CHS Dream of a Cure Research Program

/CHS Dream of a Cure Research Program
CHS Dream of a Cure Research Program2018-07-06T15:14:51+00:00

               

Supporting research towards improving the health and the quality of life of all people with inherited bleeding disorders and finding a cure have been goals of the Canadian Hemophilia Society (CHS) since it was founded in 1953. Since 1990 through funds provided by the Hemophilia Research Million Dollar Club and the CHS, the CHS provides basic scientific research grants and studentships aimed at developing treatments for hemophilia A and B, von Willebrand disease, rare factor deficiencies, platelet function disorders and ultimately, at finding a cure.

For Dream of a Cure, individual grants valued at $75,000 per year and per project will be awarded to researchers for a maximum of $150,000 which can be expended over 2 or 3 years. If a two year award is provided, the second year of funding is dependent on evidence of progress as described in the required progress report. In addition, support will be available for Canadian medical or science students for up to 4 months, for a maximum stipend of $6,000 each, who are interested to work on research projects related to inherited bleeding disorders. 

Application forms for the 2018-19 granting period as well as the general criteria and conditions can be accessed by using the links below. Deadline to submit applications: November 15, 2017.

Funds Available for Scientific Research in Fields Relevant to Inherited Bleeding Disorders

The CHS Dream of a Cure Research Program, through funds provided by the Hemophilia Research Million Dollar Club and the Canadian Hemophilia Society, supports research focused on improving the health and the quality of life of all people with inherited bleeding disorders and finding a cure. The Canadian Hemophilia Society invites applicants to apply for basic scientific research grants in fields relevant to hemophilia A and B, von Willebrand disease, rare factor deficiencies, platelet function disorders (and platelet pathophysiology) and other congenital and acquired bleeding disorders.

 

Eligibility

Applicants must be Canadian citizens or permanent residents and affiliated with a Canadian university or not-for-profit health-related organization.

 

Location of Tenure

The research will be conducted in Canada by Canadian researchers affiliated with Canadian universities or not-for-profit health-related organizations.

 

Grant amount / Duration of Support

Individual grants valued at $75,000 per year and per project will be awarded to researchers for a maximum of $150,000 which can be expended over 2 or 3 years. If a two year award is provided, the second year of funding is dependent on evidence of progress as described in the required progress report. Grant funding will begin on April 1 of each year.

Yearly grants will normally be disbursed in two payments in each year.

 

General Conditions and Application Form

Applications must be completed and submitted electronically to the Canadian Hemophilia Society and one (1) original paper copy, including signatures, must be sent to the National Office of the Canadian Hemophilia Society:

666 Sherbrooke Street West, Suite 301
Montreal, QC H3A 1E7

Please click on the following links for General Conditions and Application Form

 

Deadlines

All completed application forms and support documents must arrive at the National Office of the Canadian Hemophilia Society on or before November 15, 2017. If the CHS receives the application after the deadline date but it is postmarked on or before the deadline date, then it is considered to have been submitted on time. The names of the successful applicants will be announced by March, 2018.

 

Evaluation

Applications will be reviewed by an independent peer review committee composed of Canadian medical and healthcare professionals and a patient representative. This committee will rank the applications and will make recommendations to the CHS Board of Directors on funding of the proposals. The final decisions regarding awards will be made by the CHS Board of Directors. No appeals will be considered.

1. General Conditions

1.1 Application Forms
The Application Form may be obtained by clicking on the following link: Application Form.

Applications forms must be completed and submitted electronically to the Canadian Hemophilia Society (chs@hemophilia.ca) and one (1) original paper copy, including signatures, must be sent to the National Office of the Canadian Hemophilia Society:
666 Sherbrooke Street West, Suite 301, Montreal, QC H3A 1E7

1.2 Application Deadline
Completed application forms and supporting documents must arrive at the National Office of the Canadian Hemophilia Society by November 15, 2017. If the CHS receives the application after the deadline date but it is postmarked on or before the deadline date, then it is considered to have been submitted on time. The names of the successful applicants will be announced by March, 2018.

First time applicants are encouraged to seek advice from experienced investigators in the preparation of their applications. 

Please note that the Research Proposal (Item 16 of the application) must not exceed 5000 words, excluding figures and references. 

Supporting materials should include only previously published articles or materials accepted for publication.

1.3 Grant Year and Amount 
Individual grants valued at $75,000 per year and per project will be awarded to researchers for a maximum of $150,000 which can be expended over 2 or 3 years. If a two year award is provided, the second year of funding is dependent on evidence of progress as described in the required progress report. Grant funding will begin on April 1 of each year.

1.4 Grant Payments
Yearly grants will normally be disbursed in two payments in each year and sent to the financial officer of the host institution. 

1.5 Research Summaries 
The Canadian Hemophilia Society (CHS) requires, within the application form, a 200-word typewritten lay description of the research to be undertaken (in non-scientific, Grade 12 readability) for inclusion in the Society’s publications should the proposal be accepted.  

1.6 Notification of Grants 
Following funding decisions, successful applicants will be sent official notification informing them of the type, duration and amount of their grant. A copy of the notification is sent to the accountant at the institution concerned. The award must be acknowledged by returning an acceptance note within 15 days of the CHS notification otherwise the award will be withdrawn. Unsuccessful applicants are also advised at the conclusion of the project application review process.

1.7 Appeals 
The Research Peer Review Committee of the Canadian Hemophilia Society will make recommendations on the awarding of the grants and the final decision will be made by the CHS Board of Directors. No appeals will be considered.

 

2. Additional Grant Conditions and Grantee Obligations

2.1 Statement of Expenditures 
A statement of all expenditures for the grant, signed by the candidate and the financial officer of each institution, must be received at the CHS’s offices within 2 months of the end date of the grant term. An institution finance/expenditure report is acceptable to avoid duplication of effort by the researcher. Failure to fulfill this requirement may lead to exclusion from future research grant competitions. If delay is anticipated, the CHS must be informed.

2.2 Changes in the Use of the Grant
The use of funds for purposes other than stated in the application must be approved in advance by the CHS. 

2.3 Unexpended Balances 
The Canadian Hemophilia Society does not permit carrying forward into the next grant year an unexpected balance in excess of $5,000. Prior written request to the CHS is required to carry forward a balance that exceeds $5,000. 

2.4 Termination of the Grant 
Upon termination of the project, any unexpended balance of funds must be returned to the CHS. 

2.5 Travel Expenses

A grantee may use $1,500 annually from the award for the purpose of travel in connection with the grant and, if needed, an additional amount representing one percent (1%) of the annual value of the award. 

2.6 Title to Equipment
Title to any equipment obtained with the Canadian Hemophilia Society’s funds shall be held by the host institution on the condition that for a 12 month period following termination of grant, the CHS may transfer title to another institution. Prior written authorization for the transfer of funds or equipment by a grantee to another institution must be obtained from the CHS.

2.7 Interim, Final Report & Abstract Requirements
Research grant recipients are required to provide a project progress report for each year of funding allocation. This report will serve as the basis for review of the project and approval of second year funding, where applicable. The progress report will also provide supporting rationale, if required, for approval of project modifications, and/or extension requests.   

Within 2 months of the end of the funding period, the Canadian Hemophilia Society requires a final report on the results of the project. The CHS also requires that the researcher provide an approximately 250-word lay abstract (Grade 12 readability) describing the outcomes of the research for inclusion in the Society’s publications and for presentation at the CHS medical and scientific symposiums. 

Failure to fulfill these requirements can lead to exclusion from future research grant competitions. If delay is anticipated, the CHS must be informed.

2.8 Acknowledgement of Support
The Canadian Hemophilia Society MUST be informed of any publications that are based on research funded by the Canadian Hemophilia Society and all such publications MUST acknowledge the support of the Canadian Hemophilia Society. Researchers are encouraged to present study results, when possible, even if preliminary, at hemophilia conferences (e.g., World Federation of Hemophilia Congress, Rendez-Vous, etc.).

2.9 Proprietary Rights

The CHS must be informed of any commercial exploitation arising from the CHS-supported activity. However, the CHS does not claim proprietary rights to inventions resulting from research supported by its funds. The onus is on the grantee to seek patent protection in collaboration with the university or institute for inventions or developments arising from the CHS-supported research.

2.10 Indirect / Overhead Costs

Grant funds must contribute towards the direct costs of the research program or project for which the funds were awarded. The Institution provides for indirect or overhead costs, such as the costs associated with facilities and basic utilities, the purchase and repair of office equipment, administration fees, insurance for equipment and research vehicles, and basic communication devices such as telephones and fax machines. The funds must be used effectively and economically, and the expenses must be essential for the research supported by the grant.

Health Charities Coalition of Canada Position Statement on Indirect Costs of Research (May 14, 2007): 

It is the policy of the Health Charities Coalition of Canada (HCCC) that health charities should not fund the indirect costs associated with the research they fund. All HCCC members have agreed not to fund indirect costs. While the HCCC recognizes that these may indeed be legitimate expenditures, we believe the funding of such costs is the responsibility of governments and not donors

While the CHS is not a member of HCCC, it nonetheless supports the position that indirect costs associated with research it funds are the responsibility of governments and/or research institutions and not its donors.

 

3. Ethical Considerations

3.1 Adherence to Research Guidelines
An application to the Canadian Hemophilia Society for research support constitutes a pledge on the part of the applicants and their research institutions to respect all the guidelines of the Canadian Hemophilia Society, the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans, December 2010 (TCPS2), the Canadian Institutes of Health Research (CIHR), Natural Sciences and Engineering Research Council of Canada, Social Sciences and Humanities Research Council of Canada and the Canadian Council on Animal Care. In the event that these guidelines are not adhered to, the CHS will withhold funding. 

Completed forms required for research involving human subjects, gene therapy in humans, animals and biohazards must be received by the CHS as soon as possible; funding of successful applications for research will be withheld by the CHS until full Research Ethics Board approval is provided in writing to the CHS. CHS review of the applications, by its Peer Review Committee, can proceed prior to Research Ethics Board (REB) approval.

3.2 Research Involving Human Subjects 
Each project in a research proposal involving human subjects and gene therapy in humans must submit the complete designated form, authorized by the local institutional Research Ethics Board in accordance with the TCPS2 document of the Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada,and Social Sciences and Humanities Research Council of Canada, Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans, December 2010. The Tri-Council Policy Statement is available from the following website:www.pre.ethics.gc.ca/pdf/eng/tcps2/TCPS_2_FINAL_Web.pdf

The responsibility for filing a Clinical Trial Application ( CTA) with Health Canada for a human drug clinical trial rests with the Principal Investigator. Guidance on whether a CTA is required is found at:  

www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/guide-ld/clini/cta-eng.php See: Overview of the Clinical Trial Application Process and Institution/Investigator Initiated Clinical Trials. 

In addition, all continuing grantees involved in human subjects must submit the complete designated form on an annual basis. Receipt of this form is required for continuation of payment by the CHS of any funds committed for the following year. 

3.3 Research on Somatic Cell Gene Therapy in Humans 
The Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans, December 2010 must be adhered to. Any research related to this area must be reviewed by the local institutional Research Ethics Board.

3.4 Care and Use of Experimental Animals 

The CHS requires that all experiments involving animals be conducted in an ethical way. The facilities for, and the care and use of animals, in any investigation the CHS supports must be in strict accordance with the guidelines set out by the Canadian Council on Animal Care (CCAC) in its publication, Guide to the Care and Use of Experimental Animals (Vol. 1, 1980 and revised in 1993; Vol. 2, 1984), available from: 

The Canadian Council on Animal Care
1000 – 151 Slater St.
Ottawa, Ontario Canada K1P 5H3

Each proposal involving animals must have one copy of the designated form, completed and authorized by a local institutional Animal Care Committee, confirming its ethical acceptability (the composition of the committee is set forth in the CCAC Guide). In addition, all continuing grantees involved in research using animals must submit one complete form on an annual basis. Receipt of this form is required for continuation of payment by the CHS of any funds committed for the following year. 

3.5 Research Involving Biohazards 

Investigators proposing to engage in research involving animal and human pathogens and animal cells are required to comply with the Canadian Institutes of Health Research and Health and Welfare Canada Biosafety Laboratory Guidelines, 3rd Edition – 2004. These guidelines were jointly prepared with the Office of Biosafety of the Laboratory Centre for Disease Control of Health Canada and are available from: 

Office of Biosafety
Laboratory Centre for Disease Control
Health Protection Branch 
Health Canada 

Ottawa, Ontario Canada K1A 0L2 
Tel: 613-957-1779 

or at www.phac-aspc.gc.ca/publicat/lbg-ldmbl-04/index-eng.php

These Guidelines cover the following types of research:

a) research involving animal and human pathogens;
b) research involving animal cells in culture;
c) research involving recombinant DNA molecules which might be harmful to humans, animals or the environment. 

Each proposal involving research proposals covering the areas noted above must have one completed form, authorized by a local institutional committee, confirming that the level of containment implemented by the investigator meets the Canadian Institutes of Health Research’s requirements. 

In addition, all continuing grantees participating in research involving biohazards must submit a completed form on an annual basis. Receipt of this form is required for continuation of payment by CHS of any funds committed for the following year. 

