Hemophilia Group Research Articles

Assessment of Self-Image With the Offer Self-Image Questionnaire in Adolescents With Hemophilia: A Single-Center Experience.

Hemophilia, which is a chronic illness associated with recurrent bleeding, may occur with psychosocial and behavioral problems. The aim of this study was to evaluate the clinical characteristics and demographic features and changes in the self-image of adolescents with hemophilia. Data about hemophilia type, the severity of hemophilia, secondary prophylaxis received, and annual bleeding rate (ABR) were recorded from patient files. Hemophilia Joint Health Score (HJHS) and the Offer Self-Image Questionnaire (OSIQ) (as a measure of self-esteem) were applied to hemophilia patients and a healthy control group. Thirty-two hemophilia patients (mean age=16.2±3.06 y) and 35 healthy male individuals (mean age=16.02±1.4 y) were enrolled in the study. Hemophilia patients had lower total OSIQ score than their peers (P=0.007). There was no difference between patients who received and who did not receive secondary prophylaxis (P=0.408) in terms of total OSIQ score. The median total OSIQ score of patients with pathologic HJHS (>0 points) was lower than that of patients with normal HJHS (0 points) (P=0.010). The median of ABR was 6 (range: 0 to 20) in the whole hemophilia group. There were no differences between hemophilia patients with ABR≤4 and >4 (P=0.084). All of the subscale parameters of the OSIQ were lower for hemophilia patients compared with their peers, besides one. The subscale of sexuality attitudes was better for hemophilia patients than for the healthy control group (P=0.028). Low self-esteem in hemophilia patients indicates the importance of lifelong psychosocial support. Patients with pathologic HJHS are at risk of low-esteem. Using OSIQ with HJHS during follow-up of hemophilia patients may be useful for management.

HLA-DRB1*01:01, but not HLA-DRB1:1503 or HLA-DRB1*11, is associated with decreased inhibitor risk in Iranian hemophilia A patients

Background/objectiveHemophilia A is a genetic disorder through which patients suffer from recurrent bleeding. This can be caused by a defect in human plasma coagulation factor VIII. High incidence of FVIII inhibitors in some severe hemophilia A patients after FVIII therapy is a considerable complication. Determination of good predictive factors can improve the safety of this treatment. HLA-II have been shown as a predictive element for inhibitor development. The goal of this study is to determine the association between HLA-DRB1*15:03, HLA-DRB1*11 and HLA-DRB1*01:01 alleles and FVIII inhibitors in severe hemophilia A patients in Iran. Materials/methodsHLA-DRB1 genotyping was performed using Multiplex sequences Specific Primers (PCR-SSP) in two groups of severe hemophilia A patients comprising 51 and 50 individuals with and without FVIII inhibitors respectively. The levels of inhibitor were determined through Nijmegen-modified Bethesda assay. HLA-DRB1 allele frequencies were compared between groups by using multiple logistic regression models. ResultsHLA-DRB1*01:01 allele frequency was significantly higher in patients without inhibitor ORadj: 2.7 (95%CI: 1.08, 6.97; P = 0.034). There wasn’t any statistically significant difference in HLA-DRB1*11 allele frequency between groups ORadj: 0.7 (95%CI: 0.27, 1.82; P = 0.47). There was no connection between HLA-DRB1*15:03 and inhibitor development ORadj: 0.94 (95%CI: 0.38, 2.35; P = 0.94). ConclusionAn association between HLA-DRB1*01:01 and paucity of FVIII inhibitor showed that this allele has probably a protective effect in severe hemophilia A patients in Iran. Determination of the predictive and protective alleles are beneficial in pre-treatment activities and decrease the risk of unsuccessful therapy with FVIII in each population.

Oral hygiene and dentition status in children and adults with hemophilia: A case-control study.

People with hemophilia constitute a significant proportion of the population and an oral health care professional faces a considerable challenge while treating them. This study aimed to assess the oral health and dentition status as well as fear of dental treatment in patients with hemophilia and compare it with age-matched healthy subjects. This single-center, case-control cross-sectional study was performed on 100 subjects with hemophilia and 100 age-matched healthy controls. Oral health and dentition status was recorded for all the subjects and scored using the simplified oral hygiene index (OHI-S), plaque index, and the dmft/DMFT index. There were a total of 41 children and 59 adults in the hemophilia group and 36 children and 64 adults in the healthy group. When compared to healthy subjects it was observed that individuals with hemophilia had higher debris and calculus scores which was indicative of poor orodental status. There was no significant difference observed in the DMFT scores among the study groups. The oral hygiene of the hemophilics was poorer when compared to the healthy controls. The findings highlight the need for establishing interdisciplinary care for such individuals.

