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Gualtierotti R, Giachi A, Truma A, Arcudi S, Ciavarella A, Bucciarelli P, Consonni D, Boccalandro E, Begnozzi V, Solimeno LP, Siboni SM, Peyvandi F. Assessing joint health in haemophilia patients: The combined value of physical examination and ultrasound imaging. Haemophilia 2024; 30:1018-1024. [PMID: 38717319 DOI: 10.1111/hae.15030] [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: 10/02/2023] [Revised: 04/12/2024] [Accepted: 04/16/2024] [Indexed: 07/18/2024]
Abstract
INTRODUCTION Early diagnosis of joint damage is pivotal in haemophilia to prevent the occurrence and progression of haemophilic arthropathy thus providing optimal personalised management. The haemophilia joint health score version 2.1 (HJHS) is based on a physical examination of the mainly affected joints. Musculoskeletal ultrasound has demonstrated the capability to detect early changes in terms of synovitis and osteochondral damage. The haemophilia early detection with ultrasound (HEAD-US) score has been proposed as a simple and reliable evaluation tool. AIM This study aims to investigate the correlation between the HJHS and the HEAD-US scores performed by two independent operators (physical therapist and musculoskeletal ultrasound expert) for the evaluation of the joint health status of patients with haemophilia. METHODS Consecutive adult patients independent of the severity degree were included. Elbows, knees and ankles were evaluated by a physical therapist by HJHS and by a musculoskeletal ultrasound expert following the HEAD-US protocol. RESULTS We observed a good positive correlation between HJHS and HEAD-US (Spearman's rho 0.72). The main discrepancy in conceptually similar domains was found between the HJHS swelling and the HEAD-US synovitis (rho 0.17), as ultrasound was able to detect even mild synovitis when HJHS swelling was scored 0 in up to 40% of cases. CONCLUSIONS The HJHS and HEAD-US correlate well even when performed by two independent operators. Musculoskeletal ultrasound is particularly useful for the early detection of synovitis. The routine assessment of both scores helps clinicians define the stage and extension of joint involvement and set up a personalised treatment.
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Affiliation(s)
- Roberta Gualtierotti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Andrea Giachi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Addolorata Truma
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Sara Arcudi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Alessandro Ciavarella
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
| | - Paolo Bucciarelli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Dario Consonni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Epidemiology Unit, Milan, Italy
| | - Elena Boccalandro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Valentina Begnozzi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Luigi Piero Solimeno
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Orthopaedic Surgery and Traumatology, Milan, Italy
| | - Simona Maria Siboni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Bakeer N, Saied W, Gavrilovski A, Bailey C. Haemophilic arthropathy: Diagnosis, management, and aging patient considerations. Haemophilia 2024; 30 Suppl 3:120-127. [PMID: 38578694 DOI: 10.1111/hae.15004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/13/2024] [Accepted: 03/14/2024] [Indexed: 04/07/2024]
Abstract
Gene therapy and universal use of safer, more effective, and personalised prophylactic regimens (factor, and nonfactor) are expected to prevent joint bleeding and promote joint health in persons with haemophilia (PwH). Growing evidence suggests that subclinical bleeding, with active and inactive synovial proliferation, continues and haemophilic arthropathy remains a major morbidity in PwH despite early institution of joint prophylaxis. Joint health assessment is evolving with physical examination scores complementing imaging scores. Point-of-care ultrasound is emerging as a safe, cost-effective, and readily available tool for acute determination of musculoskeletal abnormalities, serial evaluation of joints for sonographic markers of haemophilic arthropathy, and in providing objective insight into the efficacy of new therapies. In acute haemarthrosis, arthrocentesis expedites recovery and prevent the vicious cycle of bleed-synovitis-rebleed. When synovial proliferation develops, a multidisciplinary team approach is critical with haematology, orthopaedics, and physiotherapy involvement. Synovectomy is considered for patients with chronic synovitis that fail conservative management. Non-surgical and minimally invasive procedures should always be offered and considered first. Careful patient selection, screening and early intervention increase the success of these interventions in reducing bleeding, pain, and improving joint function and quality of life. Chemical synovectomy is practical in developing countries, but radioactive synovectomy appears to be more effective. When surgical synovectomy is considered, arthroscopic/minimally invasive approach should be attempted first. In advanced haemophilic arthropathy, joint replacement and arthrodesis can be considered. While excited about the future of haemophilia management, navigating musculoskeletal challenges in the aging haemophilia population is equally important.
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Affiliation(s)
- Nihal Bakeer
- Indiana Haemophilia and Thrombosis Centre, Indianapolis, Indiana, USA
- Children's Hospital of Philadelphia, Pennsylvania, USA
| | - Walid Saied
- Department of Paediatric Orthopaedic Surgery, Children's Hospital "Bechir HAMZA", Medical School of Tunis, University Tunis-El Manar, Tunis, Tunisia
| | - Antonio Gavrilovski
- University Clinic for Orthopaedic Surgery-TOARILUC, Clinical Centre Mother Theresa Skopje, Skopje, North Macedonia
| | - Cindy Bailey
- Orthopaedic Haemophilia Treatment Centre at Orthopaedic Institute for Children Los Angeles, Los Angeles, California, USA
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Bladen M, Harbidge H, Drechsler W, Duport G, Mahaffey R, van der Net J, Pérez-Alenda S, Sayers F, Strike K, Timmer M, Stephensen D. Identifying performance-based outcome measures of physical function in people with haemophilia (IPOP). Haemophilia 2023; 29:1611-1620. [PMID: 37840142 DOI: 10.1111/hae.14886] [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: 07/10/2023] [Revised: 10/03/2023] [Accepted: 10/03/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Recent recommendations of core outcome sets for haemophilia highlight the need for including measures of performance-based physical health and physical function sustainability. To date, there is no consensus on what outcomes might be of value to clinicians and patients. AIM To identify instruments of performance-based physical function to monitor musculoskeletal health in people with haemophilia that are practical in the clinical setting. METHODS Utilising components from the Activities and Participation Category of the WHO International Classification of Functioning (WHO-ICF), a consensus-based, decision analysis approach was used to: identify activities people with haemophilia have most difficulty performing; identify quantitative performance-based measures of identified activities via a scoping review; and obtain views on acceptability of the tests utilising a DELPHI approach. RESULTS Eleven activities were identified: maintaining a standing position, walking long distances, walking up and down stairs, walking on different surfaces, running, hopping, jumping, squatting, kneeling, undertaking a complex lower limb task, undertaking a complex upper limb task. Following a 2-round DELPHI survey of international physiotherapists, the 6-min walk test, timed up and down stairs, 30-s sit to stand, single leg stance, tandem stance, single hop for distance (children only) and timed up and go (adults only) reached consensus. CONCLUSION This study is the first step in defining a core set of performance-based instruments to monitor physical health and sustainability of physical function outcomes in people with haemophilia. Establishing the psychometric properties of the instruments and whether they are meaningful to people with haemophilia is essential.
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Affiliation(s)
- Melanie Bladen
- Haemophilia Centre, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Hannah Harbidge
- Haemophilia Centre, East Kent Hospitals University NHS Trust, Canterbury, UK
| | - Wendy Drechsler
- Haemophilia Centre, East Kent Hospitals University NHS Trust, Canterbury, UK
| | | | - Ryan Mahaffey
- St Mary's University, School of Sport, Health and Applied Sciences, London, UK
| | - Janjap van der Net
- Center for Child Development, Exercise and physical literacy, UMC Utrecht, Utrecht, Netherlands
| | | | | | - Karen Strike
- Hamilton Niagara Regional Hemophilia Centre, McMaster Children's Hospital, McMaster University, Hamilton, Canada
| | - Merel Timmer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - David Stephensen
- Haemophilia Centre, East Kent Hospitals University NHS Trust, Canterbury, UK
- Royal London Hospital Haemophilia Centre, Barts Health NHS Trust, London, UK
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Li Y, Wang F, Pan C, Zhang J, Zhang Q, Ban L, Song L, Wang J, He Z, Zeng X, Tang D, Liu Y. Comparison of joint status using ultrasound assessments and Haemophilia Joint Health Score 2.1 in children with haemophilia. Front Med (Lausanne) 2023; 10:1193830. [PMID: 37534313 PMCID: PMC10390768 DOI: 10.3389/fmed.2023.1193830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 07/04/2023] [Indexed: 08/04/2023] Open
Abstract
Introduction Ultrasound (US) has gained popularity in the evaluation of haemophilic joint diseases because it enables the imaging of soft-tissue lesions in the joints and bone-cartilage lesions. We aimed to determine the correlation between US evaluations and clinical assessments performed using HJHS 2.1 and to evaluate their respective characteristics in assessing early haemophilic arthropathy. Methods A total of 178 joints (32 knees, 85 elbows, and 61 ankles) in 45 haemophilia A patients (median age, 10 years; range, 6-15) were assessed using US and HJHS 2.1. Ultrasonographic scoring was performed in consensus assessments by one imager by using the US scores. Results The total HJHS 2.1 and US scores showed a strong correlation (rS=0.651, P=0.000, CI: 0.553-0.763), with an excellent correlation for the elbows (rS=0.867, P=0.000, CI: 0.709-0.941) and a substantial correlation for the knees (rS=0.681, P=0.000, CI: 0.527-0.797). The correlation for the ankles was relatively moderate (rS=0.518, P=0.000, CI: 0.308-0.705). Nine subjects (15.5%) without abnormalities, as indicated by HJHS 2.1, showed haemophilic arthropathy in US scoring. All nine joints showed moderate (1/9) to severe (8/9) synovial thickening in the ankle (5/9) and elbow joints (4/9). In contrast, 50 joints (50.5%) showed normal US scores and abnormal changes as indicated by HJHS 2.1. S scores correlated well with HJHS 2.1 for overall and individual joints. Discussion US could identify some early pathological changes in joints showing normal clinical findings, but still cannot replace the HJHS; however, it can serve as an imaging examination complementing HJHS 2.
