Diagnostic utility of bleeding assessment tools in congenital fibrinogen deficiencies

BACKGROUND

The assessment of clinical history is crucial before referring a patient for further laboratory testing. Bleeding assessment tools (BAT) are developed to standardize clinical evaluation. A small number of patients with congenital fibrinogen deficiencies (CFDs) have been evaluated with these tools without definitive results.

AIMS

We compared the adequacy of the ISTH-BAT and the European network of rare bleeding disorders bleeding score system (EN-RBD-BSS) to identify patients with CFDs. The correlation between the two BATs and fibrinogen levels and patient clinical grade severity was further analyzed.

METHODS

We included 100 Iranian patients with CFDs. Routine coagulation and fibrinogen-specific tests (fibrinogen antigen [Fg:Ag] and activity [Fg:C]) were performed. The ISTH-BAT and EN-RBD-BSS were used to assess the bleeding score (BS) of all patients.

RESULTS

The ISTH-BAT and EN-RBD-BSS median (range) were 4 (0-16) and 2.21 (-1.49 to 6.71), with a statistically significant moderate correlation between the two systems (r = .597, P < .001). In patients with quantitative deficiencies (afibrinogenemia and hypofibrinogenemia), the correlation between Fg:C and the ISTH-BAT was moderately negative (r = -.4, P < .001), while the correlation between Fg:C and the EN-RBD-BSS was weakly negative (r = -.38, P < .001). Overall, 70% and 72% of patients with fibrinogen deficiencies were correctly identified by both the ISTH-BAT and EN-RBD-BSS, respectively.

CONCLUSION

These results suggest that in addition to the ISTH-BAT, the EN-RBD-BSS may also be useful in identifying CFD patients. We found a significant level of sensitivity for detecting fibrinogen deficiency in the two BATs, and bleeding severity classification correctly identified severity grades in almost two-thirds of patients.

Congenital Combined Bleeding Disorders, a Comprehensive Study of a Large Number of Iranian Patients

Congenital combined bleeding disorders (CBDs) are extremely rare disorders which mainly occur in regions with a high rate of consanguineous marriage. These disorders can present with a variety of symptoms ranging from mucocutaneous bleeding to life-threatening episodes. This study aims to evaluate the prevalence and clinical course of Iranian patients with congenital CBDs. This study is conducted on 450 patients with CBDs who were referred to the Iranian Comprehensive Hemophilia Care Center (ICHCC) between 2010 and 2020. All these patients were diagnosed through evaluation of past medical history and coagulation laboratory investigation. Out of 450 patients, 33 were entered in this study. Having excluded cases with factor (F) V and FVIII deficiency, as well as those with hereditary combined Vitamin K dependent clotting factor deficiency (VKCFD), We found the most common CBDs to be FV-FVII deficiency (n: 6, 18.1%), together with FVII and FX deficiency (n: 6, 18.1%). The most common reason for referral of these patients to ICHCC was postoperative bleeding (14.3%). The mean of The International Society on Thrombosis and Hemostasis-Bleeding Assessment Tool (ISTH-BAT) and condensed MCMDM-1VWD bleeding assessment tool were 9.6 ± 4.79 and 9.1 ± 4.87, respectively (P < 0.005). In 10 females of reproductive age, the mean of Pictorial Bleeding Assessment Chart (PBAC) score was 649.3 ± 554. Among all patients, 23 (69.7%) received on-demand replacement therapy, whereas 5 patients (15.1%) received prophylaxis. In Iran, the coinheritance of bleeding disorders is surprisingly higher than expected. Moreover, patients with congenital CBDs may experience serious bleeding manifestations.

The effects of six-week resistance, aerobic and combined exercises on the pro-inflammatory and anti-inflammatory markers in overweight patients with moderate haemophilia A: A randomized controlled trial

INTRODUCTION

Overweight increases the secretion of pro-inflammatory cytokines and serves as a major risk factor for arthropathy and cardiovascular diseases (CVD). This condition is becoming increasingly prevalent among patients with haemophilia (PWH). Different forms of exercise training could favourably modify weight-related complications, cardiovascular risk factors and the inflammation.

AIM

To investigate the effects of resistance, aerobic and combined exercises on the pro-inflammatory and anti-inflammatory markers in overweight patients with moderate haemophilia A.

METHODS

Forty-eight patients with moderate haemophilia A, aged 35-55 years, and body mass index (BMI) of 25-30 kg/m² were randomly assigned to resistance training (RT, n = 12), aerobic (AT, n = 12), combined training (CT, n = 12) and control (n = 12) groups. The patients participated in 45-minutes exercise sessions three times a week for 6 weeks. Waist circumference (WC), waist-to-hip ratio (WHR), fat mass, fat-free mass, interleukin-10 (IL-10), adiponectin, tumour necrosis factor-α (TNF-α), interleukin-6 (IL-6) and high sensitive C-reactive protein (hs-CRP) were measured before and after the 6 weeks of training.

RESULTS

There was significant decrease in WC, WHR, BMI and weight in the AT, RT and CT groups as compared to the control group. Total HJHS scores decreased in the AT, RT, CT groups compared to the control groups (P ≤ 0.001). The decrease in hs-CRP, IL-6 and TNF-α in the CT group was significant compared to the control group (P ≤ 0.02). The increase in IL-10 and adiponectin was not significant in the RT, AT and CT groups compared to the control group.

CONCLUSION

CT was the most effective training mode for decreasing the pro-inflammatory cytokines and increasing anti-inflammatory markers in overweight patients with haemophilia A.

Strategies for inhibitor treatment and costs in the short and long term: a critical evaluation of recent clinical studies

One important complication of patients with severe haemophilia A is the formation of inhibitory antibodies to factor VIII (FVIII). Immune tolerance induction (ITI) is the treatment of choice for patients with inhibitors, but this approach is successful in about 60% of patients. Treatment of acute bleeding in patients with inhibitors is one of the greatest challenges in haemophilia management and is costly. Bypassing agents are the mainstay of treatment in these patients. The aims of this study were to review the most recent publications concerning the costs of inhibitor treatment. We conducted a literature review using PubMed which yielded 63 papers analysing the costs of inhibitor management of which 12 were suitable for our study. Four of eight studies supported the use of activated prothrombin complex concentrate (aPCC) with lower costs, but the remaining four studies showed that recombinant factor VIIa (rFVIIa) had a lower average treatment cost. Of four ITI studies, two supported lifelong cost-effectiveness of ITI vs. bypassing agents and the remaining two papers showed a high cost of inhibitor treatment. Dosages, time between onset of bleeding and treatment, patient characteristics and the price of drugs are some of the important issues that should be considered for further studies.