Haemophilia Experience Research Articles

Health care professionals dealing with hemophilia: insights from the international qualitative study of the HERO initiative.

Background: Assessing the viewpoints of health care professionals concerning their work with chronic patients is a relatively new research topic, widely overlooked in the literature. However, understanding their subjective work experience is highly relevant for identifying problems and perceived resources, enhancing health service organisation, improving relationships or communication with patients, and maintaining well-being.Purpose and method: Qualitative data from the “Haemophilia Experience, Results and Opportunities” Initiative – a research program aimed at investigating the psychosocial aspects of hemophilia – were used to evaluate the experiences of 62 professionals from seven countries around the world. Semi-structured interviews were submitted to thematic analysis of elementary contexts with the aid of T-Lab software.Results: Five dominant themes emerged, identifying the main challenges that professionals have to deal with in their everyday work practice: caring for impaired adult patients; handling policies and stakeholders; providing counselling on diagnosis and reproductive choices; considering the role of family dynamics; coping with adolescent patients.Conclusion: The outcomes of the study provide an opportunity to develop the area of the non-technical skills in the core curriculum of those who work with chronic illnesses by focusing on cross-professional competences and by improving a comprehensive care model for hemophilia patients.

A new measure to assess pain in people with haemophilia: The Multidimensional Haemophilia Pain Questionnaire (MHPQ).

People with haemophilia (PWH) experience acute pain during joint bleeds and might develop chronic pain due to joint degeneration. However, there is a lack of standardized measures to comprehensively assess pain in PWH. This study aimed to develop a multidimensional questionnaire for haemophilia-related pain, the Multidimensional Haemophilia Pain Questionnaire (MHPQ), and to present initial validation data among adults.The questionnaire distinguishes between acute/chronic pain and queries about pain locations, duration, frequency, triggering factors, intensity, interference, strategies, specialists for pain management and satisfaction with treatment. An initial version was tested with 16 patients to ensure item comprehensibility and face validity. The final version was answered by 104 adults, with 82 (78.8%) reporting haemophilia-related pain in the previous year (mean age = 43.17; SD = 13.00). The non-response analysis revealed good item acceptability. Exploratory and confirmatory factor analysis (EFA/CFA), reliability (internal consistency, test-retest, inter-item and item-total correlations) and convergent validity were analysed for the intensity and interference dimensions of the questionnaire. A combined EFA with these two constructs supported a 2-factor structure distinguishing intensity (α = 0.88) from interference items (α = 0.91). CFA was tested for the interference dimension, demonstrating suitability for this sample. Item-total correlations were >0.30 on both dimensions and most inter-item correlations were <0.70. Test-retest reliability (n = 42) was good for intensity (r = 0.88) and interference (r = 0.73), and convergent validity was confirmed for most hypotheses (r>0.30).This questionnaire is a comprehensible tool, achieving a thorough assessment of relevant pain dimensions. The MHPQ can help guide treatment recommendations by highlighting relevant topics and contributing to more effective, integrated treatments.

Pain assessment and management in haemophilia: A survey among Italian patients and specialist physicians.

Persons with haemophilia (PWH) experience recurrent joint bleeding which leads from early synovitis to irreversible joint damage. Pain strongly affects patients' quality of life, as PWH suffer from acute pain associated with haemarthroses and chronic pain due to arthritic and degenerative complications. To investigate pain issues among PWH and their treaters in Italy. Persons with haemophilia and specialist physicians responded to a survey focused on pain characteristics, assessment, and management by phone call and online, respectively. One hundred and nineteen patients (76% severe haemophilia, 61% ≥18years) and 44 physicians were involved. Pain was reported by 61% of PWH; among those who did not experience pain, 70% were children on prophylaxis. Patients described pain as chronic (71%), acute (69%) or postoperative (8%), and rated it as severe in 65% of cases. Clinicians reported lower percentages of patients with pain (46%), classified as chronic (58%), acute (33%) or postoperative (21%), half using specific scales. Pain was systematically investigated by treaters according to 36% of patients. Paracetamol was largely the most prescribed first-line pain therapy (89%), as well the most employed analgesic by PWH (51%), who also used non-steroidal anti-inflammatory drugs (24%), cyclo-oxygenase-2 inhibitors (21%) or opioids (26%). To manage pain, 61% of clinicians stated to collaborate with other specialists. Physiotherapy was often suggested but less frequently used by PWH. Pain is under-recognized and unsatisfactorily addressed by haemophilia treatment centre (HTC) clinicians, with discrepant management compared to PWH responses. Education in systematic pain assessment and multidisciplinary treatment and development of management guidelines are highly needed.

