Background: Bypassing agents are the first line therapy in patients with acquired haemophilia A (AHA). Activated prothrombin complex concentrate (aPCC) proved to be effective as initial treatment, but 20% of patients (pts) had relapses. aPCC as short-term prophylaxis to reduce subsequent bleeds is still not clear. Aim: To evaluate whether a short-term prophylaxis with low dose of aPCC can reduce bleeding relapses after initial AHA treatment, maintaining safety. Methods: The FAIR Registry is a retrospective-prospective study started on December 2012, that collected data on all pts with AHA treated with aPCC in 12 Italian Haemophilia Centers. All statistical analyses were carried out in the 56 pts included in the registry. Results: 31 retrospective and 25 prospective pts were evaluated. 101 bleeds requiring treatment were reported, 84.1% spontaneous, 71.3% involving muscles or skin. Major bleeds were 38,6%. Low-dose aPCC as short-term prophylaxis was started after the first resolved episode in 15/56 pts, 58% of whom prospective, in a mean dose of 54.2 +/- 23.0 IU/kg, higher (61.4 +/- 23.4 IU/kg) in the prospective group than in the retrospective one (44.3 +/- 19.7 IU/kg) and it was continued up to a mean of 20.5 +/- 17.6 days, similar in both groups. A total of 32 bleeding relapses were reported, 87.5% in the retrospective group. Only 9.4% occurred during short-term prophylaxis (p < 0.05). In our Registry no thromboembolic events were found. Conclusion: Initial AHA treatment with aPCC proved to be highly effective, but a consecutive low dose as short-term prophylaxis seems to demonstrate a significant reduction in bleeding relapses maintaining safety.

