- Email: [email protected]
Conclusion
Conclusion CRAIG
M.
KESSLER,
M.D.,
washington,
D.C.
T
he spontaneous onset of autoantibodies against circulating factor VIII:C protein (FVIII:C), termed acquired hemophilia, is a clinical phenomenon whose etiology is as yet unclear. This process often has an insidious natural history that may culminate in life-threatening retropharyngeal or central nervous system hemorrhages among the persons it strikes. Hypovolemic shock is not uncommon in these patients, who initially may present with gastrointestinal bleeding, hemorrhages into muscles and joints, syncope, ecchymoses, hematuria, or sustained bleeding after either surgery or minor trauma. Often antedated by other autoimmune diseases and malignancies, acquired hemophilia results from interaction chiefly between immunoglobulin G (IgG) and distinct epitopic sites on the FVIII:C molecule. Recentstrides toward elucidating the structures of both FVIII:C and its inhibitor, together with advances in immunotherapy, warrant a reexamination of present treatment modalities for acquired hemophilia, namely, cryoprecipitate and human FVIII:C concentrate. Accordingly, after considering etiologic factors in acquired hemophilia, this symposium addressed several promising therapeutic alternatives: administration of porcine FVIII:C concentrate to reduce the potential immunologic cross-reactivity that occurs between autoantibody and human FVIII:C, chemotherapy in conjunction with FVIII:C, intravenous infusion of polyspecific immunoglobulins (IV Ig), and finally, use of activated and inactivated prothrombin complex concentrates (PCC). Many of the studies reported in this symposium have provided encouraging data to suggest that porcine FVIII:C is a safe and effective first-line treatment for spontaneous hemophilia. At the core of many therapeutic advances lie immunochemical efforts to delineate antigenic sites on the FVIII:C molecule. The cumulative progress in this area was presented by Dr. Carol Fulcher. Discrete FVIII:C epitopes interact with the inhibitor antibody. FVIII:C is a 265-kilodalton &Da)
From the Department of Medicine, Division of Hematology/Oncology, The George Washington University School of Medicine, Washington, D.C. Requests for reprints should be addressed to Craig M. Kessler, M.D., Division of Hematology/Oncology, The George Washington University, School of Medicine, 2150 Pennsylvania Avenue, N.W., Washington, D.C. 20037.
double-chain protein comprised of 2,332 amino acids distributed as follows: l-1,648 in a heavy chain, and 1,649-2,332 in a K or A light chain. The finding that 44-kDa and 72-kDa proteolytic fragments of FVIII:C block inhibitor activity in the plasma of many acquired hemophiliacs prompted studies to identify epitopes, which span only 15-22 amino acids. Results of investigations employing immunoblotting and cDNA deletion mapping have indeed begun to clarify the structures of FVIII:C antigenic determinants. Although considerable heterogeneity appears to exist, consistent evidence supports localization of at least two epitopes, to amino acid residues 379-538 and 2,178-2,332 of FVIII:C. An understanding of the kinetic properties of FVIII:C-inhibitor interactions may eventually lead to effective therapeutic interventions. Autoantibodies may alter FVIII:C activity by blocking phospholipid and von Willebrand factor (vWF)FVIII:C binding sites or by interfering directly or indirectly with the proteolytic thrombin cleavage site of the FVIII:C procoagulant molecule. Allosteric inhibition of FVIII:C activity by the autoantibody may also be relevant. Irrespective of the mechanism involved, a common clinical profile of acquired hemophilia emerges from clinical reports. One especially large survey was conducted during 1970-1980 by Drs. David Green and Klaus Lechner, under the auspices of the International Society of Thrombosis and Haemostasis (ISTH). Of the 215 patients studied, about half were women, most tended to be older than 60 years, and about 20% died as a result of the hemorrhagic complications of the disorder. All told, 18% of the patients had associated autoimmune diseases, including rheumatoid arthritis (8%), systemic lupus erythematosus (6%), and other connective-tissue disorders. In 5% the condition was related to prior treatment with penicillin, sulfa drugs, chloramphenicol, phenytoin, or other medications. Dermatologic conditions such ,as psoriasis and pemphigus were present in .5%. Finally, pregnancy preceded the onset of disease in 7% of the study population. The premise that pregnant womeh developed autoantibodies to paternal allotypes of FVIII:C represents an intriguing mechanism to explain the appearance of the inhibitor post-partum; however, it is not supported by clini-
November 4, 1991
