1
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Anandani G, Patel T, Parmar R. The Implication of New Developments in Hemophilia Treatment on Its Laboratory Evaluation. Cureus 2022; 14:e30212. [DOI: 10.7759/cureus.30212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 11/07/2022] Open
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2
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Araújo YG, Paolinelli JPV, Pichitelli JSD, Rios DRA, Baldoni NR, Baldoni AO. Quality of clinical studies present in the package inserts of coagulation factors used in the treatment of hemophilia. EINSTEIN-SAO PAULO 2022; 20:eAO6859. [PMID: 35544898 PMCID: PMC9071259 DOI: 10.31744/einstein_journal/2022ao6859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 10/15/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To identify and analyze the quality of scientific evidence from clinical efficacy studies present in the package inserts of coagulation factors, used in the treatment of hemophilia A and B. METHODS Documentary study developed in two stages. The first stage consisted of identifying the medicine packages inserts electronically registered in the Brazilian Health Regulatory Agency, and analyzing the availability of the bibliographic references cited therein. This analysis was conducted in the PubMed, SciELO, Google Scholar, and Web of Science databases. The second step was the analysis of the methodological quality of the efficacy studies. Two trained researchers used the Cochrane Collaboration Risk of Bias version 5.1.0 tools for methodological quality analysis, and Review Manager 5.4 software to generate the risk of bias graph. RESULTS Of the 17 medicines listed, 7 had referenced package inserts. Of these, 10 studies were eligible for analysis of methodological quality. More than half of the analyzed studies did not control for selection, performance, and detection bias. A total of 100% controlled attrition and reporting biases, and 50% had a high risk of conflict of interest. CONCLUSION The biases present are significant and may have influenced the overestimation of the effects of the outcomes of each of the studies.
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Affiliation(s)
- Yasmin Gonçalves Araújo
- Universidade Federal de São João del ReiDivinópolisMGBrazilUniversidade Federal de São João del Rei, Divinópolis, MG, Brazil.
| | | | - Janaina Souza Dias Pichitelli
- Universidade Federal de São João del ReiDivinópolisMGBrazilUniversidade Federal de São João del Rei, Divinópolis, MG, Brazil.
| | - Danyelle Romana Alves Rios
- Universidade Federal de São João del ReiDivinópolisMGBrazilUniversidade Federal de São João del Rei, Divinópolis, MG, Brazil.
| | - Nayara Ragi Baldoni
- Universidade de ItaúnaItaúnaMGBrazilUniversidade de Itaúna, Itaúna, MG, Brazil.
| | - André Oliveira Baldoni
- Universidade Federal de São João del ReiDivinópolisMGBrazilUniversidade Federal de São João del Rei, Divinópolis, MG, Brazil.
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3
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Tsai HHC, Moyers JT, Moore CJ, Thinn M. Activated Prothrombin Complex Concentrate-Induced Atypical Hemolytic Uremic Syndrome Treated with Eculizumab. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e929616. [PMID: 33678802 PMCID: PMC7959102 DOI: 10.12659/ajcr.929616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Patient: Male, 58-year-old Final Diagnosis: Atypical hemolytic uremic syndrome • FEIBA induced aHUS Symptoms: Anemia • renal failure • thrombocytopenia Medication: — Clinical Procedure: — Specialty: Hematology • General and Internal Medicine
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Affiliation(s)
| | - Justin Tyler Moyers
- Division of Hematology and Oncology, Department of Internal Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Christie J Moore
- Department of Hematology and Oncology, Providence Cancer Institute, Portland, OR, USA
| | - MieMie Thinn
- Department of Hematology and Oncology, Veterans Affairs Loma Linda Healthcare System, Loma Linda, CA, USA
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4
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Stubbs J, Klompas A, Thalji L. Transfusion Therapy in Specific Clinical Situations. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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5
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Wang G, Wang S. Conservative therapy for spinal epidural hematoma in a child with hemophilia A with high-titer VIII inhibitors. J Int Med Res 2021; 49:300060520979217. [PMID: 33550895 PMCID: PMC7876766 DOI: 10.1177/0300060520979217] [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: 11/16/2022] Open
Abstract
The occurrence of a spinal epidural hematoma in patients with hemophilia A with high-titer VIII inhibitors is extremely rare and intractable. A 15-year-old male patient presented to our institution with acute back pain and progressive sensorimotor disorder of the bilateral lower extremities. He had hemophilia A with high-titer VIII inhibitors and had experienced recurrent hemorrhagic episodes for many years. Prompt magnetic resonance imaging revealed a spinal epidural hematoma. We administered bypassing agent therapy with prothrombin complex concentrates and performed intensive neurological monitoring. The neurological dysfunction improved with days, and the patient recovered completely within 3 weeks. Magnetic resonance imaging 1 year later showed that the hematoma had been completely absorbed. Spinal epidural hematomas in patients with hemophilia A with high-titer inhibitors can be successfully treated using prothrombin complex concentrates. Multidisciplinary discussions based on intensive neurological monitoring should be performed as early in the clinical course as possible.
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Affiliation(s)
- Guige Wang
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Shengru Wang
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
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6
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Brackmann HH, Schramm W, Oldenburg J, Cano V, Turecek PL, Négrier C. Origins, Development, Current Challenges and Future Directions with Activated Prothrombin Complex Concentrate for the Treatment of Patients with Congenital Haemophilia with Inhibitors. Hamostaseologie 2020; 40:606-620. [PMID: 32717751 PMCID: PMC7772007 DOI: 10.1055/a-1159-4273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/16/2020] [Indexed: 12/17/2022] Open
Abstract
Congenital haemophilia A (HA) is caused by deficiency of coagulation factor VIII (FVIII) activity, leading to spontaneous or traumatic bleeding events. While FVIII replacement therapy can treat and prevent bleeds, approximately 30% of patients with severe HA develop inhibitor antibodies that render FVIII replacement therapy ineffective. The bypassing agents (BPAs), activated prothrombin complex concentrate (aPCC) and recombinant activated FVII, first approved in 1977 and 1996, respectively, act to generate thrombin independent of pathways that involve factors IX and VIII. Both may be used in patients with congenital haemophilia and inhibitors (PwHIs) for the treatment and prevention of acute bleeds and quickly became standard of care. However, individual patients respond differently to different agents. While both agents are approved for on-demand treatment and perioperative management for patients with congenital haemophilia with inhibitors, aPCC is currently the only BPA approved worldwide for prophylaxis in PwHI. Non-factor therapies (NFTs) have a mechanism of action distinct from BPAs and have reported higher efficacy rates as prophylactic regimens. Nonetheless, treatment challenges remain with NFTs, particularly regarding the potential for synergistic action on thrombin generation with concomitant use of other haemostatic agents, such as BPAs, for the treatment of breakthrough bleeds and in perioperative management. Concomitant use of NFTs with other haemostatic agents could increase the risk of adverse events such as thromboembolic events or thrombotic microangiopathy. This review focuses on the origins, development and on-going role of aPCC in the evolving treatment landscape in the management of PwHI.
