International Society on Thrombosis and Haemostasis clinical practice guideline for treatment of congenital hemophilia A and B based on the Grading of Recommendations Assessment, Development, and Evaluation methodology.

BACKGROUND: Hemophilia is a rare congenital bleeding disorder that results from complete or partial deficiency of blood coagulation factor (F)VIII (hemophilia A) or FIX (hemophilia B) due to pathogenic variants in their coding genes. Hemophilia requires complex management. To date, there is no evidence-based clinical practice guideline on hemophilia treatment based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. OBJECTIVES: This evidence-based clinical practice guideline from the International Society on Thrombosis and Haemostasis aims to provide an overview of evidence and support patients, caregivers, hematologists, pediatricians, other clinicians, researchers, and stakeholders in treatment decisions about congenital hemophilia A and B. METHODS: The International Society on Thrombosis and Haemostasis formed a multidisciplinary guideline panel of physicians and patients with global representation, balanced to minimize potential bias from conflicts of interest. The panel prioritized a set of clinical questions and outcomes according to their importance for clinicians and patients. A methodological team supported the guideline development process, including searching for evidence and performing systematic reviews. The GRADE approach was used, including GRADE Evidence to Decision frameworks. The recommendations were subject to public comment. RESULTS: The panel selected 13 questions, of which 11 addressed the treatment of hemophilia A and 2 the treatment of hemophilia B. Specifically, the panel addressed questions on prophylactic and episodic treatment with FVIII concentrates, bypassing agents, and nonfactor therapy (emicizumab) for hemophilia A (with and without inhibitors) as well as immune tolerance induction for hemophilia A. For hemophilia B, the panel addressed questions on prophylactic and episodic treatment of bleeding events with FIX concentrates. Agreement was reached for all 13 recommendations, of which 7 (54%) were based on evidence from randomized clinical trials, 3 (23%) on observational studies, and 3 (23%) on indirect comparisons. CONCLUSION: Strong recommendations were issued for prophylactic over episodic treatment for severe and moderately severe hemophilia A and B. Only conditional recommendations were issued for the remaining questions. Future research should focus on direct treatment comparisons and the treatment of hemophilia B with and without inhibitors. Future updates of this guideline will provide an updated evidence synthesis on the current questions and focus on new FVIII and FIX concentrates, novel nonfactor therapies, and gene therapy for severe and nonsevere hemophilia A and B.

Sequential Fermentation in Red Wine cv. Babic Production: The Influence of Torulaspora delbrueckii and Lachancea thermotolerans Yeasts on the Aromatic and Sensory Profile.

This research aimed to analyze the impact of two different non-Saccharomyces yeast species on the aromatic profile of red wines made from the cv. Babic (Vitis vinifera L.) red grape variety. The grapes were obtained from two positions in the Middle and South of Dalmatia. This study compared a control treatment with the Saccharomyces cerevisiae (Sc) strain as a type of sequential inoculation treatment with Lachancea thermotolerans (Lt x Sc) and Torulaspora delbrueckii (Td x Sc). The focus was on the basic wine parameters and volatile aromatic compound concentrations determined using the SPME-Arrow-GC/MS method. The results revealed significant differences in cis-linalool oxide, geraniol, neric acid, and nerol, which contribute to the sensory profile with floral and rose-like aromas; some ethyl esters, such as ethyl furoate, ethyl hexanoate, ethyl lactate, ethyl 2-hydroxy-3-methylbutanoate, ethyl 3-hydroxy butanoate, diethyl glutarate, and diethyl succinate, contribute to the aromatic profile with fruity, buttery, overripe, or aging aromas. A sensory evaluation of wines confirmed that Td x Sc treatments exhibited particularly positive aromatic properties together with a more intense fullness, harmony, aftertaste, and overall impression.

florio® HAEMO: A Longitudinal Survey of Patient Preference, Adherence and Wearable Functionality in Central Europe.

INTRODUCTION: florio® HAEMO is a hemophilia treatment monitoring application (app) offering activity tracking and wearable device connectivity. Its use might support everyday activities for people with hemophilia. The aim of this study was to evaluate user satisfaction, long-term usage and the impact on data entry when pairing a wearable with a hemophilia monitoring app. METHODS: This is a follow-up of a two-part user survey conducted in Central Europe. People with hemophilia and parents/caregivers of children with hemophilia using florio HAEMO and who completed part one were invited to complete a second online questionnaire at least 4 months later. RESULTS: Fifty participants (83.3%) who completed part one of the survey continued to use the florio HAEMO app and completed part two. Of 14 participants who chose to use the app with a wearable, more than half (57.1%) were aged between 13 and 25 years. Overall, the results demonstrated that florio HAEMO is very easy or rather easy to use, especially for individuals pairing the app with a wearable. Most people using a wearable indicated that florio HAEMO was very or rather important in bringing certainty to daily activities (85.7%). Notably, 14 of 36 (38.9%) non-wearable users indicated that they would prefer to pair the app with a wearable in the future. CONCLUSIONS: Adherence to the florio HAEMO app is maintained over an extended period of use. Pairing the app with a wearable might enable easier access to app features, increase data entry motivation and provide more certainty about daily activities for people with hemophilia.

