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Kraimer K, Scott B, Farrell N, Geltzeiler M, Smith T, Detwiller K. Postoperative Pain Following Coblation of Sinonasal Hereditary Hemorrhagic Telangiectasias. Ann Otol Rhinol Laryngol 2024; 133:58-62. [PMID: 37377016 DOI: 10.1177/00034894231182212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is a rare, autosomal dominant disease and epistaxis is the most common symptom. This can be treated conservatively but severe cases may require operative interventions. Endoscopic endonasal coblation of HHT lesions has been used successfully but postoperative pain management has not been well described. OBJECTIVES This study aimed to assess levels of postoperative pain and opioid use among patients with HHT who underwent coblation of sinonasal lesions. METHODS This is a longitudinal, prospective cohort study of adult patients undergoing endoscopic endonasal coblation for treatment of HHT lesions with or without bevacizumab injection between November 2019 and March 2020 at a single academic university hospital. Patients were given preoperative questionnaires and contacted via telephone 48 hours after surgery. If they reported using opioids for pain control, they were called every 2 days until they no longer used these medications. RESULTS Fourteen cases, including 13 unique patients, were included in this study. Opioids were ordered on discharge in 4 cases and the average morphine milligram equivalent prescribed on discharge was 41. The median pain score on postoperative day (POD) 2 was 4 of 10. Twelve patients reported using acetaminophen and 4 were using opioid pain medications. Of those using opioid pain medications, only 1 patient was using opioid pain medication by POD 4 and denied any use after POD 10. CONCLUSION This study is the first to analyze postoperative pain management and opioid prescribing patterns in HHT patients undergoing endonasal coblation of telangiectasias. Postoperative pain was mild to moderate and most patients stopped using opioid medications by POD 4, although the majority of patients solely used acetaminophen. Future studies with increased sample size will be useful to further identify predictors of need for analgesics postoperatively and other non-opioid adjuncts for pain control.
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Affiliation(s)
- Kristen Kraimer
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Brian Scott
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Nyssa Farrell
- Department of Otolaryngology-Head and Neck Surgery, Washington University, St Louis, MI, USA
| | - Mathew Geltzeiler
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Timothy Smith
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Kara Detwiller
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, OR, USA
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Yusuf HM, Rasheed A, Hetts S, Kim H, Loftus P, Conrad M. Exploring effects of atmospheric conditions in hereditary hemorrhagic telangiectasia. Int Forum Allergy Rhinol 2023; 13:2172-2179. [PMID: 37189284 DOI: 10.1002/alr.23183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant disorder characterized by recurrent epistaxis, telangiectasias, and visceral arteriovenous malformations. Individuals with HHT often identify low humidity and temperature as detrimental to epistaxis severity. We set out to assess the relationship between humidity and temperature on epistaxis severity in patients with HHT. METHODS Retrospective cross-sectional study at an academic hospital with an HHT center between July 1, 2014 and January 1, 2022. The primary outcome of this study was ESS. Pearson correlation analyses and multiple linear regression analyses were performed to test the association between weather variables and epistaxis severity scre (ESS). Results were reported as coefficient and 95% confidence interval (CI). RESULTS Four hundred twenty-nine patients were included in the analysis. Through a Pearson correlation analysis, neither humidity (regression coefficient = -0.01; 95% CI, -0.006 to 0.003; p = 0.50), daily low temperature (regression coefficient = 0.01; 95% CI, -0.011 to 0.016; p = 0.72), or daily high temperature (regression coefficient = 0.01; 95% CI, -0.004 to 0.013; p = 0.32) were significantly correlated with ESS. In a multiple linear regression analysis, adjusting for both daily low temperature and humidity, medications taken, demographics, and genotype, neither daily low temperature (regression coefficient = -0.02; 95% CI, -0.04 to 0.01; p = 0.14) nor humidity (regression coefficient = 0.01; 95% CI, -0.01 to 0.01; p = 0.64) were significantly associated with ESS. CONCLUSION We have shown in a large clinical sample that neither humidity nor temperature were strongly correlated with HHT patient epistaxis severity.
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Affiliation(s)
- Hamzah M Yusuf
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Amna Rasheed
- Touro College of Medicine, Vallejo, California, USA
| | - Steven Hetts
- Neurointerventional Radiology, University of California, San Francisco, California, USA
| | - Helen Kim
- Center for Cerebrovascular Research, University of California, San Francisco, California, USA
| | - Patricia Loftus
- Otolaryngology, University of California, San Francisco, California, USA
| | - Miles Conrad
- Radiology, School of Medicine, University of California San Francisco, San Francisco, California, USA
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Litsou E, Basiari L, Tsirves G, Psychogios GV. Hereditary Hemorrhagic Telangiectasia With Multiple Ear, Nose, and Throat (ENT) Manifestations: A Case Report. Cureus 2023; 15:e42706. [PMID: 37654935 PMCID: PMC10467641 DOI: 10.7759/cureus.42706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 09/02/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, is a rare autosomal dominant multisystem disorder. It is a mucocutaneous and fibrovascular dysplasia, the diagnosis of which is based on the fulfillment of the four Curaçao criteria: 1) recurrent epistaxis; 2) dermatovascular mucosal telangiectasias at characteristic sites: skin of the face, ears, fingertips, lips, tongue, and oral and nasal cavity; 3) arteriovenous malformations (AVMs) of visceral organs and central nervous system; and 4) family history: diagnosis of HHT in a first-degree relative. We describe a case of a 76-year-old patient who presented to our department with clinical manifestations of HHT in the skin (face, fingertips), lips, hard palate, tongue, ears, and nasal cavities. Individual and family history was obtained, as well as clinical laboratory examination, pan-endoscopy of the ear, nose, and throat (ENT) systems, and treatment of active foci of bleeding from the above areas. The otolaryngologist may be the first doctor to suspect Rendu-Osler-Weber syndrome and the one responsible for treating patients with HHT since recurrent epistaxis is the most frequent (90-96% of patients) and the earlier manifestation of the disease and the main reason for the arrival of these patients in the Emergency Department. The purpose of this study is to present a clinical case of Rendu-Osler-Weber syndrome with multiple ENT manifestations, as well as a review of the literature on their management and treatment.
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Affiliation(s)
- Eleni Litsou
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Ioannina, Ioannina, GRC
| | - Lentiona Basiari
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Ioannina, Ioannina, GRC
| | - Georgios Tsirves
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Ioannina, Ioannina, GRC
| | - Georgios V Psychogios
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Ioannina, Ioannina, GRC
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Matti E, Maiorano E, Nacu B, Luceri A, Sovardi F, Siragusa V, Ferrauto A, Spinozzi G, Olivieri C, Benazzo M, Pagella F. Silicone septal splint for recurrent epistaxis in HHT patients: experience of a national referral centre. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2023; 43:S28-S33. [PMID: 37698097 PMCID: PMC10159634 DOI: 10.14639/0392-100x-suppl.1-43-2023-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/02/2023] [Indexed: 09/13/2023]
Abstract
Objective To report our experience in the use of silicone septal splint for recurrent severe epistaxis in hereditary haemorrhagic telangiectasia patients (HHT). Methods This is a descriptive analysis carried out at the Otorhinolaryngology Department of Fondazione IRCCS Policlinico San Matteo in Pavia, a reference centre for the treatment and diagnosis of HHT. We retrospectively evaluated HHT patients who underwent silicone septal splint positioning after the endoscopic surgical treatment of epistaxis from 2000 to 2022. Results Of the 506 patients surgically treated in the period of analysis, 74 patients underwent silicone septal splint positioning and 37 were post-operatively interviewed. With a mean of 2.4 previous surgical treatments and a mean epistaxis severity of 7.38, the majority of patients presented with septal perforation (71.6%). On average, patients maintained the splint in place for 54.5 months, with a good tolerability and a significant reduction in epistaxis severity, need for blood transfusion and improvement of haemoglobin levels. Conclusions In HHT patients with recurrent severe epistaxis and with septal perforation, the placement of septal splints offers a useful additional strategy in the management of nosebleeds.
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Affiliation(s)
- Elina Matti
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Eugenia Maiorano
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Bogdan Nacu
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- University of Pavia, Pavia, Italy
| | - Andrea Luceri
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- University of Pavia, Pavia, Italy
| | - Fabio Sovardi
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Vera Siragusa
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- University of Pavia, Pavia, Italy
| | | | - Giuseppe Spinozzi
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carla Olivieri
- Molecular Medicine Department, General Biology and Medical Genetics Unit, University of Pavia, Pavia, Italy
| | - Marco Benazzo
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- University of Pavia, Pavia, Italy
| | - Fabio Pagella
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- University of Pavia, Pavia, Italy
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5
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Pyakurel S, Bohara S, Bhattarai S, Regmi S, Karki S, Adhikari M, Gurung B, Shrestha U. Osler-Weber-Rendu syndrome: A case report on a rare vascular malformation presented with lower gastrointestinal bleeding. Clin Case Rep 2023; 11:e6965. [PMID: 36817313 PMCID: PMC9932227 DOI: 10.1002/ccr3.6965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 02/18/2023] Open
Abstract
Osler-Weber-Rendu syndrome is an uncommon vascular disorder inherited as an autosomal dominant trait with varying penetrance and expression. A multidisciplinary approach is used for a detailed diagnostic workup and management based on the patient's symptoms at presentation.
