Efficacy, safety and pharmacokinetics of a new high-purity factor X concentrate in women and girls with hereditary factor X deficiency

Essentials Plasma-derived factor X concentrate (pdFX) is used to treat hereditary factor X deficiency. pdFX pharmacokinetics, safety and efficacy were assessed in factor X-deficient women/girls. Treatment success rate was 98%; only 6 adverse events in 2 subjects were possibly pdFX related. On-demand pdFX 25 IU kg-1 was effective and safe in women/girls with factor X deficiency.

SUMMARY

Background A high-purity, plasma-derived factor X concentrate (pdFX) has been approved for the treatment of hereditary FX deficiency, an autosomal recessive disorder. Objective To perform post hoc assessments of pdFX pharmacokinetics, safety and efficacy in women and girls with hereditary FX deficiency. Patients/Methods Subjects aged ≥ 12 years with moderate/severe FX deficiency (plasma FX activity of < 5 IU dL-1 ) received on-demand or preventive pdFX (25 IU kg-1 ) for ≤ 2 years. Results Of 16 enrolled subjects, 10 women and girls (aged 14-58 years [median, 25.5 years]) received 267 pdFX infusions. Mean monthly infusions per subject were higher among women and girls (2.48) than among men and boys (1.62). In women and girls, 132 assessable bleeding episodes (61 heavy menstrual bleeds, 47 joint bleeds, 15 muscle bleeds, and nine other bleeds) were treated with pdFX, with a 98% treatment success rate versus 100% in men and boys. Mean pdFX incremental recovery was similar in the two groups (2.05 IU dL-1 versus 1.91 IU dL-1 per IU kg-1 ), as was the mean half-life (29.3 h versus 29.5 h). Of 142 adverse events in women and girls, headache was the most common (12 events in six subjects). Six events (two infusion-site erythema, two fatigue, one back pain, one infusion-site pain) in two subjects were considered to be possibly pdFX-related. Following the trial, pdFX was used to successfully maintain hemostasis in two subjects undergoing obstetric delivery. Conclusions pdFX was well tolerated and effective in women and girls with FX deficiency. Although women and girls had different bleeding symptoms and sites than men and boys, their pdFX pharmacokinetic profile was comparable.

Differences in bleeding phenotype and provider interventions in postmenarchal adolescents when compared to adult women with bleeding disorders and heavy menstrual bleeding

INTRODUCTION

Due to lack of patient/health care provider awareness causing delayed diagnosis, the bleeding phenotype and provider interventions in adolescents with heavy menstrual bleeding (HMB) and bleeding disorders (BD) may be different when compared to adults.

AIM

The aim of this study was to compare/characterize bleeding phenotype and provider interventions in postmenarchal adolescents < 18 years and premenopausal adults ≥ 18 years with HMB and BD.

METHODS

Patient demographics, BD, and provider interventions/therapy details for HMB were compared between both age groups enrolled in the Centers for Disease Control and Prevention (CDC) Female Universal Data Collection (UDC) surveillance project in United States hemophilia treatment centres. Cross-sectional descriptive analyses including frequency distributions, summary statistics, bivariate and logistic regression analyses were performed.

RESULTS

Of 269 females (79 adolescents; median age 16 years, interquartile range (IQR) = 2; 190 adults; median age 27 years, IQR = 13) evaluated, BD distribution was similar in both groups. Compared to adolescents, adults more often had family history of bleeding (Adjusted odds ratios [AOR] = 2.6, 1.3-5.6), delay in diagnosis (AOR = 2.5, 1.2-4.9), bleeding with dental procedures (AOR = 2.0, 1.0-4.0), gastrointestinal bleeding (AOR = 4.6, 1.0-21.9), anaemia (AOR = 2.7, 1.4-5.2), utilized desmopressin less often (AOR = 0.4, 0.2-0.8) and underwent gynaecologic procedure/surgery more frequently (AOR = 5.9, 1.3-27.3).

CONCLUSION

Bleeding phenotypes of adolescents and adults with HMB and BD were different with more frequent bleeding complications, anaemia, gynaecologic procedures/surgeries, less desmopressin use and more delay in diagnosing BD in adults. Longitudinal studies are needed to determine whether improved patient/provider awareness and education will translate to early diagnosis and timely management of BD/HMB in adolescents that may prevent/reduce future haematologic/gynaecologic complications.

Reasons for cesarean and medically indicated deliveries in pregnancies in women with systemic lupus erythematosus

Objective

To determine reasons for cesarean and medically indicated deliveries in a registry of pregnant women with SLE compared to RA.

Methods

Pregnant women with SLE or RA were prospectively followed, and pregnancy outcomes were collected, including whether labor was spontaneous or medically indicated and delivery was vaginal or cesarean. Preterm birth was defined as a birth <37 weeks gestation. Differences in reasons for cesarean delivery and indication of delivery between term and preterm births were determined by Fisher’s exact test.

