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Gili Kenet,1,2 Thomas Moulton,3 Brian M Wicklund,4 Sanjay P Ahuja,5 Miguel Escobar,6 Johnny Mahlangu7 1National Hemophilia Center, Sheba Medical Center, Tel HaShomer, Israel; 2The Amalia Biron Thrombosis Research Institute, Tel Aviv University, Tel Aviv, Israel; 3Bayer, Whippany, NJ, USA; 4Children’s Mercy-Kansas City, Kansas City, MO, USA; 5Rainbow Babies & Children’s Hospital, Cleveland, OH, USA; 6University of Texas Health Science Center, Houston, TX, USA; 7Hemophilia Comprehensive Care Center, Faculty of Health Sciences, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, and National Health Laboratory Service, Johannesburg, South AfricaCorrespondence: Gili Kenet, Amalia Biron Thrombosis Research Institute, Tel Aviv University, Tel HaShomer, 52621, Israel, Tel +972-3-5307356, Fax +972-3-5351806, Email Gili.kenet@sheba.health.gov.ilIntroduction: Previous clinical trials established the efficacy and safety of sucrose-formulated recombinant factor (F) VIII (rFVIII-FS/Kogenate FS®/Helixate FS®) and octocog alfa (BAY 81– 8973/Kovaltry®; LEOPOLD trials).Aim: To report the results of a post hoc subgroup analysis assessing efficacy and safety outcomes in patients with hemophilia A who were receiving rFVIII-FS prior to enrolling into the LEOPOLD I Part B and LEOPOLD Kids Part A clinical trials and switching to octocog alfa.Methods: LEOPOLD I Part B (NCT01029340) and LEOPOLD Kids Part A (NCT01311648) were octocog alfa Phase 3, multinational, open-label studies in patients with severe hemophilia A aged 12– 65 years and ≤ 12 years, respectively. Annualized bleeding rate (ABR) was the efficacy endpoint for both studies. Safety endpoints included adverse events (AEs) and development of FVIII inhibitors.Results: Of the 113 patients in both LEOPOLD trials, 40 (35.4%) patients received rFVIII-FS prophylaxis pre-study and had data available for pre-study total ABR. In LEOPOLD I Part B (n = 22, 35.5%), median (Q1; Q3) total ABR decreased from 2.5 (0.0; 9.0) pre-study to 1.0 (0.0; 6.8), and from 1.0 (0.0; 6.0) pre-study to 0.0 (0.0; 6.02) in LEOPOLD Kids Part A (n = 18, 35.3%). Octocog alfa was well tolerated, and no patients had drug-related serious AEs or inhibitors.Conclusion: Treatment with octocog alfa prophylaxis appeared to have a favorable risk–benefit profile compared with rFVIII-FS and thus could be an effective and improved alternative strategy for individualized treatment for children, adolescent and adult patients with severe hemophilia A currently on rFVIII-FS treatment.Keywords: FVIII, hemophilia A, prophylaxis, recombinant proteins, octocog alfa

Accurate assessment of fibrin clot stability can predict bleeding risk in coagulopathic conditions such as thrombocytopenia and hypofibrinogenemia. Hyperfibrinolysis - a clinical phenotype characterized by an accelerated breakdown of the fibrin clot - makes such assessments challenging by obfuscating the effect of hemostatic components including platelets or fibrinogen on clot stability. In this work, we present a biofunctionalized, microfluidic, label-free, electronic biosensor to elicit unique, specific, and differential responses from the multifactorial processes of blood coagulation and fibrinolysis ex vivo. The microsensor tracks the temporal variation in the normalized real part of the dielectric permittivity of whole blood (<10 μL) at 1 MHz as the sample coagulates within a three-dimensional, parallel-plate, capacitive sensing area. Surface biofunctionalization of the microsensor's electrodes with physisorption of tissue factor (TF) and aprotinin permits real-time assessment of the coagulation and fibrinolytic outcomes. We show that surface coating with TF and manual addition of TF result in a similar degree of acceleration of coagulation kinetics in human whole blood samples. We also show that surface coating with aprotinin and manual addition of aprotinin yield similar results in inhibiting tissue plasminogen activator (tPA)-induced upregulated fibrinolysis in human whole blood samples. Validated through a clinically relevant, complementary assay - rotational thromboelastometry for clot viscoelasticity - we finally establish that a microsensor dual-coated with both TF and aprotinin detects the hemostatic rescue in the tPA-induced hyperfibrinolytic profile of whole blood and the hemostatic dysfunction due to concurrent platelet depletion in the blood sample, thus featuring enhanced ability in evaluating complex, combinatorial coagulopathies., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: M. A. Suster and P. Mohseni are inventors of foundational intellectual property related to this study that has been licensed by Case Western Reserve University to XaTek Inc. They report research funding, consulting fees, and royalties from XaTek Inc. during the conduct of this study. S. P. Ahuja reports research funding from XaTek Inc., DOD, and PCORI, as well as personal fees from Genentech, CSL Behring, BioMarin, Sanofi, and Novo Nordisk. M. D. Neal serves as the Chief Medical Officer of Haima Therapeutics and reports personal fees from CSL Behring, Haemonetics, Octapharma, Takeda, and Janssen Pharmaceuticals, as well as grants from Haemonetics, Alexion, Instrumentation Laboratories, NIH, DOD, and DARPA outside of the submitted work. A. Sen Gupta is a co-founder of Haima Therapeutics and an inventor on patents regarding hemostatic therapeutic technologies that are licensed to Haima Therapeutics. S. Pourang, D. Disharoon, and S. Hernandez report no conflict., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objectives: To report the long-term safety and efficacy of BAY 81-8973 in the LEOPOLD Kids extension phase., Methods: Patients received BAY 81-8973 (25-50 IU/kg) at least twice weekly. The primary endpoint was safety, assessed in all patients who entered the extension phase (n = 82). Efficacy endpoints were assessed in patients without high-titre inhibitors/immune tolerance induction (n = 67)., Results: Children (n = 82) received BAY 81-8973 for a median of 3.1 years per patient and a median of 405 exposure days per patient. Long-term BAY 81-8973 treatment was well tolerated, with no cases of de novo inhibitor development in the extension phase. Annualised bleeding rates (ABRs) within 48 h of prophylaxis were low for all bleeds (median [IQR], 0.7 [0-1.9]; mean, 1.4 [SD, 2.1]) and for joint bleeds (median [IQR], 0 [0-0.7]; mean, 0.5 [SD, 1.1]) (n = 67). Twenty-one of 67 patients (31.3%) had zero bleeds within 48 h of prophylaxis; the treatment response was 'good'/'excellent' in 87.9% of bleeds, and most bleeds resolved with ≤ 2 BAY 81-8973 infusions (83.5%)., Conclusion: Long-term BAY 81-8973 treatment is well tolerated and maintains low ABRs for all bleeds and joint bleeds in children with severe haemophilia A., Trial Registration: ClinicalTrials.gov identifier: NCT01311648., (© 2024 The Author(s). European Journal of Haematology published by John Wiley & Sons Ltd.)

