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Holte M, Diaconu A, Ingerslev J, Thorn J, Pinholt E. Virtual surgical analysis: long-term cone beam computed tomography stability assessment of segmental bimaxillary surgery. Int J Oral Maxillofac Surg 2022; 51:1188-1196. [DOI: 10.1016/j.ijom.2022.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/21/2022] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
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Christensen MW, Keefe D, Wang F, Hansen C, Chamani I, Sommer C, Nyegaard M, Rohde P, Nielsen A, Bybjerg-Grauholm J, Kesmodel U, Knudsen U, Kirkegaard K, Ingerslev J. P–617 Idiopathic early ovarian aging: Do biomarkers of ageing indicate premenopausal accelerated biological ageing in young women with diminished response to ART? Hum Reprod 2021. [DOI: 10.1093/humrep/deab130.616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Study question
Do young women with idiopathic early ovarian ageing have changes in telomere length and epigenetic age indicating accelerated biological aging?
Summary answer
The telomere length and epigenetic age were comparable to those in young women with normal ovarian ageing.
What is known already
Increased risk of several health events usually considered to be age-related such as cardiovascular disease, osteoporosis, over-all morbidity and mortality have been associated with premature and early menopause when compared to the risk in women with normal menopausal age suggesting an accelerated general ageing process associated to early ovarian ageing. It is unclear whether the onset of this process may start before menopause.
Study design, size, duration
A prospective cohort study. Young women (≤ 37 years) having ART at two Danish Public fertility clinics during the period 2016 to 2018 were divided into two groups dependent on their ovarian reserve status: early ovarian ageing (EOA) (N = 55) and normal ovarian ageing (NOA)( N = 52). Number of oocytes harvested in first and subsequent cycles was used as a marker of ovarian reserve. Blood samples was drawn at time of oocyte retrieval to assess biological age.
Participants/materials, setting, methods
EOA was defined as ≥ 2 IVF cycles with ≤ 5 harvested oocytes despite sufficient stimulation with FSH and NOA as ≥ 8 oocytes harvested in minimum 1 cycle. Known causes influencing the ovarian reserve (endometriosis, ovarian surgery, etc.) was reason for exclusion. Relative telomere length (qPCR) and epigenetic age acceleration (DNA methylation levels) were measured in white blood cells as markers of accelerated biological ageing.
Main results and the role of chance
Relative telomere length was comparable with a mean of 0.46 (± sd 0.12) in the EOA group and 0.47 (0.14) in the normal ovarian ageing group (p = 0.64). The difference of predicted mean epigenetic age and mean chronological age (i.e. epigenetic age acceleration) was, insignificantly, 0.5 years older in the EOA group when compared to the NOA group( (–1.02 years (2.62) and –1.57 years (2.56), respectively, p = 0.27)), but this difference disappeared when adjusting for chronological age.
Limitations, reasons for caution
Discrete changes in epigenetic age acceleration may not have been captured as the study only had power to detect an age acceleration of ≥ 2 years.
Wider implications of the findings: By analysis of biomarkers for ageing in whole blood, we did not find any indications of a premenopausal accelerated aging in young women with idiopathic EOA. Further investigations in a similar cohort of premenopausal women is needed to fully elucidate the potential relationship between premenopausal accelerated biological ageing and EOA.
Trial registration number
The study was approved by the Danish Data protection Agency (nr 1–16–02–320–14) and the Regional committee on health research ethics of Central Region Denmark (jr.no 1–10–72–142–14).
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Affiliation(s)
- M W Christensen
- Horsens Regional Hospital, Fertility Clinic- Obstetrics and Gyneacology, Horsens, Denmark
- Aarhus University, Clinical Medicine, Aarhus, Denmark
| | - D Keefe
- New York University Langone Medical Center, Department of Obstetrics and Gynecology, New York, USA
| | - F Wang
- New York University Langone Medical Center, Department of Obstetrics and Gynecology, New York, USA
| | - C Hansen
- Statens Serum Institut, Center for Neonatal Screening- Department of Congenital Disorders, Copenhagen, Denmark
| | - I Chamani
- New York University Langone Medical Center, Department of Obstetrics and Gynecology, New York, USA
| | - C Sommer
- New York University Langone Medical Center, Department of Obstetrics and Gynecology, New York, USA
| | - M Nyegaard
- Aarhus University, Department of Biomedicine, Aarhus, Denmark
| | - P Rohde
- Aalborg University, Department of Chemistry and Bioscience, Aalborg, Denmark
| | - A Nielsen
- Aarhus University, Department of Biomedicine, Aarhus, Denmark
| | - J Bybjerg-Grauholm
- Statens Serum Institut, Center for Neonatal Screening- Department of Congenital Disorders, Copenhagen, Denmark
| | - U Kesmodel
- Aalborg University Hospital, Fertility Unit, Aalborg, Denmark
- Aalborg University, Clinical Medicine, Aalborg, Denmark
| | - U Knudsen
- Horsens Regional Hospital, Fertility Clinic- Obstetrics and Gyneacology, Horsens, Denmark
- Aarhus University, Clinical Medicine, Aarhus, Denmark
| | - K Kirkegaard
- Aarhus University Hospital, Obstetrics and Gynecology, Aarhus, Denmark
| | - J Ingerslev
- Aarhus University, Clinical Medicine, Aarhus, Denmark
- Aalborg University Hospital, Fertility Unit, Aalborg, Denmark
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Jakobsen C, Stokbro K, Kier-Swiatecka E, Ingerslev J, Thorn J. Autotransplantation of premolars: does surgeon experience matter? Int J Oral Maxillofac Surg 2018; 47:1604-1608. [DOI: 10.1016/j.ijom.2018.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/26/2018] [Accepted: 08/06/2018] [Indexed: 11/30/2022]
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Abstract
SummaryAlthough several investigators have attempted to identify the site of synthesis of factor VIII (FVIII), the cellular species responsible for maintenance of plasma FVIII has not been clearly defined. Indications point at hepatocytes and certain endothelial cells. The present study investigated the FVIII coagulant antigen (VIII : Ag) of hepatocytes obtained by two-step collagenase digests of human liver pieces. Following Percoll gradient centrifugation, less than 1% of cells harvested were non-parenchymal. Lysates of freshly isolated and purified hepatocytes contained 165–250 mU of VIII: Ag/106 cells as defined by a two-site ELISA employing a haemophilic antibody against human FVIII. This material contained a single peak of VIII: Ag polypeptides as jugded from the VIII: Ag ELISA profile of Mono-Q fast protein liquid chromatography fractions. A haemophilic antibody specific for epitopes of the light chain of FVIII, employed in immunoisolation of VIII : Ag in lysate of human hepatocytes, extracted a polypeptide pattern that was studied in a reduced SDS-PAGE electrophoresis gel and compared to that of immunoisolate from normal plasma. After electroblotting onto nitrocellulose and reaction with a monoclonal antibody towards the light chain of FVIII, the appearance of a doublet at 78–79 kDa in both these materials indicated the presence of the light chain of FVIII in human hepatocyte lysate. During culture, human hepatocytes secreted 20–80 mU of VIII: Ag per 1 × 106 cells per 24 hours. Further, a significant secretion of VIII: Ag was found in media of cultured human hepatoma cells, Hep-G2, whereas human blood monocytes and human fibroblasts did not secrete detectable VIII: Ag. In all of these cell cultures, vWf : Ag was indetectable or present as trace. Our results suggest that the human hepatocyte is a production site of FVIII.
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Affiliation(s)
- J Ingerslev
- The Departments of Clinical lmmunology and Clinical Chemistry University Hospital Aarhus, Aarhus C, Denmark
| | - B Sloth Christiansen
- The Departments of Clinical lmmunology and Clinical Chemistry University Hospital Aarhus, Aarhus C, Denmark
| | - L Heickendorff
- The Departments of Clinical lmmunology and Clinical Chemistry University Hospital Aarhus, Aarhus C, Denmark
| | - C Munck Petersen
- The Departments of Clinical lmmunology and Clinical Chemistry University Hospital Aarhus, Aarhus C, Denmark
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Abstract
ZusammenfassungFortschritte im Verständnis der Pathophysiologie, verbesserte diagnostische Techniken und Erfahrungen in den Erfordernissen der Therapie während der vergangenen 20 bis 25 Jahre haben zu deutlichen Verbesserungen der Sicherheit der Diagnose und der Lebensqualität von Patienten mit von Willebrand-Syndrom (VWS) geführt. Die wissenschaftlichen Erkenntnisse aus dieser Zeit haben dazu geführt, dass das VWS zurzeit als eine extrem heterogene Erkrankung gilt. Für einige Subtypen des VWS konnten die qualitativen Veränderungen des von-Willebrand-Faktors (VWF) eindeutig auf den zugrundeliegenden Gendefekt zurückgeführt werden, während dieses für andere Subtypen nicht gelungen ist. Für die häufigste Form, als Typ 1 bezeichnet, korreliert die Verminderung des VWF mit dem Funktionsverlust. Hier stehen wir allerdings erst in der Anfangsphase der Aufklärung der kausalen Gendefekte.Behandlungsgrundlagen, welche die Kriterien evidenzbasierter Richtlinien erfüllen, existieren nicht. Daher stützen sich die Therapiestrategien weitgehend auf Empirie. Die Basis dieser Übersichtsarbeit über Therapiemodalitäten bei VWS-Patienten beruht auf der aktuellen Literatur und der klinischen Erfahrung der Autoren. Es ist unsere Absicht, die Fragen aufzuzeigen, die zurzeit bezüglich der Therapie in Abhängigkeit von der VWS-Subtypisierung diskutiert werden. Über die aktuellen Therapieoptionen auf pharmakologischer Basis oder mittels Substitution hinaus, sollen auch solche aufgezeigt werden, die sich vielleicht schon in naher Zukunft ergeben können.