Results

Compared to RA pregnancies, SLE pregnancies had modestly higher rates of preterm birth (24% SLE vs 14% RA), pre-eclampsia (15% SLE vs 7% RA), and cesarean delivery (48% SLE vs 30% RA). The majority of preterm births among women with SLE were indicated (70%), most commonly for pre-eclampsia or the health of the infant or mother. The majority of preterm births among women with RA, however, were spontaneous, primarily due to premature rupture of membranes.

Conclusion

Pre-eclampsia and maternal SLE activity appear to be the key drivers for the high rate of preterm birth and medically indicated delivery in SLE. This contrasts with RA, where preterm labor is most often due to spontaneous onset of labor.

Using antifibrinolytics in the peripartum period - concern for a hypercoagulable effect?

INTRODUCTION

Although antifibrinolytic agents are used to prevent and treat hemorrhage, there are concerns about a potential increased risk for peripartum venous thromboembolism. We sought to determine the impact of tranexamic acid and ɛ-aminocaproic acid on in vitro clotting properties in pregnancy.

METHODS

Blood samples were obtained from healthy pregnant, obese, and preeclamptic pregnant women (n = 10 in each group) prior to delivery as well as from healthy non-pregnant controls (n = 10). Maximum clot firmness (MCF) and clotting time (CT) were measured using rotation thromboelastometry in the presence of tranexamic acid (3, 30, or 300 μg/mL) or ɛ-aminocaproic acid (30, 300, or 3000 μg/mL). ANOVA and regression analyses were performed.

RESULTS

Mean whole blood MCF was significantly higher in healthy pregnant vs. non-pregnant women (66.5 vs. 57.5 mm, p < 0.001). Among healthy pregnant women, there was no significant difference between mean MCF (whole blood alone, and with increasing tranexamic acid doses = 66.5, 66.1, 66.4, 66.3 mm, respectively; p = 0.25) or mean CT (409, 412, 420, 424 sec; p = 0.30) after addition of tranexamic acid. Similar results were found using ɛ-aminocaproic acid. Preeclamptic women had a higher mean MCF after the addition of ɛ-aminocaproic acid and tranexamic acid (p = 0.05 and p = 0.04, respectively) compared to whole blood alone.

CONCLUSIONS

Pregnancy is a hypercoagulable state, as reflected by an increased MCF compared to non-pregnant women. Addition of antifibrinolytic therapy in vitro does not appear to increase MCF or CT for non-pregnant, pregnant, and obese women. Whether antifibrinolytics are safe in preeclampsia may require further study.

Factors associated with the change in prevalence of cardiomyopathy at delivery in the period 2000-2009: a population-based prevalence study

OBJECTIVE

Cardiomyopathy (CM) at delivery is increasing in prevalance. The objective of this study was to determine which medical conditions are attributable to this increasing prevalance.

DESIGN

Population prevalence study from 2000 to 2009.

SETTING

The Nationwide Inpatient Sample (NIS).

SAMPLE

Pregnant women admitted for delivery were identified in the NIS for the years 2000-2009.

METHODS

Temporal trends in pre-existing medical conditions and in medical and obstetric complications at delivery admissions were determined by linear regression. The change in the prevalence of CM among all pregnant women was compared with the change in the prevalance of CM among pregnant women without pre-existing conditions or complications.

MAIN OUTCOME MEASURE

Prevalence of CM.

RESULTS

The prevalence of CM increased from 0.25 per 1000 deliveries in 2000 to 0.43 per 1000 deliveries in 2009 (P < 0.0001). Women with chronic hypertension had increased odds of developing CM compared with women without chronic hypertension (odds ratio, OR, 13.2; 95% confidence interval, 95% CI, 12.5-13.7). The linear increase in chronic hypertension over the 10-year period was the single identified pre-existing medical condition that explained the increasing prevalence of CM at delivery (P = 0.005 for the differences in slopes for linear trends).

CONCLUSIONS

Pregnant women with chronic hypertenion are at an increased risk for CM at delivery, and the increasing prevalence of chronic hypertension is an important factor associated with the increasing prevalence of CM at the time of delivery. Among women without chronic hypertension, the prevalence of CM at delivery did not change during the time period.

Differentially expressed microRNAs and affected biological pathways revealed by modulated modularity clustering (MMC) analysis of human preeclamptic and IUGR placentas

INTRODUCTION

This study focuses on the implementation of modulated modularity clustering (MMC) a new cluster algorithm for the identification of molecular signatures of preeclampsia and intrauterine growth restriction (IUGR), and the identification of affected microRNAs

METHODS

Eighty-six human placentas from normal (40), growth-restricted (27), and preeclamptic (19) term pregnancies were profiled using Illumina Human-6 Beadarrays. MMC was utilized to generate modules based on similarities in placental transcriptome. Gene Set Enrichment Analysis (GSEA) was used to predict affected microRNAs. Expression levels of these candidate microRNAs were investigated in seventy-one human term placentas as follows: control (29); IUGR (26); and preeclampsia (16).

