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Théron A, Maumus M, Biron-Andreani C, Sirvent N, Jorgensen C, Noël D. What is the rationale for mesenchymal stromal cells based therapies in the management of hemophilic arthropathies? Osteoarthritis Cartilage 2024; 32:634-642. [PMID: 38160743 DOI: 10.1016/j.joca.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/21/2023] [Accepted: 12/07/2023] [Indexed: 01/03/2024]
Abstract
Hemophilia A and B are rare X-linked genetic bleeding disorders due to a complete or partial deficiency in the coagulation factors VIII or IX, respectively. The main treatment for hemophilia is prophylactic and based on coagulation factor replacement therapies. These treatments have significantly reduced bleeding and improved the patients' quality of life. Nevertheless, repeated joint bleedings (hemarthroses), even subclinical hemarthroses, can lead to hemophilic arthropathy (HA). This disabling condition is characterized by chronic pain due to synovial inflammation, cartilage and bone destruction requiring ultimately joint replacement. HA resembles to rheumatoid arthritis because of synovitis but HA is considered as having similarities with osteoarthritis as illustrated by the migration of immune cells, production of inflammatory cytokines, synovial hypertrophy and cartilage damage. Various drugs have been evaluated for the management of HA with limited success. The objective of the review is to discuss new therapeutic approaches with a special focus on the studies that have investigated the potential of using mesenchymal stromal cells (MSCs) in the management of HA. A systematic review of the literature has been made. Most of the studies have focused on the interest of MSCs for the delivery of missing factors VIII or IX but in some studies, more insight on the effect of MSC injection on synovial inflammation or cartilage structure were provided and put in perspective for possible clinical applications.
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Affiliation(s)
- Alexandre Théron
- IRMB, University of Montpellier, INSERM, Montpellier, France; Resources and Competence Center for Hereditary Hemorrhagic Diseases, CHU Montpellier, Montpellier, France; Department of Pediatric Oncology and Hematology, CHU Montpellier, Montpellier, France
| | - Marie Maumus
- IRMB, University of Montpellier, INSERM, Montpellier, France
| | - Christine Biron-Andreani
- Resources and Competence Center for Hereditary Hemorrhagic Diseases, CHU Montpellier, Montpellier, France
| | - Nicolas Sirvent
- Department of Pediatric Oncology and Hematology, CHU Montpellier, Montpellier, France
| | - Christian Jorgensen
- IRMB, University of Montpellier, INSERM, Montpellier, France; Clinical Immunology and Osteoarticular Disease Therapeutic Unit, Department of Rheumatology, CHU Montpellier, Montpellier, France
| | - Danièle Noël
- IRMB, University of Montpellier, INSERM, Montpellier, France; Clinical Immunology and Osteoarticular Disease Therapeutic Unit, Department of Rheumatology, CHU Montpellier, Montpellier, France.
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Chowdary P, Ofori-Asenso R, Nissen F, Grazzi EF, Aizenas M, Moreno K, Burke T, Nolan B, O'Hara J, Khair K. Disease Burden, Clinical Outcomes, and Quality of Life in People with Hemophilia A without Inhibitors in Europe: Analyses from CHESS II/CHESS PAEDs. TH OPEN 2024; 8:e181-e193. [PMID: 38628421 PMCID: PMC11018388 DOI: 10.1055/s-0044-1785524] [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: 11/22/2023] [Accepted: 03/04/2024] [Indexed: 04/19/2024] Open
Abstract
Introduction Limited data relating to treatment burden, quality of life, and mental health burden of hemophilia A (HA) are currently available. Aim To provide a comprehensive overview of unmet needs in people with HA (PwHA) using data generated from the Cost of Haemophilia in Europe: a Socioeconomic Survey-II (CHESS II) and CHESS in the pediatric population (CHESS PAEDs) studies. Methods CHESS II and CHESS PAEDs are cross-sectional surveys of European males with HA or hemophilia B (HB) aged ≥18 and ≤17 years, respectively. Participants with FVIII inhibitors, mild HA, or HB were excluded from this analysis, plus those aged 18 to 19 years. Annualized bleeding rates (ABRs), target joints, and other patient-reported outcomes were evaluated. Results Overall, 468 and 691 PwHA with available data for the outcomes of interest were stratified by hemophilia severity and treatment regimen in CHESS II and CHESS PAEDs, respectively. In these studies, 173 (37.0%) and 468 (67.7%) participants received FVIII prophylaxis, respectively; no participants received the FVIII mimetic emicizumab or gene therapy. ABRs of 2.38 to 4.88 were reported across disease severity and treatment subgroups in both studies. Target joints were present in 35.7 and 16.6% of participants in CHESS II and CHESS PAEDS; 43.8 and 23.0% had problem joints. Chronic pain was reported by a large proportion of PwHA (73.9% in CHESS II; 58.8% in CHESS PAEDs). Participants also reported low EQ-5D scores (compared with people without HA), anxiety, depression, and negative impacts on their lifestyles due to HA. Conclusions These analyses suggest significant physical, social, and mental burdens of HA, irrespective of disease severity. Optimization of prophylactic treatment could help reduce the burden of HA on patients.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Richard Ofori-Asenso
- Real-World Data Enabling Platform, Roche Products Ltd, Welwyn Garden City, United Kingdom
| | - Francis Nissen
- Department of Real-World Data, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Enrico F. Grazzi
- Health Economics and Outcomes Research, HCD Economics, Daresbury, United Kingdom
| | - Martynas Aizenas
- Department of Access Strategy, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Katya Moreno
- Department of Product Development and Medical Affairs, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Tom Burke
- Health Economics and Outcomes Research, HCD Economics, Daresbury, United Kingdom
- Department of Health and Social Care, University of Chester, Chester, United Kingdom
| | - Beatrice Nolan
- Department of Haematology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Jamie O'Hara
- Health Economics and Outcomes Research, HCD Economics, Daresbury, United Kingdom
- Department of Health and Social Care, University of Chester, Chester, United Kingdom
| | - Kate Khair
- Department of Research, Haemnet, London, United Kingdom
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Makris M, Lassila R, Kennedy M. Challenges in ageing persons with haemophilia. Haemophilia 2024; 30 Suppl 3:5-11. [PMID: 38539058 DOI: 10.1111/hae.14994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/05/2024] [Accepted: 03/05/2024] [Indexed: 04/22/2024]
Abstract
As treatments for individuals with inherited bleeding disorders improve, life expectancy increases and is approaching that of the normal population. Concomitant with this we are now seeing the problems of ageing in the bleeding disorder population. Although the clear-cut association between low clotting factor levels and risk of bleeding is well recognised, a relationship between high levels, some non-factor therapies and thrombotic risk also exists. The management of thrombosis in persons with inherited bleeding disorders is complex but manageable with modern treatments and collaboration in decision making between health care professionals and patients. Despite the improvements in treatment and reduction in bleeding, mostly musculoskeletal pain continues to be a major issue with advancing age. The management of pain amongst older people with haemophilia who may have multiple comorbidities should involve a person-centred, holistic, multi-disciplinary approach to support and optimise long-term physical functioning and overall quality of life.
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Affiliation(s)
- Michael Makris
- School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Riitta Lassila
- Helsinki University Hospital, Department of Haematology, Coagulation Disorders Unit, Comprehensive Cancer Centre, Faculty of Medicine, Research Program Unit in Systems Oncology, University of Helsinki, Helsinki, Finland
| | - Megan Kennedy
- Discipline of Physiotherapy, School of Medicine, University of Dublin, Trinity College Dublin, Dublin, Ireland
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Tory SS, Ghosh S, Nazneen H, Farhad N, Islam S, Hasan MJ, Biswas AR. Effectiveness of emicizumab in preventing bleeding events in severe and moderate hemophilia A: A single-center experience in Bangladesh. EJHAEM 2024; 5:39-46. [PMID: 38406515 PMCID: PMC10887364 DOI: 10.1002/jha2.832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/22/2023] [Indexed: 02/27/2024]
Abstract
Emicizumab is a monoclonal antibody that bridges activated factor IX (FIX) and factor X (FX) to replace the function of missing activated factor VIII (FVIII) in hemophilia A patients irrespective of FVIII inhibitor status. This study assessed the effectiveness of emicizumab in preventing bleeding episodes in patients with hemophilia A. This observational study included patients with moderate to severe hemophilia A who were undergoing episodic FVIII replacement therapy. The primary endpoint was the difference in annualized bleeding rates (ABR) and the secondary endpoint was the difference in Hemophilia Joint Health Score (HJHS) before and after emicizumab prophylaxis. A total of 30 male hemophilia patients were included, the mean age was 16.7 (SD: ±8.1) years, and most of them had moderate hemophilia A [63.3%]. Before prophylaxis, the median ABR was 48 (interquartile range [IQR]: 35-60), and 93.3% of patients had ABR greater than eight, whereas after prophylaxis the median ABR decreased significantly (median [IQR]: 0 [0.0-0.4], p < 0.001), and 56.7% had zero bleeds. ABR was not significantly different in patient with and without FVIII inhibitors. The HJHS scores significantly improved after prophylaxis (10 vs. 2.5, p < 0.001). The bleeding events were reduced significantly (23 vs. 0.0, p < 0.001), and zero new target joints were reported after prophylaxis. Most of the patients [93.3%] did not face any serious adverse events after prophylaxis. Emicizumab prophylaxis was associated with a significantly lower rate of bleeding events among participants with hemophilia A, regardless of inhibitor status.
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Affiliation(s)
| | - Sujan Ghosh
- Department of HematologyDhaka Medical College HospitalDhakaBangladesh
| | - Humayra Nazneen
- Department of HematologyDhaka Medical College HospitalDhakaBangladesh
| | - Nurul Farhad
- Department of HematologyDhaka Medical College HospitalDhakaBangladesh
| | - Salwa Islam
- Pi Research Development CenterDhakaBangladesh
| | - Mohammad Jahid Hasan
- Department of Health System ResearchTropical Disease and Health Research CenterDhakaBangladesh
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Donati D, Spinnato P, Valdrè L, Piscitelli L, Farella GM, Pagliarulo E, Benedetti MG. Ultrasound Evaluation of Tendinopathy in Hemophiliac Patients for the Purpose of Rehabilitation Indications. J Clin Med 2023; 12:4513. [PMID: 37445548 DOI: 10.3390/jcm12134513] [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: 03/26/2023] [Revised: 06/24/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Hemophilia is a inherited bleeding disorder that is characterized by intra-articular bleeding (hemarthrosis). The aim of the study was to evaluate the state of the satellite tendons of the target joints in the patient with hemophilic arthropathy and propose rehabilitation treatment with eccentric exercises. METHODS The tendons of the joints mainly affected by hemophilic arthropathy were evaluated by ultrasound. The ultrasound evaluation is associated with the use of evaluation clinical scales, such as the Hemophilia Joint Health Score (HJHS), the Functional Independence Score in Hemophilia (FISH), the Hemophilia Activity List (HAL), the DASH, the VISA-A, the VISA-P, and the VAS scale. RESULTS In 20 patients with hemophilic arthropathy, the thickness of the tendons that were examined was normal. In six subjects with severe joint damage, echostructural alterations were present, and signs of hyperemia and neo-vascularization were detected on color Doppler, as well as the presence of intratendinous calcifications. CONCLUSIONS The tendons of the target joints in patients with hemophilic arthropathy are compromised by the indirect biomechanical damage caused by the joint disease, and rehabilitation treatment with eccentric exercises can be considered safe and effective in improving the tenso-elastic properties of the tendons.