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Affiliation(s)
- Yanju Li
- Department of Hematology Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Feiqing Wang
- Clinical Medical Research Center, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin City, China
| | - Chengyun Pan
- Department of Hematology Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Jing Zhang
- Department of Hematology Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Qian Zhang
- Department of Hematology Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Lingying Ban
- Department of Hematology Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Lingling Song
- Department of Hematology Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Jishi Wang
- Department of Hematology Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Zhixu He
- Key Laboratory of Adult Stem Cell Translational Research, Chinese Academy of Medical Sciences, Guizhou Medical University, Guiyang, China
| | - Xiaojing Zeng
- Department of Hematology Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Dongxin Tang
- Clinical Medical Research Center, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
| | - Yang Liu
- Clinical Medical Research Center, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
- Key Laboratory of Adult Stem Cell Translational Research, Chinese Academy of Medical Sciences, Guizhou Medical University, Guiyang, China
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George C, Parikh S, Carter T, Morris A, Cramey C, Mcelroy K, Tran H. Haemophilia joint health score (HJHS) usage, patterns and outcome data in patients with haemophilia A and haemophilia B in Australia: A descriptive study using the Australian Bleeding Disorders Registry (ABDR). Haemophilia 2023. [PMID: 37335559 DOI: 10.1111/hae.14812] [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: 12/11/2022] [Revised: 05/17/2023] [Accepted: 05/31/2023] [Indexed: 06/21/2023]
Abstract
INTRODUCTION Assessment of joint health is an essential component of haemophilia management. A variety of clinical tools have been developed to standardise this assessment process. One such tool, the Haemophilia Joint Health Score (HJHS), is embedded for use within the Australian Bleeding Disorders Registry (ABDR). This provides a unique opportunity to analyse patterns of tool usage as well as associations between scores, demographics and clinical outcome factors. AIMS To characterise clinician practices regarding use of HJHS in routine clinical assessment of persons with haemophilia (PWH), to examine relationships between HJHS, and age, inhibitor status and body mass index (BMI), and to identify potential barriers to HJHS tool usage. METHODS A national, retrospective study was conducted using data extracted from the ABDR between 2014 and 2020, complemented by a qualitative questionnaire exploring haemophilia treatment centre (HTC) structure, resourcing and clinician perspectives about HJHS. RESULTS 28.1% (622/2220) of PWH had at least one HJHS recorded in the ABDR during the defined study period (546 haemophilia A, 76 haemophilia B). HJHS were recorded more in children than adults and performed more in severe than non-severe haemophilia. Multivariate analysis demonstrated significant association of age, severity and inhibitor status with HJHS. No association was identified between BMI and HJHS. Qualitative surveys revealed significant variation in physiotherapy funding, availability and methods of tool use between HTCs. CONCLUSION This study provides valuable insights into joint health assessment in Australia. It improved our understanding of factors influencing long-term joint outcomes. Practical limitations of HJHS tool were also discussed.
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Affiliation(s)
- Carly George
- Australian Haemophilia Centre Directors' Organisation, Melbourne, Australia
- Perth Children's Hospital, Perth, Australia
| | - Sumit Parikh
- Australian Haemophilia Centre Directors' Organisation, Melbourne, Australia
| | - Tina Carter
- Australian Haemophilia Centre Directors' Organisation, Melbourne, Australia
- Perth Children's Hospital, Perth, Australia
| | | | | | | | - Huyen Tran
- Australian Haemophilia Centre Directors' Organisation, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
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Fang Y, Guo Y, Qin T, Luan Y, Zhang C. The Correlation Between the HEAD-US-C Score and HJHS in Hemophilic Arthropathy of the Knee. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:859-868. [PMID: 35920366 DOI: 10.1002/jum.16072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES We aimed to discuss the correlation between the Hemophilia Early Detection Ultrasound in China (HEAD-US-C) score and the Hemophilia Joint Health Score version 2.1 (HJHS 2.1) of the knee joint in patients with hemophilia. METHODS We included 70 male patients with hemophilia admitted to The Second Hospital of Shanxi Medical University; the patients' bilateral knee joints were evaluated using the HEAD-US-C score and HJHS. We analyzed factors influencing hemophilia arthropathy of the knee and examined the correlation between the HEAD-US-C score and HJHS. RESULTS The joint injury severity was positively correlated with age and the number of bleeds (P < .001). Further, the HEAD-US-C score and HJHS differed according to the severity (both P < .001), but not type (P = .163 and P = .283, respectively), of hemophilia. There was a significant correlation between the HEAD-US-C score and HJHS (P < .001). CONCLUSIONS Overall, all joint lesions observed on ultrasound corresponded to clinical joint functional abnormalities. Therefore, the HEAD-US-C is important for hemophilic arthropathy evaluation and is useful in explaining abnormal joint function.
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Affiliation(s)
- Yunmei Fang
- Department of Ultrasound, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Yulin Guo
- Department of Rehabilitation, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Ting Qin
- Department of Ultrasound, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Yuting Luan
- Department of Ultrasound, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Cuiming Zhang
- Department of Ultrasound, The Second Hospital of Shanxi Medical University, Taiyuan, China
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Daffunchio C, Landro ME, Galatro G, Neme D, Cambiaggi G, Moretti N, Guerrero V, Negrete G, Primiani L, Caviglia H. How mild is mild haemophilia? Haemophilia 2023; 29:530-537. [PMID: 36696281 DOI: 10.1111/hae.14750] [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: 10/19/2022] [Revised: 12/15/2022] [Accepted: 01/06/2023] [Indexed: 01/26/2023]
Abstract
INTRODUCTION People with mild haemophilia (PWMH) experience sporadic bleeds and are less likely to receive an early diagnosis, appropriate treatment and medical care. Arthropathy is a key determinant of health-related quality of life (QoL), producing pain, limitations in mobility and daily activities. The aim of this study is to evaluate the incidence, risk factors and QoL associated with arthropathy in PWMH. MATERIALS AND METHODS Observational, cross-sectional cohort study. Data were collected in a single interview and evaluated by a physiotherapist and an orthopaedist and analysed on demographics; baseline factor levels; as well as clinical (Haemophilia Joint Health Score [HJHS]), ultrasound (Haemophilia Early Arthropathy Detection with Ultrasound [HEAD-US]), radiological (Pettersson score [PS]), pain (visual analogue scale [VAS]) and QoL evaluations. We defined arthropathy when at least one of the joints shown with a HEAD-US score ≥ 1. RESULTS Eighty-five patients and 510 joints were included. Patients' mean age was 35.9 years-old. Median age was 44.2 in patients with arthropathy versus 14.9 in patients without; the difference was statistically significant (p < .001). In patients over 20 years old, 90.5% shown arthropathy. Only 24 (28%) patients had no joint damage (HEAD-US = 0), and 61 (72%) had at least one joint with a HEAD-US ≥ 1. The ankle was the most affected joint. Patient age was found to be the most important risk factor associated with the development of arthropathy. CONCLUSIONS Joint damage as a result of prior hemarthrosis was the most relevant factor associated with lower QoL, and emphasised the importance of early diagnosis and appropriate management in this particular population.
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Affiliation(s)
- Carla Daffunchio
- Haemophilia Foundation, CABA, Argentina.,HGA Dr, Juan A. Fernández, CABA, Argentina
| | - Maria E Landro
- Haemophilia Foundation, CABA, Argentina.,HGA Dr, Juan A. Fernández, CABA, Argentina
| | - Gustavo Galatro
- Haemophilia Foundation, CABA, Argentina.,HGA Dr, Juan A. Fernández, CABA, Argentina
| | | | - Guillermo Cambiaggi
- Haemophilia Foundation, CABA, Argentina.,HGA Dr, Juan A. Fernández, CABA, Argentina
| | | | | | | | | | - Horacio Caviglia
- Haemophilia Foundation, CABA, Argentina.,HGA Dr, Juan A. Fernández, CABA, Argentina
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van Leeuwen FHP, Timmer MA, de Jong PA, Fischer K, Foppen W. Screening for subclinical synovial proliferation in haemophilia: A systematic review and meta-analysis comparing physical examination and ultrasound. Haemophilia 2023; 29:445-455. [PMID: 36595617 DOI: 10.1111/hae.14737] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 11/29/2022] [Accepted: 12/14/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Ultrasound is increasingly used as addition to physical examination for detection of subclinical joint changes in haemophilia. However, the added value of ultrasound to physical examination for detecting synovial proliferation is not fully established. AIM To determine the diagnostic accuracy of swelling at physical examination for ultrasound-detected synovial proliferation in haemophilia. METHODS PubMed and EMBASE were searched up to 2 August 2022. Studies reporting original data on occurrence of swelling at physical examination and synovial proliferation on ultrasound of index joints in persons with haemophilia were included. Risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Diagnostic accuracy parameters of swelling at physical examination for ultrasound-detected synovial proliferation were determined. Summary sensitivity and specificity were calculated using a bivariate random-effects model. RESULTS Fifteen studies reporting on swelling at physical examination and synovial proliferation on ultrasound in 2890 joints of 627 patients were included. Prevalence of subclinical synovial proliferation ranged between 0% and 55%. Sensitivity of swelling was low [summary estimate .34; 95% confidence interval (CI) .24-.46], while specificity was high (summary estimate .97; CI .92-.99). Predictive values varied widely due to inter-study differences in prevalence of synovial proliferation. CONCLUSION Joint swelling has low sensitivity for presence of ultrasound-detected synovial proliferation in haemophilia, suggesting underestimation of synovial proliferation by physical examination alone. Consequently, ultrasound screening may generate important information on synovial changes which would otherwise remain undetected.
