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Introduction: von Willebrand disease (VWD) is an inherited bleeding disorder caused by a quantitative or qualitative dysfunction of von Willebrand factor. Clinicians, patients and other stakeholders have many questions about the diagnosis and management of the disease. Aim: To identify topics of highest importance to stakeholders that could be addressed by guidelines to be developed by the American Society of Hematology (ASH), the International Society on Thrombosis and Haemostasis (ISTH), the National Hemophilia Foundation (NHF) and the World Federation of Hemophilia (WFH). Methods: A survey to determine and prioritize topics to be addressed in the collaborative development of guidelines for VWD was distributed to international stakeholders including patients, caregivers and healthcare providers (HCPs). Representatives of the four organizations coordinated the distribution strategy. The survey focused on both diagnosis and management of VWD, soliciting 7-point Likert-scale responses and open-ended comments, in English, French and Spanish. We conducted descriptive analysis with comparison of results by stakeholder type, gender and countries' income classification for the rating questions and qualitative conventional content data analysis for the open-ended responses. Results: A total of 601 participants responded to the survey (49% patients/caregivers and 51% healthcare providers). The highest priority topics identified were diagnostic criteria/classification, bleeding assessment tools and treatment options for women and surgical patients. In contrast, screening for anaemia and differentiating plasma-derived therapy versus recombinant therapies received lower ratings. Conclusion: This survey highlighted areas of importance to a diverse representation of stakeholders in the diagnosis and management of VWD, providing a framework for future guideline development and implementation.

Introduction From 2012 to 2014, a total of 17 family child care homes participated in a multisector, community-wide initiative to prevent obesity. Strategies included staff workshops, materials, site visits, and technical assistance regarding development and implementation of nutrition policies. The purpose of the evaluation was to examine the impact of the initiative on family child care home nutrition-related policies and practices and child dietary intake. Study design Pre- and post-intervention without control group. Measures taken at baseline and follow-up included structured observations and questionnaires regarding nutrition policies, practices, and environments; documentation of lunch foods served on 5 days; and lunch plate waste observations on 2 days. Paired t-tests were used to determine the significance of change over time. Setting/participants Seventeen family child care homes in a low-income diverse community in Northern California; children aged 2–5 years who attended the family child care homes. Main outcome measures Change in nutrition-related policies and practices, lunch foods served and consumed. Results Data was collected at 17 sites for an average of 5.2 children aged 2–5 years per site per day at baseline and 4.6 at follow-up for a total of 333 plate waste observations. There were significant increases in staff training, parental involvement, and several of the targeted nutrition-related practices; prevalence of most other practices either improved or was maintained over time. There were significant increases in the number of sites meeting Child and Adult Care Food Program meal guidelines, variety of fruit and frequency of vegetables offered, and reductions in frequency of juice and high-fat processed meats offered. Adequate portions of all food groups were consumed at both time points with no significant change over time. Conclusions A simple, policy-focused intervention by a child care resource and referral agency was successful at reinforcing and improving upon nutrition-related practices at family child care homes. Children consumed adequate, but not excessive, portions of the balanced meals served to them, suggesting there is no reason to offer unhealthy options. Supplement information This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

The objective of this scoping review is to summarize the current use of pharmacokinetics for tailoring prophylaxis in hemophilia patients switching between clotting factor products. Patients with hemophilia may require switching of clotting factor concentrates due to a variety of factors, but there have been perceived risks associated with switching, such as inhibitor development or suboptimal protection due to inadequate dosing while titrating treatment. Studies that look at patients switching from one clotting factor concentrate to another are categorized in terms of their primary and/or secondary objectives, notably biosimilarity and comparative pharmacokinetic studies and inhibitor development studies. Research on how best to switch concentrates with respect to dosing regimen are lacking, and currently a trial-and-error approach is used for dosing the new factor concentrate. In the future, studies looking at the predictability of pharmacokinetics (PK) of a new factor concentrate based on individual PK knowledge of the original factor concentrate may offer clinical benefit by providing a safer switching approach and protocol.