Disposal of Hazardous and Radio Active Materials

3.6 Research Involving Hazardous Compounds 
Researchers are responsible for ensuring that their research conforms with the provincial statutes regarding disposal of chemical wastes. Researchers are also responsible for ensuring that research assistants and laboratory personnel are aware of any hazards posed by materials required for the research, that these personnel are adequately trained in handling and containment of such compounds, and that protective procedures are enforced, in compliance with the Occupational Health and Safety regulations of the province in which work is carried out. 

3.7 Research Involving Radioactive Materials
Applicants who will be carrying out research using radioactive materials must be aware of, and comply with, all Atomic Energy Control Board regulations, recommended procedures, and safety precautions governing the use of such materials in Canada. Further information may be obtained from:

Office of Public Information
Atomic Energy Control Board

P.O. Box 1046, Station ‘B’
270 Albert Street
Ottawa, Ontario Canada K1P 5S9
Tel:  613-995-5894 Fax: 613-995-5086

Application Form for Dream of a Cure Research Grants.

Application Form for Dream of a Cure Summer Studentships.

or contact:
Canadian Hemophilia Society
chs@hemophilia.ca
1 800 668-2686

Funds Available for Scientific Research in Fields Relevant to Inherited Bleeding Disorders 

The Canadian Hemophilia Society will support interested Canadian Medical or Science students to work for up to 4 months during the Summer of 2018 on a research project relevant to inherited bleeding disorders. Stipend: $6,000.00.

Who can apply ?

  • Medical students in any year of training.
  • Science students in any year of an undergraduate program.
  • Applicants must be Canadian citizens or permanent residents.

What do you need ?

  • Excellent academic record.
  • Acceptance by a scientist involved in a current research project related to inherited bleeding disorders supported by CHS or another major granting agency.

 

Application Form and Where can you apply?

Applications must be completed and submitted electronically to the Canadian Hemophilia Society and one (1) original paper copy, including signatures, a copy of your current official transcript and reference letters must be sent to the National Office of the Canadian Hemophilia Society:

666 Sherbrooke Street West, Suite 301
Montreal, QC H3A 1E7

Please click on the following link for the Application Form 

 

Closing date for application 

All completed application forms and support documents must arrive at the National Office of the Canadian Hemophilia Society on or before November 15, 2017. If the CHS receives the application after the deadline date but it is postmarked on or before the deadline date, then it is considered to have been submitted on time. The names of the successful applicants will be announced by March, 2018.

 

Evaluation

Applications will be reviewed by an independent peer review committee composed of Canadian medical and scientific healthcare professionals and a patient representative. This committee will rank the applications and will make recommendations to the CHS Board of Directors on funding of the proposals. The final decisions regarding rewards will be made by the CHS Board of Directors. No appeals will be considered.

 

General Conditions and Obligations

Grant Payment
Full Payment is normally made to the financial officer of the host institution at the start of the studentship.

For studentships, the host institution is responsible for issuing a T4A. Please consult your tax advisor for the proper treatment of your studentship.

Research Summaries 
The Canadian Hemophilia Society (CHS) requires, within the application form, a 200-word typewritten lay description of the research to be undertaken (in non-scientific, Grade 12 readability) for inclusion in the Society’s publications should the proposal be accepted.  

Notification of Grants 
Following funding decisions, successful applicants will be sent official notification informing them of the type, duration and amount of their grant. A copy of the notification is sent to the accountant at the institution concerned. The award must be acknowledged by returning an acceptance note within 15 days of the CHS notification otherwise the award will be withdrawn. Unsuccessful applicants are also advised at the conclusion of the project application review process.

Final Report Requirements
The supervisor of the student must send a brief final report (in lay terms, Grade 12 readability) at the completion of the studentship describing the accomplishments of the student activities for inclusion in the Society’s publications and for presentation at the CHS medical and scientific symposiums. 

Failure to fulfill these requirements may lead to exclusion from future research grant competitions. If delay is anticipated, the CHS must be informed. Should the studentship end prematurely, the CHS must be informed immediately by the supervisor and /or the student.

VWF in megakaryocytes and the role of platelet-VWF in VWD

Dr. Walter Kahr
Hospital for Sick Children – Toronto
Second year funding

 

People with severe von Willebrand disease (VWD) have bleeding problems caused by a lack of von Willebrand factor (VWF), typically missing in their plasma and platelets. We have found, however, that patients with a particular mutation have some VWF in their platelets. They have less severe bleeding problems than most severe VWD patients, possibly owing to this platelet VWF.
 
Our study addresses two key knowledge gaps: 1) How is VWF packaged by megakaryocytes into platelets? 2) What is the role of platelet VWF in reducing bleeding symptoms in some severe VWD patients? We will address these questions using methods we have successfully employed in my laboratory involving platelet development and function, including high resolution microscopy and genetic manipulation of megakaryocytes.
 

Evaluation of the burden of bone fracture in patients with hemophilia A: A population-based study

Dr. Alfonso Iorio
McMaster University – Hamilton Ontario
One year funding

 

Co-investigators:
Dr. Chatree Chai-Adisaksopha, McMaster University
Dr. Michelle Sholzberg, University of Toronto
Dr. Adrienne Lee, University of Calgary

 

There are increasing numbers of patients with hemophilia (PWH) developed age-related co-morbidities, for instance, cardiovascular disease, diabetes or cancer. Age-related bone disease, such as, low bone mineral density and osteoporosis are the emerging concern in PWH. However, the data on the incidence of bone fracture in PWH are limited. The aims of this study are to determine the incidence of bone fracture in PWH compared with general population and to explore risk factors of bone fracture. Better understanding of the burden of fracture in PWH will enable physicians, hemophilia nurses, physiotherapists and stakeholders to allocate resources in hemophilia care. In addition, this information will enable physicians to identify patients at greater risk of fracture.
 

The Hemostatic Stress Response: Do Differences Explain Phenotypic Variability in VWD?

Dr. Paula James
Queen’s University – Kingston, Ontario
First year funding

 

Von Willebrand Disease (VWD) is the most common inherited bleeding disorder known in humans, and affects ~35,000 Canadians. It causes excessive bleeding from the skin and mucous membranes and can be highly variable in its clinical presentation. Some affected patients experience little in the way of bleeding symptoms, but some suffer from prolonged and excessive bleeding with menstruation, and following dental procedures, childbirth or surgery. In the worst cases, blood transfusions or surgical procedures such as hysterectomy are required to treat patients. At present, factors that lead to more severe bleeding are not completely understood, and new knowledge in this field could help us provide more effective treatment for patients. In this study, we will specifically test the hypothesis that Type 1 VWD patients who have more severe bleeding have a lesser capacity to respond to stresses on their blood coagulation system. We will include stressors such as exercise or treatment with a medication called desmopressin, and will also perform experiments on endothelial cells cultured from patients and healthy controls.    
 

A scanning electron microscope study of clot ultrastructure of coagulated factor VIII deficient-plasma in the presence of anticoagulants

Lab work studentship

 

Bushra Sajjad
National University of Ireland, Galway
Under the supervision of Dr. Anthony Chan and 
Jorell Gantioqui, McMaster University – Hamilton, Ontario

 

Hemophilia patients suffering from serious bleeding problems may also develop blood clot complications due to replacement in the blood of the absent clotting protein. Although blood thinner is traditionally used to treat blood clotting, this exacerbates the risk of bleeding in patients suffering from hemophilia as they are inherently more susceptible to bleeding. As a result, the management and treatment of this situation poses a challenge for clinicians. Therefore, we propose a study investigating the changes of blood clot structure through the use of electron microscopy. Information from this study will be used to provide important insight regarding blood clots in hemophilia patients treated by blood thinners. Results of this study will analyze the clotting process from another standpoint which can aid researchers in understanding the effects of blood thinner in hemophilia patients who are already deficient in a clotting protein.

VWF in megakaryocytes and the role of platelet-VWF in VWD

Dr. Walter Kahr
Hospital for Sick Children – Toronto
First year funding

People with severe von Willebrand disease (VWD) have bleeding problems caused by a lack of von Willebrand factor (VWF), typically missing in their plasma and platelets. We have found, however, that patients with a particular mutation have some VWF in their platelets. They have less severe bleeding problems than most severe VWD patients, possibly owing to this platelet VWF.

Our study addresses two key knowledge gaps: 1) How is VWF packaged by megakaryocytes into platelets? 2) What is the role of platelet VWF in reducing bleeding symptoms in some severe VWD patients? We will address these questions using methods we have successfully employed in my laboratory involving platelet development and function, including high resolution microscopy and genetic manipulation of megakaryocytes.

 

The role of FVIII glycans on the immunogenic potential of FVIII concentrates

Dr. David Lillicrap
Queen’s University – Kingston, Ontario
Second year funding

The aim of the studies described in this research proposal are to investigate possible causes for the increased risk of factor VIII inhibitor development that has been documented with one particular form of recombinant factor VIII concentrate. The theory being tested in these experiments is that the recombinant factor VIII in question is “decorated” with a different pattern of sugar molecules that trigger a response from the early, innate arm of the immune defense system. The studies that ate proposed will first determine the pattern of sugars associated with the surface of different forms of recombinant factor VIII. We will then examine the effect of the various recombinant concentrates on the immune cells that cleat factor VIII from blood and provide the initial response to the protein. These experiments will test whether the immune cells are excessively “activated” by any of the factor VIII concentrates. We will also be able change the sugar content of the factor VIII proteins through chemical means, to see whether this alters the effect on the immune cells. Finally, we will test the potential of the different factor VIII products to produce inhibitors in a novel “humanized” mouse model of hemophilia.

 

Role of Gfi1b in the formation of platelets and in inherited bleeding disorders

Dr. Tarik Möröy 
Institut de recherches cliniques de Montréal (IRCM)
Department of Hematopoiesis and Cancer
Third year funding

Platelets are essential for blood clotting and are formed in the bone marrow by large cells, so-called ‘megakaryocytes’, which form long protrusions that penetrate into blood vessels, where the shear forces of the blood stream detach small pieces, which form the platelets. Low platelet numbers can be caused by different diseases or can be the result of an inherited disorder that leaves megakaryocytes unable to produce platelets. These heritable diseases are of clinical importance since low platelet numbers can cause excessive bleeding, which can create severe complications for instance during surgery. A better understanding which factors regulate platelet production is therefore needed to develop new treatments for platelet deficiencies. Recently, mutations in a gene called ‘Gfi1b’ have been identified in patients with a bleeding disorder caused by low platelet numbers. We have generated mice deficient for this gene and have observed that they show most of the typical symptoms of the human disease associated with the mutated Gfi1b, suggesting that the Gfi1b gene is a critical element in platelet formation. We propose therefore to investigate how this gene functions and regulates platelet formation to gain new insight on how to treat patients with bleeding disorders and platelet deficiencies.

 

The link between the gut microbiome and inhibitor development in hemophilia A mice.

Lab work studentship

Matt Cormier
Queen’s University – Kingston, Ontario
Under the supervision of Dr. David Lillicrap and Julie Tarrant, Queen’s University

Hemophilia A is a genetic disorder that manifests itself through an inability to form blood clots within the body. Since this is due to the absence of a clotting protein (factor VIII), the gold-standard treatment is to inject the protein that is missing into the patient’s circulation to make up for the deficiency. Unfortunately, about 30% of hemophilia A patients develop inhibitors against this infused protein and render the treatment ineffective. The interaction between factor VIII and the body’s white blood cells are important for inhibitor generation as well as the tolerance to factor VIII, which is the absence of inhibitor generation to the protein. The gut harbours a vast population of microbes that have been shown to influence the immune response. Since different compositions of bacteria are linked to altered immune states, we are deciding to test whether different bacterial gut compositions have an affect on the development of inhibitors to factor VIII in mouse models. To do this, we are giving the hemophiliac mice antibiotics to alter their gut composition and measure many factors to determine if the presence of certain types of bacteria actually do influence the development of inhibitors.

 

Developing an evidence-based training program for mentors for a virtual peer-to-peer hemophilia mentoring program for teens.

 

 

Dr. Walter Kahr
Hospital for Sick Children – Toronto
First year fundingPeople with severe von Willebrand disease (VWD) have bleeding problems caused by a lack of von Willebrand factor (VWF), typically missing in their plasma and platelets. We have found, however, that patients with a particular mutation have some VWF in their platelets. They have less severe bleeding problems than most severe VWD patients, possibly owing to this platelet VWF.Our study addresses two key knowledge gaps: 1) How is VWF packaged by megakaryocytes into platelets? 2) What is the role of platelet VWF in reducing bleeding symptoms in some severe VWD patients? We will address these questions using methods we have successfully employed in my laboratory involving platelet development and function, including high resolution microscopy and genetic manipulation of megakaryocytes.

Dr. David Lillicrap
Queen’s University – Kingston, Ontario
Second year fundingThe aim of the studies described in this research proposal are to investigate possible causes for the increased risk of factor VIII inhibitor development that has been documented with one particular form of recombinant factor VIII concentrate. The theory being tested in these experiments is that the recombinant factor VIII in question is “decorated” with a different pattern of sugar molecules that trigger a response from the early, innate arm of the immune defense system. The studies that ate proposed will first determine the pattern of sugars associated with the surface of different forms of recombinant factor VIII. We will then examine the effect of the various recombinant concentrates on the immune cells that cleat factor VIII from blood and provide the initial response to the protein. These experiments will test whether the immune cells are excessively “activated” by any of the factor VIII concentrates. We will also be able change the sugar content of the factor VIII proteins through chemical means, to see whether this alters the effect on the immune cells. Finally, we will test the potential of the different factor VIII products to produce inhibitors in a novel “humanized” mouse model of hemophilia.

