bluuebunny/crossref_metadata_2025 huggingface dataset:
Rituximab in Three Cases of Refractory Thrombotic Thrombocytopenic Purpura.
Authors: Alcaraz Jesus , González-García Consuelo , Majado Maria Juliana , Pérez Raul , Molina José A. , Tamayo Manuel , Moreno Manuel , Morales Alfonso
Published: April 2020

Thrombotic Thrombocytopenic Purpura (TTP) etiology remains elusive, recently has been associated with von-Willebrand Factor-cleavage protein inhibitory antibodies. Plasma exchange (PE) remains the gold standard therapy, however there are some cases resistant to it. Rituximab has been proved useful in antibody mediated immune disorders. We report our experience in 3 consecutive TTP patients, refractory to PE and successfully treated with Rituximab 375 mg/m2 weekly x 6.

Case 1. A 41 years old female diagnosed with Hasimoto thyroiditis 4 years before. In January 2003 she was admitted to hospital with headache, abnormal behaviour, 16x109/L platelets and 4–5% schistocytes. 47 PE sessions with a total of 235 fresh frozen plasma units (FFP) for replacement were made. Corticosteroids, IVIG and vincristine were added, but no improvement was achieved. Then, Rituximab was administered, after the second dose a complete clinical response was attained, and she remains well by now.

Case 2. A 21 years old female was into hospital in October 2003 with bruises, paraesthesia, skin pallor and jaundice. Hb 6.5 g/dL, platelets 4.6x109/L, LDH 1223 U/L and 13% schistocytes. She received 24 PE with 96 FFP units, plus corticosteroids and vincristine, with no response. Rituximab was administered, after the third dose she experienced a complete response, and remains stable since then.

Case 3. female, 35, she was into hospital in January 2005 with diarrhoea, vomiting, jaundice, seizures and bruises, Hb 4.5 g/dL, platelets 10x109/L, LDH 2486 U/L and 20% schistocytes. She received 43 PE with 129 FFP units and corticosteroids, but her neurological situation worsened. Rituximab was administered, after the first dose she experienced a complete response which maintains nowadays

Conclusions: intense PE remains the gold standard therapy, it is expensive, scarce, and not free of secondary effects. In a group of patients refractory to PE Rituximab is emerging as useful safe option, it was very well tolerated in ours cases. Unfortunately, we were not able to test the vWF-CP activity and its inhibitor. Our results encourage us to use Rituximab earlier than the first case, in order to avoid too much PE, and now we are considering Rituximab as a second option in patients refractory to PE, but much more cases must be considered.
Evaluation of Platelets Obtained from Premature Neonates To Determine Whether Platelet Dysfunction Mediates the Development of Intraventricular Hemorrhage.
Authors: McCarthy Sean T. , Stein Howard , Stein Dagmar , Ohler Sue , Lachant Neil A. , Gunning William T.
Published: April 2020

Hemorrhagic complications occur in neonates, including intraventricular hemorrhage (IVH) in premature babies. The premature infant appears to be at greatest risk for a head bleed from days 2–3 until day 7 after birth. A relationship exists that suggests that the shorter the gestation, the greater the risk for this potentially fatal hemorrhagic event. The basis of intra-ventricular brain hemorrhage (IVH) in the premature infant is unknown. Premature birth is not necessarily the cause of IVH. The neonate is known to have a transient platelet dysfunction at the time of birth. Studies to define the transient platelet dysfunction in the neonate have been limited. Explanations in the literature include:

a diminished response to physiologic agonists, defective platelet (PL) dense granule (DG) secretion, and/or ineffective mobilization of intracellular calcium in platelets.

We and others have found that the adenine nucleotide content of platelets obtained from umbilical cord blood is significantly less than seen in adults. We have found that platelets obtained from umbilical cord blood have an average of 0.79±0.08 DG/PL (n=62), which is significantly decreased compared to the adult population (4–6 DG/PL) (Blood, 100(11):691a, 2002). Although the concentration of ADP and ATP were found to be decreased compared to normal adult platelets, the ATP/ADP ratio in neonatal platelets is 1.95 (n=61), consistent with established adult normal range ratio values (1.4–1.95). The current studies are ultimately intended to evaluate infants that have survived severe IVH for platelet dysfunction due to platelet dense granule deficiency (δ-SPD). Preliminary data have been obtained on peripheral blood from premature infants (n=15) obtained 3–5 d after birth. Their values (mean±2sd) are: gestational age 31±4.8 weeks and wt 1506±474 gr. The DG number (1.01±0.16/PL) is significantly decreased compared to normal adults, while the ATP (3.19±0.36 μM/1011 PL), ADP (2.63±0.54 μM/1011 PL) and ATP/ADP ratio (1.46±0.13) are normal. The decreased DG number in premature PL is strikingly similar to the DG content in cord blood PLs. We have studied one infant’s cord blood (2.41 DG/PL)and day 1 peripheral blood (3.87 DG/PL). The parents have had a normal DG number and adenine nucleotide content. These results would suggest that the premature infant platelets may have an incomplete incorporation of calcium into the dense granules 3–5 days after birth when compared to the normal adenine nucleotide content. A decrease in DG calcium would explain the decreased numbers of DGs calculated from whole mounted PLs by EM. Calcium is electron dense and if lacking in DGs, would result in an artificially low number of DGs determined by this method. To date, we have not obtained blood from a premature infant with a significant IVH or its parents to evaluate δ-SPD as a potential etiology of severe IVH.
Haemostasis Alterations in Sickle Cell Disease.
Authors: Van Dreden Patrick , Rousseau Aurelie , Exner Thomas , Vasse Marc , Lahary Agnes , Vannier Jean Pierre , Woodhams Barry
Published: April 2020

