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Wang D, Ito S, Waldron C, Butt A, Zhang E, Krumholz HM, Al-Samkari H, Goshua G. Cost-effectiveness of bevacizumab therapy in the care of patients with hereditary hemorrhagic telangiectasia. Blood Adv 2024; 8:2835-2845. [PMID: 38537061 PMCID: PMC11176968 DOI: 10.1182/bloodadvances.2024012589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/15/2024] [Accepted: 03/15/2024] [Indexed: 04/30/2024] Open
Abstract
ABSTRACT No US Food and Drug Administration- or European Medicines Agency-approved therapies exist for bleeding due to hereditary hemorrhagic telangiectasia (HHT), the second-most common inherited bleeding disorder worldwide. The current standard of care (SOC) includes iron and red cell supplementation, alongside the necessary hemostatic procedures, none of which target underlying disease pathogenesis. Recent evidence has demonstrated that bleeding pathophysiology is amenable to systemic antiangiogenic therapy with the anti-vascular endothelial growth factor bevacizumab. Despite its high cost, the addition of longitudinal bevacizumab to the current SOC may reduce overall health care resource use and improve patient quality of life. We conducted, to our knowledge, the first cost-effectiveness analysis of IV bevacizumab in patients with HHT with the moderate-to-severe phenotype, comparing bevacizumab added to SOC vs SOC alone. The primary outcome was the incremental net monetary benefit (iNMB) reported over a lifetime time horizon and across accepted willingness-to-pay thresholds, in US dollar per quality-adjusted life year (QALY). Bevacizumab therapy accrued 9.3 QALYs while generating $428 000 in costs, compared with 8.3 QALYs and $699 000 in costs accrued in the SOC strategy. The iNMB of bevacizumab therapy vs the SOC was $433 000. No parameter variation and no scenario analysis, including choice of iron supplementation product, changed the outcome of bevacizumab being a cost-saving strategy. Bevacizumab therapy also saved patients an average of 133 hours spent receiving HHT-specific care per year of life. In probabilistic sensitivity analysis, bevacizumab was favored in 100% of all 10 000 Monte Carlo iterations across base-case and all scenario analyses. Bevacizumab should be considered for more favorable formulary placement in the care of patients with moderate-to-severe HHT.
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Affiliation(s)
| | - Satoko Ito
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | | | - Ayesha Butt
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Ellen Zhang
- Department of Medicine, Stanford University Medical Center, Palo Alto, CA
| | - Harlan M. Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT
| | - Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Cambridge, MA
| | - George Goshua
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT
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Pearson M, McGowan R, Greene P, Lam W, Miedzybrodzka Z, Berg J. Outcomes of patients with Juvenile Polyposis-Hereditary Haemorrhagic Telangiectasia caused by pathogenic SMAD4 variants in a pan-Scotland cohort. Eur J Hum Genet 2024; 32:731-735. [PMID: 38627541 PMCID: PMC11153582 DOI: 10.1038/s41431-024-01607-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/20/2024] [Accepted: 03/28/2024] [Indexed: 06/07/2024] Open
Abstract
Constitutional loss of SMAD4 function results in Juvenile Polyposis-Hereditary Haemorrhagic Telangiectasia Overlap Syndrome (JP-HHT). A retrospective multi-centre case-note review identified 28 patients with a pathogenic SMAD4 variant from 13 families across all Scottish Clinical Genetics Centres. This provided a complete clinical picture of the Scottish JP-HHT cohort. Colonic polyps were identified in 87% (23/28) and gastric polyps in 67% (12/18) of screened patients. Complication rates were high: 43% (10/23) of patients with polyps required a colectomy and 42% (5/12) required a gastrectomy. Colorectal cancer occurred in 25% (7/28) of patients, at a median age of 33 years. Pulmonary arteriovenous malformations were identified in 42% (8/19) of screened patients. 88% (23/26) and 81% (17/21) of patients exhibited JP and HHT features respectively, with 70% (14/20) demonstrating features of both conditions. We have shown that individuals with a pathogenic SMAD4 variant are all at high risk of both gastrointestinal neoplasia and HHT-related vascular complications, requiring a comprehensive screening programme.
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Affiliation(s)
| | - Ruth McGowan
- West of Scotland Centre for Genomic Medicine, Glasgow, Scotland, UK
| | - Philip Greene
- South East of Scotland Clinical Genetics Service, Edinburgh, UK
| | - Wayne Lam
- South East of Scotland Clinical Genetics Service, Edinburgh, UK
| | - Zofia Miedzybrodzka
- School of Medicine, Medical Sciences, Nutrition and Dentistry, University of Aberdeen, Aberdeen, UK
| | - Jonathan Berg
- School of Medicine, University of Dundee, Dundee, Scotland, UK.
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McCarley SC, Murphy DA, Thompson J, Shovlin CL. Pharmacogenomic Considerations for Anticoagulant Prescription in Patients with Hereditary Haemorrhagic Telangiectasia. J Clin Med 2023; 12:7710. [PMID: 38137783 PMCID: PMC10744266 DOI: 10.3390/jcm12247710] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/10/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a vascular dysplasia that commonly results in bleeding but with frequent indications for therapeutic anticoagulation. Our aims were to advance the understanding of drug-specific intolerance and evaluate if there was an indication for pharmacogenomic testing. Genes encoding proteins involved in the absorption, distribution, metabolism, and excretion of warfarin, heparin, and direct oral anticoagulants (DOACs) apixaban, rivaroxaban, edoxaban, and dabigatran were identified and examined. Linkage disequilibrium with HHT genes was excluded, before variants within these genes were examined following whole genome sequencing of general and HHT populations. The 44 genes identified included 5/17 actionable pharmacogenes with guidelines. The 76,156 participants in the Genome Aggregation Database v3.1.2 had 28,446 variants, including 9668 missense substitutions and 1076 predicted loss-of-function (frameshift, nonsense, and consensus splice site) variants, i.e., approximately 1 in 7.9 individuals had a missense substitution, and 1 in 71 had a loss-of-function variant. Focusing on the 17 genes relevant to usually preferred DOACs, similar variant profiles were identified in HHT patients. With HHT patients at particular risk of haemorrhage when undergoing anticoagulant treatment, we explore how pre-emptive pharmacogenomic testing, alongside HHT gene testing, may prove beneficial in reducing the risk of bleeding and conclude that HHT patients are well placed to be at the vanguard of personalised prescribing.
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Affiliation(s)
- Sarah C. McCarley
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (S.C.M.); (J.T.)
| | - Daniel A. Murphy
- Pharmacy Department, Imperial College Healthcare NHS Trust, London W2 1NY, UK;
- Social, Genetic and Envionmental Determinants of Health Theme, NIHR Imperial Biomedical Research Centre, London W2 1NY, UK
| | - Jack Thompson
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (S.C.M.); (J.T.)
| | - Claire L. Shovlin
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (S.C.M.); (J.T.)
- Social, Genetic and Envionmental Determinants of Health Theme, NIHR Imperial Biomedical Research Centre, London W2 1NY, UK
- Specialist Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS, UK
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Wits M, Becher C, de Man F, Sanchez-Duffhues G, Goumans MJ. Sex-biased TGFβ signalling in pulmonary arterial hypertension. Cardiovasc Res 2023; 119:2262-2277. [PMID: 37595264 PMCID: PMC10597641 DOI: 10.1093/cvr/cvad129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/21/2023] [Accepted: 07/04/2023] [Indexed: 08/20/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare cardiovascular disorder leading to pulmonary hypertension and, often fatal, right heart failure. Sex differences in PAH are evident, which primarily presents with a female predominance and increased male severity. Disturbed signalling of the transforming growth factor-β (TGFβ) family and gene mutations in the bone morphogenetic protein receptor 2 (BMPR2) are risk factors for PAH development, but how sex-specific cues affect the TGFβ family signalling in PAH remains poorly understood. In this review, we aim to explore the sex bias in PAH by examining sex differences in the TGFβ signalling family through mechanistical and translational evidence. Sex hormones including oestrogens, progestogens, and androgens, can determine the expression of receptors (including BMPR2), ligands, and soluble antagonists within the TGFβ family in a tissue-specific manner. Furthermore, sex-related genetic processes, i.e. Y-chromosome expression and X-chromosome inactivation, can influence the TGFβ signalling family at multiple levels. Given the clinical and mechanistical similarities, we expect that the conclusions arising from this review may apply also to hereditary haemorrhagic telangiectasia (HHT), a rare vascular disorder affecting the TGFβ signalling family pathway. In summary, we anticipate that investigating the TGFβ signalling family in a sex-specific manner will contribute to further understand the underlying processes leading to PAH and likely HHT.
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Affiliation(s)
- Marius Wits
- Department of Cell and Chemical Biology, Leiden University Medical Center, Einthovenweg 20, 2333 ZC Leiden, The Netherlands
| | - Clarissa Becher
- Department of Cell and Chemical Biology, Leiden University Medical Center, Einthovenweg 20, 2333 ZC Leiden, The Netherlands
| | - Frances de Man
- Department of Pulmonary Medicine, Amsterdam University Medical Center (UMC) (Vrije Universiteit), 1081 HV Amsterdam, The Netherlands
| | - Gonzalo Sanchez-Duffhues
- Department of Cell and Chemical Biology, Leiden University Medical Center, Einthovenweg 20, 2333 ZC Leiden, The Netherlands
- Nanomaterials and Nanotechnology Research Center (CINN-CSIC), Health Research Institute of Asturias (ISPA), 33011 Oviedo, Spain
| | - Marie-José Goumans
- Department of Cell and Chemical Biology, Leiden University Medical Center, Einthovenweg 20, 2333 ZC Leiden, The Netherlands
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Grobost V, Hammi S, Pereira B, Guilhem A, Duffau P, Seguier J, Parrot A, Gautier G, Alric L, Kerjouan M, Le Guillou X, Simon D, Chaussavoine L, Rondeau-Lutz M, Leguy-Seguin V, Delagrange L, Lavigne C, Maillard H, Dupuis-Girod S. Antiplatelet and anticoagulant therapies in hereditary hemorrhagic telangiectasia: A large French cohort study (RETROPLACOTEL). Thromb Res 2023; 229:107-113. [PMID: 37437516 DOI: 10.1016/j.thromres.2023.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/02/2023] [Accepted: 07/05/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND It is unclear whether hereditary hemorrhagic telangiectasia (HHT) patients can tolerate antithrombotic therapies (AT) including antiplatelet (AP) and/or anticoagulant (AC) agents. OBJECTIVES Primary endpoint was tolerance to AT in HHT. Secondary endpoints were to identify factors associated with major bleeding events (MBE) and premature discontinuation of AT. METHODS Retrospective multicenter study in French national HHT Registry patients exposed to AT. RESULTS We included 126 patients with 180 courses of AT. Median follow-up was 24 [11-52] months. Mean age was 65.6 ± 13.1 years. The first 3 months of AT exposure had an increased risk of hospitalization for hemorrhage (p < 0.001) and transfusions (p < 0.001). MBE (n = 63) occurred more frequently in the first 3 months of AT exposure (p < 0.001). Premature discontinuation of AT occurred in 61 cases. Rate of premature discontinuation was 29 % under both AP and AT therapy but significantly higher under dual AP therapy (n = 4/7, 57 % p = 0.008). Risk factors for MBE were: age ≥ 60 years (HR 2.34 [1.12;4.87], p = 0.023), prior hospitalization in the 3 months before starting AT for hemorrhage (HR 3.59 [1.93;6.66], p < 0.001) or transfusion (HR 3.15 [1.61;6.18], p = 0.001), previous history of gastro-intestinal bleeding (HR 2.71 [1.57;4.65], p < 0.001) or MBE (HR 4.62 [2.68;7.98], p < 0.001). Frequency of MBE did not differ between groups except for a higher risk in the dual AP group (HR 3.92 [1.37;11.22], p = 0.011). CONCLUSION Tolerance of AC or AP therapy was similar in HHT population but not dual AP therapy. We identified risk factors for MBE occurrence or premature discontinuation under AT.
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Affiliation(s)
- Vincent Grobost
- Service de Médecine Interne, Clermont-Ferrand University Hospital, CHU Estaing, 63000 Clermont-Ferrand, France.
