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Sharma R, Johnson V, Pan A, Sellers A, Betensky M, Goldenberg N, Flood VH. Assessment of rare bleeding disorders in adolescents with heavy menstrual bleeding. Haemophilia 2024; 30:490-496. [PMID: 38385952 DOI: 10.1111/hae.14961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/04/2024] [Accepted: 01/11/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION There are a significant number of patients with mucocutaneous bleeding, specifically heavy menstrual bleeding (HMB), who do not have a diagnosed bleeding disorder. These patients receive nontargeted interventions and may have suboptimal treatments. Functional assays, particularly for fibrinolytic and rare platelet function defects, are not robust and not readily available. AIM We aimed to prospectively evaluate the prevalence of genetic defects associated with rare bleeding disorders and describe alterations of coagulation and fibrinolysis in a cohort of adolescents with HMB. METHODS We performed a prospective observational cohort study of patients with HMB and unexplained bleeding. The study utilized a next generation sequencing panel and investigational global assays of coagulation and fibrinolysis. Additionally, specific functional assays were performed to help characterize novel variants that were identified. RESULTS In 10 of the 17 patients (∼59%), genetic variants were identified on molecular testing. Thrombin generation by calibrated thromboelastography was not significantly altered in this patient population. The clot formation and lysis assay showed a trend towards increased fibrinolysis with rapid phase of decline in 23% of the patients. Further corresponding functional assays and study population are described. CONCLUSION Our study describes a unique correlative model in a homogenous cohort of patients with HMB and unexplained bleeding which may inform future diagnostic algorithms, genotype-phenotype correlations as well as aid in specific targeted treatment approaches. Larger future studies may inform risk stratification of patients and improve health related outcomes in patients with HMB.
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Affiliation(s)
- Ruchika Sharma
- Division of Hematology/Oncology/BMT, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Victoria Johnson
- Center for Comprehensive Bleeding Disorders, Versiti Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
| | - Amy Pan
- Division of Pediatric Hematology/Oncology/BMT, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Austin Sellers
- Institute for Clinical and Translational Research, John Hopkins All Childrens Hospital, St. Petersburg, Florida, USA
| | - Marisol Betensky
- Institute for Clinical and Translational Research, John Hopkins All Childrens Hospital, St. Petersburg, Florida, USA
| | - Neil Goldenberg
- Institute for Clinical and Translational Research, John Hopkins All Childrens Hospital, St. Petersburg, Florida, USA
| | - Veronica H Flood
- Center for Comprehensive Bleeding Disorders, Versiti Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
- Division of Pediatric Hematology/Oncology/BMT, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Gooijer K, Heidsieck G, Harsevoort A, Bout D, Janus G, Franken A. Bleeding assessment in a large cohort of patients with Osteogenesis Imperfecta. Orphanet J Rare Dis 2024; 19:61. [PMID: 38347577 PMCID: PMC10860322 DOI: 10.1186/s13023-024-03054-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/29/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Osteogenesis Imperfecta (OI) is characterised by bone fragility. Among several features, easy bruising and multiple case reports on haemorrhagic events have been reported. This paper describes the diverse manifestations of bleeding and bruising in a large cohort of 328 OI patients. The aim of this study is to provide insight in the diverse aspects and therapeutic considerations of bleedings in OI. METHODS This descriptive cohort study was conducted at the National Expert Center for adults with OI in the Netherlands. Bleeding was assessed by the validated self-bleeding assessment tool (Self-BAT) The tool was distributed among 328 adults with different clinically confirmed types of OI. RESULTS 195 of 328 invited patients (completion rate 60%) with OI type 1 (n = 144), OI type 3 (n = 17) and OI type 4 (n = 34), aged between 18 and 82 years, completed the tool. Self-BAT scores were above the normal range in 42% of all patients. For males Self-BAT scores were increased in 37% with a mean score of 3.7, ranged between 0 and 18. For females the Self-BAT scores were increased in 44% with a mean of 5.4 and a range of 0-24. No statistical differences in OI subtypes were found. CONCLUSIONS Bleeding tendency appears to be a relevant complication in OI patients as this study confirms the presumption of bleeding tendency. There are specific recommendations to clinicians who treat OI patients to consider an assessment of bleeding tendency and use potential interventions to reduce haemorrhagic complications and improve quality of life.
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Affiliation(s)
- Koert Gooijer
- Expert Center for Adults with Osteogenesis Imperfecta, Isala Hospital, Dokter van Heesweg 2, PO Box 10400, 8025 AB, Zwolle, The Netherlands.
- Department of Clinical Genetics, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.
| | - Gabriëla Heidsieck
- Expert Center for Adults with Osteogenesis Imperfecta, Isala Hospital, Dokter van Heesweg 2, PO Box 10400, 8025 AB, Zwolle, The Netherlands
| | - Arjan Harsevoort
- Expert Center for Adults with Osteogenesis Imperfecta, Isala Hospital, Dokter van Heesweg 2, PO Box 10400, 8025 AB, Zwolle, The Netherlands
| | - Daniëlle Bout
- Expert Center for Adults with Osteogenesis Imperfecta, Isala Hospital, Dokter van Heesweg 2, PO Box 10400, 8025 AB, Zwolle, The Netherlands
| | - Guus Janus
- Expert Center for Adults with Osteogenesis Imperfecta, Isala Hospital, Dokter van Heesweg 2, PO Box 10400, 8025 AB, Zwolle, The Netherlands
| | - Anton Franken
- Expert Center for Adults with Osteogenesis Imperfecta, Isala Hospital, Dokter van Heesweg 2, PO Box 10400, 8025 AB, Zwolle, The Netherlands
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Notice B, Soffer E, Tickle K, Xiang Y, Gee BE, Sidonio RF, Sokkary N, Batsuli G. Assessment of menstrual health in adolescent and young adults with sickle cell disease. Pediatr Blood Cancer 2024; 71:e30727. [PMID: 37845801 DOI: 10.1002/pbc.30727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/19/2023] [Accepted: 10/07/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Sickle cell disease (SCD) is associated with hypercoagulability, but adults with SCD also have an increased incidence of bleeding including heavy menstrual bleeding (HMB). HMB is common among adolescent females, but the impact of HMB in pediatric SCD is unclear. The objectives of this study were to examine menstrual health status, knowledge, and quality of life (QOL). METHODS We performed a single-institutional multi-clinic cross-sectional study comprised of a five-part survey in pediatric participants with SCD. The survey included the validated Menstrual Bleeding Questionnaire (MBQ) and Self-administered Bleeding Assessment Tool (Self-BAT). RESULTS Forty-eight participants with a median age of 16 years (range: 12-21 years) completed the study. The mean age at onset of menarche was 13 ± 1.3 years. On the MBQ, 29% reported heavy/very heavy menstrual flow, 61% reported moderate or severe dysmenorrhea, and 96% had menses lasting less than 1 week. The Self-BAT revealed that 42% of participants reported a history of HMB. Participants with severe dysmenorrhea or HMB had higher MBQ scores, corresponding to worse QOL. Despite this, less than 20% of participants had attempted any hormonal therapy for menstrual regulation. The odds of hormonal therapy utilization were comparable among participants on hydroxyurea versus not on hydroxyurea (odds ratio 1.58, 95% confidence interval [CI]: 0.33-7.56). CONCLUSIONS The prevalence of HMB and dysmenorrhea is high among adolescents and young women with SCD. Strategies that incorporate menstrual health assessment into routine medical care in this population would help address this important area of pediatric health.
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Affiliation(s)
- Brittany Notice
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Elizabeth Soffer
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Kelly Tickle
- Aflac Cancer and Blood Disorder Center at Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Nursing & Allied Health Research & Evidence-Based Practice Department, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Yijin Xiang
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Department of Pediatrics, Biostatistics Core, Emory School of Medicine, Atlanta, Georgia, USA
| | - Beatrice E Gee
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Morehouse School of Medicine, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorder Center at Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Robert F Sidonio
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorder Center at Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Nancy Sokkary
- Department of Obstetrics and Gynecology, Emory University, Atlanta, Georgia, USA
| | - Glaivy Batsuli
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorder Center at Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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Hoffmann MA, Knoll SN, Baqué PE, Rosar F, Scharrer I, Reuss S, Schreckenberger M. The Influence of Hypothyroid Metabolic Status on Blood Coagulation and the Acquired von Willebrand Syndrome. J Clin Med 2023; 12:5905. [PMID: 37762844 PMCID: PMC10532367 DOI: 10.3390/jcm12185905] [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: 06/12/2023] [Revised: 08/16/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
The intent of this prospective study aimed to identify the influence of hypothyroid metabolic status on the coagulation and fibrinolytic system and association with the acquired von Willebrand syndrome (VWS-ac). We compared 54 patients without substitution therapy after radical thyroidectomy with 58 control subjects without pathological thyroid-stimulating-hormone (TSH)-values. Patients with TSH > 17.5 mU/L over a period of >4 weeks were included. The control-collective was selected based on age and sex to match the patient-collective. The data were collected using laboratory coagulation tests and patient questionnaires; a bleeding score was determined. There were significant differences in the measurement of activated-partial-thromboplastin-time (aPTT/p = 0.009), coagulation-factor VIII (p < 0.001) and von-Willebrand-activity (VWF-ac/p = 0.004) between the patient and control groups. The patient cohort showed an increased aPTT and decreased factor VIII and VWF-ac. 29.7% of the patient-collective compared to 17.2% of the control subjects met the definition of VWS-Ac (p = 0.12). The bleeding score showed significantly more bleeding symptoms in patients with a laboratory constellation of VWS-ac (no family history; p = 0.04). Our results suggest hypocoagulability in hypothyroid patients. Hypothyroidism appears to have a higher incidence of VWS-ac. The increased risk of bleeding complications in hypothyroid patients may be of relevant importance for the outcome, especially in the context of invasive interventions.
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Affiliation(s)
- Manuela Andrea Hoffmann
- Department of Nuclear Medicine, University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany; (S.N.K.); (P.-E.B.); (F.R.); (S.R.); (M.S.)
- Institute for Preventive Medicine of the German Armed Forces, 56626 Andernach, Germany
| | - Sarah N. Knoll
- Department of Nuclear Medicine, University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany; (S.N.K.); (P.-E.B.); (F.R.); (S.R.); (M.S.)
| | - Pia-Elisabeth Baqué
- Department of Nuclear Medicine, University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany; (S.N.K.); (P.-E.B.); (F.R.); (S.R.); (M.S.)
| | - Florian Rosar
- Department of Nuclear Medicine, University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany; (S.N.K.); (P.-E.B.); (F.R.); (S.R.); (M.S.)
- Department of Nuclear Medicine, Saarland University Medical Center, 66421 Homburg, Germany
| | - Inge Scharrer
- Department of Haematology of the Medical Clinic and Policlinic, University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany;
| | - Stefan Reuss
- Department of Nuclear Medicine, University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany; (S.N.K.); (P.-E.B.); (F.R.); (S.R.); (M.S.)
| | - Mathias Schreckenberger
- Department of Nuclear Medicine, University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany; (S.N.K.); (P.-E.B.); (F.R.); (S.R.); (M.S.)
