Ultra-fast remote up-titration of heart failure treatment: a safe, efficient and feasible protocol

Introduction

Heart failure (HF) is a common disease with a significant economic burden, mainly caused by HF hospitalisations and significant morbi-mortality. Nevertheless, HF patients are still undertreated due to a clinical inertia that needs to be reversed as soon as possible using new, safe and available methods. Remote up-titrating HF medication might be the solution to rapidly optimize HF treatment to maximal tolerated doses.

Purpose

Our objective was to describe the safety, efficacy and feasibility of an ultra-fast remote up-titration protocol of HF treatment.

Methods

Patients with a recent hospitalization due to a HF decompensation and left ventricular ejection fraction <50% were retrospectively included in our database. We collected clinical, biological and treatment data at enrollment and at the end of HF medication optimization. Our protocol consisted in remote consultation (via telephone or video-consultation) every 15 days with a 72h prior blood test. Blood pressure (BP), heart rate (HR) and weight were recorded either by tele-monitoring or self-measurement.

Results

We evaluated 96 patients, 25% female with a mean LVEF at 29%, main etiology of HF was ischemic (48%) and mean NTproBNP was 2384 pg/mL. Mean BP was 112/70 mmHg, HR was 73 bpm, glomerular filtration rate (GFR) 71 ml/min and potassium concentration was 4,4 mEq/L. Ninety four patients were initially treated with a beta blocker (BB), 29% of our cohort was treated either with an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB) and 59% was treated with angiotensin receptor neprilysin inhibitor (ARNI). A total of 72 patients were treated with a mineralocorticoid receptor antagonist (MRA) and 58 patients were also treated with an inhibitor of sodium-glucose transport protein 2 (SLGT2i), Figure 1. Median duration of tele-titration consultation was 42 days. We up-titrated BB in 50% of our patients, of which 10% were at maximum dose, making a total of 98% of our cohort under BB treatment. Sixty percent of patients under ACEI or ARB were switched to ARNI. Of the 82% of patients under ARNI, up to 50% achieved the maximal dose.

We introduced or up-titrated ARM in 41 patients, reaching the target dose in 37%. Dose variations and mean initial and final doses are shown in Figure 2.1 and 2.2

Minor adverse events that motivated a down-titration or a cessation of treatment were, hyperkalemia 5%, acute renal failure (ARF) 6%, hypotension 3% and bradycardia 2%. Non urgent hospitalization due to ARF with hyperkalemia or HF only occurred in 2 cases.

The limiting factors for not reaching the optimal targeted dose were low HR in 20%, hypotension in 11%, high concentration of potassium 10% and chronic renal failure in 9%.

Conclusion

Remote up-titration of HF medication is a promising tool in the fight against clinical inertia and a fast, feasible, safe (only 2% of major events) and efficient solution to our undertreated patients.

Funding Acknowledgement

Type of funding sources: None.

The interplay between infection risk factors of SARS-CoV-2 and mortality: a cross-sectional study from a cohort of long-term care nursing home residents

BACKGROUND

Covid-19 pandemic has particularly affected older people living in Long-term Care settings in terms of infection and mortality.

METHODS

We carried out a cross-sectional analysis within a cohort of Long-term care nursing home residents between March first and June thirty, 2020, who were ≥ 65 years old and on whom at least one PCR test was performed. Socio-demographic, comorbidities, and clinical data were recorded. Facility size and community incidence of SARS-CoV-2 were also considered. The outcomes of interest were infection (PCR positive) and death.

RESULTS

A total of 8021 residents were included from 168 facilities. Mean age was 86.4 years (SD = 7.4). Women represented 74.1%. SARS-CoV-2 infection was detected in 27.7% of participants, and the overall case fatality rate was 11.3% (24.9% among those with a positive PCR test). Epidemiological factors related to risk of infection were larger facility size (pooled aOR 1.73; P < .001), higher community incidence (pooled aOR 1.67, P = .04), leading to a higher risk than the clinical factor of low level of functional dependence (aOR 1.22, P = .03). Epidemiological risk factors associated with mortality were male gender (aOR 1.75; P < .001), age (pooled aOR 1.16; P < .001), and higher community incidence (pooled aOR 1.19, P = < 0.001) whereas clinical factors were low level of functional dependence (aOR 2.42, P < .001), Complex Chronic Condition (aOR 1.29, P < .001) and dementia (aOR 1.33, P <0.001). There was evidence of clustering for facility and health area when considering the risk of infection and mortality (P < .001).