Living with an inhibitor: Results from the Study of Haemophilia Experiences, Results and Opportunities in Children and young adults with long-standing inhibitors (the SO-HEROIC study)

Abstract Long-standing inhibitors present many day-today difficulties for the affected individual; the unpredictability of bleeds, bleed management, pain and treatment efficacy all affect quality of life. This study explored these issues through focus groups of affected individuals aged 16-25 in the UK. The data from the focus groups was analysed for recurring themes, which were coded under three umbrella headings: ‘daily impact’, ‘education and future’ and ‘resilience and support’. Participants felt isolated through geography and being extra ‘rare’ within the bleeding disorders community; used pain as a gauge of bleed resolution, often without use of analgesia; described transition to adult care as particularly worrying; and explained the potential impact of living with an inhibitor on future career options. Peer-to-peer networking could provide emotional support for these young adults, who could also be role models for the future. Despite the burden of living with an inhibitor and its treatment, participants described a good quality of life from their own perspectives. With new therapeutic options for these individuals on the horizon, they look forward to a future with fewer bleeds and less pain.

Construct validity of patient-reported outcome instruments in US adults with hemophilia: results from the Pain, Functional Impairment, and Quality of life (P-FiQ) study.

BackgroundPeople with hemophilia (PWH) experience frequent joint bleeding, resulting in pain and functional impairment. Generic and disease-specific patient-reported outcome (PRO) instruments have been used in clinical studies, but rarely in the comprehensive hemophilia care setting.ObjectiveThe objective of this study was to assess construct validity of PRO instruments measuring pain, functional impairment, and health-related quality of life in US PWH with a history of joint pain/bleeding.MethodsAdult male PWH completed 4 PRO instruments (EQ-5D-5L with visual analog scale, Brief Pain Inventory v2 Short Form [BPI], SF-36v2, Hemophilia Activities List [HAL]) and underwent a musculoskeletal examination (Hemophilia Joint Health Score v2.1 [HJHS]). Construct validity between index and domain scores was evaluated by Pearson product-moment correlation coefficient.ResultsA total of 381 PWH were enrolled. EQ-5D-5L Mobility correlated with BPI, SF-36v2, and HAL domains related to pain, physical function, and activity of the lower extremities. EQ-5D-5L Self-Care correlated only with HAL Self-Care. EQ-5D-5L Usual Activities correlated with BPI Pain Interference and domains within SF-36v2 and HAL related to pain and physical function/activities (particularly those involving the lower extremities). EQ-5D-5L Pain/Discomfort correlated with Bodily Pain and Physical Summary on SF-36v2, HAL Overall Activity, and all BPI pain domains. EQ-5D-5L Anxiety/Depression correlated with social/emotional/mental aspects of SF-36v2. On BPI, most pain domains correlated with Bodily Pain and Physical Health Summary on SF-36v2 and Overall Activity on HAL. On SF-36v2, Physical Functioning, Role Physical, Bodily Pain, and Physical Health summary scores correlated with all the domains of HAL except Self-Care. For HJHS, Ankle and Total scores correlated with SF-36v2 Physical Functioning and HAL Lying/Sitting, Leg Function, Complex Lower Extremity Activity, and Overall Activity.ConclusionAll PRO instruments have high construct validity but provide different levels of detail in describing effects of hemophilia. Instrument choice may depend on individuals’ symptoms, treatment planning goals, or outcome tracking research objectives, with consideration for administrative burden.

Exploring some intersections between pharmacokinetics, factor VIII measurement and human morphometrics – impact of recent advances in haemophilia study design on our understanding of optimal haemophilia treatment

Exploring some intersections between pharmacokinetics, factor <scp>VIII</scp> measurement and human morphometrics – impact of recent advances in haemophilia study design on our understanding of optimal haemophilia treatment

Factor VIII delivery devices in haemophilia A. Barriers and drivers for treatment adherence.