| | - Sami Hammi
- Department of Internal Medicine, Angers University Hospital, 49100 Angers, France
| | - Bruno Pereira
- Biostatistics Unit, Clermont-Ferrand University Hospital, 63000 Clermont-Ferrand, France
| | - Alexandre Guilhem
- Hospices Civils de Lyon, Hôpital Femme-Mère-Enfants, Service de Génétique et centre de référence de la maladie de Rendu-Osler, 69677 Bron, France
| | - Pierre Duffau
- Bordeaux University Hospital, Internal Medicine and Clinical Immunology Department, Université de Bordeaux, CNRS ImmunoConcEpT UMR 5164, 33000 Bordeaux, France
| | - Julie Seguier
- Département de Médecine Interne, Marseille University Hospital, 13000 Marseille, France
| | - Antoine Parrot
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie et Centre de Compétence de la Maladie de Rendu Osler, Hôpital Tenon, 75020 Paris, France
| | - Giovanni Gautier
- Nantes Université, Nantes University Hospital, Department of Internal and Vascular Medicine, 44000 Nantes, France
| | - Laurent Alric
- Internal Medicine-Digestive Medicine, CHU Rangueil Toulouse 3 University, 31000 Toulouse, France
| | - Mallorie Kerjouan
- Service de Pneumologie, Hôpital Pontchaillou, CHU Rennes, 35000 Rennes, France
| | - Xavier Le Guillou
- Medical Genetics Department, University Hospital of Poitiers, 86000 Poitiers, France
| | - Delphine Simon
- Service de Médecine Interne, CHU Charles Nicolle, 76000 Rouen, France
| | - Laurent Chaussavoine
- Centre Hospitalier Universitaire de Caen Normandie, Service de Médecine Vasculaire, 14000 Caen, France
| | - Murielle Rondeau-Lutz
- Service de Médecine Interne, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, 67 091 Strasbourg cedex, France
| | | | - Laura Delagrange
- Hospices Civils de Lyon, Hôpital Femme-Mère-Enfants, Service de Génétique et centre de référence de la maladie de Rendu-Osler, 69677 Bron, France
| | - Christian Lavigne
- Department of Internal Medicine, Angers University Hospital, 49100 Angers, France
| | - Hélène Maillard
- Department of Internal Medicine and Clinical Immunology, Referral Centre for rare systemic autoimmune diseases for North and North-West France (CeRAINO), CHU Lille, 59000, Lille, France
| | - Sophie Dupuis-Girod
- Hospices Civils de Lyon, Hôpital Femme-Mère-Enfants, Service de Génétique et centre de référence de la maladie de Rendu-Osler, 69677 Bron, France
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Solela G, Adamseged M, Mohammed A. Hereditary hemorrhagic telangiectasia in a 42-year-old Ethiopian man presenting with severe anemia and high-output heart failure: A case report with literature review. Clin Case Rep 2023; 11:e7694. [PMID: 37448947 PMCID: PMC10337522 DOI: 10.1002/ccr3.7694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023] Open
Abstract
Key Clinical Messages Hereditary hemorrhagic telangiectasia (HHT), a rare hereditary disorder, can cause recurrent massive epistaxis and gastrointestinal bleeding leading to severe anemia. Early diagnosis of HHT is essential to provide timely interventional therapies. Abstract HHT is a rare autosomal dominant hereditary disease that results in abnormal vasculogenesis in the skin, mucous membranes, and visceral organs such as the liver, lungs, and brain. Clinical diagnosis of HHT is made using the Curacao criteria, which include recurrent spontaneous nosebleeds, mucocutaneous telangiectasias, visceral organ involvement, and first-degree family history of HHT. Here, we report a patient with HHT from Ethiopia, who presented with recurrent epistaxis and gastrointestinal bleeding, and severe anemia requiring frequent blood transfusions as well as cauterization. The presented case is a 42-year-old Black Ethiopian man with frequent hospitalization for severe anemia and high-output heart failure requiring frequent blood transfusions. His mother had bilateral epistaxis since her early adulthood. Physical examination was significant for tachycardia, pale conjunctivae, and tiny erythematous lesions over his tongue, ejection systolic murmur and peripheral edema. Laboratory investigations revealed severe anemia with iron deficiency picture. Upper gastrointestinal endoscopy showed multiple telangiectasia spots and abdominal Doppler ultrasound showed hepatic arterio-venous malformations. He received supportive management and electrocauterization of nasal, gastric, and duodenal telangiectasias. To the best of our knowledge, this is the first case of HHT to be reported from Ethiopia. High degree of suspicion and early diagnosis of HHT is essential to start preventive screening and surveillance and provide timely interventional therapies. HHT can cause recurrent massive epistaxis and gastrointestinal bleeding leading to severe anemia and high-output heart failure. In resource limited settings, selective cauterization of telangiectasia will help to control bleeding, although it does not avoid recurrent bleeding.
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Affiliation(s)
- Gashaw Solela
- Department of Internal MedicineYekatit 12 Hospital Medical CollegeAddis AbabaEthiopia
| | - Michael Adamseged
- Department of Internal MedicineYekatit 12 Hospital Medical CollegeAddis AbabaEthiopia
| | - Abdulsemed Mohammed
- Division of Gastroenterology and Hepatology, Department of Internal MedicineCollege of Health Sciences, Addis Ababa UniversityAddis AbabaEthiopia
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Chuansumrit A, Ruchutrakul T, Sirachainan N, Kitpoka P, Panuwannakorn M, Panburana P, Suwannuraks M, Sri-Udomporn N, Kijkunasathian C, Jaovisidha S, Utamakul C, Natesirinilkul R, Pongtanakul B, Traivaree C, Komvilaisak P, Suwantaroj E, Sosothikul D, Angchaisuksiri P, Rojnuckarin P. National strategic advocacy to manage patients with inherited bleeding disorders in low and lower-middle income countries. Expert Rev Hematol 2023; 16:1063-1076. [PMID: 38100503 DOI: 10.1080/17474086.2023.2293092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023]
Abstract
INTRODUCTION Inherited bleeding disorders (IBDs) including hemophilia, von Willebrand disease, platelet disorders, mucocutaneous bleeding disorders and coagulation factor deficiencies are rarely found and under-recognized in low and lower-middle-income countries. Some patients succumbed to serious bleeding without diagnosis and treatment during childhood. AREA COVERED Diagnosis, management, and prevention should be integrated into the existing health care system. Although some countries have not implemented appropriate health care infrastructure, an initiative plan should be set up by cooperation of experienced experts and health care providers. Identification of patients with IBDs should be started in the antenatal setting to search for females at risk of carrier state. The investigations include bleeding assessment, mixing venous clotting time, coagulogram, coagulation factor assay and mutation detection. Genotypic analysis is helpful for confirming the definite diagnosis, carrier detection as well as prenatal diagnosis for females at risk of bearing an offspring with severe bleeding manifestations. Management involves replacement therapy ranging from blood component to virus-inactivated factor concentrate. Appropriate research is an essential backbone for improving patients' care. EXPERT OPINION Effective national strategic advocacy to manage patients with IBDs requires intensive collaboration among policy makers, health care providers, patients, and family members.
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Affiliation(s)
- Ampaiwan Chuansumrit
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Theera Ruchutrakul
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pimpun Kitpoka
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Monratta Panuwannakorn
- Department of Rehabilitation Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Panyu Panburana
- Department of Obstetrics-Gynecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Monthon Suwannuraks
- Dental Division, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nantana Sri-Udomporn
- Dental Division, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chusak Kijkunasathian
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suphaneewan Jaovisidha
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chirawat Utamakul
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Bunchoo Pongtanakul
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanchai Traivaree
- Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Patcharee Komvilaisak
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | - Darintr Sosothikul
- Department of Pediatrics and Integrative and Innovative Hematology/Oncology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pantep Angchaisuksiri
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ponlapat Rojnuckarin
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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8
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Torres-Iglesias R, Mora-Luján JM, Iriarte A, Cerdà P, Alba E, Sánchez-Corral MÁ, Berrozpe A, Cruellas F, Gamundí E, Ribas J, Castellote J, Riera-Mestre A. Long-term use of somatostatin analogs for chronic gastrointestinal bleeding in hereditary hemorrhagic telangiectasia. Front Med (Lausanne) 2023; 10:1146080. [PMID: 37250655 PMCID: PMC10213420 DOI: 10.3389/fmed.2023.1146080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/27/2023] [Indexed: 05/31/2023] Open
Abstract
Background Chronic bleeding due to gastrointestinal (GI) involvement in patients with hemorrhagic hereditary telangiectasia (HHT) can provoke severe anemia with high red blood cells (RBC) transfusion requirements. However, the evidence about how to deal with these patients is scarce. We aimed to assess the long-term efficacy and safety of somatostatin analogs (SA) for anemia management in HHT patients with GI involvement. Methods This is a prospective observational study including patients with HHT and GI involvement attended at a referral center. SA were considered for those patients with chronic anemia. Anemia-related variables were compared in patients receiving SA before and during treatment. Patients receiving SA were divided into responders (patients with minimal hemoglobin levels improvement >10 g/L and maintaining hemoglobin levels ≥80 g/L during treatment), and non-responders. Adverse effects during follow-up were collected. Results Among 119 HHT patients with GI involvement, 67 (56.3%) received SA. These patients showed lower minimal hemoglobin levels (73 [60-87] vs. 99 [70.2-122.5], p < 0.001), and more RBC transfusion requirements (61.2% vs. 38.5%, p = 0.014) than patients without SA therapy. Median treatment period was 20.9 ± 15.2 months. During treatment, there was a statistically significant improvement in minimum hemoglobin levels (94.7 ± 29.8 g/L vs. 74.7 ± 19.7, p < 0.001) and a reduction of patients with minimal hemoglobin levels <80 g/L (39 vs. 61%, p = 0.007) and RBC transfusions requirement (33.9% vs. 59.3%, p < 0.001). Sixteen (23.9%) patients showed mild adverse effects, mostly diarrhea or abdominal pain, leading to treatment discontinuation in 12 (17.9%) patients. Fifty-nine patients were eligible for efficacy assessment and 32 (54.2%) of them were considered responders. Age was associated with non-responder patients, OR 95% CI; 1.070 (1.014-1.130), p = 0.015. Conclusion SA can be considered a long-term effective and safe option for anemia management in HHT patients with GI bleeding. Older age is associated with poorer response.
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Affiliation(s)
- Raquel Torres-Iglesias
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - José María Mora-Luján
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Adriana Iriarte
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Pau Cerdà
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Esther Alba
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Radiology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Miguel Ángel Sánchez-Corral
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Cardiology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Ana Berrozpe
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Department of Digestive Diseases, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Francesc Cruellas
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Enric Gamundí
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Cytology and Hematology Laboratory, Antamomic Pathology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Jesús Ribas
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Pneumology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
| | - Jose Castellote
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Department of Digestive Diseases, Hospital Universitari de Bellvitge, Barcelona, Spain
- Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
| | - Antoni Riera-Mestre
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
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9
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Kilian A, Latino GA, White AJ, Ratjen F, McDonald J, Whitehead KJ, Gossage JR, Krings T, Lawton MT, Kim H, Faughnan ME. Comparing Characteristics and Treatment of Brain Vascular Malformations in Children and Adults with HHT. J Clin Med 2023; 12:2704. [PMID: 37048789 PMCID: PMC10094792 DOI: 10.3390/jcm12072704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 04/14/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant disease characterized by the development of vascular malformations (VMs) in organs such as the brain and lungs, as well as telangiectases on mucosal surfaces. Prophylactic treatment of organ VMs may prevent potential complications, such as hemorrhage. However, brain VM treatment-surgical resection, embolization, and/or radiosurgery-is not recommended for all patients due to the associated risks. Given the scarcity of data regarding HHT-related brain VM presentation and treatment trends in pediatric patients, we aim to describe the clinical presentations and the patterns of treatment of HHT-related brain VMs in a pediatric cohort, and compare pediatric trends to those of adults. Demographic and clinical data were analyzed in 114 pediatric patients with HHT-related brain VMs and compared with a cohort of 253 adult patients enrolled in the multicenter Brain Vascular Malformation Consortium HHT Project. Our data demonstrated that a higher proportion of pediatric patients with HHT-related brain VMs were symptomatic at presentation (p = 0.004). Moreover, a higher proportion of pediatric patients presented with intracranial hemorrhage (p < 0.001) and seizure (p = 0.002) compared to adult patients. Surgical resection was the most common brain VM treatment modality in both children and adults. We conclude that pediatric patients may be more likely to present with symptoms and complications from brain VMs, supporting the case for screening for brain VMs in children with HHT.
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Affiliation(s)
- Alexandra Kilian
- Department of Paediatrics, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Toronto HHT Centre, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON M5B 1W8, Canada
| | - Giuseppe A. Latino
- Toronto HHT Centre, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON M5B 1W8, Canada
- Department of Pediatrics, North York General Hospital, University of Toronto, Toronto, ON M2K 1E1, Canada
| | - Andrew J. White
- Department of Pediatrics, St Louis University, St. Louis, MO 63103, USA
| | - Felix Ratjen
- Division of Respiratory Medicine and Translational Medicine, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Jamie McDonald
- Department of Pathology, University of Utah, Salt Lake City, UT 84132, USA
| | - Kevin J. Whitehead
- Department of Medicine, Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT 84132, USA
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT 84132, USA
| | - James R. Gossage
- Department of Medicine, Augusta University, Augusta, GA 30912, USA
| | - Timo Krings
- Division of Neuroradiology, Toronto Western Hospital, University Health Network, Toronto, ON M5T 2S8, Canada
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ 85013, USA
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA 94110, USA
- Institute for Human Genetics, University of California San Francisco, San Francisco, CA 94143, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA 94158, USA
| | - Marie E. Faughnan
- Toronto HHT Centre, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON M5B 1W8, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada
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10
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Roy R, Dwivedi M, Swami H. Recalcitrant Epistaxis: A case report of Hereditary Haemorrhagic Telangiectasia. Indian J Otolaryngol Head Neck Surg 2023; 75:800-803. [PMID: 37206738 PMCID: PMC10188781 DOI: 10.1007/s12070-022-03407-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
Hereditary haemorrhagic telangiectasia, also known as Rendu-Osler-Weber disease, is an autosomal dominant disorder of the fibrovascular tissue common in Western countries. It is characterized by the classical triad of mucocutaneous telangiectasia, arteriovenous malformations with recurrent epistaxis. Here we report a rare case of Hereditary haemorrhagic telangiectasia in a 66-year-old Indian male who presented with a history of recurrent epistaxis of forty years duration. The nasal telangiectasias were ablated under narrow band imaging guidance. The rarity of diagnosis was aided by clinical exome sequencing to confirm the disease.
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Affiliation(s)
- Ravi Roy
- Department of ENT-HNS, Army Hospital Research and Referral, New Delhi, India
| | - Mandavi Dwivedi
- Department of ENT-HNS, Army Hospital Research and Referral, New Delhi, India
| | - Himanshu Swami
- Department of ENT-HNS, Army Hospital Research and Referral, New Delhi, India
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11
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Aguilera C, Padró-Miquel A, Esteve-Garcia A, Cerdà P, Torres-Iglesias R, Llecha N, Riera-Mestre A. Improving Hereditary Hemorrhagic Telangiectasia Molecular Diagnosis: A Referral Center Experience. Genes (Basel) 2023; 14:genes14030772. [PMID: 36981042 PMCID: PMC10048779 DOI: 10.3390/genes14030772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/14/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is a rare vascular disease inherited in an autosomal dominant manner. Disease-causing variants in endoglin (ENG) and activin A receptor type II-like 1 (ACVRL1) genes are detected in more than 90% of the patients undergoing molecular testing. The identification of variants of unknown significance is often seen as a challenge in clinical practice that makes family screening and genetic counseling difficult. Here, we show that the implementation of cDNA analysis to assess the effect of splice site variants on mRNA splicing is a powerful tool. METHODS Gene panel sequencing of genes associated with HHT and other arteriovenous malformation-related syndromes was performed. To evaluate the effect of the splice site variants, cDNA analysis of ENG and ACVRL1 genes was carried out. RESULTS three novel splice site variants were identified in ENG (c.68-2A > T and c.1311+4_1311+8del) and ACVLR1 (c.526-6C > G) genes correspondingly in three individuals with HHT that met ≥ 3 Curaçao criteria. All three variants led to an aberrant splicing inducing exon skipping (ENG:c.68-2A > T and ACVRL1:c.526-6C > G) or intron retention (ENG:c.1311+4_1311+8del) allowing the confirmation of the predicted effect on splicing and the reclassification from unknown significance to pathogenic/likely pathogenic of two of them. CONCLUSIONS RNA analysis should be performed to assess and/or confirm the impact of variants on splicing. The molecular diagnosis of HHT patients is crucial to allow family screening and accurate genetic counseling. A multidisciplinary approach including clinicians and geneticists is crucial when dealing with patients with rare diseases.
