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Baker RI, Choi P, Curry N, Gebhart J, Gomez K, Henskens Y, Heubel-Moenen F, James P, Kadir RA, Kouides P, Lavin M, Lordkipanidze M, Lowe G, Mumford A, Mutch N, Nagler M, Othman M, Pabinger I, Sidonio R, Thomas W, O'Donnell JS. Standardization of definition and management for bleeding disorder of unknown cause: communication from the SSC of the ISTH. J Thromb Haemost 2024; 22:2059-2070. [PMID: 38518896 DOI: 10.1016/j.jtha.2024.03.005] [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: 12/22/2023] [Revised: 02/08/2024] [Accepted: 03/08/2024] [Indexed: 03/24/2024]
Abstract
In many patients referred with significant bleeding phenotype, laboratory testing fails to define any hemostatic abnormalities. Clinical practice with respect to diagnosis and management of this patient cohort poses significant clinical challenges. We recommend that bleeding history in these patients should be objectively assessed using the International Society on Thrombosis and Haemostasis (ISTH) bleeding assessment tool. Patients with increased bleeding assessment tool scores should progress to hemostasis laboratory testing. To diagnose bleeding disorder of unknown cause (BDUC), normal complete blood count, prothrombin time, activated partial thromboplastin time, thrombin time, von Willebrand factor antigen, von Willebrand factor function, coagulation factors VIII, IX, and XI, and platelet light transmission aggregometry should be the minimum laboratory assessment. In some laboratories, additional specialized hemostasis testing may be performed to identify other rare causes of bleeding. We recommend that patients with a significant bleeding phenotype but normal laboratory investigations should be registered with a diagnosis of BDUC in preference to other terminology. Global hemostatic tests and markers of fibrinolysis demonstrate variable abnormalities, and their clinical significance remains uncertain. Targeted genomic sequencing examining candidate hemostatic genes has a low diagnostic yield. Underlying BDUC should be considered in patients with heavy menstrual bleeding since delays in diagnosis often extend to many years and negatively impact quality of life. Treatment options for BDUC patients include tranexamic acid, desmopressin, and platelet transfusions.
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Affiliation(s)
- Ross I Baker
- Western Australia Centre for Thrombosis and Haemostasis, Murdoch University, Perth, Australia; Clinical Research Unit, Perth Blood Institute, Perth, Australia; Hollywood Hospital Haemophilia Centre, Haematology Academic Unit, Perth, Australia; Irish-Australian Blood Collaborative Network, Dublin, Ireland and Perth, Australia.
| | - Philip Choi
- Haematology Department, The Canberra Hospital, Canberra, Australia; Division of Genome Sciences and Cancer, John Curtin School of Medical Research, Australian National University, Canberra, Australia
| | - Nicola Curry
- Department of Clinical Haematology, Haemophilia & Thrombosis Centre, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom; Radcliffe Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Johanna Gebhart
- Department of Medicine, Division of Hematology and Hemostaseology, Medical University Vienna, Vienna, Austria
| | - Keith Gomez
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London National Health Service Foundation Trust, London, United Kingdom
| | - Yvonne Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Biochemistry, Institute for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Floor Heubel-Moenen
- Department of Hematology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Paula James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rezan Abdul Kadir
- Department of Obstetrics and Gynaecology, Katharine Dormandy Haemophilia and Thrombosis Centre, The Royal Free National Health Service Hospital, London, United Kingdom; Institute for Women's Health, University College, London, United Kingdom
| | - Peter Kouides
- Mary M. Gooley Hemophilia Center, Rochester, New York, USA
| | - Michelle Lavin
- Irish-Australian Blood Collaborative Network, Dublin, Ireland and Perth, Australia; National Coagulation Centre, St. James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Marie Lordkipanidze
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada; Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - Gillian Lowe
- West Midlands Adult Comprehensive Care Haemophilia Centre, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Andrew Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Nicola Mutch
- Aberdeen Cardiovascular and Diabetes Centre, Institute of Medical Sciences, School of Medicine, United Kingdom; Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, Bern, Switzerland; Department of Clinical Chemistry, Inselspital University Hospital Bern, Bern, Switzerland
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, Ontario, Canada; School of Baccalaureate Nursing, St Lawrence College, Kingston, Ontario, Canada; Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ingrid Pabinger
- Department of Medicine, Division of Hematology and Hemostaseology, Medical University Vienna, Vienna, Austria
| | - Robert Sidonio
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Will Thomas
