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Gong AJ, Garg T, Khalil A, Gowda PC, Mathai SC, Rowan NR, Merlo CA, Weiss CR. Health-Related Quality of Life Outcome Measures in Individuals With Hereditary Hemorrhagic Telangiectasia: A Scoping Review. Am J Rhinol Allergy 2024; 38:60-76. [PMID: 37855028 DOI: 10.1177/19458924231207123] [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] [Indexed: 10/20/2023]
Abstract
BACKGROUND Studies evaluating health-related quality of life (HRQOL) in patients with hereditary hemorrhagic telangiectasia (HHT) have expanded rapidly in the past decade. These studies have evaluated QOL aspects ranging from the general QOL for patients living with HHT to intervention-specific outcomes. However, few tools have been fully validated across the spectrum of disease manifestations and interventions in HHT. OBJECTIVE In this scoping review, we aim to map the literature on HHT-QOL metrics, identify gaps, inform future QOL research, and facilitate future metric development. METHODS We analyzed articles in English that assessed at least 1 measure of general HRQOL, including physical health, mental health, social health, or intervention-specific QOL in patients with HHT. Searches across 2 bibliographic databases (PubMed and Scopus) yielded 186 articles after duplicates were removed. Sixty-three studies met eligibility criteria: 22 prospective studies (34.9%), 20 retrospective studies (31.7%), 12 cross-sectional studies (17.5%), 6 randomized controlled trials or secondary analyses of a randomized controlled trials (9.5%), 2 qualitative studies (3.2%), and 1 case-control study (1.6%). Two additional studies-1 prospective and 1 cross-sectional study-were identified at the October 2022 14th International HHT Conference and included, making a total of 65 studies. RESULTS The 65 eligible studies used 30 QOL instruments. Twenty studies characterized baseline HRQOL, and 45 studies evaluated QOL before and after treatment. Of those 45 studies, 37 evaluated HRQOL before and after therapies targeting epistaxis and nasal symptoms, 4 targeted therapies for liver arteriovenous malformations and high-output heart failure, 3 evaluated therapies for both epistaxis and gastrointestinal bleeding, and 1 evaluated treatment targeting gastrointestinal bleeding alone. CONCLUSIONS Comparison of results across studies remains challenging given the heterogeneity in outcomes measures. Further development of HHT-specific patient-reported outcomes instruments that capture the global illness experience of HHT is needed.
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Affiliation(s)
- Anna J Gong
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tushar Garg
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adham Khalil
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Prateek C Gowda
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephen C Mathai
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nicholas R Rowan
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christian A Merlo
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Clifford R Weiss
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Bonnici M, Orabi NA, Gannon M, Williams N, Stokes CM, Ramadan HH, Turner MT, Makary CA. Complications and Outcomes of Endovascular Embolization for Intractable Epistaxis: A Systematic Review and Meta-analysis. Ann Otol Rhinol Laryngol 2023; 132:1233-1248. [PMID: 36582148 DOI: 10.1177/00034894221143187] [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] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Endovascular embolization has emerged as an effective treatment for intractable epistaxis. This systematic review and meta-analysis aimed to calculate the rates of success, rebleeds, and complications and to identify the etiologies and complications of patients who undergo endovascular embolization. METHODS This systematic review and meta-analysis was conducted per the guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles were extracted from Scopus, PubMed, Web of Science, and Cochrane Central and were filtered by a systematic review process using Rayyan software. A random-effects model was used to quantify the rates success, rebleeds, and complications. RESULTS Forty-two studies were included, totaling 1660 patients. The pooled success rate was 89% (95% confidence interval [CI] 86%-92%) and the pooled rebleed rate was 19% (95% CI 16%-22%). The pooled minor complication rate was 18% (95% CI 11%-27%). The most common major complication was soft tissue necrosis followed by stroke. The most common minor complication was facial pain. No minor complications were reported to be permanent. Of the patients who failed initial embolization, 42% underwent repeat embolization and 34% underwent surgical arterial ligation. CONCLUSIONS Endovascular embolization is an effective treatment for intractable epistaxis. The decision to perform embolization should be carefully weighed given the rare but significant major complications.
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Affiliation(s)
| | - Norman A Orabi
- Department of Otolaryngology - Head and Neck Surgery, West Virginia University, Morgantown, WV, USA
| | - Michael Gannon
- School of Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Nathan Williams
- School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Cara M Stokes
- Department of Epidemiology and Biostatistics, School of Public Health, West Virginia University, Morgantown, WV, USA
| | - Hassan H Ramadan
- Department of Otolaryngology - Head and Neck Surgery, West Virginia University, Morgantown, WV, USA
| | - Meghan T Turner
- Department of Otolaryngology - Head and Neck Surgery, West Virginia University, Morgantown, WV, USA
| | - Chadi A Makary
- Department of Otolaryngology - Head and Neck Surgery, West Virginia University, Morgantown, WV, USA
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Matti E, Maiorano E, Nacu B, Luceri A, Sovardi F, Siragusa V, Ferrauto A, Spinozzi G, Olivieri C, Benazzo M, Pagella F. Silicone septal splint for recurrent epistaxis in HHT patients: experience of a national referral centre. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2023; 43:S28-S33. [PMID: 37698097 PMCID: PMC10159634 DOI: 10.14639/0392-100x-suppl.1-43-2023-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/02/2023] [Indexed: 09/13/2023]
Abstract
Objective To report our experience in the use of silicone septal splint for recurrent severe epistaxis in hereditary haemorrhagic telangiectasia patients (HHT). Methods This is a descriptive analysis carried out at the Otorhinolaryngology Department of Fondazione IRCCS Policlinico San Matteo in Pavia, a reference centre for the treatment and diagnosis of HHT. We retrospectively evaluated HHT patients who underwent silicone septal splint positioning after the endoscopic surgical treatment of epistaxis from 2000 to 2022. Results Of the 506 patients surgically treated in the period of analysis, 74 patients underwent silicone septal splint positioning and 37 were post-operatively interviewed. With a mean of 2.4 previous surgical treatments and a mean epistaxis severity of 7.38, the majority of patients presented with septal perforation (71.6%). On average, patients maintained the splint in place for 54.5 months, with a good tolerability and a significant reduction in epistaxis severity, need for blood transfusion and improvement of haemoglobin levels. Conclusions In HHT patients with recurrent severe epistaxis and with septal perforation, the placement of septal splints offers a useful additional strategy in the management of nosebleeds.
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Affiliation(s)
- Elina Matti
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Eugenia Maiorano
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Bogdan Nacu
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- University of Pavia, Pavia, Italy
| | - Andrea Luceri
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- University of Pavia, Pavia, Italy
| | - Fabio Sovardi
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Vera Siragusa
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- University of Pavia, Pavia, Italy
| | | | - Giuseppe Spinozzi
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carla Olivieri
- Molecular Medicine Department, General Biology and Medical Genetics Unit, University of Pavia, Pavia, Italy
| | - Marco Benazzo
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- University of Pavia, Pavia, Italy
| | - Fabio Pagella
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- University of Pavia, Pavia, Italy
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Le TTT, Martinent G, Dupuis-Girod S, Parrot A, Contis A, Riviere S, Chinet T, Grobost V, Espitia O, Dussardier-Gilbert B, Alric L, Armengol G, Maillard H, Leguy-Seguin V, Leroy S, Rondeau-Lutz M, Lavigne C, Mohamed S, Chaussavoine L, Magro P, Seguier J, Kerjouan M, Fourdrinoy S. Development and validation of a quality of life measurement scale specific to hereditary hemorrhagic telangiectasia: the QoL-HHT. Orphanet J Rare Dis 2022; 17:281. [PMID: 35854330 PMCID: PMC9295423 DOI: 10.1186/s13023-022-02426-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 06/30/2022] [Indexed: 12/01/2022] Open
Abstract
Background Hereditary hemorrhagic telangiectasia (HHT) disease is a rare genetic disorder with symptoms and complications that can significantly affect patients’ daily lives. To date, no scale has been validated to assess the specific symptoms of this disease on the quality of life (QOL) of HHT patients. This makes it difficult for clinicians to accurately measure the quality of life of patients with HHT. The present study aims to develop and validate a QOL measurement tool specific to HHT disease: the QOL questionnaire in HHT (QoL-HHT). Methods A quantitative, non-interventional, multi-center study involving HHT patients in twenty French HHT expert centers was conducted. A calibration sample of 415 HHT patients and a validation sample of 228 HHT patients voluntarily participated in the study. Data were analyzed using exploratory factor analysis (EFA), confirmatory factor analysis (CFA), Exploratory Structural Equation Modeling (ESEM) analyses, reliability analyses, and correlational analyses. Results The EFA, CFA and ESEM results allowed us to provide evidence of the factorial structure of a questionnaire composed of 24 items measuring 6 domains of QOL: Physical limitations, social relationships, concern about bleeding, relationship with the medical profession, experience of symptoms, and concern about the evolution of the disease. Cronbach’s alpha coefficients (> 0.70) demonstrated reliable internal consistency of all the QoL-HHT scores (dimensions). The results of the test–retest provided further evidence of the reliability of the QOL-HHT scores over time. Correlational analyses provided evidence for the convergent validity of the QoL-HHT scores. Conclusions We developed a simple and quick self-assessment tool to measure quality of life specific to HHT disease. This study demonstrated reliability and validity of our QoL-HHT scores. It is a very promising tool to evaluate the impact of HHT disease on all aspects of the quality of life of HHT patients in order to offer them individualized medico-psycho-social support. Trial registration: ClinicalTrials, NCT03695874. Registered 04 October 2018, https://www.clinicaltrials.gov/ct2/show/NCT03695874 Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02426-2.