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Affiliation(s)
- Danilo Donati
- Physical Therapy and Rehabilitation Unit, Policlinico di Modena, 41125 Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Paolo Spinnato
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40134 Bologna, Italy
| | - Lelia Valdrè
- Inherited Bleeding Disorders Unit, IRCCS AOUBO, 40138 Bologna, Italy
| | - Lydia Piscitelli
- Inherited Bleeding Disorders Unit, IRCCS AOUBO, 40138 Bologna, Italy
| | - Giuseppina Mariagrazia Farella
- Physical Therapy and Rehabilitation Unit, IRCCS Istituto Ortopedico Rizzoli, University of Bologna, 40134 Bologna, Italy
| | - Enrico Pagliarulo
- Physical Therapy and Rehabilitation Unit, IRCCS Istituto Ortopedico Rizzoli, University of Bologna, 40134 Bologna, Italy
| | - Maria Grazia Benedetti
- Physical Therapy and Rehabilitation Unit, IRCCS Istituto Ortopedico Rizzoli, University of Bologna, 40134 Bologna, Italy
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Pain: a neglected symptom in hemophilia. Ann Hematol 2023; 102:947-953. [PMID: 36820905 DOI: 10.1007/s00277-023-05134-4] [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: 12/17/2022] [Accepted: 02/08/2023] [Indexed: 02/24/2023]
Abstract
Repetitive bleeding attacks may cause joint pain and arthropathy in patients with hemophilia (PWH). Despite being a common symptom, pain is not a well-studied topic in this disease. The aim of this cross-sectional, observational study was to assess the frequency and intensity of pain and analyze the success rates ofpain treatment methods. Adult hemophilia patients were included in the study. The Multidimensional Hemophilia Pain Questionnaire (MHPQ) was used to assess pain. In addition to the MHPQ, demographic data were collected. Fifty adult hemophilia patients were included in the study. Thirty-one (62%) of the patients reported pain due to hemophilia in the last year. Twenty-six of them (81.2%) reported pain during bleeding attacks. The most successful pain coping strategy was clotting factor replacement. None of the participants used opioids or adjuvant analgesics. None of them used a physical therapy modality or interventional pain therapy method. While 67.6% of the patients were very dissatisfied or dissatisfied with their global pain treatment, only 16.1% of the patients were satisfied or very satisfied. Patients with higher pain during bleeding episodes were more likely to continue their prophylaxis. There was no significant difference between plasma-derived or recombinant-derived factor prophylaxis in terms of pain complaints. Pain is a frequent and important symptom of hemophilia, but most of the patients are not treated sufficiently. A multidisciplinary approach is needed to improve the life quality of the patients. In addition to successful bleeding prophylaxis, administration of a proper and adequate analgesic regimen and combined physical therapy modalities may decrease pain intensity and prevent the development of arthropathy.
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Mancuso ME, Holstein K, O'Donnell JS, Lobet S, Klamroth R. Synovitis and joint health in patients with haemophilia: Statements from a European e-Delphi consensus study. Haemophilia 2023; 29:619-628. [PMID: 36622258 DOI: 10.1111/hae.14734] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/01/2022] [Accepted: 12/14/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Synovitis, a common feature in haemophilia, is triggered by the presence of blood in joints, and represents the first step towards the development of chronic arthropathy. Synovitis may be detected early by means of ultrasound or magnetic resonance imaging scan; clinical joint scores are less sensitive in this setting. Regular long-term prophylaxis with clotting factor concentrates, as primary prophylaxis and tailored to individual needs, has high efficacy in preventing synovitis. In general, higher factor levels lower bleeding risk, but no direct correlation between factor levels and synovitis incidence has been demonstrated. AIM This study aimed to develop an expert consensus relating to the definition, pathophysiology, diagnosis, prevention, follow-up and treatment of synovitis, recognising its relevance for joint health and taking into account existing knowledge gaps. METHODS A Delphi consensus study was designed and performed. An expert group prepared 22 statements based on existing literature; a wider expert panel subsequently voted on these. RESULTS Retention of panellists was high. Four statements required amending and consensus on all statements was achieved after three rounds of voting. CONCLUSION This e-Delphi consensus study addressed the importance of synovitis in joint health of people with haemophilia and highlighted knowledge gaps in this field. Studies on the natural course of synovitis are lacking and the biological mechanisms underlying this process are not yet fully elucidated. While basic and clinical research proceeds in this field, expert consensus can help guide clinicians in their routine clinical practice, and Delphi methodology is often used to produce best-practice guidelines.
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Affiliation(s)
- Maria Elisa Mancuso
- IRCCS Humanitas Research Hospital, Centre for Thrombosis and Haemorrhagic Diseases, Rozzano, Milan, Italy
| | - Katharina Holstein
- Department of Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - James S O'Donnell
- National Coagulation Centre, St. James's Hospital, Dublin, Ireland.,Irish Centre for Vascular Biology, School of Pharmacy and Biomedical Sciences, RCSI, Dublin, Ireland
| | - Sébastien Lobet
- Hematology department, Saint-Luc University Clinics, Avenue Hippocrate 10, Brussels, Belgium.,Neuromusculoskeletal Lab (NMSK), Institute for Experimental and Clinical, Catholic University of Louvain, Avenue Hippocrate, Woluwe-Saint-Lambert, Belgium.,Physical Medicine and Rehabilitation Service, Saint-Luc University Clinics, Avenue Hippocrate 10, Brussels, Belgium
| | - Robert Klamroth
- Vivantes Hospital, Friedrichshain, Berlin, Germany.,Institute of Experimental Haematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
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- IRCCS Humanitas Research Hospital, Centre for Thrombosis and Haemorrhagic Diseases, Rozzano, Milan, Italy
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8
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van der Zant FM, Knol RJ, Broos WA. Radiosynoviorthesis: almost seventy years of experience but still somewhat fameless. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF... 2022; 66:293-303. [PMID: 35708601 DOI: 10.23736/s1824-4785.22.03470-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Radiosynoviorthesis (RSO) or radiation synovectomy has been practiced for more than half a century, but in many parts of the world, it is still relatively unknown and not used to its full potential in the standard care for chronic, persistent or recurrent synovitis. The working mechanism of RSO is simple yet elegant. Radiopharmaceutical particles are, after injection in the affected synovial joint, gobbled up by phagocytizing subsynovial inflammatory cells. As a consequence, the synovium will be irradiated locally resulting in synovial cell necrosis and inhibition of cell proliferation, which eventually leads to a decrease in the inflammatory response in the joint cavity. In this review RSO is once again brought to the attention and common indications for RSO are discussed. Also, appropriate activities of the administrated radiopharmaceuticals and coadministrated glucocorticoids are provided. Furthermore, a detailed database-assisted chronological overview of published literature of RSO in inflammatory and non-inflammatory diseases, like rheumatoid arthritis, psoriatic arthritis, osteoarthritis and osteochrondomatosis, hemophilic hemarthrosis and pigmented villonodular synovitis (PVNS) is provided. Based upon the published literature an indication of level of evidence of RSO is discussed. There is evidence that RSO is effective in persistent synovitis in patients with a variety of causes for synovitis, although the effectiveness seems to decrease over time. In these patients, RSO may not be used to its full potential in many parts of the world. Results in of RSO in hemophilia patients with hemarthrosis are favourable, however the evidence for the effectiveness of RSO in these patients is less firm and mainly based on case series. The evidence for the efficacy of RSO as adjuvant therapy in PVNS is, at best, of very low quality.
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Affiliation(s)
| | - Remco J Knol
- Department of Nuclear Medicine, Northwest Clinics, Alkmaar, the Netherlands
| | - Wouter A Broos
- Department of Nuclear Medicine, Northwest Clinics, Alkmaar, the Netherlands
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McLaughlin P, Hurley M, Chowdary P, Stephensen D, Khair K. How does a lifetime of painful experiences influence sensations and beliefs about pain in adults with severe haemophilia? A qualitative study. Disabil Rehabil 2022; 44:8412-8419. [PMID: 34951551 DOI: 10.1080/09638288.2021.2018053] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE To explore the life experiences of pain in people with severe haemophilia and understand how such experiences influence beliefs and sensation of pain in adulthood. METHODS A qualitative inquiry approach using focus groups and semi-structured individual interviews was used. Participants included people with severe haemophilia living with chronic pain. Data were analysed using reflexive thematic analysis. RESULTS Fourteen men with a median age of 47 (range 23-73) agreed to take part. Eleven participated in two focus groups and three were interviewed over telephone. Two themes were conceptualised from the data: (i) haemophilia and pain - an evolving life biography (the personal narrative, historical, social, and medical context, continuous adaptation of activity choices, surveillance of pain and its meaning); (ii) "My normal isn't normal" - identity and self-agency (pain as a feature of life and identify with severe haemophilia, loss of enjoyable activities balanced against staying active, barriers to participation). CONCLUSIONS Pain is a constantly evolving, lifetime feature for many adults with haemophilia and it is viewed as part of their identity with their condition. Healthcare professionals working in haemophilia should try to better understand the influence of an individuals lived experience with their haemophilia on beliefs and behaviours of pain.Implications for rehabilitationSevere haemophilia is a rare bleeding disorder that results in musculoskeletal joint disease.Adults with severe haemophilia have experienced multiple episodes of bleeding related musculoskeletal pain since childhood.Pain beliefs and behaviours in adulthood appear to be influenced by a lifetime of painful experiences associated with haemophilia.In order to better support people with haemophilia and chronic pain, healthcare professionals in haemophilia need to better understand how an individuals lived experience of pain helps inform their beliefs about it.
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Affiliation(s)
- P McLaughlin
- Faculty of Health, Social Care and Education, St George's University of London and Kingston University, London, UK.,Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - M Hurley
- Faculty of Health, Social Care and Education, St George's University of London and Kingston University, London, UK
| | - P Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - D Stephensen
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - K Khair
- Centre for Outcomes and Experience Research in Child Health, Illness and Disability (ORCHID) Research Unit, Great Ormond Street Hospital for Children NHS Trust, London, UK.,Haemnet, London, UK
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Horneff S, Boddenberg-Pätzold B. The value of radiosynoviorthesis for treatment of chronic synovitis in hemophilic joint disease. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF... 2022; 66:334-344. [PMID: 36106913 DOI: 10.23736/s1824-4785.22.03474-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Chronic synovitis is contributing to the development of arthropathy in hemophilia A and B. In most patients with severe and moderate hemophilia, during lifetime, joint damage progresses despite early prophylaxis and intense treatment with coagulation factor concentrates. Recurrent hemorrhages into the joints and subclinical bleeding lead to chronic inflammation of the synovium, neoangiogenesis and remodeling, sustaining a vicious circle of bleeding-remodeling-bleeding and progression of osteochondral damage. Imaging techniques including ultrasound and MRI are able to early visualize synovitis and osteochondral changes. Early detection and sustained therapy of synovitis are important preconditions to prevent further deterioration of joint status. Chronic synovitis requires intensified substitution of coagulation factors and concomitant analgetic, antiphlogistic and physical therapy. The value of early radiosynoviorthesis (RSO) as effective method to control ongoing synovitis is discussed here. RSO is recommended as first choice therapy in case of persistant chronic synovitis, recorded in both national and international guidelines.
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Affiliation(s)
- Silvia Horneff
- Institute for Experimental Hematology and Transfusional Medicine, Clinical University of Bonn, Bonn, Germany -
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11
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Taylor S, Toye F, Donovan-Hall M, Barker K. Past the tipping point: a qualitative study of the views and experiences of men with haemophilia regarding mobility, balance, and falls. Disabil Rehabil 2022; 44:7237-7245. [PMID: 34651530 DOI: 10.1080/09638288.2021.1988731] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE The life expectancy of people with haemophilia is increasing due to improved medical care. This improvement is accompanied by the co-morbidities of ageing, which include musculoskeletal degeneration and the associated effect on proprioception and balance. This study aims to explore the views and everyday experiences of those living with haemophilia regarding this. MATERIALS AND METHODS Nine people with moderate or severe haemophilia aged 43-58 years participated in semi-structured interviews and thematic analysis was used to examine the data. RESULTS Participants described pain and reduced movement in joints as a result of repeated bleeds, which caused problems with mobility and balance. Constant vigilance of their surroundings together with the potential consequences of bleeds caused continual worry. Participants were resourceful in their strategies to cope with the effects of haemophilia, to reduce pain and to minimise the risk of falling. However, participants felt stigmatised because of their condition. CONCLUSION People with haemophilia have difficulties with their mobility and balance that can increase their risk of falling. Healthcare professionals need to understand and address the physical and psycho-social factors that contribute to the risk of falls. A multi-disciplinary approach to devise effective strategies to counteract and monitor the risk of falls would be useful.Implications for RehabilitationHealthcare professionals should identify movements that are fearful and work on ways to increase confidence and ability to perform these.Healthcare professionals need to identify the recovery strategies used to maintain balance and build these movements into home exercise programmes.Effective pain reduction strategies, both pharmacological and non-pharmacological, need to be investigated and optimised.Footwear choice has implications for both pain reduction and balance and should be discussed in routine reviews.Optimising vision would maximise visual input to aid balance.
