Antinociceptive Properties of Protein C in a Model of Inflammatory Hyperalgesia in Rats

We investigated the role of human protein C in an animal model of inflammatory hyperalgesia. Pain was induced by intraplantar injection of carrageenan (3 mg) into the hind paw of rats. The pain threshold was measured by exerting increasing amounts of pressure (in mmHg) on the paw until a struggle reaction was observed. Protein C (8-800 IU/kg) was administered intravenously immediately after carrageenan. Controls received either intraplantar injections of saline (100 µ1) instead of carrageenan or carrageenan alone. Effects on pain threshold were expressed in percent of the pretreatment value. Carrageenan alone lowered the mean pain threshold after 3 h to 33.2 ± 2.2% of the pretreatment level. Addition of protein C resulted in a dose-dependent rise in pain threshold towards the level observed in control animals treated with saline instead of carrageenan (pain threshold after 800 IU/kg protein C = 62.9 ± 2.3% of pretreatment level), demonstrating an antinociceptive effect. Protein C had no effect in animals not preconditioned with intraplantar carrageenan. Thus protein C clearly antagonized the inflammatory pain induced by carrageenan. The antinociceptive action of protein C was antagonized by injection of a monoclonal antibody against protein C, providing additional evidence that the effect was protein C-mediated.

Homozygous Type I Protein C Deficiency in Two Unrelated Families Exhibiting Thrombophilia Related to Ala136→Pro or Arg286→His Mutations

Separate single nucleotide mutations have been identified in two unrelated homozygous type I protein C deficient individuals suffering from thrombophilia. Each mutation, initially established by direct DNA sequencing of polymerase chain reaction amplification products, results in an amino acid substitution. The first mutation (PCClamart) results in an Ala136 to Pro substitution in the protein’s second epidermal growth factor-like domain. The second mutation (PCMtinchen) results in an Arg286 to His substitution in the serine protease domain. Comparison of the location of these two mutations and the relative conservation of the two regions in homologous vitamin K-dependent plasma proteins is consistent with the difference in severity of protein C deficiency and disease in the two individuals. Both mutations result in the abolition of a naturally occurring restriction endonuclease site, thereby allowing independent confirmation of the mutations and rapid and unambiguous genetic analysis of protein C deficiency in family members. In both families, the genetic analysis has proven useful in cases where an assignment of the protein C status based upon clinical laboratory measurements was either ambiguous or incorrect.

Die sozioökonomische Evaluation

Bedingt durch den enormen Ausgabenanstieg im Gesundheitswesen, wurde vermehrt die Notwendigkeit erkannt, daß neue medizinische Technologien einer sozioökonomischen Evaluation zu unterziehen sind. Leistungsanbieter, Kostenträger sowie Behörden verlangen verstärkt einen Vergleich von Kosten und Leistungen als Grundlage für Entscheidungen. Die am häufigsten angewandten Methoden sind die Kosten-Nutzen-, Kosten-Effektivitäts-, Nutzwertsowie Kostenminimierungsanalysen.

Insbesondere das Gebiet der Hämostaseologie ist zunehmend von Fragen der Sozioökonomie betroffen, zumal entweder sehr wenige Patienten extrem kostspielige Therapien in Anspruch nehmen (z. B. Hämophilie) oder viele Patienten von relativ kostengünstigen Interventionen profitieren können (z.B. Thromboembolie-Prophylaxe). Die vorliegende Arbeit gibt einen Überblick über die Methoden der sozioökonomischen Evaluation anhand von Beispielen aus der Hämostaseologie.

Prospects for research in haemophilia with real-world data-An analysis of German registry and secondary data

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.

Surgery – a challenge in haemophiliacs with inhibitors

Treatment of haemophiliacs with inhibitors is of great concern in low-income countries confronting shortage in substitutive treatment. Invasive interventions on these patients represent a major challenge due to the fact that costs are significantly higher in comparison to similar procedures conducted on patients without inhibitors. Objective: In the context of insufficient availability of clotting factor, we aimed at highlighting the experience of surgical treatment in inhibitor patients. We analyzed the indications, types of performed interventions and outcomes. Patients, methods: This single center, retrospective analysis has been conducted on 7 inhibitor patients registered and treated in Haemophilia Center of Timisoara over ten years (1997–2007): six patients with severe hemophilia A (3 – high titer, 3 – low titer), one patient with von Willebrand disease (low titer).Three patients developed inhibitors only after 2–5 days post surgery. Results: A total of 15 invasive procedures were carried out: 2 orthopedic interventions (1 arthrodesis, 1 arthroscopic synovectomy), 2 urogenital interventions (1 surgical testicular detorsion, 1 orchiectomy), 4 limb amputations (2 bilateral upper and 2 lower limb amputation), 2 pseudotumour (PT) surgery interventions, 5 drainages (2 massive pyohaemothorax, 1 drainage of shank haematoma, 1 drainage of compressive forearm haematoma, 1 drainage of thigh haematoma). Haemostasis was achieved in patients with low level inhibitors (< 5 BU/ml) with high doses of FVIII concentrates; in those with high inhibitor