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Affiliation(s)
- Thi Thao Truc Le
- Laboratoire de Psychologie sur les Dynamiques Relationnelles et Processus Identitaires (EA 7458), Université de Bourgogne-Franche-Comté, 3 Allée des Stades Universitaires, 21000, Dijon, France
| | - Guillaume Martinent
- Laboratoire sur les Vulnérabilités et l'Innovation dans le Sport (EA 7428), Université de Lyon, Université Claude Bernard Lyon 1, 27-29 bd du 11 Novembre 1918, 69622, Villeurbanne, France
| | - Sophie Dupuis-Girod
- Service de génétique clinique, Centre de Référence pour la Maladie de Rendu-Osler, Hospices Civils de Lyon, HFME Bâtiment A1, 59 bd Pinel, 69677, Bron Cedex, France
| | - Antoine Parrot
- Service de pneumologie, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4 rue de Chine, 75790, Paris Cedex 20, France
| | - Anne Contis
- Service de médecine interne, Hôpital Saint André, 1 rue Jean Burguet, 33000, Bordeaux, France
| | - Sophie Riviere
- Service de médecine interne, CHU de Montpellier Hôpital St Eloi, Avenue A. Fliche, 34295, Montpellier Cedex 5, France
| | - Thierry Chinet
- Consultation Maladie de Rendu-Osler, CHU Ambroise Paré, 9 av Charles de Gaulle, 92104, Boulogne Billancourt, France
| | - Vincent Grobost
- Service de médecine interne, CHU Estaing, 1 rue Lucie et Raymond Aubrac, 63100, Clermont-Ferrand, France
| | - Olivier Espitia
- Service de médecine interne - médecine vasculaire, CHU de Nantes, 1 place Alexis Ricordeau, 44093, Nantes, France
| | | | - Laurent Alric
- Service de médecine interne, CHU Rangueil, 1 av du Pr Jean Poulhès, 31059, Toulouse Cedex 9, France
| | - Guillaume Armengol
- Service de médecine interne, CHU de Rouen Ch. Nicolle, , 1 rue de Germont, 76031, Rouen Cedex, France
| | - Hélène Maillard
- Service de médecine interne, Hôpital Huriez, 1 rue Michel Polonovski, 59037, LILLE Cedex, France
| | - Vanessa Leguy-Seguin
- Service de médecine interne, Hôpital Le Bocage, 2 Bd Maréchal de Lattre de Tassigny, BP 77908, 21079, Dijon Cedex, France
| | - Sylvie Leroy
- Service de pneumologie, CHU de Nice, 30 av de la Voie Romaine, 06002, Nice Cedex, France
| | - Murielle Rondeau-Lutz
- Service de médecine interne, CHU de Strasbourg Nouvel Hôpital Civil, 1 place de l'Hôpital, 67000, Strasbourg, France
| | - Christian Lavigne
- Service de médecine interne, CHU d'Angers, 4 rue Larrey, 49933, Angers Cedex 09, France
| | - Shirine Mohamed
- Service de médecine interne, CHU de Nancy, Hôpital Brabois, Rue du Morvan, 54511, Vandoeuvre Les Nancy, France
| | - Laurent Chaussavoine
- Service de médecine vasculaire, CHU de Caen, Avenue de la Côte de Nacre, 14000, Caen, France
| | - Pascal Magro
- Service de pneumologie, CHRU de Tours Hôpital Bretonneau, 2 bd Tonnellé, 37044, Tours Cedex 9, France
| | - Julie Seguier
- Service de médecine interne, Hôpital de La Timone, 264 rue Saint Pierre, 13385, Marseille Cedex 05, France
| | - Mallorie Kerjouan
- Service de pneumologie, CHU de Rennes Hôpital Pontchaillou, 2 rue Henri Le Guilloux, 35033, Rennes Cedex 09, France
| | - Sylvie Fourdrinoy
- Service de génétique clinique, Centre de Référence pour la Maladie de Rendu-Osler, Hospices Civils de Lyon, HFME Bâtiment A1, 59 bd Pinel, 69677, Bron Cedex, France.
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Sadick H, Schäfer E, Weiss C, Rotter N, Müller C, Birk R, Sadick M, Häussler D. An in vitro study on the effect of bevacizumab on endothelial cell proliferation and VEGF concentration level in patients with hereditary hemorrhagic telangiectasia. Exp Ther Med 2022; 24:555. [PMID: 35978926 PMCID: PMC9366282 DOI: 10.3892/etm.2022.11493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/09/2022] [Indexed: 11/14/2022] Open
Abstract
Previous studies have demonstrated that vascular endothelial growth factor (VEGF) is upregulated in patients with hereditary hemorrhagic telangiectasia (HHT). The use of Bevacizumab as an anti-angiogenic treatment agent seems promising. The purpose of the present in vitro study was to determine the efficacy and potential toxicity levels of bevacizumab on cell proliferation and VEGF concentrations in endothelial cells of HHT patients. In this in vitro study, endothelial cells from patients with HHT and HUVECs (control) were incubated with different concentration levels of bevacizumab (2, 4, 6, 8 or 10 mg/ml). After 24, 48 or 72 h, the cell proliferation was assessed by Alamar Blue® Assay and the VEGF levels in the cell culture supernatants were measured by VEGF-ELISA. All endothelial cells incubated with bevacizumab showed an initial decrease in cell proliferation. Cell proliferation recovered within 72 h in cell cultures incubated with concentration levels of up to 4 mg/ml bevacizumab, whereas those incubated with higher concentration levels showed a continuous decline in cell proliferation. VEGF expression decreased after 24 h in cell cultures incubated with bevacizumab concentration levels of 2 and 4 mg/ml but increased again after 48 h. Cell cultures incubated with bevacizumab concentration levels of 10 mg/ml showed a constant decline in VEGF expression without any tendency for recovery. Translating these results into daily clinical practice, the present study suggests that the intranasal submucosal injection of bevacizumab in HHT patients should not exceed a concentration level of 4 mg/ml. Overall, higher bevacizumab concentration levels not only reduce VEGF expression but pose a higher risk of toxic effects on endothelial cells as they jeopardize cell proliferation.