Acquired haemophilia A (AHA) is a rare bleeding disorder caused by the spontaneous development of auto-antibodies against coagulation factor VIII (FVIII) in males and females with previously normal haemostasis (Kessler & Knobl, 2015). This study aimed to assess dosage, duration of treatment, as well as the effectiveness and safety of activated prothrombin complex concentrate (aPCC) in patients with AHA. Secondary objectives were the evaluation of the role of the concomitant use of antifibrinolytic agents, anamnestic response and the number of relapses, along with effectiveness of a short-term prophylactic treatment with aPCC starting after the first bleeding episode. The FAIR study is a retrospective-prospective registry that included patients with AHA treated with aPCC (FEIBA®) at 12 Italian Haemophilia Centres. The study collected data from January 2003 to December 2012 for the retrospective group, and from January 2013 to December 2015 for the prospective one. Fifty-six patients were included in the registry, seven of whom had been included in a previous study (Zanon et al, 2015). All the events occurring in the 4 weeks following resolution of the qualifying bleeding episode were recorded. Major bleeds and the resolution of acute bleeding were defined according to the International Society on Thrombosis and Haemostasis guidelines (Schulman et al, 2005). "Bleeding relapse" was defined as any bleeding event that occurred into the same site or a different site within a month after the resolution of the first episode. Short-term prophylaxis was defined as aPCC administered at a lower dosage, after resolution of an acute bleeding episode, for at least 1 week. Short-term prophylaxis was administered based on the clinical evaluation and bleeding severity of each patient and performed by local physicians. Antifibrinolytics were administered exclusively based on clinical evaluation. Anamnestic response was defined as an increase in inhibitor titre after aPCC treatment, calculated on the inhibitor titre present at the onset of the therapy with aPCC, and assessed by the clinicians of each single centre. As FAIR is a registry, no special protocols were provided for patient management. Statistical analysis included all 56 enrolled patients. Baseline characteristics and the treatment of the patients are summarised in Table 1. FEIBA® as first-line therapy was used in 82·2% of cases, with a mean dose of 72·6 ± 26·6 iu/kg. Treatment was continued for a median of 8 days (interquartile range [IQR] 1–48) and FEIBA® was evaluated as effective in 96·4% of bleeds. Antifibrinolytic agents were used in 39·6% of treated bleeds, based on both a clinical assessment and the evaluation of bleeding severity, and were more frequently used in the prospective group (P = 0·0339). 57·1% of patients treated with antifibrinolytic drugs had serious co-morbidity. Among them, 40% presented severe cardiovascular diseases (myocardial infarction, ischaemic stroke and ischaemic cardiomyopathy). The sites and severity of bleeding were not significantly different between the total population of the FAIR registry and the group treated with the combined aPCC therapy. All of the bleeds treated with double therapy required a shorter treatment duration (mean reduction 16·3%). The combined therapy was well tolerated and no thromboembolic events were reported. 89·3% of patients received at least one immunosuppressive therapy to eradicate the inhibitors. Low-dose aPCC for short-term prophylaxis to prevent bleeding relapses was initiated in 26·8% of the patients after the first episode, and 73·2% received no further treatment (P = 0·0048). The mean dose of aPCC for prophylaxis was 54·2 ± 23·0 iu/kg. Prophylaxis lasted an average of 20·5 ± 17·6 days, with a mean infusion frequency of 24 h. Bleeding relapses were significantly higher in patients who received no prophylactic treatment with FEIBA®(P < 0·05). An anamnestic response was reported in 6/101 (5·9%) bleeding treatments. The median inhibitor titre increase was 9·3 Bethesda units (IQR 0·6–41·8) after a median of 6 days (IQR 2–19) from therapy commencement. No differences were observed in the duration of treatment, severity of bleeding and outcome among either the patients who had an anamnestic response or the remaining ones. During the treatment with FEIBA®, no thromboembolic events were reported. Eight patients died. After the EACH2 registry (Knoebl et al, 2012), FAIR is the largest study on the use of FEIBA® in the treatment of AHA, but, unlike EACH2, almost half of the patients were studied prospectively. The FAIR registry included a population with a median age of 69·9 years, which was younger than in the FEIBHAC (Borg et al, 2015) and EACH2 registries (Knoebl et al, 2012), but older than in the American study (Sallah, 2004), and comparable with the French study (Goudemand, 2004). The efficacy of aPCC as a first-line therapy in AHA is consistent with the data reported by Knoebl et al (2012). However, the FAIR registry is the first study to also highlight a positive clinical response to the combination of aPCC and antifibrinolytic agents, although these outcomes need to be confirmed in adequate, larger clinical trials. One of the main problems in the management of patients with AHA is bleeding relapse rate after the first episode, which is above 20% (Baudo et al, 2012). The FAIR registry showed that short-term prophylaxis prevented most bleeding relapses, 90·6% of which occurred in patients without prophylaxis. An anamnestic response to the treatment of the first bleeding episode was reported in 4/56 patients (7·1%), while inhibitor titre increased in 2 patients, confirming the data reported by Baudo et al (2012). In our study, the patients who presented an anamnestic response to aPCC were not treated for a longer period of time and did not need a higher amount of FEIBA® than those without an anamnestic response. Patients with an anamnestic response did not show more severe bleeding or worse outcomes than the remaining patients. Differently from the EACH2 registry (Baudo et al, 2012), in which 4·8% of the patients treated with FEIBA® experienced a thrombotic event, none of the patients in the FAIR registry suffered this side effect. The overall mortality among the FAIR patients treated with aPCC was 14·3%, lower than in the other registries (Baudo et al, 2012; Borg et al, 2015). The FAIR registry showed interesting results that may be useful in clinical practice, but controlled trials are needed to confirm the data obtained. All of the authors meet the International Committee of Medical Journal Editors criteria for authorship for this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval of the version to be published. E.Z. designed the study, S.P. wrote the paper. This medical and statistical writing assistance was supported by Baxalta-Shire. This work did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. All authors have read and understood BJH policy on declaration of interests and declare that they have no competing interests.

