1
|
Yan J, Liao L, Deng D, Zhou W, Cheng P, Xiang L, Luo M, Lin F. Guideline for diagnosis and management of congenital dysfibrinogenemia. Clin Chim Acta 2024; 561:119680. [PMID: 38642629 DOI: 10.1016/j.cca.2024.119680] [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: 10/22/2023] [Revised: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION Congenital dysfibrinogenemia (CD) is characterized by dysfunction induced by an abnormal fibrinogen molecule structure that results in blood coagulation dysfunction. The clinical manifestations of CD patients are asymptomatic, bleeding and thrombosis. The majority of patient are asymptomatic. However, the single fibrinogen detection method is easy to cause missed diagnosis or misdiagnosis of CD patients. The treatment strategies of CD patients with different clinical manifestations are also different. METHODS Combing the existing experimental diagnosis technology, literature and our research results, a simple and practical CD diagnostic criteria was proposed. And based on the relevant literature and existing treatment guidelines, more comprehensive treatment recommendations are summarized. RESULTS In this new criteria, combination Clauss method and PT derived method was proposed to detect fibrinogen and its ratio was used to diagnose for CD. Diagnosis also needs to be combined the clinical manifestations, family investigation and genetic testing. According to different clinical manifestation (bleeding, thrombosis or asymptomatic), treatment methods and strategies are different. The treatment of CD patients should consider the patient's personal and family history of bleeding or thrombosis. Treatment of thrombosis and pregnancy may be more challenging. The risk of bleeding and thrombosis should be evaluated and balanced at all times during clinical treatment. These detailed treatment recommendations can provide reference for patients with different clinical manifestations of CD. CONCLUSIONS The new CD diagnosis criteria and comprehensive treatment recommendations can effectively improve the diagnosis and treatment of CD.
Collapse
Affiliation(s)
- Jie Yan
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China; Key Laboratory of Clinical Laboratory Medicine of Guangxi, Department of Education, China
| | - Lin Liao
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China; Key Laboratory of Clinical Laboratory Medicine of Guangxi, Department of Education, China; Guangxi Medical Doctor Association-Laboratory Medicine, China
| | - Donghong Deng
- Department of Hematology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Weijie Zhou
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China; Key Laboratory of Clinical Laboratory Medicine of Guangxi, Department of Education, China; Guangxi Medical Doctor Association-Laboratory Medicine, China; Clinical Laboratory, Baise People's Hospital, Baise, China
| | - Peng Cheng
- Department of Hematology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Liqun Xiang
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China; Key Laboratory of Clinical Laboratory Medicine of Guangxi, Department of Education, China
| | - Meiling Luo
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China; Key Laboratory of Clinical Laboratory Medicine of Guangxi, Department of Education, China
| | - Faquan Lin
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China; Key Laboratory of Clinical Laboratory Medicine of Guangxi, Department of Education, China; Guangxi Medical Doctor Association-Laboratory Medicine, China.
| |
Collapse
|
2
|
Ramanan R, McFadyen JD, Perkins AC, Tran HA. Congenital fibrinogen disorders: Strengthening genotype-phenotype correlations through novel genetic diagnostic tools. Br J Haematol 2023; 203:355-368. [PMID: 37583269 DOI: 10.1111/bjh.19039] [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: 05/31/2023] [Revised: 07/29/2023] [Accepted: 08/02/2023] [Indexed: 08/17/2023]
Abstract
Congenital fibrinogen disorders or CFDs are heterogenous, both in clinical manifestation and array of culprit molecular lesions. Correlations between phenotype and genotype remain poorly defined. This review examines the genetic landscape discovered to date for this rare condition. The question of a possible oligogenic model of inheritance influencing phenotypic heterogeneity is raised, with discussion of the benefits and challenges of sequencing technology used to enhance discovery in this space. Considerable work lies ahead in order to achieve diagnostic and prognostic precision and subsequently provide targeted management to this complex cohort of patients.
Collapse
Affiliation(s)
- Radha Ramanan
- Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
- Department of Pathology, Alfred Hospital, Melbourne, Victoria, Australia
| | - James D McFadyen
- Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Andrew C Perkins
- Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
- Department of Pathology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Huyen A Tran
- Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
3
|
Salah QM, AlRashayda RR, Heresh MJ, Abulehya A, Salah Al-Deen LW. Early Diagnosis and Management of Congenital Afibrinogenemia: A Case Report of Umbilical Stump Bleeding. Cureus 2023; 15:e42542. [PMID: 37637664 PMCID: PMC10460120 DOI: 10.7759/cureus.42542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2023] [Indexed: 08/29/2023] Open
Abstract
Afibrinogenemia is an extremely rare bleeding disorder characterized by the absence or severe deficiency of fibrinogen, a major protein involved in the regulation of blood clotting. This disorder can have both hemorrhagic and/or thrombotic manifestations. We present the case of a female neonate who was diagnosed with congenital afibrinogenemia within the first two weeks of life. The patient presented with persistent bleeding from the umbilical stump, prompting a thorough investigation and workup. Early diagnosis and management were essential to preventing life-threatening bleeding events.
Collapse
Affiliation(s)
- Qais M Salah
- Internal Medicine, Al-Quds University, Jerusalem, PSE
| | | | | | | | | |
Collapse
|
4
|
Abdelwahab M, de Moerloose P, Casini A. High incidence of intracranial haemorrhage in Egyptian children with congenital afibrinogenaemia. Haemophilia 2023; 29:572-577. [PMID: 36585888 DOI: 10.1111/hae.14738] [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: 10/18/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Intracerebral hemorrhage (ICH) is associated with high morbidity and mortality in patients with congenital afibrinogenaemia. Details on location of cerebral haemorrhage, management and neurological outcomes are lacking. METHODS We performed a retrospective study on Egyptian children with congenital afibrinogenaemia who experienced ICH, in order to estimate frequency, symptoms and neurological outcomes. RESULTS Among 58 children with congenital afibrinogenaemia treated on demand, 18 (31%) had an history of ICH (28 episodes). The first ICH occurred at a median age of 1 year (Q1-Q3 1-7 years). Impaired consciousness level, vomiting and seizures were the most common presenting symptoms. Spontaneous bleeding was associated with a more severe clinical presentation and worse neurological outcomes, including hydrocephaly and impaired cognitive development. Only half of ICH events (n = 14) were treated in less than 24 h from the onset of symptoms. Fibrinogen replacement by Fresh Frozen Plasma (FFP), cryoprecipitate or fibrinogen concentrates was administered in seven (25%), 19 (68%) and three (10%) ICH events, respectively. Overall, seven (25%) ICH occurring in four patients required a surgical intervention. After the ICH, six patients started secondary prophylaxis. The cumulative incidence of ICH at 10 years was 35% (95% CI 23-51) and at 20 years was 40% (95 CI% 26.7-58.8). CONCLUSION In our cohort of children with congenital afibrinogenaemia, ICH was very frequent and associated with adverse neurological outcomes and death. Further studies are required to determine whether primary prophylaxis starting early in childhood is indicated after diagnosis.
