Haemophilia treatment in the United Kingdom from 1969 to 1974

Care models in the management of haemophilia: a systematic review

BACKGROUND

Haemophilia care is commonly provided via multidisciplinary specialized management. To date, there has been no systematic assessment of the impact of haemophilia care delivery models on patient-important outcomes.

OBJECTIVE

To conduct a systematic review of published studies assessing the effects of the integrated care model for persons with haemophilia (PWH).

SEARCH METHODS

We searched MEDLINE, EMBASE and CINAHL up to April 22, 2015, contacted experts in the field, and reviewed reference lists.

SELECTION CRITERIA

Randomized and non-randomized studies of PWH or carriers, focusing mainly on the assessment of care models on delivery.

DATA COLLECTION AND ANALYSIS

Two investigators independently screened title, abstract, and full text of retrieved articles for inclusion. Risk of bias and overall quality of evidence was assessed using Cochrane's ACROBAT-NRSI tool and GRADE respectively. Relative risks, mean differences, proportions, and means and their variability were calculated as appropriate.

RESULTS

27 non-randomized studies were included: eight comparative and 19 non-comparative studies. We found low- to very low-quality evidence that in comparison to other models of care, integrated care may reduce mortality, hospitalizations and emergency room visits, may lead to fewer missed days of school and work, and may increase knowledge seeking.

CONCLUSION

Our comprehensive review found low- to very low-quality evidence from a limited number of non-randomized studies assessing the impact of haemophilia care models on some patient-important outcomes. While the available evidence suggests that adoption of the integrated care model may provide benefit to PWH, further high-quality research in the field is needed.

Rosemary Biggs MD FRCP (1912-2001) and Katharine Dormandy MD FRCP (1926-78): from laboratory to treatment and care of people with haemophilia

In 1977 the Haemophilia Society presented the first RG Macfarlane Award to Katharine Dormandy for her outstanding contribution towards the social and physical wellbeing of people with haemophilia and related disorders. In 1978 Rosemary Biggs was the second recipient of the Award given for similarly outstanding personal contributions. Dr Biggs worked under Dr RG Macfarlane at Oxford and in 1952 devised a laboratory test that identified two forms of haemophilia. Macfarlane realized the potential for replacement therapy which subsequently transformed the lives of haemophiliacs in the UK. Dr Biggs was director of the Oxford Haemophilia Centre (1967-77) and instrumental in documenting the increase in incidence of jaundice with the import of concentrates for infusion. Katharine Dormandy, Consultant Haematologist at the Royal Free Hospital in London, set up one of the country's foremost haemophilia centres, pioneered home treatment for haemophilic children and with Rosemary Biggs was involved in the social and educational welfare of affected families.

A study of variations in the reported haemophilia A prevalence around the world

The objectives of this paper were to study the reported haemophilia A prevalence (per 100 000 males) on a country-by-country basis and address the following: Does the reported prevalence of haemophilia A vary by national economies? We collected prevalence data for 106 countries from the World Federation of Hemophilia (WFH) annual global surveys and the literature. We found that the reported haemophilia A prevalence varied considerably among countries, even among the wealthiest of countries. The prevalence (per 100 000 males) for high income countries was 12.8 +/- 6.0 (mean +/- SD) whereas it was 6.6 +/- 4.8 for the rest of the world. Within a country, there was a strong trend of increasing prevalence over time--the prevalence for Canada ranged from 10.2 in 1989 to 14.2 in 2008 (R = 0.94 and P < 0.001) and for the United Kingdom it ranged from 9.3 in 1974 to 21.6 in 2006 (R = 0.94 and P < 0.001). Prevalence data reported from the WFH compared well with prevalence data from the literature. Patient registries generally provided the highest quality of prevalence data. The lack of accurate country-specific prevalence data has constrained planning efforts for the treatment and care of people with haemophilia A. With improved information, healthcare agencies can assess budgetary needs to develop better diagnostic and treatment facilities for affected patients and families and work to ensure adequate supplies of factor VIII concentrates for treatment. In addition, this information can help manufacturers plan the production of concentrates and prevent future shortages.