To capture the experience of haemophilia A patients with their devices for coagulation factor reconstitution, the barriers for treatment adherence; and to determine their preferences, presenting a new double-chamber syringe (DCS). A cross-sectional research through a supervised survey and a DCS testing session. Seventy-four (74) patients participated, 50% of them on prophylaxis treatment, and 7 years (median) with their usual treatment (IQR 17.25). In the survey, the DCS received the highest score (75/100, p < 0.001) and it was the most likely to be used in prophylactic treatment (p < 0.001). In the practical testing session (n = 29), 62.1% preferred the DCS, and required 43 seconds as median time (24.5-82) for preparation, vs. 4 minutes (1-15) with their usual treatment (p < 0.001). The favourable opinion of their doctor regarding prophylaxis was very influential on the attitude of participants towards treatment adherence (OR = 1.324, CI 95% = 1.040-1.685, p = 0.023). The DCS was the preferred device, and was likely to encourage prophylaxis.

The demographics, treatment characteristics and quality of life of adult people with haemophilia in China - results from the HERO study.

Haemophilia management in China needs to be further developed. To further improve the quality of life (QoL) of people with haemophilia (PWH) in China, it is important to investigate the peculiarities of China as compared to other countries. The primary objective of the Haemophilia Experiences, Results and Opportunities (HERO) project was to quantify the impact of key psychosocial factors affecting PWH. This article presents the demographics, treatment characteristics, and QoL of adult PWH in China as compared with the results of the other nine countries participating in the HERO study. This was a web- (except in Algeria) and questionnaire-based survey conducted in 10 countries. A total of 110 adult PWH from China and 565 from other countries completed the questionnaire. Compared with other countries, respondents in China reported: lower rate of employment (45.6% vs. 63.1%); lower percentages of being treated by prophylaxis (4.1% vs. 36.8%), being treated always at home (27.8% vs. 54.3%) and following treatment recommendation as instructed (6.2% vs. 40.5%); greater difficulty in obtaining replacement factor products (97.3% vs. 29.6%) and visiting their treatment centre (60.9% vs. 26.4%); more annual bleeds requiring treatment (mean: 29.4/year vs. 15.4/year); lower mean self-evaluated disease control score (5.5 vs. 7.7), EQ-5D index (0.71 vs. 0.75) and visual analogue scale (7.1 vs. 7.5) scores. Employed PWH in China had a better self-reported generic QoL than those unemployed. The study suggests that there is a major need for further improvement of both medical care and ongoing psychosocial support for PWH in China.

Meta-analysis: outcomes of total knee arthroplasty in the haemophilia population.

People with haemophilia (PWH) experience end stage joint disease as a result of repeated hemarthrosis, commonly leading to total knee arthroplasty (TKA). The goal of this meta-analysis is to calculate expected outcomes for range of motion (ROM), functional mobility, and complication rates in PWH following TKA. Studies published between 1980 and 2015 were identified. PWH having TKA, reporting Hospital for Special Surgery Knee Score or Knee Society Score, knee ROM, and incidence of complications for more than 5 TKAs. Inhibitor status, haemophilia severity and HIV status were not criteria for inclusion or exclusion. Meta-analysis was performed using mean, standard deviation, or P-value data to create effect sizes (ES) and 95% confidence intervals for each variable. Twenty studies met inclusion criteria; ten had sufficient data for meta-analyses. A total of 336 TKAs in 254 PWH were analysed with mean follow-up of 6.3years. Statistically significant ROM improvements were found with 9.72° improvement of flexion contracture (-0.73 effect size (ES) (-0.91 to -0.56)), and 15.69°increase into flexion (0.63 ES (0.34-0.91)). Knee scores showed statistically significant improvements: clinically, 37.9 point increase (3.21 ES [1.79-4.63]) and functionally, 13.50 point increase (1.50 ES [0.80-2.21]). A 31.5% complication rate was calculated with 106 reported in 336 TKAs. TKA is an effective procedure for improving ROM and decreasing functional deficits resulting from haemophilic arthropathy. Knee score data shows TKA improves overall function. This study guides clinicians regarding outcome expectations post-TKA in PWH.

Challenges in transition to adulthood for young adult patients with hemophilia: Quantifying the psychosocial issues and developing solutions.

Challenges in transition to adulthood for young adult patients with hemophilia: Quantifying the psychosocial issues and developing solutions.

Treatment outcomes, quality of life, and impact of hemophilia on young adults (aged 18-30 years) with hemophilia.

