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Gualtierotti R, Giachi A, Suffritti C, Bedogni L, Franco F, Poggi F, Mascetti S, Colussi M, Ahmetovic D, Begnozzi V, Boccalandro EA, Solimeno LP, Peyvandi F. Optimizing long-term joint health in the treatment of hemophilia. Expert Rev Hematol 2024; 17:713-721. [PMID: 39245933 DOI: 10.1080/17474086.2024.2396617] [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: 04/13/2024] [Accepted: 08/21/2024] [Indexed: 09/10/2024]
Abstract
INTRODUCTION The improved quality of care and increased drug availability have shifted the goal of treating people with hemophilia from life-threatening bleeding prevention to joint health preservation and quality of life amelioration. Many tools are now available to the clinician in order to optimize the management of hemophilic arthropathy. AREAS COVERED This paper reviews the pivotal role of ultrasound evaluation in early detection of joint bleeding and differential diagnosis of joint pain, with a focus on the feasibility of a long-term monitoring of joint health through the use of artificial intelligence and telemedicine. The literature search methodology included using keywords to search in PubMed and Google Scholar, and articles used were screened by the coauthors of this review. EXPERT OPINION Joint ultrasound is a practical point-of-care tool with many advantages, including immediate correlation between imaging and clinical presentation, and dynamic evaluation of multiple joints. The potential of telemedicine care, coupled with a point-of-care detection device assisted by artificial intelligence, holds promises for even earlier diagnosis and treatment of joint bleeding. A multidisciplinary approach including early intervention by physical medicine and rehabilitation (PMR) physicians and physiotherapists is crucial to ensure the best possible quality of life for the patient.
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Affiliation(s)
- Roberta Gualtierotti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Andrea Giachi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Chiara Suffritti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Luca Bedogni
- Dipartimento di Scienze Fisiche, Informatiche e Matematiche, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Francesco Franco
- Dipartimento di Scienze Fisiche, Informatiche e Matematiche, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Francesco Poggi
- Institute for Cognitive Sciences and Technologies (ISTC), National Research Council (CNR), Bologna, Italy
| | - Sergio Mascetti
- Department of Computer Science, Università degli Studi di Milano, Milan, Italy
| | - Marco Colussi
- Department of Computer Science, Università degli Studi di Milano, Milan, Italy
| | - Dragan Ahmetovic
- Department of Computer Science, Università degli Studi di Milano, Milan, Italy
| | - Valentina Begnozzi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Elena Anna Boccalandro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Luigi Piero Solimeno
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Orthopaedic Surgery and Traumatology, Milan, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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van Leeuwen FHP, Foppen W, de Jong PA, van Dijk WE, Blokzijl J, Fischer K, Timmer MA. Ultrasound in addition to clinical assessment of acute musculoskeletal complaints in bleeding disorders: impact on patient management. Res Pract Thromb Haemost 2024; 8:102372. [PMID: 38590365 PMCID: PMC10999475 DOI: 10.1016/j.rpth.2024.102372] [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: 01/07/2024] [Revised: 02/25/2024] [Accepted: 03/07/2024] [Indexed: 04/10/2024] Open
Abstract
Background Ultrasound is increasingly used for musculoskeletal assessment in hemophilia care. Objectives To evaluate the impact of point-of-care ultrasound added to clinical assessment for diagnosis and treatment of acute musculoskeletal episodes in a heterogeneous cohort of children and adults with hemophilia and von Willebrand disease (VWD). Methods This prospective cross-sectional study consecutively included children and adults with hemophilia or VWD who visited the outpatient clinic with acute musculoskeletal complaints between March 2020 and May 2023. For all episodes, initial diagnosis and treatment determined by clinical assessment were recorded on a case report form. Subsequently, a physiotherapist (M.A.T. and J.B.) with knowledge of the clinical diagnosis performed point-of-care ultrasound. After ultrasound, updated diagnosis and treatment were recorded. Diagnosis and treatment before and after ultrasound were compared, and proportions of change with 95% CIs were determined. Results We evaluated 77 episodes in 67 patients (median age, 24 years; IQR, 13-42 years). Before ultrasound, 37 joint bleeds, 13 muscle bleeds, and 27 other diagnoses were diagnosed. After ultrasound, 33 joint bleeds, 11 muscle bleeds, and 33 other diagnoses were confirmed. The diagnosis changed in 28 of 77 episodes (36%; 95% CI, 26%-48%). Nine joint bleeds and 2 muscle bleeds were missed by clinical assessment. Ultrasound findings changed treatment strategy in 30 of 77 episodes (39%; 95% CI, 28%-51%). Conclusion Ultrasound in addition to clinical assessment of acute musculoskeletal complaints in people with hemophilia and VWD has an impact on diagnosis (36%) and treatment (39%), which supports the use of ultrasound in acute musculoskeletal complaints in hemophilia and VWD.