Objective: During the COVID-19 pandemic, the authors' institution managed ventriculoatrial (VA) shunt complications in 2 teenage patients in close proximity to a symptomatic COVID-19 infection. Systemic thrombotic events are an established complication of COVID-19 infection due to a hypercoagulable state. Thrombotic complications, particularly elevated central venous pressure, can cause VA shunt failure. The true effect of COVID-19 on patients with intravascular devices is currently unknown. In this study, the authors aimed to determine if there was an association between COVID-19 infection and VA shunt failure., Methods: TriNetX, an aggregated electronic health record platform, was used to analyze data of more than 13 million US pediatric patients. Two matched cohorts of patients < 18 years of age with a VA shunt were defined. Group 1 (n = 311) had a positive laboratory test for COVID-19 from March 1, 2020, to March 31, 2022. Group 2 (n = 311), a control group, had any medical appointment from March 1, 2020, to March 31, 2022, and never had a positive laboratory test for COVID-19. The authors analyzed outcomes 1 year after testing positive for COVID-19 in group 1, and after the medical appointment in group 2. Outcomes included shunt complications, shunt revisions or replacements, and thromboembolic complications. To protect patient privacy, individual results of fewer than 10 patients are not specified in TriNetX., Results: Group 1 had a greater odds of mechanical shunt complication than group 2 (20% vs 4%, OR 5.71, 95% CI 3.07-10.62). Group 1 had a greater odds of shunt reoperation than group 2 (11% vs < 3%, OR > 3.7, 95% CI 1.72-7.62). There were 1-10 patients in group 1 (≤ 3% of group 1) who experienced a thromboembolism due to the shunt, compared with no patients in group 2 who had a thromboembolism due to the shunt., Conclusions: This analysis demonstrates an association of shunt complications, reoperations, and thromboembolic events in patients with VA shunts following COVID-19 infection.

This article presents a standalone, multichannel, miniaturized impedance analyzer (MIA) system for dielectric blood coagulometry measurements with a microfluidic sensor termed ClotChip. The system incorporates a front-end interface board for 4-channel impedance measurements at an excitation frequency of 1 MHz, an integrated resistive heater formed by a pair of printed-circuit board (PCB) traces to keep the blood sample near a physiologic temperature of 37 °C, a software-defined instrument module for signal generation and data acquisition, and a Raspberry Pi-based embedded computer with 7-inch touchscreen display for signal processing and user interface. When measuring fixed test impedances across all four channels, the MIA system exhibits an excellent agreement with a benchtop impedance analyzer, with rms errors of ≤0.30% over a capacitance range of 47-330 pF and ≤0.35% over a conductance range of 2.13-10 mS. Using in vitro-modified human whole blood samples, the two ClotChip output parameters, namely, the time to reach a permittivity peak (T peak ) and maximum change in permittivity after the peak (Δϵ r,max ) are assessed by the MIA system and benchmarked against the corresponding parameters of a rotational thromboelastometry (ROTEM) assay. T peak exhibits a very strong positive correlation (r = 0.98, p < 10 -6 , n = 20) with the ROTEM clotting time (CT) parameter, while Δϵ r,max exhibits a very strong positive correlation (r = 0.92, p < 10 -6 , n = 20) with the ROTEM maximum clot firmness (MCF) parameter. This work shows the potential of the MIA system as a standalone, multichannel, portable platform for comprehensive assessment of hemostasis at the point-of-care/point-of-injury (POC/POI).

Background: Children, adolescents, and young adults with hematologic and/or oncologic conditions experience multiple, significant symptoms (e.g., pain, stress, and anxiety), which may be addressed by nonpharmacologic approaches such as massage therapy (MT). The purpose of this study was to describe the clinical delivery of MT provided by a certified pediatric massage therapist and assess effectiveness in two patient groups: those with sickle cell disease (SCD) or hematologic and/or oncologic conditions excluding SCD (HemOnc)., Methods: Investigators conducted a retrospective review of MT sessions provided to patients 0-39 years with hematologic and/or oncologic conditions at a large pediatric academic medical center., Results: Between October 2019 and December 2021, 3015 MT sessions were provided to 243 patients (171 HemOnc; 72 SCD) and documented in the electronic health record. Patients (mean age: 12.21 ± 7.19 years) were generally White (49.4%) or Black/African American (43.2%), non-Hispanic (94.2%), and 52.3% female. Patients in the SCD group (vs. patients in the HemOnc group) reported significantly higher (p < .05) pretreatment pain (6.95 vs. 4.46), stress (6.47 vs. 4.58), and anxiety (6.67 vs. 4.59). All patients reported clinically and statistically significant (p < .001) mean reductions in pain (-2.25 ± 1.87), stress (-2.50 ± 1.73), and anxiety (-2.52 ± 1.69), with patients in the HemOnc group reporting greater mean pain change (-2.54 vs. -1.87) than patients in the SCD group., Conclusions: This study supports the clinical effectiveness of MT for addressing acute pain, stress, and anxiety among youth with hematologic and/or oncologic conditions. Future research is needed to identify optimal MT utilization., (© 2023 The Authors. Pediatric Blood & Cancer published by Wiley Periodicals LLC.)