Dr. Tarik Möröy 
Institut de recherches cliniques de Montréal (IRCM)
Department of Hematopoiesis and Cancer
Third year fundingPlatelets are essential for blood clotting and are formed in the bone marrow by large cells, so-called ‘megakaryocytes’, which form long protrusions that penetrate into blood vessels, where the shear forces of the blood stream detach small pieces, which form the platelets. Low platelet numbers can be caused by different diseases or can be the result of an inherited disorder that leaves megakaryocytes unable to produce platelets. These heritable diseases are of clinical importance since low platelet numbers can cause excessive bleeding, which can create severe complications for instance during surgery. A better understanding which factors regulate platelet production is therefore needed to develop new treatments for platelet deficiencies. Recently, mutations in a gene called ‘Gfi1b’ have been identified in patients with a bleeding disorder caused by low platelet numbers. We have generated mice deficient for this gene and have observed that they show most of the typical symptoms of the human disease associated with the mutated Gfi1b, suggesting that the Gfi1b gene is a critical element in platelet formation. We propose therefore to investigate how this gene functions and regulates platelet formation to gain new insight on how to treat patients with bleeding disorders and platelet deficiencies.

Lab work studentshipMatt Cormier
Queen’s University – Kingston, Ontario
Under the supervision of Dr. David Lillicrap and Julie Tarrant, Queen’s UniversityHemophilia A is a genetic disorder that manifests itself through an inability to form blood clots within the body. Since this is due to the absence of a clotting protein (factor VIII), the gold-standard treatment is to inject the protein that is missing into the patient’s circulation to make up for the deficiency. Unfortunately, about 30% of hemophilia A patients develop inhibitors against this infused protein and render the treatment ineffective. The interaction between factor VIII and the body’s white blood cells are important for inhibitor generation as well as the tolerance to factor VIII, which is the absence of inhibitor generation to the protein. The gut harbours a vast population of microbes that have been shown to influence the immune response. Since different compositions of bacteria are linked to altered immune states, we are deciding to test whether different bacterial gut compositions have an affect on the development of inhibitors to factor VIII in mouse models. To do this, we are giving the hemophiliac mice antibiotics to alter their gut composition and measure many factors to determine if the presence of certain types of bacteria actually do influence the development of inhibitors.

Lab work studentshipClaudia Nguyen
Ryerson University – Toronto, Ontario
Under the supervision of Dr. Vicky Breakey, McMaster University – Hamilton, OntarioHemophilia is a rare bleeding disorder that can be complicated to manage. While the child and family share management of hemophilia; teens are expected to take on a greater role in managing their hemophilia as they mature. Yet, most teens with hemophilia do not receive comprehensive education on how to manage hemophilia on their own. Peer mentoring is proposed as one solution to address this gap in clinical care. Peer mentoring can provide meaningful social support and has also been associated with improved health outcomes. An online Skype-based peer mentoring program (Virtual Peer-to-Peer Support Mentoring Program [VP2P]) exists for teens with arthritis and chronic pain. However, these diseases are different and the groups are primarily female therefore making changes to this program necessary for the male teens with hemophilia. Recently, we have completed interviews in 25 young people with hemophilia to identify their peer mentoring wants and needs of youth with hemophilia in order to determine necessary changes to the VP2P for youth with hemophilia. This information will be used to develop a tailored peer mentoring program for youth with hemophilia. Our summer student’s project will involve developing the tailored mentoring program based on the information collected from teens and young adults. This program will later be studied to determine if it is an effective approach to improving transition of care from pediatrics to adult-based clinics.
 

A study of the clot ultrastructure when factor VIII deficient-plasma is coagulated in the presence of anticoagulants.

Lab work studentship

Rachelle Li
University of Western Ontario – London, Ontario
Under the supervision of Dr. Anthony Chan, Dr. Howard Chan and Jorell Gantioqui, McMaster University – Hamilton, Ontario

Hemophilia patients may develop life-threatening bleeding problems but they may paradoxically develop blood clot issues when the missing clotting protein in the blood is being replaced. Whereas blood thinner is usually needed to treat the blood clot, this treatment imposes a high risk of bleeding in hemophilia patients because of their inherited risk of bleeding. This is a very challenging situation for the managing clinicians. Therefore, we are proposing a study using electron microscopy to investigate the changes of blood clot structure. The information of this study will provide some fundamental information regarding the blood clot in hemophilia patients if they also receive blood thinner treatment. The findings of the current proposed study will look at the clotting process from another angle that can help the researchers to understand how blood thinner affects the blood clot in hemophilia patient who has already been deficient in a clotting protein.

Role of Gfi1b in the formation of platelets and in inherited bleeding disorders

Dr. Tarik Möröy 
Institut de recherches cliniques de Montréal (IRCM)
Department of Hematopoiesis and Cancer
Second year funding

Platelets are essential for blood clotting and are formed in the bone marrow by large cells, so-called ‘megakaryocytes’, which form long protrusions that penetrate into blood vessels, where the shear forces of the blood stream detach small pieces, which form the platelets. Low platelet numbers can be caused by different diseases or can be the result of an inherited disorder that leaves megakaryocytes unable to produce platelets. These heritable diseases are of clinical importance since low platelet numbers can cause excessive bleeding, which can create severe complications for instance during surgery. A better 
understanding which factors regulate platelet production is therefore needed to develop new treatments for platelet deficiencies. Recently, mutations in a gene called ‘Gfi1b’ have been identified in patients with a bleeding disorder caused by low platelet numbers. We have generated mice deficient for this gene and have observed that they show most of the typical symptoms of the human disease associated with the mutated Gfi1b, suggesting that the Gfi1b gene is a critical element in platelet formation. We propose therefore to investigate how this gene functions and regulates platelet formation to gain new insight on how to treat patients with bleeding disorders and platelet deficiencies.

 

The role of FVIII glycans on the immunogenic potential of FVIII concentrates

Dr. David Lillicrap
Queen’s University – Kingston, Ontario
First year funding

The aim of the studies described in this research proposal are to investigate possible causes for the increased risk of factor VIII inhibitor development that has been documented with one particular form of recombinant factor VIII concentrate. The theory being tested in these experiments is that the recombinant factor VIII in question is “decorated” with a different pattern of sugar molecules that trigger a response from the early, innate arm of the immune defense system. The studies that ate proposed will first determine the pattern of sugars associated with the surface of different forms of recombinant factor VIII. We will then examine the effect of the various recombinant concentrates on the immune cells that cleat factor VIII from blood and provide the initial response to the protein. These experiments will 
test whether the immune cells are excessively “activated” by any of the factor VIII concentrates. We will also be able change the sugar content of the factor VIII proteins through chemical means, to see whether this alters the effect on the immune cells. Finally, we will test the potential of the different factor VIII products to produce inhibitors in a novel “humanized” mouse model of hemophilia.

 

Implementing the assessment of hemophilic arthropathy joint changes over time: quantitative versus semiquantitative MR imaging of cartilage

Lab work studentship

Michelle Quaye
University of Western Ontario – London, Ontario
Under the supervision of Dr. Andrea Doria, Hospital for Sick Children – Toronto, Ontario

Background: Joint disease affects 90% of hemophiliacs greatly contributing to the cost and morbidity of the disease. Cartilage degeneration is the final unfavourable outcome of non-treated hemophilic patients which can be avoided or minimized with the use of prophylaxis. Recent advances in hemophilia prophylaxis have raised the need for accurate noninvasive methods for assessment of early cartilage damage in maturing joints to guide initiation of prophylaxis. Such methods can either be quantitative or semiquantitative. 

Objective: The study purpose is to compare a quantitative methodology through manual segmentation of articular cartilage parts (proposed new method) with a semiquantitative score (a priori determined International Prophylaxis Study Group MRI scoring system) and clinical-radiographic methods for short-term (1 year) evaluation of cartilage status in growing ankles of hemophilic children and adolescents. Data from a control group of healthy boys with ages similar to those of participating hemophilic patients will be available for comparison.

Methods: We will segmentate the cartilage on MRIs of 15 hemophilic ankles at two timepoints (baseline, 1 year), and on MRIs of 7 control ankles at a single timepoint using the new quantitative method. The findings of these MRIs will be interpreted by two experienced radiologists using the IPSG score using the conventional semiquantitative method. We will assess associations between interval cartilage changes by the quantitative and semiqualitative methods, and clinical and radiographic scores.

Relevance: The methodology that will be used in this study has the potential to improve the accuracy of interpretation of cartilage findings in maturing joints with hemophilic arthropathy. The results of this research can be used to improve the monitoring of failure to therapy/prophylaxis both in clinical practice and in research in the future. Failure to therapy/prophylaxis could be detected earlier with the proposed new quantitative methodology than with currently used semiquantitative MRI methodology. 

Characterization of Common Inherited Platelet Function Disorders

Dr. Catherine Hayward
McMaster University, Ontario
Second year funding

Co-investigators:
Dr. Guillaume Pare, McMaster University
Dr. Andrew Paterson, Hospital for Sick Children (University of Toronto)

Platelets are small blood cells that help stop bleeding. If platelets don’t work, it causes bleeding. Platelet disorders are a common cause of abnormal bleeding. To improve knowledge and patient care, we are studying why platelets don’t work normally in some families with bleeding problems. Our goal is to find the causes of very common platelet problems and learn more about how they affect health. We will study genes to learn why some people have platelet problems and others don’t. Answering why platelets don’t work normally in some families with bleeding problems requires tests on samples from many persons with platelet problems. Our testing will include studying why platelets don’t work normally in individuals from families with platelets problems. Knowledge on what causes common platelet disorders will be helpful to improve patient care and develop better tests for these conditions.

Understanding Angiodysplasia in von Willebrand Disease: Studies Using BOEC (Blood Outgrowth Endothelial Cells)

Dr. Paula James
Queen’s University, Ontario
Second year funding. 

Co-investigator: Dr. Maurice Don, Queen’s University  

Von Willebrand disease (VWD) is a common, inherited bleeding disorder that causes excessive bleeding from the skin and mucous membranes.  Patients experience nosebleeds, heavy menstrual periods, easy bruising and abnormal bleeding after dental work, childbirth and surgery.  Bleeding from the GI (gastrointestinal) tract in VWD patients occurs in up to 20% of patients and can be particularly difficult to treat. We do not completely understand what causes angiodysplasia (small vascular malformations like varicose veins on the inside of the bowel), which is a common reason for GI bleeding in VWD patients.  This research project will use endothelial cells that can be cultured from blood samples from VWD patients in order to better understand the factors that lead to angiodysplasia.  We will also study the effect and mechanisms of available treatments, including concentrates of von Willebrand factor, estrogen, thalidomide and atorvastatin. Our objective is to improve treatment for VWD with GI bleeding from angiodysplasia.

Role of Gfi1b in the formation of platelets and in inherited bleeding disorders

Dr. Tarik Möröy 
Institut de recherches cliniques de Montréal (IRCM)
Department of Hematopoiesis and Cancer
First year funding.

Platelets are essential for blood clotting and are formed in the bone marrow by large cells, so-called ‘megakaryocytes’, which form long protrusions that penetrate into blood vessels, where the shear forces of the blood stream detach small pieces, which form the platelets. Low platelet numbers can be caused by different diseases or can be the result of an inherited disorder that leaves megakaryocytes unable to produce platelets. These heritable diseases are of clinical importance since low platelet numbers can cause excessive bleeding, which can create severe complications for instance during surgery. A better understanding which factors regulate platelet production is therefore needed to develop new treatments for platelet deficiencies. Recently, mutations in a gene called ‘Gfi1b’ have been identified in patients with a bleeding disorder caused by low platelet numbers. We have generated mice deficient for this gene and have observed that they show most of the typical symptoms of the human disease associated with the mutated Gfi1b, suggesting that the Gfi1b gene is a critical element in platelet formation. We propose therefore to investigate how this gene functions and regulates platelet formation to gain new insight on how to treat patients with bleeding disorders and platelet deficiencies.

Thrombin generation assay to evaluate the heparin in hemophilic plasma

Lab work studentship

Ellen Z.L. Xu
Supervised by Dr. Howard Chan, McMaster University – Hamilton

Hemophilic patients have bleeding tendency. Yet, in certain situations, these patients are also subject to high risk of clotting. Blood thinner (anticoagulant) is used to prevent or treat blood clot. However, anticoagulant treatment in hemophilic patient will further increase the risk of bleeding. In other words, this will be a ‘damn if you do, damn if you don’t’ situation. In the medical literature, the optimal use of anticoagulant in hemophilic patients having clotting disease is not well studied. With this student scholarship, Ellen Xu is going to use an advanced laboratory assay that can evaluate the clotting in real time to evaluate the effects of an anticoagulant that is commonly used to treat hemophilic patients with blood clot problem. Her work will provide important information to guide the safe use of anticoagulants in hemophilic patients.