Todesursachen bei Hämophilie-Patienten in Deutschland 2006/2007

Seit 1983 (Erhebungszeitraum zurückreichend bis 1978) wird die Untersuchung zur Epidemiologie bei Patienten mit Hämophilie mit der Unterstützung einer Vielzahl von Hämophiliezentren und Behandlungseinrichtungen jeglicher Größe jährlich durchgeführt. Die aktuelle Zusammenstellung beruht auf einer breiten Datenbasis aus inzwischen fast 30 Jahren und vermag sowohl den aktuellen als auch den retrospektiven Morbiditäts- und Mortalitätsstatus gut abzubilden. Abgefragt wurden Informationen ausschließlich zu Patienten mit Hämophilie A, B und von-Willebrand- Erkrankung. Im Einzelnen wurden anonymisierte Daten zur Gesamtzahl an behandelten Patienten, Typ und Schweregrad der Erkrankung, HIV-Status und Todesursachen abgefragt. Diese Datensätze wurden mit den vorhandenen Datensätzen zusammengeführt und statistisch ausgewertet. Insgesamt wurden im Untersuchungszeitraum 2006/2007 eine Gesamtzahl von 8188 Patienten aus 69 Behandlungseinrichtungen gemeldet. Obwohl die Mortalität durch HIV/ AIDS bei Patienten mit Hämophilie weiter abnimmt, bleibt HIV ein wichtiges Problem, insbesondere da eine HIV/HCVKoinfektion das Risiko einer progredienten Lebererkrankung erhöhen kann. Die Altersstruktur unserer Patienten hat sich in im Laufe der vergangenen Jahrzehnte erheblich verändert und nähert sich zunehmend an die der Normalbevölkerung an, so dass dies bei der Beurteilung der Mortalität und Morbidität beachtet werden muss.

Relevance of a single dose of 270 μg/kg recombinant factor VIIa for the treatment of patients with haemophilia and inhibitors

Recombinant activated factor VII (rFVIIa; Novo Seven®) is, besides other indications, authorised for the treatment of bleeding episodes in patients with hereditary haemophilia A or B and inhibitors. Based on the results of three clinical studies, marketing authorisation was granted for the single dose of 270 μg/kg body weight rFVIIa for the treatment of mild-to-moderate bleeding episodes in patients with haemophilia A or B with inhibitors in March 2007. Thereupon, an expert group analysed the relevance of this additional treatment option for clinical routine. Compared with the repeated application of 90 μg/kg body weight rFVIIa, quality of life may be improved if the single dose of 270 μg/kg body weight rFVIIa reduces the number of injections. The single dose has a benefit for those patients who require several rFVIIa applications or who do not respond adequately to low doses. Moreover, patients with poor venous access or who fear injections or reject them (especially children) may benefit from the single dose. The prescription of 270 μg/kg body weight rFVIIa as a single dose instead of multiple dosing of 90 μg/kg body weight is basically an individual and indication-related decision.

Long-term outcome of an unusual haemophilic pseudotumour

Haemophilia, a lifelong congenital bleeding disease, is a highly demanding disorder, due to the costs of its replacement therapy. In the absence of this pivotal treatment, life expectancy and quality of life are deleteriously affected.

As illustration, we present a 14 years long follow- up of a patient with severe haemophilia A, treated sporadically with fresh plasma, cryoprecipitate and factor concentrates, who developed a giant iliopsoas pseudotumor. Since he was an infant, under on demand therapy with fresh frozen plasma, cryoprecipitate and low doses of factor concentrates he presented many spontaneous bleedings, developing multiple disabling arthropathies. At the age of 14 years, an iliopsoas hematoma occurred, which relapsed several times, developing an iliopsoas pseudotumour. After 5 years, sepsis with Klebsiella was diagnosed. A CT scan revealed fistula between the pseudotumor and the gut. Under antibiotics, the evolution of sepsis improved, but over a period of 10 months 5 episodes of haematemesis and melena, followed by one episode of macroscopic haematuria occurred; two months later he developed an inguino-crural mass, which fistulized through the abdominal wall. A mixt german-romanian team solved the clinical concern. After 108 hospitalization days and consumption of 104 840 IU factor VIII he left the clinic in good condition. One year later, the temporary colostomy with anus praeter was closed. The follow-up reveals now, after almost 10 years with favourable outcome, that the patient is well, active within his family and profession.