Collapse
Affiliation(s)
- Magy Abdelwahab
- Paediatric and Paediatric Haematology Department, Cairo University Paediatric Hospital, Social and Preventive medicine, Kasralainy Hospital, Cairo, Egypt
| | | | - A Casini
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of Angiology and Haemostasis, University Hospitals of Geneva, Geneva, Switzerland
| |
Collapse
|
5
|
Trossaert M, Chamouard V, Biron-Andreani C, Casini A, De Mazancourt P, De Raucourt E, Drillaud N, Frotscher B, Guillet B, Lebreton A, Roussel-Robert V, Rugeri L, Dargaud Y. Management of rare inherited bleeding disorders: Proposals of the French Reference Centre on Haemophilia and Rare Coagulation Disorders. Eur J Haematol 2023; 110:584-601. [PMID: 36748278 DOI: 10.1111/ejh.13941] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/25/2023] [Accepted: 01/31/2023] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The rare coagulation disorders may present significant difficulties in diagnosis and management. In addition, considerable inter-individual variation in bleeding phenotype is observed amongst affected individuals, making the bleeding risk difficult to assess in affected individuals. The last international recommendations on rare inherited bleeding disorders (RIBDs) were published by the United Kingdom Haemophilia Centre Doctors' Organisation in 2014. Since then, new drugs have been marketed, news studies on surgery management in patients with RIBD have been published, and new orphan diseases have been described. AIM Therefore, the two main objectives of this review, based on the recent recommendations published by the French Reference Centre on Haemophilia and Rare Bleeding Disorders, are: (i) to briefly describe RIBD (clinical presentation and diagnostic work-up) to help physicians in patient screening for the early detection of such disorders; and (ii) to focus on the current management of acute haemorrhages and long term prophylaxis, surgical interventions, and pregnancy/delivery in patients with RIBD.
Collapse
Affiliation(s)
- Marc Trossaert
- Haemophilia Treatment Centre, University Hospital of Nantes and French Reference Centre on Haemophilia, Nantes, France
| | - Valerie Chamouard
- Haemophilia Treatment Centre, University Hospital of Lyon and French Reference Centre on Haemophilia, Lyon, France
| | | | - Alessandro Casini
- Angiology and Haemostasis Division, Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Philippe De Mazancourt
- Laboratory of Biochemistry and Molecular Genetics, Hospital Ambroise Paré-GHU APHP, Université Paris-Saclay, Boulogne-Billancourt, France
| | | | - Nicolas Drillaud
- Haemophilia Treatment Centre, University Hospital of Nantes and French Reference Centre on Haemophilia, Nantes, France
| | - Birgit Frotscher
- Haemophilia Treatment Centre, University Hospital of Nancy, Nancy, France
| | - Benoit Guillet
- Haemophilia Treatment Centre, University Hospital of Rennes, Rennes, France
| | - Aurelien Lebreton
- Haemophilia Treatment Centre, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Lucia Rugeri
- Haemophilia Treatment Centre, University Hospital of Lyon and French Reference Centre on Haemophilia, Lyon, France
| | - Yesim Dargaud
- Haemophilia Treatment Centre, University Hospital of Lyon and French Reference Centre on Haemophilia, Lyon, France
| |
Collapse
|
6
|
Guven B, Can M, Tekin A. Comparison of Fibrinogen Concentrations Determined by the Clauss Method with Prothrombin-Derived Measurements on an Automated Coagulometer. J Appl Lab Med 2022; 7:1337-1345. [PMID: 35993826 PMCID: PMC9452101 DOI: 10.1093/jalm/jfac066] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/17/2022] [Indexed: 11/28/2022]
Abstract
Background This research aims to compare fibrinogen results, obtained from the Clauss and PT-derived method on the Cobas t511 analyzer, in patients with specific categories of disease. A second aim was to determine the reference range for these 2 methods. Methods We retrospectively compared fibrinogen concentrations of 914 patients obtained by the Clauss and PT-derived methods on the Cobas t511 coagulation analyzer from the laboratory information system. Fibrinogen data was segregated into a healthy outpatient population and those populations with possible fibrinogen abnormalities including pregnancy, chronic illness, liver disease, heart and vascular diseases, and clinical suspicion of COVID-19. All data were analyzed using Passing–Bablok regression and Bland–Altman analysis. Reference ranges were determined from fibrinogen results of the healthy outpatient population who presented for a clinic check-up. Results All fibrinogen results were grouped and compared according to fibrinogen values (low, normal, and high), international normalized ratio (INR) values (<1.2, 1.2–2.0, and >2.0), and diagnosis. There were statistically significant positive correlations in all groups (P < 0.05), except for low fibrinogen values (P = 0.96). Results with INR value <1.2 had the highest correlation between 2 methods. Conclusion The PT-derived method can be used alone in the Cobas t511 analyzer, especially in patients with an INR <1.2. Reported new reference ranges of the PT-derived method could help to determine and compare the clinical significance of fibrinogen methods. Further studies must be focused on the conditions in which PT-derived fibrinogen results should be directed to the Clauss test.
Collapse
Affiliation(s)
- Berrak Guven
- Department of Biochemistry, Faculty of Medicine, Zonguldak Bulent Ecevit University , Zonguldak , Turkey
| | - Murat Can
- Department of Biochemistry, Faculty of Medicine, Zonguldak Bulent Ecevit University , Zonguldak , Turkey
| | - Abdulkadir Tekin
- Department of Biochemistry, Faculty of Medicine, Zonguldak Bulent Ecevit University , Zonguldak , Turkey
| |
Collapse
|
7
|
Rauch A, Valentino LA, Mills K, Witkop ML, Santaella ME, DiMichele D, Recht M, Susen S. Big picture initiatives in bleeding disorders. Haemophilia 2022; 28 Suppl 4:53-60. [PMID: 35521733 DOI: 10.1111/hae.14532] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/22/2022] [Accepted: 02/22/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION The inherited bleeding disorders (IBD) community has witnessed significant therapeutic advances recently, yet important gaps persist, particularly for those with rare disorders and historically underserved populations. AIMS -To create a national research blueprint agenda, led by the National Hemophilia Foundation (NHF), enhancing patient-centric principles, accelerate research progress and address important gaps in care. -To review critical gaps that remain to be addressed in women with IBDs, who face specific bleeding challenges. METHODS The NHF research blueprint research agenda was defined by input from across the community, including caregivers and patients who are considered subject matter experts of their IBD, research leaders, allied health professionals and specialists, and representatives of the biopharmaceutical industry. In addition, two medical experts in the field of IBDs performed a comprehensive review to address the knowledge gaps in women with IBDs. RESULTS Two foundational principles of the NHF blueprint are: (1) it must deliver on key issues that significantly impact the lives of those affected by IBDs, and (2) the priorities defined are relevant and actionable aimed to achieve health equity among all those affected by IBDs. A multidisciplinary approach is necessary for an optimal management of puberty, transition to adulthood and pregnancy. Even if strict guidelines are followed, recent studies show that women with IBDs are still facing a high burden. CONCLUSION NHF blueprint will be issued in 2022. A specific research agenda is needed in women with IBDs to further improve their management and quality of life.