Spontaneous hematomyelia in a child with hemophilia A: a case report

Hemorrhagic complications in patients with hemophilia have been occasionally reported in the spinal column and the spinal cord. Treatment is based on prompt replacement therapy as the occurrence and development of neurologic dysfunction are related to the length of time between the onset of symptoms and the factor replacement. We report case of a 7-year-old hemophilic boy who presented with flaccid paraparesis resulting from thoracic hematomyelia. The patient showed gradual improvement on medical management with cryoprecipitate infusions. This case calls attention to the need for prompt diagnosis of rarely reported spinal hematomyelia based on clinical manifestations and radiologic features and highlights its management options in patients with hemophilia.

Current status of Swedish hemophiliacs. I. A demographic survey

A comprehensive survey of the Swedish hemophilic population (hemophilia A and B) was undertaken in 1980. The total number of known hemophiliacs was 564. The ratio of hemophilia A to B was 4:1. The severe form constituted about 30% of each type. The incidence has remained fairly constant since 1957 and was 1.67 per year per 10,000 males born. The prevalence was 6.8 per 100,000 inhabitants. There was an increase in the prevalence in all counties but the increase varied considerably, 19-383%. The overall increase of hemophilia was 123%. Among mild cases the increase was 245%, whereas it was only 48% among the severe hemophiliacs. This skewness was attributed to better laboratory diagnoses and increased life expectancy. The proportion of mild cases increased from 35% in 1960 to 54% at the time of the present investigation. The situation was the reverse for the severe cases, a decrease from 45% to 30%. The mean and median ages among moderate and mild hemophiliacs deviated only little from the corresponding figure in the total population. Among severe cases, however, mean and median age were 8-13 years less than in the normal population.

Deaths in Swedish hemophiliacs, 1957-1980

One hundred and eighteen patients with hemophilia A or B died in Sweden between 1957 and 1980. The causes and circumstances of death have been the subject of a retrospective study. The most striking feature was the increase in age at death. In severe hemophilia cases the age increased from 19 in the first half of the period to 50 in the second. In moderate and mild hemophilia cases the increases were similar, although less pronounced. The main cause of death was intracranial hemorrhage, which accounted for one-third of all deaths. In the last 12-year period, however, no patient below the age of 45 had succumbed to this. Age-related causes of death, such as malignancy and ischemic heart disease, had increased, as was to be expected from the increase in the mean and median ages of living hemophiliacs. The proportion of deaths unrelated to hemophilia was 36%. Antibodies were found in 5 (16.7%) of the patients with severe hemophilia A.

Home treatment in haemophilia: clinical, social and economic advantages

Twenty-eight severely affected haemophiliacs were observed for 3 months under treatment as hospital out-patients and for the subsequent 9 months while treating themselves at home. Delay in receiving treatment and financial costs were both clearly reduced by home treatment, the patients recovered from individual bleeds more quickly and reported a greater sense of personal freedom and independence. The amount of treatment required did not materially change and no untoward effects were noted; the use of analgesics tended to be less.

Dose and response in haemophilia - optimization of factor replacement therapy

The mainstay of the management of haemophilia is the replacement of clotting factors, using clotting factor concentrates (CFC) in a way that prevents bleeding and its complications. Beginning with small doses, as whole blood and plasma over 50 years ago, highly purified CFCs are now administered frequently in large doses to effectively treat this condition so that even people with severe haemophilia can lead near normal lives. However, with such regimens, compliance and expense have both become significant issues. The question therefore is whether the current models of clotting factor replacement are optimal. This article reviews the literature on the dose-response relationship in haemophilia, with particular reference to management of musculoskeletal bleeding and surgical haemostasis. Current practices are based on uncontrolled observational data. Less intensive protocols could achieve similar outcomes. Large multi-centre prospective studies are needed to provide comparative data on unresolved issues so that factor replacement therapy can be optimized, based on evidence.

Factors predictive of death among HIV-uninfected persons with haemophilia and other congenital coagulation disorders

