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van Leeuwen FHP, Lena B, van Bergen EDP, van Klei JJ, Timmer MA, van Vulpen LFD, Fischer K, de Jong PA, Bos C, Foppen W. Quantitative MRI assessment of joint effusion using T2-relaxometry at 3 Tesla: a feasibility and reproducibility study. Skeletal Radiol 2024:10.1007/s00256-024-04652-0. [PMID: 38512365 DOI: 10.1007/s00256-024-04652-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 03/09/2024] [Accepted: 03/10/2024] [Indexed: 03/23/2024]
Abstract
OBJECTIVE T2-relaxometry could differentiate between physiological and haemorrhagic joint effusion (≥ 5% blood) in vitro. Are quantitative T2-relaxation time measurements of synovial fluid feasible and reproducible in vivo in clinically bleed-free joints of men with haemophilia? MATERIALS AND METHODS In this cross-sectional study, we measured T2-relaxation times of synovial fluid in clinically bleed-free ankles, knees or elbows of men with severe haemophilia A using a T2-mapping sequence (duration ≤ 7 min) at 3 Tesla MRI. Manual and circular regions of interest (ROI) were drawn in the synovial fluid of each joint by two independent observers to measure T2-relaxation times. Measurement feasibility was expressed as the success rate of the measurements by both observers. The interobserver and intraobserver reproducibility of the measurements were evaluated by the intraclass correlation coefficient of absolute agreement (ICC) and the limits of agreement (LoA) from Bland Altman analysis. RESULTS We evaluated 39 clinically bleed-free joints (11 ankles, 12 knees, 16 elbows) of 39 men (median age, 24 years; range 17-33) with severe haemophilia A. The success rate of the T2-measurements was ≥ 90%. Interobserver reliability was good to excellent (manual ROI: ICC = 0.92, 95% CI 0.76-0.97; circular ROI: ICC = 0.82, 95% CI 0.66-0.91) and interobserver agreement was adequate (manual ROI: LoA = 71 ms; circular ROI: LoA = 146 ms). Intraobserver reliability was good to excellent (manual ROI: ICC = 0.78, 95% CI - 0.06-0.94; circular RO: ICC = 0.99, 95% CI 0.98-0.99) and intraobserver agreement was good (manual ROI: LoA = 63 ms; circular ROI: LoA = 41 ms). CONCLUSION T2-relaxometry of synovial fluid in haemophilia patients is feasible with good interobserver and intraobserver reproducibility.
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Affiliation(s)
- Flora H P van Leeuwen
- Department of Radiology and Nuclear Medicine, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht University, HP: E01.132, P.O. Box 85500, 3584 CX, Utrecht, The Netherlands.
| | - Beatrice Lena
- Department of Radiology and Nuclear Medicine, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht University, HP: E01.132, P.O. Box 85500, 3584 CX, Utrecht, The Netherlands
| | - Eline D P van Bergen
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, HP C01.428, P.O. Box 85500, 3584, CX, Utrecht, The Netherlands
| | - Janoah J van Klei
- Department of Radiology and Nuclear Medicine, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht University, HP: E01.132, P.O. Box 85500, 3584 CX, Utrecht, The Netherlands
| | - Merel A Timmer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, HP C01.428, P.O. Box 85500, 3584, CX, Utrecht, The Netherlands
| | - Lize F D van Vulpen
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, HP C01.428, P.O. Box 85500, 3584, CX, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, HP C01.428, P.O. Box 85500, 3584, CX, Utrecht, The Netherlands
| | - Pim A de Jong
- Department of Radiology and Nuclear Medicine, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht University, HP: E01.132, P.O. Box 85500, 3584 CX, Utrecht, The Netherlands
| | - Clemens Bos
- Department of Radiology and Nuclear Medicine, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht University, HP: E01.132, P.O. Box 85500, 3584 CX, Utrecht, The Netherlands
| | - Wouter Foppen
- Department of Radiology and Nuclear Medicine, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht University, HP: E01.132, P.O. Box 85500, 3584 CX, Utrecht, The Netherlands
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Daffunchio C, Galatro G, Faurlin V, Neme D, Caviglia H. The hidden joint in children with haemophilia on prophylaxis. Thromb Res 2023; 226:86-92. [PMID: 37130495 DOI: 10.1016/j.thromres.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 03/22/2023] [Accepted: 04/11/2023] [Indexed: 05/04/2023]
Abstract
Prophylaxis is the gold standard treatment for children with haemophilia (CWH). MRI studies revealed joint damage, even with this treatment; this suggests the presence of subclinical bleeding. In the case of children with haemophilia, it is relevant to detect early signs of joint damage, as this allows the medical team to provide the appropriate treatment and follow-up, in order to avoid arthropathy development and its consequences. The aim of this study is to detect the hidden joint in children with haemophilia on prophylaxis (CWHP) and analyse, by age group, which joint is the most affected. We define the hidden joint in CWH on prophylaxis as the joint that presents joint damage secondary to repetitive bleeding episodes and is detected in the joint evaluation, despite being asymptomatic or with mild symptoms. It is most commonly caused by repetitive subclinical bleeding. METHODS This was an observational, analytical, cross-sectional study of 106 CWH on prophylaxis treated in our centre. Patients were divided according to age and type of treatment. Joint damage was defined as a HEAD-US score ≥ 1. RESULTS Patients' median age was 12 years. All had severe haemophilia. The median age of onset of prophylaxis was 2.7. Forty-seven (44.3 %) patients received primary prophylaxis (PP) and 59 (55.7 %), secondary prophylaxis. Six hundred and thirty-six joints were analysed. Type of prophylaxis and joint involvement showed statistically significant differences (p < 0.001). However, patients on PP had a greater number of damaged joints at older ages. Twenty-two % (140) of the joints scored ≥1 on HEAD-US. Cartilage was most frequently involved, followed by synovitis, and bone damage. We observed a greater frequency and degree of arthropathy in subjects aged 11 and above. Sixty (12.7 %) joints showed a HEAD-US score ≥ 1, with no history of bleeding. The ankle was the most affected joint, representing the hidden joint according to our definition. CONCLUSION Prophylaxis is the best treatment for CWH. However, symptomatic or subclinical joint bleeding may occur. The routine evaluation of joint health is relevant, particularly, of the ankle. In our study, early signs of arthropathy according to age and type of prophylaxis were detected by HEAD-US.
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Affiliation(s)
- Carla Daffunchio
- Haemophilia Foundation, Buenos Aires, Argentina; Department of Orthopaedics and Traumatology, Juan A. Fernández Hospital, Buenos Aires, Argentina.
| | - Gustavo Galatro
- Haemophilia Foundation, Buenos Aires, Argentina; Department of Orthopaedics and Traumatology, Juan A. Fernández Hospital, Buenos Aires, Argentina
| | | | | | - Horacio Caviglia
- Haemophilia Foundation, Buenos Aires, Argentina; Department of Orthopaedics and Traumatology, Juan A. Fernández Hospital, Buenos Aires, Argentina
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Ljung R, de Kovel M, van den Berg HM. Primary prophylaxis in children with severe haemophilia A and B-Implementation over the last 20 years as illustrated in real-world data in the PedNet cohorts. Haemophilia 2023; 29:498-504. [PMID: 36571801 DOI: 10.1111/hae.14729] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The prophylactic regimen in children with severe haemophilia is suggested in various publications and guidelines. Few data exist on its implementation in clinical practice. AIM To investigate the implementation of primary prophylaxis based on real-life data from PedNet during the last 20 years. METHODS All children from the PedNet cohort (n = 1260) with severe haemophilia A (SHA) or severe haemophilia B (SHB), FVIII/IX < .01 IU/mL, born between 2000 and 2009 (Cohort I; SHA n = 662; SHB n = 88) and 2010-2019 (Cohort II; SHA n = 598; SHB n = 94) were included. RESULTS In SHA, the median age at start of prophylaxis was 17.3 months (IQR; 12.5-26.1) in Cohort I which decreased to 13.1 months (IQR; 10.4-19.1) in Cohort II (p < .000). "Once-a-week" prophylaxis at start increased from 49% to 68% (SHA) and 38% to 70% (SHB). FVIII doses were reduced from median 43.5 (IQR; 34.6-49.0) to 30.9 IU/kg (IQR; 26.3-46.3), while dosing with FIX did not change. After 2010 approximately 60% of the patients with SHA and SHB started prophylaxis before any joint bleed. The number of CVADs needed in both cohorts was around 30%. Incidences of inhibitors were unchanged: SHA (∼31%) and SHB (∼10%). Sporadic cases were diagnosed significantly later (median 8.3 months; IQR; 3.7-11.9) and they had more joint bleeds before start of prophylaxis. CONCLUSION Primary prophylaxis nowadays starts at an earlier age: before any joint bleed (60% of patients with SHA and SHB). Approximately 70% started on a once-weekly schedule with significantly reduced doses in SHA but unchanged in SHB.
