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Bruno Fattizzo,1,2 Francesca Cavallaro,1,2 Anna Paola Maria Luisa Marcello,1 Cristina Vercellati,1 Wilma Barcellini1 1Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy; 2Department of Oncology and Hemato-Oncology, University of Milan, Milan, ItalyCorrespondence: Bruno Fattizzo, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Hematology Unit, Via F. Sforza 35, Milan, 20122, Italy, Tel +39 0255033477, Email bruno.fattizzo@unimi.itAbstract: Pyruvate kinase deficiency (PKD) is a rare autosomal recessive disease marked by chronic hemolytic anemia of various severity and frequent complications including gallstones, splenomegaly, iron overload, and others. Disease phenotype is highly heterogeneous and changes over time with children, adolescents and adult patients displaying different transfusion requirement and rates of complications. The diagnosis relies on the initial clinical suspicion in a patient with chronic hemolysis and exclusion of other more common congenital forms of hemolytic anemias; it is supported by the demonstration of reduced PK enzyme activity, and further confirmed by the detection of (homozygous or compound heterozygous) mutations of PKLR gene. Therapy is mainly supportive, with vitamin supplementation and transfusions (based on symptoms and patient growth rather than on fixed Hb thresholds). Splenectomy is widely performed, although it is less effective than in membrane defects and carries thrombotic and infectious risk. In the last decade, the allosteric PK enzyme activator mitapivat showed dramatic clinical benefit in clinical trials and gene therapy is also being studied to substitute the defective enzyme. In this review, we provide an insight in the current challenges of PKD diagnosis and management and discuss the future application of novel drugs and gene therapy, including a focus on quality of life.Keywords: pyruvate kinase deficiency, splenectomy, mitapivat, gene therapy

Bruno Fattizzo,1,2 Francesca Cavallaro,1,2 Esther Natalie Oliva,3 Wilma Barcellini1 1Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico - Haematology Unit, Milan, Italy; 2Università degli Studi di Milano - Department of Oncology and Hemato-Oncology, Milan, Italy; 3Grande Ospedale Metropolitano Bianchi Melacrino Morelli - Hematology Division, Reggio, Calabria, ItalyCorrespondence: Bruno Fattizzo, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, via Francesco Sforza 35, Milan, 20100, Italy, Tel +39 3896873204, Email bruno.fattizzo@unimi.itAbstract: The most frequently reported symptom in patients with paroxysmal nocturnal hemoglobinuria (PNH), a disease characterized by complement mediated hemolysis and chronic anemia, is “fatigue”. The latter seems the best word to communicate patient’ perception of personal health status and disease impact on daily living, namely quality of life (QoL). Objectivating QoL and grading patient’s fatigue is one of the most difficult medical tasks given the highly heterogeneous communication skills of patients and caregivers and the multitude of meanings that might be attributed to this term. Along with anemia, QoL in PNH is also affected by the emotional burden of a chronic life-long disease with heterogeneous treatment requirement, risk of hemolytic exacerbations (breakthrough hemolysis) and of thrombosis. In the last decade, structured surveys and scores have been adapted from cancer settings to evaluate fatigue and QoL in patients with PNH, and to assess the benefit of complement inhibitors in this setting. Eculizumab was the first drug utilized and was shown to improve QoL scores in the registrative trials. However, the intravenous fortnightly administration, the presence of residual anemia, and the risk of extravascular hemolysis are some of the unmet needs impacting QoL under eculizumab. Several novel drugs have been designed to improve patients’ convenience and alleviate anemia and fatigue. In this review, we focus on available studies that evaluated fatigue and QoL in PNH patients, and the effect of old and new therapeutic strategies.Keywords: paroxysmal nocturnal hemoglobinuria, novel drugs, eculizumab, quality of life, fatigue

Additional file 1: Table S1. Details on variables used for the analysis; Table S2. Determinants of HIV testing uptake among sexually active non-pregnant young women aged 15–24, Zambia 2018 DHS (N = 2457); and Table S3. Determinants of HIV testing uptake among sexually active young men aged 15–24, Zambia DHS 2018 (N = 3114).

INTRODUCTION: Almost 20 000 babies are born to teenage mothers each year in England, with poorer outcomes for mothers and babies than among older mothers. A nurse home visitation programme in the USA was found to improve a wide range of outcomes for young mothers and their children. However, a randomised controlled trial in England found no effect on short-term primary outcomes, although cognitive development up to age 2 showed improvement. Our study will use linked routinely collected health, education and social care data to evaluate the real-world effects of the Family Nurse Partnership (FNP) on child outcomes up to age 7, with a focus on identifying whether the FNP works better for particular groups of families, thereby informing programme targeting and resource allocation. METHODS AND ANALYSIS: We will construct a retrospective cohort of all women aged 13-24 years giving birth in English NHS hospitals between 2010 and 2017, linking information on mothers and children from FNP programme data, Hospital Episodes Statistics and the National Pupil Database. To assess the effectiveness of FNP, we will compare outcomes for eligible mothers ever and never enrolled in FNP, and their children, using two analysis strategies to adjust for measured confounding: propensity score matching and analyses adjusting for maternal characteristics up to enrolment/28 weeks gestation. Outcomes of interest include early childhood development, childhood unplanned hospital admissions for injury or maltreatment-related diagnoses and children in care. Subgroup analyses will determine whether the effect of FNP varied according to maternal characteristics (eg, age and education). ETHICS AND DISSEMINATION: The Nottingham Research Ethics Committee approved this study. Mothers participating in FNP were supportive of our planned research. Results will inform policy-makers for targeting home visiting programmes. Methodological findings on the accuracy and reliability of cross-sectoral data linkage will be of interest to researchers.