Prophylaktische Faktorsubstitution bei schwerer Hämophilie A

Prophylaxe kann bei Erwachsenen mit schwerer Hämophilie A klinisch notwendig sein. Ziel war es, die prophylaktische Faktor-VIII-Substitution bei erwachsenen Patienten mit Hämophilie in Deutschland ökonomisch zu bewerten. Patienten, Methoden: Für die Analysen wurde ein Entscheidungsmodell erstellt: Zeithorizont ein Jahr; Perspektive gesetzliche Krankenkassen; Referenzpatient (RP) und zwei Patientenprofile. Die Berech-nungen basieren auf Daten aus einer struktu-rierten Literatursuche, -analyse und einer Pharmakovigilanzstudie mit Patienten zu Therapiewechsel On-demand/Prophylaxe (OD/Proph). Ergebnisse: RP: 45 Jahre, 20 Blutungen p.a. OD, 16 vermiedene Blutungen mit 8,5 I.U./kg/d Proph, Zusatzkosten 141 113 Euro p.a.; Profil 1: 50 Jahre, 55 Blutungen p.a. OD, Faktorverbrauch pro Blutung 20 I.U./kg höher als bei R P, 39 vermiedene Blutungen mit 8,5 I.U./kg/d Proph, Zusatzkosten 19 134 Euro p.a.; Profil 2: 60 Jahre, 35 Blutungen p.a. OD, Faktorverbrauch pro Blutung 40–80 I.U./kg höher als bei R P, 34 vermiedene Blutungen mit 11 I.U./kg/d Proph, Einsparung 660 Euro p.a. Schlussfolgerung: In der indivi-duellen Situation kann eine prophylaktische Faktorsubstitution bei erwachsenen Patienten auch ökonomisch sinnvoll sein. Um künftig diesen Effekt umfassend zu bewerten, werden longitudinale Daten aus dem Versorgungsalltag inklusive klinischer Outcomes, Lebensqua-lität und Adhärenz benötigt.

Neue Daten aus dem Deutschen Hämophilieregister

The German Haemophilia Registry records online data from patients with haemophilia A, haemophilia B, von Willebrand`s disease and other coagulation factor deficiency disorders since 2009. Patient´s pseudonymised data will only be enrolled in the German Haemophilia Registry if the patient signs an informed consent. Without the informed consent, only aggregated data according to §21 German Transfusion Law are reported. These data include the number of persons with congenital haemostasis disorders classified to type of disease and severity as well as patients’ age, and the consumption of clotting factor according to each group. Results: The highest number of patients with haemophilia was reported in 2010: 3375 patients with haemophilia A and 614 with haemophilia B respectively; the highest number of patients with von Willebrand`s disease was 1473, reported in 2011. Conclusion: In comparison to data from registries in Austria and Switzerland it can be assumed that most of the patients with severe haemophilia are registered in the German Haemophilia Registry whereas patients with moderate and mild forms are still missing.

Morbidity and mortality of haemophilia patients in Germany

Since 1982, the multicenter study of the epidemiology of patients with haemophilia is carried out annually with the support of all sizes of haemophilia centers and treatment facilities. The long period of investigation has not only enabled the reporting of up-to-date mortality and morbidity status, but also of retrospective observations. The participating centers have made anonymized data available for patients with Haemophilia A, B and von Willebrand’s disease (total counts for treated patients, type and severity of the disease, HIV status and causes of death). For 2011–2012 3331 patients were reported with haemophilia A or B from 32 centers. Although the mortality from HIV/AIDS in haemophilia patients continues to decline, HIV infection remains clinically relevant since an HIV/HCV coinfection can raise the risk of severe liver disease. The data from the multicenter survey were, together with the anonymized data from the Foundation for Humanitarian Aid for Persons Infected with HIV though Blood Products, comparatively descriptively compared and the temporal progression illustrated by a so-called moving average. Expectedly, haemophilia patients were shown to be under-represented by the data from the multicenter survey. Otherwise, the data are consistent.

Morbidität und Mortalität der Hämo philie-Patienten in Deutschland

Since 1982 an annual multicentric survey regarding the epidemiology of patients suffering of haemophilia is performed with support of haemophilia treating centres of any size. Again, the actual compilation is resting upon a broad database returning to over 30 years of inquiry well representing both the actual and retrospective status of mortality. Prompted was exclusively information about patients with haemophilia A, B and von Willebrand disease. In particular anonymous data concerning the preceeding 12 months about number of treated patients, type and severity of illness, HIV-status and detailed information about causes of death was inquired. This data was merged with existing data and analysed statistically. In the 2009/2010 survey, a total number of 9448 patients with bleeding disorders have been reported from 47 participating centres. Despite mortality from HIV in patients with haemophilia is keeping on decreasing, HIV still remains an important factor as an HIV/HCV coinfection seems to increase risk of progression of severe liver disease. In the actual investigation the findings of the foundation “Humanitäre Hilfe für durch Blutpro-dukte HIV-infizierte Personen” were compared for the first time to our data. Time trends were visualised with a moving average. Our investigation has a smaller number of deceased patients, but contains consistent data.

