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Introduction: Contemporary haemophilia management recommends sport and physical activity in children with haemophilia. Assessment of subjective physical functioning requires standardized and validated instruments. Aims: To adapt and psychometrically test the adult Haemophilia & Exercise Project‐Test‐Questionnaire (HEP‐Test‐Q) for children (aged 6‐17 years). Methods: In discussion rounds with children, single items of the adult HEP‐Test‐Q were reformulated to make them understandable without changing the item concept. The validation of the child‐adapted version in children with haemophilia (n = 228) included pre‐testing with feasibility testing, cognitive interviewing (n = 34), pilot‐testing of the revised version in the EIS Study (n = 67) and field‐testing in the SO‐FIT Study (n = 127). Results: Pre‐testing revealed a completion time of 8.2 ± 4.1 minutes and children liked the instrument. Cognitive interviews demonstrated that most items were easy to understand; 9 items were reformulated. Pilot‐testing demonstrated good psychometric characteristics in terms of reliability (α = .94 Total Score) and validity. Convergent validity testing showed moderate correlations with the Haemo‐QoL (r = −.491), but low correlations with the Petrini Score (r = −.293). Known groups' validity revealed significant differences in clinical subgroups; chronic pain (P < .002) and target joints (P < .021). Field‐testing confirmed psychometric characteristics; Cronbach's alpha ranged from α = .80 ("endurance") to α = .94 (Total Score). The child‐adapted HEP‐Test‐Q showed moderate correlations with the PedHAL (r = .634, P < .0001) and the Haemo‐QoL SF (r = −.575, P < .0001). Known groups' validity testing proved that the HEP‐Test‐Q could discriminate between clinical subgroups. Conclusion: The child‐adapted HEP‐Test‐Q is a short, practical and acceptable instrument for the assessment of subjective physical functioning. Outcomes can be compared to adults because item concepts are identical to the adult version. [ABSTRACT FROM AUTHOR]

Introduction and aim: Open questions in haemophilia, such as effectiveness of innovative therapies, clinical and patient‐reported outcomes (PROs), epidemiology and cost, await answers. The aim was to identify data attributes required and investigate the availability, appropriateness and accessibility of real‐world data (RWD) from German registries and secondary databases to answer the aforementioned questions. Methods: Systematic searches were conducted in BIOSIS, EMBASE and MEDLINE to identify non‐commercial secondary healthcare databases and registries of patients with haemophilia (PWH). Inclusion of German patients, type of patients, data elements—stratified by use in epidemiology, safety, outcomes and health economics research—and accessibility were investigated by desk research. Results: Screening of 676 hits, identification of four registries [national PWH (DHR), national/international paediatric (GEPARD, PEDNET), international safety monitoring (EUHASS)] and seven national secondary databases. Access was limited to participants in three registries and to employees in one secondary database. One registry asks for PROs. Limitations of secondary databases originate from the ICD‐coding system (missing: severity of haemophilia, presence of inhibitory antibodies), data protection laws and need to monitor reliability. Conclusion: Rigorous observational analysis of German haemophilia RWD shows that there is potential to supplement current knowledge and begin to address selected policy goals. To improve the value of existing RWD, the following efforts are proposed: ethical, legal and methodological discussions on data linkage across different sources, formulation of transparent governance rules for data access, redefinition of the ICD‐coding, standardized collection of outcome data and implementation of incentives for treatment centres to improve data collection. [ABSTRACT FROM AUTHOR]