The Hemophilia Experiences, Results and Opportunities (HERO) initiative assessed psychosocial issues reported by people with moderate to severe hemophilia and was led by a multidisciplinary international advisory board. This analysis reports data from young adult respondents (aged 18-30 years), including both US and overall global (including US respondents) results, and investigates treatment outcomes, quality of life, and impacts of hemophilia on relationships. More young adults in HERO received prophylaxis than on-demand treatment, although a majority reported not using factor products exactly as prescribed, and 50% of global respondents and 26% of US respondents reported issues with access to factor replacement therapy in the previous 5 years. Many young adults with hemophilia reported comorbidities, including bone/skeletal arthritis, chronic pain, and viral infections, and nearly half of young adults reported anxiety/depression. Most reported pain interference with daily activities in the past 4 weeks, although a majority reported participating in lower-risk activities and approximately half in intermediate-risk activities. Most young adults were very or quite satisfied with the support of partners/spouses, family, and friends, although roughly one-third reported that hemophilia affected their ability to develop close relationships with a partner. A majority of young adults reported that hemophilia has had a negative impact on employment, and 62% of global respondents and 78% of US respondents were employed at least part-time. Together these data highlight the psychosocial issues experienced by young adults with hemophilia and suggest that increased focus on these issues may improve comprehensive care during the transition to adulthood.

Shared topics on the experience of people with haemophilia living in the UK and the USA and the influence of individual and contextual variables: Results from the HERO qualitative study

The study illuminates the subjective experience of haemophilia in people who took part in the Haemophilia Experience, Results and Opportunities (HERO) initiative, a quali-quantitative research program aimed at exploring psychosocial issues concerning this illness around the world. Applying a bottom-up analytic process with the help of software for textual data, we investigated 19 interviews in order to describe the core themes and the latent factors of speech, to explore the role of different variables in shaping the participants’ illness experiences. The five themes detected are feeling different from others, body pain, acquisition of knowledge and resources, family history, and integration of care practices in everyday life. We illustrate how nationality, age, family situation, the use of prophylaxis or on-demand treatment, and the presence of human immunodeficiency virus or hepatitis C virus affect the experience of our participants in different ways. Findings are used to bring insights on research, clinical practice, and psychosocial support.

Haemophilia Experiences, Results and Opportunities (HERO) study: treatment-related characteristics of the population.

The HERO (Haemophilia Experiences, Results and Opportunities) quantitative surveys collected information on characteristics and perceptions of adult persons with haemophilia (PWH) and parents of children with haemophilia. The aim of this article is to describe the perceptions of PWH and parents on psychosocial aspects related to treatment. Two online surveys (one for PWH, one for parents) were conducted in 10 countries. Among 675 PWH respondents, 77% reported having responsibility for their own care; 72% of 561 parent respondents had the main responsibility for their son. PWH were most commonly treated on demand (45% of 648 adults using factor concentrate), with 32% on regular prophylaxis and 23% treated on demand with short-term prophylaxis (e.g. for sports/physiotherapy). Children were most often treated with prophylaxis (65% of 549 children using factor concentrate), with 26% treated on demand and 8% treated on demand with short-term prophylaxis. Factor was generally used as instructed at home. Some respondents (41% PWH; 30% parents) had difficulties/concerns with factor availability/affordability. PWH reported more bleeds in the last 12 months than parents reporting their son's bleeds (mean 17.8 vs. 8.7). Both PWH and parents generally perceived that overall, their (their son's) haemophilia was well controlled. Results differed by country. The HERO study captured new, patient-based data regarding many facets of life relevant to PWH, including treatment. The information conveyed in this article largely represents new insights regarding perceptions of treatment and provides initial benchmark statistics for further research.

Patient-reported experience of bleeding events in haemophilia.

Patients with haemophilia experience bleeds because of absent or reduced clotting factor. The study objective was to understand the bleeding experience from the patients' perspective. Individuals with moderate/severe haemophilia participated in interviews and were asked to describe their most recent bleeding experience, including symptoms, signs of onset, impacts, when bleeding stopped and treatment effectiveness. Interview transcripts were analysed using a thematic analysis involving the coding of transcripts to identify key concepts and themes. Twenty males [10 adults, mean age = 41 (19-52); 10 adolescents, mean age = 13 (12-17)] with moderate (n = 5) or severe (n = 15) haemophilia participated. Symptoms signalling bleed onset included pain, swelling, stiffness, tingling/numbness and/or warmth. Participants reported feeling anger and frustration due to the unpredictable nature, pain and inconvenience of the episode. Adults sometimes reported delaying treatment due to inconvenience or cost; adolescents generally treated right away. Reported bleed severity was influenced by pain level, speed of symptom progression, location, continued use of the affected area, recurrence in same location of recent bleed and treatment delay. Participants reported that it was 'easy' to know when the bleed had stopped. Participants reported that symptoms might linger for days before they returned back to 'normal'. This qualitative study details the substantial impact of an acute bleed from the patient perspective. Given that treatment was reported to be delayed in part due to inconvenience, more convenient treatment options could help reduce delays in treating bleeds and thereby minimise bleed-related impacts. Clinical studies in haemophilia should include validated patient-reported measurements of acute symptoms and bleed severity to comprehensively assess the bleeding event.

