertinent management is necessary to prevent serious complications such as distortion and even erosion of the adjacent bone. This paper presents a case report of a pseudotumour affecting the anterior region of the mandible complicated by an odontogenic cyst in a young child afflicted with hemophilia A with inhibitor. Clinical management: The two-year-old patient presented with a history of recurrent trauma, and lingual displacement of tooth 81 and a bucco-lingual expansion of the lower anterior segment was observed during a follow-up visit. The submental region was grossly swollen, hard to palpation and had slowly increased in size. CT revealed mandibular destruction; almost the entire body was replaced by an expansile lytic lesion suggestive of intraosseous hemophilic pseudotumour. A biopsy reaffirmed the hemophilic pseudotumour and surgical evacuation of the lesion under the necessary factor cover was subsequently performed soon after. HPE of the tissue removed, however, showed an epithelial lining suggestive of an odontogenic cyst. He had a prolonged hospital stay and healing of the lesion was quite eventful due to his inhibitor status and active nature. A six month post-operative CT showed marked improvement with almost normal appearance of the mandible. A year later he presented with a more extensive swelling extending to the right body of the mandible which was then enucleated, followed by eventful healing. The patient was placed on a two monthly review as a preventive measure. Conclusion: Thorough understanding of pseudotumours among health providers and patients is important since it can affect quality of life and if insufficiently managed may give rise to serious complications.

Educational project: building multi-professional network for hemophilia patients dental care access in Lithuania

RUTA ZALIUNIENE,1 VYTAUTE PECIULIENE,1 JOLANTA ALEKSEJUNIENE,2 VILMA BRUKIENE,1 LINA RAGELIENE,3 ROLANDAS GERBUTAVICIUS,4 SONATA SAULYTE TRAKYMIENE,3 LIGITA MALCIUTE,5 N E R I N G A G A I L I U T E 5 and J U R A T E D A U B A R I E N E 6 1 University of Vilnius, Vilnius, Lithuania; 2University of British Columbia, Vancouver BC, Canada; 3Children’s Hospital, Affiliate of Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania; 4Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Kaunas, Lithuania; 5Klaipeda Seaman’s hospital, Hemophilia center, Klaipeda, Lithuania; and 6Panevezys hospital, Panevezys, Lithuania Introduction and Objectives: To ensure an adequate access to dental treatment for patients with hemophilia and to ensure the training of dentists, general practitioners (GP), hematologists and hemophiliacs. Materials and Methods: The project started in November 2011 and implemented in two steps: (1) Training of medical doctors and preparation of science-based guidelines about the problems during dental treatment encountered with the hemophiliacs; (2) To examine hemophiliacs oral health, identify oral health problems and to teach hemophilia patients how to avoid them. The local guidelines according to current country situation Oral care of patients with hemophilia, for dentists, hematologists and medical students was prepared by leading odontologists and hematologists, revised and approved by Research Council of Lithuania and published in order to set standards of treatment and education of dental care specialists and hematologists. Main form of education and training was oral presentations and practical examination delivered by Vilnius University Odontology Institute dentists on-site in dental care clinics. Lithuanian hematologists, GP, dentists and patients sufferring from hemophilia A and B, were invited to eight dental clinics in different regions of Lithuania. To evaluate the oral health of each person, clinical and radiographic assessments were done. Results: For a total of 76 (27 children and 49 adults) patients with hemophilia A and B (76.6 % of Lithuanian hemophiliac population) participated in this project. Forms for hemophilia dental assessment, oral and dental treatment scheme, individual factor replacement plan for required dental interventions, and suggestions for hemophiliacs special oral hygiene were prepared. Individual dental treatment and oral hygiene instructions were given for every patient participating in project. Conclusion: Project outcome is built network of dental care specialists, hematologists and patients and ensured access to safe and effective dental treatment. The project had influence on patients with hemophilia A and B attitude to their oral health, principles of oral hygiene is getting better. Approximately 50% of the participants started dental treatment. Dentists got more information about the principles of handling such patients and felt more confident.

Oral condition improving with dental extraction in two children with congenital bleeding disorders in Madagascar

SIMONE RAKOTO ALSON,1 RICHARD AURELIEN RAKOTOARISON,2  OLIVAT T A N T E L Y R A N D R I A M A N D R A N T O 3 and A I M EE RAKOTO ALSON4 Departments of 1Periodontology and 2Oral Surgery, Dental Institute, University of Mahajanga, Madagascar; 3Chirurgical Reanimation; and 4Hematology CHU HJRA, Antananarivo, Madagascar Introduction and Objectives: In children with bleeding disorders, a bleed requires special care. The aim of this study is to draw the attention of practitioners on how to manage a dental extraction when necessary for such children. Cases report: This work reports the management before, during and after dental extraction in children with bleeding disorders. The first is a boy (eight years old) with

Haemophilia (2014), 20 (Suppl. 3), 1--186

severe hemophilia A and the second a girl (six years old) with congenital afibrinogenemia. The severity of bleeding events depends primarily on the amount of coagulation factor available. The rate of coagulation factor for both patients was known less than 1 %. In many cases, the oral condition improving that may require dental extractions is essential to prevent periodontal diseases, sources of hemorrhage by gingival bleeding. They had both recurrent gingival bleeding and needed scaling and removing plaque retention factors by extraction of hopeless teeth. Normal hemostasis by increasing the rate of defect factor was required before, during and after these dental extractions. When concentrates of coagulation factors were not available, an alternative substitution was provided by fresh frozen plasma transfusion, with biological control of hemostasis. The plasma has shown its effectiveness in our two patients. An additional anti-fibrinolytic treatment with tranexamic acid kept the fibrin clot. Both patients had no bleeding problems following scaling and dental extraction. Conclusion: In Madagascar, as in other developing countries, plasma transfusion is the cheapest effective way to prevent bleeding in these cases. However, further studies should be conducted to determine the exact amount of plasma to transfuse.

Innovation from bedside: Making of effective and safe toothbrush tailormade at clinic for hemophiliac people living with joint dysfunction

YUMIKO NAKAGAWA,1 FUMIHIDE KANAYA,1 HIROYUKI GAKANAGA,1 YOSHIMI KIKUCHI,1 Y U T A K A M A R U O K A , 2 K E N J I Y A M A M O T O 3 and S H I N I C H I O K A 1 1 AIDS Clinical Center, National Center for Global Medicine, Tokyo, Japan; 2Dept. Dentistry and Oral Surgery, National Center for Global Medicine, Tokyo, Japan; and 3 Research Institute, National Center for Global Medicine, Tokyo, Japan Introduction and Objectives: Oral hygiene remains one of priority health issues of people living with hemophilia. But we found that no currently commercial toothbrush would fit the clients living with elbow joint dysfunctions at one of the largest HIV clinics in Japan. In order to prevent future oral hazards such as infections, tooth loss, bleeding and hemorrhage, a team of dental hygienists, doctors, dentists and researchers collaborated with volunteer participants in this client participatory clinical study to develop a first-ever hemophilia customized toothbrush with competent efficacy and safety in mind. Materials and Methods: A client participatory clinical study to evaluate efficacy and safety (Internal Review Board #1095). For five hemophilia patient volunteers in various states of elbow joint dysfunction, various toothbrushes with customized handle and grip extension were test-made for further evaluation such as PlaqueControl Record test (PCR) for fine-tuning. Combining with later client feedback, clinical safety evaluation and statistical efficacy analysis, improved versions of the oral hygiene aid were re-designed for the next round of trial assessment (Phase-II). In November 2013, test models for the mold template are under examination in collaboration with a plastic factory (Phase-III). Results: No adverse events were observed throughout the duration of the trial by November, 2013. Not only efficacy but also safety of the dental devise is under evaluation also with enrolled 5 volunteers without hemophilia for comparison. For the innovative idea and merit of the invention, this project was awarded with a government patent in June, 2013 (Japan Patent Office 3184367). Conclusion: Through the collaboration process of the study, the joint team of hemophilia patients and families, volunteers without hemophilia, clinicians, scholars, factory and regulatory office personnel were empowered by this mutual goal of promoting the health and welfare of people living with or without hemophilia altogether. This joint effort can be applied to various community empowerment models for people and family living with the long-term conditions with improving prognosis.

Dentistry five years’ experience in Medellın, Colombia JARAMILLO LUZ INTEGRAL IPS, Medellın, Colombia Introduction and Objectives: The initial purpose of dentistry service in patients with bleeding disorders, is to prevent bleeding complications resulting from dental care. In the comprehensive attention program instead, we focus on a preventive oral health approach that contributes to an optimal health of the patient. Materials and Methods: Our experience we confirmed that, oral morbidity of patients with inherited bleeding disorders is similar to those of other groups. Regarding treatments carried out, we emphasize on identifying the level of risk for caries and periodontal disease. Preventive and specific protection activities are the basis of our work. We do not report any bleeding complication from treatments carried out. They were outpatient with a careful postoperative follow up and carried out following the WFH (World Federation of Hemophilia) recommendations. The commitment of patients with oral health is positive and is reinforced with regular individual educational activities, depending on the level of risk for each patient. Conclusion: After identifying the patient with inherited bleeding disorder, the oral exam is part of the basic assessment. The level of risk for caries and periodontal disease and the possible limitations for oral hygiene are as important as following clinical recommendations for treatment.

New strategies for the oral care program in patients with congenital coagulopathy in Panama Children’s Hospital DRA. SOL LAIZ TORRES Hospital del Ni~ no, Panama Rep. of Panama Introduction and Objectives: Oral health is of crucial importance in the comprehensive management of patients with congenital coagulopathy. Prevention is an important fact because dental emergencies can be a big issue in patients with congenital coagulopathy. In the past two years, the health attention statistics of the

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

DENTAL ISSUES dental clinic at the Panama Children‘s Hospital reflect a decrease in the attendance of these patients to receive dental treatment. The result of this is prevalence of caries, periodontal disease, malocclusions causing occasional complications due to neglect dental care. Among relevant facts, we can mention fear to dental treatment, social and economic situation, ignorance, apathy among others. The dental situation of patients with congenital coagulopathy leads us to prepare new attention strategies in benefit of these patients. Materials and Methods: The study population consisted of patients with congenital coagulopathy that attended the dental clinic of the Panama Children’s Hospital during the period of 2010-2012. A revision of clinical records and a survey was conducted to these patients. Results: Once the information was analyzed a plan of action is developed in order to reorganize the focus of dental attention provided to patients with congenital coagulopathy. Conclusion: Once the new attention plan was installed we observed significant changes in our clinical visits and also changes in the approach these patients have regarding their illness.

Minimally invasive oral surgery: Experience and results JARAMILLO LUZ INTEGRAL IPS, Medellın, Colombia Introduction and Objectives: Clinical case: Female patient, 53 years old, with von Willebrand factor >1%. Patient has severe sequels due to hemorrhagic life events during her life, treatment on demand. Chronically anemization, Gynaecological and nutritional causes were ruled out, the conclusion points to an oral origin. Diagnosis: Severe periodontal disease, permanent gingivorragia of variable intensity, difficulty to eat, speak and smile. Materials and Methods Results: Treatment proposal Consecutive teeth extraction, 7 in the upper maxillary and 6 in the lower one in a single surgical ambulatory time. 2 extractions were previously done with: A. Oral Tranexamic, 1 gr/VO/6 hours/7 days, F.VIII +f. von Willebrand 2000 UI/iv 1 hour prior the procedure, other 6 hours later, without any complications, to earn the trust of the patient and her family, 1 hour prior the procedure: 500gr of acetaminofen, 10 mg of buspirone.1gr of A. Oral Tranexamic and 2000 UI/IV factor VIII+f. Von Willebrand. Disinfection Digluconate of Clorhexidine 0.2% washing: 4 minutes. Infiltrative Anaesthesia, Lidocaine 2%+ epinephrine, superior canines and Ag Dental in the back. Minimally traumatic extractions 14, 13, 23, 24, 25, 26, 27, 33, 32, 31, 41, 42, 43. Local hemostasis: A.Tranexamic+Lidocaine 2%, plaster form, Gelfoam plug, simple suture in each alveolus, silk 3/0 without shutting the alveolus entirely. 13th alveolus bleeds in layer, 2000 UI/IV of F.VIII+ F. von Willebrand. The immediate evolution is good. Six hours after the last dose, 2000 UI of factor. Recommendations for post-operatory care, A. Tranexamic 1 Gr/6 hrs/VO/ 7 days, Acetaminofen 500 mg/ 4 hours/3 days. No complications, suture is retired two weeks later with local hemostasis. Rehabilitation with total prosthesis and perfect health. Anaemia solved with normal alimentation. Conclusion: The recommendations of the WHF for this procedure are appropriate, anxiety management and analgesia of the patient is necessary and effective.