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Affiliation(s)
- Rolf Ljung
- Department of Clinical Sciences, Department of Paediatrics, Lund University, Lund, Sweden
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Rascevska E, Tessier DR, Doria AS, Fenster A. Proof-of-Concept Study of a 3-D Ultrasound Scanner Used for Ankle Joint Assessment. Ultrasound Med Biol 2023; 49:278-288. [PMID: 36220709 DOI: 10.1016/j.ultrasmedbio.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 07/04/2022] [Accepted: 09/04/2022] [Indexed: 06/16/2023]
Abstract
Joint arthropathies often require continuous monitoring of the joint condition, typically performed using magnetic resonance (MR) or ultrasound (US) imaging. US imaging is often the preferred screening or diagnostic tool as it is fast and inexpensive. However, conventional 2-D US has limited capability to compare imaging results between examinations because of its operator dependence and challenges related to repeat imaging in the same location and orientation. Comparison between several imaging sessions is crucial to assess the interval progression of joint conditions. We propose a novel 3-D US scanner for ankle joint assessment that can partially overcome these issues by enabling 3-D imaging. Here, we (i) present the design of the 3-D US ankle scanner system, (ii) validate the geometric reconstruction accuracy of the system, (iii) provide preliminary images of healthy volunteer ankles and (iv) compare 3-D US imaging results with MR imaging. The 3-D ankle scanner consists of a tub filled with water, a linear US probe attached to the wall of the tub and a motorized unit that rotates the US probe 360° around the center of the tub. As the probe rotates, a 3-D US image is formed of the ankle of the patient positioned in the middle of the tub. US probe height, angle and distance from the tub center can be adjusted. The reconstruction accuracy of the system was validated in each of the coordinate directions at different probe angles using two test phantoms. A phantom consisting of numerous Ø200-µm nylon threads with known spacing and a metal rod with machined grooves was used for validation in the horizontal and vertical directions, respectively. The volumetric reconstruction accuracy validation was performed by imaging an agar phantom with two embedded spheres of known volumes and comparing the segmented sphere volume and surface area with the expected. Three-dimensional US and MR images of both ankles of five healthy volunteers were acquired. Distal tibia and proximal talus were segmented in both imaging modalities and the surfaces of these segmentations were compared using the 95% Hausdorff and mean surface distances. The observed mean linear measurement error in all the coordinate directions and over several probe angles was 2.98%. The mean measured volumetric measurement error was 3.45%. The volunteer study revealed useful features for joint assessment present in the 3-D ankle scanner images, such as joint spacing, distal tibia and proximal talus. The mean 95% Hausdorff and mean surface distances between segmentations in 3-D US and MR images were 5.68 ± 0.83 and 2.01 ± 0.30 mm, respectively. In this proof-of-concept study, the 3-D US ankle scanner enabled visualization of the ankle joint features that are useful for joint assessment.
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Affiliation(s)
- Elina Rascevska
- Imaging Program, Lawson Health Research Institute, London, Ontario, Canada; School of Biomedical Engineering, Western University, London, Ontario, Canada.
| | - David R Tessier
- Robarts Research Institute, Western University, London, Ontario, Canada
| | - Andrea S Doria
- Department of Diagnostic Imaging, Hospital for Sick Children, and Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Aaron Fenster
- School of Biomedical Engineering, Western University, London, Ontario, Canada; Robarts Research Institute, Western University, London, Ontario, Canada
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Lundin B, Baghaei F, Holmström M, Petrini P, Müller G, Månsson S, Ljung R. Haemophilia A and B - evaluation of the Swedish prophylactic regimen by magnetic resonance imaging. Haemophilia 2023; 29:193-198. [PMID: 36469433 PMCID: PMC10107095 DOI: 10.1111/hae.14693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 10/26/2022] [Accepted: 10/26/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Sweden has been a pioneer in the prophylactic treatment of haemophilia. Magnetic resonance imaging (MRI) can detect small changes in joints and can therefore give an indication of a risk of developing arthropathy. AIM To use MRI to evaluate the outcome of the Swedish 'high-dose regimen' and correlate the findings to age, bleeds, joint score and physical activity. METHODS The study group comprised 48 Swedish male patients, mean age 25 years (range 12-33 years), with severe or moderate haemophilia A or B. Data on the Haemophilia Joint Health Score (HJHS) were available and physical activity was evaluated by a self-reported questionnaire. RESULTS MRI score was recorded in 188 joints. Twenty out of 48 patients had a score of ≥1 (range 1-13) in 31 joints of which 3/31 scores were in the knees and 28/31 in the ankles. No correlation was found between the number of recorded bleeds and the MRI score or between HJHS and MRI score. There was no correlation between the physical activity and the number of joint bleeds per se, but a trend (OR 3.0) that those most physically active (19/48; 39.6%), more frequently had an MRI score of ≥1 with an overweight for the right ankle. CONCLUSION The Swedish prophylactic model offers protection against haemophilia joint arthropathy but will still not prevent osteochondral changes in some patients at young age. MRI of the ankles can signal risk of future arthropathy and indicate need to modify the prophylactic regimen.
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Affiliation(s)
- Björn Lundin
- Department of Clinical Sciences Lund (IKVL) - Radiology, Lund University, Lund, Sweden and Dept. of Medical Imaging and Physiology, Skåne University Hospital, Lund/Malmö, Sweden
| | - Fariba Baghaei
- Coagulation Centre, Department of Medicine/Section of Hematology and Coagulation, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Margareta Holmström
- Coagulation Unit, Department of Hematology, Karolinska University Hospital, Stockholm, Sweden.,Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Pia Petrini
- Astrid Lindgren Children´s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Gunilla Müller
- Institut für Radiologie und Nuklearmedizin, Stadtspital Triemli, Zürich, Switzerland
| | - Sven Månsson
- Medical Radiation Physics, Department of Translational Medicine, Lund University, Malmö, Sweden.,Hematology, Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
| | - Rolf Ljung
- Department of Clinical Sciences Lund (IKVL) - Paediatrics, Lund University, Lund, Sweden
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van Leeuwen FHP, Lena B, Zwanenburg JJM, van Vulpen LFD, Bartels LW, Fischer K, Nap FJ, de Jong PA, Bos C, Foppen W. Detecting low blood concentrations in joints using T1 and T2 mapping at 1.5, 3, and 7 T: an in vitro study. Eur Radiol Exp 2021; 5:51. [PMID: 34853955 PMCID: PMC8636530 DOI: 10.1186/s41747-021-00251-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/18/2021] [Indexed: 11/18/2022] Open
Abstract
Background Intra-articular blood causes irreversible joint damage, whilst clinical differentiation between haemorrhagic joint effusion and other effusions can be challenging. An accurate non-invasive method for the detection of joint bleeds is lacking. The aims of this phantom study were to investigate whether magnetic resonance imaging (MRI) T1 and T2 mapping allows for differentiation between simple and haemorrhagic joint effusion and to determine the lowest blood concentration that can be detected. Methods Solutions of synovial fluid with blood concentrations ranging from 0 to 100% were scanned at 1.5, 3, and 7 T. T1 maps were generated with an inversion recovery technique and T2 maps from multi spin-echo sequences. In both cases, the scan acquisition times were below 5 min. Regions of interest were manually drawn by two observers in the obtained T1 and T2 maps for each sample. The lowest detectable blood concentration was determined for all field strengths. Results At all field strengths, T1 and T2 relaxation times decreased with higher blood concentrations. The lowest detectable blood concentrations using T1 mapping were 10% at 1.5 T, 25% at 3 T, and 50% at 7 T. For T2 mapping, the detection limits were 50%, 5%, and 25%, respectively. Conclusions T1 and T2 mapping can detect different blood concentrations in synovial fluid in vitro at clinical field strengths. Especially, T2 measurements at 3 T showed to be highly sensitive. Short acquisition times would make these methods suitable for clinical use and therefore might be promising tools for accurate discrimination between simple and haemorrhagic joint effusion in vivo. Supplementary Information The online version contains supplementary material available at 10.1186/s41747-021-00251-z.