- Department of Haematology, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - James S O'Donnell
- Irish-Australian Blood Collaborative Network, Dublin, Ireland and Perth, Australia; National Coagulation Centre, St. James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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Platton S, Baker P, Bowyer A, Keenan C, Lawrence C, Lester W, Riddell A, Sutherland M. Guideline for laboratory diagnosis and monitoring of von Willebrand disease: A joint guideline from the United Kingdom Haemophilia Centre Doctors' Organisation and the British Society for Haematology. Br J Haematol 2024; 204:1714-1731. [PMID: 38532595 DOI: 10.1111/bjh.19385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/20/2024] [Accepted: 02/23/2024] [Indexed: 03/28/2024]
Affiliation(s)
- Sean Platton
- Royal London Hospital Haemophilia Centre, London, UK
| | - Peter Baker
- Oxford Haemophilia and Thrombosis Centre, Nuffield Orthopaedic Hospital, Oxford, UK
| | - Annette Bowyer
- Department of Coagulation, Royal Hallamshire Hospital, Sheffield, UK
| | - Catriona Keenan
- Department of Haematology & the National Coagulation Centre, St. James's Hospital, Dublin, Ireland
| | | | - Will Lester
- Haemophilia Unit, University Hospitals, Birmingham, UK
| | - Anne Riddell
- Katharine Dormandy Haemophilia Centre, Royal Free Hospital, London, UK
| | - Megan Sutherland
- North West Genomic Laboratory Hub, Manchester University NHS Foundation Trust, Manchester, UK
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Edme E, Sola C, Cau-Diaz I, Sirvent N, Mollevi C, Biron-Andreani C, Theron A. Gingival bleeding is a useful clinical feature in the diagnosis of hereditary bleeding disorders in children. Eur J Pediatr 2024; 183:2215-2221. [PMID: 38386030 DOI: 10.1007/s00431-024-05487-6] [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: 12/18/2023] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 02/23/2024]
Abstract
The search for hereditary bleeding disorders (HBD) prior to invasive procedures in children is primarily based on personal and family bleeding history. Although several scores are available, they have only been evaluated in specific situations or in adults. Our monocentric retrospective study aimed to analyze the association between clinical history and four scores (HEMSTOP, PBQ, ISTH-BAT, TOSETTO) and the diagnosis of MHC in children referred to the University Hospital of Montpellier for hemostasis investigations. A total of 117 children were retrospectively included in the study. Of these, 57 (49%) were diagnosed with HBD, with 30 having primary bleeding disorders and 27 having coagulation disorders. The diagnosis of HBD was significantly associated with gingival bleeding, which was present in 30% of HBD patients. In our population, only the HEMSTOP score showed an association with the diagnosis of HBD, but it was positive in only 48% of patients. By including gingival bleeding as a factor, we modified the HEMSTOP score, which increased its sensitivity from 0.45 to 0.53. When examining primary bleeding disorders, the modified HEMSTOP score, with the inclusion of gingival bleeding, enables us to diagnose 63% of patients (see Fig. 1). Conclusion: Therefore, gingival bleeding should be considered a useful factor in bleeding history for HBD diagnosis. Adding this symptom to a screening score such as HEMSTOP improves its sensitivity. To confirm our findings, a prospective study is required. Trial registration: Study registration number: NCT05214300. What is Known: • Screening for hereditary bleeding disorder diseases is a necessity and a challenge in children. • Minor disorders of primary hemostasis are the most common, but often escape standard coagulation tests. What is New: • Gingival bleeding is a frequent symptom that is easy to investigate and may point to a primary hemostasis disorder. • Adding the gingival bleeding item to a routine screening score such as HEMSTOP improves sensitivity.
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Affiliation(s)
- Eleonore Edme
- Department of Pediatric Oncology and Hematology, Hôpital Arnaud de Villeneuve, Univ Montpellier, CHU Montpellier, 371 Av. du Doyen Gaston Giraud, 34090, Montpellier, France
| | - Chrystelle Sola
- Department of Pediatric Anesthesia, Univ Montpellier, CHU Montpellier, Montpellier, France
| | - Isabelle Cau-Diaz
- Department of Biological Hematology, Univ Montpellier, CHU Montpellier, Montpellier, France
- Hemophilia Treatment Center, Univ Montpellier, CHU Montpellier, Montpellier, France
| | - Nicolas Sirvent
- Department of Pediatric Oncology and Hematology, Hôpital Arnaud de Villeneuve, Univ Montpellier, CHU Montpellier, 371 Av. du Doyen Gaston Giraud, 34090, Montpellier, France
| | - Caroline Mollevi
- Institute Desbrest of Epidemiology and Public Health, Univ Montpellier, INSERM, CHU Montpellier, Montpellier, France
| | - Christine Biron-Andreani
- Department of Biological Hematology, Univ Montpellier, CHU Montpellier, Montpellier, France
- Hemophilia Treatment Center, Univ Montpellier, CHU Montpellier, Montpellier, France
| | - Alexandre Theron
- Department of Pediatric Oncology and Hematology, Hôpital Arnaud de Villeneuve, Univ Montpellier, CHU Montpellier, 371 Av. du Doyen Gaston Giraud, 34090, Montpellier, France.