CONCLUSIONS

Our results suggest a complex interplay between structural and individual factors regarding Covid-19 infection and its impact on mortality in nursing-home residents.

[Clinical and economic impact of an ambulatory cataract surgery center without anesthesia in an area with poor ophthalmologic coverage]

INTRODUCTION

The Ambulatory Clinic for Cataract Surgery (CACC) is a public department of the Bourges Medical Center, with a fast-track protocol without perioperative anesthesia care launched in 2015. This study aimed to evaluate the benefits of the CACC in terms of access to cataract surgery.

METHODS

This retrospective study included all patients undergoing cataract surgery between 2012 and 2018. Data were collected from the French PMSI database. In order to evaluate the impact of the CACC, the surgical activity and change in indicators of patient flow and usage, as well as clinical and economic factors were analyzed.

RESULTS

Between 2012 and 2018, with the same number of ophthalmologists, surgical activity increased by 50.2% in the Cher (vs. a mean increase of 22.7% in France). The patient loss ratio decreased by 5.9 points, the attraction and self-sufficiency ratios increased by 2.3 and 8.6 points respectively. The standardized rate of healthcare utilization for cataract surgery increased by 4.3 points (from 11.6 to 15.9 surgeries per 1000 inhabitants). As a result, Cher became the second highest French Department in 2018 in terms of utilization rate despite its 96th place out of 109 Departments in terms of density of ophthalmologists.

CONCLUSION

The ambulatory cataract surgery center without anesthesia for selected patients might represent a solution in medical deserts to improve access to cataract surgery without increasing costs.

[Epidemiology of ocular emergencies in a non-university hospital: Clinical characteristics and severity grading according to the Base Score]

OBJECTIVE

This study aimed to analyse the epidemiological characteristics of ophthalmological emergencies at the Bourges Medical Center (CHB) and to identify factors associated with severity according to the Base Score in a region of France considered a healthcare desert.

METHODS

All consecutive charts of patients seen for an eye-related condition between January 1 and April 30, 2019 in the ocular emergency department of the CHB were studied retrospectively. Seven demographic and nine medical variables were collected, and ocular severity was defined according to the Base Score. Linear regressions were performed to identify the factors associated with higher severity.

RESULTS

1809 patients were included (mean age: 53.3±22.7 years, 51.4% women), of whom 1619 (89.5%) were self-referred. Ocular surface disease (12.5%) was the most frequent diagnosis. The severity of the eye-related condition was significantly associated with the following factors: male gender, distance from home to the emergency department, presentation soon after the onset of symptoms, and referral from a physician (ophthalmologist or not). The regression coefficient was greater than 1 only for the patient referral pattern.

CONCLUSION

The current study highlights that when patients with ocular emergencies can self-refer to an ocular emergency department within a French healthcare desert, 9 patients out of 10 self-refer. Referral from a physician is the main factor associated with ocular severity; thus, these cases should be considered severe until proven otherwise.

Late results of bioabsorbable scaffolds implanted in spontaneous coronary artery dissection evaluated with computed tomography coronary angiography

Background

Percutaneous coronary intervention (PCI) in spontaneous coronary artery dissection (SCAD) should be reserved for cases presenting with ongoing extensive ischaemia. Bioresorbable scaffolds (BVS) have emerged as an alternative to avoid permanent stenting, an especially attractive concept for this clinical scenario. However, data of late angiographic outcome of this device in SCAD is lacking.