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Affiliation(s)
- Cinthia Aguilera
- Hereditary Hemorrhagic Telangiectasia Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
- Genetics Laboratory, Laboratori Clínic Territorial Metropolitana Sud, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
| | - Ariadna Padró-Miquel
- Hereditary Hemorrhagic Telangiectasia Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
- Genetics Laboratory, Laboratori Clínic Territorial Metropolitana Sud, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
| | - Anna Esteve-Garcia
- Hereditary Hemorrhagic Telangiectasia Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
- Clinical Genetics Unit, Laboratori Clínic Territorial Metropolitana Sud, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
| | - Pau Cerdà
- Hereditary Hemorrhagic Telangiectasia Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
| | - Raquel Torres-Iglesias
- Hereditary Hemorrhagic Telangiectasia Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
| | - Núria Llecha
- Genetics Laboratory, Laboratori Clínic Territorial Metropolitana Sud, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
- Clinical Genetics Unit, Laboratori Clínic Territorial Metropolitana Sud, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
| | - Antoni Riera-Mestre
- Hereditary Hemorrhagic Telangiectasia Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
- Faculty of Medicine and Health Sciences, Universitat de Barcelona, 08907 L'Hospitalet de Llobregat, Spain
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12
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Alkhalid Y, Darji Z, Shenkar R, Clancy M, Dyamenahalli U, Awad IA. Multidisciplinary coordinated care of hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease). Vasc Med 2023; 28:153-165. [PMID: 36890671 DOI: 10.1177/1358863x231151731] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease, is a rare disorder with a case prevalence as high as one in 5000, causing arteriovenous malformations in multiple organ systems. HHT is familial with autosomal dominant inheritance, with genetic testing allowing confirmation of the diagnosis in asymptomatic kindreds. Common clinical manifestations are epistaxis and intestinal lesions causing anemia and requiring transfusions. Pulmonary vascular malformations predispose to ischemic stroke and brain abscess and may cause dyspnea and cardiac failure. Brain vascular malformations can cause hemorrhagic stroke and seizures. Rarely, liver arteriovenous malformations can cause hepatic failure. A form of HHT can cause juvenile polyposis syndrome and colon cancer. Specialists in multiple fields may be called to care for one or more aspects of HHT, but few are familiar with evidence-based guidelines for HHT management or see a sufficient number of patients to gain experience with the unique characteristics of the disease. Primary care physicians and specialists are often unaware of the important manifestations of HHT in multiple systems and the thresholds for their screening and appropriate management. To improve familiarity, experience, and coordinated multisystem care for patients with HHT, the Cure HHT Foundation, which advocates for patients and families with this disease, has accredited 29 centers in North America with designated specialists for the evaluation and care of patients with HHT. Team assembly and current screening and management protocols are described as a model for evidence-based, multidisciplinary care in this disease.
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Affiliation(s)
- Yasmine Alkhalid
- Department of Neurological Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Zeena Darji
- Department of Neurological Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Robert Shenkar
- Department of Neurological Surgery, University of Chicago Medicine, Chicago, IL, USA
| | | | - Umesh Dyamenahalli
- Department of Pediatrics, Section of Pediatric Cardiology, University of Chicago Medicine, Chicago, IL, USA
| | - Issam A Awad
- Department of Neurological Surgery, University of Chicago Medicine, Chicago, IL, USA.,Multidisciplinary faculty of the HHT Center of Excellence at University of Chicago Medicine, Chicago, IL, USA includes: Remzi Bag, Section of Pulmonary Medicine; Fuad Baroody, Section of Otolaryngology and Head and Neck Surgery; Elizabeth Blair, Section of Otolaryngology and Head and Neck Surgery; Diana Bolotin, Section of Dermatology; James R Brorson, Department of Neurology; Kenneth S Cohen, Section of Hematology and Oncology; Brian Funaki, Section of Interventional Radiology; Hilary Jericho, Section of Pediatric Gastroenterology; Tarek Kass-Hout: Department of Neurology; Sonia Kupfer, Section of Gastroenterology; James K Liao, Section of Cardiology; Anjana Pillai, Section of Gastroenterology; Jayant Pinto, Section of Otolaryngology and Head and Neck Surgery; Christopher Roxbury, Section of Otolaryngology and Head and Neck Surgery; Carol E Semrad, Section of Gastroenterology; Sarah Stein, Section of Dermatology; Mary E Strek: Section of Pulmonary Medicine; Darrel J Waggoner, Department of Human Genetics; Steven Zangan, Section of Interventional Radiology
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- Multidisciplinary faculty of the HHT Center of Excellence at University of Chicago Medicine, Chicago, IL, USA includes: Remzi Bag, Section of Pulmonary Medicine; Fuad Baroody, Section of Otolaryngology and Head and Neck Surgery; Elizabeth Blair, Section of Otolaryngology and Head and Neck Surgery; Diana Bolotin, Section of Dermatology; James R Brorson, Department of Neurology; Kenneth S Cohen, Section of Hematology and Oncology; Brian Funaki, Section of Interventional Radiology; Hilary Jericho, Section of Pediatric Gastroenterology; Tarek Kass-Hout: Department of Neurology; Sonia Kupfer, Section of Gastroenterology; James K Liao, Section of Cardiology; Anjana Pillai, Section of Gastroenterology; Jayant Pinto, Section of Otolaryngology and Head and Neck Surgery; Christopher Roxbury, Section of Otolaryngology and Head and Neck Surgery; Carol E Semrad, Section of Gastroenterology; Sarah Stein, Section of Dermatology; Mary E Strek: Section of Pulmonary Medicine; Darrel J Waggoner, Department of Human Genetics; Steven Zangan, Section of Interventional Radiology
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13
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Sidonio RF, Bryant PC, Di Paola J, Hale S, Heiman M, Horowitz GS, Humphrey C, Jaffray J, Joyner LC, Kasthuri R, Konkle BA, Kouides PA, Montgomery R, Neeves K, Randi AM, Scappe N, Tarango C, Tickle K, Trapane P, Wang M, Waters B, Flood VH. Building the foundation for a community-generated national research blueprint for inherited bleeding disorders: research priorities for mucocutaneous bleeding disorders. Expert Rev Hematol 2023; 16:39-54. [PMID: 36920856 DOI: 10.1080/17474086.2023.2171983] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Excessive or abnormal mucocutaneous bleeding (MCB) may impact all aspects of the physical and psychosocial wellbeing of those who live with it (PWMCB). The evidence base for the optimal diagnosis and management of disorders such as inherited platelet disorders, hereditary hemorrhagic telangiectasia (HHT), hypermobility spectrum disorders (HSD), Ehlers-Danlos syndromes (EDS), and von Willebrand disease (VWD) remains thin with enormous potential for targeted research. RESEARCH DESIGN AND METHODS National Hemophilia Foundation and American Thrombosis and Hemostasis Network initiated the development of a National Research Blueprint for Inherited Bleeding Disorders with extensive all-stakeholder consultations to identify the priorities of people with inherited bleeding disorders and those who care for them. They recruited multidisciplinary expert working groups (WG) to distill community-identified priorities into concrete research questions and score their feasibility, impact, and risk. RESULTS WG2 detailed 38 high priority research questions concerning the biology of MCB, VWD, inherited qualitative platelet function defects, HDS/EDS, HHT, bleeding disorder of unknown cause, novel therapeutics, and aging. CONCLUSIONS Improving our understanding of the basic biology of MCB, large cohort longitudinal natural history studies, collaboration, and creative approaches to novel therapeutics will be important in maximizing the benefit of future research for the entire MCB community.
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Affiliation(s)
- Robert F Sidonio
- Department of Pediatrics, Aflac Cancer and Blood Disorders, Atlanta, Georgia, USA.,Hemophilia of Georgia Center for Bleeding and Clotting Disorders, Atlanta, Georgia, USA
| | - Paulette C Bryant
- Pediatric Hematology Oncology, St. Jude Affiliate Clinic at Novant Health Hemby Children's Hospital, Charlotte, North Carolina, USA.,National Hemophilia Foundation, New York, New York, USA
| | - Jorge Di Paola
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA.,Hematology/Oncology Department, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Sarah Hale
- Takeda Pharmaceuticals U.S.A, Lexington, Massachusetts, USA
| | - Meadow Heiman
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | | | | | - Julie Jaffray
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lora C Joyner
- East Carolina University Hemophilia Treatment Center, Greenville, North Carolina, USA
| | - Raj Kasthuri
- Division of Hematology, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Barbara A Konkle
- Washington Center for Bleeding Disorders, Seattle, Washington, USA
| | | | - Robert Montgomery
- Blood Center of Wisconsin, Versiti, Milwaukee, Wisconsin, USA.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Keith Neeves
- Hemophilia and Thrombosis Center, University of Colorado Denver, Denver, Colorado, USA.,Department of Bioengineering, University of Colorado Denver, Denver, Colorado, USA.,Department of Pediatrics, University of Colorado Denver, Denver, Colorado, USA.,Department of pediatrics, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Anna M Randi
- National Heart and Lung Institute, Imperial College, London, UK
| | - Nikole Scappe
- National Hemophilia Foundation, New York, New York, USA
| | - Cristina Tarango
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kelly Tickle
- Department of Pediatrics, Aflac Cancer and Blood Disorders, Atlanta, Georgia, USA.,Hemophilia of Georgia Center for Bleeding and Clotting Disorders, Atlanta, Georgia, USA.,Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Pamela Trapane
- Division of Pediatric Genetics, Department of Pediatrics, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Michael Wang
- Department of pediatrics, Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Veronica H Flood
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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14
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Zanetto A, Cossiga V, Shalaby S, Guarino M, Invernizzi F, Lapenna L, Becchetti C, Morisco F, Morelli MC, Merli M, Toniutto P, Burra P. Vascular liver diseases: A sex-oriented analysis of the literature. Dig Liver Dis 2023; 55:178-186. [PMID: 35906168 DOI: 10.1016/j.dld.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/06/2022] [Accepted: 07/11/2022] [Indexed: 02/01/2023]
Abstract
Vascular liver diseases are an heterogenous group of diseases that collectively represent an important health issue in the field of liver diseases. This narrative review was elaborated by the Special Interest Group (SIG) "Gender in Hepatology" of the Italian Association for the Study of the Liver (AISF). We aimed to review the current knowledge regarding the potential role of biological sex in patients with vascular liver diseases such as splanchnic vein thrombosis, hepatic vein thrombosis, porto-sinusoidal vascular disorder, and hereditary hemorrhagic telangiectasia. As vascular liver diseases commonly affect young individuals, including women in childbearing age, we also included a specific section on the management of pregnancy in these challenging patients.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Valentina Cossiga
- Department of Clinical Medicine and Surgery, Gastroenterology and Hepatology Unit, University of Naples "Federico II", Naples, Italy
| | - Sarah Shalaby
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Maria Guarino
- Department of Clinical Medicine and Surgery, Gastroenterology and Hepatology Unit, University of Naples "Federico II", Naples, Italy
| | - Federica Invernizzi
- Center for Liver Disease, Division of Internal Medicine and Hepatology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Lucia Lapenna
- Department of Translational and Precision Medicine, University of Rome Sapienza, Rome, Italy
| | - Chiara Becchetti
- Hepatology and Gastroenterology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Filomena Morisco
- Department of Clinical Medicine and Surgery, Gastroenterology and Hepatology Unit, University of Naples "Federico II", Naples, Italy
| | | | - Manuela Merli
- Center for Liver Disease, Division of Internal Medicine and Hepatology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Pierluigi Toniutto
- Hepatology and Liver Transplantation Unit, Academic Hospital, University of Udine, Udine, Italy
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy.
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15
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Sadick H, Schäfer E, Weiss C, Rotter N, Müller C, Birk R, Sadick M, Häussler D. An in vitro study on the effect of bevacizumab on endothelial cell proliferation and VEGF concentration level in patients with hereditary hemorrhagic telangiectasia. Exp Ther Med 2022; 24:555. [PMID: 35978926 PMCID: PMC9366282 DOI: 10.3892/etm.2022.11493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/09/2022] [Indexed: 11/14/2022] Open
Abstract
Previous studies have demonstrated that vascular endothelial growth factor (VEGF) is upregulated in patients with hereditary hemorrhagic telangiectasia (HHT). The use of Bevacizumab as an anti-angiogenic treatment agent seems promising. The purpose of the present in vitro study was to determine the efficacy and potential toxicity levels of bevacizumab on cell proliferation and VEGF concentrations in endothelial cells of HHT patients. In this in vitro study, endothelial cells from patients with HHT and HUVECs (control) were incubated with different concentration levels of bevacizumab (2, 4, 6, 8 or 10 mg/ml). After 24, 48 or 72 h, the cell proliferation was assessed by Alamar Blue® Assay and the VEGF levels in the cell culture supernatants were measured by VEGF-ELISA. All endothelial cells incubated with bevacizumab showed an initial decrease in cell proliferation. Cell proliferation recovered within 72 h in cell cultures incubated with concentration levels of up to 4 mg/ml bevacizumab, whereas those incubated with higher concentration levels showed a continuous decline in cell proliferation. VEGF expression decreased after 24 h in cell cultures incubated with bevacizumab concentration levels of 2 and 4 mg/ml but increased again after 48 h. Cell cultures incubated with bevacizumab concentration levels of 10 mg/ml showed a constant decline in VEGF expression without any tendency for recovery. Translating these results into daily clinical practice, the present study suggests that the intranasal submucosal injection of bevacizumab in HHT patients should not exceed a concentration level of 4 mg/ml. Overall, higher bevacizumab concentration levels not only reduce VEGF expression but pose a higher risk of toxic effects on endothelial cells as they jeopardize cell proliferation.