Summary Rigorous evidence is lacking on long-term outcomes of factor VIII (FVIII) prophylaxis initiated in adolescent or adult patients with severe haemophilia A. The prospective, open-label Prophylaxis versus On-demand Therapy Through Economic Report (POTTER) study (Clinical-Trials.gov NCT01159587) compared long-term late secondary prophylaxis (recombinant FVIII-FS 20–30 IU/kg thrice weekly) with on-demand treatment in patients aged 12 to 55 years with severe haemophilia A. The annual number of joint bleeding episodes (primary endpoint), total bleeding episodes, orthopaedic and radiologic (Pettersson) scores, health-related quality of life (HRQoL), pharmacoeconomic impact, and safety were evaluated over a > 5-year period (2004–2010). Fifty-eight patients were enrolled at 11 centres in Italy; 53 (27 prophylaxis, 26 on demand) were evaluated and stratified into 2 age subgroups (12–25 and 26–55 years). Patients receiving prophylaxis experienced a significantly lower number of joint bleeding episodes vs the on–demand group (annualised bleeding rate, 1.97 vs 16.80 and 2.46 vs 16.71 in younger and older patients, respectively; p=0.0043). Results were similar for total bleeding episodes. Prophylaxis was associated with significantly fewer target joints (p< 0.001), better orthopaedic (p=0.0019) and Pettersson (p=0.0177) scores, better HRQoL, and fewer days of everyday activities lost (p< 0.0001) but required significantly higher FVIII product consumption. The POTTER study is the first prospective, controlled trial documenting long-term benefits of late secondary prophylaxis in adolescents and adults with severe haemophilia A. The benefits of reduced bleeding frequency, improved joint status, and HRQoL may offset the higher FVIII consumption and costs.

Aim of this study was to present a series of neonates and ex-preterm babies who underwent inguinal hernia repair focusing on complications and possible indication to perform routine contralateral groin exploration.

Purpose Tunneled indwelling central venous catheters (CVC) are essential in the management of children with cancer, hematological, nephrological disorders and for parenteral nutrition. The aim of this study is to present the experience of a single center of the transition from traditional open surgical cut down procedure (OSC) to ultrasound (US)-guided percutaneous CVC insertion, focusing on learning curve and related complications. Methods All CVCs inserted between April 2008 and November 2009 in children at the Gaslini Children Hospital were revised, and data on methods of cannulation, intraoperative and device-related complications and re-intervention were recorded. Results 194 CVCs were positioned in 188 patients. 128 out of 194 CVCs were positioned through an OSC technique, whereas the remaining 66 CVCs were inserted percutaneously with US guidance. Of the 27 recorded complications, 15 were mechanical events, 7 cases developed infection, whereas the remaining 5 (2.6%) were classified as intraoperative complications. A second surgical procedure was described in 23 (11.8%) cases. Conclusion Shifting from OSC to US-guided percutaneous CVC insertion inevitably involves a challenging learning curve which is generally associated with high complication rates. Complications progressively decrease once a good experience in US guidance and percutaneous technique has been obtained.

AIM:Pectus excavatum is the commonest thoracic congenital malformation, but its treatment remains not well known. The authors present the results of the mini-invasive repair at G. Gaslini Institute of Genoa, Italy.METHODS:Nuss mini-invasive repair avoids anterior scars. The correction is achieved by the introduction under thoracoscopy of a retrosternal curve bar that is rotated by 180 degrees . Postoperatory pain is managed by an epidural catheter. In all the operated patients we evaluated the clinical pre-operatory parameters (spirometric, radiological and cardiological data), the surgical details and the results.RESULTS:Fifty patients were operated, 43 of them males, ranging from 7 and 22 years of age, with an average of 17 years of age. Only 8 of them were asymptomatic and required surgery for psychological reasons. The 74% presented some stress dyspnea. Some impairment in spirometric parameters were observed in 28% and mitral valve prolapse in 30%. The only significant intra-operative complication was a bleeding from a thoracic wall vessel that required a left emergency minimal thoracotomy. Postoperative complications were: 2 pneumothorax (drained for 24 hours), 2 transitory pulmonary atelectasis, 1 hemothorax in a patient with coagulation deficit, 3 wound problems (1 infection and 2 hematomas). The esthetical score after surgery, according to the patients, was 9.15 on average, in a scale from 1 to 10. None rated less than 7. The pain score with the same scale was rated 6.8 on average.CONCLUSION:The Nuss technique is safe and guarantees very satisfactory esthetical results.