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Affiliation(s)
- Hans H. Brackmann
- Haemophilia Center, Institute of Experimental Haematology and Blood Transfusion, University of Bonn, Bonn, Germany
| | - Wolfgang Schramm
- Rudolf Marx-Stiftung für Hämostaseologie, Universität München and Bluterbetreuung Bayern e. V. (BBB) - Germany
| | - Johannes Oldenburg
- Haemophilia Center, Institute of Experimental Haematology and Blood Transfusion, University of Bonn, Bonn, Germany
| | - Viridiana Cano
- Shire International GmbH, a Takeda company, Zürich, Switzerland
| | | | - Claude Négrier
- Haemophilia and Thrombosis Centre, Louis Pradel Hospital, University Claude Bernard Lyon 1, Lyon, France
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7
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Tripodi A, Chantarangkul V, Novembrino C, Scalambrino E, Boscolo-Anzoletti M, Clerici M, Rossi F, Peyvandi F. Emicizumab, the factor VIII mimetic bi-specific monoclonal antibody and its measurement in plasma. ACTA ACUST UNITED AC 2020; 59:365-371. [DOI: 10.1515/cclm-2020-0696] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/19/2020] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
Emicizumab, a monoclonal antibody mimicking the function of factor (F) VIII in the activation of FX by FIXa, is widely used for prophylaxis in hemophilia patients with or without inhibitors to FVIII. Although it is administered at fixed dose, its measurement could be occasionally required. In principle, the emicizumab procoagulant effect could be assessed by the one-stage assay (OSA) currently used to measure FVIII. However, the OSA for FVIII presents with limitations. Furthermore, owing to its potent FVIII-like activity, emicizumab interferes with the measurement of the inhibitor to FVIII, which is often needed in patients on emicizumab.
Methods
We prepared test samples by spiking a FVIII-deficient plasma with graded amounts of emicizumab. We modified the OSA for FVIII and tested plasma samples for emicizumab concentrations. Furthermore the chromogenic assay (CA) for FVIII with bovine reagents was used to assess for the FVIII inhibitor in patients on emicizumab.
Results
Slight modification of the OSA for FVIII (i.e., higher test plasma dilution and longer coagulometer acquisition time) made the regular OSA as a reliable laboratory tool to measure emicizumab concentration as shown by the identity of the regression (observed vs. expected) lines. Furthermore, the inhibitors to FVIII in patients on emicizumab, which were negative when measured by the regular Bethesda assay, were reliably measured by the CA assay employing bovine reagents.
Conclusions
The methods currently used to measure FVIII can be easily modified to make the general clinical laboratory able to assist clinicians when dealing with patients on emicizumab.
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Affiliation(s)
- Armando Tripodi
- Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Università degli Studi di Milano , Milan , Italy
- Fondazione Luigi Villa , Milan , Italy
| | - Veena Chantarangkul
- Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Università degli Studi di Milano , Milan , Italy
- Fondazione Luigi Villa , Milan , Italy
| | - Cristina Novembrino
- Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Università degli Studi di Milano , Milan , Italy
| | - Erica Scalambrino
- Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Università degli Studi di Milano , Milan , Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano , Milan , Italy
| | - Massimo Boscolo-Anzoletti
- Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Università degli Studi di Milano , Milan , Italy
| | - Marigrazia Clerici
- Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Università degli Studi di Milano , Milan , Italy
| | - Federica Rossi
- Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Università degli Studi di Milano , Milan , Italy
| | - Flora Peyvandi
- Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Università degli Studi di Milano , Milan , Italy
- Fondazione Luigi Villa , Milan , Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano , Milan , Italy
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8
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Schreuder M, Reitsma PH, Bos MHA. Reversal Agents for the Direct Factor Xa Inhibitors: Biochemical Mechanisms of Current and Newly Emerging Therapies. Semin Thromb Hemost 2020; 46:986-998. [DOI: 10.1055/s-0040-1709134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AbstractThe direct oral anticoagulants targeting coagulation factor Xa or thrombin are widely used as alternatives to vitamin K antagonists in the management of venous thromboembolism and nonvalvular atrial fibrillation. In case of bleeding or emergency surgery, reversal agents are helpful to counteract the anticoagulant therapy and restore hemostasis. While idarucizumab has been established as an antidote for the direct thrombin inhibitor dabigatran, reversal strategies for the direct factor Xa inhibitors have been a focal point in clinical care over the past years. In the absence of specific reversal agents, the off-label use of (activated) prothrombin complex concentrate and recombinant factor VIIa have been suggested as effective treatment options during inhibitor-induced bleeding complications. Meanwhile, several specific reversal agents have been developed. In this review, an overview of the current state of nonspecific and specific reversal agents for the direct factor Xa inhibitors is provided, focusing on the biochemistry and mechanism of action and the preclinical assessment of newly emerging therapies.