- Hemophilia Treatment Center, Univ Montpellier, CHU Montpellier, Montpellier, France.
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Mokhtar G, Abdelbaky A, Adly A, Ezzat D, Abdel Hakeem G, Hassab H, Youssry I, Ragab I, Sherief LM, Zakaria M, Hesham M, Salama N, Salah N, Afifi RAA, El-Ashry R, Makkeyah S, Adolf S, Amer YS, Omar TEI, Bussel J, Abd El Raouf E, Atfy M, Ellaboudy M, Florez I. Egyptian Pediatric Guidelines for the Management of Children with Isolated Thrombocytopenia Using the Adapted ADAPTE Methodology-A Limited-Resource Country Perspective. CHILDREN (BASEL, SWITZERLAND) 2024; 11:452. [PMID: 38671669 PMCID: PMC11048986 DOI: 10.3390/children11040452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/26/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Thrombocytopenia is a prevalent presentation in childhood with a broad spectrum of etiologies, associated findings, and clinical outcomes. Establishing the cause of thrombocytopenia and its proper management have obvious clinical repercussions but may be challenging. This article provides an adaptation of the high-quality Clinical Practice Guidelines (CPGs) of pediatric thrombocytopenia management to suit Egypt's health care context. METHODS The Adapted ADAPTE methodology was used to identify the high-quality CPGs published between 2010 and 2020. An expert panel screened, assessed and reviewed the CPGs and formulated the adapted consensus recommendations based on the best available evidence. DISCUSSION The final CPG document provides consensus recommendations and implementation tools on the management of isolated thrombocytopenia in children and adolescents in Egypt. There is a scarcity of evidence to support recommendations for various management protocols. In general, complete clinical assessment, full blood count, and expert analysis of the peripheral blood smear are indicated at initial diagnosis to confirm a bleeding disorder, exclude secondary causes of thrombocytopenia and choose the type of work up required. The International Society of Hemostasis and thrombosis-Bleeding assessment tool (ISTH-SCC BAT) could be used for initial screening of bleeding manifestations. The diagnosis of immune thrombocytopenic purpura (ITP) is based principally on the exclusion of other causes of isolated thrombocytopenia. Future research should report the outcome of this adapted guideline and include cost-analysis evaluations.
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Affiliation(s)
- Galila Mokhtar
- Pediatric Hematology and Oncology Unit, Pediatric Department, Ain Shams University, Cairo 11566, Egypt; (G.M.); (A.A.); (I.R.); (S.M.); (M.E.)
| | - Ashraf Abdelbaky
- Pediatric Department, Faculty of Medicine, Ain Shams University, Cairo 11566, Egypt;
| | - Amira Adly
- Pediatric Hematology and Oncology Unit, Pediatric Department, Ain Shams University, Cairo 11566, Egypt; (G.M.); (A.A.); (I.R.); (S.M.); (M.E.)
| | - Dina Ezzat
- Pediatric Hematology Unit, Pediatric Department, Beni-Suef University, Beni-Suef 62521, Egypt;
- Pediatric Department, October 6 University, Giza 12585, Egypt
| | - Gehan Abdel Hakeem
- Pediatric Hematology and Oncology Unit, Pediatric Department, Minia University, Minia 61519, Egypt;
| | - Hoda Hassab
- Pediatric Hematology and Oncology Unit, Pediatric Department, Faculty of Medicine, Alexandria University, Alexandria 21526, Egypt;
| | - Ilham Youssry
- Pediatric Hematology and Bone Marrow Transplantation Unit, Pediatric Department, Cairo University, Giza 12613, Egypt; (I.Y.); (N.S.); (R.A.A.A.); (E.A.E.R.)
| | - Iman Ragab
- Pediatric Hematology and Oncology Unit, Pediatric Department, Ain Shams University, Cairo 11566, Egypt; (G.M.); (A.A.); (I.R.); (S.M.); (M.E.)
| | - Laila M. Sherief
- Pediatric Hematology and Oncology Unit, Pediatric Department, Zagazig University, Zagazig 44519, Egypt; (L.M.S.); (M.Z.); (M.H.); (M.A.)
| | - Marwa Zakaria
- Pediatric Hematology and Oncology Unit, Pediatric Department, Zagazig University, Zagazig 44519, Egypt; (L.M.S.); (M.Z.); (M.H.); (M.A.)
| | - Mervat Hesham
- Pediatric Hematology and Oncology Unit, Pediatric Department, Zagazig University, Zagazig 44519, Egypt; (L.M.S.); (M.Z.); (M.H.); (M.A.)
| | - Niveen Salama
- Pediatric Hematology and Bone Marrow Transplantation Unit, Pediatric Department, Cairo University, Giza 12613, Egypt; (I.Y.); (N.S.); (R.A.A.A.); (E.A.E.R.)