Rapid assessment of the fibrinolytic status in whole blood at the point-of-care/point-of-injury (POC/POI) is clinically important to guide timely management of uncontrolled bleeding in patients suffering from hyperfibrinolysis after a traumatic injury. In this work, we present a three-dimensional, parallel-plate, capacitive sensor - termed ClotChip - that measures the temporal variation in the real part of blood dielectric permittivity at 1 MHz as the sample undergoes coagulation within a microfluidic channel with <10 μL of total volume. The ClotChip sensor features two distinct readout parameters, namely, lysis time (LT) and maximum lysis rate (MLR) that are shown to be sensitive to the fibrinolytic status in whole blood. Specifically, LT identifies the time that it takes from the onset of coagulation for the fibrin clot to mostly dissolve in the blood sample during fibrinolysis, whereas MLR captures the rate of fibrin clot lysis. Our findings are validated through correlative measurements with a rotational thromboelastometry (ROTEM) assay of clot viscoelasticity, qualitative/quantitative assessments of clot stability, and scanning electron microscope imaging of clot ultrastructural changes, all in a tissue plasminogen activator (tPA)-induced fibrinolytic environment. Moreover, we demonstrate the ClotChip sensor ability to detect the hemostatic rescue that occurs when the tPA-induced upregulated fibrinolysis is inhibited by addition of tranexamic acid (TXA) - a potent antifibrinolytic drug. This work demonstrates the potential of ClotChip as a diagnostic platform for rapid POC/POI assessment of fibrinolysis-related hemostatic abnormalities in whole blood to guide therapy., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Introduction: Persons with haemophilia(PWH) have been shown to have low bone mineral density likely the result of prolonged immobility, recurrent hemarthrosis, decreased weight bearing, lower physical activity level and obesity. Bone health has been poorly characterized in haemophilia carriers (HC) and persons with von Willebrand disease (PWvWD)., Aim: To estimate the prevalence of osteoporosis, osteoarthritis and bone fractures in HC and PWvWD and identify risk factors for poor bone health., Methods: This is a retrospective study using a population level, commercial database - Explorys (IBM Watson Health, Cleveland, USA). We compared prevalence rates of osteoporosis, osteoarthritis and fractures among cases (HC or PWvWD) and controls (general population without an underlying bleeding disorder) from 1999 to 2020. Prevalence of common risk factors for poor bone health were compared among cases and controls., Results: Among 72,917,850 active persons in the database, we identified 940 women with the diagnosis of HC and 19,580 PWvWD. Among HC and PWvWD, prevalence of osteoporosis, osteoarthritis and fractures were significantly higher in cases, when compared to controls. In HC, the prevalence of vitamin D deficiency, obesity, hypothyroidism, smoking, diabetes mellitus, hypocalcaemia, corticosteroid use, malignancy, renal failure and Nonsteroidal anti-inflammatory drugs (NSAID) use were significantly higher among the cases. In PWvWD, the prevalence of risk factors was significantly higher in cases when compared to controls., Conclusion: The prevalence of osteoporosis, osteoarthritis and fractures is significantly higher among HC and PWvWD. This data highlights the importance of screening patients for risk factors for poor bone health and provide education to prevent these complications., (© 2022 John Wiley & Sons Ltd.)

Purpose: Adolescent and young adult (AYA) patients (15-39 years old) with acute lymphoblastic leukemia (ALL) have less favorable outcomes and higher treatment-related mortality as compared with older children with ALL. Minimal data exist regarding how well AYA patients tolerate the intensity of chemotherapy at doses and regimens designed for children, and the toxicities suffered by this population at children's hospitals have not been thoroughly characterized. Methods: Pediatric Health Information Systems database was queried to analyze health care outcomes in pediatric (ages 10-14) and AYA patients (ages 15-39) with ALL hospitalized between January 1999 and December 2014. We extracted relevant ICD-9 data for each patient related to grades 3 or 4 toxicities as outlined by the NCI. Results: A total of 5345 hospital admissions met inclusion criteria, representing 4046 unique patients. Of these admissions, 2195 (41.1%) were in the AYA age group, and the remainder were in the 10-14-year-old group. AYA patients had a significantly higher incidence of intensive care unit stay but no difference in median hospital stay nor mortality. AYA patients had increased toxicities in almost every organ system as compared with older children. Conclusions: In this large multicenter US database study, we found an overall increased number of toxicities among AYA patients with ALL in children's hospitals. Compared with children between the ages of 10 and 15, AYA patients developed disproportionately higher toxicities from drugs commonly used in pediatric protocols for ALL. Prospective studies are needed to assess whether dose modifications for certain chemotherapeutics may improve the toxicity profile and health care burden of AYA patients with ALL treated in children's hospitals.

Anemia affects over 25% of the world's population with the heaviest burden borne by women and children. Genetic hemoglobin (Hb) variants, such as sickle cell disease, are among the major causes of anemia. Anemia and Hb variant are pathologically interrelated and have an overlapping geographical distribution. We present the first point-of-care (POC) platform to perform both anemia detection and Hb variant identification, using a single paper-based electrophoresis test. Feasibility of this new integrated diagnostic approach is demonstrated via testing individuals with anemia and/or sickle cell disease. Hemoglobin level determination is performed by an artificial neural network (ANN) based machine learning algorithm, which achieves a mean absolute error of 0.55 g dL -1 and a bias of -0.10 g dL -1 against the gold standard (95% limits of agreement: 1.5 g dL -1 ) from Bland-Altman analysis on the test set. Resultant anemia detection is achieved with 100% sensitivity and 92.3% specificity. With the same tests, subjects with sickle cell disease were identified with 100% sensitivity and specificity. Overall, the presented platform enabled, for the first time, integrated anemia detection and hemoglobin variant identification using a single point-of-care test.