Guidelines state that Ringer’s lactate (RL) should not be co-administered with packed red blood cells (PRBC) due to a potential risk of clotting. The purpose of this study was to determine whether RL causes clotting in PRBC with the currently used preservative, saline-adenine-glucose-mannitol (SAGM). Phase 1: Samples from 12 units of SAGM-PRBC were diluted from 0-97.5% with RL and normal saline (NS), incubated for 30 min, and passed through 40 μm filters. Additional samples were frozen and batch analyzed using an enzyme-linked immunosorbent assay (ELISA) to measure prothrombin activation fragment 1 + 2 (F1 + 2), indicative of thrombin generation. Packed red blood cells were also diluted, flushed with crystalloid using a rapid transfusion model, and filtered. Phase 2: Eight further units were serially diluted with RL and incubated for 30, 60, 120, 180, and 240 min. Fresh samples were analyzed by filtration and ELISA. Phase 1: No clotting was seen during filtration or using the transfusion model with NS or RL. The F1 + 2 ranged from 2.28 to 154.37 pmol·L−1 in NS dilutions and from 2.80 to 1675.93 pmol·L−1 in RL dilutions, indicating coagulation in some samples. Phase 2: No clotting was observed within 60 min by filtration or ELISA. However, 4 of the 8 units showed clots in the filters of some dilutions between 120 and 240 min. No clotting was detected at any dilution of RL with SAGM- preserved PRBC within 60 min, but clotting was detected with extended incubation. The results indicate RL can be safely co-administered with PRBC during rapid transfusion (

In this article I suggest ways in which a gorgeously crafted, colourful, compelling 20th century painting of an abandoned Ariadne highlights both her tragic and comic presence in classical literary representations. Joseph Southall's 1925-6 work Ariadne in Naxos (tempera on linen, 83.5 x 101.6 cm), can be viewed in all its glory in the Birmingham City Art Gallery (bequeathed by the artist's widow, Anne Elizabeth, in 1948) but it was featured to fine effect in the 2007 exhibition The Parrot in Art: From D rer to Elizabeth Butterworth, Barber Institute of Fine Arts, University of Birmingham. It was in this psittacine (psittaceous?) context that I first encountered Ariadne's parrot so the bird perhaps loomed larger in the painting than it might as a stand-alone Southall on its home ground in the Gallery. The very presence of the parrot in this painting suggests a symbolic array to those familiar with Ariadne's mythical traditions and simultaneously attuned to the possibilities of the parrot as a trickster in both visual and written texts. Southall's painting with its foregrounding of the parrot functions as a mnemonic for Ariadne's portrayal in the poetry of Catullus and Ovid. For this reason, Southall's painting would provide stimulating seminar material, being both a visual feast and a discussion point for Ariadne's literary registers.

Purpose. To test whether implementing a staff wellness program affects the nutrition and physical activity environment at child care centers. Design. Quasi-experimental controlled trial. Setting. Child care centers in low income neighborhoods in California. Subjects. Eighty-two staff members at 13 centers completed the study. Intervention. Intervention and control groups received training and education about nutrition and physical activity. The intervention group also participated in a worksite wellness program. Measures. Staff members' personal health habits, self-efficacy in working with families on nutrition and physical activity, and changes in children's food and physical activity environments were assessed. Analysis. Statistical software was used to analyze change scores for pre-post measures and to test differences for end point—only measures. Results. Although significant differences in staff members' personal health behaviors were not observed, staff from intervention sites exhibited more positive changes in their comfort level in talking to parents about nutrition and physical activity. Intervention sites reported providing more fresh fruits (p = .004) and vegetables (p = .03) to children as part of regular meals and snacks and serving more fresh fruits (p = .05) at children's celebrations. Control sites reported greater increases in sweetened foods (p = .02) and sweetened beverages (p = .05) at children's celebrations. Conclusion. The wellness intervention shows promise in improving the children's food environment in a child care setting.