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Affiliation(s)
- Haneen Sadick
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, D‑68135 Mannheim, Germany
| | - Elena Schäfer
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, D‑68135 Mannheim, Germany
| | - Christel Weiss
- Department of Medical Statistics, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, D‑68135 Mannheim, Germany
| | - Nicole Rotter
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, D‑68135 Mannheim, Germany
| | - Cornelia Müller
- Department of Otorhinolaryngology, University Hospital Marburg, Philipps‑Universität Marburg, D‑35043 Marburg, Germany
| | - Richard Birk
- Department of Otorhinolaryngology, University Hospital Marburg, Philipps‑Universität Marburg, D‑35043 Marburg, Germany
| | - Maliha Sadick
- Clinic for Radiology and Nuclear Medicine, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, D‑68135 Mannheim, Germany
| | - Daniel Häussler
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, D‑68135 Mannheim, Germany
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Hayama M, Maeda Y, Shikina T, Tatehara S, Inokuchi G, Hoag JB, Sato T, Obata S, Nakatani A, Amano Y, Hida E, Nibu KI, Inohara H. Validation of epistaxis severity score for hereditary hemorrhagic telangiectasia in Japan. Auris Nasus Larynx 2021; 49:415-420. [PMID: 34857410 DOI: 10.1016/j.anl.2021.11.005] [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: 09/21/2021] [Revised: 10/21/2021] [Accepted: 11/10/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study aimed to assess the health-related QoL (HR-QoL) of patients with hereditary hemorrhagic telangiectasia (HHT), with emphasis on the role/social aspects, and validate the Japanese version of the epistaxis severity score (ESS) in these patients. METHODS The Japanese version of the ESS was created through forward and reverse translation, and consultation with the original author. A validation analysis was performed by comparing ESS severity with the invasiveness of previous treatments for epistaxis and assessing the correlation between the ESS and HR-QoL. Medical history forms, ESS questionnaires, and the Medical Outcomes Study Short Form 36 (SF-36) were distributed to participants with HHT in August 2020. The relation between the ESS and summary scores of SF-36 was assessed by performing analysis of variance and Spearman's correlation. RESULTS In total, 73 participants were included in this study. The average ESS was 5.02; there were mild (32.9%), moderate (45.2%), and severe (21.9%) epistaxis groups. Patients with higher ESS received a significantly more invasive treatment (Fisher's exact test, p < 0.05). The ESS was also negatively correlated with the physical component score (PCS) (r = -0.489, p < 0.001). Comorbid liver and gastrointestinal arteriovenous malformations significantly reduced the PCS (p < 0.05). Multiple regression analysis revealed that the ESS was a significant variable (p < 0.01). The role/social component score was significantly lower in the severe ESS group than in the mild or moderate group. CONCLUSION The Japanese version of the ESS was considered valid and may be useful as an outcome measure of future HHT-associated epistaxis trials in Japan.
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Affiliation(s)
- Masaki Hayama
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita city, Osaka, Japan.
| | - Yohei Maeda
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita city, Osaka, Japan
| | | | - Shun Tatehara
- Department of Otolaryngology - Head and Neck Surgery, Kobe University Graduate School of Medicine, Kobe city, Hyogo, Japan
| | - Go Inokuchi
- Department of Otolaryngology - Head and Neck Surgery, Kobe University Graduate School of Medicine, Kobe city, Hyogo, Japan
| | - Jeffrey B Hoag
- Department of Pulmonary, Allergy and Critical Care Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Tomoharu Sato
- Department of Biostatistics and Data Science, Osaka University Graduate School of Medicine, Suita city, Osaka, Japan
| | - Sho Obata
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita city, Osaka, Japan
| | - Ayaka Nakatani
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita city, Osaka, Japan
| | - Yuta Amano
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita city, Osaka, Japan
| | - Eisuke Hida
- Department of Biostatistics and Data Science, Osaka University Graduate School of Medicine, Suita city, Osaka, Japan
| | - Ken-Ichi Nibu
- Department of Otolaryngology - Head and Neck Surgery, Kobe University Graduate School of Medicine, Kobe city, Hyogo, Japan
| | - Hidenori Inohara
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita city, Osaka, Japan
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Pagella F, Maiorano E, Ugolini S, Lizzio R, Sovardi F, Mirabella R, Nanfitò L, Tinelli C, De Silvestri A, Olivieri C, Spinozzi G, Matti E. Epidemiological, clinical and endoscopic features of epistaxis severity and quality of life in Hereditary haemorrhagic telangiectasia: a cross-sectional study. Rhinology 2021; 59:577-584. [PMID: 34726201 DOI: 10.4193/rhin21.286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Epistaxis is the main complaint in patients with Hereditary haemorrhagic telangiectasia (HHT). Even though the role of epistaxis in affecting the quality of life (QoL) is well-known, little is known about epidemiological and clinical factors contributing to epistaxis severity and QoL. METHODOLOGY This is a cross-sectional study, including adult patients with HHT with epistaxis. All patients underwent an otolaryngological evaluation with nasal endoscopy. Epistaxis severity was graded using the FID score, and QoL was evaluated with the Short-Form Health Survey (SF-36). Descriptive statistics were produced for demographic characteristics; the Shapiro-Wilk test was used to test the normal distribution of quantitative variables. Correlation between the quantitative variables was evaluated with Pearson's correlation coefficient. Both univariate and multivariate linear regression models were fitted to find associations between demographic or clinical factors and the FID score or SF-36. RESULTS A total of 234 patients with HHT were included in the study. The univariate analysis highlighted the association between high blood pressure, septal perforation, nocturnal epistaxis, surgery, blood transfusion, hormonal therapy and both FID score and QoL. Sex, allergic rhinitis and nasal polyposis were neither related to epistaxis severity nor perceived health. CONCLUSIONS Epistaxis severity and QoL in patients with HHT are influenced by several clinical factors both dependent and independent from HHT. Some of the results are consistent with those already published, but for the first time, we extended the analysis to different clinical parameters, such as endoscopic findings, never assessed before.
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Affiliation(s)
- F Pagella
- Department of Otorhinolaryngology, University of Pavia, Pavia, Italy.,Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - E Maiorano
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - S Ugolini
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - R Lizzio
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - F Sovardi
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - R Mirabella
- Department of Otorhinolaryngology, University of Pavia, Pavia, Italy.,Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - L Nanfitò
- Department of Otorhinolaryngology, University of Pavia, Pavia, Italy.,Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - C Tinelli
- Clinical Epidemiology and Biometry Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - A De Silvestri
- Clinical Epidemiology and Biometry Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - C Olivieri
- Molecular Medicine Department, General Biology and Medical Genetics Unit, University of Pavia, Italy
| | - G Spinozzi
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - E Matti
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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8
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Crouch-Smith HA, Fenn KJ, Williams SP. Epistaxis in people with hereditary haemorrhagic telangiectasia: surgical management and psychological impact. Br J Hosp Med (Lond) 2021; 82:1-10. [PMID: 34817260 DOI: 10.12968/hmed.2020.0688] [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: 11/11/2022]
Abstract
From the emergency management of acute epistaxis to the surgical procedures for chronic epistaxis, this article covers the options available to control the archetypal symptom of hereditary haemorrhagic telangiectasia while exploring the psychological effect such a disease has on the patient.
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Affiliation(s)
| | - K J Fenn
- Department of Clinical Health Psychology, Alder Hey Children's Hospital, Liverpool, UK
| | - S P Williams
- Otolaryngology Department, Arrowe Park Hospital, Wirral, UK
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9
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Beneficial Effects of Remote Medical Care for Patients with Hereditary Hemorrhagic Telangiectasia during the COVID-19 Pandemic. J Clin Med 2021; 10:jcm10112311. [PMID: 34070664 PMCID: PMC8199008 DOI: 10.3390/jcm10112311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/13/2021] [Accepted: 05/17/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Hereditary hemorrhagic telangiectasia (HHT) needs high-quality care and multidisciplinary management. During the COVID-19 pandemic, most non-urgent clinical activities for HHT outpatients were suspended. We conducted an analytical observational cohort study to evaluate whether medical and psychological support, provided through remote consultation during the COVID-19 pandemic, could reduce the complications of HHT. Methods: A structured regimen of remote consultations, conducted by either video-calls, telephone calls, or e-mails, was provided by a multidisciplinary group of physicians to a set of patients of our HHT center. The outcomes considered were: number of emergency room visits/hospitalizations, need of blood transfusions, need of iron supplementation, worsening of epistaxis, and psychological status. Results: The study included 45 patients who received remote assistance for a total of eight months. During this period, 9 patients required emergency room visits, 6 needed blood transfusions, and 24 needed iron supplementation. This was not different from what was registered among the same 45 patients in the same period of the previous year. Remote care also resulted in better management of epistaxis and improved quality of life, with the mean epistaxis severity score and the Euro-Quality of Life-Visual Analogue Scale that were significantly better at the end than at the beginning of the study. Discussion: Remote medical care might be a valid support for HHT subjects during periods of suspended outpatient surveillance, like the COVID-19 pandemic.