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Affiliation(s)
- Flora H P van Leeuwen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Merel A Timmer
- Center for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pim A de Jong
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Center for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wouter Foppen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Minno MNDD, Martinoli C, Pasta G, la Corte-Rodriguez HD, Samy I, Stephensen D, Timmer MA, Winburn I. How to assess, detect, and manage joint involvement in the era of transformational therapies: Role of point-of-care ultrasound. Haemophilia 2023; 29:1-10. [PMID: 36163646 DOI: 10.1111/hae.14657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 08/11/2022] [Accepted: 08/28/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Patients with haemophilia experience recurring hemarthroses, mainly involving knees, elbows and ankles, which lead to haemophilic arthropathy, the major chronic complication of haemophilia. With new approaches to haemophilia treatment leading to fewer joint bleeds and, in some cases, no bleeding events, assessing whether current outcome assessment tools provide adequate sensitivity and specificity for management and care of patients with haemophilia is needed. METHODS An overview of current imaging tools for monitoring joint health, novel osteochondral damage and synovial proliferation biomarkers, and the relationship between assessments for functionality and imaging modalities is provided. Usefulness and sensitivity of point-of-care ultrasound (POCUS) to complement other assessments and use of ultrasound to monitor haemophilic arthropathy are also examined. RESULTS This review provides rationale for haemophilia teams to move beyond traditional outcomes in joint imaging, as well as guidance and evidence on assessment of joint health for potential new treatment modalities, such as gene therapy. The role of POCUS in the existing paradigm for haemophilia care and management along with the use of ultrasound as a complement to other outcome assessment tools are also discussed. Finally, the clinical effects of subclinical bleeding on joint function are described, to motivate screening for synovial proliferation. CONCLUSION POCUS can facilitate the early detection of joint damage and can monitor disease progression while providing insights into the efficacy of treatment regimens, and should be considered as an essential assessment tool for managing the care of patients with haemophilia.
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Affiliation(s)
| | - Carlo Martinoli
- Department of Health Science - DISSAL, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | | | | | - David Stephensen
- Kent Haemophilia & Thrombosis Centre, Canterbury, United Kingdom and Royal London Hospital, London, UK
| | - Merel A Timmer
- Van Creveldkliniek, UMC Utrecht, Utrecht, The Netherlands
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10
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Timmer MA, Kuijlaars IAR, Kloek C, de Kleijn P, Schutgens REG, Veenhof C, Pisters MF. Proof of concept and feasibility of a blended physiotherapy intervention for persons with haemophilic arthropathy. Haemophilia 2023; 29:290-307. [PMID: 36395788 PMCID: PMC10099997 DOI: 10.1111/hae.14690] [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: 06/28/2022] [Revised: 10/11/2022] [Accepted: 10/23/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Regular physiotherapy with a physiotherapist experienced in the field is not feasible for many patients with haemophilia. We, therefore, developed a blended physiotherapy intervention for persons with haemophilic arthropathy (HA) (e-Exercise HA), integrating face-to-face physiotherapy with a smartphone application. AIM The aim of the study was to determine proof of concept of e- Exercise HA and to evaluate feasibility. METHODS Proof of concept was evaluated by a single-case multiple baseline design. Physical activity (PA) was measured with an accelerometer during a baseline, intervention and post-intervention phase and analysed using visual inspection and a single case randomisation test. Changes in limitations in activities (Haemophilia Activities List [HAL]) and a General Perceived Effect (GPE) were evaluated between baseline (T0), post-intervention (T1) and 3 months post-intervention (T2) using Wilcoxson signed rank test. Feasibility was evaluated by the number of adverse events, attended sessions and open-ended questions. RESULTS Nine patients with HA (90% severe, median age 57.5 (quartiles 50.5-63.3) and median HJHS 32 (quartiles 22-36)) were included. PA increased in two patients. HAL increased mean 15 (SD 9) points (p = .001) at T1, and decrease to mean +8 points (SD 7) (p = .012) at T2 compared to T0. At T1 and T2 8/9 participants scored a GPE > 3. Median 5 (range 4-7) face-to-face sessions were attended and a median 8 out of 12 information modules were viewed. No intervention-related bleeds were reported. CONCLUSION A blended physiotherapy intervention is feasible for persons with HA and the first indication of the effectiveness of the intervention in decreasing limitations in activities was observed.
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Affiliation(s)
- Merel A Timmer
- Van Creveldkliniek, Center for Benign Haematology, Thrombosis and Haemostasis, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Isolde A R Kuijlaars
- Van Creveldkliniek, Center for Benign Haematology, Thrombosis and Haemostasis, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Corelien Kloek
- Research Group Innovation of Human Movement Care, University of Applied Sciences Utrecht, Utrecht, the Netherlands.,Center for Physical Therapy Research and Innovation in Primary Care, Julius Health Care Centers, Utrecht, the Netherlands
| | - Piet de Kleijn
- Van Creveldkliniek, Center for Benign Haematology, Thrombosis and Haemostasis, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roger E G Schutgens
- Van Creveldkliniek, Center for Benign Haematology, Thrombosis and Haemostasis, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Cindy Veenhof
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,Research Group Innovation of Human Movement Care, University of Applied Sciences Utrecht, Utrecht, the Netherlands
| | - Martijn F Pisters
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,Center for Physical Therapy Research and Innovation in Primary Care, Julius Health Care Centers, Utrecht, the Netherlands.,Research Group Empowering Healthy Behaviour, Department of Health Innovations and Technology, Fontys University of Applied Sciences, Eindhoven, The Netherlands
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11
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Roussel NA, Chantrain VA, Foubert A, Lambert C, Hermans C, Meeus M, Guillaume S, Lecouvet F, Krüger S, Hilberg T, Lobet S. Gaining more insight into ankle pain in haemophilia: A study exploring pain, structural and functional evaluation of the ankle joint. Haemophilia 2022; 28:480-490. [PMID: 35294993 DOI: 10.1111/hae.14544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Ankle arthropathy is highly prevalent among people with haemophilia (PwH), even with prophylaxis, and leads to pain and disability. Mechanisms and consequences of painful symptoms related to ankle arthropathy have not been extensively studied. METHODS A consecutive sample of 30 adult PwH was included (60 ankles). Ankle structure was assessed with magnetic resonance imaging (IPSG-MRI) and ultrasound (HEAD-US). The HJHS 2.1 assessed function of ankles and knees. Physical functioning was assessed with the Timed Up and Go test, the 2-Minute Walking Test and activity limitations with the HAL questionnaire. Health-related quality of life was evaluated using the EQ-5D-5L questionnaire. Overall pain severity was examined using the Brief Pain Inventory questionnaire and ankle pain intensity with a visual analogue scale. Pressure pain thresholds with an algometer assessed pain sensitivity. Spearman correlations were used to calculate interrelations between joint structure, function and pain. RESULTS Twenty-five PwH (83%) reported ≥1 painful joint, with 67% reporting the ankle as most painful joint. MRI-confirmed abnormalities were seen in 76% of talocrural and 55% of subtalar joints. HEAD-US abnormalities were seen in 93% of the ankles. A large variation was seen in pain sensitivity at the ankle. While moderate to high correlations were observed between ankle structure and HJHS, no meaningful correlations were found between MRI-scores and pain intensity or sensitivity. CONCLUSIONS Structural joint damage is present in many ankles but is not related to pain in PwH. Further studies should consider somatosensory nervous system dysfunction in PwH as contributing factor to painful ankle arthropathy.