Incorporation of rFVIII into platelets as a potential therapy in patients with inhibitory antibodies to factor VIII

Dr. Walter Kahr
The Hospital for Sick Children – Toronto, Ontario
Second year funding

Current treatment of severe hemophilia A patients in Canada involves regular injections of recombinant factor VIII (rFVIII). This treatment is effective, but rFVIII injections are usually frequent because factor does not stay long in the blood stream and around 25% of patients develop inhibitors that block rFVIII effectiveness. Work is underway to develop longer-lasting forms of rFVIII and limit the effects of inhibitors. One approach involves platelets, the tiny, abundant blood cells that coordinate blood clotting. Platelets normally do not contain FVIII, but genetic engineering has been used to make mouse platelets containing FVIII that have proven to be effective in preventing bleeding in hemophilic mice even when they have inhibitors. We have been working on ways to load platelets with rFVIII that do not involve the risk, expense and uncertainties of genetic engineering. Our preliminary work shows that this is possible, and that rFVIII-loaded platelets can inhibit bleeding in hemophilic mice. The goal of our proposed project is to improve our methods for making rFVIII-loaded platelets and to demonstrate their potential for use in hemophilia patients with inhibitors, who are often difficult to treat with conventional therapies.

Understanding Angiodysplasia in von Willebrand Disease: Studies Using BOEC (Blood Outgrowth Endothelial Cells)

Dr. Paula James 
Queen’s University, Ontario
First year funding.  

Co-investigator: Dr. Maurice Don, Queen’s University   

Von Willebrand disease (VWD) is a common, inherited bleeding disorder that causes excessive bleeding from the skin and mucous membranes.  Patients experience nosebleeds, heavy menstrual periods, easy bruising and abnormal bleeding after dental work, childbirth and surgery.  Bleeding from the GI (gastrointestinal) tract in VWD patients occurs in up to 20% of patients and can be particularly difficult to treat. We do not completely understand what causes angiodysplasia (small vascular malformations like varicose veins on the inside of the bowel), which is a common reason for GI bleeding in VWD patients.  This research project will use endothelial cells that can be cultured from blood samples from VWD patients in order to better understand the factors that lead to angiodysplasia.  We will also study the effect and mechanisms of available treatments, including concentrates of von Willebrand factor, estrogen, thalidomide and atorvastatin. Our objective is to improve treatment for VWD with GI bleeding from angiodysplasia.

Characterization of Common Inherited Platelet Function Disorders

Dr. Catherine Hayward
McMaster University, Ontario
First year funding

Co-investigators: 
Dr. Guillaume Pare, McMaster University
Dr. Andrew Paterson, Hospital for Sick Children (University of Toronto)

Platelets are small blood cells that help stop bleeding. If platelets don’t work, it causes bleeding. Platelet disorders are a common cause of abnormal bleeding. To improve knowledge and patient care, we are studying why platelets don’t work normally in some families with bleeding problems. Our goal is to find the causes of very common platelet problems and learn more about how they affect health. We will study genes to learn why some people have platelet problems and others don’t. Answering why platelets don’t work normally in some families with bleeding problems requires tests on samples from many persons with platelet problems. Our testing will include studying why platelets don’t work normally in individuals from families with platelets problems. Knowledge on what causes common platelet disorders will be helpful to improve patient care and develop better tests for these conditions.

What are the Short-Term Effects of Physical Activity on the Cartilage of Hemophilic and Age-Matched Boys? Functional Imaging Perspective

Lab work studentship

Humayun Ahmed
Hospital for Sick Children
Under the supervision of Dr. Andrea Doria, the Hospital for Sick Children (Toronto)
Summer 2014 funding
            
Joint disease affects 90% of hemophiliacs greatly contributing to the cost and morbidity of the disease. Cartilage degeneration is the final unfavourable outcome of non-treated hemophilic patients which can be avoided or minimized with the use of prophylaxis. 
Imaging is an appealing tool for diagnosing early cartilage degeneration at a point where changes can potentially be reversible with appropriate therapy. T2 mapping MRI is a non-invasive technique that enables depiction of changes in cartilage microstructure which precede macroscopic cartilage loss.  Few studies have previously investigated the water-cartilage pattern of T2 mapping related to the directionality of collagen fibres in diseases other than hemophilia. 

Although there is evidence that physical activity increases risk of bleeds in children with hemophilia, exercise is thought to have a beneficial effect on hemophilic joints. Nevertheless, little is known about the effect of exercise on the cartilage status of hemophiliacs. 
We plan to apply a short-term exercise protocol (knee squats) to hemophilic and age-matched healthy boys to determine whether a change in the organization of collagen fibers can be detected in their maturing cartilage pre- and post-exercise. This information is critical for the development of future guidelines on safety and effectiveness of physical activity for hemophiliacs.

Effects of FEIBA on FXa generation in factor VIII and factor IX deficient plasma

Lab work studentship

Alice Kun Yi
McMaster University                     
Under the supervision of Dr. Howard Chan, McMaster University – Hamilton, Ontario
Summer 2014 funding

FEIBA is a plasma product containing some activated clotting proteins. It is an important treatment option for hemophilia patients refractory to regular factor replacement therapy because of the presence of inhibitors. As an off label use, it has also been used to reverse the new generation of blood thinners when non-hemophilic patients develop bleeding complications. However, the plasma in patients with hemophilia misses an important clotting factor, which may alter the ability of FEIBA to form blood clot when comparing with plasma obtained from normal population. Ms. Yi will use an assay in the laboratory to compare the differences in various types of plasma. The results will provide important information regarding the mechanistic actions of FEIBA so that its use can be optimized in various clinical settings.

Incorporation of rFVIII into platelets as a potential therapy in patients with inhibitory antibodies to factor VIII

Dr. Walter Kahr
The Hospital for Sick Children – Toronto, Ontario
First year funding

Current treatment of severe hemophilia A patients in Canada involves regular injections of recombinant factor VIII (rFVIII). This treatment is effective, but rFVIII injections are usually frequent because factor does not stay long in the blood stream and around 25% of patients develop inhibitors that block rFVIII effectiveness. Work is underway to develop longer-lasting forms of rFVIII and limit the effects of inhibitors. One approach involves platelets, the tiny, abundant blood cells that coordinate blood clotting. Platelets normally do not contain FVIII, but genetic engineering has been used to make mouse platelets containing FVIII that have proven to be effective in preventing bleeding in hemophilic mice even when they have inhibitors. We have been working on ways to load platelets with rFVIII that do not involve the risk, expense and uncertainties of genetic engineering. Our preliminary work shows that this is possible, and that rFVIII-loaded platelets can inhibit bleeding in hemophilic mice. The goal of our proposed project is to improve our methods for making rFVIII-loaded platelets and to demonstrate their potential for use in hemophilia patients with inhibitors, who are often difficult to treat with conventional therapies.

Novel imaging techniques for assessment of early cartilage and soft tissue changes in haemophilic ankles

Dr. Andrea Doria
The Hospital for Sick Children – Toronto, Ontario
Second year funding continued in 2013 due to late start.

Co-investigators: Dr. Aaron Fenster; Dr. Marshall Sussman; Dr. Victor Blanchette

RATIONALE AND BACKGROUND:
Hemophilia is an inherited bleeding disorder characterized by the lack of coagulation factors which results in an inability to control bleeding into joints, leading to long-term joint damage. Prophylaxis, reduces the joint symptoms and avoids further degeneration of the joints, however it should be started prior to the development of cartilage lesions. Repeated extravazation of blood into the joint cavity is the factor responsible for cartilage degeneration in hemophilic arthropathy. Microstructural cartilage changes are thought to precede macroscopic cartilage lesions [8] which are responsible for most of the morbidity of hemophilic arthropathy. Conventional imaging techniques are unable to visualize early soft tissue and cartilage changes. Evaluation of soft tissue changes and microstructural cartilage changes with sensitive imaging tools may direct clinical management and prophylaxis towards avoiding further irreversible macroscopic osteochondral damage. New functional MRI techniques and 3DUS anatomic imaging may be able to diagnose early joint changes at a time where treatment is still effective to avoid further degeneration of the joint. No prior studies have investigated the imaging of very early structural and physiologic events in hemophilic joints. We will pioneer the development of novel imaging techniques for assessment of early soft tissue and cartilage changes in hemophiliacs.

Oral administration of FVIII DNA to modulate inhibitors in hemophilia mice

Dr. Gonzalo Hortelano
McMaster University – Hamilton, Ontario
Second year funding

The delivery of genes as therapeutic drugs is still facing numerous challenges, particularly how to effectively deliver a therapeutic gene to the desired target cells, and the immune responses generated by the immune system to foreign DNA and to foreign or new proteins. Viruses are the most popular vehicle to deliver therapeutic genes, since they are very efficient at infecting cells. However, some human trials have revealed some safety concerns that need to be addressed. Additional and novel ways to deliver therapeutic genes would be desirable.
Ingestion of therapeutic genes would allow the intestine to produce a therapeutic protein for distribution throughout the body. However, DNA is degraded in the acidic stomach environment and by DNA-degrading proteins in the intestine. Our laboratory has shown that DNA formulated with chitosan into nanoparticles can withstand degradation under those conditions. Interestingly, we have not observed antibodies against the therapeutic protein encoded by ingested DNA. Further, we have evidence suggesting that this strategy can modulate the immune response to FVIII. The overall goal of this proposal is to understand the effect of ingested DNA on the immune system and to evaluate the potential of oral DNA in preventing and/or reducing FVIII inhibitors.

Platelet–type von Willebrand disease: Novel studies in the PT-VWD mouse model

Dr. Maha Othman
Queen’s University – Kingston, Ontario
Second year funding.

PT-VWD is a rare inherited bleeding disorder .Only 55 patients are described worldwide. The disease results from a hyper-responsive platelet protein known as GP Ib alpha due to genetic defect in the platelet GP1BA gene. The disease is characterized by low plasma VWF and platelet count. The latter can be aggravated in response to stress, infection and during pregnancy. Patients can have life threatening bleeding if not diagnosed and treated properly.
Currently the standard test for evaluating bleeding pattern is VWF:RCo (ristocetin cofactor assay) which has shown problems in relation to sensitivity and ristocetin binding. We hypothesize that the thromboelastography (TEG); a global hemostatic test is useful in evaluating hemostasis in PT-VWD and would potentially help monitor patients during pregnancy, at times of infection and following treatment. We plan to carry out novel studies in the PT-VWD
mouse model carrying a common human mutation G233V and exhibiting a similar phenotype to the human disease. We will investigate the utility of TEG in PT-VWD, evaluate the mouse model during early and late pregnancy and in response to infection and evaluate the effect of GP1b alpha inhibitors in improving the bleeding phenotype in these mice. These studies have not been previously done and are likely to improve our understanding of the PT-VWD disease and help diagnosis and follow up of patients.

The effect of FVIII on complement system activation

Lab work studentship

Joshua Foley
University of British Columbia
Under the supervision of Dr. Edward Conway
Summer 2013 funding

The blood clotting system is activated upon blood vessel damage and as a result blood loss is minimized. Individuals with hemophilia A lack an essential blood clotting factor and as a result they are at risk of excessive bleeding. State-of-the-art hemophilia treatment involves replenishing the missing clotting factor called factor VIII. Unfortunately, some of the patients receiving replacement FVIII develop antibodies, which neutralizes the treatment. This is the biggest complication of hemophilia treatment in developed countries and patients with these neutralizing antibodies require very expensive therapies. Recently, many novel connections between the blood clotting system and the complement system have been identified. The complement system is the first line of defense against invading pathogens and its activation has been shown to increase the body’s immune response. The purpose of this project is to determine the effect of FVIII on complement activation with the hope of identifying mechanisms that increase the immune response. The data generated during this project will guide future studies aimed at unraveling mechanisms contributing to neutralizing antibody development in hemophilia.

In-vitro clotting assays measuring equivalent concentration of FEIBA and rFVIIa

Lab work studentship

Xena Li
McMaster University
Under the supervision of Dr. Howard Chan, McMaster University – Hamilton, Ontario
Summer 2013 funding

Hemophilia is an inherited bleeding disorder due to the deficiency of a clotting protein. Although the usual treatment is to replace the clotting protein, some patients may become refractory to the therapy because it is rejected by patients’ own immune system. FEIBA and rFVIIa are two treatment options, but the equivalent dosing comparing these two products is not yet available. Without this information, it is not possible to evaluate which product has better effects. Our project will use some assays measuring global clot formation to determine the concentrations at which these products show equivalent clotting ability.

Investigating the Influence of SNPs (Single Nucleotide Polymorphisms) on variability of the Type 2B VWD phenotype

Lab work studentship

Malak Elbatarny
Queen’s University
Under the supervision of Dr. Paula James, Queen’s University – Kingston, Ontario
Summer 2013 funding

Type 2B von Willebrand disease (VWD) is an inherited bleeding disorder caused by mutations in the VWF gene that alter the function of a protein that is critical to clotting (von Willebrand factor). As a result, individuals who have the disease have moderate bleeding symptoms in mucocutaneous tissue, low platelet counts and low levels of the affected protein, von Willebrand factor (VWF). Interestingly, there is substantial variability among the symptoms of these patients that are not fully understood. In this study, we will attempt to investigate correlations between genotype and phenotype (the severity of the disease) using what is known as Family-Based Association Testing (FBAT). We will identify Single Nucleotide Polymorphisms (SNPs) or single base changes occurring in three large families with Type 2B VWD (27 individuals in total), and look for relationships between presence of these identified SNPs and the family members’ phenotypes. We expect to find that certain SNPs may be correlated with the severity of the patients’ disease including the bleeding symptoms, VWF levels and/or platelet count.