Pedobarographic and stabilometric analysis and exercises for children with recurrent ankle haemarthrosis

Background/Aims: To investigate the dynamic plantar loading characteristics, postural stability and the effectiveness of an exercise programme in children with recurrent ankle haemarthrosis. Methods: In an exploratory study, 56 children with haemophilia (Group A) and 23 typically developing children (Group B) were initially assessed. Group A received a progressive exercise programme twice a week for 6 weeks in succession. Midstance plantar loading and the dynamic limit of stability were measured using Tekscan HR MatTM pressure measurement system and Biodex Balance System respectively. Findings: Heel pressure in Group A was significantly lower than Group B (P<0.05), whereas mid-foot, forefoot, and hallux pressure were significantly higher (P<0.05). Also, Group A showed poorer postural stability (P<0.05). Furthermore, a significant correlation between postural stability and plantar loading measures was indicated in Group A. Following the completion of 6 weeks of exercises, the plantar pressure (except the medial mid-foot) and postural stability (except the mediolateral stability) for Group A were not significantly different in comparison to Group B (P>0.05). Conclusion: Dynamic plantar loading provides a potentially valuable directory for the clinicians to understand variations of postural stability in children with ankle haemarthrosis. Further, adherence to a 6-week exercise rehabilitation programme might be helpful.

Evidence of pathogenicity of a mutation in 3' untranslated region causing mild haemophilia A.

Despite the high mutation detection rate, in a small group of haemophilia A patients, using current screening methods, no causal mutation in F8 can be detected. In such cases, the causal mutation might be in the non-coding sequences of F8. Rarely, mutations in non-coding sequences reveal a pivotal role. Here, we analysed a mild haemophilia A patient harbouring a mutation in the 3' untranslated region (UTR) of F8 and elucidated the molecular mechanism leading to haemophilia phenotype. To find the causal mutation, the complete F8 genomic region was analysed by next generation sequencing. The effect of the identified alteration on F8 expression was evaluated in silico and analysed for the splicing effect at mRNA level. Moreover, in vitro studies using a luciferase reporter system were performed to functionally analyse the mutation. We identified an alteration in the 3' UTR (c.*56G>T) as the only change in F8 gene. Pedigree analysis showed a segregation pattern for three affected members for the presumptive mutation. Moreover, the variant was predicted in silico to create a new donor splice site, which was also detected at mRNA level, resulting in a 159 bp deletion in 3' UTR of F8. Finally, the variant showed reduced expression of the gene reporter firefly luciferase in cell line expression analysis. Our results advocate the patient specific c.*56G>T base change in the 3' UTR to be a disease-associated mutation leading to alternative splicing explaining the mild haemophilia A phenotype.

175. Double-Layered Cell Sheets Transplantation That Achieves Durable Factor VIII Delivery in the Mouse Model of Hemophilia A

Hemophilia A is an inherited bleeding disorder caused by a deficiency of the procoagulant cofactor VIII (FVIII). Currently, the patients with hemophilia A are being treated through repeated intravenous injection of FVIII concentrates. Since FVIII is a secreted protein and the tight regulation of its expression is not necessary, ex vivo gene therapy strategies for hemophilia A might be good for the therapeutic alternative. We previously demonstrated that therapeutic levels of plasma FVIII were documented from hemophilia A mice over 300 days, in which lentivirally-engineered blood outgrowth endothelial cells (BOECs) sheet were implanted subcutaneously (Tatsumi K et.al. PLoS One 2013 8(12):e83280). To enhance the viability of the implanted BOECs which boost the FVIII expression, double-layered cell sheets transplantation was performed by placing the recovered BOECs sheet onto the fibroblast sheet directly. FVIII transduced BOECs and non-transduced fibroblasts were cultured on temperature-responsive culture dish independently. Both cells were recovered as a contiguous cell sheet. Subcutaneous co-transplantation studies of BOEC and fibroblast sheet indicated that all hemophilia A mice treated with cyclophosphamide expressed between 40-50 mU/mL levels of FVIII without developing anti-FVIII inhibitory antibodies over 200 days. In contrast, the hemophilia A mice without any prior immuno-suppressive treatment developed neutralizing anti-FVIII antibodies between 5-10 Bethesda units. These therapeutic FVIII levels were two times higher than the group of hemophilia A mice that were transplanted BOECs sheet alone. Histological examination in the part of the mice revealed that the combination of BOEC and fibroblast sheet was structured as flat clusters without any cells infiltration. In conclusion, tissue engineering approach using double-layered cell sheets are viable for persistent tissue survival and providing therapeutic values. This novel ex vivo gene transfer strategy can provide the safe and efficacious delivery of FVIII in hemophilia A and merits further assessment.