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Affiliation(s)
- Flora Hendrica Pieternella van Leeuwen
- Department of Radiology and Nuclear Medicine, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Wouter Foppen
- Department of Radiology and Nuclear Medicine, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Pim A. de Jong
- Department of Radiology and Nuclear Medicine, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Wobke E.M. van Dijk
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Johan Blokzijl
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Merel A. Timmer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Lewandowska M, Nasr S, Shapiro AD. Therapeutic and technological advancements in haemophilia care: Quantum leaps forward. Haemophilia 2022; 28 Suppl 4:77-92. [PMID: 35521732 DOI: 10.1111/hae.14531] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/21/2022] [Accepted: 02/21/2022] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Recent technological innovations in haemophilia have advanced at an astounding pace, including gene therapy programmes and bioengineered molecules for prophylaxis, products that reduce treatment burden through half-life extension, unique mechanisms of action, and subcutaneous administration. Additional technological advancements have emerged that are anticipated to further transform haemophilia care. AIM Review new and emerging haemophilia therapies, including replacement and bypassing products, digital applications, utilisation of big data, and personalised medicine. METHODS Data were obtained from peer-reviewed presentations/publications, and ongoing studies in haemophilia, ultrasonography, and artificial intelligence (AI). RESULTS Available treatments include new recombinant factors VIII (FVIII) and IX (FIX), extended half-life FVIII/IX products, a new FVIIa product for inhibitor patients, and a FVIIIa-mimetic. Several novel therapeutics are in clinical trials, including FVIIIa mimetics and inhibitors of naturally-occurring anticoagulants. Ongoing gene therapy trials suggest that a single vector infusion using an optimised construct can produce factor activity that reduces bleeding to near zero for years. Today, persons with haemophilia (PwH) approach a lifespan comparable to that of the general population, presenting treatment challenges for age-related co-morbidities. Technological innovations have broadened beyond therapeutics to include large database analyses utilising remote data collection with handheld devices, and to tailor AI applications. Current development efforts include patient-performed ultrasonography, algorithms for scan interpretation, and point-of-care haemostatic testing devices. CONCLUSIONS We have entered a golden age for haemophilia treatment and care with wide-ranging advancements targeting improved quality of life (QoL). Future-focused efforts by clinical and patient communities may provide equitable access and care for people impacted by haemophilia worldwide.
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Affiliation(s)
| | | | - Amy D Shapiro
- Indiana Hemophilia & Thrombosis Center, Inc., Indianapolis, Indiana, USA
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Jiménez-Yuste V, de la Corte-Rodríguez H, Álvarez-Román MT, Martín-Salces M, Querol F, Bonanad S, Mingot-Castellano ME, Fernández-Mosteirín N, Canaro M, Santamaría A, Núñez R, García-Frade LJ, Martinoli C, Kim HK. Ultrasound evaluation of joint damage and disease activity in adult patients with severe haemophilia A using the HEAD-US system. Haemophilia 2021; 27:479-487. [PMID: 33620134 DOI: 10.1111/hae.14280] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/25/2021] [Accepted: 02/05/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The Haemophilia Early Arthropathy Detection with Ultrasound (HEAD-US) system and scoring scale has proven to be an accurate and time-efficient imaging method for identifying joint damage in patients with haemophilia. AIM Observational, multicentre, cross-sectional study conducted in 8 centres in Spain that assessed the joint status of adult patients with severe haemophilia A (SHA) using HEAD-US. METHODS Joint status of the elbow, knee and ankle was evaluated in adults with SHA receiving on-demand (OD) treatment, or primary (PP), secondary (SP), tertiary (TP) or intermittent (IP) prophylaxis. RESULTS Of the 95 patients enrolled, 87 received prophylaxis (6.3% PP, 38.9% SP, 43.2% TP and 3.2% IP). Mean age was 35.2 years, and 59% of patients had not undergone image testing in the last year. The HEAD-US score was 0 in all joints in 6.3% of patients. The ankle was the most affected joint, regardless of treatment regimen. Patients receiving OD treatment, TP or IP had the overall worst scores, mainly in the ankles and elbows; a similar but milder profile was observed in patients on SP; and patients on PP had the best score in all joints. CONCLUSION Joint function may be effectively preserved in patients with SHA on PP, but OD treatment or later initiation of prophylaxis does not seem to prevent progression of arthropathy. Disease worsening was observed in patients OD, TP or IP, most often affecting ankles and elbows. Closer ultrasound imaging monitoring may improve management of these patients.