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Affiliation(s)
- Mark Schreuder
- Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Pieter H. Reitsma
- Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Mettine H. A. Bos
- Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
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9
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Position paper on laboratory testing for patients with haemophilia. A consensus document from SISET, AICE, SIBioC and SIPMeL. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2019; 17:229-236. [PMID: 30747702 DOI: 10.2450/2019.0241-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 12/20/2018] [Indexed: 11/21/2022]
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10
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Poon MC, Card RT. Samuel Armstrong Lane's first successful treatment of haemophilia with blood transfusion in 1840: Could this also be the first successful bypassing therapy? Haemophilia 2018; 25:e45-e47. [PMID: 30461135 DOI: 10.1111/hae.13645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 10/28/2018] [Accepted: 10/30/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Man-Chiu Poon
- Departments of Medicine, Pediatrics and Oncology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,The Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - Robert T Card
- Department of Medicine, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada.,Saskatchewan Bleeding Disorders Program, Royal University Hospital, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
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11
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Tripodi A, Chantarangkul V, Novembrino C, Peyvandi F. Advances in the Treatment of Hemophilia: Implications for Laboratory Testing. Clin Chem 2018; 65:254-262. [PMID: 30282700 DOI: 10.1373/clinchem.2017.284356] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 06/26/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Until recently, clinical laboratories have monitored hemophilia treatment by measuring coagulation factors before/after infusion of human-derived or recombinant factors. Substantial changes are expected in the near future based on new therapeutic approaches that have been or are being developed. CONTENT Hemophilia treatment includes replacement therapy with human-derived/recombinant factors or treatment with bypassing agents for patients without or with inhibitors, respectively. Accordingly, laboratory methods for monitoring include one-stage clotting or chromogenic assays meant to measure either factor VIII/IX or global coagulation tests to measure the effect of bypassing agents. Recently, modified long-acting coagulation factors have been introduced for which discrepant results may be expected when measurement is performed with one-stage clotting or chromogenic assays. Currently, novel drugs not based on coagulation factors are under development and are being tested in clinical studies. These drugs do require new methods and therefore laboratory evaluation of hemophilia will undergo dramatic changes in the near future. SUMMARY From the analysis of the current practice and literature, we draw the following conclusions: (a) Thrombin generation or thromboelastometry are the logical candidate assays to monitor bypassing agents. (b) Considerable differences are expected when measuring modified long-acting coagulation factors, depending on whether one-stage or chromogenic assays are used. Although no definitive conclusions can presently be drawn, chromogenic assays are probably more suitable than one-stage clotting. (c) Novel drugs not based on coagulation factors such as emicizumab, fitusiran, or concizumab that are entering the market do require alternative methods that are not yet well established.
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Affiliation(s)
- Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, .,IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy
| | - Veena Chantarangkul
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center.,IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy
| | - Cristina Novembrino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center.,Laboratory of Clinical Chemistry and Microbiology, and.,IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy; and.,IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy
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12
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Teitel JM. Treatment and prevention of bleeding in congenital hemophilia A patients with inhibitors. Transfus Apher Sci 2018; 57:466-471. [DOI: 10.1016/j.transci.2018.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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13
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14
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Thromboembolic event rate in patients exposed to anti-inhibitor coagulant complex: a meta-analysis of 40-year published data. Blood Adv 2017; 1:2637-2642. [PMID: 29296916 DOI: 10.1182/bloodadvances.2017011536] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 11/09/2017] [Indexed: 11/20/2022] Open
Abstract
Anti-inhibitor coagulant complex (AICC), an activated prothrombin complex concentrate, has been available for the treatment of patients with inhibitors since 1977, and thromboembolic events (TEEs) have been reported after infusion of AICC in patients with congenital or acquired hemophilia. With the aim of estimating the TEE incidence rate (IR) related to AICC exposure in these patients, a systematic review of the literature was carried out in Medline, according to PRISMA guidelines, from inception date to March 2017. The IR of TEEs was estimated through a meta-analytic approach by using a generalized linear mixed model based on a Poisson distribution. Thirty-nine studies were included (1980-2016). Overall, 46 TEEs were reported; of these, 13 were reported as disseminated intravascular coagulations, 11 as myocardial infarctions, and 3 as thrombotic cerebrovascular accidents. The pooled TEE IR was 2.87 (95% confidence interval [CI], 0.32-25.40) per 100 000 AICC infusions (5.42 in retrospective studies [95% CI, 0.92-31.82]; 1.09 in prospective studies [95% CI, 0.01-238.77]). The TEE rate was 5.09 (95% CI, 0.01-1795.60) per 100 000 AICC infusions administered on demand, whereas no TEEs were reported with prophylaxis. Interestingly, the estimated IR in patients with congenital hemophilia was <0.01 per 100 000 infusions. These findings provide robust evidence of safety of AICC over almost 40 years of published studies.
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15
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Gruber A, Tinel H, Marzec U, Buetehorn U, Buchmueller A, Heitmeier S, Laux V, Perzborn E. Reversal of rivaroxaban anticoagulation by haemostatic agents in rats and primates. Thromb Haemost 2017; 110:162-72. [DOI: 10.1160/th12-12-0907] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 04/16/2013] [Indexed: 12/18/2022]
Abstract
SummaryRivaroxaban is an oral, direct factor Xa inhibitor for the management of thromboembolic disorders. Despite its short half-life, the ability to reverse rivaroxaban anticoagulation could be beneficial in life-threatening emergencies. The potential of prothrombin complex concentrate (PCC; Beriplex®), activated PCC (aPCC; FEIBA®) or recombinant activated factor VII (rFVIIa; NovoSeven®) to reverse rivaroxaban in rats and baboons was investigated. Anaesthetised rats pre-treated with intravenous rivaroxaban (2 mg/kg) received intravenous rFVIIa (100/400 μg/kg), PCC (25/50 U/kg) or aPCC (50/100 U/kg) after initiation of bleeding. Clotting times and bleeding times (BTs) were recorded. Rivaroxaban was administered as an intravenous 0.6 mg/kg bolus followed by continuous 0.6 mg/kg/hour infusion in baboons. Animals received intravenous aPCC 50 U/kg (2 U/kg/minute) or rFVIIa 210 μg/kg. BT and clotting parameters were measured. In rats pre-treated with high-dose rivaroxaban, PCC 50 U/kg, aPCC 100 U/kg and rFVIIa 400 μg/kg significantly reduced BT vs rivaroxaban alone (5.4 ± 1.4-fold to 1.5 ± 0.4-fold [p<0.05]; 3.0 ± 0.4-fold to 1.4 ± 0.1-fold [p<0.001]; and 3.5 ± 0.7-fold to 1.7 ± 0.2-fold [p<0.01] vs baseline, respectively). In baboons pre-infused with rivaroxaban and then given aPCC, BT increased by 2.0 ± 0.2-fold and aPCC returned BT to baseline for the duration of its infusion. rFVIIa reduced BT from 2.5 ± 0.3-fold over baseline to 1.7 ± 0.3-fold over baseline. Prolongation of prothrombin time was reduced by PCC, aPCC and rFVIIa in both species. Rivaroxaban reduced thrombin-antithrombin levels; application of PCC and aPCC, but not rFVIIa, increased these levels. In conclusion, PCC, aPCC or rFVIIa have the potential to reverse the anticoagulant and anti-haemostatic effects of rivaroxaban.
