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Hodroj MH, El Hasbani G, Al-Shamsi HO, Samaha H, Musallam KM, Taher AT. Clinical burden of hemophilia in older adults: Beyond bleeding risk. Blood Rev 2021; 53:100912. [PMID: 34887154 DOI: 10.1016/j.blre.2021.100912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/28/2021] [Accepted: 11/30/2021] [Indexed: 01/18/2023]
Abstract
The prospect of hemophilia patients has dramatically improved in the last few decades with the introduction of various interventions that can effectively treat or prevent their bleeding risk. The life expectancy of patients can now reach that of the healthy population, but this has paved the way for several previously unrecognized morbidities to manifest in older adults with hemophilia. Such clinical complications are attributed to suboptimal management or poor access to effective therapy during childhood as well as chronicity and prolonged exposure to the underlying pathophysiology of the disease and its treatment. Complications common in the aging population are also becoming increasingly relevant in this vulnerable patient subgroup. In this review, we highlight peculiarities of such morbidities including chronic viral infections and liver disease, debilitating joint impairment and bone disease, cardiovascular and chronic kidney disease, and cancers. We also reflect on topics of special interest in adulthood such as sexuality.
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Affiliation(s)
| | | | - Humaid O Al-Shamsi
- Burjeel Medical City, Abu Dhabi, United Arab Emirates; Emirates Oncology Society, Dubai, United Arab Emirates; University of Sharjah, Sharjah, United Arab Emirates
| | - Hanady Samaha
- Saint George Hospital University Medical Center, Beirut, Lebanon
| | | | - Ali T Taher
- American University of Beirut Medical Center, Beirut, Lebanon.
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Abstract
In recent decades, several improvements in hemophilia care have resulted in increased quality of life and life expectancy for those affected by this inherited hemorrhagic condition. Nowadays, individuals with hemophilia enjoy a life expectancy at birth close to that of males in the general population. As a consequence of the increasing age of the hemophilia population, a growing number of these patients develop age-related co-morbidities, such as cardiovascular disease and cancer, the management of which represents a new challenge for caregivers at hemophilia treatment centers. This narrative review focuses on the clinical problems arising in older people with hemophilia, with particular attention to the optimal therapeutic strategies.
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Alavian SM, Lankarani KB, Sharara AI. Treatment of Chronic HCV in Special Populations: Thalassemia, Hemophilia, and Hemodialysis Patients. CURRENT HEPATITIS REPORTS 2012. [DOI: 10.1007/s11901-012-0147-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Alavian SM, Aalaei-Andabili SH. Lack of Knowledge About Hepatitis C Infection Rates Among Patients With Inherited Coagulation Disorders in Countries Under the Eastern Mediterranean Region Office of WHO (EMRO): A Meta-Analysis. HEPATITIS MONTHLY 2012; 12:244-52. [PMID: 22690231 PMCID: PMC3360933 DOI: 10.5812/hepatmon.844] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Revised: 01/05/2012] [Accepted: 02/13/2012] [Indexed: 12/11/2022]
Abstract
CONTEXT Hepatitis C virus (HCV) infection is a public health problem. HCV alone is responsible for 90% cases of acute hepatitis among multiply transfused patients who are at risk of cirrhosis and hepatocellular carcinoma (HCC). OBJECTIVES To provide a clear picture of available data, we performed a systematic review of the epidemiological characteristics of HCV infection among patients with inherited coagulation disorders in the countries under the Eastern Mediterranean Region Office (EMRO). EVIDENCE ACQUISITION Meta-analysis was carried out on the basis of results of electronic and manual search. This analysis included studies in English, French, and Persian that met with the following criteria: (1) appropriate study design: cross-sectional, case-control, and cohort; (2) studies reporting HCV prevalence according to enzyme immune assay; (3) studies in which the sample population was enrolled from EMRO countries. According to the results of the heterogeneity tests, we used fixed-effect/random-effect model for our meta-analysis, with the "Metan" command. RESULTS We included 30 studies, most of which were from Iran. The mean age of the subjects ranged from 13 to 27.1 years. The majority of the patients were male (range, 81% to 100%). The pooled estimate of HCV infection among patients with inherited coagulation disorders was 48.07% (95% confidence interval [CI], range: 27.39-55.68) in Iran, 36.03% (95% CI, range: 4.466-67.598) in Pakistan, and 48.27% (95% CI, range: 36.12-60.43) in all the EMRO countries taken together. CONCLUSIONS In Iran and other EMRO countries, the HCV infection rate among patients with inherited coagulation disorders is high. Our study shows that there is a lack of knowledge about infections in such patients in most of the EMRO countries. It is the responsibility of health-policy makers to address this knowledge gap and provide safe and adequate treatment for patients in high-risk groups.