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Affiliation(s)
- Víctor Jiménez-Yuste
- Department of Haematology, Hospital Universitario La Paz, Autonoma University, Madrid, Spain
| | | | | | | | - Felipe Querol
- University of Valencia and Haemostasis and Thrombosis Unit, Department of Haematology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Santiago Bonanad
- Haemostasis and Thrombosis Unit. Department of Haematology, Hospital Universitari i Politècnic La Fe, University of Valencia, Valencia, Spain
| | - María Eva Mingot-Castellano
- Department of Haematology, Hospital Regional Universitario de Málaga, Malaga, Spain.,Department of Haematology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | - Mariana Canaro
- Department of Haemostasis and Thrombosis, Hospital Universitario Son Espases, Mallorca, Spain
| | - Amparo Santamaría
- Department of Thrombosis and Haemostasis, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ramiro Núñez
- Department of Haematology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | - Carlo Martinoli
- Dipartimento di Scienze della Salute Department of Health Sciences (DISSAL) and IRCCS Ospedale Policlinico San Martino, Genova, University of Genoa, Genoa, Italy
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Acquired Hemophilia A (FVIII Deficiency) Associated with Papillary Thyroid Cancer: Treatment with Recombinant Porcine FVIII. Case Rep Hematol 2019; 2019:9026121. [PMID: 31559096 PMCID: PMC6735189 DOI: 10.1155/2019/9026121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/08/2019] [Indexed: 12/05/2022] Open
Abstract
Acquired hemophilia A (AHA) is a rare autoimmune disorder caused by autoantibodies against Factor VIII (FVIII). It has a high mortality due to bleeding complications. FVIIa-based bypassing agents are the first line of treatment but not always effective. Recombinant porcine (rp) FVIII (Obizur®) was recently approved for rescue treatment but with little evidence-based information regarding efficacy. We report a case of papillary thyroid cancer associated with AHA malignancy that responded to a single dose of rpFVIII after failure to achieve hemostasis with FVIIa-based bypassing products.
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6
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Bakeer N, Shapiro AD. Merging into the mainstream: the evolution of the role of point-of-care musculoskeletal ultrasound in hemophilia. F1000Res 2019; 8. [PMID: 31431824 PMCID: PMC6619375 DOI: 10.12688/f1000research.16039.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2019] [Indexed: 01/19/2023] Open
Abstract
Bleeding with resultant hemophilic arthropathy constitutes the largest cause of morbidity in patients with hemophilia. It results from repeated bleeding episodes in the joint and is characterized by synovial hypertrophy and cartilage and bony destruction. Hemophilic arthropathy assessment is a continually evolving process and is particularly challenging in children and young adults in whom joint disease may be missed or underestimated as obtaining serial "baseline" magnetic resonance imaging scans of multiple clinically asymptomatic or nearly asymptomatic joints may be unjustifiable and cost-ineffective. Musculoskeletal ultrasound-particularly, point-of-care musculoskeletal ultrasound-has emerged as a promising imaging modality for the early detection and management of hemophilic arthropathy, and for the evaluation of hemarthrosis and painful musculoskeletal episodes in patients with hemophilia. This review summarizes currently available data on the emerging role of this new imaging modality, its limitations, and gaps in knowledge. The review also raises unanswered questions, highlights the need for consolidated research efforts, and delineates future directions expected to advance this technology and optimize its use in this patient population.
