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Pablo-Moreno JAD, Serrano LJ, Revuelta L, Sánchez MJ, Liras A. The Vascular Endothelium and Coagulation: Homeostasis, Disease, and Treatment, with a Focus on the Von Willebrand Factor and Factors VIII and V. Int J Mol Sci 2022; 23:ijms23158283. [PMID: 35955419 PMCID: PMC9425441 DOI: 10.3390/ijms23158283] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/22/2022] [Accepted: 07/23/2022] [Indexed: 11/27/2022] Open
Abstract
The vascular endothelium has several important functions, including hemostasis. The homeostasis of hemostasis is based on a fine balance between procoagulant and anticoagulant proteins and between fibrinolytic and antifibrinolytic ones. Coagulopathies are characterized by a mutation-induced alteration of the function of certain coagulation factors or by a disturbed balance between the mechanisms responsible for regulating coagulation. Homeostatic therapies consist in replacement and nonreplacement treatments or in the administration of antifibrinolytic agents. Rebalancing products reestablish hemostasis by inhibiting natural anticoagulant pathways. These agents include monoclonal antibodies, such as concizumab and marstacimab, which target the tissue factor pathway inhibitor; interfering RNA therapies, such as fitusiran, which targets antithrombin III; and protease inhibitors, such as serpinPC, which targets active protein C. In cases of thrombophilia (deficiency of protein C, protein S, or factor V Leiden), treatment may consist in direct oral anticoagulants, replacement therapy (plasma or recombinant ADAMTS13) in cases of a congenital deficiency of ADAMTS13, or immunomodulators (prednisone) if the thrombophilia is autoimmune. Monoclonal-antibody-based anti-vWF immunotherapy (caplacizumab) is used in the context of severe thrombophilia, regardless of the cause of the disorder. In cases of disseminated intravascular coagulation, the treatment of choice consists in administration of antifibrinolytics, all-trans-retinoic acid, and recombinant soluble human thrombomodulin.
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Affiliation(s)
- Juan A. De Pablo-Moreno
- Department of Genetics, Physiology and Microbiology, School of Biology, Complutense University, 28040 Madrid, Spain; (J.A.D.P.-M.); (L.J.S.)
| | - Luis Javier Serrano
- Department of Genetics, Physiology and Microbiology, School of Biology, Complutense University, 28040 Madrid, Spain; (J.A.D.P.-M.); (L.J.S.)
| | - Luis Revuelta
- Department of Physiology, School of Veterinary Medicine, Complutense University of Madrid, 28040 Madrid, Spain;
| | - María José Sánchez
- Centro Andaluz de Biología del Desarrollo (CABD), Consejo Superior de Investigaciones Científicas (CSIC), Junta de Andalucía, Pablo de Olavide University, 41013 Sevilla, Spain;
| | - Antonio Liras
- Department of Genetics, Physiology and Microbiology, School of Biology, Complutense University, 28040 Madrid, Spain; (J.A.D.P.-M.); (L.J.S.)
- Correspondence:
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Evaluation of primary care physicians' approaches to hemophilia and bleeding disorders: a questionnaire survey. Blood Coagul Fibrinolysis 2022; 33:381-388. [PMID: 35867946 DOI: 10.1097/mbc.0000000000001152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Bleeding disorders are causes of great concern and panic for parents and primary care providers. Lack of knowledge and awareness on appropriate screening tests and factor product preparation contributed to potential diagnostic delays, increased complications, and economic costs. This study aimed to determine and compare the approach of primary care physicians (including general practitioners) and emergency physicians with a questionnaire including simulation-based cases on hemophilia. This simulation and two-stage questionnaire study was conducted with 244 participants. Before-after questionnaires, two case simulations, a brief presentation, and statistical analysis were performed. Participants mostly preferred tests, such as prothrombin time (PT) or partial thromboplastin time (PTT) to bleeding time for primary hemostasis (PT/PTT n: 192, 84.2%, bleeding time n: 94, 41.2%). Similar results were found for secondary hemostasis (bleeding time n: 144, 63.4%). There was a lack of knowledge in the management of simulation-based cases of acute hemorrhagic complications and factor product preparation (complication case: correct n: 100, 55.2%; initial doses correct n: 56, 43.4%, factor preparing correct n: 37, 49.3%, factor admission correct n: 36, 24.3%). All changed significantly, after the presentation (P = 0.000). Our study shows that there is probably a lack of knowledge of diagnostic investigations and appropriate factor product preparation with possible consequences for patients and economics.
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Rey Y Formoso V, Barreto Mota R, Soares H. Developmental hemostasis in the neonatal period. World J Pediatr 2022; 18:7-15. [PMID: 34981411 DOI: 10.1007/s12519-021-00492-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The hemostatic system is complex and evolves continuously since gestation and well into the adult years, in a process known as "developmental hemostasis." DATA SOURCES A comprehensive review was performed after an extensive literature search on PubMed/MEDLINE concerning developmental hemostasis during the neonatal period. Relevant cross references were also included. RESULTS Although part of a system, each component of the hemostatic system evolves differently, with many displaying both quantitative and qualitative age-related differences. This leads to drastic disparities between the coagulation system of neonates and both other children's and adults', while still maintaining a generally balanced and physiological hemostasis. The motives behind this process remain to be fully elucidated but may be, at least in part, related to non-hemostatic factors. CONCLUSIONS Knowledge regarding "developmental hemostasis" is essential for everyone caring for newborns or even children in general and in this review, we describe each hemostatic system component's neonatal characteristics and age-related progression as well as explore some of the possible physiological motives behind the process.