Background: Inhibitor development in previously untreated patients (PUPs) with severe haemophilia A is a multifactorial event. It is unknown whether paediatric vaccinations given in close proximity to factor VIII (FVIII) are associated with inhibitor development. Objective: To assess whether paediatric vaccinations in close proximity to FVIII within the first 75 exposure days (EDs) are associated with inhibitor development in PUPs with severe haemophilia A. Methods: We included 375 PUPs with severe haemophilia A (<0.01 IU/mL) from the PedNet Registry who had received vaccinations between the first and 75th ED or inhibitor development. Inhibitor risk was compared between patients who did and who did not receive vaccinations within 24, 72 or 120 hours of FVIII infusion. Unadjusted and adjusted hazard ratios were calculated for any or repeated vaccinations in close proximity to FVIII, using Cox regression. Results: Inhibitor development occurred in 77 of 375 patients (20.5%). Overall inhibitor development appeared similar or lower in patients receiving vaccinations in close proximity to FVIII as compared to patients receiving vaccinations without FVIII: for 24 hours, this was 19.2% and 21.4% (P = .186), for 72 hours, 16.4% and 27.3% (P = .023) and for 120 hours, 18.3% and 25.0% (P = .085), respectively. Conclusion: We found no association between vaccinations given in close proximity to FVIII exposure within the first 75 EDs and inhibitor development. Our data do not support avoiding administration of FVIII at time of routine vaccinations. [ABSTRACT FROM AUTHOR]

Introduction Haemophilia Joint Health Score ( HJHS) is the most sensitive validated score for physical examination of joint health in haemophilia. HJHS performed at regular intervals can be used for clinical monitoring as well as for comparative outcomes research. Aim To determine whether routinely collected HJHS could be used to compare outcome of three different prophylactic regimens in children with severe haemophilia A (primary) and which parameters caused variability in HJHS (secondary). Methods International retrospective observational multi-centre study comparing routine HJHS in 127 children with severe haemophilia A born from 1995 to 2009, from London, Stockholm and Utrecht centres. Patient and treatment data were collected from the European Paediatric Network for Haemophilia Management registry and patient files. The independent effects of regimens, physiotherapists, age and inhibitor status on HJHS were explored, using multivariable regression analysis. Results Prophylaxis varied across participating centres, with differences in initial frequency of infusions (1× per week vs. 3× per week), age at reaching infusions ≥3× per week, and dose kg−1 week−1 at HJHS assessment. Evaluation at median age of 11 years showed an illogical association of HJHS with treatment regimen: the least intensive regimen had the lowest HJHS. The HJHS increased with age and history of inhibitor, as expected (internal validity). But the comparison of prophylactic regimens was obscured by systematic differences in assessment between physiotherapists, both within and between centres. Conclusion Inter-physiotherapist discrepancies in routine HJHS hamper comparison of scores between treatment regimens. For multi-centre research, additional inter-observer standardization for HJHS scoring is needed. [ABSTRACT FROM AUTHOR]

Introduction Inhibitory antibodies to factor VIII occur in about 30% of previously untreated patients ( PUPs) and are the most serious complication of haemophilia A. It is unclear why some patients develop inhibitors and others do not. Aims The Early Prophylaxis Immunologic Challenge ( EPIC) study was designed to test the hypothesis that inhibitor incidence in PUPs with severe or moderately severe haemophilia A could be reduced when a once-weekly FVIII prophylaxis starts with 25 IU kg−1 rAHF- PFM before 1 year of age and immunological danger signals are minimized. Methods These signals were minimized by avoiding: surgery; the first FVIII infusion during severe bleeding or an infection; central venous access devices and administering vaccinations intramuscularly 3-4 days before or after FVIII. Results Eight of the 19 treated subjects (42.1%) developed confirmed inhibitors. Eleven of the 19 treated subjects were PUPs without any prior exposure to FVIII. Three of them (27.3%) developed a confirmed inhibitor together with FVIII-binding antibodies. The study was stopped because the likelihood to reach the primary objective was minimal, a decision endorsed by the data safety monitoring board. Conclusion Because of early termination, the EPIC study hypothesis could not be corroborated. Nonetheless, our data analyses indicate that the current definition of an inhibitor only based on plasma inhibitor activity ≥0.6 BU mL−1 may not always reflect the presence of FVIII-neutralizing antibodies. The findings of this study teach us that low-level inhibitor activity results need in addition a confirmatory test and/or the assessment of the therapeutic response. [ABSTRACT FROM AUTHOR]

