Patient resources in the therapeutic education of haemophiliacs in France: their skills and roles as defined by consensus of a working group

The activities of 'expert patients' or 'patient tutors', who help educate their peers, are gaining recognition in the health care system. This study investigates the role played by such patients in therapeutic education programmes organized by caregivers to validate the role of patients in implementing the therapeutic education of haemophilic patients and to define the skills required for such activities. This study employs the consensus methodology recommended by France's National Authority for Health. The working group includes seven caregivers from Hemophiliac Treatment Centers (HTCs) and three patients from the French Association of Hemophiliacs (FAH). The role of patients in haemophilia education is recognized. Patients participating in the education of their peers are referred to as 'patient resources'. A patient resource should be an adult, a volunteer and live in the same region as his peers. Candidates are chosen by the FAH and the HTCs to serve based on their motivation to facilitate the education of other patients as well as on their psychological and pedagogical aptitudes. A patient resource participates in the conception and administration of therapeutic education programmes. He also mediates between the caregivers and the patients. He ensures that the patients understand the material and are able to apply their knowledge in daily life. His activities are governed by professional ethics. Seven categories of skills were defined, permitting the group to determine precisely which skills are required to function as a patient resource. Supervision of the patients is planned to reinforce reflexive practices in the patients. Evolution of the health care system has led patients to become involved in therapeutic education. This phenomenon calls for a framework to be developed and an evaluation of its eventual effects.

Acquired inhibitor to factor VIII in a patient with Hodgkin's disease following treatment with interferon-alpha

We describe a young woman who developed acquired haemophilia after 18 months of interferon (IFN-)-alpha therapy. This patient had been monitored since 1992 for Hodgkin's disease initially treated by chemotherapy. After two relapses, she received intensive chemotherapy followed by an autologous peripheral progenitor cell graft. IFN-alpha was then administered for 18 months. Bleeding of the limbs and tongue occurred 1 month after withdrawal of IFN-alpha and high titres (123 Bethesda units) of autoantibody to factor VIII (FVIII):C were measured. Prednisone (1 mg kg(-1) day(-1)) achieved rapid cessation of the bleeding and FVIII autoantibodies were undetectable 5 months later. This case report suggests that the activated partial thromboplastin time should be regularly checked in every patient treated with IFN-alpha in cases of unexplained bleeding, together testing for antibodies to FVIII if the bleeding is prolonged.

The kinetics of antibodies against hepatitis C virus may predict viral clearance in exposed hemophiliacs

Several studies have reported the spontaneous loss of hepatitis C virus (HCV) antibodies in HCV-exposed persons. However, the relationship between seroreversion and spontaneous virus clearance has yet to be precisely determined in a single homogeneous population of untreated immunocompetent patients. In this study, 32 human immunodeficiency virus-seronegative hemophiliacs who had been exposed to HCV were followed for a mean duration of 141 months; 22 remained chronic carriers (68.8%). All but 1 of the nonviremic patients (90.0%) showed partial (8 cases) or complete (2 cases) seroreversion. In contrast, all but 1 of the viremic patients (95.1%) had a stable serologic profile when analyzed by a recombinant immunoblot assay. The results indicate that any HCV antibody-positive immunocompetent patient with no detectable serum HCV RNA and normal alanine aminotransferase values and whose serial samples show a progressive decrease in the level of HCV antibodies present may be considered as having a resolved infection.

[HIV infection among type A and B hemophiliacs]

Evolution of HIV infection was studied in 480 hemophiliacs A and 78 hemophiliacs B treated in the "Centre-West" Region. 23.3% hemophiliacs A and 46.1% hemophiliacs B were contaminated by HIV. In this region, HIV seroprevalence in hemophiliacs A was lower than the prevalence noted at the national level (51.2%); this is certainly due to the use of frozen cryoprecipitates in the treatment of a high number of hemophiliacs A. A higher number of hemophiliacs B developed the disease: 12.5% hemophiliacs A versus 22% hemophiliacs B. Moreover hemophilic B patients had a more rapid evolution towards the disease since 6 out of 14 hemophiliacs A and 7 out of 8 hemophiliacs B with AIDS died. The fact that hemophiliacs B were significantly older than hemophiliacs A might be one of the reasons, but it must be noted that the contamination often occurred earlier in hemophiliacs B and was perhaps more important. The more severe evolution in the hemophiliac B group noted in our region is not found in American studies, which may be due to the different ways of preparing Factor IX concentrates in France and the United States.