Historically, the leading cause of death among persons with haemophilia and other congenital coagulation disorders was uncontrolled bleeding. Mortality was associated with severe deficiency of coagulation factors VIII or IX and especially with high-titre antifactor neutralizing antibodies (inhibitors). The catastrophic contamination of plasma donor pools with human immunodeficiency virus (HIV) resulted in acquired immunodeficiency syndrome replacing haemorrhage as the leading cause of death among persons with haemophilia. Rather little has been written, however, about mortality among those not infected with HIV. The objective of this study was to identify conditions associated with all-cause mortality among HIV-uninfected patients who were followed for a mean of 8.8 years in the Multicentre Hemophilia Cohort Study. Among the 364 children (mean age 8 years), there were four deaths; two related to cancer, one to trauma, and the fourth to haemorrhage, end-stage liver disease and sepsis. Among the 387 HIV-uninfected adults (mean age 35 years) there were 29 deaths, with haemorrhage the leading cause of death, followed by hepatic, stroke and cancer deaths. Prognostic factors for all-cause mortality among the adults included haemophilia Type A with neutralizing antibodies [age-adjusted relative rate (RR) 3.1, 95% confidence interval (CI) 1.4-6.9] and serologic evidence of both hepatitis B and C virus (RR 4.1, 95% CI 0.97-17.6). Although hepatitis C viral load was slightly lower in patients with hepatitis B virus surface antigenaemia, it was unrelated to vital status. We conclude that causes of death and prognostic factors for current HIV-uninfected haemophilia patients are similar to those noted before the HIV epidemic. Better understanding, prevention and control of neutralizing antibodies and hepatitis infections may substantially improve longevity for people with haemophilia.

Factor VIII inhibitors in haemophiliacs: a single-centre experience over 34 years, 1964-97

A retrospective study of the natural history of factor VIII inhibitors in haemophilia A patients experienced in a single comprehensive haemophilia centre over three decades is reported. 431 haemophilia A patients of all severities have been followed-up for a total of 5626 patient-years. The frequency of inhibitors was 10% in the severe haemophilia A patients and 37% occurred in children <10 years. The majority of the patients received several products before developing the inhibitors. 59% of patients had <50 exposure days and 48% were high responders (>5 BU). An 8-year (1987-95) inhibitor-free period was seen during which all previously untreated patients were treated with an intermediate-purity factor VIII concentrate. A moderate haemophiliac with a missense mutation that has not been described in association with inhibitor is reported. Six HIV-positive patients preserved their antibody response to factor VIII even at the advanced stage of their disease.

Case report: treatment of an intracranial arteriovenous malformation in a patient with complicated hemophilia

The authors describe a young man with hemophilia complicated by chronic hepatic dysfunction, hypodysfibrinogenemia, and immune thrombocytopenia that resulted in a complex coagulopathy. The patient had a ruptured occipital arteriovenous malformation. The malformation was managed by temporary correction of the coagulopathy using cryoprecipitate, platelet transfusions, and plasmapheresis with fresh frozen plasma replacement. The patient underwent staged preoperative embolization followed by surgical excision of the lesion. Hemostasis was acceptable during the neurointerventional and subsequent surgical management, and no complications of coagulopathy occurred. Plasmapheresis may provide effective preparation for patients with hemophilia and complex coagulation abnormalities who require neurosurgical intervention.

Protease nexin-2/amyloid beta protein precursor. A tight-binding inhibitor of coagulation factor IXa

Protease nexin-2/amyloid beta protein precursor (PN-2/A beta PP) is an abundant, secreted platelet protein which is a potent inhibitor of coagulation Factor XIa. We examined other potential anticoagulant activities of PN-2/A beta PP. Purified Kunitz protease inhibitor domain of PN-2/A beta PP and PN-2/A beta PP itself were found to prolong the coagulation time of plasma and pure Factor IXa. The Kunitz protease inhibitor domain also inhibited the ability of Factor IXa to activate Factor X. PN-2/A beta PP inhibited Factor IXa with a Ki of 7.9 to 3.9 x 10(-11) M in the absence and presence of heparin, respectively. When the second-order rate constant of PN-2/A beta PP's inhibition of Factor IXa (2.7 x 10(8) M-1min-1) was compared to that of antithrombin III (3.8 x 10(6) M-1min-1), PN-2/A beta PP was at least a 71-fold more potent inhibitor of Factor IXa than antithrombin III. PN-2/A beta PP formed a complex with Factor IXa as detected by gel filtration and ELISA. The finding that PN-2/A beta PP is a potent inhibitor of Factor IXa could help to explain the spontaneous intracerebral hemorrhages seen in patients with hereditary cerebral hemorrhage with amyloidosis Dutch-type where there is an extensive accumulation of PN-2/A beta PP in their cerebral blood vessels.