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Affiliation(s)
- Nathalie Anne Roussel
- Faculty of Medicine and Health Sciences (MOVANT), University of Antwerp, Antwerp, Belgium
| | - Valérie-Anne Chantrain
- Faculty of Medicine and Health Sciences (MOVANT), University of Antwerp, Antwerp, Belgium.,Pain in Motion International Research Group, www.paininmotion.be
| | - Anthe Foubert
- Faculty of Medicine and Health Sciences (MOVANT), University of Antwerp, Antwerp, Belgium.,Pain in Motion International Research Group, www.paininmotion.be
| | - Catherine Lambert
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Mira Meeus
- Faculty of Medicine and Health Sciences (MOVANT), University of Antwerp, Antwerp, Belgium.,Pain in Motion International Research Group, www.paininmotion.be.,Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
| | - Sylvain Guillaume
- Department of Radiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Frédéric Lecouvet
- Department of Radiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Steffen Krüger
- Department of Sports Medicine, University of Wuppertal, Wuppertal, Germany
| | - Thomas Hilberg
- Department of Sports Medicine, University of Wuppertal, Wuppertal, Germany
| | - Sebastien Lobet
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Neuromusculoskeletal Lab (NMSK), Secteur des Sciences de la Santé, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Louvain, Belgium.,Secteur de kinésithérapie, Cliniques universitaires Saint-Luc, Brussels, Belgium
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12
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Zhao L, Yang H, Li Y, Wang Z, Zhou L, Zhao X, Peng J. Joint status and related risk factors in patients with severe hemophilia A: a single-center cross-sectional study. Hematology 2021; 27:80-87. [PMID: 34964431 DOI: 10.1080/16078454.2021.2019892] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES Hemophilic arthropathy is the most common complication of severe hemophilia A. This study aims to investigated joint status and related risk factors in patients with severe hemophilia A (PWSHA). METHODS This single-center study included 31 patients. Six index joints (both elbows, knees, and ankles) were evaluated using the Hemophilia Early Arthropathy Detection with UltraSound in China (HEAD-US-C) and Hemophilia Joint Health Score (HJHS). Treatment adherence was measured using the Validated Hemophilia Regimen Treatment Adherence Scale-Prophylaxis (VERITAS-Pro). We analyzed the influence of age, treatment delay (the interval between diagnosis and the initiation of treatment), prophylaxis, and treatment adherence on joint outcomes. RESULTS All patients were male (median age, 22 years). The median age at diagnosis was 1 year; that at initial treatment was 5 years. All patients experienced joint bleeding. HEAD-US-C and HJHS scores were positively correlated (R = 0.70, P < 0.0001). Median [range] HEAD-US-C and HJHS scores were 15 [0-36] and 32 [2-49], respectively. Age was positively correlated with both HEAD-US-C (P = 0.002) and HJHS scores (P < 0.0001). The difference of HEAD-US-C scores between groups with ≤1 year and >1 year treatment delay was close to significant (P = 0.055). HJHS scores were significantly different between these two groups (P = 0.03). Joint assessment scores were not significantly different between on-demand and low-dose prophylaxis groups. VERITAS-Pro scores were correlated with both HEAD-US-C and HJHS scores (P = 0.046 and P = 0.005, respectively). CONCLUSIONS Hemophilic arthropathy was pervasive in PWSHA. Age and poor adherence were significantly correlated with joint damage. Prompt treatment and adherence improvement may reduce severity.
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Affiliation(s)
- Liang Zhao
- Department of Hematology, Xiangya Hemophilia Diagnosis and Treatment Center, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Hongbin Yang
- Department of Hematology, Xiangya Hemophilia Diagnosis and Treatment Center, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Yaochun Li
- Department of Rehabilitation, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Zhongqing Wang
- Department of Ultrasonography, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Li Zhou
- Department of Rehabilitation, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Xielan Zhao
- Department of Hematology, Xiangya Hemophilia Diagnosis and Treatment Center, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Jie Peng
- Department of Hematology, Xiangya Hemophilia Diagnosis and Treatment Center, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
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13
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Di Minno MND, Napolitano M, Giuffrida AC, Baldacci E, Carulli C, Boccalandro E, Bruno C, Forneris E, Ricca I, Passeri W, Martinelli M, Rivolta GF, Solimeno LP, Martinoli C, Rocino A, Pasta G. Diagnosis and treatment of chronic synovitis in patients with haemophilia: consensus statements from the Italian Association of Haemophilia Centres. Br J Haematol 2021; 196:871-883. [PMID: 34923621 PMCID: PMC9299781 DOI: 10.1111/bjh.17919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/28/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023]
Abstract
Although synovitis is recognized as a marker of joint disease activity, its periodic assessment is not included in routine clinical surveillance of patients with haemophilia (PwH). In order to evaluate the current knowledge and to identify controversial issues, a preliminary literature search by the Musculoskeletal Committee of the Italian Association of Haemophilia Centres (AICE) has been conducted. Statements have been established and sent to the Italian AICE members to collect their level of agreement or disagreement by a Delphi process. Thirty‐seven consensus recommendations have been drafted. We found a general agreement on the indication to consider the presence of synovitis as a marker of joint disease activity in PwH. Accordingly, there was agreement on the indication to search for synovitis both in patients reporting joint pain and in asymptomatic ones, recognizing ultrasound as the most practical imaging technique to perform periodic joint screening. Interestingly, after detection of synovitis, there was agreement on the indication to modify the therapeutic approach, suggesting prophylaxis in patients treated on demand and tailoring treatment in patients already under prophylaxis. Whereas the need of an early consultation with a physiotherapist is recommended for PwH affected by chronic synovitis, the exact timing for an orthopaedic surgeon consultation is currently unknown.
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Affiliation(s)
| | - Mariasanta Napolitano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | | | - Erminia Baldacci
- Hematology, University Hospital Policlinico Umberto I, Rome, Italy
| | - Christian Carulli
- Department of Health Sciences, Orthopaedic Clinic, University of Florence, Florence, Italy
| | - Elena Boccalandro
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Center, IRCCS Cà Granda Foundation, Maggiore Hospital Policlinic, Milan, Italy
| | - Clarissa Bruno
- Haemophilia Center and Thrombosis, Policlinico, Bari, Italy
| | - Eleonora Forneris
- Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Irene Ricca
- Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Walter Passeri
- Rehabilitation Service, "Domus Salutis" Casa di Cura, "Teresa Camplani" Foundation, Brescia, Italy
| | - Marco Martinelli
- Rehabilitation Service, "Domus Salutis" Casa di Cura, "Teresa Camplani" Foundation, Brescia, Italy
| | - Gianna Franca Rivolta
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, Parma, Italy
| | - Luigi Piero Solimeno
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Center, IRCCS Cà Granda Foundation, Maggiore Hospital Policlinic, Traumatology and Orthopaedic Unit, Milan, Italy
| | - Carlo Martinoli
- Department of Health Science (DISSAL), University of Genoa, Unit of Radiology and IRCCS San Martino Hospital, Genoa, Italy
| | - Angiola Rocino
- Haemophilia and Thrombosis Centre, Haematology, Ospedale del Mare, ASL Napoli 1 Centro, Naples, Italy
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14
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De la Corte-Rodriguez H, Rodriguez-Merchan EC, Alvarez-Roman MT, Martin-Salces M, Jimenez-Yuste V. Clinical assessment and point of care ultrasonography: How to diagnose haemophilic synovitis. Haemophilia 2021; 28:138-144. [PMID: 34668289 DOI: 10.1111/hae.14441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/28/2021] [Accepted: 10/07/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The ability of clinical tools to identify early joint changes is limited. Synovitis is a fundamental finding in understanding haemophilia activity and the response to its therapies; thus, there is a need for sensitive methods to better diagnose subclinical synovitis early. PURPOSE Our aim was to compare the frequency with which clinical assessment and ultrasound detected synovial hypertrophy in the most frequently affected joints in patients with haemophilia (elbows, knees and ankles). METHODS We analysed patients with haemophilia older than 16 years who came to the haemophilia centre for routine follow-up. From the clinical assessment carried out in the consultation, the swelling, pain and history of haemarthrosis were evaluated and compared with the findings of synovial hypertrophy detected by ultrasound. This comparison was also analysed independently for elbows, knees and ankles. RESULTS A total of 203 joints of 66 patients with haemophilia (mean age 34 years), most of them on secondary, tertiary prophylaxis or on demand treatment, were included. In joints with swelling, pain and history of haemarthrosis, 78% of the joints showed synovial hypertrophy on ultrasound. However, in joints with no swelling, no pain and no history of haemarthrosis, 40% presented subclinical synovial hypertrophy on ultrasound. This percentage was higher in elbows than in knees and ankles. CONCLUSION In adults with haemophilia, physical examination and point-of-care ultrasound study provide complementary data on their joint disease. However, without ultrasound, the ability to detect subclinical synovitis is considerably reduced, especially in the elbows.
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Affiliation(s)
| | - E Carlos Rodriguez-Merchan
- Department of Orthopaedic Surgery, La Paz University Hospital-IdiPaz, Madrid, Spain.,Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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15
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Mesleh Shayeb A, Barnes RFW, Hanacek C, Aguero P, Steiner B, Bailey C, Quon D, Kruse-Jarres R, von Drygalski A. Quantitative measurements of haemophilic joint tissues by point-of-care musculoskeletal ultrasound: Associations with clinical and functional joint outcome parameters. Haemophilia 2021; 27:866-875. [PMID: 34171150 PMCID: PMC9292691 DOI: 10.1111/hae.14368] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/16/2021] [Accepted: 06/11/2021] [Indexed: 01/06/2023]
Abstract
Background Painful arthropathy is a long‐term complication in patients with hemophilia (PWH), affecting mobility and quality of life. A major barrier for the appraisal of joint health is the absence of point‐of‐care (POC) imaging modalities to promptly identify and manage arthropathic changes. Accordingly, we developed the Joint tissue Activity and Damage Exam (JADE) POC musculoskeletal ultrasound (MSKUS) protocol. JADE is validated for haemophilic joint tissue recognition with high intra/inter‐rater and inter‐operator reliability. Aims Evaluate associations of JADE with clinical (Hemophilia Joint Health Score, [HJHS]) and functional (total arc [combined flexion and extension range of motion [ROM]]) parameters. Methodology In this multi‐centre prospective study, we recruited PWH A or B with at least one arthropathic joint. We evaluated joint health (both elbows, knees, and ankles) by comparing JADE measurements (soft tissue and cartilage thickness, and osteochondral alterations) with HJHS and total arc. Results Of 44 PWH, most had hemophilia A (35/44), were severe (36/44) and had a median age of 36 years. Increasing HJHSs and declining total arc, indicating worsening arthropathy, were associated with JADE measurements in the expected direction, including (1) increasing length of osteochondral alterations, (2) diminished cartilage thickness, and (3) greater soft tissue expansion. The ankles had the highest proportion of joints without measurable (missing) cartilage. In multivariable models MSKUS measurements explained 68% and 71% of the variation in HJHS and total arc respectively for the elbow, 55% and 29% respectively for the knee, and 50% and 73% for the ankle. Conclusions This study highlights the associations of direct intra‐articular ultrasonography measurements using the JADE protocol with clinical and functional parameters. Our findings underscore the clinical value of POC MSKUS using the JADE protocol as a complementary instrument for the diagnosis and management of haemophilic arthropathy.
