Unravelling the Spectrum of von Willebrand Factor Variants in Quantitative Von Willebrand Disease: Results from a German Cohort Study.

INTRODUCTION: Von Willebrand disease (VWD), the most prevalent hereditary bleeding disorder, results from deficiency of von Willebrand factor (VWF). OBJECTIVES: This large cohort study aims to offer a comprehensive exploration of mutation spectra and laboratory features in quantitative VWF deficiencies, shedding light on genetic underpinnings and genotype-phenotype associations. PATIENTS/METHODS: Our cohort consisted of 221 Caucasian index patients with quantitative VWD, along with 47 individuals whose plasma VWF levels fell within the lower normal boundaries (50-70%). We conducted comprehensive VWF assays and genetic analyses, encompassing VWF gene sequencing, copy number variation investigations, and bioinformatic assessments. RESULTS: Following ISTH-SSC VWF guidelines, 77 index patients characterized as type 1 VWD (VWF:Ag < 30%), 111 as type 1 VWD (VWF:Ag 30-50%), and as 33 type 3 VWD. Mutation detection rates were 88%, 65%, and 92%, respectively. Notably, blood group O overrepresentation was evident in type 1 with VWF:Ag of 30-50%, particularly among mutation-negative patients, suggesting a potential causal role of blood group O. A total of 223 VWF variants, comprising 147 distinct variations, were identified in quantitative VWD patients, of which 57 were novel variants (39%). Additionally, approximately 70% of individuals with VWF levels within the lower normal boundaries (50-70%) displayed VWF variants. CONCLUSION: Our data advances our understanding of the molecular mechanisms underlying quantitative VWD, offering valuable insights for future research and clinical management. Distinct mutation patterns were observed among subgroups, particularly the contrast between type 1 VWD (VWF:Ag <30%) and type 1 (VWF:Ag 30-50%), an area with limited prior investigation.

Structural alterations and pain perception at the ankle joint in patients with haemophilia.

BACKGROUND: Patients with haemophilia (PwH) suffer from chronic pain due to joint alterations induced by recurring haemorrhage. OBJECTIVES: This study aimed to investigate the relationship between structural alterations and pain perception at the ankle joint in PwH. PATIENTS/METHODS: Ankle joints of 79 PwH and 57 healthy controls (Con) underwent ultrasound examination (US) and assessment of pain sensitivity via pressure pain thresholds (PPT). US discriminated between joint activity (synovitis) and joint damage (cartilage and/or bone degeneration) applying the HEAD-US protocol. Based on US-findings, five subgroups were built: PwH with activity/damage, PwH with activity/no damage, PwH with no activity/no damage, controls with activity/no damage and controls with no activity/no damage. RESULTS: Joint activity and joint damage were significantly increased in ankles of PwH compared to Con (p ≤.001). Subgroup analysis revealed that structural alterations negatively impact pain perception. This is particularly evident when comparing PwH with both activity/damage to PwH with no activity/no damage at the tibiotalar joint (p = .001). At the fibulotalar joint, no significant differences were observed between PwH subgroups. Further analysis showed that both joint activity and joint damage result in an increase in pain sensitivity (p ≤.001). CONCLUSION: The data suggest a relation between joint activity, joint damage and pain perception in PwH. Even minor changes due to synovitis appear to affect pain perception, with the effect not intensifying at higher levels of inflammation. In terms of joint damage, severe degeneration leads to a sensitised pain state most robustly, whereas initial changes do not seem to significantly affect pain perception.

Physical activity and factor VIII levels in patients with haemophilia: A real-world prospective observational study.