Oral management of intraoral bleeding and postoperative infection of cystectomy in a case with hemophilia A MORIHIKO TAKASHIMA, YUICHIRO IMAI, SATOSHI FUKUTSUJI, TADAHIRO SIMOMURA, Y A S U T S U G U Y A M A N A K A and T A D A A K I K I R I T A Nara Medical University, Kashihara, Japan We report a case in which we extirpated a dentigerous cyst in a patient with hemophilia A and experienced difficulty in hemostatic management of intraoral bleeding due to postoperative infection. The patient was a 16-year-old male with a complaint of swelling in the left cheek. As a dentigerous cyst adjacent to the maxillary sinus was observed, we transfused a factor VIII preparation and extirpated the cyst. One year later, due to a postoperative infection, after transfusing a factor VIII preparation, we performed tooth extraction and curettage. In order to hemostatically manage the oral bleeding, we concomitantly used an antiplasmin agent and treated local hemostasis using a celluloid protector. When implementing invasive treatment for a patient with hemophilia A, it is important to preoperatively consider 1) the degree of factor deficiency; 2) the degree of invasiveness of the surgery; and 3) the local conditions in order to appropriately implement substitution therapy and treatment for local hemostasis.

Dental therapy with ferrous sulphate to 15.5% in a patient with a factor VII deficiency

 1 , 2 and M A R C O A N T O N I O L A U R A B E A T R I Z I S I D R O O L AN RUEDA VENTURA3,2 1 Juarez Autonomous University of Tabasco; 2Hemophilia Association of Tabasco; and 3 Ministry of Health and Children’s Hospital of Tabasco, Mexico Introduction and Objectives: Coagulation disorders affecting the management and dental treatment as they represent a risk to the patient due to spontaneous bleeding can occur in the oral cavity by intrinsic and extrinsic causes. The control of bleeding is an important factor in the treatment of these patients. This can be achieved by implementing the missing factor, local hemostatic means or both depending on the severity of the case. Objective: To implement local hemostatic (ferrous sulfate) to achieve hemostasis in a patient with gingival bleeding and factor VII deficiency. Materials and Methods: Male 16 years old diagnosed with factor VII deficiency and generalized gingival bleeding due to bad tooth position. Because there were no factor VII, ferrous sulfate to 15.5% is therefore applied in the gingival grooves to restrain bleeding in both dental arches.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


Results: The bleeding was controlled satisfactorily within 5-10 minutes after the application of ferrous sulfate to 15.5%. Conclusion: Local hemostatics are an effective adjunctive tool in controlling oral bleeding and should be an essential material in any dental office.

Dental treatment approach for Bernard-Soulier Syndrome: Three case reports

G U L S U M A K , 1 M . M E R T A C I K G O Z , 1 O Z L E M F I L I Z B A Y A R 1 and BULENT ZULFIKAR2 Istanbul University, Faculty of Dentistry, Department of Oral and Maksillofacial Surgery, Istanbul, Turkey; and 2Istanbul University, Faculty of Medicine, Department of Pediatric Hematology and Onkologi, Istanbul, Turkey


Bernard-Soulier syndrome (BSS), also known as Hemorrhagiparous thrombocytic dystrophy, is a hereditary bleeding disorder affecting the megakaryocyte/platelet lineage and characterized by prolonged bleeding time, thrombocytopenia, and extremely large platelets. BBS has a prevalence of less than 1 in 1,000,000. Clinical manifestations usually include purpura, epistaxis, menorrhagia, gingival and gastrointestinal bleeding. The syndrome is transmitted as an autosomal recessive trait. The prognosis is usually good with adequate supportive care but severe bleeding episodes can ocur with menses, trauma and surgical procedures. Treatment of bleeding or prophylaxis during surgical procedures usually requires platelet transfusion. Some patients needs recombinant factor VIIa during severe bleeding. There are no well-defined protocols for the management of perioperative bleeding associated with dental surgery yet. We present a combined systemic and topical approach that may be helpful in the control and prevention of perioperative hemorrhage of three patients from same family with Bernard-Soulier syndrome for dental treatment. Before dental treatment platelet transfussion applied. Extraction sites were packed with gel foam and topikal tranexsamic acid. Excellent hemostasis was achieved. They do not required transfusion after surgery and there were no complication at the end of cases.

Evaluation of dental findings in Turkish national hemophilia summer camp

G U L S U M A K , 1 M . M E R T A C I K G O Z , 1 O Z L E M F I L I Z B A Y A R 1 and BULENT ZULFIKAR2 1 Istanbul University, Faculty of Dentistry, Department of Oral and Maksillofacial Surgery, Istanbul, Turkey; and 2Istanbul University, Faculty of Medicine, Department of Pediatric Hematology and Onkologi, Istanbul, Turkey Introduction and Objectives: Many people have had the opportunity of attending camp organisations over the past 50 years. The organized camp experience has been an important part of the lives of hemophilic patients. The Hemophilia Society of Turkey has organized 18 camps in 17 years and hosted 66 international participants and 1753 Turkish participants from 51 cities in Turkey. The last summer camp of the Hemophilia Society of Turkey was held in DSI Dragos complex, Istanbul, between June 18 and June 22, 2013. The main theme of the last camp was “The time to discover together” and that concept had three components. These were “Discovering the health”, “Discovering the joyful life” and “Discovery the intellectuality”. We had been part in “discover the health”. In this study we aimed to evaluate the dental findings from oral examinations which held in national hemophilia summer camp. Materials and Methods: We had oral examinations and profilactic oral applications to the 30 hemophilic patients in summer camp of the Hemophilia Society of Turkey. Type of hemophilia, level of factor, dental history, frequency of tooth brushing and frequency of dental visit were determined by a questionnaire. Oral examinations were done. Results: Details of the result will be discussed in poster presentation. Conclusion: Dental management of patients with hemophilia should begin with prevention of dental disease. The parents’ approach to dental care has an importance to people with hemophilia in relation to dental care. Parents should be advised about the significance of and necessity for oral care.

Prevention of dental injuries and management of first-aid procedures in hemophilia A (HA) children: Experience of a single centre

DE PADUA VALERIA,1 GAGLIOTI DOMENICO,1 BOSCO RICCARDO,1 RIVA FRANCESCO,1 BALDACCI ERMINIA,2 DE ANGELIS FEDERICO,2 M A Z Z U C C O N I M A R I A G A B R I E L L A 2 and S A N T O R O C R I S T I N A 2 1 Department of Oral Surgery, George Eastman Hospital, Rome; and 2Hematology, Department of Cellular Biotechnology and Hematology, Sapienza University of Rome Introduction and Objectives: Dental trauma is one of the most common dental problems for 1-17 year old children, especially because of their attitude toward play and practicing sport. Children with maxillary protrusion have higher risk of dental injuries. Such risk becomes a worrying emergency in hemophilic patients. Aims of the study are: 1) to detect II class malocclusion with maxillary protrusion in hemophilic children; 2) to perform an effective educational campaign about dental care for children parents. Materials and Methods: From March to September 2013 we observed 14 patients (median age eight years, range 3-16) affected by HA: 11 severe, three moderate. During the childrens dental exam, evaluation of II class malocclusion was performed. Moreover, behaviors at risk for skeletal and dental problems (thumb and pacifier sucking), were investigated. A questionnaire to assess children attitudes and to explore parent’s knowledge about first-aid procedures in case of dental trauma was administered. The hemophilia centre informed the parents about replacement prophylactic therapy to be administered to their children in case of trauma, on the basis of coagulopathy type/severity.

Haemophilia (2014), 20 (Suppl. 3), 1--186



Results: Four severe HA children showed the following dental pathologies: first superior incisor cross-location, deep bite, maxillary protrusion and dental crowding. These patients were referred to the orthodontic department for correction treatment. The other 10 children did not present any pathology. Parents of 5/14 patients were sufficiently informed about the risk of thumb and pacifier sucking for the development of maxillary protrusion, while parents of 9/14 were informed about first-aid procedures in case of dental injuries. During the visit, a brief lecture on first-aid in case of dental trauma was given by the dentist and the hematologist with the aim to educate parents for a correct management of dental injuries and hemorrhagic complications. Conclusion: Early identification of maxillary protrusion and consciousness of sports connected risks can prevent functional dental defects and reduces the risk of dental trauma. This is particularly important for hemophilic patients because of the hemorrhagic complications. A close collaboration between the dental and the hematology department results in a better outcome of dental problems in hemophilic patients.

Dental care pathway for children with hematological disorders

F R A N C H E S C A F O N G , 1 J A N E T D A V I E S , 1 J A N I C E F E A R N E 1 and JOHN PASI2 1 Royal London Dental Institute, Barts Health NHS Trust, UK; and 2Royal London Hospital, Barts Health NHS Trust, UK The Royal London Hospital is a major referral centre for children with inherited bleeding disorders with over 250 patients. Dental disease can place a further burden on these children particularly if teeth require extraction.

Haemophilia (2014), 20 (Suppl. 3), 1--186

For this reason a care pathway has been established. The most important aspect of dental care is prevention therefore a pediatric dental specialist attends the monthly pediatric hematology clinics. Children are screened for untreated dental decay and preventive dental advice is given verbally and with a patient information leaflet. At the clinic, a letter is sent out to the GDP. Liaison of GDPs with both hematology and dental services is actively encouraged to support provision of dental care within primary care if at all possible. Depending on the severity of the bleeding diathesis and the degree of invasive dental treatment required, their GDP can undertake simple treatment or more complex cases can be referred for secondary care at the Royal London Dental Hospital. A consultation process takes place between pediatric dentist, pediatric hematologist and specialist nurse to determine the most appropriate hematological cover. This will depend on the severity of the bleeding disorder and the complexity of dental treatment, simple (restorations with no local anaesthesia or infiltration anaesthesia), moderate (restorations with ID block/lingual infiltration or involving the pulp tissue), and complex (dental extractions/surgery or children requiring treatment under general anaesthesia). At the dental hospital, the date of the dental visits and the hemostatic cover are requested via our electronic messaging system on CRS. This is directly linked to their electronic patient record so that it is accessible to all clinicians involved in their care without the need to retrieve their paper notes. The hemophilia specialist nurse will arrange to see them to provide appropriate cover prior to their appointment. This pathway encourages active involvement of the patients’ GDP which improves access to dental care, increased local involvement and confidence of GDPs and allows the secondary hospital based dental services to focus on more complex and demanding cases. The pathway is fundamentally based on the importance of a structured consultation process involving dental, medical and nursing staff.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd



30-EDUCATIONAL MODELS A new ‘App’, PtDA (Patient Decision Aid) developed specifically for young men with mild hemophilia 1



JOANN NILSON KATHY MULDER DR. KRISTY WITTMEIER and D R . C A N D I C E S C H A C H T E R 4 Saskatchewan Bleeding Disorders Program, Canada; 2Manitoba Bleeding Disorders Program; 3Physiotherapy Innovations,University of Manitoba, Winnipeg, Canada; and 4 University of Saskatchewan, Saskatoon, Canada


Motivation: It is common for young men with mild hemophilia (YMWMH) to not recognize and delay treatment of significant injuries. This can lead to prolonged resolution of the injury and / or the loss of work or school time. Problem statement: In previous research, YMWMH demonstrated limited knowledge of symptoms that could indicate an injury that would require treatment. Some were unsure about first aid treatment, and many were reluctant to call the hemophilia treatment centre (HTC) (1). However, they gave multiple examples of injuries that resolved uneventfully, despite participation in vigorous physical activities including contact sports. Approach: Phase 1 of the research used the grounded theory to analyse semi-structured interviews with eighteen young men (18-30 years old) with mild hemophilia. Based on the themes identified and current best practice, a decision aid (PtDA) was designed in the form of a flow chart. In phase 2, HTC staff evaluated the flowchart content, and 14 YMWMH were interviewed to evaluate utility. Based on feedback from the YMWMH, the flowchart was converted to an electronic application (“app”) for use on smart phones and other platforms. After user-testing by a subsample of the phase 2 YMWMH cohort, the app has been modified and finalized for release through the Canadian Hemophilia Society. Results/ Conclusion: This PtDA app will be an accessible and convenient method to provide YMWMH the relevant information to assess their injuries, identify bleeds that require medical attention, and contact the HTC in a timely manner. Phase 3 of this research will assess the effectiveness of this app in changing their behaviours.

Using oral history for patient education: The Gift of Experience II: Conversations with parents about hemophilia

L A U R A G R A Y , 1 Z I V A M A N N 2 and A L L I E B O U T I N 2 Boston Hemophilia Center, Boston, MA; and 2Boston Children’s Hospital, Boston, MA


Introduction and Objectives: We previously used oral history methods to capture the experience of older men with hemophilia. In a follow up project, we have developed, The Gift of Experience II: Conversations with Parents about Hemophilia (GOE), a book that documents parents’ experiences raising a child with hemophilia A or B from birth to age six. Their experiences provide insight into the emotional, financial, medical, social and spiritual challenges that families confront. The intent is to normalize parents’ feelings and reactions and offer hope that they will manage what might seem overwhelming at first. Materials and Methods: Eighteen parents agreed to be interviewed by one of three interviewers. The interviewees all had children with hemophilia A or B between the ages of four and twelve and received treatment at the Boston Hemophilia Center. The interviews were taped and transcribed. The interviewer focused on the ways in which parents reacted and adjusted to the diagnosis, learned how to medically manage the disease, coped with the effects on the marriage and family, managed decisions about childcare and school, explained hemophilia to their young child, and handled financial challenges. Quotations were extracted from the oral history transcripts. Interviewees had editorial and approval rights for the quotations. All participants signed consent. Results: The GOE is a collection of quotations extracted from the oral history transcripts. The book succeeds in offering insight, a practical support and a guiding light to families whose child is newly diagnosed with hemophilia. It covers pertinent issues that parents face in raising a child from birth to six. It includes a glossary of terms for new families. Conclusion: The GOE concentrates on helping families learn from other parents’ experiences what challenges lay ahead and how to manage these challenges. With the benefit of knowing others’ experiences, families have a blueprint for normalizing their own thoughts and feelings and anticipating and resolving challenges. This promotes a healthy adjustment for families living with a child who has hemophilia. For those families who are not lucky enough to have local community support, this book functions as a literary support group.