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Affiliation(s)
- Haneen Sadick
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, D‑68135 Mannheim, Germany
| | - Elena Schäfer
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, D‑68135 Mannheim, Germany
| | - Christel Weiss
- Department of Medical Statistics, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, D‑68135 Mannheim, Germany
| | - Nicole Rotter
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, D‑68135 Mannheim, Germany
| | - Cornelia Müller
- Department of Otorhinolaryngology, University Hospital Marburg, Philipps‑Universität Marburg, D‑35043 Marburg, Germany
| | - Richard Birk
- Department of Otorhinolaryngology, University Hospital Marburg, Philipps‑Universität Marburg, D‑35043 Marburg, Germany
| | - Maliha Sadick
- Clinic for Radiology and Nuclear Medicine, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, D‑68135 Mannheim, Germany
| | - Daniel Häussler
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, D‑68135 Mannheim, Germany
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16
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Jiang Y, Dennis SC, Brewin MP. Management of epistaxis in hereditary haemorrhagic telangiectasia (HHT) patients using pulsed dye laser and the effect of withholding treatment during the COVID pandemic. Lasers Med Sci 2022; 37:3147-3153. [DOI: 10.1007/s10103-022-03580-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/24/2022] [Indexed: 10/18/2022]
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17
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Diffuse Cerebral Edema and Impending Herniation Complicating Hepatic Encephalopathy in Hereditary Hemorrhagic Telangiectasia. Case Rep Med 2022; 2022:2612544. [PMID: 35222647 PMCID: PMC8881178 DOI: 10.1155/2022/2612544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/28/2021] [Indexed: 11/19/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular disease characterized by the formation of cutaneous and visceral telangiectasias and arteriovenous malformations (AVM). Multiple organs may be affected, including the nasal mucosa, skin, lungs, gastrointestinal tract, and brain. The following case highlights a unique manifestation of HHT in a patient with a gastrointestinal hemorrhage and epistaxis, resulting in hyperammonemia and diffuse cerebral edema and herniation. Clinicians should be aware of this potential complication in such patients and initiate ammonia-reducing agents early to avoid this devastating consequence.
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18
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Thiele B, Abdel-Aty Y, Marks L, Lal D, Marino M. Sclerotherapy for Hereditary Hemorrhagic Telangiectasia-Related Epistaxis: A Systematic Review. Ann Otol Rhinol Laryngol 2022; 132:82-90. [PMID: 35152768 DOI: 10.1177/00034894221078075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Hereditary hemorrhagic telangiectasia (HHT) is a common inherited condition characterized by mucosal telangiectasias, recurrent epistaxis, and arteriovenous malformations. HHT results in detriment to quality of life. Morbidity and mortality result from severe anemia. Conventional interventions for HHT-related epistaxis include nasal packing, diathermy, lasers, coblation, microdebridement, bevacizumab (topical and systemic), as well as septodermoplasty and nasal closure. Sclerotherapy has been recently described in the literature as a novel approach to HHT-related epistaxis. We hypothesize that sclerotherapy is an effective treatment for HHT-related epistaxis and improves upon the current standard of care for this disease. METHODS A systematic review was conducted to study sclerotherapy for treating HHT-related epistaxis. Ovid MEDLINE, Ovid EMBASE, Scopus, and Web of Science were searched. Articles were evaluated and excluded according to PRISMA guidelines and reviewed by 2 authors. Reported variables included number of injections, months of follow up, changes in Epistaxis Severity Score, previous treatments used to control epistaxis, and post-injection side effects. RESULTS Seven studies with a total of 196 patients met inclusion criteria. Three studies reported significant improvement as measured by the Epistaxis Severity Score scale. One reported improvement through subjective patient surveys and others used the Bergler-Sadick scale to measure frequency and intensity of epistaxis. All studies reported improvement in HHT-related epistaxis. The lack of uniform reporting measures however precluded formal meta-analysis. CONCLUSIONS Based on limited data, sclerotherapy appears to be effective for treating HHT-related epistaxis and offers promise for treating this recalcitrant condition. However, larger, prospective, multi-centered studies using universally validated instruments for epistaxis are needed to definitively evaluate outcomes from sclerotherapy.
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Affiliation(s)
| | | | - Lisa Marks
- Library Services, Mayo Clinic, Phoenix, AZ, USA
| | - Devyani Lal
- Department of Otolaryngology, Mayo Clinic, Phoenix, AZ, USA
| | - Michael Marino
- Department of Otolaryngology, Mayo Clinic, Phoenix, AZ, USA
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19
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Umscheid J, Albright J, Chazhoor J, Vasudeva R. Prolonged Asthma Exacerbation as an Initial Presentation in Hereditary Hemorrhagic Telangiectasia. Kans J Med 2021; 14:305-307. [PMID: 34888003 PMCID: PMC8647986 DOI: 10.17161/kjm.vol14.15752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/21/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jacob Umscheid
- University of Kansas School of Medicine-Wichita, Wichita, KS.,Department of Pediatrics
| | - Joshua Albright
- University of Kansas School of Medicine-Wichita, Wichita, KS.,Department of Pediatrics
| | - John Chazhoor
- University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Rhythm Vasudeva
- University of Kansas School of Medicine-Wichita, Wichita, KS.,Internal Medicine/Pediatrics Residency Program
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20
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Tessier S, Lipton BA, Ido F, Longo S, Nanda S. Pathogenesis and therapy of arteriovenous malformations: A case report and narrative review. Int J Crit Illn Inj Sci 2021; 11:167-176. [PMID: 34760664 PMCID: PMC8547675 DOI: 10.4103/ijciis.ijciis_127_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/24/2020] [Accepted: 01/05/2021] [Indexed: 12/03/2022] Open
Abstract
Arteriovenous malformations (AVMs) are abnormal communications between arteries and veins that lack intervening capillary beds. They have been described in almost every organ in the body, emerging sporadically or as part of well-described syndromes. Hereditary hemorrhagic telangiectasia (HHT) is a rare, progressive, and lifelong disease characterized by AVMs and recurrent hemorrhaging. In the last 2 decades, significant advances have been made in understanding the pathogenesis of this condition. The accumulation of knowledge has led to a natural evolution of therapy, from open surgery to endovascular procedures, and now to a role for medications in certain AVMs. Here, we review a case of HHT and describe the most up-to-date clinical practice, including diagnosis of HHT, subtypes of HHT, and medical therapy.
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Affiliation(s)
- Steven Tessier
- Lewis Katz School of Medicine, Temple University, Philadelphia, USA
| | - Brooke A Lipton
- Lewis Katz School of Medicine, Temple University, Philadelphia, USA
| | - Firas Ido
- Department of Pulmonary and Critical Care, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Santo Longo
- Department of Pathology, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Sudip Nanda
- Department of Cardiology, St. Luke's University Health Network, Bethlehem, PA, USA
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21
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Major T, Bereczky Z, Gindele R, Balogh G, Rácz B, Bora L, Kézsmárki Z, Brúgós B, Pfliegler G. Current Status of Clinical and Genetic Screening of Hereditary Hemorrhagic Telangiectasia Families in Hungary. J Clin Med 2021; 10:jcm10173774. [PMID: 34501220 PMCID: PMC8432115 DOI: 10.3390/jcm10173774] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/15/2021] [Accepted: 08/20/2021] [Indexed: 12/30/2022] Open
Affiliation(s)
- Tamás Major
- Division of Otorhinolaryngology and Head & Neck Surgery, Kenézy Gyula Campus, University of Debrecen Medical Center, University of Debrecen, H-4031 Debrecen, Hungary;
- Correspondence: (T.M.); (Z.B.); Tel.: +36-52-511777 (ext. 1756) (T.M.); +36-52-431956 (Z.B.); Fax: +36-52-511755 (T.M.); +36-52-340011 (Z.B.)
| | - Zsuzsanna Bereczky
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary; (R.G.); (G.B.)
- Correspondence: (T.M.); (Z.B.); Tel.: +36-52-511777 (ext. 1756) (T.M.); +36-52-431956 (Z.B.); Fax: +36-52-511755 (T.M.); +36-52-340011 (Z.B.)
| | - Réka Gindele
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary; (R.G.); (G.B.)
| | - Gábor Balogh
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary; (R.G.); (G.B.)
| | - Benedek Rácz
- Division of Otorhinolaryngology and Head & Neck Surgery, Kenézy Gyula Campus, University of Debrecen Medical Center, University of Debrecen, H-4031 Debrecen, Hungary;
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary; (R.G.); (G.B.)
| | - László Bora
- Department of Radiology, Szent Lázár County Hospital, H-3100 Salgótarján, Hungary;
| | - Zsolt Kézsmárki
- Division of Radiology, Kenézy Gyula Campus, University of Debrecen Medical Center, University of Debrecen, H-4031 Debrecen, Hungary;
| | - Boglárka Brúgós
- Division of Rare Diseases, Department of Internal Medicine Block B, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary; (B.B.); (G.P.)
| | - György Pfliegler
- Division of Rare Diseases, Department of Internal Medicine Block B, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary; (B.B.); (G.P.)
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22
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Haubner F, Schneider A, Schinke H, Bertlich M, Weiss BG, Canis M, Kashani F. Classification of endonasal HHT lesions using digital microscopy. Orphanet J Rare Dis 2021; 16:182. [PMID: 33865423 PMCID: PMC8053266 DOI: 10.1186/s13023-021-01801-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recurrent spontaneous epistaxis is the most common clinical manifestation and the most debilitating symptom in hereditary haemorrhagic telangiectasia (HHT) patients. To this date, there exist only a classification of HHT patients by different genetic mutations. There is no standard classification for the mucocutaneous endonasal manifestations of HHT. The aim of the present study was to document the variety of endonasal HHT lesions using digital microscopy and to propose a clinical classification. METHODS We recorded the endonasal HHT lesions of 28 patients using a digital microscope. We reconstructed the 3D images und videos recorded by digital microscope afterwards and classified the endonasal lesions of HHT in two classes: Grade A, presence of only flat telangiectasias in the mucosa level and Grade B, (additional) presence of raised berry or wart-like telangiectasia spots. We investigated also Haemoglobin level by routine laboratory procedures, plasma VEGF level by ELISA, Severity of epistaxis by epistaxis severity score (ESS) and quality of life by a linear visual analogue scale (VAS). RESULTS We found a higher quality of life and a lower severity of epistaxis in Grade A patients in comparison to Grade B patients. No difference in plasma VEGF level and in Haemoglobin between Grad A patients and Grade B patients could be detected. Plasma VEGF levels showed no gender specific differences. It could also not be correlated to the extranasal manifestation. CONCLUSION The classification for endonasal manifestation of HHT proposed in this study indicates severity of epistaxis und quality of life. Digital microscopy with the ability of 3D reconstruction of images presents a useful tool for such classifications. The classification of endonasal HHT lesions using digital microscopy allows to evaluate the dynamic of HHT lesions in the course of time independent of examiner. This allows also to evaluate the efficacy of the different treatment modalities by dynamic of HHT lesions. Moreover digital microscopy is very beneficial in academic teaching of rare diseases.
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Affiliation(s)
- F Haubner
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | | | - H Schinke
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - M Bertlich
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - B G Weiss
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - M Canis
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - F Kashani
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
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23
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Mutational and phenotypic characterization of hereditary hemorrhagic telangiectasia. Blood 2021; 136:1907-1918. [PMID: 32573726 DOI: 10.1182/blood.2019004560] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 05/17/2020] [Indexed: 12/13/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular dysplasia. Care delivery for HHT patients is impeded by the need for laborious, repeated phenotyping and gaps in knowledge regarding the relationships between causal DNA variants in ENG, ACVRL1, SMAD4 and GDF2, and clinical manifestations. To address this, we analyzed DNA samples from 183 previously uncharacterized, unrelated HHT and suspected HHT cases using the ThromboGenomics high-throughput sequencing platform. We identified 127 rare variants across 168 heterozygous genotypes. Applying modified American College of Medical Genetics and Genomics Guidelines, 106 variants were classified as pathogenic/likely pathogenic and 21 as nonpathogenic (variant of uncertain significance/benign). Unlike the protein products of ACVRL1 and SMAD4, the extracellular ENG amino acids are not strongly conserved. Our inferences of the functional consequences of causal variants in ENG were therefore informed by the crystal structure of endoglin. We then compared the accuracy of predictions of the causal gene blinded to the genetic data using 2 approaches: subjective clinical predictions and statistical predictions based on 8 Human Phenotype Ontology terms. Both approaches had some predictive power, but they were insufficiently accurate to be used clinically, without genetic testing. The distributions of red cell indices differed by causal gene but not sufficiently for clinical use in isolation from genetic data. We conclude that parallel sequencing of the 4 known HHT genes, multidisciplinary team review of variant calls in the context of detailed clinical information, and statistical and structural modeling improve the prognostication and treatment of HHT.
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24
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Pepe M, Suppressa P, Giuliano AF, Nestola PL, Bortone AS, DE Cillis E, Acquaviva T, Forleo C, Moscarelli M, Lenato GM, SabbÀ C. Safety of reduced or absent antithrombotic therapy after left atrial appendage closure in patients affected by hereditary haemorrhagic telangiectasia and atrial fibrillation. Minerva Cardiol Angiol 2021; 70:537-544. [PMID: 33703853 DOI: 10.23736/s2724-5683.20.05474-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Left atrial appendage (LAA) closure represents a novel therapeutic chance for patients with contraindications to long-term anticoagulation therapy, such as those affected by Hereditary Hemorrhagic Telangiectasia (HHT) and atrial fibrillation (AF). Nevertheless, current experts' indications suggest the post-procedural administration of antithrombotic therapies to minimize the residual thromboembolic risk due to AF and to the need for device endothelialization. The aim of our study was to investigate the safety and effectiveness of LAA closure in preventing arterial thromboembolism in a very high-bleeding risk group, such as HHT patients, who are at risk not to tolerate even the mild post-procedural antithrombotic therapy usually recommended. METHODS Eight HHT-affected patients with non-valvular AF, high-bleeding risk and/or known intolerance to antiplatelet and anticoagulant therapy were treated with interventional LAA occlusion with the Amplatzer™ Cardiac Plug™ and Amplatzer™ Amulet™ devices. Device implantation was successful in all patients. RESULTS Post-procedural antiplatelet/anticoagulation therapy was attempted in seven patients: adherence to therapy exceeded six months only for one, while four patients suspended all antithrombotic medications within 30 days from the procedure due to an increase in bleeding frequency and/or severity and the other two discontinued treatment within six months; a single patient was not prescribed any antithrombotic therapy. At a medium follow-up of 22.4±14.3 months no thromboembolic episodes attributable to AF or device related thrombosis were reported. Two deaths were recorded 1231 and 783 days after the procedure which were classified as unrelated to any cerebral or cardiovascular accident. CONCLUSIONS Our study suggests that the percutaneous LAA closure in HHT patients with AF could be safe and effective in preventing arterial systemic thromboembolism, also in the presence of reduced or absent post-interventional antithrombotic treatment. LAA occluder implantation can represent a valid and potentially life-saving alternative to lifelong anticoagulant therapy in HHT, as in other very high-bleeding risk patients.