Sickle cell disease (SCD) is considered by many workers to be a hypercoagulable state. The vaso-occlusion in sickle cell disease is complex, involving adhesive processes between sickle red blood cells, leukocytes, and the activated endothelium. Loss of normal membrane phospholipids asymetry with the appearance of phosphatidylserine on the erythrocyte surface has been documented as promoting an exacerbation of the anaemia and an activation of coagulation. The aim of this study was to monitor changes in coagulation and platelet activation (monitored by measuring the levels of procoagulant phospholipids microparticles - PPM) in SCD (both in steady state and crisis). Coagulation screening tests (PT, APPT), Protein S (PS), D-Dimer (D-Di) and PPM were measured in plasma samples obtained from 18 patients with SCD (8 in crisis state and 10 in steady state) and in twenty one normal volunteers as control. All blood samples were collected and the plasma prepared in the same hospital using the same conditions. All plasma samples were stored at -80°C until assayed. PT, aPTT, PS and D-dimers were measured using reagents from Diagnostica Stago, Asniéres, France. PPM was monitored with a novel factor Xa-based coagulation assay. In this assay shortened clotting times are associated with increased levels of PPM and thus platelet activation.

APTT Sec. PT % PPM Sec PS % D-Di μg/l Controls 34.6 (29.4–39.6) 93.1 (79–109) 57.5 (51.1–74.9) 88.8 (62–112) 0.22 (0.22–0.45) Sickle cell – in crisis 37.3 (33.4–47.4) 71.1 (56.5–86.5) 44.6 (34.0–60.0) 48.9 (25.0–89.5) 1.6 (0.6–2.6) Sickle cell – steady state. 38.0 (33.0–47.5) 75.0 (61.0–93.0) 52.2 (42.5–62.8) 84.7 (76.5–103.0) 0.7 (0.2–1.0)

In sickle cell crisis a significant increase in both coagulation and platelet activation, as monitored by PPM, was found (all at p < 0.001). The decrease in % PT and PS levels confirms the findings of others. In steady state only DDi levels are significantly higher than controls. Further studies are needed to explain these findings. Although this was a small pilot study and further studies are needed it is interesting to speculate on the possible usefulness of the PPM assay in monitoring SCD crisis.
Haemostasis Disturbances in Type I and II Diabetes Mellitus.
Authors: Van Dreden Patrick , Rousseau Aurelie , Exner Thomas , Vasse Marc , Ozenne Geneviéve , Woodhams Barry
Published: April 2020

Diabetes is associated with disturbances in haemostasis that are thought to result in an increased incidence of thrombotic complications and cardiovascular disease. The aim of this pilot study was to monitor activation of haemostasis using specific markers for platelet activation and coagulation. Plasma samples (all blood collected and plasma prepared in the same hospital under the same conditions) were obtained from twenty diabetic patients (8 with type I and 12 with type II) and twenty one normal control volunteers. To monitor coagulation these samples were evaluated with the partial thromboplastin time (APTT), prothrombin time (PT) and D-dimer (D-Di) - all reagents from Diagnostica Stago, Asniéres, France. Platelet activation was monitored with a novel method for monitoring procoagulant phospholipids microparticles (PPM) using a factor Xa-based coagulation assay. In this assay shortened clotting times are associated with increased levels of PPM and thus platelet activation.

APTT Sec. PT % PPM Sec. D-Di μg/l Controls 34.6 (29.4–39.6) 93.1 (79–109) 57.5 (51.1–74.9) 0.22 (0.22–0.45) Type I Diabetes 34.5 (33.1–36.7) 96.9 (92–102.5) 33.8 (19.1–44.2) 1.6 (0.22–3.6) Type II Diabetes 36.8 (33.2–40.4) 96 (59.4–112.5) 48.3 (44.2–51.2) 0.7 (0.22–1.7)

Significantly higher levels of both PPM and DD were found in Type I diabetes patients compared with controls (both P<0.001). In type II diabetes the levels of both were lower than those found in Type I diabetes but both were still higher than the controls (PPM and DDi at p<0.001 and p<0.01 level respectively), only the differences in levels of PPM reaching significance between type I and type II diabetes (p<0.01). The more severe the diabetes (type I > type II) the greater the level activation of haemostasis that is observed. The increases in PPM could account in part for the development or progression of arthrosclerosis in patients with diabetes mellitus. The increased level of D-Di confirms the increased hypercoagulability of these patients. Although this was a small pilot study and further studies are needed to confirm these findings it is interesting to speculate on the usefulness of both the PPM assay and D-Di assays in monitoring the development/severity of diabetes and its complications. The PPM assay may prove to be especially useful in monitoring progression of the disease.
A Relatively Low Frequency of Bleeding in Patients with Severe Factor XI Deficiency Who Undergo Surgery Involving Tissues with Low Fibrinolytic Activity Supports on Demand Rather Than Prophylactic Use of Plasma.
Authors: Salomon Ophira , Steinberg David M. , Seligsohn Uri
Published: April 2020

Severe factor XI (FXI) deficiency is an injury related bleeding tendency. Fresh frozen plasma (FFP) or FXI concentrate are usually used for achieving hemostasis in such patients undergoing surgery but this can lead to inhibitor formation in 33% of patients with FXI level <1 U/dL (Blood101:4783, 2002). Based on observations in a limited number of patients with severe FXI deficiency, we previously suggested that surgery at tissues with known fibrinolytic activity is accompanied by bleeding more frequently than in other sites (NEJM325:153, 1991). In this study we retrospectively assessed the frequency of post surgical bleeding in 165 unrelated patients with severe FXI deficiency who were not treated by hemostatic means. Criteria for bleeding included local hematoma, need for surgical arrest of bleeding, or use of blood components. Bleeding occurred in 7/57 (12.3%) patients operated at tisues with low fibrinolytic activity, and in 29/48 (60.4%) patients operated at fibrinolytic sites (Table). Bleeding following circumcision (a non-fibrinolytic site) was accompanied by bleeding only in 1/64 (1.6%) and following oral surgery in 55/110 patients (50%). The relatively low frequency of bleeding following surgery at non-fibrinolytic sites advocates on demand rather than prophylactic replacement therapy when such surgery is performed.