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Borrowing (once again) from the animal kingdom. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 15:294-295. [PMID: 27483478 DOI: 10.2450/2016.0104-16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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17
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Stewart AJ, Saint-Remy JM, Ludlam CA. Pathogenesis and Management of Acquired Haemophilia. Hematology 2016; 3:181-92. [DOI: 10.1080/10245332.1998.11746390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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18
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Abstract
Haemophilia A and B are hereditary haemorrhagic disorders characterised by deficiency or dysfunction of coagulation protein factors VIII and IX, respectively. Recurrent joint and muscle bleeds lead to severe and progressive musculoskeletal damage. Existing treatment relies on replacement therapy with clotting factors, either at the time of bleeding (ie, on demand) or as part of a prophylactic schedule. The major complication of such therapy is the development of neutralising antibodies (ie, inhibitors), which is most frequent in haemophilia A. Treatment might improve considerably with the availability of new modified drugs, which might overcome existing prophylaxis limitations by reducing dosing frequency and thereby rendering therapy less distressing for the patient. Subcutaneous administration of some new therapies would also simplify prophylaxis in children with poor venous access. Gene therapy has the potential for a definitive cure, and important results have been obtained in haemophilia B. Despite improvements in haemophilia care, the availability of clotting factor concentrates for all affected individuals worldwide remains the biggest challenge.
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Affiliation(s)
- Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Isabella Garagiola
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Guy Young
- The Saban Research Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA; University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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19
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Affiliation(s)
- Christopher J Gibson
- From the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston
| | - Nancy Berliner
- From the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston
| | - Amy L Miller
- From the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston
| | - Joseph Loscalzo
- From the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston
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20
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Abstract
There are numerous new coagulation factor concentrates that are being manufactured using recombinant technology. Some are available for use currently for the treatment of bleeding disorders and others are in clinical trials. Recombinant factor VIII concentrates are licenced in most countries and one FVIII concentrate with the B domain deleted should be available in the near future. Recombinant VIIa concentrate is in advanced phase III testing for the treatment of patients with inhibitor antibodies. Recombinant factor IX has been used successfully in animals and will be tested in humans shortly. This paper reviews these products and discusses their uses and possible side-effects.
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Affiliation(s)
- D B Brettler
- New England Hemophilia Center, The Medical Center of Central Massachusetts, 119 Belmont Street, Worcester, MA 01605-2892, USA
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21
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22
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Golestani M, Eshghi P, Rasekh HR, Cheraghali AM, Salamzadeh J, Imani A. Comparison of bypassing agents in bleeding reduction in treatment of bleeding episodes in patients with haemophilia and inhibitors. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 16:e24551. [PMID: 25763245 PMCID: PMC4341353 DOI: 10.5812/ircmj.24551] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 11/16/2014] [Accepted: 11/17/2014] [Indexed: 11/16/2022]
Abstract
CONTEXT Mild-to-moderate bleeding disorders in haemophilia are primarily treated via recombinant activated factor VII a (rFVIIa) or activated prothrombin complex concentrate (aPCC). However, the efficacy of each bypassing agents may vary and none of them is universally effective. EVIDENCE ACQUISITION After reviewing the databases of PubMed, Scopus, MD Consult, Ovid, Trip database, Google Scholar, ProQuest and the Cochrane Library, finally, 17 papers published from 2000 to 2013 were extracted. We used as a random effect model in meta-analysis. Comprehensive meta-analysis (CMA) software was used for calculating and estimating the mean of bleeding reduction and performing meta-analysis. RESULTS The mean of bleeding reduction in aPCC and rFVIIa were 71.2% with CI 95% (lower limit 86.8% and upper limit 82%) and 72.3% with CI 95% (lower limit 57.6% and upper limit 83.4%), respectively. CONCLUSIONS Although differences between the two products were very close to each other, they reported similar effects on joint bleeds. Further clinical studies should be performed by incorporating a standardized measurement in comparative efficacy of aPCC and rFVIIa.