Alterations in the deformability of red blood cells (RBCs), occurring in hemolytic blood disorders such as sickle cell disease (SCD), contribute to vaso-occlusion and disease pathophysiology. There are few functional in vitro assays for standardized assessment of RBC-mediated microvascular occlusion. Here, we present the design, fabrication, and clinical testing of the Microfluidic Impedance Red Cell Assay (MIRCA) with embedded capillary network-based micropillar arrays and integrated electrical impedance measurement electrodes to address this need. The micropillar arrays consist of microcapillaries ranging from 12 μm to 3 μm, with each array paired with two sputtered gold electrodes to measure the impedance change of the array before and after sample perfusion through the microfluidic device. We define RBC occlusion index (ROI) and RBC electrical impedance index (REI), which represent the cumulative percentage occlusion and cumulative percentage impedance change, respectively. We demonstrate the promise of MIRCA in two common red cell disorders, SCD and hereditary spherocytosis. We show that the electrical impedance measurement reflects the microvascular occlusion, where REI significantly correlates with ROI that is obtained via high-resolution microscopy imaging of the microcapillary arrays. Further, we show that RBC-mediated microvascular occlusion, represented by ROI and REI, associates with clinical treatment outcomes and correlates with in vivo hemolytic biomarkers, lactate dehydrogenase (LDH) level and absolute reticulocyte count (ARC) in SCD. Impedance measurement obviates the need for high-resolution imaging, enabling future translation of this technology for widespread access, portable and point-of-care use. Our findings suggest that the presented microfluidic design and the integrated electrical impedance measurement provide a reproducible functional test for standardized assessment of RBC-mediated microvascular occlusion. MIRCA and the newly defined REI may serve as an in vitro therapeutic efficacy benchmark for assessing the clinical outcome of emerging RBC-modifying targeted and curative therapies.

Central venous catheters (CVC) have revolutionized the care of patients requiring long-term venous access. With increasing use of CVCs, the incidence of catheter-related thrombosis (CRT) has been on the rise. CRT constitutes 10% of all deep venous thromboses (DVT) in adults and 50-80% of all DVTs among children. The incidence of CRT varies significantly based on patient characteristics, catheter-related factors and the steps involved in the process of catheter insertion. Multiple risk factors have been associated with a higher risk of CRT, including older age, hospitalization, CVC insertion in the subclavian vein, left-sided CVC insertion, longer duration of catheter, catheter-to-vein ratio > 0.45, and type of CVC. A majority of patients with CRT are asymptomatic. Duplex ultrasound is the initial diagnostic modality of choice, though other modalities like CT angiography and MRV may be necessary for certain CRT locations. Current guidelines recommend maintaining a catheter unless nonfunctional or unneeded, in addition to systemic anticoagulation. Data guiding anticoagulant management specific to upper extremity VTE is lacking, and practice is mostly extrapolated from data on lower extremities. Further studies are required to establish evidence-based guidelines in the management of adults and children with CRT, and in particular the role of direct oral anticoagulants. In this review, we describe the knowledge gaps that exist in multiple aspects of CRT and the need for large collaborative studies to improve the care of patients with CRT., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Reliable monitoring of coagulation factor replacement therapy in patients with severe haemophilia, especially those with inhibitors, is an unmet clinical need. While useful, global assays, eg thromboelastography (TEG), rotational thromboelastometry (ROTEM) and thrombin generation assay (TGA), are cumbersome to use and not widely available., Objective: To assess the utility of a novel, point-of-care, dielectric microsensor - ClotChip - to monitor coagulation factor replacement therapy in patients with haemophilia A, with and without inhibitors., Methods: The ClotChip T peak parameter was assessed using whole-blood samples from children with severe haemophilia A, with (n = 6) and without (n = 12) inhibitors, collected pre- and postcoagulation factor replacement therapy. ROTEM, TGA and chromogenic FVIII assays were also performed. Healthy children (n = 50) served as controls., Results: ClotChip T peak values exhibited a significant decrease for samples collected postcoagulation factor replacement therapy as compared to baseline (pretherapy) samples in patients with and without inhibitors. A difference in T peak values was also noted at baseline among severe haemophilia A patients with inhibitors as compared to those without inhibitors. ClotChip T peak parameter exhibited a very strong correlation with clotting time (CT) of ROTEM, endogenous thrombin potential (ETP) and peak thrombin of TGA, and FVIII clotting activity., Conclusions: ClotChip is sensitive to coagulation factor replacement therapy in patients with severe haemophilia A, with and without inhibitors. ClotChip T peak values correlate very well with ROTEM, TGA and FVIII assays, opening up possibilities for its use in personalized coagulation factor replacement therapy in haemophilia., (© 2019 John Wiley & Sons Ltd.)

Introduction: Heavy menstrual bleeding (HMB) may be expected for many adolescents after menarche. Accurate assessment of HMB, a key component in the diagnosis of a haemostatic defect (HD), is a well-recognized challenge., Aim: Our objective was to determine the diagnostic accuracy of an HMB-specific screening tool for HDs in adolescents with HMB, presenting to a secondary care setting., Methods: Adolescents with HMB were evaluated for a HD at 4 US centres. A screening tool, the Philipp Tool, developed and validated in adult women with HMB, was administered. We modified the tool by assigning a score based on the number of affirmative responses. Sensitivity, specificity and likelihood ratios (LRs) of a positive tool, modified tool, with a pictorial blood assessment chart (PBAC) score >185, and with serum ferritin ≤20 ng/mL were calculated for HDs., Results: Among 248 adolescents with HMB, 29% were diagnosed with HDs. Sensitivity, specificity and LR of a positive screening tool for HDs were 95% (range 88-99), 14% (9-21) and 1.1 (1-1.2), respectively. A score of ≥2, addition of a PBAC score >185 and ferritin ≤20 ng/mL changed the sensitivity, specificity and LR of the tool to 72% (61-81), 94% (83-99), 76% (65-85); 60% (53-68), 24% (16-34) and 39% (31-47) and 1.8 (1.4-2.2), 1.2 (1.1-1.4) and 1.2 (1-1.4), respectively., Conclusion: Although sensitive, the discriminative ability of the tool to identify adolescents with HDs from those without, who presented with HMB, was low. Further research is needed to optimize or develop an adolescent-specific HMB tool for secondary care settings., (© 2018 John Wiley & Sons Ltd.)