Analysis of Hemorrhagic Phenotype and Cardiovascular Risk of Severe Hemophilia a Carriers and Difference with Female Working Population Control Group

INTRODUCTIONRecent studies in male subjects with haemophilia have described a prevalence of cardiovascular risk factors (CVRF) and cardiovascular events (CVE) similar to the general population. This finding has not been tested in severe haemophilia A carriers so far. We have little information about whether there is a particular bleeding profile in this group and if this tendency is able to modify cardiovascular risk in these women. OBJECTIVESTo evaluate bleeding profile from laboratory and clinical point of view in haemophilia A carriers and working population controls; to define and to calculate CVRF, CVE and cardiovascular risk scores in severe haemophilia A carriers and controls; to analyse if there is any difference in cardiovascular risk between symptomatic severe haemophilia A carriers and general population. PATIENTS AND METHODSThis is a descriptive, cross-sectional, non interventional, single center study. Ethics Committee evaluation and written informed consent are requested to be included for carriers and controls. The target population are severe haemophilia A carriers from our area aged between 18 and 70 years old. The control group are women from regular health laboral checkings. We evaluate bleeding, ischemic and thrombotic personal and familiar history, bleeding profile (ISTH/SSC bleeding assessment tool, ISTH BAT), factor VIII (FVIII) genetic study, complete blood count, basic biochemistry, haemostasis (aPTT, PT, fibrinogen, platelet function tests, FVIIIc, FvWAg and FvWRCo, FXIII, homocysteine, resistence to APC, antithrombin, protein C and S, 20210A prothrombin mutation), cardiovascular risk (Framingham score and Systematic Coronary Risk Evaluation Project, SCORE). The controls have been studied in the same way with the exception of laboratory studies of hemostasis. Only in controls with pathologic ISTH BAT (greater than 3), basic and primary hemostasis have been studied. To describe continuous variables we will use mean, median, standard deviation, maximum and minimum. For categorical variables will be used the percentage of every category. RESULTSOut of a total of 81 carriers have been identified between August 2012 to December 2013. We have evaluated 69 carriers. To achieve a confidence level of 95% with 50% heterogeneity we have recruited 138 controls. The mean age of carriers and controls was 43.7+/-15 and 41.5 +/-11.7 years old (p 0.308). In the group of carriers, the mean and standard deviation (SD) of FVIII levels were 87.2+/-35.7%, FvW:RCo 75.6 +/-30% and vWF:Ag 75.6 +/-30, 1%. We found no relationship between levels of FVIII:c and haemophilia genetic defect (34.8% substitutions, 34.8% intron 22, 27.5% mutations). 20.3% of carriers and 2.2% of controls present a pathologic ISTH BAT score (p 0.001). The table describes CVRF and cardiovascular risk scores of carriers and controls. TableCARRIERSCONTROLSHigh Blood Pressure(HBP)17,4%5%0,001Smoking29%32,6%0,596Sedentariness55,1%37,7%0,025Diabetes8,7%2,9%0,069Metabolic Syndrome(ATPIII)14,5%8%0,143Dyslipemia14,5%12,8%0,474Overweight and Obesity50,7%34,8%0,027Framingham(median, IQR)2 (0,47-7,41)0,4 (0-3,75)0,001SCORE (median, IQR)1 (0,73-1,58)0 (0-0,71)0,001Family history ischemia66,7%28,3%0,001No personal CVE in carriers group. We found two cases of thrombophilia. They are two women from the same family with high homocysteine levels and family history of heart attack and stroke in haemophiliacs men. Most of family history of ischemia in carriers group comes from haemophiliac male relatives. Among controls only one patient has experienced heart attack and other a deep vein thrombosis. They both were older controls with CVRF. We have analysed separately the 14 symptomatic carriers (pathological ISTH BAT). This particular group has a similar Framingham score to general population but remains in a higher risk of death from vascular event (SCORE) compared to general population. CONCLUSIONSLow levels of FVIII do not prevent from developing vascular risk factors in syntomatic carriers of severe haemophilia A. In our media, we describe a higher prevalence of HBP, sedentariness, obesity and overweight in the group of carriers than in controls. The risk of suffering a cardiovascular event and the risk of death because of a cardiovascular events is higher in the group of severe hemophilia A carriers than in the working control population, even in symptomatic carriers. DisclosuresNo relevant conflicts of interest to declare.

Evaluation of joint findings with gait analysis in children with hemophilia

Hemophilic arthropathy due to recurrent joint bleeding leads to physical, psychological and socioeconomic problems in children with hemophilia and reduces their quality of life. The purpose of this study was to evaluate joint damage through various parameters and to determine functional deterioration in the musculoskeletal system during walking using kinetic and kinematic gait analysis. Physical examination and kinetic and kinematic gait analysis findings of 19 hemophilic patients aged 7-20 years were compared with those of age, sex and leg length matched controls. Stride time was longer in the hemophilia group (p=0.001) compared to the age matched healthy control group, while hip, knee and ankle joint rotation angles were more limited (p=0.001, p=0.035 and p=0.001, respectively). In the hemophilia group, the extensor moment of the knee joint in the stance phase was less than that in the control group (p=0.001). Stride time was longer in the severe hemophilia group compared to the mild-moderate hemophilia and control groups (p=0.011 and p=0.001, respectively). Rotation angle of the ankle was wider in the control group compared to the other two groups (p=0.001 for both). Rotation angle of the ankle joint was narrower in the severe hemophilia group compared to the others (p=0.001 for each). Extensor moment of the knee joint was greater in the control group compared to the other two groups (p=0.003 and p=0.001, respectively). Walking velocity was higher in the control group compared to the severe hemophilia group. Kinetic and kinematic gait analysis has the sensitivity to detect minimal changes in biomechanical parameters. Gait analysis can be used as a reliable method to detect early joint damage.