RESULTS

MMC identified two modules, one representing IUGR placentas and one representing preeclamptic placentas. 326 differentially expressed genes in the module representing IUGR and 889 differentially expressed genes in a module representing preeclampsia were identified. Functional analysis of molecular signatures associated with IUGR identified P13K/AKT, mTOR, p70S6K, apoptosis and IGF-1 signaling as being affected. Analysis of variance of GSEA-predicted microRNAs indicated that miR-194 was significantly down-regulated both in preeclampsia (p = 0.0001) and IUGR (p = 0.0304), and miR-149 was significantly down-regulated in preeclampsia (p = 0.0168).

DISCUSSION

Implementation of MMC, allowed identification of genes disregulated in IUGR and preeclampsia. The reliability of MMC was validated by comparing to previous linear modeling analysis of preeclamptic placentas.

CONCLUSION

MMC allowed the elucidation of a molecular signature associated with preeclampsia and a subset of IUGR samples. This allowed the identification of genes, pathways, and microRNAs affected in these diseases.

Obstetric hemorrhage

An obstetric hemorrhage may occur before or after delivery, but more than 80% of cases occur postpartum. Worldwide, a massive obstetric hemorrhage, resulting from the failure of normal obstetrical, surgical and/or systemic hemostasis, is responsible for 25% of the estimated 358,000 maternal deaths each year. Most women will not have identifiable risk factors. Nonetheless, primary prevention of a postpartum hemorrhage (PPH) begins with an assessment of identifiable risk factors. Women identified as being at high risk of a PPH should be delivered in a center with access to adequately trained staff and an onsite blood bank. A critical feature of a massive hemorrhage in obstetrics is the development of disseminated intravascular coagulation (DIC), which, in contrast to DIC that develops with hemorrhage from surgery or trauma, is frequently an early feature. Data from clinical trials to guide management of transfusion in PPH are lacking. There are likely to be similarities in the management of transfusion in severe PPH to that of major bleeding in other clinical situations, but the pathophysiological processes that contribute to a massive PPH may necessitate different transfusion strategies such as the ratio of red blood cells to plasma components, in particular fibrinogen. Caution should be exercised when considering the appropriate place for recombinant activated factor VII (rFVIIa) in the management of a major PPH. An early hysterectomy is recommended for severe bleeding as a result of placenta accreta or uterine rupture. However, in women with uterine atony who have ongoing bleeding in spite of an adequate transfusion, it may be reasonable to consider a trial of rFVIIa before a hysterectomy.

Pregnancy outcomes associated with viral hepatitis

The aim of this study was to examine the contribution of hepatitis B virus (HBV) and hepatitis C virus (HCV) to pregnancy-related complications including gestational diabetes mellitus (GDM), preterm birth (PTB), intrauterine growth restriction (IUGR), pre-eclampsia, antepartum haemorrhage and cholestasis. The Nationwide Inpatient Sample was queried for all pregnancy-related discharges, pregnancy complications and viral hepatitis from 1995 to 2005. Logistic regression was used to examine the association between HBV, HCV, HBV + HCV and pregnancy-related complications including GDM, PTB, IUGR, pre-eclampsia, antepartum haemorrhage, cholestasis and caesarean delivery. Model covariates included maternal age, race, insurance status, substance use and medical complications including liver complication, hypertension, HIV, anaemia, thrombocytopenia and sexually transmitted infections. Of 297 664 pregnant women data available for analysis, 1446 had a coded diagnosis of HBV, HCV or both. High-risk behaviours, such as smoking, alcohol and substance use were higher in women with either HBV or HCV. Women with HBV had an increased risk for PTB (aOR 1.65, CI [1.3, 2.0]) but a decreased risk for caesarean delivery (aOR 0.686, CI [0.53, 0.88]). Individuals with HCV had an increased risk for GDM (aOR 1.6, CI [1.0, 2.6]). Individuals with both HBV and HCV co-infection had an increased risk for antepartum haemorrhage (aOR 2.82, CI [1.1, 7.2]). There was no association of viral hepatitis with IUGR or pre-eclampsia. Women with hepatitis have an increased risk for complications during pregnancy. Research to determine the efficacy and cost-effectiveness of counselling patients about potential risks for adverse outcomes is warranted.