Haemophilia Experiences, Results and Opportunities (HERO) Study: influence of haemophilia on interpersonal relationships as reported by adults with haemophilia and parents of children with haemophilia.

Evidence delineating the effects of haemophilia on interpersonal relationships is sparse and largely outdated, failing to reflect the impact of current treatment strategies. HERO (Haemophilia Experiences, Results and Opportunities) was commenced to garner a more comprehensive understanding of psychosocial issues facing persons with haemophilia (PWH). This article describes the findings of the quantitative HERO survey relating to the influence of haemophilia on interpersonal relationships of adult PWH, and parents/caregivers of children with haemophilia. Separate questionnaires were completed by adult PWH and parents of minor children from 10 countries, including satisfaction with support from partners, family, friends and other social contacts; disclosure of haemophilia and carrier status and family dynamics. A total of 675 PWH and 561 parents completed the survey. Over half of PWH (57%) and parents (84%) were married. Most PWH were satisfied with support from partners (94%), family (90%) and friends (85%), with lower percentages reported among those with inhibitors. Most parents were likewise satisfied with support from partners (88%) and family (83%). Whereas PWH were reticent to disclose their diagnosis beyond family and friends, parents were more likely to share their son's diagnosis, and most were satisfied with the support from their son's peers (74%), teachers (83%) and other adults in supervisory roles (85%). PWH and parents surveyed were satisfied overall with the support they received from partners, family, friends and social contacts. Relationships are affected by haemophilia in various ways, and particularly affected in terms of disease burden, age and social life.

Clinical use of factor VIII and factor IX concentrates.

Factor VIII (FVIII) and factor IX (FIX) are the cofactor and the pro-enzyme, respectively, acting in the tenase complex, a key mechanism of physiological haemostasis in which a phospholipide-dependent reaction produces the activation of factor X1. Mutations in the genes encoding for coagulation FVIII or IX, both located in the X chromosome, are responsible for haemophilia A and haemophilia B, respectively. These congenital bleeding disorders occur overall in approximately 1 in 5,000 male live births without racial predilection. However, the prevalence of haemophilia A is estimated 4–6 times higher than haemophilia B2–3. According to the residual endogenous FVIII/FIX concentrations, individuals with plasma factor levels 5–40 IU/dL are defined as moderate and mild haemophiliacs4. Although the bleeding phenotype is recognised to be heterogeneous and affected by many genetic and environmental factors5–6, this classification reflects rather closely the severity of clinical symptoms. Thus, patients with mild haemophilia experience excessive bleeding in the large majority of cases in response to surgery, other invasive procedures or major injuries4,7. On the other hand, patients with moderate haemophilia experience excessive bleeding after relatively minor trauma and those with severe haemophilia bleed spontaneously or after trivial trauma4,8. In the latter, haemarthrosis, particularly into hinged joints (ankle, knee, elbow), is largely the most frequently reported bleeding symptom8,9. Recurrent joint bleeding is associated with progressive joint morbidity (haemophilic arthropathy), leading to chronic pain and disability, that often warrant orthopaedic surgery and joint replacement10. Soft-tissue haematomas, mucosal, parenchimal and delayed post-surgical bleeding are less common manifestations, including life-threatening intracranial, neck-throat and gastro-intestinal haemorrhages8,9,11. Replacement therapy with intravenously delivered plasma-derived or recombinant FVIII and FIX concentrates, aimed at correcting the coagulation factor deficiency in the case of, or in order to prevent, bleeding is the cornerstone of management of patients with haemophilia A and haemophilia B, respectively. Indeed, these specific and viral-inactivated products are the source of choice of the missing proteins, in preference to fresh frozen plasma (for both factors), cryoprecipitate (for FVIII) or prothrombin complex concentrates (for FIX)11. The two forms of haemophilia have been usually considered indistinguishable from a clinical point of view and, consequently, as regards patterns of treatment. In this respect, most literature data have been achieved in cohorts of patients with haemophilia A and extrapolated to those with haemophilia B. However, according to recent findings, the bleeding tendency associated with FIX deficiency is likely to be less severe, with possible better long-term outcomes12. Plasma-derived FVIII concentrates may also contain variable amounts of von Willebrand factor (VWF), therefore some products are used in the management of those patients with von Willebrand disease with severe VWF deficiencies, in whom response to endogenous release by desmopressin is impossible or insufficient13. After a historical overview of treatment of haemophilia, this article will report the current clinical use of FVIII and FIX concentrates, also with reference to the Italian clinical scenario.