Abstract 568: Biomarkers of Hemostasis and Thrombosis in Hemophilia A and B Patients

The defective hemostatic process in hemophiliacs overlaps with the underlying physiology contributing to bleeding risk in anticoagulated patients. Hemophiliacs may also develop compensatory changes in fibrinolysis, platelet reactivity, vascular inflammation, and remodeling secondarily. We therefore explored markers for these processes in hemophilia A and B as part of our larger effort to develop translational biomarkers to guide antithrombotic therapy and minimize bleeding risk. Plasmas from hemophilia A patients (11 severe; 1 moderate) and hemophilia B patients (3 severe; 3 mild or moderate), sampled after a treatment washout period, and 7 normal subjects were procured. Markers/assays pursued include: coagulation (F1+2, FPA, TAT, D-dimer), fibrinolysis (PAP, PAI-1, tPA), platelet activation (soluble P-selectin (sP-sel)), vascular inflammation (MCP-1), angiogenesis (VEGF), PT, aPTT, and thrombin generation assay (TGA). Consistent with aPTT prolongation and changes in TGA, both hemophilia groups displayed numerically lower than normal levels of all 4 coagulation markers, with hemophilia A reaching statistical significance for F1+2 and TAT. Hemophilia A also exhibited a significant decrease in PAP and a numerical increase in PAI-1 compared to normal. VEGF and MCP-1 exhibited no appreciable difference. In the combined analysis for hemophilia A and B (“A+B”), PAP displayed a strong positive correlation with F1+2 and a strong negative correlation with PAI-1; A+B exhibited a statistically significant reduction in F1+2, FPA, and TAT, and a non-significant increase in sP-sel and non-significant decrease in PAP, compared to normal. In conclusion, hemophilia A and B plasma samples had significantly reduced markers of in vivo thrombin generation, thrombin activity, and coagulation, and trends evidencing increased platelet activation and decreased fibrinolysis, possibly as compensation. Lack of signal in vascular inflammation or angiogenesis could be due to the (near optimal) hemostatic therapies. Our results illustrate the potential value of biomarkers of in vivo coagulation, fibrinolysis, and platelet activation in translational research on antithrombotic therapies for both their efficacy and bleeding risk.

Vaccination in Health Care Workers Should be Following in our Country Now?!

Dear Editor, I read with interest the published article by Bayani et al. (1) in your esteemed journal recently. The topic is important for health policy makers to find better view regarding epidemiology of hepatitis A virus (HAV) infection in the community. HAV is an enteric transmitted infection and it is the most common of causes of acute viral hepatitis in Iran and the world (2-4). This HAV is a transmitted via fecal-oral route virus through person to person contact and contaminated water and food and the mode transmission is slightly different in various parts of the world according to its prevalence in each region. The reported data from Iranian different groups showed significant differences across the regions (2-5). Different in sewage disposal with secondary contamination of drinking water and foods are the reason for this difference. Bayani et al. (1) reported the significantly increase in sero-prevalence with age, 77.4% for 30-39 years and 85.3% for more than 40 years. less prevalence in lower age has confirmed in other studies in general populations from different parts of Iran (5). Considering that the disease has more severe course as age increases, improvement of standard hygiene and prevention strategies are recommended. Furthermore, vaccination may play a significant role in the occupational health policy to protect the susceptible health care workers population in the future (6). Karimi Elizee et al. (7) reported higher rate of anti-HAV antibody in thalassemia patients in comparison with hemophilia group and they concluded that other risk for transmission in hospitalization and receiving more blood may be affective in this differences. I would like to refer to Bayani et al. (1) that they are right and other risk factors for acquiring in health care workers should more be attend by health policy makers. Around to 30% of the health workers have been seronegative and are still at risk of HA infection development. I would like to sensitize the nurses and other health care workers to be more aware and careful in approach to acute viral hepatitis patients in medical wards. Finally I would like to mention that adding to educational approach for health care workers and more attending to health precautions during work, vaccination of non-immune individuals against HAV infection in this high risk group is wisdom strategy now (8, 9). Vaccination against HAV can prevent from morbidity and mortality due to acute fulminant hepatitis and it can prevent HAV will not spread in the society, and this will decrease the probability of HAV outbreak (10). It is important to follow other studies to find the cost-benefit of screening before vaccination in future.

