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Peral C, De Lossada Juste A, Lwoff N, Espinoza-Cámac N, Casado MÁ, Burke T, Alvir J, Thakkar S, Ferri Grazzi E. Economic and Humanistic Burden of Moderate and Severe Hemophilia A and B in Spain: Real-World Evidence Insights from the CHESS II Study. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2024; 11:122-133. [PMID: 38721331 PMCID: PMC11078526 DOI: 10.36469/001c.92369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/16/2024] [Indexed: 09/16/2024]
Abstract
Background: Hemophilia is a congenital disorder characterized by deficiency or absence of clotting factor VIII in hemophilia A (HA) or clotting factor IX in hemophilia B (HB), resulting in frequent, repeated, and prolonged spontaneous or traumatic bleeding into joints or soft tissue. Severity is classified by the patient's baseline level of clotting factor activity as mild (>5%-40%), moderate (1%-5%), or severe (<1%). In Spain, there is limited information on the societal economic burden of disease. Objective: To estimate the economic and humanistic burden of disease in adult patients with non-inhibitor moderate and severe HA and HB in Spain. Methods: Spanish data from the CHESS II study (2018-2020) on patients' clinical characteristics, health-related quality of life (HRQoL) and hemophilia-related healthcare resource utilization were analyzed. Economic burden was determined by estimating condition-related annual per-patient direct (medical and nonmedical) and indirect costs, stratified according to hemophilia type and severity and presented as 2022 Euros. HRQoL was assessed via the EQ-5D-5L. Results: Of 341 patients in the Spanish CHESS II cohort, 288 patients met the inclusion criteria: 181 had HA (37% [n = 66] moderate and 63% [n=115] severe) and 107 had HB (26% [n = 28] moderate and 74% [n = 79] severe). Mean annual direct cost was higher in HB than in HA, and higher in severe than in moderate patients, resulting in an annual cost/patient of €17 251 (moderate HA), €17 796 (moderate HB), €116 767 (severe HA) and €206 996 (severe HB). The main direct cost component in all groups except moderate HA was factor replacement therapy. Mean per-patient indirect cost was €4089 (moderate HA), €797 (moderate HB), €8633 (severe HA) and €8049 (severe HB). Finally, the mean total cost (direct and indirect) for moderate and severe patients were €91 017 (HA) and €163 924 (HB). EQ-5D-5L [SD] scores were lower in patients with severe HA (0.77 [0.18]) and severe HB (0.70 [0.22]) compared with patients with moderate HA (0.81 [0.15]) and moderate HB (0.86 [0.17]). Conclusions: Independently of the type of hemophilia, greater condition severity was associated with increased costs and a decrease in HRQoL.
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Affiliation(s)
| | | | | | | | | | - Tom Burke
- HCD Economics, Daresbury, UK
- Faculty of Health and Social Care University of Chester, Chester, UK
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Singh A, Rawat S, Kushwaha R, Jain M, Verma SP, Singh US. Clinicopathological Parameters of Haemophilia Patients at a Tertiary Care Centre in Northern India. Cureus 2023; 15:e41670. [PMID: 37575728 PMCID: PMC10412897 DOI: 10.7759/cureus.41670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2023] [Indexed: 08/15/2023] Open
Abstract
INTRODUCTION Haemophilia affects a large number of people all over the world, yet very little is known about the clinical manifestations and diagnostic protocols of the condition in areas with limited access to resources in developing countries. Understanding the clinical spectrum and diagnostic approach will help with the design of measures to address the situation in these places. The primary objective of this study was to examine the clinicopathological parameters of haemophiliac patients. MATERIALS AND METHODS From the departmental archive, a thorough history of each patient was retrieved, including values of bleeding time, prothrombin time, activated partial prothrombin time, and percentage of specific factor activity. RESULTS Out of a total of 385 cases over the period of six years, 86.75% were classified as haemophilia A and 13.25% of cases were diagnosed as haemophilia B. In terms of the severity of the disease, 44.93% were classified as severe, 42.08% as moderate, and 12.99% as mild. Joint bleeding was the first and most typical clinical manifestation of the disease, accounting for 34.80% of cases, followed by ecchymosis (23.12%), post-traumatic bleeding (12.73%), epistaxis (12.20%), and gum bleeding (8.05%). 1.56% of patients had a positive screening test for the hepatitis C virus, followed by 1.30% for HIV and 0.78% for hepatitis B surface antigen. CONCLUSION In the presence of joint bleeding, ecchymosis, and post-traumatic bleeding in an otherwise healthy individual, a clinician should be alerted to the possibility that the patient has haemophilia and should request a work-up for the bleeding disorder.
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Affiliation(s)
- Anurag Singh
- Pathology, King George's Medical University, Lucknow, IND
| | - Shalini Rawat
- Pathology, King George's Medical University, Lucknow, IND
| | | | - Mili Jain
- Pathology, King George's Medical University, Lucknow, IND
| | | | - U S Singh
- Pathology, King George's Medical University, Lucknow, IND
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Mild and Moderate Hemophilia A: Neglected Conditions, Still with Unmet Needs. J Clin Med 2023; 12:jcm12041368. [PMID: 36835904 PMCID: PMC9958625 DOI: 10.3390/jcm12041368] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
Hemophilia A (HA) is an inherited X-linked bleeding disorder, caused by the deficiency of coagulation factor VIII (FVIII), with variable clinical phenotypes [...].
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Chin B, Wee I, Syn NL, O'Neill GK, Yap ES, Koh PL. Surgery for chronic arthropathy in people with haemophilia. Cochrane Database Syst Rev 2022; 11:CD013634. [PMID: 36448638 PMCID: PMC9710191 DOI: 10.1002/14651858.cd013634.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
BACKGROUND Chronic arthropathy is a potentially debilitating complication for people with haemophilia - a genetic, X-linked, recessive bleeding disorder, characterised by the absence or deficiency of a clotting factor protein. Staging classifications, such as the Arnold-Hilgartner classification for haemophilic arthropathy of the knee, radiologically reflect the extent of knee joint destruction with underlying chronic synovitis. Management of this highly morbid disease process involves intensive prophylactic measures, and chemical or radioisotope synovectomy in its early stages. However, failure of non-surgical therapy in people with progression of chronic arthropathy often prompts surgical management, including synovectomy, joint debridement, arthrodesis, and arthroplasty, depending on the type of joint and extent of the damage. To date, management of people with mild to moderate chronic arthropathy from haemophilia remains controversial; there is no agreed standard treatment. Thus, the benefits and disadvantages of non-surgical and surgical management of mild to moderate chronic arthropathy in people with haemophilia needs to be systematically reviewed. OBJECTIVES: To assess the efficacy and safety of surgery for mild to moderate chronic arthropathy in people with haemophilia A or B. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, and two trial registers to August 2022. We also handsearched relevant journals and conference abstract books. SELECTION CRITERIA Randomized controlled trials (RCTs) and quasi-RCTs comparing surgery and non-surgical interventions, for any joint with chronic arthropathy, in people with haemophilia, who were at least 12 years old. DATA COLLECTION AND ANALYSIS The review authors did not identify any trials to include in this review. MAIN RESULTS The review authors did not identify any trials to include in this review. AUTHORS' CONCLUSIONS The review authors did not identify any trials to include in this review. Due to a lack of research in this particular area, we plan to update the literature search every two years, and will update review if any new evidence is reported. There is a need for a well-designed RCT that assesses the safety and efficacy of surgical versus non-surgical interventions for chronic arthropathy in people with haemophilia.
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Affiliation(s)
- Brian Chin
- Department of Orthopaedic Surgery, National University Health System, Singapore, Singapore
| | - Ian Wee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Nicholas Lx Syn
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Gavin K O'Neill
- Department of Orthopaedic Surgery, National University Health System, Singapore, Singapore
| | - Eng Soo Yap
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Pei Lin Koh
- Department of Paediatrics, National University Health System, Singapore, Singapore
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Kloosterman FR, Zwagemaker AF, Bagot CN, Beckers EAM, Castaman G, Cnossen MH, Collins PW, Hay C, Hof M, Laros-van Gorkom B, Leebeek FWG, Male C, Meijer K, Pabinger I, Shapiro S, Coppens M, Fijnvandraat K, Gouw, SC. The bleeding phenotype in people with nonsevere hemophilia. Blood Adv 2022; 6:4256-4265. [PMID: 35533261 PMCID: PMC9327532 DOI: 10.1182/bloodadvances.2022007620] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 04/28/2022] [Indexed: 11/20/2022] Open
Abstract
Detailed information on the onset, frequency, and severity of bleeding in nonsevere hemophilia is limited. We aimed to assess the bleeding phenotype of persons with nonsevere hemophilia and to analyze the association between baseline factor VIII/IX (FVIII/IX) levels and the joint bleeding rate. In the DYNAMO (Dynamic Interplay Between Bleeding Phenotype and Baseline Factor Level in Moderate and Mild Hemophilia A and B) study, an international multicenter cohort, we included males with nonsevere hemophilia (FVIII/IX, 0.02-0.35 IU/mL) aged 12 to 55 years. Information on age at first treated (joint) bleed, annual bleeding rates (ABRs), and annual joint bleeding rates (AJBRs) was collected from the medical files. The association between baseline FVIII/IX levels and the joint bleeding rate was assessed by using a frailty model for recurrent events. In total, 304 persons (70 with moderate hemophilia and 234 with mild hemophilia) were included. The median age was 38 years (interquartile range [IQR], 25-49 years), and the median baseline FVIII/IX level was 0.12 IU/mL (IQR, 0.05-0.21 IU/mL). In total, 245 (81%) persons had experienced at least 1 bleed, and 156 (51%) had experienced at least 1 joint bleed. The median age at first bleed and first joint bleed was 8 and 10 years, respectively. The median ABR and AJBR was 0.2 (IQR, 0.1-0.5) and 0.0 (IQR, 0.0-0.2). From baseline FVIII/IX levels 0.02 to 0.05 IU/mL to >0.25 IU/mL, the median ABR decreased from 0.6 (IQR, 0.2-1.4) to 0.1 (IQR, 0.0-0.2) and the AJBR from 0.2 (IQR, 0.0-0.4) to 0.0 (IQR, 0.0-0.0). Baseline FVIII/IX was inversely associated with the joint bleeding rate (P < .001). Low bleeding rates were observed in persons with nonsevere hemophilia. However, one-half of all adolescents and adults had experienced a joint bleed.
