BACKGROUND:Musculoskeletal ultrasound (US) is a noninvasive tool for joint assessment in persons with hemophilia. Early detection of joint bleeding using a remote US system operated by patients or caregivers and reviewed by Comprehensive Care Centers could improve personalized management. A computer-aided diagnosis (CAD) system for automatic detection of joint effusion may support clinicians in prioritizing interventions. OBJECTIVES:This study aimed to validate a novel CAD system using a deep-learning algorithm to identify joint capsule distension in musculoskeletal US images. METHODS:Longitudinal scans of the subquadricipital recess of the knee were collected from people with hemophilia and varying degrees of arthropathy and labeled by an expert. The multitask learning algorithm was trained to detect the recess and classify images as distended or not. RESULTS:A total of 8634 images (2267 scans) were acquired from 158 adult persons with hemophilia (mean age 44.7 ± 18.6 years) and 66 age-matched healthy controls. After selecting longitudinal subquadricipital recess images, 814 images were used, of which 711 for training and 103 for testing, ensuring a patient-based split. The model achieved a classification accuracy of 89.2% and a balanced accuracy of 93.9% compared with expert annotations. No significant differences were observed in classification performance between male and female healthy controls, supporting its broader applicability. CONCLUSION:The CAD system for automatic detection of joint capsule distension is feasible and reliable. It represents an important step toward telemedicine in hemophilia, enabling early recognition of joint bleeding and supporting personalized, timely therapeutic interventions to prevent further joint damage.

Background: An appropriate and effective management of haemophilia is currently based on a multidimensional evaluation of treatment adequacy. Current clinical practice however is still lacking standardised tools able to combine clinical, functional, and patient-reported outcomes. In this study a structured Monitoring Tool for haemophilia A and B was developed and validated through a Delphi-based expert consensus process. This study represents an expert consensus-based validation of a monitoring framework, rather than a clinical validation in patient cohorts. The tool is intended for use by haemophilia treaters during routine follow-up visits to support structured treatment reassessment. Score categories reflect the need for clinical re-evaluation or potential treatment optimisation, rather than disease severity. Methods: Italian haemophilia specialists were asked to participate to a panel over a two-round Delphi process. Experts rated the relevance of several predefined clinical domains-pharmacokinetics, bleeding episodes, joint health, adherence and quality of life (QoL)-and the individual items within each domain for patients on prophylactic or on-demand treatment. Consensus was defined by responses within an interquartile range (IQR) < 8. Section and item weights and Likert-based scoring values were used to reach a composite score between 0 and 100. Results: Consensus was achieved for all domains and items across haemophilia types and treatments, prophylaxis and on demand (Haemophilia A: 16 and 12 participants; Haemophilia B: 12 and 9, respectively). With reference to prophylaxis domains, bleeding episodes received the highest domain weight (31-32%), followed by joint health (27-29%) and adherence/QoL (21-23%) and pharmacokinetics (18-19%). For on-demand treatment, pharmacokinetics was excluded; bleeding episodes (38-40%) and joint health (35-37%) remained dominant. At the item level, dynamic joint health indicators (HJHS and HEAD-US changes) and longitudinal QoL changes consistently received the highest weights. The final scoring system categorised results as Excellent (0-25), Suboptimal (26-50), Poor (51-75), or Critical (76-100). Conclusions: The Delphi-validated Monitoring Tools provide a structured, weighted, and clinically relevant framework for assessing treatment adequacy in haemophilia A and B across prophylactic and on-demand settings. These tools allow multidimensional outcome assessment and may support a more consistent, personalised therapeutic decision-making. A prospective validation of the tool in clinical cohorts is warranted.

Severe hemophilia A is a bleeding condition caused by a deficiency in clotting factor VIII (FVIII ≤1 IU/dL) that results in spontaneous and excessive posttraumatic bleeding. The current standard of care is prophylaxis with exogenous FVIII or bispecific antibodies that mimic FVIII function. Valoctocogene roxaparvovec is a gene therapy approved for adults with severe hemophilia A that enables endogenous FVIII production to protect against bleeding. As a newer treatment modality, workflows for gene therapy administration and postinfusion care are still unfamiliar to many health care professionals and may be perceived as implementation barriers. We are 10 hemophilia gene therapy providers across the United States, Italy, and Germany sharing our experiences of administering valoctocogene roxaparvovec in clinical practice to >25 patients with severe hemophilia A. In this study, we provide our insights into patient preparation, establishment of treatment centers and multidisciplinary teams, postinfusion management, and patient follow-up to facilitate open communication and collaboration among the treatment community.