The lively debate about the function of the fable of Cupid and Psyche in the Metamorphoses of Apuleius is continually expanding. On the narrative level, they act like pairs of star-crossed lovers in the Greek Romance tradition, but by designating them ‘Love’ and ‘Soul’ Apuleius has invited philosophical, religious and loosely symbolic interpretations of this inset story. The ambiguity surrounding Cupid and Psyche (characters or concepts) is complicated and enriched by the storyline which concerns the falling in love of Love and the falling in love with Love by Soul (the respective states.of the hero and heroine). By making the Love God suffer the passion he inflicts upon other gods and upon mortals, Apuleius fulfils the sometimes heartfelt but more usually tongue-in-cheek desire of the elegiac poets to punish their tormentor. At the same time, Psyche (Soul) becoming besotted with Love has more serious implications in Platonist doctrine and her actions throughout the story and her ultimate fate have been read both positively and negatively by Apuleian scholars.

A reference genotyping laboratory was established in 2000 at Queen's University, Kingston, to provide genetic testing for Hemophilia A (HA) and B (HB) and create a Canadian mutation database. Canadian hemophilia treatment centers and genetics clinics provided DNA and clinical information from November 2000 to March 2011. The factor VIII (F8) gene was analyzed in 1,177 patients (47% of HA population) and 787 female family members and the factor IX (F9) gene in 267 patients (47% of HB population) and 123 female family members, using Southern Blot, PCR, conformation sensitive gel electrophoresis, and/or direct sequencing. The mutation detection rates for HA and HB were 91% and 94%, respectively. 380 different F8 mutations were identified: inversions of intron 22 and intron 1, 229 missense, 45 nonsense, eight deletions, 70 frameshifts, 25 splice site, and one compound mutation with a splice site and intron 1 inversion. Of these mutations, 228 were novel to the Hemophilia A Database (HADB, http://hadb.org.uk/). A total 125 different F9 mutations were identified: 80 missense, 12 frameshift, 12 splice site, nine nonsense and seven promoter mutations, three large deletions, and two compound mutations with both missense and nonsense changes. Of these mutations, 36 were novel to the International Haemophilia B Mutation database (http://www.kcl.ac.uk/ip/petergreen/haemBdatabase.html). The Canadian F8 and F9 mutation database reflects the allelic heterogeneity of HA and HB, and is similar to previously described populations. This report represents the largest and longest duration experience of a national hemophilia genotyping program documented, to date.

Summary von Willebrand's disease (VWD) patients undergoing major surgery are prophylactically treated to promote haemostasis. There is variability in perioperative clinical practice; however, most guidelines suggest replacing the deficient factor to a level of 1.0 IU mL−1 (or 100%). A review of the literature reveals a paucity of well constructed descriptive data quantifying the changes in coagulation that occur in response to surgical stress. The aim of this study was to quantify the changes in haemostatic variables occurring in response to elective orthopaedic surgery in normal individuals. Eligible subjects >18 years of age undergoing total hip or knee replacement were recruited. Blood samples were drawn at five time points: baseline, preoperatively, 30 min after surgical incision, 30 min postoperatively, postoperative day (POD) 1. Analyses included t-tests and repeated measures anova. Overall 30 patients, 21 women and 9 men, with a mean age of 65 were included in the final analysis. All von Willebrand factor (VWF) variables were seen to significantly decrease intraoperatively and increase postoperatively. VWF multimers showed a statistically significant decrease in high molecular weight multimers intraoperatively and an increase postoperatively. On subgroup analysis, age, gender and anaesthesia type were significantly correlated with changes in VWF parameters. Data presented in the current study establish a physiological baseline for VWF parameters in the normal population and demonstrate mean VWF/factor VIII levels greater than 1.0 IU mL−1 intraoperatively. As such, current management in VWD patients does not appear to mimic the normal physiological response to surgery.

Background: Nearly two million California children regularly spend time in child care. surprisingly little is known about the nutrition environments of these settings. the aim of this study was to compare foods and beverages served to 2- to 5-year-olds by type of child care and participation in the federally funded Child and Adult Care Food Program (CACFP). Methods: A statewide survey of child care providers ( n = 429) was administered. Licensed child care was divided into six catego - ries: Head start centers, state preschools, centers that participate in CACFP, non-CACFP centers, homes that participate in CACFP, and non-CACFP homes. Results: CACFP sites in general, and Head start centers in particular, served more fruits, vegetables, milk, and meat/meat alterna - tives, and fewer sweetened beverages and other sweets and snack-type items than non-CACFP sites. Reported barriers to providing nutritious foods included high food costs and lack of training. Conclusions: CACFP participation may be one means by which reimbursement for food can be increased and food offerings improved. Further research should investigate whether promoting CACFP participation can be used to provide healthier nutrition environments in child care and prevent obesity in young children.