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Affiliation(s)
- Akram Mesleh Shayeb
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, California, USA
| | - Richard F W Barnes
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, California, USA
| | - Cris Hanacek
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, California, USA
| | - Peter Aguero
- Department of Physical Medicine and Rehabilitation, University of California San Diego, San Diego, California, USA
| | - Bruno Steiner
- Washington Center for Bleeding Disorders, Seattle, Washington, USA
| | - Cindy Bailey
- LA Orthopedic Hemophilia Treatment Center, Orthopedic Institute for Children, Los Angeles, California, USA
| | - Doris Quon
- LA Orthopedic Hemophilia Treatment Center, Orthopedic Institute for Children, Los Angeles, California, USA
| | | | - Annette von Drygalski
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, California, USA.,The Scripps Research Institute, San Diego, California, USA
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16
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Daffunchio C, Galatro G, Rossi M, Landro M, Andreu M, Neme D, Caviglia H. Clinical and ultrasound evaluation of patients with haemophilia on prophylaxis. Haemophilia 2021; 27:641-647. [PMID: 33970513 DOI: 10.1111/hae.14312] [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: 10/29/2020] [Revised: 03/08/2021] [Accepted: 03/30/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Primary prophylaxis is the current gold standard in haemophilia care for the prevention of bleeding and ensuing joint damage. Early detection of joint bleeding, whether symptomatic or subclinical, preferably during childhood, helps prevent joint deterioration and subsequent disability. The aim of this study is to evaluate the level of agreement between the Haemophilia Joint Health Score and the Haemophilia Early Arthropathy Detection with Ultrasound tools in children with severe haemophilia on primary and secondary prophylaxis. MATERIALS AND METHODS All patients were followed up regularly at our centre. Elbows, knees and ankles were evaluated by physical examination using the Haemophilia Joint Health Score 2.1 (HJHS 2.1), and by ultrasound with HEAD-US score. RESULTS A total of 80 children with haemophilia on prophylaxis were included in this study. Mean age was 10.8 years (range 4-18). We evaluated 480 joints, of which 423 (88.1%) were concordant with both tools, whereas 57 (11.9%) were discordant; 377 (78.5%) joints scored 0 on HJHS, 370 (77%) on HEAD-US and 345 (72%) on both tools. The overall Kappa concordance coefficient was .656. For elbows, knees and ankles the respective values were .783, .522 and .589. For HJHS scores greater than 3, all joints scored ≥1 on HEAD-US. CONCLUSION HJHS and HEAD-US are used to assess joint health in children with haemophilia on prophylaxis. In this study, the level of agreement between both tools was consistent with literature values only for the elbow joint.
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Affiliation(s)
- Carla Daffunchio
- Haemophilia Foundation of Argentina, Buenos Aires, Argentina.,Department of Orthopaedics and Traumatology, Juan A. Fernandez Hospital, Buenos Aires, Argentina
| | - Gustavo Galatro
- Haemophilia Foundation of Argentina, Buenos Aires, Argentina.,Department of Orthopaedics and Traumatology, Juan A. Fernandez Hospital, Buenos Aires, Argentina
| | - Martín Rossi
- Haemophilia Foundation of Argentina, Buenos Aires, Argentina
| | - María Landro
- Department of Orthopaedics and Traumatology, Juan A. Fernandez Hospital, Buenos Aires, Argentina
| | - Mauro Andreu
- Department of Orthopaedics and Traumatology, Juan A. Fernandez Hospital, Buenos Aires, Argentina
| | - Daniela Neme
- Haemophilia Foundation of Argentina, Buenos Aires, Argentina
| | - Horacio Caviglia
- Haemophilia Foundation of Argentina, Buenos Aires, Argentina.,Department of Orthopaedics and Traumatology, Juan A. Fernandez Hospital, Buenos Aires, Argentina
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17
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Prasetyo M, Moniqa R, Tulaar A, Prihartono J, Setiawan SI. Correlation between Hemophilia Early Arthropathy Detection with Ultrasound (HEAD-US) score and Hemophilia Joint Health Score (HJHS) in patients with hemophilic arthropathy. PLoS One 2021; 16:e0248952. [PMID: 33826621 PMCID: PMC8026024 DOI: 10.1371/journal.pone.0248952] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 03/09/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Hemophilic arthropathy, a condition manifested as joint destruction due to spontaneous joint bleeding, is one complication of hemophiliac patients. Early detection and intervention may improve the outcome, in which ultrasonography can be an ideal modality with the introduction of HEAD-US (Hemophilia Early Arthropathy Detection with Ultrasound) protocol. Studies have shown US benefit in hemophiliac patients, including its potential as an alternative for the Hemophiliac Joint Health Score (HJHS) system. However, many of the studies were conducted in countries with better management of hemophilia using prophylaxis treatment. It is unclear whether HEAD-US has a correlation with HJHS in countries using episodic treatment only, like in Indonesia. PURPOSE This study aimed to explore the correlation between HEAD-US and HJHS in hemophiliac patients with joint problems in Indonesia. MATERIALS AND METHODS A cross-sectional correlation study between HEAD-US and HJHS was performed with primary data collected from 120 hemophilic patients. US examination was performed on elbow, knee and ankle joints using the HEAD-US scoring method by a musculoskeletal radiologist. HJHS examination was conducted by a trained physiotherapist and a medical rehabilitation specialist. All examiner is member of multidisciplinary Hemophiliac Management Team in Cipto Mangunkusumo General Hospital in Jakarta, Indonesia. RESULTS The mean age of the participant was 9.3 (5-14) years old. The median score of HEAD-US was 8 (1-28) with most of the joint abnormalities found on the ankles. The median score of HJHS was 3 (0-35), with most joint abnormalities found on the knees. There was a moderate correlation between HEAD-US and HJHS score (p < 0.05, r = 0.65). CONCLUSION HEAD-US shows a moderate correlation to HJHS in hemophiliac patients who received episodic treatment. HEAD-US can provide additional value in the anatomical evaluation of the joint and could be complementary to HJHS in assessing the joint status in hemophilic patient.
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Affiliation(s)
- Marcel Prasetyo
- Department of Radiology, Faculty of Medicine Universitas Indonesia–Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Ratna Moniqa
- Department of Radiology, Faculty of Medicine Universitas Indonesia–Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Angela Tulaar
- Department of Medical Rehabilitation, Faculty of Medicine Universitas Indonesia–Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Joedo Prihartono
- Department of Community Medicine, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Stefanus Imanuel Setiawan
- Department of Radiology, Faculty of Medicine Universitas Indonesia–Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
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18
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Gooding R, Thachil J, Alamelu J, Motwani J, Chowdary P. Asymptomatic Joint Bleeding and Joint Health in Hemophilia: A Review of Variables, Methods, and Biomarkers. J Blood Med 2021; 12:209-220. [PMID: 33833602 PMCID: PMC8023018 DOI: 10.2147/jbm.s304597] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/19/2021] [Indexed: 12/14/2022] Open
Abstract
Joint health is a key contributor to quality of life in patients with hemophilia. However, variables that impact long-term joint outcomes have not been comprehensively defined. A systematic literature search identified publications relating to joint health in patients with hemophilia. Studies clearly show that early, sustained prophylaxis with factor replacements improves long-term joint outcomes. However, a subset of patients appear to develop arthropathy despite maintaining excellent bleeding outcomes, which suggests possible recurrent asymptomatic bleeding into the joints in these patients. Furthermore, limited data are available on how long-acting factor VIII and factor IX replacement therapies could impact long-term joint outcomes. Many variables were identified as potential indicators that a patient may develop hemophilic arthropathy, including genetic mutations, endogenous factor VIII and IX levels, bone health, and physical activity levels. Tools for the diagnosis and monitoring of hemophilic arthropathy are critical to detect early joint damage, so that management can be adjusted accordingly. Imaging techniques, particularly magnetic resonance imaging, can detect synovial changes, a strong predictor for the future development of hemophilic arthropathy. In addition, several biomarkers associated with cartilage and bone formation, vascularization, and angiogenesis could potentially identify the onset and progression of early joint damage. Since the development of hemophilic arthropathy is complex, a comprehensive therapeutic approach is necessary for the effective prevention of arthropathy in patients with hemophilia.