Collapse
Affiliation(s)
| | - Leonard A Valentino
- National Hemophilia Foundation, New York, New York, USA.,Rush University, Chicago, Illinois, USA
| | - Kevin Mills
- National Hemophilia Foundation, New York, New York, USA
| | | | | | | | - Michael Recht
- American Thrombosis and Hemostasis Network, Rochester, New York, USA
| | - Sophie Susen
- CHU Lille, Hematology Transfusion, LILLE, France
| |
Collapse
|
8
|
Özay M, Kara M, Keskin Z. Congenital afibrinogenemia in a newborn. SANAMED 2022. [DOI: 10.5937/sanamed0-40292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Introduction: Congenital afibrinogenemia is a rare coagulation disorder characterized by a deficiency in the fibrinogen molecule. Fibrinogen is a hexameric glycoprotein consisting of a polypeptide chain encoded by FGB, FGA, and FGG and is required for normal hemostasis. Changes in FGA, FGB, and FGG may affect fibrinogen at different levels. As a result of these changes, fibrinogen cannot be detected in the blood. Clinical manifestations of such changes range from asymptomatic to life-threatening bleeding or thromboembolic events. Since it is an autosomal recessive disease, the risk is higher in children whose parents are related. Therefore, the disease is more common in regions where consanguineous marriage rates are high. Diagnosis is made by laboratory tests that show the absence of fibrinogen. These patients need to be treated with fibrinogen replacement therapy. Case presentation: This study reports the case of a newborn with congenital afibrinogenemia. The baby born from a first-degree consanguineous marriage was referred to our hospital due to bleeding and ecchymosis, and afibrinogenemia was diagnosed after coagulation tests were performed. Blood samples of the patient and his parents were sent to the Genetic Diseases Diagnosis Center for a genetic diagnosis of afibrinogenemia. A new homozygous mutation of FGB exon 7: c.1220c > t (p.t407 m) (p.thr407 met) was identified in the patient. The patients' parents were heterozygous for the same mutation. Prophylaxis was not recommended for our patient who was asymptomatic in the follow-up. Conclusions: We present the case of a hemorrhagic neonatal patient diagnosed with congenital afibrinogenemia and emphasize that fibrinogen testing should be included in the evaluation of such patients. Furthermore, congenital fibrinogen disorders may be more severe when caused due to unknown specific mutation genes. Therefore, a more center-involved genetic analysis is required to identify undiagnosed fibrinogen and fibrinogen mutations.
Collapse
|
9
|
Abstract
Fibrinogen plays a fundamental role in coagulation through its support for platelet aggregation and its conversion to fibrin. Fibrin stabilizes clots and serves as a scaffold and immune effector before being broken down by the fibrinolytic system. Given its importance, abnormalities in fibrin(ogen) and fibrinolysis result in a variety of disorders with hemorrhagic and thrombotic manifestations. This review summarizes (i) the basic elements of fibrin(ogen) and its role in coagulation and the fibrinolytic system; (ii) the laboratory evaluation for fibrin(ogen) disorders, including the use of global fibrinolysis assays; and (iii) the management of congenital and acquired disorders of fibrinogen and fibrinolysis.
Collapse
Affiliation(s)
- Jori E May
- Division of Hematology/Oncology, University of Alabama at Birmingham, 1720 2nd Avenue South, NP 2503, Birmingham, AL 35294, USA
| | - Alisa S Wolberg
- UNC Department of Pathology and Laboratory Medicine, UNC Blood Research Center, 8018A Mary Ellen Jones Building, CB7035, Chapel Hill, NC 27599-7035, USA
| | - Ming Yeong Lim
- Department of Internal Medicine, Division of Hematology and Hematologic Malignancies, University of Utah, 2000 Circle Hope Drive, Room 4126, Salt Lake City, UT 84112, USA.
| |
Collapse
|
10
|
Shen MC, Wang JD, Tsai W, Lin CY, Lin JS, Kuo SF, Lin PT, Huang YC, Hung MH. Clinical features and genetic defect in six index patients with congenital fibrinogen disorders: Three novel mutations with one common mutation in Taiwan's population. Haemophilia 2021; 27:1022-1027. [PMID: 34460979 DOI: 10.1111/hae.14399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Congenital fibrinogen disorders (CFDs) are caused by mutations in fibrinogen-encoding genes, FGA, FGB, and FGG, which lead to quantitative or qualitative abnormalities of fibrinogen. Although the diagnosis of CFDs is based on antigenic and functional level of fibrinogen, few genotypes are clearly correlated with phenotype. METHODS In this study, we investigated all of the referred patients diagnosed as CFDs in Taiwan's population between 1995 and 2020. Clinical features, laboratory data and genetic defects were analysed. Functional fibrinogen level was determined by the Clauss method. Antigenic fibrinogen was measured by an enzyme-linked immunosorbent assay. Fibrinogen genes were assessed for mutations by polymerase chain reaction and sequencing. RESULTS A total of 18 patients from six unrelated families with CFDs were identified. One patient from a consanguineous family was diagnosed as afibrinogenemia type 1A with a novel homozygous frameshift mutation in FGB exon 4. The other five (83.3 %) index patients were all diagnosed as dysfibrinogenemia type 3A caused by two novel and one known mutation. Six (33.3 %) patients from three families had a novel mutation in FGB exon 8. The clinical features and laboratory data were highly variable among these patients with the same mutation. CONCLUSIONS Three novel mutations of CFDs causing afibrinogenemia and dysfibrinogenemia were identified. The point mutation in FGB exon 8 is also a common mutation in Taiwan's population. Considerable phenotypic variability among the patients with an identical mutation was observed.
Collapse
Affiliation(s)
- Ming-Ching Shen
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiaan-Der Wang
- Center for Rare Disease and Haemophilia, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan.,National Chung Hsing University, Taichung, Taiwan
| | - Woei Tsai
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Yeh Lin
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Jen-Shiou Lin
- Department of Laboratory Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Su-Feng Kuo
- Department of Laboratory Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Po-Te Lin
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Ying-Chih Huang
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Mei-Hua Hung
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| |
Collapse
|
11
|
Arai S, Kamijo T, Kaido T, Yoda M, Shinohara S, Suzuki T, Arai N, Sugano M, Uehara T, Okumura N. Automated screening procedure for the phenotypes of congenital fibrinogen disorders using novel parameters, |min1|c and Ac/|min1|c, obtained from clot waveform analysis using the Clauss method. Clin Chim Acta 2021; 521:170-176. [PMID: 34273336 DOI: 10.1016/j.cca.2021.07.012] [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: 06/07/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Fibrinogen activity (Ac) is widely measured, but fibrinogen antigen (Ag) is measured only in specialized laboratories, so it is difficult to discriminate congenital fibrinogen disorders (CFDs) from acquired hypofibrinogenemia (aHypo). In this study, to screen for CFD phenotypes we adopted novel parameters, |min1|c and Ac/ |min1|c, and compared these with validated Ac, Ag, and Ac/Ag, and previously proposed Ac/dH and Ac/|min1|. MATERIALS AND METHODS We calibrated |min1| using a CN-6000 instrument and investigated the correlation between Ag and |min1|c for aHypo (n = 131) and CFD [18 dysfibrinogenemia (Dys), two hypodysfibrinogenemia (Hypodys) and four hypofibrinpogenemia (Hypo)]. Furthermore, we proposed a schema for screening CFD phenotypes using |min1|c and Ac/|min1|c. RESULTS The |min1|c correlated well with Ag in aHypo, and Ac/|min1|c was a better parameter for screening Dys and Hypodys than Ac/dH and Ac/|min1|. With the combination of |min1|c and Ac/|min1|c parameters, 15 Dys, 2 Hypodys and four Hypo were categorized in agreement with the phenotype determined using Ag and Ac/Ag; conversely three Dys were classified as one Hypodys (AαR16C) and two Hypo (BβG15C). CONCLUSION We demonstrated that |min1|c and Ac/|min1|c are valuable parameters for screening CFD patients and phenotypes in laboratories that do not measure Ag or perform genetic analysis.