Outcomes In Adult Hemophilia and Von Willebrand Disease Patients Undergoing Surgical and Invasive Procedures

IntroductionAdults with hemophilia and von Willebrand disease (VWD) frequently require surgical and invasive procedures. There is variability in current practice of peri-operative management in major surgery and in the management of invasive procedures. The purpose of this study was to evaluate outcomes and management strategies in patients with hemophilia and VWD undergoing surgical and invasive procedures in a comprehensive hemophilia center at a tertiary care hospital. MethodsA retrospective review of electronic medical records was carried out from patients with hemophilia and VWD seen at the Weill Cornell Hemophilia Treatment Center undergoing surgery or an invasive procedure from January 2006 to December 2012. Information on demographics, diagnosis, severity, and presence of inhibitors was also collected.Procedures and treatment strategies were reviewed including the type of procedure, use of factor bolus/DDAVP, continuous infusion(CI), and antifibrinolytics. Outcomes from these cases were reviewed for acute bleeding (<48 hours after procedure), delayed bleeding (>48 hours after procedure), transfusion of blood products, inhibitor development, and post-procedure thrombosis. Data were compared using Fischer's exact test. ResultsOur study population consisted of 59 patients (mean age=58, range 21-77). Our hemophilia group included 41 with hemophilia A and 7 with hemophilia B. Our hemophilia patients were severe (n=24), mild-mod (n=12), and 12 had inhibitors. We also identified 5 female carriers of hemophilia A.We identified 6 VWD patients including Type 1 (n=3), 2A (n=1), 3 (n=2). We reviewed 34 major surgeries (26 orthopedic, 8 non-orthopedic) and 91 invasive procedures. We covered all patients an initial dose of either factor VIII/IX or DDAVP. In addition, 55.9% of major procedures were covered by continuous factor infusion (CI), whereas only 9.9% of minor procedures were covered by CI. Conversely, antifibrinolytics were used in 14.7% of major surgeries and 34.1% of minor procedures. Antifibrinolytics were used in all types of minor procedures except those involving the genitourinary tract.Hematologic outcomes are shown in Table 1. We identified 4 cases of acute bleeding and 10 cases of delayed bleeding. We also identified 5 cases of inhibitor development. We identified one thrombotic episode in an orthopedic surgery case. We further examined several classes of procedures including dental, GI endoscopies, GU procedures, biopsies, and GYN procedures in carriers. One transfusion was needed in the case of a liver biopsy; acute bleeding was noted in 2 biopsies and 1 endoscopy. Delayed bleeding accompanied 28.6% of GU procedures and 16.1% of dental procedures. Inhibitor development was noted after 1 GU procedure and 2 dental procedures.MAJORMINORSurgical OutcomeOrthopedic SurgeryNon-orthopedic SurgeryDentalGI EndoGU ProcBxGYNN268311714245Transfusion1000010Acute bleeding1001020Delayed bleeding0050410Inhibitor development2020100Thrombosis1000000Treatment UseBolus268291313226Continuous infusion16325011Antifibrinolytics41243021Surgical OutcomeAll Major SurgeriesAll minor proceduresP-ValueN3491Transfusion11P=0.47Acute bleeding13P=0.99Delayed bleeding010P=0.06Inhibitor development23P=0.62Thrombosis10P=0.27 ConclusionsOur adult hemophilia and VWD population undergoing minor procedures showed similar rates of adverse hematologic outcomes compared to major surgery. This finding highlights the significant risk of even minor procedures in adults with bleeding disorders. Appropriate treatment standards should be designed to take into account patient responses, procedure type, and anticipated outcomes. Disclosures:No relevant conflicts of interest to declare.

The Seroprevalence of Entrically Transmitted Viral Hepatitis in HCV Infected Thalassemia and Hemophilia Patients in Iran

Background: Hepatitis A and E virus (HAV and HEV) infections are acute and self-limited diseases that usually spread through oral-fecal route. Also, blood transfusion as a possible route of entrically transmitted hepatitis has been suggested. Hemophilia and thalassemia patients are highly at risk of transfusion-transmissible viruses (HBV, HCV, and HIV). Any superimposed infection with other viral hepatitis (in particular hepatitis A) cause active liver failure in hemophilia and thalassemia patients. Objectives: The aim of this study is to consider seroprevalence of anti HAV and HEV antibodies (Ab) in thalassemia and hemophilia patients with chronic hepatitis C in Iran. Patients and Methods: In a cross-sectional study and under general census sampling, sera of 219 thalassemia and hemophilia patients infected with HCV were examined in Tehran Hepatitis Center (THC) between 2009 and 2010. Enzyme-linked immunisorbentassey (ELISA) was done to observe anti HAV and HEV IgG Ab. Patients were chosen from all provinces of Iran. Results: Anti-HAV IgG antibodies were observed more frequently in thalassemia patients (60/64; 93.8%) than in hemophilia patients (104/155; 67.1%, P < 0.001). The seroprevalence of both antibodies increased with age. Among thalassemia patients, there was no significant association between HAV seropositivity and other variables, but in hemophilia group, seropositive patients were significantly older than seronegative group (P < 0.05). Totally, anti HEV Ab (1/64; 1.6% thalassemia and 5/155; 3.2% hemophilia) was seropositive in six patients. There was no significant association between HEV infection and other variables in thalassemia patients, however, in hemophilia patients, HEV positive ones were significantly older than HEV negative group (P=0.01). Conclusions: Vaccination of non-immune individuals against HAV infection in high risk groups especially hemophilia and thalassemia patients is recommended. Results did not show any differences about seroprevalence of HEV among Iranian general population.

