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Benemei S, Boni L, Castaman G. Outcome measures in hemophilia: current and future perspectives. Expert Rev Hematol 2024. [PMID: 38861342 DOI: 10.1080/17474086.2024.2365929] [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: 12/20/2023] [Accepted: 06/05/2024] [Indexed: 06/13/2024]
Abstract
INTRODUCTION Hemophilia can detrimentally affect patients' quality of life and likelihood of survival. In the evolving landscape of therapies, the therapeutic gain of each treatment must be understood to accurately position it in the therapeutic armamentarium. Accordingly, appropriate outcomes must be measured with appropriate tools. AREAS COVERED Our narrative review (PubMed search for 'hemophilia AND outcome' until June 2023), provides a compendium of outcome measures used in hemophilia clinical research. To define each outcome measure's relative value and applicability, several characteristics are critically discussed. EXPERT OPINION Bleeding assessment, first annual/annualized bleeding rate, remains central in evaluating the efficacy and safety of hemophilia treatments. As modern therapies improve clinical outcomes toward zero bleeding events, this endpoint may become less sensitive to detect differences between therapeutic approaches. Technological advancements necessitate the adaptation of outcome measures to address infrequent bleeding events, age-related comorbidities, and laboratory parameters with limited comparability after different treatments. Considerable effort has been dedicated to the development of tools that comprehensively assess coagulation, such as thrombin generation assays. Patient-reported outcome measures are gaining importance although limited by their subjectivity. A definitive set of research outcome measures remains elusive. Outcomes may need to be tailored to different therapeutic interventions.
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Affiliation(s)
| | - Luca Boni
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
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Castaman G, Jimenez-Yuste V, Gouw S, D'Oiron R. Outcomes and outcome measures. Haemophilia 2024; 30 Suppl 3:112-119. [PMID: 38504408 DOI: 10.1111/hae.14990] [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: 01/19/2024] [Revised: 02/28/2024] [Accepted: 03/01/2024] [Indexed: 03/21/2024]
Abstract
INTRODUCTION Advances in haemophilia treatment have resulted in a near-normal life expectancy, lower burden of bleeding and treatment, and improved quality of life in high-income countries. Bleeding rate is approaching zero and novel parameters should be evaluated to assess the efficacy of treatment not only from the clinical point of view by using new methodologies (e.g. joint health assessment), but also from the patient's perspective (e.g. pain, quality of life, treatment satisfaction). METHODS AND RESULTS This approach should be aimed at combining objective clinical methodologies and patient-reported outcomes (PROs). However, some instruments used for assessing PROs are still suboptimal and not properly validated. Recent evidence suggests that these tools can take advantage from a more personalized designed approach and could be effectively improved and serve to facilitate the patient's self-evaluation. For other congenital bleeding disorders (BDs), a set of patient-relevant outcomes has been also defined that overlap substantially those of haemophilia, including bleeding, side effects and complications, and PROs, such as pain, physical functioning, impact on daily life including school and work and mental health. There is a growing focus on addressing women-specific outcomes in BDs, reflecting an increased awareness of the unique challenges faced by women in this context. However, the development of tailored tools is imperative to further advance the progress in managing women with BDs, ensuring more accurate monitoring and personalized care. CONCLUSIONS How incorporating these outcome measures in the process of approval of novel treatments for these disorders by regulatory authorities remains to be established.
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Affiliation(s)
- Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
| | | | - Samanta Gouw
- Department of Paediatric Haematology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roseline D'Oiron
- Bicêtre Hospital AP-HP, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, Paris, France
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Mancuso ME, Croteau SE, Klamroth R. Benefits and risks of non-factor therapies: Redefining haemophilia treatment goals in the era of new technologies. Haemophilia 2024; 30 Suppl 3:39-44. [PMID: 38481077 DOI: 10.1111/hae.14976] [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: 01/09/2024] [Revised: 02/21/2024] [Accepted: 02/21/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION Over the last decades progress in haemophilia treatment has been remarkable and prophylaxis with clotting factor concentrates in haemophilia A and B has been established as the standard of care in individuals with haemophilia and a severe bleeding phenotype. Besides clotting factor products with prolonged half-life non-factor therapies were developed which enable prophylaxis via subcutaneous administration. Factor VIIIa mimetics like emicizumab facilitate the coagulation pathway and are used in routine clinical practice for indivdiduals with haemophilia A. Rebalancing therapeutic agents like fitusiran, concizumab, marstacimab and serpin PC block the anticoagulant pathway and clinical trials using these products in individuals with haemophilia A and B are ongoing. AIM AND METHODS A narrative review to asess the benefits and risks of non-factor therapies taking in to account re-defined haemophilia treatment goals. RESULTS Prophylaxis for prevention of bleeds using non-factor products by subcutaneous administration is effective and results in reductions of bleeding episodes in individuals with haemophilia A or B with and without inhibitors. The treatment with emicizumab showed tolerable safety both in clinical trials and long-term real-world observations with few thrombotic events. In some clinical trials with rebalancing therapies (fitusiran and concizumab) thrombotic events occurred. Monitoring of the haemostatic function of novel therapies especially with concomitant haemostatic treatment is not yet established. CONCLUSION With the advent of novel therapeutic agents including factor concentrates with ultra-long half-life and improved FVIIIa mimetics aimed at raising the bar of protection into the non-hemophilic range redefinition of haemophilia treatment goals is eagerly needed.