Surveillance of female patients with inherited bleeding disorders in United States Haemophilia Treatment Centres

Inherited bleeding disorders are especially problematic for affected girls and women due to the monthly occurrence of menstrual periods and the effects on reproductive health. Although heavy menstrual bleeding (HMB) is the most common manifestation, females with inherited bleeding disorders (FBD) experience other bleeding symptoms throughout the lifespan that can lead to increased morbidity and impairment of daily activities. The purpose of this article is to describe the utility of a female-focused surveillance effort [female Universal Data Collection (UDC) project] in the United States Haemophilia Treatment Centres (HTCs) and to describe the baseline frequency and spectrum of diagnoses and outcomes. All FBD aged 2 years and older receiving care at selected HTCs were eligible for enrollment. Demographic data, diagnoses and historical data regarding bleeding symptoms, treatments, gynaecological abnormalities and obstetrical outcomes were analysed. Analyses represent data collected from 2009 to 2010. The most frequent diagnoses were type 1 von Willebrand's disease (VWD) (195/319; 61.1%), VWD type unknown (49/319; 15.4%) and factor VIII deficiency (40/319; 12.5%). HMB was the most common bleeding symptom (198/253; 78.3%); however, 157 (49.2%) participants reported greater than four symptoms. Oral contraceptives were used most frequently to treat HMB (90/165; 54.5%), followed by desmopressin [1-8 deamino-D-arginine vasopressin (DDAVP)] (56/165; 33.9%). Various pregnancy and childbirth complications were reported, including bleeding during miscarriage (33/43; 76.7%) and postpartum haemorrhage (PPH) (41/109; 37.6%). FBD experience multiple bleeding symptoms and obstetrical-gynaecological morbidity. The female UDC is the first prospective, longitudinal surveillance in the US focusing on FBD and has the potential to further identify complications and reduce adverse outcomes in this population.

Women and bleeding disorders

SUMMARY

While women are rarely affected by haemophilia, they are equally as likely as men to have other bleeding disorders. Menorrhagia, or heavy menstrual bleeding, is the most common symptom that they experience. Not only is menorrhagia more prevalent among women with bleeding disorders, but bleeding disorders are more prevalent among women with menorrhagia. Although menorrhagia is the most common reproductive tract manifestation of a bleeding disorder, it is not the only manifestation. Women with bleeding disorders appear to be at an increased risk of developing haemorrhagic ovarian cysts and possibly endometriosis. Women suspected of having a bleeding disorder or being a carrier of haemophilia should be offered diagnostic testing before getting pregnant to allow for appropriate preconception counselling and pregnancy management. During pregnancy, women with bleeding disorders may be at an increased risk of bleeding complications. At the time of childbirth, women with bleeding disorders appear to be more likely to experience postpartum haemorrhage, particularly delayed or secondary postpartum haemorrhage. As women with bleeding disorders grow older, they may be more likely to manifest gynaecological conditions which present with bleeding. Women with bleeding disorders are more likely to undergo a hysterectomy and are more likely to have the operation at a younger age. While women with bleeding disorders are at risk for the same obstetrical and gynaecological problems that affect all women, women with bleeding disorders are disproportionately affected by conditions that manifest with bleeding. Optimal management involves the combined expertise of haemostasis experts and obstetrician-gynaecologists.

Transcriptional profiling of human placentas from pregnancies complicated by preeclampsia reveals disregulation of sialic acid acetylesterase and immune signalling pathways

The placenta plays an important role as a regulator of fetal nutrition and growth throughout development and placental factors contribute to gestational abnormalities such as preeclampsia. This study describes the genome-wide gene expression profiles of a large (n = 60) set of human placentas in order to uncover gene expression patterns associated with preeclampsia. In addition to confirming changes in expression of soluble factors associated with preeclampsia such as sFLT1 (soluble fms-like tyrosine kinase-1), sENG (soluble endoglin), and INHA (inhibin alpha), we also find changes in immune-associated signaling pathways, offering a potential upstream explanation for the shallow trophoblast invasion and inadequate uterine remodeling typically observed in pathogenesis of preeclampsia. Notably, we also find evidence of preeclampsia-associated placental upregulation of sialic acid acetylesterase (SIAE), a gene functionally associated with autoimmune diseases.

Complications of hysterectomy in women with von Willebrand disease

Case reports and small case series suggest that women with von Willebrand disease (VWD) are at a very high risk of bleeding complications with hysterectomy. As the procedure may be beneficial to women who suffer from heavy menstrual bleeding and have completed childbearing, an understanding of the true risks involved is essential for appropriate decision making. To estimate the incidence of bleeding and other complications in women with VWD who undergo hysterectomy. The United States Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality for the years 1988-2004 was queried for all hysterectomies for non-malignant conditions. Data were analysed based on the NIS sampling design. Bivariate analyses were used to examine the differences between women with and without VWD. Multivariate analysis was used to adjust for potential confounders among women who underwent hysterectomy for heavy menstrual bleeding. 545 of the 1 358 133 hysterectomies were to women with VWD. Women with VWD were significantly more likely to experience intraoperative and postoperative bleeding (2.75% vs. 0.89%, P < 0.001) and require transfusion (7.34% vs. 2.13%, P < 0.001) than women without VWD. One woman with VWD died. While the risk of bleeding complications from hysterectomy in women with VWD is smaller than previously reported, women with VWD did experience significantly more bleeding complications than women without VWD. Nonetheless, for women who have completed childbearing, the risks of hysterectomy may be acceptable.