Improvement of interest in hemophilia and other congenital disorders in medical and post graduate students: the experience of Barinas (Venezuela)

 EZDE DELGADO,1 E V E L Y N G O N Z AL  NE ~ Z,3 GIANLUCA SOTTILOTTA,2 TATIANA NU  EZ4 L U Z J A R A M I L L O 4 and R O D R I G O P ER 1 Fundaci on Hemo Hermanos Venezuela, Barinas, Venezuela; Hope and Life U.S.A. Foundation, Florida, U.S.A.; 2Hemophilia Centre - Thombosis and Hemostasis Service, Azienda Ospedaliera Reggio Calabria, Italy; Hope and Life U.S.A. Foundation, Florida, U.S.A.; 3Fundaci on Hemo Hermanos Venezuela, Barinas, Venezuela; and 4Hope and Life U.S.A. Foundation, Florida, U.S.A.

Introduction and Objectives: Educational strategy concerning specific inherited bleeding disorders courses for medical students can lead to a better knowledge of hemophilia, von Willebrand and other hemorrhagic diseases. This can result in minimizing the fear, choosing the proper medical treatment care and developing interest in comprehensive hemophilia care during their professional career. Materials and Methods: Five hundred medical students, in the final year of medical schools or in the first year of post-graduate training, from several universities in Venezuela had an internship at Barinas University (Venezuela), from June 2011 to

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

September 2013. Three groups of students attended two to four lessonsthat;lasted two hours, involving hemophilia and other congenital hemorrhagic diseases. At the end of the course specific satisfaction questionnaires were administered to the students to evaluate their interest in care of patients with congenital bleeding disorders. Results: 75% of post graduate students and 25% of those at the final year of medical school evidenced interest in treating patients with hemophilia and 35% of all students have applied to become volunteers of the local hemophilia foundation. Conclusion: The improvement of medical students and young doctor’s knowledge about hemophilia and other bleeding diseases can develop a great interest in increasing their ability to care of patients as well as in improving the quality of life of individuals with hemophilia and other severe hemorrhagic disorders. Medical Schools should initiate, maintain, and encourage courses in congenital and acquired bleeding disorders areas.

The effects of Human Potential Development Seminar (HPDS) for hemophilic arthritis patients

MYUNG CHUL YOO,1 WON SOOK BAK,1 SANG HOON LEE,1 K I Y O U N G Y O O 2 and S A N G C H U N J U 2 1 Hemophilia Center, Kyung Hee University Hospital at Gangdong Seoul, Korea; and 2 Korea Hemophilia Foundation, Seoul, Korea Aim: Most of the rehabilitation programs for patients with hemophilic arthritis are focused only on the improvement of physical activities. However, the actual hemophilic arthritis patients are accompanied by psychological problems as well as physical disabilities. In this study, the goal was to help arthritis patients with hemophilia to improve their psychological problems, through a special developed HPDS. HPDS was developed to solve these problems by increasing the interpersonal relationship, developing each potential, self-development and understanding others. HPDS was analysed by two different groups to verify the clinical effectiveness. Methods: This study used a nonequivalent control group quasi-experimental research based on data acquired through a pre-post test. The subjects for this study were a total of 48 patients with hemophilic arthritis who underwent lower extremity joint surgeries at the orthopedic. The experimental group (n = 24) was attended HPDS 10 times (2 hours/time) for four weeks, and the control group (n = 24) was not given a HPDS (Human Potential Development Seminar). The measurement tools of this study were Numerical Rating Scale in self efficacy, self esteem, Symptom Check list-90Revision(SCL-90-R). Results: The data was analyzed with X²-test and t-test using SPSS/Win 18.0. After HPDS application, self efficacy score increased significantly in the study group (p < .001), and self esteem score also increased (p < .001). Also, SCL-90-R (somatization; obsessive-compulsive; interpersonal sensitivity; depression; anxiety; hostility; phobic anxiety; paranoid ideation; psychoticism) scores decreased significantly after the program (p < .001). Conclusion: HPDS showed much more satisfactory results than the simple physical therapy to treat the physical and mental disabilities including psychosocial stresses in patients with hemophilic arthritis by increasing self efficacy & self esteem score and decreasing SCL-90-R scores. These results suggest that HPDS is highly recommended as a distinguished method of psychosocial rehabilitation for patients with hemophilic arthritis who underwent lower extremity joint surgeries at the orthopedic.

Oscar: A tool for therapeutic education to approach the pharmacokinetic concepts in hemophilia

€ T,2 T E D D Y N O V A I S , 1 D A M I E N S A L M O N , 1 M A R C T R O S S A ER  IE CHAMOUARD4 S A N D R I N E M E U N I E R 3 and V A L ER 2 Pharmacy E Herriot hospital, Lyon, France; Haemophilia Care Center, Nantes, France; 3Haemophilia Care Center, Lyon, France; and 4Haemophilia Care Center & Pharmacy, Lyon, France


Therapeutic education (TE) aims to teach young hemophiliacs key-concepts allowing comprehension of substitution strategies and respect of their treatment plan in order to improve adherence to the clotting factor concentrates (CFC) injection. For this purpose, we conducted a study to develop an educational and playful TE session. To help show these concepts to an audience of children aged 6 to 12 years, a bottle disguised as a Muppet was used to represent the child. We used coloured solutions of different concentrations in bottles and a redox chemical trick known as “the blue bottle reaction” to illustrate major pharmaceutical considerations in hemophiliacs: (i) substitution of lacking factor, (ii) its degradation kinetic within the body and (iii) therapeutic attitude towards an inhibitor. The TE session was divided in three parts. First, a blue bottle illustrated the non-hemophiliac, who has clotting factors and a transparent bottle figured a hemophilic patient that could be supplemented by CFC injection (i.e., addition of a blue colorant). Secondly, degradation kinetic of injected CFC was illustrated with a blue-to-transparent colorimetric scale in bottles. Each child was individually invited to arrange bottles on a weekly timeline according to its own treatment plan. Lastly, a slow redox reaction progressively turning injected blue colorant to transparent showed the action of an inhibitor upon injection. Afterwards, the addition of a non-reacting blue colorant illustrated the injection of activated prothrombin-complex concentrates. Children positively responded to this new TE session. They especially enjoyed the ability to demonstrate their skills in the second part of the session under the supervision of the TE team. This step allowed immediate assessment of concept acquisition. Furthermore, the real-time dynamic illustration of CFC clearance and inhibitor’s action facilitated the comprehension of complex pharmacokinetics processes. To validate this workshop, an evaluation of long-term benefit to the patient should be conducted.

Haemophilia (2014), 20 (Suppl. 3), 1--186



Evaluation of hemophilia patients’ knowledge about their treatment

MARION MOINE,1 ISABELLE VINCENT,2 FLORENCE BIALDYGA,3 ELISE TOGUYENI,3  IE ROUSSEL-ROBERT,1 NATALIE STIELTJES,1 V A L ER E R I C P E L U S , 4 V E R O N I Q U E C A H O R E A U 5 and I S A B E L L E L O P E Z 1 1 Clinical Pharmacy Department, and Hemophilia treatment centre, Cochin, APHP, France; 2Pharmacy Department, Le Kremlin-Bic^etre, APHP, France; 3Pharmacy Department, Lille, France; 4Pharmacy Department, Colmar, France; and 55Pharmacy Department, Bordeaux, France Introduction and Objectives: Most patients with severe hemophilia or von Willebrand disease benefit from home treatment for replacement therapy. Hemophilia treatment centres are in charge of the therapeutic education of the patients and their family to allow a good knowledge of the disease and an appropriate use of clotting factor concentrates (CFC). A survey has been conducted on inpatients and their relatives, in order to assess their understanding of the disease and of the treatment and of the management of the CFC. Materials and Methods: A questionnaire has been submitted during a fifteen-minute interview with a pharmacist in four hospitals. Fifty-eight persons (38 patients, 20 relatives) have participated. Results: The underlying disease was hemophilia in 55 cases. The name of the disease and its severity were known from the majority of the population (93%). The name of the drug and its origin (plasmatic or recombinant) could be mentioned by 91% and 86% respectively. All the patients or relatives knew the storage recommendation of their CFC but four of them did not ensure the waste disposal of vials and needles. Approximately one third reported they had already experienced a severe bleeding episode without their CFC being available. The loss of at least one vial of CFC was confessed by 40%. Among the 42 patients who self-infused or were treated by relatives, problems with the drug reconstitution or infusion were mentioned in 31. Conclusion: This survey points out that, although most patients are well informed about their disease, they still encounter significant problems with the manipulation of the CFC. Educational programs must pay special attention to this aspect by means of repeated information and evaluation of the patients and their relatives.

Assessment of guides describing clotting factor concentrates’ reconstitution by patients

MARION MOINE,1 ISABELLE LOPEZ,1 ISABELLE PEROT,2  IE ROBERTG O L D A H A Y A B A V I E R A , 2 S O P H I E C O M B E , 2 V A L ER R O U S S E L , 2 N A T A L I E S T I E L T J E S 2 and F R A N C ßOI S CHAST1 1 Clinical Pharmacy Department, Cochin, APHP, France; and 2Hemophilia Treatment Centre, Cochin, APHP, France Introduction and Objectives: As part of a patients’ therapeutic education which takes place in the hemophilia treatment centre (HTC) of Cochin hospital, a survey made in 2012 showed that 50% of the patients had difficulties to reconstitute anti-hemophilic factors. Specific guides explaining how to reconstitute each anti-hemophilic factor have been developed. A survey was conducted among patients to assess the practical interest of these guides. Materials and Methods: Each guide is synthetic, fits on a single page and uses colours for an easier recognition. Short texts highlight the critical points of the reconstitution. The survey includes eight different items assessing both presentation (scale of evaluation: very good, good, average and only average) and content (closed questions). During a six month period, both guide and questions of the survey were given at the same time to self-treated patients when they came to the pharmacy for their drugs. Results: Thirty five patients out of forty eight patients have completed the survey. The average age was 44 years. Guide images and texts were considered as readable or very readable by 32 patients (91%). The reading was evaluated as good or very good by 33 patients (89%). The pictures were explicit and the captions coherent. According to 33 patients (94%), critical points of reconstitution were well highlighted and 28 of them (80%) found these guides useful. Twenty three patients (66%) emphasize the importance of these kinds of guides, more synthetic and intuitive than product information forms includes in drug package. Moreover, some patients corrected some “bad “automatic reflexes or habits thanks to these guides. Conclusion: Most of the patients appreciate to be given these guides and keep asking for help to self-treatment even if several other tools exist. The guides have been created to contribute avoiding mistakes that could be done during reconstitution. This is particularly important for self-treated patients. Presently, every patient who comes to Cochin HTC and who received individual training in self-treatment is assessed every year. The guides’ impact on the patients practice will be measured during this annual assessment.

Motivational interviewing and health behavior change: an educational intervention for health care professionals

B A R T H O L O M E W T O R T E L L A , 1 B A R B A R A M . P E R R Y 2 and RICHARD N. MCLEOD2 Global Medical Affairs-Hemophilia, Pfizer, Inc., Collegeville, PA, USA; and 2Pfizer; New York, NY, USA


Introduction and Objectives: Patient adherence to complex medical treatment regimens is a key concern with non-adherence being a multifaceted problem, especially for patients with a chronic disease.1 Patients with hemophilia face many obstacles and challenges, relying on hemophilia treatment centres (HTCs) staff for support and guidance. Motivational interviewing (MI) principles impact patient adherence.2 An educational workshop explicating MI principles, health behavior change (HBC), and stages of change was developed for HTC staff. Materials and Methods: HTC staff and Specialty Pharmacy Providers (SPPs) attended workshops conducted by a Pfizer medical outcomes specialist. Workshops were interactive to facilitate learning and sharing of clinical experience. The HBC program stressed 4 general principles of MI (Roll with Resistance, Develop Discrepancy, Express Empathy, Support Self-efficacy) and stages of change. Participants completed

Haemophilia (2014), 20 (Suppl. 3), 1--186

a 10-question knowledge assessment tool prior to and after the workshop as well as a program evaluation. Results: Between 3/2012 and 11/2013, 11 workshops were conducted (Seven SPPs, four HTCs) with 102 participants. Knowledge assessments prior to and following the workshop increased from 67% to 85% correct responses, representing an overall increase of 18%. Greater than 97% of participants agreed/strongly agreed that the workshop helped them to understand the concepts of adherence, HBC and would be able to utilize techniques to enhance their own communications and effectiveness when engaging with patients. The concepts most frequently cited that could be put into practice included: MI; use of open-ended questions; elicit-provide-elicit technique; assess importance and confidence; and enhancing one’s listening skills. Conclusion: Non-adherence is a multifaceted problem. No single intervention can overcome the many challenges faced by the hemophilia patient. Motivational interviewing is not widely known or practiced by health care professionals. The potential exists for enhanced communication, collaboration, patient engagement, and patient outcomes using the concepts of MI, HBC and stages of change.