SITE OF SURGERY N BLEEDERS % BLEEDERS Non-fibrinolytic Appendicectomy 22 1 1.6 Gastric 3 0 0 Cholecystectomy 5 1 20 Herniotomy 13 3 23 Hysterectomy 5 2 40 Orthopedic 9 0 0 Fibrinolytic Tonsillectomy 33 20 60.6 Nose 12 7 58.3 Prostatectomy 3 2 66.6 Circumcision 64 1 1.6 Oral Tooth extractions 100 49 49 Gum 10 6 60
Co-Interaction and Increased Release of Tissue Factor Pathway Inhibitor by Heparanase.
Authors: Nadir Yona , Brenner Benjamin , Zetser Anna , Levy-Adam Flonia , Kaplan Victoria , Zcharia Eyal , Goldshmidt Orit , Vlodavsky Israel
Published: April 2020

Background and objectives. Tissue factor pathway inhibitor (TFPI) is a potent direct inhibitor of factor Xa and factor VIIa-tissue factor complex. In addition, TFPI was shown to be an inhibitor of angiogenesis and metastasis. Heparanase is an endo-beta-D-glucuronidase of 65 kDa that cleaves heparan sulfate chains on cell surfaces and in the extra-cellular matrix an activity that closely correlates with cell invasion, angiogenesis and tumor growth. The study hypothesis was that heparanase may reduce the level of TFPI or release it from the cell surface in an attempt to increase heparanase prometastatic potential.

Material and methods. The effect of exogenous heparanase on TFPI expression and release to the medium was studied in HUVEC by immunoblotting, real time RT-PCR, and flow-cytometry. Human cell lines (MDA-MB-435 breast carcinoma; U87 glioma; HEK-293 embryonic kidney) were transfected to over express heparanase and the effect on TFPI was studied. TFPI expression was explored in heparanase transgenic mice by immunoblotting and immunostaining. Transfections with various modified forms of heparanase were used to further explore the effect of heparanase. Interaction between TFPI and heparanase was studied by co-immunoprecipitation analysis.

Results. Heparanase was found to increase the release of TFPI to the medium, reduce the level of TFPI at the cell surface, and to up-regulate its expression in the cells. These results were verified in HUVEC, tumor cell lines, and in the animal model. The effect was independent of heparanase activity or interaction with heparan sulfate, and dependent on heparanase secretion. A protein co-interaction between TFPI and heparanase was found.

Conclusions. Overall, a cell surface interaction is suggested in which heparanase impose increased release of TFPI from the cell surface to the medium, providing a local procoagulant and a systemic anticoagulant environment.
Activation of Endothelial Cells, Coagulation and Fibrinolysis in Thai Children with Dengue Virus Infection.
Authors: Sosothikul Darintr , Lusher Jeanne M.
Published: April 2020

Dengue virus is an arthropod borne flavivirus that most commonly causes a non-specific febrile illness: Dengue Fever (DF), and less frequently causes a life-threatening illness: Dengue Hemorrhagic Fever (DHF). The fatality rates of DHF are varying from 1 to 5% in tropical countries. Although severe bleeding remains the major cause of death, the pathogenesis of bleeding is poorly understood. This study was primarily designed to determine the extent of activation of endothelial cells, coagulation cascade and fibrinolysis in correlation with clinical severity and also to detect the best prognostic factor(s) for DHF during the febrile phase. We conducted a prospective cohort study in 42 children with Dengue infections (20 with DF and 22 with DHF); 38 age-matched normal Thai children served as the control group. Endothelial cell activation, coagulation and fibrinolysis parameters were measured in each patient during 3 phases of illness: febrile (Days 1–4), toxic (Days 5–6) and convalescent (Day 7–10). Bleeding scores (Buchanan G, et al, J Pediatr 2002) were also classified.

Results: In DHF patients, during the febrile phase, plasma levels of von Willebrand Factor Antigen (VWF:Ag), tissue factor (TF), Thrombin-Antithrombin Complex (TAT), and D-dimer were significantly high, while platelet counts, fibrinogen, Protein C activity (PC:Ac) and thrombin activatable fibrinolysis inhibitor (TAFIa) were significantly low compared to the control group. During the toxic phase, activated Factor VII (FVIIa:c), tissue plasminogen activator (t-PA) and plasminogen activator inhibitor (PAI-1) were significantly increased compared to the control group. In DF patients, during the febrile phase, only plasma levels of VWF:Ag were significantly elevated, while platelet count, PC:Ac and TAFIa were significantly lowered compared to the control group. During the toxic phase, soluble thrombomodulin (sTM), FVIIa:c, and TAT were significantly raised compared to the control group. Compared to DF patients, DHF patients had significantly higher plasma concentrations of vWF:Ag (p=0.02), TF (p=0.01), and PAI-1 (p=0.038) during the febrile phase. Bleeding scores were positively correlated with plasma t-PA and clinical severity, and negatively correlated with plasma Factor VIII:C and TAFIa. Using logistic regression analysis, we found that an increase in plasma VWF:Ag was the only significant predictor (p=0.049) of progression to DHF. The endothelial cell injury and release of procoagulant components, activation of the coagulation cascade with thrombin generation, increased antifibrinolytic factors and consumption of natural anticoagulants each play important roles in the development of hemorrhage in Dengue patients. Plasma VWF:Ag is the best indicator of progression to DHF.
Ferritin Levels in a Cohort of Affected Males of Mild Hemophilia A Carriers and Their Unaffected Siblings.
Authors: Kawaja M. , Scully M.F. , Barrett B. , Walsh M. , MacGregor D.
Published: April 2020