INTRODUCTION: Regular physical activity (PA) is recommended for patients with haemophilia (PwH). For PwH it is crucial to ensure a sufficient factor level to prevent PA-induced bleedings. However, there is a gap in the literature dealing with specific factor levels, which are needed when performing specific types of PA. AIM: To provide data on factor VIII (FVIII) levels at the start of PA performed by PwH. METHODS: In this prospective 12-month real-world observational study, 23 PwH recorded every PA they performed and the FVIII levels at the start of the PA using a pharmacokinetic application. PA types were clustered according to the collision and injury risk into three categories (Cat I = low, Cat II = medium, Cat III = high risk). Haemophilia Joint Health Scores (HJHS) were performed at baseline, after 6 and 12 months. RESULTS: 795 PA sessions of Cat I, 193 of Cat II, and 23 of Cat III were documented. FVIII levels at the start of PA were different between categories (Cat I: 29.8 ± 32.1%, Cat II: 38.3 ± 33.4%, Cat III: 86.6 ± 29.2%). Out of all PA sessions, 145 (14%) were performed at a factor level of ≤3%. Three PA-induced bleeding occurred. Baseline HJHS was 14.5 ± 13.6 points and did not change throughout the study. CONCLUSION: This study provides real-life data on FVIII levels at the start of 1011 PA sessions. PwH are mainly active in low-risk sports with higher FVIII levels observed in Cat II and III, respectively. Only three PA-induced bleeding occurred, even though several PA were started with low FVIII levels.

Most subjectively affected joints in patients with haemophilia - what has changed after 20 years in Germany?

BACKGROUND: In patients with haemophilia (PwH), most frequently affected joints are the ankle, knee and elbow. Due to improved factor therapy in the last decades, these previous findings have to be verified in Germany. AIM: The aim of this study is to detect the most affected joint, evaluate the significance of the source of pain and determine the point prevalence of back pain in Germany today. PATIENTS AND METHODS: In a retrospective study, data of n = 300 patients with severe moderate and mild haemophilia were evaluated regarding the most affected joint, the most common source of pain, and the point prevalence of back pain. An anamnesis questionnaire and the German Pain Questionnaire were used for this assessment. RESULTS: The most affected joint in German PwH is still the ankle (41%), followed by the knee (27%) and the elbow (11%). The most common source of pain is also the ankle joint (32%). Back pain was also identified as one of the most common sources of pain, which is comparable to the elbow (elbow:15%; back:13%). The point prevalence in PwH for back pain was significantly higher compared to the general German population (P = .031). CONCLUSION: Our data showed that the ankle is still the most affected joint and the most common source of pain in Germany. These results also showed the relevance of back pain as a pain source. The evaluations also demonstrated the high point prevalence of back pain in PwH. Future therapies should also focus on the spine because joint changes affect posture.

Consensus Recommendations for Intramuscular COVID-19 Vaccination in Patients with Hemophilia.

BACKGROUND: Currently available coronavirus disease 2019 (COVID-19) vaccines are approved for intramuscular injection and efficacy may not be ensured when given subcutaneously. For years, subcutaneous vaccination was recommended in patients with hemophilia to avoid intramuscular bleeds. Therefore, recommendations for the application of COVID-19 vaccines are needed. METHODS: The Delphi methodology was used to develop consensus recommendations. An initial list of recommendations was prepared by a steering committee and evaluated by 39 hemophilia experts. Consensus was defined as ≥75% agreement and strong consensus as ≥95% agreement, and agreement as a score ≥7 on a scale of 1 to 9. After four rounds, a final list of statements was compiled. RECOMMENDATIONS: Consensus was achieved that COVID-19 vaccines licensed only for intramuscular injection should be administered intramuscularly in hemophilia patients. Prophylactic factor replacement, given on the day of vaccination with a maximum interval between prophylaxis and vaccination of 24 hours (factor VIII and conventional factor IX concentrates) or 48 hours (half-life extended factor IX), should be provided in patients with moderate or severe hemophilia. Strong consensus was achieved that patients with mild hemophilia and residual factor activity greater than 10% with mild bleeding phenotype or patients on emicizumab usually do not need factor replacement before vaccination. Swelling, erythema, and hyperthermia after vaccination are not always signs of bleeding but should prompt consultation of a hemophilia care center. In case of injection-site hematoma, patients should receive replacement therapy until symptoms disappear. CONCLUSIONS: Consensus was achieved on recommendations for intramuscular COVID-19 vaccination after replacement therapy for hemophilia patients depending on disease severity.