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Affiliation(s)
- Mina Golestani
- School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
- Corresponding Author: Mina Golestani, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran. Tel: +98-9125160488, Fax: +98-4133351048, E-mail:
| | - Peyman Eshghi
- Pediatric Congenital Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Hamid Reza Rasekh
- School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | | | - Jamshid Salamzadeh
- School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Ali Imani
- Iranian Center of Excellence in Health Management, Faculty of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, IR Iran
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Tran HTT, Sørensen B, Bjørnsen S, Pripp AH, Tjønnfjord GE, Andre Holme P. Monitoring bypassing agent therapy – a prospective crossover study comparing thromboelastometry and thrombin generation assay. Haemophilia 2014; 21:275-283. [DOI: 10.1111/hae.12570] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2014] [Indexed: 01/24/2023]
Affiliation(s)
- H. T. T. Tran
- Research Institute of Internal Medicine Oslo University Hospital Oslo Norway
- Department of Haematology Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | | | - S. Bjørnsen
- Research Institute of Internal Medicine Oslo University Hospital Oslo Norway
| | - A. H. Pripp
- Research Institute of Internal Medicine Oslo University Hospital Oslo Norway
- Department of Biostatistics and Epidemiology Oslo University Hospital Oslo Norway
| | - G. E. Tjønnfjord
- Department of Haematology Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - P. Andre Holme
- Research Institute of Internal Medicine Oslo University Hospital Oslo Norway
- Department of Haematology Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
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24
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Shapiro AD, Hedner U. Advances in bypassing agent therapy for hemophilia patients with inhibitors to close care gaps and improve outcomes. Ther Adv Drug Saf 2014; 2:213-25. [PMID: 25083214 DOI: 10.1177/2042098611415566] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In the past, patients with hemophilia and inhibitors have had less-than-optimal treatment and have experienced more orthopedic complications than patients without inhibitors. Bypassing agents offer the potential to close treatment gaps between inhibitor and noninhibitor patients by helping the former better attain key treatment goals, including: facilitating early initiation of treatment and hemostatic control in hemarthroses; providing effective treatment in serious hemorrhagic episodes; and performance of major surgery. Effective treatment with a bypassing agent minimizes joint and/or muscle damage and potentially can serve as an effective prophylactic agent to minimize the number of hemarthroses experienced per year, thereby mitigating the development of arthropathy. The reported efficacy of the currently available bypassing agents ranges from approximately 50-80% (50-64% in controlled studies) for plasma-derived activated prothrombin complex concentrate (pd-aPCC) and 81-91% (in controlled studies) for recombinant activated factor VII (rFVIIa), including use in major orthopedic surgery. Both bypassing agents have undergone key improvements in their formulation and/or properties in recent years. The nanofiltered, vapor-heated formulation of pd-aPCC has diminished the risk of acquiring blood-borne viral infections and the room temperature stable formulation of rFVIIa allows more convenient storage, increased ease to dissolve and inject, and smaller volumes, thereby increasing overall ease of administration. Use of recommended dosing has been demonstrated to provide effective hemostasis with a minimal number of injections for both agents. In this paper, we review the individual characteristics of pd-aPCC and rFVIIa and discuss clinical data from studies conducted in inhibitor patients that demonstrate the potential benefits of these bypassing agents in this difficult-to-treat population, and underscore the potential opportunities to close the gap in care between inhibitor and noninhibitor hemophilic patients.
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Affiliation(s)
- Amy D Shapiro
- Indiana Hemophilia and Thrombosis Center, 8402 Harcourt Road, Suite 500, Indianapolis, IN 46260, USA
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25
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Reversal of New, Factor-specific Oral Anticoagulants by rFVIIa, Prothrombin Complex Concentrate and Activated Prothrombin Complex Concentrate: A Review of Animal and Human Studies. Thromb Res 2014; 133:705-13. [DOI: 10.1016/j.thromres.2014.01.031] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Revised: 01/23/2014] [Accepted: 01/26/2014] [Indexed: 01/13/2023]
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26
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Reversal of rivaroxaban-induced anticoagulation with prothrombin complex concentrate, activated prothrombin complex concentrate and recombinant activated factor VII in vitro. Thromb Res 2014; 133:671-81. [DOI: 10.1016/j.thromres.2014.01.017] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 12/20/2013] [Accepted: 01/12/2014] [Indexed: 11/18/2022]
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27
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Tran HTT, Sørensen B, Rea CJ, Bjørnsen S, Ueland T, Pripp AH, Tjønnfjord GE, Holme PA. Tranexamic acid as adjunct therapy to bypassing agents in haemophilia A patients with inhibitors. Haemophilia 2013; 20:369-75. [DOI: 10.1111/hae.12318] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2013] [Indexed: 12/25/2022]
Affiliation(s)
- H. T. T. Tran
- Research Institute of Internal Medicine; Oslo University Hospital; Rikshospitalet; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Department of Haematology; Oslo University Hospital; Rikshospitalet; Oslo Norway
| | - B. Sørensen
- Baxter Healthcare Corporation; Westlake Village CA USA
- Haemostasis Research Unit; Guy's and St Thomas' Hospital; London UK
| | - C. J. Rea
- Haemostasis Research Unit; Guy's and St Thomas' Hospital; London UK
| | - S. Bjørnsen
- Research Institute of Internal Medicine; Oslo University Hospital; Rikshospitalet; Oslo Norway
| | - T. Ueland
- Faculty of Medicine; University of Oslo; Oslo Norway
| | - A. H. Pripp
- Department of Biostatistics and Epidemiology; Oslo University Hospital; Oslo Norway
| | - G. E. Tjønnfjord
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Department of Haematology; Oslo University Hospital; Rikshospitalet; Oslo Norway
| | - P. A. Holme
- Research Institute of Internal Medicine; Oslo University Hospital; Rikshospitalet; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Department of Haematology; Oslo University Hospital; Rikshospitalet; Oslo Norway
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28
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Yang Y, Xue F, Shi H, Wang H, Zhang L, Ji L, Yang R. Acquired hemophilia a: retrospective analysis of 49 cases from a single Chinese hemophilia center. Clin Appl Thromb Hemost 2013; 21:35-40. [PMID: 23677912 DOI: 10.1177/1076029613488937] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Acquired hemophilia A (AHA) is a rare bleeding disorder caused by the autoantibody directed against factor VIII in patients without previous history of a bleeding disorder. We retrospectively analyzed the characteristics and outcomes of 49 patients with AHA diagnosed in our center from February 1994 to October 2012. Twenty-four patients with acute bleeding episodes were treated with prothrombin complex concentrate (PCC) at a relative low dose of 30 to -50 U/kg/d and achieved good outcomes without any adverse reaction. Corticosteroids alone or in combination with cyclophosphamide were used as the first-line therapy to eradicate the inhibitors. In 39 evaluable patients, 35 (89.7%) achieved complete remission (CR). This study demonstrates that when bypassing agents such as recombinant activated factor VII and activated PCCs are not affordable or available, low dose PCC is effective and safe to control acute bleeding in patients with AHA. First-line therapy achieved good outcomes with a CR rate of 89.7%.
