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Fernandez Sanchez J, Sánchez LM, Kappa SS, Karsenty CL, O'Keefe M, Shekar M, Timothy LD, Vrana CB, Airewele G, Lee-Kim Y, Okcu MF, Cohen CT, Powers JM. Standardizing the evaluation and management of iron deficiency anemia secondary to heavy menstrual bleeding in the emergency department. Pediatr Blood Cancer 2024; 71:e31222. [PMID: 39054725 DOI: 10.1002/pbc.31222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/09/2024] [Accepted: 07/10/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Comprehensive guidelines for the management of iron deficiency anemia (IDA) in adolescents with heavy menstrual bleeding (HMB) presenting to the emergency department (ED) are lacking, leading to variability in care. We aimed to standardize the evaluation and management of these patients through the development and implementation of an evidence-based algorithm using quality improvement methodology. METHODS Baseline data of the target population identified variability across four key measures of clinical management: therapy choice and administration, laboratory evaluation, hematology service consultation, and patient disposition. Literature review and consensus from pediatric hematology and gynecology providers informed a draft algorithm that was refined in an iterative multidisciplinary process. From December 2022 to July 2023, we aimed to achieve a 25% relative increase in patients to receive optimal management per the algorithm, while using sequential Plan-Do-Study-Act (PDSA) cycles. Process measures focusing on provider documentation and balancing measures, such as ED length of stay, were assessed concurrently. RESULTS Forty-nine patients were evaluated during four PDSA cycles. Improvement of ≥40% above baseline regarding recommended therapy administration was achieved across four PDSA cycles. Adherence to recommended therapy choice improved from 57% (baseline) to 100%, minimal laboratory evaluation from 14% to 83%, hematology consultation from 36% to 100%, and appropriate disposition from 71% to 100%. ED length of stay remained stable. CONCLUSION Implementation of a standardized algorithm for management of IDA secondary to HMB in adolescents in the ED increased adherence to evidence-based patient care.
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Affiliation(s)
- Josaura Fernandez Sanchez
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - Luisanna M Sánchez
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - Sarah S Kappa
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - Cecile L Karsenty
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - Madeleine O'Keefe
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - Meghan Shekar
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - Leander D Timothy
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - Chelsea B Vrana
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - Gladstone Airewele
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - YoungNa Lee-Kim
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - M Fatih Okcu
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - Clay T Cohen
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - Jacquelyn M Powers
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
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Van ‘t Klooster SJ, de Vaan A, van Leeuwen J, Pekel L, van Rijn-van Kortenhof NM, Engelen ET, van Greevenbroek W, Huisman A, Fischer K, Schutgens RE, van Galen KP. Heavy menstrual bleeding in adolescents: incidence, diagnostics, and management practices in primary care. Res Pract Thromb Haemost 2023; 7:102229. [PMID: 38077824 PMCID: PMC10704495 DOI: 10.1016/j.rpth.2023.102229] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 09/21/2023] [Accepted: 09/22/2023] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Heavy menstrual bleeding (HMB), self-reported by 37% of adolescents, can be the first sign of a bleeding disorder (BD) during adolescence. The Dutch general practitioner (GP) guideline demands laboratory diagnostics and referral for patients at risk for a BD. How often adolescents consult the GP for HMB and which diagnostic and management strategies are used are unknown. OBJECTIVES This study aims to estimate the incidence of HMB in adolescents in primary care and to identify diagnostic and management practices for HMB, considering the HMB GP guideline. METHODS Retrospective analyses of a GP network database containing over 200 Dutch GPs were performed. Adolescents aged 10 to 21 years, with a new diagnosis of HMB between 2010 and 2020, and a 6-month follow-up were eligible. The incidence rate and diagnostic and therapeutic strategy data were extracted. RESULTS We identified 1879 new diagnoses of HMB in adolescents. The average incidence rate was 7.91 per 1000 person-years. No diagnostic studies were performed in 67%. Laboratory studies were mainly restricted to hemoglobin levels (31%). Full coagulation screening occurred in 1.3%, and ferritin levels in 10%. Medication was prescribed in 65%; mostly hormonal treatment (56%) and/or nonsteroidal antiinflammatory drugs (NSAIDs) (18%). The referral rate was higher after >2 follow-up visits (6.7%) vs after 1 GP visit for HMB (1.6%; Odds ratio: 8.8; 95% CI: 5.1-15), mostly to gynecologists (>85%). CONCLUSION According to this GP database study, few adolescents visit their GP with HMB despite its high self-reported incidence. Most adolescents were prescribed hormonal contraception without further diagnostics. Referral was rare and mostly occurred after multiple follow-up visits.