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Mei-Zahav M, Gendler Y, Bruckheimer E, Prais D, Birk E, Watad M, Goldschmidt N, Soudry E. Topical Propranolol Improves Epistaxis Control in Hereditary Hemorrhagic Telangiectasia (HHT): A Randomized Double-Blind Placebo-Controlled Trial. J Clin Med 2020; 9:jcm9103130. [PMID: 32998220 PMCID: PMC7601781 DOI: 10.3390/jcm9103130] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/18/2020] [Accepted: 09/26/2020] [Indexed: 02/07/2023] Open
Abstract
Epistaxis is a common debilitating manifestation in hereditary hemorrhagic telangiectasia (HHT), due to mucocutaneous telangiectases. The epistaxis can be difficult to control despite available treatments. Dysregulated angiogenesis has been shown to be associated with telangiectases formation. Topical propranolol has demonstrated antiangiogenic properties. We performed a two-phase study, i.e., a double-blind placebo-controlled phase, followed by an open-label phase. The aim of the study was assessment of safety and efficacy of nasal propranolol gel in HHT-related epistaxis. Twenty participants with moderate-severe HHT-related epistaxis were randomized to eight weeks of propranolol gel 1.5%, or placebo 0.5 cc, applied to each nostril twice daily; and continued propranolol for eight weeks in an open-label study. For the propranolol group, the epistaxis severity score (ESS) improved significantly (-2.03 ± 1.7 as compared with -0.35 ± 0.68 for the placebo group, p = 0.009); hemoglobin levels improved significantly (10.5 ± 2.6 to 11.4 ± 2.02 g/dL, p = 0.009); and intravenous iron and blood transfusion requirement decreased. The change in nasal endoscopy findings was not significant. During the open-label period, the ESS score improved significantly in the former placebo group (-1.99 ± 1.41, p = 0.005). The most common adverse event was nasal mucosa burning sensation. No cardiovascular events were reported. Our results suggest that topical propranolol gel is safe and effective in HHT-related epistaxis.
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Affiliation(s)
- Meir Mei-Zahav
- Pulmonary Institute, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel; (Y.G.); (D.P.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (E.B.); (E.B.); (M.W.); (E.S.)
- The National HHT Center, Pulmonary Institute, Schneider CMCI, 14 Kaplan St., Petach Tikva 49202, Israel
- Correspondence:
| | - Yulia Gendler
- Pulmonary Institute, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel; (Y.G.); (D.P.)
- The Department of Nursing, Ariel University, Ariel 40700, Israel
| | - Elchanan Bruckheimer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (E.B.); (E.B.); (M.W.); (E.S.)
- Cardiology Department, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
| | - Dario Prais
- Pulmonary Institute, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel; (Y.G.); (D.P.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (E.B.); (E.B.); (M.W.); (E.S.)
- The National HHT Center, Pulmonary Institute, Schneider CMCI, 14 Kaplan St., Petach Tikva 49202, Israel
| | - Einat Birk
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (E.B.); (E.B.); (M.W.); (E.S.)
- Cardiology Department, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
| | - Muhamad Watad
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (E.B.); (E.B.); (M.W.); (E.S.)
| | - Neta Goldschmidt
- Department of Hematology, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel;
| | - Ethan Soudry
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (E.B.); (E.B.); (M.W.); (E.S.)
- Department of Otolaryngology Head and Neck Surgery, Rabin Medical Center, Petah Tikva 49202, Israel
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Beckman JD, Li Q, Hester ST, Leitner O, Smith KL, Kasthuri RS. Integration of clinical parameters, genotype and epistaxis severity score to guide treatment for hereditary hemorrhagic telangiectasia associated bleeding. Orphanet J Rare Dis 2020; 15:185. [PMID: 32660636 PMCID: PMC7359017 DOI: 10.1186/s13023-020-01453-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 06/29/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Hereditary Hemorrhagic Telangiectasia (HHT) is a rare inherited disorder characterized by development of mucocutaneous telangiectases and visceral organ arteriovenous malformations, which can lead to recurrent, spontaneous bleeding and development of iron deficiency anemia. The primary objective of this study was to ascertain the relationship between epistaxis severity scores (ESS), laboratory values, genotype, and phenotype in HHT. Our secondary objective was to assess efficacy of systemic antifibrinolytic therapy in reducing ESS in HHT. METHODOLOGY We conducted a retrospective review of patients seen at the UNC HHT Center from January 1, 2009 to February 28, 2015. ESS, demographics, and results of genetic testing were abstracted from the medical record. Response to antifibrinolytic therapy was evaluated by comparing pre-post ESS. RESULTS One hundred and forty nine patients were eligible with 116 having genetic testing and 33 without. Age, hemoglobin and ferritin levels were predictive of ESS. Of the 116 patients that underwent genetic testing: 63 had an ACVRL1 mutation, 40 had an ENG mutation, 2 had a SMAD4 mutation, and 11 patients had no pathologic HHT genetic variation detected. Compared to patients without a detectable HHT-associated genetic variation, patients with a HHT-associated genetic variation had higher ESS scores (p < 0.05). Neither ESS nor genotype was predictive of pulmonary or brain AVMs. Twenty-four HHT patients with ESS > 4 were started on antifibrinolytic therapy (tranexamic acid or aminocaproic acid) and had a post-treatment ESS recorded. All patients had a decrease in ESS of > 0.71 (minimal meaningful difference), but patients taking antifibrinolytics displayed larger decreases. No patients on antifibrinolytics experienced a VTE with median follow up of 13 months. CONCLUSIONS We demonstrate that the ESS correlates with age, hemoglobin and ferritin. Additionally, we demonstrate that HHT patients with genetic mutations have higher ESS scores. Our data demonstrate that antifibrinolytics are effective in decreasing epistaxis severity and safe with long-term use in HHT patients.
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Affiliation(s)
- Joan D Beckman
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Quefeng Li
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Samuel T Hester
- Department of Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ofri Leitner
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Karen L Smith
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, CB#7035, 8206B Mary Ellen Jones Bldg, 116 Manning Drive, Chapel Hill, NC, 27599, USA
| | - Raj S Kasthuri
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, CB#7035, 8206B Mary Ellen Jones Bldg, 116 Manning Drive, Chapel Hill, NC, 27599, USA.
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Khoueir N, Borsik M, Camous D, Herman P, Verillaud B. Injection of bevacizumab and cyanoacrylate glue for hereditary hemorrhagic telangiectasia. Laryngoscope 2019; 129:2210-2215. [PMID: 31566760 DOI: 10.1002/lary.27889] [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: 07/02/2018] [Revised: 11/27/2018] [Accepted: 12/03/2018] [Indexed: 11/12/2022]
Abstract
OBJECTIVES/HYPOTHESIS The objective of this study was to report for the first time on the results of submucosal injections of bevacizumab used in conjunction with cyanoacrylate glue sclerotherapy in hereditary hemorrhagic telangiectasia (HHT). STUDY DESIGN Retrospective analytic chart review. METHODS We performed a chart review that included all patients with HHT treated with intranasal bevacizumab and cyanoacrylate glue for refractory epistaxis at Lariboisiere University Hospital from 2013 with a minimum follow-up of 6 months. We injected 100 mg (25 mg/mL) of bevacizumab diluted in 2 mL of serum at the base of the telangiectasias, and sclerotherapy with an injection of cyanoacrylate glue was used adjunctively. Treatment efficacy was based on changes in Epistaxis Severity Scores (ESS) and the Bergler-Sadick Scale. Quality of life and patient satisfaction were evaluated using the Cantril Self-Anchoring Ladder (CL) and Likert scale, respectively. RESULTS Thirty-one patients were included, with a mean follow-up of 26.6 months. The average ESS score significantly decreased from 7.82 to 3.89 (P < .05). The Bergler-Sadick score significantly improved (P < .05) following the treatment, including the frequency (from 2.74 to 1.64) and the quantity (from 2.54 to 1.51) scales. Quality of life was significantly improved (P < .05) using the CL score (from 4.16 to 7.22). The Likert satisfaction scale related to the treatment efficacy was high, with an average of 7.03 out of 10. No complications were noted. CONCLUSIONS Submucosal injections of bevacizumab in conjunction with cyanoacrylate glue sclerotherapy significantly reduced epistaxis and improved the quality of life in HHT. Prospective comparative studies are needed to further evaluate the significance of this treatment modality. LEVEL OF EVIDENCE 3b Laryngoscope, 129:2210-2215, 2019.