Purpose

To evaluate the long-term angiographic outcome of BVS in the setting of SCAD using computed tomography coronary angiography (CTCA)

Methods

In this multicentre prospective study, high-risk SCAD patients treated with BVS were scheduled for a follow-up CTCA at least 2 years from implantation date. Acquisition was performed according to the current recommendations. All the studies were analysed in a central core laboratory by an independent level 3 expert in CTCA blinded to the clinical and angiographic results. For this purpose, a dedicated software for coronary analysis was used to quantify coronary stenosis and evaluate coronary wall.

Results

Thirty-four BVS were implanted in 15 SCAD patients (51±12 years-old; 87% female) from 7 different centres in Spain and United Kingdom. The most common presentation was STEMI (n=9, 60%). Target vessels included 11 left anterior descending arteries (73.3%), 3 right coronary arteries (20%) and 1 left circumflex coronary artery (6.7%). One patient received target lesion revascularisation due to scaffold shrinkage in a proximal right coronary artery at 13 months. CTCA was performed 2.4±0.7 years after BVS implantation. No scaffold thrombosis or significant stenosis were detected. Patency of all scaffolds was confirmed with a median luminal area of 5.52 mm2 (IQR: 3.74–6.95) and median stenosis of 11% (IQR: 4–15%). Regarding coronary wall tissue characterization of segments with BVS, there was 32±9.3% of plaque burden and a median plaque volume of 45.3 mm3 (IQR: 26.6–61.9). The most common component of the plaque was fibrous (85±9.4%). Compared to the proximal reference segments, BVS showed more plaque burden (32.2% vs 25.3%; p=0.017) and fibrous percentage (84.7% vs 75.1%; p=0.004) whereas less fibrofatty (6 vs 4.8 mm3; p=0.007) and necrotic volume (0.4 vs 1.2 mm3; p=0.029). BVS segments showed lower absolute minimal luminal area (5.5 vs 8.9 mm2; p=0.004) and diameter (2.7 vs 3.4 mm; p=0.004) compared to the reference segment; however, non-significant differences were seen in percentage stenosis, in keeping with normal vessel tapering.

Conclusions

In this series of SCAD treated with BVS, scaffolds showed a satisfactory late angiographic outcome, with no significant restenosis and an excellent minimal luminal area and optimal coronary wall healing observed.

Funding Acknowledgement

Type of funding source: None

COVIDApp as an Innovative Strategy for the Management and Follow-Up of COVID-19 Cases in Long-Term Care Facilities in Catalonia: Implementation Study

Background

The coronavirus disease (COVID-19) pandemic has caused an unprecedented worldwide public health crisis that requires new management approaches. COVIDApp is a mobile app that was adapted for the management of institutionalized individuals in long-term care facilities.

Objective

The aim of this paper is to report the implementation of this innovative tool for the management of long-term care facility residents as a high-risk population, specifically for early identification and self-isolation of suspected cases, remote monitoring of mild cases, and real-time monitoring of the progression of the infection.

Methods

COVIDApp was implemented in 196 care centers in collaboration with 64 primary care teams. The following parameters of COVID-19 were reported daily: signs/symptoms; diagnosis by reverse transcriptase–polymerase chain reaction; absence of symptoms for ≥14 days; total deaths; and number of health care workers isolated with suspected COVID-19. The number of at-risk centers was also described.

Results

Data were recorded from 10,347 institutionalized individuals and up to 4000 health care workers between April 1 and 30, 2020. A rapid increase in suspected cases was seen until day 6 but decreased during the last two weeks (from 1084 to 282 cases). The number of confirmed cases increased from 419 (day 6) to 1293 (day 22) and remained stable during the last week. Of the 10,347 institutionalized individuals, 5,090 (49,2%) remained asymptomatic for ≥14 days. A total of 854/10,347 deaths (8.3%) were reported; 383 of these deaths (44.8%) were suspected/confirmed cases. The number of isolated health care workers remained high over the 30 days, while the number of suspected cases decreased during the last 2 weeks. The number of high-risk long-term care facilities decreased from 19/196 (9.5%) to 3/196 (1.5%).

Conclusions

COVIDApp can help clinicians rapidly detect and remotely monitor suspected and confirmed cases of COVID-19 among institutionalized individuals, thus limiting the risk of spreading the virus. The platform shows the progression of infection in real time and can aid in designing new monitoring strategies.