Spontaneous fermentation of Marastina wines: The correlation between autochthonous mycobiota and phenolic compounds.

Understanding fungal community dynamics during fermentation is important for assessing their influence on wine's phenolic content. The present study represents the first effort to explore the correlation between the autochthonous mycobiota of Marastina grapes collected from Dalmatian winegrowing sub-regions in Croatia and the phenolic composition, as well as the physicochemical parameters of wines produced through spontaneous fermentation. The metataxonomic approach revealed Metschnikowia pulcherrima, Metschnikowia fructicola and Hanseniaspora uvarum as the core mycobiota detected at the initial phase of fermentation. By contrast, Saccharomyces cerevisiae took over the dominance starting from the middle stage of fermentation. The wine's phenolic compounds were revealed by high-performance liquid chromatography, with tyrosol being the most abundant. Rhodotorula babjevae and Botrytis cinerea showed a positive correlation with p-hydroxybenzoic acid, gentisic acid, caffeic acid and cinnamic acid, while demonstrating a negative correlation with protocatechuic acid and chlorogenic acid. Heterophoma novae-verbascicola exhibited the opposite behaviour regarding the same phenolic compounds. The concentration of lactic acid was positively correlated with B. cinerea and negatively correlated with Het. novae-verbascicola. These findings serve as a foundation for in-depth investigations into the role of autochthonous grape mycobiota in phenolic transformation during spontaneous fermentation, potentially leading to the production of high-quality wines with unique terroir characteristics. Future studies should aim to explore the specific role played by individual yeast isolates in the formation of phenolic compounds.

von Willebrand factor/factor VIII concentrate (Wilate) prophylaxis in children and adults with von Willebrand disease.

ABSTRACT: Long-term prophylaxis with a von Willebrand factor (VWF) concentrate is recommended in patients with von Willebrand disease (VWD) who have a history of severe and frequent bleeds. However, data from prospective studies are scarce. WIL-31, a prospective, noncontrolled, international phase 3 trial, investigated the efficacy and safety of Wilate prophylaxis in severe patients with VWD. Male and female patients 6 years or older with VWD types 1, 2 (except 2N), or 3 who had completed a prospective, 6-month, on-demand, run-in study (WIL-29) were eligible to receive Wilate prophylaxis for 12 months. At baseline, patients (n = 33) had a median age of 18 years. Six (18%) patients had severe type 1, 5 (15%) had type 2, and 22 (67%) had type 3 VWD. The primary end point of a >50% reduction in mean total annualized bleeding rate (TABR) with Wilate prophylaxis vs prior on-demand treatment was met; mean TABR during prophylaxis was 5.2, representing an 84.4% reduction. The bleeding reduction was consistent across age, sex, and VWD types. The mean spontaneous ABR was 3.2, representing an 86.9% reduction vs on-demand treatment. During prophylaxis, 10 (30.3%) patients had 0 bleeding events and 15 (45.5%) patients had 0 spontaneous bleeding events. Of 173 BEs, 84.4% were minor and 69.9% treated. No serious adverse events related to study treatment and no thrombotic events were recorded. Overall, WIL-31 showed that Wilate prophylaxis was efficacious and well-tolerated in pediatric and adult patients with VWD of all types. The WIL-29 and WIL-31 trials were registered at www.ClinicalTrials.gov as #NCT04053699 and #NCT04052698, respectively.

Accreditation model of European Haemophilia Centres in the era of novel treatments and gene therapy.