| | - Nouran Salah
- Pediatric Department, Faculty of Medicine, Ain Shams University, Cairo 11566, Egypt;
| | - Rasha A. A. Afifi
- Pediatric Hematology and Bone Marrow Transplantation Unit, Pediatric Department, Cairo University, Giza 12613, Egypt; (I.Y.); (N.S.); (R.A.A.A.); (E.A.E.R.)
| | - Rasha El-Ashry
- Pediatric Hematology and Oncology Unit, Pediatric Department, Mansoura University, Mansoura 35516, Egypt;
| | - Sara Makkeyah
- Pediatric Hematology and Oncology Unit, Pediatric Department, Ain Shams University, Cairo 11566, Egypt; (G.M.); (A.A.); (I.R.); (S.M.); (M.E.)
| | - Sonia Adolf
- Pediatric, Hematology Department, Institute of Medical Research and Clinical Studies, National Research Center, Giza 1770, Egypt;
| | - Yasser S. Amer
- Pediatrics Department, Quality Management Department, King Saud University Medical City, Riyadh 11451, Saudi Arabia;
- Research Chair for Evidence Based Health Care and Knowledge Translation, King Saud University, Riyadh 11451, Saudi Arabia
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo (FMRP-USP), Ribeirao Preto 14040-900, SP, Brazil
| | - Tarek E. I. Omar
- Pediatrics Department, Faculty of Medicine, Alexandria University, Alexandria 21526, Egypt;
| | - James Bussel
- Pediatrics Department, Well Cornell Medical College, New York, NY 10065, USA;
| | - Eman Abd El Raouf
- Pediatric Hematology and Bone Marrow Transplantation Unit, Pediatric Department, Cairo University, Giza 12613, Egypt; (I.Y.); (N.S.); (R.A.A.A.); (E.A.E.R.)
| | - Mervat Atfy
- Pediatric Hematology and Oncology Unit, Pediatric Department, Zagazig University, Zagazig 44519, Egypt; (L.M.S.); (M.Z.); (M.H.); (M.A.)
| | - Mohamed Ellaboudy
- Pediatric Hematology and Oncology Unit, Pediatric Department, Ain Shams University, Cairo 11566, Egypt; (G.M.); (A.A.); (I.R.); (S.M.); (M.E.)
| | - Ivan Florez
- Department of Pediatrics, University of Antioquia, Medellin 050010, Colombia;
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Altahan RM, Mathews N, Bourguignon A, Tasneem S, Arnold DM, Lim W, Hayward CPM. Evaluation of a diagnostic platelet aggregation test strategy for platelet rich plasma samples with low platelet counts. Int J Lab Hematol 2024; 46:362-374. [PMID: 38148642 DOI: 10.1111/ijlh.14216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/25/2023] [Indexed: 12/28/2023]
Abstract
INTRODUCTION Light transmission aggregometry (LTA) is important for diagnosing platelet function disorders (PFD) and von Willebrand disease (VWD) affecting ristocetin-induced platelet aggregation (RIPA). Nonetheless, data is lacking on the utility of LTA for investigating thrombocytopenic patients and platelet rich plasma samples with low platelet counts (L-PRP). Previously, we developed a strategy for diagnostic LTA assessment of L-PRP that included: (1) acceptance of referrals/samples, regardless of thrombocytopenia severity, (2) tailored agonist selection, based on which are informative for L-PRP with mildly or severely low platelet counts, and (3) interpretation of maximal aggregation (MA) using regression-derived 95% confidence intervals, determined for diluted control L-PRP (C-L-PRP). METHODS To further evaluate the L-PRP LTA strategy, we evaluated findings for a subsequent patient cohort. RESULTS Between 2008 and 2021, the L-PRP strategy was applied to 211 samples (11.7% of all LTA samples) from 192 unique patients, whose platelet counts (median [range] × 109 /L) for blood and L-PRP were: 105 [13-282; 89% with thrombocytopenia] and 164 [17-249], respectively. Patient-L-PRP had more abnormal MA findings than simultaneously tested C-L-PRP (p-values <0.001). Among patients with accessible electronic medical records (n = 181), L-PRP LTA uncovered significant aggregation abnormalities in 45 (24.9%), including 18/30 (60%) with <80 × 109 platelets/L L-PRP, and ruled out PFD, and VWD affecting RIPA, in others. The L-PRP LTA strategy helped diagnose VWD affecting RIPA, Bernard Soulier syndrome, familial platelet disorder with myeloid malignancy, suspected ITGA2B/ITGB3-related thrombocytopenia, and acquired PFD. CONCLUSION Diagnostic LTA with L-PRP, using a strategy that considers thrombocytopenia severity, is feasible and informative.