Background: In 1995 Smith reported that phantom limb pain (PLP) was present in 48% of patients with cancer-related amputations. That same year Krane reported a 90% prevalence of PLP in pediatric amputees. We reviewed the charts of 30 pediatric patients receiving major limb amputation at our hospital from 200-2007 for limb malignancies for the purpose of reporting the incidence of phantom limb pain and the role of different regional analgesia therapeutic approaches to prevent patients from experiencing phantom pain.

The surface compositions of three different back-side metals: Ti/Ni/Au 0.1/0.4/0.1 mum, Ti/Ni/Ag 0.1/0.4/0.1 and 0.1/0.4/2 mum and Ti/Ni 0.1/0.4 mum after thermal treatment at 180-degrees-C in air were investigated by means of XPS technique. In the Ti/Ni/Au metal the Ni diffusion through the Au layer was observed, while in the Ti/Ni/Ag metal Ni was not found on the silver surface. Ti/Ni/Ag was found to be sensitive to contamination from elements such as sulphur and chlorine found on the silver surface after thermal treatment, while Ti/Ni metal is sensitive to oxidation. NiO, Ni(OH)2, NiOOH and Ni2O3 species were found on the Ni as deposited surface. The surface compositions were correlated to their wetting property using the Pb88-Sn10-Ag2 and Pb95.5-Sn2-Ag2.5 wt% soft solder alloys. The wetting was studied measuring the contact angle between the surface and the drop of molten solders.

Two neuraminidase (EC 3.2.1.18) comonents, A and B, were distinguished in cultured skin fibroblasts on the basis of thermolability at 37 degrees C. The more labile component (A) t1/2 = 4.7--5.3 min at 37 degrees C, comprises 66--90% of total neuraminidase activity when determined using sodium (4-methylumbelliferyl-alpha-D-N-acetylneuraminate) (MU-alpha-N) as substrate. Activity was assayed at 0 degrees C for 18 h instead of 37 degrees C to fully determine both thermolabile and thermostable components. Diminished activity was noted in cultured fibroblasts from mucolipidoses I, II and III (MLI, MLII, MLIII) and the cherry-red spot myoclonus syndrome (CRSM) patients when assayed at both 0 and 37 degrees C with either MU-alpha-N or each of a series alpha (2 leads to 3)- and alpha (2 leads to 6)-linked N-acetylneuraminyloligosaccharides. Increased sensitivity and rapidity of analyses were achieved using MJ-alpha-N as substrate in determining neuraminidase activity. Results from two obligate heterozygote MLI cell lines (14.5 and 8.0% of control activity) indicate that the MU-alpha-N substrate could be useful for heterozygote detection.

In rats, severe but partial ligation of the aorta between the renal arteries induces striking changes in the left, ischemic renal cortex: simple atrophy of the outer cortex, and atrophy with hyperplasia and poly-ploidy of the inner cortical tubular cells. In the ischemic renal cortex, there is a significant increase not only of renin activity but also of β-glucuronidase, of cathepsin D and, to a much lesser degree, of acid phosphatase. The results of isopycnic centrifugation indicate that these enhanced hydrolytic enzyme activities are localized in renal cortical tubular cell lysosomes. Since these changes occur even with minimal atrophy of the kidney, they must accompany all cases of hypertension of renal origin.