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Affiliation(s)
- Stella J. Van ‘t Klooster
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anne de Vaan
- Center for Benign Hematology, Thrombosis and Hemostasis, van Creveldkliniek, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Jeanette van Leeuwen
- Department of Reproductive Medicine & Gynaecology, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Lynnda Pekel
- Netherlands Hemophilia Patients Society, Nijkerk, Gelderland, The Netherlands
| | | | - Eveline T. Engelen
- Dutch Healthcare Network for Women With Bleeding Disorders, UMC Utrecht, Utrecht, the Netherlands
| | - Willie van Greevenbroek
- Center for Benign Hematology, Thrombosis and Hemostasis, van Creveldkliniek, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Albert Huisman
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Center for Benign Hematology, Thrombosis and Hemostasis, van Creveldkliniek, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Roger E.G. Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, van Creveldkliniek, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Karin P.M. van Galen
- Center for Benign Hematology, Thrombosis and Hemostasis, van Creveldkliniek, University Medical Center, University Utrecht, Utrecht, The Netherlands
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3
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Baldwin MK, Ahmadzia HK, Bartlett DL, Bensen-Kennedy D, Desai V, Haley KM, Herman-Hilker SL, Kilgore AM, Kulkarni R, Lavin M, Luckey S, Matteson KA, Paulyson-Nuñez K, Philipp CS, Ragosta S, Rosen K, Rotellini D, Weyand AC. Building the foundation for a community-generated national research blueprint for inherited bleeding disorders: research to advance the health of people with inherited bleeding disorders with the potential to menstruate. Expert Rev Hematol 2023; 16:71-86. [PMID: 36920864 PMCID: PMC10020871 DOI: 10.1080/17474086.2023.2175660] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/30/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND People who have or had the potential to menstruate (PPM) with inherited bleeding disorders (BD) face particular challenges receiving appropriate diagnosis and care and participating in research. As part of an initiative to create a National Research Blueprint for future decades of research, the National Hemophilia Foundation (NHF) and American Thrombosis and Hemostasis Network conducted extensive all-stakeholder consultations to identify the priorities of PPM with inherited BDs and those who care for them. RESEARCH DESIGN AND METHODS Working group (WG) 4 of the NHF State of the Science Research Summit distilled community-identified priorities for PPM with inherited BDs into concrete research questions and scored their feasibility, impact, and risk. RESULTS WG4 identified important gaps in the foundational knowledge upon which to base optimal diagnosis and care for PPM with inherited BDs. They defined 44 top-priority research questions concerning lifespan sex biology, pregnancy and the post-partum context, uterine physiology and bleeding, bone and joint health, health care delivery, and patient-reported outcomes and quality-of-life. CONCLUSIONS The needs of PPM will best be advanced with research designed across the spectrum of sex and gender biology, with methodologies and outcome measures tailored to this population, involving them throughout.