Collapse
Affiliation(s)
- Shinpei Arai
- Department of Clinical Laboratory Sciences, School of Health Sciences, Shinshu University, Matsumoto, Japan.
| | - Tomu Kamijo
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan; Department of Medical Sciences, Graduate School of Medicine, Science and Technology, Shinshu University, Matsumoto, Japan
| | - Takahiro Kaido
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan; Department of Medical Sciences, Graduate School of Medicine, Science and Technology, Shinshu University, Matsumoto, Japan
| | - Masahiro Yoda
- Department of Clinical Laboratory Investigation, Graduate School of Medicine, Shinshu University, Matsumoto, Japan
| | | | | | | | - Mitsutoshi Sugano
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Takeshi Uehara
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Nobuo Okumura
- Department of Clinical Laboratory Investigation, Graduate School of Medicine, Shinshu University, Matsumoto, Japan; Laboratory of Clinical Chemistry and Immunology, Department of Biomedical Laboratory Sciences, School of Health Sciences, Shinshu University, Matsumoto, Japan
| |
Collapse
|
12
|
Yan J, Wu Y, Liao L, Xiang L, Qiu Y, Lin F. The β-chain mutation p.Trp433Stop impairs fibrinogen secretion: A novel nonsense mutation associated with hypofibrinogenemia. Int J Lab Hematol 2021; 43:1549-1556. [PMID: 34185392 DOI: 10.1111/ijlh.13632] [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: 12/08/2020] [Revised: 05/12/2021] [Accepted: 05/27/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Congenital hypofibrinogenemia is characterized by proportional decreases in fibrinogen activity and immunoreactive fibrinogen levels. Here, we describe a new case with the bleeding risk identified in our hospital. METHODS The proband was cut and bled for 3 h. Coagulation testing, gene analysis, thrombelastogram, sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE), in vitro plasmid construction, and functional analyses were performed to explore the pathogenic mechanism. RESULTS Coagulation testing of the male proband revealed low levels of fibrinogen detected by two methods (the Clauss method and the PT-derived method); his two sons had normal coagulation results. DNA sequencing of the proband revealed a heterozygous point mutation in exon 8 of the FGB gene causing Trp→Stop substitution and a polymorphic site (p.Leu92Phe). Human Trp433 was found to be highly conserved. SDS-PAGE showed that the fibrinogen level of the proband was markedly lower than that of healthy controls. Using high-performance liquid chromatography-mass spectrometry, a mutated Bβ chain was not detected in circulation. In vitro expression analyses indicated that the mutation affected the secretion of fibrinogen. The TEG results indicated that the proband had a prolonged K time, a lower CI value, and a lower angle value. CONCLUSION We report a new case with a novel nonsense mutation that resulted in hypofibrinogenemia. The results indicate that the nonsense mutation may cause misfolding of the D domain, which then affects the secretion of fibrinogen.
Collapse
Affiliation(s)
- Jie Yan
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yangyang Wu
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lin Liao
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Liqun Xiang
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yuling Qiu
- Department of Thalassemia Laboratory, Guangxi Medical University, Nanning, China
| | - Faquan Lin
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| |
Collapse
|
13
|
Whole Blood Thromboelastometry by ROTEM and Thrombin Generation by Genesia According to the Genotype and Clinical Phenotype in Congenital Fibrinogen Disorders. Int J Mol Sci 2021; 22:ijms22052286. [PMID: 33668986 PMCID: PMC7956597 DOI: 10.3390/ijms22052286] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 12/13/2022] Open
Abstract
The outcome of congenital fibrinogen defects (CFD) is often unpredictable. Standard coagulation assays fail to predict the clinical phenotype. We aimed to assess the pheno- and genotypic associations of thrombin generation (TG) and ROTEM in CFD. We measured fibrinogen (Fg) activity and antigen, prothrombin fragments F1+2, and TG by ST Genesia® with both Bleed- and ThromboScreen in 22 patients. ROTEM was available for 11 patients. All patients were genotyped for fibrinogen mutations. Ten patients were diagnosed with hypofibrinogenemia, nine with dysfibrinogenemia, and three with hypodysfibrinogenemia. Among the 17 mutations, eight were affecting the Fg γ chain, four the Fg Bβ chain, and five the Fg Aα chain. No statistical difference according to the clinical phenotypes was observed among FGG and FGA mutations. Median F1+2 and TG levels were normal among the different groups. Fg levels correlated negatively with F1+2 and peak height, and positively with lag time and time to peak. The pheno- and genotypes of the patients did not associate with TG. FIBTEM by ROTEM detected hypofibrinogenemia. Our study suggests an inverse link between low fibrinogen activity levels and enhanced TG, which could modify the structure–function relationship of fibrin to support hemostasis.
Collapse
|
14
|
Marlu R, Naciri Bennani H, Seyve L, Noble J, Chevallier E, Motte L, Imerzoukene F, Bugnazet M, Christophe M, Malvezzi P, Jouve T, Rostaing L. Comparison of three modalities of plasmapheresis on coagulation: Centrifugal, single-membrane filtration, and double-filtration plasmapheresis. J Clin Apher 2021; 36:408-419. [PMID: 33506958 DOI: 10.1002/jca.21879] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Plasmapheresis can deplete pathogenic antibodies and allow ABO- and/or HLA-incompatible transplantation. AIM To determine the impacts of three modalities of plasmapheresis (centrifugal plasmapheresis [cTPE], single-filtration plasmapheresis [mTPE], double-filtration plasmapheresis [DFPP]) on hemostasis parameters and thrombin generation. MATERIALS/METHODS Prospective, comparative study on 21 patients that received three modalities of plasmapheresis (7 patients/group). Hemostasis (prothrombin time [PT], activated partial thromboplastin time [aPTT], procoagulant factors and natural anticoagulants) were measured before and after the first plasmapheresis session. Thrombin generation was also assessed in platelet-poor plasma using an STA-Genesia (Stago) analyzer and Thromboscreen reagents (Stago) in 4-5 patients from each group. RESULTS Both cTPE and mTPE resulted in high decreases in proteins, whatever their molecular weights. Median post/pre ratios were 0.27 to 0.55 for cTPE for most proteins (except FVIII [0.64] and VWF [0.57]). Median post/pre-ratios of mTPE were 0.28 to 0.56 for all proteins. DFPP decreased high-molecular-weight proteins (fibrinogen, FV, FVIII, FXI, VWF) and proteins strongly bound to large molecules (protein SandTFPI). Median post/pre ratios with cTPE and mTPE were similar to DFPP for fibrinogen and FXIII. Regarding thrombin generation, cTPE and mTPE did not significantly modify endogenous thrombin potential (ETP) and DFPP induced a slight decrease in ETP (median post/pre ratio at 0.73) in the absence of thrombomodulin. ETP inhibition by thrombomodulin was decreased for all procedures. CONCLUSIONS DFPP depleted high molecular-weight proteins in contrast to cTPE and mTPE, which significantly decreased all proteins. Regarding thrombin generation, depletion of procoagulant factors was counterbalanced by a decrease in some natural anticoagulants whatever plasmapheresis method used; with all methods, fibrinogen and FXIII were highly depleted.