BAY 81-8973 (Kovaltry ® ) is an unmodified, full-length recombinant factor VIII (rFVIII) approved for the prevention and treatment of bleeding episodes in patients with hemophilia A. The amino acid sequence for BAY 81-8973 is identical to that of sucrose-formulated rFVIII (rFVIII-FS; Kogenate ® FS/KOGENATE ® , Bayer), but the two products differ in their manufacturing approaches. The manufacture of BAY 81-8973 includes several modifications and enhancements, such as the introduction of the gene for human heat shock protein 70, a molecular chaperone protein that facilitates folding of proteins; no addition of human- or animal-derived proteins in the cell culture, purification process, or final formulation; and use of a 20-nm filter to remove any potential aggregates and pathogens. BAY 81-8973 was extensively studied in the LEOPOLD clinical development program, which enrolled participants of all age groups (children, adolescents, and adults) with severe hemophilia A. The pharmacokinetic profile of BAY 81-8973 was shown to be noninferior to, and for some variables more favorable than, rFVIII-FS and another commercial full-length rFVIII product. BAY 81-8973 was shown to be efficacious when used for prophylaxis, on-demand treatment, and perioperative hemostasis. The efficacious prophylaxis dose of BAY 81-8973 was approximately 20-40 IU/kg given two or three times per week, which achieved low annualized bleeding rates. Either the one-stage or the chromogenic assay provides accurate measurements for postinfusion monitoring of BAY 81-8973 levels, with no product-specific calibration standard needed. The incidence of treatment-related adverse events was ⩽7% across all LEOPOLD studies, and no previously treated patient developed anti-BAY 81-8973 inhibitors in the completed primary studies., Competing Interests: Conflict of interest statement: Dr. Mahlangu has received research grants from Bayer, Biogen, CSL Behring, Novo Nordisk, and Roche; is a member of the scientific advisory committees of Amgen, Baxalta, Biogen, CSL Behring, Novo Nordisk, and Roche; and is on the speakers bureaus of Amgen, Bayer, Biogen, Biotest, and CSL Behring. Dr. Ahuja is a member of the advisory boards of Bayer, Baxalta, and Biogen, and has been on the speakers bureaus of Biogen, Grifols, and Novo Nordisk. Dr. Windyga received honoraria or research grants from Bayer, Baxalta, CSL Behring, Novo Nordisk, Octapharma, Pfizer, and Sobi. Dr. Church and Dr. Shah are employees of Bayer. Mr. Schwartz was a Bayer employee at the time this manuscript was originally submitted.

Introduction: Prophylaxis with extended half-life factor VIII (FVIII) is approved for haemophilia A, but data regarding routine clinical use are limited., Aim: To assess real-world experience of ADYNOVATE ® (Antihemophilic Factor (Recombinant), PEGylated prophylaxis in children and adults with haemophilia A., Methods: A retrospective chart review was conducted in three US haemophilia treatment centres. Records of all patients who began Adynovate prophylaxis in routine clinical practice were identified. Demographic, clinical and patient-reported information beginning 6 months before initiation of Adynovate until the record review was analysed., Results: Fifteen patients (aged 9 months to 28 years), with median 9 months' use of Adynovate (range 1-15 months), were identified. All had switched from another prophylactic regimen, 13 (87%) from standard half-life recombinant FVIII. Nine (60%) patients had ≥1 bleed within 6 months preswitch. The most frequent reason for switching was to reduce infusion frequency (14 patients). After switching, infusion frequency reduced for 13 patients, and overall weekly factor consumption decreased by 19%. Eight (53%) patients had no bleeds postswitch, three (20%) had spontaneous joint bleeds (vs four pre-switch), and three (20%) had only mild traumatic bleeds. Patient/parental satisfaction with Adynovate was documented as positive in 13 of 15 (87%) cases; 2 patients were not satisfied and discontinued Adynovate. No adverse events were considered related to Adynovate., Conclusion: In patients who switched from a standard half-life FVIII to Adynovate prophylaxis in routine clinical practice, bleeding control was generally improved or maintained, with a lower infusion frequency and factor consumption in most patients., (© 2018 The Authors. Haemophilia Published by John Wiley & Sons Ltd.)

Introduction: Immune tolerance induction (ITI) is the gold standard for eradication of factor VIII inhibitors in severe haemophilia A; however, it usually requires treatment for extended periods with associated high burden on patients and healthcare resources., Aim: Review outcomes of ITI with recombinant factor VIII Fc fusion protein (rFVIIIFc) in patients with severe haemophilia A and high-titre inhibitors., Methods: Multicentre retrospective chart review of severe haemophilia A patients treated with rFVIIIFc for ITI., Results: Of 19 patients, 7 were first-time ITI and 12 were rescue ITI. Of 7 first-time patients, 6 had at least 1 high-risk feature for ITI failure. Four of 7 first-time patients were tolerized in a median of 7.8 months. The remaining 3 patients continue on rFVIIIFc ITI. Of 12 rescue patients, 7 initially achieved a negative Bethesda titre (≤0.6) in a median of 3.3 months, 1 had a decrease in Bethesda titre and continues on rFVIIIFc ITI and 4 have not demonstrated a decrease in Bethesda titre. Of these 4, 3 continue on rFVIIIFc ITI and 1 switched to bypass therapy alone. Two initially responsive patients transitioned to other factors due to recurrence. Overall, 16 of 19 patients remain on rFVIIIFc (prophylaxis or ITI). For those still undergoing ITI, longer follow-up is needed to determine final outcomes. No adverse events reported., Conclusions: Recombinant factor VIII Fc fusion protein demonstrated rapid time to tolerization in high-risk first-time ITI patients. For rescue ITI, rFVIIIFc showed therapeutic benefit in some patients who previously failed ITI with other products. These findings highlight the need to further evaluate the use of rFVIIIFc for ITI., (© 2018 The Authors. Haemophilia Published by John Wiley & Sons Ltd.)