Iron deficiency is often used as a surrogate marker of bleeding. According to (multiple) studies, suboptimal iron stores can affect cognitive function, energy level and hence, quality of life. Due to a founder affect certain regions of the Canadian province of Newfoundland and Labrador have a very high prevalence of mild Hemophilia A. To accurately plan for future health related needs of these patients, a base-line cross-sectional study of a large cohort segregating a known founder mutation (Val2016Ala) was undertaken. Serum ferritin concentrations, complete blood counts (CBCs), menstrual blood loss assessed using Pictorial Blood Loss Assessment Chart (PBAC), bleeding histories, BMIs, and quality of life data using the SF-36 questionnaire were collected.

Prevalence(%) of Suboptimal Iron Status for Women and Men Sub-Grouped By Menstrual Status and Mutation Status Serum Ferritin Cut-off(ug/L) **P Chi-Square <0.001 *P Chi-Square <0.01 Cohort <11 <24 <40 <50 Females(n=141) 12.1* 37.6** 55.3** 62.4** Males(n=77) 1.3* 4.1** 6.5** 6.5** Menstruating Women(n=81) 15.0 54.3** 71.6** 80.2** Non-Menstruating Women(n=58) 8.6 15.5** 31.0** 36.2** Menstruating Carriers(n=46) 8.7 50.0 65.2 73.9 Menstruating Controls(n=35) 23.5 60.0 80.0 88.6 Affected Males(n=46) 0.0 4.3 6.5 6.5 Control Males(n=31) 3.2 3.2 6.5 6.5

§ Six women had hemoglobin concentrations less than 120 g/L and 11 men had concentrations less than 140 g/L, with anemia comparably observed in patients with or without the mutation(data not shown).

Women in general reported a lower mean General Health Scale score (63.9, 59.9–67.9 vs. 70.6, 69.5–71.7) and a higher mean Role Emotional Scale score (89.3, 85.8–92.8 vs 79.5, 77.7–81.3) than norms for the general U.S. population. Men with a history of severe bleeding had significantly lower ferritin levels than men without a history of severe bleeding (123.4 g/L, 63.6–186.3 g/L, 105.9–301.5; p <0,05). Mutation status did not influence iron status in either sex or menstrual blood loss in women as measured by the PBAC. Serum ferritin level was not associated with PBAC score. Neither the means of the eight SF-36 domains, health transition scale, nor the two component summary measures were significantly lower for mildly iron-deficient or iron-deficient women. The SF-36 is a general measure of various quality of life domains and may not be sensitive enough to measure the effects iron deficiency could potentially have on women’s cognition and fatigue. A study using measures more sensitive to these affects would better investigate the impact of iron deficiency. Further research is also required to determine whether the low ferritin levels observed in women could possible be a result of inadequate dietary intake of iron or insufficient iron absorption in addition to menstrual blood loss.
Assessment of Menorrhagia in Females Followed for Bleeding Disorders at the Hemophilia Center of Western New York-Correlation between Clinical Presentation and Laboratory Parameters.
Authors: Bush Eric , Smiley Shannon , Belling Linda , Bernstein Zale P.
Published: April 2020

Menorrhagia is a common problem among women. The pathophysiology has been attributed to Von Willebrand’s disease in some patients. The lab diagnosis and confirmation of this condition in these women is often difficult. The need for easily reproducible, validated lab investigations is recognized. The platelet function analyzer (PFA-100) (described below) has recently been used as an adjunct for lab diagnosis of this condition. Use of this device is relatively recent, thus clinical correlation with its results have been lacking. Therefore, we initiated a study to determine if a correlation could be established between pictorial blood assessment chart (PBAC), PFA-100, and Von Willebrand’s screening (VWF antigen and co-factor activity levels).

Materials and methods: After obtaining informed consent 15 female patients with a diagnosis of von Villebrand’s disease were enrolled in the above study. All received verbal and written instructions of how to record their tampon/pad use on the PBAC. The PBAC was then scored on a validated and well-established point system for lightly (1point), moderately (2points) and heavily (3points) soiled pads or tampons. In addition their blood samples were analyzed for von Willebrand antigen, Ristocetin Co-Factor and on the PFA-100 (pre and post DDAVP). The PFA-100, is a high shear-inducing device which simulates primary hemostasis after injury to small vessel, which consists of a reservoir for whole blood and a small capillary surmounted by a collagen-coated membrane with a central aperture. Platelet agonist which is either epinephrine or ADP is present on the membrane. Closure time is reported as a variable which describes von Willebrand factor function. All blood samples were forwarded to Children’s Hospital of Buffalo Special Coagulation lab for examination of the PFA-100(pre and post DDAVP),and von Willebrand panel.

Conclusion: There was correlation between the number of points self-assessed on the PBAC and the PFA-100.