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Tang GH, Thachil J, Bowman M, Bekdache C, James PD, Sholzberg M. Patient-centered care in von Willebrand disease: are we there yet? Expert Rev Hematol 2023; 16:641-649. [PMID: 37581602 DOI: 10.1080/17474086.2023.2243386] [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: 04/14/2023] [Accepted: 07/28/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION Von Willebrand Disease is the most common inherited bleeding disorder. Paradoxically, affected individuals are often misdiagnosed and experience substantial diagnostic delay. There are sex-specific health disparities in VWD rooted in the stigmatization of vaginal bleeding, which leads to symptom dismissal, lack of timely access to care and lower health-related quality of life. AREAS COVERED Following the core elements of patient-centered care - respect for patient preferences, values, and needs, we describe the current state of VWD care. Challenges of diagnostic delay, serial misrecognition of abnormal bleeding, and symptom dismissal are barriers that disproportionately affect women with VWD. These negative effects are further amplified in individuals living in low- and middle-income countries. We describe the importance of coordinated multidisciplinary care, as well as the need for patient education and empowered self-advocacy. EXPERT OPINION While tremendous work has been done to improve the diagnosis and management of VWD, timely and high-quality research is urgently needed to address care gaps. Systemic changes such as resource investment, dedicated research funding for novel treatment modalities, and effective knowledge translation strategies to address structural barriers are needed to facilitate effective patient-centered care for VWD.
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Affiliation(s)
- Grace H Tang
- Hematology-Oncology Clinical Research Group, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Jecko Thachil
- Department of Hematology, Manchester University Hospitals, Manchester, UK
| | - Mackenzie Bowman
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Carine Bekdache
- Hematology-Oncology Clinical Research Group, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Paula D James
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Michelle Sholzberg
- Department of Medicine and Laboratory Medicine & Pathobiology, St. Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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Laffan M, Benson G, Farrelly C, Gomez K, Jones A, Maclean R, O'Donnell J, Lavin M. An expert consensus to define how higher standards of equitable care for von Willebrand disease can be achieved in the UK and Republic of Ireland. Haemophilia 2023; 29:819-826. [PMID: 36877609 DOI: 10.1111/hae.14765] [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: 11/22/2022] [Revised: 01/27/2023] [Accepted: 02/09/2023] [Indexed: 03/07/2023]
Abstract
INTRODUCTION Von Willebrand Disease (VWD) is the most common inherited bleeding disorder. However, recognition of the disease by both the public and healthcare professionals lags behind that of other bleeding disorders, leading to delays in diagnosis and treatment for patients. Updated national guidelines are needed to highlight an appropriate pathway for managing VWD patients in a timelier manner. AIM To identify ways in which care for VWD can be achieved on a more equitable basis. METHODS Using a modified Delphi approach, a panel of VWD experts developed 29 statements across five key themes. These were used to form an online survey that was distributed to healthcare professionals involved in VWD care across the UK and Republic of Ireland (ROI). Stopping criteria comprised 50 responses received, a 3-month window for response (February-April 2022) and 90% of statements passing consensus threshold. Threshold for consensus for each statement was agreed at 75%. RESULTS A total of 66 responses were analysed with 29/29 statements achieving consensus of which 27 attained ≥90% agreement. From the high degree of consensus, eight recommendations were derived regarding how detection and management of VWD can be improved to provide equity of care between men and women. CONCLUSION Implementation of these eight recommendations across the VWD pathway has the potential to raise the standard of care for patients in the UK and ROI by reducing delays to diagnosis and treatment initiation.
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Affiliation(s)
- Mike Laffan
- Centre for Haematology, Imperial College London, London, UK
| | - Gary Benson
- NI Haemophilia Comprehensive Care Centre, Belfast City Hospital, Belfast, UK
| | | | - Keith Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
| | | | | | - James O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, UK.,National Coagulation Centre, St James's Hospital, Dublin, UK
| | - Michelle Lavin
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, UK.,National Coagulation Centre, St James's Hospital, Dublin, UK
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7
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Hansen RS, Vinholt PJ. Prevalence of Bleeding Symptoms in Denmark Using the Patient-administered Bleeding Assessment Tool (self-BAT). Haemophilia 2023; 29:564-571. [PMID: 36563408 DOI: 10.1111/hae.14728] [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: 09/05/2022] [Revised: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The patient-administered bleeding assessment tool (self-BAT) is a screening tool developed to identify individuals in need of work-up for bleeding disorders. Nonetheless, large studies on self-BAT scores on healthy individuals according to gender and age are lacking. AIM Determine cut-offs for abnormal total score of self-BAT and investigate the prevalence of bleeding symptoms in blood donors and individuals representative of the general Danish population. METHODS Blood donors, 15,600 children (<18 years) and 18,200 adults from the general Danish population, were invited to complete a Danish version of the self-BAT. To determine cut-offs for abnormal total self-BAT score, findings from healthy young children (0-11 years old), healthy adolescents (12-17 years old), healthy adult women and healthy adult men were used. RESULTS Among healthy young children (244 girls, 260 boys), healthy adolescents (58 girls, 83 boys), healthy women (n = 437) and healthy men (n = 278) from the general population, along with healthy blood donors (116 women, 176 men), the 95th percentile for total score was two for young girls, three for young boys, four for adolescent girls, three for adolescent boys, eight for women and four for men. CONCLUSION Our findings indicate that the abnormal total self-BAT score is ≥3 for girls aged 0-11 years old, ≥4 for boys aged 0-11 years old, ≥5 for girls aged 12-17 years old, ≥4 for boys aged 12-17 years old, ≥9 for women and ≥5 for men. To establish the accuracy of these cut-offs for diagnosing bleeding disorders, further studies are needed.
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Affiliation(s)
- Rasmus Søgaard Hansen
- Dept. of Clinical Biochemistry, Odense University Hospital, Odense, Denmark.,OPEN, Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Pernille Just Vinholt
- Dept. of Clinical Biochemistry, Odense University Hospital, Odense, Denmark.,OPEN, Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark
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Sharma R, Flood V, Jobe S, Punzalan R, Simpson P, Conway C, Malec L. Utilization and optimization of an electronic self-administered bleeding assessment tool (E-Self BAT) for the screening of pediatric bleeding disorders in the hematology clinic. Haemophilia 2023; 29:685-688. [PMID: 36580378 DOI: 10.1111/hae.14717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 10/21/2022] [Accepted: 11/09/2022] [Indexed: 12/30/2022]
Affiliation(s)
- Ruchika Sharma
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Veronica Flood
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Shawn Jobe
- Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, East Lansing, Michigan, USA
| | - Rowena Punzalan
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Pippa Simpson
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Lynn Malec
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Corrales-Medina FF, Federici AB, Srivastava A, Dougall A, Millar CM, Roberts JC, Jaffray J, Berntorp E. A need to increase von Willebrand disease awareness: vwdtest.com - A global initiative to help address this gap. Blood Rev 2023; 58:101018. [PMID: 36210240 DOI: 10.1016/j.blre.2022.101018] [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: 07/22/2022] [Revised: 09/14/2022] [Accepted: 09/27/2022] [Indexed: 11/02/2022]
Abstract
Von Willebrand disease (VWD) is an inherited bleeding disorder caused by quantitative or qualitative deficiencies in von Willebrand factor (VWF). People with VWD may experience excessive, recurrent or prolonged bleeding, particularly during menstruation, childbirth, surgery or following trauma. However, many VWD patients are undiagnosed, and therefore inadequately treated. Reasons for the underdiagnosis of VWD include its relatively mild symptoms, complex diagnosis, lack of awareness among non-specialist healthcare providers and the general population, and a lack of prioritisation of disorders disproportionately affecting females. The vwdtest.com platform was launched as part of a global initiative to raise awareness and improve diagnosis of VWD. Besides providing VWD-specific educational resources, the website includes an online bleeding self-assessment tool and offers diagnostic support for individuals, and their providers, who have a score suggestive of a bleeding disorder. vwdtest.com helps to address these unmet needs, especially in regions with limited access to educational and diagnostic resources.
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Affiliation(s)
- Fernando F Corrales-Medina
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Miami-Miller School of Medicine, Miami, FL, USA; University of Miami-Hemophilia Treatment Center, Miami, FL, USA.
| | - Augusto B Federici
- University of Milan, School of Medicine, Department of Oncology and Haematology Oncology, Milan, Italy; Division of Haematology and Transfusion Medicine of Luigi Sacco University Hospital, Milan, Italy
| | - Alok Srivastava
- Christian Medical College, Department of Haematology, Vellore, India
| | - Alison Dougall
- School of Dental Science, Trinity College Dublin, Ireland; Dublin Dental University Hospital, Dublin, Ireland
| | - Carolyn M Millar
- Imperial College London, Department of Immunology and Inflammation, Centre for Haematology, London, UK
| | - Jonathan C Roberts
- Bleeding & Clotting Disorders Institute, Peoria, IL, USA; University of Illinois College of Medicine at Peoria, Department of Pediatrics and Medicine, Peoria, IL, USA
| | - Julie Jaffray
- Children's Hospital Los Angeles, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Erik Berntorp
- Clinical Coagulation Research, Department of Translational Medicine, Lund University, Malmö, Sweden
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10
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Sachs UJ. Pitfalls in Coagulation Testing. Hamostaseologie 2023; 43:60-66. [PMID: 36807821 DOI: 10.1055/a-1981-7939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Assays in the coagulation laboratory are affected by numerous variables. Variables which have impact on the test result can lead to incorrect results, and potentially to consequences for further diagnostic and therapeutic decisions made by the clinician. The interferences can be separated into three main groups: biological interferences, with an actual impairment of the patient's coagulation system (congenital or acquired); physical interferences, which usually occur in the pre-analytical phase; and chemical interferences, because of the presence of drugs (mainly anticoagulants) in the blood to be tested. This article discusses some of these interferences in seven instructive cases of (near) miss events as an approach to generate more attention to these issues.
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Affiliation(s)
- Ulrich J Sachs
- Department of Thrombosis and Haemostasis, Giessen University Hospital, Giessen, Germany.,Institute for Clinical Immunology, Transfusion Medicine, and Haemostasis, Justus Liebig University, Giessen, Germany
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11
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Malinowski AK, Abdul-Kadir R. Planning Pregnancy and Birth in Women with Inherited Bleeding Disorders. Semin Thromb Hemost 2022; 49:371-381. [PMID: 36368690 DOI: 10.1055/s-0042-1758117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AbstractInherited bleeding disorders are characterized by a diverse clinical phenotype within and across specific diagnoses. von Willebrand disease (VWD), hemophilia A, and hemophilia B comprise 95 to 97% of inherited bleeding disorders, with the remaining 3 to 5% attributed to rare bleeding disorders, including congenital fibrinogen disorders, factor deficiencies (affecting FII, FV, FV + FVIII, FVII, FX, FXI, and FXIII), and platelet function defects. The pregnancy, birth, and the puerperium may be adversely influenced in the setting of an inherited bleeding disorder depending on its type and clinical phenotype. Obstetric hemostatic challenges may sometimes also unmask the presence of a previously unknown inherited bleeding disorder. This review aims to address the approach to pregnancy and birth in the context of an inherited bleeding disorder and highlights the significance of multidisciplinary input into the care of these women.