Severe factor V deficiency presenting with intracranial haemorrhage during gestation

We present a case of intracranial haemorrhage detected by ultrasound at 36 weeks gestation in a foetus who was ultimately diagnosed with severe factor V deficiency. An abnormality of the foetal heart rate, auscultated at a routine antenatal visit, prompted an investigation that led to an ultrasound examination and detection of an intracranial haemorrhage and low amniotic fluid volume. An intrauterine foetal demise was averted. The clinical scenario in this case raises the issue of how often a stillbirth with intracranial haemorrhage may result from unrecognized factor deficiency.

Bleeding events and other complications during pregnancy and childbirth in women with von Willebrand disease

BACKGROUND

Case reports and case series suggest that women with von Willebrand disease (VWD) are at an increased risk of bleeding complications during pregnancy and delivery.

OBJECTIVES

To estimate the incidence of bleeding events and other complications in women with VWD during pregnancy and childbirth.

METHODS

The United States Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality for the years 2000-2003 was queried for all pregnancy-related discharges. Women with a diagnosis of VWD were compared with women without VWD. Data were analyzed based on the NIS sampling design. Logistic regression was used to compute odds ratios with 95% CI.

RESULTS

There were 4067 deliveries among women with VWD (1 in 4000 deliveries). Although women with VWD were more likely to experience antepartum bleeding [odds ratio (OR) 10.2, 95% CI: 7.1, 14.6], they were no more likely to experience premature labor, placental abruption, fetal growth restriction or intrauterine fetal demise. Women with VWD were more likely to experience a postpartum hemorrhage (OR, 1.5; 95% CI: 1.1, 2.0), and had a 5-fold increased risk of being transfused (OR, 4.7; 95% CI: 3.2, 7.0). Five of the 4067 women with VWD died, a maternal mortality rate 10 times higher than that for other women.

CONCLUSIONS

Although women with VWD do not appear to be at an increased risk of poor fetal outcomes, they are at an increased risk of bleeding events and possibly death during pregnancy and childbirth.

The U.S. Thrombosis and Hemostasis Centers pilot sites program

Venous thromboembolism (VTE) is a common disorder associated with significant morbidity and mortality. Despite important advances in understanding the etiology of VTE, delivery of care to patients with thrombosis and thrombophilia is frequently incomplete and highly variable. A comprehensive model of health care has been used successfully to treat and prevent complications for people with hemophilia and other chronic disorders. The effectiveness of an integrated healthcare model for patients with all coagulation disorders has yet to be evaluated. The Division of Hereditary Blood Disorders of the Centers for Disease Control and Prevention (CDC) is collaborating with eight Thrombosis and Hemostasis Centers (pilot sites) to provide health-related services and conduct research directed toward the reduction or prevention of complications of thrombosis and thrombophilia. The initial objectives of the collaboration are to (1) determine the efficacy of integrated multidisciplinary care and prevention services for people with hemostatic disorders, (2) assess unmet needs for service delivery and identify outreach strategies to improve access to care, (3) develop effective messages aimed at disease management and prevention, and (4) foster the development of training programs to enhance provider skills for the delivery of patient care. To address these objectives, the investigators and CDC have developed and implemented a web-based patient registry to follow prospectively service allocation and patient outcomes. Funding for the program began in October 2001. All eight funded centers are affiliated with U.S. medical schools. Principal investigators at the centers are hematologists (five adult, two pediatric) or cardiologists. Faculty in obstetrics-gynecology, surgery, and multiple other specialties are integral to the model of care at the centers. Other critical components at the centers are clinical laboratory services, training programs, research networks, and education and outreach programs. From August 2003 to March 2006, over 2,600 patients were enrolled in the registry, accounting for a total of more than 5,000 visits to the centers. Immediate goals of the data collection at the centers are to characterize patients receiving care at centers and document the state of health services provided. Long-term goals are to evaluate prospectively clinical outcomes for patients receiving multidisciplinary care and prevention services at centers. The network of data collection across centers will facilitate future collaborative clinical and epidemiologic investigations and enhance collective expertise in hemostasis and coagulation disorders.

Unresolved issues in diagnosis and management of inherited bleeding disorders in the perinatal period: A White Paper of the Perinatal Task Force of the Medical and Scientific Advisory Council of the National Hemophilia Foundation, USA

Haemophilia and inherited bleeding disorders in newborns and their carrier mothers pose unique challenges. The pattern of bleeding and the causes and risk factors for bleeding are decidedly different than an older child or an adult with haemophilia/inherited bleeding disorder. This document outlines the needs for further research and education, summarizes the state of the art background information and provides guidance regarding research, education and access to care issues in this population.