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Affiliation(s)
- Richard Gooding
- Leicester Haemophilia Centre, Haemostasis & Thrombosis Unit, Leicester Royal Infirmary, Leicester, UK
| | - Jecko Thachil
- Haematology Department, Manchester Royal Infirmary, Manchester, UK
| | - Jayanthi Alamelu
- Haemophilia Department, Evelina Children's Hospital - St Thomas' Hospital, London, UK
| | - Jayashree Motwani
- Haemophilia Comprehensive Care Centre, Birmingham Children's Hospital, Birmingham, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia Centre, Royal Free Hospital, London, UK
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19
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Jiménez-Yuste V, de la Corte-Rodríguez H, Álvarez-Román MT, Martín-Salces M, Querol F, Bonanad S, Mingot-Castellano ME, Fernández-Mosteirín N, Canaro M, Santamaría A, Núñez R, García-Frade LJ, Martinoli C, Kim HK. Ultrasound evaluation of joint damage and disease activity in adult patients with severe haemophilia A using the HEAD-US system. Haemophilia 2021; 27:479-487. [PMID: 33620134 DOI: 10.1111/hae.14280] [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: 10/14/2020] [Revised: 01/25/2021] [Accepted: 02/05/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The Haemophilia Early Arthropathy Detection with Ultrasound (HEAD-US) system and scoring scale has proven to be an accurate and time-efficient imaging method for identifying joint damage in patients with haemophilia. AIM Observational, multicentre, cross-sectional study conducted in 8 centres in Spain that assessed the joint status of adult patients with severe haemophilia A (SHA) using HEAD-US. METHODS Joint status of the elbow, knee and ankle was evaluated in adults with SHA receiving on-demand (OD) treatment, or primary (PP), secondary (SP), tertiary (TP) or intermittent (IP) prophylaxis. RESULTS Of the 95 patients enrolled, 87 received prophylaxis (6.3% PP, 38.9% SP, 43.2% TP and 3.2% IP). Mean age was 35.2 years, and 59% of patients had not undergone image testing in the last year. The HEAD-US score was 0 in all joints in 6.3% of patients. The ankle was the most affected joint, regardless of treatment regimen. Patients receiving OD treatment, TP or IP had the overall worst scores, mainly in the ankles and elbows; a similar but milder profile was observed in patients on SP; and patients on PP had the best score in all joints. CONCLUSION Joint function may be effectively preserved in patients with SHA on PP, but OD treatment or later initiation of prophylaxis does not seem to prevent progression of arthropathy. Disease worsening was observed in patients OD, TP or IP, most often affecting ankles and elbows. Closer ultrasound imaging monitoring may improve management of these patients.
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Affiliation(s)
- Víctor Jiménez-Yuste
- Department of Haematology, Hospital Universitario La Paz, Autonoma University, Madrid, Spain
| | | | | | | | - Felipe Querol
- University of Valencia and Haemostasis and Thrombosis Unit, Department of Haematology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Santiago Bonanad
- Haemostasis and Thrombosis Unit. Department of Haematology, Hospital Universitari i Politècnic La Fe, University of Valencia, Valencia, Spain
| | - María Eva Mingot-Castellano
- Department of Haematology, Hospital Regional Universitario de Málaga, Malaga, Spain.,Department of Haematology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | - Mariana Canaro
- Department of Haemostasis and Thrombosis, Hospital Universitario Son Espases, Mallorca, Spain
| | - Amparo Santamaría
- Department of Thrombosis and Haemostasis, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ramiro Núñez
- Department of Haematology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | - Carlo Martinoli
- Dipartimento di Scienze della Salute Department of Health Sciences (DISSAL) and IRCCS Ospedale Policlinico San Martino, Genova, University of Genoa, Genoa, Italy
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20
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Måseide RJ, Berntorp E, Astermark J, Hansen J, Olsson A, Bruzelius M, Frisk T, Aspdahl M, Nummi V, Tjønnfjord GE, Holme PA. Haemophilia early arthropathy detection with ultrasound and haemophilia joint health score in the moderate haemophilia (MoHem) study. Haemophilia 2021; 27:e253-e259. [PMID: 33550602 DOI: 10.1111/hae.14245] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/10/2020] [Accepted: 12/17/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Detection of early arthropathy is crucial for the management of haemophilia, but data on moderate haemophilia are limited. Therefore, we evaluated joint health and treatment modalities in Nordic patients with moderate haemophilia A (MHA) and B (MHB). AIM To explore and compare the Haemophilia Early Arthropathy Detection with Ultrasound (HEAD-US) and Haemophilia Joint Health Score (HJHS) to detect early arthropathy in moderate haemophilia. METHODS A cross-sectional, multicentre study covering Nordic patients with MHA and MHB. Arthropathy was evaluated by HEAD-US and HJHS 2.1. RESULTS We assessed 693 joints in 118 patients. HEAD-US scores (medians [interquartile ranges]) were as follows: elbows 0 points (0-0), knees 0 (0-0) and ankles 0 (0-1). Respectively, by HJHS: elbows 0 (0-1), knees 0 (0-1) and ankles 0 (0-1). Cartilage (14%) and bone (13%) were most commonly affected by HEAD-US. Frequent HJHS findings were crepitus on motion in knees (39%), and loss of flexion (23%) and extension (13%) in ankles. HEAD-US correlated strongly with HJHS (elbows r = .70, knees r = .60 and ankles r = .65), but 24% had discordant scores. Joints with HJHS zero points, 5% captured HEAD-US ≥1 point. Moreover, 26% had HJHS findings without HEAD-US pathology. Notably, 31% of knees had crepitus on motion and normal HEAD-US. CONCLUSION Overall, the joints attained low scores implying good joint health. HEAD-US correlated strongly with HJHS. In 5%, HEAD-US detected subclinical pathology. Crepitus on motion was frequently reported despite normal HEAD-US, thus not necessarily reflecting arthropathy. HEAD-US therefore improves the joint assessment in moderate haemophilia.
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Affiliation(s)
- Ragnhild J Måseide
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Erik Berntorp
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Jan Astermark
- Department of Translational Medicine, Lund University, Malmö, Sweden.,Department of Haematology, Skåne University Hospital, Malmö, Sweden
| | - Jessica Hansen
- Rehabilitation Unit, Emergency care/Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Anna Olsson
- Department of Medicine, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Maria Bruzelius
- Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.,Department of Haematology, Karolinska University Hospital, Stockholm, Sweden
| | - Tony Frisk
- Pediatric Coagulation, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Aspdahl
- Function Allied Health Professionals, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden
| | - Vuokko Nummi
- Coagulation Disorders Unit, Haematology, Comprehensive Cancer Centre, Helsinki University Hospital and Research Program in Systems Oncology, Faculty of Medicine, Helsinki University, Helsinki, Finland
| | - Geir E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Pål A Holme
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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21
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van Bergen EDP, van Vulpen LFD, Schutgens REG, Mastbergen SC, Lafeber FPJG. Biochemical marker research in hemophilic arthropathy: A systematic review. Blood Rev 2020; 47:100781. [PMID: 33277057 DOI: 10.1016/j.blre.2020.100781] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/10/2020] [Accepted: 11/11/2020] [Indexed: 12/14/2022]
Abstract
Hemophilic arthropathy (HA) causes major morbidity. Breakthrough therapies reduce the bleeding frequency tremendously, but well-defined joint outcome assessments with a focus on early changes and subclinical damage are lacking. Biomarkers reflecting joint tissue turnover/inflammation might be useful to predict invalidating arthropathy. This systematic review summarized and categorized publications on blood/urinary biomarkers in HA to provide leads for implementation. A PubMed/EMBASE search was performed on September 9, 2019. All publications were assessed and allocated to one or several BIPED-categories, based on the utility of biomarkers. Of the initial 1307 publications found, 27 were eligible for inclusion. The majority (81%, n = 32/42) was cross-sectional in design, including relatively small numbers of patients (median 44, interquartile range 35-78). Fourteen percent (n = 6/42) investigated dynamic changes around a bleeding or treatment. Only two studies investigated the prognostic value of biomarkers. Most promising biomarkers were serum Coll2-1, COL-18N, COMP, C1,2C, C2M, CS846, MIF, plasma sVCAM-1 and urinary CTX-II. Comparing performances and pooling data was not possible due to heterogeneity. Currently, biomarker research in HA is still in an explorative stage and not yet sufficient for translation into daily practice. Clearly, larger homogeneous longitudinal studies in well-defined populations should be performed for further development.
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Affiliation(s)
- E D P van Bergen
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands.
| | - L F D van Vulpen
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, the Netherlands.
| | - R E G Schutgens
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, the Netherlands.
| | - S C Mastbergen
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands.
| | - F P J G Lafeber
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands.
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22
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De la Corte-Rodriguez H, Rodriguez-Merchan EC, Alvarez-Roman MT, Martin-Salces M, Martinoli C, Jimenez-Yuste V. HJHS 2.1 and HEAD-US assessment in the hemophilic joints: How do their findings compare? Blood Coagul Fibrinolysis 2020; 31:387-392. [PMID: 32815914 DOI: 10.1097/mbc.0000000000000934] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: In hemophilic patients methods are needed to better diagnose joint damage early, so that treatments can be adjusted to slow the progression of hemophilic arthropathy. The aim of this study is to investigate the relationship between the Hemophilia Joint Health Score version 2.1 (HJHS 2.1) and hemophilia early arthropathy detection with ultrasound (HEAD-US) scales, as well as each of their individual items, to better understand the value each provides on the joint condition of patients with hemophilia. The study included data from patients with hemophilia older than 16 years of age, who attended a routine check-up. HJHS 2.1 and HEAD-US assessments were performed on the elbows, knees and ankles. We studied the correlations and agreements between the two scales and analyzed the relationship between the various items of the HJHS 2.1 (inflammation, duration, atrophy, crepitation, flexion deficit, extension deficit, pain, strength, gait) and HEAD-US (synovitis, cartilage and bone). The study included 203 joints from 66 patients with hemophilia (mean age, 34 years). We found a good correlation between the two scales (r = 0.717). However, HJHS 2.1 revealed only 54% of the cases with synovitis and 75% of the cases with osteochondral damage. HEAD-US detected several relevant physical and functional aspects in less than 53% of the cases. HJHS 2.1 and HEAD-US provide complementary data on joint disease in adults with hemophilia; both assessments should therefore, be made available. HEAD-US presented the added value of detecting early joint changes (synovitis and osteochondral damage), while HJHS 2.1 showed the added value of detecting relevant physical and functional changes.