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Affiliation(s)
- Nihal Bakeer
- Indiana Hemophilia and Thrombosis Center, 8326 Naab Road, Indianapolis, IN, 46260, USA
| | - Amy D Shapiro
- Indiana Hemophilia and Thrombosis Center, 8326 Naab Road, Indianapolis, IN, 46260, USA
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7
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Volland LM, Zhou JY, Barnes RFW, Kruse-Jarres R, Steiner B, Quon DV, Bailey C, Hughes TH, Moore RE, Chang EY, von Drygalski A. Development and Reliability of the Joint Tissue Activity and Damage Examination for Quantitation of Structural Abnormalities by Musculoskeletal Ultrasound in Hemophilic Joints. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:1569-1581. [PMID: 30371941 DOI: 10.1002/jum.14846] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 09/24/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Musculoskeletal ultrasound (US) is used increasingly to examine hemophilic arthropathy. However, quantitative algorithms to document findings are lacking. We developed and sought to validate a protocol quantifying hemophilic joint abnormalities. METHODS Thirty-one patients with hemophilia were examined serially for 2 years with musculoskeletal US (≈600 joint examinations and ≈6000 images). Based on the spectrum of pathologies, a quantitative algorithm, named Joint Tissue Activity and Damage Examination (JADE), was developed for soft tissue and osteochondral measurements, including power Doppler, using nominal group techniques. To study intra- and inter-rater reliability, 8 musculoskeletal US-experienced hemophilia providers performed anatomic landmark recognition and tissue measurements on 86 images with arthropathic changes, with repetition 1 month later. Twenty-three musculoskeletal US-inexperienced providers performed similar assessments. Inter-operator reliability was established by 6 musculoskeletal US-experienced hemophilia providers, each acquiring images and JADE assessments of 3 hemophilic arthropathic joints. A radiologist and musculoskeletal sonographer functioned as adjudicators. The statistical analysis was performed with the intraclass correlation coefficient (ICC), Fleiss κ, and Cohen κ where appropriate. RESULTS The musculoskeletal US-experienced providers showed excellent intra-and inter-rater reliability for tissue measurements (ICCs, 0.94-0.96). Agreement was good to excellent for landmark recognition (Fleiss κ, 0.87-0.94). Inter-operator reliability was excellent for measurements and landmark recognition (ICC, 0.90; Fleiss κ, 1.0). Agreement with adjudicators was mostly good to excellent. Musculoskeletal US-inexperienced providers showed excellent inter-rater reliability for measurements (ICC, 0.96) and moderate agreement for landmark recognition (Fleiss κ, 0.58). CONCLUSIONS The JADE protocol appears feasible for quantifying hemophilic intra-articular abnormalities. Musculoskeletal US-trained hemophilia providers showed high intra-rater, inter-rater, and inter-operator reliability, supporting JADE as a protocol for clinical management and research.
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Affiliation(s)
- Lena M Volland
- Department of Medicine, Division of Hematology/Oncology, University of California, San Diego, California, USA
| | - Jenny Y Zhou
- Department of Medicine, Division of Hematology/Oncology, University of California, San Diego, California, USA
| | - Richard F W Barnes
- Department of Medicine, Division of Hematology/Oncology, University of California, San Diego, California, USA
| | - Rebecca Kruse-Jarres
- Washington Center for Bleeding Disorders at Bloodworks Northwest, Seattle, Washington, USA
| | - Bruno Steiner
- Washington Center for Bleeding Disorders at Bloodworks Northwest, Seattle, Washington, USA
| | - Doris V Quon
- Orthopedic Hemophilia Treatment Center, Orthopedic Institute for Children, Los Angeles, California, USA
| | - Cindy Bailey
- Orthopedic Hemophilia Treatment Center, Orthopedic Institute for Children, Los Angeles, California, USA
| | - Tudor H Hughes
- Department of Radiology, University of California, San Diego, California, USA
| | - Randy E Moore
- General Musculoskeletal Imaging, Inc, Cincinnati, Ohio, USA
| | - Eric Y Chang
- Radiology Service, VA San Diego Healthcare System, San Diego, California, USA
| | - Annette von Drygalski
- Department of Medicine, Division of Hematology/Oncology, University of California, San Diego, California, USA
- Department of Molecular Medicine, Scripps Research Institute, La Jolla, California, USA
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8
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Accelerating recovery from acute hemarthrosis in patients with hemophilia: the role of joint aspiration. Blood Coagul Fibrinolysis 2019; 30:111-119. [PMID: 30958454 DOI: 10.1097/mbc.0000000000000803] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
: Arthrocentesis of an acute hemarthrosis in hemophilia remains a controversial issue. The purpose of this study is to define the role that joint aspiration can play in the recovery from acute hemarthrosis in patients with hemophilia. The study sample included 33 hemophilic patients (55 joints) with acute elbow, knee, and ankle hemarthrosis as confirmed by ultrasonography. Patients were distributed into a treatment group and a control group. Patients in the first group were subjected to joint aspiration, whereas patients in the second were not. Arthrocentesis was carried out immediately after diagnosis of acute hemarthrosis in liquid phase. Patients were infused with the deficient coagulation factor and were instructed to observe relative rest until resolution of hemarthrosis. The following parameters were analyzed: time to full resolution of hemarthrosis (determined by ultrasonography), duration of treatment with the deficient coagulation factor, time to pain relief, time to recovery of prebleed range of motion, and time to resumption of school/work (all of these measured in days). The joints treated with joint aspiration exhibited a significantly faster resolution of bleeding (fewer days). In addition, this group required fewer days of pharmacological treatment, with faster achievement of functional recovery and resumption of school/work activities. No complications were observed. This study shows that joint aspiration under hemostatic cover and in strictly aseptic conditions is a well-tolerated technique that makes the recovery of acute hemarthrosis of hemophilic patients faster.