Haemophilia Experiences, Results and Opportunities (HERO) Study: survey methodology and population demographics

Psychosocial factors have a significant impact on the quality of life of persons with haemophilia (PWH). The Haemophilia Experiences, Results and Opportunities (HERO) initiative was developed to provide a greater understanding of the psychological components which influence the lives of PWH. This article describes the HERO methodology and the characteristics of respondents. Two online surveys (one for adult PWH ≥18 years and one for parents of children <18 years with haemophilia) were developed by an international advisory board and conducted in 10 countries. The surveys included demographic and treatment characteristics, relationships, sexual intimacy, quality of life, barriers to treatment and sources of information. A total of 675 PWH [age, median (range) 36 (18-86 years)] and 561 parents [39 (23-68 years)] completed the survey. PWH/parents reported haemophilia A (74%/76%), B (13%/16%) or with inhibitors (13%/8%). Spontaneous joint bleeding was reported in 76%/52% of PWH/children with haemophilia A, 67%/47% with haemophilia B and 93%/76% with inhibitors. Median number of bleeds (interquartile range) was 7 (2-20) for PWH and 4 (2-10) for children in the past year. Most PWH and children were treated with factor concentrate. PWH reported arthritis (49%) and HIV/HCV infections (18%/43%) related to haemophilia. Most PWH and parent respondents had received formal education (85%/89%) and were employed full- or part-time (60%/72%). HERO is one of the largest multinational studies focused on psychosocial issues in haemophilia, including historical and treatment information that will allow for multivariate analyses of determinants of health in haemophilia.

Prevention of Bleeding in Hemophilia

Patients with hemophilia experience recurrent hemorrhages into soft tissues and joints, resulting in crippling and disability. Bleeding can be prevented by the prophylactic administration of clotting-factor concentrates, but the most cost-effective method of using these expensive biologics is unclear (NEJM JW Oncol Hematol Apr 17 2012). To address this issue, European investigators examined …

Hemophilia A in the third millennium

Hemophilia A is an X-linked hereditary bleeding disorder due to the deficiency of coagulation factor VIII (FVIII). According to the degree of FVIII deficiency, mild, moderate or severe forms are recognized. Although patients with mild hemophilia A usually bleed excessively only after trauma or surgery, those with severe hemophilia experience frequent episodes of spontaneous or excessive bleeding after minor trauma, particularly into joints and muscles. The modern management of hemophilia began in the 1970s and is actually based upon several plasma-derived or recombinant FVIII products. In addition, the synthetic drug desmopressin can be used to prevent or treat bleeding episodes in patients with mild hemophilia A. Long-term and continuous substitution therapy (prophylaxis), the recommended treatment in severe hemophilia, prevents bleeding and the resultant joint damage. In the last twenty years the high standard of hemophilia care has greatly improved the quality of life of patients and their life expectancy has reached that of the non-hemophilic male population, at least in high-income countries. The most serious and challenging complication of treatment of hemophilia A is the development of inhibitors, which renders FVIII concentrate infusion ineffective and exposes patients to an increased risk of morbidity and mortality. In this narrative review, the actual knowledge on the clinical features and management of patients with hemophilia A is summarized.

PSY86 - Associations between inhibitors, treatment regimen, and bleed frequency and health care practitioner utilisation in the haemophilia treatment centre (HTC): Global results from the haemophilia experiences, results and opportunities (HERO) study

PSY86 - Associations between inhibitors, treatment regimen, and bleed frequency and health care practitioner utilisation in the haemophilia treatment centre (HTC): Global results from the haemophilia experiences, results and opportunities (HERO) study