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Affiliation(s)
- Seyed Moayed Alavian
- Baqiyatallah University of Medical Sciences, Baqiyatallah Research Center for Gastroenterology and Liver Disease (BRCGL), Tehran, IR Iran
| | - Seyed Hossein Aalaei-Andabili
- Baqiyatallah University of Medical Sciences, Baqiyatallah Research Center for Gastroenterology and Liver Disease (BRCGL), Tehran, IR Iran
- Corresponding author: Seyed Hossein Aalaei-Andabili, Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Grand floor of Baqiyatallah Hospital, Mollasadra Ave., Vanak Sq. P.O. Box 14155-3651, Tehran, IR Iran. Tel.: +98-2188067114, Fax: +98-2188067114, E-mail:
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Alavian SM, Aalaei-Andabili SH. Lack of Knowledge About Hepatitis C Infection Rates Among Patients With Inherited Coagulation Disorders in Countries Under the Eastern Mediterranean Region Office of WHO (EMRO): A Meta-Analysis. HEPATITIS MONTHLY 2012. [PMID: 22690231 DOI: 10.5812/hepatmon.6050] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
CONTEXT Hepatitis C virus (HCV) infection is a public health problem. HCV alone is responsible for 90% cases of acute hepatitis among multiply transfused patients who are at risk of cirrhosis and hepatocellular carcinoma (HCC). OBJECTIVES To provide a clear picture of available data, we performed a systematic review of the epidemiological characteristics of HCV infection among patients with inherited coagulation disorders in the countries under the Eastern Mediterranean Region Office (EMRO). EVIDENCE ACQUISITION Meta-analysis was carried out on the basis of results of electronic and manual search. This analysis included studies in English, French, and Persian that met with the following criteria: (1) appropriate study design: cross-sectional, case-control, and cohort; (2) studies reporting HCV prevalence according to enzyme immune assay; (3) studies in which the sample population was enrolled from EMRO countries. According to the results of the heterogeneity tests, we used fixed-effect/random-effect model for our meta-analysis, with the "Metan" command. RESULTS We included 30 studies, most of which were from Iran. The mean age of the subjects ranged from 13 to 27.1 years. The majority of the patients were male (range, 81% to 100%). The pooled estimate of HCV infection among patients with inherited coagulation disorders was 48.07% (95% confidence interval [CI], range: 27.39-55.68) in Iran, 36.03% (95% CI, range: 4.466-67.598) in Pakistan, and 48.27% (95% CI, range: 36.12-60.43) in all the EMRO countries taken together. CONCLUSIONS In Iran and other EMRO countries, the HCV infection rate among patients with inherited coagulation disorders is high. Our study shows that there is a lack of knowledge about infections in such patients in most of the EMRO countries. It is the responsibility of health-policy makers to address this knowledge gap and provide safe and adequate treatment for patients in high-risk groups.
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Affiliation(s)
- Seyed Moayed Alavian
- Baqiyatallah University of Medical Sciences, Baqiyatallah Research Center for Gastroenterology and Liver Disease (BRCGL), Tehran, IR Iran
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Liver transplantation for patients with human immunodeficiency virus and hepatitis C virus coinfection with special reference to hemophiliac recipients in Japan. Surg Today 2011; 41:1325-31. [PMID: 21922353 DOI: 10.1007/s00595-010-4556-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2010] [Accepted: 11/09/2010] [Indexed: 10/17/2022]
Abstract
Liver transplantation for patients with hepatitis C virus (HCV) and human immunodeficiency virus (HIV) remains challenging. The advent of highly active antiretroviral therapy (HAART) for HIV has reduced mortality from opportunistic infection related to acquired immunodeficiency syndrome dramatically, while about 50% of patients die of end-stage liver cirrhosis resulting from HCV. In Japan, liver cirrhosis frequently develops after HCV-HIV coinfection resulting from previously transfused infected blood products for hemophilia. The problems of liver transplantation for those patients arise from the need to control calcineurin inhibitor with HAART drugs, the difficulty of using interferon after liver transplantation with HAART, and the need to control intraoperative coagulopathy associated with hemophilia. We review published reports of liver transplantation for these patients in the updated world literature.