Physical Properties of Lithium-Cobalt Oxides Grown by Laser Ablation

We have studied the growth and the physical properties of LiCoO2 films as a function of formation conditions, i.e., substrate temperature and partial oxygen pressure. These films were grown on various substrates by the laser ablation technique using a Nd:YAG laser at 100 MW/cm2 power density. LiCoO2 films were characterized by XRD, SEM, and vibrational spectroscopy. The synthesized compounds show high homogeneity in composition and in particle dimension. The main advantage of this method is the less time needed for the reaction to occur completely. Raman scattering spectroscopy provides information on the local environment of cations.

Vibrational Spectroscopic Studies of the Local Environment in 4-Volt Cathode Materials

We report the vibrational spectra of numerous 4-volt cathode materials, the transition metal oxides which are potential materials for advanced Li-ion batteries. They provide high specific energy density, high voltage, and remarkable reversibility for lithium intercalation-deintercalation process. Studied were carried out by Raman and FTIR spectroscopies. Oxides such as LiMn2O4, LiNiVO4, LiCoVO4 spinels, LiMeO2 (Me=Co, Ni, Cr) layered compounds and their mixed compounds have been investigated. The local environment of cations against oxygen neighboring atoms has been determined by considering tetrahedral and octahedral units building the lattice. Structural modifications induced by the intercalation-deintercalation process, by the cation substitution, or by the low-temperature preparation route are also examined. The results are compared with those of end members.

Colour variation and alternative reproductive strategies in females of the common lizard Lacerta vivipara

Within-sex colour variation is a widespread phenomenon in animals that often plays a role in social selection. In males, colour variation is typically associated with the existence of alternative reproductive strategies. Despite ecological conditions theoretically favourable to the emergence of such alternative strategies in females, the social significance of colour variation in females has less commonly been addressed, relative to the attention given to male strategies. In a population of the common lizard, females display three classes of ventral colouration: pale yellow, orange and mixed. These ventral colours are stable through individual's life and maternally heritable. Females of different ventral colourations displayed different responses of clutch size, clutch hatching success and clutch sex-ratio to several individual and environmental parameters. Such reaction patterns might reflect alternative reproductive strategies in females. Spatial heterogeneity and presence of density- and frequency-dependent feedbacks in the environment could allow for the emergence of such alternative strategies in this population and the maintenance of colour variation in females.

Ontogenic sources of variation in sexual size dimorphism in a viviparous lizard

To elucidate the developmental aspects of the evolution of sexual size dimorphism (SSD), an understanding of the sex-specific ontogeny of body size is critical. Here, we evaluate the relative importance of genetic and environmental determinants of SSD in juvenile common lizards (Lacerta vivipara). We examined the prenatal and post-natal effects of population density and habitat humidity on SSD, as well as the maternal effects of food availability, corticosterone level, humidity and heat regime during gestation. Analyses indicated strong prenatal and post-natal plasticity in body size per se and yielded three main results with respect to SSD. First, SSD in juvenile common lizards matches qualitatively the SSD observed in adults. Secondly, SSD was influenced by none of the prenatal factors investigated here, suggesting poor sex-biased maternal effects on offspring size. Thirdly, SSD was sensitive to post-natal habitat humidity, which positively affected growth rate more strongly in females than in males. Thus, natural variation in SSD in juvenile common lizards appears to be primarily determined by a combination of sex-biased genetic factors and post-natal conditions. We discuss the possibility that viviparity may constrain the evolution of sex-biased maternal effects on offspring size.

Female common lizards (Lacerta vivipara) do not adjust their sex-biased investment in relation to the adult sex ratio

Sex allocation theory predicts that facultative maternal investment in the rare sex should be favoured by natural selection when breeders experience predictable variation in adult sex ratios (ASRs). We found significant spatial and predictable interannual changes in local ASRs within a natural population of the common lizard where the mean ASR is female-biased, thus validating the key assumptions of adaptive sex ratio models. We tested for facultative maternal investment in the rare sex during and after an experimental perturbation of the ASR by creating populations with female-biased or male-biased ASR. Mothers did not adjust their clutch sex ratio during or after the ASR perturbation, but produced sons with a higher body condition in male-biased populations. However, this differential sex allocation did not result in growth or survival differences in offspring. Our results thus contradict the predictions of adaptive models and challenge the idea that facultative investment in the rare sex might be a mechanism regulating the population sex ratio.

