An ‘ice age’ concept? The use of ice in the treatment of acute haemarthrosis in haemophilia

Unresolved hemostasis issues in haemophilia

Despite rapid technological advancement in factor and nonfactor products in the prevention and treatment of bleeding in haemophilia patients, it is imperative that we acknowledge gaps in our understanding of how hemostasis is achieved. The authors will briefly review three unresolved issues in persons with haemophilia (PwH) focusing on the forgotten function that red blood cells play in hemostasis, the critical role of extravascular (outside circulation) FIX in hemostasis in the context of unmodified and extended half-life FIX products and finally on the role that skeletal muscle myosin plays in prothrombinase assembly and subsequent thrombin generation that could mitigate breakthrough muscle hematomas.

Management of Haemarthrosis in Patients On Oral Anticoagulants

Aims

Our aim was to investigate the management of patients who were admitted to hospital with an acute haemarthrosis whilst taking oral anticoagulants, and highlight the outcomes of different management strategies.

Methods

A retrospective review was performed of all orthopaedic admissions over a 42-month period (January 2015–July 2018) to the Orthopaedic Department of a London District General Hospital. All patients admitted with a spontaneous joint haemarthrosis and concomitant use of oral anticoagulants was identified. Anonymised data was placed on a secure trust database.

Findings

A total of 31 patients were included. 22 patients (71%) had their anticoagulant temporarily held during admission. 9 patients (32%) had their anticoagulation reversed with 10 mg of vitamin K. 5 patients had their haemarthrosis aspirated either on admission or during their hospital stay. The overall mean length of stay in patients with a haemarthrosis was 7.0 days. The mean length of stay in patients who had their anticoagulation held was 8.6 days. In contrast, patients who continued taking their anticoagulation were found to have an average length of stay of 2.3 days. No patients suffered a thrombotic event in the 60 days following discharge. No adverse events were recorded following joint aspiration.

Conclusion

There is currently no consensus on the management of haemarthrosis in patients on oral anticoagulants. Continuing the anticoagulants did not increase length of hospital stay. Further research may focus on assessing the effect of management adjuncts on patient outcomes and their cost effectiveness to aid the development of local and/or national guidelines.

Glanzmann Thrombasthenia: Perspectives from Clinical Practice on Accurate Diagnosis and Optimal Treatment Strategies

Glanzmann thrombasthenia (GT) is a rare autosomal recessive disorder of fibrinogen-mediated platelet aggregation due to a quantitative or qualitative deficit of the α_IIbβ₃ integrin at the platelet surface membrane resulting from mutation(s) in ITGA2B and/or ITGB3. Patients tend to present in early childhood with easy bruising and mucocutaneous bleeding. The diagnostic process requires consideration of more common disorders of haemostasis and coagulation prior to confirming the disorder with platelet light transmission aggregation, flow cytometry of CD41 and CD61 expression, and/or exon sequencing of ITGA2B and ITGB3. Antifibrinolytic therapy, recombinant activated factor VII, and platelet transfusions are the mainstay of therapy, although the latter may trigger formation of anti-platelet antibodies in GT patients and inadvertent platelet-refractory disease. The management of these patients therefore remains complex, particularly in the context of trauma, labour and delivery, and perioperative care. Bone marrow transplantation remains the sole curative option, although the venue of gene therapy is being increasingly explored as a future alternative for definitive treatment of GT.