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Khleif AA, Rodriguez N, Brown D, Escobar MA. Multiple Comorbid Conditions among Middle-Aged and Elderly Hemophilia Patients: Prevalence Estimates and Implications for Future Care. J Aging Res 2011; 2011:985703. [PMID: 21912745 PMCID: PMC3168380 DOI: 10.4061/2011/985703] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Revised: 05/27/2011] [Accepted: 07/07/2011] [Indexed: 12/23/2022] Open
Abstract
Introduction. Advances in hemophilia care and treatment have led to increases in the life expectancy among hemophiliacs. As a result, persons with hemophilia are reaching an older age and experiencing various age-related health conditions never seen before in this population. Aim. To determine the prevalence of comorbidities among middle-aged and elderly hemophilia A and hemophilia B patients. Methods. Retrospective chart review among all hemophilia patients, who attended the Gulf States Hemophilia and Thrombophilia Center. Results. All patients had at least one comorbid condition other than hemophilia, and the majority had between 3 and 6 comorbidities. The most common conditions identified were chronic hepatitis C, hypertension, HIV, chronic arthropathy, and overweight/obesity. Conclusions. Since persons with comorbidities are more likely to have poorer health outcomes and require greater care in managing their health needs, caring for aging hemophiliacs is likely to pose various social and economic challenges for both patients and providers.
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Affiliation(s)
- Aroub A Khleif
- Department of Pediatrics and Gulf States Hemophilia & Thrombophilia Center, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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Yokoyama S, Bartlett A, Dar FS, Heneghan M, O'Grady J, Rela M, Heaton N. Outcome of liver transplantation for haemophilia. HPB (Oxford) 2011; 13:40-5. [PMID: 21159102 PMCID: PMC3019540 DOI: 10.1111/j.1477-2574.2010.00237.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prior to routine screening of blood products many patients with haemophilia were infected with hepatitis C virus (HCV) and have subsequently gone on to develop end-stage liver disease (ESLD). PATIENTS AND METHODS We report our experience of liver transplantation (LT) in patients with haemophilia that developed ESLD secondary to HCV. Patients transplanted from 1994 to 2008 were identified retrospectively. Patient demographics pre-, intra- and post-operative details and outcome were documented. RESULTS A total of 3800 LT were performed of which 13 had haemophilia A, 4 haemophilia B and one factor (F)X deficiency. All patients were male with a median age of 52 years (range 26-59), all were HCV antibody positive, 5 (28%) were human immunodeficiency virus (HIV) positive and 4 (22%) had hepatocellular carcinoma. Median intra-operative blood loss was 4.2 l (range 0.8-12) and all received coagulation factor support peri-operatively. Coagulation was unsupported by 72 h post-operatively in all recipients. Two patients developed complications as a result of post-operative bleeding. At a median follow-up of 90 months, 8 patients have died, including 4 of the 5 patients that were HIV positive. The median survival of patients with and without HIV co-infection was 26 and 118 months, respectively. CONCLUSION LT in patients with haemophilia cures the coagulation disorder and in the absence of HIV/HCV co-infection is associated with long-term patient survival.
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Affiliation(s)
- Satoshi Yokoyama
- King's College London School of Medicine at King's College Hospital, Institute of Liver Studies, King's College HospitalDenmark Hill, London, UK
| | - Adam Bartlett
- King's College London School of Medicine at King's College Hospital, Institute of Liver Studies, King's College HospitalDenmark Hill, London, UK,Department of Surgery, The University of Auckland, Faculty of Medicine and Health Sciences, Auckland City HospitalGrafton, Auckland, New Zealand
| | - Faisal S Dar
- King's College London School of Medicine at King's College Hospital, Institute of Liver Studies, King's College HospitalDenmark Hill, London, UK
| | - Michael Heneghan
- King's College London School of Medicine at King's College Hospital, Institute of Liver Studies, King's College HospitalDenmark Hill, London, UK
| | - John O'Grady
- King's College London School of Medicine at King's College Hospital, Institute of Liver Studies, King's College HospitalDenmark Hill, London, UK
| | - Mohamed Rela
- King's College London School of Medicine at King's College Hospital, Institute of Liver Studies, King's College HospitalDenmark Hill, London, UK
| | - Nigel Heaton
- King's College London School of Medicine at King's College Hospital, Institute of Liver Studies, King's College HospitalDenmark Hill, London, UK
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Zhubi B, Mekaj Y, Baruti Z, Bunjaku I, Belegu M. Transfusion-transmitted infections in haemophilia patients. Bosn J Basic Med Sci 2010; 9:271-7. [PMID: 20001991 DOI: 10.17305/bjbms.2009.2777] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