Multiple paternity in clutches of common lizard Lacerta vivipara: data from microsatellite markers

The common lizard (Lacerta vivipara) is a small live-bearing lacertid that reproduces once a year. In order to document the poorly known mating system of this species, we present here an assessment of multiple paternity using microsatellite markers. Paternities were established within 122 clutches belonging to two wild populations from contrasted areas and to four seminatural enclosed populations. The proportion of multiply sired clutches was found to be very high (between 50.0% and 68.2%) and similar among populations, which suggests that the mating system of this species may be insensitive to environmental and population conditions.

Lattice vibrations of manganese oxides. Part I. Periodic structures

Raman scattering (RS) and Fourier transform-infrared (FT-IR) spectroscopy have been applied to the structural characterisation of manganese dioxides (MDOs). A variety of synthetic battery-grade MDOs are investigated for comparison to the natural phases. The RS and FT-IR spectra are analysed on the basis of the local environment in the MDO structures considering the vibrations of the MnO6 octahedral building the lattices. The vibrational modes of the MnO6 units expand over 400-650 cm(-l) with additional bands in the low-wavelength region. Structural trends are deduced from the comparison of the vibrational spectra of the MDO phases investigated: birnessite, bixbyite, coronadite, groutite, hausmannite, hollandite, manganosite, pyrolusite, ramsdellite, romanechite, spinel, and todorokite.

Influence of von Willebrand factor on the reactivity of human factor VIII inhibitors with factor VIII

In order to determine the difference in reactivity of factor (F) VIII inhibitors against the FVIII/von Willebrand factor (vWF) complex and against vWF-deficient FVIII, we investigated a panel of 10 antibodies to FVIII from multitransfused individuals with severe haemophilia A and other pathologies. Immunoblotting of purified FVIII and purified thrombin-cleaved FVIII revealed that in all cases inhibitor epitopes could be localized in the heavy chain (A2 subunit) while in four cases they were also present in the light chain. One of the FVIII inhibitors remained unclassified. The effect on FVIII:C of purified IgG from inhibitor plasmas was tested against a high purity FVIII/vWF concentrate and a monoclonally purified FVIII concentrate with only trace contents of vWF, by two different functional assays. Our results suggest that for those inhibitors showing A2 plus light chain (LC) reactivity, the IgG concentration required to inhibit 50% of FVIII activity in vitro is higher for the FVIII/vWF complex than for the vWF-deficient FVIII. We conclude that there might be a protective role of vWF (at least in vitro) against FVIII inhibitors with A2 and LC subunit specificity.

The contribution of phenotypic plasticity to adaptation in Lacerta vivipara

Correlation between intraspecific phenotypic variability and variation of environmental conditions could reflect adaptation. Different phenotypes may result from differential expression of a genotype in different environments (phenotypic plasticity) or from expression of different genotypes (genetic diversity). Populations of Lacerta vivipara exhibit larger adult body length, lower age at maturity, higher fecundity, and smaller neonatal size in humid habitats compared to dry habitats. We conducted reciprocal transplants of juvenile L. vivipara to test for the genetic or plastic origin of this variation. We captured gravid females from four populations that differed in the relative humidity of their habitats, and during the last 2 to 4 weeks of gestation, we manipulated heat and water availability under laboratory conditions. Juveniles were released into the different populations and families were divided to compare growth rate and survival of half-sibs in two environments. Growth rate and survival were assessed using capture-recapture techniques. Growth rate was plastic in response to postnatal conditions and did not differ between populations of origin. Survival differed between populations of origin, partially because of differences in neonatal body length. The response of juvenile body length and body condition to selection in the different habitats was affected by the population of origin. This result cannot be simply interpreted in terms of adaptation; however, phenotypic plasticity of fecundity or juvenile size most probably resulted in adaptive reproductive strategies. Adaptation to the habitat by means of genetic specialization was not detected. Further investigation is needed to discriminate between genetic and long-term maternal effects.

