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Çakil Güzin A, Oymak Y, Oral A, Vergin C. Diagnostic Value of the Pediatric Bleeding Questionnaire in Prediction of Bleeding in Minor Surgery. J Pediatr Hematol Oncol 2024:00043426-990000000-00408. [PMID: 38691048 DOI: 10.1097/mph.0000000000002874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 04/04/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVE Preoperative coagulation tests have not been shown to be effective in predicting bleeding complications. The Pediatric Bleeding Questionnaire (PBQ) is a proven and sensitive tool for diagnosing children with a predisposition to bleeding. The aim of this study was to evaluate the usefulness of PBQ as a preoperative screening tool for the prediction of bleeding after minor surgical interventions. METHODS Preoperative coagulation tests and PBQ were performed in all patients who underwent minor surgery. The postoperative bleeding status was evaluated and then compared with the coagulation tests and PBQ of the patients. RESULTS Evaluation was made of a total of 706 patients, comprising 91.2% males and 8.8% females, with a mean age of 4.8 years (median: 4 y, QR: 1 to 7 y). Prolongation in coagulation tests was observed in 131 (18.5%) patients. Repeated tests in 116 patients were within the normal range, and 5 patients received treatment. Postoperative bleeding occurred in 4 (0.5%) patients. The relationship between coagulation tests and postoperative bleeding was not significant. PBQ was found to be ≥2 in 14 patients, but none of these patients had postoperative bleeding. No significant relationship was found between postoperative bleeding status and PBQ (p:0.77). The sensitivity, specificity, positive predictive, and negative predictive values of PBQ were 0%, 98%, 0%, and 97.4%, respectively. CONCLUSIONS The results of this study demonstrated that neither coagulation tests nor PBQ will be sufficient to predict bleeding after minor surgery, that prolongation in coagulation tests does not always indicate a bleeding tendency, and that bleeding history should also be recorded in detail.
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Affiliation(s)
- Ayşe Çakil Güzin
- Department of Pediatric Infectious Disease, Faculty of Medicine, Dokuz Eylül University
| | - Yeşim Oymak
- Department of Pediatric Hematology, University of Health Sciences Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital
| | - Akgün Oral
- Department of Pediatric Surgery, University of Health Sciences Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Izmir, Turkey
| | - Canan Vergin
- Department of Pediatric Hematology, University of Health Sciences Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital
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Mohsenian S, Palla R, Menegatti M, Cairo A, Lecchi A, Casini A, Neerman-Arbez M, Asselta R, Scardo S, Siboni SM, Blatny J, Zapletal O, Schved JF, Giansily-Blaizot M, Halimeh S, Daoud MA, Platokouki H, Pergantou H, Schutgens REG, Van Haaften-Spoor M, Brons P, Laros-van Gorkom B, Van Pinxten E, Borhany M, Fatima N, Mikovic D, Saracevic M, Özdemir GN, Ay Y, Makris M, Lockley C, Mumford A, Harvey A, Austin S, Shapiro A, Williamson A, McGuinn C, Goldberg I, De Moerloose P, Peyvandi F. Congenital fibrinogen disorders: a retrospective clinical and genetic analysis of the Prospective Rare Bleeding Disorders Database. Blood Adv 2024; 8:1392-1404. [PMID: 38286442 PMCID: PMC10950829 DOI: 10.1182/bloodadvances.2023012186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/11/2024] [Accepted: 01/13/2024] [Indexed: 01/31/2024] Open
Abstract
ABSTRACT Congenital fibrinogen deficiency (CFD) is a rare bleeding disorder caused by mutations in FGA, FGB, and FGG. We sought to comprehensively characterize patients with CFD using PRO-RBDD (Prospective Rare Bleeding Disorders Database). Clinical phenotypes, laboratory, and genetic features were investigated using retrospective data from the PRO-RBDD. Patients were classified from asymptomatic to grade 3 based on their bleeding severity. In addition, FGA, FGB, and FGG were sequenced to find causative variants. A total of 166 CFD cases from 16 countries were included, of whom 123 (30 afibrinogenemia, 33 hypofibrinogenemia, 55 dysfibrinogenemia, and 5 hypodysfibrinogenemia) were well characterized. Considering the previously established factor activity and antigen level thresholds, bleeding severity was correctly identified in 58% of the cases. The rates of thrombotic events among afibrinogenemic and hypofibrinogenemic patients were relatively similar (11% and 10%, respectively) and surprisingly higher than in dysfibrinogenemic cases. The rate of spontaneous abortions among 68 pregnancies was 31%, including 86% in dysfibrinogenemic women and 14% with hypofibrinogenemia. Eighty-six patients received treatment (69 on-demand and/or 17 on prophylaxis), with fibrinogen concentrates being the most frequently used product. Genetic analysis was available for 91 cases and 41 distinct variants were identified. Hotspot variants (FGG, p.Arg301Cys/His and FGA, p.Arg35Cys/His) were present in 51% of dysfibrinogenemia. Obstetric complications were commonly observed in dysfibrinogenemia. This large multicenter study provided a comprehensive insight into the clinical, laboratory, and genetic history of patients with CFDs. We conclude that bleeding severity grades were in agreement with the established factor activity threshold in nearly half of the cases with quantitative defects.
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Affiliation(s)
- Samin Mohsenian
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Roberta Palla
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Marzia Menegatti
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| | - Andrea Cairo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| | - Anna Lecchi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| | - Alessandro Casini
- Division of Angiology and Hemostasis, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Marguerite Neerman-Arbez
- Department of Genetic Medicine and Development, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Rosanna Asselta
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Sara Scardo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| | - Simona Maria Siboni
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| | - Jan Blatny
- Department of Paediatrics Haematology and Biochemistry, University Hospital Brno and Masaryk University, Brno, Czech Republic
| | - Ondrej Zapletal
- Department of Paediatrics Haematology and Biochemistry, University Hospital Brno and Masaryk University, Brno, Czech Republic
| | - Jean-Francois Schved
- Department of Biological Hematology, CHU Montpellier, Université de Montpellier, Montpellier, France
| | - Muriel Giansily-Blaizot
- Department of Biological Hematology, CHU Montpellier, Université de Montpellier, Montpellier, France
| | | | | | - Helen Platokouki
- Haemophilia-Centre-Haemostasis Unit, Aghia Sophia Children’s Hospital, Athens, Greece
| | - Helen Pergantou
- Haemophilia-Centre-Haemostasis Unit, Aghia Sophia Children’s Hospital, Athens, Greece
| | - Roger E. G. Schutgens
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Monique Van Haaften-Spoor
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Paul Brons
- Department of Pediatric Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Elise Van Pinxten
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Munira Borhany
- Clinical Hematology, National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, Pakistan
| | - Naveena Fatima
- Clinical Hematology, National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, Pakistan
| | - Danijela Mikovic
- Hemostasis Department, Blood Transfusion Institute of Serbia, Belgrade, Serbia
| | - Marko Saracevic
- Hemostasis Department, Blood Transfusion Institute of Serbia, Belgrade, Serbia
| | - Gül Nihal Özdemir
- Pediatric Hematology Department, Istinye University, Istanbul, Turkey
| | - Yılmaz Ay
- University of Health Sciences Kartal Health Application and Research Center, Pediatric Hematology and Oncology Clinic, Istanbul, Turkey
| | - Michael Makris
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Caryl Lockley
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Andrew Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Andrew Harvey
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Steve Austin
- Department of Haematology, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Amy Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN
| | | | | | - Ilene Goldberg
- Division of Pediatric Hematology Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY
| | - Philippe De Moerloose
- Division of Angiology and Hemostasis, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
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Mehic D, Schramm T, Forstner-Bergauer B, Haslacher H, Ay C, Pabinger I, Gebhart J. Activated protein C and free protein S in patients with mild to moderate bleeding disorders. Thromb Res 2024; 235:98-106. [PMID: 38324941 DOI: 10.1016/j.thromres.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/29/2023] [Accepted: 01/22/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND Underlying mechanisms for bleeding and impaired thrombin generation (TG) and plasma clot formation (PCF) in patients with mild to moderate bleeding disorders (MBDs) are still to be elucidated, especially in bleeding disorder of unknown cause (BDUC). The role of the natural anticoagulants activated protein C (APC) and free protein S (PS) has not yet been investigated in this patient population. AIMS To analyze antigen levels of APC and PS in patients with MBDs and BDUC and investigate associations to clinical bleeding phenotype and severity as well as and hemostatic capacity. METHODS Antigen levels of APC and free PS were measured in 262 patients from the Vienna Bleeding Biobank (VIBB), a single-center cohort study, by ELISA and compared to 61 healthy controls (HC). RESULTS Antigen levels of APC were higher in MBD patients than in HC when adjusted for age, sex and BMI (median (IQR) 33.1 (20.6-52.6) and 28.6 (16.4-47.2) ng/mL). This was most pronounced in patients with BDUC (35.3 (21.7-54.3) ng/mL). No differences in PS antigen levels between patients and HC were seen overall, or according to specific diagnoses. Further, no association between APC or PS and bleeding severity or global tests of hemostasis or TG were identified, while paradoxically APC weakly correlated with shorter lag time and time to peak of PCF in BDUC. CONCLUSION Our data demonstrate increased antigen levels of APC in BDUC, which might contribute to the bleeding tendency in some patients and could be a future therapeutic target in BDUC.
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Affiliation(s)
- Dino Mehic
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Theresa Schramm
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Birgit Forstner-Bergauer
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Helmuth Haslacher
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Johanna Gebhart
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
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Gooijer K, Heidsieck G, Harsevoort A, Bout D, Janus G, Franken A. Bleeding assessment in a large cohort of patients with Osteogenesis Imperfecta. Orphanet J Rare Dis 2024; 19:61. [PMID: 38347577 PMCID: PMC10860322 DOI: 10.1186/s13023-024-03054-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/29/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Osteogenesis Imperfecta (OI) is characterised by bone fragility. Among several features, easy bruising and multiple case reports on haemorrhagic events have been reported. This paper describes the diverse manifestations of bleeding and bruising in a large cohort of 328 OI patients. The aim of this study is to provide insight in the diverse aspects and therapeutic considerations of bleedings in OI. METHODS This descriptive cohort study was conducted at the National Expert Center for adults with OI in the Netherlands. Bleeding was assessed by the validated self-bleeding assessment tool (Self-BAT) The tool was distributed among 328 adults with different clinically confirmed types of OI. RESULTS 195 of 328 invited patients (completion rate 60%) with OI type 1 (n = 144), OI type 3 (n = 17) and OI type 4 (n = 34), aged between 18 and 82 years, completed the tool. Self-BAT scores were above the normal range in 42% of all patients. For males Self-BAT scores were increased in 37% with a mean score of 3.7, ranged between 0 and 18. For females the Self-BAT scores were increased in 44% with a mean of 5.4 and a range of 0-24. No statistical differences in OI subtypes were found. CONCLUSIONS Bleeding tendency appears to be a relevant complication in OI patients as this study confirms the presumption of bleeding tendency. There are specific recommendations to clinicians who treat OI patients to consider an assessment of bleeding tendency and use potential interventions to reduce haemorrhagic complications and improve quality of life.
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Affiliation(s)
- Koert Gooijer
- Expert Center for Adults with Osteogenesis Imperfecta, Isala Hospital, Dokter van Heesweg 2, PO Box 10400, 8025 AB, Zwolle, The Netherlands.