One of the largest therapeutic problem during the continuous treatment of the patients with Hemophilia A and B, are viral infections as Hepatitis B and C, and HIV, and the other infective diseases, which can be transmitted by the transfusion of blood products. The aim of this study is to analyze the complications of the hemophiliacs in Kosovo which have been treated with fresh frozen plasma, cryoprecipitate and concentrated products of FVIII and FIX. We have tested 75 patients with hemophilia A or B and there were used enzyme immunoassay test-Elisa method for the following: anti-HCV, HBsAg, HIV and TPHA.The serological data showed that HCV infection was positive in 29 cases or 38,7%, whereas infection with HBV and HIV were present in a smaller percentage of the patients (2,7% HBV and 1,4% for HIV). HCV infection was present only in 9,5% of the cases of the age group under 18 years. Infected hemophiliacs with one or two infective agents were found in 34,7%, respectively 4%. Infection with T. pallidum was present at none of the examined patients with hemophilia. HCV infection was higher in severe forms of hemophilia B (44,4%), compared with severe form of hemophilia A (30%).Based on our results, despite the infrequent application of FVIII and FIX concentrates, and other anti hemophilic preparations used in treating hemophilia patients, the number of infected hemophiliacs with blood-transmittable infectious agents was substantially high, especially with hepatitis C virus.
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Affiliation(s)
- Bukurije Zhubi
- National Blood Transfusion Centre of Kosovo Prishtina (NBTCK). Mother Theresa str., 10000 Prishtina, Kosovo
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Lapecorella M, Napolitano M, Tudini M, Bruera G, Lucchesi A, Giordano AV, Mariani G, Ricevuto E. Sorafenib as a feasible therapeutic option in haemophiliacs with hepatocellular carcinoma. Haemophilia 2010; 16:185-187. [PMID: 19804385 DOI: 10.1111/j.1365-2516.2009.02114.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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Franchini M, Mannucci PM. Co-morbidities and quality of life in elderly persons with haemophilia. Br J Haematol 2009; 148:522-33. [PMID: 19958358 DOI: 10.1111/j.1365-2141.2009.08005.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The life expectancy and quality of life of persons with haemophilia has dramatically increased since the 1970s, with the exception of the increased rate of deaths observed during the 1980s and the 1990s due to blood-borne viral infections. Improvements of factor replacement therapy, treatment of infectious diseases and comprehensive health care provided by specialised haemophilia centres are the main determinants of the increasing age of the haemophilia population. As a consequence, a growing number of these patients develop age-related co-morbidities, such as cardiovascular disease and cancer. The care of these previously rare conditions is a new challenge for caregivers in haemophilia centres. This review focuses on co-morbidities in the ageing haemophilia patients, their impact on quality of life and their complex management.
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Affiliation(s)
- Massimo Franchini
- Immunohaematology and Transfusion Centre, Department of Pathology and Laboratory Medicine, University Hospital of Parma, Italy
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Franchini M, Mengoli C, Veneri D, Mazzi R, Lippi G, Cruciani M. Treatment of chronic hepatitis C in haemophilic patients with interferon and ribavirin: a meta-analysis. J Antimicrob Chemother 2008; 61:1191-200. [DOI: 10.1093/jac/dkn119] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Posthouwer D, Mauser-Bunschoten EP, Fischer K, Makris M. Treatment of chronic hepatitis C in patients with haemophilia: a review of the literature. Haemophilia 2006; 12:473-8. [PMID: 16919076 DOI: 10.1111/j.1365-2516.2006.01317.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Chronic hepatitis C is a major cause of morbidity and mortality in haemophilia patients. In contrast to studies in the general population, the studies of antiviral therapy in haemophilia patients are limited and often include small numbers of patients. A review of the literature was performed to assess the efficacy of interferon (IFN)-based therapy for patients with haemophilia chronically infected with hepatitis C virus (HCV). Studies were identified by electronic searches (Medline, Embase) and hand searches in references of key articles. Data of the included studies were pooled, and responses to therapy were stratified according to treatment regimen, HIV co-infection status, and treatment history. The main outcome was a sustained virological response (SVR) defined as absence of HCV RNA both at the end of treatment and 24-week post-treatment. Thirty-five studies were identified that included 1151 patients. After pooling the data of included patients, the SVR in HIV-negative treatment naïve patients was 22% for IFN monotherapy, 43% for IFN and ribavirin, and 57% for pegylated IFN and ribavirin, respectively. Re-treatment with IFN and ribavirin of those who failed to respond to previous IFN monotherapy was successful in 33%. In HCV/HIV-coinfected patients, response to IFN monotherapy was 8% and to IFN combined with ribavirin 39%. Responses to IFN-based therapy in patients with haemophilia have been improved over time and are nowadays approximately 50-60%. However, data on haemophilic HCV/HIV-coinfected patients and in patients who failed to respond to previous therapy are limited and future studies in these specific patient population are necessary.