Interaction of incontinentia pigmenti and factor VIII mutations in a female with biased X inactivation, resulting in haemophilia

We report a female infant born to a mother with incontinentia pigmenti (IP) and a father with haemophilia A, who manifests both disorders. Analysis of peripheral blood DNA from the infant, her mother, and two female relatives with IP showed a highly skewed pattern of X inactivation. Random patterns were observed in the infant's two sisters, who do not have IP and have normal carrier activity of factor VIII. Preferential inactivation of the X chromosome bearing the IP mutation, probably by negative selection, appears to have unmasked the factor VIII mutation on the infant's other X chromosome. This illustrates an unusual mechanism for the manifestation of an X linked disease in a heterozygous female.

Hepatocellular carcinoma in hemophilia

A questionnaire-based survey involving 11,801 hemophiliacs from 54 hemophilia centers in the USA and Europe documented the occurrence of hepatocellular carcinoma (HCC) in 10 patients. The crude rate of HCC was 3.2/100,000 patients/year, at least 30 times higher than the background incidence of this tumor in the countries of origin of the patients. All patients were Caucasians with hemophilia A, 39 to 74 years of age, and had liver cirrhosis. All had one or more risk factor for cirrhosis and HCC: 5 were positive for serum hepatitis B surface antigen, 4 had the antibody to hepatitis C virus, and 4 had histories of alcohol abuse. Serum alpha-fetoprotein, measured in 6 patients, was significantly elevated in 4 (range: 807-1399 ng/ml), and only moderately elevated in 2 (25 and 171 ng/ml). The onset of HCC was asymptomatic in 5 patients, whereas it was accompanied by jaundice, abdominal pain, or ascites in the remaining patients. Thus, HCC seems to be a more important secondary disease for hemophiliacs than formerly recognized. Since HCC is often asymptomatic, screening hemophiliacs with chronic liver disease with periodic ultrasound scans might increase the changes of detecting HCC at a stage amenable to surgical treatment.

Modern haemophilia treatment: medical improvements and quality of life

Adequate replacement therapy in haemophilia has been available for two decades. This has led to considerable improvements in the life expectancy and physical status of haemophilia patients. A study was conducted to investigate whether this has also led to improvements in quality of life. With this aim, information was obtained from 935 Dutch haemophiliacs by mailed questionnaires on relationships, marriage, family life and employment. Haemophilia patients were less often married than men in the general population (13% fewer) and had a lower total number of children (30% lower, 17% for those who were married). Twenty-two per cent of the patients were not employed and received an income from the disability funds. While severity of haemophilia, joint damage and age increased the risk of disability, it was noted that home treatment was associated with a 50% reduction in this risk. Remarkably, haemophilia patients did not differ from the general population in their view of the quality of their own health. The results of this study show a positive influence of modern haemophilia treatment on quality of life. At present, AIDS overshadows all optimistic feelings one may have about this field. However, the results described here demonstrate the benefits that can be achieved with adequate replacement therapy, and justify the expectation of further improvements in the near future.

Hemophilic pseudotumor of the spinal canal. Case report

Hemophilic pseudotumor is an uncommon complication among hemophiliacs. Most of these lesions are located in the long bones and the pelvis. The authors describe a case of hemophilic pseudotumor in a patient who presented with symptoms of L-5 radiculopathy and evidence of a destructive lesion on computerized tomography scans. Histologically, the lesion consisted of an organizing hematoma with reactive fibrosis. The diagnosis requires a high index of suspicion. Surgery is recommended for symptomatic patients.

Cause of death in hemophilia A patients in the United States from 1968 to 1979

Death data on 949 hemophiliacs for the years 1968-1979 have been analyzed. The median age at death has increased from 33 to 55 years. There was no evidence of new diseases caused by the more intensive therapy during this time interval. The leading infectious disease was hepatitis, accounting for eight deaths. Only one acute hepatitis death was listed after 1974, when sensitive tests for hepatitis B antigen screening of plasma were implemented. Cirrhosis was a primary or associated cause of death in 76 cases (8%) and pneumonia was a primary or associated cause of death in 62 deaths (6.5%). The types of malignancies in hemophiliacs were similar to those in the male US population with no evidence of excessive retrovirus malignancies prior to infection with HIV-1.

Incidence of inhibitors in patients with severe and moderate hemophilia A treated with factor VIII concentrates

Recent data published on the prevalence of inhibitors to factor VIII in hemophiliacs on treatment show great variations, with prevalence rates ranging from 3.6 to 14.2%. We have studied the cumulative risk of inhibitor development in a cohort of 62 patients with hemophilia A. All patients were born after 1960, were natives of the Vienna area, had a factor VIII activity of less than 5%, and were treated at least once. Using the method of Cutler and Ederer, the cumulative risk of inhibitor development was found to be 24% at the age of 25 years. Most inhibitors developed between the ages of 3 and 7 years. The current prevalence of F VIII inhibitors in the group of patients studied is 17.5%. It is concluded that prevalence data underestimate the true risk of inhibitor development.