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Affiliation(s)
- Nadim Khoueir
- Department of Otolaryngology-Head and Neck Surgery/Skull Base Surgery, Hospital Groups Saint Louis, Lariboisière, Fernand-Widal, Public Assistance Paris Hospitals, Paris-Diderot University, Paris, France.,Department of Otolaryngology-Head and Neck Surgery, Hotel Dieu de France University Hospital, Saint Joseph University, Faculty of Medicine, Beirut, Lebanon
| | - Michel Borsik
- Department of Otolaryngology-Head and Neck Surgery/Skull Base Surgery, Hospital Groups Saint Louis, Lariboisière, Fernand-Widal, Public Assistance Paris Hospitals, Paris-Diderot University, Paris, France
| | - Domitille Camous
- Department of Otolaryngology-Head and Neck Surgery/Skull Base Surgery, Hospital Groups Saint Louis, Lariboisière, Fernand-Widal, Public Assistance Paris Hospitals, Paris-Diderot University, Paris, France
| | - Philippe Herman
- Department of Otolaryngology-Head and Neck Surgery/Skull Base Surgery, Hospital Groups Saint Louis, Lariboisière, Fernand-Widal, Public Assistance Paris Hospitals, Paris-Diderot University, Paris, France
| | - Benjamin Verillaud
- Department of Otolaryngology-Head and Neck Surgery/Skull Base Surgery, Hospital Groups Saint Louis, Lariboisière, Fernand-Widal, Public Assistance Paris Hospitals, Paris-Diderot University, Paris, France
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Abiri A, Goshtasbi K, Maducdoc M, Sahyouni R, Wang MB, Kuan EC. Laser-Assisted Control of Epistaxis in Hereditary Hemorrhagic Telangiectasia: A Systematic Review. Lasers Surg Med 2019; 52:293-300. [PMID: 31441079 DOI: 10.1002/lsm.23147] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease, causes recurrent mucous membrane hemorrhage, especially epistaxis. In this systematic review, we discuss the efficacies of the three most common laser photocoagulation treatments for HHT-related epistaxis. STUDY DESIGN/MATERIALS AND METHODS A systematic literature search was conducted in PubMed and MEDLINE from database inception to March 2019. Studies reporting epistaxis outcomes following argon, neodymium-doped yttrium aluminum garnet (Nd:YAG), and diode laser photocoagulation for HHT were included. χ2 and Barnard's exact tests were utilized to detect differences in reduced epistaxis frequency and intensity rates. RESULTS Fifteen out of 157 published studies met our eligibility criteria, spanning a collective 362 patients. Argon, Nd:YAG, and diode laser therapy reduced epistaxis frequency in 90.4%, 88.9%, and 71.1% of patients, respectively, and reduced epistaxis intensity in 87.8%, 87.2%, and 71.1% of patients, respectively. Diode laser photocoagulation significantly underperformed in both outcome measurements when compared with argon (frequency: P = 0.005; intensity: P = 0.034) and Nd:YAG (frequency: P = 0.012; intensity: P = 0.041). There was no significant difference between argon and Nd:YAG in reducing HHT epistaxis frequency (P = 0.434) or intensity (P = 0.969). Categorizing HHT patients by clinical severity demonstrated a higher rate of improvement in the mild-moderate group compared with the severe group in both argon (P < 0.001) and Nd:YAG (P < 0.001) therapeutic methods. While no significant differences were found in rates of improved epistaxis outcomes between argon and Nd:YAG in mild-moderate HHT patients (frequency: P = 0.061; intensity: P = 0.061), Nd:YAG demonstrated greater rates of reduction in epistaxis frequency (P = 0.040) and intensity (P = 0.028) than argon among severe HHT patients. CONCLUSIONS HHT is a lifelong disease, plaguing patients with debilitating epistaxis. Intranasal laser photocoagulation of telangiectasias using argon or Nd:YAG laser therapy can yield improved epistaxis outcomes compared with diode laser photocoagulation. In severe cases of HHT, Nd:YAG laser therapy provides greater improvements in epistaxis outcomes than argon photocoagulation. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Arash Abiri
- University of Irvine School of Medicine, University of California, 1001 Health Sciences Rd, Irvine, CA, 92617
| | - Khodayar Goshtasbi
- University of Irvine School of Medicine, University of California, 1001 Health Sciences Rd, Irvine, CA, 92617
| | - Marlon Maducdoc
- Department of Otolaryngology-Head and Neck Surgery, University of California, 101 The City Dr. S., Bldg 56, Ste. 500, Orange, Irvine, CA, 92868
| | - Ronald Sahyouni
- University of Irvine School of Medicine, University of California, 1001 Health Sciences Rd, Irvine, CA, 92617
| | - Marilene B Wang
- Department of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles (UCLA), 10833 Le Conte Avenue, CHS 62-132, Los Angeles, CA, 90095-1624
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, 101 The City Dr. S., Bldg 56, Ste. 500, Orange, Irvine, CA, 92868
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Steineger J, Geirdal AØ, Osnes T, Heimdal KR, Dheyauldeen S. Intranasal bevacizumab injections improve quality of life in HHT patients. Laryngoscope 2019; 130:E284-E288. [DOI: 10.1002/lary.28179] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/15/2019] [Accepted: 06/19/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Johan Steineger
- Division of Head and Neck and Reconstructive Surgery, Department of Otorhinolaryngology, Head and Neck SurgeryOslo University Hospital Rikshospitalet Oslo Norway
- Institute of Clinical MedicineUniversity of Oslo Norway
| | | | - Terje Osnes
- Division of Head and Neck and Reconstructive Surgery, Department of Otorhinolaryngology, Head and Neck SurgeryOslo University Hospital Rikshospitalet Oslo Norway
- Institute of Clinical MedicineUniversity of Oslo Norway
| | | | - Sinan Dheyauldeen
- Division of Head and Neck and Reconstructive Surgery, Department of Otorhinolaryngology, Head and Neck SurgeryOslo University Hospital Rikshospitalet Oslo Norway
- Institute of Clinical MedicineUniversity of Oslo Norway
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Clark M, Berry P, Martin S, Harris N, Sprecher D, Olitsky S, Hoag JB. Nosebleeds in hereditary hemorrhagic telangiectasia: Development of a patient-completed daily eDiary. Laryngoscope Investig Otolaryngol 2018; 3:439-445. [PMID: 30599027 PMCID: PMC6302722 DOI: 10.1002/lio2.211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2018] [Indexed: 11/29/2022] Open
Abstract
Objective A prospective, qualitative study was conducted to develop a patient‐reported outcome measure (PROM) for daily administration via electronic diary (eDiary) to assess the severity of nosebleeds in patients with hereditary hemorrhagic telangiectasia (HHT), in accordance with Food and Drug Administration (FDA) PROM guidance criteria. Methods Three expert clinicians who treat patients with HHT provided input during instrument development, which comprised: 1) Peer‐reviewed literature and instrument review; 2) Development of draft Nosebleed Diary items; 3a) Three rounds of qualitative interviews (two with a paper‐based diary, one with an eDiary) with patients with documented severe epistaxis related to HHT, for concept elicitation and cognitive debriefing; 3b) Face validity and translatability assessment; 3c) Patient evaluation of the usability and acceptability of the eDiary device; and 4) Preparation of the final Nosebleed eDiary and conceptual framework. Results No existing instruments were identified that evaluate HHT‐related nosebleed severity daily and meet FDA PROM guidance criteria. Frequency, duration, and/or speed of flow (i.e., intensity) were reported by most participants with HHT when asked to describe their nosebleed severity. The Nosebleed eDiary was refined based on 17 patient interviews, clinical expert input and the face validity and translatability assessment. The final four‐item eDiary was acceptable to patients with HHT. Conclusion The Nosebleed eDiary is “fit for purpose” to assess the severity of HHT‐related nosebleeds, and has established face and content validity. Further adaptation may be required for use in mild or moderate HHT populations. Psychometric testing to evaluate construct validity and reliability are recommended next steps. Level of Evidence 2c “Outcomes research”
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Affiliation(s)
- Marci Clark
- RTI Health Solutions Ann Arbor Michigan U.S.A
| | - Pamela Berry
- GlaxoSmithKline King of Prussia Pennsylvania U.S.A
| | | | | | | | - Scott Olitsky
- Department of Ophthalmology Kansas City School of Medicine/University of Missouri Kansas City Missouri U.S.A
| | - Jeffrey B Hoag
- Division of Pulmonary & Critical Care Cancer Treatment Centers of America Philadelphia Pennsylvania U.S.A
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Halderman AA, Ryan MW, Marple BF, Sindwani R, Reh DD, Poetker DM. Bevacizumab for Epistaxis in Hereditary Hemorrhagic Telangiectasia: An Evidence-based Review. Am J Rhinol Allergy 2018; 32:258-268. [DOI: 10.1177/1945892418768588] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Objective Epistaxis is a primary complaint in 90% to 96% of patients with hereditary hemorrhagic telangiectasia (HHT). Numerous surgical and medical treatments aim to decrease the frequency and severity of epistaxis in this patient population. Bevacizumab is a recombinant, humanized monoclonal antibody to vascular endothelial growth factor, an angiogenic factor elevated in HHT. It has been used in several forms to treat epistaxis in HHT but thus far, evidence-based recommendations are limited. Study Design Systematic review with evidence-based recommendations. Methods A systematic review of the literature following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed using Embase, MEDLINE, MEDLINE In-Process/Epub, and Cochrane databases. English language abstracts were reviewed for relevance. Results Eleven manuscripts met inclusion criteria and were analyzed. Submucosal injection, submucosal injection plus laser coagulation, intravenous (IV), and topical formulations of bevacizumab were evaluated for their therapeutic impact on epistaxis in patients with HHT. Three randomized controlled trials failed to show topical bevacizumab to be more effective in controlling epistaxis than saline or other moisturizers. Conclusions The use of submucosal and IV bevacizumab shows promise, but further study is necessary to determine the true efficacy in the treatment of epistaxis as only grade C level exists currently. Based on the available literature, the use of topical bevacizumab is not recommended (grade B).