Novel imaging techniques for assessment of early cartilage and soft tissue changes in haemophilic ankles

Dr. Andrea Doria 
The Hospital for Sick Children – Toronto, Ontario
First year funding continued in 2012 due to late start.

Co-investigators: Dr. Aaron Fenster; Dr. Marshall Sussman; Dr. Victor Blanchette

RATIONALE AND BACKGROUND:
Hemophilia is an inherited bleeding disorder characterized by the lack of coagulation factors which results in an inability to control bleeding into joints, leading to long-term joint damage. Prophylaxis, reduces the joint symptoms and avoids further degeneration of the joints, however it should be started prior to the development of cartilage lesions. Repeated extravazation of blood into the joint cavity is the factor responsible for cartilage degeneration in hemophilic arthropathy. Microstructural cartilage changes are thought to precede macroscopic cartilage lesions [8] which are responsible for most of the morbidity of hemophilic arthropathy. Conventional imaging techniques are unable to visualize early soft tissue and cartilage changes. Evaluation of soft tissue changes and microstructural cartilage changes with sensitive imaging tools may direct clinical management and prophylaxis towards avoiding further irreversible macroscopic osteochondral damage. New functional MRI techniques and 3DUS anatomic imaging may be able to diagnose early joint changes at a time where treatment is still effective to avoid further degeneration of the joint. No prior studies have investigated the imaging of very early structural and physiologic events in hemophilic joints. We will pioneer the development of novel imaging techniques for assessment of early soft tissue and cartilage changes in hemophiliacs.

Oral administration of FVIII DNA to modulate inhibitors in hemophilia mice

Dr. Gonzalo Hortelano
McMaster University – Hamilton, Ontario
First year funding

The delivery of genes as therapeutic drugs is still facing numerous challenges, particularly how to effectively deliver a therapeutic gene to the desired target cells, and the immune responses generated by the immune system to foreign DNA and to foreign or new proteins. Viruses are the most popular vehicle to deliver therapeutic genes, since they are very efficient at infecting cells. However, some human trials have revealed some safety concerns that need to be addressed. Additional and novel ways to deliver therapeutic genes would be desirable.
Ingestion of therapeutic genes would allow the intestine to produce a therapeutic protein for distribution throughout the body. However, DNA is degraded in the acidic stomach environment and by DNA-degrading proteins in the intestine. Our laboratory has shown that DNA formulated with chitosan into nanoparticles can withstand degradation under those conditions. Interestingly, we have not observed antibodies against the therapeutic protein encoded by ingested DNA. Further, we have evidence suggesting that this strategy can modulate the immune response to FVIII. The overall goal of this proposal is to understand the effect of ingested DNA on the immune system and to evaluate the potential of oral DNA in preventing and/or reducing FVIII inhibitors.

Platelet–type von Willebrand disease: Novel studies in the PT-VWD mouse model

Dr. Maha Othman
Queen’s University – Kingston, Ontario
First year funding.

PT-VWD is a rare inherited bleeding disorder .Only 55 patients are described worldwide. The disease results from a hyper-responsive platelet protein known as GP Ib alpha due to genetic defect in the platelet GP1BA gene. The disease is characterized by low plasma VWF and platelet count. The latter can be aggravated in response to stress, infection and during pregnancy. Patients can have life threatening bleeding if not diagnosed and treated properly.
Currently the standard test for evaluating bleeding pattern is VWF:RCo (ristocetin cofactor assay) which has shown problems in relation to sensitivity and ristocetin binding. We hypothesize that the thromboelastography (TEG); a global hemostatic test is useful in evaluating hemostasis in PT-VWD and would potentially help monitor patients during pregnancy, at times of infection and following treatment. We plan to carry out novel studies in the PT-VWD
mouse model carrying a common human mutation G233V and exhibiting a similar phenotype to the human disease. We will investigate the utility of TEG in PT-VWD, evaluate the mouse model during early and late pregnancy and in response to infection and evaluate the effect of GP1b alpha inhibitors in improving the bleeding phenotype in these mice. These studies have not been previously done and are likely to improve our understanding of the PT-VWD disease and help diagnosis and follow up of patients.

Effects of anticoagulants on clot formation in factor VIII deficient plasma

Lab work studentship

Frank Lee 
McMaster University

Under the supervision of Dr Howard Chan
McMaster University 
Summer 2012 funding

Hemophilia patients have bleeding tendency. Yet, in certain situations, these patients are also subject to high risk of clotting. Blood thinner (anticoagulant) is used to prevent or treat blood clot. However, anticoagulants also carry the risk of bleeding. The optimal use of anticoagulant in these conditions has not been well studied. Mr. Lee has set up an assay system in the laboratory mimicking the clotting system in hemophilia patients. He will use this assay to determine the effects of anticoagulants on blood clot formation. His work will provide important information to guide the safe use of anticoagulants in hemophilia patients.

Determinants of health-related quality of life among patients with von Willebrand disease

Lab work studentship

Yan Xu 
Queen’s University

Under the supervision of Dr Paula James
Queen’s University
Summer 2012 funding

von Willebrand disease (VWD) is a common bleeding disorder. Among its patients, there is a significant health burden associated with the bleeding symptoms from the disease. While methods of numerically determining patients’ bleeding symptoms have recently been developed and tested, very little research has gone into investigating the quality of life among those afflicted with this disease, especially in the Canadian patient population. This project aims to determine the quality of life among patients with mild, moderate and severe forms of VWD. Further, we hope to find out whether a patient’s quality of life can be predicted by his or her levels of bleeding symptoms, social support and geographical access to treatment. By understanding the relative contributions of these 3 factors on quality of life, we hope to inform better ways to ensure that day-today living for all VWD patients can be improved.

Treatment adherence on the Canadian Hemophilia Prophylaxis Study

Lab work studentship

Daniel Kazandjian 
Carleton University

Under the supervision of Dr Brian Feldman
The Hospital for Sick Children
Summer 2012 funding

Research Question: How does treatment adherence affect outcomes?
The Canadian Hemophilia Prophylaxis Study is on ongoing prospective cohort study. The first subject was enrolled in 1997. We have followed 56 boys for a median of 106 months. With this large data set we would like to examine adherence with various aspects of the protocol. Last summer we performed some preliminary analysis of adherence with the protocol in regards to treatment, escalation and prescribed infusions. This preliminary work led to this proposal in which we are looking at adherence in much great details. We will first look at adherence with all aspects of the protocol including infusion, visits, escalations and treatment of joint bleeds. After this early analysis is complete we will look at some more interesting questions that will include the following: how does adherence with the protocol affect outcomes? How does adherence with infusions (per protocol) relate to bleeding, physiotherapy scores and other outcomes? We will also look at adherence related to the time on study as well as adherence within each of the steps of the protocol.

Factor XIII deficiency in Canada

Lab work studentship

Jodie Odame

University of Western Ontario

Under the supervision of Dr. Vicky Breakey
McMaster
Summer 2012 funding

Factor XIII deficiency is a rare, but important bleeding disorder. The Rare Inherited Bleeding Disorder Registry in Canada shows that there are approximately 50 Canadians with factor XIII deficiency. Although individuals with severe factor XIII deficiency often receive prophylaxis, little is known about compliance with prophylaxis and any breakthrough bleeding that may occur. A survey will be completed to document the current management of this bleeding disorder and to better understand the impact of factor XIII deficiency for patients in Canada. Although factor XIII deficiency is uncommon, it is important that pediatricians are knowledgeable about this condition, as it often presents with intracranial bleeding in the neonatal period.In addition, women with factor XIII deficiency need special care to maintain pregnancy. An educational module will enrich the current education of medical students, residents and fellows, with the goal of increasing awareness of rare bleeding disorders.

An evaluation of FVIII expression in phenotypically distinct endothelial cells

Dr. Christine Hough
Dept. of Pathology and Molecular Medicine
Queen’s University
Second year funding

Co-Investigator: Dr. David Lillicrap

Factor VIII (FVIII) is synthesized in some but not all endothelial cells. Our understanding of mechanisms that regulate this FVIII expression is very poor, in large part because expression of FVIII is rapidly lost when these cells are isolated and cultured. However, culture conditions do not reflect the natural endothelial environment in blood vessels. Flowing blood exerts shear stress (frictional) forces on endothelial cells, and this causes them to alter the expression of many genes. We want to provide culture conditions that reflect the different endothelial environments throughout the vasculature by exposing the cells to different levels of shear stress. These cells will then be evaluated for the affect that this has on the production of FVIII.
 
Endothelial cells throughout the body are quite heterogeneous and we want to generate a number of phenotypically distinct endothelial cells that are found in large or small arteries and veins. To do this we will differentiate endothelial progenitor cells under shear stress conditions that are reflective of the conditions where these vessels are normally located.
 
This study will provide insights into how shear stress affects FVIII expression in endothelial cells and how inherent phenotypic differences between endothelial cells modify FVIII expression. Overall, we expect to advance our understanding of mechanisms that regulate FVIII expression in endothelial cells.

Novel imaging techniques for assessment of early cartilage and soft tissue changes in haemophilic ankles

Dr. Andrea Doria 
Diagnostic and Imaging Department
The Hospital for Sick Children – Toronto, Ontario
First year funding

Co-investigators: Dr. Aaron Fenster; Dr. Marshall Sussman; Dr. Victor Blanchette

Hemophilia is an inherited bleeding disorder characterized by the lack of coagulation factors which results in an inability to control bleeding into joints, leading to long-term joint damage. Prophylaxis, reduces the joint symptoms and avoids further degeneration of the joints, however it should be started prior to the development of cartilage lesions. Repeated extravazation of blood into the joint cavity is the factor responsible for cartilage degeneration in hemophilic arthropathy. Microstructural cartilage changes are thought to precede macroscopic cartilage lesions [8] which are responsible for most of the morbidity of hemophilic arthropathy. Conventional imaging techniques are unable to visualize early soft tissue and cartilage changes. Evaluation of soft tissue changes and microstructural cartilage changes with sensitive imaging tools may direct clinical management and prophylaxis towards avoiding further irreversible macroscopic osteochondral damage. New functional MRI techniques and 3DUS anatomic imaging may be able to diagnose early joint changes at a time where treatment is still effective to avoid further degeneration of the joint. No prior studies have investigated the imaging of very early structural and physiologic events in hemophilic joints. We will pioneer the development of novel imaging techniques for assessment of early soft tissue and cartilage changes in hemophiliacs.

Validation of the HEI-Q in adolescents with hemophilia

Lab work studentship

Ms. Ashley Warias
McMAster University

Under the direct supervision of Dr Vicky Breakey & indirect supervision of Dr V. Blanchette
The Hospital for Sick Children, Toronto
Summer 2011 funding

Transition is a difficult time for adolescents with hemophilia.  We are in the process of completing an Internet-based education program for adolescents with hemophilia.  “Teens Taking Charge: Managing Hemophilia Online” will provide teens with eight modules of learning and help them to build self-management skills prior to transition to adult care.  As a key part of our evaluation of this program, we will use validated tools that are hemophilia-specific.  Our assessment of the website will include determination of quality of life, self-efficacy and stress.  We will also see if teens gain knowledge and are satisfied with the program.  The Health Education Intervention Questionnaire (HEI-Q, Osborne et al. 2007) is a suitable tool to assess the impact of the program, but has not yet been validated in adolescents. We aim to validate the HEI-Q in teens with hemophilia.  This process will include clinical adaption of the language of the survey tool as needed, consensus discussion with investigators, cognitive testing with teens, revisions as needed, application in the field and psychometric evaluations. Ms Warias will be involved in the cognitive testing and revisions of the tool.  If there is time, she will begin the process of application in the field; if not, this will be completed by a clinical research assistant.

Quantitative ultrasound in a rabbit model of blood-induced arthropathy

Lab work studentship

Mr. Kuan-Chieh (Jackson) Wang
University of Toronto

Under the supervision of Dr Andrea Doris
The Hospital for Sick Children, Toronto
Summer 2011 funding

Bleeding inside the body causes many troubles. Blood might build up in joints and cause extreme pain which prevents the patients to do normal physical activities. This leads to a decrease in bone quality. For children, it reduces the quality of life and may affect their growth. We will try to establish the reliability of quatitative ultrasound which is a diagnostic tool that can be easily used to monitor children’s bone.

An evaluation of FVIII expression in phenotypically distinct endothelial cells.

Dr. Christine Hough
Dept. of Pathology and Molecular Medicine
Queen’s University
First year funding

Co-Investigator: Dr. David Lillicrap

Factor VIII (FVIII) is synthesized in some but not all endothelial cells. Our understanding of mechanisms that regulate this FVIII expression is very poor, in large part because expression of FVIII is rapidly lost when these cells are isolated and cultured. However, culture conditions do not reflect the natural endothelial environment in blood vessels. Flowing blood exerts shear stress (frictional) forces on endothelial cells, and this causes them to alter the expression of many genes. We want to provide culture conditions that reflect the different endothelial environments throughout the vasculature by exposing the cells to different levels of shear stress. These cells will then be evaluated for the affect that this has on the production of FVIII.
 