Summary Data Patient # Age # points/PBAC VWF Ristocetin Co Factor Factor VIII PFA 100 Pre DDAVP 1 48 10 56 52 70 104 2 47 23 73 53 138 90 3 21 9 69 70 63 151 4 47 180 75 51 120 280 5 44 25 107 68 114 124 6 49 47 102 93 74 63 7 25 12 74 51 84 177 8 26 8 30 28 77 216 9 30 24 47 64 115 125 10 27 11 76 45 60 118 11 25 10 66 49 79 136 12 48 11 51 48 121 117 13 25 9 59 42 44 99 14 23 41 33 11 34 275 15 46 84 3 2 11 300
Enhanced Fibrin Clot Formation and Stability with a Superactive Analog of Factor VIIa in an In Vitro Model of Hemophilia.
Authors: Wolberg Alisa S. , Ezban Mirella , Hedner Ulla , Persson Egon
Published: April 2020

Recombinant factor VIIa (rFVIIa, NovoSeven; Novo Nordisk A/S, Copenhagen, Denmark) has demonstrated its clinical efficacy in treating bleeding in hemophilia patients with inhibitors. Using in vitro assays, we and others have previously shown that high dose rFVIIa shortens the onset of fibrin clot formation and normalizes the fibrin structure and porosity of clots formed under hemophilic conditions (absence of factors VIII and/or IX (Wolberg et al. (2001) 98(11): 826a). Recently, several superactive analogs of rFVIIa have been described, demonstrating increased thrombin-generating activity on platelets (Persson et al. (2001) 98(24): 13583–8), and increased capability to reduce the tail bleeding time and total blood loss in a mouse model of hemophilia A (Tranholm et al. (2003) 102(10): 3615–20).

In the current study, we have used a cell-based reconstituted model system of coagulation to compare the abilities of rFVIIa and one of the superactive analogues, NN1731, to modulate the onset and rate of fibrin clot formation, as well as the ability of these molecules to increase the stability of fibrin clots formed in the presence of a fibrinolytic challenge. The model system consists of tissue factor-bearing monocytes, purified pro- and anti-coagulant proteins (XI, X, IX, VIII, VIIa, V, II, AT, TFPI), freshly-isolated, unactivated platelets and fibrinogen. This system permits the inclusion of protein and cell concentrations at their physiologic levels. “Coagulation” is initiated by combining the components and following clot formation by optical density. “Hemophilia” is simulated by omitting factors IX and VIII. We observed that NN1731 shortened the clot time of hemophilic conditions to normal and did so at lower doses than were required of rFVIIa. Further, NN1731 increased the rate of clot formation to normal. To test the ability of clots to form in a fibrinolytic environment, we performed a Plasmin Challenge Assay, in which clot formation is initiated in the presence of a low concentration of plasmin. In this assay, clot formation is indicated as an increase in turbidity, and clot lysis is seen as a subsequent decrease in turbidity. There is no turbidity development (no clot formation) under hemophilic conditions. We observed that NN1731 increased the rate of clot formation and the length of time that fibrin was present under hemophilic conditions, and did so at lower concentrations than were required for rFVIIa. Moreover, in all of these assays, NN1731 normalized hemophilic conditions. Our results suggest that NN1731 promotes clot formation and stability to a greater degree than equal doses of rFVIIa and may possess clinical utility in patients that are refractory to current doses of rFVIIa.
Management of Recurring Epistaxis in Hereditary Hemorrhagic Teleangectasia.
Authors: Corinaldesi Giorgio , Corinaldesi Christian
Published: April 2020

The hereditary hemorrhagic teleangectasia of Rendu-Osler-Weber (HHT), is an autosomal dominant disease with a genetic angiodysplasia affecting multiple organs: skin, lung, gastrointestinal and genitourinary tract, and brain; the diagnosis is based on the following criteria: familiarity, epistaxis, teleangectasies, and visceral arterovenous malformations with a different degree of expression. The HHT is genetically heterogeneous involving two loci: HHT-1 (chromosome 9q-34.1), and HHT-2 (chromosome 12q11-q14). The loci have been identified as endoglin (ENG) CD105, and activin receptor like-kinase-1 (ALK-1) serine/threonine kinase receptor type-1 of TGF-beta superfamily.

We have studied a 52 years old patient presented with a story of recurrent bleeding and acute anemia secondary to strong epistaxis and upper bleeding: the endoscopic study disclosed multiple spots of duodeno-jejunal angiodysplasia with mucous angectasia spider-like 1–2 mm, macular spots, tortuous vessels. This patients also had frequent spontaneous epistaxis, in particular the management of most common anterior forms (locus Valsalvae, Kiesselbach area) is based on nostril pinching and the former abstersion of clots, irrigation with antifibrinolytic drugs and also on more packing with Lyofoam, Surgical, or Merocel leaflet or with Clauden or Vasenol lint which has to stay on site for 3–4 days with an antibiotic coverage, the relapsing cases were treated with sequential photocoagulation with argon-laser. In order to control high posterior epistaxis in case of emergency, the super-selective angiographic embolization with jelly sponge, polyvinyl-alcohol particles, detachable or endoscopic ultraligation of the anterior ethmoidal and or the sphenopalatine artery. All recurrent bleeding events responded to initial standard treatment strategies: blood transfusion with fresh frozen plasma, PRBC, drugs therapy including A-PCCS, tranexamic acid until 6 g/day, danazol, combined estrogen/progesterone therapy, octreotide (50 mcg iv followed by an infusion of 30 mcg/h for 5 days), anaemia required iron supplement. Recently severe clinical symptoms and a severe epistaxis and hematemesis combined with an hemodinamic instability required an urgent EGS followed by endoscopic therapy with termal probes together with high dose rFVII (220 mcg/kg), obtaining immediate benefit; no bleeding recurrence was detected after six months. This therapeutical approach may require some more studies, but it can be a great choice for controlling refractory re-bleeding in selected patients.
Rituximab in the Treatment of Factor VIII Inhibitor.
Authors: Maruscak Mercedes , Cohan Barry , Aghakhanian Linda , Ucar Kalust
Published: April 2020