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Affiliation(s)
| | | | | | | | - Carlo Martinoli
- Department of Health Sciences (DISSAL), University of Genoa
- Department of Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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23
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Måseide RJ, Berntorp E, Astermark J, Olsson A, Bruzelius M, Frisk T, Nummi V, Lassila R, Tjønnfjord GE, Holme PA. Joint health and treatment modalities in Nordic patients with moderate haemophilia A and B – The MoHem study. Haemophilia 2020; 26:891-897. [DOI: 10.1111/hae.14114] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/29/2020] [Accepted: 07/08/2020] [Indexed: 01/10/2023]
Affiliation(s)
- Ragnhild J. Måseide
- Department of Haematology Oslo University Hospital Oslo Norway
- Research Institute of Internal Medicine Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Erik Berntorp
- Department of Translational Medicine Lund University Malmö Sweden
| | - Jan Astermark
- Department of Translational Medicine Lund University Malmö Sweden
- Department of Haematology Skåne University Hospital Malmö Sweden
| | - Anna Olsson
- Department of Medicine Sahlgrenska University Hospital Gothenburg Sweden
| | - Maria Bruzelius
- Molecular Medicine and Surgery Karolinska Institute Stockholm Sweden
- Department of Haematology Karolinska University Hospital Stockholm Sweden
| | - Tony Frisk
- Pediatric Coagulation Karolinska University Hospital Stockholm Sweden
| | - Vuokko Nummi
- Coagulation Disorders Unit Haematology Comprehensive Cancer Centre Helsinki University Hospital and Research Program in Systems Oncology Faculty of Medicine Helsinki University Helsinki Finland
| | - Riitta Lassila
- Coagulation Disorders Unit Haematology Comprehensive Cancer Centre Helsinki University Hospital and Research Program in Systems Oncology Faculty of Medicine Helsinki University Helsinki Finland
| | - Geir E. Tjønnfjord
- Department of Haematology Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Pål A. Holme
- Department of Haematology Oslo University Hospital Oslo Norway
- Research Institute of Internal Medicine Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
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24
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Zhou JY, Barnes RFW, Foster G, Iorio A, Cramer TJ, von Drygalski A. Joint Bleeding Tendencies in Adult Patients With Hemophilia: It's Not All Pharmacokinetics. Clin Appl Thromb Hemost 2020; 25:1076029619862052. [PMID: 31298044 PMCID: PMC6714908 DOI: 10.1177/1076029619862052] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Hemophilic arthropathy from joint bleeding remains a complication with major morbidity in the increasingly aging patients with hemophilia. Prophylactic clotting factor infusions, based on pharmacokinetic dosing to reduce bleeding rates, are being explored more and more. However, there is little evidence on the benefits of pharmacokinetic dosing in direct association with bleeding events. Here, we prospectively followed a cohort of adult patients with hemophilia A and B (n = 26) and arthropathic joints on various clotting factor products over a period of 2 years with clinical and radiographic joint health assessments, frequent joint ultrasound, and pharmacokinetic studies. Joint bleeds and synovitis with synovial vascularity changes were objectively diagnosed by musculoskeletal ultrasound and power Doppler and analyzed in relation to pharmacokinetic, joint- and patient-specific parameters. Results revealed that, contrary to common beliefs, bleeding episodes were not readily explained by pharmacokinetic features, as they were not associated with more time spent below certain clotting factor thresholds. Joint bleeding was found to be associated with prominent vascularity changes, suggesting that vascular remodeling and leakiness may contribute to joint bleeding that cannot be prevented by clotting factor replacement alone.
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Affiliation(s)
- Jenny Y Zhou
- 1 Division of Hematology/Oncology, Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Richard F W Barnes
- 1 Division of Hematology/Oncology, Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Gary Foster
- 2 Department of Health Evidence, Research Methodology and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Alfonso Iorio
- 2 Department of Health Evidence, Research Methodology and Impact, McMaster University, Hamilton, Ontario, Canada.,3 Department of Medicine, McMaster-Bayer Endowed Research Chair in Clinical Epidemiology of Congenital Bleeding Disorders, McMaster University, Hamilton, Ontario, Canada
| | - Thomas J Cramer
- 1 Division of Hematology/Oncology, Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Annette von Drygalski
- 1 Division of Hematology/Oncology, Department of Medicine, University of California, San Diego, San Diego, CA, USA.,4 Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
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25
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Liu S, Zhou R, Jin Z, Wu M, Zhang P. Age‐related severity and distribution of haemophilic arthropathy of the knee, ankle and elbow among Chinese patients with haemophilia. Haemophilia 2019; 26:129-135. [DOI: 10.1111/hae.13858] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/12/2019] [Accepted: 09/18/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Sha Liu
- Department of Ultrasound Medicine Nanjing Drum Tower HospitalClinical College of Nanjing Medical University Nanjing China
| | - Rong‐fu Zhou
- Department of Hematology Nanjing Drum Tower HospitalClinical College of Nanjing Medical University Nanjing China
| | - Zhi‐bin Jin
- Department of Ultrasound Medicine Nanjing Drum Tower HospitalClinical College of Nanjing Medical University Nanjing China
| | - Min Wu
- Department of Ultrasound Medicine Nanjing Drum Tower HospitalClinical College of Nanjing Medical University Nanjing China
| | - Ping‐yang Zhang
- Department of Ultrasound Medicine Nanjing First Hospital Nanjing Medical University Nanjing China
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26
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Bakeer N, Shapiro AD. Merging into the mainstream: the evolution of the role of point-of-care musculoskeletal ultrasound in hemophilia. F1000Res 2019; 8. [PMID: 31431824 PMCID: PMC6619375 DOI: 10.12688/f1000research.16039.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2019] [Indexed: 01/19/2023] Open
Abstract
Bleeding with resultant hemophilic arthropathy constitutes the largest cause of morbidity in patients with hemophilia. It results from repeated bleeding episodes in the joint and is characterized by synovial hypertrophy and cartilage and bony destruction. Hemophilic arthropathy assessment is a continually evolving process and is particularly challenging in children and young adults in whom joint disease may be missed or underestimated as obtaining serial "baseline" magnetic resonance imaging scans of multiple clinically asymptomatic or nearly asymptomatic joints may be unjustifiable and cost-ineffective. Musculoskeletal ultrasound-particularly, point-of-care musculoskeletal ultrasound-has emerged as a promising imaging modality for the early detection and management of hemophilic arthropathy, and for the evaluation of hemarthrosis and painful musculoskeletal episodes in patients with hemophilia. This review summarizes currently available data on the emerging role of this new imaging modality, its limitations, and gaps in knowledge. The review also raises unanswered questions, highlights the need for consolidated research efforts, and delineates future directions expected to advance this technology and optimize its use in this patient population.
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Affiliation(s)
- Nihal Bakeer
- Indiana Hemophilia and Thrombosis Center, 8326 Naab Road, Indianapolis, IN, 46260, USA
| | - Amy D Shapiro
- Indiana Hemophilia and Thrombosis Center, 8326 Naab Road, Indianapolis, IN, 46260, USA
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27
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Accelerating recovery from acute hemarthrosis in patients with hemophilia: the role of joint aspiration. Blood Coagul Fibrinolysis 2019; 30:111-119. [PMID: 30958454 DOI: 10.1097/mbc.0000000000000803] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
: Arthrocentesis of an acute hemarthrosis in hemophilia remains a controversial issue. The purpose of this study is to define the role that joint aspiration can play in the recovery from acute hemarthrosis in patients with hemophilia. The study sample included 33 hemophilic patients (55 joints) with acute elbow, knee, and ankle hemarthrosis as confirmed by ultrasonography. Patients were distributed into a treatment group and a control group. Patients in the first group were subjected to joint aspiration, whereas patients in the second were not. Arthrocentesis was carried out immediately after diagnosis of acute hemarthrosis in liquid phase. Patients were infused with the deficient coagulation factor and were instructed to observe relative rest until resolution of hemarthrosis. The following parameters were analyzed: time to full resolution of hemarthrosis (determined by ultrasonography), duration of treatment with the deficient coagulation factor, time to pain relief, time to recovery of prebleed range of motion, and time to resumption of school/work (all of these measured in days). The joints treated with joint aspiration exhibited a significantly faster resolution of bleeding (fewer days). In addition, this group required fewer days of pharmacological treatment, with faster achievement of functional recovery and resumption of school/work activities. No complications were observed. This study shows that joint aspiration under hemostatic cover and in strictly aseptic conditions is a well-tolerated technique that makes the recovery of acute hemarthrosis of hemophilic patients faster.