The American Journal of Medicine
Volume 91 (suppl 5A)
5A-45s
SYMPOSIUM
ON ACQUIRED Nlll
INHlBlTORS I KESSLER
cal experience, which shows no recurrence of high inhibitor titers with subsequent pregnancies. FVIII:C autoantibodies are frequently associated with lymphoproliferative malignancies. Malignant B-cell lymphocytes are known to produce monoclonal immunoglobulins, some of which may be directed specifically against FVIII:C. As Dr. Hultin has reported, immunoglobulins with properties of FVIII:C antibodies have been detected in patients with IgG and IgA myelomas, Waldenstrom’s macroglobulinemia, chronic lymphocytic leukemias, Hodgkin’s and non-Hodgkin’s lymphoma, .and other related conditions. Finally, FVIII:C inhibitors have also been isolated from persons with various solid tumors, but any direct causal relationship is largely obscured because these patients also received chemotherapy, which may have altered the normal immunoregulatory mechanisms.’ Chemotherapy with steroids or cyclophosphamide in combination with FVIII:C aclministration is one management strategy that has produced frequently encouraging results in suppressing FVIII:C inhibitor activity with good clinical outcomes. The success of cytotoxic therapy with alkylating agents, antifolates, cyclosporine, or steroids .depends on their effectiveness in suppressing the actively dividing cell line that synthesizes the autoantibody. Dr. David Green has demonstrated that, for autoantibody inhibitors, as with acquired alloantibodies that develop in some patients with congenital hemophilia, cytotoxic therapy to suppress inhibitor formation is most effective when dealing with low titer inhibitors. His data indicate that the FVIII:C autoantibody activity typically dissipates with chemotherapy, in a matter of weeks. This limited exposure to cytotoxic agents minimizes the potential complications of bone marrow suppression and carcinogenesis. Because FVIII:C autoantibodies often disappear spontaneously, a controlled prospective study should be conducted in a larger population to confirm these preliminary observations in the case of acquired hemophilia. The preliminary findings from an on-going ISTH investigation coordinated by Dr. Green indicate that the FVIII:C autoantibodies in 12 of 13 patients have completely or partially remitted in response to chemotherapy. Notably, prednisone therapy alone (1 mglkglday) was associated with the complete disappearance of FVIII:C inhibitors in some patients with extremely high initial titers. Only one patient, who manifested high titer FVIII:C inhibitor activity, was refractory to all therapeutic efforts to suppress the autoantibody. This suggests that steroid therapy should be initiated as a single first-line M-4&
November 4, 1991 The American Journal of Medicine
treatment, with subsequent modification of the regimen when it is determined that the titer of inhibitor remains unaltered or unacceptably elevated. The infusion of porcine FVIII:C became clinically feasible in 1980, with the introduction of FVIII:C purification by polyelectrolyte fractionation. Increasingly devoid of impurities such as vWF and/or platelet activating factor, the porcine FVIII:C preparation can be administered with a minimal risk of transfusion induced thrombocytopenia. Furthermore, as Dr. Kernoff has explained, the autoantibody inhibitors of acquired hemophiliacs usually possess only minimal cross-reactivity against animal forms of FVIII:C. Thus, porcine FVIII:C concentrates can be administered in repeated and prolonged courses as a safe, effective means to attain hemostasis. Drs. Ludlam and Hay presented their recent successful experiences with porcine FVIII:C concentrate replacement therapy for acquired and congenital hemophilia. A similar degree of efficacy and safety for porcine FVIII:C administration was reported by Dr. Hultin in her series of seven patients with acquired hemophilia treated over the past decade. In the European stuclies, inhibitor patients received a mean total close of 930 U/kg of body weight of porcine FVIII:C over 8 days. Porcine FVIII:C was used in conjunction with cyclophosphamide, steroids, azathioprine, or intravenous immunoglobulin (IV Ig), given concomitantly or sequentially, in over half of the patients. The 29 patients with acquired hemophilia treated in 15 medical centers experienced good to excellent therapeutic response in 78% of bleeding episodes. Two episodes of recurrent bleeding resolved upon retreatment using the same porcine FVIII:C product. Significant anamnestic rises in FVIII:C inhibitor titers occurred in a few patients; however, as indicated by Dr. Ludlam, the patients in their studies had been preselected for the absence of significant cross-reactivity of their inhibitors against the porcine