In renal cortices of hypertensive rats the activity of renin and β-glucuronidase is significantly enhanced, while the activity of acid phosphatase remains pratically unchanged. A significant decrease in protein content accompanies the rise in enzyme activity. The distribution pattern of renin, β-glucuronidase and acid phosphatase after isopycnic centrifugation of cortical homogenates from hypertensive animals is different from that of controls.

The significance of neuraminidase deficiency reported to be the primary defect in mucolipidosis II has been evaluated by determination of this enzyme activity in cultured fibroblasts, culture medium, and leucocytes from homozygote and heterozygous carriers of the disease. A new and sensitive fluorometric assay of neuraminidase was used with sodium (4-methylumbeliferyl-alpha-D-N-acetylneuraminate) as substrate. We report: 1) nearly total deficiency of neuraminidase in mucolipidosis fibroblasts, 2) partial deficiency of this enzyme in leucocytes of one patient, 3) this decreased activity ceases to exist following Triton X-100 treatment, and 4) intermediary mean neuraminidase activity in fibroblasts and leucocytes from obligate heterozygotes. Although these results would be consistent with the suggestion that neuraminidase deficiency is the primary defect in this disease, evidence from the work of other authors suggests that the enzyme deficiency results from a secondary effect of the mucolipidosis II mutation.

This report describes the preparation of a sodium (4-methylumbelliferyl-α-d-N-acetylneuraminate) substrate and its use in a sensitive fluorometric assay of neuraminidase (EC 3.2.1.18) from Vibrio cholerae, cultured fibroblasts, and human leucocytes. V. cholerae neuraminidase showed maximum activity at pH 4.6 and an apparent Km of 1.5 mm and was activated by CaCl2 and inhibited by ethylenediaminetetraacetate, NaCl, and N-acetylneuraminic acid. The inhibition by N-acetylneuraminic acid was competitive (Ki = 6.1 mm). Cultured fibroblast and leucocyte neuraminidases showed maximum activity between pH 4.2 and 4.4 and apparent Km values of 0.13 and 0.22 mm, respectively. Neuraminidase activity was considerably reduced in cultured fibroblasts of patients with mucolipidosis types I, II, and III.

ICD is characterized by deficiency of several lysosomal hydrolases in cultured fibroblasts and by higher than normal activities of these enzymes in culture medium and physiological fluids. Deficiency of neuraminidase activity in ICD was suggested by reports of higher than normal amounts of N-acetylneuraminic acid in glycosphingolipids and oligosaccharides excreted in urine or extracted from tissues. We developped a sensitive and simple fluorometric assay of NEU using MU-NAN as substrate and report NEU deficiency in ICD. With MU-NAN, cultured fibroblast NEU showed optimum pH at 4.2-4.4 and apparent Km of 0.13 mM. The NEU activity in cultured fibroblasts from 4 patients with ICD was less than 3% normal (0.35 ± 0.06(S.D.) U/g of protein). In one obligate heterozygote enzyme activity was about 50% of normal (0.21). NEU activity was not detectable in both normal and ICD culture medium although the assay method could detect as little as 0.01 mU of enzyme activity. Other hydrolases did not show such a profound deficiency in both ICD fibroblasts and culture medium and therefore neuraminidase assay was the method of choice for diagnosis of ICD. Preliminary studies indicate that the fluorometric method could also be used for NEU assay in white blood cells and cultured amniotic fluid cells.

Rat liver microsomes, free of lysosomal β-glucuronidase, were subjected to sonication. Under the experimental conditions used, 95 % of the microsomal β-glucuronidase activity was solubilized while only 11 % of the albumin was released in the soluble fraction. The results indicate that microsomal β-glucuronidase is not contained in the cisternae of the microsomal vesicles but is attached to the membranes by bonds that are broken by sonication before the membranes are disrupted.

Crude, soluble β-glucuronidase (EC 3.2.1.31) preparations from rat-liver lysosomes and microsomes were submitted to disc electrophoresis on polyacrylamide gel. Under the experimental conditions used the lysosomal β-glucuronidase migrates faster than the microsomal enzyme.