Don’t Push Your Luck! Evaluation of evidence-based educational board games for children living with hemophilia

LISA SEMPLE,1 ANDREA PRITCHARD KENNEDY,1 KERRI ALDERSON,1 VANESSA BOUSKILL,2 J A N I C E K A R A S E V I C H , 3 B R E N D A R I S K E 4 and S H E R I V A N GUNST1 1 Mount Royal University, Calgary, Canada; 2Comprehensive Bleeding Disorders Clinic, The Hospital for Sick Children, Toronto, Canada; 3Manitoba Bleeding Disorders Program, Winnipeg, Canada; 4Mountain States Hemophilia Network, Hemophilia and Thrombosis Center, University of Colorado, Denver, USA; and 5 Hemophilia Comprehensive Care Clinic, Alberta Children’s Hospital, Calgary Canada

Objectives: Preliminary findings will be reported on an innovative educational family board game, Don’t Push Your Luck!, designed to encourage discussion about hemophilia self-care, and help school-age children learn about decision making. Secondary objectives included comparing child and parent perspectives on how the board game affects engagement in decision-making. Methods: Children with hemophilia have a life-long disorder, and learn to make selfcare decisions as they transition to adulthood. The game was developed based on previous research with children on partnership roles in hemophilia care. Each player assumes the role of a child with hemophilia, exploring choices for a balanced healthy lifestyle, while managing risks in their daily activities. This mixed-method research was coordinated by Mount Royal University, with sub-sites in Canada and United States. Phase I informed game prototype development, and compared evaluation between boys (n = 3), ages 8 - 12 and parents (n = 5) living with hemophilia and boys (n = 3) and parents (n = 5) living with cystic fibrosis. Phase II evaluated the final board game exploring how playing an educational board game affected school age children’s engagement in decision-making for self-care and quality of life. Purposive sampling was used to recruit household family members (n = 52), including at least one parent/guardian (n = 22) and children aged 8-12 years living with hemophilia (n = 16). Participants completed a pre- and post-game questionnaire on decisionmaking and Haemo-Qol Index ©, and post-game enjoyment survey. Audio recordings and field notes were documented to record participant interactions. Quantitative analysis of questionnaire items on decision-making, quality of life observations, and game enjoyment were analyzed using descriptive statistics. Qualitative analysis of written, verbal and observed behaviours was summarized in thematic categories to further evaluate the board game intervention. Results: Preliminary findings indicated this game is an enjoyable and effective resource for school-age families to engage in discussions relevant to hemophilia self-care skills and decision-making. Further analysis is being conducted on decision making, HRQOL indicators, and recommendations for future game-based learning. Conclusion: This method of introducing an enjoyable learning exchange between school age children and their caretakers can have a positive effect on child/parent relationships and communication. This project is generously funded by an unrestricted grant from Bayer Healthcare.

Global utilization of the International Prophylaxis Study Group (IPSG) physical therapy education web-site module

PAMELA HILLIARD,1 AUDREY ABAD,1 BRIAN M. FELDMAN,1 SHARON FUNK,2 MARILYN J. MANCO-JOHNSON,2 PIA PETRINI,3 JANJAAPVAN DER NET,4 NICHAN ZOURIKIAN5 and VICTOR S BLANCHETTE1 ON BEHALF OF THE INTERNATIONAL PROPHYLAXIS STUDY GROUP 1 The Hospital for Sick Children, Toronto, Canada; 2University of Colorado, Hemophilia & Thrombosis Center, Denver,USA; 3Karolinska University Hospital, Stockholm, Sweden; 4Wilhelmina Children’s Hospital at UMC, Utrecht, The Netherlands; and 5Sainte-Justine University Hospital Center, Montreal, Canada The International Prophylaxis Study Group (IPSG) is a not-for-profit collaborative group of health care professionals involved with the assessment and care of individuals with inherited bleeding disorders, and with a special interest in prophylaxis. Initiated in 2001, it is currently composed of six expert working groups. The physical therapy expert working group, formed in 2002, developed and tested the Hemophilia Joint Health Score (HJHS), a scoring tool for the evaluation of musculoskeletal impairment. The HJHS was initially developed to help capture early clinical signs of joint disease in children and is currently being studied in other populations. It is included in the World Federation of Hemophilia (WFH) Compendium of assessment tools. An IPSG website was launched in February 2013 to increase global awareness about the activities of the International Prophylaxis Study Group and disseminate knowledge and outcome measurement tools developed by the expert working groups. The physical therapy module, the initial expert working group

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

EDUCATIONAL MODELS component of the website, is comprised of the original English HJHS score sheet, worksheets and instruction manual and has been translated into French, German and Spanish. An English language HJHS instructional video can be downloaded or streamed for viewing and is currently being translated into French, German, and Spanish using systematic processes to ensure technical accuracy and content relevance. Other language translations in progress include Simplified Chinese (Mandarin) and Portuguese. To date, the number of unique IPSG website visits is 932 from 67 countries on six continents (Africa =7; Asia = 20; Australia = 2; Europe=26; North America =5; South America=7). As of October 2013, there have been 168 registrants with 53.9% requesting the HJHS materials for clinical use, 4.8% for research, 18.0% for clinical and research, and 23.4% for education and training. The materials have been requested for teaching purposes in physiotherapy/musculoskeletal hemophilia workshops and for use in collaborative clinical research projects. The IPSG website continues to contribute to the education of health professionals involved in the care of patients with hemophilia and other bleeding disorders worldwide.

Discovering hemophilia

S T E P H A N I E D E L I E N N E , 1 F A B I E N N E V O L O T 1 and  INE CHENUEL2 C EL 1 CRTH Dijon, France; and 2CRTH Nancy Brabois, France Introduction and Objectives: The aim of therapeutic education for patients with emophilia is helping them acquire and maintain skills so than they can cope with the disease, become independent and thus improve their quality of life. At the Regional Centre for Haemophilia Treatment (CRTH) of Dijon, we believe that the acquisition and maintenance of safety notions must start at a very early age. It is important for children with hemophilia to be able to describe and particularly to tell their parents as soon as possible if clinical signs occur. Therefore, therapeutic education sessions on disease awareness were proposed to children to develop their knowledge on the disease, to understand more about it, to live better with it and to play an increasingly active role with regard to the treatment they receive. Materials and Methods: Collective sessions were proposed to 3-4 years old patients with severe hemophilia A and B. The objectives were to: Become aware of their body and understand what is happening during a hemorrhagic accident; Express them about the disease; Become aware that they are not alone with this pathology; Begin to deal with the disease; Talking with their relatives about brochures given after the session. Tools adapted to their cognitive stage: eye-catching, in paper version and customizable. Bones and joints: described with a jumping-jack. Muscles and hematomas: visualized inside a design contour of child body and hand hygiene: creation of a personal handbook, given at the end of the session Conclusion: The young children who took part in these sessions were happy to exchange on their disease. Therapeutic education sessions allow a progressive approach to it, adapted to their age and maturity. Over the years, this knowledge should be expanded in order for them to make the right decisions to manage their disease especially as they enter their teenage years.

Preparing gelatin as a pedagogical tool for teaching cryotherapy in hemophilia CLAUDIA SOFIA TABOADA SAAVEDRA Hospital General de Zona Villahermosa, Mexico; Tabasque~ na de Hemofilia A. C. Villahermosa, Mexico Introduction and Objectives: In the treatment of acute bleeding like hemarthrosis or muscle hemorrhage, the early onset of clotting factor concentrates is very important, as well as the cryotherapy. The physiological principle of that is because at low temperatures the colloidal substances will condense, besides the cold therapy decrease the pain and the local blood supply. In some cases, the cryotherapy is not used by the patient and the medical team. Materials and Methods: To highlights the relevance of using cryotherapy, we designed an educational tool by preparing gelatin comparing this with the clotting phenomenon. The pedagogic tool was used in the hemophilia camps through 2012 and 2013. Working by couples, a group of 20 patients or his relatives was formed, using simple and secure materials like plastic plates, cups, a bag of powdered gelatin, one liter of water and ice cubes. Each team prepared two cups with one tablespoon of gelatin powder and 60 mL of hot water, one with two cubes of ice and other without it. The cups were allowed to stand for 10 minutes. Meanwhile the teacher would explain the theoretical basis of using cold therapy in hemarthrosis and muscle hemorrhage. At the end of the class, the cups were turned over onto the plates to show the great differences between them. The educational team must highlight the aspect of the cup with ice, the effect of 10 minutes of cold on the gelatin which is similar to blood. Results: The teacher asked the opinion of each of attendees, most said that this experience improves their knowledge about hemophilia a lot and that it seems to be very important to use cryotherapy while bleeding. This experiment was described like a fun way to learn about hemophilia. Knowledge was reinforced by giving them a well prepared gelatin dessert to eat. Conclusion: The design of educational strategies must include recreational life experiences. The pedagogical tool showed here allows them to learn by playing, it will translate into more self-adherence to the correct treatment and less days of pain and physical impairment. This method could be used in the hemophilia camps or in the permanent educational program.

Patient education for adult patients with hemophilia at Manchester Royal Infirmary: a service review CAROLINE CLEG Keele University, Keele, UK; Central Manchester NHS Trust, Manchester, UK


Materials and Methods: Data was collected with the help of anonymised questionnaire; submission signalled consent. Patients were supplied with an information sheet for consent purposes. Postal recruitment was added to clinic recruitment to boost low numbers. Patients’ notes were screened for eligibility, prior to approaching the patient to join the study, either in clinic or using the electronic patient notes system, the MediSec for postal recruitment. The questionnaire collected diagnostic, education information, and qualitative information about responders’ thoughts and feelings on education provided. Fisher’s exact test, Wilcoxon rank sum or Pearson chi square test and thematic analysis were used for analysis as appropriate. Results: 58% of patients had received education. Patients indicating a history of joint pain were statistically more likely to have received education. No other significant associations were found. There was variation across the responders regarding content of education received, with generally low numbers across a broad range of topics. Higher numbers of responders had received education via clinic appointments although there was variation across categories. No responders had received education via the internet after being directed there by staff; several had accessed internet-based resources of their own volition. Patients who had received written information felt that the length, frequency, and detail of the education received was appropriate. Thematic analysis revealed staff having been helpful, across most responders, irrespective of education received. Responders felt education was provided when asked for; some felt this was a strength and others a weakness of the service. Conclusion: There is evidence of individualised education provided, mainly in the clinic setting but it does not have a standardised approach and is not satisfactory to all responders. Some education resources appear to be underutilised such as internetbased. Demographic data did not have a bearing on education received. Many felt staff was helpful regardless of whether education was received or not.

Retrospective identification of factors which contribute to hepatitis C treatment decisions in a population of people with haemophilia in Ireland

D E C L A N N O O N E , 1 A N N E D U F F Y , 1 B R I A N O ’ M A H O N Y 1 and DR. PAMELA GALLAGHER2 Irish Haemophilia Society, Dublin, Ireland; and 2Dublin City University, Glasnevin, Dublin, Ireland


Introduction and Objectives: In 2012, two new protease inhibitors for hepatitis C Genotype 1 were licensed in Ireland. In 2011 and 2012, the Irish Haemophilia Society initiated a strategic communications plan informing members of the new treatments, through meetings, peer groups, specific newsletters, and personal stories from patients on treatment. Materials and Methods: Following the initiation of treatment we carried out a survey in an initial cohort of 11 patients with hemophilia to retrospectively identify the factors which contributed to their hepatitis C treatment decisions. The survey was sent out to all 11 PWH who were currently on triple treatment and received a 100% response rate. The survey examined quantitative data based on the expectations from treatment, preparation for side effects, preparation for impact on daily life including work, daily activities and the subsequent reality of treatment. The survey was then used to form the basis of a group interview with PWH on treatment and their partners which was assessed using qualitative analysis. Results: The results showed that the main factors influencing the decision to start treatment were the availability of new treatments, discussions with the hepatology nurses and clinicians and meetings organised by the Irish Haemophilia Society. 72% of respondents rated the impact of the triple therapy treatments as severe to very severe as well as more severe or much more severe than had been anticipated. Conclusion: The survey and the group interview examined the major areas of support which assisted PWH in coping with treatment. The largest impact during treatment were identified as support from spouse/family member, clinical support from the hepatology clinicians and peer support from other PWH undergoing treatment.