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Affiliation(s)
- A. Kinga Malinowski
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada
| | - Rezan Abdul-Kadir
- Department of Obstetrics and Gynaecology and Katharine Dormandy Haemophilia and Thrombosis Centre, The Royal Free NHS Foundation Hospital, London, United Kingdom
- Institute for Women's Health, University College London, London, United Kingdom
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12
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Lavin M, Christopherson P, Grabell J, Abshire T, Flood V, Haberichter SL, Lillicrap D, O’Donnell JS, Montgomery RR, James PD. Longitudinal bleeding assessment in von Willebrand disease utilizing an interim bleeding score. J Thromb Haemost 2022; 20:2246-2254. [PMID: 35780487 PMCID: PMC10193460 DOI: 10.1111/jth.15807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 05/24/2022] [Accepted: 06/10/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Assessment of bleeding phenotype is critically important in the diagnosis of von Willebrand disease (VWD). Despite advances in bleeding assessment tools (BATs), standardized tools to evaluate bleeding following diagnosis (interim bleeding) are lacking. OBJECTIVES We assessed the clinical utility of an interim bleeding protocol in a multicenter, international study involving patients with VWD. METHODS The enrolment ISTH BAT formed the original bleeding score (0 BS). At follow-up, the International Society on Thrombosis and Haemostasis BAT was repeated but included only interval bleeding (Interim BS, 1 BS). Both scores were annualized (0 BS/yr, 1 BS/yr). BS were analyzed by VWD subtype, plasma VWF level, sex, and age. RESULTS Interim BS discriminated by subtype, with significantly increased 0 BS and 1 BS in patients with type 3 VWD. In patients with type 1 VWD, a positive or negative 0 BS did not predict future bleeding, with similar 1 BS/yr (median 1.0 vs. 0.7, p = .2). Despite significantly higher 0 BS in females with type 1 VWD than males (median 7 vs. 5, p = .0012), 1 BS were not significantly different (median 4 vs. 4, p = .16). While 0 BS were lower in children than adults with type 1 VWD, interim BS were similar (median 5 vs. 3, p = .5; 1BS/yr, median 1 vs. 0.8, p = .7). Interestingly, in those with plasma von Willebrand factor:ristocetin cofactor levels >50 IU/dl, interim BS rates were similar to those 30-50 IU/dl (1 BS/yr 0.8 vs. 1.3, p = .5). CONCLUSION This study provides both a new approach to longitudinal bleeding assessment and insights into the evolution of bleeding in VWD.
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Affiliation(s)
- Michelle Lavin
- National Coagulation Centre, St. James’s Hospital, Dublin, Ireland
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Julie Grabell
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Thomas Abshire
- Blood Research Institute, Versiti, Milwaukee, Wisconsin, USA
| | - Veronica Flood
- Blood Research Institute, Versiti, Milwaukee, Wisconsin, USA
| | | | - David Lillicrap
- Department of Pathology & Molecular Medicine, Queen’s University, Kingston, Ontario, Canada
| | - James S. O’Donnell
- National Coagulation Centre, St. James’s Hospital, Dublin, Ireland
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Paula D. James
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
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13
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O'Brien SH, Zia A. Hemostatic and thrombotic disorders in the pediatric patient. Blood 2022; 140:533-541. [PMID: 34724564 DOI: 10.1182/blood.2020006477] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 06/14/2021] [Indexed: 11/20/2022] Open
Abstract
This review focuses on significant advances in the field of pediatric hemostasis and thrombosis, with a focus on published studies within the past decade. The evaluation and management of patients with excessive bleeding remain cornerstones of consultative hematology. We will describe the development of validated bleeding assessment tools relevant to pediatric practice, laboratory advances in the evaluation of von Willebrand disease, and a shift in clinical practice regarding the interpretation of normal coagulation studies in patients with significant bleeding phenotypes. There have also been critical advances in the management of hemostatic disorders. This review highlights new treatment paradigms in hemophilia and the rise of multidisciplinary medical homes for women living with bleeding disorders. Given the continued increase in the incidence of thrombosis, particularly in the hospital setting, a full call to arms against pediatric venous thromboembolism is now essential. We will describe recently completed clinical trials of direct oral anticoagulants in children and adolescents and ongoing work to elucidate the appropriate duration of therapy for children with provoked thrombosis. Recent work regarding the prevention of pediatric venous thromboembolism is highlighted, including studies of thromboprophylaxis and the development of risk prediction models for hospital-acquired thrombosis. Finally, we review advances in our understanding of thrombotic sequelae and the need for continued refinement of our evaluation tools. Despite the significant advances in pediatric hemostasis and thrombosis over the past decade, many unanswered questions remain for the next generation of investigators.
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Affiliation(s)
- Sarah H O'Brien
- Division of Pediatric Hematology/Oncology and
- Department of Pediatrics, The Ohio State University, Columbus, OH
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH; and
| | - Ayesha Zia
- Division of Pediatric Hematology/Oncology and
- University of Texas Southwestern Medical Center, Dallas, TX
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14
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Yeung K, McGrath C, Howse K, James P. Management of patients with elevated Self-BAT scores or other bleeding symptoms: Updated overview for primary care practitioners. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2022; 68:494-499. [PMID: 35831073 PMCID: PMC9842138 DOI: 10.46747/cfp.6807494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To provide recommendations for management of patients presenting with elevated self-administered bleeding assessment tool (Self-BAT) scores or other bleeding symptoms in a primary care setting. SOURCES OF INFORMATION Primary research sources, clinical review articles, and interviews with research staff, hematologists, and family physicians were used to create the poster tools and reference guide resources. MAIN MESSAGE Recommendations to manage a patient with an elevated Self-BAT score or other bleeding symptoms include reviewing the results of the Self-BAT to clarify relevant symptoms, performing initial diagnostic laboratory tests, and doing basic symptom management. Clinical judgment should be used when determining whether referral to a hematologist is necessary, but referral should be considered if the bleeding score is abnormal or if initial management options are ineffective. Some bleeding symptoms warrant evaluation by a gastroenterologist, obstetrician-gynecologist, or otolaryngologist. CONCLUSION Primary care providers should conduct a thorough review of the Self-BAT results and associated management recommendations when working with a patient presenting with an elevated score or other bleeding manifestations. A review consists of the clarification of relevant symptoms, appropriate initial laboratory workups, and patient education. Treatment options for symptom management should be explored while recognizing the threshold for referral to a hematologist.
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Affiliation(s)
- Katie Yeung
- Medical student at Queen’s University in Kingston, Ont
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15
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Yeung K, McGrath C, Howse K, James P. Prise en charge des patients ayant des scores élevés au Self-BAT ou d’autres symptômes hémorragiques. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2022; 68:501-506. [PMID: 35831077 PMCID: PMC9842154 DOI: 10.46747/cfp.6807501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Katie Yeung
- Étudiante en médecine à l'Université Queen's à Kingston (Ontario)
| | - Clare McGrath
- Étudiante en médecine à l'Université Queen's à Kingston (Ontario)
| | - Kelly Howse
- Étudiante en médecine à l'Université Queen's à Kingston (Ontario)
| | - Paula James
- Professeure au Département de médecine à l'Université Queen's à Kingston (Ontario).
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16
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Valentino LA, Hardy ML, James P, Connell NT, Flood V, Scappe N, Frick N. von Willebrand disease (VWD) and BATs: How do they connect and why should I care? Haemophilia 2022; 28:e89-e90. [PMID: 35294992 DOI: 10.1111/hae.14549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/11/2022] [Accepted: 03/03/2022] [Indexed: 11/30/2022]
Affiliation(s)
| | - Marci L Hardy
- National Hemophilia Foundation, New York, New York, USA
| | - Paula James
- Fellow of the Royal College of Physicians and Surgeons of Canada, Queen's University, Kingston, Canada
| | - Nathan T Connell
- Boston Hemophilia Center, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Veronica Flood
- Comprehensive Center for Bleeding Disorders, Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nikole Scappe
- National Hemophilia Foundation, New York, New York, USA
| | - Neil Frick
- National Hemophilia Foundation, New York, New York, USA
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17
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Laboratory Assays of VWF Activity and Use of Desmopressin Trials in the Diagnosis of VWD: A Systematic Review and Meta-Analysis. Blood Adv 2022; 6:3735-3745. [PMID: 35192687 PMCID: PMC9631556 DOI: 10.1182/bloodadvances.2021005431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 02/02/2022] [Indexed: 11/20/2022] Open
Abstract
The findings of these reviews support VWF multimer analysis or VWF:CB/VWF:Ag to diagnose type 2 VWD. The reviews confirm that desmopressin trial is the test of choice to confirm increased VWF clearance in patients with suspected VWD type 1C.
von Willebrand Disease (VWD) is associated with significant morbidity because of excessive bleeding. Early diagnosis and treatment are important to prevent and treat these symptoms. We systematically reviewed the accuracy of any von Willebrand factor (VWF) activity assay in the diagnosis and classification of patients for VWD. We searched Cochrane Central, MEDLINE, and EMBASE for eligible studies. The risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 and the certainty of evidence using the GRADE framework. We pooled estimates of sensitivity and specificity. The review included 77 studies that evaluated the use of newer tests of VWF platelet binding activity (VWF:GPIbR, VWF:GPIbM) and VWF:RCo for the diagnosis of VWD (13 studies), VWF propeptide to VWF:Ag ratio, and desmopressin trial for the diagnosis of type 1C VWD (5 studies), VWF multimer analysis and VWF:CB/VWF:Ag ratio for the classification of type 2 VWD (11 studies), genetic testing and ristocetin-induced platelet aggregation to diagnose type 2B VWD (14 studies), genetic testing and FVIII:VWF binding to diagnose type 2N VWD (17 studies). Based on available diagnostic test accuracy, there appear to be comparable test accuracy results between newer tests of platelet binding activity of VWF function and VWF:RCo. The findings of these reviews support VWF multimer analysis or VWF:CB/VWF:Ag to diagnose type 2 VWD. The desmopressin trial test with 1- and 4-hour postinfusion blood work is the test of choice to confirm increased VWF clearance in patients with suspected VWD type 1C. Additionally, genetic testing is most useful in diagnosing type 2B VWD and has a role in the diagnostic algorithm of suspected type 2N VWD.
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18
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Lapić I, Radić Antolic M, Dejanović Bekić S, Coen-Herak D, Bilić E, Rogić D, Zadro R. Reevaluation of von Willebrand disease diagnosis in a Croatian paediatric cohort combining bleeding scores, phenotypic laboratory assays and next generation sequencing: a pilot study. Biochem Med (Zagreb) 2022; 32:010707. [PMID: 35210927 PMCID: PMC8833252 DOI: 10.11613/bm.2022.010707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/29/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction This study reevaluated von Willebrand disease (vWD) diagnosis in a Croatian paediatric cohort by combining bleeding scores (BS), phenotypic laboratory testing, and next-generation sequencing (NGS). Materials and methods A total of 25 children (11 males and 14 females, median age 10 years, from 2 to 17) previously diagnosed with vWD were included. BS were calculated using an online bleeding assessment tool. Phenotypic laboratory analyses included platelet count, platelet function analyser closure times, prothrombin time, activated partial thromboplastin time, von Willebrand factor antigen (vWF:Ag), vWF gain-of-function mutant glycoprotein Ib binding activity (vWF:GPIbM), vWF collagen binding activity (vWF:CBA), factor VIII activity (FVIII:C) and multimeric analysis. Next-generation sequencing covered regions of both vWF and FVIII genes and was performed on MiSeq (Illumina, San Diego, USA). Results Disease-associated variants identified in 15 patients comprised 11 distinct heterozygous vWF gene variants in 13 patients and one novel FVIII gene variant (p.Glu2085Lys) in two male siblings. Four vWF variants were novel (p.Gln499Pro, p.Asp1277Tyr, p.Asp1277His, p.Lys1491Glu). Three patients without distinctive variants had vWF:GPIbM between 30 and 50%. Patients with identified vWF gene variants had statistically significant lower values of vWF:GPIbM (P = 0.002), vWF:Ag (P = 0.007), vWF:CBA (P < 0.001) and FVIII:C (P = 0.002), compared to those without. Correlations between BS and phenotypic laboratory test results were not statistically significant for either of the tests. Conclusion The applied diagnostic approach confirmed the diagnosis of vWD in 13 patients and mild haemophilia A in two. Limited utility of BS in the paediatric population was evidenced.