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Affiliation(s)
- Fabienne R. Kloosterman
- Emma Children’s Hospital, Pediatric Hematology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Anne-Fleur Zwagemaker
- Emma Children’s Hospital, Pediatric Hematology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Catherine N. Bagot
- Department of Haematology, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Erik A. M. Beckers
- Division of Hematology, Department of Internal Medicine, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders, Careggi University Hospital, Florence, Italy
| | - Marjon H. Cnossen
- Department of Pediatric Hematology, Erasmus University Medical Center–Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Peter W. Collins
- Cardiff Haemophilia Centre, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Charles Hay
- University Department of Haematology, The University of Manchester, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Michel Hof
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | | | - Frank W. G. Leebeek
- Department of Hematology, Erasmus University Medical Center, Erasmus MC, Rotterdam, The Netherlands
| | - Christoph Male
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Karina Meijer
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Susan Shapiro
- Department of Haematology, Oxford University Hospitals NHS Foundation, Oxford NIHR Biomedical Research Centre, Oxford, United Kingdom
- Radcliffe Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands; and
| | - Karin Fijnvandraat
- Emma Children’s Hospital, Pediatric Hematology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Department of Molecular Cellular Hemostasis, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Samantha C. Gouw,
- Emma Children’s Hospital, Pediatric Hematology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
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Islam MN, Biswas AR, Nazneen H, Chowdhury N, Alam M, Banik J, Hassan MK, Khan AAZ, Karim N, Hasan MJ, Khan MAS. Clinical profile and demographic characteristics of moderate and severe hemophilia patients in a tertiary care hospital of Bangladesh. Orphanet J Rare Dis 2022; 17:254. [PMID: 35804421 PMCID: PMC9264493 DOI: 10.1186/s13023-022-02413-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 06/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hemophilia is one of the commonest inherited bleeding disorders which may lead to chronic bleeding tendencies and life-long disabilities if not properly managed. Knowing the pattern of the disease aids in the prevention of disability and improvement of quality of life in hemophilia. However, there is a dearth of literature on the issue in Bangladesh. So, this study was designed to explore the frequency and site of spontaneous bleeding in moderate and severe hemophilia patients visiting in a tertiary level hospital. METHODS This descriptive cross-sectional study was conducted at the department of Hematology and Bone Marrow Transplantation (BMT) Center in Dhaka Medical College Hospital, Dhaka between February 2020 and August 2020. A total of 44 diagnosed cases of moderate to severe hemophilia were included in the study according to inclusion criteria. A detailed inquiry of history, thorough physical examination and relevant investigations were done and were recorded in case-record form. Informed written consent was taken from patients or their guardians where appropriate. All procedures were done according to Declaration of Helsinki. After entry and checking, data was analysed using SPSS version 26. RESULTS Out of 44 participants, 25 (56.8%) and 19 (43.2%) had moderate and severe hemophilia. Mean age of the study population was 21.31 (± 9.78) years with the majority aged between 11 and 20 years (45.5%). All sociodemographic features were similar across severity. Hemophilia A and B was found in 90.9% and 9.1%, respectively. However, all type B patients severe hemophilia making it statistically significantly different from type A (p = 0.029). The median age of first bleeding was 3.5 years and median age of first diagnosis was 5 years. Nevertheless, approximately 67.4% patients were diagnosed as a case of hemophilia at the time of their first diagnosis. The median spontaneous bleedings episodes among all patients was 32 (range: 0-97) which did not different significantly between severe and moderate patients. The most common affected (target) joint was knee joint (88.6%) followed by elbow joint (64%) among all patients. The knee joint was more commonly involved in severe than moderate disease. CONCLUSION This study observed the variations in pattern and frequency of spontaneous bleeding in patients with hemophilia. Severe disease was more frequent in hemophilia B than A and knee joint was the most frequent site of bleeding. However, further extensive studies are recommended.
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Affiliation(s)
| | - Akhil Ranjon Biswas
- Department of Haematology and BMT, Dhaka Medical College Hospital, Dhaka, Bangladesh
| | - Humayra Nazneen
- Department of Haematology, Dhaka Medical College Hospital, Dhaka, Bangladesh
| | | | - Mahbubul Alam
- Sheikh Russell National Gastroliver Institute and Hospital, Dhaka, Bangladesh
| | | | - Md Kamrul Hassan
- Department of Pathology, Shaheed Syed Nazrul Islam Medical College, Kishoreganj, Bangladesh
| | - Abdullah Az Zubayer Khan
- Department of Haematology, National Institute of Laboratory Medicine and Referral Center, Dhaka, Bangladesh
| | - Najmul Karim
- Medicine Department, Rangpur Medical College Hospital, Rangpur, Bangladesh
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Cadé M, Muñoz-Garcia J, Babuty A, Paré L, Cochonneau D, Fekir K, Chatelais M, Heymann MF, Lokajczyk A, Boisson-Vidal C, Heymann D. FVIII regulates the molecular profile of endothelial cells: functional impact on the blood barrier and macrophage behavior. Cell Mol Life Sci 2022; 79:145. [PMID: 35190870 PMCID: PMC11072670 DOI: 10.1007/s00018-022-04178-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/10/2022] [Accepted: 01/28/2022] [Indexed: 12/20/2022]
Abstract
Hemophilia A is an inherited X-linked recessive bleeding disorder caused by deficient activity of blood coagulation factor VIII (FVIII). In addition, hemophilia patients show associated diseases including osteopenia, altered inflammation and vascular fragility which may represent the consequence of recurrent bleeding or may be related to the direct FVIII deficiency. Nowadays, recombinant FVIII is proposed to treat hemophilia patients with no circulating FVIII inhibitor. Initially described as a coenzyme to factor IXa for initiating thrombin generation, there is emerging evidence that FVIII is involved in multiple biological systems, including bone, vascular and immune systems. The present study investigated: (i) the functional activities of recombinant human FVIII (rFVIII) on endothelial cells, and (ii) the impact of rFVIII activities on the functional interactions of human monocytes and endothelial cells. We then investigated whether rFVIII had a direct effect on the adhesion of monocytes to the endothelium under physiological flow conditions. We observed that direct biological activities for rFVIII in endothelial cells were characterized by: (i) a decrease in endothelial cell adhesion to the underlying extracellular matrix; (ii) regulation of the transcriptomic and protein profiles of endothelial cells; (iii) an increase in the vascular tubes formed and vascular permeability in vitro; and (iv) an increase in monocyte adhesion activated endothelium and transendothelial migration. By regulating vascular permeability plus leukocyte adhesion and transendothelial migration, the present work highlights new biological functions for FVIII.
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Affiliation(s)
- Marie Cadé
- Nantes Université, CNRS, US2B, UMR 6286, 44000, Nantes, France
- Institut de Cancérologie de l'Ouest, "Tumor Heterogeneity and Precision Medicine" Laboratory, Blvd Jacques Monod, 44805, Saint-Herblain cedex, France
| | - Javier Muñoz-Garcia
- Institut de Cancérologie de l'Ouest, "Tumor Heterogeneity and Precision Medicine" Laboratory, Blvd Jacques Monod, 44805, Saint-Herblain cedex, France
| | - Antoine Babuty
- Nantes Université, CNRS, US2B, UMR 6286, 44000, Nantes, France
- Department of Hemostasis, CHU de Nantes, Nantes, France
| | - Louis Paré
- Université de Paris, CNRS, Institut Jacques Monod, UMR 7592, Paris, France
| | - Denis Cochonneau
- Institut de Cancérologie de l'Ouest, "Tumor Heterogeneity and Precision Medicine" Laboratory, Blvd Jacques Monod, 44805, Saint-Herblain cedex, France
| | | | | | - Marie-Françoise Heymann
- Institut de Cancérologie de l'Ouest, "Tumor Heterogeneity and Precision Medicine" Laboratory, Blvd Jacques Monod, 44805, Saint-Herblain cedex, France
| | | | | | - Dominique Heymann
- Nantes Université, CNRS, US2B, UMR 6286, 44000, Nantes, France.
- Institut de Cancérologie de l'Ouest, "Tumor Heterogeneity and Precision Medicine" Laboratory, Blvd Jacques Monod, 44805, Saint-Herblain cedex, France.
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.
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Soto I, Mateo J, García-Diego DA, Gil B, Ruiz-Beato E, Ivanova Y, Martín Lorenzo T, Maravilla-Herrera P, Hidalgo-Vega Á, Merino M. The impact of improving haemophilia A management within the Spanish National Healthcare System: a social return on investment analysis. BMC Health Serv Res 2022; 22:115. [PMID: 35081958 PMCID: PMC8793183 DOI: 10.1186/s12913-021-07447-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 12/22/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Haemophilia A (HA) has been associated with poor health-related quality of life and a large economic burden, accentuated by severity, arthropathy, and inhibitors. To meet global standards of care, the management of HA should align with the principles of care outlined by the World Federation of Haemophilia. The aims of the present study were to establish a set of proposals to improve HA management within the Spanish National Health System (SNHS) and to estimate the impact its hypothetical implementation would generate from a clinical, healthcare, economic, and social perspective. METHODS A multidisciplinary group of experts agreed on a set of 15 proposals to improve HA management within the SNHS. Thereafter, a forecast-type Social Return on Investment analysis was carried out to estimate the impact of implementing this set of proposals within the SNHS over a one-year timeframe, in relation to the required investment. RESULTS This study estimated that the implementation of the complete set of 15 proposals would require a total investment of 2.34 M€ and have a total impact of 14.60 M€. Accordingly, every euro invested in the complete set of 15 proposals would yield a social return of €6.23 (€3.37 in the worst-case scenario and €9.69 in the best-case scenario) of both tangible and intangible nature in similar proportions (45.71 and 54.29%, respectively). CONCLUSIONS These results can be used to inform policy and practice such that interventions that may potentially improve current public health challenges associated with the management of HA may be implemented.