preparation. Their clata support the fact that low anti-porcine FVIII:C antibody titers constitute a reasonable selection criterion for porcine VIII:C management in acquired hemophilia. Because significant anamnestic responses do occur, with the effectiveness of porcine FVIII:C thus negated, constant laboratory monitoring and &mica1 vigilance are required, as with the use of all products for treating FVIII:C inhibitor patients. The safety profile of porcine FVIII:C concentrates has allowecl physicians to employ them in immune tolerance incluction regimens to suppress the alloantibody inhibitors in congenital hemophilia patients. Five inhibitor patients tolerated daily porcine FVIII:C infusions over 2-8 years without
Volume 91 (suppl 5A)
SYMWSlUhl
exhibiting allergy or other adverse events. Only one of four patients with transient antiporcine FVIII:C antibodies proved refractory to treatment; the others enjoyed good clinical outcomes despite 30% cross-reactivity of patient antibody to porcine FVIII:C. These data are encouraging for the 80% of patients with acquired hemophilia who never develop antiporcine FVIII:C antibodies. Unactivated and activated factor IX (FIX) complex concentrates were the first replacement products employed successfully for the treatment of bleeding complications in acquired hemophilia after their usefulness had been established for inhibitor patients with congenital hemophilia A. Unfortunately, these products have not been effective in all inhibitor patients and may be variably effective in the same patient, requiring changes in product choice to achieve adequate hemostasis. Furthermore, as reported by Dr. Jeanne Lusher, most of the activated and unactivated FIX complex concentrates have been implicated with the transmission of non-A, non-B hepatitis and hepatitis B (current viral attenuation processes appear to have effectively eliminated transmission of the human immunodeficiency virus; the risk of hepatitis B in the recipients of these products can be minimized by administering the hepatitis B vaccine). By virtue of their contamination by activated clotting factors, these treatments have precipitated episodes of hyper-coagulability, including lethal pulmonary thromboembolism, myocardial infarction, .cerebrovascular accidents, and disseminated intravascular coagulation in otherwise healthy young patients. These complications have heightened the urgency to increase the safety-efficacy profiles of existing products and to increase the use of products such as porcine FVIII:C that is free of human blood-borne viral pathogens and that is not associated with increased thrombogenicity. An innovative and promising approach to the treatment of FVIII:C autoantibodies involves the
ON ACQUIRED FVlll INHIBITORS/
KESSLER
infusion of human polyspecific IV Ig (0.4 g/kg/day). As reported by Dr. Yvette Sultan, IV Ig administration reduced the level of FVIII:C autoantibody inhibitor activity by 95% in two patients with acquired hemophilia A treated for 5 consecutive days and has sustained autoantibody suppression over several years without retreatment. In addition, IV Ig neutralized the allo-FVIII:C inhibitors in six of seven with congenital hemophilia. It has been hypothesized that IV Ig preparations contain antiidiotypic antibodies which recognize key F(ab) domains on the FVIII:C inhibitory proteins, and subsequently complex with them to neutralize their inhibitory capacity. Dr. Leon Hoyer concluded the symposium by describing theoretical treatment modalities for FVIII inhibitor patients through modifications in immune system responsiveness to restore immune self-tolerance to FVIII. Although the ability to study this objective probably will require the development of an in vivo model for acquired hemophilia, Dr. Hoyer speculated that such innovative regimens could potentially be directed toward (a) interfering with antigen binding by the inhibitor; (b) augmentation of antigen-specific T suppressor cell lines to modulate inhibitor production; or (c) genetically engineering FVIII epitope-specific amino acid sequences, which when placed onto a solid phase extracorporeal circulation apparatus could bind and remove the circulating inhibitor from the patient’s plasma. Alternatively, it may be possibie to develop recombinant FVIII mutants for replacement therapy that are devoid of antigenic determinants. No matter which approach is chosen, research such as that discussed throughout this symposium is likely to extend our understanding of the structural and functional relationships between FVIII:C and its allo- and autoantibody inhibitors and will eventually provide a solid basis for innovative and safe immunomodulatory therapies.
November 4,
1991 The American Journal of Medicine
Volume 91 (suppl 5A)
5&47s
M.