. Severe haemophilia is associated with recurrent joint bleeds, which can lead to haemophilic arthropathy. Subclinical joint bleeds have also been associated with joint damage detected using magnetic resonance imaging (MRI). We investigated the development of early changes in clinically asymptomatic joints using MRI in haemophilia A or B patients receiving prophylactic therapy. In this single-centre retrospective cohort study, patients with clinical evidence of joint damage in one ankle and one clinically asymptomatic ankle, in which we performed an MRI scan of both ankles in one session, were enrolled. MRI findings were graded using a 4-point scoring system (0 = normal findings and III = severe joint damage). Since 2000, 38 MRIs in 26 patients have been performed. Starting at a median age of 4 years, 23 patients received prophylaxis 2-3 times weekly. On-demand treatment was performed in three patients. Eight patients (31%) presented with an MRI score of 0, 12 (46%) had a score of I, four (15%) had a score of II, and two (8%) had a score of III in the clinically unaffected ankle. The six patients with MRI scores of II and III had started regular prophylaxis between the ages of 2 years and 15 years; none had developed an inhibitor or experienced a clinically evident bleed in the asymptomatic ankle. During our study, five of 26 patients had a worsening of MRI findings without experiencing a joint bleed. Early morphological changes in clinically asymptomatic ankles can be detected using MRI, despite adequate prophylaxis. [ABSTRACT FROM AUTHOR]

This meeting report presents an overview of the discussions at the ninth and tenth workshops of the European Paediatric Network for Haemophilia Management (PedNet) that occurred in 2005 and 2006. Among numerous topics, a major theme of these workshops was the formation of inhibitors to replacement factor. [ABSTRACT FROM AUTHOR]

Although the concept of continuous infusion (CI) of factor concentrates is well known, prospective paediatric data are rare. We present a prospective open-labelled non-randomized study focusing on safety, efficacy and factor VIII (FVIII) usage compared with bolus injections (BI) in children. In 43 consecutive patients (0.5–17 years; median: 9.6) undergoing different operations, CI was started with an initial FVIII-bolus of 70 IU kg−1 bodyweight, followed by a median infusion rate of 4.4 IU kg−1 h−1 (range: 2.8–9.5) dose adjusted for daily FVIII levels (target: 60–80%). No direct serious adverse events occurred; however, two out of 43 patients, both from the group of four patients with less than 20 exposure days (ED) before starting CI, developed a high-responding inhibitor. Two CI patients showed mild thrombophlebitis or rash. Infusion rates needed to achieve adequate FVIII levels were highly predictable and could be reduced because of decreasing FVIII clearance. Bleeding, requiring additional boli, was observed in eight out of 43 patients. Therapy duration and factor usage of CI were influenced by the procedure, but not by the product used or thrombophilia. Twelve of these CI patients were compared with 12 contemporary consecutive age- and procedure-matched BI patients. Compared with BI patients, CI patients saved 30% FVIII (812.9 vs. 563.2 IU kg−1, P < 0.006). We conclude that CI forms a safe and effective method for perioperative care in children and reduces factor usage. Because of the unknown risk of inhibitor development, we will use CI only in patients beyond 20 ED. [ABSTRACT FROM AUTHOR]