Background: The incidence of venous thromboembolism (VTE) is rising among inpatients in US hospitals, especially among kids with central venous catheters (CVCs) in the pediatric intensive care unit (PICU)., Objectives: To identify a sub-group of "VTE-rich" population among PICU children, and to assess the effect of VTE on morbidity and mortality., Methods: Data was extracted from a multicenter Virtual PICU Database, or VPS, for children with a CVC and presence of a VTE. The primary outcome variable was all cause mortality and secondary outcome measure was prolonged mechanical ventilation. Primary diagnoses and Pediatric risk of mortality 2 (PIM 2) score were also recorded., Results: The database identified 158,299 PICU patients who had a CVC. A total of 1602 patients had VTE (103 per 10,000 PICU patients). Multivariate analysis showed increased risk of VTE in patients who were <1year old (OR 1.48; 1.30-1.68), mechanically ventilated (OR 2.48; 2.07-2.98), had either a diagnostic (OR 2.32; 1.94-2.78) or therapeutic cardiac catheterization (OR 2.06; 1.66-2.55), PICC (OR 3.91; 3.50-4.37), and percutaneous CVC (OR 3.99; 3.48-4.61). Primary diagnoses associated with VTE were endocrinologic, immunologic, and gastrointestinal disorders. PICU patients with CVC and VTE had increased odds of mortality (OR 1.71; 1.47-2.00) after adjusting for factors associated with mortality, and fewer Ventilator Free Days (VFD) than patients without VTE., Conclusions: Critically ill children with CVC have a significant risk of developing VTE. Identification of the above "VTE-rich" population may aid in design of clinical trials aimed at prevention of VTE among hospitalized PICU children., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Acute lymphoblastic leukemia (ALL) is a hematologic malignancy that predominantly occurs in children between 2 and 10 years of age. L-asparaginase is an integral component of treatment for patients with ALL and since its introduction into pediatric treatment protocols in the 1960s, survival rates in children have progressively risen to nearly 90%. Outcomes for adolescent and young adult (AYA) patients, aged 15-39 years and diagnosed with ALL, have historically been less favorable. However, recent reports suggest substantially increased survival in AYA patients treated on pediatric-inspired protocols that include a greater cumulative dose of asparaginase. All  currently available asparaginases share the same mechanism of action - the deamination and depletion of serum asparagine levels - yet each displays a markedly different pharmacokinetic profile. Pegylated asparaginase derived from the bacterium Escherichia coli is used as first-line therapy; however, up to 30% of patients develop a treatment-limiting hypersensitivity reaction. Patients who experience a hypersensitivity reaction to an E. coli-derived asparaginase can continue treatment with Erwinia chrysanthemi asparaginase. Erwinia asparaginase is immunologically distinct from E. coli-derived asparaginases and exhibits no cross-reactivity. Studies have shown that with adequate dosing, therapeutic levels of Erwinia asparaginase activity can be achieved, and patients switched to Erwinia asparaginase due to hypersensitivity can obtain outcomes similar to patients who do not experience a hypersensitivity reaction. Therapeutic drug monitoring may be required to ensure that therapeutic levels of asparaginase activity are maintained.

Women bleed with menses, during childbirth, and after childbirth. Women are more likely to manifest a bleeding disorder as they have more opportunities to experience bleeding challenges in their lifetime. Bleeding disorders such as hemophilia and von Willebrand disease affect 2.5-3 million American women. The most common inherited bleeding disorder in the population is von Willebrand disease with an estimated prevalence of 1-2%. von Willebrand factor (vWF) is required to adhere platelets to exposed subendothelium and protects factor VIII from proteolysis in the circulation. The prevalence of vWF rises in studies involving women with menorrhagia, with estimates ranging as high as 10-20% in white women, and 1-2% among African American women. Other bleeding disorders seen in adolescents with menorrhagia are disorders of inherited platelet dysfunction, clotting factor deficiencies, thrombocytopenia, and disorders of the fibrinolytic pathway. Not only are women more likely to present early in their life with a bleeding disorder, they are also more likely to have other gynecologic manifestations as a result of these disorders. This article presents an overview of the problem and touches upon the different management strategies available., (Copyright © 2010 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

We describe the management of a young boy with mild haemophilia A and a massive iliac pseudotumour with a multi modality approach involving factor replacement, radiation therapy, embolization and surgery. The patient was initially treated with recombinant factor VIII and radiation therapy. Because of inadequate response and worsening of bony erosion, the patient had a preoperative embolization followed by surgical excision. The surgical procedure was associated with minimal blood loss and the patient had a relatively smooth postoperative course with no physical morbidity. This case illustrates successful aggressive management of a large, proximally located pelvic pseudotumour, which resulted in an excellent outcome despite the need for a normally morbid operation.

The optimal method to assess pediatric bone mass remains controversial. Dual x-ray absorptiometry (DXA) is commonly used but quantitative ultrasound is less expensive, free of ionizing radiation, and predicts fractures as well as DXA does, in adults. Broadband ultrasound attenuation (BUA) was determined using a portable calcaneal ultrasonometer and, compared with DXA derived areal bone mineral density (BMD) values in 42 young patients (ages 4.5 to 20.3 y) with leukemia. Reduced BMD was defined as a DXA z score of <-1. Mean z scores for lumbar spine BMD were significantly lower than zero (-0.77+/-1.23 SD, P=0.0004). Mean z scores for whole body BMD were also significantly lower than different from 0 (-0.34+/-1.04 SD, P=0.05). Calcaneal BUA was highly correlated with DXA measurement of lumbar, whole body, and femoral neck BMD. BUA was significantly associated with the probability of having a reduced lumbar BMD z score (P=0.03) and having a reduced whole body z score of (P=0.03). Area under the receiver operator characteristic curves for model including BUA predicting reduced bone density by DXA were 0.77 and 0.86 for lumbar and whole body z score cutoffs, respectively. Our data suggest that calcaneal BUA may serve as a reliable screening tool to detect reduced bone mass in pediatric patients with leukemia.