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Affiliation(s)
- Flora H P van Leeuwen
- Department of Radiology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Beatrice Lena
- Image Sciences Institute, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jaco J M Zwanenburg
- Department of Radiology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Lize F D van Vulpen
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Lambertus W Bartels
- Image Sciences Institute, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Frank J Nap
- Department of Radiology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Department of Radiology, Central Military Hospital, Ministry of Defence, Lundlaan 1, 3584 EZ, Utrecht, The Netherlands
| | - Pim A de Jong
- Department of Radiology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Clemens Bos
- Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Wouter Foppen
- Department of Radiology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Kampen WU, Boddenberg-Pätzold B, Fischer M, Gabriel M, Klett R, Konijnenberg M, Kresnik E, Lellouche H, Paycha F, Terslev L, Turkmen C, van der Zant F, Antunovic L, Panagiotidis E, Gnanasegaran G, Kuwert T, Van den Wyngaert T; EANM Bone & Joint Committee, the Dosimetry Committee, the Oncology & Theranostics Committee. The EANM guideline for radiosynoviorthesis. Eur J Nucl Med Mol Imaging 2021. [PMID: 34671820 DOI: 10.1007/s00259-021-05541-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/23/2021] [Indexed: 12/30/2022]
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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Abstract
Haemophilia A and B are rare congenital, recessive X-linked disorders caused by lack or deficiency of clotting factor VIII (FVIII) or IX (FIX), respectively. The severity of the disease depends on the reduction of levels of FVIII or FIX, which are determined by the type of the causative mutation in the genes encoding the factors (F8 and F9, respectively). The hallmark clinical characteristic, especially in untreated severe forms, is bleeding (spontaneous or after trauma) into major joints such as ankles, knees and elbows, which can result in the development of arthropathy. Intracranial bleeds and bleeds into internal organs may be life-threatening. The median life expectancy was ~30 years until the 1960s, but improved understanding of the disorder and development of efficacious therapy based on prophylactic replacement of the missing factor has caused a paradigm shift, and today individuals with haemophilia can look forward to a virtually normal life expectancy and quality of life. Nevertheless, the potential development of inhibitory antibodies to infused factor is still a major hurdle to overcome in a substantial proportion of patients. Finally, gene therapy for both types of haemophilia has progressed remarkably and could soon become a reality.
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Gooding R, Thachil J, Alamelu J, Motwani J, Chowdary P. Asymptomatic Joint Bleeding and Joint Health in Hemophilia: A Review of Variables, Methods, and Biomarkers. J Blood Med 2021; 12:209-220. [PMID: 33833602 PMCID: PMC8023018 DOI: 10.2147/jbm.s304597] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/19/2021] [Indexed: 12/14/2022] Open
Abstract
Joint health is a key contributor to quality of life in patients with hemophilia. However, variables that impact long-term joint outcomes have not been comprehensively defined. A systematic literature search identified publications relating to joint health in patients with hemophilia. Studies clearly show that early, sustained prophylaxis with factor replacements improves long-term joint outcomes. However, a subset of patients appear to develop arthropathy despite maintaining excellent bleeding outcomes, which suggests possible recurrent asymptomatic bleeding into the joints in these patients. Furthermore, limited data are available on how long-acting factor VIII and factor IX replacement therapies could impact long-term joint outcomes. Many variables were identified as potential indicators that a patient may develop hemophilic arthropathy, including genetic mutations, endogenous factor VIII and IX levels, bone health, and physical activity levels. Tools for the diagnosis and monitoring of hemophilic arthropathy are critical to detect early joint damage, so that management can be adjusted accordingly. Imaging techniques, particularly magnetic resonance imaging, can detect synovial changes, a strong predictor for the future development of hemophilic arthropathy. In addition, several biomarkers associated with cartilage and bone formation, vascularization, and angiogenesis could potentially identify the onset and progression of early joint damage. Since the development of hemophilic arthropathy is complex, a comprehensive therapeutic approach is necessary for the effective prevention of arthropathy in patients with hemophilia.
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Affiliation(s)
- Richard Gooding
- Leicester Haemophilia Centre, Haemostasis & Thrombosis Unit, Leicester Royal Infirmary, Leicester, UK
| | - Jecko Thachil
- Haematology Department, Manchester Royal Infirmary, Manchester, UK
| | - Jayanthi Alamelu
- Haemophilia Department, Evelina Children's Hospital - St Thomas' Hospital, London, UK
| | - Jayashree Motwani
- Haemophilia Comprehensive Care Centre, Birmingham Children's Hospital, Birmingham, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia Centre, Royal Free Hospital, London, UK
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Aydin Köker S, Kaygusuz A, Oymak Y, Karapϊnar TH, Çubukçu D, Gözmen S, Ay Y, Vergϊn RC. Assessment of Self-Image With the Offer Self-Image Questionnaire in Adolescents With Hemophilia: A Single-Center Experience. J Pediatr Hematol Oncol 2020; 42:e159-63. [PMID: 31725545 DOI: 10.1097/MPH.0000000000001664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hemophilia, which is a chronic illness associated with recurrent bleeding, may occur with psychosocial and behavioral problems. AIM The aim of this study was to evaluate the clinical characteristics and demographic features and changes in the self-image of adolescents with hemophilia. MATERIALS AND METHODS Data about hemophilia type, the severity of hemophilia, secondary prophylaxis received, and annual bleeding rate (ABR) were recorded from patient files. Hemophilia Joint Health Score (HJHS) and the Offer Self-Image Questionnaire (OSIQ) (as a measure of self-esteem) were applied to hemophilia patients and a healthy control group. RESULTS Thirty-two hemophilia patients (mean age=16.2±3.06 y) and 35 healthy male individuals (mean age=16.02±1.4 y) were enrolled in the study. Hemophilia patients had lower total OSIQ score than their peers (P=0.007). There was no difference between patients who received and who did not receive secondary prophylaxis (P=0.408) in terms of total OSIQ score. The median total OSIQ score of patients with pathologic HJHS (>0 points) was lower than that of patients with normal HJHS (0 points) (P=0.010). The median of ABR was 6 (range: 0 to 20) in the whole hemophilia group. There were no differences between hemophilia patients with ABR≤4 and >4 (P=0.084). All of the subscale parameters of the OSIQ were lower for hemophilia patients compared with their peers, besides one. The subscale of sexuality attitudes was better for hemophilia patients than for the healthy control group (P=0.028). CONCLUSIONS Low self-esteem in hemophilia patients indicates the importance of lifelong psychosocial support. Patients with pathologic HJHS are at risk of low-esteem. Using OSIQ with HJHS during follow-up of hemophilia patients may be useful for management.
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Gouw SC, Timmer MA, Srivastava A, de Kleijn P, Hilliard P, Peters M, Blanchette V, Fischer K. Measurement of joint health in persons with haemophilia: A systematic review of the measurement properties of haemophilia-specific instruments. Haemophilia 2019; 25:e1-e10. [PMID: 30427100 PMCID: PMC7379965 DOI: 10.1111/hae.13631] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 04/20/2018] [Accepted: 05/04/2018] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Accurate assessment of joint health in persons with haemophilia is crucial. Several haemophilia-specific measurement tools are available, but an overview of the measurement properties is lacking. AIM To provide an overview of the measurement properties of haemophilia-specific measurement tools to assess clinical joint health. METHODS MEDLINE and EMBASE were searched for reports on reliability, validity or responsiveness of the World Federation of Haemophilia Orthopedic Joint Score (WFH), Colorado Physical Examination Score (CPE), joint examination score by Petrini (PJS) and Hemophilia Joint Health Score (HJHS). Methodological quality of the studies was assessed using an adapted COSMIN checklist. RESULTS The search yielded 2905 unique hits, and 98 papers were included. The methodological quality of the included studies was limited. The HJHS was studied most extensively, which yielded limited evidence for good internal consistency and structural validity, moderate evidence for hypothesis testing in adults and conflicting evidence for hypothesis testing in children. Reliability, measurement error and responsiveness were rated unknown due to low COSMIN scores. For the CPE and PJS, we found limited to moderate evidence for good responsiveness and conflicting evidence for hypothesis testing. CONCLUSION Only patchy evidence is available on the quality of measurement properties of all haemophilia-specific joint health scores. Although significant gaps in the evidence for all instruments remain, measurement properties of the HJHS were most extensively studied and show no drawbacks for use in clinical practice. This review forms the basis for further research aimed at the assessment of measurement properties of measurement tools to assess joint health.
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Affiliation(s)
- Samantha C. Gouw
- Department of Pediatric HematologyAcademic Medical CenterAmsterdamThe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterAmsterdamThe Netherlands
| | - Merel A. Timmer
- Van Creveldkliniek, Department of HematologyUniversity Medical CenterUtrechtThe Netherlands
| | - Alok Srivastava
- Department of HematologyChristian Medical CollegeVelloreIndia
| | - Piet de Kleijn
- Van Creveldkliniek, Department of HematologyUniversity Medical CenterUtrechtThe Netherlands
- Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf MagnusUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Pamela Hilliard
- Department of RehabilitationHospital for Sick ChildrenTorontoOntarioCanada
| | - Marjolein Peters
- Department of Pediatric HematologyAcademic Medical CenterAmsterdamThe Netherlands
| | - Victor Blanchette
- Department of Paediatrics, Division of Hematology/Oncology, Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Kathelijn Fischer
- Van Creveldkliniek, Department of HematologyUniversity Medical CenterUtrechtThe Netherlands
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12
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Roh YY, Choi YH, Park M, Hahn JH, Kim SH, Shin YJ, Hahn SM, Lee HY, Park JM, Hong JP, Lyu CJ, Han JW. Joint Health Status in Hemophilia Patients Using Hemophilia Joint Health Score and Pettersson Score. Clin Pediatr Hematol Oncol 2018. [DOI: 10.15264/cpho.2018.25.2.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Yun Young Roh
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Young Ha Choi
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Mina Park
- Department of Nursing, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Jung Hwa Hahn
- Department of Nursing, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Sun Hee Kim
- Department of Nursing, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Yoon Jung Shin
- Department of Nursing, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Seung Min Hahn
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Hee Young Lee
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Jung Min Park
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Jun Pyo Hong
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Chuhl Joo Lyu
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Jung Woo Han
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
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13
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Abstract
The concept of joint microbleeding in hemophilia patients was first proposed over 10 years ago. This was based on unexpected abnormalities found in medical imaging studies of asymptomatic joints. Since then, there have been no published studies confirming the presence of joint microbleeds. This critique will review the evidence for and against joint microbleeding in hemophilia patients and the potential implications.