More than menorrhagia: a review of the obstetric and gynaecological manifestations of bleeding disorders

In women, menorrhagia may be the most common manifestation of a bleeding disorder, but it is not the only reproductive tract abnormality that women with bleeding disorders experience. Women with bleeding disorders appear to be at an increased risk of developing haemorrhagic ovarian cysts and possibly endometriosis. As they grow older, they may be more likely to manifest conditions, which present with bleeding such as fibroids, endometrial hyperplasia and polyps. Women with bleeding disorders are more likely to undergo a hysterectomy and are more likely to have the operation at a younger age. During pregnancy, they may be at greater risk of miscarriage and bleeding complications. At the time of childbirth, women with bleeding disorders appear to be more likely to experience postpartum haemorrhage, particularly delayed or secondary postpartum haemorrhage. Vaginal or vulvar haematomas, extremely rare in women without bleeding disorders, are not uncommon. While women with bleeding disorders are at risk for the same obstetrical and gynaecological problems that affect all women, they appear to be disproportionately affected by conditions that manifest with bleeding.

Combined deficiency of factors II, VII, IX, and X (Borgschulte-Grigsby deficiency) in pregnancy

BACKGROUND

Combined deficiency of vitamin K-dependent coagulation factors (II, VII, IX, X) is an uncommon challenge for the expectant gravida.

CASE

A 34-year-old primigravida had congenital combined deficiency of factors II, VII, IX, and X that were incompletely sensitive to vitamin K. She had an altered form of vitamin K-dependent factors that retained immunologic activity but lacked coagulant activity and the normal complement of gamma-carboxyglutamic acid residues. She required vitamin K supplementation throughout her life. After an uneventful pregnancy she had postpartum hemorrhage resulting from an episiotomy. Fresh frozen plasma was administered to achieve hemostasis. The remainder of her postpartum course was normal.

CONCLUSION

Combined congenital deficiency of factors II, VII, IX, and X can be managed in pregnancy with the use of vitamin K and fresh frozen plasma.

Assessment of primary hemostasis by PFA-100 analysis in a tertiary care center

We evaluated the utility of the PFA-100 platelet function analyzer in identifying disorders in platelet function and/or von Willebrand factor (vWF) in patients with various systemic disorders being followed at a tertiary care center. Closure times were determined with collagen/ ADP (CADP) and collagen/epinephrine (CEPI) cartridges for 305 patients, and abnormal results were further evaluated with platelet aggregometry and vWF analysis. Prolonged CADP and/or CEPI closure times were identified in 114 patients (37.3%), but most were isolated prolonged CEPI closure times predominantly due to aspirin therapy (79 patients). Prolonged CADP closure times were most frequently due to qualitative platelet defects and/or decreased vWF levels. Prolonged CADP closure times were encountered most frequently in patients with sickle cell disease and were associated with a decreased hematocrit. This study demonstrated that the PFA-100 analyzer can accurately assess vWF-dependent platelet function and detect other platelet defects under high shear stress in complex patient populations.

Gum health product formulations: what is in them and why?

Two dominant factors dictate which ingredients are used in formulating toothpaste and mouthwashes. The major one is the type of active ingredient chosen, especially cationic active ingredients such as chlorhexidine; the other factor is the needs of the consumer. Apart from gum health benefits, the consumer expects to obtain from gum health toothpaste and mouthwashes other benefits of clean teeth (abrasive and detergent), fresh breath (antimicrobial agents and flavor) and protection from caries and possibly tartar. Exhaustive testing involving experimental design and validated laboratory and clinical tests is essential to ensure that all these benefits are delivered. Unless products are developed systematically, then products with relatively poor activity can find their way on to the market.

In vivo study of stainless steel and Ti-13Nb-13Zr bone plates in a sheep model

A sheep study was performed to compare the in vivo performance of bone plates of 316L stainless steel and a new titanium alloy, titanium + 13% niobium + 13% zirconium (Ti-13Nb-13Zr), which had been subjected to a diffusion hardening treatment to produce a blue, wear resistant surface. Bone plates and screws of stainless steel and diffusion hardened Ti-13Nb-13Zr were implanted in adult sheep, in one group (with unosteotomized femurs) for 16 weeks, and in the other (with osteotomized femurs) for 8 weeks. At harvest, the diffusion hardened Ti-13Nb-13Zr devices had superior fixation strength, with greater screw torque out strength and fewer loose screws. In the osteotomized animals, the femurs with diffusion hardened Ti-13Nb-13Zr plates had higher torsional strength after removal of the implants; however, the difference was not statistically significant. In the unosteotomized animals, the torsional strength of the femurs was identical for both materials. There was a slightly reduced incidence of infection (bacterial adhesion) for the sheep with diffusion hardened Ti-13Nb-13Zr implants. In a parallel in vitro study, the magnetic resonance imaging compatibility of Ti-13Nb-13Zr was significantly superior to that of stainless steel. This indicates that diffusion hardened Ti-13Nb-13Zr may be an attractive alternative material for osteosynthesis.