The activity of protease(s) was observed separately in cytosolic and membrane-bound protease(s) from male and female Hae monchus contortus (Nematoda: Trichostrongylidae). Different fractions showed optimum protease activity at 37 degrees C, pH 8.5 and 8.0 mg casein concentration. The female fractions had a particularly high activity of protease(s) in comparison with the male fractions, especially of membrane-bound enzymes in the anterior half. Inhibition, activation studies revealed the presence of four kinds of protease(s) in cytosolic and membrane-bound fractions. Protease(s) in different fractions are purified to a greater extent by higher concentrations of saturated ammonium sulphate solution, i.e. ranging from 50 to 65%. The purification study revealed the presence of multiple forms of protease(s) in cytosolic and membrane-bound extracts of H. contortus.

The activity of protease(s) has been examined separately in excretory/secretory (E/S) products from male and female Haemonchus contortus (Nematoda: Trichostrongylidae). The E/S proteolytic activity indicated the presence of preabsorptive digestion of host blood and/or tissues. Protease activity was optimum at 37 degrees C, pH 8.5 and 8.0 mg casein. These protease(s) were purified to 32.16- and 88.80-folds from male and female E/S products, respectively, by sequential purification with saturated ammonium sulphate followed by ion-exchange chromatography. The purification study revealed the presence of isomeric forms of protease(s) in the E/S products of H. contortus.

Higher lipid content in gall bladder bile of sheep and goats as compared with monogastric species was due to higher proportion of glycerides. The volume of bile per gall bladder was higher in sheep than in goats. Bile from sheep and goats has a higher content of proteins and lower contents of dry matter, cholesterol and phospholipids compared with monogastric species. Biliary proteins partially purified by the ammonium sulfate precipitation method were characterized and quantified by polyacrylamide gel electrophoresis (PAGE), fast protein liquid chromatography (FPLC) and immunodiffusion. FPLC and PAGE profiles indicate that biliary proteins of sheep and goats are mainly of low mol. wt. of upto 65 KDa. Proportions of immunoglobulin (Ig) like molecules in biliary proteins precipitated by ammonium sulfate of different degrees of saturation, were 10.4 to 26.7 and 21.9 to 30.7 per cent of total proteins in bile of goats and sheep. IgG and IgA like molecules were the predominant Ig and lacked carbohydrates. On immunodiffusion such Ig like molecules did not show cross reactivity with humoral Ig. It was concluded that sheep and goats appear to secrete Ig into bile after deglycosylation and partial degradation. The proteins of smaller molecular weight may be secretory fragments or degradation products of Ig.

The total protein and Ig content in the first colostrum was higher in buffalo cows than in dairy crossbred cows. Individual variation in Ig content of first colostrum may be responsible for differences in susceptibility of calves to infections. The decline in Ig content during subsequent milkings was faster in dairy crossbred cows. The major class was IgG in both species. Absorption of colostral proteins and Ig was 14.0 g (68%) and 4.6 g (75.4%), respectively, within 1 h of feeding colostrum to a 7-h-old female buffalo calf. Absorption was decreased to 2.1 and .83 g/h after the first feeding, suggesting that the intestinal absorption of macromolecules declined 1 h after the first feeding. Marginal placental transfer of maternal Ig also was demonstrated in buffalo. An albuminlike protein was predominant in blood plasma of the precolostral buffalo calf. This protein decreased, and IgG in blood plasma increased, after colostrum was fed, indicating that albuminlike protein may be involved in the transfer of maternal nutrients to the fetus.

Biochemical changes of the milk were studied in 7 lactating goats. The right udder halves of the animals were inoculated through the teat canal with 1 ml of Mycoplasma ovine/caprine serogroup 11 (2-D) culture containing 6x10(6) colony forming units ml-1. The left udder halves of these goats were kept as control. The experiment was continued for 35 days during which period one goat was killed every 5th day. All the goats developed clinical mastitis within 24 h and the infected udder halves remained enlarged for 4-5 days. The milk from these halves was yellow-tinged and showed slight separation of proteins. Subsequently, there was marked reduction in the size and secretion of the infected udder halves, followed by agalactia from post-inoculation (PI) day 22. The mycoplasmas were reisolated from milk samples of the infected halves up to PI day 20. Histopathological examination of these halves revealed changes indicative of acute and chronic mastitis. Biochemical analysis of mastitic milk/mammary secretions showed a marked increase in the concentration of total proteins, immunoglobulins, free fatty acids and phospholipids, while the concentration of total lipids and glycerides initially underwent a considerable decrease as compared to the basal and control values. However, the level of total cholesterol decreased sharply during the initial days while later, from PI day 5, it markedly increased. This study shows that Mycoplasma ovine/caprine serogroup 11 is pathogenic to the lactating udder of goats and produces marked biochemical alterations in the milk.

Hematological, biochemical, histoenzymological, and histopathological changes in serum and tissues were studied in chickens during outbreaks of nephritis. Hematological studies revealed normocytic-normochromic anemia characterized by increased total erythrocyte counts, hemoglobin, packed cell volume, and erythrocyte sedimentation rate. Albumin-to-globulin ratio and sodium levels in serum, glucose in blood, and alkaline phosphatase and glucose-6-phosphatase in liver and kidneys were decreased. Glutamate pyruvate transaminase, uric acid, non-protein-nitrogen, and potassium levels in serum were increased. No significant change in the calcium, phosphorus, and total protein levels in serum was observed. These changes were directly related to the severity of the nephritis.