[No ELISA detectable alterations in immunogenicity following dry-hear treatment (72 hours at 80 degrees C) of FANHDI]

OBJECTIVE

Neoantigen formation during heat treatment (HT) of factor VIII:von Willebrand Factor (FVIII:vWF) concentrates may induce an immune response against the modified protein, which may also affect the native protein. We present a comparative in vitro study on the immunogenicity of a dual virally inactivated (solvent-detergent and 80 degrees C 72 hours) high purity FVIII:vWF concentrate (Fanhdi) versus the same product without heat treatment.

MATERIAL AND METHODS

For this purpose rabbit antisera were prepared using both Fanhdi and the same product from which the human albumin, used as stabilizer, had been removed (these were both HT products). Also, antisera were prepared against the same products made without the dry-heat treatment step (non-HT products). Antisera were analysed by Elisa. Mixtures of antisera with increasing amounts of product (incubation-absorption in liquid phase) were assayed in plates coated with HT and non-HT products.

RESULTS

The binding of antibodies against HT products to ELISA plates coated with HT products, could be blocked (in a saturable manner) with non-HT products, following liquid phase incubation. These results strongly suggest the absence of neonantigens. Furthermore, the binding of antibodies against non-HT products to ELISA plates coated with non-HT products, could be blocked (also in a saturable manner) with HT products. This result indicates that there is no epitope loss.

CONCLUSIONS

The data obtained in these studies suggest that the heat treatment of viral inactivation as applied in Fanhdi, does not give rise to any major alteration in immunogenicity of the product. The data from clinical and drug surveillance studies carried out with Fanhdi do not show any indication of an increase in the frequency of inhibitors.

Characterization and viral safety validation study of a pasteurized therapeutic concentrate of antithrombin III obtained through affinity chromatography

BACKGROUND AND OBJECTIVE

Antithrombin III (ATIII) concentrates are employed as therapy for congenital or acquired deficiencies. These concentrates are obtained from Cohn's fraction IV1. To improve yields, purity and safety, our group developed a procedure to obtain a pasteurized ATIII concentrate from the supernatant of Cohn's fraction II + III including a highly efficient heparin affinity chromatography purification and pasteurization as a viral inactivation step.

DESIGN AND METHODS

Three steps of the manufacturing procedure (Cohn's fraction II + III precipitation, affinity chromatography and pasteurization) were selected to examine their efficacy in inactivating and/or removing the selected viruses.

RESULTS

The industrial batches show a purity higher than 99% with approximately 95% native heparin binding ATIII. Only albumin and IgG could be detected at trace levels (0.07% and 0.16% of the total protein present, respectively). The specific activity of the product was approximately 6.65 IU/mg protein. Five viruses were spiked into the manufacturing starting materials and samples were collected at various points to determine the infection level of virus. The study showed a reduction factor (log 10) > or = 11.7 for HIV-1; > or = 8.1 for bovine herpes virus (analyzed as a model for herpes and hepatitis B viruses); > or = 8.1 for bovine diarrhea virus (model for hepatitis C and G) and > or = 6.0 for encephalomyocarditis virus (model for hepatitis A and other non-enveloped viruses).

INTERPRETATION AND CONCLUSIONS

No biochemical alterations of the ATIII were detected in the final product. A high viral elimination capacity of the production process was demonstrated. So far, more than 32 million units of ATIII have been transfused in the form of this therapeutic concentrate without any detected seroconversion.

Natal dispersal and senescence

The potential existence of natal dispersal strategies depending on parental age has been suggested by Hamilton and May [Hamilton, W. D. & May, R. M. (1977) Nature 269, 578-581] for organisms whose survival rates decline with age. When competition between parent and offspring is strong, any individual should disperse a smaller fraction of its offspring when it ages. Here, we verify their verbal prediction. First, we determine the evolutionarily stable dispersal strategy conditional on parental age, associated with a particular senescence curve. We show that such a conditional dispersal strategy should evolve independently from the genotype controlling the offspring dispersal behavior. Second, studying a population of common lizards, we provide empirical evidence of a relation between dispersal of female offspring and maternal senescence, in agreement with our theoretical predictions.