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Affiliation(s)
- Vicente Rey Y Formoso
- Neonatology Department (Reference Center for Congenital Heart Diseases), São João University Hospital Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
| | - Ricardo Barreto Mota
- Neonatology Department (Reference Center for Congenital Heart Diseases), São João University Hospital Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Henrique Soares
- Neonatology Department (Reference Center for Congenital Heart Diseases), São João University Hospital Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Faculty of Medicine, Porto University, Porto, Portugal
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Naderi M, Cohan N, Shahramian I, Miri-Aliabad G, Haghpanah S, Imani M, Moghadam M, Dehvari A, Dorgalaleh A, Karimi M. A retrospective study on clinical manifestations of neonates with FXIII-A deficiency. Blood Cells Mol Dis 2019; 77:78-81. [PMID: 31005750 DOI: 10.1016/j.bcmd.2019.04.006] [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] [Received: 02/20/2019] [Revised: 04/08/2019] [Accepted: 04/10/2019] [Indexed: 11/28/2022]
Abstract
We assessed clinical presentations and the rate of central nervous system (CNS) bleeding in neonates with FXIIID who exhibited bleeding diathesis in the early days of their lives. A total of 27 neonates presented bleeding or abnormal clinical symptoms, diagnosed with FXIII deficiency were evaluated. Factor XIII concentrate was initiated as the first-line of treatment, and prophylactic therapy was given to all patients. Umbilical cord bleeding, delayed detachment of umbilical stunt, seizure, hematoma, and ecchymosis were concurrent complications in 27 (100%), 5 (18.5%), 5 (18.5%), 3 (11.1%), and 1 (3.7%) of the patients, respectively. History of having CNS bleeding was detected in 13 (48.1%) patients. There was no significant association between CNS bleeding and gender, familial history of FXIIID, or other clinical presentations. Also, there was no significant difference in the mean age of the patients who had CNS bleeding (3.4 ± 0.9 days) and without CNS bleeding (2.9 ± 0.7 days). However, a near significant threshold difference between the patients with and without CNS bleeding was found regarding the mean number of suspicious FXIIID death in their family (1.8 ± 0.5 and 0.7 ± 0.1, respectively, P = 0.05). Therefore, a suggested diagnostic algorithm based on prenatal diagnosis could be useful for timely detection of FXIII deficiency in neonates.
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Affiliation(s)
- Majid Naderi
- Department of Pediatrics Hematology & Oncology, Ali Ebn-e Abitaleb Hospital Research Center For Children and Adolescents Health [RCCAH], Zahedan University of Medical Sciences, Zahedan, Iran
| | - Nader Cohan
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Iraj Shahramian
- Pediatric Digestive and Hepatic Research Center, Zabol University of Medical Sciences, Zabol, Iran
| | - Ghasem Miri-Aliabad
- Department of Pediatric, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Sezaneh Haghpanah
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahmood Imani
- Zahedan University of Medical Sciences, Zahedan, Iran
| | - Mohamad Moghadam
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Akbar Dorgalaleh
- Department of Hematology and Blood Transfusion, School of Allied Medical Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mehran Karimi
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
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Revel-Vilk S. Neonatal haemostasis. Hamostaseologie 2017; 36:261-264. [DOI: 10.5482/hamo-15-11-0032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 01/14/2016] [Indexed: 11/05/2022] Open
Abstract
SummaryThe maturation and postnatal development of the human coagulation system results in significant and important differences in the coagulation and fibrinolysis of neonates and young children compared to older children and adults. Importantly, these differences, which mostly reflect the immaturity of the neonatal haemostasis system, are functionally balanced. Healthy neonates show no signs of easy bruising or other bleeding diathesis and no increased tendency to thrombosis for any given stimulus compared to adults.Systemic diseases may affect haemostasis, thus predisposing ill neonates to increased risk for haemorrhagic or thrombotic complications. In hospitalized children, neonates have increased risk of developing thrombosis compared to infants and children, mostly associated with the presence of central venous catheter. For diagnosis of haemostasis disorders, diagnostic laboratories processing pediatric samples should use age, analyzer and reagent appropriate reference ranges. Age specific guidelines should be followed for the management of neonates with hemostatic disorders.