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Affiliation(s)
- J Puetz
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, SSM Health Cardinal Glennon Children's Hospital, Saint Louis University, St. Louis, MO, USA
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14
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De la Corte-Rodriguez H, Rodriguez-Merchan EC, Alvarez-Roman MT, Martin-Salces M, Martinoli C, Jimenez-Yuste V. The value of HEAD-US system in detecting subclinical abnormalities in joints of patients with hemophilia. Expert Rev Hematol 2018; 11:253-261. [PMID: 29383965 DOI: 10.1080/17474086.2018.1435269] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Prevention of hemarthrosis is the key factor in the adequate management of people with hemophilia (PWH). If hemarthrosis occurs, early diagnosis of joint damage is essential to make personalized treatments. This study is aimed at gaining an understanding of the ability of point-of-care ultrasound (US) using the `Hemophilia Early Arthropathy Detection with Ultrasound´ (HEAD-US) protocol to detect abnormalities in joints without history of hemarthrosis and clinically asymptomatic joints of PWH. METHODS The sample included 976 joints from 167 PWH (mean age 24.86 years). Data were collected from routine practice over a 3-year period and analyzed based on history of hemarthrosis and results of clinical (HJHS 2.1) and HEAD-US examinations. RESULTS In our series, 14% of patients exhibited HEAD-US signs of incipient arthropathy in joints with no history of bleeding and with a HJHS 2.1 score of 0. The most severely involved joint was the right ankle. Synovitis, articular cartilage and subchondral bone damage scores in joints with subclinical findings were slower than in joints with previous hemarthroses or HJHS 2.1 > 1 Conclusions: Our study demonstrates that HEAD-US is better than hemarthrosis records and the HJHS 2.1 scale in detecting the early signs of joint damage in PWH.
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Affiliation(s)
| | | | | | | | - Carlo Martinoli
- d Radiologia III - Ospedale Policlinico San Martino - Dept. of Health Science , University of Genoa , Genova , Italy
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15
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Kjeld NG, Hua B, Karsdal MA, Sun S, Manon-Jensen T. The endothelial specific isoform of type XVIII collagen correlates to annual bleeding rate in haemophilia patients. PLoS One 2018; 13:e0190375. [PMID: 29320534 PMCID: PMC5761888 DOI: 10.1371/journal.pone.0190375] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 12/13/2017] [Indexed: 01/12/2023] Open
Abstract
Introduction The medical need in the haemophilic (HF) field to reduce bleeding incidents requires measurement of the annual bleeding rate (ABR) in haemophiliacs. Vascular rupture is associated with damage to the vascular endothelium causing exposure of the basement membrane. Endothelial cells and matrix impairment may be associated with joint bleeds and later development of HF arthropathy. Imbalanced extracellular matrix turnover is a central pathological feature in many diseases consequent to epithelial or endothelial cell damage. Type XVIII collagen is an essential basement membrane component, with an endothelial specific isoform. Aim To quantify the basement membrane specifically for the endothelial cells, as that may have particular relevance to endothelial cell stability and rupture in haemophiliacs. A newly developed ELISA assay detecting endothelial type XVIII collagen (COL-18N) was used to assess the clinical relevance of endothelial basement membrane turnover in patients diagnosed with HF arthropathy and correlation to ABR. Methods We developed an ELISA assay for quantification of COL-18N. Serum from 35 male HF patients was investigated using the COL-18N ELISA. Results COL-18N correlated to the ABR of haemophiliacs, r = 0.45, P<0.006. Conclusion Vascular rupture and consequent bleeding are associated with joint damage and deterioration of life quality in haemophiliacs. Quantification of ABR is an important part in efficacy assessment of different interventions, and the benchmark of these. Objective biomarkers reflecting endothelial dysfunction, vascular leaks and rupture, like the COL-18N biomarker that associate with ABR, may assist in identifying the most optimal treatment and monitoring of HF patients.
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Affiliation(s)
| | - Baolai Hua
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences (CAMS) & Peking Union Medical College (PUMC), Beijing, China
- Department of Hematology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
| | | | - Shu Sun
- Nordic Bioscience A/S, Herlev Hovedgade, Herlev, Denmark
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16
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Affiliation(s)
- Rolf C. R. Ljung
- Department of Clinical Sciences - Paediatrics; Lund University; Lund Sweden
- Centre for Thrombosis and Haemostasis; Skåne University Hospital Malmö; Malmo Sweden
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17
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Fischer K, Carcao M, Santagostino E, Manco-Johnson MJ, Mathew P, Ljung R. Practical considerations in choosing a factor VIII prophylaxis regimen: Role of clinical phenotype and trough levels. Thromb Haemost 2017; 115:913-20. [DOI: 10.1160/th15-08-0664] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 12/28/2015] [Indexed: 11/05/2022]
Abstract
SummaryCurrent therapy for haemophilia A is guided by severity of the disease, which in turn is best reflected in patients' endogenous factor VIII activity levels. For patients with severe haemophilia (particularly children), prophylaxis with continuous routine factor replacement has become standard of care in developed countries and is gradually becoming the standard of care in developing countries. The question arises then: what is an appropriate prophylaxis regimen to prevent bleeding events and arthropathy, while also maximizing patient quality of life and taking into consideration the costs of prophylaxis? Should all patients be treated with one standard, fixed prophylaxis regimen, or should prophylaxis be individualised for each patient? If so, what factors need to be considered in choosing the appropriate dose and frequency of factor administration? If prophylaxis is tailored to the individual patient, then patient-related factors (bleeding phenotype, activity profiles, age, joint status) and product-specific factors (half-life of the replacement factor in the individual patient) will determine the choice of regimen, whether it be a fixed-regimen prophylaxis or prophylaxis that is tailored to patient activity and bleeding risk. Regardless of the choice of prophylaxis regimen, for any regimen to be effective, adherence to therapy is key to optimising outcomes.
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18
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Fischer K, Ljung R. Primary prophylaxis in haemophilia care: Guideline update 2016. Blood Cells Mol Dis 2017; 67:81-85. [DOI: 10.1016/j.bcmd.2017.02.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/15/2017] [Indexed: 10/20/2022]
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19
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Fischer K, Ljung R. WITHDRAWN: Primary prophylaxis in haemophilia care: Guideline update 2016. Blood Cells Mol Dis 2017; 80:102172. [PMID: 28363466 DOI: 10.1016/j.bcmd.2017.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 03/08/2017] [Accepted: 03/13/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Kathelijn Fischer
- Van Creveld kliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rolf Ljung
- Lund University, Dept. of Clinical Sciences Lund, Paediatrics, Lund, Sweden; Skåne University Hospital, Department of Paediatrics and Malmö Centre for Thrombosis and Haemostasis, Malmö, Sweden.
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20
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Abstract
Retrospective and prospective studies unambiguously show that prophylactic treatment of severe hemophilia A or B should be started as primary prophylaxis at 1–2 years’ of age and ideally before the first joint bleed. The dose and dose frequency should be individually tailored depending on the goal of treatment, venous access and the bleeding phenotype. The circumstances during the first exposures of factor VIII concentrates in hemophilia A may have an impact on the risk of developing inhibitors. Enhanced half-life products, in particular in hemophilia B, will facilitate treatment in patients with difficult venous access but also in achieving a higher trough level. Evidence accumulate that prophylactic treatment is beneficial also in adults and in patients with inhibitors.