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Affiliation(s)
- Martino Pepe
- Division of Cardiology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Patrizia Suppressa
- C. Frugoni Internal Medicine Unit, Department of Interdisciplinary Medicine, Center for Rare Diseases, VascERN HHT Reference Center Policlinico University Hospital, University of Bari, Bari, Italy
| | - Antonio F Giuliano
- C. Frugoni Internal Medicine Unit, Department of Interdisciplinary Medicine, Center for Rare Diseases, VascERN HHT Reference Center Policlinico University Hospital, University of Bari, Bari, Italy
| | - Palma L Nestola
- Division of Cardiology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy -
| | - Alessandro S Bortone
- Division of Heart Surgery, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Emanuela DE Cillis
- Division of Heart Surgery, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Tommaso Acquaviva
- Division of Heart Surgery, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Cinzia Forleo
- Division of Cardiology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Marco Moscarelli
- Cardiothoracic and Vascular Department, Maria Cecilia Hospital GVM Care & Research, Cotignola, Ravenna, Italy
| | - Gennaro M Lenato
- C. Frugoni Internal Medicine Unit, Department of Interdisciplinary Medicine, Center for Rare Diseases, VascERN HHT Reference Center Policlinico University Hospital, University of Bari, Bari, Italy
| | - Carlo SabbÀ
- C. Frugoni Internal Medicine Unit, Department of Interdisciplinary Medicine, Center for Rare Diseases, VascERN HHT Reference Center Policlinico University Hospital, University of Bari, Bari, Italy
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25
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Thompson KP, Nelson J, Kim H, Pawlikowska L, Marchuk DA, Lawton MT, Faughnan ME. Predictors of mortality in patients with hereditary hemorrhagic telangiectasia. Orphanet J Rare Dis 2021; 16:12. [PMID: 33407668 PMCID: PMC7789194 DOI: 10.1186/s13023-020-01579-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 10/13/2020] [Indexed: 12/20/2022] Open
Abstract
Background Retrospective questionnaire and healthcare administrative data suggest reduced life expectancy in untreated hereditary hemorrhagic telangiectasia (HHT). Prospective data suggests similar mortality, to the general population, in Denmark’s centre-treated HHT patients. However, clinical phenotypes vary widely in HHT, likely affecting mortality. We aimed to measure predictors of mortality among centre-treated HHT patients. HHT patients were recruited at 14 HHT centres of the Brain Vascular Malformation Consortium (BVMC) since 2010 and followed annually. Vital status, organ vascular malformations (VMs) and clinical symptoms data were collected at baseline and during follow-up (N = 1286). We tested whether organ VMs, HHT symptoms and HHT genes were associated with increased mortality using Cox regression analysis, adjusting for patient age, sex, and smoking status.
Results 59 deaths occurred over average follow-up time of 3.4 years (max 8.6 years). A history of anemia was associated with increased mortality (HR = 2.93, 95% CI 1.37–6.26, p = 0.006), as were gastro-intestinal (GI) bleeding (HR = 2.63, 95% CI 1.46–4.74, p = 0.001), and symptomatic liver VMs (HR = 2.10, 95% CI 1.15–3.84, p = 0.015). Brain VMs and pulmonary arteriovenous malformations (AVMs) were not associated with mortality (p > 0.05). Patients with SMAD4 mutation had significantly higher mortality (HR = 18.36, 95% CI 5.60–60.20, p < 0.001) compared to patients with ACVRL1 or ENG mutation, but this estimate is imprecise given the rarity of SMAD4 patients (n = 33, 4 deaths). Conclusions Chronic GI bleeding, anemia and symptomatic liver VMs are associated with increased mortality in HHT patients, independent of age, and in keeping with the limited treatment options for these aspects of HHT. Conversely, mortality does not appear to be associated with pulmonary AVMs or brain VMs, for which patients are routinely screened and treated preventatively at HHT Centres. This demonstrates the need for development of new therapies to treat chronic anemia, GI bleeding, and symptomatic liver VMs in order to reduce mortality among HHT patients.
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Affiliation(s)
- K P Thompson
- Toronto HHT Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B-1W8, USA.,Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada
| | - J Nelson
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, CA, USA
| | - H Kim
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, CA, USA.,Institute for Human Genetics, University of California, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - L Pawlikowska
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, CA, USA.,Institute for Human Genetics, University of California, San Francisco, CA, USA
| | - D A Marchuk
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC, USA
| | - M T Lawton
- Barrow Neurological Institute, Phoenix, AZ, USA
| | - Marie E Faughnan
- Toronto HHT Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B-1W8, USA. .,Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada.
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26
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Kilian A, Clancy MS, Olitsky S, Gossage JR, Faughnan ME. Screening for pulmonary and brain vascular malformations is the North American standard of care for patients with hereditary hemorrhagic telangiectasia (HHT): A survey of HHT Centers of Excellence. Vasc Med 2020; 26:53-55. [PMID: 33375920 PMCID: PMC7879226 DOI: 10.1177/1358863x20974452] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alexandra Kilian
- Department of Medicine, Division of Respirology, Toronto HHT Centre, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | | | - James R Gossage
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Augusta University, Augusta, GA, USA
| | - Marie E Faughnan
- Department of Medicine, Division of Respirology, Toronto HHT Centre, St Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute and the Keenan Research Centre for Biomedical Science, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
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27
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Embolic Stroke Caused by Hereditary Hemorrhagic Telangiectasia with Pulmonary Arteriovenous Malformation. J Gen Intern Med 2020; 35:3707-3710. [PMID: 32815056 PMCID: PMC7728913 DOI: 10.1007/s11606-020-06126-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/10/2020] [Indexed: 02/03/2023]
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28
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Swietlik EM, Prapa M, Martin JM, Pandya D, Auckland K, Morrell NW, Gräf S. 'There and Back Again'-Forward Genetics and Reverse Phenotyping in Pulmonary Arterial Hypertension. Genes (Basel) 2020; 11:E1408. [PMID: 33256119 PMCID: PMC7760524 DOI: 10.3390/genes11121408] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/17/2020] [Accepted: 11/23/2020] [Indexed: 02/07/2023] Open
Abstract
Although the invention of right heart catheterisation in the 1950s enabled accurate clinical diagnosis of pulmonary arterial hypertension (PAH), it was not until 2000 when the landmark discovery of the causative role of bone morphogenetic protein receptor type II (BMPR2) mutations shed new light on the pathogenesis of PAH. Since then several genes have been discovered, which now account for around 25% of cases with the clinical diagnosis of idiopathic PAH. Despite the ongoing efforts, in the majority of patients the cause of the disease remains elusive, a phenomenon often referred to as "missing heritability". In this review, we discuss research approaches to uncover the genetic architecture of PAH starting with forward phenotyping, which in a research setting should focus on stable intermediate phenotypes, forward and reverse genetics, and finally reverse phenotyping. We then discuss potential sources of "missing heritability" and how functional genomics and multi-omics methods are employed to tackle this problem.
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Affiliation(s)
- Emilia M. Swietlik
- Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK; (E.M.S.); (M.P.); (J.M.M.); (D.P.); (K.A.); (N.W.M.)
- Royal Papworth Hospital NHS Foundation Trust, Cambridge CB2 0AY, UK
- Addenbrooke’s Hospital NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Matina Prapa
- Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK; (E.M.S.); (M.P.); (J.M.M.); (D.P.); (K.A.); (N.W.M.)
- Addenbrooke’s Hospital NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Jennifer M. Martin
- Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK; (E.M.S.); (M.P.); (J.M.M.); (D.P.); (K.A.); (N.W.M.)
| | - Divya Pandya
- Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK; (E.M.S.); (M.P.); (J.M.M.); (D.P.); (K.A.); (N.W.M.)
| | - Kathryn Auckland
- Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK; (E.M.S.); (M.P.); (J.M.M.); (D.P.); (K.A.); (N.W.M.)
| | - Nicholas W. Morrell
- Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK; (E.M.S.); (M.P.); (J.M.M.); (D.P.); (K.A.); (N.W.M.)
- Royal Papworth Hospital NHS Foundation Trust, Cambridge CB2 0AY, UK
- Addenbrooke’s Hospital NHS Foundation Trust, Cambridge CB2 0QQ, UK
- NIHR BioResource for Translational Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK
| | - Stefan Gräf
- Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK; (E.M.S.); (M.P.); (J.M.M.); (D.P.); (K.A.); (N.W.M.)
- NIHR BioResource for Translational Research, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK
- Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0PT, UK
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29
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Healthcare Utilization and Costs associated with Hereditary Hemorrhagic Telangiectasia Patients in a Large US Claims Database. Mayo Clin Proc Innov Qual Outcomes 2020; 5:55-64. [PMID: 33718784 PMCID: PMC7930864 DOI: 10.1016/j.mayocpiqo.2020.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective To assess the health care costs and utilization in patients with hereditary hemorrhagic telangiectasia (HHT) in the United States. Patients and Methods Retrospective analysis of patients with HHT diagnosed between 2007 and 2017 was performed using deidentified administrative claims data from the OptumLabs Data Warehouse. Adult patients with new (incident) diagnosis of HHT between January 1, 2007, and December 31, 2017, were included. Comparisons were made using the Wilcoxon rank sum test. Results Three thousand nine hundred seventy-seven patients with a first diagnosis of HHT between 2007 and 2017 were identified, of which 3590 were matched 1:1 to non-HHT patients with similar baseline characteristics and comorbidities. These 3590 patients with HHT were 63.1% female and 83.9% white with a mean age of 51.1 ± 18.5 years, and a mean follow-up period of 3.2 ± 2.2 years (range, 1.0-11.7 years). Compared with the control group, the cumulative 5-year median total health care cost for patients with HHT was 41.4% higher ($21,118 vs $14,929; P < .001) in those with private commercial insurance and 31.7% higher ($35,462 vs $26,925; P < .001) in those with Medicare Advantage coverage. The median annual health care costs were significantly higher in patients with HHT with commercial insurance and Medicare Advantage in the first year after diagnosis ($4,333 vs $1,804; P < .001), and ($7,322 vs $5,245; P < .001), respectively, and remained higher throughout the duration of follow-up. Further analysis showed that outpatient clinic visits, hospital admission, imaging rates, invasive procedures, iron infusions, and blood transfusions were all significantly higher in the HHT group. Conclusion Patients with HHT have significantly higher health care costs compared with a matched control group. A better understanding of the reasons underlying these cost differences will provide opportunities for patients, providers, and other stakeholders to better manage this rare condition.
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Genotype-Phenotype Correlations in Children with HHT. J Clin Med 2020; 9:jcm9092714. [PMID: 32842615 PMCID: PMC7565052 DOI: 10.3390/jcm9092714] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 12/15/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT), a rare autosomal dominant disease mostly caused by mutations in three known genes (ENG, ACVRL1, and SMAD4), is characterized by the development of vascular malformations (VMs). Patients with HHT may present with mucocutaneous telangiectasia, as well as organ arteriovenous malformations (AVMs) of the central nervous system, lungs, and liver. Genotype-phenotype correlations have been well described in adults with HHT. We aimed to investigate genotype-phenotype correlations among pediatric HHT patients. Demographic, clinical, and genetic data were collected and analyzed in 205 children enrolled in the multicenter Brain Vascular Malformation Consortium HHT Project. A chi-square test was used to determine the association between phenotypic presentations and genotype. Among 205 patients (age range: 0-18 years; mean: 11 years), ENG mutation was associated with the presence of pulmonary AVMs (p < 0.001) and brain VM (p < 0.001). The presence of a combined phenotype-defined as both pulmonary AVMs and brain VMs-was also associated with ENG mutation. Gastrointestinal bleeding was rare (4.4%), but was associated with SMAD4 genotype (p < 0.001). We conclude that genotype-phenotype correlations among pediatric HHT patients are similar to those described among adults. Specifically, pediatric patients with ENG mutation have a greater prevalence of pulmonary AVMs, brain VMs, and a combined phenotype.
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Eker OF, Boccardi E, Sure U, Patel MC, Alicante S, Alsafi A, Coote N, Droege F, Dupuis O, Fialla AD, Jones B, Kariholu U, Kjeldsen AD, Lefroy D, Lenato GM, Mager HJ, Manfredi G, Nielsen TH, Pagella F, Post MC, Rennie C, Sabbà C, Suppressa P, Toerring PM, Ugolini S, Buscarini E, Dupuis-Girod S, Shovlin CL. European Reference Network for Rare Vascular Diseases (VASCERN) position statement on cerebral screening in adults and children with hereditary haemorrhagic telangiectasia (HHT). Orphanet J Rare Dis 2020; 15:165. [PMID: 32600364 PMCID: PMC7322871 DOI: 10.1186/s13023-020-01386-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/22/2020] [Indexed: 12/13/2022] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a multisystemic vascular dysplasia inherited as an autosomal dominant trait. Approximately 10 % of patients have cerebral vascular malformations, a proportion being cerebral arteriovenous malformations (AVMs) and fistulae that may lead to potentially devastating consequences in case of rupture. On the other hand, detection and treatment related-risks are not negligible, and immediate. While successful treatment can be undertaken in individual cases, current data do not support the treatment of unruptured AVMs, which also present a low risk of bleeding in HHT patients. Screening for these AVMs is therefore controversial. Structured discussions, distinctions of different cerebrovascular abnormalities commonly grouped into an “AVM” bracket, and clear guidance by neurosurgical and neurointerventional radiology colleagues enabled the European Reference Network for Rare Vascular Disorders (VASCERN-HHT) to develop the following agreed Position Statement on cerebral screening: 1) First, we emphasise that neurological symptoms suggestive of cerebral AVMs in HHT patients should be investigated as in general neurological and emergency care practice. Similarly, if an AVM is found accidentally, management approaches should rely on expert discussions on a case-by-case basis and individual risk-benefit evaluation of all therapeutic possibilities for a specific lesion. 2) The current evidence base does not favour the treatment of unruptured cerebral AVMs, and therefore cannot be used to support widespread screening of asymptomatic HHT patients. 3) Individual situations encompass a wide range of personal, cultural and clinical states. In order to enable informed patient choice, and avoid conflicting advice, particularly arising from non-neurovascular interpretations of the evidence base, we suggest that all HHT patients should have the opportunity to discuss knowingly brain screening issues with their healthcare provider. 4) Any screening discussions in asymptomatic individuals should be preceded by informed pre-test review of the latest evidence regarding preventative and therapeutic efficacies of any interventions. The possibility of harm due to detection of, or intervention on, a vascular malformation that would not have necessarily caused any consequence in later life should be stated explicitly. We consider this nuanced Position Statement provides a helpful, evidence-based framework for informed discussions between healthcare providers and patients in an emotionally charged area.