Collapse
Affiliation(s)
- Raphaël Marlu
- Hemostasis Laboratory, CHU Grenoble-Alpes, Grenoble, France.,Therex, TIMC-IMAG, CNRS UMR5525, Grenoble-Alpes, Grenoble, France.,Université Grenoble Alpes, Grenoble, France
| | - Hamza Naciri Bennani
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
| | - Landry Seyve
- Hemostasis Laboratory, CHU Grenoble-Alpes, Grenoble, France
| | - Johan Noble
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
| | - Eloi Chevallier
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
| | - Lionel Motte
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
| | - Farida Imerzoukene
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
| | - Mathilde Bugnazet
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
| | | | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
| | - Thomas Jouve
- Université Grenoble Alpes, Grenoble, France.,Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
| | - Lionel Rostaing
- Université Grenoble Alpes, Grenoble, France.,Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
| |
Collapse
|
15
|
Acevedo Viales K, Valverde Muñoz K, Gutiérrez Valverde D. Congenital Hypofibrinogenemia: Presentation of a Rare Coagulation Disorder. Cureus 2020; 12:e12397. [PMID: 33532157 PMCID: PMC7845748 DOI: 10.7759/cureus.12397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Fibrinogen is a precursor of fibrin, which acts as a procoagulant plasma soluble protein. It is involved in blood viscosity and clot stability to help in the recovery of damaged blood vessels. We describe the case of a preterm newborn who presented with abdominal distension and manifestations of bleeding in venipuncture sites. In the initial laboratories, prolonged coagulation times were observed with a decreased concentration of fibrinogen. This newborn had transfusion support, with recovery in factor levels and a subsequent decrease in them. Based on this trend and ruling out other possible causes of hypofibrinogenemia, such as liver disease, sepsis, or disseminated intravascular coagulation, the diagnosis of congenital hypofibrinogenemia was made. This case report includes the diagnostic and therapeutic approach of an unusual hemorrhagic presentation in the newborn, highlighting the need for transfusion and dynamic fibrinogen replacement to prevent complications and seek rapid improvement in symptoms.
Collapse
|
16
|
Casini A, Neerman-Arbez M, de Moerloose P. Heterogeneity of congenital afibrinogenemia, from epidemiology to clinical consequences and management. Blood Rev 2020; 48:100793. [PMID: 33419567 DOI: 10.1016/j.blre.2020.100793] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 11/06/2020] [Accepted: 12/06/2020] [Indexed: 12/17/2022]
Abstract
Fibrinogen is a complex protein playing a major role in coagulation. Congenital afibrinogenemia, characterized by the complete absence of fibrinogen, is associated with major hemostatic defects. Even though the clinical course is unpredictable and can be completely different among patients, severe bleeding is the prominent symptom. Patients are also at increased risk of thrombosis and sometimes suffer from spontaneous spleen rupture, bone cysts and defective wound healing. Due to the relative rarity of afibrinogenemia, there are no evidence-based strategies for helping physicians in care of these patients. Fibrinogen supplementation is the keystone to prevent or treat bleeding events. In addition, fibrinogen, a pleiotropic protein with numerous physiological roles in immunity, angiogenesis and tissue repair, is involved in many diseases. Indeed, depletion of fibrinogen in animal models of infections, tumors and neurological diseases has an effect on the clinical course. The consequences for patients with afibrinogenemia still need to be investigated.
Collapse
Affiliation(s)
- Alessandro Casini
- Division of Angiology and Hemostasis, University Hospitals of Geneva, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland.
| | - Marguerite Neerman-Arbez
- Department of Genetic Medicine and Development, Faculty of Medicine, University of Geneva, 1 Rue Michel Servet, 1211 Geneva, Switzerland.
| | - Philippe de Moerloose
- Faculty of Medicine, University of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland.
| |
Collapse
|
17
|
Zdziarska J, Wypasek E, Iwaniec T, Vilar R, Neerman-Arbez M, Undas A. Afibrinogenemia caused by a novel homozygous missense mutation, FGB p.Cys241Tyr, in a male patient with recurrent intracranial bleeding: case report and review of literature. Haemophilia 2020; 27:26-32. [PMID: 33245842 DOI: 10.1111/hae.14211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 10/27/2020] [Accepted: 11/03/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Congenital afibrinogenemia is a severe bleeding disorder, sometimes manifesting as thrombosis and/or pregnancy complications. Intracranial haemorrhage (ICH) constitutes the major cause of death in this disease. METHODS We present the case of a male patient with congenital afibrinogenemia, who presented with recurrent intracranial hemorrhages, despite prophylactic fibrinogen substitution. We also review the literature for the risk of intracranial hemorrhages in afibrinogenemia. RESULT Molecular analysis revealed a novel homozygous missense mutation in FGB exon 5, p.Cys241 Tyr, that was named "Fibrinogen Krakow V". DISCUSSION AND CONCLUSION Intracranial hemorrhage is a severe manifestation of afibrinogenemia, also in children. The clinical presentation of afibrinogenemia is variable. Fibrinogen substitution carries a risk of thrombotic complications.
Collapse
Affiliation(s)
- Joanna Zdziarska
- Hematology Department, Hematology Clinic, Jagiellonian University Medical College, University Hospital in Krakow, Kraków, Poland
| | - Ewa Wypasek
- Faculty of Medicine and Health Sciences, Krakow Specialist Hospital named after John Paul II, Andrzej Frycz Modrzewski Krakow University, Kraków, Poland
| | - Teresa Iwaniec
- Hematology Department, Hematology Clinic, Jagiellonian University Medical College, University Hospital in Krakow, Kraków, Poland
| | - Rui Vilar
- Department of Genetic Medicine and Development, University Medical School of Geneva, Geneva, Switzerland
| | - Marguerite Neerman-Arbez
- Department of Genetic Medicine and Development, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Anetta Undas
- Krakow Specialist Hospital named after John Paul II, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| |
Collapse
|
18
|
Marlu R, Bennani HN, Seyve L, Malvezzi P, Janbon B, Noble J, Christophe M, Motte L, Imerzoukene F, Chevallier E, Rostaing L, Jouve T. Effect of immunoadsorption alone or combined with membrane filtration on hemostasis parameters. J Clin Apher 2020; 35:444-452. [DOI: 10.1002/jca.21825] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Raphaël Marlu
- Haemostasis Laboratory, CHU Grenoble France
- Therex, TIMC‐IMAG, CNRS UMR5525 Grenoble France
- de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale CHU Grenoble France
| | - Hamza Naciri Bennani
- de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale CHU Grenoble France
| | | | - Paolo Malvezzi
- de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale CHU Grenoble France
| | - Bénédicte Janbon
- de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale CHU Grenoble France
| | - Johan Noble
- de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale CHU Grenoble France
| | | | - Lionel Motte
- de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale CHU Grenoble France
| | - Farida Imerzoukene
- de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale CHU Grenoble France
| | - Eloi Chevallier
- de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale CHU Grenoble France
| | - Lionel Rostaing
- de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale CHU Grenoble France
- Université Grenoble Alpes Grenoble France
| | - Thomas Jouve
- de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale CHU Grenoble France
- Université Grenoble Alpes Grenoble France
| |
Collapse
|
19
|
Saes JL, Laros‐van Gorkom BAP, Coppens M, Schols SEM. Pregnancy outcome in afibrinogenemia: Are we giving enough fibrinogen concentrate? A case series. Res Pract Thromb Haemost 2020; 4:343-346. [PMID: 32110766 PMCID: PMC7040545 DOI: 10.1002/rth2.12300] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 12/04/2019] [Accepted: 12/05/2019] [Indexed: 12/17/2022] Open
Abstract
Congenital afibrinogenemia is a rare autosomal recessive disorder associated with an increased risk of hemorrhage, thrombosis, and obstetric complications. This case series of 4 pregnancies in 2 related patients seeks to address the key clinical question of the necessary doses of fibrinogen concentrate during pregnancy and puerperium. One pregnancy without the prophylactic use of fibrinogen concentrate resulted in spontaneous abortion. The second pregnancy was complicated by a subchorionic hematoma despite the prophylactic administration of fibrinogen concentrate to maintain the plasma trough levels at ≥0.6 g/L. Labor was complicated by postpartum hemorrhage with a blood loss volume of 1480 cc. Two weeks later, the patient presented with postpartum thrombosis. The other 2 pregnancies were uncomplicated with fibrinogen trough levels ≥1.0 g/L during pregnancy and ≥1.5 g/L during labor. These cases illustrate that during pregnancy, patients may benefit from fibrinogen trough levels ≥1.0 g/L. In addition, the increased risk of postpartum thrombosis with prolonged fibrinogen supplementation warrants personalized postpartum advice that is guided by postpartum blood loss.