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9
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von Drygalski A, Moore RE, Nguyen S, Barnes RFW, Volland LM, Hughes TH, Du J, Chang EY. Advanced Hemophilic Arthropathy: Sensitivity of Soft Tissue Discrimination With Musculoskeletal Ultrasound. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:1945-1956. [PMID: 29363781 PMCID: PMC6057843 DOI: 10.1002/jum.14541] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 10/24/2017] [Accepted: 10/25/2017] [Indexed: 05/09/2023]
Abstract
OBJECTIVES Point-of-care musculoskeletal ultrasound (US) is increasingly used by hemophilia providers to guide management; however, pathologic tissue differentiation with US is uncertain. We sought to determine the extent to which point-of-care musculoskeletal US can identify and discriminate pathologic soft tissue changes in hemophilic arthropathy. METHODS Thirty-six adult patients with hemophilia A/B were prospectively enrolled. Point-of-care musculoskeletal US examinations were performed on arthropathic joints (16 knees, 10 ankles, and 10 elbows) using standard views by a musculoskeletal US-trained and certified hematologist, who recorded abnormal intra-articular soft tissue accumulation. Within 3 days, magnetic resonance imaging was performed using conventional and multiecho ultrashort echo time sequences. Soft tissue identification (synovial proliferation with or without hemosiderin, fat, and/or blood products) was performed by a musculoskeletal radiologist. Findings obtained with both imaging modalities were compared and correlated in a blinded fashion. RESULTS There was perfect agreement between the modalities on the presence of abnormal soft tissue (34 of 36 cases). However, musculoskeletal US was unable to discriminate between coagulated blood, synovium, intrasynovial or extrasynovial fat tissue, or hemosiderin deposits because of wide variations in echogenicity. CONCLUSIONS Musculoskeletal US is valuable for point-of-care imaging to determine the presence of soft tissue accumulation in discrete areas. However, because of limitations of musculoskeletal US in discriminating the nature of pathologic soft tissues and detecting hemosiderin, magnetic resonance imaging will be required if such discrimination is clinically important.
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Affiliation(s)
- Annette von Drygalski
- University of California San Diego, Department of Medicine, Division of Hematology/Oncology, San Diego, CA, USA
- The Scripps Research Institute, Department of Molecular and Experimental Medicine, La Jolla, CA, USA
| | - Randy E Moore
- General Musculoskeletal Imaging Inc, Cincinnati, OH, USA
| | - Sonha Nguyen
- University of California San Diego, Department of Medicine, Division of Hematology/Oncology, San Diego, CA, USA
| | - Richard FW Barnes
- University of California San Diego, Department of Medicine, Division of Hematology/Oncology, San Diego, CA, USA
| | - Lena M Volland
- University of California San Diego, Department of Medicine, Division of Hematology/Oncology, San Diego, CA, USA
| | - Tudor H. Hughes
- University of California San Diego, Department of Radiology, San Diego, CA, USA
| | - Jiang Du
- University of California San Diego, Department of Radiology, San Diego, CA, USA
| | - Eric Y Chang
- VA San Diego Healthcare System, Radiology Service, San Diego, USA
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10
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Foppen W, van der Schaaf IC, Beek FJA, Mali WPTM, Fischer K. Diagnostic accuracy of point-of-care ultrasound for evaluation of early blood-induced joint changes: Comparison with MRI. Haemophilia 2018; 24:971-979. [PMID: 29790633 DOI: 10.1111/hae.13524] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2018] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Recurrent joint bleeding is the hallmark of haemophilia. Synovial hypertrophy observed with Magnetic Resonance Imaging (MRI) is associated with an increased risk of future joint bleeding. AIM The aim of this study was to investigate whether point-of-care ultrasound (POC-US) is an accurate alternative for MRI for the detection of early joint changes. METHODS In this single centre diagnostic accuracy study, bilateral knees and ankles of haemophilia patients with no or minimal arthropathy on X-rays were scanned using POC-US and 3 Tesla MRI. POC-US was performed by 1 medical doctor, blinded for MRI, according to the "Haemophilia Early Arthropathy Detection with Ultrasound" (HEAD-US) protocol. MRIs were independently scored by 2 radiologists, blinded for clinical data and ultrasound results. Diagnostic accuracy parameters were calculated with 95% confidence intervals (CI). RESULTS Knees and ankles of 24 haemophilia patients (96 joints), aged 18-34, were studied. Synovial hypertrophy on MRI was observed in 20% of joints. POC-US for synovial tissue was correct (overall accuracy) in 97% (CI: 91-99) with a positive predictive value of 94% (CI: 73-100) and a negative predictive value of 97% (CI: 91-100). The overall accuracy of POC-US for cartilage abnormalities was 91% (CI: 83-96) and for bone surface irregularities 97% (CI: 91-99). CONCLUSION POC-US could accurately assess synovial hypertrophy, bone surface irregularities and cartilage abnormalities in haemophilia patients with limited joint disease. As POC-US is an accurate and available alternative for MRI, it can be used for routine evaluation of early joint changes.