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Affiliation(s)
- Rahaf Mahmoud Altahan
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Pathology and Clinical Laboratory Medicine Administration, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Natalie Mathews
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Alex Bourguignon
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Subia Tasneem
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Wendy Lim
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
| | - Catherine P M Hayward
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
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Schaefer JH, Lieschke F, Urban H, Bohmann FO, Gatzke F, Miesbach W. Feasibility and comparability of different platelet function tests in acute stroke with or without prior antiplatelet therapy. Front Neurol 2024; 15:1361751. [PMID: 38410198 PMCID: PMC10894916 DOI: 10.3389/fneur.2024.1361751] [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: 12/26/2023] [Accepted: 01/30/2024] [Indexed: 02/28/2024] Open
Abstract
Background The clinical course of ischemic and hemorrhagic strokes can be influenced by the coagulation status of individual patients. The prior use of antiplatelet therapy (APT) such as acetylsalicylic acid (ASA) or P2Y12-antagonists has been inconsistently described as possibly increasing the risk of hemorrhagic transformation or expansion. Since clinical studies describing prior use of antiplatelet medication are overwhelmingly lacking specific functional tests, we aimed to implement testing in routine stroke care. Methods We used fluorescence-activated cell sorting (FACS) with antibodies against CD61 for thrombocyte identification and CD62p or platelet activation complex-1 (PAC-1) to determine platelet activation. Aggregometry and automated platelet functioning analyzer (PFA-200) were employed to test thrombocyte reactivity. FACS and aggregometry samples were stimulated in vitro with arachidonic acid (AA) and adenosine diphosphate (ADP) to measure increase in CD62p-/PAC-1-expression or aggregation, respectively. Results Between February and July 2023, 20 blood samples (n = 11 ischemic strokes; n = 7 hemorrhagic strokes; n = 2 controls) were acquired and analyzed within 24 h of symptom onset. N = 11 patients had taken ASA, n = 8 patients no APT and n = 1 ASA+clopidogrel. ASA intake compared to no APT was associated with lower CD62p expression after stimulation with AA on FACS analysis (median 15.8% [interquartile range {IQR} 12.6-37.2%] vs. 40.1% [IQR 20.3-56.3%]; p = 0.020), lower platelet aggregation (9.0% [IQR 7.0-12.0%] vs. 88.5% [IQR 11.8-92.0%]; p = 0.015) and longer time to plug formation with PFA-200 (248.0 s [IQR 157.0-297] vs. 121.5 s [IQR 99.8-174.3]; p = 0.027). Significant correlations were noted between AA-induced CD62p expression and aggregometry analysis (n = 18; ρ = 0.714; p < 0.001) as well as a negative correlation between CD62p increase and PFA clot formation time (n = 18; ρ = -0.613; p = 0.007). Sensitivity for ASA intake was highest for PFA (81.8% for values ≥155.5 s). The combination of ASA + clopidogrel also affected ADP-induced CD62p and PAC-1 expression. Conclusion In the clinical setting it is feasible to use differentiated platelet analytics to determine alterations caused by antiplatelet therapy. Among the tests under investigation, PFA-200 showed the highest sensitivity for the intake of ASA in stroke patients. FACS analysis on the other hand might be able to provide a more nuanced approach to altered platelet reactivity.
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Affiliation(s)
- Jan Hendrik Schaefer
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Franziska Lieschke
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Hans Urban
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Ferdinand O Bohmann
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Florian Gatzke
- Department of Internal Medicine II, Haemostaseology and Haemophilia Centre, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Wolfgang Miesbach
- Department of Internal Medicine II, Haemostaseology and Haemophilia Centre, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
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Regan IE, Cox D, Kelleher ST, Nolan B, Shaw K, Smith OP, McMahon CJ. Towards a greater understanding of reduced response to aspirin in children with congenital heart disease post-cardiac surgery using immature platelet fraction. Thromb Res 2024; 233:101-108. [PMID: 38039722 DOI: 10.1016/j.thromres.2023.11.014] [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: 07/04/2023] [Revised: 10/10/2023] [Accepted: 11/13/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE A high platelet turnover rate may produce a population of platelets that confers an inadequate response to aspirin. We aimed to investigate the relationship between residual platelet aggregation and platelet turnover in paediatric cardiology patients on aspirin monotherapy by evaluating the fraction of immature platelets as a marker for turnover and secondly to test the predictive value of the immature platelet fraction (IPF) to classify patients as responsive or non-responsive to aspirin. METHODS Sixty patients divided into two age categories (≤90 days, >90 days of age) were included in this prospective observational study. Patients were then stratified into tertiles using their IPF level. Platelet studies included thromboelastography with platelet mapping (TEGPM). RESULTS The overall incidence of 'inadequate response to aspirin' was 38 % in our patient cohort recently post-cardiac surgery a consequence that warrants further study. The frequency of inadequate response to aspirin was higher in the upper tertile of IPF when compared to the lower tertile, (88 %) versus (4 %) respectively (p < 0.05). The 'cut off' for IPF was determined to be 3.9 % with a sensitivity of 95.7 %, and a specificity of 92.9 % (area under the curve of 0.955 [CI 0.896-1.014, p < 0.05]). CONCLUSION This study demonstrates that inadequate response to aspirin occurs in approximately 38 % of patients undergoing specific high-risk congenital cardiac procedures using the dosing practice of a national centre. This study supports the hypothesis that an elevated platelet turnover may result in aspirin being less effective in patients who are recently post cardiac surgery. These data are of direct translational relevance.