Long-Term Safety and Efficacy Data of a Plasma-Derived Factor VIII Concentrate with von Willebrand Factor for Treatment of Patients with Hemophilia A Covering 18 Years.

We describe the results of the (to our knowledge) longest long-term noninterventional study so far performed to obtain real-life data on the treatment of hemophilia A patients with a single plasma-derived FVIII concentrate containing von Willebrand factor (pdFVIII; Haemoctin/Faktor VIII SDH Intersero). A total of 198 patients (146 in Germany and 52 in Hungary), of whom 160 had severe and 38 nonsevere hemophilia A, representing all age groups (0-88 years; mean ∼25 years at inclusion) were analyzed during prophylactic or on-demand treatment over 18 years (overall 1,418 patient-years; mean >7 years). pdFVIII was very effective and well tolerated. The mean annual bleeding rate, including spontaneous and traumatic bleeds, was considerably lower for patients treated prophylactically (mean 5.4; median 3.1) than for patients treated on demand (mean 26.1; median 21.9). Inhibitors were found in 13% (3/23) and high-titer inhibitors in 4% (1/23) of previously untreated patients with severe hemophilia A. Four previously treated patients with severe hemophilia A developed inhibitors, thereof three high-titer inhibitors (3.3 and 2.5 high-titer inhibitors in 1,000 patient-years). No unexpected adverse effect on the health of the patients, no pdFVIII-related thrombosis, thromboembolic event, or hypersensitivity reaction, and no suspected viral transmission related to pdFVIII were documented.

Smart Medication ™, an Electronic Diary for Surveillance of Haemophilia Home Care and Optimization of Resource Distribution.

This report describes the technical features and potential advantages of the application of electronic haemophilia treatment diary smart medication ™ and an evaluation of real-life electronic treatment data collected from haemophilia patients. Since 2012, a total of 663 patients from 30 German haemophilia treatment centres (HTCs) have used the device. Data of nine HTCs were merged for real-life data analysis. Patients were divided into four subgroups according to above versus below mean values for annual factor consumption (AFC) and annual joint bleeds (AJB), respectively. The largest subgroup comprised patients with low mean AFC and AJB less than 2.25 (group A: 42%). Second largest was the group with low mean AJB but high AFC (group B: 32%), suggesting that resources could be saved in some patients. The group with low AFC but high AJB may need increased factor dosing (group D: 13%). Patients who showed a high mean AJB despite high AFC (group C: 13%) may require special medical attention, such as pharmacokinetic-adapted treatment modification or orthopaedic measures. Smart medication ™ enables the HTC to quickly identify patients in need of treatment changes and, thus, to plan individualized therapy modifications prior to patient visits. The growing pool of real-life data facilitates data analysis and may play an important role in the optimization of resource distribution.

Iron-catalyzed oxidative tandem reactions with TEMPO oxoammonium salts: synthesis of dihydroquinazolines and quinolines.

A straightforward iron-catalyzed divergent oxidative tandem synthesis of dihydroquinazolines and quinolines from N-alkylanilines using a TEMPO oxoammonium salt as a mild and nontoxic oxidant has been developed. Fe(OTf)2 was the Lewis acid catalyst of choice for the formation of dihydroquinazolines, whereas FeCl3 led to better results for the synthesis of quinolines. This divergent approach implies that, for both syntheses, direct oxidative functionalization of a α-C(sp(3))-H bond of the N-alkylanilines occurs, leading to C-N bond formation or C-C bond formation upon homocondensation or reaction with simple olefins, respectively. Cyclization followed by a final oxidation generates these classes of interesting bioactive heterocycles in one synthetic transformation. Additionally, the one-pot multicomponent synthesis of quinolines from anilines, aldehydes, and olefins has also been successfully developed under these mild oxidative conditions.

Mild metal-free tandem α-alkylation/cyclization of N-benzyl carbamates with simple olefins.