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Affiliation(s)
- Sulav Pyakurel
- Department of NephrologyNepal Mediciti HospitalLalitpurNepal
| | - Sujan Bohara
- Department of General and Gastrointestinal SurgeryNepal Mediciti HospitalLalitpurNepal
| | - Sanjeet Bhattarai
- Department of Pulmonary MedicineNepal Mediciti HospitalLalitpurNepal
| | - Sachit Regmi
- Department of Gastrointestinal MedicineNepal Mediciti HospitalLalitpurNepal
| | | | | | - Bibek Gurung
- Department of RadiologyNepal Mediciti HospitalLalitpurNepal
| | - Umid Shrestha
- Department of Gastrointestinal MedicineNepal Mediciti HospitalLalitpurNepal
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6
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Thompson KP, Sykes J, Chandakkar P, Marambaud P, Vozoris NT, Marchuk DA, Faughnan ME. Randomized, double-blind, placebo-controlled, crossover trial of oral doxycycline for epistaxis in hereditary hemorrhagic telangiectasia. Orphanet J Rare Dis 2022; 17:405. [PMCID: PMC9640829 DOI: 10.1186/s13023-022-02539-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 10/04/2022] [Indexed: 11/09/2022] Open
Abstract
Background Vascular malformations in hereditary hemorrhagic telangiectasia (HHT) lead to chronic recurrent bleeding, hemorrhage, stroke, heart failure, and liver disease. There is great interest in identifying novel therapies for epistaxis in HHT given its associated morbidity and impact on quality of life. We aimed to measure the effectiveness of oral doxycycline for the treatment of epistaxis and explore mechanisms of action on angiogenic, inflammatory and pathway markers in HHT using a randomized controlled trial. Methods 13 HHT patients with epistaxis were recruited from the Toronto HHT Center at St. Michael’s Hospital. Recruitment was stopped early due to COVID-19-related limitations. The study duration was 24 months. Patients were randomly assigned to the treatment-first or placebo-first study arm. We compared the change in weekly epistaxis duration and frequency, biomarkers, blood measurements, and intravenous iron infusion and blood transfusion requirements between treatment and placebo. Results There was no significant difference in the change in weekly epistaxis duration (p = 0.136) or frequency (p = 0.261) between treatment and placebo. There was no significant difference in the levels of MMP-9, VEGF, ANG-2, IL-6 or ENG with treatment. Hemoglobin levels were significantly higher (p = 0.0499) during treatment. Ferritin levels were not significantly different between treatment and placebo. There was no significant difference in RBC transfusions between treatment periods (p = 0.299). Conclusion Overall, our study did not demonstrate effectiveness of doxycycline as a treatment for epistaxis in patients with HHT, though the study was underpowered. Secondary analyses provided new observations which may help guide future trials in HHT. Trial Registration ClinicalTrials.gov, NCT03397004. Registered 11 January 2018 – Prospectively registered, https://clinicaltrials.gov/ct2/show/NCT03397004 Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02539-8.
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Affiliation(s)
- K. P. Thompson
- grid.415502.7Toronto HHT Centre, St. Michael’s Hospital and Li Ka Shing Knowledge Institute, 30 Bond St, Toronto, ON M5B-1W8 Canada ,grid.17063.330000 0001 2157 2938Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada
| | - J. Sykes
- grid.415502.7Department of Respirology, St. Michael’s Hospital, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
| | - P. Chandakkar
- grid.250903.d0000 0000 9566 0634The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY USA
| | - P. Marambaud
- grid.250903.d0000 0000 9566 0634The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY USA
| | - N. T. Vozoris
- grid.415502.7Toronto HHT Centre, St. Michael’s Hospital and Li Ka Shing Knowledge Institute, 30 Bond St, Toronto, ON M5B-1W8 Canada ,grid.17063.330000 0001 2157 2938Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada
| | - D. A. Marchuk
- grid.189509.c0000000100241216Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC USA
| | - M. E. Faughnan
- grid.415502.7Toronto HHT Centre, St. Michael’s Hospital and Li Ka Shing Knowledge Institute, 30 Bond St, Toronto, ON M5B-1W8 Canada ,grid.17063.330000 0001 2157 2938Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada
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7
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Joyce KE, Onabanjo E, Brownlow S, Nur F, Olupona K, Fakayode K, Sroya M, Thomas GA, Ferguson T, Redhead J, Millar CM, Cooper N, Layton DM, Boardman-Pretty F, Caulfield MJ, Shovlin CL. Whole genome sequences discriminate hereditary hemorrhagic telangiectasia phenotypes by non-HHT deleterious DNA variation. Blood Adv 2022; 6:3956-3969. [PMID: 35316832 PMCID: PMC9278305 DOI: 10.1182/bloodadvances.2022007136] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/21/2022] [Indexed: 11/20/2022] Open
Abstract
The abnormal vascular structures of hereditary hemorrhagic telangiectasia (HHT) often cause severe anemia due to recurrent hemorrhage, but HHT causal genes do not predict the severity of hematological complications. We tested for chance inheritance and clinical associations of rare deleterious variants in which loss-of-function causes bleeding or hemolytic disorders in the general population. In double-blinded analyses, all 104 patients with HHT from a single reference center recruited to the 100 000 Genomes Project were categorized on new MALO (more/as-expected/less/opposite) sub-phenotype severity scales, and whole genome sequencing data were tested for high impact variants in 75 HHT-independent genes encoding coagulation factors, or platelet, hemoglobin, erythrocyte enzyme, and erythrocyte membrane constituents. Rare variants (all gnomAD allele frequencies <0.003) were identified in 56 (75%) of these 75 HHT-unrelated genes. Deleteriousness assignments by Combined Annotation Dependent Depletion (CADD) scores >15 were supported by gene-level mutation significance cutoff scores. CADD >15 variants were identified in 38/104 (36.5%) patients with HHT, found for 1 in 10 patients within platelet genes; 1 in 8 within coagulation genes; and 1 in 4 within erythrocyte hemolytic genes. In blinded analyses, patients with greater hemorrhagic severity that had been attributed solely to HHT vessels had more CADD-deleterious variants in platelet (Spearman ρ = 0.25; P = .008) and coagulation (Spearman ρ = 0.21; P = .024) genes. However, the HHT cohort had 60% fewer deleterious variants in platelet and coagulation genes than expected (Mann-Whitney test P = .021). In conclusion, patients with HHT commonly have rare variants in genes of relevance to their phenotype, offering new therapeutic targets and opportunities for informed, personalized medicine strategies.
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Affiliation(s)
- Katie E. Joyce
- Imperial College School of Medicine, Imperial College, London, United Kingdom
- Genomics England Respiratory Clinical Interpretation Partnership (GeCIP), London, United Kingdom
| | - Ebun Onabanjo
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Sheila Brownlow
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fadumo Nur
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Kike Olupona
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Kehinde Fakayode
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Manveer Sroya
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | | | - Teena Ferguson
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Julian Redhead
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Carolyn M. Millar
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College, London, United Kingdom
| | - Nichola Cooper
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College, London, United Kingdom
| | - D. Mark Layton
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College, London, United Kingdom
| | | | - Mark J. Caulfield
- Genomics England Research Consortium, Genomics England, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; and
| | | | - Claire L. Shovlin
- Genomics England Respiratory Clinical Interpretation Partnership (GeCIP), London, United Kingdom
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
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8
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Egido-Turrión C, Rossi E, Ollauri-Ibáñez C, Pérez-García ML, Sevilla MA, Bastida JM, González-Porras JR, Rodríguez-Barbero A, Bernabeu C, Lopez-Novoa JM, Pericacho M. Functional Alterations Involved in Increased Bleeding in Hereditary Hemorrhagic Telangiectasia Mouse Models. Front Med (Lausanne) 2022; 9:871903. [PMID: 35665360 PMCID: PMC9160577 DOI: 10.3389/fmed.2022.871903] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/06/2022] [Indexed: 12/11/2022] Open
Abstract
Hereditary Hemorrhagic Telangiectasia (HHT) is an autosomal-dominant genetic disorder involving defects in two predominant genes known as endoglin (ENG; HHT-1) and activin receptor-like kinase 1 (ACVRL1/ALK1; HHT-2). It is characterized by mucocutaneous telangiectases that, due to their fragility, frequently break causing recurrent epistaxis and gastrointestinal bleeding. Because of the severity of hemorrhages, the study of the hemostasis involved in these vascular ruptures is critical to find therapies for this disease. Our results demonstrate that HHT patients with high bleeding, as determined by a high Epistaxis Severity Score (ESS), do not have prolonged clotting times or alterations in clotting factors. Considering that coagulation is only one of the processes involved in hemostasis, the main objective of this study was to investigate the overall mechanisms of hemostasis in HHT-1 (Eng+/−) and HHT-2 (Alk1+/−) mouse models, which do not show HHT vascular phenotypes in the meaning of spontaneous bleeding. In Eng+/− mice, the results of in vivo and in vitro assays suggest deficient platelet-endothelium interactions that impair a robust and stable thrombus formation. Consequently, the thrombus could be torn off and dragged by the mechanical force exerted by the bloodstream, leading to the reappearance of hemorrhages. In Alk1+/− mice, an overactivation of the fibrinolysis system was observed. These results support the idea that endoglin and Alk1 haploinsufficiency leads to a common phenotype of impaired hemostasis, but through different mechanisms. This contribution opens new therapeutic approaches to HHT patients' epistaxis.
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Affiliation(s)
- Cristina Egido-Turrión
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Elisa Rossi
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, Paris, France
| | - Claudia Ollauri-Ibáñez
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - María L. Pérez-García
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Department of Internal Medicine, Complejo Asistencial Universitario de Salamanca (CAUSA)-SACYL, Salamanca, Spain
| | - María A. Sevilla
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - José María Bastida
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Department of Hematology, Complejo Asistencial Universitario de Salamanca (CAUSA)-SACYL, Salamanca, Spain
| | - José Ramón González-Porras
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Department of Hematology, Complejo Asistencial Universitario de Salamanca (CAUSA)-SACYL, Salamanca, Spain
| | - Alicia Rodríguez-Barbero
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Carmelo Bernabeu
- Centro de Investigaciones Biológicas Margarita Salas, Consejo Superior de Investigaciones Científicas (CSIC), Madrid, Spain
| | - José M. Lopez-Novoa
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Miguel Pericacho
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- *Correspondence: Miguel Pericacho
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9
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Zhang J, Pan G, Zou Y, Chen X, Pan J, Wang Y, Quan S, Zou H. A missed case of hereditary hemorrhagic telangiectasia: A case report. SAGE Open Med Case Rep 2022; 10:2050313X221124060. [DOI: 10.1177/2050313x221124060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/17/2022] [Indexed: 12/15/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia is a rare autosomal dominant disorder characterized by abnormal blood vessel formation. When an abnormal vascular architecture affects the lungs and central nervous system, serious complications can occur. We report a missed case of hereditary hemorrhagic telangiectasia with pulmonary arteriovenous malformations and cerebral arteriovenous malformations. A 22-year-old Chinese female was taken to the emergency room because of unconsciousness. Emergency head contrast-enhanced computed tomography and transthoracic contrast echocardiography showed that she had cerebral arteriovenous malformations and pulmonary arteriovenous malformations. The patient experienced multiple spontaneous epistaxis since childhood, for which she was treated at a local hospital for a brief period. Her mother also had pulmonary arteriovenous malformations. The patient was diagnosed with hereditary hemorrhagic telangiectasia according to the consensus Curaçao diagnostic criteria and eventually died of hereditary hemorrhagic telangiectasia. The case report highlights the importance of early diagnosis and intervention for hereditary hemorrhagic telangiectasia. Given that hereditary hemorrhagic telangiectasia is frequently undiagnosed, increasing the physician’s awareness of hereditary hemorrhagic telangiectasia can play an important role in the timely diagnosis and treatment of these patients.