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Affiliation(s)
- Irene E Regan
- Department of Coagulation/Haematology, Children's Health Ireland at Crumlin, Dublin, Ireland; School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland; National Children's Research Centre, Children's Health Ireland, Dublin, Ireland
| | - Dermot Cox
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons Ireland, Dublin, Ireland
| | - Sean T Kelleher
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Beatrice Nolan
- Department of Coagulation/Haematology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Kathryn Shaw
- Department of Paediatric Pharmacy, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Owen P Smith
- Department of Coagulation/Haematology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Colin J McMahon
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland; School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland; School of Health Professions Education (SHE), Maastricht University, Maastricht, Netherlands; National Children's Research Centre, Children's Health Ireland, Dublin, Ireland.
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8
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Babuty A, Debord C, Drillaud N, Eveillard M, Trossaert M, Ternisien C, Sigaud M, Cador E, Béné MC, Fouassier M. Prothrombin consumption as an indicator of hemorrhagic phenotype in mild platelet function disorders. Eur J Haematol 2023; 111:787-795. [PMID: 37553915 DOI: 10.1111/ejh.14079] [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: 05/17/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND The bleeding risk of patients with mild platelet function disorders is difficult to assess and their phenotype remains ill-explored. AIM This study was designed to establish a comprehensive biological phenotype of patients with mild platelet function disorders. METHODS Twenty patients were included with persistent abnormal light transmission aggregometry (LTA). The ISTH bleeding assessment tool (ISTH-BAT) was assessed to identify laboratory analyses associated with an abnormal hemorrhagic score. RESULTS The majority of patients had defects that might affect Gαi protein signaling pathways or minor abnormalities. No LTA nor flow cytometry parameters were associated with an above-normal hemorrhagic score. However, prothrombin consumption, which corresponds to the ratio of serum residual factor II to plasma residual factor II, was significantly higher (p = .006) in the abnormal ISTH-BAT group (mean = 14%, SD = 6) compared with the normal ISTH-BAT group (mean = 8%, SD 4). Prothrombin consumption was significantly associated with ISTH-BAT score (r = .5287, IC 95% 0.0986-0.7924, p = .0165). CONCLUSION In this group of patients, there was an association between a pathological bleeding score and increased prothrombin consumption. This test could be used as an additional indicator of platelet function abnormality liable to be related to bleeding risk.
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Affiliation(s)
- Antoine Babuty
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
- Nantes Université, CHU Nantes, Centre de Ressource et de Compétence-Maladies Hémorragiques Constitutionnelles, Nantes, France
| | - Camille Debord
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
| | - Nicolas Drillaud
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
- Nantes Université, CHU Nantes, Centre de Ressource et de Compétence-Maladies Hémorragiques Constitutionnelles, Nantes, France
| | - Marion Eveillard
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
| | - Marc Trossaert
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
- Nantes Université, CHU Nantes, Centre de Ressource et de Compétence-Maladies Hémorragiques Constitutionnelles, Nantes, France
| | - Catherine Ternisien
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
- Nantes Université, CHU Nantes, Centre de Ressource et de Compétence-Maladies Hémorragiques Constitutionnelles, Nantes, France
| | - Marianne Sigaud
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
- Nantes Université, CHU Nantes, Centre de Ressource et de Compétence-Maladies Hémorragiques Constitutionnelles, Nantes, France
| | - Emmanuelle Cador
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
| | - Marie C Béné
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
| | - Marc Fouassier
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
- Nantes Université, CHU Nantes, Centre de Ressource et de Compétence-Maladies Hémorragiques Constitutionnelles, Nantes, France
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9