Objectives: To assess effectiveness of recombinant factor VIII Fc fusion protein (efmoroctocog alfa; referred to herein as rFVIIIFc) prophylaxis in people with haemophilia A (PwHA) stratified by age, body mass index (BMI), disease severity and inhibitor history included in the A-SURE (NCT02976753) and PREVENT (NCT03055611) real-world studies. Methods: PwHA receiving at least one prescription of rFVIIIFc and ≥3 months follow-up during the prospective periods were included. Post-hoc analyses were performed for the overall analysis population and subgroups based on age, BMI, disease severity and those with and without previous inhibitors. Effectiveness endpoints were annualised bleeding rate (ABR), annualised joint bleeding rate (AjBR), injection frequency and factor consumption in the prospective period. Results: Overall, 333 PwHA were analysed. ABRs and AjBRs, generally, were low across the different subgroups (range of medians, 0.0–0.6 for both ABRs and AjBRs, except for ABRs in PwHA aged ≥65 years). Injection frequencies (n injections/week) were comparable across subgroups (range of medians, 2.0–2.3), and factor consumption was generally similar (range of medians, 68.3–100.0 international units/kg/week), though with slightly higher factor consumption in paediatric PwHA and lower consumption in the overweight or obese BMI groups. Conclusions: These post-hoc analyses support the effectiveness and, therefore, use of rFVIIIFc prophylaxis in PwHA across all ages, BMI categories, severities and for those with a history of inhibitors. Trial registration: ClinicalTrials.gov. A-SURE: NCT02976753; PREVENT: NCT03055611

The conjugation of biological drugs with polyethylenglycole is widely used to reduce their immunogenicity, thereby enhancing the safety and efficacy of the drugs. For instance, some extended half-life drugs for hemophilia A patients are PEGylated FVIII products. Unfortunately, it was observed that PEG itself, whether derived from PEGylated drugs or present in everyday products (such as cosmetics or medical devices) may induce the production of anti-PEG antibodies, resulting in hypersensitivity reactions and/or loss of efficacy of PEGylated drugs. There is therefore a demand for cost-effective and rapid point-of-care (POC) measurements. To this end, a POC device based on the principle of surface plasmon resonance (SPR) is here presented. The sensor chip is functionalized directly with PEG chains via thiol chemistry and inserted into a holder manufactured in 3D printing technology. The functionalization process has been optimized to recognize anti-PEG antibodies (both IgG and IgM isotypes) and characterized using X-ray Photoelectron Spectroscopy and contact angle measurements. Dose-response curves were obtained using commercially available antibodies, both in buffer solution and in diluted human serum, achieving a limit of detection in the nanomolar range. The reusability of the optical chip was also evaluated and, as proof of concept, plasma from control subjects and hemophilia A patients treated with PEGylated FVIII were measured, comparing the results with standard techniques such as a commercial SPR instrument and an enzyme-linked immunosorbent assay. The results were obtained within 15 min from tenfold diluted human plasma, paving the way for an easy-to-use, small-sized, portable, and low-cost POC device capable of detecting anti-PEG antibodies.