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Affiliation(s)
- Rolf Ljung
- Department of Clinical Sciences Lund-Paediatrics, Lund University, Lund, Sweden ; Department of Paediatrics and Malmö Centre for Thrombosis and Haemostasis, Skåne University Hospital, Malmö, Sweden
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21
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Fischer K, Poonnoose P, Dunn AL, Babyn P, Manco-Johnson MJ, David JA, van der Net J, Feldman B, Berger K, Carcao M, de Kleijn P, Silva M, Hilliard P, Doria A, Srivastava A, Blanchette V. Choosing outcome assessment tools in haemophilia care and research: a multidisciplinary perspective. Haemophilia 2016; 23:11-24. [DOI: 10.1111/hae.13088] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2016] [Indexed: 01/23/2023]
Affiliation(s)
- K. Fischer
- Van Creveldkliniek; University Medical Center Utrecht; Utrecht The Netherlands
| | - P. Poonnoose
- Department of Orthopaedics; Christian Medical College; Vellore Tamil Nadu India
| | - A. L. Dunn
- Division of Hematology and Oncology; Nationwide Children's Hospital and The Ohio State University; Columbus OH USA
| | - P. Babyn
- Department of Medical Imaging; University of Saskatchewan and Saskatoon Health Region Royal University Hospital; Saskatoon SK Canada
| | - M. J. Manco-Johnson
- Section of Hematology/Oncology/Bone Marrow Transplantation; Department of Pediatrics; University of Colorado Anschutz Medical Campus and Children's Hospital; Aurora CO USA
| | - J. A. David
- Department of PMR; Christian Medical College; Vellore Tamil Nadu India
| | - J. van der Net
- Child Health Services; Child Development and Exercise Center; University Medical Center and Children's Hospital; Utrecht The Netherlands
| | - B. Feldman
- Division of Rheumatology; Department of Paediatrics and Child Health Evaluative Sciences; Research Institute; Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - K. Berger
- Division of Haematology/Oncology; University Hospital of Munich; Munich Germany
| | - M. Carcao
- Division of Haematology/Oncology; Department of Paediatrics and Child Health Evaluative Sciences; Research Institute; Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - P. de Kleijn
- Department of Rehabilitation, Nursing Science and Sports, and Van Creveldkliniek; University Medical Center Utrecht; Utrecht The Netherlands
| | - M. Silva
- Department of Orthopaedic Surgery; Orthopaedic Institute for Children; David Geffen School of Medicine at UCLA; Los Angeles CA USA
| | - P. Hilliard
- Department of Rehabilitation; Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - A. Doria
- Department of Diagnostic Imaging; Research Institute; Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - A. Srivastava
- Department of Haematology; Christian Medical College; Vellore Tamil Nadu India
| | - V. Blanchette
- Division of Haematology/Oncology; Department of Paediatrics and Child Health Evaluative Sciences; Research Institute; Hospital for Sick Children; University of Toronto; Toronto ON Canada
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22
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Sørensen B, Auerswald G, Benson G, Elezović I, Felder M, Lambert T, Morfini M, Remor E, Salaj P, Santagostino E, Šalek SZ, Ljung R. Rationale for individualizing haemophilia care. Blood Coagul Fibrinolysis 2015; 26:849-57. [PMID: 25396764 DOI: 10.1097/MBC.0000000000000225] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Owing to the heterogeneity in the clinical phenotype of haemophilia A and B, it is now recognized that disease severity (based on factor VIII/IX activity) may no longer be the most appropriate guide for treatment and that a 'one-size-fits-all' approach is unlikely to achieve optimal therapy. Based on the present literature and consensus views of a group of experts in the field, this article highlights key gaps in the understanding of the diverse relationships between bleeding phenotype and factors such as joint health, genetic susceptibility, laboratory parameters, quality of life and management of pain. Early prophylaxis is a potential 'gold standard' therapy and issues surrounding inhibitor development, variations in its clinical use and long-term outcomes are discussed. Comprehensive treatment should be individualized for all patients (including those with mild or moderate haemophilia and carriers). Wherever possible all patients should be given prophylaxis. However, adult patients with a milder haemophilia phenotype may be candidates for ceasing prophylaxis and switching to on-demand treatment. Regardless, all treatment (on-demand and prophylaxis) should be tailored towards both the patient's personal needs and their clinical profile. In addition, as the associations between risk factors (psychosocial, condition-related and treatment-related) and clinical features are unique to each patient, an individualized approach is required to enable patients to alter their behaviour in response to them. The practical methodologies needed to reach this goal of individualized haemophilia care, and the health economic implications of this strategy, are ongoing topics for discussion.
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23
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Altisent C, Martorell M, Crespo A, Casas L, Torrents C, Parra R. Early prophylaxis in children with severe haemophilia A: clinical and ultrasound imaging outcomes. Haemophilia 2015; 22:218-224. [DOI: 10.1111/hae.12792] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2015] [Indexed: 01/03/2023]
Affiliation(s)
- C. Altisent
- Haemophilia Centre; Hospital Universitari Vall d'Hebron; Barcelona Spain
| | - M. Martorell
- Haemophilia Centre; Hospital Universitari Vall d'Hebron; Barcelona Spain
| | - A. Crespo
- Department of Rehabilitation; Hospital Universitari Vall d'Hebron; Barcelona Spain
| | - L. Casas
- Department of Radiology,; Hospital Universitari Vall d'Hebron; Barcelona Spain
| | - C. Torrents
- Department of Radiology,; Hospital Universitari Vall d'Hebron; Barcelona Spain
| | - R. Parra
- Haemophilia Centre; Hospital Universitari Vall d'Hebron; Barcelona Spain
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24
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Foppen W, van der Schaaf IC, Fischer K. Value of routine ultrasound in detecting early joint changes in children with haemophilia using the ‘Haemophilia Early Arthropathy Detection with UltraSound’ protocol. Haemophilia 2015; 22:121-5. [DOI: 10.1111/hae.12769] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2015] [Indexed: 11/29/2022]
Affiliation(s)
- W. Foppen
- Department of Radiology; University Medical Center (UMC) Utrecht; Utrecht The Netherlands
| | - I. C. van der Schaaf
- Department of Radiology; University Medical Center (UMC) Utrecht; Utrecht The Netherlands
| | - K. Fischer
- Van Creveldkliniek; Department of Hematology; University Medical Center (UMC) Utrecht; Utrecht The Netherlands
- Julius Center for Health Sciences and Primary Care; University Medical Center (UMC) Utrecht; Utrecht The Netherlands
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25
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Abstract
Haemophilia A and B are hereditary X-linked disorders due to deficiency (or absence) of coagulation factor VIII or IX, respectively. Bleeding risk is related to the severity of factor deficiency. Repeated joint bleeding can lead to a severe haemophilic arthropathy resulting in disabilities. Outcome measurements in persons with haemophilia (PWH) have been limited to laboratory evaluation (factor VIII or IX levels) and clinical outcomes (such as bleeding frequency), morbidity (for example linked with arthropathy) and mortality. Due to the new standard of care of PWH, there is a need to consider other outcome measures, such as the early detection and quantification of joint disease, health-related quality of life (QoL) and economic or cost-utility analyses. To investigate this, we performed a 10-yr systematic overview of outcome measures in haemophilia. Only clinical trials including at least 20 patients with haemophilia A or B were included. To facilitate the search strategy, eight issues of outcome measures were selected: physical scores, imaging technique scores, functional scores, QoL measurement, mortality, bleeding frequency, cost and outcome and bone mineral density. The results of these will be discussed. Clearly defined outcomes in haemophilia care are important for many reasons, to evaluate new treatments, to justify treatment strategies, to allow a good follow-up, to perform studies and to allocate resources. The use of such scoring systems is clearly recommended by experts in haemophilia care. However, most centres do not perform such scores outside clinical trials due to reasons such as lack of time and resources.
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Affiliation(s)
- Françoise Boehlen
- Division of Angiology and Haemostasis, University Hospitals and School of Medicine, Geneva, Switzerland
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26
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Ljung R, Gretenkort Andersson N. The current status of prophylactic replacement therapy in children and adults with haemophilia. Br J Haematol 2015; 169:777-86. [DOI: 10.1111/bjh.13365] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Rolf Ljung
- Department of Clinical Sciences Lund-Paediatrics; Lund University; Lund Sweden
- Department of Paediatrics and Malmö Centre for Thrombosis and Haemostasis; Skåne University Hospital; Malmö Sweden
| | - Nadine Gretenkort Andersson
- Department of Paediatrics and Malmö Centre for Thrombosis and Haemostasis; Skåne University Hospital; Malmö Sweden
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27
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Oymak Y, Yildirim AT, Yaman Y, Gurcinar M, Firat A, Cubuckcu D, Carti O, Ozek G, Vergin RC. The effectiveness of tools for monitoring hemophilic arthropathy. J Pediatr Hematol Oncol 2015; 37:e80-5. [PMID: 25000469 DOI: 10.1097/MPH.0000000000000210] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Hemophilic arthropathy is the most important cause of morbidity in patients with hemophilia. The earliest alterations that occur during the development of hemophilic arthropathy can be shown using magnetic resonance imaging (MRI). In addition, various tools have been developed to monitor joint health. AIM : The purpose of this study was to determine the correlation between these tools when used to assess hemophilia patients. METHODS This cross-sectional study enrolled 38 hemophilia patients between 2 and 18 years of age. Hemophilia Joint Health Score (HJHS) and radiologic scores (Pettersson and Arnold-Hilgartner) were used to evaluate the joints of the patients (n=236). Magnetic resonance imaging (MRI) was performed on 46 joints that were pathologic according to the HJHS. These joints were imaged bilaterally; therefore, 14 normal joints were imaged. In addition, the Functional Independence Score in Hemophilia (FISH) was used to evaluate the joints of 33 patients. RESULTS The HJHS scores were correlated with the MRI and FISH scores. The annual bleeding rate was not correlated with any scores; however, the number of painful joints was correlated with the MRI scores. The radiologic scores were correlated weakly with progressive score and HJHS. CONCLUSION The agreement between the HJHS scores and the MRI scores suggests that the HJHS may be used safely as a first-line tool. We recommend that the FISH should be used in the routine follow-up of hemophilia patients as a functional evaluation tool. Painful joints may be useful in deciding to apply MRI, whereas the bleeding frequency may not be useful.