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Affiliation(s)
- Ivana Lapić
- Department of Laboratory Diagnostics,University Hospital Center Zagreb, Zagreb, Croatia
- Corresponding author:
| | | | - Sara Dejanović Bekić
- Referral Center for Pediatrics Hematology and Oncology, Department of Pediatrics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Désirée Coen-Herak
- Department of Laboratory Diagnostics,University Hospital Center Zagreb, Zagreb, Croatia
| | - Ernest Bilić
- Referral Center for Pediatrics Hematology and Oncology, Department of Pediatrics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Dunja Rogić
- Department of Laboratory Diagnostics,University Hospital Center Zagreb, Zagreb, Croatia
- Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Renata Zadro
- Medical Biochemistry Laboratory, St Catherine Specialty Hospital, Zagreb, Croatia
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19
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Bleeding assessment tools in the diagnosis of VWD in adults and children: a systematic review and meta-analysis of test accuracy. Blood Adv 2021; 5:5023-5031. [PMID: 34597385 PMCID: PMC9153010 DOI: 10.1182/bloodadvances.2021004368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/14/2021] [Indexed: 12/29/2022] Open
Abstract
Von Willebrand disease (VWD) can be associated with significant morbidity. Patients with VWD can experience bruising, mucocutaneous bleeding, and bleeding after dental and surgical procedures. Early diagnosis and treatment are important to minimize the risk of these complications. Several bleeding assessment tools (BATs) have been used to quantify bleeding symptoms as a screening tool for VWD. We systematically reviewed diagnostic test accuracy results of BATs to screen patients for VWD. We searched Cochrane Central, MEDLINE, and EMBASE for eligible studies, reference lists of relevant reviews, registered trials, and relevant conference proceedings. Two investigators screened and abstracted data. Risk of bias was assessed using the revised tool for the quality assessment of diagnostic accuracy studies and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. We pooled estimates of sensitivity and specificity. The review included 7 cohort studies that evaluated the use of BATs to screen adult and pediatric patients for VWD. The pooled estimates for sensitivity and specificity were 75% (95% confidence interval, 66-83) and 54% (29-77), respectively. Certainty of evidence varied from moderate to high. This systematic review provides accuracy estimates for validated BATs as a screening modality for VWD. A BAT is a useful initial screening test to determine who needs specific blood testing. The pretest probability of VWD (often determined by the clinical setting/patient population), along with sensitivity and specificity estimates, will influence patient management.
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20
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Carter-Febres ME, Lim MY. Evaluation of ISTH-BAT as a predictor for factor deficiency in haemophilia carriers: a single-centre experience. Blood Coagul Fibrinolysis 2021; 32:611-613. [PMID: 34433178 DOI: 10.1097/mbc.0000000000001078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | - Ming Y Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
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21
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Gomez K, Anderson J, Baker P, Biss T, Jennings I, Lowe G, Platton S. Clinical and laboratory diagnosis of heritable platelet disorders in adults and children: a British Society for Haematology Guideline. Br J Haematol 2021; 195:46-72. [PMID: 34435350 DOI: 10.1111/bjh.17690] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Keith Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London
| | - Julia Anderson
- Haemophilia Thrombosis and Immunology Centre, Royal Infirmary, NHS Lothian, Edinburgh
| | - Peter Baker
- Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - Tina Biss
- Haemophilia Comprehensive Care Centre, Royal Victoria Infirmary, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne
| | - Ian Jennings
- UK NEQAS for Blood Coagulation, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | - Gillian Lowe
- Haemophilia Comprehensive Care Centre, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sean Platton
- Haemophilia Centre, The Royal London Hospital, Barts Health NHS Trust, London, UK
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22
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Approach to the Patient with Bleeding. Hematol Oncol Clin North Am 2021; 35:1039-1049. [PMID: 34535288 DOI: 10.1016/j.hoc.2021.07.001] [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: 11/21/2022]
Abstract
Approach to the patient with bleeding begins with a thorough bleeding, medical, and family history to determine the nature of bleeding and severity of bleeding symptoms. Use of a Bleeding Assessment Tool allows the clinician to obtain a comprehensive bleeding history and ultimately determine the individual bleeding score that reflects bleeding severity and is classifiable as either normal or abnormal. In the absence of significant findings within patient history or presenting symptoms clearly pointing to a specific bleeding pathology, an approach to laboratory investigation is presented that proceeds through first-line, second-line, and third-line testing.
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23
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van Galen K, Lavin M, Skouw-Rasmussen N, Fischer K, Noone D, Pollard D, Mauser-Bunschoten E, Khair K, Gomez K, van Loon E, Bagot CN, Elfvinge P, d'Oiron R, Abdul-Kadir R. European principles of care for women and girls with inherited bleeding disorders. Haemophilia 2021; 27:837-847. [PMID: 34343384 DOI: 10.1111/hae.14379] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/29/2021] [Accepted: 07/07/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Despite increasing awareness of issues faced by women and girls with inherited BDs (WGBD), standards of care are lacking, with disparities in diagnosis and treatment for WGBD across Europe. We aimed to develop practical principles of care (PoC) to promote standardization of care for WGBD within European Haemophilia Treatment and Comprehensive Care Centres (HTC/CCCs). METHODS The co-creation process, supported by the European Association for Haemophilia and Allied Disorders, consisted of four multidisciplinary meetings with health care providers (HCPs) experienced in WGBD care, and European Haemophilia Consortium representatives, combined with broad patient and HCP consultations in the European haemophilia community. Relevant medical societies outside Europe were contacted for confirmation. RESULTS We developed ten PoC for WGBD, stressing the importance and benefits of a centralized, multidisciplinary, comprehensive, family-centred approach to support and manage WGBD during all life stages. These PoC emphasise the right to equitable access and quality of care for all people with BDs, irrespective of gender. Multiple medical societies outside Europe also confirmed their support for endorsement. CONCLUSIONS Ten PoC for WGBD evolved from an iterative process among stakeholders, supported by relevant medical societies worldwide. These PoC can serve as a benchmark for diagnosis and comprehensive multidisciplinary management of WGBD, and improve awareness of their unique challenges. They offer a framework to guide HTC/CCCs in providing equitable care for all WGBD, both in their own services and in other healthcare settings. Implementation of these principles aims to positively impact the health, wellbeing and quality of life for WGBD.
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Affiliation(s)
- Karin van Galen
- Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Michelle Lavin
- Irish Centre for Vascular Biology, School of Pharmacy and Biomedical Sciences, RCSI, Dublin and National Coagulation Centre, St. James' Hospital, Dublin, Ireland
| | | | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Declan Noone
- President, European Haemophilia Consortium, Brussels, Belgium
| | - Debra Pollard
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
| | | | - Kate Khair
- Director of Research, Haemnet, London, UK
| | - Keith Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
| | | | | | - Petra Elfvinge
- Department of Haematology, Karolinska University, Stockholm, Sweden
| | - Roseline d'Oiron
- Centre de Référence de l'Hémophilie et des Maladies Hémorragiques Constitutionnelles, APHP Paris Saclay - Hôpital Bicêtre and Inserm, U 1176 Le Kremlin Bicêtre, France
| | - Rezan Abdul-Kadir
- Department of Obstetrics and Gynaecology, Royal Free London NHS Foundation Trust and Institute for Women's Health, University College London, London, UK
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Kaur D, Kerlin BA, Stanek JR, O'Brien SH. Use of electronic self-administered bleeding assessment tool in diagnosis of paediatric bleeding disorders. Haemophilia 2021; 27:710-716. [PMID: 34089545 DOI: 10.1111/hae.14349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 01/06/2023]
Abstract
INTRODUCTION In the era of electronic medical records, pen-and-paper-based physician-administered bleeding assessment tools (BAT) remain under-utilized in the clinical setting, as they are noted to be time-consuming. AIM The current study reviews the use of an electronic self-administered bleeding assessment tool (eBAT) prospectively in a paediatric haematology clinic and in comparison with a physician administered BAT (pBAT). MATERIALS AND METHODS This was reviewed and approved in the current form because the aims statement includes the method regarding comparison of 2 groups. So no additional section required. RESULTS A total of 94 BAT response pairs were available for analysis. The median time required for patients or parents to complete the eBAT was 8 min, with less than a third of the patients requiring over 10 min. The median bleeding scores noted in this study were 4 for both the BATs, with strong positive correlation between the eBAT and the physician administered bleeding questionnaire. The eBAT had a sensitivity of 93.8% (95% CI 82.8%-98.7%), a specificity of 34.8% (95% CI 21.4%-50.3%), a positive predictive value (PV) of 60.0% (95% CI 54.5%-65.2%) and a negative PV of 84.2% (95% CI 62.5%-94.5%) for identifying a bleeding disorder. CONCLUSIONS Findings indicate that eBAT is a valid and time-efficient screening tool for evaluating patients' bleeding symptoms, which can improve clinical applicability of BATs by reducing time for bleeding history review.
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Affiliation(s)
- Dominder Kaur
- Department of Paediatrics, Division of Paediatric Haematology/Oncology and Stem Cell Transplantation, Columbia University Medical Centre, New York, USA
| | - Bryce A Kerlin
- Division of Paediatric Haematology/Oncology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA.,Centre for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Joseph R Stanek
- Division of Paediatric Haematology/Oncology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Sarah H O'Brien
- Department of Paediatrics, Division of Paediatric Haematology/Oncology and Stem Cell Transplantation, Columbia University Medical Centre, New York, USA.,Centre for Innovation in Paediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
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25
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ASH ISTH NHF WFH 2021 guidelines on the diagnosis of von Willebrand disease. Blood Adv 2021; 5:280-300. [PMID: 33570651 DOI: 10.1182/bloodadvances.2020003265] [Citation(s) in RCA: 214] [Impact Index Per Article: 71.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/23/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND von Willebrand disease (VWD) is the most common inherited bleeding disorder known in humans. Accurate and timely diagnosis presents numerous challenges. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH), the International Society on Thrombosis and Haemostasis (ISTH), the National Hemophilia Foundation (NHF), and the World Federation of Hemophilia (WFH) are intended to support patients, clinicians, and other health care professionals in their decisions about VWD diagnosis. METHODS ASH, ISTH, NHF, and WFH established a multidisciplinary guideline panel that included 4 patient representatives and was balanced to minimize potential bias from conflicts of interest. The Outcomes and Implementation Research Unit at the University of Kansas Medical Center (KUMC) supported the guideline-development process, including performing or updating systematic evidence reviews up to 8 January 2020. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subsequently subject to public comment. RESULTS The panel agreed on 11 recommendations. CONCLUSIONS Key recommendations of these guidelines include the role of bleeding-assessment tools in the assessment of patients suspected of VWD, diagnostic assays and laboratory cutoffs for type 1 and type 2 VWD, how to approach a type 1 VWD patient with normalized levels over time, and the role of genetic testing vs phenotypic assays for types 2B and 2N. Future critical research priorities are also identified.