Endothelial cells throughout the body are quite heterogeneous and we want to generate a number of phenotypically distinct endothelial cells that are found in large or small arteries and veins. To do this we will differentiate endothelial progenitor cells under shear stress conditions that are reflective of the conditions where these vessels are normally located.
 
This study will provide insights into how shear stress affects FVIII expression in endothelial cells and how inherent phenotypic differences between endothelial cells modify FVIII expression. Overall, we expect to advance our understanding of mechanisms that regulate FVIII expression in endothelial cells.

Use of amphipathic helical peptides coupled to nanofibrous microspheres to control hemorrhagic external bleeding in hemophiliacs

Dr. Mark Blostein
Lady Davis Institute for Medical Research
McGill University – Montreal, Quebec
Second year funding

Co-investigator:  Dr. Jake Baralet

The hereditary hemophilias are the most common inherited severe bleeding disorders and are characterized by lifelong bleeding, both spontaneous, internal bleeding as well external bleeding due to injury, most commonly from surgical procedures. The current research grant proposes to develop a new biocompatible matrix employing nanotechnology that is hemostatic by incorporating a peptide that accelerates blood coagulation and will therefore stop bleeding. This peptide was discovered in my laboratory and reduces bleeding in animal models of hemorrhage. Therefore, attaching this peptide to „nanotechnology‟ based materials has great promise as a novel agent to reduce bleeding from external hemorrhagic injuries. The methodology will include utilizing standard biochemical techniques to characterize the material followed by the testing of the biocompatible material in animal models. The development of this product is especially relevant to the goals of the Canadian Hemophilia Society by discovering new materials to control external bleeding in hemophiliacs particularly after surgical procedures.

Markers of fibrinolysis and endothelial function in adult males with hemophilia.

Lab work studentship 

Ms. Kathleen De Asis
University of British Columbia
Under the supervision of Dr. Shannon Jackson
St-Paul’s Hospital, Vancouver (B.C.)
Summer 2010 funding

The endothelium is a protective surface on the arteries that if disturbed can increase the risk of developing atherosclerosis and its complications including heart attacks and strokes.  Heart attack (myocardial infarction) and stroke are caused by the long term build-up of atherosclerosis (plaques of fatty material and cholesterol) and then sudden clot that occurs over a ruptured atherosclerotic plaque.  Blood flow to heart muscle or brain tissue downstream from the blockage slows or stops and the tissue suffers damage. When a heart attack or stroke occurs doctors sometimes use drugs called ‘anti-fibrinolytics’ in large doses to dissolve the clot and allow more blood flow to downstream tissue.  
Early studies suggest that haemophiliacs are less likely to die from heart attacks and strokes than the average person.  As part of a Canadian study  (‘Risk of Ischemic Heart Disease in Hemophilia: Evaluating Endothelial Function and the Development of Atherosclerotic Vascular Disease in Hemophilia’) our summer student, Kathleen De Asis, will study 3 major fibrinolytic substances using blood samples from the subjects with hemophilia enrolled to date and controls. Time permitting she may work with basic scientists to look at more novel markers in these samples.

The role of X-inactivation in the expression of hemophilia A in women

Dr. Wenda L. Greer, FCCMG
Professor, Department of Pathology
Dalhousie University – Halifax, Nova Scotia
Second year funding

Co-investigators: Dr. Sue Robinson, Dr. Sarah Dyack

Hemophilia A (HA) is an X-linked bleeding disorder resulting from mutations in the F8 gene. One functional F8 gene is sufficient for normal clotting. Thus, typically XY males who interit one mutated F8 gene are affected while heterozygous XX females are not. Rarely, heterozygous females with HA have been described. These can arise due to unfavourably skewed X chromosome inactivation (XCI). This is a dosage compensation mechanism that causes one X in every female cell to be inactivated early in development. In most females, approximately half of their cells inactivate their maternal and half their paternal X. In rare cases, XCI is skewed. If it is skewed toward the activation of a mutated gene, a heterozygous female can be affected. A family has presented with several males and several females affected with HA. In the females, most cells were expressing the mutated paternal X chromosome. It is unlikely that chance could account for the dramatic skewing of XCI leading to 3 affected females. 

Our objective is to understand why these females are expressing HA. Our hypothesis is that is is due to skewed XCIR resulting from an inherited predisposition for the mutated X-chromosome to remain active. 

Our aims are to: 

  • determine XCI patterns and correlate these with disease expression
  • determine whether XCIR skewing is more consistent with genetically influenced or random XCI.
  • delineate, through microsatellite analysis, a region of the X-chromosome that is associated with varied   susceptibility of XCI
  • consider potential candidate genes from this region.
  • identify the clinical symptoms and standards of care of carrier females, and their experiences with medical treatment by interviewing carrier females and healthcare professionals.

We believe that this family provides a unique opportunity to study XCI and its role in the expression of HA in heterozygous females. It also provides an opportunity to document the clinical phenotype of female carriers who differ in their factor VIII activities according to their respective XCIR.

This project was extended until August 31, 2011.

An evaluation of the prevalence and functional significance of non-neutralizing antibodies to factor VIII

Dr. David Lillicrap
Department of Pathology and Molecular Medicine
Queen’s University – Kingston, Ontario
Second year funding

Co-investigators: Dr. Jerome Teitel, Dr. Georges-Étienne Rivard, Dr. Irwin Walker

Funded through an unrestricted research grant to the Canadian Hemophilia Society from Bayer HealthCare

The development of antibodies to factor VIII (FVIII) represents the main treatment-related complication of current therapies for hemophilia A. For the past 30 years, this complication has been evaluated by a laboratory test that detects only those antibodies that interfere with FVIII’s clotting function. There is growing evidence to suggest that in addition to antibodies that inhibit the functional activity of FVIII, some “non-neutralizing” antibodies are also generated by FVIII exposure. The prevalence of these antibodies, their overlap with neutralizing inhibitors and their clinical significance are all factors that are very poorly characterized and form the basis for the studies proposed in this research project. In this project, we will establish a laboratory test to detect and quantify the levels of antibodies that bind to FVIII in plasma. The test plasma samples have already been characterized with a functional antibody test (the Bethesda assay) and thus overlapping patterns of reactivity will be apparent. Finally, when detected, we will attempt to correlate the presence of non-neutralizing antibodies with in vivo FVIII recovery and half-life.

Phenotypic Characterization of Three Candidate Type 2B von Willebrand Disease Missense Mutants

Dr. Maha Othman
Adjunct Assistant Professor, Department of Pathology and Molecular Medicine
Queen’s University – Kingston, Ontario 
One year funding

Co-investigator: Dr. David Lillicrap

Type 2B von Willerband disease (VWD) is a unique bleeding disorder among all types of VWD where there is an enhanced interaction between blood platelets and the VWF protein. The disease is known to result from mutations in certain area of the VWF gene producing an abnormally adhesive VWF protein leading to excessive mucocutaneous bleeding. Not all patients with type 2B VWD show similar clinical picture and/or labaoratory features. In addition, some of the confirmatory laboratory testing are not available in all laboratories or are poorly applied. This infuences the diagnostic certainity of the disease with an implication on treatment decisions. A conclusive evidence towards the clinical diagnosis can be provided by identification of the genetic mutations responsible for the disease and to functionally study these mutations to prove its link to the clinical/ laboratory picture. In this project we aim to study three novel candidate mutations that we have identified in patients with type 2B VWD through the Canadian PT-VWD project. This study will prove whether or not these mutations are responsible for the clinical and laboratory features observed in these patients and will validate the treatment decisions.

Use of amphipathic helical peptides coupled to nanofibrous microspheres to control hemorrhagic external bleeding in hemophiliacs

Dr. Mark Blostein
Lady Davis Institute for Medical Research
McGill University – Montreal, Quebec
First year funding

Co-investigator:  Dr. Jake Baralet

The hereditary hemophilias are the most common inherited severe bleeding disorders and are characterized by lifelong bleeding, both spontaneous, internal bleeding as well external bleeding due to injury, most commonly from surgical procedures. The current research grant proposes to develop a new biocompatible matrix employing nanotechnology that is hemostatic by incorporating a peptide that accelerates blood coagulation and will therefore stop bleeding. This peptide was discovered in my laboratory and reduces bleeding in animal models of hemorrhage. Therefore, attaching this peptide to „nanotechnology‟ based materials has great promise as a novel agent to reduce bleeding from external hemorrhagic injuries. The methodology will include utilizing standard biochemical techniques to characterize the material followed by the testing of the biocompatible material in animal models. The development of this product is especially relevant to the goals of the Canadian Hemophilia Society by discovering new materials to control external bleeding in hemophiliacs particularly after surgical procedures.

Risk of Ischemic Heart Disease in Hemophilia: Evaluating Endothelial Function and the Development of Atherosclerotic Vascular Disease in Hemophilia

Dr. Shannon Jackson
Department of Medicine and Hematology
University of Calgary – Calgary, Alberta
One year funding

Co-investigators: Dr. Man Chiu Poon, Dr. Robert Card

The deposition of cholesterol and inflammatory cells within arteries is termed atherosclerosis and is the leading cause of death in Canada.  The endothelium is a protective surface on the arteries that if disturbed can increase the risk of developing atherosclerosis and its complications including heart attacks and strokes.  Early studies suggest that haemophiliacs are less likely to die from heart attacks and strokes than the average person.  However, that has not been proven and research is needed to find out. In this study, function of endothelium will be tested with a specialized ultrasound and finger probe.  Abnormal function of the endothelium is felt to represent early disease of the arteries which may develop into atherosclerosis and cause heart attack or stroke. In this study,  an interview will be completed to collect information on general medical history, risk factors for heart disease and stroke, hemophilia history, dietary and activity habits, quality of life, and family history.  A physical examination will be performed and fasting laboratory testing completed (including collection of blood for storage so that in the future we can examine the DNA for genetic factors that may affect endothelial function and/or the development of heart disease).  Finally, each subject will be followed for 5 or more years to see what the rate of developing heart disease and strokes is.  This and the above data will be compared to a control group of male firefighters who have participated in a study called Firefighters and Their Endothelium (FATE). This study will start in Calgary with approximately 30 subjects with hemophilia and eventually be expanded to at least one other hemophilia centre in Canada and include a total of approximately 100 subjects with hemophilia.

Use of Ports in Canadian Hemophilia Prophylaxis Study (CHPS)

Lab work studentship 

Ms. Samatha Chait
University of Western Ontario
Under the supervision of Dr. Brian Feldman
Hospital for Sick Children in Toronto
Summer 2009 funding

Funded through a research grant to the Canadian Hemophilia Society from Bayer Health Care 

Preventative treatment with blood clotting factor for severe hemophilia A is likely to be more effective than treatment given only when joint bleeding occurs.  However, preventative treatment is very expensive.  For the past 11 years we have been studying 55 boys on an ongoing basis to determine whether preventative treatment using a “tailored” approach can help prevent some of the problems associated with hemophilia, while at the same time minimizing frequency and cost of treatment.  At the beginning of the study, patients are given weekly treatments of clotting factor.  If an unacceptable amount of bleeding occurs, the frequency of factor infusions is increased to twice a week.  If unacceptable bleeding continues, infusions are increased to alternate day frequency.   In order to determine how well the patients are doing, we are recording the number of joint bleeds, number of joints with recurrent bleeding, as well as physiotherapy assessments.  In addition, we are collecting data on the cost of tailored prophylaxis.  We are also following the use of ports in patients, as our experience with ports in this study is noticeably better than that in the published literature. Enrollment onto the study is now closed, with continuing follow-up of those enrolled.  The cohort will be followed for an additional 5 years.

Platelet type von Willebrand disease: An underdiagnosed cause of excessive mucocutaneous bleeding?

Dr. Maha Othman
Adjunct Assistant Professor, Department of Pathology and Molecular Medicine
Queen’s University – Kingston, Ontario Second year funding

Co-investigator: Dr. David Lillicrap

Platelet type von Willebrand disease (PT-VWD) and type 2B von Willebrand disease have similar clinical as well as laboratory features while resulting from abnormalities in two different genes. Type 2B VWD results from a defective von Willebrand factor (VWF) and PT-VWD is caused by platelet GP1BA gene defect. The discrimination between the two disorders is often a challenge. The general tests necessary for the identification require particular technical experience and necessitate fresh blood samples. Definitive diagnoses can be made by revealing the gene defect in either the VWF or the GP1BA. The correct diagnosis and discrimination between the two disorders has important implication on treatment decision. The VWF/FVIII concentrate, the major treatment in type 2B-VWD, may worsen platelet count and bleeding conditions in PT-VWD. Platelet concentrate is the ideal treatment for PT-VWD. In this study, we propose that patients with PT- VWD are being under / miss diagnosed among type 2B VWD and we adopt the use of a genetic approach for a definitive diagnosis of PT-VWD. The DNA analysis will include the related area of the VWF gene responsible for type 2B VWD and also the platelet GP1BA gene responsible for PT-VWD in 100 patients initially diagnosed with type 2B VWD from Canada and worldwide. Under the auspices of the International Society for Thrombosis and Hemostasis: Scientific and Standardization Committee on von Willebrand Factor, we established an online database/disease registry now accessible at www.pt-vwd.org. The project /registry will address the question of how many PT-VWD cases are being misdiagnosed among the type 2B VWD cases, increase awareness among physicians, specialists and patients about this diagnostic problem and will indicate the significance of the genetic analysis in these patients with subsequent implication on treatment decision.