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6
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Napolitano M, Di Minno MND, Batorova A, Dolce A, Giansily-Blaizot M, Ingerslev J, Schved JF, Auerswald G, Kenet G, Karimi M, Shamsi T, Ruiz de Sáez A, Dolatkhah R, Chuansumrit A, Bertrand MA, Mariani G. Women with congenital factor VII deficiency: clinical phenotype and treatment options from two international studies. Haemophilia 2016; 22:752-9. [PMID: 27338009 DOI: 10.1111/hae.12978] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2016] [Indexed: 12/01/2022]
Abstract
INTRODUCTION A paucity of data exists on the incidence, diagnosis and treatment of bleeding in women with inherited factor VII (FVII) deficiency. AIM Here we report results of a comprehensive analysis from two international registries of patients with inherited FVII deficiency, depicting the clinical picture of this disorder in women and describing any gender-related differences. METHODS A comprehensive analysis of two fully compatible, international registries of patients with inherited FVII deficiency (International Registry of Factor VII deficiency, IRF7; Seven Treatment Evaluation Registry, STER) was performed. RESULTS In our cohort (N = 449; 215 male, 234 female), the higher prevalence of mucocutaneous bleeds in females strongly predicted ensuing gynaecological bleeding (hazard ratio = 12.8, 95% CI 1.68-97.6, P = 0.014). Menorrhagia was the most prevalent type of bleeding (46.4% of patients), and was the presentation symptom in 12% of cases. Replacement therapies administered were also analysed. For surgical procedures (n = 50), a receiver operator characteristic analysis showed that the minimal first dose of rFVIIa to avoid postsurgical bleeding during the first 24 hours was 22 μg kg(-1) , and no less than two administrations. Prophylaxis was reported in 25 women with excellent or effective outcomes when performed with a total weekly rFVIIa dose of 90 μg kg(-1) (divided as three doses). CONCLUSION Women with FVII deficiency have a bleeding disorder mainly characterized by mucocutaneous bleeds, which predicts an increased risk of ensuing gynaecological bleeding. Systematic replacement therapy or long-term prophylaxis with rFVIIa may reduce the impact of menorrhagia on the reproductive system, iron loss and may avoid unnecessary hysterectomies.
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Affiliation(s)
- M Napolitano
- Haematology Unit, Thrombosis and Hemostasis Reference Regional Center, University of Palermo, Palermo, Italy.
| | - M N D Di Minno
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - A Batorova
- The National Haemophilia Centre, Institute of Haematology and Blood Transfusion, School of Medicine of Comenius University, University Hospital, Bratislava, Slovakia
| | - A Dolce
- National Institute of Statistics, Palermo, Italy
| | | | - J Ingerslev
- Centre for Haemophilia & Thrombosis, University Hospital Skejby, Aarhus, Denmark
| | - J-F Schved
- Laboratory of Haematology, University Hospital, Montpellier, France
| | - G Auerswald
- Klinikum Bremen-Mitte, Prof.-Hess Kinderklinik, Bremen, Germany
| | - G Kenet
- National Hemophilia Center, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Karimi
- Haematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - T Shamsi
- National Institute of Blood Diseases & Bone Marrow Transplantation, Karachi, Pakistan
| | - A Ruiz de Sáez
- Centro Nacional de Hemophilia, Banco Municipal de Sangre, Caracas, Venezuela
| | - R Dolatkhah
- Haematology and Oncology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - A Chuansumrit
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Napolitano M, Dolce A, Batorova A, Giansily-Blaizot M, Ingerslev J, Mirbehbahani N, Di Minno MND, Lopez Fernandez MF, Karimi M, Charoenkwan P, Kavakli K, Mariani G. Replacement therapy in inherited factor VII deficiency: occurrence of adverse events and relation with surgery. Haemophilia 2015; 21:e513-e517. [PMID: 26249164 DOI: 10.1111/hae.12782] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2015] [Indexed: 06/04/2023]
Affiliation(s)
- M Napolitano
- Haematology Unit, Thrombosis and Hemostasis Reference Regional Center, Università di Palermo, Palermo, Italy
| | - A Dolce
- National Institute of Statistics, Palermo, Italy
| | - A Batorova
- The National Haemophilia Centre, Institute of Haematology and Blood Transfusion, University Hospital, Bratislava, Slovakia
| | | | - J Ingerslev
- Centre for Haemophilia & Thrombosis, University Hospital Skejby, Aarhus, Denmark
| | - N Mirbehbahani
- Hematology and Oncology Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - M N D Di Minno
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | | | - M Karimi
- Haematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - P Charoenkwan
- Division of Hematology, Chiang Mai University, Chiang Mai, Thailand
| | - K Kavakli
- Children's Hospital, Ege University Faculty of Medicine, Izmir, Turkey
| | - G Mariani
- Università di Ferrara Medical School, Ferrara, Italy
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8
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Morfini M, Batorova A, Mariani G, Auerswald G, Bernardi F, Di Minno G, Dolce A, Fede C, Giansily-Blaizot M, Ingerslev J, Martinowitz U, Napolitano M, Pinotti M, Schved JF. Pharmacokinetic properties of recombinant FVIIa in inherited FVII deficiency account for a large volume of distribution at steady state and a prolonged pharmacodynamic effect. Thromb Haemost 2014; 112:424-5. [PMID: 24763923 DOI: 10.1160/th13-12-1045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 03/11/2014] [Indexed: 12/17/2022]
Affiliation(s)
- M Morfini
- Massimo Morfini, Agency for Hemophilia and Regional Reference Center for Inherited Bleeding Disorders, Azienda Ospedalieriero, Universitaria Careggi, Florence, Italy, Tel.: +39 055 7947587, Fax: +39 055 7947794, E-mail:
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9
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Batorova A, Mariani G, Kavakli K, de Saez AR, Caliskan Ü, Karimi M, Pinotti M, Napolitano M, Dolce A, Sørensen B, Ingerslev J. Inhibitors to factor VII in congenital factor VII deficiency. Haemophilia 2014; 20:e188-91. [DOI: 10.1111/hae.12376] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2013] [Indexed: 11/27/2022]
Affiliation(s)
- A. Batorova
- The National Haemophilia Centre; University Hospital; Bratislava Slovakia
| | - G. Mariani
- University of Ferrara Medical School; Ferrara Italy
| | - K. Kavakli
- Department of Paediatric Haematology; Ege University Hospital; Haemophilia Center; Izmir Turkey
| | - A. R. de Saez
- National Haemophilia Centre; Banco Municipal de Sangre DC; Caracas Venezuela
| | - Ü. Caliskan
- Department of Paediatric Haematology; Necmettin Erbakan University; Konya Turkey
| | - M. Karimi
- Shiraz University; Haematology Research Center; Shiraz Iran
| | - M. Pinotti
- Department of Life Sciences and Biotechnology; University of Ferrara; Ferrara Italy
| | - M. Napolitano
- Haematology Unit; University of Palermo; Palermo Italy
| | - A. Dolce
- National Institute of Statistics; Palermo Italy
| | - B. Sørensen
- Haemostasis and Thrombosis Centre; Guy's & St Thomas' Hospital; London UK
| | - J. Ingerslev
- Centre for Haemophilia and Thrombosis; Aarhus University Hospital; Aarhus Denmark
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Ingerslev J, Lethagen S, Hvitfeldt Poulsen L, Sørensen B, Lopatina E, Tentsova I, Yastrubinetskaya O, Plyushch OP. Long-standing prophylactic therapy vs. episodic treatment in young people with severe haemophilia: a comparison of age-matched Danish and Russian patients. Haemophilia 2013; 20:58-64. [DOI: 10.1111/hae.12242] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2013] [Indexed: 11/27/2022]
Affiliation(s)
- J. Ingerslev
- National Haemophilia Center; Skejby University Hospital; Copenhagen Denmark
| | - S. Lethagen
- National Haemophilia Center; University Hospital, Rigshospitalet; Copenhagen Denmark
| | | | - B. Sørensen
- National Haemophilia Center; Skejby University Hospital; Copenhagen Denmark
- Center for Haemostasis and Thrombosis; St. Thomas Hospital; London UK
| | - E. Lopatina
- Center for Hematological Research; Moscow Russia
| | - I. Tentsova
- Center for Hematological Research; Moscow Russia
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Lalezari S, COPPOLA A, Lin J, Enriquez MM, Tseneklidou-Stoeter D, Powell J, Ingerslev J. Patient characteristics that influence efficacy of prophylaxis with rFVIII-FS three times per week: a subgroup analysis of the LIPLONG study. Haemophilia 2013; 20:354-61. [DOI: 10.1111/hae.12306] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- S. Lalezari
- The National Hemophilia Center; Chaim Sheba Medical Center; Tel-Hashomer Israel
| | - A. COPPOLA
- Regional Reference Center for Coagulation Disorders; Federico II University Hospital; Naples Italy
| | - J. Lin
- Brigham and Women's Hospital; Boston MA USA
| | | | | | - J. Powell
- University of California, Davis; Sacramento CA USA
| | - J. Ingerslev
- Centre for Haemophilia and Thrombosis; Skejby University Hospital; Aarhus Denmark
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Abstract
In the past decades von Willebrand disease (vWD) has, in several respects, fallen into the shadow of classical haemophilia due to all problems that have faced those dealing with congenital bleeding disorders, not least regarding blood-borne diseases. The time has come to revisit and refocus on vWD, probably the most common bleeding disorder. Accordingly, a number of Nordic physicians and scientists working in this field organized a meeting on the ferry boat from Stockholm to Mariehamn, in the Aland islands, the home of the index families with this disease, as described by Erik von Willebrand in 1926. The objective of the meeting was to make a comprehensive survey of vWD as seen from the situation in the Nordic countries. In order to achieve all goals some scientists of note from countries outside the Nordic area were invited as well. This paper gives a summary of the symposium, mainly based on the separate papers published in this issue.
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Affiliation(s)
- E Berntorp
- Department for Coagulation Disorders, University Hospital, Malmö, Sweden.