Deep intronic ‘mutations’ cause hemophilia A: application of next generation sequencing in patients without detectable mutation in F8 cDNA

In a small group of typical hemophilia A (HA) patients no mutations in the F8 coding sequence (cDNA) could be found. In the current study, we performed a systematic screening of genetic and non-genetic parameters associated with reduced FVIII:C levels in a group of mostly mild HA (only one moderate) patients with no detectable mutations in F8 cDNA. We determined FVIII and VWF activity and antigen levels and performed VWF-FVIII binding (VWF:FVIIIB) and VWF-collagen binding assays (VWF:CB) as well as VWF multimer analysis. VWF was completely sequenced to exclude mutations. The F8 locus, including the introns, was sequenced using overlapping long-range PCRs (LR-PCRs) combined with a next generation sequencing (NGS) approach. Moreover, the F8 mRNA was analyzed quantitatively and qualitatively by real-time PCR (qRT) and overlapping reverse transcription (RT) PCRs, respectively. All VWF tests were normal. The LR-PCRs demonstrated the integrity of the F8 locus. Eight unique polymorphisms were found in the patients, with two being recurrent. Furthermore, RT-PCRs analysis confirmed that two of the unique variants create detectable new cryptic splice sites in the patients that result in the introduction of intronic DNA sequences into the mRNA and create premature stop codons. By systematically excluding all possible causes of HA, we could with great certainty conclude that deep intronic mutations in F8, although rare, cause abnormal mRNA splicing, leading to mild HA.

The effect of neutral-cushioned running shoes on the intra-articular force in the haemophilic ankle

BackgroundThe ankle continues to be one of the most affected joints in the haemophilia patient, and as cartilage damage progresses, the joint can feel unstable, painful and stiff. Anecdotally, patients often report that sports trainers can improve their pain and daily function, however the actual mechanism for this remains unclear. MethodsNine patients with ankle haemarthropathy and three controls were examined using ‘CODAmotion’ analysis and a force plate. Kinematic and kinetic variables of the hip, knee and ankle were recorded. Data was imported from CODA to Excel, where a programme using 2D modelling of the ankle joint forces was employed. This calculated intra-articular force from heel strike to toe-off. FindingsThe haemophilia group at midstance showed an increase in intra-articular force in the ankle when wearing the trainer compared to the shoe (P=<0.05). Overall the haemophilia cohort had an increased joint force in both the trainers and shoes, compared to controls. InterpretationThe type of footwear worn by individuals with ankle arthropathy has a significant effect on the amount of force acting at the joint surface. Sports shoes, in providing better comfort and foot support, may facilitate an increased muscular activity around the ankle and therefore improved dynamic joint stability, accounting for why some patients with ankle arthropathy report less pain. Further research is needed to establish levels of acceptable force and the combined effects of orthotics and footwear.

PM.33 The Obstetric Management of Haemophilia Carriers and Patients with Von Willebrand’s Disease in Leeds

Background Haemophilia and von Willebrand’s disease (vWD) are inherited bleeding disorders that present significant obstetric challenges, including risks of neonatal intracranial haemorrhage and postpartum haemorrhage (PPH). The ideal mode of...

The effects of repetitive haemarthrosis on postural balance in children with haemophilia

Sensory information from visual, vestibular and proprioceptive systems is necessary to control posture and balance. Impairment in proprioception due to repetitive joints bleeding may lead to a deficit in postural balance which, in turn, leads to high joint stress and risk of bleeding recurrence. Despite the increase in attention in this field during the past few years, the data concerning to how bleeds can affect postural control in children with haemophilia (CWH) remain scarce. This study aimed to evaluate the postural balance in CWH. Twenty CWH Haemophilia Group (HG) and 20 age-matched children Control Group (CG) were recruited to this study. A force plate was used to record centre of pressure (COP) displacement under four different postural conditions during quiet standing: eyes open on firm surface, eyes open on foam surface, eyes closed on firm surface and eyes closed on a foam surface. Variables of COP as sway area and mean velocity and in anterior-posterior (y) medio-lateral (x) direction were processed and for each variable sensory, quotients were calculated and compared between groups. No differences were found in visual and vestibular quotients variables between groups. A higher value was found in sway area variable on proprioception quotient in the HG when compared with CG (P = 0.042). CWH with repetitive joint bleed on lower limbs showed differences in postural balance when compared with non-haemophiliac children. The identification of early balance impairments in CWH can help us understand better the effects of bleeds inside joints on postural control and plan a more effective preventive and rehabilitative treatment.