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Affiliation(s)
- Stephanie Taylor
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospital NHS Foundation Trust, UK
| | - Francine Toye
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospital NHS Foundation Trust, UK
| | | | - Karen Barker
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospital NHS Foundation Trust, UK.,Nuffield Department of Orthopaedics and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
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12
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Evers BJ, Van Den Bosch MHJ, Blom AB, van der Kraan PM, Koëter S, Thurlings RM. Post-traumatic knee osteoarthritis; the role of inflammation and hemarthrosis on disease progression. Front Med (Lausanne) 2022; 9:973870. [PMID: 36072956 PMCID: PMC9441748 DOI: 10.3389/fmed.2022.973870] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
Knee injuries such as anterior cruciate ligament ruptures and meniscal injury are common and are most frequently sustained by young and active individuals. Knee injuries will lead to post-traumatic osteoarthritis (PTOA) in 25–50% of patients. Mechanical processes where historically believed to cause cartilage breakdown in PTOA patients. But there is increasing evidence suggesting a key role for inflammation in PTOA development. Inflammation in PTOA might be aggravated by hemarthrosis which frequently occurs in injured knees. Whereas mechanical symptoms (joint instability and locking of the knee) can be successfully treated by surgery, there still is an unmet need for anti-inflammatory therapies that prevent PTOA progression. In order to develop anti-inflammatory therapies for PTOA, more knowledge about the exact pathophysiological mechanisms and exact course of post-traumatic inflammation is needed to determine possible targets and timing of future therapies.
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Affiliation(s)
- Bob J. Evers
- Department of Experimental Rheumatology, Radboud Institute for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
- Canisius Wilhelmina Hospital, Nijmegen, Netherlands
- *Correspondence: Bob J. Evers
| | - Martijn H. J. Van Den Bosch
- Department of Experimental Rheumatology, Radboud Institute for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Arjen B. Blom
- Department of Experimental Rheumatology, Radboud Institute for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Peter M. van der Kraan
- Department of Experimental Rheumatology, Radboud Institute for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | | | - Rogier M. Thurlings
- Department of Experimental Rheumatology, Radboud Institute for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
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13
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Wang R, Wang Z, Gu Y, Zhang J, Wang P, Tong P, Lv S. Total knee arthroplasty in patients with haemophilic arthropathy is effective and safe according to the outcomes at a mid-term follow-up. J Orthop Traumatol 2022; 23:31. [PMID: 35819639 PMCID: PMC9276882 DOI: 10.1186/s10195-022-00648-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 06/12/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Haemophilic arthropathy (HA), a common complication of haemophilia, is secondary to recurrent joint bleeding and increases the prevalence of end-stage osteoarthritis (OA). Total knee arthroplasty (TKA) is a reliable treatment for haemophilia patients. This study was performed to evaluate the mid-term outcomes of TKA for end-stage HA. We hypothesized that the rate of complications of TKA is higher for patients with haemophilia than for patients without haemophilia. METHODS Patients with HA undergoing TKA from January 2015 to December 2016 in our centre were retrospectively reviewed. All patients were managed by a multidisciplinary team. The improvements in flexion contracture, range of motion (ROM), Knee Society Score (KSS; clinical and functional), Visual Analogue Scale (VAS) score, and satisfaction at final follow-up were analysed to evaluate the effectiveness of TKA in HA. The complications were analysed to evaluate the safety of TKA in HA. RESULTS Twenty-eight patients (32 knees) were included in the study. The follow-up was 69.1 ± 5.1 months. Significant differences between the preoperative and final follow-up values of flexion contracture (which changed from 21.1 ± 6.5° to 14.3 ± 4.1°, P < 0.001), ROM (from 53.9 ± 15.0° to 70.3 ± 16.3°, P < 0.001), clinical KSS (from 33.5 ± 14.4° to 62.7 ± 9.5°, P < 0.001), functional KSS (from 46.1 ± 15.5° to 62.9 ± 9.7°, P < 0.001), and VAS score (from 6.8 ± 1.4 to 4.9 ± 1.3, P < 0.01) were observed. Importantly, the incidence of complications was 15.6% and the satisfaction was 100% in our mid-term study. CONCLUSION Under elaborative and comprehensive management, TKA is effective and safe in patients with advanced HA on the basis of mid-term follow-up outcomes.
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Affiliation(s)
- Rui Wang
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Zhengming Wang
- Shi's Center of Orthopedics and Traumatology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Institute of Traumatology & Orthopedics, Shanghai Academy of Traditional Chinese Medicine, Shanghai, China
| | - Yong Gu
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Jingjing Zhang
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Penghe Wang
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Peijian Tong
- The First Affiliated Hospital of Zhejiang, Chinese Medical University, 54 Youdian Road, Hangzhou, 310006, Zhejiang Province, China
| | - Shuaijie Lv
- The First Affiliated Hospital of Zhejiang, Chinese Medical University, 54 Youdian Road, Hangzhou, 310006, Zhejiang Province, China.
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14
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Wu PH, Chang CP, Chang CY, Kuo YT, Lin LC, Wu KH. A Woman with Unilateral Leg Swelling. Ann Emerg Med 2022; 79:e15-e16. [DOI: 10.1016/j.annemergmed.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Indexed: 11/01/2022]
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15
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St-Louis J, Chowdary P, Dolan G, Goodyear D, Strike K, Pollard D, Teitel J. Multidisciplinary Team Care of Patients with Hemophilic Arthropathy: A Qualitative Assessment of Contemporary Practice in the UK and Canada. Clin Appl Thromb Hemost 2022; 28:10760296211070002. [PMID: 35060765 PMCID: PMC8796082 DOI: 10.1177/10760296211070002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
We used a structured interview to explore approaches to comprehensive hemophilia and arthropathy care among 24 healthcare professionals (HCPs) from multidisciplinary teams (MDTs) in Canada and the UK. Represented MDTs typically comprise a hematologist, nurse, physiotherapist, and sometimes an orthopedic surgeon; pediatric (and some adult) MDTs also include a social worker/psychologist. HCPs emphasized the centrality of a team approach, facilitated through MDT meetings and involvement of all MDT members in patient care. In both countries, nurses and physiotherapists play critical, multifaceted roles. Respondents agreed that MDTs are crucial for successful transitioning, which can be facilitated by close collaboration between pediatric and adult MDTs, even when they are not co-located. Physiotherapists are instrumental in providing non-pharmacological pain relief. Hematologists or physiotherapists typically make orthopedic referrals, with the nurse, physiotherapist and hematologist working together in patient preparation for (and follow-up after) surgery. MDT best practices include a non-hierarchical team approach, ensuring that all MDT members know all patients, and regular MDT meetings. Together, these real-life insights from the MDT perspective emphasize the value of the MDT approach in comprehensive hemophilia care.
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Affiliation(s)
| | | | - Gerry Dolan
- Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | | | - Karen Strike
- Hamilton Niagara Regional Hemophilia Treatment Centre, McMaster Children's Hospital, McMaster University, Hamilton, Canada
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16
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Wilkins RA, Stephensen D, Siddle H, Scott MJ, Xiang H, Horn E, Palmer B, Chapman GJ, Richards M, Walwyn R, Redmond A. Twelve-month prevalence of haemarthrosis and joint disease using the Haemophilia Joint Health score: evaluation of the UK National Haemophilia Database and Haemtrack patient reported data: an observational study. BMJ Open 2022; 12:e052358. [PMID: 35022172 PMCID: PMC8756269 DOI: 10.1136/bmjopen-2021-052358] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To report the 12-month prevalence of joint bleeds from the National Haemophilia Database (NHD) and Haemtrack, a patient-reported online treatment diary and concurrent joint disease status using the haemophilia joint health score (HJHS) at individual joint level, in children and adults with severe haemophilia A and B (HA/HB) without a current inhibitor. DESIGN A 2018 retrospective database study of NHD from which 2238 cases were identified, 463 patients had fully itemised HJHS of whom 273 were compliant in recording treatment using Haemtrack. SETTING England, Wales and Scotland, UK. PARTICIPANTS Children (<18 years) and adults (≥18 years) with severe HA and HB (factor VIII/factor IX, <0.01 iu/mL) without a current inhibitor. PRIMARY AND SECONDARY OUTCOMES Prevalence of joint haemarthrosis and concurrent joint health measured using the HJHS. RESULTS The median (IQR) age of children was 10 (6-13) and adults 40 (29-50) years. Haemarthrosis prevalence in HA/HB children was 33% and 47%, respectively, and 60% and 42%, respectively, in adults. The most common site of haemarthrosis in children was the knee in HA and ankle in HB. In adults, the incidence of haemarthrosis at the ankles and elbows was equal. The median total HJHS in HA/HB children was 0 and in adults with HA/HB, were 18 and 11, respectively. In adults with HA/HB, the median ankle HJHS of 4.0 was higher than the median HJHS of 1.0 for both the knee and elbow. CONCLUSION Despite therapeutic advances, only two-thirds of children and one-third of adults were bleed-free, even in a UK cohort selected for high compliance with prophylaxis. The median HJHS of zero in children suggests joint health is relatively unaffected during childhood. In adults, bleed rates were highest in ankles and elbows, but the ankles led to substantially worse joint health scores.
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Affiliation(s)
- Richard A Wilkins
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Leeds Haemophilia Comprehensive Care Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - David Stephensen
- Haemophilia Centre, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
- Haemophilia Centre, Barts Health NHS Trust, London, UK
| | - Heidi Siddle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Martin J Scott
- University Department of Clinical Haematology, Manchester Royal Infirmary, Manchester, UK
- Institute of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Hua Xiang
- National Haemophilia Database, United Kingdom Haemophilia Centre Doctors' Organisation (UKHCDO), Manchester, UK
| | - Elizabeth Horn
- Leeds Haemophilia Comprehensive Care Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ben Palmer
- National Haemophilia Database, United Kingdom Haemophilia Centre Doctors' Organisation (UKHCDO), Manchester, UK
| | - Graham J Chapman
- School of Sport and Health Sciences, University of Central Lancashire, Preston, UK
| | - Michael Richards
- Leeds Haemophilia Comprehensive Care Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rebecca Walwyn
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Anthony Redmond
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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17
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Di Minno MND, Napolitano M, Giuffrida AC, Baldacci E, Carulli C, Boccalandro E, Bruno C, Forneris E, Ricca I, Passeri W, Martinelli M, Rivolta GF, Solimeno LP, Martinoli C, Rocino A, Pasta G. Diagnosis and treatment of chronic synovitis in patients with haemophilia: consensus statements from the Italian Association of Haemophilia Centres. Br J Haematol 2021; 196:871-883. [PMID: 34923621 PMCID: PMC9299781 DOI: 10.1111/bjh.17919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/28/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023]
Abstract
Although synovitis is recognized as a marker of joint disease activity, its periodic assessment is not included in routine clinical surveillance of patients with haemophilia (PwH). In order to evaluate the current knowledge and to identify controversial issues, a preliminary literature search by the Musculoskeletal Committee of the Italian Association of Haemophilia Centres (AICE) has been conducted. Statements have been established and sent to the Italian AICE members to collect their level of agreement or disagreement by a Delphi process. Thirty‐seven consensus recommendations have been drafted. We found a general agreement on the indication to consider the presence of synovitis as a marker of joint disease activity in PwH. Accordingly, there was agreement on the indication to search for synovitis both in patients reporting joint pain and in asymptomatic ones, recognizing ultrasound as the most practical imaging technique to perform periodic joint screening. Interestingly, after detection of synovitis, there was agreement on the indication to modify the therapeutic approach, suggesting prophylaxis in patients treated on demand and tailoring treatment in patients already under prophylaxis. Whereas the need of an early consultation with a physiotherapist is recommended for PwH affected by chronic synovitis, the exact timing for an orthopaedic surgeon consultation is currently unknown.