KESSLER,
M.D.,
washington,
D.C.
T
he spontaneous onset of autoantibodies against circulating factor VIII:C protein (FVIII:C), termed acquired hemophilia, is a clinical phenomenon whose etiology is as yet unclear. This process often has an insidious natural history that may culminate in life-threatening retropharyngeal or central nervous system hemorrhages among the persons it strikes. Hypovolemic shock is not uncommon in these patients, who initially may present with gastrointestinal bleeding, hemorrhages into muscles and joints, syncope, ecchymoses, hematuria, or sustained bleeding after either surgery or minor trauma. Often antedated by other autoimmune diseases and malignancies, acquired hemophilia results from interaction chiefly between immunoglobulin G (IgG) and distinct epitopic sites on the FVIII:C molecule. Recentstrides toward elucidating the structures of both FVIII:C and its inhibitor, together with advances in immunotherapy, warrant a reexamination of present treatment modalities for acquired hemophilia, namely, cryoprecipitate and human FVIII:C concentrate. Accordingly, after considering etiologic factors in acquired hemophilia, this symposium addressed several promising therapeutic alternatives: administration of porcine FVIII:C concentrate to reduce the potential immunologic cross-reactivity that occurs between autoantibody and human FVIII:C, chemotherapy in conjunction with FVIII:C, intravenous infusion of polyspecific immunoglobulins (IV Ig), and finally, use of activated and inactivated prothrombin complex concentrates (PCC). Many of the studies reported in this symposium have provided encouraging data to suggest that porcine FVIII:C is a safe and effective first-line treatment for spontaneous hemophilia. At the core of many therapeutic advances lie immunochemical efforts to delineate antigenic sites on the FVIII:C molecule. The cumulative progress in this area was presented by Dr. Carol Fulcher. Discrete FVIII:C epitopes interact with the inhibitor antibody. FVIII:C is a 265-kilodalton &Da)
From the Department of Medicine, Division of Hematology/Oncology, The George Washington University School of Medicine, Washington, D.C. Requests for reprints should be addressed to Craig M. Kessler, M.D., Division of Hematology/Oncology, The George Washington University, School of Medicine, 2150 Pennsylvania Avenue, N.W., Washington, D.C. 20037.
double-chain protein comprised of 2,332 amino acids distributed as follows: l-1,648 in a heavy chain, and 1,649-2,332 in a K or A light chain. The finding that 44-kDa and 72-kDa proteolytic fragments of FVIII:C block inhibitor activity in the plasma of many acquired hemophiliacs prompted studies to identify epitopes, which span only 15-22 amino acids. Results of investigations employing immunoblotting and cDNA deletion mapping have indeed begun to clarify the structures of FVIII:C antigenic determinants. Although considerable heterogeneity appears to exist, consistent evidence supports localization of at least two epitopes, to amino acid residues 379-538 and 2,178-2,332 of FVIII:C. An understanding of the kinetic properties of FVIII:C-inhibitor interactions may eventually lead to effective therapeutic interventions. Autoantibodies may alter FVIII:C activity by blocking phospholipid and von Willebrand factor (vWF)FVIII:C binding sites or by interfering directly or indirectly with the proteolytic thrombin cleavage site of the FVIII:C procoagulant molecule. Allosteric inhibition of FVIII:C activity by the autoantibody may also be relevant. Irrespective of the mechanism involved, a common clinical profile of acquired hemophilia emerges from clinical reports. One especially large survey was conducted during 1970-1980 by Drs. David Green and Klaus Lechner, under the auspices of the International Society of Thrombosis and Haemostasis (ISTH). Of the 215 patients studied, about half were women, most tended to be older than 60 years, and about 20% died as a result of the hemorrhagic complications of the disorder. All told, 18% of the patients had associated autoimmune diseases, including rheumatoid arthritis (8%), systemic lupus erythematosus (6%), and other connective-tissue disorders. In 5% the condition was related to prior treatment with penicillin, sulfa drugs, chloramphenicol, phenytoin, or other medications. Dermatologic conditions such ,as psoriasis and pemphigus were present in .5%. Finally, pregnancy preceded the onset of disease in 7% of the study population. The premise that pregnant womeh developed autoantibodies to paternal allotypes of FVIII:C represents an intriguing mechanism to explain the appearance of the inhibitor post-partum; however, it is not supported by clini-
November 4, 1991
The American Journal of Medicine
Volume 91 (suppl 5A)