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Affiliation(s)
- Jia Zhang
- Department of Inspection Medical, Wenzhou People’s Hospital, The Wenzhou Third Clinical Institute Affiliated with Wenzhou Medical University, Wenzhou, China
- School of Laboratory Medicine and Life Sciences, Wenzhou Medical University, Wenzhou, China
| | - Gaoyun Pan
- Department of Ultrasound, Wenzhou People’s Hospital, The Wenzhou Third Clinical Institute Affiliated with Wenzhou Medical University, Wenzhou, China
| | - Yingying Zou
- Department of Digestive System, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar, China
| | - Xiaoshu Chen
- Department of Cardiovascular Medicine, Wenzhou People’s Hospital, The Wenzhou Third Clinical Institute Affiliated with Wenzhou Medical University, Wenzhou, China
| | - Jingye Pan
- Department of General and Intensive Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yi Wang
- Department of Cardiovascular Medicine, Wenzhou People’s Hospital, The Wenzhou Third Clinical Institute Affiliated with Wenzhou Medical University, Wenzhou, China
| | - Shichao Quan
- Department of General Practice, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - He Zou
- Department of Cardiovascular Medicine, Wenzhou People’s Hospital, The Wenzhou Third Clinical Institute Affiliated with Wenzhou Medical University, Wenzhou, China
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10
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Pagella F, Pusateri A, Maiorano E, Spinozzi G, Ugolini S, Lizzio R, Mirabella R, Tinelli C, Olivieri C, Matti E. Endoscopic surgical treatment of epistaxis in hereditary haemorrhagic telangiectasia: our experience. ACTA ACUST UNITED AC 2021; 41:59-68. [PMID: 33746224 PMCID: PMC7982753 DOI: 10.14639/0392-100x-n0915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 10/16/2020] [Indexed: 11/23/2022]
Abstract
Objectives Hereditary haemorrhagic telangiectasia (HHT) is a rare autosomal dominant disease characterised by epistaxis. Surgical procedures for epistaxis vary from diathermocoagulation to nasal closure. The aim of this paper is to report our experience in endoscopic surgical management of epistaxis in HHT patients. Methods This is a descriptive, longitudinal study carried out at the Otorhinolaryngology Department of IRCCS Policlinico San Matteo in Pavia, a reference centre for the treatment and diagnosis of HHT. We retrospectively evaluated HHT patients who underwent surgery for epistaxis from 1996 to 2015, including only those treated with endoscopic surgery. Results Among the 591 patients hospitalised and screened for HHT, 323 (54.7%) underwent endoscopic surgery for epistaxis, for a total of 679 procedures. General anaesthesia was used in 77.2% of procedures; argon plasma coagulation was the instrument of choice in the majority of patients, followed by lasers and quantum molecular resonance technology. Conclusions We report one of the largest cohorts undergoing endoscopic treatment of epistaxis in HHT patients. This mini-invasive surgical treatment allowed us to control epistaxis without major complications and nasal packaging and can be repeated over time. For these reasons, we recommend it as first choice in case of epistaxis in HHT patients.
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Affiliation(s)
- Fabio Pagella
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,University of Pavia, Italy
| | - Alessandro Pusateri
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Eugenia Maiorano
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,University of Pavia, Italy
| | - Giuseppe Spinozzi
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Sara Ugolini
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,University of Pavia, Italy
| | - Roberta Lizzio
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Rosolino Mirabella
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,University of Pavia, Italy
| | - Carmine Tinelli
- Clinical Epidemiology and Biometric Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Carla Olivieri
- University of Pavia, Italy.,General Biology and Medical Genetics, Department of Molecular Medicine, Pavia, Italy
| | - Elina Matti
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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11
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Hayama M, Maeda Y, Tsuda T, Akazawa H, Nakatani A, Obata S, Takeda K, Inohara H. Epistaxis limits the performed activities of daily living in proportion to its severity: a cross-sectional survey among patients with hereditary haemorrhagic telangiectasia. RHINOLOGY ONLINE 2021. [DOI: 10.4193/rhinol/21.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: We examined the severity of epistaxis in patients with hereditary haemorrhagic telangiectasia (HHT) and its relationship with the performed activities of daily living. Methodology: This cross-sectional survey included 36 patients with HHT in Japan. An anonymous questionnaire survey was conducted regarding the severity of epistaxis, the measures adopted to prevent epistaxis, and the limitations in the performed activities of daily living. The latter was assessed using a visual analogue scale (VAS). The correlation between epistaxis severity and the VAS score was analysed using Spearman’s rank correlation coefficient. Results: Of the 36 participants surveyed, 94.4% had >1 episode of epistaxis/week. The mean epistaxis severity score (ESS) was 4.3 (range, 0.9–8.4). Limitations in daily life, going out (within a day), meeting with others, eating with others, and going on overnight trips were positively correlated with the ESS. To prevent nosebleeds, 44.4% and 41.7% of the participants used medications and avoided drying their nasal cavities, respectively. Conclusions: Epistaxis impacted the daily life of patients with HHT in proportion to its severity. Nonetheless, less than half of the patients used medications or took precautions. Hence, further educational activities should be considered for medical professionals and patients.
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12
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Mufti A, Sachdeva M, Maliyar K, Joseph M. Hereditary haemorrhagic telangiectasia: A case report. SAGE Open Med Case Rep 2021; 9:2050313X211003076. [PMID: 34394937 PMCID: PMC8358483 DOI: 10.1177/2050313x211003076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/25/2021] [Indexed: 11/16/2022] Open
Abstract
Background Hereditary haemorrhagic telangiectasia is an autosomal dominant genetic disorder characterized by abnormalities in blood vessel formation. The clinical manifestations of patients affected with hereditary haemorrhagic telangiectasia include mucocutaneous telangiectasias and visceral arteriovenous malformations. Case Summary We report the case of a 30-year-old female diagnosed with hereditary haemorrhagic telangiectasia presenting with the classic triad of recurrent epistaxis, mucocutaneous telangiectasias and family history of hereditary haemorrhagic telangiectasia with activin receptor-like kinase 1 mutation. Upon skin examination, she was noted to have telangiectasias under left naris, inner lower lip and surface of the tongue, and a vascular malformation on the right forearm. Conclusion Although the skin involvement and epistaxis may be mild symptoms and signs of hereditary haemorrhagic telangiectasia, timely recognition of these can ensure vigilant monitoring of potential severe complications from cerebral and pulmonary visceral arteriovenous malformations.
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Affiliation(s)
- Asfandyar Mufti
- Division of Dermatology, University of Toronto, Toronto, ON, Canada
| | | | - Khalad Maliyar
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Marissa Joseph
- Women's College Hospital, University of Toronto, Toronto, ON, Canada.,Section of Dermatology, Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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13
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Kroon S, Snijder R, Hosman A, Vorselaars V, Disch F, Post M, Mager J. Oral itraconazole for epistaxis in hereditary hemorrhagic telangiectasia: a proof of concept study. Angiogenesis 2021; 24:379-386. [PMID: 33211216 PMCID: PMC7615075 DOI: 10.1007/s10456-020-09758-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 11/09/2020] [Indexed: 10/23/2022]
Abstract
The inhibiting effects of itraconazole, an antifungal drug on vascular endothelial growth factor (VEGF) have recently been discovered. By inhibiting VEGF, itraconazole has shown potential in clinical trials as anti-cancer treatment. In hereditary hemorrhagic telangiectasia (HHT) patients, VEGF levels are elevated and inhibition of VEGF can decrease bleeding. Itraconazole could potentially serve as anti-angiogenic therapy for HHT-related bleeding. We report a proof of concept study with HHT patients and severe epistaxis. Patients were treated with daily 200 mg orally administered itraconazole for sixteen weeks. Twenty-one HHT patients, 8 females (38%), 13 males (62%), median age of 59 years (interquartile range (IQR) 55-69) were enrolled. Of these patients, 13 (62%) were diagnosed with HHT type 1, seven (33%) with HHT type 2 and in one patient (5%), no pathognomonic HHT mutation was found. Four patients (19%) prematurely terminated the study (3 due to mild or moderate side-effects) resulting in 17 patients included in the analyses. The median epistaxis severity score significantly decreased during treatment from 6.0 (IQR 5.1-7.2) to 3.8 (IQR 3.1-5.2) (p = 0.006). The monthly epistaxis frequency decreased from 56 to 38 epistaxis episodes (p = 0.004) and the monthly duration from 407 to 278 minutes (p = 0.005). Hemoglobin levels did not significantly change. The quality of life showed a small but significant improvement. In conclusion, oral itraconazole significantly improved epistaxis in HHT patients. The potential benefit of itraconazole in HHT should be further investigated.
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Affiliation(s)
- S. Kroon
- Departments of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - R.J. Snijder
- Departments of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - A.E. Hosman
- Departments of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - V.M.M Vorselaars
- Department of Cardiology and Ear, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - F.J.M. Disch
- Department of Nose and Throat, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - M.C. Post
- Department of Cardiology and Ear, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - J.J. Mager
- Departments of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
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14
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Embolic Stroke Caused by Hereditary Hemorrhagic Telangiectasia with Pulmonary Arteriovenous Malformation. J Gen Intern Med 2020; 35:3707-3710. [PMID: 32815056 PMCID: PMC7728913 DOI: 10.1007/s11606-020-06126-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/10/2020] [Indexed: 02/03/2023]
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15
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Bowers EMR, Lee S. Treatment of tongue telangiectasia in a patient with hereditary haemorrhagic telangiectasia. BMJ Case Rep 2020; 13:13/11/e238485. [PMID: 33139375 DOI: 10.1136/bcr-2020-238485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 61-year-old Caucasian woman presented to an outpatient otolaryngology clinic with increased bleeding from a dorsal tongue telangiectasia for 3 weeks. Her history was significant for hereditary haemorrhagic telangiectasia (HHT), a rare condition that causes vascular dysplasia, and recent symptomatic anaemia requiring blood transfusions. After failing medical management with topical haemostatic agents, she was offered and underwent surgical intervention to remove the tongue telangiectasia with duel therapy potassium titanyl phosphate (KTP) laser coblation and bevacizumab injections. A team of otolaryngologists removed the lesion without complications, and the patient denied bleeding, had minimal pain, and endorsed increased quality of life postoperatively. Tongue telangiectasias can cause life-threatening bleeding in some patients with HHT, and no surgical management guidelines exist to treat them. This case demonstrates the efficacy of KTP laser followed by bevacizumab injections in treating tongue telangiectasias in a patient with HHT.
