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Alito A, Bellone F, Portaro S, Leonardi G, Cannavò V, Coppini F, Leonetti D, Catalano A, Squadrito G, Fenga D. Haemophilia and Fragility Fractures: From Pathogenesis to Multidisciplinary Approach. Int J Mol Sci 2023; 24:ijms24119395. [PMID: 37298347 DOI: 10.3390/ijms24119395] [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: 04/21/2023] [Revised: 05/13/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
Haemophilia A (HA) and haemophilia B (HB) are X-linked inherited bleeding disorders caused by the absence or deficiency of coagulation factors VIII (FVIII) and IX (FIX), respectively. Recent advances in the development of effective treatments for haemophilia have led to a significant increase in life expectancy. As a result, the incidence of some comorbidities, including fragility fractures, has increased in people with haemophilia (PWH). The aim of our research was to perform a review of the literature investigating the pathogenesis and multidisciplinary management of fractures in PWH. The PubMed, Scopus and Cochrane Library databases were searched to identify original research articles, meta-analyses, and scientific reviews on fragility fractures in PWH. The mechanism underlying bone loss in PWH is multifactorial and includes recurrent joint bleeding, reduced physical activity with consequent reduction in mechanical load, nutritional deficiencies (particularly vitamin D), and FVIII and FIX deficiency. Pharmacological treatment of fractures in PWH includes antiresorptive, anabolic and dual action drugs. When conservative management is not possible, surgery is the preferred option, particularly in severe arthropathy, and rehabilitation is a key component in restoring function and maintaining mobility. Appropriate multidisciplinary fracture management and an adapted and tailored rehabilitation pathway are essential to improve the quality of life of PWH and prevent long-term complications. Further clinical trials are needed to improve the management of fractures in PWH.
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Affiliation(s)
- Angelo Alito
- Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, 98100 Messina, Italy
| | - Federica Bellone
- Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria, 1, 98100 Messina, Italy
| | - Simona Portaro
- Department of Physical and Rehabilitation Medicine, University Hospital "G. Martino", 98100 Messina, Italy
| | - Giulia Leonardi
- Department of Physical and Rehabilitation Medicine, University Hospital "G. Martino", 98100 Messina, Italy
| | - Vittorio Cannavò
- Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria, 1, 98100 Messina, Italy
| | - Francesca Coppini
- Department of Orthopaedics and Traumatology, University Hospital A.O.U. "G. Martino", 98100 Messina, Italy
| | - Danilo Leonetti
- Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, 98100 Messina, Italy
| | - Antonino Catalano
- Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria, 1, 98100 Messina, Italy
| | - Giovanni Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria, 1, 98100 Messina, Italy
| | - Domenico Fenga
- Department of Orthopaedics and Traumatology, University Hospital A.O.U. "G. Martino", 98100 Messina, Italy
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Pai YY, Wang JD, Ho HE, Chou YJ, Ho WC, Chan WC, Chu WM, Tsan YT. Risk of Fractures, Repeated Fractures and Osteoporotic Fractures among Patients with Hemophilia in Taiwan: A 14-Year Population-Based Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:ijerph20010525. [PMID: 36612847 PMCID: PMC9819339 DOI: 10.3390/ijerph20010525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/22/2022] [Accepted: 12/25/2022] [Indexed: 06/12/2023]
Abstract
The world is aging, and hemophilia patients are as well. The association between patients with hemophilia (PWH) and low bone mineral density is clear. However, the incidence of fractures in patients with hemophilia is inconclusive, and no research has yet explored repeated fractures among PWH. In this study, we investigated the incidence of all-site fractures, repeated fractures and osteoporotic fractures amongst PWH. The study compared the incidence of all-site fractures, repeated fractures and osteoporotic fractures occurring in all PWH who were enrolled in Taiwan's National Health Insurance Research Database between 1997 and 2013 with an age- and gender-matched group from the general population. Eight-hundred thirty-two PWH, along with 8320 members of the general population, were included in the final analysis. After multivariate COX regression analysis with an adjustment for confounding factors, it was found that PWH experienced a higher risk of osteoporotic fracture (HR: 1.25 with 95% CI of 1.03-2.52) but only saw a neutral effect with regards to both all-sites of fracture (HR: 1.00 with 95% CI of 0.92-1.09) and repeated fractures (HR: 1.01 with 95% CI of 0.92-1.10), when compared with the general population. This 14-year population-based cohort study showed that PWH had a higher risk of osteoporotic fracture, but that hemophilia only had a neutral effect in all-sites of fracture and repeated fractures. Screening, prevention and treatment for osteoporosis and further osteoporotic fractures among PWH, in order to improve quality of life and achieve healthy aging in this particular population, remain essential.