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13
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Jensen MS, Larsen OH, Christiansen K, Fenger-Eriksen C, Ingerslev J, Sørensen B. Platelet activation and aggregation: the importance of thrombin activity-A laboratory model. Haemophilia 2013; 19:403-8. [DOI: 10.1111/hae.12099] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2012] [Indexed: 12/28/2022]
Affiliation(s)
| | | | | | - C. Fenger-Eriksen
- Centre for Haemophilia and Thrombosis; Aarhus University Hospital; Skejby; Denmark
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14
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Saulyte Trakymiene S, Clausen N, Poulsen LH, Ingerslev J, Rageliene L. Progression of haemophilic arthropathy in children: a Lithuanian--Danish comparative study. Haemophilia 2012; 19:212-8. [PMID: 23167920 DOI: 10.1111/hae.12058] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2012] [Indexed: 11/29/2022]
Abstract
Recurrent bleeding into joints initiates a sequence of events leading to a progressive joint damage in people with severe haemophilia. This is a continuous process during childhood and adolescence, therefore joint abnormalities may be minimal on physical examination in very young children - even those receiving on-demand treatment. The aim of our study was to quantify the burden of arthropathy in Lithuanian patients who had been treated exclusively by on-demand substitution and compare their physical joint health with age-matched Danish patients who received prophylaxis from an early age. Boys, aged 4-17 years, with severe haemophilia and no signs of inhibitors were included in the study. Joint outcome based on the Haemophilia Joint Health Score (HJHS) was analysed in two different treatment groups and compared within the matched pairs. In total, 32 (16 in each treatment group) patients were enroled. A total of 192 joints were evaluated. Joint status according to treatment strategy was strikingly different: 27.4 for on-demand vs. 3.3 for prophylaxis (<0.001) group. Significance of the difference in joint status comparing different treatment strategies was equally strong both in younger (4-9 years) and older (10-17 years) patient groups: 2.2 vs. 12.5 (P = 0.0002) and 3.9 vs. 36.3 (P < 0.0001) respectively. The results further demonstrate the unequivocal effect of prophylaxis on joint status and give an insight into early and late manifestations of joint impairment based on the HJHS in haemophilia patients with treatment on-demand compared with joint changes that may develop over the time with the preventative treatment.
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Affiliation(s)
- S Saulyte Trakymiene
- Clinic of Children's Diseases, Vilnius University and Centre for Pediatric Hematology/Oncology, Children's Hospital, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania.
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15
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Kirkegaard K, Hindkjær J, Ingerslev J. Hatching of human embryos evaluated by time-lapse analysis: the influence of fertilization method. Fertil Steril 2012. [DOI: 10.1016/j.fertnstert.2012.07.365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Astermark J, Makris M, Mauser-Bunschoten E, Nemes L, D'oiron R, Oldenburg J, Ingerslev J. Malignant disease in the haemophilic population: moving towards a management consensus? Haemophilia 2012; 18:664-71. [DOI: 10.1111/j.1365-2516.2012.02846.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2012] [Indexed: 12/12/2022]
Affiliation(s)
- J. Astermark
- Centre for Thrombosis and Hemostasis, Skåne University Hospital Malmö; Malmö; Sweden
| | - M. Makris
- Department of Cardiovascular Science; University of Sheffield, Royal Hallamshire Hospital; Sheffield; UK
| | - E. Mauser-Bunschoten
- Van Creveldkliniek and Hematology University Medical Center Utrecht; Utrecht; The Netherlands
| | - L. Nemes
- National Haemophilia Centre and Haemostasis Department; State Health Centre; Budapest; Hungary
| | - R. D'oiron
- Haemophilia Centre, AP-HP Bicêtre Hospital, Paris-XI University; Le Kremlin-Bicêtre; Paris; France
| | - J. Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic; Bonn; Germany
| | - J. Ingerslev
- Kings College London School of Medicine; London; UK
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Peyvandi F, Palla R, Menegatti M, Siboni SM, Halimeh S, Faeser B, Pergantou H, Platokouki H, Giangrande P, Peerlinck K, Celkan T, Ozdemir N, Bidlingmaier C, Ingerslev J, Giansily-Blaizot M, Schved JF, Gilmore R, Gadisseur A, Benedik-Dolničar M, Kitanovski L, Mikovic D, Musallam KM, Rosendaal FR. Coagulation factor activity and clinical bleeding severity in rare bleeding disorders: results from the European Network of Rare Bleeding Disorders. J Thromb Haemost 2012; 10:615-21. [PMID: 22321862 DOI: 10.1111/j.1538-7836.2012.04653.x] [Citation(s) in RCA: 278] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The European Network of Rare Bleeding Disorders (EN-RBD) was established to bridge the gap between knowledge and practise in the care of patients with RBDs. OBJECTIVES To explore the relationship between coagulation factor activity level and bleeding severity in patients with RBDs. PATIENTS/METHODS Cross-sectional study using data from 489 patients registered in the EN-RBD. Coagulation factor activity levels were retrieved. Clinical bleeding episodes were classified into four categories according to severity. RESULTS The mean age of patients at data collection was 31 years (range, 7 months to 95 years), with an equal sex distribution. On linear regression analysis, there was a strong association between coagulation factor activity level and clinical bleeding severity for fibrinogen, factor (F) X, FXIII, and combined FV and FVIII deficiencies. A weaker association was present for FV and FVII deficiencies. There was no association between coagulation factor activity level and clinical bleeding severity for FXI. The coagulation factor activity levels that were necessary for patients to remain asymptomatic were: fibrinogen, > 100 mg dL(-1); FV, 12 U dL(-1); combined FV + VIII, 43 U dL(-1); FVII, 25 U dL(-1); FX, 56 U dL(-1) ; FXI, 26 U dL(-1); FXIII, 31 U dL(-1). Moreover, coagulation factor activity levels that corresponded with Grade III bleeding were: undetectable levels for fibrinogen, FV and FXIII, < 15 U dL(-1) for combined FV + VIII; < 8 U dL(-1) for FVI; < 10 U dL(-1) for FX; and < 25 U dL(-1) for FXI. CONCLUSIONS There is a heterogeneous association between coagulation factor activity level and clinical bleeding severity in different RBDs. A strong association is only observed in fibrinogen, FX and FXIII deficiencies.
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Affiliation(s)
- F Peyvandi
- UOS Dipartimentale per la Diagnosi e la Terapia delle Coagulopatie, A Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano and Luigi Villa Foundation, Milan, Italy.
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18
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Abstract
BACKGROUND Patients with a history of venous thrombosis occasionally have shortened APTTs when compared with those of healthy references, but the clinical applicability of a shortened APTT is limited. OBJECTIVES The present study aimed to characterize dynamic APTT profiles in patients with previously documented venous thrombosis and hypothesized that the APTT-MaxVel was significantly elevated in patients with a history of venous thrombosis as compared with healthy controls. METHODS We performed a case control study, enrolling a total of 38 patients, 17 males and 21 females, with a verified recent venous thrombotic event, as well as 88 healthy controls. Fifty-three per cent of patients were found to have a biochemical risk factor. A standard APTT was recorded in platelet-poor plasma, and the digital clotting signal was processed using simple algorithms developed to derive dynamic coagulation parameters. RESULTS Patients had a significantly higher mean APTT-MaxVel (195.5 s(-1) ; SD = 57; 95% CI, 176.8-214.1) as compared with healthy controls (137.3 s(-1) ; SD = 21; 95% CI, 130.7-143.8). Patients also had significantly shorter mean APTTs (26.9 s; SD = 3.2; 95% CI, 25.9-28.0) than healthy controls (28.5 s; SD = 2.8; 95% CI, 27.9-29.0). While only one out of 38 patients (2.6%) had a standard APTT below the lower reference interval, 15 of the 38 patients (38.5%) had an APTT-MaxVel above the upper reference limit. Regression analysis revealed linear correlation between FVIII:C, the level of fibrinogen and APTT-MaxVel (R(2) = 0.89, P < 0.05). CONCLUSIONS Simple signal processing of the APTT and the use of dynamic parameters represents a stronger predictive marker for hypercoagulation in patients with verified venous thrombosis than the standard APTT measurement.
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Affiliation(s)
- B Sørensen
- Haemostasis Research Unit, Centre for Haemostasis and Thrombosis, Guy's and St Thomas' NHS Foundation & King's College London School of Medicine, London, UK.
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Swiatecka E, Thorn J, Ingerslev J. Bone Harvest from the Iliac Crest for Pre-Prosthetic Procedures in Denmark. Donor Site Morbidity of the Anterior and the Posterior Approach. J Oral Maxillofac Surg 2011. [DOI: 10.1016/j.joms.2011.06.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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20
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Moessner BK, Andersen ES, Weis N, Laursen AL, Ingerslev J, Lethagen S, Pedersen C, Christensen PB. Previously unrecognized advanced liver disease unveiled by transient elastography in patients with Haemophilia and chronic hepatitis C. Haemophilia 2011; 17:938-43. [PMID: 21435119 DOI: 10.1111/j.1365-2516.2011.02520.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Before the introduction of viral inactivation procedures and viral screening of plasma-products, haemophiliacs were at high risk of infection with HCV. Those who acquired HCV infection in the 1980s, and are still alive today, may have developed significant liver fibrosis or cirrhosis. However, liver biopsy has not routinely been utilized in the evaluation of haemophiliacs with HCV in Denmark. The aim of this study was to investigate the prevalence of significant fibrosis/cirrhosis among haemophiliacs as evaluated by transient elastography (TE). Cross-sectional investigation of adult patients with haemophilia A or B. TE with liver stiffness measurements (LSM) ≥ 8 kPa were repeated after 4-6 weeks. Significant fibrosis and cirrhosis was defined as measurements ≥ 8 kPa or ≥ 12 kPa respectively. Among 307 patients with haemophilia A or B registered at the two Haemophilia centres, 141(46%) participate in this study. Forty (28.4%) had chronic hepatitis C, 33 (23.4%) past hepatitis C and 68 (48.2%) had never been infected, at screening LSM ≥ 8 kPa were found in 45.7%, 24.7% and 4.6% respectively. Among patients with chronic hepatitis C significant fibrosis was confirmed in 17.1% and cirrhosis in 2.9% by repeated LSM ≥ 8 and ≥ 12 kPa respectively. The median TE-value in never HCV-infected haemophiliacs was comparable with what has been found in healthy non-haemophiliacs. In Danish haemophiliacs where liver biopsy has not routinely been used for assessing severity of liver fibrosis, LSM identified advanced liver disease in one-fifth of cases that had not been recognized during clinical follow-up.