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Alessi MC, Coxon C, Ibrahim-Kosta M, Bacci M, Voisin S, Rivera J, Greinacher A, Raster J, Pulcinelli F, Devreese KMJ, Mullier F, McCormick AN, Frontroth JP, Pouplard C, Sachs UJ, Diaz I, Bermejo N, Camera M, Fontana P, Bauters A, Stepanian A, Cozzi MR, Sveshnikova AN, Faille D, Hollon W, Chitlur M, Casonato A, Lasne D, Lavenu-Bombled C, Fiore M, Hamidou B, Hurtaud-Roux MF, Saultier P, Goumidi L, Gresele P, Lordkipanidzé M. Multicenter evaluation of light transmission platelet aggregation reagents: communication from the ISTH SSC Subcommittee on Platelet Physiology. J Thromb Haemost 2023; 21:2596-2610. [PMID: 37331519 DOI: 10.1016/j.jtha.2023.05.027] [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: 10/28/2022] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND Light transmission aggregation (LTA) is used widely by the clinical and research communities. Although it is a gold standard, there is a lack of interlaboratory harmonization. OBJECTIVES The primary objective was to assess whether sources of activators (mainly adenosine diphosphate [ADP], collagen, arachidonic acid, epinephrine, and thrombin receptor activating peptide6) and ristocetin contribute to poor LTA reproducibility. The secondary objective was to evaluate interindividual variability of results to appreciate the distribution of normal values and consequently better interpret pathologic results. METHODS An international multicenter study involving 28 laboratories in which we compared LTA results obtained with center-specific activators and a comparator that we supplied. RESULTS We report variability in the potency (P) of activators in comparison with the comparator. Thrombin receptor activating peptide 6 (P, 1.32-2.68), arachidonic acid (P, 0.87-1.43), and epinephrine (P, 0.97-1.34) showed the greatest variability. ADP (P, 1.04-1.20) and ristocetin (P, 0.98-1.07) were the most consistent. The data highlighted clear interindividual variability, notably for ADP and epinephrine. Four profiles of responses were observed with ADP from high-responders, intermediate-responders, and low-responders. A fifth profile corresponding to nonresponders (5% of the individuals) was observed with epinephrine. CONCLUSION Based on these data, the establishment and adoption of simple standardization principles should mitigate variability due to activator sources. The observation of huge interindividual variability for certain concentrations of activators should lead to a cautious interpretation before reporting a result as abnormal. Confidence can be taken from the fact that difference between sources is not exacerbated in patients treated with antiplatelet agents.
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Affiliation(s)
- Marie-Christine Alessi
- Laboratory of Hematology, Centre de référence des pathologies plaquettaires, C2VN, INRAE, INSERM, Aix Marseille Université, Marseille, France.
| | - Carmen Coxon
- National Institute for Biological Standards and Control, Blanche Lane, South Mimms, Potters Bar, Hertfordshire, United Kingdom
| | - Manal Ibrahim-Kosta
- Laboratory of Hematology, Centre de référence des pathologies plaquettaires, C2VN, INRAE, INSERM, Aix Marseille Université, Marseille, France
| | - Monica Bacci
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Sophie Voisin
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - José Rivera
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, Instituto Murciano De Investigación Biosanitaria, IMIB-Arrixaca, Murcia, Spain
| | - Andreas Greinacher
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Johannes Raster
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Fabio Pulcinelli
- Department of Experimental Medicine, Sapienza University of Rome, Roma, Italy
| | - Katrien M J Devreese
- Department of Diagnostic Sciences, Coagulation Laboratory, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Francois Mullier
- Namur Thrombosis and Hemostasis Center, CHU UCLouvain Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - Aine N McCormick
- Haemostasis and Thrombosis Laboratory, Viapath Analytics, St Thomas' Hospital, London, United Kingdom
| | - Juan Pablo Frontroth
- Laboratorio de Hemostasia y Trombosis, Hospital de Pediatría "Prof. Dr. Juan P. Garrahan," Buenos Aires, Argentina
| | - Claire Pouplard
- Department of Hemostasis, University Hospital of Tours, University of Tours, Tours, France
| | - Ulrich J Sachs
- Department of Thrombosis and Haemostasis, Giessen University Hospital, Giessen, Germany
| | - Isabelle Diaz
- Laboratory of Hematology, University Hospital of Montpellier, Montpellier, France
| | - Nuria Bermejo
- Servicio de Hematología, Hospital San Pedro de Alcántara, Complejo Hospitalario Universitario de Cáceres, Cáceres, Spain
| | - Marina Camera
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico, Milan, Italy
| | - Pierre Fontana
- Division of Angiology and Haemostasis, Geneva University Hospitals, and Geneva Platelet Group, Faculty of Medicine, Geneva, Switzerland
| | - Anne Bauters
- Hemostasis Unit, Hospital University Center Lille, Lille, France
| | - Alain Stepanian
- Hematology Laboratory and Thrombosis Unit, Université Paris Cité, Hospital Group Lariboisière-Fernand Widal, Assistance Publique-Hôpitaux de Paris AP-HP, Paris, France
| | - Maria R Cozzi
- Immunopathology and Cancer Biomarkers Unit Centro di Riferimento Oncologico di Aviano, Aviano, Italy
| | - Anastasia N Sveshnikova
- Hemostasis Research Department, Dmitry Rogachev Pediatric Hematology and Immunology Hospital, Moscow, Russia
| | - Dorothée Faille
- Département d'Hématologie Biologique, Assistance Publique-Hôpitaux de Paris AP-HP, Centre Hospitalo-Universitaire CHU Bichat-Claude Bernard, Paris, France