Translation of a Hemophilia poster into ten official languages ALICE BANZE South African Haemophilia Foundation Background: Haemophilia is a rare inherited, sex linked, lifelong bleeding disorder. The South African Haemophilia National Registry shows 40% of people with bleeding disorder remain undiagnosed in the community due to lack of information and understanding of the condition. Purpose: Translation of the English version of the hemophilia poster into ten other official South African languages was done to ensure that all the racial and ethnic groups have access to hemophilia information regardless of their level of literacy, to be able to understand the condition and be cooperative. “The single aim of providing translation is to ensure the written materials are effective, meaning that they provide clear and comprehensible information and influences the beliefs, attitudes and intentions of individuals so that they make health orientated decision”. (Nxumalo Thandiwe et al. 2013). “Informed medical decision making leads to increased Quality of Care”. (Mark Skinner- 2013). Method: Translation was originally carried out by hemophilia trained nurses from different clinics serving different language groups. The translated scripts were taken to the University of the Witwatersrand for a professional translation and validation via back translation, this highlighted the isomorphic and idiosyncrasy of languages. The processes and difficulties of translation will be discussed, e.g. “The concept “gene” was not understood. As there are no equivalent Xhosa words or terms for genes, the interpreter initially used the word i-genes (borrowed from English) and afterwards tried to paraphrase the meaning. Further, the concepts of “genes” “DNA” or “chromosome” were not easily understood, even when there were no language barriers. (Solomon et al. 2012). The translated versions were formatted as posters and referred to the National Department of Health for approval.

Introduction and Objectives: To review the uptake of patient education service provided by the adult hemophilia service at Manchester Royal Infirmary.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

Haemophilia (2014), 20 (Suppl. 3), 1--186



Innovative teaching tool for young children with severe hemophilia

 and S T EP  HANIE PRIVE  CLAUDINE AMESSE, CLAIRE LONGPRE CHU Ste-Justine, Montreal, Canada Introduction: In order for children to manage the psychological suffering at the time of diagnosis, defense mechanisms, especially denial, are necessary and adaptive. However, they can rigidify and become non-adaptive, hence impairing one’s healthy adaptation (for example, through non-adherence to treatment). A teaching tool proves to be necessary in order to help parents and healthcare providers better approach the topic of hemophilia with young children. Objectives: To provide a tool for healthcare providers and for parents of children with hemophilia that can promote adaptation to the illness and can support the child’s mastery of hemophilia and its treatment. Methodology: The tool suggested consists of a life-size book with large illustrations and a simplified vocabulary adapted for young children. This tool will be used in the context of parent-child workshops led by the nurse navigator and the psychologist. This workshop consists of addressing children aged 0-5 by telling them about hemophilia via the stuffed animal represented in the book. The exchange will be done using real words, by acting out the treatment, by talking about emotions with the stuffed animal, by playing games with the group, and by allowing for a relaxing time with the parent. Results: The book will contribute to the child’s acclimation to the treatment by naming the difficult emotions it can evoke and, in turn, help the child to better tolerate these emotions, leading to healthier adaptive mechanisms. Conclusion: This tool enables helping children to adapt to their treatment by offering them a simple and age-appropriate explanation. Furthermore, it allows for the elaboration of emotions brought on by the medical condition. As such, the long-term therapeutic goal of this approach is to lead the child towards a better control of the illness instead of denying its existence and its impacts. Contribution to the evidence/practice base in bleeding disorders: This book has significant potential for healthcare providers in hemophilia treatment centers. It can serve as a teaching instrument for young children and can help them acclimate to painful medical procedures and better understand the limits imposed by their illness.

The creation and implementation of a nursing fellowship in bleeding disorders GEORGINA FLOROS St. Michael’s Hospital, Toronto, Canada Overview: Introduction and Objectives: Hemophilia treatment centres (HTC) and home infusion of clotting factor concentrates are the standard of care in Canada and have thus decreased the number of hospital admissions. While this can impact a patient positively, when the need does arise to come to the hospital, they encounter nurses and other health care professional that have little understanding of their disease. A previous patient of the St. Michael’s HTC reached out to financially support a nursing based education initiative to improve the knowledge of nurses practicing in key areas of the hospital. Materials and Methods: Recognizing the important role nurses play in caring for patients, the idea to create a nursing fellowship was conceived. Nurses from key areas within the hospital would participate in an education and mentorship program designed to expose them to a variety of aspects crucial to understanding the lived experience of patients with a bleeding disorder. Initially a module based curriculum was developed with the input of external nursing medical curriculum experts. Each module guides the fellow through specific goals and objectives related to a specific area of learning. Experiential learning as well as exposure to specific education content was included in the modules. The nursing fellow spent a total of 28 shifts over a six month period gaining knowledge and comfort in bleeding disorders. Results: Two fellows, one from the emergency room and one from the orthopedic unit, were accepted to participate in the mentorship program. Each fellow was responsible for bringing knowledge and expertise back to their home unit. Each fellow worked to implement a dissemination strategy that was most effective for their peers. Initial feedback from staff in the key areas indicates a much higher level of comfort with bleeding disorders. Conclusion: An intense learning program targeting nurses in key areas can assist in educating and maintaining expertise in bleeding disorders. The fellowship aims to enroll three more nurses over the next three years in order to improve nursing knowledge and comfort when caring for patients with bleeding disorders.

Awareness of early signs of hemarthrosis: Training designed by and for patients

 2 J E A N - C H A R L E S V E R H E Y E , 1 T H O M A S S A N N I E, CAROLE BAEZA,1 VINCENTDE ANDRADE,1 1 € M A X I M E G I G N O N , N A D I A B O U D R A I- M I H O U B I , 1 C Y R I L C R O Z E T , 1 L U D O V I C R O B I N 2 and J E A N FRANC ßOI S D’IVE RNOI S1 1 Laboratoire de pedagogie de la sante Health Education Laboratory LPS, Paris, France; and 2French Hemophilia Society AFH, Paris, France

Introduction and Objectives: Hemophilia is expressed through crises during hemorrhagic accidents. Medicine has listed certain clinical signs indicating the presence of the hemorrhage. This medical semiology transmitted by health care professionals is well known to hemophiliacs. However what they actually physically feel enables them to detect more subtle signs than those described by the professionals. What they feel often is often difficult to translate into words. However, certain hemophiliacs have developed, through their personal experience, the faculty to detect early signs of hemorrhages. These patients, called “sentries,” have gradually worked out their personal semiology which enables them to react earlier and so limit the consequences of the bleeds. Collaborative research between the Laboratoire de pedagogie de la sante (Health Education Laboratory) (LPS), EA3412, Universite Paris 13, and the French Hemophilia Society (AFH) aims to define this personal semiology,

Haemophilia (2014), 20 (Suppl. 3), 1--186

then to develop a therapeutic patient education (TPE) module on the awareness of early signs of hemarthrosis, led by the health care providers and resource patients. Material and Methods: According to the saturation technique, in depth interviews were carried out with 10 sentry patients enabling the words and metaphors used to indicate the first signs of hemarthrosis to be listed. Organised according to tools adapted from the classification of sensory science, these expressions were grouped into sensation families which corresponded to early signs. Based on this initial lexicon, a TPE workshop was then tested with the hemophilia treatment centres (HTC) in order to help patients identify their signs, the timing of their onset and the confidence they had in their awareness of the signs. Results: Unlike medical semiology, personal semiology is difficult to communicate. Resorting to the abstract helps ideas to be put into words. Following the sessions of TPE, the patients were able on the one hand to constitute a list of words to express their early signs and on the other hand to reinforce their feeling of confidence, often enabling them to plan more suitable management of their treatment. Conclusion: This research opens new perspectives in the patient/health professional relationship as well as in the involvement of patients in training their peers in conjunction with health professionals.

The impact of school visits by multidisciplinary team in the integration of children with hemophilia in recreational and physical activities at school  CIA A P MATTA, SULAMITA BATISTA, ROSALVA ROVERI, M AR G L E N D A F E L D B E R G , A R I A N E S T E F A N E L L I , J A N A IN A B S R I C C I A R D I , A N D R E A L A S A M B O , S A M U E L S M E D I N A and MARGARETH C OZELO Hemophilia Unit “Cl audio L. P. Correa”, INCT do Sangue Hemocentro Unicamp, University of Campinas, Campinas, SP, Brazil

Introduction: Musculoskeletal complications worsen quality of life (QoL) of people with hemophilia (PWH). In Brazil, the lack of knowledge about the disease causes pediatric patients to be excluded in recreational and physical activities at school. Objectives (1) To detected children with hemophilia with limited participation in physical activities at school, and (2) To determine the impact of school visits by a multidisciplinary team in the integration of these patients. Methods: QoL and functional assessment tools (PedsQL and PedHAL) were used to determine if children and adolescents with hemophilia, from a Brazilian centre, were integrated in physical activities performed at their schools. If patients were not participating in the same activities as other students, a visit to the school by the multidisciplinary team was scheduled. During the visit basic concepts about hemophilia were presented. The participants from the visited schools were asked to answer questionnaires before and after the meeting, in order to assess the gain of knowledge and confidence. Results: Thirty-eight PWH aged between 3 and 17 years-old, were evaluated to assess their functional status or QoL. It was detected that eight (21%) PWH did not participate of recreational activities or physical education classes with other students at their own school. Seven schools where contacted and six schools where visited. A total of 48 education professionals answered the pre and post visit questionnaires. Qualitative analysis of the answers showed that before the meetings 58.4% of the professionals did not know or had wrong concepts about hemophilia, and only 9% did not find difficult dealing with students with hemophilia. After the meetings, 96.2% of the professionals stated that they had understood the concepts about the disease and 88.7% felt more confident in performing regular activities with students with hemophilia. All the visited schools have started to include the hemophilia patients in the physical and recreational activities along with other students. Conclusion: Lack of knowledge about hemophilia contributes to exclusion of patients in physical and recreational activities at school, and the information sharing through educational meetings can constitute a powerful tool to ensure full inclusion of hemophilia patients in the educational setting.

Patients, family and healthcare professionals and mild hemophilia: Qualitative analysis of needs

 1 MORGAN BERGER,1 S O P H I E A Y C A G U E R , 1 T H O M A S S A N N I E,  IE CHAMOUARD,3 A N N I E B O R E L - D E R L O N , 2 V A L ER  IE GAY,5 C H R I S T I A N F O N D A N E S C H E , 4 V A L ER P A T R I C I A G U I L L O N , 6 T H I E R R Y L A M B E R T 7 and 8 PIERRE-YVES TRAYNARD 1 French Hemophilia Society AFH, Paris, France; 2CHU Caen, CRMW, CTH, Caen, France;3Unite d’hemostase clinique/CRTH, GH Est, Hospices Civiles de Lyon, PERMEDES, Lyon, France; 4GRIKH, Montpellier, France; 5CTH, Chambery, France; 6 CHU Caen, FIDEL’HEM, CTH, Caen, France; 7CRMH and Haemophila Center H^ opital Bic^etre APHP, Le Kremlin Bic^etre, France; and 8Therapeutic Patient Education Consultant, Paris, France Introduction and objectives: In France, therapeutic patient education (TPE) is very much on the rise but the programmes practically never cover mild hemophilia. The needs of patients who are affected by this are not well known and studies on the subject are rare. In order to determine the most appropriate educational approach, the needs expressed by people living with mild hemophilia have been explored. Materials and Methods: Under the aegis of the French interdisciplinary working group on TPE (Therapeutic Education Patients, Parents, Professionals - ThE 3P group), a study was carried out in the form of three focus groups with patients and parents (n = 22) 1 of which integrated health care professionals from HTCs (Hemophilia Treatment Centres) (n = 11). Results: Patients and families reported a paradox: On the one hand they neglect and play down the disorder but on the other hand when an accident occurs it becomes a burdensome reality they have to cope with it. From their point of view, communication with health care professionals is usually not very or not at all appropriate to their situation. For their part, health care professionals express difficulties in finding the appropriate terms. This is probably linked to their wish to

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

EDUCATIONAL MODELS both reassure patients and to warn them about risks. Even if patients and families acknowledge they are sufficiently informed about the disorder, they feel misunderstood and would like health care professionals to take into account their own experience as a patient of mild hemophilia (or his family), more empathy, and the possibility of sharing with the professionals an a priori assessment of risk situations and an analysis afterwards of incidents already experienced. In an emergency, they point out their limits and dread underestimation by emergency

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


professionals (except in HTCs). These results are quite similar to those of a Canadian study published in 2012. Conclusion: To improve the management of care for mild hemophiliacs, the working group studied the educational needs of patients and families in order to deduce new implications in terms of educational strategies (structured programme, exchanges with peers, social accompaniment for example) and development of appropriate tools.