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Affiliation(s)
- D Posthouwer
- Van Creveldkliniek, University Medical Center, Utrecht, The Netherlands.
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del Amo J, Pérez-Hoyos S, Moreno A, Quintana M, Ruiz I, Cisneros JM, Ferreros I, González C, García de Olalla P, Pérez R, Hernández I. Trends in AIDS and Mortality in HIV-Infected Subjects With Hemophilia From 1985 to 2003. J Acquir Immune Defic Syndr 2006; 41:624-31. [PMID: 16652037 DOI: 10.1097/01.qai.0000194232.85336.dc] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To study trends in progression to AIDS, all-cause mortality, and cause-specific mortality (AIDS-related, liver disease, and hemorrhagic complications) over calendar periods with different exposure to highly active antiretroviral therapy (HAART) in a cohort of hemophiliacs in Spain, taking into account the competing risks of the causes of death. METHODS Multicenter cohort of HIV-infected hemophiliacs. HIV seroconversion was estimated using mathematic techniques for interval-censored data from 1979 through 1985. Rates of AIDS and cause-specific death were calculated by Poisson regression, allowing for late entry, for the periods 1985 through 1992, 1993 through 1996, 1997 through 2000 (early HAART), and 2001 through 2003 (late HAART), also allowing for competing risks. RESULTS Of 585 subjects, 44% were younger than 15 years of age, 82% had severe hemophilia, 86% had type A hemophilia, and the median seroconversion date was October 1982. Calendar period and age at HIV seroconversion strongly influenced AIDS and death rates. Compared with 1993 through 1996, decreases of 75% (relative risk [RR] = 0.25, 95% confidence interval [CI]: 0.14 to 0.43) and 72% (RR = 0.28, 95% CI: 0.12 to 0.63) in the RR of AIDS were observed in early and late HAART. For all-cause mortality, 72% (RR = 0.28, 95% CI: 0.18 to 0.42) and 83% (RR = 0.17, 95% CI: 0.09 to 0.33) decreases were observed by 1997 through 2000 and 2001 through 2003. For liver-related deaths, increases were observed in the late-HAART period (RR = 2.80, 95% CI: 0.94 to 8.36) compared with 1993 through 1996, but using competing risks, this RR was substantially reduced (RR = 1.70, 95% CI: 0.57 to 5.04). DISCUSSION Major reductions in AIDS and death rates were observed from 1997 to 2003 in hemophiliacs. These survival improvements are largely attributable to decreases in AIDS-related deaths and have been accompanied by increases in liver disease death rates, which are overestimated if competing risks are not taken into account.
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Affiliation(s)
- Julia del Amo
- Department of Public Health, Universidad Miguel Hernández, Campus de San Juan Ctra, Alicante-Valencia, Km 87, 03550 San Juan-Alicante, Spain.
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Abstract
Haemophilia A and B are inherited bleeding disorders whose diagnosis and management is generally well established and best provided by specialists in a comprehensive care setting. Patients may be put at unnecessary risk if appropriate expertise is not sought for the management of accidents and surgery. The delivery of a high quality comprehensive service to patients with bleeding disorders depends upon defined standards and a network of haemophilia centres in the UK with similar models in other countries. In developing countries, despite a shortage or absence of treatment products, development of local expertise results in an improved outlook and reduction in mortality. Optimal care for severe haemophilia includes accurate diagnosis, early and adequate factor replacement for bleeding episodes and the provision of prophylaxis from an early age to prevent joint bleeding and the consequent arthropathy. Haemophilia treatment is expensive resulting in considerable inequity in provision of care across the world. Despite decades of experience, optimal treatment levels are not robustly defined. Transfusion-transmitted infections continue to have a significant impact on patient management. The development of inhibitory antibodies seriously complicates the management both in morbidity and cost. While gene therapy has not yet produced the hoped-for cure, new technologies will produce improved products.
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Affiliation(s)
- Paula H B Bolton-Maggs
- Manchester Haemophilia Comprehensive Care Centre, Manchester Royal Infirmary, Manchester, UK.
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