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Affiliation(s)
- Maureen K. Baldwin
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Homa K. Ahmadzia
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | | | | | - Vidhi Desai
- CSL Behring, King of Prussia, Pennsylvania, USA
| | - Kristina M. Haley
- The Hemophilia Center, Oregon Health and Science University, Portland, Oregon, USA
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Sherry L. Herman-Hilker
- Hemophilia and Coagulation Disorders Program, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Roshni Kulkarni
- MSU Center of Bleeding and Clotting Disorders, Department Pediatrics and Human Development, Michigan State University, East Lansing, Michigan, USA
| | - Michelle Lavin
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Coagulation Centre, St. James’s Hospital, Dublin, Ireland
| | - Shari Luckey
- Hemophilia Foundation of Michigan, Ypsilanti, Michigan, USA
| | - Kristen A. Matteson
- Department of Obstetrics and Gynecology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Kristin Paulyson-Nuñez
- Duke Health Women & Children’s Services, Duke University Health Systems, Durham, North Carolina, USA
| | - Claire S. Philipp
- Division of Hematology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | | | - Kimberly Rosen
- Bayer HealthCare Pharmaceuticals, Whippany, New Jersey, USA
| | | | - Angela C. Weyand
- Division of Pediatric Hematology and Oncology, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Kalvehalli Kashinath S, Kouides PA. The diagnosis, natural history, and management of von Willebrand disease in women in the age of guidelines. Expert Rev Hematol 2023:1-16. [PMID: 36609196 DOI: 10.1080/17474086.2023.2166925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Women and girls with bleeding disorders face multiple bleeding challenges throughout their life. The most significant morbidity and mortality are due to heavy menstrual bleeding and postpartum hemorrhage in their reproductive years. The ASH/ISTH/NHF/WFH 2021 guidelines on diagnosing and managing von Willebrand disease (VWD) provide several new updates. AREAS COVERED Women with VWD have a higher prevalence of heavy menstrual bleeding. The subpopulation of adolescents is particularly vulnerable, as the diagnosis is often delayed with increased comorbidity of iron deficiency anemia and associated symptoms. A detailed review is done on the prevalence of bleeding-related complications, especially heavy menstrual bleeding (HMB) and post-partum hemorrhage (PPH). The management strategies are also reviewed in detail, with a specific focus on the target factor levels and the use of antifibrinolytics. EXPERT OPINION The 2021 ASH/ISTH/NHF/WFH diagnostic and management recommendations are reviewed with a specific focus on hormonal methods of HMB management and antifibrinolytics in this situation. The reviewed topics include neuraxial anesthesia, factor cutoff, and tranexamic acid use in the postpartum period.
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Affiliation(s)
- Sanjana Kalvehalli Kashinath
- Department of Hematology Oncology, Mary M. Gooley Hemophilia Center, Inc., The Rochester General Hospital, 14621, Rochester, NY, USA
| | - Peter A Kouides
- Department of Hematology Oncology, Mary M. Gooley Hemophilia Center, Inc., The Rochester General Hospital, 14621, Rochester, NY, USA.,Department of Hematology Oncology, University of Rochester School of Medicine, Rochester, NY, USA
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Tàssies Penella M. Papel de los trastornos de la hemostasia en el sangrado uterino anormal. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2023. [DOI: 10.1016/j.gine.2022.100820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Byams VR, Miller CH, Bethea FM, Abe K, Bean CJ, Schieve LA. Bleeding Disorders in Women and Girls: State of the Science and CDC Collaborative Programs. J Womens Health (Larchmt) 2022; 31:301-309. [PMID: 35275742 PMCID: PMC11005793 DOI: 10.1089/jwh.2022.0008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Women and girls with bleeding disorders experience abnormal and excessive bleeding that can negatively impact their overall health and quality of life. In this report, we provide an overview of the biology, types, clinical care, and state of the science related to bleeding disorders in girls and women and describe Centers for Disease Control and Prevention (CDC) activities related to (1) surveillance of bleeding disorders in women; (2) scientific review, research, and collaboration to inform health care gaps in identifying and caring for women with bleeding disorders; and (3) development of health promotion and education programs to bring awareness about bleeding disorders to both women and girls in the population at large and various health care providers who care for women. Findings generated from surveillance and research activities inform the development of new public health programs aimed at improving diagnostic and health care services and empowering women with bleeding disorders with the knowledge they need to navigate a complex health care system with the need for specialty care services. Additional work is needed to improve provider awareness and understanding of the unique needs of women and girls with bleeding disorders to achieve appropriate care and treatment and ensure optimal outcomes and quality of life.