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Affiliation(s)
- Yanhui Yang
- Institute of Hematology and Hospital of Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Feng Xue
- Institute of Hematology and Hospital of Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Hao Shi
- Institute of Hematology and Hospital of Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Hongmei Wang
- Institute of Hematology and Hospital of Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Lei Zhang
- Institute of Hematology and Hospital of Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Linxiang Ji
- Institute of Hematology and Hospital of Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Renchi Yang
- Institute of Hematology and Hospital of Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
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29
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Witmer C, Young G. Factor VIII inhibitors in hemophilia A: rationale and latest evidence. Ther Adv Hematol 2013; 4:59-72. [PMID: 23610614 DOI: 10.1177/2040620712464509] [Citation(s) in RCA: 155] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Factor VIII (FVIII) replacement therapy is the foundation of treatment in hemophilia A and is effective unless a patient develops an alloantibody (inhibitor) against exogenous FVIII. Inhibitor development is currently the most significant treatment complication seen in patients with hemophilia and is associated with considerable morbidity and a decreased quality of life. The development of an inhibitor is the result of a complex interaction between a patient's immune system and genetic and environmental risk factors. The mainstay of treatment is the eradication of the inhibitor through immune tolerance. This review summarizes the current evidence regarding inhibitor risk factors, eradication, and hemostatic bypassing agents.
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Affiliation(s)
- Char Witmer
- Division of Hematology, The Children's Hospital of Philadelphia, 3501 Civic Center Boulevard, CTRB 11th Floor, Room 11026, Philadelphia, PA 19104, USA
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30
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Teitel JM, Sholzberg M. Current status and future prospects for the prophylactic management of hemophilia patients with inhibitor antibodies. Blood Rev 2013; 27:103-9. [DOI: 10.1016/j.blre.2013.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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31
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2013 revised edition : hemostatic treatment guidelines for inhibitors possess congenital hemophilia patients. ACTA ACUST UNITED AC 2013. [DOI: 10.2491/jjsth.24.640] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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32
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Parcel TW, Raye J, Polikandriotis JA, Bernasek TL. Immune-Mediated Coagulopathy Complicating Elective Orthopaedic Knee Surgery: A Report of Three Cases. JBJS Case Connect 2012; 2:e73. [PMID: 29252369 DOI: 10.2106/jbjs.cc.l.00027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Ted W Parcel
- Foundation for Orthopaedic Research and Education, 13020 Telecom Parkway North, Tampa, FL 33637. . .
| | - Justin Raye
- DeBusk College of Osteopathic Medicine, Lincoln Memorial University, 6965 Cumberland Gap Parkway, Harrogate, TN 37752.
| | - John A Polikandriotis
- Foundation for Orthopaedic Research and Education, 13020 Telecom Parkway North, Tampa, FL 33637. . .
| | - Thomas L Bernasek
- Foundation for Orthopaedic Research and Education, 13020 Telecom Parkway North, Tampa, FL 33637. . .
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33
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Haghpanah S, Karimi M, Bordbar M, Kamfiroozi R, Asgharzadeh H. Experience on Using Prothrombin Complex Concentrate in Urgent Warfarin Reversal. Clin Appl Thromb Hemost 2012; 19:277-81. [DOI: 10.1177/1076029612450772] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We evaluated the effectiveness and safety of prothrombin complex concentrate (PCC) in urgent warfarin reversal in Iran. This is a nonrandomized, pre–post intervention study. Thirty-seven high-risk patients with prolonged international normalized ratio ([INR] >8) or with bleeding symptoms were enrolled in this study. Prothrombin complex concentrate was infused with a dose of 22.4 ± 11.2 IU/kg. The INR was measured 30 minutes postinfusion. Mean age of the participants was 63.9 ± 14.5 (22-89 years). After 30 minutes of PCC injection, INR reversed to <3.5 in 31 patients (84%) in whom 12 patients achieved INR 1.5 to 2.5, and 19 patients achieved INR 2.5 to 3.5. Bleeding symptoms were subsided during 0.5 hour after PCC infusion in patients with hemorrhagic symptoms. Not any adverse reaction was observed in patients during 3-month follow-up. Our experience in use of single injection of PCC in high-risk patients with prolonged INR or with bleeding symptoms was successful without any complication.
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Affiliation(s)
- Sezaneh Haghpanah
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehran Karimi
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Rosa Kamfiroozi
- Alzahra Heart Hospital, Shiraz University of Medical Science, Shiraz, Iran
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34
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Leissinger CA. The literature on inhibitors: articles that influence my management of patients with hemophilia A and high-titer inhibitors. Am J Hematol 2012; 87 Suppl 1:S23-6. [PMID: 22473571 DOI: 10.1002/ajh.23191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 02/29/2012] [Accepted: 03/01/2012] [Indexed: 11/11/2022]
Abstract
High-titer inhibitors represent the greatest management challenge faced by clinicians who treat patients with hemophilia A, as bleeding episodes no longer respond to standard factor VIII replacement therapy. Over the last seven decades, major strides have been made in inhibitor treatment. This article focuses on the seminal clinical observations and studies that provided the foundation for these advances in hemophilia care.
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Affiliation(s)
- Cindy A Leissinger
- Louisiana Center for Bleeding and Clotting Disorders, Tulane University Medical Center, New Orleans, Louisiana 70112, USA.
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35
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Efficacy of Bypassing Agents in Patients With Hemophilia and Inhibitors: A Systematic Review and Meta-Analysis. Clin Ther 2012; 34:434-45. [DOI: 10.1016/j.clinthera.2012.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Revised: 12/24/2011] [Accepted: 01/02/2012] [Indexed: 11/18/2022]
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36
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ZÜLFIKAR B, AYDOGAN G, SALCIOGLU Z, ONER AF, KAVAKLI K, GURSEL T, ZÜLFIKAR H. Efficacy of FEIBA for acute bleeding and surgical haemostasis in haemophilia A patients with inhibitors: a multicentre registry in Turkey. Haemophilia 2011; 18:383-91. [DOI: 10.1111/j.1365-2516.2011.02693.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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38
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Abstract
Haemophilia A and B are X-linked bleeding disorders due to the inherited deficiency of factor VIII or factor IX, respectively. Of the approximately 1 per 5000-10000 male births affected by haemophilia, 80% are deficient in factor VIII and 20% are deficient in factor IX. Haemophilia is characterized by spontaneous and provoked joint, muscle, gastrointestinal and CNS bleeding leading to major morbidity and even mortality if left untreated or under-treated. The evolution of haemophilia management has been marked by tragedy and triumph over recent decades. Clotting factors and replacement strategies continue to evolve for patients without inhibitors. For patients with an inhibitor, factor replacement for acute bleeding episodes and immune tolerance, immune modulation and extracorporeal methods for inhibitor reduction are the cornerstone of care. In addition, adjuvant therapies such as desmopressin, antifibrinolytics and topical agents also contribute to improved outcomes for patients with and without inhibitors. The future direction of haemophilia care is promising with new longer-acting clotting factors and genetic therapies, including gene transfer and premature termination codon suppressors. With these current and future treatment modalities, the morbidity and mortality rates in patients with haemophilia certainly will continue to improve.