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Affiliation(s)
| | - José Mateo
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | | | - Yoana Ivanova
- Weber, Calle Moreto, 17, 5 Dcha, 28014 Madrid, Spain
| | | | | | | | - María Merino
- Weber, Calle Moreto, 17, 5 Dcha, 28014 Madrid, Spain
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Costs of the management of hemophilia A with inhibitors in Spain. GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2021; 8:35-42. [PMID: 36627877 PMCID: PMC9616192 DOI: 10.33393/grhta.2021.2234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 02/24/2021] [Indexed: 01/13/2023] Open
Abstract
Introduction Emicizumab is a first-in-class monoclonal antibody, recently authorized for the treatment of hemophilia A with inhibitors. This study aims to estimate the direct and indirect costs of the management of hemophilia A with inhibitors, in adult and pediatric patients, including the prophylaxis with emicizumab. Methods We calculated the costs of the on-demand and prophylactic treatments with bypassing agents (activated prothrombin complex concentrate and recombinant activated factor VII) and the emicizumab prophylaxis, from the societal perspective, over 1 year. The study considered direct healthcare costs (drugs, visits, tests, and hospitalizations), direct non-healthcare costs (informal caregivers), and indirect costs (productivity loss). Data were obtained from a literature review and were validated by an expert group. Costs were expressed in 2019 euros. Results Our results showed that the annual costs of the prophylactic treatment per patient varied between €543,062.99 and €821,415.77 for adults, and €182,764.43 and €319,826.59 for children, while on-demand treatment was €532,706.84 and €789,341.91 in adults, and €167,523.05 and €238,304.71 in pediatric patients. In relation to other prophylactic therapies, emicizumab showed the lowest costs, with up to a 34% and 43% reduction in the management cost of adult and pediatric patients, respectively. It reduced the bleeding events and administration costs, as this drug is less frequently administered by subcutaneous route. Emicizumab prophylaxis also decreased the cost of other healthcare resources such as visits, tests, and hospitalizations, as well as indirect costs. Conclusion In comparison to prophylaxis with bypassing agents, emicizumab reduced direct and indirect costs, resulting in cost savings for the National Health System and society.
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Abdi A, Kloosterman FR, Eckhardt CL, Male C, Castaman G, Fischer K, Beckers EAM, Kruip MJHA, Peerlinck K, Mancuso ME, Santoro C, Hay CR, Platokouki H, van der Bom JG, Gouw SC, Fijnvandraat K, Hart DP. The factor VIII treatment history of non-severe hemophilia A. J Thromb Haemost 2020; 18:3203-3210. [PMID: 32877570 PMCID: PMC7756346 DOI: 10.1111/jth.15076] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 08/01/2020] [Accepted: 08/18/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND In patients with non-severe hemophilia A, we lack detailed knowledge on the timing of treatment with factor VIII (FVIII) concentrates. This knowledge could provide information about the expected treatment timing in patients with severe hemophilia A treated with non-replacement therapies. OBJECTIVE To assess the FVIII treatment history in patients with non-severe hemophilia A. METHODS Patients with non-severe hemophilia (baseline FVIII activity [FVIII:C] 2-40 IU/dL) were included from the INSIGHT study. The primary outcome was median age at first FVIII exposure (ED1). In a subgroup of patients for whom more detailed information was available, we analyzed the secondary outcomes: median age at first 20 EDs, annualized bleeding rate for all bleeds (ABR), joint bleeds (AJBR), and major spontaneous bleeds (ASmBR). RESULTS In the total cohort (n = 1013), median baseline FVIII activity was 8 IU/dL (interquartile range [IQR] 4-15) and the median age at ED1 was 3.7 years (IQR 1.4-7.7). Median age at ED1 rose from 2.5 years (IQR 1.2-5.7) in patients with FVIII:C 2-5 IU/dL to 9.7 years (IQR 4.8-16.0) in patients with FVIII:C 25-40 IU/dL. In the subgroup (n = 104), median age at ED1, ED5, ED10, and ED20 was 4.0 years (IQR 1.4-7.6), 5.6 years (IQR 2.9-9.3), 7.5 years (IQR 4.4-11.3), and 10.2 years (IQR 6.5-14.2), respectively. Median ABR, AJBR, and ASmBR were 1.1 (IQR 0.5-2.6), 0.3 (IQR 0.1-0.7), and 0 (IQR 0-0), respectively. CONCLUSION This study demonstrates that in non-severe hemophilia A, the age at first FVIII exposure increases with baseline FVIII:C and that major spontaneous bleeds rarely occur.
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Affiliation(s)
- Amal Abdi
- Department of Pediatric HematologyEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Fabienne R. Kloosterman
- Department of Pediatric HematologyEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Corien L. Eckhardt
- Department of Pediatric HematologyEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Christoph Male
- Department of PediatricsMedical University of ViennaViennaAustria
| | - Giancarlo Castaman
- Department of OncologyCenter for Bleeding DisordersCareggi University HospitalFlorenceItaly
| | - Kathelijn Fischer
- Van CreveldkliniekUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Erik A. M. Beckers
- Department of HematologyMaastricht University Medical CenterMaastrichtthe Netherlands
| | | | - Kathelijne Peerlinck
- Department of Cardiovascular SciencesHemophilia CenterUniversity of LeuvenUniversity Hospitals LeuvenLeuvenBelgium
| | - Maria Elisa Mancuso
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca' GrandaOspedale Maggiore PoliclinicoMilanItaly
| | | | - Charles R. Hay
- Department of HematologyManchester Royal InfirmaryManchester UniversityManchesterUK
| | - Helen Platokouki
- Haemophilia Centre‐Haemostasis UnitAghia Sophia Children's HospitalAthensGreece
| | - Johanna G. van der Bom
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Center for Clinical Transfusion ResearchSanquin ResearchLeidenthe Netherlands
| | - Samantha C. Gouw
- Department of Pediatric HematologyEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric HematologyEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
- Department of Molecular Cellular HemostasisSanquin Research and Landsteiner LaboratoryAmsterdamthe Netherlands
| | - Dan P. Hart
- The Royal London Haemophilia CentreQMULBarts and the London School of Medicine and DentistryLondonUK
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11
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Nichols TC, Levy H, Merricks EP, Raymer RA, Lee ML. Preclinical evaluation of a next-generation, subcutaneously administered, coagulation factor IX variant, dalcinonacog alfa. PLoS One 2020; 15:e0240896. [PMID: 33112889 PMCID: PMC7592742 DOI: 10.1371/journal.pone.0240896] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 10/05/2020] [Indexed: 01/12/2023] Open
Abstract
Introduction The rapid clearance of factor IX necessitates frequent intravenous administrations to achieve effective prophylaxis for patients with hemophilia B. Subcutaneous administration has historically been limited by low bioavailability and potency. Dalcinonacog alfa was developed using a rational design approach to be a subcutaneously administered, next-generation coagulation prophylactic factor IX therapy. Aim This study aimed to investigate the pharmacokinetic, pharmacodynamic, and safety profile of dalcinonacog alfa administered subcutaneously in hemophilia B dogs. Methods Two hemophilia B dogs received single-dose daily subcutaneous dalcinonacog alfa injections for six days. Factor IX antigen and activity, whole blood clotting time, and activated partial thromboplastin time were measured at various time points. Additionally, safety assessments for clinical adverse events and evaluations of laboratory test results were conducted. Results There was an increase in plasma factor IX antigen with daily subcutaneous dalcinonacog alfa. Bioavailability of subcutaneous dalcinonacog alfa was 10.3% in hemophilia B dogs. Daily subcutaneous dosing of dalcinonacog alfa demonstrated the effects of bioavailability, time to maximal concentration, and half-life by reaching a steady-state activity sufficient to correct severe hemophilia to normal, after four days. Conclusion The increased potency of dalcinonacog alfa facilitated the initiation and completion of the Phase 1/2 subcutaneous dosing study in individuals with hemophilia B.
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Affiliation(s)
- Timothy C. Nichols
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Howard Levy
- Catalyst Biosciences, South San Francisco, California, United States of America
- * E-mail:
| | - Elizabeth P. Merricks
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Robin A. Raymer
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Martin L. Lee
- Department of Biostatistics, UCLA Fielding School of Public Health, Los Angeles, California, United States of America
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12
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Etranacogene dezaparvovec (AMT-061 phase 2b): normal/near normal FIX activity and bleed cessation in hemophilia B. Blood Adv 2020; 3:3241-3247. [PMID: 31698454 DOI: 10.1182/bloodadvances.2019000811] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 09/16/2019] [Indexed: 12/23/2022] Open
Abstract
Etranacogene dezaparvovec (AMT-061) is a recombinant AAV5 vector including a gene cassette containing the factor IX (FIX) Padua variant under the control of a liver-specific promoter. A phase 2b study was conducted to confirm that a single dose of 2 × 1013 genome copies per kilogram of etranacogene dezaparvovec will result in FIX activity ≥5% 6 weeks after dosing. Secondary end points included FIX activity at other time points, bleed frequency, FIX replacement, and safety. Etranacogene dezaparvovec was administered as a single IV infusion to 3 adults with severe to moderately severe hemophilia B. Before treatment, participants had low levels of preexisting neutralizing antibodies to AAV5. This article reports a planned 26-week interim assessment. At week 6, mean FIX activity was 31% (23.9%-37.8%), increasing to 47% (33.2%-57.0%) at 26 weeks, with 2 subjects exhibiting sustained activity >40%. Consistent with the FIX activity, etranacogene dezaparvovec was associated with a complete bleed cessation with no need for FIX replacement therapy up to 26 weeks. Etranacogene dezaparvovec was generally well tolerated. No clinically significant elevations in levels of liver enzymes or inflammatory markers were observed, and no use of corticosteroids related to treatment was required. In individuals with severe to moderately severe hemophilia B, etranacogene dezaparvovec resulted in clinically relevant increases in FIX activity, cessation of bleeds, and abrogation of the need for FIX replacement, despite the presence of preexisting anti-AAV5 neutralizing antibodies detected by using a highly sensitive luciferase assay. Consistency of results in the 3 participants supported an expanded evaluation of the safety/efficacy of etranacogene dezaparvovec in the HOPE-B (Health Outcomes With Padua Gene; Evaluation in Hemophilia-B) phase 3 trial. The current trial was registered at www.clinicaltrials.gov as #NCT03489291.