Haemophilia (2014), 20 (Suppl. 3), 1--186



31-HEALTH AND SOCIAL ECONOMICS Association between health status of persons with hemophilia B and consumption of factor IX concentrate – Hemophilia Utilization Group Study Part Vb (HUGS Vb)

XIAOLI NIU,1 JIAT-LING POON,1 MIMI LOU,1 ROSHNI KULKARNI,2 BRENDA RISKE,3 MEGAN ULLMAN,4 J U D I T H B A K E R , 1 J E F F R E Y H O R D , 5 R A N D A L L C U R T I S 6 and MICHAEL B. NICHOL1 1 University of Southern California, Los Angeles, United States; 2Michigan State University, Center for bleeding and Clotting Disorders, East Lansing, United States; 3 University of Colorado, Hemophilia and Thrombosis Center, Aurora, United States; 4 Gulf States Hemophilia & Thrombosis Center, Houston, United States; 5Akron Children’s Hospital, Division of Hematology-Oncology, Akron, United States; and 6 Factor VIII computing, Berkeley, United States Introduction and Objectives: The infusion of factor concentrate, both prophylactically and episodically, is central to modern hemophilia care and is responsible for reduced morbidity and mortality among persons with hemophilia. This study is to examine the relationship between patient/parent-reported health status and the utilization of factor IX concentrate among persons with hemophilia B (factor IX deficiency). Materials and Methods: Data were obtained from HUGS Vb, a prospective, multicenter observational study evaluating the cost and burden of illness among the US hemophilia B population. Bleeding frequency and health status were either selfreported by adults or by parent-proxies, for children 5000 IU/kg/year. Treatment strategy should be adjusted with severity levels and health status of each individual to maximize treatment effect.

this age groups and effective interventions recommended for improving the client’s global health.

Biosimilars: What the hemophilia community should know?

 CUESTAD A N I E L - A N IB A L G A R C IA - D I E G O 1 , 2 and R U B EN BARRIUSO1,3,4 1 Federaci on Espa~ nola de Hemofilia – Fedhemo, Madrid, Spain; 2Instituto Universitario Ortega y Gasset – UCM, Madrid, Spain; 3Degree of Physiotherapy, Faculty of Health Sciences, Catholic University San Antonio, Murcia, Spain; and 4 Real Fundaci on Victoria Eugenia – RFVE, Madrid, Spain Introduction and Objectives: Biosimilar medicine, or biological similar medicine, is a biological medicine that demonstrates biosimilarity to a protection-expired biological medicine (known as “reference product”). This new kind of medicine will be the breakthrough in the biological medical community and, by extension, the hemophilia community. Concerns: There are some concerns about biosimilars, mainly, clinical trials to demonstrate biosimilarity. This kind of clinical trial will be head-to-head comparison, assuring only biosimilarity among reference and biosimilars medicines. Nowadays, there is a huge portfolio of new innovative medicines that will compete with biosimilar products to recruit patients, causing a delay in approval of both products. Different immunogenicity: Biological medicines are large and complex products with a big variability among different batches of the same product. A biosimilars products is not “the same” product that reference and, like the experience state, minor change in the amino acid structure would be an important factor in the immunogenicity of this products. Interchangeability: Regulatory pathways implemented by the FDA and EMA assures the biosimilarity of this products but the national regulatory authorities in most countries assures that biological medicines are not interchangeable medicines. The interchange among reference and biosimilar product will be a consensus decision among clinician and patient. Pricing: Biosimilars, as biological medicines, have a huge production cost and regulatory expenses, however, the introduction of this products in the hemophilia market will lead the cost down, but, in any case, it will lead to the introduction of generic chemical products. Less economically developed countries (LEDC) will have an advantage with the introduction of biosimilars. New R&D: Past regulatory framework (data protection, no biosimilars pathway. . .) was an important step in the R&D of biological products. New framework would decrease the interest of the biopharma industry in the biological products and, therefore, in hemophilia products. Conclusion: Biosimilars provide important changes in the hemophilia community. In one hand, LEDC will improve the access to treatment, one of the objectives of the WFH. But, in the other one, this would affect negatively in the future of the hemophilia community.

Factor IX consumption IU/kg/year, mean (median) std

Age group Children ( 0.80). For other tasks, and for the total score, reliability indices were considered good (Kp > 0.61 and 3METs). Patient adherence was excellent with the majority of the patients wearing the accelerometer consistently for 7 days. Conclusion: This pilot study indicates that an accelerometer is a practical and valuable tool to measure physical activity of adults with hemophilia. Patients with hemophilia are inactive compared with a general adult population. Future research will investigate the benefits of individualized prophylaxis on increasing physical activity in adult patients with hemophilia.

Hydrotherapy for severe hemophilia patients in Korea

J O N G - S E O N K I M , 1 B Y U N G - R Y O N G L E E 2 and H E E J O B A E K 3 Korea Hemophilia Foundation, Seoul, Korea; 2Korea Hemophilia Foundation, Kwangju, korea; and 3Chonnam National University, Gwangju, Korea


Objectives: Hydrotherapy is one of the useful methods in treating painful or stiff joints and muscles after an acute hemarthrosis, muscle bleeds and chronic arthropathy. However, there are neither sufficient nor accessible reports for hemophilia. This study aims at evaluating the effect of hydrotherapy on hemophilic arthropathy. Methods: We have conducted hydrotherapy for eight weeks from Aug. 2011 to Jul. 2013. Nineteen patients with severe hemophilia (HA:17, HB:2) were enrolled and divided into two groups (hydrotherapy group vs. control group) Each groups were composed of 9 and 10 patients, respectively. Hydrotherapy is composed of aquatic exercise and Bad Ragaz Ring Method. Hydrotherapy also consisted of two or three sessions having 40 min period per a week. Control group is getting general home exercise three times a week. We evaluated quadriceps muscle strength, gait speed and balance ability of patients before and after exercise. Results: The hydrotherapy group showed the improved quadriceps muscle power (left: 11.5%, right: 11.6%, p = 0.01), One legged stance time (left: 4.48 sec to 5.65 sec, right: 3.50 sec to 5.75 sec, p = 0.05), Time up and go test (12.96 sec to 11.22 sec, p = 0.01), and 10 m Gait speed (12.26 sec to 10.59 sec, p = 0.01). However, no difference can be observed between before and after exercise in the control groups. Conclusion: The hydrotherapy program has improved the musculoskeletal functions on patients with hemophilia. Consequently, various hydrotherapy programs for hemophilia patients need to be developed.

Evaluation of a Portuguese version of the Functional Independence Score for Hemophilia (FISH) in the Brazilian population

 CIA A P MATTA,1 ELAINE G L E N D A F E L D B E R G , M AR V B A S T O S , B R U N A G R I B E I R O , J A N A IN A B S R I C C I A R D I ,  I A P D F U R T A D O , S A M U E L S M E D I N A and M A R G A R E T H N A T AL C OZELO Hemophilia Unit “Claudio L. P. Correa”, INCT do Sangue Hemocentro Unicamp, University of Campinas, Campinas, SP, Brazil Introduction: Joint damage is a frequent complication of hemophilia and may lead to deformities and limitations in functional activities. In order to measure the functional impairments generated by hemophilic arthropathy, the Functional Independence Score for Hemophilia (FISH) was developed by the group from Vellore, India. Objective: This study aimed to translate the FISH into Portuguese, and to evaluate its applicability and reliability among Brazilian patients with hemophilia. Methods: Both the FISH form and its manual were translated from English into Portuguese. The translation was validated after the translation of the Portuguese version into the original language. The final and approved Portuguese version was applied by two trained physiotherapists, and the inter-rater reliability was evaluated. The weighted Kappa (Kp) was used to assess the FISH inter-rater reliability, and intraclass correlation coefficient (ICC) was used for comparison with the literature data.

Haemophilia (2014), 20 (Suppl. 3), 1--186

The UK Buddy Award Swimming Academy

PAUL MCLAUGHLIN,1 MELANIE BLADEN,2 JULIA SPIRES,2 J A C K B R I D G E , 3 A N D Y S C A N L O N , 4 J A M I N A G I B S O N 5 and DAN HART6 1 Katharine Dormandy Haemophilia Centre, Royal Free Hospital NHS Foundation Trust, London, UK; 2Great Ormond Street Hospital for Children, London, UK; 3 Team GB Swimming, Newcastle, UK; 4Team GB Swimming, Preston, UK; 5 Novonordisk, UK; and 6The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine & Dentistry, QMUL, London, UK Introduction and Objectives: Swimming is a popular activity for children in the UK. However, even with the skill of being able to swim, only a minority continue to swim regularly through adolescence and into adulthood. Swimming is an acceptable activity for individuals living with hemophilia regardless of joint status and offers an opportunity for continued cardiovascular and musculoskeletal health. To maximise the value of swimming, boys need to engage with swimming technically and require inspiration and support to help establish it as part of their lives. The Buddy Award Swimming Academy aims to inspire boys living with hemophilia to improve their swimming technique and see it as fun healthy activity. Materials and Methods: Thirty boys (aged 9-13 years) from 16 UK hemophilia centres, attended the inaugural Academy event in November 2013. Fifteen described their swimming capability as “strong”, 10 as “intermediate”, five as “beginner” prior to the event. Results: The group training session provided hemophilia specific and swimming specific training. Jack Bridge, a 19 year old Paralympian (London 2012) breast stroke specialist, who lives with severe hemophilia A and a history of an inhibitor, provided the key inspirational link between hemophilia and swimming excellence. Jack and two Team GB swimming coaches designed and delivered the swimming programme. After the session, boys were paired with “swimming buddies” of similar swimming ability. Buddy to buddy contact was encouraged and facilitated through a portal on the inherited bleeding disorder social networking site, SixVibe. Conclusions: Important benefits from such an event for young adolescents include training with a group of similarly aged peers living with hemophilia and confidence building at both hemophilia and physical activity levels. An annual event is planned to follow up progress and engage new recruits. It is hoped a national academy event for boys living with hemophilia will provide an attractive focus for on-going training, improvement and contact with buddies.

Surface electromyography evaluation in patients with hemophilia undergoing swimming classes

 C I A A P M A T T A , J A N A IN A B G L E N D A F E L D B E R G , M AR S R I C C I A R D I , S A M U E L S M E D I N A and M A R G A R E T H C O Z E L O Hemophilia Unit “Cl audio L. P. Correa”, INCT do Sangue Hemocentro Unicamp, University of Campinas, Campinas, SP, Brazil Introduction: Recurrent musculoskeletal bleeds in patients with hemophilia (PWH) lead to deformities and limitations in functional activities. It has been shown that swimming is a safe and effective sport activity for these patients. However, it is difficult to objectively assess the benefits of this activity. Objective: To evaluate the thigh muscles strength and function using surface electromyography (EMG) before and after swimming program in PWH. Methods: Severe hemophilia A (sHA) and B (sHB) patients were evaluated using the surface EMG measurements of the thigh muscles. The evaluation was performed with the maximal voluntary contraction (MVC) test, and strength test using dynamometer with the peak value of the repetitions. After the initial assessment, patients underwent swimming classes for beginners, consisting of 45-minute classes twice a week for 12 weeks. EMG responses expressed in microvolts (uV) were subjected to statistical analysis with the nonparametric Wilcoxon test. Results: Fifteen PWH (11 sHA e 4 sHB), aged 6 to 38 years (13  8.7y), without previous regular physical activities, were enrolled. 14/15 patients started secondary prophylaxis for different reasons, during the year before they started the swimming classes. Comparing the results between pre and post- swimming program, it was observed an increase in muscle strength of 50.4% in R knee extensor (p = 0.006), and 22.5% of L knee extensor (p = 0.03). Muscle strength of knee flexors showed an increase of 39.1% (p = 0.003) in R side, and 22.9% (p = 0.004) in L side. The analysis of each muscle function, based on the increase in electric activity by EMG, demonstrated a statistically significant difference between pre and post evaluation for all thigh muscles in L side (vastus lateralis, p = 0.03; vastus medialis, p = 0.04; and biceps femoris, p = 0.04). Although for R side it was observed an improvement, this was not statistically significant. Conclusion: The EMG results showed an increase in the strength and function of thigh muscles in PWH after a swimming program. The surface EMG demonstrated to be a safe and effective method for muscle evaluation in patients with hemophilia. The results showed that swimming is effective with considered benefits in a short period of time.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd



36-PSYCHOSOCIAL ISSUES Rights, duties, challenges and tips for employable people with hemophilia CLAUDE BARTHOLEMEW Hemophilia Program - Adult Division, St. Paul’s Hospital, Vancouver, Canada Introduction: My practice as a social worker working with adults living with hemophilia has provided me with a wide range of issues and concerns. This abstract will focus on vocational challenges. Methods: wo groups come to the forefront when addressing vocational challenges: youth (18-30) and mid-career adults (35-45). Youth are forging a vocational plan beginning with self-discovery, ample questions, and educational pressures. It is also about wonder, anticipation, and perceived hurdles. In this phase family, friends, healthcare professionals, and societies have a role in cultivating sound vocational decision-making. Interventions impacting this process include the encouragement of job shadowing, engagement in field practice, co-operatives, higher education, and reflecting on one’s bleeding disorder (severity and management) and how it correlates with the vocational options. The key is to offer choices. Mid-career adults present a different situation. With a chosen career or having experienced multiple jobs in a range of occupations they are brought back to the question of what vocation best suits their needs. This evaluation can be necessitated by physical limitation, lack of advancement and/or benefits, marital breakdown, and/or the lack of desire to continue in their chosen vocation. Often, financial challenges from returning to school may persist; extended rehabilitation periods from bleeds, family stress, and depression may exist. Practical queries in reevaluation may include: Can you transfer within your vocation? Or purchase extended benefits? Does the company have an educational fund? Are there local regional, national, educational funding options available? As a social work clinician, our program has participated in unique forms of engagement given the noted situation. Results: A skill set was fostered from which patients have access to practical tools via vocational benefits and planning to best achieve the career outcomes they most desire. Conclusion: Regardless of age or professional development individuals with bleeding disorders need assistance to maintain engagement in the vocational lifecycle. At present social work is one of the key disciplines, which can and will continue to have a significant input in this arena of vocational development.