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Affiliation(s)
- Omer F Eker
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France.
| | - Edoardo Boccardi
- Niguarda Hospital, Milan, Italy and VASCERN HHT Reference Centre, Crema, Italy
| | - Ulrich Sure
- VASCERN HHT Reference Centre, Essen University Hospital, Essen, Germany
| | - Maneesh C Patel
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Saverio Alicante
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy
| | - Ali Alsafi
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Nicola Coote
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Freya Droege
- VASCERN HHT Reference Centre, Essen University Hospital, Essen, Germany
| | - Olivier Dupuis
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France
| | - Annette Dam Fialla
- VASCERN HHT Reference Centre, Odense Universitetshospital, Syddansk Universitet, Odense, Denmark
| | - Bryony Jones
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Ujwal Kariholu
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Anette D Kjeldsen
- VASCERN HHT Reference Centre, Odense Universitetshospital, Syddansk Universitet, Odense, Denmark
| | - David Lefroy
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Gennaro M Lenato
- VASCERN HHT Reference Centre, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Policlinico, Bari, Italy
| | - Hans Jurgen Mager
- VASCERN HHT Reference Centre, St Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - Guido Manfredi
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy
| | - Troels H Nielsen
- VASCERN HHT Reference Centre, Odense Universitetshospital, Syddansk Universitet, Odense, Denmark
| | - Fabio Pagella
- VASCERN HHT Reference Centre, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Marco C Post
- VASCERN HHT Reference Centre, St Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - Catherine Rennie
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Carlo Sabbà
- VASCERN HHT Reference Centre, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Policlinico, Bari, Italy.
| | - Patrizia Suppressa
- VASCERN HHT Reference Centre, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Policlinico, Bari, Italy
| | - Pernille M Toerring
- VASCERN HHT Reference Centre, Odense Universitetshospital, Syddansk Universitet, Odense, Denmark
| | - Sara Ugolini
- VASCERN HHT Reference Centre, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | | | | | - Claire L Shovlin
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK and Imperial College London, London, UK.
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Bertlich M, Kashani F, Weiss BG, Wiebringhaus R, Ihler F, Freytag S, Gires O, Kühnel T, Haubner F. Safety and Efficacy of Blue Light Laser Treatment in Hereditary Hemorrhagic Telangiectasia. Lasers Surg Med 2020; 53:309-315. [PMID: 32573010 DOI: 10.1002/lsm.23289] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/09/2020] [Accepted: 06/14/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND OBJECTIVES Hereditary hemorrhagic telangiectasia (HHT) is a hereditary condition that is associated with arteriovenous malformations. A common site for these malformations is the nasal mucosa, which is associated with severe epistaxis and debilitation for affected patients. We evaluated the efficacy and safety of blue light laser technology in treating these endonasal manifestations in a retrospective chart analysis. Additionally, we compared blue light laser technology to bipolar coagulation in an animal model. STUDY DESIGN/MATERIALS AND METHODS We performed a retrospective chart analysis of all patients that were diagnosed with HHT and received endonasal blue light laser treatment between 10/2017 and 04/2019. In addition, we performed bipolar or blue light laser coagulation of all macroscopically visible vessels on thyroid gland lobes (n = 4) from Dunkin-Hartley Guinea Pigs. Hematoxylin-eosin (HE) staining was then used to visualize depth and area of coagulation surrounding these vessels. RESULTS One hundred and fifty-one treatments in 23 patients were analyzed. Under regular blue light laser treatment, quality of life (QOL), indicated on a visual analog scale from 1 to 10, gradually increased significantly from 5.6 ± 0.5 (before the first treatment) to 7.5 ± 0.9 (after the second treatment). Following this, QOL remained steady throughout additional treatments. Adverse effects were not recorded. HE staining showed that coagulation depth (162 ± 56 vs. 586 ± 192 µm) and area (74 ± 35 vs. 1015 ± 449 µm2 ) were significantly lower after laser treatment. CONCLUSION Blue light laser therapy is safe and efficient in treating HHT. Damage to the surrounding tissue is significantly lower compared with bipolar coagulation. © 2020 The Authors. Lasers in Surgery and Medicine published by Wiley Periodicals LLC.
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Affiliation(s)
- Mattis Bertlich
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Munich, Marchioninistr. 15, Munich, 81377, Germany
| | - Fatemeh Kashani
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Munich, Marchioninistr. 15, Munich, 81377, Germany
| | - Bernhard G Weiss
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Munich, Marchioninistr. 15, Munich, 81377, Germany
| | - Robert Wiebringhaus
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Munich, Marchioninistr. 15, Munich, 81377, Germany
| | - Friedrich Ihler
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Munich, Marchioninistr. 15, Munich, 81377, Germany
| | - Saskia Freytag
- Epigenetics and Genomics, The Harry Perkins Institute of Medical Research, 6 Verdun St, Nedlands, Western Australia, 6009, Australia
| | - Olivier Gires
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Munich, Marchioninistr. 15, Munich, 81377, Germany.,Clinical Cooperation Group "Personalized Radiotherapy in Head and Neck Cancer", Helmholtz Zentrum, Marchioninistr. 25, Munich, 81377, Germany
| | - Thomas Kühnel
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg, 93047, Germany
| | - Frank Haubner
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Munich, Marchioninistr. 15, Munich, 81377, Germany
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Lim DR, Kim DB, Kim HK, Shin EJ. Surgery of hereditary hemorrhagic telangiectasia with severe refractory gastrointestinal bleeding: A case report of a rare condition. Int J Surg Case Rep 2020; 72:503-506. [PMID: 32698275 PMCID: PMC7317164 DOI: 10.1016/j.ijscr.2020.06.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 11/06/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) affects the vascular structure of numerous organs. Clinical symptoms of HHT is epistaxis, GI bleeding, and iron deficiency anemia caused by mucocutaneous telangiectasias. The treatment of HHT with gastrointestinal bleeding may need surgical treatment.
Introduction Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant genetic disease that affects the vasculature of numerous organs. HHT is characterized by the presence of multiple arteriovenous malformations that lack intervening capillaries and result in direct connections between arteries and veins. Presentation of case A 58-year-old South Korean female was admitted presenting with severe anemia, dizziness, and intermittent hematochezia. The patient had experienced chronic severe refractory gastrointestinal bleeding for years. She had an intermittent spontaneous epistaxis, telangiectasias in the oral cavity (tongue), and hepatic arteriovenous malformations and gastrointestinal telangiectasia. She underwent a segmental resection of a segment of the ileum and cecum (about 77 cm). After surgery, the patient experienced no more drops in hemoglobin count or symptoms of anemia and melena. She is living a normal life. Conclusion The present case report is a surgical case of undiagnosed HHT with chronic refractory gastrointestinal bleeding. Surgical treatment is rarely required for gastrointestinal bleeding unless nonsurgical methods such as endoscopy/colonoscopy and angiography have failed.
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Affiliation(s)
- Dae Ro Lim
- Division of Colon and Rectal Surgery, Department of Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
| | - Da Bin Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
| | - Hee Kyung Kim
- Department of Pathology, Soonchunhyang University College of Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
| | - Eung Jin Shin
- Division of Colon and Rectal Surgery, Department of Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea.
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Sánchez-Martínez R, Iriarte A, Mora-Luján JM, Patier JL, López-Wolf D, Ojeda A, Torralba MA, Juyol MC, Gil R, Añón S, Salazar-Mendiguchía J, Riera-Mestre A. Current HHT genetic overview in Spain and its phenotypic correlation: data from RiHHTa registry. Orphanet J Rare Dis 2020; 15:138. [PMID: 32503579 PMCID: PMC7275435 DOI: 10.1186/s13023-020-01422-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 05/27/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is a rare vascular disease with autosomal dominant inheritance. Disease-causing variants in endoglin (ENG) and activin A receptor type II-like 1 (ACVRL1) genes are detected in more than 90% of cases submitted to molecular diagnosis. METHODS We used data from the RiHHTa (Computerized Registry of Hereditary Hemorrhagic Telangiectasia) registry to describe genetic variants and to assess their genotype-phenotype correlation among HHT patients in Spain. RESULTS By May 2019, 215 patients were included in the RiHHTa registry with a mean age of 52.5 ± 16.5 years and 136 (63.3%) were women. Definitive HHT diagnosis defined by the Curaçao criteria were met by 172 (80%) patients. Among 113 patients with genetic test, 77 (68.1%) showed a genetic variant in ACVRL1 and 36 (31.8%) in ENG gene. The identified genetic variants in ACVRL1 and ENG genes and their clinical significance are provided. ACVRL1 mutations were more frequently nonsense (50%) while ENG mutations were more frequently, frameshift (39.1%). ENG patients were significantly younger at diagnosis (36.9 vs 45.7 years) and had pulmonary arteriovenous malformations (AVMs) (71.4% vs 24.4%) and cerebral AVMs (17.6% vs 2%) more often than patients with ACVRL1 variants. Patients with ACVRL1 variants had a higher cardiac index (2.62 vs 3.46), higher levels of hepatic functional blood tests, and anemia (28.5% vs 56.7%) more often than ENG patients. CONCLUSIONS ACVRL1 variants are more frequent than ENG in Spain. ACVRL1 patients developed symptomatic liver disease and anemia more often than ENG patients. Compared to ACVRL1, those with ENG variants are younger at diagnosis and show pulmonary and cerebral AVMs more frequently.
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Affiliation(s)
- Rosario Sánchez-Martínez
- Internal Medicine Department, Hospital General Universitario de Alicante - ISABIAL, Alicante, Spain.,Rare Diseases Working Group, Spanish Society of Internal Medicine, Madrid, Spain
| | - Adriana Iriarte
- Rare Diseases Working Group, Spanish Society of Internal Medicine, Madrid, Spain.,Hereditary Hemorrhagic Telangiectasia Unit, Internal Medicine Department, Hospital Universitari de Bellvitge - IDIBELL, Feixa Llarga s/n. 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - José María Mora-Luján
- Rare Diseases Working Group, Spanish Society of Internal Medicine, Madrid, Spain.,Hereditary Hemorrhagic Telangiectasia Unit, Internal Medicine Department, Hospital Universitari de Bellvitge - IDIBELL, Feixa Llarga s/n. 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - José Luis Patier
- Rare Diseases Working Group, Spanish Society of Internal Medicine, Madrid, Spain.,Department of Internal Medicine, Systemic and Orphan Diseases Unit, University Hospital Ramón y Cajal, University of Alcalá, IRYCIS, Madrid, Spain
| | - Daniel López-Wolf
- Rare Diseases Working Group, Spanish Society of Internal Medicine, Madrid, Spain.,Internal Medicine Department, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Ana Ojeda
- Rare Diseases Working Group, Spanish Society of Internal Medicine, Madrid, Spain.,Internal Medicine Department, Hospital Insular Universitario de Gran Canaria, Gran Canaria, Spain
| | - Miguel Angel Torralba
- Rare Diseases Working Group, Spanish Society of Internal Medicine, Madrid, Spain.,Internal Medicine Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - María Coloma Juyol
- Rare Diseases Working Group, Spanish Society of Internal Medicine, Madrid, Spain.,Internal Medicine Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Ricardo Gil
- Rare Diseases Working Group, Spanish Society of Internal Medicine, Madrid, Spain.,Internal Medicine Department, Hospital La Fe, Valencia, Spain
| | - Sol Añón
- Rare Diseases Working Group, Spanish Society of Internal Medicine, Madrid, Spain.,Internal Medicine Department, Hospital Arnau de Vilanova, Valencia, Spain
| | - Joel Salazar-Mendiguchía
- Health in Code, A Coruña, Spain.,Clinical Genetics Program, Hospital Universitari de Bellvitge - IDIBELL, Barcelona, Spain.,Genetics Department, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antoni Riera-Mestre
- Rare Diseases Working Group, Spanish Society of Internal Medicine, Madrid, Spain. .,Hereditary Hemorrhagic Telangiectasia Unit, Internal Medicine Department, Hospital Universitari de Bellvitge - IDIBELL, Feixa Llarga s/n. 08907 L'Hospitalet de Llobregat, Barcelona, Spain. .,Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain.
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McCann MD, Newlon C, Krawiec C. Hypoxemia without Respiratory Distress: Hereditary Hemorrhagic Telangiectasia in a Child. J Pediatr Intensive Care 2020; 10:155-158. [PMID: 33884218 DOI: 10.1055/s-0040-1710499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 04/08/2020] [Indexed: 10/24/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an underrecognized genetic disorder of vascular development in pediatric patients. Its presentation can range from mild cutaneous findings to life-threatening hemorrhage from arteriovenous malformations. Clinical diagnosis can be challenging in the pediatric population as disease manifestations evolve over time and may be difficult to identify in younger patients. This case highlights how nonspecific symptoms and signs in the preanesthesia period can be misleading, potentially placing a patient with unrecognized HHT at risk for significant morbidity and mortality.
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Affiliation(s)
- Michael D McCann
- Department of Pediatrics, Penn State Hershey Children's Hospital, Pennsylvania, United States
| | - Claire Newlon
- Department of Pediatrics, Penn State Hershey Children's Hospital, Pennsylvania, United States
| | - Conrad Krawiec
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Pennsylvania, United States
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Mora-Luján JM, Iriarte A, Alba E, Sánchez-Corral MA, Cerdà P, Cruellas F, Ordi Q, Corbella X, Ribas J, Castellote J, Riera-Mestre A. Gender differences in hereditary hemorrhagic telangiectasia severity. Orphanet J Rare Dis 2020; 15:63. [PMID: 32122373 PMCID: PMC7053104 DOI: 10.1186/s13023-020-1337-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 02/25/2020] [Indexed: 12/13/2022] Open
Abstract
Background Gender differences in organ involvement and clinical severity have been poorly described in hereditary hemorrhagic telangiectasia (HHT). The aim of this study was to describe differences in the severity of HHT manifestations according to gender. Methods Severity was measured according to Epistaxis Severity Score (ESS), Simple Clinical Scoring Index for hepatic involvement, a general HHT-score, needing for invasive treatment (pulmonary or brain arteriovenous malformations -AVMs- embolization, liver transplantation or Young’s surgery) or the presence of adverse outcomes (severe anemia, emergency department -ED- or hospital admissions and mortality). Results One hundred forty-two (58.7%) women and 100 (41.3%) men were included with a mean age of 48.9 ± 16.6 and 49 ± 16.5 years, respectively. Women presented hepatic manifestations (7.1% vs 0%) and hepatic involvement (59.8% vs 47%), hepatic AVMs (28.2% vs 13%) and bile duct dilatation (4.9% vs 0%) at abdominal CT, and pulmonary AVMs at thoracic CT (35.2% vs 23%) more often than men. The Simple Clinical Scoring Index was higher in women (3.38 ± 1.2 vs 2.03 ± 1.2), and more men were considered at low risk of harboring clinically significant liver disease than women (61% vs 25.3%). These differences were mantained when considering HHT1 and HHT2 patients separetely. Duodenal telangiectasia were more frequent in men than women (21% vs 9.8%). Invasive treatments were more frequently needed in women (28.2% vs 16%) but men needed attention at the ED more often than women (48% vs 28.2%), with no differences in ESS, HHT-score, anemia hospital admissions or mortality. Conclusions HHT women showed more severe hepatic involvement than men, also among HHT1 and HHT2 patients. Women had higher prevalence of pulmonary AVMs and needed invasive procedures more frequently, while men needed attention at the ED more often. These data might help physicians to individualize HHT patients follow-up.