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28
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Oldenburg J, Zimmermann R, Katsarou O, Theodossiades G, Zanon E, Niemann B, Kellermann E, Lundin B. Controlled, cross-sectional MRI evaluation of joint status in severe haemophilia A patients treated with prophylaxis vs. on demand. Haemophilia 2014; 21:171-179. [PMID: 25470205 PMCID: PMC4359687 DOI: 10.1111/hae.12539] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2014] [Indexed: 01/06/2023]
Abstract
In patients with haemophilia A, factor VIII (FVIII) prophylaxis reduces bleeding frequency and joint damage compared with on-demand therapy. To assess the effect of prophylaxis initiation age, magnetic resonance imaging (MRI) was used to evaluate bone and cartilage damage in patients with severe haemophilia A. In this cross-sectional, multinational investigation, patients aged 12-35 years were assigned to 1 of 5 groups: primary prophylaxis started at age <2 years (group 1); secondary prophylaxis started at age 2 to <6 years (group 2), 6 to <12 years (group 3), or 12-18 years (group 4); or on-demand treatment (group 5). Joint status at ankles and knees was assessed using Compatible Additive MRI scoring (maximum and mean ankle; maximum and mean of all 4 joints) and Gilbert scores in the per-protocol population (n = 118). All prophylaxis groups had better MRI joint scores than the on-demand group. MRI scores generally increased with current patient age and later start of prophylaxis. Ankles were the most affected joints. In group 1 patients currently aged 27-35 years, the median of maximum ankle scores was 0.0; corresponding values in groups 4 and 5 were 17.0 and 18.0, respectively [medians of mean index joint scores: 0.0 (group 1), 8.1 (group 2) and 13.8 (group 4)]. Gilbert scores revealed outcomes less pronounced than MRI scores. MRI scores identified pathologic joint status with high sensitivity. Prophylaxis groups had lower annualized joint bleeds and MRI scores vs. the on-demand group. Primary prophylaxis demonstrated protective effects against joint deterioration compared with secondary prophylaxis.
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29
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Gilbert L, Rollins L, Hilmes M, Luo Y, Gailani D, Debaun MR, Sidonio RF. Haemophilia A carriers demonstrate pathological and radiological evidence of structural joint changes. Haemophilia 2014; 20:e426-9. [PMID: 25251752 DOI: 10.1111/hae.12535] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2014] [Indexed: 01/22/2023]
Affiliation(s)
- L Gilbert
- Vanderbilt University, Nashville, TN, USA
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Affiliation(s)
| | - B. Ewenstein
- Baxter Healthcare Corporation; Westlake Village CA USA
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31
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Stephensen D, Drechsler WI, Scott OM. Outcome measures monitoring physical function in children with haemophilia: a systematic review. Haemophilia 2013; 20:306-21. [PMID: 24252123 DOI: 10.1111/hae.12299] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2013] [Indexed: 12/13/2022]
Abstract
Our objective was to provide a synthesis of measurement properties for performance-based outcome measures used to evaluate physical function in children with haemophilia. A systematic review of articles published in English using Medline, PEDro, Cinahl and The Cochrane Library electronic databases was conducted. Studies were included if a performance-based method, clinical evaluation or measurement tool was used to record an aspect of physical function in patients with haemophilia aged ≤ 18 years. Recording of self-perceived or patient-reported physical performance, abstracts, unpublished reports, case series reports and studies where the outcome measure was not documented or cross-referenced was excluded. Description of outcome measures, patient characteristics, measurement properties for construct validity, internal consistency, repeatability, responsiveness and feasibility was extracted. Data synthesis of 41 studies evaluating 14 measures is reported. None of the outcome measures demonstrated the requirements for all the measurement properties. Data on validity and test-retest repeatability were most lacking together with studies of sufficient size. Measurement of walking and muscle strength demonstrated good repeatability and discriminative properties; however, correlation with other measures of musculoskeletal impairment requires investigation. The Haemophilia Joint Health Score demonstrated acceptable construct validity, internal consistency and repeatability, but the ability to discriminate changes in physical function is still to be determined. Rigorous evaluation of the measurement properties of performance-based outcome measures used to monitor physical function of children with haemophilia in larger collaborative studies is required.
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Affiliation(s)
- D Stephensen
- School of Health, Sport and Bioscience, University of East London, London, UK; Kent Haemophilia Centre, Kent and Canterbury Hospital, Canterbury, UK
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Chan MW, Leckie A, Xavier F, Uleryk E, Tadros S, Blanchette V, Doria AS. A systematic review of MR imaging as a tool for evaluating haemophilic arthropathy in children. Haemophilia 2013; 19:e324-34. [PMID: 23919318 DOI: 10.1111/hae.12248] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2013] [Indexed: 12/26/2022]
Abstract
Our purposes were to determine: (i) whether there is direct evidence that currently available MRI techniques are accurate for early diagnosis of pathological findings in haemophilic arthropathy; (ii) whether there is an MRI scoring system that best correlates with clinical/radiological constructs for evaluation of haemophilic arthropathy; (iii) whether there is an MRI scoring system that best correlates with clinical/radiological constructs for evaluation of haemophilic arthropathy. Articles were screened using MEDLINE (n = 566), EMBASE (n = 201), and the Cochrane Library (n = 1). Two independent reviewers assessed articles for inclusion under the overarching purposes of the review by using the Standards for Reporting of Diagnostic Accuracy (STARD) tool, and the quality of the studies were graded using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. The electronic literature search retrieved 777 references (after duplicates were removed). A total of 32 studies were chosen for inclusion from the results of the search and review of bibliographical references. Using the STARD tool, seven studies were of excellent quality of reporting, and using the QUADAS-2 tool, 10 studies were judged to be of adequate quality. There is 'fair' evidence to recommend MRI as an accurate test for detecting evidence of haemophilic arthropathy and the use of second or third generation MRI scales for assessing haemophilic arthropathy. However, there is no evidence that screening of early intra-articular soft tissue bleed with MRI improves the functional status of joints over time.
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Affiliation(s)
- M W Chan
- Departments of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada
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Abstract
Clinical experience over decades and numerous retrospective and, recently, also prospective studies clearly demonstrate that prophylactic treatment, albeit much more expensive, is superior to on-demand treatment regardless of whether the outcome is number of joint- or life-threatening bleeds or arthropathy optimal prophylactic treatment should be started early (primary prophylaxis) but various opinions exist on the model. The optimal model should be to individualize prophylaxis taking into account the bleeding phenotype and the individual susceptibility to arthropathy and further develop monitoring by global coagulation assays and pharmacokinetic parameters. This review covers proof of concept of primary prophylaxis in children, comparisons between prophylaxis and on demand treatment, and future trends of prophylactic treatment of hemophilia.
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Affiliation(s)
- Rolf Ljung
- Departments of Pediatrics, Malmö & Lund and Malmö Centre for Thrombosis and Haemostasis, Skåne University Hospital, Lund University, Malmö, Sweden.
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Saulyte Trakymiene S, Clausen N, Poulsen LH, Ingerslev J, Rageliene L. Progression of haemophilic arthropathy in children: a Lithuanian--Danish comparative study. Haemophilia 2012; 19:212-8. [PMID: 23167920 DOI: 10.1111/hae.12058] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2012] [Indexed: 11/29/2022]
Abstract
Recurrent bleeding into joints initiates a sequence of events leading to a progressive joint damage in people with severe haemophilia. This is a continuous process during childhood and adolescence, therefore joint abnormalities may be minimal on physical examination in very young children - even those receiving on-demand treatment. The aim of our study was to quantify the burden of arthropathy in Lithuanian patients who had been treated exclusively by on-demand substitution and compare their physical joint health with age-matched Danish patients who received prophylaxis from an early age. Boys, aged 4-17 years, with severe haemophilia and no signs of inhibitors were included in the study. Joint outcome based on the Haemophilia Joint Health Score (HJHS) was analysed in two different treatment groups and compared within the matched pairs. In total, 32 (16 in each treatment group) patients were enroled. A total of 192 joints were evaluated. Joint status according to treatment strategy was strikingly different: 27.4 for on-demand vs. 3.3 for prophylaxis (<0.001) group. Significance of the difference in joint status comparing different treatment strategies was equally strong both in younger (4-9 years) and older (10-17 years) patient groups: 2.2 vs. 12.5 (P = 0.0002) and 3.9 vs. 36.3 (P < 0.0001) respectively. The results further demonstrate the unequivocal effect of prophylaxis on joint status and give an insight into early and late manifestations of joint impairment based on the HJHS in haemophilia patients with treatment on-demand compared with joint changes that may develop over the time with the preventative treatment.