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28
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Li J, Guo XJ, Ding XL, Lyu BM, Xiao J, Sun QL, Li DS, Zhang WF, Zhou JC, Li CP, Yang RC. [Clinical application and optimization of HEAD-US quantitative ultrasound assessment scale for hemophilic arthropathy]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 39:132-136. [PMID: 29562448 PMCID: PMC7342577 DOI: 10.3760/cma.j.issn.0253-2727.2018.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
目的 评价HEAD-US评估量表在血友病性关节病临床应用的可行性,提出优化的超声评估量表HEAD-US-C。 方法 2015年7月至2017年8月期间,91例血友病患者接受1 035例次关节超声检查,分别采用Melchiorre、HEAD-US、HEAD-US-C量表进行评分,分析与血友病关节健康评分量表(HJHS)评分之间的相关性并比较上述量表评价血友病性关节病的敏感性。 结果 91例患者均为男性,中位年龄16(4~55)岁,血友病A 86例,血友病B 5例。1 035例次关节检查Melchiorre、HEAD-US、HEAD-US-C量表的评分[M(P25, P75)]分别为2(0,6)、1(0,5)、2(0,6),均与HJHS评分之间存在相关关系(相关系数分别为0.747、0.762、0.765,P值均<0.001)。Melchiorre、HEAD-US-C、HEAD-US评分量表的阳性率分别为63.0%(95%CI 59.7%~65.9%)、59.5%(95%CI 56.5%~62.4%)、56.6%(95%CI 53.6%~59.6%),差异有统计学意义(P<0.001)。336例次无症状关节(HJHS评分0分)Melchiorre、HEAD-US-C、HEAD-US评分量表的阳性率分别为25.0%(95%CI 20.6%~29.6%)、17.0%(95%CI12.6%~21.1%)、11.9%(95%CI 8.4%~15.7%)(P<0.001)。40例有关节出血症状的血友病患者(107例次)关节出血前、出血后超声评分差异有统计学意义(P<0.05)。HEAD-US-C与HEAD-US评分的变化幅度比较,差异有统计学意义(P<0.001)。 结论 与Melchiorre比较,HEAD-US、HEAD-US-C与HJHS之间具有相似的良好的相关性。HEAD-US-C评分量表较HEAD-US更为敏感,尤其适合亚临床状态血友病性关节病的评估。
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Affiliation(s)
- J Li
- Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | | | | | | | | | | | | | | | | | | | - R C Yang
- Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
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29
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Jiménez-Yuste V, Álvarez-Román MT, Martín-Salces M, De la Corte-Rodríguez H, Altisent C, Parra R, Núñez R, Pérez R, García-Candel F, Bonanad S, Querol F, Alonso N, Fernández-Mosteirín N, López-Ansoar E, García-Frade LJ, Bermejo N, Pérez-González N, Gutiérrez-Pimentel MJ, Martinoli C, Fernández-Arias I, Kim HK. Joint status in Spanish haemophilia B patients assessed using the Haemophilia Early Arthropathy Detection with Ultrasound (HEAD-US) score. Haemophilia 2018; 25:144-153. [DOI: 10.1111/hae.13628] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/05/2018] [Accepted: 10/10/2018] [Indexed: 01/05/2023]
Affiliation(s)
| | | | | | | | | | - Rafael Parra
- Hospital Universitario Vall d’Hebron; Barcelona Spain
| | - Ramiro Núñez
- Hospital Universitario Virgen del Rocio; Seville Spain
| | - Rosario Pérez
- Hospital Universitario Virgen del Rocio; Seville Spain
| | | | | | - Felipe Querol
- Hospital Universitario y Politécnico La Fe; Valencia Spain
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30
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De la Corte-Rodriguez H, Rodriguez-Merchan EC, Jimenez-Yuste V. Point-of-care Ultrasonography in Orthopedic Management of Hemophilia: Multiple Uses of an Effective Tool. HSS J 2018; 14:307-313. [PMID: 30258338 PMCID: PMC6148577 DOI: 10.1007/s11420-018-9604-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 01/25/2018] [Indexed: 02/07/2023]
Abstract
Even in our current era of hemophilia prophylaxis, articular complications can arise and there is a growing need for strategies in the prevention, diagnosis, and treatment of hemophilic arthropathy, a significant contributor to disability in patients with hemophilia. One useful tool, point-of-care ultrasonography (POC-US), offers diverse diagnostic and therapeutic possibilities. This article reviews the literature on the uses of POC-US in hemophilia, including early diagnosis of joint damage, differential diagnosis of articular pain, follow-up of joint injury, and guidance for both arthrocentesis and intra-articular injection. Studies show that for patients with hemophilia, POC-US enhances diagnostic accuracy and targeted treatments. Further research is required into the most efficient use of POC-US and the training needed to develop clinicians' skills. The attributes of POC-US should be understood more fully to enable its widespread application.
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Affiliation(s)
| | - E. Carlos Rodriguez-Merchan
- Department of Orthopaedic Surgery, La Paz University Hospital–IdiPaz, Paseo de la Castellana 261, 28046 Madrid, Spain
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31
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Stephensen D, Bladen M, McLaughlin P. Recent advances in musculoskeletal physiotherapy for haemophilia. Ther Adv Hematol 2018; 9:227-237. [PMID: 30181843 PMCID: PMC6116756 DOI: 10.1177/2040620718784834] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 05/27/2018] [Indexed: 12/16/2022] Open
Abstract
Physiotherapy is directed towards the movement needs and potential of individuals, providing treatment and rehabilitation to develop, maintain and restore maximum movement and functional ability throughout the lifespan. Recent systematic reviews and randomized controlled trials have extended evidence for the clinical efficacy of physiotherapy interventions and rehabilitation for people with haemophilia. This narrative review synthesizes recent evidence to discuss; differentiating musculoskeletal bleeding and haemophilic arthropathy, efficacy of physiotherapy and rehabilitation for acute musculoskeletal bleeding and arthropathy, as well as monitoring musculoskeletal health. Whilst robust evidence is emerging, there is a need for more well designed randomized clinical studies with larger numbers and homogeneity of participants and collaboration of all researchers and clinicians to identify a core set of outcome measures that can be used to monitor musculoskeletal health.
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Affiliation(s)
- David Stephensen
- East Kent Hospitals University NHS Foundation
Trust, Ethelbert Road, Canterbury CT1 3NG, UK
| | - Melanie Bladen
- Great Ormond Street Hospital for Children NHS
Foundation Trust, London, UK
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32
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De la Corte-Rodriguez H, Rodriguez-Merchan EC, Alvarez-Roman MT, Martin-Salces M, Martinoli C, Jimenez-Yuste V. The value of HEAD-US system in detecting subclinical abnormalities in joints of patients with hemophilia. Expert Rev Hematol 2018; 11:253-261. [PMID: 29383965 DOI: 10.1080/17474086.2018.1435269] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Prevention of hemarthrosis is the key factor in the adequate management of people with hemophilia (PWH). If hemarthrosis occurs, early diagnosis of joint damage is essential to make personalized treatments. This study is aimed at gaining an understanding of the ability of point-of-care ultrasound (US) using the `Hemophilia Early Arthropathy Detection with Ultrasound´ (HEAD-US) protocol to detect abnormalities in joints without history of hemarthrosis and clinically asymptomatic joints of PWH. METHODS The sample included 976 joints from 167 PWH (mean age 24.86 years). Data were collected from routine practice over a 3-year period and analyzed based on history of hemarthrosis and results of clinical (HJHS 2.1) and HEAD-US examinations. RESULTS In our series, 14% of patients exhibited HEAD-US signs of incipient arthropathy in joints with no history of bleeding and with a HJHS 2.1 score of 0. The most severely involved joint was the right ankle. Synovitis, articular cartilage and subchondral bone damage scores in joints with subclinical findings were slower than in joints with previous hemarthroses or HJHS 2.1 > 1 Conclusions: Our study demonstrates that HEAD-US is better than hemarthrosis records and the HJHS 2.1 scale in detecting the early signs of joint damage in PWH.
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Affiliation(s)
| | | | | | | | - Carlo Martinoli
- d Radiologia III - Ospedale Policlinico San Martino - Dept. of Health Science , University of Genoa , Genova , Italy
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Di Minno MND, Pasta G, Airaldi S, Zaottini F, Storino A, Cimino E, Martinoli C. Ultrasound for Early Detection of Joint Disease in Patients with Hemophilic Arthropathy. J Clin Med 2017; 6:E77. [PMID: 28758960 PMCID: PMC5575579 DOI: 10.3390/jcm6080077] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/12/2017] [Accepted: 07/24/2017] [Indexed: 11/16/2022] Open
Abstract
Joint bleeding represents the most commonly reported type of hemorrhage in patients affected by hemophilia. Although the widespread use of prophylaxis has been able to significantly reduce the onset of arthropathy, it has been shown that a non-negligible percentage of patients develop degenerative changes in their joints despite this type of treatment. Thus, periodic monitoring of the joint status in hemophilia patients has been recommended to identify early arthropathic changes and prevent the development or progression of hemophilic arthropathy. Ultrasound (US) has proven able to detect and quantify the most relevant biomarkers of disease activity (i.e., joint effusion and synovial hypertrophy) and degenerative damages (i.e., osteo-chondral changes) by means of scoring scales of increasing disease severity. In the present review, we have detailed major literature evidence about the use of US to assess joint status in hemophilia patients, focusing on signs of disease activity and degenerative damages. In particular, we have discussed recent evidence about "point-of-care" use patients with hemophilia.
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Affiliation(s)
| | - Gianluigi Pasta
- Dipartimento di Ortopedia-Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy.
| | - Sonia Airaldi
- Radiologia III-IRCCS San Martino-IST-DISSAL, Università di Genova, 16132 Genova, Italy.
| | - Federico Zaottini
- Radiologia III-IRCCS San Martino-IST-DISSAL, Università di Genova, 16132 Genova, Italy.
| | - Antonio Storino
- Department of Public Health, Federico II University, 80131 Naples, Italy.
| | - Ernesto Cimino
- Department of Clinical Medicine and Surgery, Federico II University, 80131 Naples, Italy.
| | - Carlo Martinoli
- Radiologia III-IRCCS San Martino-IST-DISSAL, Università di Genova, 16132 Genova, Italy.
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