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Affiliation(s)
- Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Humanitas University, Pieve Emanuele, Milan, Italy
| | - Stacy E Croteau
- Boston Children's Hospital, Boston Hemophilia Center, Harvard Medical School, Boston, USA
| | - Robert Klamroth
- Department of Internal Medicine, Hemophilia Treatment Center, Vivantes Klinikum im Friedrichshain, Berlin, Germany
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
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van Bergen EDP, van Leeuwen FHP, Foppen W, Timmer MA, Schutgens REG, Mastbergen SC, Lafeber FPJG, de Jong PA, Fischer K, van Vulpen LFD. Subclinical synovial proliferation in patients with severe haemophilia A: The value of ultrasound screening and biochemical markers. Haemophilia 2023; 29:1580-1588. [PMID: 37694775 DOI: 10.1111/hae.14861] [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: 06/14/2023] [Revised: 08/24/2023] [Accepted: 08/30/2023] [Indexed: 09/12/2023]
Abstract
AIM Subclinical bleeding and inflammation play a role in progression of haemophilic arthropathy. Synovial proliferation is predictive of joint bleeding and its early detection may guide treatment changes and prevent arthropathy progression. This study evaluated the prevalence of active and inactive subclinical synovial proliferation and investigated potential biochemical blood/urine markers to identify patients with active subclinical synovial proliferation. METHODS This cross-sectional study included patients with severe haemophilia A born 1970-2006 who were evaluated during routine clinic visits. Patients with (a history of) inhibitors or recent joint bleeding were excluded. Elbows, knees and ankles were examined for subclinical synovial proliferation by ultrasound and physical examination. Active synovial proliferation was distinguished from inactive synovial proliferation using predefined criteria. Blood/urine biochemical markers (serum osteopontin, sVCAM-1, Coll2-1, COMP, CS846, TIMP, and urinary CTX-II) were compared individually and as combined indexes between patients with and without active synovial proliferation. RESULTS This cohort consisted of 79 patients with a median age of 31 years (range 16.5-50.8 years) with 62/79 (78%) of the patients using continuous prophylaxis. The annualized joint bleeding rate over the last 5 years was .6 (.2-1.1). Active (17/79, 22%) and inactive subclinical synovial proliferation (17/79, 22%) were both prevalent in this cohort. Biochemical markers were not correlated with active subclinical synovial proliferation. CONCLUSION Subclinical synovial proliferation, both active and inactive, was prevalent in patients with severe haemophilia A with access to prophylaxis and would be overlooked without routinely performed ultrasounds. Biochemical markers were unable to identify patients with active subclinical synovial proliferation.
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Affiliation(s)
- Eline D P van Bergen
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Flora H P van Leeuwen
- Department of Radiology & Nuclear Imaging, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Wouter Foppen
- Department of Radiology & Nuclear Imaging, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Merel A Timmer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Roger E G Schutgens
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Simon C Mastbergen
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Floris P J G Lafeber
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Pim A de Jong
- Department of Radiology & Nuclear Imaging, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Lize F D van Vulpen
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
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Mizoguchi Y, Tani C, Aizawa M, Tomioka K, Shimomura M, Nishimura S, Matsubara Y, Iwaki D, Tanaka K, Kawaguchi H, Nakashima Y, Mikami Y, Okada S, Kobayashi M. Age-specific incidence of joint disease in paediatric patients with haemophilia: A single-centre real-world outcome based on consecutive US examination. Haemophilia 2023; 29:1359-1365. [PMID: 37639381 DOI: 10.1111/hae.14848] [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: 03/27/2023] [Revised: 08/06/2023] [Accepted: 08/10/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Joint health is one of the most important factors contributing to a healthy life in patients with haemophilia. Recent study revealed that starting early prophylaxis was not enough to prevent joint disease in most paediatric patients with haemophilia. AIM In this study, we aimed to determine the age-specific incidence of acute joint disease during childhood at single haemophilia treatment centre (HTC). METHOD The joint health in 48 patients was evaluated based on consecutive US testing for 5 years at annual multidisciplinary comprehensive care. RESULTS During the study period, 23 patients (47.9%) had no joint disease since the initial examination, whereas 13 patients (27.0%) showed development from negative to positive findings. The incidence of joint disease increased with age: 0% in preschool, 5.3% in elementary school, 14.3% in junior high school and 35% beyond high school age. Among the 13 patients who developed joint disease, two experienced acquired synovitis that resolved during the follow-up period. Statistical analysis revealed that the patients who routinely underwent follow-up by the HTC exhibited a significantly lower incidence of joint disease than did those followed up at other institutions (p < .001). CONCLUSION These results indicated that close check-up, including routine joint examination using US as well as frequent assessment of pharmacokinetic profile at the HTC, might play an important role in avoiding joint disease among paediatric patients with haemophilia.