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26
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Gresele P, Falcinelli E, Bury L, Pecci A, Alessi MC, Borhany M, Heller PG, Santoro C, Cid AR, Orsini S, Fontana P, De Candia E, Podda G, Kannan M, Jurk K, Castaman G, Falaise C, Guglielmini G, Noris P. The ISTH bleeding assessment tool as predictor of bleeding events in inherited platelet disorders: Communication from the ISTH SSC Subcommittee on Platelet Physiology. J Thromb Haemost 2021; 19:1364-1371. [PMID: 33880867 DOI: 10.1111/jth.15263] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/18/2021] [Accepted: 02/04/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The ISTH Bleeding Assessment Tool (ISTH-BAT) has been validated for clinical screening of suspected von Willebrand disease (VWD) and for bleeding prediction. Recently it has been validated for subjects with inherited platelet disorders (IPD) (BAT-VAL study). OBJECTIVES To determine whether the ISTH-BAT bleeding score (BS) predicts subsequent bleeding events requiring treatment in IPD patients. METHODS Patients with IPD, type 1 VWD (VWD-1) and age- and sex-matched healthy controls enrolled in the BAT-VAL study were prospectively followed-up for 2 years and bleeding episodes requiring treatment were recorded. RESULTS Of the 1098 subjects initially enrolled, 955 were followed-up and 124 suffered hemorrhages during follow-up, 60% of whom had inherited platelet function disorders (IPFD). Total number of events was significantly higher in IPFD (n = 235) than VWD-1 (n = 52) or inherited thrombocytopenia (IT; n = 20). Events requiring transfusions were 66% in IPFD, 5.7% in VWD-1, and 3% in IT. Baseline BS was significantly higher in IPFD patients with a bleeding event at follow-up than in those without (p < .01) and the percentage of subjects suffering a bleeding event increased proportionally to baseline BS quartile. A significant association between the BS and the chance of suffering severe bleeding was found in the overall, IPFD, and VWD-1 populations. Similar results were obtained for the pediatric population. CONCLUSIONS Inherited platelet function disorder patients with high BS at enrollment are more likely to suffer from bleeding events requiring treatment at follow-up. Moreover, the higher the baseline BS quartile the greater the incidence of subsequent events, suggesting that independently from diagnosis a high BS is associated with a greater risk of subsequent hemorrhage.
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Affiliation(s)
- Paolo Gresele
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Emanuela Falcinelli
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Loredana Bury
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Alessandro Pecci
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Marie-Christine Alessi
- Centre for CardioVascular and Nutrition Research (C2VN, INSERM 1263, INRA 1260, Marseille, France
| | - Munira Borhany
- Department of Hematology, Haemostasis & Thrombosis at National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, Pakistan
| | - Paula G Heller
- Instituto de Investigaciones Médicas A. Lanari, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
- Departamento Hematología Investigación, Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET, Universidad de Buenos Aires, Instituto de Investigaciones Médicas (IDIM, Buenos Aires, Argentina
| | - Cristina Santoro
- Hematology, Azienda Ospedaliera Universitaria Policlinico Umberto I, Rome, Italy
| | - Ana Rosa Cid
- Unidad de Hemostasia y Trombosis, Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | - Sara Orsini
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Pierre Fontana
- Geneva Platelet Group and Division of Angiology and Hemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Erica De Candia
- Hemostasis and Thrombosis Unit, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
- Institute of Internal Medicine and Geriatrics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianmarco Podda
- Medicina III, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Meganathan Kannan
- Division of Blood and Vascular Biology, Department of Life Sciences, School of Life Sciences, Central University of Tamil Nadu, Thiruvarur, India
| | - Kerstin Jurk
- Center for Thrombosis and Hemostasis, University Medical Center, Mainz, Germany
| | - Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Céline Falaise
- Centre for CardioVascular and Nutrition Research (C2VN, INSERM 1263, INRA 1260, Marseille, France
| | - Giuseppe Guglielmini
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Patrizia Noris
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
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Hansen RS, Carlsen M, Rasmussen KF, Vinholt PJ. Translation, validation, and usability of the International Society on Thrombosis and Haemostasis Bleeding Assessment Tool (Self-ISTH-BAT). Eur J Haematol 2021; 107:104-110. [PMID: 33740833 DOI: 10.1111/ejh.13625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Bleeding questionnaires are effective and recommended screening tools for potential bleeding disorder, but healthcare practitioner-administered bleeding assessment tools (expert-ISTH-BATs) are time-consuming. A patient-administered ISTH-BAT (self-ISTH-BAT) has been developed and validated. We translated, validated, and evaluated the usability of self-ISTH-BAT. METHODS We conducted a forward-backward translation of self-ISTH-BAT from English to Danish. Expert-ISTH-BAT and Danish self-ISTH-BAT were administered to 106 random individuals aged ≥18 years attending Odense University Hospital between August and November 2020 for elective blood sampling. Results comprise a score of bleeding symptoms. RESULTS Mean age of included individuals were 49 years (range: 18-83), and 59% were female. Median self-ISTH-BAT score was 2 (range: 0-18) and 1 (range: 0-22) for expert-ISTH-BAT (P = .09). All organ systems had ≥90% exact score agreement between expert-ISTH-BAT and self-ISTH-BAT, except gastrointestinal bleeding (77%) and other bleedings (72%). We found an acceptable correlation (r2 = .80) between expert-ISTH-BAT and self-ISTH-BAT. The self-ISTH-BAT had 82% sensitivity and 89% specificity at the recommended cutoff for expert-BAT (female:<6; male:<4). At this cutoff, 10 had abnormal self-ISTH-BAT scores with normal expert-ISTH-BAT. Three (3%) had normal self-ISTH-BAT with abnormal expert-ISTH-BAT. CONCLUSION Self-ISTH-BAT can replace expert-ISTH-BAT as a screening tool for bleeding disorders in Danish individuals as only 3% were not identified with the self-ISTH-BAT tool.
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Affiliation(s)
- Rasmus Søgaard Hansen
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense C, Denmark.,OPEN, Open Patient data Explorative Network, Odense University Hospital, Odense C, Denmark
| | - Mette Carlsen
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense C, Denmark
| | | | - Pernille Just Vinholt
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense C, Denmark.,OPEN, Open Patient data Explorative Network, Odense University Hospital, Odense C, Denmark
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Hossenbaccus L, Thibeault L, Grabell J, Braund H, Hopman W, James P. Evaluating the effectiveness of let's talk period's high school educational outreach program: A pilot study. Haemophilia 2021; 27:470-478. [PMID: 33626190 DOI: 10.1111/hae.14277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/27/2021] [Accepted: 02/05/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Menorrhagia impacts ~40% of adolescent females, with about half having an underlying bleeding disorder, most commonly von Willebrand Disease (VWD). VWD affects ~1 in 1000 individuals, though many are unaware of their condition. Let's Talk Period (LTP) is an online knowledge translation platform aimed at increasing awareness of bleeding disorders symptoms, with a validated self-administered bleeding assessment tool (Self-BAT). AIM To evaluate the effectiveness of the LTP high school outreach program in Grade 9 girls' health classes quantitatively, using baseline, post-presentation, and follow-up quiz scores, and qualitatively, with student and teacher feedback forms. METHODS The 75-minute in-class presentations, developed in alignment with the 2015 Ontario Curriculum for Grade 9 Health and Physical Activity, were led by a haemophilia nurse, clinical research assistant, and undergraduate student from the LTP team. Students completed baseline, post-presentation, and 4-6-week follow-up Kahoot quizzes featuring the same nine questions to evaluate change in knowledge levels and retention. Both student and teacher feedback were collected. RESULTS There was a significant increase (p < 0.001) from baseline to post-presentation scores, with a significant gain in knowledge, for all questions (p < 0.01). Students found content related to the basics and management of menstruation to be most interesting. Many had constructive feedback on how the presentation method could be improved. On average, the presentations were rated an 8.6 of 10 by students and 8.75 of 10 by teachers. CONCLUSION The LTP high school outreach program effectively increases student knowledge of menorrhagia and bleeding disorders. It was well-received by students and staff alike.
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Affiliation(s)
- Lubnaa Hossenbaccus
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
| | - Lisa Thibeault
- Clinical Research Centre, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Julie Grabell
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Heather Braund
- Faculty of Education and the Office of Professional Development and Educational Scholarship, Queen's University, Kingston, ON, Canada
| | - Wilma Hopman
- Clinical Research Centre, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Paula James
- Department of Medicine, Queen's University, Kingston, ON, Canada
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29
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James PD. Women and bleeding disorders: diagnostic challenges. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:547-552. [PMID: 33275722 PMCID: PMC7727580 DOI: 10.1182/hematology.2020000140] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Women with bleeding disorders suffer from multiple bleeding symptoms, including easy bruising, epistaxis, bleeding from minor wounds and the oral cavity, and bleeding after dental work or surgery. However, women with bleeding disorders especially suffer from gynecologic and obstetrical bleeding. These symptoms often are not recognized as abnormal, and many women are left undiagnosed and without access to appropriate medical care. Additional challenges to diagnosing women with bleeding disorders include lack of access to appropriate laboratory testing and issues around disease classification and nomenclature. Efforts have been undertaken to address these challenges, including the development and validation of bleeding assessment tools and strategies to clarify diagnostic thresholds and algorithms for von Willebrand disease (VWD) and platelet function disorders. Efforts to improve communication with the nomenclature used for hemophilia carriers are also underway.
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Gebhart J, Hofer S, Kaider A, Rejtö J, Ay C, Pabinger I. The discriminatory power of bleeding assessment tools in adult patients with a mild to moderate bleeding tendency. Eur J Intern Med 2020; 78:34-40. [PMID: 32317240 DOI: 10.1016/j.ejim.2020.04.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/24/2020] [Accepted: 04/06/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Bleeding assessment tools (BATs) have been developed to quantify bleeding severity. Their ability to predict for the diagnosis of a bleeding disorder has not been thoroughly investigated. OBJECTIVES To evaluate the ability of the Vicenza BAT and the ISTH BAT to distinguish patients with an established bleeding disorder from those with bleeding of unknown cause (BUC). PATIENTS/METHODS Three-hundred fifty-nine patients (228 with BUC, 64%) from the Vienna Bleeding Biobank were assessed in this study. RESULTS The bleeding scores were similar in patients with an established diagnosis of a bleeding disorder compared to patients with BUC. Both BATs had a low sensitivity and specificity for the diagnosis of a bleeding disorder with areas under the receiver operating characteristic (ROC) curves of 0.53 (95% confidence interval 0.47-0.60) for the Vicenza BAT and 0.52 (0.46-0.59) for the ISTH BAT. In terms of specific diagnoses, both scores were most accurate in diagnosing von Willebrand disease (VWD, areas under the ROC curve; Vicenza BAT 0.67 (0.45-0.90); ISTH BAT 0.70 (0.50-0.90)). A separate evaluation of different bleeding symptoms in patients who had undergone surgery and tooth extraction revealed that postpartum bleeding and bleeding from small wounds was predictive for diagnosing a MBD in multivariable analysis. CONCLUSIONS The Vicenza- and the ISTH BAT have a low ability to distinguish patients with an established bleeding disorder from those with BUC.
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Affiliation(s)
- Johanna Gebhart
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
| | - Stefanie Hofer
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Alexandra Kaider
- Section for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Austria
| | - Judit Rejtö
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
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Development and Validation of the Warfarin-Aspirin Bleeding Assessment Tool (WA-BAT) in Children. J Pediatr Hematol Oncol 2020; 42:e513-e514. [PMID: 31259820 DOI: 10.1097/mph.0000000000001540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Bleeding assessment tools (BATs) aim to screen and estimate bleeding risk in patients with inherited bleeding disorders. However, the use of BAT as a standardized measure for comparing bleeding in patients on long-term thromboprophylaxis has not yet been validated. We developed a self-administrable BAT to assess bleeding in patients undergoing long-term thromboprophylaxis with aspirin or warfarin. Eligible participants were invited to complete the warfarin-aspirin -BAT (WA-BAT) online. The WA-BAT was readministered a number of weeks later to determine intrarater reliability. The WA-BAT showed substantial intrarater reliability and assesses major and minor bleeding associated with long-term warfarin or aspirin use.