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Affiliation(s)
- Yuan-Yi Pai
- Department of Family Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- Division of Occupational Medicine, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Jiaan-Der Wang
- Center for Rare Disease and Hemophilia, Department of Pediatrics, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Hsin-En Ho
- Department of Family Medicine, Taichung Armed Force General Hospital, Taichung 411228, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- School of Medicine, National Defense Medical Center, Taipei 11490, Taiwan
| | - Yi-Jung Chou
- Division of Insurance Services, National Defense Medical Center, Taipei 11490, Taiwan
| | - Wen-Chao Ho
- Department of Public Health, China Medical University, Taichung 406040, Taiwan
| | - Wei-Cheng Chan
- Division of Occupational Medicine, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Wei-Min Chu
- Department of Family Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 40227, Taiwan
- Education and Innovation Center for Geriatrics and Gerontology, National Center for Geriatrics and Gerontology, Moriokamachi 474-8511, Japan
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
| | - Yu-Tse Tsan
- Division of Occupational Medicine, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
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Czajkowska S, Rupa-Matysek J, Wojtasińska E, Nijakowski K, Surdacka A, Gil L. The Profile of Markers of Bone Turnover, Inflammation and Extracellular Neutrophil Traps on Bone Mass in Haemophilia and the Development of Haemophilic Arthropathy. J Clin Med 2022; 11:jcm11164711. [PMID: 36012950 PMCID: PMC9410524 DOI: 10.3390/jcm11164711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/03/2022] [Accepted: 08/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The aim of the study is to evaluate selected biomarkers of bone turnover, inflammation, neutrophil trap and factors predisposing haemophiliacs to bone loss, and to analyse their relationship with clinical features, treatment and complications. Methods: The levels of interleukin 6 (IL-6); citrullinated histone (CH3); osteocalcin (BGLAP); bone alkaline phosphatase (BALP); N-terminal procollagen type I propeptide (P1NP); and C-terminal collagen type I telopeptide (C1CP) were examined in 60 patients with haemophilia. Results: The cut-off value for BGLAP is 26.41 ng/mL, and 929.7 pg/mL for CH3. There is a statistically significant difference between BGLAP, BALP, C1CP and CH3 concentrations, depending on the prophylaxis used. The median concentration of BGLAP in patients taking the factor on demand is 28.0 ng/mL, BALP 322.5 U/L, C1CP 191.2 ng/mL and CH3 1114.4 pg/mL. In patients taking recombinant coagulation factor VIII/IX as prophylaxis of bleeding, the median BGLAP concentrations are 35.9 ng/mL, BALP 280.9 U/L, C1CP 161.6 ng/mL and CH3 952.5 pg/mL. BGLAP and BALP concentrations are dependent on the development of haemophilic arthropathic. Conclusions: The concentrations of selected markers of bone turnover and NETs may help to identify patients at particular risk of developing haemophilic arthropathy and bone metabolic turnover abnormalities.
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Affiliation(s)
- Sylwia Czajkowska
- Department of Conservative Dentistry and Endodontics, Poznan University of Medical Sciences, 60-812 Poznan, Poland
- Correspondence:
| | - Joanna Rupa-Matysek
- Department of Haematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, 60-569 Poznan, Poland
| | - Ewelina Wojtasińska
- Department of Haematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, 60-569 Poznan, Poland
| | - Kacper Nijakowski
- Department of Conservative Dentistry and Endodontics, Poznan University of Medical Sciences, 60-812 Poznan, Poland
| | - Anna Surdacka
- Department of Conservative Dentistry and Endodontics, Poznan University of Medical Sciences, 60-812 Poznan, Poland
| | - Lidia Gil
- Department of Haematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, 60-569 Poznan, Poland
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Petkovic MJ, Tran HA, Ebeling PR, Zengin A. Osteoporosis management and falls prevention in patients with haemophilia: Review of haemophilia guidelines. Haemophilia 2022; 28:388-396. [PMID: 35290707 PMCID: PMC9310867 DOI: 10.1111/hae.14540] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 02/21/2022] [Accepted: 02/25/2022] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Patients with haemophilia (PWH) have a high prevalence of osteoporosis, falls and fractures at all ages. The role of haemophilia itself may contribute to low bone mineral density (BMD) due to coagulation factor deficiency. Guidelines for the management of osteoporosis, fracture and fall risk may help to reduce fracture and fall risk, and delay osteoporosis onset. AIM We aim to review current haemophilia guidelines regarding osteoporosis prevention, screening, diagnosis and management, and fall prevention. METHOD A database search (Ovid MEDLINE) revealed two haemophilia guidelines (World and British) published within the last ten years. Local Australian haemophilia guidelines were identified through a manual search. RESULTS All haemophilia guidelines were found to contain inadequate recommendations for osteoporosis management and fall prevention due to a lack of evidence in the literature. CONCLUSION Further studies are required to assess the trajectory of bone health in PWH, the mechanism of bone loss in PWH, and the effectiveness of weight-bearing exercises, interventions for fall prevention, screening programmes, and use of anti-osteoporosis medications in PWH across the lifecourse.