More than a decade of international experience with a pdFVIII/VWF concentrate in immune tolerance

Approximately 20-30% of patients with severe haemophilia A develop alloantibodies ('inhibitors') to infused FVIII rendering use of such replacement therapy ineffective. Once an inhibitor emerges, immune tolerance induction (ITI) is the standard treatment. ITI involves giving regular doses of FVIII concentrate to eradicate the inhibitor and achieve immunogenic acceptance of administered FVIII. In the early 2000s, a retrospective analysis of inhibitor patients treated at a single centre in Germany indicated that success rates were higher when patients were treated with von Willebrand factor (VWF)-containing plasma-derived FVIII (pdFVIII/VWF) concentrate compared with recombinant or non-VWF-containing pdFVIII products. Importantly, pdFVIII/VWF as rescue therapy was able to convert 8 of 10 patients who had failed primary ITI with recombinant or non-VWF-containing pdFVIII product. A subsequent study from Italy in patients with poor prognostic factors for ITI success also reported good success rates with pdFVIII/VWF as rescue therapy (53% success; 41% partial success). The Grifols-Immune Tolerance Induction (G-ITI) Study represents the largest group of haemophilia A inhibitor patients treated with a single pdFVIII/VWF concentrate (Alphanate(®)/Fanhdi(®)) to be reported to date. Data have been collected for 95 patients who underwent primary or rescue ITI at 46 centres in Europe and the US. Currently, published data are available for 33 patients in the US cohort (11 centres), and data from the European cohort are being analysed. Both groups contained patients with poor prognostic factors and most patients received a high-dose regimen (≥ 100 IU pdFVIII/VWF kg(-1) daily). As expected, the success rate was better for primary vs. rescue ITI and for patients with good vs. poor prognostic factors. However, more than half the patients in the US cohort receiving rescue ITI achieved success (33% complete success; 20% partial success). These results should encourage clinicians to consider the use of pdFVIII/VWF concentrates for rescue ITI. Published outcomes data from the total global G-ITI cohort (95 patients) are awaited with anticipation.

Transfusion Transmitted Hepatitis: Where Do We Stand Now? A One Center Study in Upper Egypt

: Background: Despite progress made in the prevention of transfusion-transmitted infections (TTI) over the last few years, they continue to be a problem in many parts of the world, particularly in multitransfused patients.Objectives: The aim of this study was to estimate the prevalence of hepatitis B virus (HBV), hepatitis C virus (HCV), and to evaluate the screening and vaccination program among our cohort of multitransfused children from Qena, Upper Egypt.Patients and Methods: One-hundred children suffering from diseases requiring repeated blood transfusions were included in the study. They were classified into group 1, which included 67 children with thalassemia, and group 2, which included 33 children with hemophilia. Screening for hepatitis B surface antigen, hepatitis B surface antibody, hepatitis B core antibody and antibody to HCV was done using a second-generation enzyme-linked immunosorbent assay technique.Results: Only 12% of all patients were either acutely or chronically infected with HBV. 46% were immune due to previous vaccination, whereas 39% of patients were not protected from HBV infection. HCV antibodies were positive in 45% of cases. Seventy-eight patients had a complete hepatitis B vaccination in the form of three doses as documented by birth certificate. Thirty-six patients mentioned history suggestive of hepatitis. The prevalence of the studied hepatitis markers was similar in both the thalassemia and hemophilia groups of children.Conclusions: Transfusion-transmitted hepatitis is still a major problem for multitransfused children in Egypt. More effort is required to reduce the infection rate through proper screening of blood and blood products, strict emphasis on receiving the vaccine, regular follow-up for those children with a hepatitis B antibody titer, and providing booster doses for those in need. Implication for health policy/practice/research/medical education:As Egypt is a country of intermediate prevalence regarding HBV and of high prevalence regarding HCV infection, great effort should be made to prevent and control these infections .updating the knowledge about the prevalence of these infections particularly among the high risk groups is important to assess the efficacy of preventive measures and to highlight weak points in the strategy aiming to decrease the infection rate. This study is recommended to all clinicians involved in treatment of polytransfused patients for better outcome. Please cite this paper as:El-Faramawy AA, El-Rashidy OF, Tawfik PH, Hussein GH. Transfusion Transmitted Hepatitis: Where Do We Stand Now? A One Center Study in Upper Egypt. Hepat Mon. 2012;12(4): 286-291. DOI: 10.5812/hepatmon.852 Copyright © 2012 Kowsar Corp. All rights reserved.

Transfusion transmitted hepatitis: where do we stand now? A one center study in upper egypt.