Introduction Plasma-Derived von Willebrand factor concentrates (pd-VWFC) are the mainstay of treatment in inherited von Willebrand disease type 3 (VWD3). Aim of 3Winters-Ips was to collect prospective clinical observations concerning treatment with pd-VWFC used in European (EU-VWD3) versus Iranian (IR-VWD3) patients. Methods 3Winters-Ips is an investigator-initiated, non-interventional, non-crossover, retrospective and prospective clinical study on VWD3. While different types of pd-VWFC could be chosen by EU investigators only HAEMATE-P was available in Iran. Therefore, for appropriate comparison with IR-VWD3, we have included only EU-VWD3 treated with HAEMATE-P/VONCENTO either on demand (OD) or under secondary long-term prophylaxis (SLTP). Annualized Bleeding Rates (ABR) were calculated and safety of this pd-VWFC was assessed according to FDA-agreed objective criteria following regulatory procedures. Results 23/93(33%) EU-VWD3 and 70/93(67%) IR-VWD3 were analyzed during a 2-year clinical prospective observation. 69/93(74%) were exposed to HAEMATE-P/VONCENTO OD to manage 629 bleeding episodes [mucosal (83%) - joint bleeds (17%)] with excellent/good efficacy in 96%. Moderate/poor responses were reported in 25 bleeds [Menorrhagia (n=11), GI bleeds (n=7), Joint bleeds (n=4) and epistaxis (n=3)]. 24/93(26%) were selected for SLTP at enrolment. When compared to their previous retrospective OD treatments, ABR during SLTP were significantly reduced by 66% in those patients. Only 2 patients with GI bleeding relapsed. No adverse events were reported. Conclusions Results from this large cohort of VWD3 patients confirm that pd-VWFC are effective and safe to treat or prevent mucosal and non-mucosal bleeds in the rarest and most severe form of VWD. Patients under SLTP can reduce substantially their ABR.

BACKGROUND:Transplant-associated thrombotic microangiopathy is a severe and often fatal complication of allogeneic hematopoietic cell transplantation; early identification of the involved mechanisms may enable timely therapy. STUDY DESIGN:Adult recipients of allogeneic hematopoietic cell transplantation (n = 195) were studied in the early post-transplant period. The recent harmonizing criteria from the world's leading blood and marrow transplant societies, such as ≥4 of 7 specific clinical/laboratory features for thrombotic microangiopathy diagnosis were applied. Plasma levels of sC5b-9, a marker of complement activation, was measured by an enzyme-linked immunosorbent assay and complement-related genes in blood cells were evaluated by both rapid genomic analyses using nanopore sequencing and conventional methods (targeted next generation sequencing and multiplex ligation-dependent probe amplification assay). RESULTS:Ten patients who met ≥4 criteria (confirmed transplant-associated thrombotic microangiopathy) had high 1-year non-relapse mortality (60%) and high complement activation. In this group, plasma levels of sC5b-9 were higher than in patients without confirmed disease (p-value = 0.04) and normal controls (p-value <0.001). At the same time (after full chimerism), they showed seven rare variants of complement related genes (minor allele frequency <0.03). Rapid genomic analysis identified these alterations with complete concordance to conventional methods. CONCLUSIONS:These results support the utility of applying harmonized criteria for early diagnosis of transplant-associated thrombotic microangiopathy and performing rapid genomic analysis with nanopore sequencing for the identification of variants in complement-related genes within 72h. Future studies on larger cohorts could explore the integration of rapid genomic analysis in this patient population and potentially for screening donors whose cells may carry genetic alterations for real-time clinical decision making.

The voluntary withdrawal of valoctocogene roxaparvovec (Roctavian) represents an inflection point in hemophilia A gene therapy. Notably, this decision was not driven by safety or efficacy concerns, but by challenges to economic sustainability, market access, and healthcare system readiness. This paper examines the clinical evidence supporting gene therapy, including durability and safety, and highlights how uncertainty in long-term transgene expression complicates both clinical management and economic evaluation. The Roctavian case is not isolated but reflects a broader pattern observed across gene therapies, where high costs, limited uptake, and system-level constraints have led to market withdrawal or restricted access. These dynamics reveal a gap between scientific innovation and healthcare delivery, suggesting that the barriers to gene therapy are not biological but structural. Addressing this gap will require not only technological advances but also sustainable reimbursement models, coordinated long-term follow-up infrastructure, and healthcare systems capable of supporting advanced therapies beyond their approval.