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Affiliation(s)
- Madison J Petkovic
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Huyen A Tran
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia.,Clinical Haematology Department, Alfred Hospital, Thrombosis & Haemostasis Unit, Melbourne, Australia
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Ayse Zengin
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
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Kempton CL, Makris M, Holme PA. Management of comorbidities in haemophilia. Haemophilia 2020; 27 Suppl 3:37-45. [PMID: 32476243 DOI: 10.1111/hae.14013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/07/2020] [Indexed: 02/06/2023]
Abstract
With the introduction of clotting factor concentrates in the early 1970s, significant improvements in quality of life and life expectancy of persons with haemophilia (PWH) were realized. Unfortunately, as a result of transmission of HIV and hepatitis C virus (HCV) by contaminated concentrates in the 1980s, many of these gains were lost. Now with four decades of PWH unexposed to contaminated factor products and current treatments capable of suppressing and eliminating HIV and HCV, respectively, the survival rate is once again increasing. In addition to the usual comorbidities associated with advanced age in the general population, several specific issues occur in patients with bleeding disorders. This manuscript explores the incidence and management of the comorbidities of the ageing PWH with a focus on cardiovascular disease and osteoporosis.
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Affiliation(s)
- Christine L Kempton
- Department of Hematology and Medical Oncology and Hemophilia of Georgia Center for Bleeding & Clotting Disorders of Emory, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael Makris
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - Pål Andre Holme
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Tuan SH, Hu LY, Sun SF, Huang WY, Chen GB, Li MH, Liou IH. Risk of osteoporotic fractures as a consequence of haemophilia: A nationwide population-based cohort study. Haemophilia 2019; 25:876-884. [PMID: 31282066 DOI: 10.1111/hae.13814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 06/04/2019] [Accepted: 06/10/2019] [Indexed: 01/07/2023]
Abstract
AIM Low bone mineral density occurs more commonly in patients with haemophilia (PWH) than the general population. However, the risk of haemophilia-related osteoporotic fractures has not been well established. We aim to explore the relationship between haemophilia and the development of osteoporotic fractures following haemophilia. METHODS This was a nationwide population-based cohort study based on the data in the Taiwan National Health Insurance Research Database (TNHIRD). Patients who were diagnosed with haemophilia were selected. A comparison cohort was formed of patients without haemophilia who were matched according to age and sex. The incidence rate and the hazard ratios (HRs) of new-onset osteoporotic fractures were calculated for both cohorts. RESULTS The haemophilia cohort consisted of 75 patients, and the comparison cohort comprised 300 matched control patients without haemophilia. The risk of osteoporotic fractures was higher in the haemophilia cohort than in the comparison cohort (HR = 5.41, 95% confidence interval [CI] = 2.42-12.1, P < 0.001). After adjustments for age, sex, comorbidities, urbanizations and socio-economic status, PWH were 4.37 times more likely to develop osteoporotic fractures (95% CI = 1.88-10.17, P = 0.001) as compared to matched cohort. In addition, the incidence of newly diagnosed osteoporotic fractures was significantly increased after 5-year follow-up durations. CONCLUSION Though our study by TNHIRD presented methodologic flaws by its design nature, we observed that haemophilia may increase the risk of osteoporotic fractures and the cumulative incidence was significantly higher for PWH diagnosed more than 5 years. Clinicians should pay particular attention to osteoporotic fractures following haemophilia in PWH as they age.