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Affiliation(s)
- Ashleigh A. Halderman
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern, Dallas, Texas
| | - Matthew W. Ryan
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern, Dallas, Texas
| | - Bradley F. Marple
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern, Dallas, Texas
| | - Raj Sindwani
- Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Douglas D. Reh
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - David M. Poetker
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin
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Thomson RS, Molin NL, Whitehead KJ, Ashby S, Johnson L, Ward PD, McRae BR, Wilson KF, McDonald J. The effects of nasal closure on quality of life in patients with hereditary hemorrhagic telangiectasia. Laryngoscope Investig Otolaryngol 2018; 3:178-181. [PMID: 30062132 PMCID: PMC6057218 DOI: 10.1002/lio2.157] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 03/08/2018] [Accepted: 03/12/2018] [Indexed: 11/07/2022] Open
Abstract
Introduction Epistaxis is the most common symptom of hereditary hemorrhagic telangiectasia (HHT). Complete nasal closure is one of the treatment options for patients with severe, intractable epistaxis. In our experience, this surgery can be life changing in a positive sense; but many patients as well as their physicians understandably fear that such a procedure will diminish certain aspects of quality of life (QOL). Methods Case-control study of HHT patients treated at the University of Utah HHT Center of Excellence with and without nasal closure from January 2005 to January 2016. Patients were matched according to epistaxis severity. Each included patient was issued three surveys: Epistaxis Severity Score (ESS), the Pittsburg Sleep Quality Index (PSQI), and the Nasal Obstruction Symptom Evaluation (NOSE). Results After treatment, the mean PSQI and NOSE scores were not significantly different between the two groups. However, the mean ESS score in the nasal closure group was significantly lower at 1.10 compared to the severe epistaxis group with a mean score of 3.99 (P = .027). Conclusion The results of this study demonstrate that nasal closure significantly improves epistaxis severity without having a significant effect on sleep or nasal obstruction as they relate to QOL. These findings suggest that nasal closure should be considered for HHT patients with chronic severe epistaxis. Level of Evidence 4.
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Affiliation(s)
- Rhett S Thomson
- School of Medicine, University of Utah Salt Lake City Utah U.S.A
| | - Nicole L Molin
- School of Medicine, University of Utah Salt Lake City Utah U.S.A
| | - Kevin J Whitehead
- HHT Center for Excellence, University of Utah Salt Lake City Utah U.S.A
| | - Shaelene Ashby
- HHT Center for Excellence, University of Utah Salt Lake City Utah U.S.A
| | - Leland Johnson
- Division of Otolaryngology University of Utah Salt Lake City Utah U.S.A
| | - P Daniel Ward
- Division of Otolaryngology University of Utah Salt Lake City Utah U.S.A
| | - Bryan R McRae
- Division of Otolaryngology University of Utah Salt Lake City Utah U.S.A
| | - Kevin F Wilson
- Division of Otolaryngology University of Utah Salt Lake City Utah U.S.A
| | - Jamie McDonald
- HHT Center for Excellence, University of Utah Salt Lake City Utah U.S.A
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Halderman AA, Ryan MW, Clark C, Sindwani R, Reh DD, Poetker DM, Invernizzi R, Marple BF. Medical treatment of epistaxis in hereditary hemorrhagic telangiectasia: an evidence-based review. Int Forum Allergy Rhinol 2018; 8:713-728. [PMID: 29393992 DOI: 10.1002/alr.22094] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 01/02/2018] [Accepted: 01/10/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant hereditary disorder resulting in vascular dysplasia and formation of arteriovenous malformations. Recurrent epistaxis is a hallmark of the disease. An array of medical therapies are used in this patient population, but robust evidence-based recommendations regarding the medical treatment of epistaxis are lacking. This systematic review was performed to look at the current literature and make meaningful evidence-based recommendations. METHODS A search of the Ovid MEDLINE, Embase, and Cochrane databases was conducted by a research librarian. Abstracts in the English language and published in a peer-review journal were reviewed for relevance and inclusion. PRISMA guidelines were followed. RESULTS Eighteen studies met the inclusion criteria. In a few small studies, thalidomide was shown to consistently improve severity and frequency of epistaxis and improve hemoglobin concentrations while decreasing the need for transfusion. Tranexamic acid appeared to only impact the epistaxis severity score and not other clinical outcomes. Selective estrogen modulators (SERMs), propranolol, rose geranium oil, and N-acetylcysteine, have demonstrated promising efficacy in small trials. CONCLUSION Appropriate medical therapies for epistaxis outcomes in HHT remain undefined, and there is no "gold standard." Many of the studies are small and the data reported are heterogeneous, and therefore the ability to make strong evidence-based recommendations is limited. However, many different medications appear to be promising options.
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Affiliation(s)
- Ashleigh A Halderman
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern, Dallas, TX
| | - Matthew W Ryan
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern, Dallas, TX
| | - Christopher Clark
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern, Dallas, TX
| | - Raj Sindwani
- Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Douglas D Reh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - David M Poetker
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI
| | | | - Bradley F Marple
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern, Dallas, TX
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Frew JW, Davidson M, Murrell DF. Disease-specific health related quality of life patient reported outcome measures in Genodermatoses: a systematic review and critical evaluation. Orphanet J Rare Dis 2017; 12:189. [PMID: 29284525 PMCID: PMC5747090 DOI: 10.1186/s13023-017-0739-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 12/07/2017] [Indexed: 12/30/2022] Open
Abstract
Background Health Related Quality of Life (HR-QoL) Patient reported outcome measures (PROMs) have high utility in evaluation of new interventions in genodermatoses, however inconsistent standards of development and validation have hampered widespread acceptance and adoption. Objectives To identify all published HR-QoL PROMs in genodermatoses and critically evaluate their development and measurement properties. Methods This systematic review was registered with PROSPERO (CRD42016053301). Ovid Medline, Embase and PsycINFO databases were utilised for literature review using predefined inclusion and exclusion criteria. PROM development was assessed using the COSMIN Checklist and measurement properties were assessed against quality criteria for measurement properties of health standard questionnaires. Results 15 HRQoL PROMs in genodermatoses were identified. Major areas of deficiency in development were internal consistency, reliability and structural validity. No PROM satisfied measurement property standards for agreement, responsiveness or floor and ceiling effects. Four PROMs included Minimal Important Change scores for interpretability. Issues regarding the generalisability of the evaluated PROMs in culturally diverse and paediatric populations remain unresolved. Conclusions The overall standards of development and measurement properties in PROMs in genodermatoses is fair, despite no single instrument meeting all requirements. None are perfectly validated according to COSMIN criteria but seven of the fifteen PROMs may be appropriate pending further validation. The development of culturally appropriate and child-specific variants of PROMs should be a priority in order to increase the utility of patient based outcome measures in genodermatoses in various patient populations. Electronic supplementary material The online version of this article (10.1186/s13023-017-0739-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- John W Frew
- Department of Dermatology, Liverpool Hospital, Sydney, Australia. .,Faculty of Medicine, UNSW, Sydney, Australia.