Prevalence and significance of hepatitis C virus (HCV) viremia in HCV antibody-positive subjects from various populations

Hepatitis C virus (HCV) infection is currently assessed by detection of antibodies to HCV with immunoassays. However, in the absence of an in vitro system to isolate the virus, or an immunoassay to identify HCV antigen in blood, an ongoing acute or chronic HCV infection can be diagnosed only by detection of HCV RNA by polymerase chain reaction. We used a reverse transcription-nested polymerase chain reaction to detect an HCV 5' noncoding viral RNA sequence in serum specimens collected from anti-HCV-positive individuals belonging to different risk groups and compared the results with those obtained with a prototype recombinant immunoblot assay (Chiron HCV SIA prototype recombinant immunoblot assay [RIBA]) containing four different viral peptides (c22, c33c, c100, and NS5). The prevalence of HCV viremia ranged from 25.9% in HCV antibody-positive blood donors to 92% in HCV antibody-positive hemophiliacs. Elevated alanine aminotransferase values in HCV antibody-positive patients were clearly associated with viremia. Ninety-six percent of HCV RNA-positive patients reacted to two viral antigens or more, compared with only 64% of HCV RNA-negative patients. Contrary to previous reports, HCV viremia was not associated with either the presence or the absence of a particular antibody specificity. The newly introduced NS5 peptide did not improve the sensitivity or specificity of the RIBA. Although 20% of the patients in our study whose sera reacted to all of the antigens were HCV RNA negative, the positive predictive value of a RIBA considered positive by the manufacturer (two or more bands), was rather high (78%) and may allow suspicion of viremia in EIA2 enzyme-linked immunosorbent assay-positive patients.

Comparison of anti-human and anti-porcine factor VIII inhibitor levels in 63 patients with severe haemophilia A. A French Multicentric Study

The levels of anti-human and anti-porcine factor VIII inhibitors, measured in 63 severe haemophilia A patients, lay in the ranges of < 0.2-2,600 and < 0.2-1,300 Bethesda units per ml (BU/ml), respectively, with a median cross-reactivity of 33%. In 4 patients, human and porcine inhibitor levels were determined using both plasma, either human or porcine, and factor VIII concentrate, either very high purity human or porcine (Hyate:C). A good correlation between titres was found, whatever the source of factor VIII (plasma or concentrate). The cross-reactivity varies from 0 to over 100%, indicating that the evaluation of both human and porcine inhibitors should be mandatory before any treatment with Hyate:C. Results show that of the 46 patients with human inhibitor of more than 5 BU/ml, 21 (46%) with a low porcine inhibitor (< 5 BU/ml) could benefit from Hyate:C.

[Efficacy in viral inactivation of the concentrates of factor VIII and IX by the solvent/detergent procedure. Evaluation in patients with hemophilia]

Human immunodeficiency virus (HIV) infection and hepatitis virus B or C (HBV, HCV) transmission are major risks following infusion of coagulation factor concentrates. Thus, several methods have been used to achieve viral inactivation of concentrates prepared from plasma collected from a large number of donors. In this study, 32 patients with haemophilia A or B (n = 31) or von Willebrand's disease (n = 1) were treated between 1987 and 1990 only with factor VIII or IX concentrates inactivated by the solvent-detergent procedure. During this period, none of these cases exhibited elevated liver enzymes (alanine amino transferase), and serological tests for HIV, HBV and HCV infections always remained negative. This suggests that the solvent-detergent procedure of concentrate inactivation is an efficient method to prevent not only HIV or HBV transmission but also HCV infection in haemophiliacs.

The white clot syndrome or heparin associated thrombocytopenia and thrombosis (WCS or HATT) (26 cases)

The Authors report a new iatrogenic complication of preventive or curative standard heparinotherapy. This so called "white clot syndrome" or "Heparin associated thrombocytopenia and thrombosis" is an anatomico-clinical entity characterized by severe, multiple, recurrent, arterial and/or venous thromboembolic accidents which are sometimes fatal. They appear, paradoxically, under heparin treatment and are concomitant with thrombocytopenia (generally less than 100 10(9)/l). Antiplatelet immunoallergic phenomena, via type IgG antibodies, induced by heparin, are the most commonly admitted in physiopathology; however they remain controversial. Treatment of "WCS" includes urgent suppression of standard heparin, administration of antivitamin K, or the new generation of low molecular weight heparin. This series presents 26 cases of HATT treated by LMWH (CY 216 CHOAY). Severe complications must be surgically cured. Prevention of WCS or HATT is mandatory by the systematic survey of platelet count during heparinotherapy.