INTRODUCTION: The international certification of haemophilia centres in Europe is run by the European Association of Haemophilia and Allied Disorders (EAHAD) and European Haemophilia Consortium (EHC) since 2013. The centres are designated as European Haemophilia Comprehensive Care Centres (EHCCC) or European Haemophilia Treatment Centres (EHTC), based on the specific requirements which evaluate centres' ability to provide care for patients with haemophilia and allied disorders. AIM: To establish the new protocol for accreditation of European Haemophilia Centres. METHODS: EAHAD, in collaboration with EHC, established Accreditation Working Group with the aim to define necessary measures to safeguard quality and improvement of bleeding disorders care throughout Europe and to build a novel model for accreditation of European Haemophilia Centres. RESULTS: The European guidelines for certification of haemophilia centres have been updated to guidelines for the accreditation and include all the requirements regarding facilities, laboratory and personnel needed for optimal management of novel treatment options, including the introduction of the hub-and-spoke model for delivery of gene therapy. A pilot project for the accreditation of haemophilia centres including on-site audit has been designed. CONCLUSION: Implementation of the novel accreditation protocol of the haemophilia treatment and haemophilia gene therapy centres has been made to further improve the quality of care for patients with haemophilia and other inherited bleeding disorders.

Complement Inhibition in Paroxysmal Nocturnal Hemoglobinuria (PNH): A Systematic Review and Expert Opinion from Central Europe on Special Patient Populations.

INTRODUCTION: Hemolysis in paroxysmal nocturnal hemoglobinuria (PNH) is complement-mediated due to the lack of complement inhibitors in the hemopoietic cell membranes, making complement inhibition the best approach to manage PNH. Three complement inhibitors are approved by the European Medicines Agency as targeted therapy for PNH: eculizumab and ravulizumab, two humanized monoclonal antibodies targeting the same complement 5 (C5) epitope, approved in 2007 and 2019, respectively, and the more recently approved cyclic peptide, the complement 3 (C3) inhibitor pegcetacoplan. Although national and international PNH treatment guidelines exist, they do not take into consideration the latest clinical trial evidence. Given the lack of evidence-based data for some clinical situations encountered in real life, we identified specific populations of patients who may benefit from switching to proximal C3 from terminal C5 inhibition. METHODS: The expert recommendations presented here were created using a Delphi-like process by a group of expert PNH specialists across Central Europe. Based on an initial advisory board meeting discussion, recommendations were prepared and reviewed as part of a Delphi survey to test agreement. RESULTS: Using a systematic approach, literature databases were searched for relevant studies, and 50 articles were reviewed by the experts and included as supporting evidence. CONCLUSION: Implementation of these recommendations uniformly across healthcare institutions will promote the best use of complement inhibition in managing PNH, and has the potential to positively impact patient outcomes in Central Europe and worldwide.

A Targeted and an Untargeted Metabolomics Approach to the Volatile Aroma Profile of Young 'Marastina' Wines.

This study investigated the detailed volatile aroma profile of young white wines of Marastina, Vitis Vinifera L., produced by spontaneous fermentation. The wines were produced from 10 vineyards located in two Dalmatian subregions (Northern Dalmatia and Central and Southern Dalmatia). Volatile compounds from the wine samples were isolated by solid-phase extraction (SPE) and analyzed by an untargeted approach using two-dimensional gas chromatography coupled with time-of-flight mass spectrometry (GC×GC/TOF-MS) and a targeted approach by gas chromatography-tandem mass spectrometry (GC-MS/MS). A comprehensive two-dimensional GC×GC analysis detailed the total volatile metabolites in the wines due to its excellent separation ability. More than 900 compounds were detected after untargeted profiling; 188 of them were identified or tentatively identified. A total of 56 volatile compounds were identified and quantified using GC-MS/MS analysis. The predominant classes in Marastina wines were acids, esters, and alcohols. The key odorants with odor activity values higher than one were ß-damascenone, ethyl caprylate, ethyl isovalerate, ethyl 2-methylbutyrate, ethyl caproate, isopentyl acetate, ethyl butyrate, and phenylacetaldehyde. The metabolomics approach can provide a large amount of information and can help to anticipate variation in wines or change winemaking procedures.

Croatian white grape variety Marastina: First taste of its indigenous mycobiota.