“What will I be when I grow up?” FREDERICA R.M. Y CASSIS Haemophilia Center, University of S~ ao Paulo Faculty of Medicine Clinics Hospital, S~ao Paulo, Brazil Objective: To show from the perspective of developmental psychology and with the use of psycho-education, the different phases in the cycle of life of a child with a bleeding disorder. Some interventions are helpful for parents and caregivers to educate an affected child by enhacing their potential and minimizing the negative impact of this chronic condition. Background: Education and employment satisfaction are likely to be interrelated, suggesting that people who have completed a formal education have more career options and can better choose which way to earn money, be productive and independent. For women and men with bleeding disorders this is not different. Living with a bleeding disorder means learning to integrate daily life treatment management from an early age and developping self-awareness of their disease, coping with pain, with some restrictions in their physical and social activities and school and work absenteeism. Implementation of strategy: Clinical experience and qualitative studies demonstrate that issues like disclosure and how to deliver information about oneself to various people and in different job situations is one of the major difficulties to be faced with later on. The psycho-educational approach from childhood is beneficial in that it teaches people to be more natural about the chronic health condition and its management. As caregivers, we must also understand how different a young child’s cognitive development is, compared to a young adolescent or compared to a late teenager. These differences must be considered when they express their desires, expectations and doubts regarding the future. Conclusion: This understanding is essential in order to deliver a more specific and optimal support to the child with a bleeding disorder during this particularly challenging phase of development.

Overview of social and cultural Aspects of disclosing a bleeding disorder BRIAN O’MAHONY Irish Haemophilia Society, Dublin, Ireland As a genetic and rare disorder, hemophilia impacts the individual and the family. A lack of public education about and awareness of hemophilia can lead to myths, stigma, isolation or discrimination against the person with hemophilia or against carriers. These factors and others such as not wanting to be perceived as different from peers may lead the person with hemophilia or their family to not disclose. Myths such as bleeding to death from a minor cut, stigma and isolation associated with HIV and Hepatitis C and discrimination in employment and insurance, all lead to a reluctance to disclose. In societies where there are arranged marriages, disclosure may be perceived as damaging the marriage prospects of the daughter who may be a carrier. The impact of religious belief in coping with hemophilia will be discussed. Concerns about disclosure are related to the degree of access to treatment and care. With inadequate treatment, the individual will have many bleeding episodes, joint damage and may have limited education and employment opportunities and a relatively poor quality of life. As access to treatment improves, quality of life, education and employment opportunities increase and confidence grows. Disclosure

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

becomes easier. Confidence in disclosing is impacted by knowledge, understanding, and perception of your hemophilia in the context of your education, religion and the country and prevailing culture where you live. However, the primary determinant in having confidence to disclose, when required, is the level of access to treatment and care.

Psychological aspects of disclosure AF ROBERTS South African Haemophilia Foundation Disclosure is a complex phenomenon (Shafer-Landau, 2012). It is entwined with issues of ethics, law, medical and psychosocial practices. A thorough exploration of disclosure takes cognizance of the entire eco-systemic spectrum (Bronfenbrenner, 1986), including individual personalities, family constellations and dynamics, cultural and religious settings, as well as the wider socio-political milieu. The presentation explores psychological aspects such as ‘the psychology of self-esteem’ (Monbourquette, 2006), protecting the self, fear of rejection, disclosure through the stages of human development, confidentiality, disclosure of co-morbidities such as HIV/AIDS (Armistead, 1997), and the role of the psychosocial practitioner / mentor / counselor as ‘facilitator and environment enabler’.

Disclosure: When, how and who to tell about a bleeding disorder SHIRIN RAVANBOD Iranian Hemophilia Society, Iran Objective: To explore the different circumstances leading to decide to a decision as to whether or not to disclose a bleeding disorder with a focus upon women living in conservative societies. Background: Disclosure appears to be a very selective behavior. Summary: Deciding to disclose a hereditary bleeding disorder is a potentially critical act that can lead to positive and negative outcomes and it is highly dependent upon prevailing socio-cultural norms of a society. This decision may be particularly difficult for women who are either affected or are carriers of an inherited bleeding disorder. Disclosure, in some circumstances may result in rejection, discrimination and stigma by relatives and friends. This is especially true for women living in impoverished communities, where the burdens of chronic disease are overwhelming and social acceptance of having an inheritable genetic defect is low. Therefore, social stigma and fear of social exclusion attached to disclosure is a justified reason not to disclose. On the other hand, in a supportive environment where mutual trust and respect exists, disclosure and open communication occurs. Conclusion: Honest dialogue about concerns significantly reduces stress. Within this framework, confidence in the medical establishment is of paramount importance and it can bring the individual back to normal social life.

Confronting disclosure NEIL BOAL Haemophilia Foundation Australia, Melbourne, Australia Objective: I’m going to share my personal experience of how I made decisions about disclosing my hemophilia and the reactions I received. Background: I am a 51 y/o with hemophilia A. I was diagnosed with non-A/non-B hepatitis in the mid 1970’s. In 1985 I tested positive for HIV and in 1990 tested positive for HCV. I have successfully cleared HCV thanks to treatment. Throughout my life revealing the fact I have hemophilia has rarely been a negative experience. Being open and honest, I believe, gains respect and understanding. Summary: Advances in the management of hemophilia today, in the developed world, means it should have minimal impact on your life. The introduction of a prophylactic treatment regime should minimize potential bleeds and, therefore, joint damage. So today, those fortunate enough to live in a developed country and living with hemophilia can lead a full, productive work and social life. Conclusion: Although there are no certainties, you can reassure any person that enters your life (be-it a partner or boss) that there are no major reasons to fear loving or employing a person with hemophilia. You can use up to date information from either your treatment centre or from the internet to help explain about hemophilia, or perhaps even ask your doctor, nurse or social worker for advice. We also have our “family” network in the hemophilia foundations that can help with any support group information that can put you in touch with others with the same condition.

The Power of Resilience: Finding Balance and Navigating Resources EDWARD J. KUEBLER The University of Texas Gulf States Hemophilia & Thrombophilia Center, Houston, USA Primary Objective: To identify resilience training for psychosocial professionals to assist them with their patient and families with a bleeding disorder by teaching about resilience as a practical tool they can utilize in their practice. The concept of resilience as a therapeutic intervention can help a patient/family cope with stress, find balance and define their “normal” within their family system. Providing psychosocial professionals with resources to assist in their practice with patients will offer additional options in their practice to help their patients/families cope. Background: Professionals who work in the bleeding disorders community require training and education specific to the community’s needs. It is the professional’s

Haemophilia (2014), 20 (Suppl. 3), 1--186



responsibility to receive training and education maintaining a high level of skill allowing them to provide coping skills and resources to assist patients and families. The concept of resilience is a skill that can be taught to patients/families as a way to cope with difficult situations. A.J. Zautra, J.S Hall and K.E Murray, in their book Resilience written in 2010 talks about psychological resilience as an individual’s tendency to cope with stress and adversity and that most research now shows that resilience is the result of individuals being able to interact with their environments and the processes that either promote well-being or protect them against the overwhelming influence of risk factors. Summary: Training psychosocial professionals to utilize resilience work as a tool to teach patients and families can provide long lasting coping skills for dealing with the many stressors and issues they face. By the very definition of resilience it offers a patient/family a set of skills they may not otherwise possess. It speaks to the wellknown idea of teaching a man to fish instead of giving him a meal. The skill of resilience can take the patient much farther in life in terms of coping skills. Conclusions: Training and education in the concept of resilience will be beneficial to psychosocial professionals when working with patients and families with a bleeding disorder. It can especially help with patients who do not have adequate access to factor concentrate as a means to cope with their condition.

The Power of Resilience RICHA MOHAN Society for Hemophilia Care, Delhi, India Purpose: To explain that the resilience is a special ability to take charge of one’s lives. Resilience can give person with hemophilia the ability to align themselves with their strengths and to recognize the inner potential or personal power. Method: Review of vast variety of literature and participants interviews gives enough evidence on the psychological aspects and attributes of resilience. The three fundamental building blocks of resilience are identified as a secure base, good selfesteem, and a sense of self-efficacy. Findings: Resilience is built upon the complex interaction and operation of risk and protective factors at individual, family, and community levels. It is important to understand resilience as a process rather than a particular character trait. It is found that resilience is a component of adequate psychosocial adjustment and is associated with mental health. Support can help PWH build resilience and give opportunities for self-discovery. Implication: A greater understanding of resilience as resource to stress response highlights the need for processes that support strategies for building resilience in person with hemophilia. The findings suggest promoting resilience in PWH and their families so as to promote better quality of life.

Finding balance and navigating resources: Helping patients and families identify resources LEONIE MUDGE Royal Prince Alfred Hospital, Sydney, Australia Primary Objective: This session will seek to identify the range of resources and networks available to psychosocial professionals. I will use Australia as an example to explore what is available for the bleeding disorder community: individual and group programs which are targeted for different stages of the life cycle and address particular health information needs. The aim of these programs and resources is to facilitate the community to become more resilient, proactive and self-reliant as they manage their bleeding disorder. Background: Psychosocial professionals have an ongoing challenge to provide support for individuals, couples and families. Many resources are accessible and can match the changing needs of the bleeding disorders community members. Much of the community may be unaware of existing resources and peer support networks. Summary: In Australia there is strong commitment through the psychosocial health professionals based in a network of Hemophilia Treatment Centres (HTCs). Most Australian states have strong member organizations which work closely with the HTCs and psychosocial health professionals. Member organizations are involved in the development of print-based and internet resources, with reference groups providing consumer and health professional feedback throughout their development. Member organizations are often more agile in responding to perceived needs and new opportunities. One-off grants can be used to trial innovative support programs which enable networking beyond the boundaries of health systems. The international networks expand the access and availability of resources. Recommendations: Health professionals themselves need to stay up to date with current and future technological capabilities. We need to be aware of the demographic profile of our community, and the range and availability of treatment and care so we can continually tailor and adapt the resources.

Growing up with hemophilia: Impact on children with hemophilia SILVINA GRANA Hemophilia Foundation, Buenos Aires, Argentina Hemophilia is a disease that impacts an entire family. This should be addressed taking into account the implications involving all family members. And, following the WFH’s concepts, this approach should be faced from a multidisciplinary point of view. Multiple demands, some explicit and others tacit or hidden, arise in the process of the acceptance of the disease. Different models of intervention have been made from the field of psychology in order to approach this situation. The outstanding intervention model on the subjective level is psychotherapy, but it is not the only one. The implementation of workshops and their development will show that they are a valid tool to handle feelings and sensations, physical and psychic pain, the development of related fantasies and their working-through process. From an intersubjective point of view, “socializing” the pathology, by presenting it to peer groups (relatives, school

Haemophilia (2014), 20 (Suppl. 3), 1--186

population, among others), allows the reduction of isolation, discrimination and overprotection, favoring self-esteem and autonomy. To report these processes we will describe the work done through the implementation of interdisciplinary workshops for families, schools and teenagers during a 20 year period and present clinical cases involving children and adolescents. The challenge of this work will be to demonstrate that through these different strategies and their application, the progressive transformation of passive subjects, objects of the medicine, into active subjectchildren, who are able to grow in autonomy and handle their disease is possible.

Growing up with hemophilia: Impact on parents and caregivers SHARON HAWKINS Haemophilia Centre of Western Australia, Royal Perth Hospital Perth, Australia Primary Objective: To outline parents/caregivers responses and needs to their child’s diagnosis of hemophilia and treatment throughout their developing years and to identify psychosocial interventions enabling parents/caregivers to develop coping skills to adapt with their child’s changing needs. Psychosocial workers have a key role in identifying parents/caregivers needs and strengths to cope with their child’s diagnosis and treatment of hemophilia. The benefits of initial psychosocial assessment specific to hemophilia including the use of genograms and regular review assessments with parents/caregivers of children with hemophilia will be highlighted. A full assessment including the parents/caregivers own physical and mental health, financial, employment, level of education, housing, existing support systems, religious and cultural beliefs and beliefs about their child’s diagnosis will provide the psychosocial worker with information on where to target psychosocial interventions based on the parents/caregivers and family needs and strengths. Psychosocial interventions to strengthen coping skills will be highlighted, including information and education on hemophilia, strategies for building resilience, individual and family counselling, peer support, parenting programs and referrals for community support. Children will grow to self-manage their hemophilia more effectively and the whole family system will be enhanced when their parents/caregivers have coped well through their early developmental stages. Addressing parents/caregivers needs to be well informed and connected will increase their psychological, emotional acceptance and adaption to their child’s hemophilia and assist in their child developing similar strengths and resilience.