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Affiliation(s)
- Sheng-Hui Tuan
- Department of Rehabilitation Medicine, Cishan Hospital, Ministry of Health and Welfare, Kaohsiung, Taiwan
| | - Li-Yu Hu
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shu-Fen Sun
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Physical Medicine and Rehabilitation, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wan-Yun Huang
- Department of Physical Medicine and Rehabilitation, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Institute of Allied Health Sciences, National Cheng Kung University, Tainan, Taiwan
| | - Guan-Bo Chen
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - Min-Hui Li
- Department of Physical Medicine and Rehabilitation, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - I-Hsiu Liou
- Department of Physical Medicine and Rehabilitation, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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Ulivieri FM, Rebagliati GAA, Piodi LP, Solimeno LP, Pasta G, Boccalandro E, Fasulo MR, Mancuso ME, Santagostino E. Usefulness of bone microarchitectural and geometric DXA-derived parameters in haemophilic patients. Haemophilia 2018; 24:980-987. [DOI: 10.1111/hae.13611] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/01/2018] [Accepted: 08/26/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Fabio Massimo Ulivieri
- Nuclear Medicine, Bone Metabolic Unit; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; Milano Italy
| | | | - Luca Petruccio Piodi
- Former: Gastroenterology and Endoscopy Unit; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; Milano Italy
| | - Luigi Piero Solimeno
- Ortopedic and Traumatology Unit; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; Milano Italy
| | - Gianluigi Pasta
- Orthopedics and Traumatology Clinic; IRCCS Fondazione San Matteo; Pavia Italy
| | - Elena Boccalandro
- Ortopedic and Traumatology Unit; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; Milano Italy
| | - Maria Rosaria Fasulo
- Former: Angelo Bianchi Bonomi Haemophilia and Thrombosis Center; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; Milano Italy
| | - Maria Elisa Mancuso
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Center; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; Milano Italy
| | - Elena Santagostino
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Center; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; Milano Italy
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Anagnostis P, Vakalopoulou S, Christoulas D, Paschou SA, Papatheodorou A, Garipidou V, Kokkoris P, Terpos E. The role of sclerostin/dickkopf-1 and receptor activator of nuclear factor kB ligand/osteoprotegerin signalling pathways in the development of osteoporosis in patients with haemophilia A and B: A cross-sectional study. Haemophilia 2017; 24:316-322. [PMID: 29194852 DOI: 10.1111/hae.13384] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2017] [Indexed: 12/19/2022]
Abstract
AIM Haemophilia A and B are associated with reduced bone mineral density (BMD). The aim of this study was to assess circulating sclerostin and dickkopf-1 (Dkk-1), (inhibitors of osteoblastic differentiation), as well as the receptor activator of nuclear factor kB ligand (RANKL)/osteoprotegerin (OPG) system (the major regulator of osteoclastogenesis), in patients with haemophilia (PWH), their possible correlations with clinical risk factors and the effect of ibandronate on these markers. METHODS Eighty-nine male PWH (mean age 45.9 ± 15.3 years) and 30 age-matched healthy male controls participated. BMD was assessed by DXA. Sclerostin, Dkk-1, RANKL and OPG were measured in serum of patients, controls, as well as in ten patients receiving oral ibandronate (150 mg/mo), at baseline and after 12 months. RESULTS Patients with haemophilia had lower circulating sclerostin (median ± IQR: 47.4 ± 26.93 vs 250 ± 250 pmol/L, P < .001), Dkk-1 (21.24 ± 17.18 vs 26.16 ± 15.32pg/mL, P = .04) and higher levels of RANKL (0.23 ± 0.03 vs 0.04 ± 0.03 pmol/L, P = .001), RANKL/OPG ratio (0.063 ± 0.25 vs 0.005 ± 0.11, P = .001) compared with controls. Patients with low BMD had higher OPG concentrations compared to those with normal BMD. Sclerostin and RANKL/OPG correlated positively with BMD. Patients with severe haemophilia had lower sclerostin concentrations compared with those with mild or moderate disease. The degree of arthropathy negatively correlated with sclerostin and Dkk-1 levels. PWH who received ibandronate showed a decrease in serum Dkk-1 without any significant effect on sclerostin and RANKL/OPG. CONCLUSIONS Patients with haemophilia present increased osteoclastic activity coupled with compensatory increased osteoblastic activity. Ibandronate did not affect RANKL/OPG ratio, but it decreased Dkk-1.
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Affiliation(s)
- P Anagnostis
- Haemophilia Centre of Northern Greece, 2nd Propedeutic Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - S Vakalopoulou
- Haemophilia Centre of Northern Greece, 2nd Propedeutic Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - D Christoulas
- Department of Haematology, 251 General Air Force Hospital, Athens, Greece
| | - S A Paschou
- Division of Endocrinology and Diabetes, "Aghia Sophia" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - A Papatheodorou
- Department of Haematology, 251 General Air Force Hospital, Athens, Greece
| | - V Garipidou
- Haemophilia Centre of Northern Greece, 2nd Propedeutic Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - P Kokkoris
- Department of Endocrinology, 251 General Air Force Hospital, Athens, Greece
| | - E Terpos
- Department of Clinical Therapeutics, School of Medicine, Alexandra General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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