Despite progress made in the prevention of transfusion-transmitted infections (TTI) over the last few years, they continue to be a problem in many parts of the world, particularly in multitransfused patients. The aim of this study was to estimate the prevalence of hepatitis B virus (HBV), hepatitis C virus (HCV), and to evaluate the screening and vaccination program among our cohort of multitransfused children from Qena, Upper Egypt. One-hundred children suffering from diseases requiring repeated blood transfusions were included in the study. They were classified into group 1, which included 67 children with thalassemia, and group 2, which included 33 children with hemophilia. Screening for hepatitis B surface antigen, hepatitis B surface antibody, hepatitis B core antibody and antibody to HCV was done using a second-generation enzyme-linked immunosorbent assay technique. Only 12% of all patients were either acutely or chronically infected with HBV. 46% were immune due to previous vaccination, whereas 39% of patients were not protected from HBV infection. HCV antibodies were positive in 45% of cases. Seventy-eight patients had a complete hepatitis B vaccination in the form of three doses as documented by birth certificate. Thirty-six patients mentioned history suggestive of hepatitis. The prevalence of the studied hepatitis markers was similar in both the thalassemia and hemophilia groups of children. Transfusion-transmitted hepatitis is still a major problem for multitransfused children in Egypt. More effort is required to reduce the infection rate through proper screening of blood and blood products, strict emphasis on receiving the vaccine, regular follow-up for those children with a hepatitis B antibody titer, and providing booster doses for those in need.

Co-Administration Therapy Modulates Immunity to FVIII In Hemophilia A Mice

Abstract 1219Our long-term objective is the development of novel therapies for the safe and effective treatment of hemophilia. In particular a safe and economic prophylactic modality to prevent inhibitors development is therefore highly desirable. To this end we have explored strategies to modulate inhibitor development based on the co-administration of FVIII with other proteins, specifically albumin and IVIG. We hypothesise that such co-administration may modulate immunity to FVIII and result in a safe and cost-effective therapy. Based on some published evidence that FIX and vWF may have a modulatory effect on FVIII, we reasoned that perhaps albumin might also play an immunomodulatory effect on FVIII. We have developed a protocol for infusing recombinant FVIII in hemophilia A mice modelled on the current therapy of hemophiliacs, and in response to this protocol hemophilia mice develop high titre of inhibitors. Thus, this model can be used to assess potential immununomodulatory strategies.Groups of hemophilia A mice (n=5) were infused weekly IV with 2IU rFVIII for a total of 4 weeks. Three of these groups of mice were also administered human albumin (either 25mg IV, 25mg IP, or 500mg IV) at the same time as FVIII. Mice were bled before the treatment and weekly for the 4 weeks, and total antibodies to FVIII were detected by ELISA. Importantly, while mice receiving FVIII had high antibody titer and were in good health, there was significant mortality in the mice treated with FVIII and albumin. Interestingly, the surviving mice had a very low antibody titre, statistically significant from mice receiving only rFVIII.Given the mortality, another experiment was designed to test the effect of reduced doses of albumin. Groups of hemophilia A mice (n=5) were infused IV with a weekly injection of 2IU rFVIII for a total of 4 weeks supplemented with either 25μg, 50μg or 100μg of human albumin. Mice were bled at weekly intervals until the end of the experiment (day 28), and the titre of anti-FVIIII antibodies was determined. Most All mice survived the entire treatment and were found in good health. Further, the FVIII antibody titre in the group that received albumin was detectable, but significantly reduced with respect to the mice that received only FVIII. Marked variability among individual mice was observed.A group of hemophilia A mice (n=5) received weekly IP injections of 2IU rFVIII. Another group of mice received the same regimen of FVIII in addition to human IVIG (1g/kg). A third group of hemophilia mice received 2IU rFVIII and a higher dose of human IVIG (2g/kg). These doses mimic the established human IVIG regimen. Mice were bled before treatment and at weekly intervals thereafter. The titre of anti-FVIII antibodies in mice was determined by ELISA. By day 21, the antibody titre in mice injected with FVIII was high, as expected. In contrast, the titre in mice receiving FVIII and IVIG was low, and comparable to that of all the mice prior to the treatment (na•ve mice), strongly suggesting an immune modulatory effect by IVIG (Figure 1). Our data supports the limited use of IVIG to treat inhibitors. [Display omitted] Our findings suggest that co-administration of FVIII with albumin and IVIG can modulate the humoral immune response to recombinant human FVIII in hemophilia mice. Further, the observed effect appears to be dependent on the dose of albumin co-administered. It is hypothesized that the observed modulation is due to antigen competition, as previously speculated. Importantly, while IVIG was well tolerated by mice, very serious adverse effects were observed in mice treated with high doses of albumin. Interestingly, even the high dose used represents a small fraction of the physiological levels of albumin in human plasma, which is 3–5 g/dL. IVIG, in contrast, is a known modulator of the immune response in humans, and the study of this modulatory effect in a hemophilia mouse may lead to novel therapeutic strategies, relevant for the management of hemophilia. Disclosures:No relevant conflicts of interest to declare.