Rituximab is a monoclonal antibody directed against the CD20 antigen found on both malignant and normal B lymphocytes. It was given FDA approval in 1997 for relapsed or refractory, low grade or follicular, CD20+ non-Hodgkin’s lymphoma. We report the use of selective B-cell depletion with Rituximab on a fifty-nine year old male with acquired Factor VIII inhibitor who failed to respond to convential therapy. The patient presented with compartment syndrome of the left calf due to spontaneous severe hematoma, and was subsequently hospitalized. The patient was found to have a PTT of 86, Factor VIII <3%, and Factor VIII inhibitor 108 b.u. The patient had completed forty-eight weeks of interferon and ribavirin for Hepatitis C one month prior to admission. The PTT was normal nineteen months prior when liver biopsies were obtained. The patient was subsequently diagnosed with acquired Factor VIII deficiency, thought to be secondary to either the Hepatitis C infection or the interferon therapy. He improved with Factor VIII concentrate therapy, but did not spontaneously recover from the inhibitor. He had minimal response to IVIG. Rituxin was subsequently started (intravenously at 375mg/m2) once a week for eight consecutive weeks, and repeated every six months. After four cycles, a consistent response was documented by increased Factor VIII activity (as high as 62%), and decreased Factor VIII inhibitor (stable at <0.5%). The treatment was well tolerated, and no infusion related side effects were observed. The patient did well with no bleeding on maintenance therapy for approximately twenty-one months. Unfortunately, two weeks after completion of the fourth cycle the patient suffered a ruptured AAA, and upon surgical intervention became unresponsive and a right cerebral infarct was identified. The patient’s family subsequently discontinued life support and the patient died. This experience suggests that further investigation of Rituximab therapy in this defined population might benefit similar patients.
Evaluation of Thrombotic Events in Haemophiliacs Undergoing Major Orthopaedic Surgery without Thrombosis Prophylaxis.
Authors: Krause Manuela , von Auer Charis , Kurth Andreas , Boehm Martina , Hovy L. , Scharrer Inge
Published: April 2020

Introduction:Major orthopaedic procedures and the presence of thrombophilia are risk factors of thrombotic events. In patients with haemophilia undergoing hip or knee replacement the importance of thrombosis prophylaxis with heparin in the postoperative period is still unknown. The aim of the present study was to evaluate the occurence of thrombotic events in haemophiliacs undergoing major surgery without thrombosis prophylaxis.

Patients: A total of 32 pts with haemophilia A (severe:27 pts, moderate:4 pts, mild:1pt; median age:47yrs, range:27–73yrs) undergoing hip (n=9)or knee (n=35) replacement were analysed in our haemophilia treatment center. Pts with inhibitors were excluded. Surgical interventions were performed using recombinant (n=37) or plasma-derived (n=7) FVIII for 12 to 15 postoperative days. The median initial dose of FVIII was 82 IU/Kg−1, followed by median FVIII doses of 54 IU/kg−1over the first four days. All pts received thrombosis prophylaxis with graduated compression stockings only. In addition to factor VIII activity, APC resistance, FV G1691A mutation and the FII G20210A variant (FII) were investigated.

Results: No thrombotic events in the postoperative period was dokumented. The median FVIII activity was 153% (range:85–347%), the Body mass index (BMI:kg/m2) was 23.1(range:18.2–30.5). During the first four postoperative days FVIII levels >150% were measured in 24/44 (55%) operative procedures. BMI>25 were shown in 12/32 (38%) pts, and age >40yrs was documented in 23/32 (72%) pts. In 1/30 (3%) pt APC resistance and none of our pts FII were identified.

Conclusion: In our study group elevated FVIII levels and additional risk factors (BMI>25, age>40years) seems not to influence relevantly the occurrence of thrombotic events in pts with haemophilia undergoing hip or knee replacement without thrombosis prophylaxis. Further studies are required to confirm whether a thrombosis prophylaxis with heparin is needed in haemophiliacs undergoing high risk surgery.
Administration of Vaccines to Infants and Children with Hemophilia. A Survey of the Region III Comprehensive Hemophilia Treatment Centers.
Authors: Ritchey Arthur K.
Published: April 2020

There appears to be variability in both recommendations and practice regarding the route of administration of immunizations to infants and children with hemophilia. The CDC Advisory Committee on Immunizations, the American Academy of Pediatrics Red Book, and the Medical and Scientific Advisory Council (MASAC) of the National Hemophilia Foundation all recommend intramuscular vaccination; the risk of bleeding can be minimized by concomitant administration of antihemophilic factor. However, informal discussions among practicing hematologists suggest that common practice is subcutaneous administration.

METHODS: To determine the standard practice regarding immunizations a survey was completed by 12 Hemophilia Treatment Centers in Federal Region III (Mid-Atlantic states). The number of pediatric patients followed in each institution ranged from 9 to 182 (average 73).

RESULTS: All centers have a policy or standard practice regarding the administration of vaccines and 10 of 12 recommend subcutaneous administration of all vaccines. Of the two centers that recommend following manufacturer guidelines one does and one does not routinely recommend concomitant factor administration. One center, whose policy is subcutaneous administration, recommends simultaneous factor administration if the primary care provider insists on intramuscular administration. Half of the centers do not offer immunizations on site; those that do usually offer only hepatitis A and B vaccines. All but one center have seen hematoma formation following immunizations, but none have seen sterile abscesses, necrosis, or granuloma formation. Hematomas have been seen following both subcutaneous and intramuscular injection. Estimates of hematoma formation are difficult to calculate, but one large program (folowing 182 patients) sees about 1 hematoma per year or an estimated 2–5% incidence.

