In contrast with the results of the other studies, the HOVON trial [75] included three arms: PCs

stored in full plasma, in PAS III without INTERCEPT, and in PAS III with INTERCEPT. Although the primary outcome of this study was CCI and not bleeding, even prior to publication major concerns arose about a possible reduction in clinical efficacy for PCs treated with amotosalen/UVA: 32% of patients in the INTERCEPT arm presented a bleeding episode compared to 19% in the plasma arm, and CCIs in the INTERCEPT arm were lower by 31% compared to the plasma arm. However, this study had serious flaws, including a lack of blinding, the absence of bleeding assessment by independent and trained observers, and the use of a bleeding grading system different from the WHO scale. Furthermore, the only statistically significant differences were found between the Alectinib plasma arm and the PAS III + INTERCEPT arm, leaving

some doubts about the specific effects of additive solution and INTERCEPT treatment [83]. One of the advantages of PI-treated PCs is that shelf life can be extended from 5 to 6 or 7 days, since the 5-day limitation was based on the risk of bacterial contamination [84]. In the TESSI trial (Efficacy and Safety Study of Platelets Treated for Pathogen Inactivation and check details Stored for Up to Seven Days), Lozano et al. [76] opted for an innovative study design: they compared the therapeutic efficacy of amotosalen/UVA-treated vs. standard platelets that had been stored for 6 or 7 days. Every patient was included for only a single transfusion. The authors confirmed the noninferiority of PCs treated with INTERCEPT and stored for 6

or 7 days: the mean CCIs (after 1 h) were 8.163 and 9.383, respectively, for amotosalen/UVA-treated Janus kinase (JAK) and standard platelets. To minimize confounding variables, a Swiss team from Basel performed an open prospective study that compared a group of 44 patients who received amotosalen/UVA-treated apheresis platelets with a group of 72 patients who received γ-irradiated standard platelets in PAS III over a period of 28 days. The platelet content of the bags was identical (around 2.8 × 1011/unit) between the two groups. There was no difference in the CCI (after 1 h) between the two study arms (11.400 ± 4.900 vs. 11.000 ± 4.900, respectively, for amotosalen/UVA-treated apheresis platelets and γ-irradiated standard platelets) [78]. Due to a lack of availability of INTERCEPT-treated PCs, 38% of the transfusions in the INTERCEPT arm were given with standard platelets. A per-protocol analysis (including only transfusions with INTERCEPT-treated platelets) revealed a CCI (after 1 h) of 10.700 ± 5.600. The MIRACLE study is the only published RCT thus far of PCs treated with riboflavin/UV (MIRASOL). It was published in 2010 and included 118 patients. The CCI (after 1 h) was significantly lower in the riboflavin/UV arm than in the control arm (11.725 ± 1.14 vs. 16.939 ± 1.15, respectively).