Background: Rare bleeding disorders (RBDs) are a group of inherited conditions caused by deficiencies in specific coagulation factors, excluding hemophilia A/B and von Willebrand disease. Individually rare, they pose a significant challenge for diagnosis and management due to diverse clinical presentations and low awareness. This study aimed to provide an overview of RBDs. Methods: An online survey was sent to Italian hemophilia treatment centers. Results: Nineteen centers responded. The diagnostic approach was tiring, but key definitions showed significant variability. This included defect severity, target hemostatic levels for surgery, eligibility thresholds for rare disease exemptions. The use of prophylaxis varied, although favored in severe FII, FVII, FX, and FXIII defects. Treatment primarily involved factor-specific concentrates and tranexamic acid. While inhibitor development was considered uncommon, it was a recognized risk. Bleeding management during dental procedures, pregnancy, and delivery also showed variability. Additionally, normal factor levels in neonates differed across centers. Conclusions: This study highlights a good consensus for managing certain RBDs (FII, FVII, FX, FXIII) in Italy. However, significant heterogeneity persists, emphasizing the need for greater standardization and further research in several key areas.

Hemophilia is a rare bleeding disorder that can significantly impact various aspects of life. In recent years, a number of treatments have become available for persons with hemophilia. One of the most novel treatments, now accessible to adults in a few countries, is gene therapy. Due to its nature as a single-shot treatment, this treatment regimen not only influences physical health but also exerts a profound impact on psychological well-being. This review provides a comprehensive overview of the psychological outcomes associated with gene therapy and explores the role of psychologists at different stages of the treatment process. Additionally, it examines various measurement tools that can be used to assess the psychological aspects of individuals undergoing gene therapy.

von Willebrand disease (VWD) and hemophilia A (HA) are the most common inherited bleeding disorders, caused by quantitative or qualitative defects of von Willebrand factor (VWF) and coagulation factor VIII (FVIII). Over the past decades, both diseases have undergone a profound therapeutic transformation, evolving from supportive care to highly effective replacement, pharmacological, and prophylactic strategies. This perspective article compares the parallel but distinct trajectories of therapeutic developments in HA and VWD, highlighting shared milestones and disease-specific limitations. In HA, advances in recombinant technology, extended half-life factor concentrates, nonfactor therapies such as FVIII mimetics and emerging gene therapy approaches have established prophylaxis as the standard of care. VWD therapy has evolved more slowly, largely owing to the marked clinical and molecular heterogeneity of this disease, that often causes difficult and delayed diagnosis. Current management is based on desmopressin, plasma-derived products, and recombinant VWF, with limited prophylaxis implementation. Nevertheless, a rapidly expanding pipeline of novel therapies -- including VWF half-life extension strategies, VWF-independent coagulation rebalancing agents, antifibrinolytics, platelet-mimetic technologies, and gene-based approaches -- suggests an imminent shift in VWD management. Collectively, these developments indicate a transition toward more individualized and mechanism-driven therapy, with the potential to fill the therapeutic gap between VWD and HA and improve long-term outcomes and quality of life in patients with these inherited bleeding disorders.

Background: Severe hemophilia traditionally requires lifelong prophylactic treatment, which cannot fully prevent joint damage and significantly impacts patients’ quality of life. In recent years, gene therapy has been extensively researched as a potential cure with a single infusion, but it has not yet gained widespread acceptance. Objectives: This study examines the knowledge and attitudes of people with severe hemophilia regarding gene therapy to provide guidance to practitioners in the context of shared decision-making. Design: Cross-sectional observational study based on a standardized questionnaire. Methods: A questionnaire developed by Cutica, Ilaria et al. was evaluated in a self-reported, anonymized survey for a German cohort of 59 people with severe hemophilia. It covered sociodemographic and clinical characteristics, knowledge, attitudes, risk tolerance, and decision-making preferences. Results: Among 59 people with severe hemophilia A and 10 with severe hemophilia B, 59% expressed a predominantly rejective attitude toward gene therapy. Most had only general knowledge of gene therapy. Concerns about long-term side effects (e.g., cancer development) significantly contribute to a negative attitude toward gene therapy ( p = 0.005). People with hemophilia and an annual bleeding rate ⩾1 show a significantly higher willingness to consider or accept gene therapy ( p = 0.001). Rejection of gene therapy is significantly associated with high expectations regarding its duration of efficacy and the minimum clotting factor level. Conclusion: Further studies are needed to refine educational concepts for people with hemophilia and clear out misconceptions about gene therapy.