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13
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Jang H, von Drygalski A, Wong J, Zhou JY, Aguero P, Lu X, Cheng X, Ball ST, Ma Y, Chang EY, Du J. Ultrashort echo time quantitative susceptibility mapping (UTE-QSM) for detection of hemosiderin deposition in hemophilic arthropathy: A feasibility study. Magn Reson Med 2020; 84:3246-3255. [PMID: 32662904 DOI: 10.1002/mrm.28388] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/31/2020] [Accepted: 06/01/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE The purpose of this study was to investigate the feasibility of ultrashort echo time quantitative susceptibility mapping (UTE-QSM) for assessment of hemosiderin deposition in the joints of hemophilic patients. METHODS The UTE-QSM technique was based on three sets of dual-echo 3D UTE Cones data acquired with TEs of 0.032/2.8, 0.2/3.6, and 0.4/4.4 ms. The images were processed with iterative decomposition of water and fat with echo asymmetry and least-squares estimation to estimate the B0 field map in the presence of fat. Then, the projection onto dipole field (PDF) algorithm was applied to acquire a local field map generated by tissues, followed by application of the morphology-enabled dipole inversion (MEDI) algorithm to estimate a final susceptibility map. Three healthy volunteers and three hemophilic patients were recruited to evaluate the UTE-QSM technique's ability to assess hemosiderin in the knee or ankle joint at 3T. One patient subsequently underwent total knee arthroplasty after the MR scan. The synovial tissues harvested from the knee joint during surgery were processed for histological analysis to confirm iron deposition. RESULTS UTE-QSM successfully yielded tissue susceptibility maps of joints in both volunteers and patients. Multiple regions with high susceptibility over 1 ppm were detected in the affected joints of hemophilic patients, while no localized regions with high susceptibility were detected in asymptomatic healthy volunteers. Histology confirmed the presence of iron in regions where high susceptibility was detected by UTE-QSM. CONCLUSION The UTE-QSM technique can detect hemosiderin deposition in the joint, and provides a potential sensitive biomarker for the diagnosis and prognosis of hemophilic arthropathy.
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Affiliation(s)
- Hyungseok Jang
- Department of Radiology, University of California San Diego, San Diego, California, USA
| | - Annette von Drygalski
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Jonathan Wong
- Department of Radiology, University of California San Diego, San Diego, California, USA
| | - Jenny Y Zhou
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Peter Aguero
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Xing Lu
- Department of Radiology, University of California San Diego, San Diego, California, USA
| | - Xin Cheng
- Department of Histology and Embryology, Jinan University, Guangzhou, China
| | - Scott T Ball
- Orthopedic Surgery, University of California San Diego, San Diego, California, USA
| | - Yajun Ma
- Department of Radiology, University of California San Diego, San Diego, California, USA
| | - Eric Y Chang
- Department of Radiology, University of California San Diego, San Diego, California, USA.,Radiology Service, Veterans Affairs San Diego Healthcare System, San Diego, California, USA
| | - Jiang Du
- Department of Radiology, University of California San Diego, San Diego, California, USA
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14
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Noone D, O'Mahony B, Peyvandi F, Makris M, Bok A. Evolution of Haemophilia Care in Europe: 10 years of the principles of care. Orphanet J Rare Dis 2020; 15:184. [PMID: 32660500 PMCID: PMC7358930 DOI: 10.1186/s13023-020-01456-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/29/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The European principles of care in haemophilia marked their first decade in 2018. These guiding principles were the beginning of the European Haemophilia Consortium (EHC) review of countries' adherence to these principles in 2009, 2012, 2015 and 2018. The aim of this paper was to examine the implementation of the principles and how they have impacted the evolution of care in the last decade, as well as to identify remaining gaps and proposes future directions. METHODS In 2018, the EHC distributed a survey to EHC national member organisations in English and Russian and encouraged them to discuss responses with local clinicians for accuracy. Data was also cross-referenced and validated for countries in earlier surveys using additional available resources. RESULTS The 10-year-old European principles had a significant impact on the development of care for haemophilia and related bleeding disorders in Europe. They set objectives around which multi-stakeholder groups have established recommendations and specific steps for the progressive improvement of care for bleeding disorders. However, some have been promoted and implemented more than others. CONCLUSION Monitoring adherence to, and impact of, the European Principles of Care significantly assists in tracking developments and highlighting gaps. Countries' inability to report consistent and coherent data remains a challenge and hinders both provision of treatment and care for patients as well as optimal national and European healthcare systems.
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Affiliation(s)
- D Noone
- European Haemophilia Consortium, Brussels, Belgium.
| | - B O'Mahony
- European Haemophilia Consortium, Brussels, Belgium.,Trinity College Dublin, Dublin, Ireland
| | - F Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M Makris
- Department of Coagulation, Sheffield Haemophilia and Thrombosis Centre, Sheffield, UK
| | - A Bok
- European Haemophilia Consortium, Brussels, Belgium
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15
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Chin B, Wee I, Syn NLX, Yap ES, Koh PL. Surgery for chronic arthropathy in people with haemophilia. Hippokratia 2020. [DOI: 10.1002/14651858.cd013634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Brian Chin
- Faculty of Medicine; University of New South Wales; Sydney Australia
| | - Ian Wee
- Department of Haematology-Oncology; National University Cancer Institute; Singapore Singapore
| | - Nicholas LX Syn
- Department of Haematology-Oncology; National University Cancer Institute; Singapore Singapore
| | - Eng Soo Yap
- Department of Laboratory Medicine; National University Hospital; Singapore Singapore
| | - Pei Lin Koh
- Department of Paediatrics; National University Health System; Singapore Singapore
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Kloosterman F, Zwagemaker A, Abdi A, Gouw S, Castaman G, Fijnvandraat K. Hemophilia management: Huge impact of a tiny difference. Res Pract Thromb Haemost 2020; 4:377-385. [PMID: 32211572 PMCID: PMC7086468 DOI: 10.1002/rth2.12314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 12/27/2019] [Indexed: 12/22/2022] Open
Abstract
Hemophilia A and B are inherited X-linked disorders of hemostasis, associated with an increased bleeding tendency. Patients with severe hemophilia have undetectable clotting factor levels and experience spontaneous bleeds. In patients with nonsevere hemophilia, the clotting factor levels are 2% to 40% of normal and bleeds predominantly occur after provocative events such as trauma and surgery. Despite this milder phenotype, patients with nonsevere hemophilia may suffer from considerable morbidity and have an increased mortality risk. However, many aspects of the course of disease and treatment remain unclear. Information on the factors influencing interindividual differences in bleeding phenotype is lacking, and misdiagnosis may occur due to assay discrepancies in the diagnostic workup. Desmopressin is the preferred treatment modality, but some patients and indications require treatment with clotting factor concentrates. This may elicit inhibitor formation, which is associated with an increased burden of disease and a higher mortality rate. It has been found that patients with nonsevere hemophilia A carry a lifelong risk for this serious complication. In this review, we provide an overview of the current knowledge of the diagnosis and management of nonsevere hemophilia. A report of science presented at the International Society on Thrombosis and Haemostasis 2019 Annual Congress is also provided.
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Affiliation(s)
- Fabienne Kloosterman
- Pediatric HematologyAmsterdam UMCEmma Children's HospitalUniversity of AmsterdamAmsterdamThe Netherlands
| | - Anne‐Fleur Zwagemaker
- Pediatric HematologyAmsterdam UMCEmma Children's HospitalUniversity of AmsterdamAmsterdamThe Netherlands
| | - Amal Abdi
- Pediatric HematologyAmsterdam UMCEmma Children's HospitalUniversity of AmsterdamAmsterdamThe Netherlands
| | - Samantha Gouw
- Pediatric HematologyAmsterdam UMCEmma Children's HospitalUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Giancarlo Castaman
- Department of OncologyCenter for Bleeding DisordersCareggi University HospitalFlorenceItaly
| | - Karin Fijnvandraat
- Pediatric HematologyAmsterdam UMCEmma Children's HospitalUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Molecular Cellular HemostasisSanquin ResearchAmsterdamThe Netherlands
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17
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Villarreal-Martínez L, García-Chávez J, Sánchez-Jara B, Moreno-González AM, Soto-Padilla J, Aquino-Fernández E, Paredes-Aguilera R, Maldonado-Silva K, Rodríguez-Castillejos C, González-Ávila AI, Mora-Torres M, Tiznado-García HM, Padilla-Durón NE, Luna-Silva NC, Gutiérrez-Juárez EI, Nemi-Cueto J, Gómez-González CS, De León-Figueroa R, López-Miranda A, Ríos-Osuna MG, Tamez-Gómez EL, Reyes-Espinoza EA, Domínguez-Varela IA, González-Martínez G, Godoy-Salinas EA. Prevalence of inhibitors and clinical characteristics in patients with haemophilia in a middle-income Latin American country. Haemophilia 2020; 26:290-297. [PMID: 32141696 DOI: 10.1111/hae.13951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 02/04/2020] [Accepted: 02/10/2020] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Development of inhibitors is the most serious complication in patients with haemophilia (PWH). The prevalence of inhibitors in patients with severe haemophilia A (HA) is approximately 25%-30%. Inhibitor prevalence differs among populations. Some studies report a prevalence of almost twice in Hispanic as compared to Caucasian patients. Most data available, on the prevalence of inhibitors and their predisposing factors, originate from centres in developed countries. AIM Establish the prevalence of inhibitors of FVIII and FIX in Mexico. METHODS This was an observational, cross-sectional and descriptive study. The records of all patients diagnosed with haemophilia A (HA) or B (HB), with and without inhibitors, were included. Clinical and demographical characteristics of patients with inhibitors were assessed. Statistical analysis was performed using IBM SPSS version 22. The Ethics Committees of the various participating institutions approved this study. RESULTS A total of 1455 patients from the 20 participating centres were recruited, from which 1208 (83.02%) had HA and 247 (16.97%) were diagnosed with HB. The presence of inhibitors in severe HA was reported in 93/777(11.96%), and 10/162 (6.17%) in severe HB. Of them, 91.7% exhibited high titres in HA and 100% in HB. CONCLUSION In Mexico, the general prevalence of inhibitors varies considerably among centres. This study established a basis of comparison for future development and advances in the treatment and follow-up of patients. These findings also augment our understanding of risk factors related to inhibitor development.