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Affiliation(s)
- W Foppen
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - I C van der Schaaf
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - F J A Beek
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - W P T M Mali
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - K Fischer
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands.,Van Creveldkliniek, Department of Hematology, University Medical Centre Utrecht, Utrecht, The Netherlands
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11
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Nguyen S, Lu X, Ma Y, Du J, Chang EY, von Drygalski A. Musculoskeletal ultrasound for intra-articular bleed detection: a highly sensitive imaging modality compared with conventional magnetic resonance imaging. J Thromb Haemost 2018; 16:490-499. [PMID: 29274196 PMCID: PMC5826858 DOI: 10.1111/jth.13930] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Indexed: 11/29/2022]
Abstract
Essentials The best imaging modality for joint blood detection in hemophilia is unknown. Blood appearance and detection thresholds were studied with ultrasound and conventional MRI. Ultrasound is sensitive to low volume and concentration of blood, whereas conventional MRI is not. The findings establish the validity of ultrasound for rapid bleed detection in hemophilia care. SUMMARY Background There is increasing demand for musculoskeletal ultrasound (MSKUS) to detect hemophilic joint bleeding, but there is uncertainty regarding blood detection concentration thresholds or if magnetic resonance imaging (MRI) is more accurate. Aims Compare the sensitivity of blood detection by MSKUS and MRI. Methods Increasing blood concentrations in plasma were imaged with MSKUS and MRI 1-2 h, 3-4 days and 7 days after blood withdrawal in vitro, and after injection into cadaveric pig joints. Additionally, effusions in the joints of two patients with hemophilia joints were imaged, followed by aspiration. MSKUS was performed using an 8-18-MHz linear transducer; MRI was performed at 3T using T1-weighted and T2-weighted fat-suppressed sequences. Images were reviewed by a hematologist certified in MSKUS and a musculoskeletal radiologist. Results MSKUS permitted the detection of blood in vitro and in pig joint spaces at concentrations as low as 5%, demonstrated by the presence of echogenic signals that were absent with plasma alone. In contrast, no differences between fluids were discernible on the T1-weighted or T2-weighted MRI images. Results were confirmed in the two patients with hemophilia. Blood clots demonstrated varying and dynamic echogenicity patterns over time and, using MRI, were visualized best with T2 sequences. Conclusion MSKUS is extremely sensitive in detecting low concentrations of intra-articular blood and in discriminating between bloody and non-bloody fluid, whereas conventional MRI is not. These observations demonstrate the advantages of MSKUS over MRI in detecting intra-articular blood, and show that MSKUS is ideal for rapid bleed detection in the clinic.