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Affiliation(s)
- Trisha Wong
- Puget Sound Blood Center, Seattle, Washington, USA
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39
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Abstract
This review describes the background for the development of recombinant FVIIa (rFVIIa; NovoSeven) for use in haemophilic patients with inhibitors. The first proof of principle for using pharmacological doses of FVIIa as a haemostatic agent was obtained by producing small amounts of pure plasma-derived FVIIa, which showed encouraging effect in two patients with haemophilia A and inhibitors. To make pure FVIIa available for use in a larger number of patients, rFVIIa was produced that was approved for use in patients with inhibitors against coagulation factors (congenital haemophilia and acquired haemophilia) in 1996 (EU), 1999 (USA) and 2000 (Japan). The efficacy rate in severe bleedings and in major surgery including major orthopaedic surgery has been found to be around 90% in controlled studies, and no serious safety concerns have been demonstrated. The availability of rFVIIa has facilitated the performance of elective major surgery in haemophilia patients with inhibitors. Further steps along the vision of providing a treatment for inhibitor patients similar to non-inhibitor patients have been the efficacy of rFVIIa in home-treatment and recently the encouraging experience in prophylaxis. The concept of using pharmacological doses of rFVIIa as a haemostatic agent is a new one, which has caused difficulties in finding the correct dose. A step forward has been the demonstration that similar efficacy can be achieved after one single dose of 270 μg kg(-1) instead of three injections of a dose of 90 μg kg(-1). The higher clearance rate in children suggests that higher doses may be beneficial in children. The availability of rFVIIa has made advances in the understanding of coagulation processes possible. In a cell-based in vitro model, it has been shown that rFVIIa binds to preactivated platelets if present in concentrations of 30 nm or higher. By doing so, it activates FX into FXa and enhances the thrombin generation on the activated platelet surface in the absence of FVIII/FIX. Through the increased thrombin generation, a firm, well-structured fibrin haemostatic plug, which is resistant to premature lysis, is formed. By exploiting this mechanism of action, rFVIIa may also be effective in situations other than haemophilia, characterized by an impaired thrombin generation.
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Affiliation(s)
- U Hedner
- Department of Medicine, University of Lund, Lund, Sweden.
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40
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Balkan C, Karapinar D, Aydogdu S, Ozcan C, Ay Y, Akin M, Kavakli K. Surgery in patients with haemophilia and high responding inhibitors: Izmir experience. Haemophilia 2011; 16:902-9. [PMID: 20518817 DOI: 10.1111/j.1365-2516.2010.02329.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This report evaluates the haemostatic efficacy of recombinant factor VIIa (rFVIIa) and activated prothrombin complex concentrate (APCC) in patients with haemophilia and high responding inhibitors who underwent major and minor surgery. Data pertaining to surgeries from 2001 to 2009 at a single centre were retrospectively analysed. During this period, 53 surgical procedures were performed in 30 haemophiliacs with high responding inhibitors. Mean age was 16.2±9.4 years. Eleven major surgeries in 4 patients, 41 radioisotope synovectomies (RS) and one circumcision classified as minor surgery in 28 patients were performed. Among the major surgery procedures, four were treated with rFVIIa, five with APCC and two with sequential use of APCC and rFVIIa. We used rFVIIa at the dosage of 80-120 μg kg(-1) every 2 h and APCC 100 IU kg(-1) every 12 h for the major surgery. When performing RS, we used rFVIIa in 18 patients with 26 target joints and APCC in 9 patients with 15 target joints. Three consecutive doses of rFVIIa (90 μg kg(-1) ) were used at 2-h intervals followed by additional three doses at 6-h intervals. The initial dose of APCC was 75 IU kg(-1) followed by a second and third dose of 50 IU kg(-1) at 12-h intervals. APCC and rFVIIa demonstrated excellent efficacy in our major and minor surgical interventions [100% (22/22) and 94% (31/33), respectively]. We had only two bleeding complications with rFVIIa. There were no thromboembolic complications. APCC and rFVIIa provide an effective and safe first line haemostatic therapy for inhibitor-positive haemophiliacs, allowing both major and minor surgery to be successfully performed.
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Affiliation(s)
- C Balkan
- Department of Pediatric Hematology, Ege University Hospital, Ege Hemophilia Center, Izmir, Turkey.
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41
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Abstract
SUMMARY Anamestic inhibitors represent the major complication of haemophilia therapy now that clotting factor concentrates are virtually free of pathogen-transmission risk. Conventional clotting factor replacement is usually insufficient to prevent or treat bleeding in a haemophilia patient with a high responding inhibitor so that alternative treatment with bypassing agents is required. Despite their relative efficacy, their use does not achieve the same invariable haemostasis that patients without inhibitors do following treatment with factor concentrate replacement. This has led to the attempt to eradicate such inhibitors with immune tolerance induction. Success is not invariable, however, and many patients with long-term persistent high-titre inhibitors continue to experience great morbidity. Recently, this has given rise on a limited basis to attempts to use bypassing agents in prophylaxis regimens in an effort to alleviate this extreme morbidity. Each of these strategies is discussed in the context of their relative benefits and risks.