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Affiliation(s)
- Laura Villarreal-Martínez
- Hospital Universitario "Dr. José Eleuterio González" Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Jaime García-Chávez
- Hospital de Especialidades "Antonio Fraga Mouret" del CMN La Raza, Mexico City, Mexico
| | - Berenice Sánchez-Jara
- Hospital General "Dr. Gaudencio González Garza " del CMN La Raza, Mexico City, Mexico
| | | | | | - Efraín Aquino-Fernández
- Hospital de especialidades pediátricas "Centro Regional de Alta Especialidad en Chiapas", Tuxtla Gutierrez, Mexico
| | | | | | | | | | | | | | | | | | | | - Jorge Nemi-Cueto
- Hospital General de Especialidades de Campeche "Dr. Javier Buenfil Osorio", Campeche, Mexico
| | | | | | | | | | | | | | | | - Gerardo González-Martínez
- Hospital Universitario "Dr. José Eleuterio González" Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Elias Adán Godoy-Salinas
- Hospital Universitario "Dr. José Eleuterio González" Universidad Autónoma de Nuevo León, Monterrey, Mexico
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18
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Cooke EJ, Wyseure T, Zhou JY, Gopal S, Nasamran CA, Fisch KM, Manon-Jensen T, Karsdal MA, Mosnier LO, von Drygalski A. Mechanisms of vascular permeability and remodeling associated with hemarthrosis in factor VIII-deficient mice. J Thromb Haemost 2019; 17:1815-1826. [PMID: 31301687 PMCID: PMC6824926 DOI: 10.1111/jth.14567] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 06/19/2019] [Accepted: 07/06/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Vascular remodeling associated with hemophilic arthropathy (HA) may contribute to bleed propagation, but the mechanisms remain poorly understood. OBJECTIVES To explore molecular mechanisms of HA and the effects of hemostasis correction on synovial vascular remodeling after joint injury in hypocoagulable mice. METHODS Factor VIII (FVIII)-deficient mice +/- FVIII treatment and hypocoagulable wild-type mice (Hypo BALB/c) were subjected to subpatellar puncture. Hypo BALB/c mice were treated with warfarin and anti-FVIII before injury, after which warfarin was continued for 2 weeks or reversed +/- continuous anti-FVIII until harvest. Synovial vascularity was analyzed at baseline and 2 to 4 weeks post injury by histology, musculoskeletal ultrasound with power Doppler (microvascular flow), and Evans blue extravasation (vascular permeability). Synovial gene expression and systemic markers of vascular collagen turnover were studied in FVIII-deficient mice by RNA sequencing and enzyme-linked immunosorbent assay. RESULTS Vascular changes occurred in FVIII-deficient and Hypo BALB/c mice after injury with minimal effect of hemostasis correction. Increased vascular permeability was only significant in FVIII-deficient mice, who exhibited more pronounced vascular remodeling than Hypo BALB/c mice despite similar bleed volumes. FVIII-deficient mice exhibited a strong transcriptional response in synovium that was only partially affected by FVIII treatment and involved genes relating to angiogenesis and extracellular matrix remodeling, with vascular collagen turnover markers detected systemically. CONCLUSIONS Intact hemostasis at the time of hemarthrosis and during healing are both critical to prevent vascular remodeling, which appears worse with severe and prolonged FVIII deficiency. Unbiased RNA sequencing revealed potential targets for intervention and biomarker development to improve management of HA.
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Affiliation(s)
- Esther J Cooke
- University of California San Diego, Department of Medicine,
Division of Hematology/Oncology, La Jolla, CA, USA
- The Scripps Research Institute, Department of Molecular
Medicine, La Jolla, CA, USA
| | - Tine Wyseure
- The Scripps Research Institute, Department of Molecular
Medicine, La Jolla, CA, USA
| | - Jenny Y Zhou
- University of California San Diego, Department of Medicine,
Division of Hematology/Oncology, La Jolla, CA, USA
| | - Srila Gopal
- University of California San Diego, Department of Medicine,
Division of Hematology/Oncology, La Jolla, CA, USA
| | - Chanond A Nasamran
- University of California San Diego, Center for
Computational Biology and Bioinformatics, La Jolla, CA, USA
| | - Kathleen M Fisch
- University of California San Diego, Center for
Computational Biology and Bioinformatics, La Jolla, CA, USA
| | | | | | - Laurent O Mosnier
- The Scripps Research Institute, Department of Molecular
Medicine, La Jolla, CA, USA
| | - Annette von Drygalski
- University of California San Diego, Department of Medicine,
Division of Hematology/Oncology, La Jolla, CA, USA
- The Scripps Research Institute, Department of Molecular
Medicine, La Jolla, CA, USA
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19
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Álvarez-Román MT, Cuervo-Arango I, Pérez-Santamarina R, Poveda JL, Romero JA, Santamaría A, Trillo-Mata JL, Tort M, Badia X. Determining the value contribution of emicizumab (Hemlibra®) for the prophylaxis of haemophilia A with inhibitors in Spain by multi-criteria decision analysis. GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2019. [DOI: 10.1177/2284240319880534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Patients with moderate to severe haemophilia A are at a higher risk of developing FVIII inhibitors that require the use of more costly and less effective treatments. The objective of this study was to determine the value of emicizumab for the prophylaxis of haemophilia A with inhibitors compared to the current therapeutic alternatives, activated prothrombin complex concentrate and recombinant factor VIIa through reflective Multi-Criteria Decision Analysis. The EVIDEM framework adapted to orphan drugs and weighted by a sample of 98 national and regional Spanish evaluators was used. Two structured evidence matrices were developed: emicizumab against activated prothrombin complex concentrate and emicizumab against recombinant factor VIIa. A multidisciplinary team of haemophilia experts rated each of the criteria. Mean and standard deviation were calculated by each criterion and discussed among all participants. Haemophilia A with inhibitors was perceived as a severe disease with high unmet needs. Emicizumab was rated with higher efficacy, therapeutic benefit and quality of life than comparators. When administered alone for the prevention of bleeding events, emicizumab had slightly better safety and tolerability profile than activated prothrombin complex concentrate and similar with recombinant factor VIIa. The inclusion of emicizumab in clinical practice guidelines was valued positively by the members of the panel. Overall, value of emicizumab was higher than activated prothrombin complex concentrate and recombinant factor VIIa, mostly because of efficacy and therapeutic benefit in reducing treated haemorrhages. Reflective Multi-Criteria Decision Analysis has proven to be a feasible method to determine the value contribution of comparative therapies in haemophilia.
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20
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Wyseure T, Yang T, Zhou JY, Cooke EJ, Wanko B, Olmer M, Agashe R, Morodomi Y, Behrendt N, Lotz M, Morser J, von Drygalski A, Mosnier LO. TAFI deficiency causes maladaptive vascular remodeling after hemophilic joint bleeding. JCI Insight 2019; 4:128379. [PMID: 31465300 PMCID: PMC6795396 DOI: 10.1172/jci.insight.128379] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 08/23/2019] [Indexed: 12/23/2022] Open
Abstract
Excessive vascular remodeling is characteristic of hemophilic arthropathy (HA) and may contribute to joint bleeding and the progression of HA. Mechanisms for pathological vascular remodeling after hemophilic joint bleeding are unknown. In hemophilia, activation of thrombin-activatable fibrinolysis inhibitor (TAFI) is impaired, which contributes to joint bleeding and may also underlie the aberrant vascular remodeling. Here, hemophilia A (factor VIII-deficient; FVIII-deficient) mice or TAFI-deficient mice with transient (antibody-induced) hemophilia A were used to determine the role of FVIII and TAFI in vascular remodeling after joint bleeding. Excessive vascular remodeling and vessel enlargement persisted in FVIII-deficient and TAFI-deficient mice, but not in transient hemophilia WT mice, after similar joint bleeding. TAFI-overexpression in FVIII-deficient mice prevented abnormal vessel enlargement and vascular leakage. Age-related vascular changes were observed with FVIII or TAFI deficiency and correlated positively with bleeding severity after injury, supporting increased vascularity as a major contributor to joint bleeding. Antibody-mediated inhibition of uPA also prevented abnormal vascular remodeling, suggesting that TAFI's protective effects include inhibition of uPA-mediated plasminogen activation. In conclusion, the functional TAFI deficiency in hemophilia drives maladaptive vascular remodeling in the joints after bleeding. These mechanistic insights allow targeted development of potentially new strategies to normalize vascularity and control rebleeding in HA.
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Affiliation(s)
- Tine Wyseure
- Deptartment of Molecular Medicine, The Scripps Research Institute, La Jolla, California, USA
| | - Tingyi Yang
- Deptartment of Molecular Medicine, The Scripps Research Institute, La Jolla, California, USA
| | - Jenny Y. Zhou
- Department of Medicine, UCSD, San Diego, California, USA
| | - Esther J. Cooke
- Deptartment of Molecular Medicine, The Scripps Research Institute, La Jolla, California, USA
- Department of Medicine, UCSD, San Diego, California, USA
| | - Bettina Wanko
- Division of Hematology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Clinical Division of Endocrinology and Metabolism, Department of Medicine III, Medical University Vienna, Vienna, Austria
| | - Merissa Olmer
- Deptartment of Molecular Medicine, The Scripps Research Institute, La Jolla, California, USA
| | - Ruchi Agashe
- Deptartment of Molecular Medicine, The Scripps Research Institute, La Jolla, California, USA
| | - Yosuke Morodomi
- Deptartment of Molecular Medicine, The Scripps Research Institute, La Jolla, California, USA
| | - Niels Behrendt
- The Finsen Laboratory, Rigshospitalet/Biotech Research and Innovation Centre (BRIC), University of Copenhagen, Copenhagen, Denmark
| | - Martin Lotz
- Deptartment of Molecular Medicine, The Scripps Research Institute, La Jolla, California, USA
| | - John Morser
- Division of Hematology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Annette von Drygalski
- Deptartment of Molecular Medicine, The Scripps Research Institute, La Jolla, California, USA
- Department of Medicine, UCSD, San Diego, California, USA
| | - Laurent O. Mosnier
- Deptartment of Molecular Medicine, The Scripps Research Institute, La Jolla, California, USA
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21
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Peyvandi F, Tavakkoli F, Frame D, Quinn J, Kim B, Lawal A, Lee MC, Wong WY. Burden of mild haemophilia A: Systematic literature review. Haemophilia 2019; 25:755-763. [PMID: 31294906 PMCID: PMC6852304 DOI: 10.1111/hae.13777] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 04/12/2019] [Accepted: 05/03/2019] [Indexed: 01/19/2023]
Abstract
Introduction Although the clinical manifestations of severe haemophilia A (HA) are well studied, the challenges, if any, of living with mild HA are not clearly delineated to date. Aim To assess available evidence of clinical risks and societal/economic impacts of disease in adult patients with mild HA using a systematic literature review. Methods Prespecified study selection criteria were applied in a comprehensive literature search. Included studies varied in design and reported outcomes of interest for adults (≥13 years of age) with mild HA. Results Seventeen studies with a total of 3213 patients met eligibility criteria (published or presented in English, 1966‐2017). Most studies were observational, and the outcomes reported were too sparse and dissimilar to support a formal meta‐analysis. Mean annual bleeding rates ranged from 0.44 to 4.5 episodes per patient per year. Quality of life (QoL; SF‐36 General Health) was impacted compared to healthy controls. Health care costs and productivity were seldom assessed and no robust comparisons to healthy controls were available. Conclusion Quantifying outcomes for adult patients with mild HA remains challenging, with estimates of key QoL and cost data often based on small data sets and without comparison to population norms. Therefore, the clinical impact of mild haemophilia may be under‐represented and unmet needs may remain unaddressed. As paradigm‐changing therapies for HA emerge, stronger knowledge of mild HA can guide the development of care options that minimize burden and enhance the QoL for this segment of the haemophilia community, and for the haemophilia community in totality.