| | - Wendy Hollon
- Jeanne M. Lusher Special Coagulation Laboratory, Children's Hospital of Michigan, Wayne State University, Detroit, Michigan, USA
| | - Meera Chitlur
- Central Michigan University, Jeanne M. Lusher Special Coagulation Laboratory, Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Alessandra Casonato
- Department of Medicine, University of Padua Medical School, First chair of Internal Medicine, Padua, Italy
| | - Dominique Lasne
- Laboratoire d'Hématologie, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, Paris, France
| | - Cécile Lavenu-Bombled
- Service Hématologie Biologique, Centre de ressources et compétences de la filière de santé des maladies Hémorragiques constitutionnelles MHEMO, Centre Hospitalo-Universitaire CHU Bicêtre, Assistance Publique-Hôpitaux de Paris, Faculté de médecine Paris Saclay, Le Kremlin-Bicêtre, France
| | - Mathieu Fiore
- Bordeaux University Hospital, Laboratory of Hematology, Centre de Reference des Pathologies Plaquettaires Pessac, France
| | - Bello Hamidou
- Laboratory of Hematology, Centre de référence des pathologies plaquettaires, C2VN, INRAE, INSERM, Aix Marseille Université, Marseille, France
| | - Marie-Francoise Hurtaud-Roux
- Assistance Publique-Hôpitaux de Paris, Centre de Reference des Pathologies Plaquettaires, Hôpital Robert Debré, Paris, France
| | - Paul Saultier
- Laboratory of Hematology, Centre de référence des pathologies plaquettaires, C2VN, INRAE, INSERM, Aix Marseille Université, Marseille, France
| | - Louisa Goumidi
- Laboratory of Hematology, Centre de référence des pathologies plaquettaires, C2VN, INRAE, INSERM, Aix Marseille Université, Marseille, France
| | - Paolo Gresele
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Marie Lordkipanidzé
- Faculté de Pharmacie, Research Center and The Montreal Heart Institute, Université de Montréal, Montréal, Quebec, Canada
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10
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Biss T, Sibson K, Baker P, Macartney C, Grayson C, Grainger J, Chalmers E, Dixon S. Haematological evaluation of bruising and bleeding in children undergoing child protection investigation for possible physical maltreatment: A British Society for Haematology Good Practice Paper. Br J Haematol 2022; 199:45-53. [PMID: 35881677 DOI: 10.1111/bjh.18361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/01/2022] [Accepted: 07/05/2022] [Indexed: 01/12/2023]
Affiliation(s)
- Tina Biss
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Peter Baker
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Caroline Grayson
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - John Grainger
- Royal Manchester Children's Hospital, Manchester, UK
| | | | - Sarah Dixon
- Manchester Health and Care Commissioning, Manchester, UK
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11
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Gomez K. Advances in the diagnosis of heritable platelet disorders. Blood Rev 2022; 56:100972. [PMID: 35595614 DOI: 10.1016/j.blre.2022.100972] [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: 04/20/2022] [Revised: 05/09/2022] [Accepted: 05/10/2022] [Indexed: 11/02/2022]
Abstract
The last decade has seen large increases in the number of patients registered with heritable platelet disorders in national databases of bleeding disorders. Although individually rare, collectively they are a relatively common cause of heritable bleeding. This revolution has come about through the application of high-throughput sequencing strategies and efforts to standardize diagnostic testing. There is renewed interest in established parameters such as platelet volume and utilising simple tools such as blood smears. The diagnostic yield from peripheral blood smears can be improved with new microscopy techniques that could potentially assist in determining which patients need to be referred to tertiary centres for specialist testing. A better understanding of the other clinical features that can accompany abnormalities of platelet number or function, can lead to better clinical management and prevention of serious complications. There are challenges for clinicians who need to be aware of these developments, understand the limitations of new diagnostic techniques and keep abreast of strategies for incorporation into clinical practice. This review discusses some of these approaches, the limitations that clinicians need to be aware of and techniques that may enter clinical use in the future.
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Affiliation(s)
- Keith Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK.
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12
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Bussel JB, Peerschke E. Heritable platelet disorders: an enigma even guidelines can't unravel. Br J Haematol 2021; 195:13-14. [PMID: 34494258 DOI: 10.1111/bjh.17809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/16/2021] [Indexed: 11/27/2022]
Affiliation(s)
| | - Ellinor Peerschke
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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