The indigenous vineyard mycobiota contribute both to wine quality and vineyard sanitary status. Wines made from same grape variety but from different geographical locations are appreciated for their diversity. Because no information on indigenous mycobiota of Croatian grapevines is available, the aim of the present study was to start filling this knowledge gap by characterizing the indigenous mycobiota of Marastina variety. The use of metataxonomic approach has enabled the identification of 25 different fungal genera present on Marastina grape berries collected from 11 vineyards located within the Croatian coastal winegrowing region of Dalmatia (Northern Dalmatia, Dalmatian hinterland, Central and Southern Dalmatia). The substantial regional and local scale differences in their distribution were observed. Overall, Aureobasidium was the dominant genus followed by Cladosporium and Metschnikowia. Botrytis and Plenodomus were associated with the vineyards located in Central and Southern Dalmatia, whereas Pichia was associated with Northern Dalmatia vineyards. The largest abundance of Buckleyzyma, Cladosporium, Eremothecium, Fusarium, Papiliotrema, and Rhodotorula was observed in Dalmatian hinterland. Moreover, data suggested that climate conditions and soil type partially influenced the distribution of fungal communities. The local-scale differences emerged also for the physicochemical characteristics of fresh musts. The high malic acid content supported the development of Metschnikowia, and inhibited Fusarium growth, whereas a positive correlation between Erysiphe and pH values was observed. Sporobolomyces and Cystobasidium were negatively associated with high glucose concentration. The revealing of Marastina indigenous mycobiota provided information on the members of fungal community negatively influencing the grapevine sanitary status as well as those which could be employed in disease biocontrol.

Individualized Management of Coagulopathy in Patients with End-Stage Liver Disease.

Over the last decades, individualized approaches and a better understanding of coagulopathy complexity in end-stage liver disease (ESLD) patients has evolved. The risk of both thrombosis and bleeding during minimally invasive interventions or surgery is associated with a worse outcome in this patient population. Despite deranged quantitative and qualitative coagulation laboratory parameters, prophylactic coagulation management is unnecessary for patients who do not bleed. Transfusion of red blood cells (RBCs) and blood products carries independent risks for morbidity and mortality, including modulation of the immune system with increased risk for nosocomial infections. Optimal coagulation management in these complex patients should be based on the analysis of standard coagulation tests (SCTs) and viscoelastic tests (VETs). VETs represent an individualized approach to patients and can provide information about coagulation dynamics in a concise period of time. This narrative review will deliver the pathophysiology of deranged hemostasis in ESLD, explore the difficulties of evaluating the coagulopathies in liver disease patients, and examine the use of VET assays and management of coagulopathy using coagulation factors. Methods: A selective literature search with PubMed as the central database was performed with the following.

Expert opinion on current and future prophylaxis therapies aimed at improving protection for people with hemophilia A.

The next frontier in hemophilia A management has arrived. However, questions remain regarding the broader applicability of new and emerging hemophilia A therapies, such as the long-term safety and efficacy of non-factor therapies and optimal regimens for individual patients. With an ever-evolving clinical landscape, it is imperative for physicians to understand how available and future hemophilia A therapies could potentially be integrated into real-life clinical practice to improve patient outcomes. Against this background, nine hemophilia experts from Central European countries participated in a pre-advisory board meeting survey. The survey comprised 11 multiple-choice questions about current treatment practices and future factor and non-factor replacement therapies. The survey questions were developed to reflect current unmet needs in hemophilia management reflected in the literature. The experts also took part in a follow-up advisory board meeting to discuss the most important unmet needs for hemophilia management as well as the pre-meeting survey results. All experts highlighted the challenge of maintaining optimal trough levels with prophylaxis as their most pressing concern. Targeting trough levels of ≥30-50 IU/L or even higher to achieve less bleeding was highlighted as their preferred strategy. However, the experts had an equal opinion on how this could be achieved (i.e., more efficacious non-factor therapies or factor therapy offering broader personalization possibilities such as targeting trough levels to individual pharmacokinetic data). In summary, our study favors personalized prophylaxis to individual pharmacokinetic data rather than a "one-size-fits-all" approach to hemophilia A management to maintain optimal trough levels for individual patients.

Next-generation sequencing of von Willebrand factor and coagulation factor VIII genes: a cross-sectional study in Croatian adult patients diagnosed with von Willebrand disease.

AIM: To identify the von Willebrand factor (VWF) gene variant status in Croatian adult patients diagnosed with von Willebrand disease (VWD), provide differential diagnosis of VWD subtypes, and identify patients with mild hemophilia A (HA) who were earlier misdiagnosed as VWD. METHODS: Coagulation testing included determination of VWF gain-of-function mutant glycoprotein Ib binding activity (VWF:GPIbM), VWF antigen, VWF collagen-binding activity, and multimeric analysis. Genetic analysis of VWF and FVIII genes was performed with next-generation sequencing (NGS). RESULTS: The study enrolled 50 patients (72% women; median age 37 years, range 18-75) from 44 unrelated families. Fourteen patients were heterozygous for VWF gene variants compatible with type-1 VWD. Twelve had variants associated with type 2, of whom seven were classified as type 2A, four as type 2B, and one as type 2N. Six type-3 VWD patients were either homozygotes for null variants or combined heterozygotes. Eleven variants within the VWF gene were novel. Three female patients had variants within the FVIII gene, and were re-classified as mild-HA carriers, of whom one had causative novel variants both within VWF and FVIII genes. Fifteen patients remained without a defined genetic cause of their disorder, of whom five had VWF:GPIbM levels below 50%. CONCLUSION: Croatian adult patients with VWD have considerable genetic heterogeneity. NGS of both VWF and FVIII genes provided accurate differential diagnosis of VWD subtypes and distinction of VWD from mild HA.