Risks and challenges of orthopaedic invasive interventions in haemo -philia in a low-resource country

Haemophilic arthropathy is a defining feature and a debilitating condition of persons with haemophilia (PwH) in low resource countries. Orthopaedic surgery is unavoidable for patients with high occurrence of joint damage. Aims: We aimed to evaluate the spectrum and outcome of invasive orthopaedic therapies in PwH and von Willebrand diseases (VWD). Patients and methods: Our descriptive observational retrospective study included 131 invasive surgical procedures, performed on 76 consecutive patients, most of them (93.4%) with severe disease, treated in Timisoara’s Haemophilia Center over a period of 12 years; 17.1% had pre-operation anti-FVIII inhibitors. Invasive elective procedures were predominant (90.8%) as compared to emergency measures (9.2%); according to their invasiveness, 20.6% of interventions were major, 44.3% intermediate and 35.1% minor. Results: were good in the majority of cases; significantly reduced joint bleed rate and pain score were the most consistent achievements. The greatest proportion of complications occurred after major (66.7%), compared to moderate (25.6%) and minor (7.7%) interventions. The main threatening complication was the development (3.8%) or increase (4.6%) of inhibitor titer. Local bacterial infections and wound dehiscence complicated the evolution in 4.6% and 0.8 % of cases, respectively; we noticed no blood-borne infections or thrombotic accidents. Low dosage (10.7%) and short duration of substitution (21.4%) led to increased post-surgical bleeding and post-haemorrhagic anaemia. Conclusions: Surgery is a highly demanding intervention in haemophilia, which cannot be ignored in a low resource country. It represents a life or limb-saving and quality of life-improving measure.

2% Hämophilie-A-Patienten ohne Mutation im FVIII-Gen

In Deutschland leben rund 6000 Hämophilie-A-Patienten. Mit Screening-Methoden können ca. 97% der Mutationen erfasst werden. Für die restlichen Patienten werden alle kodierenden Regionen des FVIII-Gens sequenziert.

Von 1350 Patienten wurde bei 80 Patienten zunächst keine Mutation gefunden. In fünf Fällen war eine Inversion im Intron 1 verantwortlich, in 16 Patienten wurden bekannte und bei 19 Patienten neue Mutationen identifiziert. Von den neuen Mutationen lagen 14 in kodierenden Bereichen, die restlichen fünf befanden sich in flankierenden Bereichen von Exons. Neben den als kausal betrachteten Mutationen wurden fünf Polymorphismen identifiziert. Weitere Untersuchungen müssen klären, ob diese Polymorphismen Krankheitsbild und -verlauf beeinflussen.

Überraschenderweise wurde bei 23 der 80 Patienten keine kausale Mutation in den untersuchten Regionen identifiziert. Das bedeutet, dass in etwa 2% der Hämophilie-A-Patienten keine Mutation in der cDNA des FVIII-Gens gefunden werden kann. Daher müssen auch Mutationen in nicht kodierenden Regionen oder sogar in anderen Genen in Betracht gezogen werden. Eines dieser Gene kodiert für den von-Willebrand-Faktor (vWF). Wir identifizieren in zwei Fällen eine Mutation im vWF-Gen.

Charakterisierung von Faktor-VIII-Antikörperepitopen mit Faktor-VIII-Peptid-Bibliotheken

Etwa 30% der Patienten die an schwerer Hämophilie A leiden, entwickeln als Komplikation einer Substitutionstherapie gegen Faktor VIII gerichtete Antikörper, die die prokoagulatorische Aktivität von intravenös injizierten FVIII-Proteinen neutralisieren. In der Regel werden verschiedene Epitope auf dem FVIII-Molekül durch diese Antikörper gebunden. Die detaillierte Struktur dieser Epitope ist unbekannt. In dieser Studie werden Epitope auf dem Faktor-VIII-Molekül mit Hilfe festphasengebundener Peptid-Arrays identifiziert, auf denen die Aminosäuresequenz des FVIII in Oligopeptiden dargestellt wird. Die Bindung von FVIII-Antikörpern an bestimmte Peptidsequenzen zeigt potenzielle Epitopstrukturen. FVIII-Antikörper von Inhibitorpatienten und gesunden Blutspendern werden zurzeit mit dieser Methode charakterisiert. Identifizierte Epitope können zur Entwicklung neuer Therapiekonzepte führen, die dazu dienen, eine Hemmkörperentwicklung zu vermeiden bzw. bereits entstandene Hemmkörper besser zu eliminieren. Als Teilprojekt des Konsortiums »Hämophilie A« wird im Rahmen des Gesamtvorhabens »Genotyp-Phänotyp-Korrelation bei der Hämophilie A« untersucht, ob die Epitopcharakteristik mit dem Typ und der Position der FVIII-Genmutationen korreliert sowie Zusammenhänge zwischen Epitop und klinischem Verlauf der Krankheit bestehen. Zusätzlich wird der Einfluss der Epitope auf den therapeutischem Effekt und Erfolg der Immuntoleranzinduktion untersucht.

Kreuth IV: European consensus proposals for treatment of haemophilia with coagulation factor concentrates

INTRODUCTION

This report summarizes recommendations relating to haemophilia therapy arising from discussions among experts from 36 European countries during the 'Kreuth IV' meeting in May 2016.

AIM

The objective of the meeting was for experts in the field of haemophilia from across Europe to draft resolutions regarding current issues relating to the treatment of haemophilia.