Factor VII(a) clearance behaviour

Dr. William P. Sheffield
Associate Professor, Department of Pathology and Molecular Medicine
McMaster University – Hamilton, Ontario
Second year funding

Co-investigator: Dr. B.J. Clarke

The hemophilia community knows all too well that the replacement therapy that can restore hemophiliacs to an active life is not always problem-free. For individuals with hemophilia A, replacement therapy with purified recombinant factor VIII (fVIII) can sometimes be complicated by inhibitor formation. Inhibitors are antibodies directed against the injected fVIII. Fortunately, administration of recombinant factor VIIa (fVIIa) can bypass this potentially serious problem. However, fVII is one of the coagulation factors that leaves the circulation the most rapidly. This clearance behaviour is not completely understood. For this reason, Drs. Bill Sheffield and Bryan Clarke, of McMaster University and Canadian Blood Services have received a CHS research grant to study the clearance of fVII(a) in mice genetically altered to have hemophilia A. The investigators will use DNA and cell culture technology to make both human fVII identical to current clinical products, and new forms of fVII in their laboratories. Once purified, how long the fVII-related proteins last in the mouse circulation, and how well they control bleeding will be determined. The most unusual products to be tested are “fusions” – in which fVII and human serum albumin, ordinarily separate proteins, are combined into a single chain. The researchers propose that fVII will continue to work in this new format, and will remain in the circulation for much longer than the current product. The longer it remains, the more effective it should be in combating bleeding. Sheffield and Clarke hope that their research will lead to better understanding of the mechanism of action of rfVIIa, and to the design of improved rfVII(a) products to provide caregivers with novel tools to help hemophiliac patients with inhibitors.

Structural and genetic analysis of the complexes between factor VIII and low density lipoprotein receptor-related protein: Toward a long-acting factor VIII

Ann English, PhD
Department of Chemistry and Biochemistry
Concordia University – Montreal, Quebec
First year funding

Co-investigator: Dr. Tongpil Min (CO-PI)

Scientific developments have provided a new generation of safer factor VIII (FVIII) biopharmaceuticals that are free of blood-born pathogens. However, the high cost of FVIII still remains a big hurdle in hemophilia treatment. Only certain countries can afford prophylaxis or on-demand treatment while many others cannot even meet on-demand requirements. Clearly, FVIII has to be further developed to yield a product with a prolonged half-life. 

Our project that is being supported by the CHS Dream of a Cure Research Program will provide the critical structural information to inform the development of longer acting FVIII.  It is well known that low-density lipoprotein receptor-related protein (LRP), a receptor molecule, is responsible for eliminating FVIII from blood. FVIII clearance by LRP requires that the two proteins bind to each other. Thus, if the FVIII-LRP binding interaction is decreased, FVIII will remain in the blood stream longer. However, FVIII/LRP binding mechanisms have to be well understood to avoid possible side effects such as the induction of inhibitory antibodies. We will generate a 3D model of the FVIII/LRP binding interfaces using x-ray crystallography. Complexes between specific FVIII domains and LRP clusters will elucidate at the molecular level how LRP binds and eliminates FVIII. Such atomic-level structural details of the binding interfaces will indicate how the sequence of FVIII should be modified to decrease its interaction with LRP. Reduced affinity between FVIII and LRP will be evaluated using state-of-the art biophysical techniques. The results will guide the development of the next generation of FVIII biopharmaceuticals with a prolonged biological half-life. Longer lasting FVIII will allow treatment for all and bring us one step closer to a cure.

The role of X-inactivation in the expression of hemophilia A in women

Dr. Wenda L. Greer, FCCMG
Professor, Department of Pathology
Dalhousie University – Halifax, Nova Scotia
First year funding

Co-investigators: Dr. Sue Robinson, Dr. Sarah Dyack

Hemophilia A (HA) is an X-linked bleeding disorder resulting from mutations in the F8 gene. One functional F8 gene is sufficient for normal clotting. Thus, typically XY males who interit one mutated F8 gene are affected while heterozygous XX females are not. Rarely, heterozygous females with HA have been described. These can arise due to unfavourably skewed X chromosome inactivation (XCI). This is a dosage compensation mechanism that causes one X in every female cell to be inactivated early in development. In most females, approximately half of their cells inactivate their maternal and half their paternal X. In rare cases, XCI is skewed. If it is skewed toward the activation of a mutated gene, a heterozygous female can be affected. A family has presented with several males and several females affected with HA. In the females, most cells were expressing the mutated paternal X chromosome. It is unlikely that chance could account for the dramatic skewing of XCI leading to 3 affected females. 

Our objective is to understand why these females are expressing HA. Our hypothesis is that is is due to skewed XCIR resulting from an inherited predisposition for the mutated X-chromosome to remain active. 

Our aims are to:

  • determine XCI patterns and correlate these with disease expression
  • determine whether XCIR skewing is more consistent with genetically influenced or random XCI.
  • delineate, through microsatellite analysis, a region of the X-chromosome that is associated with varied susceptibility of XCI
  • consider potential candidate genes from this region.
  • identify the clinical symptoms and standards of care of carrier females, and their experiences with medical treatment by interviewing carrier females and healthcare professionals.

We believe that this family provides a unique opportunity to study XCI and its role in the expression of HA in heterozygous females. It also provides an opportunity to document the clinical phenotype of female carriers who differ in their factor VIII activities according to their respective XCIR.

An evaluation of the prevalence and functional significance of non-neutralizing antibodies to factor VIII

Dr. David Lillicrap
Department of Pathology and Molecular Medicine
Queen’s University – Kingston, Ontario
First year funding

Co-investigators: Dr. Jerome Teitel, Dr. Georges-Étienne Rivard, Dr. Irwin Walker

Funded through an unrestricted research grant to the Canadian Hemophilia Society from Bayer HealthCare

The development of antibodies to factor VIII (FVIII) represents the main treatment-related complication of current therapies for hemophilia A. For the past 30 years, this complication has been evaluated by a laboratory test that detects only those antibodies that interfere with FVIII’s clotting function. There is growing evidence to suggest that in addition to antibodies that inhibit the functional activity of FVIII, some “non-neutralizing” antibodies are also generated by FVIII exposure. The prevalence of these antibodies, their overlap with neutralizing inhibitors and their clinical significance are all factors that are very poorly characterized and form the basis for the studies proposed in this research project. In this project, we will establish a laboratory test to detect and quantify the levels of antibodies that bind to FVIII in plasma. The test plasma samples have already been characterized with a functional antibody test (the Bethesda assay) and thus overlapping patterns of reactivity will be apparent. Finally, when detected, we will attempt to correlate the presence of non-neutralizing antibodies with in vivo FVIII recovery and half-life.

Carrier frequency among mothers of children with hemophilia

The correlation between responsiveness to DDAVP and hemophilia genotype among patients with mild hemophilia as followed at the Hospital for Sick Children.

David Feldman
University of Western Ontario
Under the supervision of Dr. Manuel Carcao
Hospital for Sick Children in Toronto – Toronto, Ontario

Funded through a research grant to the Canadian Hemophilia Society from Bayer HealthCare.

David Feldman worked at the Hospital for Sick Children from May-August 2008 on a study examining the concordance between hemophilia mutation and DDAVP responsiveness in patients with mild and moderate hemophilia A. He was also involved in a study which examined the carrier status of mothers of patients with hemophilia A. All patients included in these studies were followed in the hemophilia clinic at the Hospital for Sick Children, Toronto.

DDAVP responsiveness and genetics
David was responsible for the collection and organization of the raw data for his primary project which examined the correlation between DDAVP responsiveness and hemophilia genotype. He compiled a list of patients (n=105) that met the inclusion criteria of the study. David then reviewed the charts of all of these eligible patients. Of the 105 patients, 74 met both the inclusion and the exclusion criteria. All the data was incorporated into a database which David designed. David was responsible for all aspects of collecting, entering and checking the data, which he completed before the end of the summer term.

David submitted an abstract to the Summer Student Research (SSuRe) Program Symposium at the Hospital for Sick Children. At the symposium he presented a poster using preliminary data from this study.

Data collection is now closed for the study. David started the process of writing a paper before completing his work term. He is currently involved in finishing up the paper so that it can be submitted to a peer reviewed journal – either Haemophilia or the British Journal of Haematology.

The results of this study have revealed a tremendous concordance of DDAVP responsiveness in individuals with the same genetic mutation responsible for their hemophilia. It also showed that DDAVP response is associated with older age at testing and with higher baseline factor VIII levels. Awareness of this should allow physicians to be able to predict who will and who will not respond to DDAVP and as such may result in less need for DDAVP challenge tests to be done. It also alerts physicians to the need to repeat DDAVP testing in patients tested at young ages and found not to respond to DDAVP.

The incidence of carrier status in mothers of children with hemophilia
The second project on which David worked examined the incidence of carriership in mothers of children with hemophilia. For this project David reviewed a previously developed genetics data base at the Hospital for Sick Children and then updated this database.

Preliminary results have demonstrated that approximately 95% of mothers of children with hemophilia are carriers. Final analysis of the data is pending the completion of the DDAVP project. After analysis has been done the plan is to write a paper to be published in a peer reviewed journal reporting the results.

Transfusions and regional anesthesia of the knee

Lab work studentship

Valérie Oulette
Université de Montréal
Under the supervision of Dr. Jean-François Hardy
Centre Hospitalier de l’Université de Montréal (CHUM)

Protocol and Objectives:

To determine prospectively through observation the minimum level of hemoglobin necessary to allow for optimal recovery after major orthopedic surgery.

Expected Results:

It will be possible for us to determine the level of hemoglobin below which functional recovery becomes difficult. This value of hemoglobin will be used in phases 3 and 4 of the TRIOS project (Transfusion strategies in orthopedic surgery of the lower limb within a rehabilitative context).

The role of X-inactivation in the expression of hemophilia A in women

Dr. Wenda L. Greer, FCCMG
Professor, Department of Pathology
Dalhousie University – Halifax, Nova Scotia
Second year funding

Hemophilia A is an X-linked recessive bleeding disorder resulting from mutations in the F8 gene. It is usually expressed in males who inherit only one X chromosome from their mother. Females inherit one X from each parent. Those who inherit only one mutated f8 gene usually do not express the disease. Rare examples of hemophilia A manifesting in heterozygous females occur due to an unusual pattern of X chromosome inactivation. This is a mechanism that causes one X in every female cell to be inactivated early in development. It is a mechanism which compensates for the fact that females have a double dose of X chromatin compared to males. In most females, approximately half of the cells inactivate their maternal X and half their paternal X. In rare cases, X chromosome inactivation is skewed. If it is skewed toward the expression of a mutated X chromosome, a heterozygous female can be affected with an X-linked recessive disease. 

A family has presented with several males and several females affected with hemophilia A. Analysis of one female showed that most of her cells were expressing the mutated paternal X chromosome. We therefore hypothesized that affected females in this family are expressing hemophilia A due to nonrandom X inactivation patterns. It is unlikely that random chance could account for the putative dramatic skewing of X chromosome inactivation leading to 3 affected females. This led us to consider that these females have inherited a predisposition to skewed X chromosome inactivation patterns. 

XCI is controlled in cis by an untranslated RNA coded by the XIST gene. Xist is regulated by the Tsix RNA that is antisense to Xist. It is believed from studies in mice that there is an X chromosome controlling element (XCE) that down regulates Tsix expression and alters the probability of an X chromosome being inactivated. 

Our objective is to understand why females in this family are expressing hemophilia A. Our hypothesis is that their X chromosomes containing the normal F8 gene have been selectively inactivated, leaving only the mutated f8 available for expression. More specifically, we propose to test the hypothesis that there is a region on the X chromosome that contains an XCE that influences selection and accounts for disease in this family. 

Our specific aims are:

  • To use polymorphic micosatellite markers at 5cm intervals to compare the X chromosomes of affected and unaffected female siblings with skewed and random X-inactivation patterns, respectively. Hypothetically, regions where they differ should define the critical region of the putative XCE.
  • To further compare these X chromosomes using microarray CGH to look for regions of duplication, deletion and differential methylation (collaboration with Dr Wan Lam, Toronto).
  • To develop a cell culture model system to study the process of X-chromosome inactivation in females. With this testable system, we will determine if X-inactivation is under genetic control. It will also provide a tool to localize the XCE gene.

This study will provide answers for this family and insight into the basic biology of X-chromosome inactivation. 

Gene therapy of hemophilia A

Dr. Gonzalo Hortelano
Assistant Professor, Department of Pathology
McMaster University – Hamilton, Ontario
Second year funding

We will evaluate the feasibility of cell transplantation therapy to reverse severe hemophilia A in mice. Although current factor VIII (FVIII) products are safe, patients must endure life-long regular FVIII infusions. Thus, a safe and more economic treatment is desirable. 