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Affiliation(s)
| | - Mariasanta Napolitano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | | | - Erminia Baldacci
- Hematology, University Hospital Policlinico Umberto I, Rome, Italy
| | - Christian Carulli
- Department of Health Sciences, Orthopaedic Clinic, University of Florence, Florence, Italy
| | - Elena Boccalandro
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Center, IRCCS Cà Granda Foundation, Maggiore Hospital Policlinic, Milan, Italy
| | - Clarissa Bruno
- Haemophilia Center and Thrombosis, Policlinico, Bari, Italy
| | - Eleonora Forneris
- Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Irene Ricca
- Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Walter Passeri
- Rehabilitation Service, "Domus Salutis" Casa di Cura, "Teresa Camplani" Foundation, Brescia, Italy
| | - Marco Martinelli
- Rehabilitation Service, "Domus Salutis" Casa di Cura, "Teresa Camplani" Foundation, Brescia, Italy
| | - Gianna Franca Rivolta
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, Parma, Italy
| | - Luigi Piero Solimeno
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Center, IRCCS Cà Granda Foundation, Maggiore Hospital Policlinic, Traumatology and Orthopaedic Unit, Milan, Italy
| | - Carlo Martinoli
- Department of Health Science (DISSAL), University of Genoa, Unit of Radiology and IRCCS San Martino Hospital, Genoa, Italy
| | - Angiola Rocino
- Haemophilia and Thrombosis Centre, Haematology, Ospedale del Mare, ASL Napoli 1 Centro, Naples, Italy
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18
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Potpally N, Rodeo S, So P, Mautner K, Baria M, Malanga GA. A Review of Current Management of Knee Hemarthrosis in the Non-Hemophilic Population. Cartilage 2021; 13:116S-121S. [PMID: 32698601 PMCID: PMC8808899 DOI: 10.1177/1947603520942937] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The knee joint is one of the most frequently injured joints in the body, and the resulting injury may often lead to the presence of a bloody effusion, or hemarthrosis. The acute management of this condition can have long-lasting implications, and may ultimately result in the early onset of osteoarthritis in this population. Heme, a breakdown product of erythrocytes, and associated pro-inflammatory mediators, are known to have deleterious interactions with cartilage and synovium. The presence of blood in a joint following injury can precipitate these effects and accelerate the degenerative changes in the joint. Currently, there is no consensus on the optimal management of a traumatic knee joint injury with a hemarthrosis. Nontraumatic hemarthosis, seen most commonly in hemophilia patients, has a set of established guidelines that does not routinely recommend drainage of the joint. This article presents a rationale for joint aspiration to minimize the harmful effects of blood following traumatic hemarthrosis.
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Affiliation(s)
| | - Scott Rodeo
- Hospital for Special Surgery, New
York, NY, USA
| | - Paul So
- Rutgers New Jersey Medical School,
Newark, NJ, USA
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19
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Septic Arthritis in Pediatric Hemophilia A: A Case Report and Review of Literature. Indian J Orthop 2021; 56:705-715. [PMID: 35342520 PMCID: PMC8921430 DOI: 10.1007/s43465-021-00565-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/01/2021] [Indexed: 02/04/2023]
Abstract
Hemophilia A is a hereditary bleeding disorder due to coagulation factor VIII deficiency. Septic arthritis is in itself a dreaded infective condition of the joint. It is much more common in hemophilia patients than the general population and is associated with considerably higher morbidity. It presents as a difficult clinical and therapeutic problem, necessitating prompt diagnosis and intensive therapy. There was under-diagnosis of blood coagulation disorders in developing countries like India which has improved in the present time. But there is still considerable uncertainty about proper management guidelines, protocols and resources settings for treating this complication in hemophilia patients. Hereby we present a case of a 9-year-old hemophilia A patient with septic arthritis of knee joint treated at a tertiary hospital centre with available present recommended guidelines in literature, and stress upon the necessity of further formulating and improvising management guidelines for treatment and prevention of this complication in Hemophilia.
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Abstract
Purpose Radiosynoviorthesis (RSO) using the intraarticular application of beta-particle emitting radiocolloids has for decades been used for the local treatment of inflammatory joint diseases. The injected radiopharmaceuticals are phagocytized by the superficial macrophages of the synovial membrane, resulting in sclerosis and fibrosis of the formerly inflamed tissue, finally leading to reduced joint effusion and alleviation of joint pain. Methods The European Association of Nuclear Medicine (EANM) has written and approved these guidelines in tight collaboration with an international team of clinical experts, including rheumatologists. Besides clinical and procedural aspects, different national legislative issues, dosimetric considerations, possible complications, and side effects are addressed. Conclusion These guidelines will assist nuclear medicine physicians in performing radiosynoviorthesis. Since there are differences regarding the radiopharmaceuticals approved for RSO and the official indications between several European countries, this guideline can only give a framework that must be adopted individually.
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21
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Stromer W, Pabinger I, Ay C, Crevenna R, Donnerer J, Feistritzer C, Hemberger S, Likar R, Sevelda F, Thom K, Wagner B, Streif W. Pain management in hemophilia: expert recommendations. Wien Klin Wochenschr 2021; 133:1042-1056. [PMID: 33661391 PMCID: PMC8500904 DOI: 10.1007/s00508-020-01798-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/11/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION As a typical consequence of bleeding into muscles and joints, patients with severe hemophilia suffer from acute and chronic pain. In spite of its high prevalence, pain in this patient group is not always sufficiently considered or treated in an effective manner. AIM The recommendations presented in this paper address possible improvements in pain management in hemophilia patients and particularities that have to be taken into account in this patient group. METHOD The manifold aspects of pain management in hemophilia patients were discussed within the framework of an expert meeting. Based on the available literature and the experts' clinical experience, the participants developed a set of recommendations presented in this paper. RESULTS Pain management in patients with hemophilia is often insufficient, a fact that not only influences the patients' quality of life but also implies the risk of difficult to manage chronic pain. Both the prevalent polypharmacy (due to comorbidities) as well as the underlying disease itself present special challenges to pain therapy in this patient group. The present review and recommendations are intended to support medical professionals in recognising the risks of pain chronicity, applying basic principles of multimodal pain therapy, including the options of psychological intervention and modalities of physical medicine in therapy concepts, and reaching a comprehensive understanding of the range of analgesic options available.
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Affiliation(s)
- Waltraud Stromer
- Department for Anaesthesia and General Intensive Care, Horn State Hospital, Spitalgasse 10, 3580, Horn, Austria
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna/Vienna General Hospital, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna/Vienna General Hospital, Vienna, Austria
| | - Richard Crevenna
- University Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna/Vienna General Hospital, Vienna, Austria
| | - Josef Donnerer
- Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Clemens Feistritzer
- University Hospital for Internal Medicine V/Haematology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sophie Hemberger
- University Department of Paediatric and Adolescent Medicine, Medical University of Vienna/Vienna General Hospital, Vienna, Austria
| | - Rudolf Likar
- Department for Anaesthesia and Intensive Care, State Hospital Klagenfurt am Woerthersee, Klagenfurt, Austria
- Wolfsberg State Hospital, Wolfsberg, Austria
- Palliative Care, Sigmund Freud University Vienna, Klagenfurt, Austria
| | - Florian Sevelda
- University Department of Orthopaedics and Trauma Surgery, Medical University of Vienna/Vienna General Hospital, Vienna, Austria
| | - Katharina Thom
- University Department of Paediatric and Adolescent Medicine, Medical University of Vienna/Vienna General Hospital, Vienna, Austria
| | - Barbara Wagner
- University Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna/Vienna General Hospital, Vienna, Austria
| | - Werner Streif
- Department of Pediatrics, Medical University of Innsbruck, Innrain 52, 6020, Innsbruck, Austria.
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22
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Levy-Mendelovich S, Brutman-Barazani T, Budnik I, Avishai E, Barg AA, Levy T, Misgav M, Livnat T, Kenet G. Real-World Data on Bleeding Patterns of Hemophilia A Patients Treated with Emicizumab. J Clin Med 2021; 10:jcm10194303. [PMID: 34640320 PMCID: PMC8509656 DOI: 10.3390/jcm10194303] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 09/01/2021] [Accepted: 09/15/2021] [Indexed: 02/05/2023] Open
Abstract
Emicizumab (Hemlibra™) is approved for prophylaxis of hemophilia A (HA) patients. The HAVEN studies addressed bleeding reduction in emicizumab-treated patients, but real-world data on bleeding patterns during emicizumab therapy are lacking. We aimed to compare the occurrence of breakthrough bleeding at different time points, starting from emicizumab initiation. This longitudinal prospective observational cohort study included HA patients (n = 70, aged 1 month to 74.9 years) that completed at least 18 months of follow-up in our center. We analyzed the number of spontaneous and traumatic bleeds during selected time points of the study (“bleeding periods”). The percentage of traumatic and spontaneous bleeding episodes was not significantly different among “bleeding periods” (P = 0.053 and P = 0.092, respectively). Most trauma-related treated bleeds resulted from either hemarthrosis (53%) or head trauma (33%). Spontaneous bleeding episodes were mostly hemarthroses (80%). Potential associations of the patients’ age, annualized bleeding rate before emicizumab treatment, and the presence of inhibitors with spontaneous bleed occurrence were analyzed with binomial logistic regression. The odds of bleeding while on emicizumab increased by a factor of 1.029 (P = 0.034) for every one year of age. Conclusions: Our real-world data revealed that the risk of bleeding persists, especially in older patients, despite therapy with emicizumab. These data may help clinicians in counselling their patients and in planning their management.
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Affiliation(s)
- Sarina Levy-Mendelovich
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Ramat Gan 52621, Israel; (S.L.-M.); (T.B.-B.); (E.A.); (A.A.B.); (M.M.); (T.L.)
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv 52621, Israel;
- The Sheba Talpiot Medical Leadership Program, Sheba Medical Center, Tel Hashomer, Ramat Gan 52621, Israel
| | - Tami Brutman-Barazani
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Ramat Gan 52621, Israel; (S.L.-M.); (T.B.-B.); (E.A.); (A.A.B.); (M.M.); (T.L.)
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv 52621, Israel;
| | - Ivan Budnik
- Department of Pathophysiology, Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia;
| | - Einat Avishai
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Ramat Gan 52621, Israel; (S.L.-M.); (T.B.-B.); (E.A.); (A.A.B.); (M.M.); (T.L.)
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv 52621, Israel;
| | - Assaf A. Barg
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Ramat Gan 52621, Israel; (S.L.-M.); (T.B.-B.); (E.A.); (A.A.B.); (M.M.); (T.L.)
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv 52621, Israel;
| | - Tamara Levy
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv 52621, Israel;
| | - Mudi Misgav
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Ramat Gan 52621, Israel; (S.L.-M.); (T.B.-B.); (E.A.); (A.A.B.); (M.M.); (T.L.)
| | - Tami Livnat
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Ramat Gan 52621, Israel; (S.L.-M.); (T.B.-B.); (E.A.); (A.A.B.); (M.M.); (T.L.)
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv 52621, Israel;
| | - Gili Kenet
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Ramat Gan 52621, Israel; (S.L.-M.); (T.B.-B.); (E.A.); (A.A.B.); (M.M.); (T.L.)
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv 52621, Israel;
- Correspondence: ; Tel.: +972-3-5302104; Fax: +972-3-5351568
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23
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Timmer MA, Blokzijl J, Schutgens REG, Veenhof C, Pisters MF. Coordinating physiotherapy care for persons with haemophilia. Haemophilia 2021; 27:1051-1061. [PMID: 34492151 PMCID: PMC9292005 DOI: 10.1111/hae.14404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/02/2021] [Accepted: 08/23/2021] [Indexed: 01/12/2023]
Abstract
Introduction Physiotherapy is highly recommended for persons with haemophilia (PWH), to regain functioning after bleeding and to maintain functioning when dealing with haemophilic arthropathy. However, many PWH live too far from their Haemophilia Comprehensive Care Centre (HCCC) to receive regular treatment at their HCCC. Physiotherapists in primary care may have limited experience with a rare disease like haemophilia. Aim To explore experiences of stakeholders with primary care physiotherapy for PWH and develop recommendations to optimize physiotherapy care coordination. Methods A RAND approach was used, consisting of a Delphi procedure with e‐mailed questionnaires and a consensus meeting. Included stakeholders were PWH, physiotherapists from HCCC's and primary care physiotherapists. HCCC physiotherapists approached patients from their centre and primary care physiotherapists from their network to fill in the questionnaires. Purposive sampling was used to select participants from the survey sample for the consensus meeting. Results Ninety‐six primary care physiotherapists, 54 PWH and eight HCCC physiotherapists completed the questionnaire. Subsequently, four PWH, three primary care physiotherapists and four HCCC physiotherapists participated in the consensus meeting. The questionnaires yielded 33 recommendations, merged into a final list of 20 recommendations based on the consensus meeting. The final rank‐order consists of 13 recommendations prioritized by at least one stakeholder. Conclusion Commitment to a formal network is considered not feasible for a rare disease like haemophilia. Development of a practice guideline, easy‐accessible information and contact details, two‐way and open communication between HCCC and primary care and criteria to refer back to the HCCC are recommended.