- Department of Clinical Genetics, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.
| | - Gabriëla Heidsieck
- Expert Center for Adults with Osteogenesis Imperfecta, Isala Hospital, Dokter van Heesweg 2, PO Box 10400, 8025 AB, Zwolle, The Netherlands
| | - Arjan Harsevoort
- Expert Center for Adults with Osteogenesis Imperfecta, Isala Hospital, Dokter van Heesweg 2, PO Box 10400, 8025 AB, Zwolle, The Netherlands
| | - Daniëlle Bout
- Expert Center for Adults with Osteogenesis Imperfecta, Isala Hospital, Dokter van Heesweg 2, PO Box 10400, 8025 AB, Zwolle, The Netherlands
| | - Guus Janus
- Expert Center for Adults with Osteogenesis Imperfecta, Isala Hospital, Dokter van Heesweg 2, PO Box 10400, 8025 AB, Zwolle, The Netherlands
| | - Anton Franken
- Expert Center for Adults with Osteogenesis Imperfecta, Isala Hospital, Dokter van Heesweg 2, PO Box 10400, 8025 AB, Zwolle, The Netherlands
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Mehic D, Kraemmer D, Tolios A, Bücheler J, Quehenberger P, Haslacher H, Ay C, Pabinger I, Gebhart J. The necessity of repeat testing for von Willebrand disease in adult patients with mild to moderate bleeding disorders. J Thromb Haemost 2024; 22:101-111. [PMID: 37741511 DOI: 10.1016/j.jtha.2023.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/23/2023] [Accepted: 09/13/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND In patients with mild-to-moderate bleeding disorders (MBD), von Willebrand disease (VWD) is diagnosed at von Willebrand factor (VWF) levels ≤50 IU/dL. Although VWF levels are unstable, repeated testing for VWD diagnosis is not necessarily advised in recent guidelines. OBJECTIVES To analyze the relevance of repeated VWF testing to diagnose VWD in patients with MBD. METHODS Data of 277 patients with MBD from the Vienna Bleeding Biobank with at least 2 separate assessments of VWF antigen (VWF:Ag) and activity (VWF:Act) were analyzed. RESULTS In repeated VWF measurements, 36 patients (13.0%) had "changing" VWF levels (≤/>50 IU/dL), 27 (9.7%) had persistent levels ≤50 IU/dL ("pathologic"), and 214 (77.3%) had levels >50 IU/dL ("normal"). Of the 36 changing patients, 22 (61%) were diagnosed with VWD at baseline, whereas the others only met VWD diagnostic criteria at repeated measurements. Using logistic regression, we estimated a probability of change of 26.4% (95% CI, 12.5-47.4) at baseline VWF levels of 30 IU/dL, 50.8% (95% CI, 35.6-65.8) at 50 IU/dL, 18.8% (95% CI, 12.3-27.6) at 60 IU/dL, and 1.2% (95% CI, 0.3-4.9) at 80 IU/dL. Baseline VWF was a strong predictor for changing status (Χ2 = 49.9; P < .001), while age, sex, Vicenza score, and blood type O had limited added value (Χ2 = 5.1; P = .278). Baseline VWF:Ag or VWF:Act cutoffs of 80 IU/dL had negative predictive values of 98.1% and 99.1% for changing status, respectively. CONCLUSION Our data emphasize an overlap between patients with VWD and MBD with bleeding disorder of unknown cause and underline the need for repeated VWF testing, especially in patients with VWF levels <80 IU/dL.
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Affiliation(s)
- Dino Mehic
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria; Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria. https://twitter.com/dino_mehic
| | - Daniel Kraemmer
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Alexander Tolios
- Department of Transfusion Medicine and Cell Therapy, Medical University of Vienna, Vienna, Austria
| | - Julia Bücheler
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Peter Quehenberger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Helmuth Haslacher
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria. https://twitter.com/Cihan_Ay_MD
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria. https://twitter.com/IngridPabinger
| | - Johanna Gebhart
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
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Mehic D, Schwarz S, Shulym I, Ay C, Pabinger I, Gebhart J. Health-related quality of life is impaired in bleeding disorders of unknown cause: results from the Vienna Bleeding Biobank. Res Pract Thromb Haemost 2023; 7:102176. [PMID: 37720482 PMCID: PMC10502434 DOI: 10.1016/j.rpth.2023.102176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 09/19/2023] Open
Abstract
Background Bleeding disorder of unknown cause (BDUC) is a diagnosis of exclusion after extensive investigation of coagulation and platelet function and is commonly seen among patients with mild-to-moderate bleeding disorders. Despite increasing awareness among treating physicians, little is known about the health-related quality of life (HrQoL) in BDUC. Objectives To investigate HrQoL in patients with BDUC in comparison to the general population and patients diagnosed with other established bleeding disorders. Methods Patients with mild-to-moderate bleeding disorders from the Vienna Bleeding Biobank, a prospective cohort study, were contacted via mail and phone to complete the 36-Item Health Survey Questionnaire form. Results In total, 333/657 (50.7%) patients completed the 36-Item Health Survey Questionnaire. Patients with BDUC (n = 207, 62%) had significantly impaired HrQoL both in physical (47.8 vs 49.2) and mental health parameters (42.9 vs 51.0) compared to the general population (n = 2914, 56% females), which remained after adjustment for sex and age in multivariable linear regression. The impairment in HrQoL, compared to patients with von Willebrand disease, platelet function defects, or mild clotting factor deficiencies, did not prevail after adjustment for age and sex. In patients with BDUC, age and the presence of at least 1 comorbidity were associated with impaired physical health but not sex or bleeding severity. Of all analyzed bleeding symptoms, only joint bleeding was associated with impaired physical health and gastrointestinal bleeding with mental health in BDUC. Conclusion The impairments in HrQoL in patients with BDUC emphasize the burden of BDUC on mental and physical well-being, encouraging early recognition and better counseling of patients with BDUC.
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Affiliation(s)
- Dino Mehic
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
- Centre of Physiology and Pharmacology, Institute of Vascular Biology and Thrombosis Research, Medical University of Vienna, Vienna, Austria
| | - Stephan Schwarz
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Ihor Shulym
- IT-Systems and Communications, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Johanna Gebhart
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
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Franchini M, Focosi D. Targeting von Willebrand disease: the current status and future directions of management therapies. Expert Rev Hematol 2023; 16:871-878. [PMID: 37800892 DOI: 10.1080/17474086.2023.2268282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/04/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION von Willebrand disease (VWD) is the commonest inherited bleeding disorder, and is typically caused by deficits in the quantity or quality of von Willebrand factor (VWF). AREAS COVERED This review describes the main clinical, diagnostic, and therapeutic aspects of VWD, with particular attention to its management. In addition, standard and avant-garde replacement therapies based on the use of VWF are discussed. EXPERT OPINION The goal of treatment for VWD is to reverse the double hemostatic defect resulting from the abnormal or reduced expression of VWF and the concomitant factor VIII (FVIII) deficiency. Treatment consists of managing any bleeds and both short-term prophylaxis (i.e. for surgery or invasive procedures) and long-term prophylaxis. While desmopressin is suitable for most patients with type 1 VWD, VWF/FVIII concentrates are the treatment of choice for the other types of VWD. Beside plasma-derived VWF/FVIII concentrates, whose safety and efficacy have been demonstrated by several clinical trials, products containing only VWF, obtained by plasma fractionation and recombinant DNA technology, have become available and marketed more recently. The clinical use of these VWF-only products is particularly attractive in the setting of surgery and long-term prophylaxis, such as the prevention of recurrent gastrointestinal bleeding in cases of angiodysplasia.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
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Mehic D, Neubauer G, Janig F, Kaider A, Ay C, Pabinger I, Gebhart J. Risk factors for future bleeding in patients with mild bleeding disorders: longitudinal data from the Vienna Bleeding Biobank. J Thromb Haemost 2023; 21:1757-1768. [PMID: 36924834 DOI: 10.1016/j.jtha.2023.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/15/2023] [Accepted: 03/05/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND The future bleeding risk, especially after hemostatic challenges, and thus the requirement for hemostatic treatment in patients with mild-to-moderate bleeding disorders (MBDs) is largely unknown. OBJECTIVES This study aimed to prospectively examine the recurrence of bleeding symptoms and clinical risk factors for future bleeding in patients with MBD, including patients with bleeding disorder of unknown cause (BDUC). METHODS Bleeding symptoms of patients with MBD included in the Vienna Bleeding Biobank were re-evaluated at in-person follow-up visits or by mail. RESULTS In total, 392 patients, including 62.8% with BDUC, were investigated for the recurrence of bleeding events. During the follow-up time of median (IQR) 4.3 years (2.6-6.7), 72% of patients had at least 1 bleeding event. Most persistent bleeding manifestations were hematomas (n = 146/245, 59.6%) and bleeding from small wounds (n = 69/141, 48.9%), followed by epistaxis (n = 42/132, 31.8%), oral mucosal bleeding (n = 26/87, 29.9%), and joint bleeding (n = 7/14, 50.0%). Patients with previous postinterventional bleeding had a significantly increased risk for bleeding events after surgery (n = 33/114, 29.0 %) or tooth extraction (n = 16/39, 41.0%). A high bleeding score (OR [95% CI], 1.14 [1.05 to 2.94], per 1 unit) and follow-up time (OR [95% CI], 1.23 [1.12 to 1.36], per 1 year) were independently associated with any bleeding event. For bleeding after hemostatic challenges, blood group O (OR, 3.17 [1.57 to 6.40]), previous postsurgical bleeding (OR, 2.40 [1.06 to 5.46]), and an established diagnosis (OR, 2.07 [1.04 to 4.10]) were independent risk factors. CONCLUSION Patients with MBD have a high risk for recurrent bleeding. This encourages prophylactic hemostatic treatment in patients with MBD, particularly when they face hemostatic challenges.
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Affiliation(s)
- Dino Mehic
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria; Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria. https://twitter.com/dino_mehic
| | - Georg Neubauer
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Florian Janig
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Alexandra Kaider
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria. https://twitter.com/Cihan_Ay_MD
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Johanna Gebhart
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
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Doherty D, Grabell J, Christopherson PA, Montgomery RR, Coller BS, Lavin M, O'Donnell JS, James PD. Variability in International Society on Thrombosis and Haemostasis-Scientific and Standardization Committee endorsed Bleeding Assessment Tool (ISTH-BAT) score with normal aging in healthy females: contributory factors and clinical significance. J Thromb Haemost 2023; 21:880-886. [PMID: 36696194 PMCID: PMC11008594 DOI: 10.1016/j.jtha.2022.11.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Bleeding assessment tools are key screening tests used in the evaluation of patients with suspected inherited bleeding disorders. The International Society on Thrombosis and Haemostasis-Scientific and Standardization Committee endorsed Bleeding Assessment Tool (ISTH-BAT) has differing reference ranges for adult males (0-3), adult females (0-5), and children (0-2), reflecting differing bleeding symptoms and exposure to hemostatic challenges in these healthy population subgroups. Age is known to markedly impact bleeding score in individuals with von Willebrand disease. However, the influence of age on bleeding score in healthy adult controls is poorly understood. OBJECTIVES We aimed to assess variability in ISTH-BAT score with age among healthy control females. METHODS We used the legacy "Merging Project" dataset of normal healthy controls upon which current ISTH-BAT normal ranges are based. We included women, totaling 646 individuals. The normal range (middle 95th percentile) of total ISTH-BAT and grouped subdomain scores between age quartiles was assessed. RESULTS The normal range of ISTH-BAT scores increased with age, ranging from 0 to 4 in the youngest quartile (age range, 18-30) to 0 to 6 in the oldest (age range, 52-88). This increased variability with aging was related both to high menorrhagia domain scores in older women and an increase in postprocedural bleeding with accumulated exposure to hemostatic challenges. CONCLUSIONS Cumulatively, our data highlight that normal aging leads to increased variability in bleeding scores in healthy adult females. Further refinement of the ISTH-BAT with age-adjusted reference ranges may improve the sensitivity and specificity of the tool among females.