Continuous infusion (CI) of coagulation factor concentrates has been used since the early 1990s. Recent reports of the occurrence of an inhibitor after CI have raised concerns about this method of treatment. We conducted a retrospective study to investigate the development of inhibitors after CI of Factor VIII concentrates in Germany. So far, 13 hemophilia centers have been contacted, and data have been collected by a questionnaire. Of the 13 centers, CI had never been performed in three, no inhibitors had been detected in five, and inhibitor development after CI was recorded in 10 patients in the remaining five centers. Of these 10 patients (ages 7 months to 57 years), five were suffering from severe, one from moderate, and four from mild hemophilia. Indications for treatment were major bleeds and surgical procedures. Plasmaderived (6 cases) and recombinant (4 cases) factor concentrates were given in various infusion sets. Data concerning amount infused (4300 to >100,000 IU), number of days of exposure to factor concentrates (1 to >100), and inhibitor characteristics (alloantibodies, 3 LR, 7 HR) were collected. Regarding hemophilia genotype, we found missense mutations in four patients, intron-22 inversions in two, and one small deletion in one; the genotype in three was unknown. In conclusion, only 3 out of 10 patients who developed an inhibitor after CI showed the typical risk profile for inhibitor formation, which is severe hemophilia A with a severe gene defect and less than 50 days of exposure to coagulation factor concentrates. Especially striking was the finding that 50% of the patients who developed inhibitors had mild to moderate hemophilia A. Our data point to the existence of a so-far unknown factor, related to CI, that might lead to inhibitor formation. [ABSTRACT FROM AUTHOR]

To evaluate current treatment patterns and resource utilization as well as related cost in the management of severe haemophilia patients with inhibitors in Germany, a cost-of-illness study was conducted. Generally, data were generated by structured literature search. Missing data were collected by expert interviews. All data were validated by a panel of German experts in haemophilia care. In Germany, immune tolerance therapy (ITT) is first-line therapy in inhibitor management for children in the initial year after inhibitor development, particularly for high responders (HR). In adult HR patients ITT is applied but to a remarkably lower extent than in children. To treat bleeding episodes, factor VIII (FVIII) is first-line therapy in low responders (LR). For paediatric HR patients, bleeds are mainly treated with recombinant FVIIa (rFVIIa). In adult HR patients, activated prothrombin complex concentrate (aPCC) and rFVIIa are more equally distributed as treatment options. Treatment costs were calculated for paediatric patients (15 kg) and adult patients (75 kg) from third party payers’ perspective. Cost for ITT ranges from€70 290 (2 months; LR) to€3 812 400 (24 months; with aPCC; HR) in a paediatric patient. For an adult patient ITT cost ranges from€287 500 (6 months; LR) to€17 253 000 (36 months; HR). For on average 12.5 acute bleeds, average annual treatment costs amount to€77 000 for a child and€354 000 for an adult. Assessing the results it has been taken into consideration that ITT can last longer and annual number of bleeds can be extremely higher than on average 12.5 episodes. This indicates more health care resource consumption in some patients. [ABSTRACT FROM AUTHOR]

The introduction of new needleless devices as demanded by the US Department of Labor Occupational Safety and Health Administration (OSHA) has caused problems with the reconstitution of antihaemophilic factor in emergency situations. Our aim therefore was to evaluate the feasibility of a needleless device for reconstitution of antihaemophilic factor for non-haemophilia experts and to define evidence of the need for coaching these physicians via providing two additional photographs illustrating the two key points of the factor reconstitution process. Twenty-eight physicians of a tertiary care university children's hospital were randomized into two groups, either with no further explanation of the reconstitution device or with two additional photographs, showing the two key steps of the procedure. Reconstitution of dummy-factor concentrate was video-taped and evaluated by a blinded helper. Main outcome measure was the successful reconstitution of dummy-factor concentrate and procedure failure respectively. Of the group without explanation of the reconstitution device, only two of 14 physicians were able to reconstitute the dummy-factor concentrate. Of the group receiving two photographs, nine of 14 completed the task successfully ( P = 0.0068). The needleless device is not self explaining to non-haemophilia physicians involved in emergency services. Coaching via short to the point instructions as provided by simple visual educational material therefore is crucial to enable these physicians to resolve the expensive emergency drug quickly and correctly. Companies concerned with the production of any devices to dissolve drugs, especially for treatment of rare diseases as haemophilia, therefore should take measures to simplify therapy. [ABSTRACT FROM AUTHOR]

A letter to the editor related to early prophylaxis/FVIII tolerization regime is presented.