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32
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Elbaz C, Sholzberg M. An illustrated review of bleeding assessment tools and common coagulation tests. Res Pract Thromb Haemost 2020; 4:761-773. [PMID: 32685885 PMCID: PMC7354401 DOI: 10.1002/rth2.12339] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/08/2020] [Accepted: 02/26/2020] [Indexed: 12/17/2022] Open
Abstract
Recognizing the complexity of coagulation tests and currently used anticoagulants, we developed this illustrated review on bleeding assessment tools and common coagulation screening tests. Quantitative bleeding assessment tools (BATs) are available to standardize the bleeding history and improve the pretest probability prior to coagulation testing. We describe use of BATs and the principles, indications, and limitations of the prothrombin time (PT)/International Normalized Ratio, activated partial thromboplastin time (APTT), and 50:50 mix. Use of these tests to identify coagulation factor deficiencies, specific and nonspecific inhibitors, coagulopathy of liver disease, disseminated intravascular coagulation, and commonly used anticoagulant medications are reviewed. Current literature suggests that unnecessary coagulation testing is rampant. The PT and APTT have astoundingly low sensitivity (1.0%-2.1%) for detection of clinically significant bleeding disorders. Thus, current guidelines recommend against the use of screening PT and APTT in preoperative patients undergoing noncardiac/vascular surgery.
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Affiliation(s)
- Carolyne Elbaz
- Department of MedicineUniversity of TorontoTorontoONCanada
| | - Michelle Sholzberg
- Departments of Medicine and Laboratory Medicine & PathobiologySt. Michael’s HospitalToronto and University of TorontoTorontoONCanada
- Li Ka Shing Knowledge InstituteTorontoONCanada
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33
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Cornelissen LL, Caram-Deelder C, van der Bom JG, Middelburg RA, Zwaginga JJ. Risk factors for bleeding in haemato-oncology patients-a nested case-control study: The BITE study protocol (Bleeding In Thrombocytopenia Explained). BMJ Open 2020; 10:e034710. [PMID: 32606056 PMCID: PMC7328810 DOI: 10.1136/bmjopen-2019-034710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Haemato-oncological patients often receive platelet count driven prophylactic platelet transfusions to prevent bleeding. However, many prophylactically transfused patients still bleed. More knowledge on risk factors for bleeding is therefore needed. This will enable identification of bleeding risk profiles on which future transfusion policy can be optimised. The present BITE study (Bleeding In Thrombocytopenia Explained) aims to identify clinical conditions and biomarkers that are associated with clinically relevant bleeding events. METHODS AND ANALYSIS A matched case-control study nested in a cohort of haemato-oncological patients in the Netherlands. We collect a limited number of variables from all eligible patients, who together form the source population. These patients are followed for the occurrence of clinically relevant bleeding. Consenting patients of the source population form the cohort. Cases from the cohort are frequency matched to selected control patients for the nested case-control study. Of both case and control patients more detailed clinical data is collected. STUDY POPULATION Adult haemato-oncological patients, who are admitted for intensive chemotherapeutic treatment or stem cell transplantation, or who received such treatments in the past and are readmitted for disease or treatment-related adverse events. STATISTICAL ANALYSIS Bleeding incidences will be calculated for the total source population, as well as for different subgroups. The association between potential risk factors and the occurrence of bleeding will be analysed using conditional logistic regression, to account for matching of case and control patients. ETHICS AND DISSEMINATION The study was approved by the Medical Research Ethics Committee Leiden Den Haag and Delft, and the Radboudumc Committee on Research Involving Human Subjects. Approval in seven other centres is foreseen. Patients will be asked for written informed consent and data is coded before analyses, according to Dutch privacy law. Results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NL62499.058.17. NCT03505086; Pre-results.
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Affiliation(s)
- Loes L Cornelissen
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin/LUMC, Leiden, The Netherlands
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Camila Caram-Deelder
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin/LUMC, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna G van der Bom
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin/LUMC, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Rutger A Middelburg
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin/LUMC, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jaap Jan Zwaginga
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin/LUMC, Leiden, The Netherlands
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
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Guelcher CJ, Chase J, Pollard D. Women and girls with heavy menstrual bleeding and inherited bleeding disorders: A call to action for the Haemophilia Treatment Centre Nurse. Haemophilia 2020; 27 Suppl 3:82-86. [PMID: 32469119 DOI: 10.1111/hae.14019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/09/2020] [Indexed: 12/27/2022]
Abstract
Over the last several decades, the increasing focus on women with inherited bleeding disorders (WBD) has brought more patients into Haemophilia Treatment Centres (HTC) around the world. These women present with unique challenges including a significant risk of heavy menstrual bleeding (HMB). The influx of a new patient group has necessitated expansion of the services provided by the multi-disciplinary team in HTCs. Nurses already play a central role in patient and family education within the HTC. As such, they are well positioned to participate in the development of adaptations within the HTC infrastructure to provide clinical care and education specifically for WBD. The nursing experts in HTCs should play an active role in outreach as well as providing education to WBD. Despite this supposition, review of the growing body of literature surrounding the topic of WBD is notable for a paucity of literature highlighting the role of the HTC nurse and potential impact on this, relatively new, but steadily increasing, patient population.
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Affiliation(s)
| | - Jaime Chase
- John Hunter Children's Hospital, New Lambton Heights, NSW, Australia
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35
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Fogarty H, Doherty D, O'Donnell JS. New developments in von Willebrand disease. Br J Haematol 2020; 191:329-339. [PMID: 32394456 DOI: 10.1111/bjh.16681] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 12/19/2022]
Abstract
Von Willebrand disease (VWD) constitutes the most common inherited human bleeding disorder. It is associated with a mucocutaneous bleeding phenotype that can significantly impact upon quality of life. Despite its prevalence and associated morbidity, the diagnosis and subclassification of VWD continue to pose significant clinical challenges. This is in part attributable to the fact that plasma von Willebrand factor (VWF) levels vary over a wide range in the normal population, together with the multiple different physiological functions played by VWF in vivo. Over recent years, substantial progress has been achieved in elucidating the biological roles of VWF. Significant advances have also been made into defining the pathophysiological mechanisms underpinning both quantitative and qualitative VWD. In particular, several new laboratory assays have been developed that enable more precise assessment of specific aspects of VWF activity. In the present review, we discuss these recent developments in the field of VWD diagnosis, and consider how these advances can impact upon clinical diagnostic algorithms for use in routine clinical practice. In addition, we review some important recent advances pertaining to the various treatment options available for managing patients with VWD.
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Affiliation(s)
- Helen Fogarty
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Dearbhla Doherty
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Coagulation Centre, St James's Hospital, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
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36
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Haley KM, Sidonio RF, Abraham S, Cheng D, Recht M, Kulkarni R. A Cross-Sectional Study of Women and Girls with Congenital Bleeding Disorders: The American Thrombosis and Hemostasis Network Cohort. J Womens Health (Larchmt) 2020; 29:670-676. [DOI: 10.1089/jwh.2019.7930] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Kristina M. Haley
- The Hemophilia Center, Oregon Health & Science University, Portland, Oregon
| | - Robert F. Sidonio
- Emory University School of Medicine and Aflac Cancer and Blood Disorders, Atlanta, Georgia
| | - Shirley Abraham
- Department of Pediatrics, University of New Mexico, Albuquerque, New Mexico
| | - Dunlei Cheng
- American Thrombosis and Hemostasis Network, Chicago, Illinois
| | - Michael Recht
- The Hemophilia Center, Oregon Health & Science University, Portland, Oregon
| | - Roshni Kulkarni
- Centers for Bleeding and Clotting Disorders, Michigan State University, East Lansing, Michigan
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Spradbrow J, Letourneau S, Grabell J, Liang Y, Riddel J, Hopman W, Blanchette VS, Rand ML, Coller BS, Paterson AD, James PD. Bleeding assessment tools to predict von Willebrand disease: Utility of individual bleeding symptoms. Res Pract Thromb Haemost 2020; 4:92-99. [PMID: 31989089 PMCID: PMC6971303 DOI: 10.1002/rth2.12256] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 08/19/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Bleeding assessment is part of the diagnostic workup of von Willebrand disease (VWD). Bleeding assessment tools (BATs) have standardized obtaining this information but have been criticized because they are time consuming. OBJECTIVE To use our legacy data to determine which questions from BATs are the strongest predictors of a VWD diagnosis. PATIENTS/METHODS Bleeding score data from 3 different BATs were used. Patients aged <12 years were excluded. Questions on BATs relate to different bleeding symptoms, and each symptom is scored by severity. Scores for each symptom were sorted based on whether they indicated clinically significant bleeding, and nonsignificant scores were set as the reference category. Multivariable logistic regression was used to determine the symptoms that were the strongest predictors of a laboratory-confirmed VWD diagnosis. RESULTS A total of 927 participants were included; 144 (16%) were patients with VWD, and 783 (84%) were healthy controls. The top 3 symptoms for which a clinically significant positive response increased the likelihood of VWD were hemarthrosis (odds ratio [OR], 19.2; 95% confidence interval [CI], 3.7-100.4), postsurgical bleeding (OR, 15.2; 95% CI, 5.9-38.9), and menorrhagia (OR, 10.3; 95% CI, 4.9-21.9). With each increase in number of bleeding symptom categories with clinically significant scores, subjects had a stepwise increase in odds of a VWD diagnosis. CONCLUSIONS Our results suggest that most of the bleeding symptoms on BATs are significant predictors of VWD, and there is value in assessing multiple bleeding symptoms when eliciting a bleeding history. Certain bleeding symptoms are more useful predictors than others. Future BAT revisions may consider adding a relative weighting to each symptom.
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Affiliation(s)
| | | | - Julie Grabell
- Department of MedicineQueen's UniversityKingstonONCanada
| | - Yupu Liang
- Research BioinformaticsRockefeller UniversityNew YorkNYUSA
| | - James Riddel
- Division of Hematology/OncologyUniversity of CaliforniaSan FranciscoCAUSA
| | - Wilma Hopman
- Clinical Research CentreKingston General HospitalKingstonONCanada
| | - Victor S. Blanchette
- Department of PediatricsUniversity of TorontoTorontoONCanada
- Division of Haematology/OncologyThe Hospital for Sick ChildrenTorontoONCanada
| | - Margaret L. Rand
- Departments of Laboratory Medicine & Pathobiology, Biochemistry and PaediatricsUniversity of TorontoTorontoONCanada
- SickKids, Division of Haematology/Oncology and Translational Medicine, Research InstituteHospital for Sick ChildrenTorontoONCanada
| | - Barry S. Coller
- Allen and Frances Adler Laboratory of Blood and Vascular BiologyRockefeller UniversityNew YorkNYUSA
| | - Andrew D. Paterson
- Program in Genetics and Genome BiologyThe Hospital for Sick ChildrenTorontoONCanada
| | - Paula D. James
- Department of MedicineQueen's UniversityKingstonONCanada
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Abstract
Abnormal bleeding or bruising is a relatively common clinical concern, frequently causing parents to seek care from their children's primary care provider. Although ecchymosis from playful trauma, occasional epistaxis, and heavy menstrual bleeding around the time of menarche and beyond are common occurrences, it can be difficult for pediatricians and other primary care providers to determine if their patient has age-appropriate symptoms versus abnormal or excessive bleeding. This review discusses considerations for abnormal bleeding in pediatrics and discusses an initial approach for evaluation of hemostasis in a child with bleeding symptoms. [Pediatr Ann. 2020;49(1):e36-e42.].