Collapse
Affiliation(s)
- Joline L. Saes
- Department of HematologyRadboud Universisty Medical CenterNijmegenThe Netherlands
- Hemophilia Treatment Center NijmegenEindhovenThe Netherlands
| | - Britta A. P. Laros‐van Gorkom
- Department of HematologyRadboud Universisty Medical CenterNijmegenThe Netherlands
- Hemophilia Treatment Center NijmegenEindhovenThe Netherlands
| | - Michiel Coppens
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam University Medical CentersUniversity of AmsterdamAmsterdamThe Netherlands
| | - Saskia E. M. Schols
- Department of HematologyRadboud Universisty Medical CenterNijmegenThe Netherlands
- Hemophilia Treatment Center NijmegenEindhovenThe Netherlands
| |
Collapse
|
20
|
Simurda T, Casini A, Stasko J, Hudecek J, Skornova I, Vilar R, Neerman-Arbez M, Kubisz P. Perioperative management of a severe congenital hypofibrinogenemia with thrombotic phenotype. Thromb Res 2020; 188:1-4. [PMID: 32018167 DOI: 10.1016/j.thromres.2020.01.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 12/11/2019] [Accepted: 01/24/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Tomas Simurda
- National Centre of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, University Hospital Martin, Martin, Slovakia.
| | - Alessandro Casini
- Division of Angiology and Hemostasis, University Hospitals of Geneva, Faculty of Medicine, Geneva, Switzerland
| | - Jan Stasko
- National Centre of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, University Hospital Martin, Martin, Slovakia
| | - Jan Hudecek
- National Centre of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, University Hospital Martin, Martin, Slovakia
| | - Ingrid Skornova
- National Centre of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, University Hospital Martin, Martin, Slovakia
| | - Rui Vilar
- Department of Genetic Medicine and Development, University Medical School of Geneva, Geneva, Switzerland
| | - Marguerite Neerman-Arbez
- Department of Genetic Medicine and Development, University Medical School of Geneva, Geneva, Switzerland
| | - Peter Kubisz
- National Centre of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, University Hospital Martin, Martin, Slovakia
| |
Collapse
|
21
|
Simeonova-Krstevska S, Todorovska E, Makarovska-Bojadjieva T, Petković E, Stojčevski S, Samardžiski I, Spasovski S, Dejanova V, Grubović R, Raka F, Jovanovska V, Todorovska I, Livrinova V, Sima A, Jovčevski S, Milkovski D. Multidisciplinary approach to management of hypofibrinogenaemia in pregnancy: A case report. SCRIPTA MEDICA 2020. [DOI: 10.5937/scriptamed51-26499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
|
22
|
Casini A, Moerloose P. Fibrinogen concentrates in hereditary fibrinogen disorders: Past, present and future. Haemophilia 2019; 26:25-32. [DOI: 10.1111/hae.13876] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/22/2019] [Accepted: 10/22/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Alessandro Casini
- Division of Angiology and Hemostasis Faculty of Medicine Geneva University Hospitals Geneva Switzerland
| | | |
Collapse
|
23
|
“The Other Side of the Coin”: Hemorrhagic Stroke in Congenital Hypofibrinogenemia. Can J Neurol Sci 2019; 46:635-636. [DOI: 10.1017/cjn.2019.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
24
|
Phenotypic and genetic analysis of hypofibrinogenemia because of a novel missense mutation in the FGB: Leu121Arg. Blood Coagul Fibrinolysis 2019; 30:233-238. [PMID: 31259773 DOI: 10.1097/mbc.0000000000000827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
: In this study, we found a novel missense gene mutation of fibrinogen (FIB) and it will help us to understand the pathogenesis of this type of disease. The FIB activity (FIB:C) and FIB antigen (FIB:Ag) were detected using matched commercially available kits. To identify the novel missense mutation, the fibrinogen gene sequencing was carried out. Bioinformatics and model analysis were used to study the harm of the mutation. The FIB:C and FIB:Ag of the proband were 0.82 and 1.19 g/l, respectively. Sequencing analysis detected a heterozygous c.425T>G in exon three of FGB gene resulting in p.Leu121Arg. The Leu121Arg mutation was responsible for the decrease of FIB:C, and it was the first report of such a mutation in the world.
Collapse
|
25
|
Qiao J, Chen Y, Dong C, Li J. Clinical significance of galectin-3 expression in malformed hepatic venous tissue. Indian J Med Res 2019; 148:728-733. [PMID: 30778007 PMCID: PMC6396557 DOI: 10.4103/ijmr.ijmr_500_17] [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
Background & objectives: Hepatic venous malformation gradually develops over time and exhibits the malignant biological behaviours of being locally invasive, causing morphological and functional damage to local tissue, and may even cause systemic coagulopathy. Studies show that galectin-3(Gal-3) expression is closely associated with local invasion of malignant tumours. In this study an attempt was made to assess the clinical significance of Gal-3 in local invasion during hepatic venous malformation in patients. Methods: Gal-3 protein and its mRNA expression were examined using immunohistochemistry and in situ hybridization in a total of 126 patients with hepatic venous malformation. For control tissue, 20 cases of normal tissue distal to surgical margins were also examined. In addition, the association between Gal-3 expression and pathological parameters was analyzed in hepatic venous malformation patients. Results: Gal-3 mRNA positivity was observed in 65.08 per cent (82/126) of hepatic venous malformation tissue samples, which was higher than the rate of 20 per cent (4/20) (P<0.05) seen in control tissues. Gal-3 protein positivity was observed in 58.73 per cent (74/126) of hepatic venous malformation tissue samples, which was higher than the rate of 15 per cent (3/20) (P<0.05) seen in the normal tissue. Gal-3 expression was not significantly associated with age or gender. However, there was a significant association between Gal-3 positivity and lesion size, local invasion depth, and involvement with the hepatic vein and the portal system. Interpretation & conclusions: Local tissue invasion and destruction by hepatic venous malformation may be related to the upregulation of Gal-3. Gal-3 expression and the development of venous malformation may be related and needs to be studied further.