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Affiliation(s)
- Merel A Timmer
- Van Creveldkliniek, University Medical Centre Utrecht, Utrecht University, The Netherlands.,Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, UMC Utrecht Brain Centre, Utrecht University, The Netherlands
| | - Johan Blokzijl
- Van Creveldkliniek, University Medical Centre Utrecht, Utrecht University, The Netherlands.,Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, UMC Utrecht Brain Centre, Utrecht University, The Netherlands
| | - Roger E G Schutgens
- Van Creveldkliniek, University Medical Centre Utrecht, Utrecht University, The Netherlands
| | - Cindy Veenhof
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, UMC Utrecht Brain Centre, Utrecht University, The Netherlands.,Research Group Innovation of Human Movement Care, University of Applied Sciences Utrecht, The Netherlands
| | - Martijn F Pisters
- Center for Physical Therapy Research and Innovation in Primary Care, Julius Health Care Centres, The Netherlands
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Wells AJ, Stephensen D. The role of the physiotherapist in the management of people with haemophilia: defining the new normal. Br J Hosp Med (Lond) 2021; 81:1-8. [PMID: 32845767 DOI: 10.12968/hmed.2020.0016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Physiotherapists aim to maximise quality of life and movement potential within the spheres of promotion, prevention, treatment/intervention and rehabilitation. Haemophilia care is witnessing a significant shift towards a new era of potentially life-changing treatments which offer a future of minimal or no bleeds for people with haemophilia. As such, physiotherapy intervention should be more proactive rather than reactive to treat and rehabilitate recurrent bleeding episodes. The role of the physiotherapist within the multidisciplinary team includes the differential diagnosis of musculoskeletal bleeding, supporting and encouraging higher levels of physical activity, rehabilitation to maximise physical potential and capabilities, assessment and treatment of non-bleed-related musculoskeletal issues, managing comorbidities and falls risk, and improving the longitudinal surveillance of musculoskeletal health. Encouraging and supporting people with haemophilia to become more active will improve wellbeing and improve health and health outcomes, and physical activity is becoming one of the most important outcomes for people with haemophilia. Recommendations on the best way to accurately capture these data are vital to ensure the full health benefits of new treatments for people with haemophilia are clear.
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Affiliation(s)
- A J Wells
- Haemophilia, Haemostasis and Thrombosis Centre, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - D Stephensen
- Haemophilia Centre, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK.,Haemophilia Centre, Royal London Hospital, Bart's Health NHS Trust, London, UK Conflicts of interest
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25
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MRI predicts 5-year joint bleeding and development of arthropathy on radiographs in hemophilia. Blood Adv 2021; 4:113-121. [PMID: 31917842 DOI: 10.1182/bloodadvances.2019001238] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 12/11/2019] [Indexed: 01/01/2023] Open
Abstract
Magnetic resonance imaging (MRI) is considered as the reference standard to assess early joint changes in hemophilia. However, the clinical relevance of MRI findings is still unknown. The aim of this prospective study was to assess the predictive value of MRI for 5-year joint bleeding and progression of arthropathy in patients with hemophilia. Both knees and ankles of patients with hemophilia and absent or limited arthropathy on radiographs were assessed by using MRI and radiographs. MRI scans were scored according to the International Prophylaxis Study Group MRI score for hemophilic arthropathy. Patients were followed up for 5 years, including assessment of joint bleeding and repeated radiographic assessment. Associations between baseline MRI findings with 5-year bleeding and progression of arthropathy were expressed as odds ratios (OR), adjusted for severity of disease and joint bleeding history. Baseline assessment included 104 joints of 26 patients with hemophilia (median age, 21 years). Four ankles with severe joint changes were excluded. Follow-up was available for 96 (92%) of 104 joints. During 5 years of follow-up, bleeding was reported for 36% of joints. Five-year bleeding was significantly increased in joints with synovial hypertrophy at 80% vs 27% in joints without synovial hypertrophy (OR, 10.1; 95% confidence interval, 3.4-31.3). In joints with normal baseline radiographs, any osteochondral or synovial changes on MRI were associated with radiographic changes 5 years later (positive predictive value, 75%; negative predictive value, 98%). Joints with synovial hypertrophy on MRI had a significantly higher chance of 5-year bleeding. All MRI changes, except effusion, were strong predictors for development of arthropathy on radiographs.
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26
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Keret S, Kaly L, Shouval A, Eshed I, Slobodin G. Approach to a patient with monoarticular disease. Autoimmun Rev 2021; 20:102848. [PMID: 33971340 DOI: 10.1016/j.autrev.2021.102848] [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] [Revised: 03/07/2021] [Accepted: 03/16/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To reassess the diagnostic approach to a patient with a monoarticular disease in light of the up-to-date medical literature and to examine the practical utility of traditional and newer imaging tools in the setting of monoarthritis. RESULTS The monoarticular disease can represent a medical emergency on the one hand and be a diagnostic conundrum on the other. The management rules of patients with monoarthritis have been established long ago, but various pitfalls still lead physicians off the right diagnosis at times. Septic, pseudoseptic arthritis and hemarthrosis are the most common diagnoses made in patients with an acute presentation, and a decision not to perform a diagnostic arthrocentesis is the most prevalent cause of misdiagnosis in this setting. Many rheumatic and infectious diseases can present with more indolent monoarthritis; careful history and physical examination frequently provide clues to the straightforward diagnosis in some cases, but the extensive investigation is needed in others. Imaging methods become indispensable in individuals with the non-inflammatory monoarticular disease, with magnetic resonance imaging being the gold standard for diagnosing pigmented villonodular synovitis, lipoma arborescence, avascular necrosis, or neuropathic arthropathy. CONCLUSIONS A great variety of medical disorders can present as a monoarticular disease. The disease presentation dictates different diagnostic behavior, while knowing the available imaging methods' diagnostic potential should further shorten the diagnostic process.
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Affiliation(s)
- Shiri Keret
- Internal Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Lisa Kaly
- Rheumatology Unit, Bnai-Zion Medical Center and Technion, Haifa, Israel; Ruth & Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Aniela Shouval
- Rheumatology Unit, Bnai-Zion Medical Center and Technion, Haifa, Israel
| | - Iris Eshed
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Gleb Slobodin
- Rheumatology Unit, Bnai-Zion Medical Center and Technion, Haifa, Israel; Ruth & Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.
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27
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Thorpe N, Harniess P, Main E, Hubert N, Rand S, Stephensen D, Liesner R, Bladen M. Feasibility, safety and acceptability of select outcome measures in a physiotherapy study protocol for boys with haemophilia. Pilot Feasibility Stud 2021; 7:105. [PMID: 33957997 PMCID: PMC8099992 DOI: 10.1186/s40814-021-00831-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 04/03/2021] [Indexed: 12/20/2022] Open
Abstract
Background There is a lack of functional performance measures for children and young people with haemophilia (CYPwH) with associated control data from typically developing boys (TDB). The literature advocates development of a core set of outcome measures for different chronic conditions. As medical treatment improves, CYPwH are experiencing better outcomes; therefore, more challenging measures are required to monitor physical performance. Such testing is not performed routinely, due to practical and safety concerns. Aim Evaluate the feasibility, safety and acceptability of select outcome measures as part of a study protocol testing CYPwH; including myometry, 10 metre incremental shuttle walk test (10-m ISWT), iSTEP (an incremental step test, with data from TDB), and 1 week of accelerometry-wear at home. Methods Sixty-six boys aged 6–15 years with mild, moderate or severe haemophilia A or B (including inhibitors) attending routine clinics at Great Ormond Street Hospital were approached to participate. Descriptive statistics and content analysis were used to assess outcomes of feasibility, safety and acceptability, which included recruitment/retention rates, protocol completion within routine appointment timeframes, performance testing without serious adverse events/reactions (SAE/SARs), and acceptability to CYPwH of high-level performance measures. Results Outcomes were met: 43 boys completed testing at clinic review (Jan–Nov 2018) within a 10-month timeframe, retention was 95% at completion of protocol and no SAE/SARs were reported throughout testing. Conclusion Feasibility, safety and acceptability of the study protocol have been established in this population. Both high-level performance tests, iSTEP and 10-m ISWT, were an acceptable addition to boys’ routine clinic appointments and could be safe, acceptable choices of outcome measure as part of a core set of tests for CYPwH. Further investigation of the psychometric properties for the iSTEP is now justified, in order for it to be used as a standardised, validated, reliable outcome measure in clinical or research settings. Trial registration Retrospectively registered on September 3, 2019, on ClinicalTrials.gov (ID: NCT04076306). Supplementary Information The online version contains supplementary material available at 10.1186/s40814-021-00831-1.
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Affiliation(s)
- Nicola Thorpe
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
| | - Phillip Harniess
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Eleanor Main
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Nicola Hubert
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Sarah Rand
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - David Stephensen
- Kent Haemophilia Centre, Kent and Canterbury Hospital, Canterbury, UK
| | - Ri Liesner
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Melanie Bladen
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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28
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Jiménez-Yuste V, de la Corte-Rodríguez H, Álvarez-Román MT, Martín-Salces M, Querol F, Bonanad S, Mingot-Castellano ME, Fernández-Mosteirín N, Canaro M, Santamaría A, Núñez R, García-Frade LJ, Martinoli C, Kim HK. Ultrasound evaluation of joint damage and disease activity in adult patients with severe haemophilia A using the HEAD-US system. Haemophilia 2021; 27:479-487. [PMID: 33620134 DOI: 10.1111/hae.14280] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/25/2021] [Accepted: 02/05/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The Haemophilia Early Arthropathy Detection with Ultrasound (HEAD-US) system and scoring scale has proven to be an accurate and time-efficient imaging method for identifying joint damage in patients with haemophilia. AIM Observational, multicentre, cross-sectional study conducted in 8 centres in Spain that assessed the joint status of adult patients with severe haemophilia A (SHA) using HEAD-US. METHODS Joint status of the elbow, knee and ankle was evaluated in adults with SHA receiving on-demand (OD) treatment, or primary (PP), secondary (SP), tertiary (TP) or intermittent (IP) prophylaxis. RESULTS Of the 95 patients enrolled, 87 received prophylaxis (6.3% PP, 38.9% SP, 43.2% TP and 3.2% IP). Mean age was 35.2 years, and 59% of patients had not undergone image testing in the last year. The HEAD-US score was 0 in all joints in 6.3% of patients. The ankle was the most affected joint, regardless of treatment regimen. Patients receiving OD treatment, TP or IP had the overall worst scores, mainly in the ankles and elbows; a similar but milder profile was observed in patients on SP; and patients on PP had the best score in all joints. CONCLUSION Joint function may be effectively preserved in patients with SHA on PP, but OD treatment or later initiation of prophylaxis does not seem to prevent progression of arthropathy. Disease worsening was observed in patients OD, TP or IP, most often affecting ankles and elbows. Closer ultrasound imaging monitoring may improve management of these patients.