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Affiliation(s)
- Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | | | | | | | - Benjamin Kim
- BioMarin Pharmaceutical Inc., Novato, California
| | | | - Mimi C Lee
- BioMarin Pharmaceutical Inc., Novato, California
| | - Wing Y Wong
- BioMarin Pharmaceutical Inc., Novato, California
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22
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Wyseure T, Cooke EJ, Declerck PJ, Behrendt N, Meijers JCM, von Drygalski A, Mosnier LO. Defective TAFI activation in hemophilia A mice is a major contributor to joint bleeding. Blood 2018; 132:1593-1603. [PMID: 30026184 PMCID: PMC6182268 DOI: 10.1182/blood-2018-01-828434] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 07/11/2018] [Indexed: 02/02/2023] Open
Abstract
Joint bleeds are common in congenital hemophilia but rare in acquired hemophilia A (aHA) for reasons unknown. To identify key mechanisms responsible for joint-specific bleeding in congenital hemophilia, bleeding phenotypes after joint injury and tail transection were compared in aHA wild-type (WT) mice (receiving an anti-factor VIII [FVIII] antibody) and congenital HA (FVIII-/-) mice. Both aHA and FVIII-/- mice bled severely after tail transection, but consistent with clinical findings, joint bleeding was notably milder in aHA compared with FVIII-/- mice. Focus was directed to thrombin-activatable fibrinolysis inhibitor (TAFI) to determine its potentially protective effect on joint bleeding in aHA. Joint bleeding in TAFI-/- mice with anti-FVIII antibody was increased, compared with WT aHA mice, and became indistinguishable from joint bleeding in FVIII-/- mice. Measurements of circulating TAFI zymogen consumption after joint injury indicated severely defective TAFI activation in FVIII-/- mice in vivo, consistent with previous in vitro analyses in FVIII-deficient plasma. In contrast, notable TAFI activation was observed in aHA mice, suggesting that TAFI protected aHA joints against bleeding. Pharmacological inhibitors of fibrinolysis revealed that urokinase-type plasminogen activator (uPA)-induced fibrinolysis drove joint bleeding, whereas tissue-type plasminogen activator-mediated fibrinolysis contributed to tail bleeding. These data identify TAFI as an important modifier of hemophilic joint bleeding in aHA by inhibiting uPA-mediated fibrinolysis. Moreover, our data suggest that bleed protection by TAFI was absent in congenital FVIII-/- mice because of severely defective TAFI activation, underscoring the importance of clot protection in addition to clot formation when considering prohemostatic strategies for hemophilic joint bleeding.
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Affiliation(s)
- Tine Wyseure
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA
| | - Esther J Cooke
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA
- Department of Medicine, University of California San Diego, San Diego, CA
| | - Paul J Declerck
- Department of Pharmaceutical and Pharmacological Sciences, University of Leuven, Leuven, Belgium
| | - Niels Behrendt
- The Finsen Laboratory, Rigshospitalet/Biotech Research and Innovation Centre, University of Copenhagen, Copenhagen, Denmark
| | - Joost C M Meijers
- Department of Plasma Proteins, Sanquin Research, Amsterdam, The Netherlands; and
- Department of Experimental Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Annette von Drygalski
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA
- Department of Medicine, University of California San Diego, San Diego, CA
| | - Laurent O Mosnier
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA
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23
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Cooke EJ, Zhou JY, Wyseure T, Joshi S, Bhat V, Durden DL, Mosnier LO, von Drygalski A. Vascular Permeability and Remodelling Coincide with Inflammatory and Reparative Processes after Joint Bleeding in Factor VIII-Deficient Mice. Thromb Haemost 2018; 118:1036-1047. [PMID: 29847841 PMCID: PMC6191040 DOI: 10.1055/s-0038-1641755] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Vascular remodelling is a prominent feature of haemophilic arthropathy (HA) that may underlie re-bleeding, yet the nature of vascular changes and underlying mechanisms remain largely unknown. Here, we aimed to characterize synovial vascular remodelling and vessel integrity after haemarthrosis, as well as temporal changes in inflammatory and tissue-reparative pathways. Thirty acutely painful joints in patients with haemophilia (PWH) were imaged by musculoskeletal ultrasound with Power Doppler (MSKUS/PD) to detect vascular abnormalities and bloody effusions. Nineteen out of 30 painful joint episodes in PWH were associated with haemarthrosis, and abnormal vascular perfusion was unique to bleeding joints. A model of induced haemarthrosis in factor VIII (FVIII)-deficient mice was used for histological assessment of vascular remodelling (α-smooth muscle actin [αSMA] expression), and monitoring of in vivo vascular perfusion and permeability by MSKUS/PD and albumin extravasation, respectively. Inflammatory (M1) and reparative (M2) macrophage markers were quantified in murine synovium over a 10-week time course by real-time polymerase chain reaction. The abnormal vascular perfusion observed in PWH was recapitulated in FVIII-deficient mice after induced haemarthrosis. Neovascularization and increased vessel permeability were apparent 2 weeks post-bleed in FVIII-deficient mice, after a transient elevation of inflammatory macrophage M1 markers. These vascular changes subsided by week 4, while vascular remodelling, evidenced by architectural changes and pronounced αSMA expression, persisted alongside a reparative macrophage M2 response. In conclusion, haemarthrosis leads to transient inflammation coupled with neovascularization and associated vascular permeability, while subsequent tissue repair mechanisms coincide with vascular remodelling. Together, these vascular changes may promote re-bleeding and HA progression.
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Affiliation(s)
- Esther J Cooke
- University of California San Diego, Department of Medicine, Division of Hematology/Oncology, La Jolla, CA, USA
- The Scripps Research Institute, Department of Molecular Medicine, La Jolla, CA, USA
| | - Jenny Y Zhou
- University of California San Diego, Department of Medicine, Division of Hematology/Oncology, La Jolla, CA, USA
- The Scripps Research Institute, Department of Molecular Medicine, La Jolla, CA, USA
| | - Tine Wyseure
- The Scripps Research Institute, Department of Molecular Medicine, La Jolla, CA, USA
| | - Shweta Joshi
- University of California San Diego, Department of Pediatrics, Moores UCSD Cancer Center, La Jolla, CA, USA
| | - Vikas Bhat
- University of California San Diego, Department of Medicine, Division of Hematology/Oncology, La Jolla, CA, USA
- The Scripps Research Institute, Department of Molecular Medicine, La Jolla, CA, USA
| | - Donald L Durden
- University of California San Diego, Department of Pediatrics, Moores UCSD Cancer Center, La Jolla, CA, USA
| | - Laurent O Mosnier
- The Scripps Research Institute, Department of Molecular Medicine, La Jolla, CA, USA
| | - Annette von Drygalski
- University of California San Diego, Department of Medicine, Division of Hematology/Oncology, La Jolla, CA, USA
- The Scripps Research Institute, Department of Molecular Medicine, La Jolla, CA, USA
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24
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Aznar JA, Altisent C, Álvarez-Román MT, Bonanad S, Mingot-Castellano ME, López MF. Moderate and severe haemophilia in Spain: An epidemiological update. Haemophilia 2018; 24:e136-e139. [PMID: 29578308 DOI: 10.1111/hae.13462] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2018] [Indexed: 11/29/2022]
Affiliation(s)
- J A Aznar
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - C Altisent
- Hospital Valle de Hebrón, Barcelona, Spain
| | | | - S Bonanad
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | - M F López
- Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
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25
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Thomson T, Strandberg-Larsen M, Gater A. Haemophilia B: impact on patients and economic burden of disease. Thromb Haemost 2017; 106:398-404. [DOI: 10.1160/th11-03-0193] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 06/18/2011] [Indexed: 11/05/2022]
Abstract
SummaryWorldwide, haemophilia is the most common hereditary bleeding disorder. The incidence of haemophilia B, however, is considerably less than haemophilia A and consequently appears to have received less attention in the research literature. This article aims to summarise the available evidence documenting the patient and economic burden associated with haemophilia B and current methods of disease management. Both the immediate and long-term clinical consequences of haemophilia B can have significant implications for patients in terms of functional limitations and diminished health-related quality of life (HRQOL). Evidence demonstrates that primary prophylaxis is the optimal strategy for replacing missing clotting factor IX (FIX) and managing haemophilia B. Use of recombinant FIX (rFIX) over plasma-derived FIX (pd-FIX) is also generally preferred for safety reasons. Prophylaxis using currently available rFIX products, however, requires a demanding regimen of intravenous infusions 2–3 times a week which may have significant implications for adherence and ultimately the long-term efficacy of such regimens. Only limited assessments of the cost-effectiveness of prophylactic versus on-demand FIX treatment regimens have been conducted to date. Prophylaxis, however, is generally more costly as greater quantities of FIX are consumed. Any reduction in FIX replacement dosing frequency is expected to improve patient adherence and contribute to improved clinical outcomes, further supporting the costeffectiveness of such interventions. Although a rare disease, as economic constraints for healthcare increase, generating further information regarding the key clinical, patient and economic outcomes associated with haemophilia B will be essential for supporting improvements in care for people with haemophilia B.