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Affiliation(s)
| | - Stella Lee
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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16
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Cavalcoli F, Gandini A, Matelloni IA, Catalano F, Alicante S, Manfredi G, Brambilla G, Menozzi F, Perolini F, Costi E, Bertè R, Buscarini E. Dietary iron intake and anemia: food frequency questionnaire in patients with hereditary hemorrhagic telangiectasia. Orphanet J Rare Dis 2020; 15:295. [PMID: 33081831 PMCID: PMC7574540 DOI: 10.1186/s13023-020-01554-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/22/2020] [Indexed: 11/10/2022] Open
Abstract
Background Hereditary hemorrhagic telangiectasia (HHT) is a multisystemic inherited vascular disease characterized by a heterogeneous clinical presentation and prognosis. Dietary evaluation is relevant in HHT patients to provide adequate iron and nutrient intake. Additionally, different dietary items have been reported to precipitate epistaxis in this setting. Our primary aim was to investigate the dietary habits of HHT patients through a food-frequency questionnaire (FFQ) to evaluate the presence of precipitants and/or protective factors for epistaxis and the occurrence of possible dietary modifications. The secondary aims were to evaluate the nutritional intake of iron in HHT patients and the self-reported effect of iron treatments on epistaxis. From April 2018 to October 2018, a 138-item FFQ was provided to HHT patients followed up at the HHT Referral Center of Crema Maggiore Hospital. The relationship between food items and epistaxis was ascertained on a separate form. Daily iron intake was calculated to establish the mean iron content of food items reported in the FFQ. Results One hundred forty-nine questionnaires were evaluated [72 females, median age 54 years (12–76). Overall, 26 (18%) patients reported dietary items that improved epistaxis (mostly blueberries and red fruits, green vegetables and legumes), while 38 (26%) reported some dietary items that exacerbated epistaxis (spices, chocolate, alcohol, strawberries and ginger). Dietary modifications were reported in up to 58% of cases. In HHT patients, the mean daily iron intake was 8.46 ± 2.78 mg, and no differences were observed in the iron intake of patients reporting a diet modification and those who did not. Conclusions In the comprehensive management of HHT a healthy and balanced diet, with increased consumption of dietary items with a high iron content, should be encouraged.
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Affiliation(s)
- Federica Cavalcoli
- Gastroenterology Department, HHT Reference Center, Maggiore Hospital, ASST Crema, Largo Ugo Dossena 2, 26013, Crema, Italy.
| | - Alberto Gandini
- Gastroenterology Department, HHT Reference Center, Maggiore Hospital, ASST Crema, Largo Ugo Dossena 2, 26013, Crema, Italy
| | - Irene Aglaia Matelloni
- Gastroenterology Department, HHT Reference Center, Maggiore Hospital, ASST Crema, Largo Ugo Dossena 2, 26013, Crema, Italy
| | | | - Saverio Alicante
- Gastroenterology Department, HHT Reference Center, Maggiore Hospital, ASST Crema, Largo Ugo Dossena 2, 26013, Crema, Italy
| | - Guido Manfredi
- Gastroenterology Department, HHT Reference Center, Maggiore Hospital, ASST Crema, Largo Ugo Dossena 2, 26013, Crema, Italy
| | - Gianfranco Brambilla
- Gastroenterology Department, HHT Reference Center, Maggiore Hospital, ASST Crema, Largo Ugo Dossena 2, 26013, Crema, Italy
| | - Fernanda Menozzi
- Gastroenterology Department, HHT Reference Center, Maggiore Hospital, ASST Crema, Largo Ugo Dossena 2, 26013, Crema, Italy
| | - Federica Perolini
- Gastroenterology Department, HHT Reference Center, Maggiore Hospital, ASST Crema, Largo Ugo Dossena 2, 26013, Crema, Italy
| | - Egon Costi
- Gastroenterology Department, HHT Reference Center, Maggiore Hospital, ASST Crema, Largo Ugo Dossena 2, 26013, Crema, Italy
| | - Roberto Bertè
- Gastroenterology Department, HHT Reference Center, Maggiore Hospital, ASST Crema, Largo Ugo Dossena 2, 26013, Crema, Italy
| | - Elisabetta Buscarini
- Gastroenterology Department, HHT Reference Center, Maggiore Hospital, ASST Crema, Largo Ugo Dossena 2, 26013, Crema, Italy
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17
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Andrejecsk JW, Hosman AE, Botella LM, Shovlin CL, Arthur HM, Dupuis-Girod S, Buscarini E, Hughes CCW, Lebrin F, Mummery CL, Post MC, Mager JJ. Executive summary of the 12th HHT international scientific conference. Angiogenesis 2019; 21:169-181. [PMID: 29147802 DOI: 10.1007/s10456-017-9585-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hereditary hemorrhagic telangiectasia is an autosomal dominant trait affecting approximately 1 in 5000 people. A pathogenic DNA sequence variant in the ENG, ACVRL1 or SMAD4 genes, can be found in the majority of patients. The 12th International Scientific HHT Conference was held on June 8-11, 2017 in Dubrovnik, Croatia to present and discuss the latest scientific achievements, and was attended by over 200 scientific and clinical researchers. In total 174 abstracts were accepted of which 58 were selected for oral presentations. This article covers the basic science and clinical talks, and discussions from three theme-based workshops. We focus on significant emergent themes and unanswered questions. Understanding these topics and answering these questions will help to define the future of HHT research and therapeutics, and ultimately bring us closer to a cure.
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Affiliation(s)
- Jillian W Andrejecsk
- Department of Molecular Biology and Biochemistry, University of California Irvine, Irvine, CA, USA
| | - Anna E Hosman
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Luisa M Botella
- Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas (CSIC), and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Ramiro de Maeztu 9, 28040, Madrid, Spain
| | - Claire L Shovlin
- Vascular Science, National Heart and Lung Institute, Imperial College London, London, UK
| | - Helen M Arthur
- Institute of Genetic Medicine, Centre for Life, Newcastle University, Newcastle, NE1 3BZ, UK
| | - Sophie Dupuis-Girod
- Hospices Civils de Lyon, Genetic Unit and HHT Reference Center, Bron, School of Medical and University Lyon 1, Lyon, France
| | - Elisabetta Buscarini
- Gastroenterology and Endoscopy Department, Reference Center for Hereditary Hemorrhagic Telangiectasia, Maggiore Hospital, ASST Crema, Crema, Italy
| | - Christopher C W Hughes
- Department of Molecular Biology and Biochemistry, University of California Irvine, Irvine, CA, USA
| | - Franck Lebrin
- Einthoven Laboratory for Experimental Vascular Medicine, Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands. .,CNRS UMR 7587, INSERM U979, Institut Langevin, ESPCI, Paris, France.
| | - Christine L Mummery
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marco C Post
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Johannes J Mager
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
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18
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Syndromes that predispose to epistaxis. Eur Arch Otorhinolaryngol 2019; 276:939-944. [DOI: 10.1007/s00405-019-05310-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 01/19/2019] [Indexed: 01/10/2023]
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19
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Sexton A, Gargan B, Taylor J, Bogwitz M, Winship I. Living with Hereditary Haemorrhagic Telangiectasia: stigma, coping with unpredictable symptoms, and self-advocacy. Psychol Health 2019; 34:1141-1160. [PMID: 30931645 DOI: 10.1080/08870446.2019.1583341] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: Hereditary Haemorrhagic Telangiectasia (HHT) is a genetic condition causing frequent nose bleeds, skin lesions (telangiectasia) and arteriovenous malformations. Approximately, 50% of people experience life-threatening HHT symptoms including haemorrhages in the brain, lungs and liver. This study aimed to gain a qualitative understanding of the psychosocial impact of HHT over time. Design: Using a phenomenological framework, a rigorous narrative analysis was performed on 20 semi-structured interviews with individuals with HHT aged 20s-60s. Main outcome measures: Qualitative themes explaining life experiences prior to and following a clinical diagnosis of HHT. Results: Narratives highlighted four psychosocial themes: (i) the psychological impact of visible symptoms was significant and related to experiences of social stigma, (ii) individuals struggled to identify triggers of symptoms in order to reduce unpredictability, (iii) an illness identity was rejected by minimising HHT when talking about the present self, and by positive reframing as 'lucky' and (iv) self-advocacy was necessitated due to lack of expert coordinated care. Conclusion: HHT has a demanding impact on social, physical and psychological well-being. These findings have significant implications for health care, as narratives about interactions with health professionals often used the terms 'frustrating' and 'not being heard'.