CONCLUSION: Contrary to CDC and MASAC guidelines, it is standard practice at most Hemophilia Treatment Centers in Federal Region III to recommend subcutaneous administration of all vaccines without coverage of factor replacement. Hematoma formation is uncommon and can be seen following either subcutaneous or intramuscular administration. There appears to be little indication for prophylactic factor treatment before vaccine administration.
Management of Refractory Intracranial Hemorrhage in a Coagulopathic Patient with Liver Disease by Using Recombinant Factor VIIa (rFVIIa).
Authors: Leblebisatan Goksel , Sasmaz Ilgen , Mert Kurthan , Ozates Ebru , Antmen Bulent , Kilinc Yurdanur
Published: April 2020

Objective: Coagulopathy resulting from liver pathologies and the hemorrhages secondary to this are the complications observed in chronic liver diseases, fulminant hepatitis, hepatocellular cancer, liver transplantation and other similar conditions. The literature on the use of rFVIIa which was initially used in hemophiliac patients with inhibitors for hemorrhages that can not be managed with conventional methods or operations that can not be performed safely, is increasingly growing. Here we will present a patient that was successfully operated by using rFVIIa for recurrent intracranial hemorrhage secondary to liver disease.

Case: The 7 months old female infant was brought to our clinic due to abdominal distention and bleeding from anus. Her medical history included a treatment by hospitalization in the Regional Hospital when two months old due to high fever, forceful vomiting, foaming at mouth and yellow coloring of skin (convulsion?), operation due to hemorrhage detected at cerebral imaging, two subsequent operations at the same hospital due to hemorrhage upon sudden purple coloring of skin observed 1.5 months later and finally, dismission from hospital following a 25-day monitoring under conditions of intensive care. Following the yellow coloring of eyes, hematemesis, abdominal distention, echhymoses in the back and chest observed in the patient, she was referred to our clinic and her cerebral CT findings revealed pressure effect and subdural hematoma extending from temporal localization to frontoparietal cranium at left and to tentorium superior section and anterior interhemispheric fissure in cranium at posterior, with the widest part reaching 1.5 cm. The patient, for whom an operation was planned, was twice supplemented with platelet suspension at a dose of 10 cc/kg (53000/mm3) for her thrombocytopenia. Despite the administration of Frozen Plasma supplement, PT, PTT and Fibrinogen was detected as 18, 42.8 and 117 mg/dl, respectively and 1.2 mg of Novoseven was administered to the patient once preoperatively and twice postoperatively at a two-hour interval due to her history of postoperative hemorrhage. Upon the preoperative detection of PT, PTT, Fibrinogen as 12.1, 43.1 and 145 mg/dl and KZ and PZ as 6 and 5 minutes respectively, the patient was operated. No new postoperative hemorrhages or other complications were observed. The diagnosis of Gaucher disease was made at the bone marrow examination and the relevant treatment was planned.

Conclusion: rFVIIa can be safely used in high-risk patients with a history of recurrent hemorrhage, for whom no improvement can be achieved in the hemostasis tests.
Analysis of Structural Changes of the Factor VIII Gene: Intron 1 and 22, in Costarrican Families with Severe Haemophilia A.
Authors: Salazar-Sanchez Lizbeth , Jimenez-Cruz Guillermo , Chaverri Pilar , Schroeder Winnie , Wulff Karin , Sandoval Miriam , Auerswald Guenter K.H. , Herrmann Falko H.
Published: April 2020

Hemophilia A (HA) is X-chromosome linked bleeding disorders caused by deficiency of the coagulation factor VIII. The disease is caused by Factor VIII gene intron 22 inversion in approximately 50% of the patients and by intron 1 inversion in 5% of the patients. Both inversions occur as a result of intrachromosomal recombination between homologous region, in intron 1 or 22 and their extragenic copy located telomeric to the FVIII gene. The goal of the present study was to analyze the presence of these mutations in 15 HA severe Costarrican families.

Methods: We studied 122 unrelated HA patients and obligate or possible carriers for the presence of intron 22 or intron 1 by Southern blotting and polymerase chain reaction (PCR).

Results: We found altered intron 22 restriction profiles by Southern analyses in 14 of the families, 12 cases type 1 (Figure 1) and 2 cases type 2 inversion. During the screening for intron 1 inversion among the HA patient, who were intron 22 inversion negative, we did not identified this mutation.

Interpretation and Conclusions: This report is the first in our haemophilia families dealing with mutations in the intron 22 and intron 1. Our data highlight the importance of the analysis of intron 22 inversion for the association with development of inhibitors in the HA patients and we are continuous searching of intron 1 mutation. This will benefit both genetic counselling and the study of the relationship between genotype and inhibitor development.

Fig. 1 Southern blot of HA-I showing the intron 22 inversion of the factor VIII gene. Lane 1 and 2 normal Lane 3: heterozygote carrier and lane 4: patient with the altered fragment, (inversion of the intron 22). Fig. 1. Southern blot of HA-I showing the intron 22 inversion of the factor VIII gene. Lane 1 and 2 normal Lane 3: heterozygote carrier and lane 4: patient with the altered fragment, (inversion of the intron 22).
Peginterferon Alfa 2a: Treatment Option for Coagulopathy Associated with Vascular Malformation?.
Authors: von Auer Charis , Krause Manuela , Miesbach Wolfgang , Scharrer Inge
Published: April 2020

We applied peginterferon alfa 2a for off label use therapy in a 44 year old male patient (pat.) with extensive venous malformation (VM) and associated localized intravascular coagulation (LIC). Since birth he had huge VMs in the left leg and left lower abdomen. During surgery and tooth extraction he had severe bleeding complications. In 2003 he reported a sensation of continually growing VMs and requested for therapy.

Clinical findings (examination, contrast medium CT) showed no considerable growth of VMs in comparison to former examinations. Laboratory findings were low fibrinogen, low factor VIII activity (FVIII:C) and factor XIII activity (FXIII:C), prolonged aPTT, mild thrombocytopenia and elevated d-dimers. Vascular surgeons disadvised another surgery. LMWH therapy had been carried out before and was ineffective considering coagulopathy and sizereduction of vascular malformations. Considering antiproliferative properties we decided for off label use therapy with peginterferon alfa 2a (Pegasys), 180 μg once a week. Therapy started September 2004 and was applied for 16 weeks. Laboratory tests, clinical examination and photo documentation were done before, during and after therapy.