Easy does it! The chemoselective oxidative α-C(sp(3))-H alkylation/cyclization reaction of N-benzyl carbamates using simple mono-, di-, and trisubstituted olefins provides functionalized N-heterocycles such as oxazinones. A TEMPO oxoammonium salt serves as the oxidant, making it possible to carry out the reaction at low temperatures. Neither a metal catalyst nor preactivation in the α-position to the nitrogen group are needed.

TEMPO oxoammonium salt-mediated dehydrogenative Povarov/oxidation tandem reaction of N-alkyl anilines.

The synthesis of a variety of substituted quinolines from N-alkyl anilines by a one-pot dehydrogenative Povarov/oxidation tandem reaction with mono- and 1,2-disubstituted aryl and alkyl olefins was developed. A simple protocol using cheap and benign iron(III)chloride as the Lewis acid catalyst and a TEMPO oxoammonium salt as a nontoxic, mild, efficient oxidant is reported.

Catalyzed selective direct α- and γ-alkylation of aldehydes with cyclic benzyl ethers by using T(+)BF4- in the presence of an inexpensive organic acid or anhydride.

The cross dehydrogenative coupling (CDC) of cyclic benzyl ethers with aliphatic and α,ß-unsaturated aldehydes has been developed. The mild reaction conditions, in which an N-oxoammonium salt derived from TEMPO (2,2,6,6-tetramethyl-1-piperidinoxyl) is employed as the oxidant in combination with a Cu catalyst, allow the use of relatively redox-unstable aldehydes under oxidative CDC conditions. The addition of a catalytic amount of trifluoroacetic acid (TFA) or Ac(2)O facilitates the reaction and increases the efficiency and selectivity. In contrast to the expected α-alkylation obtained with aliphatic aldehydes, α,ß-unsaturated aldehydes led preferentially to the more challenging γ-alkylated products. The utility of the developed methodology was demonstrated by the synthesis of isochromane-derived bioactive compounds, such as the dopamine antagonist sonepiprazole.

A photochemical precursor for carbon monoxide release in aerated aqueous media.

Interest in therapeutic applications of carbon monoxide release to physiological targets has led us to explore a photochemical strategy for such CO delivery. Here, we describe the photoactivated carbon monoxide releasing moiety (photoCORM), W(CO)(5)(TPPTS)(3-) (1), an air-stable, water-soluble tungsten(0) carbonyl complex of the trianionic ligand tris(sulphonatophenyl)phosphine. Near-UV photolysis of 1 in an aqueous buffer solution leads to the high quantum yield release of a single CO, the formation of which has been verified by three analytical methodologies. Furthermore, in aerated media, additional CO is slowly released from the W(CO)(4)(H(2)O)(TPPTS)(3-) photoproduct owing to autoxidation of the tungsten center. Thus, 1 serves as a carbon monoxide releasing moiety both in the primary photochemical reaction and in the secondary reactions of the initially formed photoproduct. The three methodologies for quantifying CO release under these physiologically relevant conditions are also described.

Need for Prophylactic Treatment in Adult Haemophilia A Patients.

BACKGROUND AND METHODS: A single centre study including 52 German patients aged ≥16 years with severe haemophilia A was performed to compare the amount of clotting factor and outcome between on-demand therapy (26 patients) and continuous prophylaxis (26 patients) over 1 year. RESULTS: Prophylaxis reduced the number of bleeds significantly. Compared to on-demand treatment (20.5 ± 3.0 bleeds/year/patient), under prophylaxis 7.8 ± 1.3 bleeds/year/patient were observed. Joint bleeds were reduced from 12.2 ± 1.5 to 4.7 ± 1.0/year/ patient. In the on-demand group 38% of the patients suffered from more than 2 bleeds/month, whereas in the prophylaxis group no patient was found with more than 2 bleeds/month. Mean annual factor VIII (FVIII) consumption increased from 767 ± 110 IU/kg body weight under on-demand treatment to 2,841 ± 341 IU/kg body weight under continuous prophylaxis, displaying a nearly fourfold increase in FVIII consumption. Furthermore, prophylaxis implies a more than four-fold increase in treatment days which escalated from a mean weekly injection rate of 0.56 ± 0.08 FVIII injections/week when bleeds were treated on demand to 2.52 ± 0.30 FVIII injections/week during prophylaxis. CONCLUSION: Even though the results reflect a benefit also for prophylactically treated patients regarding their bleeding frequency, one has to take into account a substantial increase of the costs for coagulation concentrates when all patients with severe haemophilia A switch to continuous prophylaxis.