Clostridium difficile infection in obstetric and gynecologic patients

We reviewed hospital records of women on the obstetrics and gynecologic services with a diagnosis of antibiotic-associated diarrhea, pseudomembranous colitis, or Clostridium difficile infection to better characterize the incidence and course of women with C difficile infection. Cases were included if there was identification of C difficile by culture or toxin or endoscopic verification of pseudomembranous colitis. Between January 1985 and June 1995, there were 74,120 admissions to the obstetrics and gynecology services at two tertiary level hospitals. Eighteen women were found to have documented C difficile infection (0.02%)--3 from the obstetric services, 10 from the benign gynecologic services, and 5 from the gynecologic/oncology services. Diarrhea developed from 2 days to 30 days after antibiotics had been given (mean, 10 days). Nine patients had fever, six had nausea and vomiting, and five had abdominal pain. Antimicrobial agents given before infection included cephalexin, cefoxitin, imipenem, ciprofloxacin, trimethoprim/sulfamethoxazole, ampicillin, gentamicin, and clindamycin. All patients were treated successfully with inpatient antimicrobial agents-15 with metronidazole and 3 with vancomycin. There was one possible recurrence.

Lipid fuel metabolism after abdominal surgery

The work investigated fuel interrelationships in surgical patients infused with saline (Group I) or glucose (Group II) (13 patients in each group) on the day of surgery and subsequently maintained solely on saline until the fifth postoperative day. Blood concentrations of non-esterified fatty acids (NEFA) and ketone bodies were markedly increased in response to surgical stress on the day of surgery only in patients who were not administered carbohydrate. Increased concentrations of lactate and glucose were observed on the day of surgery in patients infused with either saline or glucose. As both fatty acid and ketone body concentrations were decreased by glucose infusion, impaired glucose utilization immediately after surgery is not a simple consequence of increased oxidation of lipid fuels. Glucose and lactate concentrations declined after the day of surgery. Despite a progressive fall in plasma non-esterified fatty acid concentrations from the first to fifth post-operative days, blood ketone body concentrations were strikingly elevated in both groups of patients. The findings emphasize the role of the liver in post-operative fatty acid turnover.

Prospective comparative study of computer programs used for management of warfarin

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Factors affecting the precision of warfarin treatment

AIM

To determine what factors influence the precision of anticoagulant control using warfarin by examining the computerised records of 2207 patients.

METHODS

Records from seven district general hospitals were combined and analysed. The precision of anticoagulant control was taken as the absolute deviation of International Normalised Ratio (INR) from target at the most recent determination. This quantity was examined using univariate and multiple regression analyses.

RESULTS

Deviation of INR from target was continuously distributed, almost symmetrically about a mean of zero. The patients' age and sex had little bearing on control. Patients with a high target INR were more likely to be undertreated, and patients taking higher doses of warfarin were more likely to be overtreated. Previous over- or undertreatment were strongly related to poorer current control. The control of treatment varied substantially among the seven hospitals. One possible cause of this variation was the dose adjustment coefficient: the greater the dose adjustment for a given deviation from target INR, the better was the control achieved.

CONCLUSION

Several groups of patients were identified whose control was less satisfactory and in whom anticoagulant treatment needs particular scrutiny: these include patients with a record of previous over- or undertreatment, but not elderly patients in general. The variation in control among hospitals is a source of concern that merits further attention to achieve better uniformity of anticoagulant treatment.

Factors affecting the maintenance dose of warfarin

AIM

To identify the possible factors determining the dose of warfarin prescribed in patients receiving anticoagulant treatment.

METHODS

The computerised records of 2305 patients maintained on the drug in seven hospitals were amalgamated and classified into one of seven diagnostic groups. The associations with the dose of warfarin prescribed were investigated by univariate and multiple regression analysis. Differences between hospitals were studied with regard to the coagulometric method and the thromboplastin preparation used.

RESULTS

The geometric mean dose of warfarin was 4.57 mg and 5% of patients were prescribed 10 mg or greater. There was a noticeable decrease in dose with increasing age, which averaged about 6 mg for patients aged 30 but 3.5 mg for those aged 80. Men required slightly more warfarin than women. Patients with heart disease or atrial fibrillation required lower doses of warfarin, while higher doses were required by patients with deep vein thrombosis. Significant differences in mean warfarin dose among the seven hospitals were evident. These differences could not be explained entirely by the use of different coagulometric methods or thromboplastins.

CONCLUSIONS

Clinicians should be aware that older patients need reduced doses of warfarin. The considerable differences in doses of warfarin among hospitals indicates that further efforts to improve uniformity are required.

Stenosis of pulmonary veins in Down syndrome

Two patients with Down syndrome, intracardiac communications and elevated pulmonary arteriolar resistance presented early in life. Both patients had significant stenosis of pulmonary veins. The progressive nature of the stenosis is illustrated in one patient. Pulmonary venous stenosis in Down syndrome has been recorded only twice before in the literature, and may play a part in the early onset of pulmonary vascular occlusive disease in some patients.