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Affiliation(s)
- Dearbhla Doherty
- National Coagulation Centre, St James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Julie Grabell
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Robert R Montgomery
- Blood Research Institute, Versiti, Milwaukee, WI, USA; Children's Research Institute, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Barry S Coller
- Allen and Frances Adler Laboratory of Blood and Vascular Biology, Rockefeller University, NY, USA
| | - Michelle Lavin
- National Coagulation Centre, St James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James S O'Donnell
- National Coagulation Centre, St James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; National Children's Research Centre, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
| | - Paula D James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
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Mehic D, Machacek J, Schramm T, Buresch L, Kaider A, Eichelberger B, Haslacher H, Fillitz M, Dixer B, Flasch T, Anderle T, Rath A, Assinger A, Ay C, Pabinger I, Gebhart J. Platelet function and soluble P-selectin in patients with primary immune thrombocytopenia. Thromb Res 2023; 223:102-110. [PMID: 36738663 DOI: 10.1016/j.thromres.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/22/2022] [Accepted: 01/12/2023] [Indexed: 01/17/2023]
Abstract
BACKGROUND The bleeding phenotype in immune thrombocytopenia (ITP) is heterogeneous, but usually mild and only partly dependent on the severity of thrombocytopenia. Platelet reactivity has previously been suggested to underly the mild phenotype. METHODS Platelet function was assessed as basal and agonist-induced surface expression of P-selectin and activation of GPIIb/IIIa via flow cytometry, and soluble (s)P-selectin levels were assessed in plasma of 77 patients with primary ITP, 19 hemato-oncologic thrombocytopenic controls (TC) and 20 healthy controls (HC). The association of platelet function with laboratory and clinical parameters such as bleeding manifestations at inclusion and previous thrombosis was analyzed. RESULTS ITP patients showed tendency towards increased surface P-selectin and elevated levels of activated GPIIb/IIIa. Platelet activation after stimulation with all agonists including TRAP-6, ADP, arachidonic acid and CRP was decreased compared to HC. Compared to TC, only GPIIb/IIIa activation but not surface P-selectin was higher in ITP. Levels of soluble (s)P-selectin were significantly higher in ITP patients compared to TC, but similar to HC. Higher sP-selectin levels were associated with blood group O and current therapy, with highest levels in TPO-RA treated patients. Platelet reactivity was not associated with platelet count or size, platelet antibodies, treatment regime, or blood group. No correlation between platelet activation with the bleeding phenotype or previous thrombotic events could be observed. CONCLUSION ITP patients did not have hyper-reactive platelets compared to HC, but partly higher reactivity compared to TC. Further studies are needed to understand the underlying mechanism behind the bleeding and pro-thrombotic phenotype in ITP. 250/250.
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Affiliation(s)
- Dino Mehic
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria; Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Jennifer Machacek
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Theresa Schramm
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Lisbeth Buresch
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Alexandra Kaider
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | | | - Helmuth Haslacher
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Fillitz
- Department of Internal Medicine, Hanusch Hospital, Vienna, Austria
| | - Barbara Dixer
- Department of Internal Medicine, Hanusch Hospital, Vienna, Austria
| | - Tanja Flasch
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Theresa Anderle
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Anja Rath
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Alice Assinger
- Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Johanna Gebhart
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
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11
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Corrales-Medina FF, Federici AB, Srivastava A, Dougall A, Millar CM, Roberts JC, Jaffray J, Berntorp E. A need to increase von Willebrand disease awareness: vwdtest.com - A global initiative to help address this gap. Blood Rev 2023; 58:101018. [PMID: 36210240 DOI: 10.1016/j.blre.2022.101018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/14/2022] [Accepted: 09/27/2022] [Indexed: 11/02/2022]
Abstract
Von Willebrand disease (VWD) is an inherited bleeding disorder caused by quantitative or qualitative deficiencies in von Willebrand factor (VWF). People with VWD may experience excessive, recurrent or prolonged bleeding, particularly during menstruation, childbirth, surgery or following trauma. However, many VWD patients are undiagnosed, and therefore inadequately treated. Reasons for the underdiagnosis of VWD include its relatively mild symptoms, complex diagnosis, lack of awareness among non-specialist healthcare providers and the general population, and a lack of prioritisation of disorders disproportionately affecting females. The vwdtest.com platform was launched as part of a global initiative to raise awareness and improve diagnosis of VWD. Besides providing VWD-specific educational resources, the website includes an online bleeding self-assessment tool and offers diagnostic support for individuals, and their providers, who have a score suggestive of a bleeding disorder. vwdtest.com helps to address these unmet needs, especially in regions with limited access to educational and diagnostic resources.
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Affiliation(s)
- Fernando F Corrales-Medina
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Miami-Miller School of Medicine, Miami, FL, USA; University of Miami-Hemophilia Treatment Center, Miami, FL, USA.
| | - Augusto B Federici
- University of Milan, School of Medicine, Department of Oncology and Haematology Oncology, Milan, Italy; Division of Haematology and Transfusion Medicine of Luigi Sacco University Hospital, Milan, Italy
| | - Alok Srivastava
- Christian Medical College, Department of Haematology, Vellore, India
| | - Alison Dougall
- School of Dental Science, Trinity College Dublin, Ireland; Dublin Dental University Hospital, Dublin, Ireland
| | - Carolyn M Millar
- Imperial College London, Department of Immunology and Inflammation, Centre for Haematology, London, UK
| | - Jonathan C Roberts
- Bleeding & Clotting Disorders Institute, Peoria, IL, USA; University of Illinois College of Medicine at Peoria, Department of Pediatrics and Medicine, Peoria, IL, USA
| | - Julie Jaffray
- Children's Hospital Los Angeles, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Erik Berntorp
- Clinical Coagulation Research, Department of Translational Medicine, Lund University, Malmö, Sweden
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12
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Sachs UJ. Pitfalls in Coagulation Testing. Hamostaseologie 2023; 43:60-66. [PMID: 36807821 DOI: 10.1055/a-1981-7939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Assays in the coagulation laboratory are affected by numerous variables. Variables which have impact on the test result can lead to incorrect results, and potentially to consequences for further diagnostic and therapeutic decisions made by the clinician. The interferences can be separated into three main groups: biological interferences, with an actual impairment of the patient's coagulation system (congenital or acquired); physical interferences, which usually occur in the pre-analytical phase; and chemical interferences, because of the presence of drugs (mainly anticoagulants) in the blood to be tested. This article discusses some of these interferences in seven instructive cases of (near) miss events as an approach to generate more attention to these issues.
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Affiliation(s)
- Ulrich J Sachs
- Department of Thrombosis and Haemostasis, Giessen University Hospital, Giessen, Germany.,Institute for Clinical Immunology, Transfusion Medicine, and Haemostasis, Justus Liebig University, Giessen, Germany
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Abdelhamid BM, Ahmed A, Ramzy M, Rady A, Hassan H. Pre-anaesthetic ultrasonographic assessment of neck vessels as predictors of spinal anaesthesia induced hypotension in the elderly: A prospective observational study. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2082051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Bassant M. Abdelhamid
- Faculty of Medicine, Cairo UniversityDepartment of Anaesthesiology, Surgical ICU and Pain Management, Kasr-Alainy, Giza, Egypt
- Department of Anaesthesiology, Surgical ICU and Pain Management, Armed Forces College of Medicine, Cairo, Egypt
| | - Abeer Ahmed
- Faculty of Medicine, Cairo UniversityDepartment of Anaesthesiology, Surgical ICU and Pain Management, Kasr-Alainy, Giza, Egypt
| | - Mai Ramzy
- Faculty of Medicine, Cairo UniversityDepartment of Anaesthesiology, Surgical ICU and Pain Management, Kasr-Alainy, Giza, Egypt
| | - Ashraf Rady
- Faculty of Medicine, Cairo UniversityDepartment of Anaesthesiology, Surgical ICU and Pain Management, Kasr-Alainy, Giza, Egypt
| | - Haitham Hassan
- Faculty of Medicine, Cairo UniversityDepartment of Anaesthesiology, Surgical ICU and Pain Management, Kasr-Alainy, Giza, Egypt
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Diagnostic pitfalls and conundrums in type 1 von Willebrand disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:618-623. [PMID: 36485079 PMCID: PMC9821407 DOI: 10.1182/hematology.2022000389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Most people with von Willebrand disease (VWD) have a partial quantitative deficiency of plasma von Willebrand factor (VWF) or type 1 VWD. In contrast to type 2 and type 3 VWD, laboratory assays will not always establish the diagnosis in type 1 VWD. This is because plasma VWF levels in type 1 VWD, especially those with levels closer to 50 IU/dL, overlap with the general population. Assessment is further complicated by increased plasma VWF levels in response to physiologic stressors or aging. Diagnosis of those with type 1 VWD with plasma VWF levels 30 to 50 IU/dL (previously referred to as "low VWF") requires expert assessment of bleeding phenotype as well as an understanding of the limitations of both bleeding assessment tools (BATs) and laboratory testing. Using the available evidence and highlighting research gaps, we discuss common dilemmas facing providers relating to assessment of adolescents, transition from pediatrics to adult care, and older individuals with type 1 VWD.
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15
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Lavin M, Christopherson P, Grabell J, Abshire T, Flood V, Haberichter SL, Lillicrap D, O’Donnell JS, Montgomery RR, James PD. Longitudinal bleeding assessment in von Willebrand disease utilizing an interim bleeding score. J Thromb Haemost 2022; 20:2246-2254. [PMID: 35780487 PMCID: PMC10193460 DOI: 10.1111/jth.15807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 05/24/2022] [Accepted: 06/10/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Assessment of bleeding phenotype is critically important in the diagnosis of von Willebrand disease (VWD). Despite advances in bleeding assessment tools (BATs), standardized tools to evaluate bleeding following diagnosis (interim bleeding) are lacking. OBJECTIVES We assessed the clinical utility of an interim bleeding protocol in a multicenter, international study involving patients with VWD. METHODS The enrolment ISTH BAT formed the original bleeding score (0 BS). At follow-up, the International Society on Thrombosis and Haemostasis BAT was repeated but included only interval bleeding (Interim BS, 1 BS). Both scores were annualized (0 BS/yr, 1 BS/yr). BS were analyzed by VWD subtype, plasma VWF level, sex, and age. RESULTS Interim BS discriminated by subtype, with significantly increased 0 BS and 1 BS in patients with type 3 VWD. In patients with type 1 VWD, a positive or negative 0 BS did not predict future bleeding, with similar 1 BS/yr (median 1.0 vs. 0.7, p = .2). Despite significantly higher 0 BS in females with type 1 VWD than males (median 7 vs. 5, p = .0012), 1 BS were not significantly different (median 4 vs. 4, p = .16). While 0 BS were lower in children than adults with type 1 VWD, interim BS were similar (median 5 vs. 3, p = .5; 1BS/yr, median 1 vs. 0.8, p = .7). Interestingly, in those with plasma von Willebrand factor:ristocetin cofactor levels >50 IU/dl, interim BS rates were similar to those 30-50 IU/dl (1 BS/yr 0.8 vs. 1.3, p = .5). CONCLUSION This study provides both a new approach to longitudinal bleeding assessment and insights into the evolution of bleeding in VWD.