5A-45s
SYMPOSIUM
ON ACQUIRED Nlll
INHlBlTORS I KESSLER
cal experience, which shows no recurrence of high inhibitor titers with subsequent pregnancies. FVIII:C autoantibodies are frequently associated with lymphoproliferative malignancies. Malignant B-cell lymphocytes are known to produce monoclonal immunoglobulins, some of which may be directed specifically against FVIII:C. As Dr. Hultin has reported, immunoglobulins with properties of FVIII:C antibodies have been detected in patients with IgG and IgA myelomas, Waldenstrom’s macroglobulinemia, chronic lymphocytic leukemias, Hodgkin’s and non-Hodgkin’s lymphoma, .and other related conditions. Finally, FVIII:C inhibitors have also been isolated from persons with various solid tumors, but any direct causal relationship is largely obscured because these patients also received chemotherapy, which may have altered the normal immunoregulatory mechanisms.’ Chemotherapy with steroids or cyclophosphamide in combination with FVIII:C aclministration is one management strategy that has produced frequently encouraging results in suppressing FVIII:C inhibitor activity with good clinical outcomes. The success of cytotoxic therapy with alkylating agents, antifolates, cyclosporine, or steroids .depends on their effectiveness in suppressing the actively dividing cell line that synthesizes the autoantibody. Dr. David Green has demonstrated that, for autoantibody inhibitors, as with acquired alloantibodies that develop in some patients with congenital hemophilia, cytotoxic therapy to suppress inhibitor formation is most effective when dealing with low titer inhibitors. His data indicate that the FVIII:C autoantibody activity typically dissipates with chemotherapy, in a matter of weeks. This limited exposure to cytotoxic agents minimizes the potential complications of bone marrow suppression and carcinogenesis. Because FVIII:C autoantibodies often disappear spontaneously, a controlled prospective study should be conducted in a larger population to confirm these preliminary observations in the case of acquired hemophilia. The preliminary findings from an on-going ISTH investigation coordinated by Dr. Green indicate that the FVIII:C autoantibodies in 12 of 13 patients have completely or partially remitted in response to chemotherapy. Notably, prednisone therapy alone (1 mglkglday) was associated with the complete disappearance of FVIII:C inhibitors in some patients with extremely high initial titers. Only one patient, who manifested high titer FVIII:C inhibitor activity, was refractory to all therapeutic efforts to suppress the autoantibody. This suggests that steroid therapy should be initiated as a single first-line M-4&
November 4, 1991 The American Journal of Medicine
treatment, with subsequent modification of the regimen when it is determined that the titer of inhibitor remains unaltered or unacceptably elevated. The infusion of porcine FVIII:C became clinically feasible in 1980, with the introduction of FVIII:C purification by polyelectrolyte fractionation. Increasingly devoid of impurities such as vWF and/or platelet activating factor, the porcine FVIII:C preparation can be administered with a minimal risk of transfusion induced thrombocytopenia. Furthermore, as Dr. Kernoff has explained, the autoantibody inhibitors of acquired hemophiliacs usually possess only minimal cross-reactivity against animal forms of FVIII:C. Thus, porcine FVIII:C concentrates can be administered in repeated and prolonged courses as a safe, effective means to attain hemostasis. Drs. Ludlam and Hay presented their recent successful experiences with porcine FVIII:C concentrate replacement therapy for acquired and congenital hemophilia. A similar degree of efficacy and safety for porcine FVIII:C administration was reported by Dr. Hultin in her series of seven patients with acquired hemophilia treated over the past decade. In the European stuclies, inhibitor patients received a mean total close of 930 U/kg of body weight of porcine FVIII:C over 8 days. Porcine FVIII:C was used in conjunction with cyclophosphamide, steroids, azathioprine, or intravenous immunoglobulin (IV Ig), given concomitantly or sequentially, in over half of the patients. The 29 patients with acquired hemophilia treated in 15 medical centers experienced good to excellent therapeutic response in 78% of bleeding episodes. Two episodes of recurrent bleeding resolved upon retreatment using the same porcine FVIII:C product. Significant anamnestic rises in FVIII:C inhibitor titers occurred in a few patients; however, as indicated by Dr. Ludlam, the patients in their studies had been preselected for the absence of significant cross-reactivity of their inhibitors against the porcine preparation. Their clata support the fact that low anti-porcine FVIII:C antibody titers constitute a reasonable selection criterion for porcine VIII:C management in acquired hemophilia. Because significant anamnestic responses do occur, with the effectiveness of porcine FVIII:C thus negated, constant laboratory monitoring and &mica1 vigilance are required, as with the use of all products for treating FVIII:C inhibitor patients. The safety profile of porcine FVIII:C concentrates has allowecl physicians to employ them in immune tolerance incluction regimens to suppress the alloantibody inhibitors in congenital hemophilia patients. Five inhibitor patients tolerated daily porcine FVIII:C infusions over 2-8 years without