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Affiliation(s)
- Vanessa R. Byams
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Connie H Miller
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
- Synergy America, Inc., Duluth, GA
| | - Fiona M. Bethea
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Karon Abe
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Christopher J. Bean
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Laura A. Schieve
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
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Hou MY, Davis SL, Ponzini MD, Wilson MD, Pawar A, Melo J, Chen MJ. Complex family planning and pediatric hematology oncology integrated clinic for young people with blood disorders and heavy or abnormal menstrual bleeding. Contraception 2022; 108:69-72. [PMID: 35031306 PMCID: PMC8901554 DOI: 10.1016/j.contraception.2021.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/19/2021] [Accepted: 12/22/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe practice patterns of an integrated complex family planning-pediatric hematology oncology clinic for patients with blood disorders STUDY DESIGN: : We retrospectively evaluated the outcomes of patients who had an initial consultation for blood disorders impacting menstrual bleeding in an integrated complex family planning-pediatric hematology oncology clinic from October 2015 to September 2020. We reviewed all charts to extract medical and gynecologic history, blood disorder diagnosis, hormonal treatment prior to and following initial consultation, subsequent visits to the integrated clinic, and hormonal treatment up to 24 months after initial consultation. RESULTS We saw 47 patients; their most common blood disorder diagnosis was protein defect (14/47, 30%). Most patients (30/47, 64%) were not using any hormonal treatment prior to their initial consultation. After the initial consultation, 26 (55%) elected to start, change, or discontinue hormonal treatment for abnormal menstrual bleeding, the most common treatment being combined hormonal contraception (CHC, 22/47, 47%), alone or as dual therapy. Over the study duration, 36 patients (77%) initiated, changed, or discontinued their hormone treatment, 22 (61%) of whom changed their treatment plan more than once. CHC usage decreased from 19/47 (40%) to 8/37 (22%) and hormonal device usage, particularly the implant, increased from 9/47 (19%) to 11/37 (30%) over the 24 months from initial consultation. CONCLUSION Most patients in an integrated complex family planning-pediatric hematology oncology clinic will change their menstrual bleeding hormone treatment with initial consultation, although management may require multiple changes. The most common treatment 24 months following the initial consultation was hormonal devices. IMPLICATIONS Patients with blood disorders affecting menstrual bleeding have complex needs that could be addressed by an integrated complex family planning-pediatric hematology oncology clinic. Most patients require multiple changes in treatment to achieve adequate control of their bleeding, and patients were more likely to choose hormonal devices for management over time.
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Affiliation(s)
- Melody Y Hou
- Department of Obstetrics and Gynecology, Family Planning, University of California, Davis; Sacramento CA USA.
| | - Sophia L Davis
- University of California, Davis School of Medicine; Sacramento CA USA
| | - Matthew D Ponzini
- Department of Public Health Sciences, University of California, Davis Sacramento CA
| | - Machelle D Wilson
- Department of Public Health Sciences, University of California, Davis Sacramento CA
| | - Anjali Pawar
- Department of Pediatrics, Hematology Oncology, University of California, Davis; Sacramento CA USA
| | - Juliana Melo
- Department of Obstetrics and Gynecology, Family Planning, University of California, Davis; Sacramento CA USA
| | - Melissa J Chen
- Department of Obstetrics and Gynecology, Family Planning, University of California, Davis; Sacramento CA USA
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van Galen K, Lavin M, Skouw-Rasmussen N, Fischer K, Noone D, Pollard D, Mauser-Bunschoten E, Khair K, Gomez K, van Loon E, Bagot CN, Elfvinge P, d'Oiron R, Abdul-Kadir R. European principles of care for women and girls with inherited bleeding disorders. Haemophilia 2021; 27:837-847. [PMID: 34343384 DOI: 10.1111/hae.14379] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/29/2021] [Accepted: 07/07/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Despite increasing awareness of issues faced by women and girls with inherited BDs (WGBD), standards of care are lacking, with disparities in diagnosis and treatment for WGBD across Europe. We aimed to develop practical principles of care (PoC) to promote standardization of care for WGBD within European Haemophilia Treatment and Comprehensive Care Centres (HTC/CCCs). METHODS The co-creation process, supported by the European Association for Haemophilia and Allied Disorders, consisted of four multidisciplinary meetings with health care providers (HCPs) experienced in WGBD care, and European Haemophilia Consortium representatives, combined with broad patient and HCP consultations in the European haemophilia community. Relevant medical societies outside Europe were contacted for confirmation. RESULTS We developed ten PoC for WGBD, stressing the importance and benefits of a centralized, multidisciplinary, comprehensive, family-centred approach to support and manage WGBD during all life stages. These PoC emphasise the right to equitable access and quality of care for all people with BDs, irrespective of gender. Multiple medical societies outside Europe also confirmed their support for endorsement. CONCLUSIONS Ten PoC for WGBD evolved from an iterative process among stakeholders, supported by relevant medical societies worldwide. These PoC can serve as a benchmark for diagnosis and comprehensive multidisciplinary management of WGBD, and improve awareness of their unique challenges. They offer a framework to guide HTC/CCCs in providing equitable care for all WGBD, both in their own services and in other healthcare settings. Implementation of these principles aims to positively impact the health, wellbeing and quality of life for WGBD.