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Affiliation(s)
- Yoko Mizoguchi
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Chihiro Tani
- Department of Diagnostic Radiology, Hiroshima University Hospital, Hiroshima, Japan
| | - Mika Aizawa
- Graduate School of Advanced Science and Engineering, Hiroshima University, Hiroshima, Japan
| | - Keita Tomioka
- Department of Pediatrics, Hiroshima Prefectural Rehabilitation Center, Hiroshima, Japan
| | - Maiko Shimomura
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Shiho Nishimura
- Department of Pediatrics, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Yoshiko Matsubara
- Department of Diagnostic Radiology, Hiroshima University Hospital, Hiroshima, Japan
| | - Daisuke Iwaki
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Kiyoto Tanaka
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Hiroshi Kawaguchi
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Yuko Nakashima
- Collaborative Research laboratory of Musculoskeletal Ultrasound in Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Yukio Mikami
- Department of Rehabilitation Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Satoshi Okada
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Masao Kobayashi
- Japanese Red Cross, Chugokushikoku Block Blood Center, Hiroshima, Japan
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Rodriguez-Merchan EC. Point-of-care ultronography can help detect subclinical hemarthrosis in hemophilic patients undergoing regular optimal clotting factor prophylaxis to achieve zero bleeding. Expert Rev Hematol 2023; 16:565-566. [PMID: 37289642 DOI: 10.1080/17474086.2023.2223927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/14/2023] [Accepted: 06/06/2023] [Indexed: 06/10/2023]
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Rodriguez-Merchan EC. Synovitis in hemophilia: preventing, detecting, and treating joint bleeds. Expert Rev Hematol 2023:1-10. [PMID: 37119182 DOI: 10.1080/17474086.2023.2209717] [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] [Indexed: 05/01/2023]
Abstract
INTRODUCTION Most bleeding events in individuals with hemophilia occur within the ankle, knee, and elbow joints. Should the bleeding persist, the synovial membrane starts to hypertrophy and a vicious cycle of chronic hemophilic synovitis (CHS) occurs, leading to joint destruction. AREAS COVERED This article covers the prompt diagnosis of CHS by point-of-care ultrasonography (POC-US) and its treatment by means of several types of synovectomy. EXPERT OPINION It is essential to prevent, detect and treat hemophilic synovitis, because it indicates that the joint has bled and is at risk of bleeding further. Prophylaxis with standard half life (SHL) factor VIII (FVIII) concentrate is the standard of care for individuals with severe hemophilia A and can also be considered for selected patients with moderate disease. Several years of real-world experience with extended half life (EHL) FVIII, emicizumab, and other drugs in development will be needed to ascertain their final effect on bleeding and its complications. We must look for synovitis in individuals declaring joint pain and in asymptomatic patients, and POC-US is the most reasonable imaging instrument with which to carry out periodic joint screening. Radiosynovectomy, chemical synovectomy, and arthroscopic synovectomy markedly reduce bleeding events.