Collapse
Affiliation(s)
- Junbo Qiao
- Department of Hemangioma Surgery, The Third Affiliated Hospital of Zhengzhou University, Henan Provincial People's Hospital, Zhengzhou, Henan, PR China
| | - Yongwei Chen
- Department of Hepatobiliary Surgery, Liberation Army General 301 Hospital, Beijing, PR China
| | - Changxian Dong
- Department of Hemangioma Surgery, The Third Affiliated Hospital of Zhengzhou University, Henan Provincial People's Hospital, Zhengzhou, Henan, PR China
| | - Jin Li
- Department of Ophthalmology, Henan Eye Institute & Henan Provincial Eye Hospital, Zhengzhou, Henan, PR China
| |
Collapse
|
26
|
Abstract
To investigate the obstetrical outcomes and plasma concentrations of fibrinogen (FIB) in patients with congenital hypofibrinogenemia in pregnancy, 11 cases with hypofibrinogenemia in pregnancy were analyzed retrospectively. The demographic database, bleeding tendency, plasma levels of FIB throughout pregnancy, peripartum management, as well as, maternal and neonatal outcomes were assessed. FIB levels in our patients remained relatively stable throughout the pregnancy. The mean FIB levels during the three trimesters of pregnancy were 75.7 ± 43.9 (25–148), 67.6 ± 33.7 (22–146), and 77.9 ± 29.2 (32–148) mg/dl, respectively. Twelve full-term deliveries were achieved using FIB replacement therapy only on the group of labor or cesarean deliveries. The postpartum courses were unremarkable without hemorrhagic or thrombotic complications. Five out of twelve neonates were diagnosed with low levels of FIB in 6 weeks after birth. The pregnancies were uneventful with no signs of bleeding in these congenital hypofibrinogenemia women. Vaginal delivery, instead of cesarean section, may be the superior choice. Successful maternal and neonatal outcomes could be achieved by accurate monitoring of the FIB levels and adequate supportive therapy.
Collapse
|
27
|
Marlu R, Malvezzi P, Seyve L, Jouve T, Maurizi J, Defendi F, Carron P, Christophe M, Le Gouellec A, Polack B, Rostaing L. Effect of double-filtration plasmapheresis for antibody-mediated rejection on hemostasis parameters and thrombin generation. Thromb Res 2018; 166:113-121. [DOI: 10.1016/j.thromres.2018.04.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 03/31/2018] [Accepted: 04/16/2018] [Indexed: 12/11/2022]
|
28
|
Tiscia GL, Margaglione M. Human Fibrinogen: Molecular and Genetic Aspects of Congenital Disorders. Int J Mol Sci 2018; 19:ijms19061597. [PMID: 29844251 PMCID: PMC6032319 DOI: 10.3390/ijms19061597] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 05/23/2018] [Accepted: 05/25/2018] [Indexed: 12/19/2022] Open
Abstract
Congenital fibrinogen disorders can be quantitative (afibrinogenemia, hypofibrinogenemia) or functional (dysfibrinognemia). To date, several genetic variants have been identified in individuals with fibrinogen disorders. The complexity of the fibrinogen molecules, formed by three non-identical chains and with a trinodal organization, renders the identification of molecular causes and of clinical and biochemical phenotypes very challenging. However, the acknowledgement of the type of molecular defect is crucial for a safer therapy, which is going to improve the clinical management of these patients. In this review, some aspects concerning molecular and clinical findings available on congenital fibrinogen disorders will be discussed.
Collapse
Affiliation(s)
- Giovanni Luca Tiscia
- Atherosclerosis and Thrombosis Unit, I.R.C.C.S. "Casa Sollievo della Sofferenza", 71013 San Giovanni Rotondo, Italy.
| | - Maurizio Margaglione
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, 71122 Foggia, Italy.
| |
Collapse
|
29
|
Le Quellec S, Desjonqueres A, Rugeri L, Desmurs Clavel H, Farhat F, Mechtouff L, Dargaud Y. Combined life-threatening thromboses and hemorrhages in a patient with afibrinogenemia and antithrombin deficiency. Thromb J 2018; 16:6. [PMID: 29636644 PMCID: PMC5883424 DOI: 10.1186/s12959-018-0162-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 01/04/2018] [Indexed: 11/10/2022] Open
Abstract
Background Patients with congenital afibrinogenemia suffer from spontaneous recurrent severe bleeding. While fibrinogen concentrates are known to effectively treat bleeding episodes, thrombotic complications often occur upon replacement therapy, rendering clinical management highly challenging. Case Presentation We hereby report a case of combined afibrinogenemia and congenital antithrombin deficiency manifested by recurrent life-threatening bleeding, as well as spontaneous severe arterial occlusion, such as acute coronary syndrome and stroke, and venous thromboses like pulmonary embolism. Secondary fibrinogen prophylaxis is recommended following any initial life-threatening bleeding episode in patients with afibrinogenemia, yet the high associated risk of thrombosis illustrates the complexity of choosing the most effective prophylaxis strategy combining fibrinogen concentrate with antithrombotic agent for optimal protection against the risk of both severe bleeding and thrombosis. For our patient, the thrombin generation assay objectively confirmed her prothrombotic tendency. Conclusion This case may help us better understand the pathophysiology of arterial thrombosis in afibrinogenemia, while highlighting the difficulty of managing such complications.
Collapse
Affiliation(s)
- S Le Quellec
- 1Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, 28, avenue Doyen J. Lepine, Bron, F-69500 Lyon, France
| | - A Desjonqueres
- 1Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, 28, avenue Doyen J. Lepine, Bron, F-69500 Lyon, France
| | - L Rugeri
- 1Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, 28, avenue Doyen J. Lepine, Bron, F-69500 Lyon, France
| | - H Desmurs Clavel
- 2Service de Médecine Interne, Hôpital Edouard Herriot, Lyon, France
| | - F Farhat
- 3Service de Chirurgie Cardiaque, Hôpital Cardiologique Louis Pradel, Lyon, France
| | - L Mechtouff
- Service Neuro-Vasculaire, Hôpital Neurologique Wertheimer, Lyon, France
| | - Y Dargaud
- 1Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, 28, avenue Doyen J. Lepine, Bron, F-69500 Lyon, France
| |
Collapse
|
30
|
Simurda T, Zolkova J, Snahnicanova Z, Loderer D, Skornova I, Sokol J, Hudecek J, Stasko J, Lasabova Z, Kubisz P. Identification of Two Novel Fibrinogen Bβ Chain Mutations in Two Slovak Families with Quantitative Fibrinogen Disorders. Int J Mol Sci 2017; 19:ijms19010100. [PMID: 29286337 PMCID: PMC5796050 DOI: 10.3390/ijms19010100] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 12/21/2017] [Accepted: 12/23/2017] [Indexed: 12/19/2022] Open
Abstract
Congenital fibrinogen disorders are caused by mutations in one of the three fibrinogen genes that affect the synthesis, assembly, intracellular processing, stability or secretion of fibrinogen. Functional studies of mutant Bβ-chains revealed the importance of individual residues as well as three-dimensional structures for fibrinogen assembly and secretion. This study describes two novel homozygous fibrinogen Bβ chain mutations in two Slovak families with afibrinogenemia and hypofibrinogenemia. Peripheral blood samples were collected from all subjects with the aim of identifying the causative mutation. Coagulation-related tests and rotational thromboelastometry were performed. All exons and exon–intron boundaries of the fibrinogen genes (FGA, FGB and FGG) were amplified by PCR followed by direct sequencing. Sequence analysis of the three fibrinogen genes allowed us to identify two novel homozygous mutations in the FGB gene. A novel Bβ chain truncation (BβGln180Stop) was detected in a 28-year-old afibrinogenemic man with bleeding episodes including repeated haemorrhaging into muscles, joints, and soft tissues, and mucocutaneous bleeding and a novel Bβ missense mutation (BβTyr368His) was found in a 62-year-old hypofibrinogenemic man with recurrent deep and superficial venous thromboses of the lower extremities. The novel missense mutation was confirmed by molecular modelling. Both studying the molecular anomalies and the modelling of fibrinogenic mutants help us to understand the extremely complex machinery of fibrinogen biosynthesis and finally better assess its correlation with the patient’s clinical course.