Volume 91 (suppl 5A)
SYMWSlUhl
exhibiting allergy or other adverse events. Only one of four patients with transient antiporcine FVIII:C antibodies proved refractory to treatment; the others enjoyed good clinical outcomes despite 30% cross-reactivity of patient antibody to porcine FVIII:C. These data are encouraging for the 80% of patients with acquired hemophilia who never develop antiporcine FVIII:C antibodies. Unactivated and activated factor IX (FIX) complex concentrates were the first replacement products employed successfully for the treatment of bleeding complications in acquired hemophilia after their usefulness had been established for inhibitor patients with congenital hemophilia A. Unfortunately, these products have not been effective in all inhibitor patients and may be variably effective in the same patient, requiring changes in product choice to achieve adequate hemostasis. Furthermore, as reported by Dr. Jeanne Lusher, most of the activated and unactivated FIX complex concentrates have been implicated with the transmission of non-A, non-B hepatitis and hepatitis B (current viral attenuation processes appear to have effectively eliminated transmission of the human immunodeficiency virus; the risk of hepatitis B in the recipients of these products can be minimized by administering the hepatitis B vaccine). By virtue of their contamination by activated clotting factors, these treatments have precipitated episodes of hyper-coagulability, including lethal pulmonary thromboembolism, myocardial infarction, .cerebrovascular accidents, and disseminated intravascular coagulation in otherwise healthy young patients. These complications have heightened the urgency to increase the safety-efficacy profiles of existing products and to increase the use of products such as porcine FVIII:C that is free of human blood-borne viral pathogens and that is not associated with increased thrombogenicity. An innovative and promising approach to the treatment of FVIII:C autoantibodies involves the
ON ACQUIRED FVlll INHIBITORS/
KESSLER
infusion of human polyspecific IV Ig (0.4 g/kg/day). As reported by Dr. Yvette Sultan, IV Ig administration reduced the level of FVIII:C autoantibody inhibitor activity by 95% in two patients with acquired hemophilia A treated for 5 consecutive days and has sustained autoantibody suppression over several years without retreatment. In addition, IV Ig neutralized the allo-FVIII:C inhibitors in six of seven with congenital hemophilia. It has been hypothesized that IV Ig preparations contain antiidiotypic antibodies which recognize key F(ab) domains on the FVIII:C inhibitory proteins, and subsequently complex with them to neutralize their inhibitory capacity. Dr. Leon Hoyer concluded the symposium by describing theoretical treatment modalities for FVIII inhibitor patients through modifications in immune system responsiveness to restore immune self-tolerance to FVIII. Although the ability to study this objective probably will require the development of an in vivo model for acquired hemophilia, Dr. Hoyer speculated that such innovative regimens could potentially be directed toward (a) interfering with antigen binding by the inhibitor; (b) augmentation of antigen-specific T suppressor cell lines to modulate inhibitor production; or (c) genetically engineering FVIII epitope-specific amino acid sequences, which when placed onto a solid phase extracorporeal circulation apparatus could bind and remove the circulating inhibitor from the patient’s plasma. Alternatively, it may be possibie to develop recombinant FVIII mutants for replacement therapy that are devoid of antigenic determinants. No matter which approach is chosen, research such as that discussed throughout this symposium is likely to extend our understanding of the structural and functional relationships between FVIII:C and its allo- and autoantibody inhibitors and will eventually provide a solid basis for innovative and safe immunomodulatory therapies.
November 4,
1991 The American Journal of Medicine
Volume 91 (suppl 5A)
5&47s