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Affiliation(s)
- J M Mora-Luján
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Internal Medicine Department, Hospital Universitari Bellvitge, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - A Iriarte
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Internal Medicine Department, Hospital Universitari Bellvitge, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - E Alba
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.,Radiology Department, Hospital Universitari Bellvitge, Barcelona, Spain
| | - M A Sánchez-Corral
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.,Cardiology Department, Hospital Universitari Bellvitge, Barcelona, Spain
| | - P Cerdà
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Internal Medicine Department, Hospital Universitari Bellvitge, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - F Cruellas
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.,Otorhinolaryngology Department, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Q Ordi
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.,Radiology Department, Hospital Universitari Bellvitge, Barcelona, Spain
| | - X Corbella
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Internal Medicine Department, Hospital Universitari Bellvitge, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.,Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
| | - J Ribas
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.,Pneumology Department, Hospital Universitari Bellvitge, Barcelona, Spain
| | - J Castellote
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.,Liver Transplant Unit, Department of Digestive Diseases, Hospital Universitari Bellvitge, Barcelona, Spain.,Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
| | - A Riera-Mestre
- HHT Unit, Hospital Universitari de Bellvitge, C/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain. .,Internal Medicine Department, Hospital Universitari Bellvitge, Barcelona, Spain. .,Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain. .,Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain.
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Ortega-Torres A, Sánchez-Díaz G, Villaverde-Hueso A, Posada de la Paz M, Alonso-Ferreira V. Mortalidad atribuida a telangiectasia hemorrágica hereditaria y variabilidad geográfica en España (1981-2016). GACETA SANITARIA 2020; 34:37-43. [DOI: 10.1016/j.gaceta.2018.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 11/17/2022]
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Gastrointestinal Bleeding in Patients with Hereditary Hemorrhagic Telangiectasia: Risk Factors and Endoscopic Findings. J Clin Med 2019; 9:jcm9010082. [PMID: 31905627 PMCID: PMC7019907 DOI: 10.3390/jcm9010082] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 12/20/2019] [Accepted: 12/25/2019] [Indexed: 12/11/2022] Open
Abstract
Background: We aimed to describe risk factors for gastrointestinal (GI) bleeding and endoscopic findings in patients with hereditary hemorrhagic telangiectasia (HHT). Methods: This is a prospective study from a referral HHT unit. Endoscopic tests were performed when there was suspicion of GI bleeding, and patients were divided as follows: with, without, and with unsuspected GI involvement. Results: 67 (27.9%) patients with, 28 (11.7%) patients without, and 145 (60.4%) with unsuspected GI involvement were included. Age, tobacco use, endoglin (ENG) mutation, and hemoglobin were associated with GI involvement. Telangiectases were mostly in the stomach and duodenum, but 18.5% of patients with normal esophagogastroduodenoscopy (EGD) had GI involvement in video capsule endoscopy (VCE). Telangiectases ≤ 3 mm and ≤10 per location were most common. Among patients with GI disease, those with hemoglobin < 8 g/dL or transfusion requirements (65.7%) were older and had higher epistaxis severity score (ESS) and larger telangiectases (>3 mm). After a mean follow-up of 34.2 months, patients with GI involvement required more transfusions and more emergency department and hospital admissions, with no differences in mortality. Conclusions: Risk factors for GI involvement have been identified. Patients with GI involvement and severe anemia had larger telangiectases and higher ESS. VCE should be considered in patients with suspicion of GI bleeding, even if EGD is normal.
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Ferry AM, Wright AE, Baillargeon G, Kuo YF, Chaaban MR. Epidemiology and Trends of Hereditary Hemorrhagic Telangiectasia in the United States. Am J Rhinol Allergy 2019; 34:230-237. [DOI: 10.1177/1945892419886756] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background To our knowledge, no national studies have investigated the epidemiology of hereditary hemorrhagic telangiectasia (HHT) in the United States since the incorporation of the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification (ICD-10 CM). Objective Our objective is to analyze the epidemiology of HHT from 2013 to 2017 and to determine the relationships between epistaxis and other associated complications of this rare disease. Methods We analyzed the epidemiology of HHT between 2013 and 2017 by accessing data of 87 709 738 patients from the Clinformatics Data Mart using ICD-9 CM and ICD-10 CM codes. Variables analyzed included age, gender, region, clinical setting of diagnosis, hospitalizations, and complications. Bivariate analyses using generalized linear models were conducted to determine the likelihood of HHT patients with epistaxis enduring associated life-threatening complications such as cerebral hemorrhage, thrombosis, and pulmonary hemorrhage compared to HHT patients without epistaxis during the study period. Results The prevalence of HHT increased from 6.1 to 12.1 per 100 000 persons, with patients of ages 18 to 29 years and those older than 60 years seeing the greatest percent increase. The prevalence of HHT in the Southern United States saw a 147% increase. Compared to HHT patients without epistaxis, HHT patients with epistaxis were 3.4 times more likely to experience pulmonary hemorrhage, 3.3 times more likely to have pulmonary emboli, 2.8 times more likely to experience cerebral hemorrhage, and 2.0 times more likely to have thrombosis during the study period. Conclusion Our national study has provided the first incidence and prevalence rates of HHT in the United States since the incorporation of the ICD-10 CM. HHT patients with epistaxis require prompt multidisciplinary treatment of their condition due to their increased risk of life-threatening complications.
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Affiliation(s)
- Andrew M. Ferry
- School of Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Alex E. Wright
- School of Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Gwen Baillargeon
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
| | - Mohamad R. Chaaban
- Department of Otolaryngology, University of Texas Medical Branch, Galveston, Texas
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Castillo E, Prada-Arismendy J. Bevacizumab as a treatment option in gastrointestinal bleeding associated to hereditary hemorrhagic telangiectasia. Case Report. REVISTA DE LA FACULTAD DE MEDICINA 2019. [DOI: 10.15446/revfacmed.v67n3.68417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction: Hereditary Hemorrhagic Telangiectasia (HHT) is an autosomal dominant genetic disease characterized by the presence of arteriovenous malformations in the nasal mucosa, the tips of fingers, and sometimes in the lungs, the gastrointestinal tract, the liver, the pancreas, the marrow and the brain. Its treatment is based on symptomatic control measures, but recently, the administration of anti-vascular endothelial growth factor (VEGF) molecules has been proposed as a treatment alternative, especially in patients with recurrent bleeding.Case presentation: The case of a 67-year-old man diagnosed with HHT and suffering from potentially life-threatening gastrointestinal GI bleeding is presented. The patient underwent several esophagogastric cauterization procedures but not positive outcomes were obtained, so he had to go to the Emergency Service of the hospital multiple times due to having low levels of hemoglobin (as low as 3.5g/dl). A bevacizumab based treatment was started by using a novel dosage regimen consisting of the administration of 6 5mg/kg bevacizumab dosages every 14 days. During the first week of treatment, hemoglobin levels increased to 14g/dl and the condition was stabilized.Conclusions: The findings reported here suggest that bevacizumab may be a therapeutic choice to be considered when treating patients with recurrent and refractory GI bleeding caused by HHT. However, a larger sample is required to determine if administering this medication is safe for these patients, as well as the appropriate dosage.
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Overview of Pulmonary Arteriovenous Malformations and Hereditary Hemorrhagic Telangiectasia. J Nurse Pract 2019. [DOI: 10.1016/j.nurpra.2019.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abdulla Kyzy R, Durojaiye V, Walsh JL. Hereditary haemorrhagic telangiectasia with multiple complications presenting in an older patient. Age Ageing 2019; 48:307-309. [PMID: 30295705 DOI: 10.1093/ageing/afy160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 07/20/2018] [Indexed: 11/14/2022] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a rare autosomal dominant multi-organ vascular disorder associated with bleeding and a reduced life expectancy. We present a 91-year-old woman with complications of previously undiagnosed HHT. This case demonstrates three potential complications: pulmonary arteriovenous malformation (AVM) resulting in a right to left shunt, cerebral infarctions and pericardial effusion. Despite these potentially life-threatening complications and the reduced life-expectancy associated with HHT the patient has survived to an advanced age. Due to the patient's late diagnosis and frailty, the treatment options of AVM embolization and pericardiocentesis were deemed inappropriate. The patient was treated with tranexamic acid to reduce bleeding severity and discharged home with a care package and home oxygen.
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Affiliation(s)
| | - Victoria Durojaiye
- American University of the Caribbean, 1 University Drive at Jordan Road Cupecoy, St. Maarten
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Aagaard KS, Kjeldsen AD, Tørring PM, Green A. Comorbidity among HHT patients and their controls in a 20 years follow-up period. Orphanet J Rare Dis 2018; 13:223. [PMID: 30547819 PMCID: PMC6295040 DOI: 10.1186/s13023-018-0962-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 11/26/2018] [Indexed: 11/10/2022] Open
Abstract
Background Hereditary Haemorrhagic Telangiectasia (HHT) is an autosomal dominant genetic disorder with a wide variety of clinical manifestations due to the presence of multiple arteriovenous malformations in various tissues and organs. Objective To study the need for hospital admittance in a group of HHT patients and matched controls during a 20 years follow-up period commencing in 1995. Methods All HHT patients in the County of Funen, Denmark, were included. For each patient, three age and sex matched controls were identified at the time of enrolment. Data on all hospitalisations were extracted from the national health registers and compared with clinical records. The hospitalisations were grouped as HHT relevant or not HHT relevant based on the discharge diagnosis (International Classification of Diseases, ICD10) and with particular focus on infections, bleedings and thromboembolic events. Patients with HHT were compared with controls concerning the first time incidence of each discharge diagnosis. Results We included 73 HHT patients and 219 controls of which one control was lost to follow-up. HHT-patients had significantly more hospitalisations per person caused by infections in joints and bones, but not caused by infections in general. Bleeding episodes were, as expected, more frequent among the HHT-patients. The study revealed a similar incidence of abscesses and thromboembolisms, including in the central nervous system, among the HHT patients and controls. Conclusions Based on this study Danish HHT patients had an increased comorbidity of infections in joints and bones and of bleeding episodes. However, the incidence of thromboembolisms, cerebral abscesses and other conditions commonly considered related to HHT was comparable between the patients and the controls. The patients included in this study were closely monitored at a highly specialised HHT Centre where they received relevant diagnostic evaluation, treatment and counselling. Since this is assumed to benefit the overall health of the patients, it may explain why these patients were less prone to comorbidity than other studies have suggested. Electronic supplementary material The online version of this article (10.1186/s13023-018-0962-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katrine Saldern Aagaard
- Danish HHT Center OUH, Department of Otorhinolaryngology, Odense University Hospital, 5000, Odense C, Denmark.
| | - Anette Drøhse Kjeldsen
- Danish HHT Center OUH, Department of Otorhinolaryngology, Odense University Hospital, 5000, Odense C, Denmark. .,Clinical institute University of Southern Denmark, Odense, Denmark.
| | | | - Anders Green
- Odense Patient data Explorative Network (OPEN), Odense University Hospital/Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Cannavicci A, Zhang Q, Dai SC, Faughnan ME, Kutryk MJB. Decreased levels of miR-28-5p and miR-361-3p and increased levels of insulin-like growth factor 1 mRNA in mononuclear cells from patients with hereditary hemorrhagic telangiectasia 1. Can J Physiol Pharmacol 2018; 97:562-569. [PMID: 30512964 DOI: 10.1139/cjpp-2018-0508] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a rare vascular disorder inherited in an autosomal dominant manner. Patients with HHT can develop vascular dysplasias called telangiectasias and arteriovenous malformations (AVMs). Our objective was to profile and characterize micro-RNAs (miRNAs), short noncoding RNAs that regulate gene expression posttranscriptionally, in HHT patient-derived peripheral blood mononuclear cells (PBMCs). PBMCs, comprised mostly of lymphocytes and monocytes, have been reported to be dysfunctional in HHT. A total of 40 clinically confirmed HHT patients and 22 controls were enrolled in this study. PBMCs were isolated from 16 mL of peripheral blood and purified for total RNA. MiRNA expression profiling was conducted with a human miRNA array analysis. Select dysregulated miRNAs and miRNA targets were validated with reverse transcription-quantitative polymerase chain reaction. Of the 377 miRNAs screened, 41 dysregulated miRNAs were identified. Both miR-28-5p and miR-361-3p, known to target insulin-like growth factor 1 (IGF1), a potent angiogenic growth factor, were found to be significantly downregulated in HHT patients. Consequently, IGF1 mRNA levels were found to be significantly elevated. Our research successfully identified miRNA dysregulation and elevated IGF1 mRNA levels in PBMCs from HHT patients. This novel discovery represents a potential pathogenic mechanism that could be targeted to alleviate clinical manifestations of HHT.