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Affiliation(s)
- J Astermark
- Centre for Thrombosis and Haemostasis, Skane University Hospital, Malmö, Sweden
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42
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A retrospective study of Octaplex in the treatment of bleeding in patients with haemophilia A complicated by inhibitors. Blood Coagul Fibrinolysis 2010; 21:577-83. [DOI: 10.1097/mbc.0b013e32833c9ab9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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43
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Johansson PI, Ostrowski SR. Evidence supporting the use of recombinant activated factor VII in congenital bleeding disorders. DRUG DESIGN DEVELOPMENT AND THERAPY 2010; 4:107-16. [PMID: 20689697 PMCID: PMC2915535 DOI: 10.2147/dddt.s11764] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/26/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND Recombinant activated factor VII (rFVIIa, NovoSeven) was introduced in 1996 for the treatment of hemophilic patients with antibodies against coagulation factor VIII or IX. OBJECTIVE To review the evidence supporting the use of rFVIIa for the treatment of patients with congenital bleeding disorders. PATIENTS AND METHODS English-language databases were searched in September 2009 for reports of randomized controlled trials (RCTs) evaluating the ability of rFVIIa to restore hemostasis in patients with congenital bleeding disorders. RESULTS Eight RCTs involving 256 hemophilic patients with antibodies against coagulation factors, also known as inhibitors, were identified. The evidence supporting the use of rFVIIa in these patients was weak with regard to dose, clinical setting, mode of administration, efficacy, and adverse events, given the limited sample size of each RCT and the heterogeneity of the studies. CONCLUSION The authors suggest that rFVIIa therapy in hemophilic patients with inhibitors should be based on the individual's ability to generate thrombin and form a clot, and not on the patient's weight alone. Therefore, assays for thrombin generation, such as whole-blood thromboelastography, have the potential to significantly improve the treatment of these patients.
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Affiliation(s)
- Pär I Johansson
- Capital Region Blood Bank, Section for Transfusion Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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44
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Santagostino E, Morfini M, Auerswald GKH, Benson GM, Salek SZ, Lambert T, Salaj P, Jimenez-Yuste V, Ljung RCR. Paediatric haemophilia with inhibitors: existing management options, treatment gaps and unmet needs. Haemophilia 2010; 15:983-9. [PMID: 19712172 DOI: 10.1111/j.1365-2516.2009.01999.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Development of inhibitors is a severe complication of haemophilia posing many management challenges. While a long-term goal in inhibitor patients is eradication of inhibitors through immune tolerance induction, bypassing agents such as recombinant activated factor VII (rFVIIa) and activated prothrombin complex concentrate (aPCC) are essential for control of bleeding episodes. Paediatric patients with haemophilia and inhibitors are at particular risk of recurrent haemarthroses, and management of these patients should seek to avoid joint damage and support the child's full social and physical development. Current options for management of bleeding complications include on-demand treatment of acute bleeding episodes, secondary prophylaxis to avoid recurrent bleeds and surgery to treat affected joints. There is also a rationale for adopting prophylactic approaches to prevent bleeding in inhibitor patients, allowing this group similar opportunities for protection against arthropathy development as are given to non-inhibitor patients. This paper, based on a roundtable meeting of haematology experts at the first Zürich Haemophilia Forum in May 2008, reviews the current evidence supporting more intense and prophylactic approaches to manage bleeding risk in paediatric haemophilia patients with inhibitors, and highlights the need for investigations of primary prophylaxis in this vulnerable patient group, to support best long-term outcome.
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Affiliation(s)
- E Santagostino
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, IRCCS Maggiore Hospital, Mangiagalli and Regina Elena Foundation, University of Milan, Milan, Italy.
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46
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Acquired factor VIII hemophilia in a trauma patient: case report and literature review. ACTA ACUST UNITED AC 2010; 68:E35-8. [PMID: 20154529 DOI: 10.1097/ta.0b013e318156869b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Smejkal P, Brabec P, Matyskova M, Bulikova A, Slechtova M, Kissova J, Chlupova G, Muzik J, Penka M. FEIBA in treatment of acute bleeding episodes in patients with haemophilia A and factor VIII inhibitors: a retrospective survey in regional haemophilia centre. Haemophilia 2010; 15:743-51. [PMID: 19432925 DOI: 10.1111/j.1365-2516.2009.02012.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
FEIBA (factor eight inhibitor by-passing activity) is used to achieve haemostasis in haemophiliacs with inhibitor. The aim of this study was to evaluate efficacy and consumption of the product in treatment of haemorrhages in haemophiliacs with factor VIII inhibitor, and determine factors that can influence the results of treatment. We used data from our haemophilia centre from years 2000-2008. Six haemophiliacs with factor VIII inhibitor were treated on demand with FEIBA for 61 bleeding episodes (45 haemarthroses, six muscle bleeds, six other sites bleeds and four multiple sites bleeds). The median cumulative dose of FEIBA per bleeding episode was 205 U kg(-1). Bleeding was stopped in 96.7% (59 of 61) of events but re-bleeding occurred in 3 events (4.9%) within 48 h after cessation of bleeding. In home treatment (20 of 61) bleeding stopped in 90% (18 of 20) without recurrence and the median consumption per event was reduced to 153 U kg(-1). Without the use of home treatment the median consumption was 250 U kg(-1) per event and bleeding ceased definitely in 92.7% (38 of 41) of cases. The cumulative dose of FEIBA was lower for three episodes with re-bleeding: median 96 U kg(-1) but not in the two cases of ineffective treatment: 361 U kg(-1). FEIBA in management of bleeding episodes completely resolved the haemorrhage in 91.8% of events and in a further 4.9% if treatment was restarted. Using home treatment saved expenditure due to the lower cumulative dose needed for treatment of haemorrhage.
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Affiliation(s)
- P Smejkal
- Department of Clinical Haematology, Faculty Hospital and Medical School of Masaryk University, Brno, Czech Republic.
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MARTINOWITZ U, LIVNAT T, ZIVELIN A, KENET G. Concomitant infusion of low doses of rFVIIa and FEIBA in haemophilia patients with inhibitors. Haemophilia 2009; 15:904-10. [DOI: 10.1111/j.1365-2516.2009.02028.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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SALAJ P, BRABEC P, PENKA M, POHLREICHOVA V, SMEJKAL P, CETKOVSKY P, DUSEK L, HEDNER U. Effect of rFVIIa dose and time to treatment on patients with haemophilia and inhibitors: analysis of HemoRec registry data from the Czech Republic. Haemophilia 2009; 15:752-9. [DOI: 10.1111/j.1365-2516.2009.02007.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Johnson AJ, Mathews RW, Fulton AJ. Fractionation of factor VIII and IX--an overview. SCANDINAVIAN JOURNAL OF HAEMATOLOGY. SUPPLEMENTUM 2009; 40:513-24. [PMID: 6433474 DOI: 10.1111/j.1600-0609.1984.tb02611.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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