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Affiliation(s)
- S Saulyte Trakymiene
- Clinic of Children's Diseases, Vilnius University and Centre for Pediatric Hematology/Oncology, Children's Hospital, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania.
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Lundin B, Manco-Johnson ML, Ignas DM, Moineddin R, Blanchette VS, Dunn AL, Gibikote SV, Keshava SN, Ljung R, Manco-Johnson MJ, Miller SF, Rivard GE, Doria AS. An MRI scale for assessment of haemophilic arthropathy from the International Prophylaxis Study Group. Haemophilia 2012; 18:962-70. [DOI: 10.1111/j.1365-2516.2012.02883.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2012] [Indexed: 11/29/2022]
Affiliation(s)
- B. Lundin
- Department of Clinical Sciences Lund, Division of Diagnostic Radiology and Center for Medical Imaging and Physiology; Lund University, Skåne University Hospital; Lund; Sweden
| | - M. L. Manco-Johnson
- Department of Radiology and Hemophilia & Thrombosis Center; University of Colorado; Denver; CO; USA
| | - D. M. Ignas
- Child Health Evaluative Sciences; The Hospital for Sick Children; Toronto; Ontario; Canada
| | - R. Moineddin
- University of Toronto; Public Health, Family and Community Medicine; Toronto; Ontario; Canada
| | - V. S. Blanchette
- Division of Pediatric Hematology/Oncology, The Hospital for Sick Children and Department of Pediatrics; University of Toronto; Toronto; Ontario; Canada
| | - A. L. Dunn
- Aflac Cancer Center and Blood Disorders Service, Children's Healthcare of Atlanta; Emory University School of Medicine; Atlanta; GA; USA
| | - S. V. Gibikote
- Department of Radiology; Christian Medical College; Vellore; Tamil Nadu; India
| | - S. N. Keshava
- Department of Radiology; Christian Medical College; Vellore; Tamil Nadu; India
| | - R. Ljung
- Department of Paediatrics; Lund University; Skåne University Hospital; Malmö-Lund; Sweden
| | - M. J. Manco-Johnson
- Department of Pediatrics and the Hemophilia & Thrombosis Center; University of Colorado; Denver; CO; USA
| | - S. F. Miller
- St. Jude Children's Research Hospital; Memphis; TN; USA
| | - G. E. Rivard
- CHU Sainte Justine; University of Montreal; Montreal; Quebec; Canada
| | - A. S. Doria
- Department of Diagnostic Imaging; The Hospital for Sick Children; Toronto; Ontario; Canada
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van Genderen FR, van Meeteren NLU, Fischer K, Helders PJM. Determinants of participation in patients with severe haemophilia. Haemophilia 2012; 18:860-7. [DOI: 10.1111/j.1365-2516.2012.02884.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2012] [Indexed: 11/29/2022]
Affiliation(s)
| | | | | | - P. J. M. Helders
- Child Development and Exercise Center; University Childrens' Hospital; University Medical Center Utrecht; Utrecht; The Netherlands
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RODRIGUEZ-MERCHAN EC, JIMENEZ-YUSTE V, AZNAR JA, HEDNER U, KNOBE K, LEE CA, LJUNG R, QUEROL F, SANTAGOSTINO E, VALENTINO LA, CAFFARINI A. Joint protection in haemophilia. Haemophilia 2011; 17 Suppl 2:1-23. [DOI: 10.1111/j.1365-2516.2011.02615.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ozülker T, Ozülker F, Derin E, Altun M, Aydoğan G, Türkkan E, Adaş M, Tonbul M, Ozpaçacı T, Sezgin F, Değirmenci H. The efficacy of magnetic resonance imaging and x-ray in the evaluation of response to radiosynovectomy in patients with hemophilic arthropathy. Mol Imaging Radionucl Ther 2011; 20:38-44. [PMID: 23487524 PMCID: PMC3590945 DOI: 10.4274/mirt.25] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 06/29/2011] [Indexed: 02/07/2023] Open
Abstract
Objective: We aimed to assess the role of Magnetic Resonance Imaging (MRI) and X-Ray in the evaluation of response to radiosynovectomy (RS) in patients with hemophilic arthropathy. Material and Methods: Eleven patients who suffered from hemophilic arthropathy with a mean age of 11.7 (range between 7-15) were included in this study. 148-185 MBq Yttrium 90 silicate (Y-90) was administered intraarticularly to ten knee joints and one patient was treated with intraarticular 74 MBq Rhenium 186 (Re-186) injection into his ankle. Before radiosynovectomy, plain anteroposterior and lateral X-rays of the target joints were obtained by standard technique. The follow-up MRI and X-ray studies of the patients were done 6 months after RS. Pettersson hemophilic arthropathy scales were utilized to stage the condition of the joints on plain X-ray and classification of the investigated joints on MRI were done according to Denver score. The clinical assessment of the efficacy of the RS was made with the comparison of the average bleedings before and after the intervention. Results: During the 6-month follow-up period after RS, an improvement in number of hemarthrosis 75% or greater compared with the prior six months occurred in six joints (54.5%). The Pettersson scores worsened in 1/11 (9%), remained unchanged in 9/11 (81.8%), and improved in 1/11 (9%) joints. At the 6-month follow-up, the MRI score worsened in one (9%) and was unchanged in 10/11 joints (90.9%). Conclusion: MRI is a more sensitive tool than plain radiography for evaluating and follow-up of joint disease in persons with hemophilia, but both methods don’t show correlation with the therapeutic response Conflict of interest:None declared.
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Affiliation(s)
- Tamer Ozülker
- Okmeydanı Training Hospital, Nuclear Medicine, İstanbul, Turkey
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Abstract
Hemophilia is a hereditary disease in which circulating levels of coagulation factors are lacking, resulting in a propensity toward bleeding. Intra-articular hemorrhages are a hallmark of hemophilia and may lead a cascade of cytokine elaboration and inflammatory-mediated changes, which ultimately result in cartilage loss and arthropathy. Diarthrodial joints, such as the knee, elbow, and ankle, are most commonly affected. This article highlights issues surrounding hemophilic arthropathy of the elbow and focuses on preventive measures, management strategies of the hemophilic elbow, and treatment options for established arthropathy.
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Affiliation(s)
- Julie E Adams
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue, R200, Minneapolis, MN 55454, USA.
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Den Uijl IEM, De Schepper AMA, Camerlinck M, Grobbee DE, Fischer K. Magnetic resonance imaging in teenagers and young adults with limited haemophilic arthropathy: baseline results from a prospective study. Haemophilia 2011; 17:926-30. [PMID: 21435115 DOI: 10.1111/j.1365-2516.2011.02513.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The clinical relevance of subtle changes on magnetic resonance imaging (MRI) for evaluating haemophilia treatment is unknown. To determine the relationship of findings on MRI with joint function and bleeding in joints with apparently very mild arthropathy, a prospective study was performed. Knees and ankles of 26 patients, 13-26 years, were scanned. Two blinded radiologists scored the MRI (IPSG consensus score) and the radiography [Pettersson score (PS)]. Clinical function (HJHS) was scored by one physiotherapist. Life-time number of bleeds was collected from patient files. Of 104 joints scanned, three were excluded because of previous arthrodesis or trauma. Remaining 101 MRI scores correlated weakly with clinical function (r = 0.27, P = 0.01) and less with lifetime number of bleeds (r = 0.16, P = 0.14). MRI scores were 0 in 58 joints, including 27 with major bleeds. In three joints of patients playing intensive sports MRI showed minor changes (MRI score = 1) in the absence of bleeds. Agreement was reasonable between PS and MRI score (r = 0.41, P < 0.01). In 30% of joints, MRI detected abnormalities in soft-tissue and cartilage, while PS was 0 points. No evidence of occult haemorrhages was found. Instead, we found no abnormalities on MRI in 43 joints with a history of repeated joint bleeding. Haemosiderin seemed associated with the time between assessment and last bleed; joints that had suffered a bleed long before MRI had hardly haemosiderin, while those with a recent bleed showed haemosiderin, suggesting joint damage may be reversible. Abnormalities detected by MRI, but not by PS were minor and their clinical implications are not yet clear.