Isotope angiocardiography established prosthetic tricuspid valve obstruction in a patient 6 years after triple valve replacement. Thrombus formation is a common complication of prosthetic cardiac valves, particularly in the tricuspid position where engagement of cage with myocardium is an additional potentially obstructive hazard. Comparison is made between the information yield of the isotope investigation and cardiac catheterization with contrast cineangiography. It is suggested that the isotope technique can noninvasively provide valuable anatomic and functional data, particularly where the right side of the heart is to be examined.

Nephritis was induced in 300, 18-day-old male Arbor Acre broiler chicks by feeding diets high (42.28%) in protein, high (3.27%) in calcium, containing urea (5%), or deficient in vitamin A. Various hematological parameters were studied at weekly intervals. Normocytic-normochromic anemia, characterized by a decrease in total erythrocyte counts, hemoglobin, packed cell volume, and an increase in erythrocyte sedimentation rate, was evident in the birds kept on diets high in protein, high in calcium, or deficient in vitamin A. Increased total erythrocytes, hemoglobin packed cell volume, and erythrocyte sedimentation rate was observed in birds fed urea. Differential leucocyte counts revealed lymphopenia, heterophilia and monocytosis in birds kept on diets high in protein, containing urea, or deficient in vitamin A. However, lymphocytosis, heteropenia , and monocytosis were recorded in birds fed the high calcium diet.

Splanchnic metabolism was studied to quantify changes underlying the fatty liver, hyperlipemia, and hypoglycemia produced by ethanol. Four subjects fasted for 15 h were compared with five subjects fasted for 69 h under basal conditions and during continuous intravenous infusion of sufficient ethanol to give a concentration of 3-5 mM in arterial blood plasma. Splanchnic storage of fatty acids was estimated from the difference between uptake of FFA and secretion of derived products. Basal values for splanchnic uptake of FFA were twofold higher after the 69-h fast while splanchnic storage of fatty acids and production of ketone bodies increased threefold. Values for basal secreation into the blood of triglycerides derived from FFA were similar in the two groups. In both nutritional states, the fraction of FFA taken up in the splanchnic region oxidized to ketone bodies and to CO2 fell when ethanol was given because of preferential oxidation of ethanol to acetate, and the fraction esterified rose. However, systemic transport and splanchnic uptake of FFA fell with ethanol in subjects fasted 15 h, so that neither storage of triglycerides in splanchnic tissues nor secretion into the blood increased. In subjects fasted 69 h, ethanol increased transport of FFA and splanchnic storage of fat. In all but one subject it also increased secretion of triglycerides into the blood. The concentration of glucose in blood fell during ethanol infusion in all five subjects undergoing the 69-h fast. Mean splanchnic glucose production was maintained at about one-half of the pre-ethanol value, despite virtual cessation of splanchnic uptake of lactate and of those amino acids that are metabolized via malate. Quantitative estimates of extrasplanchnic metabolism suggest that enhanced formation of alpha-glycerophosphate from glucose, in addition to impaired hepatic gluconeogenesis, may contribute to ethanol-induced hypoglycemia in man.

Insertion of transvenous permanent pacemaker leads through the subclavian vein is relatively safe and simple. This procedure was performed in 29 patients. The only serious complication was dislocation of the lead in eight patients. With this technique the endocardial lead can be positioned quite readily in the right ventricle. Use of the technique should be considered whenever the cephalic vein cannot be located readily or is too small to permit placement of an endocardial lead.

30 rats were divided into 3 groups to study the effects of erucic-acid-rich mustard oil (MO) and MO plus fish oil and carnitine (MOFOC) diet as compared to groundnut oil (GNO) diet on the collagen biosynthesis in various tissues. Changes in collagen content and monoamine oxidase (MAO) of hearts, aorta, skeletal muscles, lungs and skin were determined after 24, 60 and 80 days of feeding, respectively. Incorporation of U-14C-proline into collagen of these tissues was also studied. MO diets increased the incorporation of U-14C-proline into total and acid-insoluble collagen in heart, skeletal muscles and lungs but this increase was of lower magnitude in heart and skeletal muscles as compared with MOFOC diet. Total and acid-insoluble collagen contents in all these tissues, except skin, were increased by MO diet and MOFOC diet retarded this increase. Similar trends were observed in the activities of MAO. The results suggest that the MO diet increases both the biosynthesis and maturation of collagen and MOFOC diet retards this trend. The response of various tissues being variable in this respect.

The effects of short-term feeding of a 20% mustard oil (containing 47% erucic acid) diet with 0.1% carnitine and/or fish oil on the activity of enzymes of lipid metabolism in mitochondrial and post-mitochondrial fractions of heart, liver, and skeletal muscles of rats were determined to study the reversal of erucic acid-induced lipidosis. Histopathological changes were also studied. The inclusion of fish oil or fish oil plus carnitine in a mustard oil diet, especially the latter, eliminated the histopathologically detectable lipidosis in heart and skeletal muscles. The reason for this appears to be the increased activity of lipase and phospholipase in tissue homogenates and of cholesterol ester hydrolase in the post-mitochondrial fraction; and also an increase in mitochondrial succinate dehydrogenase which may increase the utilization of the liberated fatty acids. The results suggest that the erucic acid-induced lipidosis is prevented or eliminated by increased lipolysis and oxidation of fatty acids when such a diet is supplemented with carnitine and/or fish oil.

In 39 consecutive patients with unequivocally positive postexercise ECG we have correlated the location and severity of the coronary artery stenoses with the ECG leads in which ischemic ST changes occured. Patients with major stenoses of the right coronary artery, with or without disease of the left coronary system, showed ischemic ST changes in Leads II, III, and aVF. Patients with major stenoses of the left coronary system, many of whom had suffered old inferior wall infarction, showed ST changes in Leads I, aVL, and the chest leads. A group of 11 patients showed ischemic ST changes in leads other than those expected on the basis of the location and severity of coronary artery stenoses. In each of these 11 patients large collateral channels were donated by the vessel in whose territory the ischemic changes occurred. This finding lends support to the concept of intercoronary "steal" during exercise in coronary artery disease, at the same time reducing the value of the postexercise 12 lead ECG in predicting the location and severity of coronary artery stenoses.