RESULTS

Hospitals providing clinical care for people with haemophilia and related disorders are strongly recommended to seek formal designation as either European Haemophilia Treatment Centres (EHTC) or European Haemophilia Comprehensive Care Centres (EHCCC). There should be agreed national protocols or guidelines on management of the ageing patient with haemophilia. The minimum consumption of factor VIII and IX concentrate in any country should be 4 IU and 0.5 IU per capita of general population respectively. Treatment for hepatitis C with direct-acting antiviral agents should be provided to all people with haemophilia on a priority basis. Genotype analysis should be offered to all patients with severe haemophilia. Genetic counselling, when given, should encompass the recommendation that genetic relatives of the affected person be advised to seek genetic counselling. People with inhibitors should have access to bypassing agents, immune tolerance and elective surgery. National or regional tenders for factor concentrates are encouraged. Outcome data including health related quality of life should be collected. Treatment with extended half-life factors should be individualized and protection against bleeding should be improved by increasing trough levels. Steps should be taken to understand and minimize the risk of inhibitor development.

CONCLUSION

It is hoped that these recommendations will help to foster equity of haemophilia care throughout Europe.

Kreuth III: European consensus proposals for treatment of haemophilia with coagulation factor concentrates

This report summarizes recommendations relating to haemophilia therapy arising from discussions among experts from 36 European countries during the Kreuth III meeting in April 2013. To optimize the organization of haemophilia care nationally, it is recommended that a formal body be established in each country to include the relevant clinicians, national haemophilia patient organization, health ministry, paying authority and (if appropriate) regulatory authorities. The minimum factor VIII consumption level in a country should be 3 I.U. per capita. Decisions on whether to adopt a new product should not be based solely on cost. Prophylaxis for children with severe haemophilia is already recognized as the optimum therapy. Ongoing prophylaxis for individual adults should also be provided when required based on clinical decision making by the clinician in consultation with the patient. Children with inhibitors who have failed, or who are not suitable for, immune tolerance therapy should be offered prophylaxis with bypassing agents. Single factor concentrates should be used as therapy wherever possible in patients with rare bleeding disorders. Orphan drug designation for a factor concentrate should not be used to hinder the development, licencing and marketing of other products for the same condition which have demonstrably different protein modification or enhancement.

Computerized in vivo classification of methylene blue stained fallopian tube mucosal damage: preliminary results

OBJECTIVE

Fertiloscopy is a simple minimal invasive method which allows salpingoscopy and microsalpingoscopy in order to examine the mucosa of the fallopian tubes of patients with unexplained infertility. Infectious tubal damage is a common cause of tubal infertility. In 1998 it was demonstrated that nuclear staining of cellular nuclei during microsalpingoscopy with methylene blue provides a simple in vivo method to evaluate cellular damage of the tubal epithelium. The purpose of this study was to introduce and statistically test a new computerized method to objectively evaluate the extent of tubal damage. DESIGN OF RETROSPECTIVE STUDY: Cooperation of two Departments of Gynecology and Obstetrics (Krankenanstalt Rudolfstiftung, Vienna, Austria and CRES Center, Hôpital Natecia, Lyon, France) with the University of Art and Design, Linz, Austria and University Hospital, Vienna, Austria.

MATERIALS AND METHODS

Microsalpingoscopic images from ten female patients, aged between 18 and 45 years with primary infertility, showing stained nuclei in damaged intrafallopian tubal epithelium were provided by Antoine Watrelot, CRES Center, Hôpital Natecia, Lyon, France. These images were evaluated by an experienced medical expert staff examiner and a computerized standard method called cross-correlation and template matching. The obtained numbers of nuclear stainings were statistically evaluated.

RESULTS

Computerized evaluation of nuclear staining of damaged intrafallopian epithelial cells in female patients with infertility obtains similar but more reproducible results compared to manual evaluation (p = 0.007).

CONCLUSION

Normalized cross-correlation can be used to measure tubal damage diagnosed by in vivo methylene blue dyeing during microsalpingoscopy and might facilitate the decision for in vitro fertilisation in patients with unclear unexplained infertility in further studies.

Switching clotting factor concentrates: considerations in estimating the risk of immunogenicity

The development of neutralizing antibodies to factor VIII (FVIII) is the most serious complication of therapy for haemophilia A. There is now excellent documentation that a large number of both genetic and environmental factors contribute to the risk of FVIII inhibitor incidence. One of the environmental factors that has been proposed as an influence on this complication is the occurrence of FVIII product switching. There are only a small number of clinical studies that have addressed this question, and thus, the amount of objective information available to assess this association is limited. In this review, in addition to summarizing past evidence pertinent to this subject, we present the results of a complementary strategy, a Delphi analysis, to add to the considerations of product switching and FVIII immunogenicity. With the imminent arrival in the clinic of several new FVIII products, the haemophilia community must be prepared to collect prospectively controlled data to better address this important management issue.

[New data from the German Haemophilia Registry]

The German Haemophilia Registry records online data from patients with haemophilia A, haemophilia B, von Willebrand`s disease and other coagulation factor deficiency disorders since 2009. Patient's pseudonymised data will only be enrolled in the German Haemophilia Registry if the patient signs an informed consent. Without the informed consent, only aggregated data according to §21 German Transfusion Law are reported. These data include the number of persons with congenital haemostasis disorders classified to type of disease and severity as well as patients' age, and the consumption of clotting factor according to each group.