Growing Up with hemophilia: Impact on siblings DAWNVON MAYRHAUSER Connecticut Bleeding Disorders Center, UConn Health Center, Farmington, Connecticut, USA The diagnosis of hemophilia and its treatment impact every member of the family. Few studies have examined the influence of a hemophilia diagnosis on siblings of the affected child. Studies that look at the impact of other chronic illnesses on siblings identify both positive and negative effects. It is important to understand the coping demands of siblings of children with hemophilia at each stage of development in order to create interventions that support siblings’ strengths and enhance resilience. Factors that appear to predict sibling adjustment include depression in a parent, marital adjustment of the parents to the hemophilia diagnosis, the availability of support to the parents, and communication patterns between parents and siblings. Common mistakes include failing to educate siblings about hemophilia, giving siblings responsibilities beyond their level of maturity, failing to include siblings in decisions that impact them, and encouraging guilt. Interventions include assessing parents’ mental health, marital issues, and support systems; educating parents about the importance of addressing the needs of siblings; providing siblings with education about hemophilia in a way that is appropriate to their developmental stages; and providing emotional support to siblings by encouraging them to ask questions and to openly express their feelings.

Haemophilia LIVE!: Ethnographic research into the daily lives of people with haemophilia and their families in the UK

K A T E K H A I R , 1 S U S A N H O O K , 2 A N I C A P H I L L O T T 3 and CHRISTINE LORAN4 1 Great Ormond Street Hospital for Children, London, UK; 2Edinburgh Royal Infirmary, Edinburgh, UK; 3North Hampshire Hospital, Basingstoke, UK; and 4 Arthur Bloom Haemophilia Centre, Cardiff, UK

Introduction and Objectives: Ethnography can provide a deep insight into the daily lives of individuals and families living with haemophilia; thereby identifying support needs. Materials and Methods: Sixteen families from 4 Comprehensive Care Centres consented to take part in the study. Each family received a Haemophilia LIVE! kit comprising video recording equipment, 7 sealed envelopes each containing a “secret question” and pre-paid envelopes for secure return of the SD memory cards. After a 3 day trial run, families recorded aspects of their daily lives at home, every day over 2 weeks. For the first few days, the person with haemophilia (PwH) or his parent was asked to open, on-camera, one “secret envelope” which contained a question to stimulate conversation, e.g. “If you could change one thing about your haemophilia, what would it be?” “How do you feel when you have to have your treatment?” Questions were adapted for adults, children and families, and opened at random during the filming period. Results: Over 2000 minutes of footage was obtained from 4 families with children aged up to 5 years; 4 with children aged 8 – 12 years; 2 teenagers aged 16 &19; 2 young adults aged 22 & 24 years and 3 men aged 41 – 62. Six of the PwH had an inhibitor. Pain was most commonly mentioned. Many families had complex health and social issues. Family relationships, school, employment, and travel were often significantly impacted, particularly for those affected by an inhibitor who worried about carrying large volumes of medication. PwH expressed fear about pending

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd

PSYCHOSOCIAL ISSUES surgery and loss of mobility. Although parents expressed anger and sadness about their child’s haemophilia, the PwH generally felt that this was part of who they are. Many reported that their employers were understanding and made provision for their haemophilia, yet teachers often did not fully understand its implications. Conclusions: Haemophilia has a significant impact on the PwH and his family. Ethnographic research may help identify support needs for the PwH and his family.

Economic, social and intimate aspects of life as predictors of general life satisfaction in adults with hemophilia

M A R K O M A R I N I C , 1 S T A N K O R I H T A R 1 and SILVA ZUPANCIC-SALEK2 1 Institute of Social Sciences ‘Ivo Pilar’, Zagreb, Croatia; and 2Division of Haematology, Department of Internal Medicine, National Haemophilia and Thrombophilia Centre, University Hospital Centre Rebro, Zagreb, Croatia

Introduction and Objectives: Based on the literature overview about the characteristics of hemophilia, we hypothesized that the nature of the illness can significantly influence certain aspects of patients’ lives, as well as their general life satisfaction. Consequently, we examined the degree of satisfaction with economic, social and intimate/sexual aspects of life in people with hemophilia, and how these factors determine their overall life satisfaction. Since severity of the disease can vary dramatically, we specifically included severity of the patients’ illness as a parameter in the analysis. Methods: An empirical survey among adults with hemophilia was conducted in Croatia (N = 135). General life-satisfaction was assessed on a 5-point rating scale, whereas 10-point scales, extracted from the Personal Wellbeing Index – PWI (Cummins, 2002), were used to measure satisfaction with economic and social aspects of life. The satisfaction with the intimate aspects of life was measured using an instrument constructed specifically for the purpose of this study. Results: There are no significant differences regarding satisfaction with intimate life between those with severe and milder forms of the illness (although more severely affected patients have less frequent sexual intercourse), but also in satisfaction with material status and social support, as well as in the degree of life satisfaction in general. With regard to the predictive roles of the chosen factors, material status was significant in predicting general life satisfaction in both groups of patients’. As opposed to these results, the role of social support and intimacy varied depending on illness severity. Among milder cases, intimacy proved to be more important in determining general life satisfaction than social support. On the other hand, social support played a more important role than intimate relations in patients with severe illness. Conclusion: These results point to the conclusion that all aspects of life included in our analysis determine general life satisfaction of persons with hemophilia, only their influence varies. An individual’s needs, and consequently the ways in which they are met, differ depending on the severity of their illness.

Psychosocial functioning of mothers of boys with hemophilia

PERRINE LIMPERG,1 LOTTE HAVERMAN,1 VIVIAN COLLAND,1 HELEENVAN OMMEN,2,3 M A R J O L E I N P E T E R S 2 , 3 and M A R T H A G R O O T E N H U I S 1 Departments of 1Psychosocial and 2Pediatric-Hematology, Emma Children’s Hospital; 3 Hemophilia Comprehensive Care Treatment Center, Academic Medical Center, Amsterdam, the Netherlands Introduction and Objectives: Research has shown that parents, mainly mothers, of children with chronic health conditions are prone to have more psychosocial problems than parents of healthy children. Up to date, research on psychosocial functioning of mothers of boys with hemophilia in particular is limited. The aim of the present study is to assess the degree of anxiety, depression, parental distress and perceived child vulnerability in mothers of boys with hemophilia in comparison to a Dutch reference group. Materials and Methods: In this multicenter study, the Hospital Anxiety and Depression Scale (HADS), the Distress Thermometer for Parents (DT-P) and the Child Vulnerability Scale (CVS) were completed by mothers of children with severe and non-severe hemophilia, aged 8-12 years. Descriptive statistics were performed to assess the percentage of mothers reporting clinical anxiety and depression (HADS; ≥8), parental distress (DT-P; ≥4) and parental perceptions of child vulnerability (CVS; >10). To compare the outcomes on the HADS and the CVS to reference groups, one way t-tests and Chi² tests were performed respectively. Results: In total, 30 mothers (mean 41.6 years, SD 4.3) completed the questionnaires. Regarding the HADS, 9.7% of mothers reported clinical levels of anxiety and 6.5% reported clinical levels of depression. The mean score of reported anxiety (M 4.5, SD 2.9) and depression (M 3.3, SD 4.0) was comparable to mothers in the reference group (M 4.8, SD 3.5 for anxiety and M 3.1, SD 3.3 for depression). In total, 21.9% of the mothers reported clinical scores of parental distress on the DT-P, indicating problems on the emotional domain mostly (57%). In total, 9.4% of mothers indicated they might want to talk to a professional. Regarding the CVS, 9.4% of mothers indicated to perceive their child as vulnerable; this is significantly (p < .05) more than the reference group (1.9%). Conclusion: Mothers of school-aged boys with hemophilia report average levels of anxiety and depression. However, one in five mothers of boys with hemophilia report clinical levels of parental distress and almost 10% regard their child as vulnerable. This stresses the importance of monitoring parental psychosocial functioning and distress systematically in daily clinical practice.

© 2014 The Authors Haemophilia © 2014 John Wiley & Sons Ltd


Racial differences in chronic pain and quality of life among adolescent and young adults with moderate or severe hemophilia

ANGELA LAMBING,1 MICHELLE L. WITKOP,2 TERRY L. ANDERSON,3 JAMES MUNN,4 BARTHOLOMEW TORTELLA3 and J O H N M . M C L A U G H L I N 3 1 Henry Ford Adult Hemophilia & Thrombosis Treatment Center, Detroit, USA; 2 Northern Regional Bleeding Disorders Center, Traverse City, USA; 3Pfizer Specialty Care, Medicines Development Group, Collegeville, USA; and 4University of Michigan Hemophilia Treatment Center, Ann Arbor, USA Introduction and Objectives: We explored racial differences in chronic pain and overall quality of life (QoL) among adolescents and young adults (AYAs) diagnosed with moderate or severe hemophilia. Materials and Methods: A convenience sample of hemophilia patients aged 1325 years completed an online survey addressing regimen-specific adherence, chronic pain, and QoL from April through December 2012. Adherence was assessed for prophylactic (VERITAS-Pro) and on-demand (VERITAS-PRN) participants. Chronic pain was measured using the revised Faces Pain Scale (FPS-R) and was dichotomized as high (FPS-R ≥ 4) or low (FPS-R < 4). QoL was measured via SF-36 physical (PCS) and mental composite summary scores (MCS). Multivariable, parsimonious logistic regression models assessed factors associated with high vs low chronic pain. Additionally, multivariable, nonparametric quantile regression models assessed factors associated with skewed SF-36 PCS and MCS. Results: Ninety-three AYAs with hemophilia participated. Mild patients (n = 13) were excluded. Of the remaining 80 participants (79 male), nearly all had severe disease (91%) and Hemophilia A (91%). Most were aged 13-17 years (51%), white (76%), non-Hispanic (88%), never married (93%), and had some type of health insurance (94%). At the univariate level, compared to whites, non-whites were more likely to report high chronic pain (63% vs, 26% p < .01) and have worse median PCS scores (59.0 vs 83.8, p = .02). Adjusted logistic regression modeling revealed that non-whites were 5.31 (95%CI: 1.62, 17.4; p = .01) times more likely to report high chronic pain. Adjusted quantile regression models revealed that non-whites had median PCS scores that were 16.9 (95%CI: 3.7, 30.1; p = .01) points lower than whites. This effect, however, disappeared after controlling for self-reported chronic pain level which was the primary driver of physical QoL. Conclusions: Targeted efforts should be made to prevent and manage chronic pain among non-white AYAs with moderate or severe hemophilia. Non-whites were >5 times more likely to report high levels of chronic pain which predicted worse QoL. This finding remained even after statistical adjustment for demographic (e.g., insurance status and age) and clinical (e.g., severity and inhibitors) factors, and highlights the need for more research on racial differences.

Psychosocial problems in pediatric patients with hemophilia

RUNGROTE NATESIRINILKUL,1 ORAWAN LOUTHRENOO,1 SIRANEE WONGRUANGSRI,2 SOMJAI SITTIPRECHACHARN,1 W O R A W U T C H O E Y P R A S E R T 1 and P I M L A K C H A R O E N K W A N 1 1 Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; and 2Department of Pediatrics, Lampang Hospital, Lampang, Thailand Introduction and Objectives: Pediatric patients with hemophilia, especially those who are given on-demand treatment, suffered from recurrent bleeding into their joints, causing limitation of their daily activities and risking irreversible joint damages. Restriction of physical activities, unpredictable bleeding, and concerns about joint destruction in the future have a great psychosocial impact on patients with hemophilia and their families. The objective of this study is to assess psychosocial problems in pediatric patients with hemophilia comparing to healthy controls. Materials and Methods: Patients with hemophilia, aged 8-18 years and age-matched healthy male controls, were enrolled into the study. The Children Depression Inventory (CDI) and the Multidimensional Anxiety Scale for Children (MASC) were used to assess emotional problems. The questionnaires were completed by the patients. The Child Behavior Checklist (CBCL) rated by caregivers, were used to assess emotional and behavioral problems. Results: Twenty patients with hemophilia and 20 controls were enrolled. The mean age was 12.1  2.8 years. Demographic characteristics were similar in both groups. Most patients had hemophilia A (85%). Almost all (95%) had moderate or severe disease. All patients were given on-demand treatment and had negative tests for HIV antibody. The CDI and MASC scores were comparable in the patients with hemophilia and the controls. However, the internalizing, aggressive behavior and total problems scores as tested by CBCL were significantly higher in the patient group (p =

Abstracts of the WFH 2014 World Congress, May 11-15, 2014, Melbourne, Australia.

Abstracts of the WFH 2014 World Congress, May 11-15, 2014, Melbourne, Australia. - PDF Download Free
2MB Sizes 95 Downloads 17 Views