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Affiliation(s)
- Adrienne Sexton
- Genomic Medicine, Royal Melbourne Hospital , Parkville , Victoria, Australia.,Department of Paediatrics, The University of Melbourne , Parkville , VIC, Australia
| | - Bridget Gargan
- Department of Paediatrics, The University of Melbourne , Parkville , VIC, Australia
| | - Jessica Taylor
- Genomic Medicine, Royal Melbourne Hospital , Parkville , Victoria, Australia
| | - Michael Bogwitz
- Genomic Medicine, Royal Melbourne Hospital , Parkville , Victoria, Australia
| | - Ingrid Winship
- Genomic Medicine, Royal Melbourne Hospital , Parkville , Victoria, Australia.,Department of Medicine, The University of Melbourne , Parkville VIC , Australia
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20
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Esteban-Casado S, Martín de Rosales Cabrera AM, Usarralde Pérez A, Martínez Simón JJ, Zhan Zhou E, Marcos Salazar MS, Pérez Encinas M, Botella Cubells L. Sclerotherapy and Topical Nasal Propranolol: An Effective and Safe Therapy for HHT-Epistaxis. Laryngoscope 2019; 129:2216-2223. [PMID: 30908653 DOI: 10.1002/lary.27930] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 01/30/2019] [Accepted: 02/22/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Epistaxis is the most frequent clinical manifestation of hereditary hemorrhagic telangiectasia (HHT). Several topical, systemic, and surgical treatments have been tried, but none have been completely effective. The aim of the present study is to evaluate whether a combined treatment sclerotherapy and topical therapy with propranolol 0.5% nasal formulation would reduce the epistaxis due to HHT and improve patient's quality of life. METHODS An observational cross-sectional study was carried out. The primary outcome measure was frequency and severity of epistaxis as measured by the epistaxis severity score (ESS) at baseline (4 weeks before therapy) and at least 4 weeks after the treatment was implemented. Quality of life was analyzed using EuroQol-5D (EQ-5D) scale and visual analogue (VAS) scale before and after treatment. RESULTS A total of 38 consecutive patients subjected to the combined treatment were evaluated (mean age: 57.2 years, standard deviation [SD] = 13.9; 60.5% women). The mean time of treatment was 37.1 weeks (SD = 14.9). Combined therapy significantly reduces frequency and severity of epistaxis, with an ESS improvement of 5 points from 6.9 ± 2.6 to 1.9 ± 1.3 (P < 0.05); however, the EQ-5D scale increased from 0.66 ± 0.27 to 0.93 ± 0.12 (P < 0.05). The difference in VAS means showed an increase from 44.6 ± 28.3 to 82.5 ± 12.5 (P < 0.05). The increases in quality of life are in line with the drop in ESS. CONCLUSION The study demonstrated that combined therapy (sclerotherapy and topical nasal propranolol) significantly reduced the epistaxis due to HHT and increased patients' quality of life. LEVEL OF EVIDENCE 2c Laryngoscope, 129:2216-2223, 2019.
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Affiliation(s)
| | | | | | | | - Estefanía Zhan Zhou
- Pharmacy Department, University Hospital Alcorcón Foundation, Alcorcón, Madrid
| | - M Sol Marcos Salazar
- Otorhinolaryngology Department, University Hospital Alcorcón Foundation, Alcorcón, Madrid
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21
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Abstract
PURPOSE OF REVIEW Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant inherited disease characterized by telangiectasia and arteriovenous malformations (AVMs). To date, five genetic types of HHT and one combined juvenile polyposis syndrome and HHT are known. Clinical and genetic screening of patients suspected with HHT is recommended to confirm the diagnosis and to prevent complications associated with HHT. The aim of this article is to give an overview of the evidence and to formulate a recommendation for clinicians concerning screening for HHT. RECENT FINDINGS Complications of HHT such as stroke, brain abscess and intracranial hemorrhage are caused by pulmonary and cerebral AVMs (CAVMs) and can often be prevented by screening and treatment when possible. Screening and treatment of these AVMs will result in an increased life expectancy comparable with that of the general population as opposed to unscreened and untreated HHT patients. SUMMARY Screening of HHT patients and their first-degree relatives is recommended to prevent severe complications including stroke, brain abscess and intracranial hemorrhage.
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22
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Shovlin CL, Buscarini E, Kjeldsen AD, Mager HJ, Sabba C, Droege F, Geisthoff U, Ugolini S, Dupuis-Girod S. European Reference Network For Rare Vascular Diseases (VASCERN) Outcome Measures For Hereditary Haemorrhagic Telangiectasia (HHT). Orphanet J Rare Dis 2018; 13:136. [PMID: 30111344 PMCID: PMC6094583 DOI: 10.1186/s13023-018-0850-2] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 06/20/2018] [Indexed: 12/13/2022] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a multisystemic vascular dysplasia that leads to nosebleeds, anaemia due to blood loss, and arteriovenous malformations (AVMs) in organs such as the lungs, liver and brain. HHT is estimated to affect 85,000 European citizens, but most health care providers have limited prior HHT exposure or training. Outcome Measures were developed and implemented by the HHT Working Group of the European Reference Network for Rare Vascular Diseases (VASCERN), in order to maximise the number of patients receiving good care. The measures specifically target areas where optimal management reduces morbidity and mortality in HHT patients, and were designed to be robust to emerging new evidence. Thresholds are the percentage of patients in particular settings who have been recommended screening, or provided with written advice. The 5 Outcome Measures cover (1) pulmonary AVM screening; (2) written nosebleed advice, (3) assessment of iron deficiency; (4) antibiotic prophylaxis prior to dental and surgical procedures for patients with pulmonary AVMs, and (5) written advice on pregnancy. They are not a blueprint for detailed HHT management, but are suitable for all clinicians to be aware of and implement. In summary, these 5 Outcome Measures provide metrics to identify healthcare providers of good care, and encourage care improvement by all healthcare providers.
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Affiliation(s)
- Claire L Shovlin
- Respiratory Medicine, and VASCERN HHT European Reference Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK. .,NHLI Vascular Science, Imperial College London, London, UK.
| | - Elisabetta Buscarini
- Gastroenterology Department and VASCERN HHT European Reference Centre, Maggiore Hospital, ASST Crema, Crema, Italy.
| | - Anette D Kjeldsen
- Department of Otorhinolaryngology and VASCERN HHT European Reference Centre, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Hans Jurgen Mager
- Department of Pulmonology and VASCERN HHT European Reference Centre, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, the Netherlands
| | - Carlo Sabba
- Center for Rare Diseases, "Frugoni" Internal Medicine Unit, Interdepartmental HHT Center, Interdisciplinary Department of Medicine and VASCERN HHT European Reference Centre, University of Bari School of Medicine, Bari, Italy
| | - Freya Droege
- Department of Otorhinolaryngology and VASCERN HHT European Reference Centre, Essen University Hospital, Essen, Germany
| | - Urban Geisthoff
- Department of Otorhinolaryngology and VASCERN HHT European Reference Centre, Essen University Hospital, Essen, Germany.,Present address: Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
| | - Sara Ugolini
- Department of Otorhinolaryngology and VASCERN HHT European Reference Centre, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S) Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Sophie Dupuis-Girod
- Hospices Civils de Lyon, Hôpital Femme-Mère-Enfants, Service de Génétique, and VASCERN HHT European Reference Centre/ centre de Référence pour la maladie de Rendu-Osler, F-69677, Bron, France. .,Université de Lyon, Faculté de médecine, Université Lyon 1, F-69008, Lyon, France.
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Abstract
PURPOSE OF REVIEW Hereditary hemorrhagic telangiectasia (HHT), or Osler Weber-Rendu disease, is a rare inherited disorder of fibrovascular tissue affecting various organs. Epistaxis is the most common symptom of HHT but as the disease affects multiple organs, a multisystem and multidisciplinary approach to management is required. The purpose of this article is to provide an overview of the multidisciplinary approach to HHT for the otolaryngologist and to discuss the current pharmacologic and procedural treatment options available for HHT-related epistaxis. RECENT FINDINGS Multidisciplinary expert guidelines have better defined what screening tests are advised for the multisystem evaluation of the HHT patient. New pharmacologic therapies including bevacizumab (Avastin) used submucosally or topically have shown promise as in-office treatment modalities. Sclerotherapy of telangiectasia, including in-office applications, has recently proven safe and effective. SUMMARY HHT remains a difficult disease to treat. Being aware of the common organ systems involved by the disease will help the practicing otolaryngologist to ensure the patient receives appropriate multidisciplinary care. For HHT-related epistaxis, new medical and surgical options allow for a wider range of treatments than were previously available.
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Sacco KM, Barkley TW. Hereditary Hemorrhagic Telangiectasia: A Primer for Critical Care Nurses. Crit Care Nurse 2018; 36:36-48. [PMID: 27252100 DOI: 10.4037/ccn2016270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Hereditary hemorrhagic telangiectasia is a rare, autosomal dominant genetic disease that causes abnormal growth of blood vessels and, subsequently, life-threatening arteriovenous malformations in vital organs. Epistaxis may be one of the initial clues that a patient has more serious, generalized arteriovenous malformations. Recommended treatment involves careful evaluation to determine the severity and risk of spontaneous rupture of the malformations and the management of various signs and symptoms. The disease remains undiagnosed in many patients, and health care providers may miss the diagnosis until catastrophic events happen in multiple family members. Prompt recognition of hereditary hemorrhagic telangiectasia and early intervention can halt the dangerous course of the disease. Critical care nurses can assist with early diagnosis within families with this genetic disease, thus preventing early death and disability.
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Affiliation(s)
- Kathleen M Sacco
- Kathleen M. Sacco is the director, Intensive Care Unit and Cardiopulmonary Services, Simi Valley Hospital, Simi Valley, California.Thomas W. Barkley, Jr, is president of Barkley and Associates, West Hollywood, California.
| | - Thomas W Barkley
- Kathleen M. Sacco is the director, Intensive Care Unit and Cardiopulmonary Services, Simi Valley Hospital, Simi Valley, California.Thomas W. Barkley, Jr, is president of Barkley and Associates, West Hollywood, California
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25
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Cohen O, Shoffel-Havakuk H, Warman M, Tzelnick S, Haimovich Y, Kohlberg GD, Halperin D, Lahav Y. Early and Late Recurrent Epistaxis Admissions: Patterns of Incidence and Risk Factors. Otolaryngol Head Neck Surg 2017; 157:424-431. [PMID: 28463569 DOI: 10.1177/0194599817705619] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Epistaxis is a common complaint, yet few studies have focused on the incidence and risk factors of recurrent epistaxis. Our objective was to determine the patterns of incidence and risk factors for recurrent epistaxis admission (REA). Study Design Case series with chart review. Settings Single academic center. Subjects and Methods The medical records of patients admitted for epistaxis between 1999 and 2015 were reviewed. The follow-up period was defined as 3 years following initial admission. REAs were categorized as early (30 days) and late (31 days to 3 years) following initial admission. Logistic regression was used to identify potential predictors of REAs. Results A total of 653 patients were included. Eighty-six patients (14%) had REAs: 48 (7.5%) early and 38 (6.5%) late. Nonlinear incidence curve was demonstrated for both early and late REAs. Based on logistic regression, prior nasal surgery and anemia were independent risk factors for early REAs. According to multivariate analysis, thrombocytopenia was significantly associated with late REAs. Conclusion Early and late REAs demonstrate different risk predictors. Knowledge of such risk factors may help in risk stratification for this selected group of patients. All patients at risk should be advised on possible preventive measures. Patients at risk for early REA may benefit from a more proactive approach.