RESULTS

The highest number of patients with haemophilia was reported in 2010: 3375 patients with haemophilia A and 614 with haemophilia B respectively; the highest number of patients with von Willebrand's disease was 1473, reported in 2011.

CONCLUSION

In comparison to data from registries in Austria and Switzerland it can be assumed that most of the patients with severe haemophilia are registered in the German Haemophilia Registry whereas patients with moderate and mild forms are still missing.

Morbidity and mortality of haemophilia patients in Germany. Survey results 2011/2012

Since 1982, the multicenter study of the epidemiology of patients with haemophilia is carried out annually with the support of all sizes of haemophilia centers and treatment facilities. The long period of investigation has not only enabled the reporting of up-to-date mortality and morbidity status, but also of retrospective observations. The participating centers have made anonymized data available for patients with Haemophilia A, B and von Willebrand's disease (total counts for treated patients, type and severity of the disease, HIV status and causes of death). For 2011-2012 3331 patients were reported with haemophilia A or B from 32 centers. Although the mortality from HIV/AIDS in haemophilia patients continues to decline, HIV infection remains clinically relevant since an HIV/HCV coinfection can raise the risk of severe liver disease. The data from the multicenter survey were, together with the anonymized data from the Foundation for Humanitarian Aid for Persons Infected with HIV though Blood Products, comparatively descriptively compared and the temporal progression illustrated by a so-called moving average. Expectedly, haemophilia patients were shown to be under-represented by the data from the multicenter survey. Otherwise, the data are consistent.

[Regional analysis of drug treatment prevalence and medication of diabetes mellitus in Germany]

BACKGROUND AND AIM

Diabetes mellitus is a widespread chronic disease. Diabetes prevalence was already analyzed in multiple complex studies. The goal of this analysis was the determination of the regional drug treatment prevalence and medication of diabetes mellitus in Germany. Simultaneously, we examined and validated the applicability of prescription data of the German statutory health insurance (SHI) as the basis for reliable and comparable prevalence estimations.

PATIENTS AND METHODS

For the analysis, we used anonymized data from a prescription database as well as the member statistics of the German federal Ministry of Health. By using defined prescription profiles with anti-diabetic medication, we determined the diabetic patients and treatment schemes per Association of SHI Physicians. Subsequently, we calculated and described the drug treatment prevalence and medication. A differentiation between type 1 and type 2 diabetes was not possible.

RESULTS

The total prevalence of drug-treated patients in Germany was 7.77%. The regional values ranged from 6.40% in Schleswig-Holstein until 11.37% in Saxony-Anhalt. The highest numbers of drug treatment prevalence were found in the East of Germany. Insulin treatment was frequent in Hamburg, but rare in Bavaria. Insulin combined with oral anti-diabetic medication was mainly dispensed in Saxony-Anhalt and Brandenburg, least in Hamburg. A treatment with one or more oral anti-diabetics was most common in Bavaria and Bremen, lowest in Rhineland-Palatinate and Mecklenburg-West Pomerania.

CONCLUSION

We developed an easy to use evaluation algorithm for prescription data to estimate the drug treatment prevalence of a chronic disease. The estimated prevalence confirms the increasing trend reported from other studies and appears to be plausible in comparison. More research is required to validate and enhance the method.

Haemophilia care in Europe: the ESCHQoL study

The aim of this study was to determine the clinical conditions of patients with haemophilia within Europe as recommended by the European Commission. In this multicentre, cross-sectional, ambispective study, conducted within 21 European countries patients' clinical data were collected, amongst others haemophilia type, severity, treatment pattern, use of factor products, bleeding, orthopaedic joint scores and infections. A total of 1400 patients, 84.3% with haemophilia A and 15.7% with haemophilia B were enrolled by 42 centres between 2004 and 2006. Thereof, 417 were children (30.0%) and 983 were adults (70.0%). About 70% of patients had severe factor deficiency (<1%). More than half of the adults were carriers of chronic infections (12.6% HIV, 55.8% HCV), compared to only 3.8% children (no HIV, 2.9% HCV). Patients were grouped according to per capita amount of clotting factor used in patients' region of residence in 2005: region 1: >5 IU; region 2: 2-5 IU; region 3: <2 IU. Paediatric and adult patients in region 3 had median numbers of three and eight joint bleeds, respectively, with worse joint scores compared to region 1 with zero and one bleed. Prophylactic therapy was used in only 31.3% children and 8.9% adults with severe haemophilia in region 3 compared to 93.7% and 54.1%, respectively, in region 1. Statistical analysis revealed that residence in areas with low factor consumption/availability is the most prominent risk factor for joint disease. Access of European patients with haemophilia to optimal care with safe factor VIII concentrates is limited and depends on the region of residence.

Haemophilia prophylaxis: how can we justify the costs?