| | | | - Dedee F Murrell
- Faculty of Medicine, UNSW, Sydney, Australia.,Department of Dermatology St George Hospital, Sydney, Australia
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Zarrabeitia R, Fariñas-Álvarez C, Santibáñez M, Señaris B, Fontalba A, Botella LM, Parra JA. Quality of life in patients with hereditary haemorrhagic telangiectasia (HHT). Health Qual Life Outcomes 2017; 15:19. [PMID: 28114930 PMCID: PMC5259834 DOI: 10.1186/s12955-017-0586-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 01/11/2017] [Indexed: 11/10/2022] Open
Abstract
Background There are very few studies about general quality of life parameters, standards for the description of health status and comparison with general population data on patients with Hereditary hemorrhagic telangiectasia (HHT), a rare disease in which epistaxis is a cardinal symptom. Purpose To assess the quality of life in a population of Spanish patients with HHT and compare it with the general population. Design and methods Between January 1st 2005 and December 31st 2013, 187 adult patients diagnosed with HHT who were admitted to the HHT Unit of the Hospital Sierrallana, completed on their first visit, the EuroQol 5D-3L (five dimensions and three levels) quality of life descriptive test and the visual analog scale (VAS). The numerical social index value was also determined and the subjective effect of the nasal epistaxis on their quality of life was estimated classified as mild, moderate or severe. Results Patients with HHT had greater problems than the general population in the five dimensions of the EuroQol 5D-3L, particularly considering pain/discomfort and anxiety/depression. In the VAS and the social index value, patients with HHT also scored lower than the general population, particularly older patients, males, and patients with HHT2. They also had values similar to those of populations with chronic illnesses. The subjective perception of the severity of epistaxis correlated strongly with the VAS and social index values. Conclusions The quality of life of patients with HHT, estimated using the EuroQol 5D-3L scale, is affected across all dimensions. The scores are similar to those seen in cases of other chronic diseases. Older patients, males and the carriers of the ACVRL1 mutation generally have worse scores on these scales. The VAS and the social index value are index that correlate well with the severity of the clinical symptoms associated mainly with epistaxis.
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Affiliation(s)
- Roberto Zarrabeitia
- Department of Internal Medicine (Hospital Sierrallana) and Centro de Investigación Biomédica en red de Enfermedades Raras (CIBERER) and Instituto de Investigación Valdecilla (IDIVAL), Torrelavega, Cantabria, Spain.
| | | | | | - Blanca Señaris
- ENT Department, Hospital Sierrallana, Torrelavega, Cantabria, Spain
| | - Ana Fontalba
- Department of Genetics, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Luisa María Botella
- Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas (CSIC) and Centro de Investigación Biomédica en red de Enfermedades Raras (CIBERER), Madrid, Spain
| | - José Antonio Parra
- Department of Radiology, Hospital Universitario Marqués de Valdecilla and Instituto de Investigación Valdecilla (IDIVAL), Santander, Spain
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Shovlin CL, Gilson C, Busbridge M, Patel D, Shi C, Dina R, Abdulla FN, Awan I. Can Iron Treatments Aggravate Epistaxis in Some Patients With Hereditary Hemorrhagic Telangiectasia? Laryngoscope 2016; 126:2468-2474. [PMID: 27107394 PMCID: PMC5095791 DOI: 10.1002/lary.25959] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 01/31/2016] [Accepted: 02/10/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVES/HYPOTHESIS To examine whether there is a rationale for iron treatments precipitating nosebleeds (epistaxis) in a subgroup of patients with hereditary hemorrhagic telangiectasia (HHT). STUDY DESIGN Survey evaluation of HHT patients, and a randomized control trial in healthy volunteers. METHODS Nosebleed severity in response to iron treatments and standard investigations were evaluated by unbiased surveys in patients with HHT. Serial blood samples from a randomized controlled trial of 18 healthy volunteers were used to examine responses to a single iron tablet (ferrous sulfate, 200 mg). RESULTS Iron tablet users were more likely to have daily nosebleeds than non-iron-users as adults, but there was no difference in the proportions reporting childhood or trauma-induced nosebleeds. Although iron and blood transfusions were commonly reported to improve nosebleeds, 35 of 732 (4.8%) iron tablet users, in addition to 17 of 261 (6.5%) iron infusion users, reported that their nosebleeds were exacerbated by the respective treatments. These rates were significantly higher than those reported for control investigations. Serum iron rose sharply in four of the volunteers ingesting ferrous sulfate (by 19.3-33.1 μmol/L in 2 hours), but not in 12 dietary controls (2-hour iron increment ranged from -2.2 to +5.0 μmol/L). High iron absorbers demonstrated greater increments in serum ferritin at 48 hours, but transient rises in circulating endothelial cells, an accepted marker of endothelial damage. CONCLUSIONS Iron supplementation is essential to treat or prevent iron deficiency, particularly in patients with pathological hemorrhagic iron losses. However, in a small subgroup of individuals, rapid changes in serum iron may provoke endothelial changes and hemorrhage. LEVEL OF EVIDENCE 4. Laryngoscope, 126:2468-2474, 2016.
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Affiliation(s)
- Claire L Shovlin
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom.
- Respiratory Medicine, Imperial College Healthcare National Health Service Trust, London, United Kingdom.
| | - Clare Gilson
- Respiratory Medicine, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Mark Busbridge
- Clinical Chemistry, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Dilip Patel
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Chenyang Shi
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Roberto Dina
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - F Naziya Abdulla
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College London School of Medicine, London, United Kingdom
| | - Iman Awan
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College London School of Medicine, London, United Kingdom
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22
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The Subjective Experience of Patients Diagnosed with Hereditary Hemorrhagic Telangiectasia: a Qualitative Study. J Genet Couns 2016; 26:612-619. [DOI: 10.1007/s10897-016-0033-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 10/07/2016] [Indexed: 02/02/2023]
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Chamali B, Finnamore H, Manning R, Laffan MA, Hickson M, Whelan K, Shovlin CL. Dietary supplement use and nosebleeds in hereditary haemorrhagic telangiectasia - an observational study. Intractable Rare Dis Res 2016; 5:109-13. [PMID: 27195194 PMCID: PMC4869576 DOI: 10.5582/irdr.2016.01019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 04/05/2016] [Accepted: 04/07/2016] [Indexed: 12/18/2022] Open
Abstract
Understanding potential provocations of haemorrhage is important in a range of clinical settings, and particularly for people with abnormal vasculature. Patients with hereditary haemorrhagic telangiectasia (HHT) can report haemorrhage from nasal telangiectasia in real time, and suggested dietary factors may precipitate nosebleeds. To examine further, nosebleed severity, dietary supplement use, and blood indices were evaluated in an unselected group of 50 HHT patients recruited from a specialist UK service. Using the validated Epistaxis Severity Score, nosebleed severity ranged from 0 to 9.1 out of 10 (median 3.9). Using a Food Frequency Questionnaire, 24/50 (48%) participants reported use of dietary supplements in the previous year. A third (18/50; 36%) had used self prescribed, non-iron containing dietary supplements, ingesting between 1 and 3 different supplements each day. Eight (16%) used fish oils. Despite having more severe epistaxis (p = 0.012), the 12 iron supplement users had higher serum iron concentrations, and were able to maintain their red blood cell indices. In contrast, there was no evident benefit for the participants using non iron supplements. Furthermore, platelet counts and serum fibrinogen tended to be lower in fish oil/supplement users, and one fish oil user demonstrated reduced in vitro platelet aggregation. In conclusion, in this small study, a third of HHT patients used non-iron dietary supplements, and one in six ingested fish oils, unaware of their known anti-platelet activity. The scale of use, and potential of these "natural health supplements" to exacerbate nosebleeds has not been appreciated previously in HHT.
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Affiliation(s)
- Basel Chamali
- National Heart and Lung Institute Cardiovascular Sciences, Imperial College London, UK
- Imperial College School of Medicine, Imperial College London, UK
| | - Helen Finnamore
- National Heart and Lung Institute Cardiovascular Sciences, Imperial College London, UK
- Diabetes and Nutritional Sciences Division, King's College London, UK
| | - Richard Manning
- Haematology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Michael A Laffan
- Haematology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
- Centre for Haematology, Imperial College London, UK
| | - Mary Hickson
- Nutrition and Dietetics, Imperial College Healthcare NHS Trust, London, UK (Current address: School of Health Professions, Plymouth University, Plymouth, UK)
| | - Kevin Whelan
- Diabetes and Nutritional Sciences Division, King's College London, UK
| | - Claire L Shovlin
- National Heart and Lung Institute Cardiovascular Sciences, Imperial College London, UK
- HHTIC London, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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Ramakrishnan Y, Iqbal IZ, Puvanendran M, ElBadawey MR, Carrie S. A postal survey of hereditary hemorrhagic telangectasia in the northeast of England. ALLERGY & RHINOLOGY 2015; 6:20-7. [PMID: 25860167 PMCID: PMC4388872 DOI: 10.2500/ar.2015.6.0114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The aim of this study is to identify the demographics and epistaxis burden of hereditary hemorrhagic telangiectasia (HHT). A questionnaire was sent to participants with HHT who were recruited from a prospectively maintained respiratory clinic data base in a tertiary hospital. Details on demographics, HHT symptoms, family history, epistaxis severity, and treatment received were recorded. There were 34 of 60 responses (57%). Two responses were from families of the deceased. Of the 32 evaluable patients (men, 14; women 18), the average age was 51 years (range, 23-78 years). The average age of HHT diagnosis was 31 years (range, 3-61 years). The diagnosis of HHT was made by the respiratory team in 13 patients; neurologist (2); ear, nose, and throat (ENT) specialist (4); general practitioner (5); hematologist (4); gastroenterologist (1); and not mentioned in two patients. Twenty-seven of 32 patients (84%) had a positive family history of HHT. Only 13 patients had formal genetic testing (4 endoglin, 1 activin receptor-like kinase, 8 unknown gene). All patients who presented to the respiratory clinic had a background of epistaxis, which was noted on presentation. The average age at initial epistaxis was 14 years (range, 2-50 years). The frequency of epistaxis was daily 63% (n = 20), weekly 9% (3), monthly 16% (5), and a few times a year 10% (3), and unstated in one patient. Nine of 32 patients (28%) required a transfusion. Six patients thought that they were unable to perform daily activities due to epistaxis. Only 15 of 32 patients (47%) were under the care of an ENT specialist. The treatment plan for epistaxis management was deemed good by 7 patients, adequate in 8, poor in 6, and not stated by 11 patients. In conclusion, this survey is the first to quantify the epistaxis burden within the northeast of England. The management of epistaxis needs specific education and treatment to optimize the quality of life among these patients.