[Development and characterization of a high-purity human factor VIII concentrate submitted to 2 specific virus inactivation treatments (FANDHI)]

AIM

To develop a therapeutic human high purity FVIII concentrate, treated with two documented and complementary specific inactivation methods, for the treatment of haemophilia A.

MATERIAL AND METHODS

Cryoprecipitate was obtained from human plasma, normal for ALT levels and negative for HBsAg and antibodies to HIV and to HCV. The cryoprecipitate was resuspended and purified with PEG. The PEG precipitate was resuspended and treated with TNBP/Polysorbate 80. The mixture was processed by heparin affinity chromatography. The eluate was concentrated and precipitated with glycine and salts. After resuspension, stabilizers were added and the solution was sterile filtered, dispensed in vials and lyophilized. These final vials were treated at 80 degrees C for 72 hours: FVIII:C, vWF:RCo, vWF:Ag, vWF multimeric structure and the concentration of other plasmatic proteins were analyzed.

RESULTS

FVIII: C specific activity was between 1000 and 3000 U/mg (after elimination of vWF, present as a stabilizer and before the addition of human pasteurized albumin). vWF:RCo activity (0.7 U vWF:RCo/U FVIII:C) and the multimeric structure of vWF showed a good degree of conservation. Other plasmatic proteins analyzed were undetectable or at trace amounts. No prekalllikrein, kallikrein or activated coagulation factors activity could be detected.

CONCLUSION

The FVIII concentrate described shows a high degree of purity and stability, which makes it very suitable for haemophilia A treatment.

[Evaluation of viral safety of a high-purity human factor VIII concentrate submitted to 2 specific virus inactivation treatments (FANDHI)]

AIM

To perform a validation study of the production process of a human high purity FVIII concentrate, obtained by affinity chromatography and treated with solvent-detergent and 80 degrees C, 72- hour dry heating in the final vial, in order to demonstrate its viral safety.

MATERIAL AND METHODS

The ability to inactivate or eliminate viruses was studied in the steps of PEG precipitation, solvent-detergent treatment (6 h 25 degrees C), affinity chromatography and lyophilization plus heating 80 degrees C for 72 h. HIV and models for hepatitis A, B and C, as well as a model for parvovirus B-19 were employed. The experiments were carried out by spiking the samples at each step with 10% of their volume with the highest titer available virus culture. The samples were processed under validated conditions (mimicking the industrial process) and the residual infectivity was determined (as well as p24 antigen and reverse transcriptase for HIV at the solvent-detergent step).

RESULTS

No residual infectivity could be detected for enveloped viruses (HIV and models for hepatitis B and C) after the first minutes of solvent-detergent treatment, which lasts 6 hours. Lyophilization followed by heating 80 degrees C for 72 hours caused complete disappearance of infectivity for the models of hepatitis A and C, before 24 hours of a treatment which lasts 72. Furthermore, lyophilization plus heating reduced infectivity for the models of hepatitis B and parvovirus B-19 by 3.4 and 4.1 logs, respectively. The affinity chromatography reduced infectivity by 7.6 logs for the model of hepatitis B and 2 logs for HIV. PEG precipitation also reduced the infectivity by 3.3 logs for the model of hepatitis A and by 1.2 logs for the model of parvovirus B-19. Taking the process as whole, the study showed cumulative reduction values between 5.3 and > 19 logs of the analyzed viruses. 25 million FVIII units have been transfused so far as FANHDI, with no seroconversion detected. Furthermore, no increase in FVIII inhibitor frequency has been described.

CONCLUSION

The FVIII concentrate described shows outstanding viral safety characteristics. These data, together with the preliminary clinical experience after one year usage of the product, indicate that FANHDI is a suitable preparation for haemophilia A treatment.