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Sharma R, Haberichter SL. New advances in the diagnosis of von Willebrand disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:596-600. [PMID: 31808831 PMCID: PMC6913428 DOI: 10.1182/hematology.2019000064] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
von Willebrand disease (VWD) is the most common autosomal inherited bleeding disorder, with an estimated prevalence of 1 in 1000 individuals. VWD is classified into quantitative and qualitative forms. Diagnosis of VWD is complex and requires (1) a personal history of bleeding symptoms, (2) family history of bleeding or VWD, and (3) confirmatory laboratory testing. There are certain bleeding assessment tools to objectively measure bleeding symptoms in patients that have been shown to correlate with the diagnosis as well as the severity of VWD. Laboratory diagnosis requires at least initially a measurement of von Willebrand factor (VWF) antigen levels, VWF platelet binding activity (VWF:RCo, VWF:GPIbM, and VWF:GPIbR), and factor VIII (FVIII) activity. Additional testing to confirm the specific subtype may include VWF collagen binding activity, low-dose ristocetin VWF-platelet binding, FVIII-VWF binding, VWF multimer analysis, and VWF propeptide antigen. Recent advances have been made regarding some of these assays. Molecular testing in VWD is not found to be useful in "low VWF" or most type 1 VWD cases but may be informative in patients with severe type 1 VWD, type 1C VWD, type 2 VWD, or type 3 VWD for accurate diagnosis, genetic counseling, and appropriate treatment. The diagnostic algorithm for VWD is complex, but advances continue to be made in improving VWF functional assays and diagnostic pathways.
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Affiliation(s)
- Ruchika Sharma
- Diagnostic Laboratories and Blood Research Institute, Versiti, Milwaukee, WI
- Pediatric Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI; and
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Sandra L Haberichter
- Diagnostic Laboratories and Blood Research Institute, Versiti, Milwaukee, WI
- Pediatric Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI; and
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI
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Tang GH, Norris E, Petrucci J, James PD, Lee A, Poon MC, Floros G, Boma-Fischer L, Teitel J, Nisenbaum R, Sholzberg M. Bone health in symptomatic carriers of haemophilia A: a protocol for a multicentre prospective matched-cohort study. BMJ Open 2019; 9:e032891. [PMID: 31796490 PMCID: PMC7003383 DOI: 10.1136/bmjopen-2019-032891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Haemophilia A is an X linked inherited bleeding disorder, caused by a decrease in coagulation factor VIII. Persons with haemophilia experience repeated musculoskeletal bleeding, which can lead to decreased range of motion, irreversible joint damage, low bone mineral density (BMD), and are at greater risk for osteoporosis. Women heterozygous for this mutation, also known as haemophilia A carriers, can have bleeding symptoms and even experience joint bleeding evidenced by radiological soft tissue and osteochondral changes. The prevalence of low BMD as a risk factor for osteoporosis has never been evaluated in carriers of haemophilia, and given the recent findings which suggest subclinical musculoskeletal bleeding in carrier women, we hypothesise that they too are at risk of impaired bone health. METHODS AND ANALYSIS This is a national multicentre prospective matched-cohort study to compare BMD T-scores among symptomatic haemophilia A carriers, 50 years of age or older, with age-matched and body mass index-matched non-carriers (1:1). A total of 40 symptomatic carriers and 40 matched non-carriers will be recruited from St. Michael's Hospital, Kingston General Hospital in Ontario, Canada and Foothills Medical Centre in Alberta, Canada. Multivariable linear regression models will be used to estimate the effect of haemophilia carriership on BMD T-scores, adjusting for age, body mass index and other relevant covariates. ETHICS AND DISSEMINATION The protocol was designed and will be conducted in compliance with applicable laws, rules and regulations. Research ethics approval was obtained from St. Michael's Hospital, Foothills Medical Centre, and Kingston General Hospital. Findings will be presented at international venues such as the American Society of Haematology and the World Federation of Haemophilia World Congress. The authors of this study will seek publication in journals such as Blood, Journal of Thrombosis and Haemostasis, American Journal ofHematology and British Journal ofHaematology.
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Affiliation(s)
- Grace H Tang
- Hematology/Oncology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Erin Norris
- Rheumatology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Jessica Petrucci
- Hematology/Oncology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Paula D James
- Hematology, Kingston General Hospital, Kingston, Ontario, Canada
| | - Adrienne Lee
- Hematology, University of Calgary, Calgary, Alberta, Canada
| | - Man-Chiu Poon
- Hematology, University of Calgary, Calgary, Alberta, Canada
| | - Georgina Floros
- Hematology/Oncology, St. Michael's Hospital, Toronto, Ontario, Canada
| | | | - Jerry Teitel
- Hematology/Oncology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Rosane Nisenbaum
- Applied Health Research Centre, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Punt MC, Blaauwgeers MW, Timmer MA, Welsing PMJ, Schutgens REG, van Galen KPM. Reliability and Feasibility of the Self-Administered ISTH-Bleeding Assessment Tool. TH OPEN 2019; 3:e350-e355. [PMID: 31799494 PMCID: PMC6884422 DOI: 10.1055/s-0039-3400483] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/11/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction
Standardized bleeding assessment tools (BATs), such as the International Society for Thrombosis and Hemostasis (ISTH)-BAT, are screening instruments used during the diagnostic workup of suspected bleeding disorders. A self-administered ISTH-BAT (self-BAT) would enhance screening and save time during an outpatient clinic visit.
Aim
This study was aimed to investigate the reliability and feasibility of the self-BAT.
Methods
The electronic self-BAT was created from the ISTH-BAT and paper-version of self-BAT and optimized by patients and physicians. Patients with a (suspected) congenital platelet defect (CPD), who had previously undergone physician-administered ISTH-BAT assessment, were invited to complete the self-BAT. Optimal self-BAT cut-off values to detect a bleeding tendency, as defined by the ISTH-BAT, were evaluated by receiver operator characteristic (ROC) curve analysis to reach a sensitivity ≥95%. Reliability was tested by assessing sensitivity, specificity, and intraclass correlation (ICC). Feasibility was evaluated on comprehension and length of self-BAT.
Results
Both versions of the BAT were completed by 156 patients. Optimal cut-off values for self-BAT to define a bleeding tendency were found to be identical to those of the ISTH-BAT. Normal/abnormal scores of the ISTH-BAT and self-BAT were agreed in 88.5% (138/156, 95% confidence interval [CI]: 0.83–0.93) of patients. The sensitivity and specificity of the self-BAT to detect a bleeding tendency were 96.9 and 48.1%, respectively. The ICC was 0.73. Self-BAT questions were graded by 96.8% (151/156) as “very easy,” “easy,” and “satisfactory” and questionnaire length as “exactly right” by 91% (142/156) of patients.
Conclusion
In patients with a (suspected) CPD, the self-BAT is sufficiently reliable and feasible to detect a bleeding tendency, which supports its use as a screening tool.
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Affiliation(s)
- Marieke C Punt
- Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Maaike W Blaauwgeers
- Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Merel A Timmer
- Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Paco M J Welsing
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Roger E G Schutgens
- Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Karin P M van Galen
- Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
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42
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Berger J, Schwartz J, Ramachandran S, Leff JD. Review of von Willebrand Disease and Acquired von Willebrand Syndrome for Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:3446-3457. [PMID: 31570241 DOI: 10.1053/j.jvca.2019.08.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 08/10/2019] [Accepted: 08/17/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Jay Berger
- Department of Anesthesiology, Montefiore Hospital and Medical Center, Bronx, NY.
| | - Joseph Schwartz
- Department of Anesthesiology, Montefiore Hospital and Medical Center, Bronx, NY
| | | | - Jonathan D Leff
- Department of Anesthesiology, Montefiore Hospital and Medical Center, Bronx, NY
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Winikoff R, Scully MF, Robinson KS. Women and inherited bleeding disorders - A review with a focus on key challenges for 2019. Transfus Apher Sci 2019; 58:613-622. [PMID: 31582329 DOI: 10.1016/j.transci.2019.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The area of women and inherited bleeding disorders has undergone quick expansion in recent years. More patients are being identified and expertise to diagnose and manage these patients is now essential for practising physicians. Programs to help educate and empower patients and caregivers are now in place. Common inherited bleeding disorders affecting women include von Willebrand disease (VWD), inherited platelet disorders, and rare inherited bleeding disorders such as factor VII (FVII) deficiency and factor XI (FXI) deficiency. Specific clinical tools have been developed to help clinicians and patients screen for the presence of these bleeding disorders in both adult and pediatric populations. Affected women can experience heavy menstrual bleeding and resulting iron deficiency anemia, postpartum hemorrhage, and hemorrhagic ovarian cysts which need to be properly managed. Excessive bleeding can adversely affect quality of life in these women. Front line therapy for bleeding in mild cases focuses on the use of non-specific hemostatic agents such as DDAVP ®, tranexamic acid and hormonal agents but specific factor replacement and/or blood products may be required in more severe cases, in severe bleeding or as second line treatment when bleeding is not responsive to first line agents. Iron status should be optimised in these women especially in pregnancy and use of an electronic app can now help clinicians achieve this. These patients should ideally be managed by a multidisciplinary team whenever possible even remotely. Although clinical research has closed some knowledge gaps regarding the diagnosis and management of these women, there remains significant variation in practise and lack of evidence-based guidelines still exists in many spheres of clinical care in which caregivers must rely on expert opinion. Ongoing efforts in education and research will continue to improve care for these women and restore quality of life for them.
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Affiliation(s)
- R Winikoff
- Division of Hematology-Oncology, Sainte-Justine University Hospital Center, Montréal, QC, Canada
| | - M F Scully
- Department of Medicine, Memorial University of Newfoundland Medical School, NL, Canada.
| | - K S Robinson
- Division of Hematology, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Department of Medicine, Halifax, NS, Canada.
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44
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Gooijer K, Rondeel JMM, van Dijk FS, Harsevoort AGJ, Janus GJM, Franken AAM. Bleeding and bruising in Osteogenesis Imperfecta: International Society on Thrombosis and Haemostasis bleeding assessment tool and haemostasis laboratory assessment in 22 individuals. Br J Haematol 2019; 187:509-517. [PMID: 31304589 DOI: 10.1111/bjh.16097] [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: 03/13/2019] [Accepted: 05/21/2019] [Indexed: 11/29/2022]
Abstract
Osteogenesis imperfecta (OI) is characterized by susceptibility to bone fractures. Other symptoms, such as easy bruising and bleeding complications during surgery necessitating transfusions, have also been reported. The aim of the cross-sectional pilot study was to assess the bleeding and bruising tendency in OI patients and to screen for possible underlying haematological disorders. Bleeding tendency was investigated using the International Society on Thrombosis and Haemostasis bleeding assessment tool (ISTH-BAT) in 22 adult OI patients. Laboratory testing was performed to investigate for bleeding disorders or abnormal coagulation. Four patients [OI type 1(n = 3), OI type 4(n = 1)] had a bleeding score (BS) fitting with a bleeding tendency, but without test results pointing to a coagulopathy. Two patients [OI type 1(n = 1), OI type 3 (n = 1)] without a bleeding tendency according to the BS had increased fibrinolysis. This is the second largest study to date addressing bleeding tendency in OI and the first study to use ISTH-BAT and elaborate laboratory testing for coagulopathies. Four patients had an increased bleeding tendency. However, laboratory testing demonstrated no bleeding disorder or abnormal coagulation. Increased fibrinolysis was demonstrated in two patients without bleeding tendency on BS. Vascular fragility as a cause of bleeding tendency in OI has been suggested earlier. Further research on bleeding tendency in OI is important.