Experience with a computer-assisted anticoagulant clinic

A microcomputer has been used for 6 years to assist in the running of the anticoagulant clinic for over 300 patients in a district general hospital. The dose adjustments and the time intervals to the next visit are decided automatically. The system has proved very satisfactory in practice, as shown by data presented. There is considerable saving of medical and secretarial time. There has been no equipment failure necessitating reversion to manual methods. The system produces letters (or labels), lists and continuous statistics, and allows the selection of various options, which makes it adaptable to the requirements of other hospitals.

Pinch skin grafting or porcine dermis in venous ulcers: a randomised clinical trial

Chronic venous ulcers are common, and even with effective compression or elevation large ulcers may take months to heal. Pinch skin grafting may allow healing from epithelial islands throughout the surface area of the ulcer, and a prospective randomised trial was therefore conducted comparing this treatment with porcine dermis dressings. Most patients were treated as outpatients, 25 ulcers being randomised to treatment with pinch skin grafts and 28 to treatment with porcine dermis. Though the groups were well matched, the mean healing rate in the first week was 15 cm2 for pinch skin grafts compared with 3.5 cm2 with porcine dermis (p less than 0.02). By life table analysis 64% of ulcers treated by pinch grafts were healed at six weeks and 74% by 12 weeks compared with 29% and 46% of ulcers, respectively, treated with porcine dermis dressings (chi2 = 4.1; p less than 0.05). All ulcers that failed to heal within 12 weeks included an area posterior to the medial malleolus, where local compression may have been inadequate. Pinch skin grafting improves the rate of healing in large venous ulcers and is a simple technique that may be performed as an outpatient procedure under local anaesthesia.

Squamous cell carcinoma of the breast

We saw two cases of pure squamous cell carcinoma of the breast, one of which is associated with dermatomyositis. Electron microscopy of appropriately fixed tissue obtained from one tumor confirmed the squamous nature of the polyhedral and spindle-shaped tumor cells. One tumor was assayed for estrogen and progesterone receptor proteins and was found to be lacking both. Test results for mucin and carcinoembryonic antigen (CEA) were negative in both tumors. In contrast, a similarly examined case of invasive ductal carcinoma with areas of squamous metaplasia had slightly elevated concentrations of estrogen and progesterone receptor proteins, and test results for mucin and CEA were positive.

Computer assisted management of warfarin treatment

Maintenance of anticoagulation is laborious and costly, and the results are often indifferent. An automatic system which adjusts the dose of warfarin has been designed using a formula devised after a survey of prescribing habits. Programs running on a microcomputer maintain a file of the necessary information and deal with the bulk of the weekly clinic. Dosage is advised, the date of the next visit determined, and the file updated. A doctor uses the console to advise some 10% of patients reserved for special reasons. The system produces clinic and ambulance lists, copies of the advice sent to patients, and, as a protection against machine failure, a weekly copy of the updated file. The results after 16 months are at least as good as those achieved manually. Medical and secretarial time is saved, and statistics about the clinic and its efficacy are made available.

Recognition and Management of Patients Who Repeatedly Swallow Foreign Bodies

Repeated swallowing of foreign bodies, in adults, is part of a syndrome comprising personality disorder, drug overdose, and other self-inflicted injuries. The management should be conservative, as in many cases the foreign body will pass naturally or can be left in the bowel, if necessary for several years. Surgical intervention should be reserved for the complications of perforation, severe haemorrhage and persistent complete bowel obstruction, or for the removal of a toxic substance from the bowel. Five cases are reported which illustrate the natural history and management of the problem.

Breakfast and Crohn's disease

The breakfast habits in adult life of 34 patients with Crohns disease were compared with those of 68 matched controls. Cornflakes were being eaten at least weekly by 23 of the patients (67--6%) at the time that their symptoms began, compared with 17 (25%) of the controls at the corresponding time. Only one of the 34 patients had not eaten cornflakes at all, compared with half of the controls. A significant but weaker association was found between Crohn's disease and the eating of wheat cereals. However, in both patients and controls the taking of cornflakes and of wheat cereals were correlated, and the observed preponderance of wheat eating among the patients was almost entirely ascribable to this association of habits. Eating of rice cereals and of porridge was not associated with Crohn's disease, though it was correlated with eating cornflakes. There was an excess of bran eaters among the propositi, but this, too, was attributable to their being also cornflake eaters. Other breakfast foods were taken with equal frequency, and omission of breakfast was equally common. Six of the 68 controls, but none of the patients, ate cornflakes later in the day but not at breakfast. The results need confirmation. There was no evidence that bias could have caused the correlation found. The association of Crohn's disease with the eating of cornflakes is strong and unlikely to be indirect. Variable digestive secretory behaviour after waking may play a part in determining susceptibility to Crohn's disease.