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Affiliation(s)
- Anthony Cannavicci
- a Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A8, Canada.,b Division of Cardiology, Keenan Research Center for Biomedical Sciences, St. Michael's Hospital, University of Toronto, Toronto, ON M5B 1T8, Canada
| | - Qiuwang Zhang
- b Division of Cardiology, Keenan Research Center for Biomedical Sciences, St. Michael's Hospital, University of Toronto, Toronto, ON M5B 1T8, Canada
| | - Si-Cheng Dai
- b Division of Cardiology, Keenan Research Center for Biomedical Sciences, St. Michael's Hospital, University of Toronto, Toronto, ON M5B 1T8, Canada
| | - Marie E Faughnan
- c Division of Respirology, Keenan Research Center for Biomedical Sciences, St. Michael's Hospital, University of Toronto, Toronto, ON M5B 1T8, Canada
| | - Michael J B Kutryk
- a Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A8, Canada.,b Division of Cardiology, Keenan Research Center for Biomedical Sciences, St. Michael's Hospital, University of Toronto, Toronto, ON M5B 1T8, Canada
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Faughnan ME, Gossage JR, Chakinala MM, Oh SP, Kasthuri R, Hughes CCW, McWilliams JP, Parambil JG, Vozoris N, Donaldson J, Paul G, Berry P, Sprecher DL. Pazopanib may reduce bleeding in hereditary hemorrhagic telangiectasia. Angiogenesis 2018; 22:145-155. [PMID: 30191360 PMCID: PMC6510884 DOI: 10.1007/s10456-018-9646-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 08/14/2018] [Indexed: 12/22/2022]
Abstract
Pazopanib (Votrient) is an orally administered tyrosine kinase inhibitor that blocks VEGF receptors potentially serving as anti-angiogenic treatment for hereditary hemorrhagic telangiectasia (HHT). We report a prospective, multi-center, open-label, dose-escalating study [50 mg, 100 mg, 200 mg, and 400 mg], designed as a proof-of-concept study to demonstrate efficacy of pazopanib on HHT-related bleeding, and to measure safety. Patients, recruited at 5 HHT Centers, required ≥ 2 Curacao criteria AND [anemia OR severe epistaxis with iron deficiency]. Co-primary outcomes, hemoglobin (Hgb) and epistaxis severity, were measured during and after treatment, and compared to baseline. Safety monitoring occurred every 1.5 weeks. Seven patients were treated with 50 mg pazopanib daily. Six/seven showed at least 50% decrease in epistaxis duration relative to baseline at some point during study; 3 showed at least 50% decrease in duration during Weeks 11 and 12. Six patients showed a decrease in ESS of > 0.71 (MID) relative to baseline at some point during study; 3/6 showed a sustained improvement. Four patients showed > 2 gm improvement in Hgb relative to baseline at one or more points during study. Health-related QOL scores improved on all SF-36 domains at Week 6 and/or Week 12, except general health (unchanged). There were 19 adverse events (AE) including one severe AE (elevated LFTs, withdrawn from dosing at 43 days); with no serious AE. In conclusion, we observed an improvement in Hgb and/or epistaxis in all treated patients. This occurred at a dose much lower than typically used for oncologic indications, with no serious AE. Further studies of pazopanib efficacy are warranted.
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Affiliation(s)
- Marie E Faughnan
- Toronto HHT Program, Division of Respirology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
- Li Ka Shing Knowledge Institute of St. Michaels Hospital, 30 Bond St, Toronto, ON, M5B-1W8, Canada.
| | - James R Gossage
- Division of Pulmonary and Critical Care Medicine, Augusta University, Augusta, GA, USA
| | - Murali M Chakinala
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, MO, USA
| | - S Paul Oh
- Barrow Aneurysm & AVM Research Center, Barrow Neurological Institute/Dignity Health, Phoenix, AZ, USA
| | - Raj Kasthuri
- Division of Hematology and Oncology, Department of Medicine, UNC School of Medicine, Chapel Hill, NC, USA
| | - Christopher C W Hughes
- Department of Molecular Biology & Biochemistry, and Department of Biomedical Engineering, University of California Irvine, Irvine, CA, USA
| | - Justin P McWilliams
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Nicholas Vozoris
- Toronto HHT Program, Division of Respirology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St. Michaels Hospital, 30 Bond St, Toronto, ON, M5B-1W8, Canada
| | | | | | - Pamela Berry
- Patient Reported Outcomes, Janssen Global Services, LLC, Horsham, PA, USA
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Shovlin CL, Buscarini E, Kjeldsen AD, Mager HJ, Sabba C, Droege F, Geisthoff U, Ugolini S, Dupuis-Girod S. European Reference Network For Rare Vascular Diseases (VASCERN) Outcome Measures For Hereditary Haemorrhagic Telangiectasia (HHT). Orphanet J Rare Dis 2018; 13:136. [PMID: 30111344 PMCID: PMC6094583 DOI: 10.1186/s13023-018-0850-2] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 06/20/2018] [Indexed: 12/13/2022] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a multisystemic vascular dysplasia that leads to nosebleeds, anaemia due to blood loss, and arteriovenous malformations (AVMs) in organs such as the lungs, liver and brain. HHT is estimated to affect 85,000 European citizens, but most health care providers have limited prior HHT exposure or training. Outcome Measures were developed and implemented by the HHT Working Group of the European Reference Network for Rare Vascular Diseases (VASCERN), in order to maximise the number of patients receiving good care. The measures specifically target areas where optimal management reduces morbidity and mortality in HHT patients, and were designed to be robust to emerging new evidence. Thresholds are the percentage of patients in particular settings who have been recommended screening, or provided with written advice. The 5 Outcome Measures cover (1) pulmonary AVM screening; (2) written nosebleed advice, (3) assessment of iron deficiency; (4) antibiotic prophylaxis prior to dental and surgical procedures for patients with pulmonary AVMs, and (5) written advice on pregnancy. They are not a blueprint for detailed HHT management, but are suitable for all clinicians to be aware of and implement. In summary, these 5 Outcome Measures provide metrics to identify healthcare providers of good care, and encourage care improvement by all healthcare providers.
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Affiliation(s)
- Claire L Shovlin
- Respiratory Medicine, and VASCERN HHT European Reference Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK. .,NHLI Vascular Science, Imperial College London, London, UK.
| | - Elisabetta Buscarini
- Gastroenterology Department and VASCERN HHT European Reference Centre, Maggiore Hospital, ASST Crema, Crema, Italy.
| | - Anette D Kjeldsen
- Department of Otorhinolaryngology and VASCERN HHT European Reference Centre, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Hans Jurgen Mager
- Department of Pulmonology and VASCERN HHT European Reference Centre, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, the Netherlands
| | - Carlo Sabba
- Center for Rare Diseases, "Frugoni" Internal Medicine Unit, Interdepartmental HHT Center, Interdisciplinary Department of Medicine and VASCERN HHT European Reference Centre, University of Bari School of Medicine, Bari, Italy
| | - Freya Droege
- Department of Otorhinolaryngology and VASCERN HHT European Reference Centre, Essen University Hospital, Essen, Germany
| | - Urban Geisthoff
- Department of Otorhinolaryngology and VASCERN HHT European Reference Centre, Essen University Hospital, Essen, Germany.,Present address: Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
| | - Sara Ugolini
- Department of Otorhinolaryngology and VASCERN HHT European Reference Centre, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S) Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Sophie Dupuis-Girod
- Hospices Civils de Lyon, Hôpital Femme-Mère-Enfants, Service de Génétique, and VASCERN HHT European Reference Centre/ centre de Référence pour la maladie de Rendu-Osler, F-69677, Bron, France. .,Université de Lyon, Faculté de médecine, Université Lyon 1, F-69008, Lyon, France.
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Kühnel T, Wirsching K, Wohlgemuth W, Chavan A, Evert K, Vielsmeier V. Hereditary Hemorrhagic Telangiectasia. Otolaryngol Clin North Am 2018; 51:237-254. [PMID: 29217066 DOI: 10.1016/j.otc.2017.09.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) describes the presenting manifestations of a disorder that is characterized by pathologic blood vessels. HHT is inherited as an autosomal dominant trait with variable penetrance. The abnormal vascular structures (dysplasias) can affect all the organs in the human body. The link between a physical stimulus and new lesion development has been established for mucosal trauma owing to nasal airflow turbulence, for ultraviolet exposure to the fingers, and for mechanical trauma to the dominant hand. The pressing question then is whether HHT treatment constitutes a stimulus that is sufficient to trigger new lesion development.
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Affiliation(s)
- Thomas Kühnel
- University of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany.
| | - Kornelia Wirsching
- University of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Walter Wohlgemuth
- University of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Ajay Chavan
- University of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Katja Evert
- University of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Veronika Vielsmeier
- University of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
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Boother EJ, Brownlow S, Tighe HC, Bamford KB, Jackson JE, Shovlin CL. Cerebral Abscess Associated With Odontogenic Bacteremias, Hypoxemia, and Iron Loading in Immunocompetent Patients With Right-to-Left Shunting Through Pulmonary Arteriovenous Malformations. Clin Infect Dis 2018; 65:595-603. [PMID: 28430880 PMCID: PMC5849101 DOI: 10.1093/cid/cix373] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 04/17/2017] [Indexed: 12/18/2022] Open
Abstract
Background Cerebral abscess is a recognized complication of pulmonary arteriovenous malformations (PAVMs) that allow systemic venous blood to bypass the pulmonary capillary bed through anatomic right-to-left shunts. Broader implications and mechanisms remain poorly explored. Methods Between June 2005 and December 2016, at a single institution, 445 consecutive adult patients with computed tomography–confirmed PAVMs (including 403 [90.5%] with hereditary hemorrhagic telangiectasia) were recruited to a prospective series. Multivariate logistic regression was performed and detailed periabscess histories were evaluated to identify potential associations with cerebral abscess. Rates were compared to an earlier nonoverlapping series. Results Thirty-seven of the 445 (8.3%) patients experienced a cerebral abscess at a median age of 50 years (range, 19–76 years). The rate adjusted for ascertainment bias was 27 of 435 (6.2%). Twenty-nine of 37 (78.4%) patients with abscess had no PAVM diagnosis prior to their abscess, a rate unchanged from earlier UK series. Twenty-one of 37 (56.7%) suffered residual neurological deficits (most commonly memory/cognition impairment), hemiparesis, and visual defects. Isolation of periodontal microbes, and precipitating dental and other interventional events, emphasized potential sources of endovascular inoculations. In multivariate logistic regression, cerebral abscess was associated with low oxygen saturation (indicating greater right-to-left shunting); higher transferrin iron saturation index; intravenous iron use for anemia (adjusted odds ratio, 5.4 [95% confidence interval, 1.4–21.1]); male sex; and venous thromboemboli. There were no relationships with anatomic attributes of PAVMs, or red cell indices often increased due to secondary polycythemia. Conclusions Greater appreciation of the risk of cerebral abscess in undiagnosed PAVMs is required. Lower oxygen saturation and intravenous iron may be modifiable risk factors.
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Affiliation(s)
- Emily J Boother
- NHLI Cardiovascular Sciences, Imperial College London, London, UK.,Imperial College School of Medicine, Imperial College London
| | - Sheila Brownlow
- Respiratory Medicine, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Hannah C Tighe
- Respiratory Medicine, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Kathleen B Bamford
- Department of Microbiology, Hammersmith Campus, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - James E Jackson
- Department of Imaging, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Claire L Shovlin
- NHLI Cardiovascular Sciences, Imperial College London, London, UK.,Respiratory Medicine, Imperial College Healthcare NHS Trust, London, United Kingdom
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Impact of Age on Outcomes in Hospitalized Patients with Hereditary Hemorrhagic Telangiectasia. Adv Hematol 2018; 2018:4798425. [PMID: 29610574 PMCID: PMC5828469 DOI: 10.1155/2018/4798425] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 12/01/2017] [Accepted: 01/15/2018] [Indexed: 11/17/2022] Open
Abstract
Background There is little published literature regarding the impact of age on outcomes amongst hospitalized HHT (hereditary hemorrhagic telangiectasia) patients. Methods The Nationwide Inpatient Sample (NIS) was used to obtain data on all hospital discharges occurring in HHT patients from 2000 to 2012. The association between admission age and HHT-related complications and outcomes were studied. Results 10293 hospitalizations in HHT patients from 2000 to 2012 were included. Patients > 50 accounted for 77% of all admissions with 30% of admissions occurring in the 51–65 age group. Bleeding related complications were the most frequent (62.7%, n = 6455 hospitalizations), followed by cardiovascular (41%, n = 4216), neurological (12.4%, n = 1276), and hepatobiliary (6.4%, n = 660) complications. Patients older than 50 accounted for 83% of bleeding events, 90% of cardiovascular events, 58% of neurologic events, and 81% of hepatobiliary events. The vast majority (83%) of medical and surgical procedures were performed in those older than 50 years of age. Older patients also experienced higher rates of death. Conclusion Aging has significant adverse impacts on rates of hospitalization, complications, and outcomes amongst HHT patients in the United States. Except for neurologic complications, the vast majority of this disease burden is borne by patients older than 50 years.
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High Rates of Bleeding Complications among Hospitalized Patients with Hereditary Hemorrhagic Telangiectasia in the United States. Ann Am Thorac Soc 2018; 13:1505-11. [PMID: 27387823 DOI: 10.1513/annalsats.201603-200oc] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
RATIONALE There is sparse published literature on the causes and outcomes of hospitalization of patients with hereditary hemorrhagic telangiectasia (HHT). OBJECTIVES To evaluate rates of various complications, comorbidities, and in-hospital outcomes of patients with HHT using a large, multihospital inpatient database. METHODS We identified patients with HHT in the U.S. Nationwide Inpatient Sample between 2000 and 2012. Rates of hemorrhagic, neurological, hepatic, and cardiopulmonary complications among hospitalized patients with HHT were evaluated. We also studied procedure use rates for blood transfusion, endoscopy, and epistaxis treatment. Hospitalization outcomes, including in-hospital mortality, discharge status, charges, and length of stay, were evaluated. MEASUREMENTS AND MAIN RESULTS We identified 10,293 patients with HHT. The mean age of the HHT population was 60.7 years. Sixty percent of patients were female. More than 75% of HHT hospitalizations occurred in those older than 50 years of age. Patients with HHT had high rates of bleeding-related complications, including anemia (53.3%), epistaxis (16.2%), and gastrointestinal bleeding (10.8%). Overall, bleeding complications accounted for 62.7% of HHT-related complications. Thirty-eight percent of hospitalized patients with HHT received one or more transfusions of a blood product. Cardiopulmonary complications were present in 41.0% of the cases. Congestive heart failure was the second most common individual complication among patients with HHT, affecting 19.9% of patients. The in-hospital mortality rate was 1.9%. CONCLUSIONS In this large, nationwide study, we found that nearly two-thirds of patients hospitalized with HHT experienced a bleeding-related complication. Nearly 40% of hospitalized patients with HHT required transfusion of blood products. Cardiopulmonary complications, including congestive heart failure, were the second most common complication. The high burden of bleeding-related complications points to a significant unmet clinical need for these patients.
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