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Affiliation(s)
- B K Moessner
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
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21
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Abstract
BACKGROUND Abnormal thrombin generation is considered the key defect in hemophilia. Conventional treatment seeks to correct this using coagulation factor replacement or bypassing agents, for example recombinant factor VIIa (rFVIIa). Previous studies demonstrate abnormal FXIII activation in patients with hemophilia. FXIII activation is essential for formation of structurally normal, stable clots. OBJECTIVES The present study challenges the hypothesis that in hemophilia the use of plasma-derived FXIII (pdFXIII) in combination with rFVIIa will produce a greater improvement in clot stability than promotion of thrombin generation alone. METHODS Fourteen individuals with severe hemophila A were enrolled. Whole blood was spiked ex vivo with buffer, rFVIIa (2 μg mL(-1)) or rFVIIa (2 μg mL(-1)) plus pdFXIII (10 μg mL(-1)). Whole blood thromboelastometry assessed clot stability, after activation with tissue factor (TF) (0.15 pm) plus tissue-type plasminogen activator (tPa) (2 nm). The primary outcome measure of clot stability was area under the elasticity curve (AUEC). RESULTS The combination of pdFXIII and rFVIIa significantly improved clot stability as measured by AUEC (P < 0.05) compared with rFVIIa alone. CONCLUSION The use of pdFXIII resulted in superior clot stability compared with solely enhancing thrombin generation and we suggest that increasing thrombin generation alone fails to fully correct dysregulation of clot-stabilizing mechanisms associated with bleeding disorders. Hemorrhage control in hemophilia may be improved using clot stabilizing drugs. FXIII shows potential as a novel agent.
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Affiliation(s)
- C J Rea
- Haemostasis Research Unit, Guy's & St Thomas' NHS Foundation Trust and King's College London School of Medicine, London, UK
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22
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Chitlur M, Sorensen B, Rivard GE, Young G, Ingerslev J, Othman M, Nugent D, Kenet G, Escobar M, Lusher J. Standardization of thromboelastography: a report from the TEG-ROTEM working group. Haemophilia 2011; 17:532-7. [PMID: 21323795 DOI: 10.1111/j.1365-2516.2010.02451.x] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Laboratory evaluation of bleeding disorders has been performed with the standard clotting assays such as the PT and PTT for several decades. Our improved understanding of the process of blood coagulation has now revealed the important role played by the cellular elements such as platelets, monocytes and red blood cells. The need for a test that can assess clotting in a more 'global' manner, beyond the initiation of clot formation, has led to greater interest in assays such as thrombin generation and thromboelastography. Even though there are several publications using thromboelastography it remains a research tool as the methodology is not standardized. In an attempt to show reproducibility and consistency using thromboelastography, a group of investigators from different countries joined hands to form the TEG-ROTEM Working Group. Two studies were performed using PRP and FVIII deficient plasma and an intrinsic pathway activator. This article summarizes the results of the first international effort at standardization of thromboelastography. Both of the instruments using this technology (TEG(®) and ROTEM(®)) were used. Nine laboratories from countries around the globe participated in this effort. The results showed a significant inter-laboratory variance with CV's greater than 10%. Although these results were not satisfactory, this has been the first effort to standardize this methodology and significant work remains to be done to improve reliability and reproducibility. These studies were performed on PRP and the results may be more reliable when preformed on whole blood samples. We believe that it is important to continue this work so that we may investigate the usefulness and potential applications of thromboelastography in the evaluation of bleeding and thrombosis.
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Affiliation(s)
- M Chitlur
- Division of Hematology/Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University/Children's Hospital of Michigan, Detroit, MI 48201, USA.
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Castaman G, Tosetto A, Cappelletti A, Goodeve A, Federici A, Batlle J, Meyer D, Goudemand J, Eikenboom J, Schneppenheim R, Budde U, Ingerslev J, Lethagen S, Hill F, Peake I, Rodeghiero F. Validation of a rapid test (VWF-LIA) for the quantitative determination of von Willebrand factor antigen in type 1 von Willebrand disease diagnosis within the European multicenter study MCMDM-1VWD. Thromb Res 2010; 126:227-31. [DOI: 10.1016/j.thromres.2010.06.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Revised: 06/16/2010] [Accepted: 06/17/2010] [Indexed: 10/19/2022]
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Tefre KL, Ingerslev J, Sørensen B. Clinical benefit of recombinant factor VIIa in management of bleeds and surgery in two brothers suffering from the Bernard-Soulier syndrome. Haemophilia 2009; 15:281-4. [PMID: 19149853 DOI: 10.1111/j.1365-2516.2008.01902.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Bernard-Soulier syndrome (BSS) is a rare congenital bleeding disorder characterized by thrombocytopenia and giant platelets that display impaired or absent platelet agglutination with ristocetin. The disease is caused by mutations in genes controlling the expression of the platelet glycoprotein Ib-IX complex. The most severely affected patients suffer from profound muco-cutaneous bleeding tendency. Patients suffering from BSS may require platelet transfusion in prevention and management of severe bleeding. However, recent publications have suggested that recombinant factor VIIa (rFVIIa) infusion may support haemostasis in BSS. The present report describes two brothers who received treatment with rFVIIa together with tranexamic acid on a total of six occasions in management of haemostasis in minor surgery and for a serious spontaneous upper gastrointestinal tract bleed. Although platelet transfusion was omitted, haemostasis was regarded excellent in all of these treatment episodes.
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Affiliation(s)
- K L Tefre
- University of Aarhus, Faculty of Health Sciences, Aarhus, Denmark
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25
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Eikenboom J, Hilbert L, Ribba AS, Hommais A, Habart D, Messenger S, Al-Buhairan A, Guilliatt A, Lester W, Mazurier C, Meyer D, Fressinaud E, Budde U, Will K, Schneppenheim R, Obser T, Marggraf O, Eckert E, Castaman G, Rodeghiero F, Federici AB, Batlle J, Goudemand J, Ingerslev J, Lethagen S, Hill F, Peake I, Goodeve A. Expression of 14 von Willebrand factor mutations identified in patients with type 1 von Willebrand disease from the MCMDM-1VWD study. J Thromb Haemost 2009; 7:1304-12. [PMID: 19566550 DOI: 10.1111/j.1538-7836.2009.03486.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Candidate von Willebrand factor (VWF) mutations were identified in 70% of index cases in the European study 'Molecular and Clinical Markers for the Diagnosis and Management of type 1 von Willebrand Disease'. The majority of these were missense mutations. OBJECTIVES To assess whether 14 representative missense mutations are the cause of the phenotype observed in the patients and to examine their mode of pathogenicity. METHODS Transfection experiments were performed with full-length wild-type or mutant VWF cDNA for these 14 missense mutations. VWF antigen levels were measured, and VWF multimer analysis was performed on secreted and intracellular VWF. RESULTS For seven of the missense mutations (G160W, N166I, L2207P, C2257S, C2304Y, G2441C, and C2477Y), we found marked intracellular retention and impaired secretion of VWF, major loss of high molecular weight multimers in transfections of mutant constructs alone, and virtually normal multimers in cotransfections with wild-type VWF, establishing the pathogenicity of these mutations. Four of the mutations (R2287W, R2464C, G2518S, and Q2520P) were established as being very probably causative, on the basis of a mild reduction in the secreted VWF or on characteristic faster-running multimeric bands. For three candidate changes (G19R, P2063S, and R2313H), the transfection results were indistinguishable from wild-type recombinant VWF and we could not prove these changes to be pathogenic. Other mechanisms not explored using this in vitro expression system may be responsible for pathogenicity. CONCLUSIONS The pathogenic nature of 11 of 14 candidate missense mutations identified in patients with type 1 VWD was confirmed. Intracellular retention of mutant VWF is the predominant responsible mechanism.
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Affiliation(s)
- J Eikenboom
- Department of Thrombosis and Haemostasis, Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Centre, Leiden, The Netherlands.
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26
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Hvitfeldt Poulsen L, Christiansen K, Sørensen B, Ingerslev J. Whole blood thrombelastographic coagulation profiles using minimal tissue factor activation can display hypercoagulation in thrombosis‐prone patients. Scandinavian Journal of Clinical and Laboratory Investigation 2009; 66:329-36. [PMID: 16777761 DOI: 10.1080/00365510600672783] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Recently, our laboratory devised a dynamic whole blood (WB) thrombelastographic coagulation model employing activation with minute amounts of tissue factor. A series of studies were conducted to validate the feasibility of the model to illustrate hypocoagulation in various bleeding disorders and its usefulness in detecting the haemostatic effect of pro-coagulants by ex vivo titration experiments. In this context, the present study hypothesized that the thrombelastographic model also can reveal hypercoagulation. Hence, the objective of the present study was to record dynamic WB coagulation profiles in a series of patients (n=76) who had previously suffered from a venous (n=34) or arterial (n=42) thrombo-embolic event and to compare the results with those of a group of healthy reference subjects (n=60). MATERIAL AND METHODS Patients receiving vitamin K antagonist treatment were not enrolled in the study. Forty-four of the patients had no known thrombophilia risk factor and 32 patients had at least one thrombophilia risk factor. RESULTS The most commonly found risk factors were mild hyperhomocysteinaemia and heterozygosity for the factor V Leiden polymorphism. The data showed that, as compared with the healthy controls, patients with a history of venous or arterial thromboembolism had a significantly greater hypercoagulant WB coagulation clot signature as defined by a shortened clotting time together with an accelerated maximum velocity of clot propagation. CONCLUSIONS In future studies with ex vivo dose titration assessment of pro-coagulant components mixed with blood from a patient suffering from compromised haemostasis, observation of a significantly shortened clot initiation concomitant with a distinctly accelerated clot propagation is likely to indicate an increased risk of thrombosis.