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van Leeuwen FHP, Timmer MA, de Jong PA, Fischer K, Foppen W. Screening for subclinical synovial proliferation in haemophilia: A systematic review and meta-analysis comparing physical examination and ultrasound. Haemophilia 2023; 29:445-455. [PMID: 36595617 DOI: 10.1111/hae.14737] [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: 05/11/2022] [Revised: 11/29/2022] [Accepted: 12/14/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Ultrasound is increasingly used as addition to physical examination for detection of subclinical joint changes in haemophilia. However, the added value of ultrasound to physical examination for detecting synovial proliferation is not fully established. AIM To determine the diagnostic accuracy of swelling at physical examination for ultrasound-detected synovial proliferation in haemophilia. METHODS PubMed and EMBASE were searched up to 2 August 2022. Studies reporting original data on occurrence of swelling at physical examination and synovial proliferation on ultrasound of index joints in persons with haemophilia were included. Risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Diagnostic accuracy parameters of swelling at physical examination for ultrasound-detected synovial proliferation were determined. Summary sensitivity and specificity were calculated using a bivariate random-effects model. RESULTS Fifteen studies reporting on swelling at physical examination and synovial proliferation on ultrasound in 2890 joints of 627 patients were included. Prevalence of subclinical synovial proliferation ranged between 0% and 55%. Sensitivity of swelling was low [summary estimate .34; 95% confidence interval (CI) .24-.46], while specificity was high (summary estimate .97; CI .92-.99). Predictive values varied widely due to inter-study differences in prevalence of synovial proliferation. CONCLUSION Joint swelling has low sensitivity for presence of ultrasound-detected synovial proliferation in haemophilia, suggesting underestimation of synovial proliferation by physical examination alone. Consequently, ultrasound screening may generate important information on synovial changes which would otherwise remain undetected.
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Affiliation(s)
- Flora H P van Leeuwen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Merel A Timmer
- Center for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pim A de Jong
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Center for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wouter Foppen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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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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Minno MNDD, Martinoli C, Pasta G, la Corte-Rodriguez HD, Samy I, Stephensen D, Timmer MA, Winburn I. How to assess, detect, and manage joint involvement in the era of transformational therapies: Role of point-of-care ultrasound. Haemophilia 2023; 29:1-10. [PMID: 36163646 DOI: 10.1111/hae.14657] [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: 11/05/2021] [Revised: 08/11/2022] [Accepted: 08/28/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Patients with haemophilia experience recurring hemarthroses, mainly involving knees, elbows and ankles, which lead to haemophilic arthropathy, the major chronic complication of haemophilia. With new approaches to haemophilia treatment leading to fewer joint bleeds and, in some cases, no bleeding events, assessing whether current outcome assessment tools provide adequate sensitivity and specificity for management and care of patients with haemophilia is needed. METHODS An overview of current imaging tools for monitoring joint health, novel osteochondral damage and synovial proliferation biomarkers, and the relationship between assessments for functionality and imaging modalities is provided. Usefulness and sensitivity of point-of-care ultrasound (POCUS) to complement other assessments and use of ultrasound to monitor haemophilic arthropathy are also examined. RESULTS This review provides rationale for haemophilia teams to move beyond traditional outcomes in joint imaging, as well as guidance and evidence on assessment of joint health for potential new treatment modalities, such as gene therapy. The role of POCUS in the existing paradigm for haemophilia care and management along with the use of ultrasound as a complement to other outcome assessment tools are also discussed. Finally, the clinical effects of subclinical bleeding on joint function are described, to motivate screening for synovial proliferation. CONCLUSION POCUS can facilitate the early detection of joint damage and can monitor disease progression while providing insights into the efficacy of treatment regimens, and should be considered as an essential assessment tool for managing the care of patients with haemophilia.
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Affiliation(s)
| | - Carlo Martinoli
- Department of Health Science - DISSAL, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | | | | | - David Stephensen
- Kent Haemophilia & Thrombosis Centre, Canterbury, United Kingdom and Royal London Hospital, London, UK
| | - Merel A Timmer
- Van Creveldkliniek, UMC Utrecht, Utrecht, The Netherlands
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Rodriguez-Merchan EC. Past, present and future of orthopedic surgery in hemophilia: looking to a world without bleeding and arthropathy in the near future. Expert Rev Hematol 2022; 15:821-831. [PMID: 35930399 DOI: 10.1080/17474086.2022.2110063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The purpose of this article is to review the literature on orthopedic surgery in people with hemophilia (PWH), to better understand its past and present and attempt to predict the future. AREAS COVERED A Cochrane Library and PubMed (MEDLINE) search of studies related to orthopedic surgery in PWH was analyzed. A downward trend in orthopedic surgery in PWH has been observed. Patients on continuous prophylaxis are less likely to require orthopedic surgery. In patients with hemophilia, the risk of major bleeding remains high after total joint arthroplasty, even with factor replacement. Cases of acute compartment syndrome, pseudotumors and even limb amputations are still observed in PWH. EXPERT OPINION Orthopedic surgery for PWH should always be performed in specialized centers with multidisciplinary expertise in the correct management of hemophilia. It is paramount to perform an accurate preoperative coagulation screening before surgery. The availability of prophylaxis through replacement and the recent non-replacement therapy in the well-developed countries will diminish substantially or hopefully abolish completely the need for surgery in the treatment of PWH. Therefore, we are looking to a world without bleeding and arthropathy in the next future. Unfortunately, this is not true for the under-development countries.
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Affiliation(s)
- E Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital, Madrid, Spain.,Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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