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Merlo CA, Yin LX, Hoag JB, Mitchell SE, Reh DD. The effects of epistaxis on health-related quality of life in patients with hereditary hemorrhagic telangiectasia. Int Forum Allergy Rhinol 2014; 4:921-5. [PMID: 25145809 DOI: 10.1002/alr.21374] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 06/07/2014] [Accepted: 06/13/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease mainly characterized by epistaxis in more than 96% of patients. Recently, a validated questionnaire known as the HHT Epistaxis Severity Score (ESS) was developed. However, little is known about the relationship between epistaxis and quality of life. We hypothesize that epistaxis severity is a major factor predicting health-related quality of life (HR-QoL) in HHT patients. METHODS This is a cross-sectional study. The ESS questionnaire and Medical Outcomes Study 36-item short form (SF-36) were administered to subjects through an Internet survey. All participants had a definitive diagnosis of HHT through Curaçao criteria or genetic testing. Demographic information, genetics, and extensive histories were also collected. Descriptive analyses were performed with calculations of means and standard deviations (SDs) for continuous variables and proportions for categorical variables. Linear regressions were then performed to assess the association between HR-QoL and ESS. RESULTS A total of 604 subjects participated between April and August 2008. All patients reported epistaxis, 285 (47.2%) had telangiectasias, and 545 (90.2%) had a family history of HHT; 167 (27.6%) patients had mild epistaxis (ESS <4), 285 (47.2%) reported moderate epistaxis (≥4 ESS <7), and 152 (25.2%) reported severe epistaxis (ESS ≥7). Patients with severe epistaxis had lower scores for both the Physical Component Summary (PCS) and the Mental Component Summary (MCS) of HR-QoL when compared to those with mild epistaxis (p < 0.001, p < 0.001). CONCLUSION The ESS is a major determinant of HR-QoL and should be considered as a measurement of treatment efficacy in HHT-related epistaxis.
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Affiliation(s)
- Christian A Merlo
- Department of Medicine and Epidemiology, Johns Hopkins Medicine, Baltimore, MD
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Elphick A, Shovlin CL. Relationships between epistaxis, migraines, and triggers in hereditary hemorrhagic telangiectasia. Laryngoscope 2014; 124:1521-8. [DOI: 10.1002/lary.24526] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 11/13/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Amy Elphick
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare National Health Service Trust; London United Kingdom
- Cardiovascular Sciences; National Heart and Lung Institute, Imperial College London; London United Kingdom
- School of Life Sciences; Imperial College London; London United Kingdom
| | - Claire L. Shovlin
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare National Health Service Trust; London United Kingdom
- Cardiovascular Sciences; National Heart and Lung Institute, Imperial College London; London United Kingdom
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Silva BM, Hosman AE, Devlin HL, Shovlin CL. Lifestyle and Dietary Influences on Nosebleed Severity in Hereditary Hemorrhagic Telangiectasia. Laryngoscope 2013; 123:1092-9. [DOI: 10.1002/lary.23893] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2012] [Indexed: 12/31/2022]
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Dheyauldeen S, Østertun Geirdal A, Osnes T, Vartdal LS, Dollner R. Bevacizumab in hereditary hemorrhagic telangiectasia-associated epistaxis: effectiveness of an injection protocol based on the vascular anatomy of the nose. Laryngoscope 2012; 122:1210-4. [PMID: 22565282 DOI: 10.1002/lary.23303] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 02/20/2012] [Accepted: 02/22/2012] [Indexed: 01/28/2023]
Abstract
OBJECTIVE/HYPOTHESIS To evaluate the effectiveness of a standardized intranasal bevacizumab injection in treating hereditary hemorrhagic telangiectasia (HHT)-associated epistaxis. STUDY DESIGN Prospective pilot study. METHODS A total dose of 100 mg bevacizumab (25 mg/mL Avastin) was injected submucosally, 50 mg on each side. A total of 0.5 mL was injected in the sphenopalatine area, upper part of bony septum, upper part of the later nasal wall, and the anterior part of nasal floor. No cauterizations or laser therapy were done during or after the procedure. The hemoglobin level and grades of epistaxis were recorded before and monthly after the procedure. The IFT grading system (intensity [I], frequency [F] of epistaxis, and the amount of blood transfusion [T]) and epistaxis severity score (ESS) for hereditary hemorrhagic telangiectasia system were used. Quality of life (QoL) was evaluated before and 4 weeks after the procedure using the Short Form-36 Health Survey questionnaire, Cantril's Self-Anchoring Ladder questionnaire, and Slotosch disease-specific QoL questionnaire. RESULTS A significant improvement was found in IFT grading (P = .007), ESS grading (P = .001), and hemoglobin level (P = .01). The QoL differences were statistically not significant. CONCLUSIONS The four-injection site technique of intranasal administration of bevacizumab is an effective treatment option in HHT-associated epistaxis, at least on the short-term effect. Long-term and comparative studies are needed to further evaluate the significance of this treatment modality.
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Affiliation(s)
- Sinan Dheyauldeen
- Department of Otorhinolaryngology, Head and Neck Surgery, Division of Surgery and Neuroscience, Oslo University Hospital-Rikshospitalet, Oslo, Norway.
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Sautter NB, Smith TL. Hereditary hemorrhagic telangiectasia-related epistaxis: innovations in understanding and management. Int Forum Allergy Rhinol 2012; 2:422-31. [PMID: 22566463 DOI: 10.1002/alr.21046] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 03/15/2012] [Accepted: 03/20/2012] [Indexed: 12/26/2022]
Abstract
BACKGROUND Epistaxis is the most common manifestation of hereditary hemorrhagic telangiectasia (HHT), affecting approximately 90% of patients at some point during their lifetime. Bleeding is chronic and varies from mild, self-limited episodes to severe, transfusion-dependent or life-threatening epistaxis. Treatment options vary from conservative, nonsurgical management to more aggressive surgical approaches. A number of treatment options have been introduced in recent years. There is little consensus in the literature regarding treatment algorithms. The objective of this investigation was to provide a contemporary review of HHT-related epistaxis, including pathophysiology, disease manifestations, and state-of-the-art treatment modalities. METHODS A systematic review of the literature for HHT-related epistaxis was performed using the search terms "hereditary hemorrhagic telangiectasia" and "epistaxis." Additional literature search regarding current recommendations for HHT evaluation and recent developments in genetic mechanisms, pathophysiology, and treatment of HHT was also performed. RESULTS A total of 308 articles were identified and reviewed for appropriateness of inclusion whereas 64 articles met inclusion criteria. Treatment options range from topical and hormonal therapy to more aggressive surgical modalities. Most treatment descriptions are case series, with few randomized controlled trials. A number of new and novel therapies have been introduced in recent years. CONCLUSION HHT is a heterogeneous disease requiring multidisciplinary evaluation and treatment. Therapeutic options for HHT-related epistaxis vary from conservative, nonsurgical measures to more aggressive surgical treatments. A graduated treatment plan is recommended. Patients present with a wide degree in variation of severity of epistaxis, and treatment is best tailored to the individual patient.
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Affiliation(s)
- Nathan B Sautter
- Oregon Sinus Center, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR 97239, USA.
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