Cyclophosphamide vs rituximab for eradicating inhibitors in acquired hemophilia A: A randomized trial in 108 patients

BACKGROUND

Acquired hemophilia A (AHA) is a rare autoimmune disorder due to autoantibodies against Factor VIII, with a high mortality risk. Treatments aim to control bleeding and eradicate antibodies by immunosuppression. International recommendations rely on registers and international expert panels.

METHODS

CREHA, an open-label randomized trial, compared the efficacy and safety of cyclophosphamide and rituximab in association with steroids in patients with newly diagnosed AHA. Participants were treated with 1 mg/kg prednisone daily and randomly assigned to receive either 1.5-2 mg/kg/day cyclophosphamide orally for 6 weeks, or 375 mg/m2 rituximab once weekly for 4 weeks. The primary endpoint was complete remission over 18 months. Secondary endpoints included time to achieve complete remission, relapse occurrence, mortality, infections and bleeding, and severe adverse events.

RESULTS

Recruitment was interrupted because of new treatment recommendations after 108 patients included (58 cyclophosphamide, 50 rituximab). After 18 months, 39 cyclophosphamide patients (67.2 %) and 31 rituximab patients (62.0 %) were in complete remission (OR 1.26; 95 % CI, 0.57 to 2.78). In the poor prognosis group (FVIII < 1 IU/dL, inhibitor titer > 20 BU mL-1), significantly more remissions were observed with cyclophosphamide (22 patients, 78.6 %) than with rituximab (12 patients, 48.0 %; p = 0.02). Relapse rates, deaths, severe infections, and bleeding were similar in the 2 groups. In patients with severe infection, cumulative doses of steroids were significantly higher than in patients without infection (p = 0.03).

CONCLUSION

Cyclophosphamide and rituximab showed similar efficacy and safety. As first line, cyclophosphamide seems preferable, especially in poor prognosis patients, as administered orally and less expensive.

FUNDING

French Ministry of Health.

CLINICALTRIALS

gov number: NCT01808911.

Sub-wavelength energy concentration with electrically generated mid-infrared surface plasmons

While freely propagating photons cannot be focused below their diffraction limit, surface-plasmon polaritons follow the metallic surface to which they are bound, and can lead to extremely sub-wavelength energy volumes. These properties are lost at long mid-infrared and THz wavelengths where metals behave as quasi-perfect conductors, but can in principle be recovered by artificially tailoring the surface-plasmon dispersion. We demonstrate - in the important mid-infrared range of the electromagnetic spectrum - the generation onto a semiconductor chip of plasmonic excitations which can travel along long distances, on bent paths, to be finally focused into a sub-wavelength volume. The demonstration of these advanced functionalities is supported by full near-field characterizations of the electromagnetic field distribution on the surface of the active plasmonic device.

Semiconductor surface plasmon sources

Surface-plasmon polaritons (SPPs) are propagating electromagnetic modes bound at a metal-dielectric interface. We report on electrical generation of SPPs by reproducing the analogue in the near field of the slit-doublet experiment, in a device which includes all the building blocks required for a fully integrated plasmonic active source: an electrical generator of SPPs, a coupler, and a passive metallic waveguide. SPPs are generated upon injection of electrical current, and they are then launched at the edges of a passive metallic strip. The interference fringes arising from the plasmonic standing wave on the surface of the metallic strip are unambiguously detected with apertureless near-field scanning optical microscopy.

A semiconductor laser device for the generation of surface-plasmons upon electrical injection

Surface plasmons are electromagnetic waves originating from electrons and light oscillations at metallic surfaces. Since freely propagating light cannot be coupled directly into surface-plasmon modes, a compact, semiconductor electrical device capable of generating SPs on the device top metallic surface would represent an advantage: not only SP manipulation would become easier, but Au-metalized surfaces can be easily functionalized for applications. Here, we report a demonstration of such a device. The direct proof of surface-plasmon generation is obtained with apertureless near-field scanning optical microscopy, which detects the presence of an intense, evanescent electric field above the device metallic surface upon electrical injection.