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Affiliation(s)
- Michelle Lavin
- National Coagulation Centre, St. James’s Hospital, Dublin, Ireland
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Julie Grabell
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Thomas Abshire
- Blood Research Institute, Versiti, Milwaukee, Wisconsin, USA
| | - Veronica Flood
- Blood Research Institute, Versiti, Milwaukee, Wisconsin, USA
| | | | - David Lillicrap
- Department of Pathology & Molecular Medicine, Queen’s University, Kingston, Ontario, Canada
| | - James S. O’Donnell
- National Coagulation Centre, St. James’s Hospital, Dublin, Ireland
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Paula D. James
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
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16
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Laboratory Assays of VWF Activity and Use of Desmopressin Trials in the Diagnosis of VWD: A Systematic Review and Meta-Analysis. Blood Adv 2022; 6:3735-3745. [PMID: 35192687 PMCID: PMC9631556 DOI: 10.1182/bloodadvances.2021005431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 02/02/2022] [Indexed: 11/20/2022] Open
Abstract
The findings of these reviews support VWF multimer analysis or VWF:CB/VWF:Ag to diagnose type 2 VWD. The reviews confirm that desmopressin trial is the test of choice to confirm increased VWF clearance in patients with suspected VWD type 1C.
von Willebrand Disease (VWD) is associated with significant morbidity because of excessive bleeding. Early diagnosis and treatment are important to prevent and treat these symptoms. We systematically reviewed the accuracy of any von Willebrand factor (VWF) activity assay in the diagnosis and classification of patients for VWD. We searched Cochrane Central, MEDLINE, and EMBASE for eligible studies. The risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 and the certainty of evidence using the GRADE framework. We pooled estimates of sensitivity and specificity. The review included 77 studies that evaluated the use of newer tests of VWF platelet binding activity (VWF:GPIbR, VWF:GPIbM) and VWF:RCo for the diagnosis of VWD (13 studies), VWF propeptide to VWF:Ag ratio, and desmopressin trial for the diagnosis of type 1C VWD (5 studies), VWF multimer analysis and VWF:CB/VWF:Ag ratio for the classification of type 2 VWD (11 studies), genetic testing and ristocetin-induced platelet aggregation to diagnose type 2B VWD (14 studies), genetic testing and FVIII:VWF binding to diagnose type 2N VWD (17 studies). Based on available diagnostic test accuracy, there appear to be comparable test accuracy results between newer tests of platelet binding activity of VWF function and VWF:RCo. The findings of these reviews support VWF multimer analysis or VWF:CB/VWF:Ag to diagnose type 2 VWD. The desmopressin trial test with 1- and 4-hour postinfusion blood work is the test of choice to confirm increased VWF clearance in patients with suspected VWD type 1C. Additionally, genetic testing is most useful in diagnosing type 2B VWD and has a role in the diagnostic algorithm of suspected type 2N VWD.
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Ambika PL, Basu D, Nair SC, Kar R. Utility of International Society on Thrombosis and Hemostasis Bleeding Assessment Tool (ISTH-BAT) in Patients with Inherited Bleeding Disorders: A Cross-Sectional Study from Southern India. Indian J Hematol Blood Transfus 2022; 38:122-131. [PMID: 35125720 PMCID: PMC8804127 DOI: 10.1007/s12288-021-01435-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 03/29/2021] [Indexed: 01/03/2023] Open
Abstract
The International Society on Thrombosis and Hemostasis bleeding assessment tool (ISTH-BAT) was developed to record bleeding symptoms and aid in patient diagnosis. This study was done to investigate the utility of ISTH-BAT in patients suspected to have inherited bleeding disorders. This cross-sectional study was conducted in a tertiary care hospital in Southern India over 3 and 1/2 years. A trained investigator administered the ISTH-BAT questionnaire to 432 patients undergoing evaluation for inherited bleeding disorder prior to routine coagulation screening and confirmatory tests and to 131 healthy volunteers as controls. Among patients, 42(9.7%) had primary hemostatic defect, 150(34.7%) had secondary hemostatic defects and 229(53%) had normal screening coagulogram with mean bleeding scores (BS) being 5.9, 6.9, and 4.2 respectively and the proportion of patients with abnormal BS being 69%, 88.7% and 59.4% respectively; the latter qualifying as unknown hemostatic defect. 11(2.5%) with acquired hemostatic defect on workup were excluded. The mean BS was 1.52 among healthy volunteers. Common bleeding patterns were epistaxis (73.8%), cutaneous bleeding (52.4%), hematuria (54.8%), menorrhagia (50%) in primary hemostatic defect; cutaneous bleeding (72%), muscle hematoma (58.7%), hemarthrosis (46.7%), menorrhagia (58.7%) in secondary hemostatic defects and epistaxis (45.9%), cutaneous bleeding (62.4%), menorrhagia (30.7%) in normal screening coagulogram group. Grade of bleeding was mostly 2 and sometimes 4 in primary, 2-4 in secondary and 1-2 in normal screening coagulogram group. ISTH-BAT is a valuable tool to record lifelong bleeding history. The pattern and score give clues regarding the nature and severity of the bleeding disorder.
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Affiliation(s)
- Pagadalu Lokababu Ambika
- Department of Pathology, Institute Block-2nd Floor, Jawaharlal Institute of Post-Graduate Medical Education and Research, Dhanvantari Nagar, Puducherry, 605006 India
| | - Debdatta Basu
- Department of Pathology, Institute Block-2nd Floor, Jawaharlal Institute of Post-Graduate Medical Education and Research, Dhanvantari Nagar, Puducherry, 605006 India
| | - Sukesh Chandran Nair
- Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, India
| | - Rakhee Kar
- Department of Pathology, Institute Block-2nd Floor, Jawaharlal Institute of Post-Graduate Medical Education and Research, Dhanvantari Nagar, Puducherry, 605006 India
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OUP accepted manuscript. Lab Med 2022; 53:349-359. [DOI: 10.1093/labmed/lmac005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Bleeding assessment tools in the diagnosis of VWD in adults and children: a systematic review and meta-analysis of test accuracy. Blood Adv 2021; 5:5023-5031. [PMID: 34597385 PMCID: PMC9153010 DOI: 10.1182/bloodadvances.2021004368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/14/2021] [Indexed: 12/29/2022] Open
Abstract
Von Willebrand disease (VWD) can be associated with significant morbidity. Patients with VWD can experience bruising, mucocutaneous bleeding, and bleeding after dental and surgical procedures. Early diagnosis and treatment are important to minimize the risk of these complications. Several bleeding assessment tools (BATs) have been used to quantify bleeding symptoms as a screening tool for VWD. We systematically reviewed diagnostic test accuracy results of BATs to screen patients for VWD. We searched Cochrane Central, MEDLINE, and EMBASE for eligible studies, reference lists of relevant reviews, registered trials, and relevant conference proceedings. Two investigators screened and abstracted data. Risk of bias was assessed using the revised tool for the quality assessment of diagnostic accuracy studies and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. We pooled estimates of sensitivity and specificity. The review included 7 cohort studies that evaluated the use of BATs to screen adult and pediatric patients for VWD. The pooled estimates for sensitivity and specificity were 75% (95% confidence interval, 66-83) and 54% (29-77), respectively. Certainty of evidence varied from moderate to high. This systematic review provides accuracy estimates for validated BATs as a screening modality for VWD. A BAT is a useful initial screening test to determine who needs specific blood testing. The pretest probability of VWD (often determined by the clinical setting/patient population), along with sensitivity and specificity estimates, will influence patient management.
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Approach to the Patient with Bleeding. Hematol Oncol Clin North Am 2021; 35:1039-1049. [PMID: 34535288 DOI: 10.1016/j.hoc.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Approach to the patient with bleeding begins with a thorough bleeding, medical, and family history to determine the nature of bleeding and severity of bleeding symptoms. Use of a Bleeding Assessment Tool allows the clinician to obtain a comprehensive bleeding history and ultimately determine the individual bleeding score that reflects bleeding severity and is classifiable as either normal or abnormal. In the absence of significant findings within patient history or presenting symptoms clearly pointing to a specific bleeding pathology, an approach to laboratory investigation is presented that proceeds through first-line, second-line, and third-line testing.
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21
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Ambaglio C, Zane F, Russo MC, Preti PS, Scudeller L, Klersy C, Gamba G, Squizzato A. Preoperative bleeding risk assessment with ISTH-BAT and laboratory tests in patients undergoing elective surgery: A prospective cohort study. Haemophilia 2021; 27:717-723. [PMID: 34265124 DOI: 10.1111/hae.14376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 06/15/2021] [Accepted: 07/02/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients with inherited haemorrhagic disorders may bleed during surgery. No questionnaire on bleeding diathesis has been yet validated for the preoperative period and current guidelines provide conflicting recommendations. AIM We aimed to assess if preoperative assessment with ISTH-BAT (International Society on Thrombosis and Haemostasis Bleeding Assesment Tool) and laboratory screening tests is useful to identify mild previously undiagnosed bleeding disorders (BDs) and to predict bleeding complications in selected patients undergoing elective surgery. METHODS Consecutive patients undergoing elective surgery received ISTH-BAT evaluation and laboratory screening for platelet count, Prothrombin Time (PT) and activated Partial Thromboplastin Time (aPTT). Subjects with an abnormal ISTH-BAT and/or laboratory results underwent further testing, and they were compared with a 1:1 random gender-, age- and type of surgery- matched control group. RESULTS Overall, 1502 consecutive surgical patients (1186 adults, 316 children) were enrolled. Of these, 83 (5.5%, 95% confidence interval 4.4-6.8) patients (37 adults and 46 children) had an abnormal ISTH-BAT, and/or prolonged PT and/or prolonged aPTT and/or low platelet count; of them, one subject had low von Willebrand factor level, three Factor XII deficiency and four anticardiolipin and/or antiB2GPI antibodies. No major bleeding was reported in these 83 patients and their controls. CONCLUSION ISTH-BAT and laboratory screening tests do not accurately detect mild BDs in selected patients undergoing elective surgery.
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Affiliation(s)
- Chiara Ambaglio
- Department of Internal Medicine, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,SIMT, ASST Bergamo Ovest, Treviglio, Italy
| | - Federica Zane
- Department of Internal Medicine, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maria Concetta Russo
- Department of Internal Medicine, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Paola Stefania Preti
- Department of Internal Medicine, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Luigia Scudeller
- IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano Foundation, Milan, Italy
| | - Catherine Klersy
- Service of Biometry and Clinical Epidemiology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Gabriella Gamba
- Department of Internal Medicine, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Como, Italy
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Association of ABO blood group with bleeding severity in patients with bleeding of unknown cause. Blood Adv 2021; 4:5157-5164. [PMID: 33095871 DOI: 10.1182/bloodadvances.2020002452] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/08/2020] [Indexed: 12/22/2022] Open
Abstract
Blood group O has been associated with an increased bleeding tendency due to lower von Willebrand factor (VWF) and factor VIII (FVIII) levels. We explored whether blood group O is independently associated with bleeding severity in patients with mild-to-moderate bleeding of unknown cause (BUC) in the Vienna Bleeding Biobank cohort. Bleeding severity was recorded with the Vicenza bleeding score (BS). Blood group O was overrepresented in 422 patients with BUC compared with its presence in 23 145 healthy blood donors (47.2% vs 37.6%; odds ratio, 1.48; 95% confidence interval [CI], 1.22-1.79). The BS and the number of bleeding symptoms were significantly higher in patients with blood group O than in patients with non-O after adjustment for VWF and FVIII levels and sex (least-square [LS] means of BSs: 6.2; 95% CI, 5.8-6.6 vs 5.3; 4.9-5.7; and of number of symptoms: LS, 3.5; 95% CI, 3.2-3.7 vs 3.0; 2.8-3.2, respectively). Oral mucosal bleeding was more frequent in those with blood group O than in those with other blood types (group non-O; 26.1% vs 14.3%), independent of sex and VWF and FVIII levels, whereas other bleeding symptoms did not differ. Patients with blood group O had increased clot density in comparison with those with blood group non-O, as determined by rotational thromboelastometry and turbidimetric measurement of plasma clot formation. There were no differences in thrombin generation, clot lysis, or platelet function. Our data indicate that blood group O is a risk factor for increased bleeding and bleeding severity in patients with BUC, independent of VWF and FVIII levels.