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Affiliation(s)
- L Hvitfeldt Poulsen
- Centre for Haemophilia and Thrombosis, Department of Biochemistry, Aarhus University Hospital, Skejby, Denmark
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27
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Abstract
BACKGROUND The biochemical mechanisms causing dilutional coagulopathy following infusion of hydroxyethyl starch 130/0.4 (HES) are not known in detail. OBJECTIVES To give a detailed biochemical description of the mechanism of coagulopathy following 30%in vivo dilution with HES, to present a systematic ex vivo test of various hemostatic agents, and to investigate the hypothesis that acquired fibrinogen deficiency constitutes the most important determinant of the coagulopathy. METHODS Dynamic whole blood clot formation assessed by thromboelastometry, platelet count, thrombin generation, and the activities of von Willebrand factor, coagulation factor II, FVII, FVIII, FIX, FX and FXIII were measured in 20 bleeding patients enrolled in a prospective clinical study investigating in vivo substitution of blood loss with HES up to a target level of 30%. Thromboelastometry parameters were further evaluated after ex vivo spiking experiments with fibrinogen, prothrombin complex concentrate (PCC), FXIII, activated recombinant FVIIa (rFVIIa), fresh frozen plasma, and platelets. RESULTS Hemodilution reduced maximum clot firmness (MCF), whereas whole blood clotting time (CT) and maximum velocity remained unaffected. All coagulation factor activities were reduced. Fibrinogen, FII, FXIII and FX activities decreased significantly below the levels expected from dilution. The endogenous thrombin potential was unchanged. Ex vivo addition of fibrinogen normalized the reduced MCF and increased the maximum velocity, whereas PCC, rFVIIa and platelets shortened the CT but showed no effect on the reduced MCF. CONCLUSIONS Acquired fibrinogen deficiency seems to be the leading determinant in dilutional coagulopathy, and ex vivo addition corrected the coagulopathy completely.
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Affiliation(s)
- C Fenger-Eriksen
- Department of Anaesthesiology, Centre for Haemophilia and Thrombosis, Aarhus University Hospital, Aarhus, Denmark.
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28
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Fenger-Eriksen C, Jensen TM, Kristensen BS, Jensen KM, Tønnesen E, Ingerslev J, Sørensen B. Fibrinogen substitution improves whole blood clot firmness after dilution with hydroxyethyl starch in bleeding patients undergoing radical cystectomy: a randomized, placebo-controlled clinical trial. J Thromb Haemost 2009; 7:795-802. [PMID: 19320829 DOI: 10.1111/j.1538-7836.2009.03331.x] [Citation(s) in RCA: 197] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
SUMMARY BACKGROUND Infusion of artificial colloids such as hydroxyethyl starch (HES) induces coagulopathy to a greater extent than simple dilution. Several studies have suggested that the coagulopathy could be corrected by substitution with a fibrinogen concentrate. OBJECTIVES The aims of the present prospective, randomized, placebo-controlled trial were to investigate the hemostatic effect of a fibrinogen concentrate after coagulopathy induced by hydroxyethyl starch in patients experiencing sudden excessive bleeding during elective cystectomy. METHODS Twenty patients were included. Blood loss was substituted 1:1 with HES 130/0.4. At a dilution level of 30%, patients were randomly selected for intra-operative administration of a fibrinogen concentrate or placebo. The primary endpoint was maximum clot firmness (MCF), as assessed by thromboelastometry. Secondary endpoints were blood loss and transfusion requirements, other thromboelastometry parameters, thrombin generation and platelet function. RESULTS Whole-blood MCF was significantly reduced after 30% dilution in vivo with HES. The placebo resulted in a further decline of the MCF, whereas randomized administration of fibrinogen significantly increased the MCF. Furthermore, only 2 out of 10 patients randomly chosen to receive fibrinogen substitution required postoperative red blood cell transfusions, compared with 8 out of 10 in the placebo group (P = 0.023). Platelet function and thrombin generation were reduced after 30% hemodilution in vivo, and fibrinogen administration caused no significant changes. CONCLUSIONS During cystectomy, fluid resuscitation with HES 130/0.4 during sudden excessive bleeding induces coagulopathy that shows reduced whole-blood maximum clot firmness. Randomized administration of fibrinogen concentrate significantly improved maximum clot firmness and reduced the requirement for postoperative transfusion.
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Affiliation(s)
- C Fenger-Eriksen
- Department of Anaesthesiology, Center for Haemophilia and Thrombosis, Aarhus, Denmark
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29
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Bernardi F, Dolce A, Pinotti M, Shapiro AD, Santagostino E, Peyvandi F, Batorova A, Lapecorella M, Schved JF, Ingerslev J, Mariani G. Major differences in bleeding symptoms between factor VII deficiency and hemophilia B. J Thromb Haemost 2009; 7:774-9. [PMID: 19245420 DOI: 10.1111/j.1538-7836.2009.03329.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
SUMMARY BACKGROUND The autosomally-inherited factor VII (FVII) deficiency and X-linked hemophilia B offer an attractive model to investigate whether reduced levels of FVII and FIX, acting in the initiation and amplification of coagulation respectively, influence hemostasis to a different extent in relation to age and bleeding site. METHODS Hemophilia B patients (n = 296) and FVII-deficient males (n = 109) were compared for FVII/FIX clotting activity, F7/F9 genotypes and clinical phenotypes in a retrospective, multi-centre, cohort study. RESULTS Major clinical differences between diseases were observed. Bleeding occurred earlier in hemophilia B (median age 2.0 years, IR 0.9-5.0) than in FVII deficiency (5.2 years, IR 1.9-15.5) and the bleeding-free survival in FVII deficiency was similar to that observed in 'mild' hemophilia B (P = 0.96). The most frequent disease-presenting symptoms in hemophilia B (hematomas and oral bleeding) differed from those in FVII deficiency (epistaxis and central nervous system bleeding). Differences were confirmed by analysis of FVII-deficient women. CONCLUSIONS Our data support the notion that low FVII levels sustain hemostasis better than similarly reduced FIX levels. On the other hand, minute amounts of FVII, differently to FIX, are needed to prevent fatal bleeding, as indicated by the rarity of null mutations and the associated life-threatening symptoms in FVII deficiency, which contributes towards shaping clinical differences between diseases in the lowest factor level range. Differences between diseases are only partially explained by mutational patterns and could pertain to the specific roles of FVII and FIX in coagulation phases and to vascular bed-specific components.
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Affiliation(s)
- F Bernardi
- Department of Biochemistry and Molecular Biology, University of Ferrara, Ferrara, Italy.
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Fenger-Eriksen C, Tønnesen E, Ingerslev J, Sørensen B. Recombinant factor VIIa and fibrinogen display additive effect during in vitro haemodilution with crystalloids. Acta Anaesthesiol Scand 2009; 53:332-8. [PMID: 19243319 DOI: 10.1111/j.1399-6576.2008.01875.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Major blood loss requires fluid resuscitation for maintaining hemodynamic stability. Excessive volume infusions predispose to dilutional coagulopathy through loss, consumption and dilution of cells and proteins involved in haemostasis. Further treatment with fibrinogen concentrate and/or recombinant activated factor VII (rFVIIa) may be initiated, although the haemostatic effects in a situation with haemodilution are not fully detailed. The present study evaluates haemostatic effect of fibrinogen and rFVIIa and their combination in an in vitro model of haemodiluted whole blood with two commonly used crystalloids. METHODS Eight healthy, male volunteers were enrolled. Outcome variables were clot initiation, propagation and strength assessed by thrombelastographic parameters: clotting time, clot formation time, maximum velocity, time until maximum velocity, maximum clot firmness evaluated at dilution levels of 0% (control), 10%, 30% and 50% with isotonic saline and Ringer's lactate in a model of tissue factor-activated whole blood. Fibrinogen and rFVIIa were additional final reaction concentrations, reflecting commonly used clinically therapeutic dosages. RESULTS Dose-dependent coagulopathy developed following haemodilution with isotonic saline and Ringer's lactate, characterised by a prolonged clot initiation, reduced clot propagation and reduced clot strength. Fibrinogen improved clot strength and propagation phase while rFVIIa shortened clot initiation, both with a positive dose dependency. CONCLUSIONS The combination of fibrinogen and rFVIIa displays an additive effect and improves overall in vitro whole blood clot formation in a model of in vitro crystalloid-induced haemodilution.
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Affiliation(s)
- C Fenger-Eriksen
- Department of Anesthesiology, Center for Haemophilia and Thrombosis, Aarhus University Hospital, Aarhus, Denmark.
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Tuddenham EG, Ingerslev J, Sørensen LN, Christiansen K, Mariani G, Peyvandi F, Waddington SN, Buckley SMK, Kochanek S, Chuah MK, Vandendriessche T, Berntorp E. Genetic aspects and research development in haemostasis. Haemophilia 2008; 14 Suppl 3:113-8. [PMID: 18510530 DOI: 10.1111/j.1365-2516.2008.01740.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- E G Tuddenham
- Haemophilia Centre and Haemostasis Unit, Royal Free Hospital, London, United Kingdom
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32
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Fenger-Eriksen C, Lindberg-Larsen M, Christensen AQ, Ingerslev J, Sørensen B. Fibrinogen concentrate substitution therapy in patients with massive haemorrhage and low plasma fibrinogen concentrations. Br J Anaesth 2008; 101:769-73. [PMID: 18818192 DOI: 10.1093/bja/aen270] [Citation(s) in RCA: 172] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients experiencing massive haemorrhage are at high risk of developing coagulopathy through loss, consumption, and dilution of coagulation factors and platelets. It has been reported that plasma fibrinogen concentrations may reach a critical low level relatively early during bleeding, calling for replacement fibrinogen therapy. Cryoprecipitate has been widely used in the past, but more recently, a pasteurized fibrinogen concentrate has become available. We audited the effects of fibrinogen concentrate therapy on laboratory and clinical outcome in patients with massive haemorrhage. METHODS We identified 43 patients over the previous 2 yr to whom a fibrinogen concentrate had been administered as treatment for hypofibrinogenaemia during serious haemorrhage. Platelet count, P-fibrinogen, activated partial thromboplastin time (APTT), prothrombin time (PT), D-dimer, and volume of blood lost were obtained from medical and laboratory records. Numbers of units of red blood cells (RBC), fresh frozen plasma (FFP), and pooled platelet concentrates were recorded before and after fibrinogen substitution. RESULTS A significant increase in plasma fibrinogen concentration was observed after fibrinogen concentrate therapy. Platelet counts and fibrin D-dimer values remained unchanged, whereas the APTT and PT improved significantly. Requirements for RBC, FFP, and platelets were significantly reduced. Blood loss decreased significantly. CONCLUSIONS Off-label substitution therapy with a fibrinogen concentrate generally improved global laboratory coagulation results and as supplementary intervention, appeared to diminish the requirements for RBC, FFP, and platelet substitution in this patient cohort.