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26
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O’Hara J, Hughes D, Camp C, Burke T, Carroll L, Diego DAG. The cost of severe haemophilia in Europe: the CHESS study. Orphanet J Rare Dis 2017; 12:106. [PMID: 28569181 PMCID: PMC5452407 DOI: 10.1186/s13023-017-0660-y] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 05/22/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Severe haemophilia is associated with major psychological and economic burden for patients, caregivers, and the wider health care system. This burden has been quantified and documented for a number of European countries in recent years. However, few studies have taken a standardised methodology across multiple countries simultaneously, and sought to amalgamate all three levels of burden for severe disease. The overall aim of the 'Cost of Haemophilia in Europe: a Socioeconomic Survey' (CHESS) study was to capture the annualised economic and psychosocial burden of severe haemophilia in five European countries. A cross-section of haemophilia specialists (surveyed between January and April 2015) provided demographic and clinical information and 12-month ambulatory and secondary care activity for patients via an online survey. In turn, patients provided corresponding direct and indirect non-medical cost information, including work loss and out-of-pocket expenses, as well as information on quality of life and adherence. The direct and indirect costs for the patient sample were calculated and extrapolated to population level. RESULTS Clinical reports for a total of 1,285 patients were received. Five hundred and fifty-two patients (43% of the sample) provided information on indirect costs and health-related quality of life via the PSC. The total annual cost of severe haemophilia across the five countries for 2014 was estimated at EUR 1.4 billion, or just under EUR 200,000 per patient. The highest per-patient costs were in Germany (mean EUR 319,024) and the lowest were in the United Kingdom (mean EUR 129,365), with a study average of EUR 199,541. As expected, consumption of clotting factor replacement therapy represented the vast majority of costs (up to 99%). Indirect costs are driven by patient and caregiver work loss. CONCLUSIONS The results of the CHESS study reflect previous research findings suggesting that costs of factor replacement therapy account for the vast majority of the cost burden in severe haemophilia. However, the importance of the indirect impact of haemophilia on the patient and family should not be overlooked. The CHESS study highlights the benefits of observational study methodologies in capturing a 'snapshot' of information for patients with rare diseases.
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Affiliation(s)
- Jamie O’Hara
- Faculty of Health and Social Care, University of Chester, Chester, UK
| | - David Hughes
- Faculty of Health and Social Care, University of Chester, Chester, UK
| | - Charlotte Camp
- Faculty of Health and Social Care, University of Chester, Chester, UK
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27
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Protocol for oral implant rehabilitation in a hemophilic HIV-positive patient with type C hepatitis. IMPLANT DENT 2016; 23:622-5. [PMID: 25238270 DOI: 10.1097/id.0000000000000145] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
CASE REPORT A 46-year-old man with severe hemophilia A, stage A2 HIV infection and chronic hepatitis C genotype 1A, for whom the treatment plan included implant-supported prostheses in 2 mandibular edentulous sections. The protocol followed included factor VIII replacement concentrate and oral antifibrinolytic therapy. The right mandibular section was fitted with 3 Straumann implants (Ø 4.1 mm, length 10 mm), and the left mandibular section received 2 implants of the same characteristics. The patient showed no postoperative complications. After implant placement, the patient attended scheduled review appointments. After a 3-month period of osseointegration, the prosthesis was fitted. CONCLUSIONS Although, in this case, the treatment proved successful 2 years postrehabilitation and the protocol used seems safe and effective, long-term prospective studies are needed to evaluate the implant success rate in these patients.
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28
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Bhat V, Olmer M, Joshi S, Durden DL, Cramer TJ, Barnes RFW, Ball ST, Hughes TH, Silva M, Luck JV, Moore RE, Mosnier LO, von Drygalski A. Vascular remodeling underlies rebleeding in hemophilic arthropathy. Am J Hematol 2015; 90:1027-35. [PMID: 26257191 DOI: 10.1002/ajh.24133] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 07/17/2015] [Accepted: 07/20/2015] [Indexed: 01/10/2023]
Abstract
Hemophilic arthropathy is a debilitating condition that can develop as a consequence of frequent joint bleeding despite adequate clotting factor replacement. The mechanisms leading to repeated spontaneous bleeding are unknown. We investigated synovial, vascular, stromal, and cartilage changes in response to a single induced hemarthrosis in the FVIII-deficient mouse. We found soft-tissue hyperproliferation with marked induction of neoangiogenesis and evolving abnormal vascular architecture. While soft-tissue changes were rapidly reversible, abnormal vascularity persisted for months and, surprisingly, was also seen in uninjured joints. Vascular changes in FVIII-deficient mice involved pronounced remodeling with expression of α-Smooth Muscle Actin (SMA), Endoglin (CD105), and vascular endothelial growth factor, as well as alterations of joint perfusion as determined by in vivo imaging. Vascular architecture changes and pronounced expression of α-SMA appeared unique to hemophilia, as these were not found in joint tissue obtained from mouse models of rheumatoid arthritis and osteoarthritis and from patients with the same conditions. Evidence that vascular changes in hemophilia were significantly associated with bleeding and joint deterioration was obtained prospectively by dynamic in vivo imaging with musculoskeletal ultrasound and power Doppler of 156 joints (elbows, knees, and ankles) in a cohort of 26 patients with hemophilia at baseline and during painful episodes. These observations support the hypothesis that vascular remodeling contributes significantly to bleed propagation and development of hemophilic arthropathy. Based on these findings, the development of molecular targets for angiogenesis inhibition may be considered in this disease.
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Affiliation(s)
- Vikas Bhat
- Department of Molecular and Experimental Medicine; The Scripps Research Institute; La Jolla California
- Department of Medicine; University of California San Diego; San Diego California
| | - Merissa Olmer
- Department of Molecular and Experimental Medicine; The Scripps Research Institute; La Jolla California
| | - Shweta Joshi
- Department of Pediatrics; University of California San Diego; California
| | - Donald L. Durden
- Department of Pediatrics; University of California San Diego; California
| | - Thomas J. Cramer
- Department of Medicine; University of California San Diego; San Diego California
| | - Richard FW Barnes
- Department of Medicine; University of California San Diego; San Diego California
| | - Scott T. Ball
- Department of Orthopaedic Surgery; University of California San Diego; San Diego California
| | - Tudor H. Hughes
- Department of Radiology; University of California San Diego; San Diego California
| | - Mauricio Silva
- Orthopedic Institute for Children University of California Los Angeles; Los Angeles California
| | - James V. Luck
- Orthopedic Institute for Children University of California Los Angeles; Los Angeles California
| | | | - Laurent O. Mosnier
- Department of Molecular and Experimental Medicine; The Scripps Research Institute; La Jolla California
| | - Annette von Drygalski
- Department of Molecular and Experimental Medicine; The Scripps Research Institute; La Jolla California
- Department of Medicine; University of California San Diego; San Diego California
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29
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Wyseure T, Mosnier LO, von Drygalski A. Advances and challenges in hemophilic arthropathy. Semin Hematol 2015; 53:10-9. [PMID: 26805902 DOI: 10.1053/j.seminhematol.2015.10.005] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2004] [Revised: 11/05/2004] [Accepted: 12/01/2005] [Indexed: 12/13/2022]
Abstract
Hemophilic arthropathy is a form of joint disease that develops secondary to joint bleeding and presents with synovial hypertrophy, cartilage and bony destruction. The arthropathy can develop despite clotting factor replacement and is especially disabling in the aging population. Pathobiological tissue changes are triggered by release of hemoglobin and iron deposition in the joint, but the sequence of events and the molecular mechanisms resulting in joint deterioration are incompletely understood. Treatment options other than clotting factor replacement are limited. Improvements in the treatment of hemophilia necessitate a better understanding of the processes that lead to this disabling condition and better diagnostic tools. Towards that end, studies of the molecular mechanisms leading to the arthropathy, as well as the development of sensitive imaging techniques and biomarkers are needed. These will pave the way to identify the cause of acute pain such as joint bleeding or synovitis, detect early, potentially reversible structural changes, and predict progression of disease. This review describes current imaging techniques and the development of high resolution musculoskeletal ultrasound with power Doppler to afford point-of-care diagnosis and management, the potential utility of diagnostic biomarkers, and summarizes our current knowledge of the pathobiology of hemophilic arthropathy.
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Affiliation(s)
- Tine Wyseure
- The Scripps Research Institute, Department of Molecular and Experimental Medicine, La Jolla, CA, USA
| | - Laurent O Mosnier
- The Scripps Research Institute, Department of Molecular and Experimental Medicine, La Jolla, CA, USA
| | - Annette von Drygalski
- The Scripps Research Institute, Department of Molecular and Experimental Medicine, La Jolla, CA, USA; University of California at San Diego, Department of Medicine, San Diego, CA, USA.