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Affiliation(s)
- Koert Gooijer
- Expert Centre for adults with Osteogenesis Imperfecta, Isala Hospital, Zwolle, The Netherlands
| | - Jan M M Rondeel
- Department of Clinical Chemistry, Isala Hospital, Zwolle, The Netherlands
| | - Fleur S van Dijk
- Expert Centre for adults with Osteogenesis Imperfecta, Isala Hospital, Zwolle, The Netherlands.,North West Thames Regional Genetics Service, Ehlers-Danlos Syndrome National Diagnostic Service London, North West Health Care University NHS Trust, Harrow, Middlesex, UK
| | - Arjan G J Harsevoort
- Expert Centre for adults with Osteogenesis Imperfecta, Isala Hospital, Zwolle, The Netherlands
| | - Guus J M Janus
- Expert Centre for adults with Osteogenesis Imperfecta, Isala Hospital, Zwolle, The Netherlands
| | - Anton A M Franken
- Expert Centre for adults with Osteogenesis Imperfecta, Isala Hospital, Zwolle, The Netherlands
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Bui J, Martyres D, James PD, Grabell J, Wu J, Steele M, Silva M, Rand ML, Blanchette VS, Barrowman N, Klaassen RJ. Validation of the school age self-administered pediatric bleeding questionnaire (Self-PBQ) in children aged 8-12 years. Pediatr Blood Cancer 2019; 66:e27709. [PMID: 30900820 PMCID: PMC7643750 DOI: 10.1002/pbc.27709] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 02/05/2019] [Accepted: 02/21/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND In the pediatric population, pathologic bleeding is often challenging to identify. The pediatric bleeding questionnaire (PBQ) was developed as a screening tool for von Willebrand disease (VWD) but was designed to be self-completed by children above 12 years of age. The study objective was to determine whether a modified Self-PBQ could be completed by 8- to 12-year-old children with adult assistance. PROCEDURE The initial phase involved seven children who underwent cognitive debriefing to identify problems in the questionnaire, resulting in modifications to wording and response options. In phase 2, children completed the modified Self-PBQ independently or with assistance from their parent at five Canadian treatment centers. Parents filled out the Self-PBQ separately to serve as a comparison. Bleeding scores derived from the child self-report were compared to those of the parent proxy. RESULTS Twenty-nine out of 31 patient/parent pairs successfully completed the Self-PBQ. Child and parent scores demonstrated a high level of agreement with an intraclass correlation (ICC) of 0.825. In the age subgroup analysis, the ICC was 0.834 and 0.824 for the 8- to 9-year-old and 10- to 12-year-old groups, respectively. The ICC was also determined in children with type 1 VWD (ICC = 0.829) versus those with more severe bleeding disorders (ICC = 0.802). Thus, age and disease severity had no significant effect on degree of agreement. CONCLUSIONS Our study shows that agreement was maintained even in younger children aged 8-9 years and in children with varying bleeding phenotypes. This supports the administration of the modified Self-PBQ to 8- to 12-year-old children.
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Affiliation(s)
- Jessica Bui
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | | | - Paula D. James
- Department of Medicine, Queen’s University, Kingston, Canada
| | | | - John Wu
- Division of Hematology/Oncology, British Columbia Children’s Hospital, Vancouver, Canada
| | - MacGregor Steele
- Section of Pediatric Hematology, Alberta Children’s Hospital, Calgary, Canada
| | | | - Margaret L. Rand
- Division of Hematology/Oncology and Translational Medicine, The Hospital for Sick Children; Departments of Laboratory Medicine & Pathobiology, Biochemistry, and Pediatrics, University of Toronto, Toronto, Canada
| | - Victor S. Blanchette
- Division of Hematology/Oncology, Department of Pediatrics, University of Toronto, Hospital for Sick Children, Toronto, Canada
| | - Nick Barrowman
- Department of Pediatrics, University of Ottawa, Ottawa, Canada
| | - Robert J. Klaassen
- Department of Pediatrics, Division of Hematology/Oncology, Children’s Hospital of Eastern Ontario, Ottawa, Canada
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Gillissen A, van den Akker T, Caram-Deelder C, Henriquez DDCA, Nij Bijvank SWA, Bloemenkamp KWM, Eikenboom J, van der Bom JG. Predictive value of a bleeding score for postpartum hemorrhage. Res Pract Thromb Haemost 2019; 3:277-284. [PMID: 31011712 PMCID: PMC6462748 DOI: 10.1002/rth2.12194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/01/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND A reliable screening tool that could contribute to the identification of women with an increased risk of postpartum hemorrhage would be of great clinical significance. OBJECTIVES The aim of this study was to examine the added predictive value of a bleeding assessment tool for postpartum hemorrhage exceeding 1000 mL. PATIENTS/METHODS Prospective two-center cohort study among 1147 pregnant women visiting the outpatient clinic or the maternity ward who completed a bleeding assessment tool prior to birth. The condensed MCMDM-1VWD bleeding assessment tool was adjusted to a questionnaire that could be used as a self-assessment bleeding tool. A score of ≥4 was considered to be abnormal. RESULTS In the 1147 pregnant women in our cohort, bleeding scores ranged from -3 to 13, with a median of 1 (IQR -1 to 3); 197 (17%) women developed postpartum hemorrhage. Among women with a history of postpartum hemorrhage 29% developed postpartum hemorrhage. Among 147 women with an abnormal bleeding score (≥4), 27 (18%) developed postpartum hemorrhage, whereas the remaining 170 cases of postpartum hemorrhage had a normal bleeding score. Despite the high incidence of postpartum hemorrhage, the ability of the bleeding score to predict postpartum hemorrhage was poor: area under receiver operating curve 0.53 (95% CI 0.49-0.58) for postpartum hemorrhage (PPH) ≥1000 mL. CONCLUSIONS A history of significant postpartum hemorrhage was associated with an increased risk of subsequent postpartum hemorrhage. However, screening with a bleeding assessment tool did not help to discriminate women who will develop postpartum hemorrhage from women who will not.
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Affiliation(s)
- Ada Gillissen
- Centre for Clinical Transfusion Research Sanquin Research Leiden The Netherlands
- Department of Clinical Epidemiology Leiden University Medical Centre Leiden The Netherlands
- Department of Obstetrics Leiden University Medical Centre Leiden The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics Leiden University Medical Centre Leiden The Netherlands
- National Perinatal Epidemiology Unit University of Oxford Oxford United Kingdom
| | - Camila Caram-Deelder
- Centre for Clinical Transfusion Research Sanquin Research Leiden The Netherlands
- Department of Clinical Epidemiology Leiden University Medical Centre Leiden The Netherlands
| | - Dacia D C A Henriquez
- Centre for Clinical Transfusion Research Sanquin Research Leiden The Netherlands
- Department of Clinical Epidemiology Leiden University Medical Centre Leiden The Netherlands
- Department of Obstetrics Leiden University Medical Centre Leiden The Netherlands
| | | | - Kitty W M Bloemenkamp
- Department of Obstetrics Birth Centre Wilhelmina's Children Hospital University Medical Centre Utrecht Utrecht The Netherlands
| | - Jeroen Eikenboom
- Department of Internal Medicine Division of Thrombosis and Hemostasis Leiden University Medical Centre Leiden The Netherlands
| | - Johanna G van der Bom
- Centre for Clinical Transfusion Research Sanquin Research Leiden The Netherlands
- Department of Clinical Epidemiology Leiden University Medical Centre Leiden The Netherlands
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47
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Bleeding by the numbers: The utility and the limitations of bleeding scores, bleeding prediction tools, and bleeding case definitions. Transfus Apher Sci 2018; 57:458-462. [DOI: 10.1016/j.transci.2018.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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48
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Rao ES, Ng CJ. Current approaches to diagnostic testing in von Willebrand Disease. Transfus Apher Sci 2018; 57:463-465. [DOI: 10.1016/j.transci.2018.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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49
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Moenen FCJI, Nelemans PJ, Schols SEM, Schouten HC, Henskens YMC, Beckers EAM. The diagnostic accuracy of bleeding assessment tools for the identification of patients with mild bleeding disorders: A systematic review. Haemophilia 2018; 24:525-535. [DOI: 10.1111/hae.13486] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2018] [Indexed: 11/27/2022]
Affiliation(s)
- F. C. J. I. Moenen
- Department of Haematology, Internal Medicine; Maastricht University Medical Centre+; Maastricht The Netherlands
| | - P. J. Nelemans
- Department of Epidemiology; Maastricht University; Maastricht The Netherlands
| | - S. E. M. Schols
- Department of Haematology, Internal Medicine; Radboud University Medical Centre; Nijmegen The Netherlands
| | - H. C. Schouten
- Department of Haematology, Internal Medicine; Maastricht University Medical Centre+; Maastricht The Netherlands
| | - Y. M. C. Henskens
- Central Diagnostic Laboratory, Unit for Haemostasis and Transfusion; Maastricht University Medical Centre+; Maastricht The Netherlands
| | - E. A. M. Beckers
- Department of Haematology, Internal Medicine; Maastricht University Medical Centre+; Maastricht The Netherlands
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Pathare A, Al Hajri F, Al Omrani S, Al Obaidani N, Al Balushi B, Al Falahi K. Bleeding score in type 1 von Willebrand disease patients using the condensed MCMDM-1 vWD validated questionnaire. Int J Lab Hematol 2018; 40:515-520. [PMID: 29754468 DOI: 10.1111/ijlh.12850] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/08/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Assessment of the severity of bleeding symptom has led to the evolution of bleeding assessment tools which are now validated. AIMS To administer the condensed molecular and clinical markers for the diagnosis and management of type 1 von Willebrand disease VWD (MCMDM-1 vWD) questionnaire to the Omani type 1 vWD patients and correlate it with the laboratory parameters. METHODS Patients and controls were personally interviewed and the condensed MCMDM-1 vWD questionnaire administered by a single investigator. Bleeding score (BS) was calculated, based on the presence or absence of the bleeding symptoms according to a standard validated questionnaire in both the patients and the controls. RESULTS The median age of the patient cohort was 27 (range, 7-49) years with 60.87% of females. The median time to administer condensed MCMDM-1 BS questionnaire was 11 minutes (interquartile range-IQR;7,16). Overall, bleeding from the oral cavity was the most predominant symptom (63%). The median BS was 5 (IQR;1,8) although individual scores ranged between 0 and 29. However, there was no statistically significant difference in BS between genders (males: median 4; IQR 1,6 and females: median 5, IQR 1,10) (P > .05, Kruskal-Wallis test) The Spearman's correlation value of BS was weak with FVIII:C levels and von Willebrand Ristocetin co-factor activity; very weak with von Willebrand Antigen level, and moderate with vonWillebrand Collagen Binding activity being -0.29, -0.28, -0.14 and -0.43, respectively. CONCLUSION The BS reflects the severity of bleeding among the vWD patients. Although the BS was abnormal, it did not correlate significantly with the surrogate laboratory parameters [P > .05].
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Affiliation(s)
- A Pathare
- Sultan Qaboos University Hospital, Muscat, Oman
| | - F Al Hajri
- College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - S Al Omrani
- College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
| | | | | | - K Al Falahi
- Sultan Qaboos University Hospital, Muscat, Oman
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