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Elevated levels of tissue factor pathway inhibitor in patients with mild to moderate bleeding tendency. Blood Adv 2021; 5:391-398. [PMID: 33496735 DOI: 10.1182/bloodadvances.2020003464] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/05/2020] [Indexed: 12/26/2022] Open
Abstract
High levels of tissue factor pathway inhibitor (TFPI), caused by a longer TFPIα half-life after binding to a factor V splice variant and variants in the F5 gene, were recently identified in 2 families with an as-yet-unexplained bleeding tendency. This study aimed to investigate free TFPIα in a well-characterized cohort of 620 patients with mild to moderate bleeding tendencies and its association to genetic alterations in the F5 gene. TFPIα levels were higher in patients with bleeding compared with healthy controls (median [interquartile range], 8.2 [5.5-11.7] vs 7.8 [4.3-11.1]; P = .026). A higher proportion of patients had free TFPIα levels more than or equal to the 95th percentile compared with healthy controls (odds ratio [OR] [95% confidence interval (CI)], 2.82 [0.98-8.13]). This was pronounced in the subgroup of patients in whom no bleeding disorder could be identified (bleeding of unknown cause [BUC; n = 420]; OR [95% CI], 3.03 [1.02-8.98]) and in platelet function defects (PFDs) (n = 121; OR [95% CI], 3.47 [1.09-11.08]). An increase in free TFPIα was associated with a mild delay in thrombin generation (prolonged lag time and time to peak), but not with alterations in routinely used global clotting tests. We could neither identify new or known genetic variations in the F5 gene that are associated with free TFPIα levels, nor an influence of the single-nucleotide variant rs10800453 on free TFPIα levels in our patient cohort. An imbalance of natural coagulation inhibitors such as TFPIα could be an underlying cause or contributor for unexplained bleeding, which is most probably multifactorial in a majority of patients.
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ASH ISTH NHF WFH 2021 guidelines on the diagnosis of von Willebrand disease. Blood Adv 2021; 5:280-300. [PMID: 33570651 DOI: 10.1182/bloodadvances.2020003265] [Citation(s) in RCA: 214] [Impact Index Per Article: 71.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/23/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND von Willebrand disease (VWD) is the most common inherited bleeding disorder known in humans. Accurate and timely diagnosis presents numerous challenges. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH), the International Society on Thrombosis and Haemostasis (ISTH), the National Hemophilia Foundation (NHF), and the World Federation of Hemophilia (WFH) are intended to support patients, clinicians, and other health care professionals in their decisions about VWD diagnosis. METHODS ASH, ISTH, NHF, and WFH established a multidisciplinary guideline panel that included 4 patient representatives and was balanced to minimize potential bias from conflicts of interest. The Outcomes and Implementation Research Unit at the University of Kansas Medical Center (KUMC) supported the guideline-development process, including performing or updating systematic evidence reviews up to 8 January 2020. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subsequently subject to public comment. RESULTS The panel agreed on 11 recommendations. CONCLUSIONS Key recommendations of these guidelines include the role of bleeding-assessment tools in the assessment of patients suspected of VWD, diagnostic assays and laboratory cutoffs for type 1 and type 2 VWD, how to approach a type 1 VWD patient with normalized levels over time, and the role of genetic testing vs phenotypic assays for types 2B and 2N. Future critical research priorities are also identified.
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Gresele P, Falcinelli E, Bury L, Pecci A, Alessi MC, Borhany M, Heller PG, Santoro C, Cid AR, Orsini S, Fontana P, De Candia E, Podda G, Kannan M, Jurk K, Castaman G, Falaise C, Guglielmini G, Noris P. The ISTH bleeding assessment tool as predictor of bleeding events in inherited platelet disorders: Communication from the ISTH SSC Subcommittee on Platelet Physiology. J Thromb Haemost 2021; 19:1364-1371. [PMID: 33880867 DOI: 10.1111/jth.15263] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/18/2021] [Accepted: 02/04/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The ISTH Bleeding Assessment Tool (ISTH-BAT) has been validated for clinical screening of suspected von Willebrand disease (VWD) and for bleeding prediction. Recently it has been validated for subjects with inherited platelet disorders (IPD) (BAT-VAL study). OBJECTIVES To determine whether the ISTH-BAT bleeding score (BS) predicts subsequent bleeding events requiring treatment in IPD patients. METHODS Patients with IPD, type 1 VWD (VWD-1) and age- and sex-matched healthy controls enrolled in the BAT-VAL study were prospectively followed-up for 2 years and bleeding episodes requiring treatment were recorded. RESULTS Of the 1098 subjects initially enrolled, 955 were followed-up and 124 suffered hemorrhages during follow-up, 60% of whom had inherited platelet function disorders (IPFD). Total number of events was significantly higher in IPFD (n = 235) than VWD-1 (n = 52) or inherited thrombocytopenia (IT; n = 20). Events requiring transfusions were 66% in IPFD, 5.7% in VWD-1, and 3% in IT. Baseline BS was significantly higher in IPFD patients with a bleeding event at follow-up than in those without (p < .01) and the percentage of subjects suffering a bleeding event increased proportionally to baseline BS quartile. A significant association between the BS and the chance of suffering severe bleeding was found in the overall, IPFD, and VWD-1 populations. Similar results were obtained for the pediatric population. CONCLUSIONS Inherited platelet function disorder patients with high BS at enrollment are more likely to suffer from bleeding events requiring treatment at follow-up. Moreover, the higher the baseline BS quartile the greater the incidence of subsequent events, suggesting that independently from diagnosis a high BS is associated with a greater risk of subsequent hemorrhage.
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Affiliation(s)
- Paolo Gresele
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Emanuela Falcinelli
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Loredana Bury
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Alessandro Pecci
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Marie-Christine Alessi
- Centre for CardioVascular and Nutrition Research (C2VN, INSERM 1263, INRA 1260, Marseille, France
| | - Munira Borhany
- Department of Hematology, Haemostasis & Thrombosis at National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, Pakistan
| | - Paula G Heller
- Instituto de Investigaciones Médicas A. Lanari, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
- Departamento Hematología Investigación, Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET, Universidad de Buenos Aires, Instituto de Investigaciones Médicas (IDIM, Buenos Aires, Argentina
| | - Cristina Santoro
- Hematology, Azienda Ospedaliera Universitaria Policlinico Umberto I, Rome, Italy
| | - Ana Rosa Cid
- Unidad de Hemostasia y Trombosis, Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | - Sara Orsini
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Pierre Fontana
- Geneva Platelet Group and Division of Angiology and Hemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Erica De Candia
- Hemostasis and Thrombosis Unit, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
- Institute of Internal Medicine and Geriatrics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianmarco Podda
- Medicina III, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Meganathan Kannan
- Division of Blood and Vascular Biology, Department of Life Sciences, School of Life Sciences, Central University of Tamil Nadu, Thiruvarur, India
| | - Kerstin Jurk
- Center for Thrombosis and Hemostasis, University Medical Center, Mainz, Germany
| | - Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Céline Falaise
- Centre for CardioVascular and Nutrition Research (C2VN, INSERM 1263, INRA 1260, Marseille, France
| | - Giuseppe Guglielmini
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Patrizia Noris
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
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Baronciani L, Peyvandi F. How we make an accurate diagnosis of von Willebrand disease. Thromb Res 2020; 196:579-589. [DOI: 10.1016/j.thromres.2019.07.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/27/2019] [Accepted: 07/14/2019] [Indexed: 11/28/2022]
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Castaman G. How I treat von Willebrand disease. Thromb Res 2020; 196:618-625. [DOI: 10.1016/j.thromres.2020.07.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 01/17/2023]
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28
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Prevalence of bleeding symptoms in Nigerian population: A cross-sectional study of the three major ethnic groups. THROMBOSIS UPDATE 2020. [DOI: 10.1016/j.tru.2020.100016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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29
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Thomas W, Downes K, Desborough MJR. Bleeding of unknown cause and unclassified bleeding disorders; diagnosis, pathophysiology and management. Haemophilia 2020; 26:946-957. [PMID: 33094877 DOI: 10.1111/hae.14174] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/03/2020] [Accepted: 09/21/2020] [Indexed: 12/24/2022]
Abstract
Bleeding of unknown cause (BUC), also known as unclassified bleeding disorders (UBD), has been defined as a clear bleeding tendency in the presence of normal haemostatic tests. There are challenges in the diagnosis and management of these patients. BUC/UBD encompasses a heterogenous group of disorders which may include undiagnosed rare monogenic diseases, polygenic reasons for bleeding; and patients without a clear bleeding disorder but with a previous bleeding event. Nevertheless, these patients may have heavy menstrual bleeding or be at risk of bleeding when undergoing surgical procedures, or childbirth; optimizing haemostasis and establishing a mode of inheritance is important to minimize morbidity. The bleeding score has been used to clinically assess and describe these patients, but its value remains uncertain. In addition, accurate distinction between normal and pathological bleeding remains difficult. Several studies have investigated cohorts of these patients using research haemostasis tests, including thrombin generation and fibrinolytic assays, yet no clear characteristics have consistently emerged. Thus far, detailed genetic analysis of these patients has not been fruitful in unravelling the cause of bleeding. There is a need for standardization of diagnosis and management guidelines for these patients. This review gives an overview of this field with some suggestions for future research.
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Affiliation(s)
- Will Thomas
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kate Downes
- East Midlands and East of England Genomic Laboratory Hub, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Department of Haematology, University of Cambridge, Cambridge, UK
| | - Michael J R Desborough
- Haemostasis and Thrombosis Centre, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
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Jain S, Zhang S, Acosta M, Malone K, Kouides P, Zia A. Prospective evaluation of ISTH-BAT as a predictor of bleeding disorder in adolescents presenting with heavy menstrual bleeding in a multidisciplinary hematology clinic. J Thromb Haemost 2020; 18:2542-2550. [PMID: 32654321 DOI: 10.1111/jth.14997] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/30/2020] [Accepted: 07/02/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) can be the first manifestation of an undiagnosed bleeding disorder (BD). Identifying a BD can be challenging in the adolescent age group. The utility of bleeding assessment tools (BAT) remains elusive in this population. AIM We evaluated the ability of the International Society on Thrombosis and Haemostasis-BAT (ISTH-BAT) in predicting a BD in adolescents referred for HMB to a multidisciplinary hematology clinic. METHODS Two hundred adolescents with HMB underwent a standardized evaluation for BD. The clinical characteristics, laboratory data, and bleeding scores (BS) assessed using ISTH-BAT were prospectively collected. Comparisons were made between patients based on the diagnosis of BD receiver operating characteristic (ROC) curve analyses of ISTH-BAT were performed to assess its value for predicting BD. RESULTS Overall, 33% (n = 67) of adolescents were diagnosed with a BD. The mean ISTH-BAT BS was higher in BD as compared to those without (4.1 versus 3.1, P < .0001), but the mean menorrhagia-specific scores did not differ (2.9 in both groups). The ISTH-BAT demonstrated a modest discriminative ability as a screening tool to identify BD in girls with HMB with an area under the curve (AUC) of 0.71. The ROC analysis demonstrated that with increasing BS, the sensitivity decreased, but the specificity increased. At BS = 3, sensitivity was 88%, specificity 31%, and accuracy 50%; at BS = 5, sensitivity was 37%, specificity 94%, and accuracy was 75%. There was no change thereafter. CONCLUSION In adolescents with HMB, an ISTH-BAT BS of >4 instead of the established cut-off of >2 in children is highly specific in predicting a BD.