Severe haemophilia results in increased mortality and poorer quality of life. Factor prophylaxis leads to a more normal life, but is very costly; most of the cost is due to the high cost of replacement factor. Despite its high cost, factor prophylaxis has been adopted throughout the developed world--even in different health care systems. We argue that there are at least five possible reasons why societies may value factor prophylaxis despite its cost: (i) it is directed towards an inherited disease, (ii) the treatment is largely directed towards children, (iii) the disease is rare and the overall cost to society is small, (iv) the treatment is preventative, and v) the high cost is largely the result of providing safe products. In an era of rising health care costs, there is a strong research agenda to establish the factors that determine the value of expensive therapies for rare diseases like haemophilia.

[Morbidity and mortality of patients with haemophilia in Germany--update 2010/2011]

Since 1982 an annual multicentric survey regarding the epidemiology of patients suffering of haemophilia is performed with support of haemophilia treating centres of any size. Again, the actual compilation is resting upon a broad database returning to over 30 years of inquiry well representing both the actual and retrospective status of mortality. Prompted was exclusively information about patients with haemophilia A, B and von Willebrand disease. In particular anonymous data concerning the preceeding 12 months about number of treated patients, type and severity of illness, HIV-status and detailed information about causes of death was inquired. This data was merged with existing data and analysed statistically. In the 2009/2010 survey, a total number of 9448 patients with bleeding disorders have been reported from 47 participating centres. Despite mortality from HIV in patients with haemophilia is keeping on decreasing, HIV still remains an important factor as an HIV/HCV coinfection seems to increase risk of progression of severe liver disease. In the actual investigation the findings of the foundation "Humanitäre Hilfe für durch Blutprodukte HIV-infizierte Personen" were compared for the first time to our data. Time trends were visualised with a moving average. Our investigation has a smaller number of deceased patients, but contains consistent data.

Long-term outcome of an unusual haemophilic pseudotumour

Haemophilia, a lifelong congenital bleeding disease, is a highly demanding disorder, due to the costs of its replacement therapy. In the absence of this pivotal treatment, life expectancy and quality of life are deleteriously affected. As illustration, we present a 14 years long follow-up of a patient with severe haemophilia A, treated sporadically with fresh plasma, cryoprecipitate and factor concentrates, who developed a giant iliopsoas pseudotumor. Since he was an infant, under on demand therapy with fresh frozen plasma, cryoprecipitate and low doses of factor concentrates he presented many spontaneous bleedings, developing multiple disabling arthropathies. At the age of 14 years, an iliopsoas hematoma occurred, which relapsed several times, developing an iliopsoas pseudotumour. After 5 years, sepsis with Klebsiella was diagnosed. A CT scan revealed fistula between the pseudotumor and the gut. Under antibiotics, the evolution of sepsis improved, but over a period of 10 months 5 episodes of haematemesis and melena, followed by one episode of macroscopic haematuria occurred; two months later he developed an inguino-crural mass, which fistulized through the abdominal wall. A mixt german-romanian team solved the clinical concern. After 108 hospitalization days and consumption of 104840 IU factor VIII he left the clinic in good condition. One year later, the temporary colostomy with anus praeter was closed. The follow-up reveals now, after almost 10 years with favourable outcome, that the patient is well, active within his family and profession.

Development of inhibitors in haemophilia. Ongoing epidemiological study

A number of 513 consecutive patients (494-haemophilia A and 19-haemophilia B) from eight haemophilia treatment centers have been investigated with Bethesda assay for the presence of factor VIII or IX inhibitors. The overall prevalence of inhibitors was 15.20%, 18.48% in severe, 5.60% in moderate and 12.24% in mild forms. The prevalence was higher than reported in most of the western countries. The age at start of substitution (p = 0.9775), the frequent switching of factor concentrates (p = 0.8931) were not relevant factors for the development of inhibitors. It is worth to be mentioned the unexpectedly occurrence of inhibitors in prior inhibitor negative (6/72) patients (during surgical interventions) probably due to their previous scarce substitution, occurrence which seems not being connected with the continuous infusion modality of factor VIII administration (p = 0.8341). In controversial situations, in the field of low titer (≤ 1 BU/ml) inhibitors for a reliable interpretation of the results the performance of recovery index and half-life time assessment of FVIII/IX was undertaken.

Haemophilia patients with HIV- and HCV-infection. Long term survival

At present (2010), we investigate in a long term study on psychosocial aspects of haemophilia at the Munich Haemophilia Centre factors which could be held responsible for the large number of still living HIV+ patients while many patients died from AIDS or from diseases caused by HCV during the 1990ies.

PATIENTS, METHODS

We retrospectively compare medical and psychosocial data of 15 HIV+ long term survivors (L-S), 15 HIV+ later on deceased patients and 15 HIV-, all of them deriving from the original investigation group from 1985 including 52 patients (30 HIV+, 22 HIV-). We prove the validity of our psychosocial factors by the SF 36 which currently serves as gold standard. The actual psychosocial factors and medical parameters of the 15 L-S are checked against the data of the 15 HIV- patients.

RESULTS, CONCLUSION

In 1985 already, we retrospectively found significantly higher values regarding psychosocial factors within the group of the L-S as opposed to the later on deceased ones. Highly significant are the facts that more than 90 % of HIV+ L-S have had a good relationship to their fathers and are still employed today in contrast to the deceased HIV+ patients. At present, the differences regarding psychosocial factors between HIV+ L-S and HIV-negative patients are vanishing.