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Affiliation(s)
- Karin van Galen
- Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Michelle Lavin
- Irish Centre for Vascular Biology, School of Pharmacy and Biomedical Sciences, RCSI, Dublin and National Coagulation Centre, St. James' Hospital, Dublin, Ireland
| | | | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Declan Noone
- President, European Haemophilia Consortium, Brussels, Belgium
| | - Debra Pollard
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
| | | | - Kate Khair
- Director of Research, Haemnet, London, UK
| | - Keith Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
| | | | | | - Petra Elfvinge
- Department of Haematology, Karolinska University, Stockholm, Sweden
| | - Roseline d'Oiron
- Centre de Référence de l'Hémophilie et des Maladies Hémorragiques Constitutionnelles, APHP Paris Saclay - Hôpital Bicêtre and Inserm, U 1176 Le Kremlin Bicêtre, France
| | - Rezan Abdul-Kadir
- Department of Obstetrics and Gynaecology, Royal Free London NHS Foundation Trust and Institute for Women's Health, University College London, London, UK
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Walsh C, Boggio L, Brown-Jones L, Miller R, Hawk S, Savage B, Hansen K, Molter D, Baumann K, Dunn S, Skinner MW, Haugstad K, Johnson S, Davenport T, Bradbury M, Witkop M, Saad H, Cooper DL. Identified unmet needs and proposed solutions in mild-to-moderate haemophilia: A summary of opinions from a roundtable of haemophilia experts. Haemophilia 2021; 27 Suppl 1:25-32. [PMID: 33522653 DOI: 10.1111/hae.14168] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 08/18/2020] [Accepted: 09/15/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The experiences of patients with mild-to-moderate haemophilia differ from those of patients with severe haemophilia or those without a bleeding disorder and include a challenging diagnosis and variability in bleeding symptoms and treatment needs. In addition, there is a significant lack of data on mild-to-moderate haemophilia, and many unmet needs remain to be identified and addressed in this group of patients. METHODS Challenges for these patients, including women with haemophilia, were identified during a roundtable meeting attended by a group of US-based experts including healthcare professionals (e.g., physicians, nurses, and physical therapists) and patients who live with a bleeding disorder. RESULTS Identified unmet needs included a lack of proper education on the management of their disorder and prompt treatment of bleeds, absenteeism from school and work, and challenges with personal relationships. Initiatives to assist with alleviating these unmet needs were proposed and include suggestions for healthcare professionals, haemophilia treatment centres (HTCs) and national and local organizations within the bleeding disorders community. These included HTC and community engagement programmes for patients with mild-to-moderate haemophilia, revised transition guidelines for these patients as they approach adulthood and revised diagnostic classification of mild and moderate haemophilia. Challenges unique to women with haemophilia and ways to address these issues were also discussed. CONCLUSION This paper summarizes the challenges, initiatives and suggestions that were identified by the haemophilia experts during the roundtable meeting.