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Affiliation(s)
- Shilpa Jain
- Division of Pediatric Hematology-Oncology, John R. Oishei Children's Hospital, University at Buffalo, Buffalo, NY, USA
- Western New York BloodCare, Buffalo, NY, USA
| | - Song Zhang
- Department of Population and Data Sciences, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Kendra Malone
- Division of Hematology/Oncology, Department(s) of Pediatrics, Children's Medical Center, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Peter Kouides
- Mary M. Gooley Hemophilia Center, University of Rochester School of Medicine, Rochester, NY, USA
| | - Ayesha Zia
- Division of Hematology/Oncology, Department(s) of Pediatrics, Children's Medical Center, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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31
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Tosetto A, Badiee Z, Baghaipour MR, Baronciani L, Battle J, Berntorp E, Bodó I, Budde U, Castaman G, Eikenboom JCJ, Eshghi P, Ettorre C, Goodeve A, Goudemand J, Hay CRM, Hoorfar H, Karimi M, Keikhaei B, Lassila R, Leebeek FWG, Lopez Fernandez MF, Mannucci PM, Mazzucconi MG, Morfini M, Oldenburg J, Peake I, Parra Lòpez R, Peyvandi F, Schneppenheim R, Tiede A, Toogeh G, Trossaert M, Zekavat O, Zetterberg EMK, Federici AB. Bleeding symptoms in patients diagnosed as type 3 von Willebrand disease: Results from 3WINTERS-IPS, an international and collaborative cross-sectional study. J Thromb Haemost 2020; 18:2145-2154. [PMID: 32379400 DOI: 10.1111/jth.14886] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/09/2020] [Accepted: 04/28/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Type 3 von Willebrand's disease (VWD) patients present markedly reduced levels of von Willebrand factor and factor VIII. Because of its rarity, the bleeding phenotype of type 3 VWD is poorly described, as compared to type 1 VWD. AIMS To evaluate the frequency and the severity of bleeding symptoms across age and sex groups in type 3 patients and to compare these with those observed in type 1 VWD patients to investigate any possible clustering of bleeding symptoms within type 3 patients. METHODS We compared the bleeding phenotype and computed the bleeding score (BS) using the MCMDM-1VWD bleeding questionnaire in patients enrolled in the 3WINTERS-IPS and MCMDM-1VWD studies. RESULTS In 223 unrelated type 3 VWD patients, both the BS and the number of clinically relevant bleeding symptoms were increased in type 3 as compared to type 1 VWD patients (15 versus 6 and 5 versus 3). Intracranial bleeding, oral cavity, hemarthroses, and deep hematomas were at least five-fold over-represented in type 3 VWD. A more severe bleeding phenotype was evident in patients having von Willebrand factor antigen levels < 20 IU/dL at diagnosis in the two merged cohorts. In type 3 patients, there was an apparent clustering of hemarthrosis with gastrointestinal bleeding and epistaxis, whereas bleeding after surgery or tooth extraction clusters with oral bleeding and menorrhagia. CONCLUSIONS In the largest cohort of type 3 VWD patients, we were able to describe a distinct clinical phenotype that is associated with the presence of a more severe hemostatic defect.
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Affiliation(s)
- Alberto Tosetto
- Hemophilia and Thrombosis Center, Hematology Department, San Bortolo Hospital, Vicenza, Italy
| | - Zahra Badiee
- Hemophilia-Thalassemia Center, Mashhad University of Medical Science, Mashad, Islamic Republic of Iran
| | | | - Luciano Baronciani
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Fondazione Luigi Villa, Milan, Italy
| | - Javier Battle
- Complejo Hospitalario Universitario de A Coruña-Servicio de Hematología y Hemoterapia, A Coruña, Spain
| | | | - Imre Bodó
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | | | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Jeroen C J Eikenboom
- Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Peyman Eshghi
- Pediatric Congenital Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Cosimo Ettorre
- Hemostasis and Thrombosis Center, Azienda Ospedaliera Policlinico Consorziale, Bari, Italy
| | | | - Jenny Goudemand
- Department of Haematology Transfusion, University Lille-CRMW, CHRU Lille, Lille, France
| | | | - Hamid Hoorfar
- Hemophilia Center-Esfahan University of Medical Science, Esfahan, Islamic Republic of Iran
| | - Mehran Karimi
- Hematology Research Center, Nemazee Hospital, Shiraz University of Medical Science, Shiraz, Islamic Republic of Iran
| | - Bijan Keikhaei
- Thalassemia and Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Riitta Lassila
- Coagulation Disorders, Helsinki University Central Hospital, Helsinki, Finland
| | | | | | - Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Fondazione Luigi Villa, Milan, Italy
| | | | - Massimo Morfini
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University of Bonn, Bonn, Germany
| | - Ian Peake
- University of Sheffield, Sheffield, UK
| | - Rafael Parra Lòpez
- Unidad de Hemofilia-Hospital Universitari General Vall d'Hebron, Barcelona, Spain
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Fondazione Luigi Villa, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Reinhard Schneppenheim
- Department of Pediatric Hematology and Oncology, University Medical Centre, Hamburg, Germany
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Gholamreza Toogeh
- Thrombosis Hemostasis Research Center-Vali-Asr Hospital-Emam Khameini Complex Hospital, Tehran University of Medical Science, Tehran, Islamic Republic of Iran
| | - Marc Trossaert
- Centre Régional de Traitement de l'Hémophilie-Laboratoire d'Hématologie, Nantes, France
| | - Omidreza Zekavat
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran
| | | | - Augusto B Federici
- Hematology and Transfusion Medicine, Department of Oncology and Oncohematology, L. Sacco University Hospital, University of Milan, Milano, Italy
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Malec L, Crowther M. The value of bleeding scores in the assessment of patients presenting with bleeding of unknown cause: Complex algorithms with little predictive value. Eur J Intern Med 2020; 78:26-27. [PMID: 32522445 DOI: 10.1016/j.ejim.2020.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 05/14/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Lynn Malec
- Versiti Blood Research Institute, Milwaukee, WI, USA; Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
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Gebhart J, Hofer S, Kaider A, Rejtö J, Ay C, Pabinger I. The discriminatory power of bleeding assessment tools in adult patients with a mild to moderate bleeding tendency. Eur J Intern Med 2020; 78:34-40. [PMID: 32317240 DOI: 10.1016/j.ejim.2020.04.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/24/2020] [Accepted: 04/06/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Bleeding assessment tools (BATs) have been developed to quantify bleeding severity. Their ability to predict for the diagnosis of a bleeding disorder has not been thoroughly investigated. OBJECTIVES To evaluate the ability of the Vicenza BAT and the ISTH BAT to distinguish patients with an established bleeding disorder from those with bleeding of unknown cause (BUC). PATIENTS/METHODS Three-hundred fifty-nine patients (228 with BUC, 64%) from the Vienna Bleeding Biobank were assessed in this study. RESULTS The bleeding scores were similar in patients with an established diagnosis of a bleeding disorder compared to patients with BUC. Both BATs had a low sensitivity and specificity for the diagnosis of a bleeding disorder with areas under the receiver operating characteristic (ROC) curves of 0.53 (95% confidence interval 0.47-0.60) for the Vicenza BAT and 0.52 (0.46-0.59) for the ISTH BAT. In terms of specific diagnoses, both scores were most accurate in diagnosing von Willebrand disease (VWD, areas under the ROC curve; Vicenza BAT 0.67 (0.45-0.90); ISTH BAT 0.70 (0.50-0.90)). A separate evaluation of different bleeding symptoms in patients who had undergone surgery and tooth extraction revealed that postpartum bleeding and bleeding from small wounds was predictive for diagnosing a MBD in multivariable analysis. CONCLUSIONS The Vicenza- and the ISTH BAT have a low ability to distinguish patients with an established bleeding disorder from those with BUC.
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Affiliation(s)
- Johanna Gebhart
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
| | - Stefanie Hofer
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Alexandra Kaider
- Section for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Austria
| | - Judit Rejtö
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
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Tosetto A. The value of bleeding scores in the assessment of patients presenting with bleeding of unknown cause: Bleeding assessment tools have still a place. Eur J Intern Med 2020; 78:28-29. [PMID: 32553584 DOI: 10.1016/j.ejim.2020.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/06/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Alberto Tosetto
- Institution: Hemophilia and Thrombosis Center, Hematology Department, San Bortolo Hospital, AULSS 8 "Berica", viale Rodolfi 37, 36100 Vicenza, Italy.
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Elbaz C, Sholzberg M. An illustrated review of bleeding assessment tools and common coagulation tests. Res Pract Thromb Haemost 2020; 4:761-773. [PMID: 32685885 PMCID: PMC7354401 DOI: 10.1002/rth2.12339] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/08/2020] [Accepted: 02/26/2020] [Indexed: 12/17/2022] Open
Abstract
Recognizing the complexity of coagulation tests and currently used anticoagulants, we developed this illustrated review on bleeding assessment tools and common coagulation screening tests. Quantitative bleeding assessment tools (BATs) are available to standardize the bleeding history and improve the pretest probability prior to coagulation testing. We describe use of BATs and the principles, indications, and limitations of the prothrombin time (PT)/International Normalized Ratio, activated partial thromboplastin time (APTT), and 50:50 mix. Use of these tests to identify coagulation factor deficiencies, specific and nonspecific inhibitors, coagulopathy of liver disease, disseminated intravascular coagulation, and commonly used anticoagulant medications are reviewed. Current literature suggests that unnecessary coagulation testing is rampant. The PT and APTT have astoundingly low sensitivity (1.0%-2.1%) for detection of clinically significant bleeding disorders. Thus, current guidelines recommend against the use of screening PT and APTT in preoperative patients undergoing noncardiac/vascular surgery.
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Affiliation(s)
- Carolyne Elbaz
- Department of MedicineUniversity of TorontoTorontoONCanada
| | - Michelle Sholzberg
- Departments of Medicine and Laboratory Medicine & PathobiologySt. Michael’s HospitalToronto and University of TorontoTorontoONCanada
- Li Ka Shing Knowledge InstituteTorontoONCanada
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Srivastava A. Diagnosis of haemophilia and other inherited bleeding disorders ‐ Is a new paradigm needed? Haemophilia 2020; 27 Suppl 3:14-20. [DOI: 10.1111/hae.14042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Alok Srivastava
- Department of Haematology Christian Medical College Vellore India
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37
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Fogarty H, Doherty D, O'Donnell JS. New developments in von Willebrand disease. Br J Haematol 2020; 191:329-339. [PMID: 32394456 DOI: 10.1111/bjh.16681] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 12/19/2022]
Abstract
Von Willebrand disease (VWD) constitutes the most common inherited human bleeding disorder. It is associated with a mucocutaneous bleeding phenotype that can significantly impact upon quality of life. Despite its prevalence and associated morbidity, the diagnosis and subclassification of VWD continue to pose significant clinical challenges. This is in part attributable to the fact that plasma von Willebrand factor (VWF) levels vary over a wide range in the normal population, together with the multiple different physiological functions played by VWF in vivo. Over recent years, substantial progress has been achieved in elucidating the biological roles of VWF. Significant advances have also been made into defining the pathophysiological mechanisms underpinning both quantitative and qualitative VWD. In particular, several new laboratory assays have been developed that enable more precise assessment of specific aspects of VWF activity. In the present review, we discuss these recent developments in the field of VWD diagnosis, and consider how these advances can impact upon clinical diagnostic algorithms for use in routine clinical practice. In addition, we review some important recent advances pertaining to the various treatment options available for managing patients with VWD.