Purpose: There have been numerous reports with evidence detailing the presence of non-stereoscopic or “monocular”clues in commonly used stereoacuity tests. The purpose of this study was to quantify the influence of monocularclues in the Titmus, Randot®, Randot® Special Edition, Randot® Preschool, Lang, Lang II, and Frisby stereoacuitytests. Stereoacuity testing is typically performed and/or interpreted by eye care professionals and other health/occupational professionals. Methods: Two separate prospective studies were conducted. The first assessed the monocular responses of 100subjects aged 8 to 67 with normal stereoacuity, and no previous exposure to any of the seven tests administered.The second assessed the monocular responses of 33 subjects aged 8 to 65 with longstanding, manifest, horizontalstrabismus of 20 prism diopters or greater, on the aforementioned stereotests. Results: Monocular clues were found to be present for the normal group on the Titmus (61%), Randot® (6%), Randot®Special Edition (5%), Randot® Preschool (7%), Lang (13%), and Lang II (37%). Monocular clues were found to be presentfor the strabismic group on the Titmus (100%), Randot® (9%), Randot® Special Edition (9%), Randot® Preschool (12%),Lang (3%), and Lang II (27%). There was no monocular identification for either group on the Frisby stereotest, butthere was minimal binocular identification by a subject with manifest strabismus. Conclusion: Monocular clues were present for both the normal and strabismic group on 6 of the 7 stereotestsinvestigated. Based on these findings the authors conclude that caution must be used when interpreting patientresponses on the 7 aforementioned stereotests.

Ringer's lactate (RL) may be preferable to normal saline (NS) for large volume resuscitation. Authorities recommend against its mixture with packed red blood cells (PRBC) due to a theoretical risk of clotting. The purpose of this study was to test whether RL, as compared with NS, leads to a risk of clotting when used to dilute AS-3 preserved PRBC in a clinically relevant model.Following Ethics Board approval, eight units of unused, unexpired AS-3 preserved PRBC were obtained. Four sets of two parallel studies were performed, comparing RL with NS as the diluent for PRBC. The mixtures were infused using gravity flow through standard blood filter tubing and fluid warmer, to simulate an intraoperative blood transfusion. A series of progressively more dilute samples was collected. These were filtered and analyzed macroscopically, then using enzyme-linked immunosorbent assay to quantify the amount of F1+2 (the breakdown products of thrombin generation).No filters in any of the NS and RL mixtures contained evidence of clot or debris. In the NS group, the F1+2 levels ranged from 2.7 to 38.0 pmol x L(-1). In the RL group, the F1+2 levels ranged from 3.2 to 289.7 pmol x L(-1). All of these values were below the physiologic levels determined in previous studies.In this simulation of intraoperative blood transfusion, RL did not lead to visible or molecular evidence of activation of the clotting cascade. The current study challenges recommendations that AS-3 PRBC should not be mixed with RL for rapid transfusion.

����� �� Ovid’s account of Marsyas at Metamorphoses 6.382–400 invites completion. The tale itself is but partially told and demands to be supplemented by other texts and other tales within the Metamorphoses. This task, in turn, as the following essays will argue, involves the reader in juggling contradictory judgments on the tale’s protagonists and the nature and purpose of the narrative itself. Given the many different paths available through the episode’s complexity, we thought it appropriate to present in the same place two different readings of the passage. A further word about the genesis of this project may be helpful for the reader. The authors of these pieces met at a conference and discovered that they were both working on Ovid’s Marsyas and shared many similar interests in the Metamorphoses as a whole. Both of our readings were animated by the belief that the debate about the role of violence in the passage had occluded other important motifs and issues. Specifically, Andrew Feldherr relates the theme of dismemberment to the generic ambiguity of the episode and to issues of imitation. Paula James, drawing on the remarkably varied network of associations that the figure of Marsyas came to assume in Roman culture, demonstrates links to other tales in the Metamorphoses that both integrate the passage more closely into the work and supply contrasting frameworks for understanding it. Each of us has been influenced by the other, but our essays make their own points and are designed to be read on their own—hence some repetition in citation. Our offering them together also has a methodological point: the Metamorphoses is not a poem that invites consensus or scholarly closure; even critics working with largely shared assumptions will track their own paths through it, and this variety, privileging as it does the interpretative role of the audience, seems to us to give a much more complete picture of how the