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Affiliation(s)
- Víctor Jiménez-Yuste
- Department of Haematology, Hospital Universitario La Paz, Autonoma University, Madrid, Spain
| | | | | | | | - Felipe Querol
- University of Valencia and Haemostasis and Thrombosis Unit, Department of Haematology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Santiago Bonanad
- Haemostasis and Thrombosis Unit. Department of Haematology, Hospital Universitari i Politècnic La Fe, University of Valencia, Valencia, Spain
| | - María Eva Mingot-Castellano
- Department of Haematology, Hospital Regional Universitario de Málaga, Malaga, Spain.,Department of Haematology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | - Mariana Canaro
- Department of Haemostasis and Thrombosis, Hospital Universitario Son Espases, Mallorca, Spain
| | - Amparo Santamaría
- Department of Thrombosis and Haemostasis, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ramiro Núñez
- Department of Haematology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | - Carlo Martinoli
- Dipartimento di Scienze della Salute Department of Health Sciences (DISSAL) and IRCCS Ospedale Policlinico San Martino, Genova, University of Genoa, Genoa, Italy
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29
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EPCR deficiency or function-blocking antibody protects against joint bleeding-induced pathology in hemophilia mice. Blood 2021; 135:2211-2223. [PMID: 32294155 DOI: 10.1182/blood.2019003824] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 03/18/2020] [Indexed: 02/06/2023] Open
Abstract
We recently showed that clotting factor VIIa (FVIIa) binding to endothelial cell protein C receptor (EPCR) induces anti-inflammatory signaling and protects vascular barrier integrity. Inflammation and vascular permeability are thought to be major contributors to the development of hemophilic arthropathy following hemarthrosis. The present study was designed to investigate the potential influence of FVIIa interaction with EPCR in the pathogenesis of hemophilic arthropathy and its treatment with recombinant FVIIa (rFVIIa). For this, we first generated hemophilia A (FVIII-/-) mice lacking EPCR (EPCR-/-FVIII-/-) or overexpressing EPCR (EPCR++ FVIII-/-). Joint bleeding was induced in FVIII-/-, EPCR-/-FVIII-/-, and EPCR++FVIII-/- mice by needle puncture injury. Hemophilic synovitis was evaluated by monitoring joint bleeding, change in joint diameter, and histopathological analysis of joint tissue sections. EPCR deficiency in FVIII-/- mice significantly reduced the severity of hemophilic synovitis. EPCR deficiency attenuated the elaboration of interleukin-6, infiltration of macrophages, and neoangiogenesis in the synovium following hemarthrosis. A single dose of rFVIIa was sufficient to fully prevent the development of milder hemophilic synovitis in EPCR-/-FVIII-/- mice. The development of hemophilic arthropathy in EPCR-overexpressing FVIII-/- mice did not significantly differ from that of FVIII-/- mice, and 3 doses of rFVIIa partly protected against hemophilic synovitis in these mice. Consistent with the data that EPCR deficiency protects against developing hemophilic arthropathy, administration of a single dose of EPCR-blocking monoclonal antibodies markedly reduced hemophilic synovitis in FVIII-/- mice subjected to joint bleeding. The present data indicate that EPCR could be an attractive new target to prevent joint damage in hemophilia patients.
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30
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Liu W, Li H, Tong H, Hu H, Zhao Y, Ye B. A rare case of long-term complications of squamous cell carcinoma in haemophilia B after arthrocentesis, and review of the literature. Haemophilia 2021; 27:e406-e408. [PMID: 33471935 DOI: 10.1111/hae.14255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 12/08/2020] [Accepted: 12/20/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Wenbin Liu
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Hangchao Li
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Hongxuan Tong
- Institute of Basic Theory for Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Huijin Hu
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Yuechao Zhao
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Baodong Ye
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
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31
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Santos AO, Ricciardi JBS, Pagnano R, Pereira LFM, Sakuma ET, Matsuda MMN, Bernardes ES, Araújo EB, Brunetto SQ, Takahashi MES, Brunetto EM, Zulli R, Ozelo MC, Etchebehere ECSC. Knee radiosynovectomy with 153Sm-hydroxyapatite compared to 90Y-hydroxyapatite: initial results of a prospective trial. Ann Nucl Med 2021; 35:232-240. [PMID: 33389651 DOI: 10.1007/s12149-020-01557-5] [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: 07/30/2020] [Accepted: 11/19/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Radiosynovectomy (RS) with 90Y-hydroxyapatite (90Y-HyA) aims to control knee hemarthrosis in hemophiliac patients to prevent secondary arthropathy. However, knee RS using 153Sm-hydroxyapatite (153Sm-HyA) is considered less suitable due to the lower average soft tissue range and energy of 153Sm for large joints, such as the knees. PURPOSE The objective of this investigation was to assess the efficacy and safety of knee RS with 153Sm-HyA, compared to 90Y-HyA. METHODS Forty patients were prospectively assigned to undergo knee RS with 153Sm-HyA (n = 19) or with 90Y-HyA (n = 21). The frequency of hemarthrosis episodes before and after treatment were compared. RESULTS After six months of knee RS, 153Sm-HyA and 90Y-HyA promoted a similar reduction of hemarthrosis episodes (50% and 66.7%, respectively). However, after 12 months of knee RS, the reduction of hemarthrosis episodes was significantly (p = 0.037) higher using 153Sm-HyA (87.5%) compared to 90Y-HyA (50.0%). This discrepancy was more pronounced (p = 0.002) for 153Sm-HyA compared to 90Y-HyA in adults/adolescents. CONCLUSION Knee radiosynovectomy with 153Sm-HyA is safe, reduces hemarthrosis episodes after 12 months of treatments, especially in adults/adolescents and even with grades III/IV arthropathy, similar to 90Y-HyA. 90Y-HyA seems to promote better hemarthrosis control in small children.
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Affiliation(s)
- Allan O Santos
- Division of Nuclear Medicine of the Department of Radiology, University of Campinas (UNICAMP), Campinas, Brazil.
| | - Janaina B S Ricciardi
- Hemophilia Unit of Hemocentro UNICAMP, University of Campinas (UNICAMP), Campinas, Brazil
| | - Rodrigo Pagnano
- Department of Orthopedics and Traumatology of the Department of Surgery, University of Campinas (UNICAMP), Campinas, Brazil
| | - Luis Fernando M Pereira
- Division of Nuclear Medicine of the Department of Radiology, University of Campinas (UNICAMP), Campinas, Brazil
| | - Emerson T Sakuma
- Division of Ultrasound of the Department of Radiology, University of Campinas (UNICAMP), Campinas, Brazil
| | - Margareth M N Matsuda
- Radiopharmacy Center of the Nuclear and Energy Research Institute (IPEN/CNEN), São Paulo, Brazil
| | - Emerson S Bernardes
- Radiopharmacy Center of the Nuclear and Energy Research Institute (IPEN/CNEN), São Paulo, Brazil
| | - Elaine B Araújo
- Radiopharmacy Center of the Nuclear and Energy Research Institute (IPEN/CNEN), São Paulo, Brazil
| | - Sérgio Q Brunetto
- Center of Biomedical Engineering, University of Campinas, Campinas, Brazil
| | | | - Edna M Brunetto
- Division of Nuclear Medicine of the Department of Radiology, University of Campinas (UNICAMP), Campinas, Brazil
| | - Roberto Zulli
- Hemophilia Unit of Hemocentro UNICAMP, University of Campinas (UNICAMP), Campinas, Brazil
| | - Margareth C Ozelo
- Hemophilia Unit of Hemocentro UNICAMP, University of Campinas (UNICAMP), Campinas, Brazil
| | - Elba C S C Etchebehere
- Division of Nuclear Medicine of the Department of Radiology, University of Campinas (UNICAMP), Campinas, Brazil
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Woo E, Kumbhare D, Winston P. Incapacitating pain from Tenofovir Induced Hypophosphatemic Osteomalacia in a Hemophilia Patient - A Case Report. CANADIAN JOURNAL OF PAIN-REVUE CANADIENNE DE LA DOULEUR 2020; 4:287-291. [PMID: 33987506 PMCID: PMC7951154 DOI: 10.1080/24740527.2020.1838890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background: Pain in patients with hemophilia is common and usually a result of arthropathy. Clinicians should, however, consider a wide range of etiologies for pain in patients with hemophilia including infection, osteoporotic fractures, arthritis, and osteomalacia. Aims: This case demonstrates an instance of poorly localized back and hip pain, severe enough to prevent ambulation, caused by hypophosphatemic osteomalacia due to tenofovir treatment for blood transfusion acquired Human Immunodeficiency Virus (HIV) in a patient with hemophilia A. Methods: Case Report. Results: With termination of tenofovir treatment, this patient returned to baseline function. Conclusion: This report serves to emphasize the need for accurate diagnosis of pain in hemophilia patients, especially among the aging demographic of people with hemophilia in which there is a significant likelihood of an HIV infection and among patients who may be on Pre-exposure Prophylaxis (PrEP) or clinical trials involving tenofovir.
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Affiliation(s)
- Emma Woo
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dinesh Kumbhare
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Paul Winston
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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33
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Rodriguez-Merchan EC, De la Corte-Rodriguez H. Complications of hemophilia in the elbow: current management. Expert Rev Hematol 2020; 13:991-1001. [PMID: 32723183 DOI: 10.1080/17474086.2020.1803061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION After the ankle and knee, the elbow is the most commonly impaired joint in patients with hemophilia. AREAS COVERED A Cochrane Library and PubMed (MEDLINE) search related to elbow problems in hemophilia was conducted. Early and continuous primary hematological prophylaxis (ideally starting in infancy) is essential, given that the juvenile elbow is highly prone to the musculoskeletal complications of hemophilia. If primary hematological prophylaxis is not administered (due either to lack of affordability or lack of venous access), persistent hemarthrosis can occur in the elbow. Hemarthroses will then require aggressive treatment (through arthrocentesis under factor factor coverage) to prevent progression to synovitis (requiring prompt radiosynovectomy or arthroscopic synovectomy) and ultimately hemophilic arthropathy (requiring rehabilitation and orthopedic surgery). Between the second and fourth decade of life, many patients with hemophilia present elbow joint destruction. EXPERT OPINION In the initial stage of joint destruction, rehabilitation and intraarticular injections of hyaluronic acid can relieve the symptoms. In the advanced stage of hemophilic arthropathy, however, surgery is necessary. The main surgical procedures currently available are arthroscopic debridement, radial head resection, and total elbow arthroplasty. Transposition of the ulnar nerve and removal of heterotopic ossifications might also be necessary.
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Lin PC, Chiou SS, Hsu WY, Liao YM, Tsai SP, Su HL, Lu PT, Tseng YH. Plasma levels of IL-1β and IL-37 in patients with severe haemophilia. J Int Med Res 2020; 48:300060520940512. [PMID: 32691667 PMCID: PMC7375719 DOI: 10.1177/0300060520940512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objective Haemophilia A and B are disorders caused by the lack of clotting factors VIII and IX, respectively. Repeated bleeding into the same joint leads to haemophilic arthropathy (HA). Interleukin (IL)-1β is responsible for the pro-inflammatory response and IL-37 is induced by IL-1β stimuli to have an anti-inflammatory response and prevent uncontrolled inflammation and tissue damage. Our objective was to investigate plasma levels of IL-1β and IL-37 in patients with severe haemophilia with different severities of HA. Methods Peripheral blood samples were collected from 14 patients with severe haemophilia A and 6 with severe haemophilia B, and 18 healthy individuals. Plasma levels of IL-1β and IL-37 were detected by immunoassay, and severity of HA was evaluated using the Pettersson scoring system. Plasma levels of IL-1β and IL-37 were analysed in patients with severe haemophilia grouped by Pettersson score and in healthy individuals. Results Plasma levels of IL-1β and IL-37 were significantly higher in patients with severe haemophilia compared with healthy individuals and significantly lower in those with moderate to severe HA than in those with no or mild HA. Conclusions Plasma levels of IL-1β and IL-37 may be useful to track HA progression in patients with severe haemophilia.
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Affiliation(s)
- Pei-Chin Lin
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Special Hematologic Disease Service Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shyh-Shin Chiou
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Special Hematologic Disease Service Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wan-Yi Hsu
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Special Hematologic Disease Service Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Mei Liao
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Special Hematologic Disease Service Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shih-Pien Tsai
- Special Hematologic Disease Service Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsiu-Lan Su
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ping-Tao Lu
- Special Hematologic Disease Service Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Hsin Tseng
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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Calcaterra I, Iannuzzo G, Dell'Aquila F, Di Minno MND. Pathophysiological Role of Synovitis in Hemophilic Arthropathy Development: A Two-Hit Hypothesis. Front Physiol 2020; 11:541. [PMID: 32581836 PMCID: PMC7296047 DOI: 10.3389/fphys.2020.00541] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 04/30/2020] [Indexed: 12/13/2022] Open
Abstract
Despite an increasing access to prophylaxis with clotting factor concentrates, arthropathy still represents the main chronic complication of hemophilia. Whereas previous studies described hemophilic arthropathy (HA) as a degenerative arthropathy, somehow resembling osteoarthritis (OA), most recent evidence suggests that complex inflammatory and immunologic mechanisms are also involved in the pathophysiology of HA. In the present review, we described available data on major mechanisms leading to arthropathic changes in patients with hemophilia, with a specific focus on the role of synovium. The presence of hemosiderin in the joint space induces synovium proliferation, thus leading to formation of several lytic enzymes determining chondrocytes apoptosis and proteoglycans levels reduction. This leads to a direct joint “chemical” damage representing early damages in the pathogenesis of HA (first hit). In parallel, synovial membrane and synovial endothelial cells become a dynamic reservoir of inflammatory cells and mediators, and propagate the inflammatory response (second hit), switching the process from a chemical damage to an inflammatory damage. Overall, consistent data pointed out synovitis as the keystone in HA pathophysiology. This opens novel potential therapeutic targets in this clinical setting.