Haemophilia patients with HIV- and HCV-infection

At present (2010), we investigate in a long term study on psychosocial aspects of haemophilia at the Munich Haemophilia Centre factors which could be held responsible for the large number of still living HIV+ patients while many patients died from AIDS or from diseases caused by HCV during the 1990ies.

Patients, methods We retrospectively compare medical and psychosocial data of 15 HIV+ long term survivors (L-S), 15 HIV+ later on deceased patients and 15 HIV–, all of them deriving from the original investigation group from 1985 including 52 patients (30 HIV+, 22 HIV–). We prove the validity of our psychosocial factors by the SF 36 which currently serves as gold standard. The actual psychosocial factors and medical parameters of the 15 L-S are checked against the data of the 15 HIV-patients.

Results, conclusion In 1985 already, we retrospectively found significantly higher values regarding psychosocial factors within the group of the L-S as opposed to the later on deceased ones. Highly significant are the facts that more than 90 % of HIV+ L-S have had a good relationship to their fathers and are still employed today in contrast to the deceased HIV+ patients. At present, the differences regarding psychosocial factors between HIV+ L-S and HIV-negative patients are vanishing.

Development of inhibitors in haemophilia

A number of 513 consecutive patients (494-haemophilia A and 19-haemophilia B) from eight haemophilia treatment centers have been investigated with Bethesda assay for the presence of factor VIII or IX inhibitors. The overall prevalence of inhibitors was 15.20%, 18.48% in severe, 5.60% in moderate and 12.24% in mild forms. The prevalence was higher than reported in most of the western countries. The age at start of substitution (p = 0.9775), the frequent switching of factor concentrates (p = 0.8931) were not relevant factors for the development of inhibitors. It is worth to be mentioned the unexpectedly occurrence of inhibitors in prior inhibitor negative (6/72) patients (during surgical interventions) probably due to their previous scarce substitution, occurrence which seems not being connected with the continuous infusion modality of factor VIII administration (p = 0.8341). In controversial situations, in the field of low titer (≤1 BU/ml) inhibitors for a reliable interpretation of the results the performance of recovery index and half-life time assessment of FVIII/IX was undertaken.

[Haemophilia patients in Germany 2008/2009. Morbidity and mortality]

Since 1978 an annual multicentric survey regarding the epidemiology of patients suffering of haemophilia is performed with support of hemophilia treating centres of any size. Again the actual compilation is resting upon a broad database returning to over 30 years of inquiry well representing both the actual and retrospective status of mortality. Prompted was exclusively information about patients with haemophilia A, B and von Willebrand disease. In particular anonymous data concerning the last 12 months about number of treated patients, type and severity of illness, HIV-status and detailed information about causes of death was inquired. This data was merged with existing data and analyzed statistically. In the 2008/2009 survey, a total number of 9101 patients with bleeding disorders have been reported from 66 participating centres. Despite mortality from HIV in patients with haemophilia is keeping on decreasing, HIV still remains an important factor as an HIV/HCV coinfection seems to increase risk of progression of severe liver disease. Age structure in our patients has been shifting significantly over the last decades bringing age distribution into line with the entire population. This has to be considered assessing mortality and morbidity.

[Documentation of haemophilia treatment supported by the German Hemophilia Registry]

The DHR (Deutsches Hämophilieregister, German Haemophilia Register) records patient data on haemophilia A, haemophilia B, von Willebrand disease, and other coagulation factor deficiency disorders. The DHR has been online since 2009. The participation in the DHR leads to additional administrative workload for the hospitals and physicians, but provides many advantages as well: A standard of documentation will be developed to give evidence for the hospitals. They may use their own data as well as with new possibilities for data processing at any time. Reports in accordance with Section21 TFG (Transfusionsgesetz, German Transfusion Act) are compiled automatically and transmitted to the Paul-Ehrlich-Institut. The DHR may support the searching for patients fulfilling the requirements for participation in a study.

[A quarter century of psychosocial haemophilia-counseling]

With the development of clotting-factors in the seventies the haemophilia patients were released from being handicapped and began to live a quite normal life. Thus, psychosocial counselling did not seem to be necessary. But the impact of HIV-infection to the world of haemophilia was so intense that professional help was offered at the Munich Hemophilia Centre since 1985. During the preceeding 25 years we talked to about 120 patients and relatives every year in more than 10000 psychotherapeutic talks. 70 of our patients were HIV-infected. For about half of them we took care until they died on AIDS or of liver-disease. The other 50 patients (HIV-negative) were also distressed enormously. At the beginning the highlights in counselling were e. g. fear of manifestation of AIDS, dying and death, social stigma. Around 1993 with the decoding of HCV and the first useful HIV therapies the topics in counselling changed: New HIV-medical-treatment, menacing by HCV, wish for own children due to improved HIV medical care etc.

CONCLUSION

Our experiences have shown that self esteem and social integration of haemophilia patients have reached again normality. By our psychosocial counselling we would like to contribute.