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Affiliation(s)
- S Nguyen
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - X Lu
- Radiology Service, VA San Diego Healthcare System, San Diego, CA, USA
- Department of Radiology, University of California, San Diego, CA, USA
| | - Y Ma
- Radiology Service, VA San Diego Healthcare System, San Diego, CA, USA
- Department of Radiology, University of California, San Diego, CA, USA
| | - J Du
- Radiology Service, VA San Diego Healthcare System, San Diego, CA, USA
- Department of Radiology, University of California, San Diego, CA, USA
| | - E Y Chang
- Radiology Service, VA San Diego Healthcare System, San Diego, CA, USA
- Department of Radiology, University of California, San Diego, CA, USA
| | - A von Drygalski
- Department of Medicine, University of California San Diego, San Diego, CA, USA
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
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12
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Berro M, Elichiry M, Wasen K, Insagaray J, Rodríguez I. Use of ultrasound for evaluation of painful joint episodes perceived as haemarthrosis in adult patients with severe haemophilia. Haemophilia 2018; 24:e124-e125. [PMID: 29493844 DOI: 10.1111/hae.13439] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2018] [Indexed: 02/05/2023]
Affiliation(s)
- M Berro
- Department of Transfusion Medicine, Faculty of Medicine, Hospital de Clínicas, University of the Republic, Montevideo, Uruguay
| | - M Elichiry
- Department of Transfusion Medicine, Faculty of Medicine, Hospital de Clínicas, University of the Republic, Montevideo, Uruguay
| | - K Wasen
- Department of Transfusion Medicine, Faculty of Medicine, Hospital de Clínicas, University of the Republic, Montevideo, Uruguay
| | - J Insagaray
- Department of Transfusion Medicine, Faculty of Medicine, Hospital de Clínicas, University of the Republic, Montevideo, Uruguay
| | - I Rodríguez
- Department of Transfusion Medicine, Faculty of Medicine, Hospital de Clínicas, University of the Republic, Montevideo, Uruguay
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13
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Zhou JY, Rappazzo KC, Volland L, Barnes RFW, Brackman M, Steiner B, Kruse-Jarres R, Quon DV, Bailey C, Chang EY, von Drygalski A. Pocket handheld ultrasound for evaluation of the bleeding haemophilic joint: A novel and reliable way to recognize joint effusions. Haemophilia 2018; 24:e77-e80. [PMID: 29436079 DOI: 10.1111/hae.13429] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2017] [Indexed: 11/28/2022]
Affiliation(s)
- J Y Zhou
- Division of Hematology/Oncology, Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - K C Rappazzo
- Division of Hematology/Oncology, Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - L Volland
- Division of Hematology/Oncology, Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - R F W Barnes
- Division of Hematology/Oncology, Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - M Brackman
- Division of Hematology/Oncology, Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - B Steiner
- Washington Center for Bleeding Disorders at BloodWorks NW, Seattle, WA, USA
| | - R Kruse-Jarres
- Washington Center for Bleeding Disorders at BloodWorks NW, Seattle, WA, USA
| | - D V Quon
- Orthopaedic Hemophilia Treatment Center, Orthopaedic Institute for Children, Los Angeles, CA, USA
| | - C Bailey
- Orthopaedic Hemophilia Treatment Center, Orthopaedic Institute for Children, Los Angeles, CA, USA
| | - E Y Chang
- VA San Diego Healthcare System, Radiology Service, San Diego, CA, USA
| | - A von Drygalski
- Division of Hematology/Oncology, Department of Medicine, University of California, San Diego, San Diego, CA, USA.,Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
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14
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Di Minno MND, Pasta G, Airaldi S, Zaottini F, Storino A, Cimino E, Martinoli C. Ultrasound for Early Detection of Joint Disease in Patients with Hemophilic Arthropathy. J Clin Med 2017; 6:E77. [PMID: 28758960 PMCID: PMC5575579 DOI: 10.3390/jcm6080077] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/12/2017] [Accepted: 07/24/2017] [Indexed: 11/16/2022] Open
Abstract
Joint bleeding represents the most commonly reported type of hemorrhage in patients affected by hemophilia. Although the widespread use of prophylaxis has been able to significantly reduce the onset of arthropathy, it has been shown that a non-negligible percentage of patients develop degenerative changes in their joints despite this type of treatment. Thus, periodic monitoring of the joint status in hemophilia patients has been recommended to identify early arthropathic changes and prevent the development or progression of hemophilic arthropathy. Ultrasound (US) has proven able to detect and quantify the most relevant biomarkers of disease activity (i.e., joint effusion and synovial hypertrophy) and degenerative damages (i.e., osteo-chondral changes) by means of scoring scales of increasing disease severity. In the present review, we have detailed major literature evidence about the use of US to assess joint status in hemophilia patients, focusing on signs of disease activity and degenerative damages. In particular, we have discussed recent evidence about "point-of-care" use patients with hemophilia.