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30
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Villarrubia R, Oyagüez I, Álvarez-Román MT, Mingot-Castellano ME, Parra R, Casado MA. Cost analysis of prophylaxis with activated prothrombin complex concentrate vs. on-demand therapy with activated factor VII in severe haemophilia A patients with inhibitors, in Spain. Haemophilia 2015; 21:320-329. [DOI: 10.1111/hae.12681] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2015] [Indexed: 11/29/2022]
Affiliation(s)
- R. Villarrubia
- Pharmacoeconomics & Outcomes Research Iberia; Madrid Spain
| | - I. Oyagüez
- Pharmacoeconomics & Outcomes Research Iberia; Madrid Spain
| | | | | | - R. Parra
- Vall d'Hebron University Hospital; Barcelona Spain
| | - M. A. Casado
- Pharmacoeconomics & Outcomes Research Iberia; Madrid Spain
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31
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Berger K, Schopohl D, Hilger A, Behr Gross ME, Giangrande P, Peyvandi F, Seitz R, Schramm W. Research in haemophilia B - approaching the request for high evidence levels in a rare disease. Haemophilia 2014; 21:4-20. [DOI: 10.1111/hae.12603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2014] [Indexed: 01/01/2023]
Affiliation(s)
- K. Berger
- Department of Haematology/Oncology; University Hospital of Munich; Munich Germany
| | - D. Schopohl
- Department of Haematology/Oncology; University Hospital of Munich; Munich Germany
| | - A. Hilger
- Paul-Ehrlich-Institute; Langen Germany
| | - M. -E. Behr Gross
- European Directorate for the Quality of Medicines & HealthCare (EDQM); Council of Europe; Strasbourg France
| | - P. Giangrande
- Oxford Haemophilia & Thrombosis Centre; Oxford University Hospitals NHS Trust; Oxford Oxfordshire UK
| | - F. Peyvandi
- Department of Pathophysiology and Transplantation; Angelo Bianchi Bonomi Haemophilia and Thrombosis Center; Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico; Università degli Studi di Milano; Luigi Villa Foundation; Milan Italy
| | - R. Seitz
- Paul-Ehrlich-Institute; Langen Germany
| | - W. Schramm
- Rudolf-Marx-Foundation; University of Munich; Munich Germany
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Cuesta-Barriuso R, Gómez-Conesa A, López-Pina JA. Manual therapy in the treatment of ankle hemophilic arthropathy. A randomized pilot study. Physiother Theory Pract 2014; 30:534-9. [DOI: 10.3109/09593985.2014.902148] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Sierra Aisa C, Lucía Cuesta JF, Rubio Martínez A, Fernández Mosteirín N, Iborra Muñoz A, Abío Calvete M, Guillén Gómez M, Moretó Quintana A, Rubio Félix D. Comparison of ultrasound and magnetic resonance imaging for diagnosis and follow-up of joint lesions in patients with haemophilia. Haemophilia 2013; 20:e51-7. [DOI: 10.1111/hae.12268] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2013] [Indexed: 11/28/2022]
Affiliation(s)
- C. Sierra Aisa
- Hospital Universitario de Cruces; San Vicente de Barakaldo Spain
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34
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Jimenez-Yuste V, Núñez R, Romero JA, Montoro B, Espinós B. Cost-effectiveness of recombinant activated factor VII vs. plasma-derived activated prothrombin complex concentrate in the treatment of mild-to-moderate bleeding episodes in patients with severe haemophilia A and inhibitors in Spain. Haemophilia 2013; 19:841-6. [DOI: 10.1111/hae.12199] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2013] [Indexed: 11/27/2022]
Affiliation(s)
- V. Jimenez-Yuste
- Hospital Universitario La Paz; Autonoma University; Madrid Spain
| | - R. Núñez
- Hospital Virgen del Rocío; Sevilla Spain
| | - J. A. Romero
- Hospital Universitario La Paz; Autonoma University; Madrid Spain
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35
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Franchini M, Frattini F, Crestani S, Sissa C, Bonfanti C. Treatment of hemophilia B: focus on recombinant factor IX. Biologics 2013; 7:33-8. [PMID: 23430394 PMCID: PMC3575125 DOI: 10.2147/btt.s31582] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Hemophilia B is a recessive X-linked bleeding disorder characterized by deficiency of the coagulation factor IX (FIX). In hemophilia B patients the severity of the bleeding phenotype is related to the degree of the FIX defect. Hemophilia B treatment has improved greatly in the last 20 years with the introduction first of plasma-derived and then of recombinant FIX concentrates. Replacement therapy may be administered through on-demand or prophylaxis regimens, but the latter treatment modality has been shown to be superior in prevention of hemophilic arthropathy and in improvement of patients' quality of life. The purpose of this narrative review is to summarize the current knowledge on treatment strategies for hemophilia B, focusing on recombinant FIX products either clinically used or in development. There is only one rFIX product that is licensed to treat hemophilia B patients; from the analysis of the literature data presented in this review, the authors conclude that this rFIX product has demonstrated an excellent safety profile and excellent clinical efficacy for halting and preventing bleeds in hemophilia B patients. While prophylaxis has emerged as the best therapeutic strategy for such patients because of its ability to prevent hemophilic arthropathy and to improve patients' quality of life, the pharmacokinetically tailored dosing of rFIX is another key point when planning hemophilia B treatment, as it allows optimization of the factor concentrate usage. Further clinical studies are needed to better assess the safety and efficacy (ie, the incidence of adverse reactions and inhibitor development) of newer rFIX products.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantua, Italy
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36
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Franchini M, Frattini F, Crestani S, Bonfanti C. Haemophilia B: current pharmacotherapy and future directions. Expert Opin Pharmacother 2012; 13:2053-63. [PMID: 22946758 DOI: 10.1517/14656566.2012.721780] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Hemophilia B is a rare hereditary hemorrhagic disorder characterized by deficiency of the clotting factor IX (FIX). Hemophilia B patients experience mild to severe bleeding complications according to the degree of FIX defect. Nowadays, the most challenging complication of individuals with hemophilia B is the development of alloantibodies, which render the standard replacement therapy with FIX concentrates ineffective, exposing them to a significantly increased morbidity and mortality. AREAS COVERED This review summarizes the most important events leading to the development of the current FIX products available for the treatment of hemophilia B patients. In addition, it focuses on the more recent advances in the production of new FIX molecules aimed at improving the clinical management of such patients. EXPERT OPINION Although the availability of plasma-derived FIX concentrates has greatly improved the clinical management of hemophilia B patients, the introduction of FIX products using recombinant DNA technology has represented the most significant therapeutic progress in hemophilia B therapy, ensuring an advanced level of safety. The development of rFIX products with extended half lives will further improve the therapeutic armamentarium for hemophilia B patients.
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Affiliation(s)
- Massimo Franchini
- Carlo Poma Hospital, Department of Transfusion Medicine and Hematology, Mantova, Italy.
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Schramm W, Gringeri A, Ljung R, Berger K, Crispin A, Bullinger M, Giangrande PLF, Von Mackensen S, Mantovani LG, Nemes L, Serban M. Haemophilia care in Europe: the ESCHQoL study. Haemophilia 2012; 18:729-37. [PMID: 22639833 DOI: 10.1111/j.1365-2516.2012.02847.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2012] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- W Schramm
- Department of Transfusion Medicine and Haemostasis, University Hospital of Munich, Munich, Germany.
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Aznar JA, Marco A, Jiménez-Yuste V, Fernández-Fontecha E, Pérez R, Soto I, Parra R, Moreno M, Mingot ME, Moret A. Is on-demand treatment effective in patients with severe haemophilia? Haemophilia 2012; 18:738-42. [PMID: 22537601 DOI: 10.1111/j.1365-2516.2012.02806.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
On-demand therapy enables stopping haemorrhages rapidly, reducing joint pain and restoring joint mobility, but does not prevent the beginning and subsequent development of haemophilic arthropathy. The main objective of this study was to identify the clinical and orthopaedic status of severe haemophilic patients with bleeding phenotype receiving on-demand treatment in Spain. We conducted an epidemiological, observational, retrospective study, recruiting 167 patients from 36 centres (92% of them with haemophilia A), median age at enrolment of 35 years. Forty per cent of the patients received a combination of on-demand and short-term prophylaxis regimen; the rest was under on-demand treatment. One hundred and forty-five patients (87%) reported at least one bleeding episode and 22 (13%) of the biologically severe patients had no bleeding phenotype. Seventy-one per cent of the studied population presented established haemophilic arthropathy, reaching 80% if we exclude patients without bleeding phenotype. Forty-three per cent of these patients had one or two joints affected, 28% of them had three or four affected joints, 20% reported five or six affected joints and 9% more than six injured joints. An increase in established haemophilic arthropathy with age was observed. Forty-six patients underwent orthopaedic surgery at least once. These data show that on-demand therapy is not effective in preventing the development of haemophilic arthropathy in severe haemophilic population with bleeding phenotype. Therefore, we suggest that the optimal treatment in these patients should be based on prophylaxis. We recommend analysing the reasons for ending prophylaxis, in case its reinstatement should be necessary.
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Affiliation(s)
- J A Aznar
- Haemostasis and Thrombosis Unit, University and Polytechnic Hospital La Fe, Valencia.
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AZNAR JA, MARCO A, PARRA R, JIMÉNEZ-YUSTE V, LUCÍA F, BALDA I, SOTO I. Liver transplantation in Spanish haemophiliacs. Haemophilia 2011; 18:e15-6. [DOI: 10.1111/j.1365-2516.2011.02658.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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RODRIGUEZ-MERCHAN EC, JIMENEZ-YUSTE V, AZNAR JA, HEDNER U, KNOBE K, LEE CA, LJUNG R, QUEROL F, SANTAGOSTINO E, VALENTINO LA, CAFFARINI A. Joint protection in haemophilia. Haemophilia 2011; 17 Suppl 2:1-23. [DOI: 10.1111/j.1365-2516.2011.02615.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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TEIXEIRA L, FERREIRA C, SANTOS BS, SAAVEDRA V. Web-enabled registry of inherited bleeding disorders in Portugal: conditions and perception of the patients. Haemophilia 2011; 18:56-62. [DOI: 10.1111/j.1365-2516.2011.02574.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Querol F, Pérez-Alenda S, Gallach JE, Devís-Devís J, Valencia-Peris A, Moreno LMG. Hemofilia: ejercicio y deporte. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.apunts.2010.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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AZNAR JA, LUCIA JF, ABAD-FRANCH L, RUBIO R, JIMENEZ-YUSTE V, PEREZ R, BATLLE J, BALDA I, MUÑOZ-ROBLES J, PARRA R. Focusing on haemophilia B: prophylaxis in Spanish patients. Haemophilia 2010; 17:542-3. [DOI: 10.1111/j.1365-2516.2010.02412.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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LUCÍA JF, AZNAR JA, ABAD-FRANCH L, ESCUIN RR, JIMÉNEZ-YUSTE V, PÉREZ R, BATLLE J, BALDA I, ALPEROVICH G, PARRA R. Prophylaxis therapy in haemophilia A: current situation in Spain. Haemophilia 2010; 17:75-80. [DOI: 10.1111/j.1365-2516.2010.02378.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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