Characterization of interaction between protein and carbohydrate using CZE.

The present study describes the application of the capillary zone electrophoresis (CZE) to investigate interactions between Concanavalin A (Con A) and the one of their major components (L-asparagin) with a variety of carbohydrates (D-glucose, D-fructose, D-mannose D-galactose, maltose and lactose). It was observed that the carbohydrates show different interactions with Con A and L-asparagin. Addition of carbohydrates to the electrolyte buffer and different concentrations of carbohydrates led to a change of the migration time and the ionic mobility of Con A and L-asparagin. A mathematical model for quantitative evaluation to calculate the aggregation constants (K) was used. Our investigations show that it is possible to characterize the interaction between carbohydrates and proteins or amino acid quantitatively using CZE.

Stress and fatty liver--possible indications for dietary long-chain n-3 fatty acids.

The favourable effects of eicosapentaenoic acid (EPA)- and doco-sahexaenoic acid (DHA)-rich diets (marine fish, fish oil) on several risk factors for cardiovascular disease are well established. The present survey describes possible new indications for diets supplemented with long-chain n-3 fatty acids. During a standardized psychophysiological stress test (arithmetic, sentence completion tasks) systolic blood pressure after 2 weeks of diets supplemented with either 60 ml/day of sunflower or linseed oil was significantly decreased. During the sunflower oil-rich diet 45 g/day of linoleic acid (LA) and during the linseed oil-rich period 38 g/day of alpha-linolenic acid (LNA) were ingested. After a 2-week diet supplemented with mackerel (2 cans/day equivalent to 2.2 g/day of EPA and 2.8 g/day of DHA) systolic and diastolic blood pressure within the same test design appeared significantly lower. After a herring diet providing 2 cans/day, equivalent to 1.0 g of EPA and 1.8 g of DHA, the blood pressure-lowering effect was minor. The increase of thromboxane B2 (TxB2) during the stress test failed to occur after the fish diets. The results suggest a stress-protective effect of polyenoic acid-rich diets, which appears most pronounced and dose-related after long-chain n-3 fatty acids. In human liver an increase of fat droplet size in hepatocytes is associated with a decrease of the percentage of EPA in liver triglycerides. A diminution of plasma free fatty acids (FFA) after a mackerel diet might contribute to a depressed synthesis of liver triglycerides.(ABSTRACT TRUNCATED AT 250 WORDS)

[A pilot study on the long-term effects of combined drug therapy and psychophysiologically-oriented therapy in patients with severe essential hypertension]. / Pilotstudie zur Langzeitwirkung einer kombinierten medikamentösen und psychophysiologisch orientierten Therapie bei Patienten mit einer essentiellen Hypertonie höheren Schweregrades.

15 patients with a severe degree of essential hypertension, which had not responded satisfactorily to pharmacological management, received an additional regimen of psychophysiological treatment. This schedule consisted of relaxation training, self-recording of the blood pressure by the patients and conversations geared at improving stress management. After 1 year 9 patients showed a lowered mean blood pressure from 162/106 mmHg to 141/95 mmHg (responders). 2 patients were excluded from the study and 4 patients failed to show any lowering of their blood pressure (non-responders). In 6 responders it was possible to reduce the dose of antihypertensive drugs by 8-71%. These results were confirmed over a 4-year follow-up period. Responders and non-responders did not differ with regard to their age, stages and duration of hypertension. Patients with a very high reactivity of blood pressure under psychological stress and a low frankness with regard to their own weaknesses and problems seem to respond to the therapy with a lower probability of success.