Changing paradigms of hemophilia care across larger specialized treatment centers in the European region.

Introduction: In early 2021, the European Collaborative Haemophilia Network (ECHN) conducted a survey to determine whether the paradigms of care across the European region have changed with the introduction of novel therapies for people with hemophilia. Methods: We conducted a survey in 19 ECHN centers from 17 countries in the European region. The aim was to track recent changes in the hemophilia treatment landscape, determine the impact of these changes on hemophilia treatment centers and comprehensive care centers in the region, and to look into the future of care as applied to people with hemophilia. The survey was structured to include three key areas: demographics and organization; current challenges and opportunities; and future directions. Discussion: Our survey provides a snapshot of the current approach to hemophilia treatment that highlights a move toward preventive, rather than reactive care, but that also raises a number of key concerns related to costs and accessibility (particularly as related to novel therapies), time limitations for clinical research, and ongoing issues regarding human resources (particularly in terms of new doctors entering the field) and availability of laboratory resources as the use of novel therapies (some with unique modes of action and unusual adverse events, some with specialized monitoring requirements) becomes commonplace. Conclusion: While our survey suggests that specialized care will continue to play a central role in the management of hemophilia, the standards and protocols, as well as the centers themselves, will have to continue to evolve if they are to continue to provide the highest level of care. To meet this requirement, there is a clear need for engaging, ongoing education programs for healthcare professionals working in the field of hemophilia that can be adjusted to the changing landscape of hemophilia therapy and monitoring.

Novel Application of NIR Spectroscopy for Non-Destructive Determination of 'Marastina' Wine Parameters.

This study investigates the colour and standard chemical composition of must and wines produced from the grapes from Vitis vinifera L., 'Marastina', harvested from 10 vineyards located in two different viticultural subregions of the Adriatic region of Croatia: Northern Dalmatia and Central and Southern Dalmatia. The aim was to explore the use of NIR spectroscopy combined with chemometrics to determine the characteristics of Marastina wines and to develop calibration models relating NIR spectra and physicochemical/colour data. Differences in the colour parameters (L*, a*, hue) of wines related to the subregions were confirmed. Colour difference (ΔE) of must vs. wine significantly differed for the samples from the Marastina grapes grown in both subregions. Principal component regression was used to construct the calibration models based on NIR spectra and standard physicochemical and colour data showing high prediction ability of the 13 studied parameters of must and/or wine (average R2 of 0.98 and RPD value of 6.8). Principal component analysis revealed qualitative differences of must and wines produced from the same grape variety but grown in different subregions.

First experience of a hemophilia monitoring platform: florio HAEMO.

Background: florio HAEMO is a new hemophilia treatment monitoring application consisting of a patient smartphone application (app) and a web-based dashboard for healthcare professionals, providing several novel features, including activity tracking, wearable connectivity, kids and caregiver mode, and real-time pharmacokinetic factor level estimation. Objectives: To assess intuitiveness, ease-of-use, and patient preference of florio HAEMO in Central Europe using a cross-sectional survey. Methods: This survey was conducted in six Central European countries between 9 December 2020 and 24 May 2021. The online questionnaire included 17 questions about overall satisfaction, ease-of-use, intuitiveness, and patient preference. Adults or children with hemophilia on regular prophylaxis and using the florio HAEMO app for a minimum of 1 week were invited to complete the online questionnaire by their treating physician. Results: Sixty-six participants took part in the survey. The median duration for all respondents using the florio HAEMO app was 3 to 4 weeks. Overall, 89.4% of users reported being very satisfied or rather satisfied after using florio HAEMO. Of the 23 respondents who had switched from another hemophilia app, 87.0% indicated that they strongly preferred or preferred using florio HAEMO. Most florio HAEMO users reported that the app was very easy or rather easy to use (97.0%) and intuitive (94.0%). florio HAEMO had a positive impact on daily living, with 78.8% of users reporting that the app was very important or rather important to them. Conclusions: This survey suggests that florio HAEMO is an easy-to-use and intuitive app to assist self-management of home prophylaxis.