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Affiliation(s)
- Ilenia Calcaterra
- Department of Clinical Medicine and Surgery, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Gabriella Iannuzzo
- Department of Clinical Medicine and Surgery, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Francesco Dell'Aquila
- Department of Clinical Medicine and Surgery, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
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36
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Valentino LA, Khair K. Prophylaxis for hemophilia A without inhibitors: treatment options and considerations. Expert Rev Hematol 2020; 13:731-743. [PMID: 32573295 DOI: 10.1080/17474086.2020.1775576] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Hemophilia A is a bleeding disorder traditionally managed with standard half-life (SHL) factor (F) VIII concentrates. Extended half-life (EHL) FVIII products and emicizumab-kywh, a nonfactor therapy, are newer treatment options. Additional nonfactor agents and gene therapy are expected to reach the market in the near future. AREAS COVERED A PubMed (MEDLINE) search from 1962 to April 2020 related to hemophilia A, its management, and the products currently available for prophylaxis was performed to comprehensively review these topics and analyze the benefits and drawbacks of each therapeutic. EXPERT OPINION Prophylaxis with SHL FVIII concentrates remains the standard of care for patients with severe hemophilia A and may also be considered for selected individuals with moderate disease. Several years of real-world experience with EHL FVIII, emicizumab-kywh, and other agents in development will be necessary to determine their ultimate roles in the prevention of bleeding and its complications. Gene therapy may not provide a permanent cure for hemophilia A.
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Affiliation(s)
- Leonard A Valentino
- Rush University , Chicago, IL, USA.,National Hemophilia Foundation , New York, NY, USA
| | - Kate Khair
- Centre for Outcomes Research and Experience in Children's Health, Illness, and Disability, Great Ormond Street Hospital for Children, NHS Trust , London, UK
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Ratajová K, Blatný J, Poláčková Šolcová I, Meier Z, Horňáková T, Brnka R, Tavel P. Social support and resilience in persons with severe haemophilia: An interpretative phenomenological analysis. Haemophilia 2020; 26:e74-e80. [PMID: 32291937 PMCID: PMC7383587 DOI: 10.1111/hae.13999] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 03/25/2020] [Indexed: 12/21/2022]
Abstract
Introduction Haemophilia is a hereditary haemorrhagic disorder characterized by deficiency or dysfunction of coagulation factors. Recurrent joint and muscle bleeds lead to progressive musculoskeletal damage. Haemophilia affects patients physically but also socially and psychologically. Traumatic experiences, chronic stress and illnesses can lead to mental disorders, but many persons with haemophilia maintain a highly positive outlook. Aim To explore qualitatively which coping mechanisms persons with haemophilia use and in what way they help them to live with their diagnosis. Methods We recruited five adults with haemophilia and conducted semi‐structured face‐to‐face interviews. Transcripts were analysed using interpretative phenomenological analysis (IPA). Results Two core themes emerged from the analysis: social support as an external factor and resilience as an internal factor of coping with the disease. Persons with haemophilia usually need help with health‐related complications, and this affects the social support they require. Their wider support network tends to involve family and friends but also healthcare professionals and other specialists. This network provides practical help but also functions as an important psychological protective factor. An unexpected finding was that persons with haemophilia want not only to receive support but are also keen to offer support to others. Conclusion These findings can help identify persons who provide most support to people suffering from haemophilia. Haemophilic centres should include in their teams psychologists and social workers and offer individual and group therapy to their clients, group meetings for friends and families of persons with haemophilia, provide learning resources to teachers aiming to incorporate children with haemophilia in their peer group, and organize Balint groups for physicians, psychologists and other healthcare professionals.
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Affiliation(s)
- Kateřina Ratajová
- Olomouc University Social Health Institute, Palacky University Olomouc, Olomouc, Czech Republic
| | - Jan Blatný
- Department of Paediatric Haematology, Haemophilia Comprehensive Care Centre, Children's University Hospital Brno and Masaryk University, Brno, Czech Republic
| | - Iva Poláčková Šolcová
- Olomouc University Social Health Institute, Palacky University Olomouc, Olomouc, Czech Republic.,Institute of Psychology, Czech Academy of Sciences, Praha, Czech Republic
| | - Zdeněk Meier
- Olomouc University Social Health Institute, Palacky University Olomouc, Olomouc, Czech Republic
| | - Tekla Horňáková
- Olomouc University Social Health Institute, Palacky University Olomouc, Olomouc, Czech Republic
| | - Robert Brnka
- Olomouc University Social Health Institute, Palacky University Olomouc, Olomouc, Czech Republic.,First Department of Internal Medicine, Faculty of Medicine Comenius University Bratislava, Bratislava, Slovak Republic
| | - Peter Tavel
- Olomouc University Social Health Institute, Palacky University Olomouc, Olomouc, Czech Republic
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38
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Tebo C, Gibson C, Mazer-Amirshahi M. Hemophilia and von Willebrand Disease: A Review of Emergency Department Management. J Emerg Med 2020; 58:756-766. [PMID: 32249010 DOI: 10.1016/j.jemermed.2020.02.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 01/19/2020] [Accepted: 02/16/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hemophilia and von Willebrand disease (VWD) are the most common congenital coagulation factor deficiencies. Patients with these disorders who experience bleeding complications are often initially managed in the emergency department (ED). OBJECTIVE OF THE REVIEW This review will focus on the emergency department management of patients with these disorders and provide an update on current treatment options. DISCUSSION The mainstay of management is initial stabilization, control of bleeding when possible, and administration of specific factors. Early coordination of care with hematology is critical. CONCLUSIONS Emergency medicine providers must have an understanding of the pathophysiology, clinical presentation, and management strategies in order to optimally care for these complex patients.
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Affiliation(s)
- Collin Tebo
- Georgetown University School of Medicine, Washington, DC
| | - Colin Gibson
- Georgetown University School of Medicine, Washington, DC
| | - Maryann Mazer-Amirshahi
- Georgetown University School of Medicine, Washington, DC; Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC
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Forsyth A, Blamey G, Lobet S, McLaughlin P. Practical Guidance for Non-Specialist Physical Therapists Managing People with Hemophilia and Musculoskeletal Complications. Health (London) 2020. [DOI: 10.4236/health.2020.122014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Damoctocog alfa pegol (Jivi®) is approved in the USA, EU, Japan and Canada for the treatment and prophylaxis of previously treated patients aged ≥ 12 years with haemophilia A. Formulated with a 60 kDa polyethylene glycol (PEG) moiety, damoctocog alfa pegol is an intravenously (IV) administered recombinant factor VIII (rFVIII) product with a longer terminal half-life than non-PEGylated FVIII and rFVIII products. In the multinational phase II/III PROTECT VIII trial, prophylaxis with damoctocog alfa pegol reduced the likelihood of bleeding in previously treated patients aged ≥ 12 years with severe haemophilia A, with dosing schedules ranging from twice weekly to once every 7 days. Interim data from the ongoing extension phase indicated that the reduced annualized bleeding rates (ABRs) were maintained for up to 5.2 years of prophylaxis with damoctocog alfa pegol. Damoctocog alfa pegol was also effective in treating bleeding episodes and in providing haemostatic control during surgery. Damoctocog alfa pegol was generally well tolerated in adult and adolescent patients with severe haemophilia A, with most adverse events considered to be unrelated to treatment. There were no new or confirmed cases of FVIII inhibitor development and anti-PEG antibodies, observed in some patients, were of low titre and transient. Damoctocog alfa pegol extends the available treatment options in previously treated adults and adolescents with haemophilia A, offering the possibility of up to once-weekly administration for suitable patients.
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Affiliation(s)
- Julia Paik
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
| | - Emma D Deeks
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand
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Taves S, Sun J, Livingston EW, Chen X, Amiaud J, Brion R, Hannah WB, Bateman TA, Heymann D, Monahan PE. Hemophilia A and B mice, but not VWF -/-mice, display bone defects in congenital development and remodeling after injury. Sci Rep 2019; 9:14428. [PMID: 31594977 PMCID: PMC6783554 DOI: 10.1038/s41598-019-50787-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 09/19/2019] [Indexed: 12/31/2022] Open
Abstract
While joint damage is the primary co-morbidity of hemophilia, osteoporosis and osteopenia are also observed. Coagulation factor VIII deficient (FVIII−/−) mice develop an osteoporotic phenotype in the absence of induced hemarthrosis that is exacerbated two weeks after an induced joint injury. Here we have compared comprehensively the bone health of clotting factor VIII, factor IX, and Von Willebrand Factor knockout (FVIII−/−, FIX−/−, and VWF−/− respectively) mice both in the absence of joint hemorrhage and following induced joint injury. We found FVIII−/− and FIX−/− mice, but not VWF−/− mice, developmentally have an osteoporotic phenotype. Unilateral induced hemarthrosis causes further bone damage in both FVIII−/− and FIX−/− mice, but has little effect on VWF−/− bone health, indicating that the FVIII.VWF complex is not required for normal bone remodeling in vivo. To further investigate the bone healing following hemarthrosis in hemophilia we examined a two week time course using microCT, serum chemistry, and histological analysis. Elevated ratio of osteoprotegerin (OPG)/receptor activator of nuclear factor-kappa B ligand (RANKL), increased osterix+ osteoblastic cells, and decreased smoothness of the cortical bone surface were evident within several days of injury, indicative of acute heterotopic mineralization along the cortical surface. This was closely followed by increased interleukin-6 (IL-6) levels, increased osteoclast numbers, and significant trabecular bone loss. Uncoupled and disorganized bone formation and resorption continued for the duration of the study resulting in significant deterioration of the joint. Further elucidation of the shared mechanisms underlying abnormal bone homeostasis in the absence of FVIII or FIX is needed to guide evidence-based approaches to the screening and treatment of the prevalent bone defects in hemophilia A and B.
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Affiliation(s)
- Sarah Taves
- Department of Biomedical Engineering, University of North Carolina, Chapel Hill, NC, USA.,Global Research, Novo Nordisk A/S, Maløv, Denmark
| | - Junjiang Sun
- Gene Therapy Center, University of North Carolina, Chapel Hill, NC, USA.,Division of Molecular Pharmaceutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Eric W Livingston
- Department of Biomedical Engineering, University of North Carolina, Chapel Hill, NC, USA
| | - Xin Chen
- Gene Therapy Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jerome Amiaud
- INSERM, U1238, Faculty of Medicine, Université de Nantes, Nantes, F-44093, France
| | - Regis Brion
- INSERM, U1238, Faculty of Medicine, Université de Nantes, Nantes, F-44093, France
| | - William B Hannah
- Gene Therapy Center, University of North Carolina, Chapel Hill, NC, USA
| | - Ted A Bateman
- Department of Biomedical Engineering, University of North Carolina, Chapel Hill, NC, USA.,Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC, USA
| | - Dominique Heymann
- INSERM, U1232, CRCiNA, Institut de Cancérologie de l'Ouest, Université de Nantes, Université d'Angers, Saint-Herblain, F-44805, France. .,University of Sheffield, INSERM, Associated European Laboratory Sarcoma Research Unit, Department of Oncology and Metabolism, Sheffield, S10 2RX, UK.
| | - Paul E Monahan
- Gene Therapy Center, University of North Carolina, Chapel Hill, NC, USA. .,Harold R. Roberts Comprehensive Hemophilia Diagnosis and Treatment Center, University of North Carolina, Chapel Hill, NC, USA. .,Spark Therapeutics, Philadelphia, PA, USA.