Background:Coronary artery disease (CAD) is a leading cause of death worldwide. Evidence of genetic predisposition is derived mostly from studies of Europeans and East Asians. Objectives:To test selected variants for association with early-onset CAD. Methods:We performed a case-control study of 697 young angiography-defined CAD cases (women aged <55 years, men <45) and 911 age- and sex-matched controls in Iran. We tested 24 variants (12 established CAD loci, 12 candidates in hemostasis genes) using age- and sex-adjusted logistic regression, stratified by ethnicity. A 6-variant unweighted genetic risk score (GRS) was built from the top loci. Additive interaction with cardiovascular risk factors was assessed by relative excess risk due to interaction. Results:Of 12 established loci, HCG27-HLA-C, CDKN2A/CDKN2B, and SORT1 showed nominal or near-nominal replication and 4 were directionally aligned with prior literature, whereas 5 showed no association. Among hemostasis candidates, F5 rs4524 was nominally associated with increased risk, and TSPAN15 rs78707713 and F11 rs2289252 suggested reduced risk. Ethnicity-stratified analyses indicated nominal or suggestive ancestry-specific effects at SORT1, HCG27-HLA-C, CDKN2A/CDKN2B, LPA, VWF, MIA3, and CXCL12. The GRS (range, 2-11 alleles/person) yielded a per-allele odds ratio of 1.20 (95% CI, 1.12-1.29), ie, a 5.2-fold higher risk across the observed range. Combining GRS with metabolic comorbidities showed super-additive effects (relative excess risk due to interaction, 6.66; 95% CI, 2.04-11.28). Conclusion:Ten variants, including 3 previously linked to venous thrombosis, showed nominal or suggestive association with early-onset CAD in Iranians or specific ethnic groups. Genetic burden substantially amplified risk in the presence of metabolic comorbidities. Our findings underscore the need for ancestry-aware studies in multiethnic populations.

Factor VII deficiency (FVIID) is among the most common rare bleeding disorders. The ability of FVII coagulant activity (FVII:C) levels and genetic variants to predict clinical outcomes remains limited. We evaluated the discriminative performance of FVII:C, genotype–phenotype associations, and the accuracy of in silico tools in identifying pathogenic variants. In total, 422 FVIID cases from three international registries were analyzed. Overall, 61% experienced bleeding, predominantly spontaneous (73%); 20% had grade I, 27% grade II, and 14% grade III bleeding. Lower FVII:C showed a moderate inverse correlation with EN-RBD bleeding scores and was more frequently observed in individuals with spontaneous bleeding (r=−0.49, p<0.0001). FVII:C showed moderate discrimination for asymptomatic status (AUC=0.72) and strong discrimination for grade III bleeding (AUC=0.84). An optimal cut-off of ≥19 IU/dL improved identification of asymptomatic individuals, while <11 IU/dL was associated with grade III bleeding. We identified 90 variants, including 10 novel; 60% were missense and 63% located in serine protease domain. According to ACMG/AMP criteria, 86% were pathogenic/likely pathogenic. The sensitivity of in silico tools was 96%, 85% and 60% for REVEL, CADD, and AlphaMissense. Severe deficiency was more common in homozygous individuals (90%), while heterozygous individuals predominantly exhibited mild/moderate deficiency (91%). Consistently, bleeding phenotypes were frequent in individuals with homozygous/compound heterozygous variants, whereas most heterozygous were asymptomatic (71%). Collectively, FVII:C showed a moderate ability to stratify bleeding severity. Homozygous/compound heterozygous variants are associated with lower FVII:C and more severe bleeding, whereas heterozygous are mostly asymptomatic. Among in silico tools, REVEL demonstrated the highest sensitivity.