Abstract 1296 Poster Board I-318 Background Patients with inherited bleeding disorders undergoing surgery typically receive therapy to correct the deficient factor to a level of ∼1.0 IU/mL. There is a paucity of well-constructed descriptive data quantifying the changes in coagulation that occur in response to surgical stress in normal individuals, however. Additionally, von Willebrand factor (VWF) and factor VIII (FVIII) are acute phase reactants, and thus, supratherapeutic levels of these proteins that might develop in response to the surgical stress would predispose patients to thrombotic events. Aim: With this in mind, our objective was to quantify the changes in hemostatic variables that occur in response to elective orthopedic surgery in normal individuals. Methods Eligible subjects > 18 years of age undergoing total knee or total hip replacement were recruited. Exclusion criteria included a known bleeding disorder, hormone replacement therapy, use of oral contraceptives or pregnancy. Following informed consent, blood samples were drawn at five time points: 1) baseline - in clinic 1-2 weeks pre-operatively (pre-op), 2) pre-op the morning of surgery – same day admitting center, 3) intra-operatively (intra-op) – 30 minutes after the start of surgery, 4) 30 minutes post-operatively (post-op) - recovery room, and 5) post-op day one (POD 1) – on the ward. Samples were analyzed for complete blood counts (CBC), prothrombin time (PT), activated partial thromboplastin time (aPTT), VWF antigen (VWF:Ag), VWF ristocetin cofactor activity (VWF:RCo), FVIII coagulant activity (FVIII:C) and whole blood thromboelastography (TEG) without tissue factor activation. Repeated measures analysis of variance was used to evaluate trends over time; paired samples t-tests were done to maximize the sample size for pairwise comparisons. Results 37 subjects were recruited (25 females, 12 males) with a mean age of 64 years (range 33 – 87). Means and ranges for all laboratory parameters are displayed in Table 1 in addition to statistical analysis of the change in all variables over the 5 time points. Statistically significant changes were seen in all variables except PTT and TEG angle. In general, VWF and FVIII indices decreased during surgery (presumably due to consumption) and then increased in the post-operative period (presumably due to a stress response). A great deal of variability was seen in post-operative levels of VWF and FVIII between individuals with some showing borderline low levels and some achieving very high levels. Conclusion These data establish a baseline on which to reconsider current strategies for the peri-operative management of patients with inherited bleeding disorders, and provide relevant information when considering the relative risks of bleeding or thrombosis associated with surgery. Disclosures No relevant conflicts of interest to declare.

Background: Careful assessment of bleeding history is the first step in the evaluation of patients with mild/moderate bleeding disorders, and the use of a bleeding assessment tool (BAT) is strongly encouraged. Although a few studies have assessed the utility of the ISTH-BAT in patients with inherited platelet function disorders (IPFD) none of them was sufficiently large to draw conclusions and/or included appropriate control groups. Objectives: The aim of the present study was to test the utility of the ISTH-BAT in a large cohort of patients with a well-defined diagnosis of inherited platelets disorder in comparison with two parallel cohorts, one of patients with type-1 von Willebrand disease (VWD-1) and one of healthy controls (HC). Patients/Methods: We enrolled 1098 subjects, 482 of whom had inherited platelet disorders (196 IPFD and 286 inherited platelet number disorders [IT]) from 17 countries. Results: IPFD patients had significantly higher bleeding score (BS; median 9) than VWD-1 patients (median 5), a higher number of hemorrhagic symptoms (4 versus 3), and higher percentage of patients with clinically relevant symptoms (score > 2). The ISTH-BAT showed excellent discrimination power between IPFD and HC (0.9