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Affiliation(s)
- C Fenger-Eriksen
- Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Brendstrupgaardsvej, 8200 Aarhus N, Denmark
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Ovlisen K, Kristensen AT, Valentino LA, Hakobyan N, Ingerslev J, Tranholm M. Hemostatic effect of recombinant factor VIIa, NN1731 and recombinant factor VIII on needle-induced joint bleeding in hemophilia A mice. J Thromb Haemost 2008; 6:969-75. [PMID: 18363814 DOI: 10.1111/j.1538-7836.2008.02954.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hemophilia A is the most common serious bleeding disorder, and the hallmark of this disease is joint bleeding episodes. These result in hemophilic synovitis, an inflammatory and proliferative condition of the joint, which progresses into a chronic degenerative arthritis, hemophilic arthropathy. METHODS In this paper, we describe the effect of recombinant factor VIIa (rFVIIa), and an analogue NN1731 as well as rFVIII on needle-induced bleeding in hemophilia A mice. CONCLUSIONS Here we show a reducing effect of rFVIIa and NN1731 on bleeding induced in hemophilic mice, and we show that preventive treatment with rFVIII normalizes bleeding.
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Budde U, Schneppenheim R, Eikenboom J, Goodeve A, Will K, Drewke E, Castaman G, Rodeghiero F, Federici AB, Batlle J, Pérez A, Meyer D, Mazurier C, Goudemand J, Ingerslev J, Habart D, Vorlova Z, Holmberg L, Lethagen S, Pasi J, Hill F, Peake I. Detailed von Willebrand factor multimer analysis in patients with von Willebrand disease in the European study, molecular and clinical markers for the diagnosis and management of type 1 von Willebrand disease (MCMDM-1VWD). J Thromb Haemost 2008; 6:762-71. [PMID: 18315556 DOI: 10.1111/j.1538-7836.2008.02945.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Type 1 von Willebrand disease (VWD) is a congenital bleeding disorder characterized by a partial quantitative deficiency of plasma von Willebrand factor (VWF) in the absence of structural and/or functional VWF defects. Accurate assessment of the quantity and quality of plasma VWF is difficult but is a prerequisite for correct classification. OBJECTIVE To evaluate the proportion of misclassification of patients historically diagnosed with type 1 VWD using detailed analysis of the VWF multimer structure. PATIENTS AND METHODS Previously diagnosed type 1 VWD families and healthy controls were recruited by 12 expert centers in nine European countries. Phenotypic characterization comprised plasma VWF parameters and multimer analysis using low- and intermediate-resolution gels combined with an optimized visualization system. VWF genotyping was performed in all index cases (ICs). RESULTS Abnormal multimers were present in 57 out of 150 ICs; however, only 29 out of these 57 (51%) had VWF ristocetin cofactor to antigen ratio below 0.7. In most cases multimer abnormalities were subtle, and only two cases had a significant loss of the largest multimers. CONCLUSIONS Of the cases previously diagnosed as type 1 VWD, 38% showed abnormal multimers. Depending on the classification criteria used, 22 out of these 57 cases (15% of the total cohort) may be reclassified as type 2, emphasizing the requirement for multimer analysis compared with a mere ratio of VWF functional parameters and VWF:Ag. This is further supported by the finding that even slightly aberrant multimers are highly predictive for the presence of VWF mutations.
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Affiliation(s)
- U Budde
- Coagulation Laboratory, Hamburg, Germany.
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Abstract
CONTEXT There is limited data regarding the use of activated recombinant factor VII (rFVIIa) in anticoagulated patients requiring reversal. AIMS To identify and describe characteristics of subjects who received rFVIIa as part of emergency treatment aimed at improving hemostasis. SETTINGS AND DESIGN Data was obtained from an international peer-reviewed registry haemostasis.com. This registry contains data reported by physicians, who had elected to use rFVIIa to control bleeding in an emergency clinical situation. The contributors' approval for inclusion in the study was obtained and they were requested to validate and update information. MATERIALS AND METHODS Database review of cases receiving rFVIIa to manage bleeding coherent with the use of anticoagulant therapy. STATISTICAL ANALYSIS The Wilcoxon signed rank test was used to compare requirements for blood products and crystalloids/colloids during the 24h preceding and following rFVIIa administration, as well as changes in the levels of clotting factors during that period. RESULTS Eighteen patients were treated with rFVIIa (median dose: 87.35 microg/kg; range: 20.0-106.0 microg/kg) for bleeding. Anticoagulants requiring reversal included low-molecular-weight heparin (n = 6), unfractionated heparin (n =8), coumarin (n =3) and warfarin (n=1). All patients had failed to respond to traditional antidotes and blood products. Following administration, bleeding stopped in 10, markedly decreased in five and slowed in the remaining three. Amongst 12/16 patients, a response was observed within 2.0 h of first administration. The requirement for blood products and crystalloids/colloids decreased ( P < 0.05) after rFVIIa administration. rFVIIa was well tolerated. CONCLUSIONS rFVIIa may play a role in control of untoward bleeding in subjects receiving anticoagulation therapy.
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Affiliation(s)
- J Ingerslev
- Centre for Hemophilia and Thrombosis, University Hospital Skejby, Denmark.
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Hvas AM, Sørensen HT, Norengaard L, Christiansen K, Ingerslev J, Sørensen B. Tranexamic acid combined with recombinant factor VIII increases clot resistance to accelerated fibrinolysis in severe hemophilia A. J Thromb Haemost 2007; 5:2408-14. [PMID: 18034766 DOI: 10.1111/j.1538-7836.2007.02755.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Most patients with severe hemophilia A suffer from a profoundly compromised hemostatic response. In addition to both the delayed and slow development of a clot, previous studies have documented that severe hemophilia A is also associated with reduced clot stability. OBJECTIVES We examined whether the clot stability in hemophiliacs could be improved by treatment with tranexamic acid (TXA) in combination with recombinant factor VIII (rFVIII). PATIENTS/METHODS Baseline blood samples were obtained from eight males with severe hemophilia A. Thereafter, a bolus injection of rFVIII was administered to increase the functional level of FVIII to approximately 50%. After 10 min, blood was collected followed by an intravenous injection of TXA. A third blood sample was obtained after a further 10 min. Whole blood clotting profiles were determined by thrombelastography using minimal tissue factor activation. Clot formation was assessed by both clot initiation and clot propagation. At clot termination, the maximum clot firmness and area under the elasticity curve were used to illustrate clot stability. Tissue-plasminogen activator was included in those experiments designed to assess clot stability. RESULTS As expected, rFVIII increased clot formation, whereas TXA had no effect upon this parameter. Assays including tissue-plasminogen activator revealed that rFVIII increased the maximum clot firmness 3-fold; whereas the presence of TXA induced an additional 4-fold increase. The area under the elasticity curve increased 5-fold after rFVIII and 24-fold after addition of TXA. CONCLUSIONS The study demonstrates that simultaneous treatment with TXA and rFVIII significantly improves the clot stability in patients with hemophilia A.
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Affiliation(s)
- A-M Hvas
- Center for Hemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Skejby, Brendstrupgaardsvej 100, Aarhus N, Denmark.
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Knudsen ST, Jeppesen P, Frederiksen CA, Andersen NH, Bek T, Ingerslev J, Mogensen CE, Poulsen PL. Endothelial dysfunction, ambulatory pulse pressure and albuminuria are associated in Type 2 diabetic subjects. Diabet Med 2007; 24:911-5. [PMID: 17559428 DOI: 10.1111/j.1464-5491.2007.02197.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM Elevated pulse pressure (PP) is associated with microvascular complications in Type 2 diabetic patients. In non-diabetic subjects, elevated PP has been associated with endothelial dysfunction. The relation between endothelial dysfunction and PP in diabetic subjects has not previously been examined. We examined the relation between PP, markers of endothelial activation and albuminuria in Type 2 diabetic patients. METHODS In 46 Type 2 diabetic patients and 19 non-diabetic subjects, we performed 24-h ambulatory blood pressure (AMBP) monitoring. Urinary albumin excretion rate was measured as three urinary albumin/creatinine ratios. Von Willebrand factor (vWF), fibrinogen, E-selectin and soluble intercellular adhesion molecule 1 (ICAM-1) were measured in plasma. RESULTS Thirty-four patients had normoalbuminuria (group N) and 12 had micro- or macroalbuminuria (group A). PP levels increased in a stepwise manner from the control group (group C) to group N and group A; night PP 43 +/- 5, 48 +/- 10 and 59 +/- 12 mmHg (groups C, N and A, respectively, P < 0.001). Likewise, plasma levels of vWF, fibrinogen, E-selectin and ICAM-1 increased from group C to group A; e.g. ICAM-1 [median (interquartile range)] 191 (160-217), 213 (189-262) and 316 (260-417) ng/ml, groups C, N and A, respectively, P < 0.001). In diabetic patients, night PP and plasma levels of E-selectin and ICAM-1 correlated (r = 0.38, P < 0.01 and r = 0.37, P = 0.01, night PP with E-selectin and ICAM-1, respectively). CONCLUSION Increased PP is associated with endothelial activation and albuminuria in Type 2 diabetic patients. Thus, endothelial dysfunction may represent a pathophysiological link between an elevated PP and microvascular complications in these subjects. Prospective studies are needed to further elucidate these associations.
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Affiliation(s)
- S T Knudsen
- Medical Department M (Diabetes and Endocrinology), Aarhus University Hospital, Aarhus, Denmark.