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Affiliation(s)
- Helen Fogarty
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Dearbhla Doherty
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Coagulation Centre, St James's Hospital, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
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Veen CSB, Huisman EJ, Cnossen MH, Kom‐Gortat R, Rijken DC, Leebeek FWG, Maat MPM, Kruip MJHA. Evaluation of thromboelastometry, thrombin generation and plasma clot lysis time in patients with bleeding of unknown cause: A prospective cohort study. Haemophilia 2020; 26:e106-e115. [DOI: 10.1111/hae.13991] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/01/2020] [Accepted: 03/18/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Caroline S. B. Veen
- Department of Haematology Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - Elise J. Huisman
- Department of Paediatric Haematology Erasmus University Medical Center - Sophia Children's Hospital Rotterdam The Netherlands
| | - Marjon H. Cnossen
- Department of Paediatric Haematology Erasmus University Medical Center - Sophia Children's Hospital Rotterdam The Netherlands
| | - Regina Kom‐Gortat
- Department of Haematology Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - Dingeman C. Rijken
- Department of Haematology Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - Frank W. G. Leebeek
- Department of Haematology Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - Moniek P. M. Maat
- Department of Haematology Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - Marieke J. H. A. Kruip
- Department of Haematology Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
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Gresele P, Orsini S, Noris P, Falcinelli E, Alessi MC, Bury L, Borhany M, Santoro C, Glembotsky AC, Cid AR, Tosetto A, De Candia E, Fontana P, Guglielmini G, Pecci A. Validation of the ISTH/SSC bleeding assessment tool for inherited platelet disorders: A communication from the Platelet Physiology SSC. J Thromb Haemost 2020; 18:732-739. [PMID: 31750621 DOI: 10.1111/jth.14683] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 11/11/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Careful assessment of bleeding history is the first step in the evaluation of patients with mild/moderate bleeding disorders, and the use of a bleeding assessment tool (BAT) is strongly encouraged. Although a few studies have assessed the utility of the ISTH-BAT in patients with inherited platelet function disorders (IPFD) none of them was sufficiently large to draw conclusions and/or included appropriate control groups. OBJECTIVES The aim of the present study was to test the utility of the ISTH-BAT in a large cohort of patients with a well-defined diagnosis of inherited platelets disorder in comparison with two parallel cohorts, one of patients with type-1 von Willebrand disease (VWD-1) and one of healthy controls (HC). PATIENTS/METHODS We enrolled 1098 subjects, 482 of whom had inherited platelet disorders (196 IPFD and 286 inherited platelet number disorders [IT]) from 17 countries. RESULTS IPFD patients had significantly higher bleeding score (BS; median 9) than VWD-1 patients (median 5), a higher number of hemorrhagic symptoms (4 versus 3), and higher percentage of patients with clinically relevant symptoms (score > 2). The ISTH-BAT showed excellent discrimination power between IPFD and HC (0.9 < area under the curve [AUC] < 1), moderate (0.7 < AUC < 0.9) between IPFD and VWD-1 and between IPFD and inherited thrombocytopenia (IT), while it was inaccurate (AUC ≤ 0.7) in discriminating IT from HC. CONCLUSIONS The ISTH-BAT allows to efficiently discriminate IPFD from HC, while it has lower accuracy in distinguishing IPFD from VWD-1. Therefore, the ISTH-BAT appears useful for identifying subjects requiring laboratory evaluation for a suspected IPFD once VWD is preliminarily excluded.
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Affiliation(s)
- Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Sara Orsini
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Patrizia Noris
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Emanuela Falcinelli
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | | | - Loredana Bury
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Munira Borhany
- Department of Hematology, Haemostasis & Thrombosis at National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, Pakistan
| | - Cristina Santoro
- Hematology, Azienda Ospedaliera Universitaria Policlinico Umberto I, Rome, Italy
| | - Ana C Glembotsky
- Instituto de Investigaciones Médicas A. Lanari, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
- Departamento Hematología Investigación, Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Universidad de Buenos Aires, Instituto de Investigaciones Médicas (IDIM), Buenos Aires, Argentina
| | - Ana Rosa Cid
- Unidad de Hemostasia y Trombosis, Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | | | - Erica De Candia
- Hemostasis and Thrombosis Unit, Fondazione Policlinico Agostino Gemelli IRCCS, Roma, Italy
- Institute of Internal Medicine and Geriatrics, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Pierre Fontana
- Platelet Group and Division of Angiology and Hemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Giuseppe Guglielmini
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Alessandro Pecci
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
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Belen Apak FB, Ümit EG, Zengin Y, Sezgin Evim M, Ünal E, Özbaş HM, Acıpayam C. Assessment of Patients with von Willebrand Disease with ISTH/BAT and PBQ Scores. Turk J Haematol 2020; 37:57-58. [PMID: 31718118 PMCID: PMC7057742 DOI: 10.4274/tjh.galenos.2019.2019.0446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Fatma Burcu Belen Apak
- Başkent University Faculty of Medicine, Department of Pediatric Hematology Oncology, Ankara, Turkey
| | - Elif Gülsüm Ümit
- Trakya University Faculty of Medicine, Department of Hematology, Edirne, Turkey
| | - Yağmur Zengin
- Başkent University Faculty of Medicine, Department of Biostatistics, Ankara, Turkey
| | - Melike Sezgin Evim
- Uludağ University Faculty of Medicine, Department of Pediatric Hematology Oncology, Bursa, Turkey
| | - Ekrem Ünal
- Erciyes University Faculty of Medicine, Department of Pediatric Hematology Oncology, Kayseri, Turkey
| | - Hasan Mücahit Özbaş
- Giresun University Faculty of Medicine, Department of Hematology, Giresun, Turkey
| | - Can Acıpayam
- Kahramanmaraş Sütçü İmam University Faculty of Medicine, Department of Pediatric Hematology and Oncology, Kahramanmaraş, Turkey
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Shah A, Palmer AJR, Klein AA. Strategies to minimize intraoperative blood loss during major surgery. Br J Surg 2020; 107:e26-e38. [DOI: 10.1002/bjs.11393] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/12/2019] [Indexed: 12/19/2022]
Abstract
Abstract
Background
Reducing operative blood loss improves patient outcomes and reduces healthcare costs. The aim of this article was to review current surgical, anaesthetic and haemostatic intraoperative blood conservation strategies.
Methods
This narrative review was based on a literature search of relevant databases up to 31 July 2019 for publications relevant to reducing blood loss in the surgical patient.
Results
Interventions can begin early in the preoperative phase through identification of patients at high risk of bleeding. Directly acting anticoagulants can be stopped 48 h before most surgery in the presence of normal renal function. Aspirin can be continued for most procedures. Intraoperative cell salvage is recommended when anticipated blood loss is greater than 500 ml and this can be continued after surgery in certain situations. Tranexamic acid is safe, cheap and effective, and routine administration is recommended when anticipated blood loss is high. However, the optimal dose, timing and route of administration remain unclear. The use of topical agents, tourniquet and drains remains at the discretion of the surgeon. Anaesthetic techniques include correct patient positioning, avoidance of hypothermia and regional anaesthesia. Permissive hypotension may be beneficial in selected patients. Promising haemostatic strategies include use of pharmacological agents such as desmopressin, prothrombin complex concentrate and fibrinogen concentrate, and use of viscoelastic haemostatic assays.
Conclusion
Reducing perioperative blood loss requires a multimodal and multidisciplinary approach. Although high-quality evidence exists in certain areas, the overall evidence base for reducing intraoperative blood loss remains limited.
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Affiliation(s)
- A Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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O’Brien SH. All bleeding matters … but the details may not. Res Pract Thromb Haemost 2020; 4:16-18. [PMID: 31989080 PMCID: PMC6971328 DOI: 10.1002/rth2.12262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 09/10/2019] [Indexed: 11/09/2022] Open
Affiliation(s)
- Sarah H. O’Brien
- Center for Innovation in Pediatric PracticeThe Research Institute at Nationwide Children’s HospitalColumbusOhio
- Division of Pediatric Hematology/OncologyNationwide Children’s Hospital/The Ohio State UniversityColumbusOhio
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Spradbrow J, Letourneau S, Grabell J, Liang Y, Riddel J, Hopman W, Blanchette VS, Rand ML, Coller BS, Paterson AD, James PD. Bleeding assessment tools to predict von Willebrand disease: Utility of individual bleeding symptoms. Res Pract Thromb Haemost 2020; 4:92-99. [PMID: 31989089 PMCID: PMC6971303 DOI: 10.1002/rth2.12256] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 08/19/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Bleeding assessment is part of the diagnostic workup of von Willebrand disease (VWD). Bleeding assessment tools (BATs) have standardized obtaining this information but have been criticized because they are time consuming. OBJECTIVE To use our legacy data to determine which questions from BATs are the strongest predictors of a VWD diagnosis. PATIENTS/METHODS Bleeding score data from 3 different BATs were used. Patients aged <12 years were excluded. Questions on BATs relate to different bleeding symptoms, and each symptom is scored by severity. Scores for each symptom were sorted based on whether they indicated clinically significant bleeding, and nonsignificant scores were set as the reference category. Multivariable logistic regression was used to determine the symptoms that were the strongest predictors of a laboratory-confirmed VWD diagnosis. RESULTS A total of 927 participants were included; 144 (16%) were patients with VWD, and 783 (84%) were healthy controls. The top 3 symptoms for which a clinically significant positive response increased the likelihood of VWD were hemarthrosis (odds ratio [OR], 19.2; 95% confidence interval [CI], 3.7-100.4), postsurgical bleeding (OR, 15.2; 95% CI, 5.9-38.9), and menorrhagia (OR, 10.3; 95% CI, 4.9-21.9). With each increase in number of bleeding symptom categories with clinically significant scores, subjects had a stepwise increase in odds of a VWD diagnosis. CONCLUSIONS Our results suggest that most of the bleeding symptoms on BATs are significant predictors of VWD, and there is value in assessing multiple bleeding symptoms when eliciting a bleeding history. Certain bleeding symptoms are more useful predictors than others. Future BAT revisions may consider adding a relative weighting to each symptom.
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Affiliation(s)
| | | | - Julie Grabell
- Department of MedicineQueen's UniversityKingstonONCanada
| | - Yupu Liang
- Research BioinformaticsRockefeller UniversityNew YorkNYUSA
| | - James Riddel
- Division of Hematology/OncologyUniversity of CaliforniaSan FranciscoCAUSA
| | - Wilma Hopman
- Clinical Research CentreKingston General HospitalKingstonONCanada
| | - Victor S. Blanchette
- Department of PediatricsUniversity of TorontoTorontoONCanada
- Division of Haematology/OncologyThe Hospital for Sick ChildrenTorontoONCanada
| | - Margaret L. Rand
- Departments of Laboratory Medicine & Pathobiology, Biochemistry and PaediatricsUniversity of TorontoTorontoONCanada
- SickKids, Division of Haematology/Oncology and Translational Medicine, Research InstituteHospital for Sick ChildrenTorontoONCanada
| | - Barry S. Coller
- Allen and Frances Adler Laboratory of Blood and Vascular BiologyRockefeller UniversityNew YorkNYUSA
| | - Andrew D. Paterson
- Program in Genetics and Genome BiologyThe Hospital for Sick ChildrenTorontoONCanada
| | - Paula D. James
- Department of MedicineQueen's UniversityKingstonONCanada
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Zegers SAM, Smit Y, Saes JL, van Duren C, Schuijt TJ, van Heerde WL, Schols SEM. Diagnostic work up of patients with increased bleeding tendency. Haemophilia 2019; 26:269-277. [PMID: 31886943 PMCID: PMC7155060 DOI: 10.1111/hae.13922] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/30/2019] [Accepted: 12/06/2019] [Indexed: 12/13/2022]
Abstract
Introduction The diagnostic trajectory of patients with increased bleeding tendency can be very costly and time‐consuming. In addition, previous studies have shown that half of these patients remain without final diagnosis despite all efforts. Aim This study aimed to improve insight into the current diagnostic process of these patients. Methods A total of 117 adult patients, referred to an academic hospital because of being suspected to have an increased bleeding tendency, were included. Different parameters were compared between patients receiving final diagnosis, patients without final diagnosis but a high Tosetto bleeding assessment tool (BAT) score (classified as bleeding of unknown cause, or BUC) and a control group consisting of patients without final diagnosis and a low BAT score. Results The BAT score was significantly higher in patients in the BUC group as compared to patients reaching final diagnosis (8.1 vs 4.9). Interestingly, the two subcategories most prevalently increased were surgery and post‐partum haemorrhage‐associated bleeding (surgery: 2.1 vs 1.1; post‐partum haemorrhage: 0.7 vs 0.0). Laboratory screening results were more often abnormal in patients reaching final diagnosis compared to patients remaining without diagnosis and a high BAT score (n = 32 (78%) vs n = 14 (46%), 95% CI 1.5‐12), especially concerning the PFA (=27 (66%) vs n = 10 (33%), 95% CI 1.4‐10) and von Willebrand factor activity levels (n = 11 (27%) vs n = 1 (3%), 95% CI 1.3‐91). Conclusion Isolated high bleeding score on surgical or post‐partum bleeding correlates with a lower chance of receiving final diagnosis. Withholding extensive haemostatic testing should be considered. Better screening and confirmative haemostatic assays are still needed.