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Bradshaw E, McClellan C, Whybrow P, Cramp F. Physiotherapy outcome measures of haemophilia acute bleed episodes: What matters to patients? Haemophilia 2019; 25:1066-1072. [PMID: 31522466 DOI: 10.1111/hae.13840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/22/2019] [Accepted: 08/05/2019] [Indexed: 01/23/2023]
Abstract
INTRODUCTION The research was conducted at a UK teaching hospital and Haemophilia Comprehensive Care Centre (CCC) as part of a research programme investigating physiotherapy for acute bleed management. AIM The aim of the study was to understand the perspectives of people with haemophilia (PWH) on validated outcome measures (OM) and whether these measures capture changes relevant to them whilst recovering from an acute bleed episode. METHODS Any person with haemophilia registered to the CCC who reported an acute bleed within the past 2 years was invited to participate. Semi-structured interviews or workshops (activity-focused discussions with small groups) were conducted with PWH who had received physiotherapy treatment in the previous two years. These were used to explore opinions of PWH of commonly used outcome measures. RESULTS Eight male PWH participated, mean age 61 years, ranging between 39 and 71. Seven participants had severe haemophilia A and 1 had von Willebrands. Participants described numerical rating scales of pain as abstract and expressed a preference for verbal or visual descriptors. In relation to function, the men generally found haemophilia-specific OM to be more relevant. The EuroQol 5-Dimension 5-Level (EQ5D-5L) and Haemophilia and Exercise Project Test Questionnaire (HEP-Test-Q) were considered as good measures due to brevity and ability to capture relevant changes promptly. CONCLUSION Participants in this study reported a preference for short OMs that allow them to reference their ability during the acute bleed episode in comparison with their normal function.
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Affiliation(s)
| | - Carey McClellan
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - Fiona Cramp
- University of the West of England, Bristol, UK
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Leroy V, Freyssenge J, Renard F, Tazarourte K, Négrier C, Chamouard V. Access to treatment among persons with hemophilia: A spatial analysis assessment in the Rhone-Alpes region, France. J Am Pharm Assoc (2003) 2019; 59:797-803. [PMID: 31405805 DOI: 10.1016/j.japh.2019.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 04/23/2019] [Accepted: 07/08/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES In France, only hospital pharmacies can dispense clotting factor concentrates to persons with hemophilia, which limits the access to care for the treatment and the prevention of bleeding episodes. Moreover, the cost of clotting factor concentrates may restrain the maintenance of sufficient stocks in hospital pharmacies. The aim of this study was to investigate the accessibility of clotting factor concentrates to persons with hemophilia in the context of long-term prophylaxis and emergency treatment in the Rhone-Alpes region of France. METHODS A geographic information system was used for evaluating accessibility of clotting factor concentrates. Persons with hemophilia and hospital pharmacies were geolocalized with the use of postal data, and the evaluation of accessibility was based on the road network. RESULTS Approximately 72% of the study area was accessible in less than 30 minutes to a hospital pharmacy. Eighty-five percent of persons with hemophilia had access to clotting factor concentrates for prophylactic treatment in less than 20 minutes. Most of them were patients with severe or moderate hemophilia. Regarding emergency doses, factor VIII was accessible in less than 30 minutes in 45.6% of the study area, and factor IX in 30.5%. CONCLUSION This study highlights that spatial access to clotting factor concentrates by persons with hemophilia in the Rhône-Alpes region is good for prophylactic treatment but is more uneven for emergency doses.
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44
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Lee A. Emergency management of patients with bleeding disorders: Practical points for the emergency physician. Transfus Apher Sci 2019; 58:553-562. [PMID: 31416711 DOI: 10.1016/j.transci.2019.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Emergency department (ED) physicians are often the first point of contact for patients who present with bleeding symptoms. Work up and management of bleeding in the emergency room can be a daunting task as it requires: (1) accurate diagnosis of the bleeding cause, of which there is long list of common and rare etiologies (2); appropriate investigations and interpretation of the results; and (3) timely management of bleeding symptoms to prevent limb- or life-threatening complications. Crucial to the management of a bleeding patient is a thorough yet focused history exploring bleeding symptoms, medications/drugs (anticoagulants, antiplatelets), mechanism of trauma/injury, personal and family history of diagnosed bleeding disorders or bleeding symptoms and recognizing acuity and severity of bleeding that requires immediate intervention. Physical examination should focus on signs of mucocutaneous versus deep tissue or joint bleeding and assessing for structural lesions that may contribute to bleeding symptoms in patients with known bleeding diathesis. In patients with diagnosed bleeding disorders, emergency care cards will usually outline the initial treatment (e.g. clotting factor replacement, DDAVP) which should be administered before pursuing investigations/imaging studies. Special attention must be paid to the patient with recurrent or unexplained bleeding, or unexplained coagulation studies. There should be a low threshold to consult hematology in these cases and involvement of hematology early in managing patients with bleeding disorders to improve outcomes. This paper is directed toward emergency physicians, pediatricians, and general internists and will highlight key concepts in the primary care and work up of diagnosed and undiagnosed bleeding disorders requiring urgent treatment.
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Affiliation(s)
- Adrienne Lee
- Departments of Medicine, Cumming School of Medicine, University of Calgary and the Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, 1403-29th Street NW, Calgary, AB T2N 2T9, Canada.
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45
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Geesala R, Issuree PD, Maretzky T. Novel functions of inactive rhomboid proteins in immunity and disease. J Leukoc Biol 2019; 106:823-835. [PMID: 31369701 DOI: 10.1002/jlb.3vmr0219-069r] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/03/2019] [Accepted: 06/20/2019] [Indexed: 12/11/2022] Open
Abstract
iRhoms are related to a family of intramembrane serine proteinases called rhomboids but lack proteolytic activity. In mammals, there are two iRhoms, iRhom1 and iRhom2, which have similar domain structures and overlapping specificities as well as distinctive functions. These catalytically inactive rhomboids are essential regulators for the maturation and trafficking of the disintegrin metalloprotease ADAM17 from the endoplasmic reticulum to the cell surface, and are required for the cleavage and release of a variety of membrane-associated proteins, including the IL-6 receptor, l-selectin, TNF, and EGFR ligands. iRhom2-dependent regulation of ADAM17 function has been recently implicated in the development and progression of several autoimmune diseases including rheumatoid arthritis, lupus nephritis, as well as hemophilic arthropathy. In this review, we discuss our current understanding of iRhom biology, their implications in autoimmune pathologies, and their potential as therapeutic targets.
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Affiliation(s)
- Ramasatyaveni Geesala
- Inflammation Program, Roy J. and Lucille A. Carver College of Medicine University of Iowa, Iowa City, Iowa, USA.,Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine University of Iowa, Iowa City, Iowa, USA
| | - Priya D Issuree
- Inflammation Program, Roy J. and Lucille A. Carver College of Medicine University of Iowa, Iowa City, Iowa, USA.,Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine University of Iowa, Iowa City, Iowa, USA
| | - Thorsten Maretzky
- Inflammation Program, Roy J. and Lucille A. Carver College of Medicine University of Iowa, Iowa City, Iowa, USA.,Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine University of Iowa, Iowa City, Iowa, USA.,Holden Comprehensive Cancer Center, University of Iowa, Iowa City, Iowa, USA
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Lapinski J, Maurer LM, Ragni MV, McShea C, Cooper JD, Xavier F. Unsuspected Lyme disease presenting in refractory haemophilic haemarthrosis. Haemophilia 2019; 25:e331-e333. [PMID: 31359551 DOI: 10.1111/hae.13821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 06/21/2019] [Accepted: 06/24/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Jillian Lapinski
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lisa M Maurer
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Margaret V Ragni
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,The Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania
| | - Cheryl McShea
- The Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania
| | - James D Cooper
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Frederico Xavier
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania.,The Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania
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TNF-α/TNF-R System May Represent a Crucial Mediator of Proliferative Synovitis in Hemophilia A. J Clin Med 2019; 8:jcm8070939. [PMID: 31261789 PMCID: PMC6678637 DOI: 10.3390/jcm8070939] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/17/2019] [Accepted: 06/26/2019] [Indexed: 12/14/2022] Open
Abstract
Hemophilic arthropathy (HA) typically begins with proliferative synovitis that shares some similarities with inflammatory arthritides, in which the proinflammatory cytokine tumor necrosis factor (TNF)-α has a crucial pathogenetic role. Inappropriate release of TNF-α was shown to contribute to arthropathy development following intra-articular bleeding in hemophilic mice. Here, we were interested in determining whether systemic levels of TNF-α and synovial tissue expression of the TNF-α/TNF receptor (TNF-R) system could be increased and related to joint damage in hemophilia A patients with severe HA. Serum levels of TNF-α measured by quantitative enzyme-linked immunosorbent assay (ELISA) were significantly increased in HA patients (n = 67) compared to healthy controls (n = 20). In HA patients, elevated TNF-α levels were significantly associated with the number of hemarthroses, the grade of synovial hypertrophy, and both the clinical World Federation of Hemophilia score and ultrasound score. The expression of TNF-α, TNF-R1, and TNF-R2 was strongly increased in HA synovium (n = 10) compared to the non-inflamed osteoarthritis control synovium (n = 8), as assessed by both immunohistochemistry and Western blotting. Increased protein levels of TNF-α, TNF-R1, and TNF-R2 were retained in vitro by HA fibroblast-like synoviocytes (n = 6) with respect to osteoarthritis control fibroblast-like synoviocytes (n = 6). Stimulation with TNF-α resulted in a significant increase in HA fibroblast-like synoviocyte proliferation quantified by the water-soluble tetrazolium (WST)-1 assay, while it had no relevant effect on osteoarthritis fibroblast-like synoviocytes. Quantification of active/cleaved caspase-3 by ELISA demonstrated that TNF-α did not induce apoptosis either in HA or in osteoarthritis fibroblast-like synoviocytes. The TNF-α/TNF-R system may represent a crucial mediator of proliferative synovitis and, therefore, a new attractive target for the prevention and treatment of joint damage in HA patients. Our findings provide the groundwork for further clinical investigation of anti-TNF-α therapeutic feasibility in hemophiliacs.
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Efficacy, safety, and pharmacokinetics of emicizumab prophylaxis given every 4 weeks in people with haemophilia A (HAVEN 4): a multicentre, open-label, non-randomised phase 3 study. LANCET HAEMATOLOGY 2019; 6:e295-e305. [DOI: 10.1016/s2352-3026(19)30054-7] [Citation(s) in RCA: 178] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/01/2019] [Accepted: 03/05/2019] [Indexed: 01/04/2023]
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Accelerating recovery from acute hemarthrosis in patients with hemophilia: the role of joint aspiration. Blood Coagul Fibrinolysis 2019; 30:111-119. [PMID: 30958454 DOI: 10.1097/mbc.0000000000000803] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
: Arthrocentesis of an acute hemarthrosis in hemophilia remains a controversial issue. The purpose of this study is to define the role that joint aspiration can play in the recovery from acute hemarthrosis in patients with hemophilia. The study sample included 33 hemophilic patients (55 joints) with acute elbow, knee, and ankle hemarthrosis as confirmed by ultrasonography. Patients were distributed into a treatment group and a control group. Patients in the first group were subjected to joint aspiration, whereas patients in the second were not. Arthrocentesis was carried out immediately after diagnosis of acute hemarthrosis in liquid phase. Patients were infused with the deficient coagulation factor and were instructed to observe relative rest until resolution of hemarthrosis. The following parameters were analyzed: time to full resolution of hemarthrosis (determined by ultrasonography), duration of treatment with the deficient coagulation factor, time to pain relief, time to recovery of prebleed range of motion, and time to resumption of school/work (all of these measured in days). The joints treated with joint aspiration exhibited a significantly faster resolution of bleeding (fewer days). In addition, this group required fewer days of pharmacological treatment, with faster achievement of functional recovery and resumption of school/work activities. No complications were observed. This study shows that joint aspiration under hemostatic cover and in strictly aseptic conditions is a well-tolerated technique that makes the recovery of acute hemarthrosis of hemophilic patients faster.
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50
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Barton CA, Bierman J. Factor products. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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