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Affiliation(s)
- I E M Den Uijl
- van Creveldkliniek, dept Haematology, UMC Utrecht, The Netherlands.
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Melchiorre D, Linari S, Innocenti M, Biscoglio I, Toigo M, Cerinic MM, Morfini M. Ultrasound detects joint damage and bleeding in haemophilic arthropathy: a proposal of a score. Haemophilia 2010; 17:112-7. [PMID: 21070482 DOI: 10.1111/j.1365-2516.2010.02380.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Haemarthrosis triggers haemophilic arthropathy (HA) because bleeding starts synovitis immediately, damages cartilage and leads to loss of function and disability. The aim of our study was to investigate the capacity of ultrasonography (US) in detecting bleeding and joint damage in HA. The joints of 62 patients (pts) with haemophilia A or haemophilia B were consecutively evaluated and scored (score ranging from 0 to 21) for effusion (E), bone remodelling (BR), cartilage damage (CD), synovial hypertrophy (SH), haemosiderin (H), osteophytes (O), haemarthrosis (Hae), erosion (Er) and fibrotic septa (FS) with US. X-rays [Pettersson Score (PXS)] were performed in 61 patients and clinical evaluation [World Federation Haemophiliac orthopaedic score (WFHO)] was performed in all patients. A total of 20 healthy subjects and 20 patients affected by Rheumatoid Arthritis (RA) were used as controls. Power Doppler US (PDUS) was performed in all patients on the knee, ankle and elbow joints. A total of 83 joints were studied (50 knees; 12 elbows and 21 ankles). US showed effusion in 57 joint, bone remodelling in 62, cartilage damage in 64, synovial hypertrophy in 45, haemosiderin in 39, osteophytes in 30, haemarthrosis in 24, erosion in 5 and fibrotic septa in 3. The X-rays score showed remodelling in 47 joints, narrowing joint space in 44, displacement/angulation in 39, osteoporosis in 42, subchondral irregularity in 44, subchondral cyst formation in 37, osteophytes in 36 and erosions in 25. The US score in healthy subjects was always ≤ 5 (range 0 to 4). In haemophiliacs, 34 of 83 joints showed US score ≤ 5, and 49 US score > 5. Joints with US score ≤ 5 had a low PXS (SRCC = 0.375, P < 0.01) and joints with US score > 5 showed a high PXS (SRCC = 0.440, P < 0.01). A significant correlation between US score and PXS for bone remodelling [Spearman's rho Correlation Coefficient (SRCC) = 0.429, P < 0.01] and for osteophytes (SRCC = 0.308, P < 0.05) was found. The correlation between the US score and number of bleedings in 83 joints was very significant (SRCC = 0.375, P < 0.01). A total of 24 bleeding joints were identified and verified with aspiration of haematic fluid. US may detect bone and cartilage alterations and synovitis. Indeed, PDUS identified bleeding also in asymptomatic joints and was able to show different entity of haemarthrosis. US may be a feasible and reliable tool to evaluate joint modifications in HA.
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Affiliation(s)
- D Melchiorre
- Department of Bio Medicine, University of Florence, Florence, Italy.
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Jelbert A, Vaidya S, Fotiadis N. Imaging and staging of haemophilic arthropathy. Clin Radiol 2009; 64:1119-28. [DOI: 10.1016/j.crad.2009.07.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Revised: 07/16/2009] [Accepted: 07/20/2009] [Indexed: 11/22/2022]
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Maclachlan J, Gough-Palmer A, Hargunani R, Farrant J, Holloway B. Haemophilia imaging: a review. Skeletal Radiol 2009; 38:949-57. [PMID: 18807029 DOI: 10.1007/s00256-008-0586-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Revised: 08/16/2008] [Accepted: 08/18/2008] [Indexed: 02/02/2023]
Abstract
Haemophilia disorders are characterised by a blood coagulation anomaly leading to prolonged and excessive bleeding. Imaging provides an essential role in the investigation of both the musculoskeletal and the non-musculoskeletal complications of haemophilia. Our institution is home to a large tertiary referral centre for haemophilia treatment. Using our broad experience, we present a multi-modality pictorial review of the musculoskeletal manifestations of haemophilia, including haemophilic arthropathy, intra-muscular haemorrhage and haemophilic pseudotumour. The main imaging features of haemophilic arthropathy are described, including synovial hypertrophy, haemosiderin deposition, sub-chondral cyst formation and loss of joint space.
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Pergantou H, Platokouki H, Matsinos G, Papakonstantinou O, Papadopoulos A, Xafaki P, Petratos D, Aronis S. Assessment of the progression of haemophilic arthropathy in children. Haemophilia 2009; 16:124-9. [PMID: 19744251 DOI: 10.1111/j.1365-2516.2009.02109.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Arthropathy is considered as an irreversible and progressive complication in patients with haemophilia, even in children on prophylaxis. To estimate the progression of haemophilic arthropathy, 85 joints of 24 boys with severe (n = 18) and moderate (n = 6) haemophilia (A: 22, B: 2) were investigated with clinical examination, X-rays and magnetic resonance imaging (MRI) at two time periods (time 0 and 1). Patients' age at time 0 was 10.5 +/- 3.6 years and time elapsed to time 1 was 3.8 +/- 1.4 years. At time 0: all investigated joints had more than three bleeds. Sixteen boys were on secondary prophylaxis for 5.4 +/- 2.8 years. Clinical score (a modification of World Federation of Haemophilia's scale): 2.0 +/- 3.6, X-ray score (Pettersson): 2.1 +/- 2.8, MRI score (Denver): 4.5 +/- 3.8. After the first evaluation, prophylaxis was intensified in 11 children and initiated in four. At time 1: clinical score: 1.5 +/- 3.1, X-ray: 1.7 +/- 2.7, MRI score: 5.1 +/- 4.1. On average, the clinical and X-ray scores showed a significant improvement (26% and 40% of the joints respectively, P < 0.01) and the number of haemarthroses evidenced a threefold reduction from time 0 to 1 (P < 0.01), findings that could be associated with the modification of prophylaxis after time 0. MRI findings showed deterioration in 34% of the joints. Conversely, 14 joints (16.5%) with mild or moderate synovitis without cartilage degradation at time 0 showed an improvement at time 1. The information carried by the three scales could be divided into information shared by the three scores and information specific to each score, thus giving a more complete picture of joint damage caused by bleedings.
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Affiliation(s)
- H Pergantou
- Haemophilia Centre-Haemostasis Unit, Aghia Sophia Children's Hospital, Aghia Sophia Children's Hospital, Athens, Greece.
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Pergantou H, Matsinos G, Platokouki H, Papadopoulos A, Aronis S. An attempt to improve the clinical scale for assessment of haemophilic arthropathy in children. J Pediatr Orthop B 2009; 18:204-10. [PMID: 19458553 DOI: 10.1097/BPB.0b013e32832bf5ad] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Of the methods used to evaluate haemophilic arthropathy, clinical joint score can only detect advanced and not minor changes, which usually occur in younger patients. In addition, the currently used clinical scores are poorly correlated with the MRI and X-rays scales. In an attempt to address these shortcomings, a modification of Stockholm clinical scale was designed in which elements of clinical information were included. This new scale was applied in 165 joints of 40 patients with haemophilia A and B and the results were statistically analyzed for its capacity to detect early joints alterations. Furthermore, the adjusted score was compared with Pettersson's radiological score and Denver's MRI score, which can detect early signs of arthropathy. The adjusted scale (a) revealed the earliest abnormalities of haemophilic arthropathy and its correlation with the Pettersson and Denver scores is better than those of Stockholm's scale, (b) provided prediction of the Denver score and (c) was simple and safe to be performed and it could easily be repeated.
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Feldman BM, Funk S, Lundin B, Doria AS, Ljung R, Blanchette V. Musculoskeletal measurement tools from the International Prophylaxis Study Group (IPSG). Haemophilia 2008; 14 Suppl 3:162-9. [PMID: 18510537 DOI: 10.1111/j.1365-2516.2008.01750.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- B M Feldman
- Division of Rheumatology, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, ON, Canada.
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Gatt A, Chowdary P. Proceedings of the first annual congress of the European association for haemophilia and allied disorders. Haemophilia 2008; 15:329-36. [PMID: 18976251 DOI: 10.1111/j.1365-2516.2008.01911.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- A Gatt
- The Katharine Dormandy Haemophilia Centre & Thrombosis Unit, Royal Free Hospital, Pond Street, Hampstead, London.
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FOTIADIS N, EKONOMOU I, HARITANTI A, TSATRA I, ATHANASSIOU-METAXA M, DIMITRIADIS AS. The compatible MRI scoring system for staging of haemophilic arthropathy. Haemophilia 2008; 14:866-7. [DOI: 10.1111/j.1365-2516.2008.01778.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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