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Affiliation(s)
- Suzanne A M Zegers
- Department of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Yolba Smit
- Department of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joline L Saes
- Department of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands.,Haemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Clint van Duren
- Department of Laboratory Medicine, Laboratory of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tim J Schuijt
- Department of Laboratory Medicine, Laboratory of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Waander L van Heerde
- Department of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands.,Haemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Radboud University Medical Center, Nijmegen, The Netherlands.,Enzyre BV, Novio Tech Campus, Nijmegen, The Netherlands
| | - Saskia E M Schols
- Department of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands.,Haemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Radboud University Medical Center, Nijmegen, The Netherlands
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Doshi BS, Rogers RS, Whitworth HB, Stabnick EA, Britton J, Butler RB, Obstfeld AE, Witmer CM. Utility of repeat testing in the evaluation for von Willebrand disease in pediatric patients. J Thromb Haemost 2019; 17:1838-1847. [PMID: 31350816 DOI: 10.1111/jth.14591] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/23/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Von Willebrand disease (VWD) is the most common inherited bleeding disorder and is caused by quantitative and qualitative defects in von Willebrand factor (VWF). The laboratory diagnosis of VWD in pediatric patients is complicated by VWF interassay and intra-assay variability, stress-induced elevations in VWF levels, and a lack of significant bleeding history with which to correlate test results. OBJECTIVE Guidelines recommend repeat testing in patients with a high suspicion of VWD and unclear laboratory assay results; however, no studies have evaluated the utility of repeat VWF testing in pediatric patients. METHODS This retrospective single-center cohort study aimed to determine clinical variables associated with requiring more than one test to diagnose VWD and to establish a cutoff VWF value above which further testing is not informative. RESULTS Of 811 patients evaluated for a suspected bleeding disorder, 22.2% were diagnosed with VWD, with ~70% diagnosed on the first test. Patients with VWD were younger (5.8 vs. 8.5 years, P = .002) and more likely to have a family history of VWD (38% vs. 22%, P < .001) than those without VWD. Univariate analysis failed to identify any clinical variables that correlated with needing multiple tests for a VWD diagnosis. A cutoff of 100 IU/dL for VWF antigen or activity on the first test yielded negative predictive values >95%. CONCLUSIONS We demonstrate that the majority of pediatric patients had diagnostic VWF values on the first set of testing. Pediatric patients without a family history of VWD and VWF levels >100 IU/dL may not need further testing to rule out the diagnosis of VWD.
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Affiliation(s)
- Bhavya S Doshi
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel S Rogers
- Biostatistical and Data Management Core, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hilary B Whitworth
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Emily A Stabnick
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jessica Britton
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Regina B Butler
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Amrom E Obstfeld
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Char M Witmer
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania
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46
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Bello A, Salazar E, Heyne K, Varon J. Aortic Valve Replacement in Severe Factor V Deficiency and Inhibitor: Diagnostic and Management Challenges. Cureus 2019; 11:e5918. [PMID: 31788376 PMCID: PMC6857824 DOI: 10.7759/cureus.5918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Factor V (FV) deficiency (F5D) is a rare hematological disorder with a variable spectrum of bleeding manifestations. Until now, no specific protocols for the management of these patients have been established. However, available literature suggests that perioperative infusion of fresh frozen plasma (FFP) may help maintain FV levels to prevent bleeding. We present the case of a 64-year-old man with previously undiagnosed severe FV deficiency and mild FV inhibitor, who underwent aortic valve replacement with no bleeding complications.
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Affiliation(s)
- Alexa Bello
- Research, Dorrington Medical Associates, Houston, USA
| | - Eric Salazar
- Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, USA
| | - Kirk Heyne
- Medical Oncology and Hematology, Houston Methodist Hospital, Houston, USA
| | - Joseph Varon
- Critical Care, United General Hospital, Houston, USA
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Ahmed S, Yadegari H, Naz A, Biswas A, Budde U, Saqlain N, Amanat S, Tariq S, Raziq F, Masood S, Pavlova A, Shamsi TS, Oldenburg J. Characterization of the mutation spectrum in a Pakistani cohort of type 3 von Willebrand disease. Haemophilia 2019; 25:1035-1044. [PMID: 31532876 DOI: 10.1111/hae.13841] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/23/2019] [Accepted: 08/05/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Type 3 von Willebrand disease (VWD), a severe autosomal recessive hereditary bleeding disorder, is described by the virtual absence of von Willebrand factor (VWF). In consanguineous populations, for example Pakistan, the disease is reported with a higher incidence rate than the worldwide prevalence. AIMS This study aims to characterize molecular pathology and clinical profile of type 3 VWD cohort of Pakistani origin. METHODS In total, 48 patients were enrolled in the current study. Initially, the index patients (IPs) were evaluated by a standardized questionnaire for recording bleeding manifestations and by performing conventional coagulation tests. The diagnosis of VWD type 3 was confirmed by VWF antigens less than 5 IU/dL. Direct sequencing of VWF gene (VWF) was carried out to identify causative gene variations. We evaluated the potential consequence of novel splice site and missense variations by predictive computational programs and in silico structural analysis. RESULTS VWF mutations were detected in 46 out of 48 IPs (95.8%), predominantly as homozygous variants. In total, twenty-nine different gene defects were characterized in this cohort from which 10 (34.5%) are novel. The majority of the mutations were null alleles (66%; including gene conversions, nonsense, splice site variations, small deletions and insertions), and 34% of them were missense substitutions. CONCLUSION Herein, we reported for the first time, the pattern of gene defects in Pakistani type 3 VWD cohort. We identified a wide heterogeneous mutation spectrum along with variability in the type of bleeding episodes.
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Affiliation(s)
- Shariq Ahmed
- National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, Pakistan
| | - Hamideh Yadegari
- Institute of Experimental Haematology and Transfusion Medicine, University Clinics Bonn, Bonn, Germany
| | - Arshi Naz
- National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, Pakistan
| | - Arijit Biswas
- Institute of Experimental Haematology and Transfusion Medicine, University Clinics Bonn, Bonn, Germany
| | - Ulrich Budde
- Hämostaseology, Medilys Laborgesellschaft mbH, Hamburg, Germany
| | | | - Samina Amanat
- Atomic Energy Commission Islamabad, Islamabad, Pakistan
| | | | - Fazle Raziq
- Hayatabad Medical Complex Peshawar, Peshawar, Pakistan
| | | | - Anna Pavlova
- Institute of Experimental Haematology and Transfusion Medicine, University Clinics Bonn, Bonn, Germany
| | - Tahir Sultan Shamsi
- National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, Pakistan
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinics Bonn, Bonn, Germany
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Fundamentals for a Systematic Approach to Mild and Moderate Inherited Bleeding Disorders: An EHA Consensus Report. Hemasphere 2019; 3:e286. [PMID: 31942541 PMCID: PMC6919472 DOI: 10.1097/hs9.0000000000000286] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/08/2019] [Accepted: 07/15/2019] [Indexed: 01/05/2023] Open
Abstract
Healthy subjects frequently report minor bleedings that are frequently ‘background noise’ of normality rather than a true disorder. Nevertheless, unexpected or unusual bleeding may be alarming. Thus, the distinction between normal and pathologic bleeding is critical. Understanding the underlying pathologic mechanism in patients with an excessive bleeding is essential for their counseling and treatment. Most of these patients with significant bleeding will result affected by non-severe inherited bleeding disorders (BD), collectively denominated mild or moderate BD for their relatively benign course. Unfortunately, practical recommendations for the management of these disorders are still lacking due to the current state of fragmented knowledge of pathophysiology and lack of a systematic diagnostic approach. To address this gap, an International Working Group (IWG) was established by the European Hematology Association (EHA) to develop consensus-based guidelines on these disorders. The IWG agreed that grouping these disorders by their clinical phenotype under the single category of mild-to-moderate bleeding disorders (MBD) reflects current clinical practice and will facilitate a systematic diagnostic approach. Based on standardized and harmonized definitions a conceptual unified framework is proposed to distinguish normal subjects from affected patients. The IWG proposes a provisional comprehensive patient-centered initial diagnostic approach that will result in classification of MBD into distinct clinical-pathological entities under the overarching principle of clinical utility for the individual patient. While we will present here a general overview of the global management of patients with MBD, this conceptual framework will be adopted and validated in the evidence-based, disease-specific guidelines under development by the IWG.
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Clinical and laboratory diagnosis of rare coagulation disorders (RCDs). Thromb Res 2019; 196:603-608. [PMID: 31515069 DOI: 10.1016/j.thromres.2019.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 12/17/2022]
Abstract
Rare coagulation disorders (RCDs) are a group of diseases due to coagulation factors deficiency leading to life-long bleeding diathesis. The diagnosis of RCDs is challenging due to the limited knowledge of these disorders and the large heterogeneity of their bleeding patterns. The clinical symptoms of RCDs are extremely diverse in terms of bleeding type, site, severity, age at onset, and duration. The strength of the association between clotting factor activity level in plasma and clinical symptoms is also variable within each RCD. The clinical evaluation of RCDs starts with a detailed collection of clinical history and has been facilitated by bleeding assessment tools, however their effectiveness in diagnosing RCDs requires further investigation. The following laboratory diagnosis of RCDs involves coagulation screening tests, including activated partial thromboplastin time, prothrombin time, and thrombin time. After ruling out the presence of an inhibitor by mixing studies, in case of abnormal results, the specific deficiency is identified by performing one-stage clotting assays using the specific factor-depleted plasmas as substrate. In fibrinogen and FXIII deficiencies coagulation screening tests are not informative, therefore additional tests are needed. Global assays have been developed and are thought to aid in patient management, however, they are not well standardized yet. In addition to outlining the principles of clinical and laboratory diagnosis, this review explores molecular basis of RCDs and laboratory techniques for genetic analysis, and discusses the importance and effectiveness of quality control programs to ensure standardized laboratory results.
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Hofer S, Ay C, Rejtö J, Wolberg AS, Haslacher H, Koder S, Pabinger I, Gebhart J. Thrombin-generating potential, plasma clot formation, and clot lysis are impaired in patients with bleeding of unknown cause. J Thromb Haemost 2019; 17:1478-1488. [PMID: 31177606 PMCID: PMC6851858 DOI: 10.1111/jth.14529] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/16/2019] [Accepted: 06/03/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND In a large proportion of patients with a mild to moderate bleeding tendency no diagnosis can be established (bleeding of unknown cause, BUC). OBJECTIVES To investigate possible dysfunctions in thrombin generation and plasma clot formation and lysis in patients with BUC from the Vienna Bleeding Biobank (VIBB). PATIENTS AND METHODS Thrombin generation and plasma clot properties of 382 BUC patients were compared to those of 100 healthy controls and 16 patients with factor VIII (FVIII) activity ≤50%. RESULTS Thrombin generation was significantly impaired in BUC patients compared to healthy controls, exhibiting a prolonged lag time and time to peak and decreased maximum thrombin generation, velocity index, and area under the curve (AUC). The assessment of clot formation and lysis in BUC patients revealed a lower clot formation rate (Vmax), resulting in a longer TTP, increased absorbance (ΔAbs), and a shorter clot lysis time (CLT) than in healthy controls. Comparing patients with FVIII activity ≤ 50% to those with BUC, parameters of thrombin generation and clot formation and lysis were either stronger or comparably impaired. Bleeding severity did not correlate with parameters of thrombin generation, clot formation, or clot lysis. CONCLUSION Patients with BUC have an impaired hemostatic capacity reflected by a lower thrombin-generation potential, a lower clot formation rate, increased clot turbidity, and shorter clot lysis time, which might contribute to their increased bleeding tendency. Assays monitoring these parameters can alert physicians of hemostatic impairment and should be considered in situations where traditional hemostatic lab tests fail to reveal the clinical bleeding tendency.
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Affiliation(s)
- Stefanie Hofer
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Cihan Ay
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Judit Rejtö
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory MedicineUniversity of North Carolina at Chapel HillChapel HillNorth Carolina
| | - Helmuth Haslacher
- Department of Laboratory MedicineMedical University of ViennaViennaAustria
| | - Silvia Koder
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Ingrid Pabinger
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Johanna Gebhart
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
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