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Affiliation(s)
| | - Gianluigi Pasta
- Dipartimento di Ortopedia-Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy.
| | - Sonia Airaldi
- Radiologia III-IRCCS San Martino-IST-DISSAL, Università di Genova, 16132 Genova, Italy.
| | - Federico Zaottini
- Radiologia III-IRCCS San Martino-IST-DISSAL, Università di Genova, 16132 Genova, Italy.
| | - Antonio Storino
- Department of Public Health, Federico II University, 80131 Naples, Italy.
| | - Ernesto Cimino
- Department of Clinical Medicine and Surgery, Federico II University, 80131 Naples, Italy.
| | - Carlo Martinoli
- Radiologia III-IRCCS San Martino-IST-DISSAL, Università di Genova, 16132 Genova, Italy.
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15
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Gringeri A, Steinitz-Trost K, Doralt J. Current and future approaches to overcoming the challenges of hemophilia treatment personalization. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1334551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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16
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Acharya SS, Rule B, McMillan O, Humphries TJ. Point-of-care ultrasonography (POCUS) in hemophilia A: a commentary on current status and its potential role for improving prophylaxis management in severe hemophilia A. Ther Adv Hematol 2017; 8:153-156. [PMID: 28491266 DOI: 10.1177/2040620717690316] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In patients with severe hemophilia A, recurrent bleeding into joints results in increased morbidity and reduced quality of life. Prophylaxis using replacement factor products, especially when initiated early, has established benefits in terms of reducing joint bleeds and preserving joint function. Poor adherence to prophylactic regimens is a common cause for breakthrough bleeds and resultant arthropathy. Improving prophylaxis management, especially in the transitional age group, is a challenge. Here, we discuss the current status of ultrasonography (US) in hemophilia A, challenges in its wider implementation, and the potential for use of point-of-care US (POCUS) as an adjunct in the routine management of patients with hemophilia following prophylaxis regimens. Using POCUS, in which US is performed by trained hematologists and nonphysician operators (rather than comprehensive US performed by imaging specialists), specific clinical questions can be addressed in a time-efficient, user-friendly manner to promote adherence to prophylaxis and guide or modify treatment approaches. This review also discusses barriers to acceptance of POCUS as a part of routine management of patients with hemophilia, including questions related to its diagnostic accuracy, dependence on trained operators, agreement on appropriate scoring systems, and potential usefulness in patient management.
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Affiliation(s)
- Suchitra S Acharya
- Hofstra Northwell School of Medicine, Cohen Children's Medical Center of New York, 269-01 76th Avenue, Suite 255, New Hyde Park, NY 11040, USA
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17
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Wyseure T, Mosnier LO, von Drygalski A. Advances and challenges in hemophilic arthropathy. Semin Hematol 2015; 53:10-9. [PMID: 26805902 DOI: 10.1053/j.seminhematol.2015.10.005] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2004] [Revised: 11/05/2004] [Accepted: 12/01/2005] [Indexed: 12/13/2022]
Abstract
Hemophilic arthropathy is a form of joint disease that develops secondary to joint bleeding and presents with synovial hypertrophy, cartilage and bony destruction. The arthropathy can develop despite clotting factor replacement and is especially disabling in the aging population. Pathobiological tissue changes are triggered by release of hemoglobin and iron deposition in the joint, but the sequence of events and the molecular mechanisms resulting in joint deterioration are incompletely understood. Treatment options other than clotting factor replacement are limited. Improvements in the treatment of hemophilia necessitate a better understanding of the processes that lead to this disabling condition and better diagnostic tools. Towards that end, studies of the molecular mechanisms leading to the arthropathy, as well as the development of sensitive imaging techniques and biomarkers are needed. These will pave the way to identify the cause of acute pain such as joint bleeding or synovitis, detect early, potentially reversible structural changes, and predict progression of disease. This review describes current imaging techniques and the development of high resolution musculoskeletal ultrasound with power Doppler to afford point-of-care diagnosis and management, the potential utility of diagnostic biomarkers, and summarizes our current knowledge of the pathobiology of hemophilic arthropathy.
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Affiliation(s)
- Tine Wyseure
- The Scripps Research Institute, Department of Molecular and Experimental Medicine, La Jolla, CA, USA
| | - Laurent O Mosnier
- The Scripps Research Institute, Department of Molecular and Experimental Medicine, La Jolla, CA, USA
| | - Annette von Drygalski
- The Scripps Research Institute, Department of Molecular and Experimental Medicine, La Jolla, CA, USA; University of California at San Diego, Department of Medicine, San Diego, CA, USA.
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