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Affiliation(s)
- Oded Cohen
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel.,2 Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Hagit Shoffel-Havakuk
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel.,2 Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Meir Warman
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel.,2 Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Sharon Tzelnick
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel
| | - Yaara Haimovich
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel
| | - Gavriel D Kohlberg
- 3 Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital-Columbia and Weill Cornell Campuses, New York, New York, USA
| | - Doron Halperin
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel.,2 Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Yonatan Lahav
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel.,2 Hadassah Medical School, Hebrew University, Jerusalem, Israel
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26
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Finnamore H, Silva BM, Hickson BM, Whelan K, Shovlin CL. 7-day weighed food diaries suggest patients with hereditary hemorrhagic telangiectasia may spontaneously modify their diet to avoid nosebleed precipitants. Orphanet J Rare Dis 2017; 12:60. [PMID: 28347346 PMCID: PMC5368947 DOI: 10.1186/s13023-017-0576-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 01/20/2017] [Indexed: 11/10/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) poses substantial burdens due to nosebleeds and iron deficiency resulting from recurrent hemorrhagic iron losses. Recent studies by our group found surprising links between HHT nosebleeds and certain food groups. In this letter, we report 7-day weighed food diary assessments of an unselected group of 25 UK patients with HHT whose nosebleeds ranged from mild to severe (median epistaxis severity score 4.66, range 0.89– 9.11). The diaries provide evidence that food items most commonly reported to provoke nosebleeds were ingested by fewer HHT patients, compared to food items less commonly reported to provoke nosebleeds (chi-squared p <0.001).
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Affiliation(s)
- Helen Finnamore
- National Heart and Lung Institute Cardiovascular Sciences, Imperial College London, London, UK.,Diabetes and Nutritional Sciences Division, King's College London, London, UK
| | - B Maneesha Silva
- Imperial College School of Medicine, Imperial College London, London, UK
| | - B Mary Hickson
- Nutrition and Dietetics, Plymouth University, Plymouth, UK
| | - Kevin Whelan
- Diabetes and Nutritional Sciences Division, King's College London, London, UK
| | - Claire L Shovlin
- National Heart and Lung Institute Cardiovascular Sciences, Imperial College London, London, UK. .,Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK.
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27
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Sinonasal quality of life outcomes following laser treatment of epistaxis related to hereditary hemorrhagic telangiectasia. Lasers Med Sci 2017; 32:527-531. [DOI: 10.1007/s10103-017-2144-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 01/05/2017] [Indexed: 10/20/2022]
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Shovlin CL, Gilson C, Busbridge M, Patel D, Shi C, Dina R, Abdulla FN, Awan I. Can Iron Treatments Aggravate Epistaxis in Some Patients With Hereditary Hemorrhagic Telangiectasia? Laryngoscope 2016; 126:2468-2474. [PMID: 27107394 PMCID: PMC5095791 DOI: 10.1002/lary.25959] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 01/31/2016] [Accepted: 02/10/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVES/HYPOTHESIS To examine whether there is a rationale for iron treatments precipitating nosebleeds (epistaxis) in a subgroup of patients with hereditary hemorrhagic telangiectasia (HHT). STUDY DESIGN Survey evaluation of HHT patients, and a randomized control trial in healthy volunteers. METHODS Nosebleed severity in response to iron treatments and standard investigations were evaluated by unbiased surveys in patients with HHT. Serial blood samples from a randomized controlled trial of 18 healthy volunteers were used to examine responses to a single iron tablet (ferrous sulfate, 200 mg). RESULTS Iron tablet users were more likely to have daily nosebleeds than non-iron-users as adults, but there was no difference in the proportions reporting childhood or trauma-induced nosebleeds. Although iron and blood transfusions were commonly reported to improve nosebleeds, 35 of 732 (4.8%) iron tablet users, in addition to 17 of 261 (6.5%) iron infusion users, reported that their nosebleeds were exacerbated by the respective treatments. These rates were significantly higher than those reported for control investigations. Serum iron rose sharply in four of the volunteers ingesting ferrous sulfate (by 19.3-33.1 μmol/L in 2 hours), but not in 12 dietary controls (2-hour iron increment ranged from -2.2 to +5.0 μmol/L). High iron absorbers demonstrated greater increments in serum ferritin at 48 hours, but transient rises in circulating endothelial cells, an accepted marker of endothelial damage. CONCLUSIONS Iron supplementation is essential to treat or prevent iron deficiency, particularly in patients with pathological hemorrhagic iron losses. However, in a small subgroup of individuals, rapid changes in serum iron may provoke endothelial changes and hemorrhage. LEVEL OF EVIDENCE 4. Laryngoscope, 126:2468-2474, 2016.
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Affiliation(s)
- Claire L Shovlin
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom.
- Respiratory Medicine, Imperial College Healthcare National Health Service Trust, London, United Kingdom.
| | - Clare Gilson
- Respiratory Medicine, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Mark Busbridge
- Clinical Chemistry, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Dilip Patel
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Chenyang Shi
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Roberto Dina
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - F Naziya Abdulla
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College London School of Medicine, London, United Kingdom
| | - Iman Awan
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College London School of Medicine, London, United Kingdom
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29
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Nasal closure for the treatment of epistaxis secondary to hereditary hemorrhagic telangiectasia. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2016. [DOI: 10.1016/j.otoeng.2015.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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30
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Robaina Cabrera DM, Verde González MP, Tarazona Chocano B, Amado Fernández C, Zarrabeitia Puente R. Telangiectasia hemorrágica hereditaria: enfermedad de Rendu-Osler-Weber. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.fmc.2016.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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31
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Shovlin C, Awan I, Cahilog Z, Abdulla F, Guttmacher A. Reported cardiac phenotypes in hereditary hemorrhagic telangiectasia emphasize burdens from arrhythmias, anemia and its treatments, but suggest reduced rates of myocardial infarction. Int J Cardiol 2016; 215:179-85. [DOI: 10.1016/j.ijcard.2016.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/02/2016] [Indexed: 01/17/2023]
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32
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Sautter NB, Smith TL. Treatment of Hereditary Hemorrhagic Telangiectasia–Related Epistaxis. Otolaryngol Clin North Am 2016; 49:639-54. [DOI: 10.1016/j.otc.2016.02.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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33
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Chamali B, Finnamore H, Manning R, Laffan MA, Hickson M, Whelan K, Shovlin CL. Dietary supplement use and nosebleeds in hereditary haemorrhagic telangiectasia - an observational study. Intractable Rare Dis Res 2016; 5:109-13. [PMID: 27195194 PMCID: PMC4869576 DOI: 10.5582/irdr.2016.01019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 04/05/2016] [Accepted: 04/07/2016] [Indexed: 12/18/2022] Open
Abstract
Understanding potential provocations of haemorrhage is important in a range of clinical settings, and particularly for people with abnormal vasculature. Patients with hereditary haemorrhagic telangiectasia (HHT) can report haemorrhage from nasal telangiectasia in real time, and suggested dietary factors may precipitate nosebleeds. To examine further, nosebleed severity, dietary supplement use, and blood indices were evaluated in an unselected group of 50 HHT patients recruited from a specialist UK service. Using the validated Epistaxis Severity Score, nosebleed severity ranged from 0 to 9.1 out of 10 (median 3.9). Using a Food Frequency Questionnaire, 24/50 (48%) participants reported use of dietary supplements in the previous year. A third (18/50; 36%) had used self prescribed, non-iron containing dietary supplements, ingesting between 1 and 3 different supplements each day. Eight (16%) used fish oils. Despite having more severe epistaxis (p = 0.012), the 12 iron supplement users had higher serum iron concentrations, and were able to maintain their red blood cell indices. In contrast, there was no evident benefit for the participants using non iron supplements. Furthermore, platelet counts and serum fibrinogen tended to be lower in fish oil/supplement users, and one fish oil user demonstrated reduced in vitro platelet aggregation. In conclusion, in this small study, a third of HHT patients used non-iron dietary supplements, and one in six ingested fish oils, unaware of their known anti-platelet activity. The scale of use, and potential of these "natural health supplements" to exacerbate nosebleeds has not been appreciated previously in HHT.
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Affiliation(s)
- Basel Chamali
- National Heart and Lung Institute Cardiovascular Sciences, Imperial College London, UK
- Imperial College School of Medicine, Imperial College London, UK
| | - Helen Finnamore
- National Heart and Lung Institute Cardiovascular Sciences, Imperial College London, UK
- Diabetes and Nutritional Sciences Division, King's College London, UK
| | - Richard Manning
- Haematology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Michael A Laffan
- Haematology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
- Centre for Haematology, Imperial College London, UK
| | - Mary Hickson
- Nutrition and Dietetics, Imperial College Healthcare NHS Trust, London, UK (Current address: School of Health Professions, Plymouth University, Plymouth, UK)
| | - Kevin Whelan
- Diabetes and Nutritional Sciences Division, King's College London, UK
| | - Claire L Shovlin
- National Heart and Lung Institute Cardiovascular Sciences, Imperial College London, UK
- HHTIC London, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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34
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Shovlin CL, Patel T, Jackson JE. Embolisation of PAVMs reported to improve nosebleeds by a subgroup of patients with hereditary haemorrhagic telangiectasia. ERJ Open Res 2016; 2:00035-2016. [PMID: 27730189 PMCID: PMC5005172 DOI: 10.1183/23120541.00035-2016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 04/02/2016] [Indexed: 11/07/2022] Open
Abstract
Pulmonary arteriovenous malformations (PAVMs) are structurally abnormal vessels that provide direct capillary-free communications between the pulmonary and systemic circulations, and hence, right-to-left shunts [1]. Due to impaired gas exchange, hypoxaemia is common but exercise tolerance is usually preserved through haematological (erythrocytotic) and cardiovascular compensations [2, 3], and patients are frequently asymptomatic [1–3]. Treatment of PAVMs is recommended to prevent paradoxical embolic sequelae such as ischaemic strokes [4] and brain abscess [5], commonly improves migraine headaches [6], and is a successful emergency treatment for haemorrhage. Pulmonary AVM embolisation appears to improve nosebleed severity for nearly one in six people with HHThttp://ow.ly/4mJqip
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Affiliation(s)
- Claire L Shovlin
- NHLI Cardiovascular Sciences, Imperial College London, London, UK
| | - Trishan Patel
- NHLI Cardiovascular Sciences, Imperial College London, London, UK; Dept of Medicine, St George's, University of London, London, UK
| | - James E Jackson
- Dept of Imaging, Imperial College Healthcare NHS Trust, London, UK
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35
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Sena Esteves S, Cardoso C, Silva A, Abrunhosa J, Almeida E Sousa C. Nasal closure for the treatment of epistaxis secondary to hereditary hemorrhagic telangiectasia. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2016; 67:345-348. [PMID: 27079134 DOI: 10.1016/j.otorri.2015.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 11/26/2015] [Accepted: 12/08/2015] [Indexed: 12/01/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT), also known by the eponym Osler-Weber-Rendu syndrome, is an autosomal dominant disorder characterised by the presence of multiple arteriovenous malformations (AVMs) affecting multiple organs. Many procedures have been used for epistaxis control in patients with this disorder. The objective of this study was to report the treatment of severe HHT-related epistaxiswith the modified Young's procedure. MATERIALS AND METHODS We describe the treatment of 4 patients with severe blood-transfusion-dependent epistaxis who underwent a modified Young's procedure in a tertiary hospital. The nasal closure was bilateral and complete in all cases. All patients were followed for 12 months or longer. RESULTS The procedure was well tolerated and complete cessation of bleeding was achieved in all the patients. CONCLUSION Young's technique is a safe surgical procedure, well tolerated by patients with severe epistaxis and HHT.