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Sewell EK, Forman KR, Wong ECC, Gallagher M, Luban NLC, Massaro AN. Thromboelastography in term neonates: an alternative approach to evaluating coagulopathy. Arch Dis Child Fetal Neonatal Ed 2017; 102:F79-F84. [PMID: 27178714 DOI: 10.1136/archdischild-2016-310545] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 04/19/2016] [Accepted: 04/20/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To develop normative ranges for citrate-modified and heparinase-modified thromboelastography (TEG) in term neonates. DESIGN Prospective observational study. SETTING An outborn neonatal and cardiac intensive care unit in a free-standing academic children's hospital. PATIENTS Thirty term neonates were enrolled as control subjects. Seventeen infants with clinically documented bleeding requiring blood transfusion were enrolled in the comparison group. MAIN OUTCOME MEASURES Citrate-modified and heparinase-modified TEG parameters were calculated from blood specimens drawn via peripheral arterial stick or arterial line. RESULTS TEG in neonates differs from older children and adults; clotting time (R) and clot kinetics (K) values are generally lower while fibrinolysis or rate of clot breakdown (LY30) and coagulation index (CI) are often higher in neonates. TEG values in term neonates calculated as median (Q1-Q3) are as follows: R 4.150 (3.200-6.200), K 1.550 (1.200-1.800), α angle (α) 70.100 (66.000-72.900), maximum amplitude (MA) 61.850 (59.400-66.000), LY30 1.050 (0.100-1.600) and CI 1.950 (0.100 to 2.900). Cut points selected for optimal predictive value for bleeding using receiver operating curve analyses were R>6.3 (sensitivity 82.4%, specificity 80%); K>2.5 (sensitivity 82.4%, specificity 96.7%); α<59 (sensitivity 82.4%, specificity 96.7%); MA<57 (sensitivity 82.4%, specificity 86.7%); CI<-0.15 (sensitivity 88.2%, specificity 83.3%). CONCLUSIONS The reference ranges and cut points for citrate-modified and heparinase-modified TEG can be used to diagnose and evaluate coagulopathy in term neonates.
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Affiliation(s)
- Elizabeth K Sewell
- Divisions of Neonatology, Children's National Health Systems, Washington DC, USA.,Departments of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Katie R Forman
- Divisions of Neonatology, Children's National Health Systems, Washington DC, USA.,Departments of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington DC, USA.,Department of Neonatal-Perinatal Medicine, Children's Hospital of Montefiore, Bronx, New York, USA
| | - Edward C C Wong
- Divisions of Laboratory Medicine, Children's National Health Systems, Washington DC, USA.,Departments of Pathology, The George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Meanavy Gallagher
- Divisions of Laboratory Medicine, Children's National Health Systems, Washington DC, USA
| | - Naomi L C Luban
- Divisions of Laboratory Medicine, Children's National Health Systems, Washington DC, USA.,Departments of Pathology, The George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - An N Massaro
- Divisions of Neonatology, Children's National Health Systems, Washington DC, USA.,Departments of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington DC, USA
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Toulon P. Developmental hemostasis: laboratory and clinical implications. Int J Lab Hematol 2016; 38 Suppl 1:66-77. [DOI: 10.1111/ijlh.12531] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 04/21/2016] [Indexed: 11/28/2022]
Affiliation(s)
- P. Toulon
- Laboratoire d'Hématologie; Faculté de Médecine; Université Nice Sophia-Antipolis; Nice France
- CHU; Hôpital Pasteur; Service d'Hématologie Biologique; Nice France
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Jaffray J, Young G, Ko RH. The bleeding newborn: A review of presentation, diagnosis, and management. Semin Fetal Neonatal Med 2016; 21:44-9. [PMID: 26778526 DOI: 10.1016/j.siny.2015.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The neonatal hemostatic system is continuously developing with rapidly changing concentrations of many coagulation proteins. Thus, determining the etiology of bleeding in a newborn has additional challenges beyond those seen in older children or adults. Bleeding can be seen in both well and sick newborns due to congenital causes, such as hemophilia or von Willebrand disease, and acquired causes, such as liver failure or disseminated intravascular coagulation. Traditional coagulation testing should be interpreted with caution and with the help of a hematologist, if possible, due to the greatly different normal ranges between neonates as compared with older children and adults. However, despite these challenges, both clinical and laboratory clues can guide physicians appropriately to diagnose and treat the bleeding newborn.
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Affiliation(s)
- Julie Jaffray
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, CA, USA; Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Guy Young
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, CA, USA; Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Richard H Ko
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, CA, USA; Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Abstract
The diagnosis of congenital and acquired bleeding disorders in infants requires an understanding of developmental haemostasis and the effect on laboratory testing. A systematic approach to bleeding in neonates will aid clinicians in the diagnosis and treatment, which may be caused by a wide variety of diseases. The clinical setting will help to direct the diagnostic pathway. This review will focus on the presentation and diagnosis of congenital and acquired bleeding disorders, including platelet disorders. Current research in this field is ongoing, including investigation into neonatal platelets and their different functionalities, platelet transfusion thresholds and how changes in coagulation factors may be linked to other homeostatic mechanisms.
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Affiliation(s)
- Sally Elizabeth Campbell
- Royal Children's Hospital, 50 Flemington Road, Parkville, Melbourne 3052 Australia; Clinical Haematology - Royal Children's Hospital, University of Melbourne, Melbourne Australia.
| | - Paula H B Bolton-Maggs
- Serious Hazards of Transfusion UK Haemovigilance Scheme, Manchester Blood Centre, Plymouth Grove, Manchester M13 9LL, UK.
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