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Ingerslev J, Herlin T, Sørensen B, Clausen N, Chu KC, High KA. Severe factor X deficiency in a pair of siblings: clinical presentation, phenotypic and genotypic features, prenatal diagnosis and treatment. Haemophilia 2007; 13:334-6. [PMID: 17498086 DOI: 10.1111/j.1365-2516.2007.01466.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tosetto A, Rodeghiero F, Castaman G, Bernardi M, Bertoncello K, Goodeve A, Federici AB, Batlle J, Meyer D, Mazurier C, Goudemand J, Eikenboom J, Schneppenheim R, Budde U, Ingerslev J, Vorlova Z, Habart D, Holmberg L, Lethagen S, Pasi J, Hill F, Peake I. Impact of plasma von Willebrand factor levels in the diagnosis of type 1 von Willebrand disease: results from a multicenter European study (MCMDM-1VWD). J Thromb Haemost 2007; 5:715-21. [PMID: 17408405 DOI: 10.1111/j.1538-7836.2007.02444.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Presence of bleeding symptoms, inheritance and reduced von Willebrand factor (VWF) contribute to the diagnosis of type 1 von Willebrand disease (VWD). However, quantitative analysis of the importance of VWF antigen (VWF:Ag) and ristocetin cofactor activity (VWF:RCo) levels in the diagnosis is lacking. OBJECTIVES To evaluate the relative contribution of VWF measurement to the diagnosis of VWD. PATIENTS AND METHODS From the MCMDM-1VWD study cohort, 204 subjects (considered as affected by VWD based on the enrolling Center diagnoses and the presence of linkage with the VWF locus) were compared with 1155 normal individuals. Sensitivity, specificity and diagnostic positive likelihood ratios (LR) of VWF:Ag and VWF:RCo were computed. RESULTS ABO blood group was the variable most influencing VWF levels, but adjustment of the lower reference limit for the ABO group did not improve sensitivity and specificity of VWF:Ag or VWF:RCo. The lower reference limit (2.5th percentile) was 47 IU dL(-1) for both VWF:Ag and VWF:RCo and showed similar diagnostic performance [receiver-operator curve area: 0.962 and 0.961 for VWF:Ag and VWF:RCo, respectively; P = 0.81]. The probability of VWD was markedly increased only for values below 40 IU dL(-1) (positive LR: 95.1 for VWF:Ag), whereas intermediate values (40 to 60 IU dL(-1)) of VWF only marginally indicated the probability of VWD. CONCLUSIONS Although the conventional 2.5 lower percentile has good sensitivity and specificity, only VWF:Ag or VWF:RCo values below 40 IU dL(-1) appear to significantly indicate the likelihood of type 1 VWD. The LR profile of VWF level could be used in a diagnostic algorithm.
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Affiliation(s)
- A Tosetto
- San Bortolo Hospital, Vicenza, Italy.
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Affiliation(s)
- J Ingerslev
- Centre for Haemophilia and Thrombosis, Aarhus University Hospital, Skejby Sygehus, Brendstrupgaardsvej, Aarhus N, Denmark.
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Sadler JE, Budde U, Eikenboom JCJ, Favaloro EJ, Hill FGH, Holmberg L, Ingerslev J, Lee CA, Lillicrap D, Mannucci PM, Mazurier C, Meyer D, Nichols WL, Nishino M, Peake IR, Rodeghiero F, Schneppenheim R, Ruggeri ZM, Srivastava A, Montgomery RR, Federici AB. Update on the pathophysiology and classification of von Willebrand disease: a report of the Subcommittee on von Willebrand Factor. J Thromb Haemost 2006; 4:2103-14. [PMID: 16889557 DOI: 10.1111/j.1538-7836.2006.02146.x] [Citation(s) in RCA: 746] [Impact Index Per Article: 41.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
von Willebrand disease (VWD) is a bleeding disorder caused by inherited defects in the concentration, structure, or function of von Willebrand factor (VWF). VWD is classified into three primary categories. Type 1 includes partial quantitative deficiency, type 2 includes qualitative defects, and type 3 includes virtually complete deficiency of VWF. VWD type 2 is divided into four secondary categories. Type 2A includes variants with decreased platelet adhesion caused by selective deficiency of high-molecular-weight VWF multimers. Type 2B includes variants with increased affinity for platelet glycoprotein Ib. Type 2M includes variants with markedly defective platelet adhesion despite a relatively normal size distribution of VWF multimers. Type 2N includes variants with markedly decreased affinity for factor VIII. These six categories of VWD correlate with important clinical features and therapeutic requirements. Some VWF gene mutations, alone or in combination, have complex effects and give rise to mixed VWD phenotypes. Certain VWD types, especially type 1 and type 2A, encompass several pathophysiologic mechanisms that sometimes can be distinguished by appropriate laboratory studies. The clinical significance of this heterogeneity is under investigation, which may support further subdivision of VWD type 1 or type 2A in the future.
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Affiliation(s)
- J E Sadler
- Howard Hughes Medical Institute, Washington University, St Louis, MO 63110, USA.
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Fenger-Eriksen C, Ingerslev J, Sørensen B. Coagulopathy induced by colloid plasma expanders--search for an efficacious haemostatic intervention. Acta Anaesthesiol Scand 2006; 50:899-900. [PMID: 16879481 DOI: 10.1111/j.1399-6576.2006.01054.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Barrowcliffe TW, Cattaneo M, Podda GM, Bucciarelli P, Lussana F, Lecchi A, Toh CH, Hemker HC, Béguin S, Ingerslev J, Sørensen B. New approaches for measuring coagulation. Haemophilia 2006; 12 Suppl 3:76-81. [PMID: 16684000 DOI: 10.1111/j.1365-2516.2006.01262.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Although specific assays of coagulation factors are essential for diagnostic purposes they only give partial information about an individual's haemostatic state. This can be better assessed by various global tests, and recent developments and evaluations of five such tests are described in this symposium: the PFA-100; waveform analysis; thrombin generation; overall haemostasis potential; thrombelastography. Each test has advantages in various applications, but the thrombin generation test and waveform analysis have been found most useful in haemophilia, whilst the PFA-100 is helpful in von Willebrand's disease.
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Affiliation(s)
- T W Barrowcliffe
- Unità di Ematologia e Trombosi, Ospedale San Paolo, Università di Milano, Italy.
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Tosetto A, Rodeghiero F, Castaman G, Goodeve A, Federici AB, Batlle J, Meyer D, Fressinaud E, Mazurier C, Goudemand J, Eikenboom J, Schneppenheim R, Budde U, Ingerslev J, Vorlova Z, Habart D, Holmberg L, Lethagen S, Pasi J, Hill F, Peake I. A quantitative analysis of bleeding symptoms in type 1 von Willebrand disease: results from a multicenter European study (MCMDM-1 VWD). J Thromb Haemost 2006; 4:766-73. [PMID: 16634745 DOI: 10.1111/j.1538-7836.2006.01847.x] [Citation(s) in RCA: 377] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND A quantitative description of bleeding symptoms in type 1 von Willebrand disease (VWD) has never been reported. OBJECTIVES The aim was to quantitatively evaluate the severity of bleeding symptoms in type 1 VWD and its correlation with clinical and laboratory features. PATIENTS AND METHODS Bleeding symptoms were retrospectively recorded in a European cohort of VWD type 1 families, and for each subject a quantitative bleeding score (BS) was obtained together with phenotypic tests. RESULTS A total of 712 subjects belonging to 144 families and 195 controls were available for analysis. The BS was higher in index cases than in affected family members (BS 9 vs. 5, P < 0.0001) and in unaffected family members than in controls (BS 0 vs. -1, P < 0.0001). There was no effect of ABO blood group. BS showed a strong significant inverse relation with either von Willebrand ristocetin cofactor (VWF:RCo), von Willebrand antigen (VWF:Ag) or factor VIII procoagulant activity (FVIII:C) measured at time of enrollment, even after adjustment for age, sex and blood group (P < 0.001 for all the four upper quintiles of BS vs. the first quintile, for either VWF:RCo, VWF:Ag or FVIII:C). Higher BS was related with increasing likelihood of VWD, and a mucocutaneous BS (computed from spontaneous, mucocutaneous symptoms) was strongly associated with bleeding after surgery or tooth extraction. CONCLUSIONS Quantitative analysis of bleeding symptoms is potentially useful for a more accurate diagnosis of type 1 VWD and to develop guidelines for its optimal treatment.
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Affiliation(s)
- A Tosetto
- San Bortolo Hospital, Vicenza, Italy
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45
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Eikenboom J, Van Marion V, Putter H, Goodeve A, Rodeghiero F, Castaman G, Federici AB, Batlle J, Meyer D, Mazurier C, Goudemand J, Schneppenheim R, Budde U, Ingerslev J, Vorlova Z, Habart D, Holmberg L, Lethagen S, Pasi J, Hill F, Peake I. Linkage analysis in families diagnosed with type 1 von Willebrand disease in the European study, molecular and clinical markers for the diagnosis and management of type 1 VWD. J Thromb Haemost 2006; 4:774-82. [PMID: 16634746 DOI: 10.1111/j.1538-7836.2006.01823.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND von Willebrand disease (VWD) type 1 is a congenital bleeding disorder caused by genetic defects in the von Willebrand factor (VWF) gene and characterized by a reduction of structurally normal VWF. The diagnosis of type 1 VWD is difficult because of clinical and laboratory variability. Furthermore, inconsistency of linkage between type 1 VWD and the VWF locus has been reported. OBJECTIVES To estimate the proportion of type 1 VWD that is linked to the VWF gene. PATIENTS AND METHODS Type 1 VWD families and healthy control individuals were recruited. An extensive questionnaire on bleeding symptoms was completed and phenotypic tests were performed. Linkage between VWF gene haplotypes and the diagnosis of type 1 VWD, the plasma levels of VWF and the severity of bleeding symptoms was analyzed. RESULTS Segregation analysis in 143 families diagnosed with type 1 VWD fitted a model of autosomal dominant inheritance. Linkage analysis under heterogeneity resulted in a summed lod score of 23.2 with an estimated proportion of linkage of 0.70. After exclusion of families with abnormal multimer patterns the linkage proportion was 0.46. LOD scores and linkage proportions were higher in families with more severe phenotypes and with phenotypes suggestive of qualitative VWF defects. About 40% of the total variation of VWF antigen could be attributed to the VWF gene. CONCLUSIONS We conclude that the diagnosis of type 1 VWD is linked to the VWF gene in about 70% of families, however after exclusion of qualitative defects this is about 50%.