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Affiliation(s)
- Sara Sena Esteves
- Department of Otolaryngology, Oporto Hospital Center, Oporto, Portugal.
| | - Carla Cardoso
- Department of Otolaryngology, Oporto Hospital Center, Oporto, Portugal
| | - Ana Silva
- Department of Otolaryngology, Oporto Hospital Center, Oporto, Portugal
| | - José Abrunhosa
- Department of Otolaryngology, Oporto Hospital Center, Oporto, Portugal
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Ramakrishnan Y, Iqbal IZ, Puvanendran M, ElBadawey MR, Carrie S. A postal survey of hereditary hemorrhagic telangectasia in the northeast of England. ALLERGY & RHINOLOGY 2015; 6:20-7. [PMID: 25860167 PMCID: PMC4388872 DOI: 10.2500/ar.2015.6.0114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The aim of this study is to identify the demographics and epistaxis burden of hereditary hemorrhagic telangiectasia (HHT). A questionnaire was sent to participants with HHT who were recruited from a prospectively maintained respiratory clinic data base in a tertiary hospital. Details on demographics, HHT symptoms, family history, epistaxis severity, and treatment received were recorded. There were 34 of 60 responses (57%). Two responses were from families of the deceased. Of the 32 evaluable patients (men, 14; women 18), the average age was 51 years (range, 23-78 years). The average age of HHT diagnosis was 31 years (range, 3-61 years). The diagnosis of HHT was made by the respiratory team in 13 patients; neurologist (2); ear, nose, and throat (ENT) specialist (4); general practitioner (5); hematologist (4); gastroenterologist (1); and not mentioned in two patients. Twenty-seven of 32 patients (84%) had a positive family history of HHT. Only 13 patients had formal genetic testing (4 endoglin, 1 activin receptor-like kinase, 8 unknown gene). All patients who presented to the respiratory clinic had a background of epistaxis, which was noted on presentation. The average age at initial epistaxis was 14 years (range, 2-50 years). The frequency of epistaxis was daily 63% (n = 20), weekly 9% (3), monthly 16% (5), and a few times a year 10% (3), and unstated in one patient. Nine of 32 patients (28%) required a transfusion. Six patients thought that they were unable to perform daily activities due to epistaxis. Only 15 of 32 patients (47%) were under the care of an ENT specialist. The treatment plan for epistaxis management was deemed good by 7 patients, adequate in 8, poor in 6, and not stated by 11 patients. In conclusion, this survey is the first to quantify the epistaxis burden within the northeast of England. The management of epistaxis needs specific education and treatment to optimize the quality of life among these patients.
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Shovlin CL. Circulatory contributors to the phenotype in hereditary hemorrhagic telangiectasia. Front Genet 2015; 6:101. [PMID: 25914716 PMCID: PMC4391027 DOI: 10.3389/fgene.2015.00101] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 02/25/2015] [Indexed: 12/11/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is mechanistically and therapeutically challenging, not only because of the molecular and cellular perturbations that generate vascular abnormalities, but also the modifications to circulatory physiology that result, and are likely to exacerbate vascular injury. First, most HHT patients have visceral arteriovenous malformations (AVMs). Significant visceral AVMs reduce the systemic vascular resistance: supra-normal cardiac outputs are required to maintain arterial blood pressure, and may result in significant pulmonary venous hypertension. Secondly, bleeding from nasal and gastrointestinal telangiectasia leads to iron losses of such magnitude that in most cases, diet is insufficient to meet the ‘hemorrhage adjusted iron requirement.’ Resultant iron deficiency restricts erythropoiesis, leading to anemia and further increases in cardiac output. Low iron levels are also associated with venous and arterial thromboses, elevated Factor VIII, and increased platelet aggregation to circulating 5HT (serotonin). Third, recent data highlight that reduced oxygenation of blood due to pulmonary AVMs results in a graded erythrocytotic response to maintain arterial oxygen content, and higher stroke volumes and/or heart rates to maintain oxygen delivery. Finally, HHT-independent factors such as diet, pregnancy, sepsis, and other intercurrent illnesses also influence vascular structures, hemorrhage, and iron handling in HHT patients. These considerations emphasize the complexity of mechanisms that impact on vascular structures in HHT, and also offer opportunities for targeted therapeutic approaches.
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Affiliation(s)
- Claire L Shovlin
- NHLI Cardiovascular Sciences, Imperial Centre for Translational and Experimental Medicine, Imperial College London London, UK ; Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust London, UK
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38
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Garg N, Khunger M, Gupta A, Kumar N. Optimal management of hereditary hemorrhagic telangiectasia. J Blood Med 2014; 5:191-206. [PMID: 25342923 PMCID: PMC4206399 DOI: 10.2147/jbm.s45295] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT), also known by the eponym Osler-Weber-Rendu syndrome, is a group of related disorders inherited in an autosomal dominant fashion and characterized by the development of arteriovenous malformations (AVM) in the skin, mucous membranes, and/or internal organs such as brain, lungs, and liver. Its prevalence is currently estimated at one in 5,000 to 8,000. Most cases are due to mutations in the endoglin (HHT1) or ACVRLK1 (HHT2) genes. Telangiectasias in nasal and gastrointestinal mucosa generally present with recurrent/chronic bleeding and iron deficiency anemia. Larger AVMs occur in lungs (~40%-60% of affected individuals), liver (~40%-70%), brain (~10%), and spine (~1%). Due to the devastating and potentially fatal complications of some of these lesions (for example, strokes and brain abscesses with pulmonary AVMs), presymptomatic screening and treatment are of utmost importance. However, due to the rarity of this condition, many providers lack an appreciation for the whole gamut of its manifestations and complications, age-dependent penetrance, and marked intrafamilial variation. As a result, HHT remains frequently underdiagnosed and many families do not receive the appropriate screening and treatments. This article provides an overview of the clinical features of HHT, discusses the clinical and genetic diagnostic strategies, and presents an up-to-date review of literature and detailed considerations regarding screening for visceral AVMs, preventive modalities, and treatment options.
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Affiliation(s)
- Neetika Garg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Monica Khunger
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Arjun Gupta
- Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Nilay Kumar
- Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA
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Purkey MR, Seeskin Z, Chandra R. Seasonal variation and predictors of epistaxis. Laryngoscope 2014; 124:2028-33. [DOI: 10.1002/lary.24679] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 02/17/2014] [Accepted: 03/12/2014] [Indexed: 11/05/2022]
Affiliation(s)
- Matthew R. Purkey
- Department of Otolaryngology-Head and Neck Surgery; Northwestern University Feinberg School of Medicine; Chicago
| | - Zachary Seeskin
- Department of Statistics; Northwestern University; Evanston Illinois U.S.A
| | - Rakesh Chandra
- Department of Otolaryngology-Head and Neck Surgery; Northwestern University Feinberg School of Medicine; Chicago
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40
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Santhirapala V, Williams LC, Tighe HC, Jackson JE, Shovlin CL. Arterial oxygen content is precisely maintained by graded erythrocytotic responses in settings of high/normal serum iron levels, and predicts exercise capacity: an observational study of hypoxaemic patients with pulmonary arteriovenous malformations. PLoS One 2014; 9:e90777. [PMID: 24637882 PMCID: PMC3956463 DOI: 10.1371/journal.pone.0090777] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 02/04/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Oxygen, haemoglobin and cardiac output are integrated components of oxygen transport: each gram of haemoglobin transports 1.34 mls of oxygen in the blood. Low arterial partial pressure of oxygen (PaO2), and haemoglobin saturation (SaO2), are the indices used in clinical assessments, and usually result from low inspired oxygen concentrations, or alveolar/airways disease. Our objective was to examine low blood oxygen/haemoglobin relationships in chronically compensated states without concurrent hypoxic pulmonary vasoreactivity. METHODOLOGY 165 consecutive unselected patients with pulmonary arteriovenous malformations were studied, in 98 cases, pre/post embolisation treatment. 159 (96%) had hereditary haemorrhagic telangiectasia. Arterial oxygen content was calculated by SaO2 x haemoglobin x 1.34/100. PRINCIPAL FINDINGS There was wide variation in SaO2 on air (78.5-99, median 95)% but due to secondary erythrocytosis and resultant polycythaemia, SaO2 explained only 0.1% of the variance in arterial oxygen content per unit blood volume. Secondary erythrocytosis was achievable with low iron stores, but only if serum iron was high-normal: Low serum iron levels were associated with reduced haemoglobin per erythrocyte, and overall arterial oxygen content was lower in iron deficient patients (median 16.0 [IQR 14.9, 17.4]mls/dL compared to 18.8 [IQR 17.4, 20.1]mls/dL, p<0.0001). Exercise tolerance appeared unrelated to SaO2 but was significantly worse in patients with lower oxygen content (p<0.0001). A pre-defined athletic group had higher Hb:SaO2 and serum iron:ferritin ratios than non-athletes with normal exercise capacity. PAVM embolisation increased SaO2, but arterial oxygen content was precisely restored by a subsequent fall in haemoglobin: 86 (87.8%) patients reported no change in exercise tolerance at post-embolisation follow-up. SIGNIFICANCE Haemoglobin and oxygen measurements in isolation do not indicate the more physiologically relevant oxygen content per unit blood volume. This can be maintained for SaO2 ≥78.5%, and resets to the same arterial oxygen content after correction of hypoxaemia. Serum iron concentrations, not ferritin, seem to predict more successful polycythaemic responses.