Background & aims:Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection has a wide spectrum of clinical presentations ranging from asymptomatic viral replication to hyper-inflammatory syndrome and respiratory failure and can trigger immune disorders and long-COVID. Interleukin-32 (IL-32) is a pro-inflammatory cytokine induced during viral infections and chronic pulmonary disease. Aim:Aim of this study was to investigate the impact of the SARS-CoV-2 pandemic and severe COVID-19 on circulating IL-32 levels. Study design:Observational retrospective biomarker study. Patients & methods:We analyzed 949 healthy blood donors (pre-pandemic and pandemic-era) and 212 patients hospitalized due to severe COVID-19 during the first five infection waves. IL-32 levels were measured by ELISA. Results:Pandemic-era blood plasma donors showed a +0.78 ± 0.09 log10 pg/ml mean increase in IL-32 (pandemic-era 2.91 ± 0.05 vs. pre-pandemic 2.14 ± 0.07 log10 pg/ml, p<0.0001). COVID-19 patients exhibited a similar elevated IL-32 compared to unexposed controls (+0.29 ± 0.11 log10 pg/ml, p=0.016; 2.43 ± 0.08 hospital admission vs. pre-pandemic). Among patients, mean IL-32 was higher in first-wave patients (2.68 ± 0.11 log10 pg/ml) than later waves (2.12 ± 0.11 log10 pg/ml). In setting of severe COVID-19, IL-32 levels were associated with corticosteroids administration (estimate1.99 ± 0.50; p<0.0001), whereas decreased during the later waves of infection (-0.56 ± 0.16; p=0.0005) and with age (estimate -0.01 ± 0.01; p=0.020). No links were found with sex, Intensive care unit admission, comorbidities, or mortality. A subset of the COVID patient cohort was tested for pro-inflammatory biomarkers: IL-32 displayed an inverse correlation with patients' neutrophil-to-lymphocyte ratio (NLR) (estimate -0.23 ± 0.81; p=0.005) and not with IL-6 and biomarkers of endothelial dysfunction (n=42, p=NS). In patients with available follow-up (n=96), IL-32 remained stable up to one-year post-discharge (+0.03 ± 0.12 log10 pg/ml, p=0.970; 2.55 ± 0.15 hospital admission vs. follow-up 3-12 months 2.58 ± 0.15 log10 pg/ml). Conclusions:IL-32 levels increased following COVID-19, especially during the initial severe wave, and correlated with some markers of inflammation. IL-32 remained elevated up to one-year post-discharge, suggesting ongoing inflammation and supporting its potential as a biomarker for long-term sequelae.

Background: Valoctocogene roxaparvovec, a gene therapy for severe hemophilia A, enables endogenous factor VIII (FVIII) expression and confers bleed control. Objectives: To present the final 5-year efficacy and safety results from the phase 3 GENEr8-1 trial. Methods: Adult men (N = 134) with severe hemophilia A without inhibitors who were using FVIII prophylaxis received one 6 × 1013 vg/kg infusion of valoctocogene roxaparvovec. End points included annualized bleeding rate (ABR), FVIII infusion rate, FVIII activity, Haemophilia-Specific Quality of Life Questionnaire for Adults, adverse events, and immunosuppressant use. Results: Median follow-up was 261.1 weeks; 128 of 134 participants completed the study. For the 112 participants who enrolled from a previous noninterventional study (rollover population), mean ABR for treated bleeds declined by 83.3% (P < .0001), mean FVIII infusion rate declined by 94.9% (P < .0001), and mean ABR for all bleeds declined by 78.1% in the 5-year efficacy evaluation period vs baseline. In 132 modified intention-to-treat participants, mean and median FVIII activity at week 260 was 13.7 and 6.2 IU/dL, respectively (chromogenic assay). In year 5, 77.8% of rollover participants had 0 treated bleeds. One participant resumed prophylaxis since the 4-year data cutoff (25/134 across all follow-up). Haemophilia-Specific Quality of Life Questionnaire for Adults total score was improved from baseline at year 5. In year 5, alanine aminotransferase elevations occurred in 51 of 129 participants who entered year 5. Immunosuppressants were not used to manage them. No serious treatment-related adverse events occurred after year 1. Conclusion: Valoctocogene roxaparvovec provides durable hemostatic efficacy, FVIII activity, and improved health-related quality of life for ≥5 years, with no new safety signals.