[Physician compliance in the treatment of hypertension]. / Die Arzt-Compliance in der Hypertoniebehandlung.

The physician compliance is determined by knowledge, skill and behaviour. In 103 physicians working in the basic medical care investigations of the compliance were performed. Partly clear deviations from the guidelines recommended were found in the habits of diagnostics and therapy. These deviations frequently concerned even the majority of the physicians asked for. While the knowledge can relatively easily be judged according to objective criteria, the behaviour is difficult to be measured. Of 4 physicians with comparable knowledge concerning the clinical picture of hypertension the influence of the behaviour of the physician on the success of therapy was investigated during a psycho-physiologically orientated group therapy and the breath-induced relaxation training. The univariate and discriminance-analytic investigations as well as the factor analyses showed the behaviour of the physician as essentially determinating for the success of the therapy. The determination of the physician compliance gives the possibility to recognize still existing insufficiencies in the treatment of hypertension. It serves for the further optimization of the therapy of hypertension. Measures increasing the compliance among others can be derived also for the training and further training.

Effects of dietary oleic, linoleic and alpha-linolenic acids on blood pressure, serum lipids, lipoproteins and the formation of eicosanoid precursors in patients with mild essential hypertension.

Forty-four male in-patients with mild essential hypertension were randomly allocated to three groups and put on diets supplemented with 60 ml/day of olive (n = 15), sunflowerseed (n = 15) or linseed oils (n = 14), respectively, for two weeks within a blind study. In the group receiving sunflowerseed oil an increase of linoleic acid in serum lipids could be observed, whereas arachidonic and eicosapentaenoic acids appeared unchanged in serum triglycerides and even significantly lower in cholesterol esters. The subjects ingesting the linseed oil-rich diet showed an increase of alpha-linolenic acid in serum lipids, whereas arachidonic and eicosapentaenoic acids remained unchanged in serum triglycerides. In cholesterol esters, however, arachidonic acid was significantly decreased and eicosapentaenoic acid appeared increased only to a low level of significance. In the group put on the olive oil-rich regimen only a significant fall of linoleic acid was obvious in serum triglycerides. The results might indicate a defective desaturation and elongation of linoleic and alpha-linolenic acids and, consequently, a slow formation of arachidonic and eicosapentaenoic acids in patients with mild essential hypertension, which should be considered in dietary studies. After the sunflowerseed oil-rich diet a significant decrease of total cholesterol, low density lipoprotein (LDL) cholesterol and the LDL/high density lipoprotein (HDL) cholesterol ratio was found. Systolic blood pressure during a psychophysiological stress test and urinary sodium excretion appeared significantly lower after the linoleic acid-rich diet. After the linseed oil-rich diet, in addition to total cholesterol, LDL cholesterol and the LDL/HDL cholesterol ratio, serum triglycerides and lecithin cholesterol acyl transferase (LCAT) activity were significantly depressed.(ABSTRACT TRUNCATED AT 250 WORDS)

[The comparative effectiveness of different psychological methods for treating patients with a labile course of hypertension (based on international research data)]. / Sravnitel'naia éffektivnost' razlichnykh psikhologicheskikh metodov lecheniia bol'nykh s labil'nym techeniem gipertonicheskoi bolezni (po dannym mezhdunarodnogo issledovaniia).

Examination of 110 patients with essential hypertension (EH) carried out in the USSR and GDR revealed, by the end of the observation period (one year), a significant lowering and normalization of arterial pressure at rest and a certain reduction of the intensity of the hypertensive response to psychoemotional stress influences in the presence of psychological relaxation therapy (PRT). The survey made it possible to try the designed methods for PRT in both countries and demonstrated that the intensity of the hypotensive action of the methods appeared comparable in different populations of patients suffering from essential hypertension. The intensity of the hypotensive action of PRT correlated with the level of arterial pressure before treatment, with the age of EH patients, and with their psychological characteristics.