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Affiliation(s)
- Vatshalan Santhirapala
- Imperial College School of Medicine, Imperial College, London, United Kingdom
- National Heart and Lung Institute (NHLI) Cardiovascular Science, Imperial College, London, United Kingdom
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Louisa C. Williams
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Hannah C. Tighe
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - James E. Jackson
- Department of Imaging, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Claire L. Shovlin
- National Heart and Lung Institute (NHLI) Cardiovascular Science, Imperial College, London, United Kingdom
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- * E-mail:
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Ischaemic strokes in patients with pulmonary arteriovenous malformations and hereditary hemorrhagic telangiectasia: associations with iron deficiency and platelets. PLoS One 2014; 9:e88812. [PMID: 24586400 PMCID: PMC3929507 DOI: 10.1371/journal.pone.0088812] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 01/13/2014] [Indexed: 01/24/2023] Open
Abstract
Background Pulmonary first pass filtration of particles marginally exceeding ∼7 µm (the size of a red blood cell) is used routinely in diagnostics, and allows cellular aggregates forming or entering the circulation in the preceding cardiac cycle to lodge safely in pulmonary capillaries/arterioles. Pulmonary arteriovenous malformations compromise capillary bed filtration, and are commonly associated with ischaemic stroke. Cohorts with CT-scan evident malformations associated with the highest contrast echocardiographic shunt grades are known to be at higher stroke risk. Our goal was to identify within this broad grouping, which patients were at higher risk of stroke. Methodology 497 consecutive patients with CT-proven pulmonary arteriovenous malformations due to hereditary haemorrhagic telangiectasia were studied. Relationships with radiologically-confirmed clinical ischaemic stroke were examined using logistic regression, receiver operating characteristic analyses, and platelet studies. Principal Findings Sixty-one individuals (12.3%) had acute, non-iatrogenic ischaemic clinical strokes at a median age of 52 (IQR 41–63) years. In crude and age-adjusted logistic regression, stroke risk was associated not with venous thromboemboli or conventional neurovascular risk factors, but with low serum iron (adjusted odds ratio 0.96 [95% confidence intervals 0.92, 1.00]), and more weakly with low oxygen saturations reflecting a larger right-to-left shunt (adjusted OR 0.96 [0.92, 1.01]). For the same pulmonary arteriovenous malformations, the stroke risk would approximately double with serum iron 6 µmol/L compared to mid-normal range (7–27 µmol/L). Platelet studies confirmed overlooked data that iron deficiency is associated with exuberant platelet aggregation to serotonin (5HT), correcting following iron treatment. By MANOVA, adjusting for participant and 5HT, iron or ferritin explained 14% of the variance in log-transformed aggregation-rate (p = 0.039/p = 0.021). Significance These data suggest that patients with compromised pulmonary capillary filtration due to pulmonary arteriovenous malformations are at increased risk of ischaemic stroke if they are iron deficient, and that mechanisms are likely to include enhanced aggregation of circulating platelets.
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Elphick A, Shovlin CL. Relationships between epistaxis, migraines, and triggers in hereditary hemorrhagic telangiectasia. Laryngoscope 2014; 124:1521-8. [DOI: 10.1002/lary.24526] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 11/13/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Amy Elphick
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare National Health Service Trust; London United Kingdom
- Cardiovascular Sciences; National Heart and Lung Institute, Imperial College London; London United Kingdom
- School of Life Sciences; Imperial College London; London United Kingdom
| | - Claire L. Shovlin
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare National Health Service Trust; London United Kingdom
- Cardiovascular Sciences; National Heart and Lung Institute, Imperial College London; London United Kingdom
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Hosman AE, Devlin HL, Silva BM, Shovlin CL. Specific cancer rates may differ in patients with hereditary haemorrhagic telangiectasia compared to controls. Orphanet J Rare Dis 2013; 8:195. [PMID: 24354965 PMCID: PMC3891994 DOI: 10.1186/1750-1172-8-195] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 12/13/2013] [Indexed: 12/24/2022] Open
Abstract
Background Hereditary haemorrhagic telangiectasia (HHT) is inherited as an autosomal dominant trait, affects ~1 in 5,000, and causes multi-systemic vascular lesions and life-limiting complications. Life expectancy is surprisingly good, particularly for patients over 60ys. We hypothesised that individuals with HHT may be protected against life-limiting cancers. Methods To compare specific cancer rates in HHT patients and controls, we developed a questionnaire capturing data on multiple relatives per respondent, powered to detect differences in the four most common solid non skin cancers (breast, colorectal, lung and prostate), each associated with significant mortality. Blinded to cancer responses, reports of HHT-specific features allowed assignment of participants and relatives as HHT-subjects, unknowns, or controls. Logistic and quadratic regressions were used to compare rates of specific cancer types between HHT subjects and controls. Results 1,307 participants completed the questionnaire including 1,007 HHT-subjects and 142 controls. The rigorous HHT diagnostic algorithm meant that 158 (12%) completed datasets were not assignable either to HHT or control status. For cancers predominantly recognised as primary cancers, the rates in the controls generally matched age-standardised rates for the general population. HHT subjects recruited through the survey had similar demographics to controls, although the HHT group reported a significantly greater smoking habit. Combining data of participants and uniquely-reported relatives resulted in an HHT-arm of 2,161 (58% female), and control-arm of 2,817 (52% female), with median ages of 66ys [IQR 53–77] and 77ys [IQR 65–82] respectively. In both crude and age-adjusted regression, lung cancers were significantly less frequent in the HHT arm than controls (age-adjusted odds ratio 0.48 [0.30, 0.70], p = 0.0012). Breast cancer prevalence was higher in HHT than controls (age-adjusted OR 1.52 [1.07, 2.14], p = 0.018). Overall, prostate and colorectal cancer rates were equivalent, but the pattern of colorectal cancer was modified, with a higher prevalence in younger HHT patients than controls. Conclusions These preliminary survey data suggest clinically significant differences in the rates of lung, breast and colorectal cancer in HHT patients compared to controls. For rare diseases in which longitudinal studies take decades to recruit equivalent datasets, this type of methodology provides a good first-step method for data collection.
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Affiliation(s)
| | | | | | - Claire L Shovlin
- NHLI Cardiovascular Sciences, Imperial College London, London, UK.
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Finnamore H, Le Couteur J, Hickson M, Busbridge M, Whelan K, Shovlin CL. Hemorrhage-adjusted iron requirements, hematinics and hepcidin define hereditary hemorrhagic telangiectasia as a model of hemorrhagic iron deficiency. PLoS One 2013; 8:e76516. [PMID: 24146883 PMCID: PMC3797784 DOI: 10.1371/journal.pone.0076516] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 08/27/2013] [Indexed: 12/27/2022] Open
Abstract
Background Iron deficiency anemia remains a major global health problem. Higher iron demands provide the potential for a targeted preventative approach before anemia develops. The primary study objective was to develop and validate a metric that stratifies recommended dietary iron intake to compensate for patient-specific non-menstrual hemorrhagic losses. The secondary objective was to examine whether iron deficiency can be attributed to under-replacement of epistaxis (nosebleed) hemorrhagic iron losses in hereditary hemorrhagic telangiectasia (HHT). Methodology/Principal Findings The hemorrhage adjusted iron requirement (HAIR) sums the recommended dietary allowance, and iron required to replace additional quantified hemorrhagic losses, based on the pre-menopausal increment to compensate for menstrual losses (formula provided). In a study population of 50 HHT patients completing concurrent dietary and nosebleed questionnaires, 43/50 (86%) met their recommended dietary allowance, but only 10/50 (20%) met their HAIR. Higher HAIR was a powerful predictor of lower hemoglobin (p = 0.009), lower mean corpuscular hemoglobin content (p<0.001), lower log-transformed serum iron (p = 0.009), and higher log-transformed red cell distribution width (p<0.001). There was no evidence of generalised abnormalities in iron handling Ferritin and ferritin2 explained 60% of the hepcidin variance (p<0.001), and the mean hepcidinferritin ratio was similar to reported controls. Iron supplement use increased the proportion of individuals meeting their HAIR, and blunted associations between HAIR and hematinic indices. Once adjusted for supplement use however, reciprocal relationships between HAIR and hemoglobin/serum iron persisted. Of 568 individuals using iron tablets, most reported problems completing the course. For patients with hereditary hemorrhagic telangiectasia, persistent anemia was reported three-times more frequently if iron tablets caused diarrhea or needed to be stopped. Conclusions/significance HAIR values, providing an indication of individuals’ iron requirements, may be a useful tool in prevention, assessment and management of iron deficiency. Iron deficiency in HHT can be explained by under-replacement of nosebleed hemorrhagic iron losses.
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Affiliation(s)
- Helen Finnamore
- National Heart and Lung Institute, Cardiovascular Sciences, Imperial College London, London, United Kingdom
- Diabetes and Nutritional Sciences Division, King’s College London, School of Medicine, London, United Kingdom
- University of Liverpool Medical School, Liverpool, United Kingdom
| | - James Le Couteur
- Nutrition and Dietetics, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Mary Hickson
- Nutrition and Dietetics, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Mark Busbridge
- Clinical Chemistry, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Kevin Whelan
- Diabetes and Nutritional Sciences Division, King’s College London, School of Medicine, London, United Kingdom
| | - Claire L. Shovlin
- National Heart and Lung Institute, Cardiovascular Sciences, Imperial College London, London, United Kingdom
- Respiratory Medicine, Imperial College Healthcare NHS Trust, London, United Kingdom
- * E-mail:
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