The epidemiology of selected chronic childhood health conditions

The chronic illnesses of childhood as a whole show similar trends in rates of incidence and prevalence; within this general class, subgroups of the illnesses have distinct epidemiological characteristics and different histories of response to improvements in medical technology. This article selects 11 disorders as representative of the large class of childhood chronic illnesses. It reviews trends in the contribution of these illnesses to the overall morbidity and mortality rates among children. The current survival patterns for children with these illnesses are detailed in light of the probable demands generated for health care providers by similar patterns of survival. It is likely that these children will place heavy demands on the health care system for the foreseeable future. Epidemiological trends and improvements in survival patterns associated with these illnesses raise perplexing questions of resource allocation. New knowledge is needed to address emerging problems.

Treatment of haemophilia and related disorders in Britain and Northern Ireland during 1976-80: report on behalf of the directors of haemophilia centres in the United Kingdom

A five year survey of the treatment of patients in the United Kingdom suffering from haemophilia and related disorders was carried out on behalf of the directors of haemophilia centres. The survey showed an increase in the number of patients receiving treatment from the centres, a substantial increase in the total amount of therapeutic materials used, and an increase in the average amount of factor VIII or factor IX used yearly per patient. Home treatment became established for severely affected patients and accounted for roughly half of the total amount of material used. Study of the acquisition of factor VIII or factor IX antibodies (inhibitors) in patients with haemophilia A or haemophilia B showed no increase in antibodies during the survey period, despite the increased use of factor VIII and factor IX concentrates. The occurrence of acute hepatitis in treated patients was also studied and no increased incidence was observed. A near normal median expectation of life in patients with severe haemophilia A was found.

Neurological complications in hemophilia

The clinical data of 59 patients with hemophilia A or B are reviewed. Intracranial bleeding was observed in 6 patients and a minor bleeding episode was assumed in a further 8 patients. Neurosurgical evacuation of the hematoma was necessary in 2 cases and the remaining patients were treated solely with factor VIII or IX. In 10 patients a peripheral nerve lesion was observed, paresis of the femoral nerve being the most frequent (5 cases). Two patients showed a lesion of the lumbar and sacral plexus, 2 patients a lesion of the radial nerve and one patient a lesion of the cutaneous femoris lateralis nerve.

Social and psychological responses to home treatment of haemophilia

A pilot home treatment programme was set up in 1975 by the Department of Haematology and Community Medicine, St. Thomas's Hospital, London, and the Haemophilia Centre, Churchill Hospital, Oxford. The purpose of the study was to assess the clinical, social, and economic effects of enabling haemophiliacs to treat themselves at home. The clinical and economic aspects of the project have been discussed by Ingram et al. In this paper the immediate social and psychological impact of the home treatment programme is described.

A randomized study of factor VIII or prothrombin complex concentrate infusions in children with haemophilia and antibodies to factor VIII

In four children with haemophilia A and antibodies to factor VIII, 18 bleeding episodes were randomized for treatment with factor VIII concentrate (30 units/kg) and 18 for treatment with a prothrombin-complex concentrate (prothrombinex) given in a dose of 30 units of factor IX/kg. Treatment with prothrombinex was associated with a better clinical response, a significantly greater shortening of the kaolin partial thromboplastin time and significantly lower incidence of post-infusion increase of levels of factor VIII antibodies. Although treatment with factor VIII concentrate was clinically successful in 15 episodes, treatment failures occurred in three instances leading to parental request for withdrawal from study in two families.

Regional co-ordinator for haemophilia in domiciliary practice

The North-east Thames Region has appointed a nursing sister to co-ordinate the organisation of care for haemophiliacs in the region. As a result of the appointment, facilities for home treatment have expanded rapidly. Several associate centres providing care to haemophiliacs have been set up around the region in addition to the four main haemophilia centres, which are all in the south-west corner of the region. As well as providing support and supervision of patients on home treatment, the co-ordinator helps to place haemophiliac children in suitable schools, maintains the regional register of haemophiliacs, and has a more general role in ensuring that services are available where they are needed throughout the region.