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Affiliation(s)
- J Eikenboom
- Department of Hematology, Hemostasis and Thrombosis Research Center, Leiden University Medical Center, Leiden, the Netherlands.
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Abstract
Acquired haemophilia is a rare bleeding disorder caused by autoimmune antibodies interacting with factor VIII (FVIII) or factor IX. Anticipating a high degree of heterogeneity amongst cases, we recently initiated systematic recording of whole blood (WB) coagulation dynamic profiles using our recently developed thrombelastographic method employing very small amounts of tissue factor for activation. Six newly diagnosed patients with acquired haemophilia A in our University Hospital were investigated with the purpose to characterize the WB clotting phenotypes in each patient, as well as inspecting the ex vivo and in vivo response to supplementation with various haemostatic agents. Our results show a striking heterogeneity in patients WB clotting profiles, each patient having a particular pattern and an individual type of response to bypassing agents. Profiles in some of patients resembled severe haemophilia A, even if there was a measurable residual FVIII:C activity while others were more similar moderate-to-mild haemophilia. In one case the profile was very close to normal. Each patient seemed to respond individually to bypassing agents. WB clotting profiles assisted us in selecting an optimal treatment modality in each case and whenever possible, we compared the clinical effects of the treatment selected with the appearance of the WB clotting pattern. In one patient, the ex vivo response to FVIII looked promising, and a approximately 200 IU kg-1 per 24 h high-dose programme nearly normalized the clotting profile in 2-week time. Our preliminary small series of data should be concluded with caution. However, it seems that WB clotting profile studies at baseline, with ex vivo addition of haemostasis promoting agents, and during treatment may hold the potential to predict the success of treatment.
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Affiliation(s)
- R F Johansen
- Department of Biochemistry, Centre for Haemophilia and Thrombosis, Aarhus University Hospital, Aarhus, Skejby, Denmark
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47
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Abstract
Congenital factor VII (FVII) deficiency is a rare bleeding disorder with high phenotypic variability, and optimal management has yet to be determined. Treatment has traditionally involved FVII replacement therapy using fresh frozen plasma, prothrombin complex concentrates or plasma-derived FVII concentrates. Recombinant activated FVII (rFVIIa, NovoSeven(R)), the first recombinant treatment option, has recently been approved in the European Union for use in congenital FVII deficiency, but has been available on an emergency and compassionate use basis since 1988. In FVII deficiency, rFVIIa serves as substitution therapy as it provides the physiological ligand (FVIIa) for tissue factor, its receptor exposed at the site of vascular injury. This paper provides an overview of published and unpublished experience with rFVIIa in patients with congenital FVII deficiency from the NovoSeven compassionate and emergency use programmes (1988-99) and of independent reports in the literature. Recombinant FVIIa has been reported to provide effective haemostasis in patients of all ages and in a range of bleeding situations, including acute central nervous system/life-threatening bleeding episodes (15 episodes in 12 patients), non-life-threatening bleeding episodes (>32 episodes in 17 patients), surgery (>40 interventions in 25 patients) and childbirth (three women). Preliminary reports suggest that it may also be effective prophylactically. The risk of thrombosis in FVII-deficient patients treated with rFVIIa is unknown, as is the occurrence of inhibiting antibodies. A postlicensure pharmacovigilance registry (Seven Treatment Evaluation Registry) has been set up to continue to monitor the efficacy and safety (including alloantibody development) of rFVIIa in patients with FVII deficiency.
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Affiliation(s)
- G Mariani
- Department of Internal Medicine and Public Health, University of L'Aquila, L'Aquila, Italy.
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Lambalk CB, Leader A, Olivennes F, Fluker MR, Andersen AN, Ingerslev J, Khalaf Y, Avril C, Belaisch-Allart J, Roulier R, Mannaerts B. Treatment with the GnRH antagonist ganirelix prevents premature LH rises and luteinization in stimulated intrauterine insemination: results of a double-blind, placebo-controlled, multicentre trial*. Hum Reprod 2005; 21:632-9. [PMID: 16361296 DOI: 10.1093/humrep/dei386] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND This study was designed to assess whether the use of ganirelix in women undergoing stimulated IUI could prevent the occurrence of premature LH rises and luteinization (LH+progesterone rises). METHODS Women of infertile couples, diagnosed with unexplained or male factor infertility, were randomized to receive either ganirelix (n=103) or placebo (n=100) in a double-blind design. All women were treated with an individualized, low-dose rFSH regimen started on day 2-3 of cycle. Ganirelix (0.25 mg/day) was started if one or more follicles>or=14 mm were visualized. Ovulation was triggered by HCG injection when at least one follicle>or=18 mm was observed and a single IUI was performed 34-42 h later. The primary efficacy outcome was the incidence of premature LH rises (+/-progesterone rise). RESULTS In the ganirelix group, four subjects had a premature LH rise (value>or=10 IU/l), one LH rise prior to the start of ganirelix and three LH rises during ganirelix treatment, whereas in the placebo group 28 subjects had a premature LH rise, six subjects prior to the start of placebo and 22 subjects during placebo treatment. The incidence of LH rises was significantly lower in ganirelix cycles compared to placebo cycles (3.9 versus 28.0%; P=0.003 for ITT analysis). When excluding subjects with an LH value>or=10 IU/l before the start of ganirelix/placebo the incidence of LH rises was also significantly lower in ganirelix cycles compared to placebo cycles (2.9 versus 23.4%; P=0.003 for ITT analysis). Premature luteinization (LH rise with concomitant progesterone rise>or=1 ng/ml) was observed in one subject in the ganirelix group and in 17 subjects in the placebo group of which three subjects had a premature spontaneous ovulation. Ongoing pregnancy rates per attempt were 12.6 and 12.0% for the ganirelix and placebo groups respectively. CONCLUSIONS Treatment with ganirelix effectively prevents premature LH rises, luteinization in subjects undergoing stimulated IUI. Low-dose rFSH regimen combined with a GnRH antagonist may be an alternative treatment option for subjects with previous proven luteinization or in subjects who would otherwise require insemination when staff are not working.
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Affiliation(s)
- C B Lambalk
- Department of Reproductive Medicine, Vrije Universiteit Medical Centre, Amsterdam, the Netherlands, and Civic Parkdale Clinic, Ottawa, Ontario, Canada.
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Sørensen B, Ingerslev J. Tailoring haemostatic treatment to patient requirements - an update on monitoring haemostatic response using thrombelastography. Haemophilia 2005; 11 Suppl 1:1-6. [PMID: 16219042 DOI: 10.1111/j.1365-2516.2005.01156.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Currently, there is no single haemostasis laboratory test that has the capacity to accurately illustrate the clinical effects of procoagulant or anticoagulant interventions. Although the time course of thrombin generation in plasma and the endogenous thrombin potential (ETP) may be useful coagulation parameters, clotting involves components other than thrombin (e.g. platelets, fibrinogen). The continuous coagulation profiles of thrombelastography may provide a more accurate reflection of in vivo biology, covering initiation, development and final clot strength during whole blood clot formation. This method has helped to clarify the mechanism of action of whole blood clot formation, demonstrating the differences from clotting in plasma, and the importance of platelets and tissue factor titrations. It has also been used to investigate hypocoagulation (in haemophilia A, rare coagulation disorders, anticoagulant therapy and dilutional coagulopathy), hypercoagulation and the ex vivo testing of haemostatic interventions. Thrombelastography has been shown to reflect the clinical efficacy of activated prothrombin complex concentrate (aPCC) and recombinant activated factor VII (rFVIIa) in patients with haemophilia A with inhibitors and in patients with acquired haemophilia. Overall, tailoring laboratory assays to illustrate and correlate with clinical phenotypes is essential for effective coagulation monitoring. Applying an algorithm of preoperative, perioperative and postoperative tests, including thrombelastography, may enable physicians to achieve this.
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Affiliation(s)
- B Sørensen
- Center for Hemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Skejby, Denmark.
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van Dijk K, Fischer K, van der Bom JG, Scheibel E, Ingerslev J, van den Berg HM. Can long-term prophylaxis for severe haemophilia be stopped in adulthood? Results from Denmark and the Netherlands. Br J Haematol 2005; 130:107-12. [PMID: 15982352 DOI: 10.1111/j.1365-2141.2005.05546.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Prophylaxis is the treatment of choice for children with severe haemophilia. As prophylaxis is especially important during the period of growth, the need for continued prophylaxis in adulthood should be considered. The aim of this study was to describe the incidence and outcome of stopping prophylaxis in patients with severe haemophilia who were offered prophylaxis during childhood. All patients with severe haemophilia (factor VIII/IX <0.01 IU/ml), born 1970-80, treated in two Danish and one Dutch treatment centre were studied. Data on discontinuation of prophylaxis, treatment, joint bleed frequency, clinical scores and radiological scores were collected. Eighty patients were studied. Median follow-up was 19 years (range 7-29). A total of 35% of patients discontinued prophylaxis at a median age of 21.5 years [interquartile range (IQR) 18.4-24.4], experiencing only three joint bleeds per year (IQR 1.4-8.7). Median clinical scores were similar in patients who discontinued prophylaxis [4 points (IQR 0-6)] and those who continued [3 points (IQR 1-6)], as were median Pettersson scores at 13 (IQR 1-24) vs. 13 points (IQR 5-23) respectively. In conclusion one-third of young adults with severe haemophilia on a prophylactic regimen discontinued prophylaxis in early adulthood, while maintaining a low joint bleed frequency and similar arthropathy after 4 years.
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Affiliation(s)
- K van Dijk
- Van Creveldkliniek, UMC Utrecht, The Netherlands.
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