Collapse
Affiliation(s)
- Tomas Simurda
- National Centre of Haemostasis and Thrombosis, Department of Haematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine and University Hospital in Martin, Kollarova Str. N. 2, Martin 036 59, Slovakia.
| | - Jana Zolkova
- National Centre of Haemostasis and Thrombosis, Department of Haematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine and University Hospital in Martin, Kollarova Str. N. 2, Martin 036 59, Slovakia.
| | - Zuzana Snahnicanova
- Department of Molecular Biology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, BioMed Martin Mala Hora 4, Martin 036 01, Slovakia.
| | - Dusan Loderer
- Department of Molecular Biology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, BioMed Martin Mala Hora 4, Martin 036 01, Slovakia.
| | - Ingrid Skornova
- National Centre of Haemostasis and Thrombosis, Department of Haematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine and University Hospital in Martin, Kollarova Str. N. 2, Martin 036 59, Slovakia.
| | - Juraj Sokol
- National Centre of Haemostasis and Thrombosis, Department of Haematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine and University Hospital in Martin, Kollarova Str. N. 2, Martin 036 59, Slovakia.
| | - Jan Hudecek
- National Centre of Haemostasis and Thrombosis, Department of Haematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine and University Hospital in Martin, Kollarova Str. N. 2, Martin 036 59, Slovakia.
| | - Jan Stasko
- National Centre of Haemostasis and Thrombosis, Department of Haematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine and University Hospital in Martin, Kollarova Str. N. 2, Martin 036 59, Slovakia.
| | - Zora Lasabova
- Department of Molecular Biology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, BioMed Martin Mala Hora 4, Martin 036 01, Slovakia.
| | - Peter Kubisz
- National Centre of Haemostasis and Thrombosis, Department of Haematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine and University Hospital in Martin, Kollarova Str. N. 2, Martin 036 59, Slovakia.
| |
Collapse
|
31
|
Zhou J, Zhu P, Zhang X. A Chinese family with congenital Dysfibrinogenemia carries a heterozygous missense mutation in FGA: Concerning the genetic abnormality and clinical treatment. Pak J Med Sci 2017; 33:968-972. [PMID: 29067075 PMCID: PMC5648974 DOI: 10.12669/pjms.334.12828] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objectives: Congenital dysfibrinogenemia is a rare hereditary disease characterized by normal antigen level but lower function level of fibrinogen. Patients with congenital dysfibrinogenemia usually present as bleeding and/or thrombotic events. In this study, we explored the genetic abnormality and clinical treatment of a Chinese family with dysfibrinogenemia. Methods: This study was conducted in Jan 2015 to Jan 2016 in the Second Medical College (Shenzhen People’s Hospital, Jinan University, Shenzhen, Guangdong Province, P.R. China. Coagulation function test were used to screen patients in this family. For all family members, DNA from peripheral blood was isolated. Whole-genome exon sequencing was carried out to screen possible mutations. And sanger sequencing was employed to further confirm the mutation in patients. Results: The proband is a woman who had anemia and increased menstruation. Hypofibrinogenemia was found after admission. However, a pulmonary embolism occurred after the fibrinogen replacement treatment. Whole exon sequencing was conducted afterward. A candidate mutation in FGA gene (c.103C>A) was identified and validated in the woman and in two siblings. Conclusion: From this case, we learned that1) point mutation of c.103C>A is the pathogenesis for congenital dysfibrinogemia in this family; 2) thromboprophylaxis should always be in consideration when fibrinogen replacement is conducted. Prospective studies are needed to determine the best fibrinogen replacement strategy in order to achieve adequate hemostasis while minimize risk of thrombosis.
Collapse
Affiliation(s)
- Jihao Zhou
- Jihao Zhou, M.D. Department of Hematology, The Second Medical College (Shenzhen People's Hospital), Jinan University, Shenzhen, Guangdong Province, P.R. China
| | - Peng Zhu
- Peng Zhu, M.D. Key Laboratory, The Second Medical College (Shenzhen People's Hospital), Jinan University, Shenzhen, Guangdong Province, P.R. China
| | - Xinyou Zhang
- Xinyou Zhang, M.D. Department of Hematology, The Second Medical College (Shenzhen People's Hospital), Jinan University, Shenzhen, Guangdong Province, P.R. China
| |
Collapse
|
32
|
Londero A, Hall DA. Call for an Evidence-Based Consensus on Outcome Reporting in Tinnitus Intervention Studies. Front Med (Lausanne) 2017; 4:42. [PMID: 28484698 PMCID: PMC5399023 DOI: 10.3389/fmed.2017.00042] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 03/27/2017] [Indexed: 01/08/2023] Open
Affiliation(s)
- Alain Londero
- Service ORL et CCF, Hôpital Européen G. Pompidou, Paris, France
| | - Deborah A Hall
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK.,Otology and Hearing Group, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
| |
Collapse
|
33
|
Casini A, Vilar R, Beauverd Y, Aslan D, Devreese K, Mondelaers V, Alberio L, Gubert C, de Moerloose P, Neerman-Arbez M. Protein modelling to understandFGBmutations leading to congenital hypofibrinogenaemia. Haemophilia 2017; 23:583-589. [DOI: 10.1111/hae.13190] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2017] [Indexed: 12/17/2022]
Affiliation(s)
- A. Casini
- Division of Angiology and Haemostasis; Faculty of Medicine; Geneva University Hospitals; Geneva Switzerland
| | - R. Vilar
- Department of Genetic Medicine and Development; University Medical School of Geneva; Geneva Switzerland
| | - Y. Beauverd
- Haematology Division; Faculty of Medicine; Geneva University Hospitals; Geneva Switzerland
| | - D. Aslan
- Pediatric Hematology Unit; Faculty of Medicine; Gazi University; Ankara Turkey
| | - K. Devreese
- Coagulation Laboratory; Ghent University Hospital; Ghent Belgium
| | - V. Mondelaers
- Department of Pediatric Hemato-oncology and Stem Cell Transplantation; Ghent University Hospital; Ghent Belgium
| | - L. Alberio
- Service et Laboratoire central d'Hématologie; Centre Hospitalier Universitaire Vaudois; Lausanne Switzerland
| | - C. Gubert
- Department of Genetic Medicine and Development; University Medical School of Geneva; Geneva Switzerland
| | - P. de Moerloose
- Division of Angiology and Haemostasis; Faculty of Medicine; Geneva University Hospitals; Geneva Switzerland
| | - M. Neerman-Arbez
- Department of Genetic Medicine and Development; University Medical School of Geneva; Geneva Switzerland
| |
Collapse
|