During and after therapy laboratory findings showed normalization of fibrinogen, FVIII:C levels, aPTT and rising FXIII:C levels. We saw no significant change of VMs in clinical examination and photographs. The pat. reported no sense of vascular size reduction but also no sense of growing malformations. Due to interferon side effects such as lowered blood count, therapy was finished after 16 weeks.

In conclusion the LIC in the VMs seemed to improve under interferon therapy with normalization of fibrinogen and FVIII:C. Even though there was no significant size reduction of VMs yet, this therapy could be an important treatment option for normalization of coagulation parameters e.g. before surgery. In our patient interferon therapy seemed to be more effective than LMWH therapy. In literature only heparin was reported to be effective in coagulopathies associated with VMs, not interferon. Therefore the positive laboratory findings in our patient are remarkable.
Factor VIII Inhibitors in Haemophilia A Patients Who Are Considered as Previously Treated Patients.
Authors: von Auer Charis , Oldenburg Johannes , Krause Manuela , Miesbach Wolfgang , Scharrer Inge ,   PTT- Study Group Germany
Published: April 2020

Previously treated patients (PTP), who have not developed an inhibitor (inh.) so far, are considered to be tolerant to factor VIII and at low risk for inh. development. Therefore inh. detection in a PTP should raise concerns about the concomitant variables such as product neo-antigenicity or way of application.

To find out about the current situation regarding inh. development in PTP in Germany, we conduct a retrospective study. A questionnaire was sent to 87 haemophilia treating centers, so far 46 of them answered. 28 PTP-inh. developments during the last 5 years were reported. Age of the patient (median 35), severity of haemophilia A (18 severe, 2 moderate, 8 mild), exposuer days (median 30) and gene mutation (intron-22-inversions 31%, large deletions 13%, missense mutations 25%, stop mutation 6%, small deletion 13%) were recorded. 8 different factor VIII concentrates were given during inh. development (5 plasma derived, 3 recombinant). Way of application (16 times bolus infusion, 3 times continuous infusion, 5 times both), former change of product, infused amount until inh. development, inh. characteristic, concomitant diseases and medication were registered.

In conclusion most of the patients were over 18 years old (17/28) when the inh. developed. Most of them had severe haemophilia A (18/28) and had at least one change of product before inh. detection. Our data are still too small to draw any conclusion concerning product neo-antigenicity or treatment modalities. Nevertheless it became obvious that inh. development in PTP is still a serious and underestimated problem in haemophilia treatment today. Secondly data showed that there is a variety of PTP definitions in Germany, referring to age of pat, number of exposure days and former change of product. An international definition for PTP would be helpful. A national haemophilia register would make it easier to evaluate data in the future and a prospective, not product related study should be conducted.
Thromboembolism in Children with Sarcoma.
Authors: Athale Uma H. , Cox Stephanie , Siciliano Sabrina , Chan Anthony K.C.
Published: April 2020

Background: Thromboembolism (TE) is one of the common causes of death in adults with cancer. Cancer is a major risk factor in children with TE and over 40% of children with central venous line (CVL)-related deep venous thrombosis (DVT) had underlying cancer. However, the epidemiology of TE in children with cancer, especially in association with childhood solid tumors is still unknown.

Objective: To define the prevalence and epidemiology of TE in association with sarcoma in children.

Methods: Hospital records of children ≤18 years of age with sarcoma diagnosed and treated at McMaster Children’s Hospital during January 1990 to September 2004 were reviewed for demographic details, details of diagnosis and therapy for sarcoma, and details of diagnosis and management of TE. Statistical analysis was performed using Fisher’s exact test.

Results: Seven of 63 (11.11%) patients with sarcoma developed TE (Table). Six patients had DVT and one patient had right atrial thrombosis. All, but one, patients had central venous line (CVL); three patients had CVL-associated DVT. Four of 28 girls (14.29%; 95% CI 5.7, 31.49) developed TE. Six of 36 patients ≥ 12 years of age developed TE (16.67%; 95% CI 7.87, 31.89) compared to 1 out of 27 (3.7%; 95% CI 0.66, 18.28) patients <12 years of age (p =0.222). Three out of 16 patients with metastatic disease at diagnosis developed TE (18.75%; 95% CI 6.59, 43.01) compared to 4 out of 47 (8.51%; 95% CI 3.36,19.93) (p=0.356) patients with localized disease. Six patients received anticoagulant therapy; one of these six patients required thrombectomy. Four patients received secondary thromboprophylaxis. One patient had recurrence of TE while being off of anticoagulant. Although none of the patients died because of TE or TE-related complication, patients with TE were at high risk for adverse outcome. Four out of 7 (57.1%) patients with TE have died compared to 22 of 56 (39.3%) patients without TE.

Conclusions: TE is a significant complication in children with sarcoma and may increase the risk of overall adverse outcome. Older patients and patients with Ewing’s sarcoma seem to be at are at higher, albeit statistically non-significant, risk of TE compared to younger patients and those with other types of sarcoma. Prospective studies of larger patient-populations are needed to define the epidemiology of TE in association with childhood sarcoma.

Type of Sarcoma N Patients with TE % TE (95% CI) * Comparison of Ewing’s sarcoma versus rest of patients, p = 0.184 Osteosarcoma 23 1/23 4.35 (0.77, 20.99) Ewing’s sarcoma 19 4/19 21.05 (8.51, 43.33) Rhabdomyosarcoma 14 1/14 7.14 (1.27, 31.47) Other 7 1/7 14.29 (2.57, 51.31) Overall 63 7/63 11.11 (5.99, 21.20)