Gene therapy is an alternative. Gene therapy strategies use virus as vehicles to introduce the FVIII gene, but they are associated with undesirable immune responses. Alternatively, transplanted cells producing FVIII are only temporarily functional. We propose the transplantation of non-autologous cells (not from the patient) genetically engineered to continuously produce FVIII. To avoid rejection of the transplanted cells, they are enclosed in tiny microcapsules (less than 1mm in diameter) before being transplanted. The microcapsules allow the free flow of FVIII, but are impermeable to immune cells, therefore protecting the enclosed cells. 

We found that mice transplanted with microcapsules containing muscle cells engineered to secrete factor IX contained high amounts of factor IX in the blood for at least 120 days and did not mount an immune response to human FIX. More importantly, this treatment was able to reverse the disease in severe hemophilia B mice. If this were achieved in humans, it would eliminate severe and moderate hemophiliacs. Therefore, we will apply the same strategy to hemophilia A. 

Initially, we will engineer muscle cells to produce FVIII, and determine the amount of FVIII they produced. Second, we will enclose FVIII-producing cells in microcapsules that will then be transplanted into mice to determine how much FVIII is found in blood, and for how long. Any immune responses to FVIII will be studied. Finally, the correction of the disease in hemophilia A mice will be investigated. 

This transplantation therapy could reduce and ultimately eliminate the need for regular FVIII injections. Importantly, the microcapsules can be removed, increasing the safety of the treatment.

Platelet type von Willebrand disease: An underdiagnosed cause of excessive mucocutaneous bleeding?

Dr. Maha Othman
Adjunct Assistant Professor, Department of Pathology and Molecular Medicine
Queen’s University – Kingston, Ontario
First year funding

The overall aim of this project is to investigate the occurrence of platelet type (PT)-VWD among patients who are provisionally diagnosed as type 2B VWD based on clinical and laboratory data. This study will address the question of whether platelet type VWD is being under- or misdiagnosed in this cohort of patients. The correct discrimination between the two disorders is critical as it directs the treatment decision. 

We hypothesize that the apparent rarity of PT-VWD is at least partly due to the fact that we are missing the diagnosis of this condition because of the high degree of similarity with type 2B VWD. We also hypothesize that the molecular genetic approach is essential to make a conclusive discrimination. Finally, we emphasize that this issue carries a significant implication in terms of treatment decisions. 

Specific Project Aims:
To discriminate type 2B VWD from the closely similar platelet type VWD using a molecular approach: evaluation of sequence variations in each of the exon 28 of the VWF gene (platelet binding region) and the platelet GPIBA gene. 

To identify the percentage of misdiagnosed PT-VWD among clinically diagnosed type 2B VWD cases. 

To functionally characterize novel mutations, if any, in PT-VWD cases.

Factor VII(a) clearance behaviour

Dr. William P. Sheffield
Associate Professor, Department of Pathology and Molecular Medicine
McMaster University – Hamilton, Ontario
First year funding

The hemophilia community knows all too well that the replacement therapy that can restore hemophiliacs to an active life is not always problem-free. For individuals with hemophilia A, replacement therapy with purified recombinant factor VIII (fVIII) can sometimes be complicated by inhibitor formation. Inhibitors are antibodies directed against the injected fVIII. Fortunately, administration of recombinant factor VIIa (fVIIa) can bypass this potentially serious problem. However, fVII is one of the coagulation factors that leaves the circulation the most rapidly. This clearance behaviour is not completely understood. For this reason, Drs. Bill Sheffield and Bryan Clarke, of McMaster University and Canadian Blood Services have received a CHS research grant to study the clearance of fVII(a) in mice genetically altered to have hemophilia A. The investigators will use DNA and cell culture technology to make both human fVII identical to current clinical products, and new forms of fVII in their laboratories. Once purified, how long the fVII-related proteins last in the mouse circulation, and how well they control bleeding will be determined. The most unusual products to be tested are “fusions” – in which fVII and human serum albumin, ordinarily separate proteins, are combined into a single chain. The researchers propose that fVII will continue to work in this new format, and will remain in the circulation for much longer than the current product. The longer it remains, the more effective it should be in combating bleeding. Sheffield and Clarke hope that their research will lead to better understanding of the mechanism of action of rfVIIa, and to the design of improved rfVII(a) products to provide caregivers with novel tools to help hemophiliac patients with inhibitors.

The Role of X-inactivation in the Expression of Hemophilia A in Women

1st year funding
Wenda L. Greer, PhD
Dalhousie University, Halifax, Nova Scotia

Hemophilia A is an X-linked recessive bleeding disorder resulting from mutations in the F8 gene. It is usually expressed in males who inherit only one X chromosome from their mother. Females inherit one X from each parent. Those who inherit only one mutated f8 gene usually do not express the disease. Rare examples of hemophilia A manifesting in heterozygous females occur due to an unusual pattern of X chromosome inactivation. This is a mechanism that causes one X in every female cell to be inactivated early in development. It is a mechanism which compensates for the fact that females have a double dose of X chromatin compared to males. In most females, approximately half of the cells inactivate their maternal X and half their paternal X. In rare cases, X chromosome inactivation is skewed. If it is skewed toward the expression of a mutated X chromosome, a heterozygous female can be affected with an X-linked recessive disease.

A family has presented with several males and several females affected with hemophilia A. Analysis of one female showed that most of her cells were expressing the mutated paternal X chromosome. We therefore hypothesized that affected females in this family are expressing hemophilia A due to nonrandom X inactivation patterns. It is unlikely that random chance could account for the putative dramatic skewing of X chromosome inactivation leading to 3 affected females. This led us to consider that these females have inherited a predisposition to skewed X chromosome inactivation patterns.

XCI is controlled in cis by an untranslated RNA coded by the XIST gene. Xist is regulated by the Tsix RNA that is antisense to Xist. It is believed from studies in mice that there is an X chromosome controlling element (XCE) that down regulates Tsix expression and alters the probability of an X chromosome being inactivated.

Our objective is to understand why females in this family are expressing hemophilia A. Our hypothesis is that their X chromosomes containing the normal F8 gene have been selectively inactivated, leaving only the mutated f8 available for expression. More specifically, we propose to test the hypothesis that there is a region on the X chromosome that contains an XCE that influences selection and accounts for disease in this family.

Our specific aims are:

  • To use polymorphic micosatellite markers at 5cm intervals to compare the X chromosomes of affected and unaffected female siblings with skewed and random X-inactivation patterns, respectively. Hypothetically, regions where they differ should define the critical region of the putative XCE.
  • To further compare these X chromosomes using microarray CGH to look for regions of duplication, deletion and differential methylation (collaboration with Dr Wan Lam, Toronto).
  • To develop a cell culture model system to study the process of X-chromosome inactivation in females. With this testable system, we will determine if X-inactivation is under genetic control. It will also provide a tool to localize the XCE gene.

This study will provide answers for this family and insight into the basic biology of X-chromosome inactivation.

Genetic Differences Between Obligate Carriers of Type 3 VWD and Individuals with Type 1 VWD

2nd year funding
Dr. Paula James
Queen’s University, Kingston, Ontario
CHS Research Program

Von Willebrand disease (VWD) is the most common known inherited bleeding disorder in humans, affecting as many as 1% of the population. People with VWD have difficulty with bleeding from mucous membranes such as the nose, mouth or lining of the uterus, or can have problems with bleeding after injuries, dental work or surgical procedures. There are 3 subtypes: Type 1 VWD is the most common and least severe and is caused by a mild to moderate deficiency of a blood clotting factor called von Willebrand factor (VWF). Type 3 VWD is the least common and most severe and is caused by a severe deficiency of VWF. Type 2 VWD is caused by VWF that doesn’t function properly.

Type 1 VWD is inherited from one parent while Type 3 VWD is inherited from both parents. In this study, entitled Genetic Differences Between Obligate Carriers of Type 3 VWD and Individuals with Type 1 VWD, we are interested in examining the genetic changes in VWD. A person affected with Type 1 VWD would have inherited it from one parent, while a person affected with Type 3 VWD must have inherited it from both parents. A parent of an individual with Type 3 VWD is usually not affected by any bleeding problem and is referred to as a “carrier”. By using special techniques that allow us to examine an individual’s genetic make-up, we hope to improve our understanding of the types of genetic changes that might lead to Type 1 VWD and those that would lead to being a carrier for Type 3 VWD.

Implantable Microcapsules as Gene Therapy for Hemophilia A

1st year funding
Dr. Gonzalo Hortelano
McMaster University, Hamilton, Ontario

We will evaluate the feasibility of cell transplantation therapy to reverse severe hemophilia A in mice. Although current factor VIII (FVIII) products are safe, patients must endure life-long regular FVIII infusions. Thus, a safe and more economic treatment is desirable.

Gene therapy is an alternative. Gene therapy strategies use virus as vehicles to introduce the FVIII gene, but they are associated with undesirable immune responses. Alternatively, transplanted cells producing FVIII are only temporarily functional. We propose the transplantation of non-autologous cells (not from the patient) genetically engineered to continuously produce FVIII. To avoid rejection of the transplanted cells, they are enclosed in tiny microcapsules (less than 1mm in diameter) before being transplanted. The microcapsules allow the free flow of FVIII, but are impermeable to immune cells, therefore protecting the enclosed cells.

We found that mice transplanted with microcapsules containing muscle cells engineered to secrete factor IX contained high amounts of factor IX in the blood for at least 120 days and did not mount an immune response to human FIX. More importantly, this treatment was able to reverse the disease in severe hemophilia B mice. If this were achieved in humans, it would eliminate severe and moderate hemophiliacs. Therefore, we will apply the same strategy to hemophilia A.

Initially, we will engineer muscle cells to produce FVIII, and determine the amount of FVIII they produced. Second, we will enclose FVIII-producing cells in microcapsules that will then be transplanted into mice to determine how much FVIII is found in blood, and for how long. Any immune responses to FVIII will be studied. Finally, the correction of the disease in hemophilia A mice will be investigated.

This transplantation therapy could reduce and ultimately eliminate the need for regular FVIII injections. Importantly, the microcapsules can be removed, increasing the safety of the treatment.

Fibrinolytic Variables in Severe Hemophilic A Patients

1st year funding
Dr. Jerome Teitel
St. Michael’s Hospital

The bleeding tendency of people with severe hemophilia varies considerably. This can be explained by differences in levels of their deficient proteins (clotting factor VIII or IX) which are too small to be easily measurable. We think that an additional source of variability could lie in fibrinolysis, the process by which blood clots dissolve. Severe hemophilia patients who have rapid fibrinolysis (clots that dissolve quickly) might tend to bleed more severely than others. In this project, we propose to conduct a thorough and systematic study to test the hypothesis that the bleeding tendency in severe hemophilia is correlated with increased fibrinolytic activity. We will measure the levels of four key blood proteins which contribute to fibrinolysis in 100 severe hemophilia patients. We will also monitor the number of bleeding episodes as well as the amount of factor VIII or IX concentrate that these patients have needed over the preceding 2 years. We will statistically determine whether increased values of the fibrinolytic proteins correlate with increased bleeding tendency, and vice versa. At the end of this project, we hope to better our understanding of why bleeding tendencies in severe hemophilia patients are variable. If our hypothesis is confirmed, we will be able to provide a novel rationale for individualized management approaches. These may include selecting target amount of factor VIII or IX for treatment or prevention of bleeding in hemophilia patients. It may also include selecting patients for prophylaxis with clotting factor concurrently with factor VIII or IX replacement therapy, after surgery and other interventions. We may also be able to predict the risk of clotting of central venous catheters, a serious complication of propylactic factor VIII or IX treatment in young children.

Genetic Differences Between Obligate Carriers of Type 3 VWD and Individuals with Type 1 VWD

1st year funding
Dr. Paula James
Queen’s University, Kingston, Ontario
CHS Research Program

Von Willebrand disease (VWD) is the most common known inherited bleeding disorder in humans, affecting as many as 1% of the population. People with VWD have difficulty with bleeding from mucous membranes such as the nose, mouth or lining of the uterus, or can have problems with bleeding after injuries, dental work or surgical procedures. There are 3 subtypes: Type 1 VWD is the most common and least severe and is caused by a mild to moderate deficiency of a blood clotting factor called von Willebrand factor (VWF). Type 3 VWD is the least common and most severe and is caused by a severe deficiency of VWF. Type 2 VWD is caused by VWF that doesn’t function properly.

Type 1 VWD is inherited from one parent while Type 3 VWD is inherited from both parents. In this study, entitled Genetic Differences Between Obligate Carriers of Type 3 VWD and Individuals with Type 1 VWD, we are interested in examining the genetic changes in VWD. A person affected with Type 1 VWD would have inherited it from one parent, while a person affected with Type 3 VWD must have inherited it from both parents. A parent of an individual with Type 3 VWD is usually not affected by any bleeding problem and is referred to as a “carrier”. By using special techniques that allow us to examine an individual’s genetic make-up, we hope to improve our understanding of the types of genetic changes that might lead to Type 1 VWD and those that would lead to being a carrier for Type 3 VWD.