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Affiliation(s)
| | - Lisa Boggio
- Rush Hemophilia and Thrombophilia Center, Chicago, IL, USA
| | | | | | - Sarah Hawk
- Oklahoma Center for Bleeding Disorders, Oklahoma City, OK, USA
| | - Brittany Savage
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN, USA
| | - Kerry Hansen
- Center for Bleeding and Clotting Disorders, M Health Fairview, Minneapolis, MN, USA
| | - Don Molter
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN, USA
| | - Kim Baumann
- Center for Bleeding and Clotting Disorders, M Health Fairview, Minneapolis, MN, USA
| | - Spencer Dunn
- Center for Comprehensive Care and Diagnosis of Inherited Bleeding Disorders, Orange, CA, USA
| | - Mark W Skinner
- Institute for Policy Advancement Ltd, Washington, DC, USA
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10
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Zia A, Kouides P, Khodyakov D, Dao E, Lavin M, Kadir RA, Othman M, Bauman D, Halimeh S, Winikoff R, Revel-Vilk S. Standardizing care to manage bleeding disorders in adolescents with heavy menses-A joint project from the ISTH pediatric/neonatal and women's health SSCs. J Thromb Haemost 2020; 18:2759-2774. [PMID: 32573942 DOI: 10.1111/jth.14974] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 05/19/2020] [Accepted: 06/08/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Bleeding disorders (BD) are under-recognized in adolescents with heavy menstrual bleeding (HMB). OBJECTIVES The lack of clinical guidelines and variable symptomatic management of HMB created the imperative to standardize HMB care to identify and manage BD in adolescents. METHODS We convened an international working group (WG), utilized the results of a literature review to define knowledge gaps in HMB care, and used the collective clinical experience of the WG to develop care considerations for adolescents with BD and HMB. We then solicited input on the appropriateness of HMB care considerations from expert stakeholders representing hematology, adolescent medicine, and obstetrics-gynecology. We conducted an expert panel online, using the ExpertLens platform. During a three-round online modified-Delphi process, the expert panel rated the appropriateness of 21 care considerations using a 9-point scale to designate care as appropriate (7-9), uncertain (4-6), or inappropriate (1-3) covering screening for BD, the laboratory work-up, and management of adolescents with BD that present with HMB. We used the RAND/UCLA appropriateness method to determine the existence of consensus among the interdisciplinary panel of experts. RESULTS Thirty-nine experts participated in the panel. The experts rated fifteen HMB care considerations as appropriate, six as uncertain, and none as inappropriate. CONCLUSIONS The HMB care statements represent the first set of HMB care considerations in adolescents with BD, developed with broad expert input on appropriateness. Although likely to be of interest to a range of clinicians who routinely manage adolescents with HMB, additional research is required in many key areas.
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Affiliation(s)
- Ayesha Zia
- The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Division of Pediatric Hematology Oncology, Children's Health, Dallas, TX, USA
| | - Peter Kouides
- The University of Rochester and the Mary M. Gooley Hemophilia Treatment Center, Rochester, NY, USA
| | | | - Emily Dao
- RAND Corporation, Santa Monica, CA, USA
| | - Michelle Lavin
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Rezan Abdul Kadir
- The Royal Free Foundation Hospital and Institute for Women's Health, University College, London, UK
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, Queen's University Kingston, School of Baccalaureate Nursing, St Lawrence College Kingston, Kingston, ON, Canada
| | - Dvora Bauman
- Department of Pediatric and Adolescent Gynecology, Hadassah University Medical Center, Jerusalem, Israel
| | - Susan Halimeh
- Medical Thrombosis and Haemophilia Treatment Center, Duisburg, Germany
| | - Rochelle Winikoff
- Division of Hematology-Oncology, Sainte-Justine University Health Center, Montréal, Canada
| | - Shoshana Revel-Vilk
- Pediatric Hematology/Oncology Unit, Shaare Zedek Medical Center, Hebrew University Medical School, Jerusalem, Israel
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11
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Srivaths L, Minard CG, O'Brien SH, Wheeler AP, Mullins E, Sharma M, Sidonio R, Jain S, Zia A, Ragni MV, Kulkarni R, Dietrich JE, Kouides PA. The spectrum and severity of bleeding in adolescents with low von Willebrand factor-associated heavy menstrual bleeding. Blood Adv 2020; 4:3209-3216. [PMID: 32663297 PMCID: PMC7362347 DOI: 10.1182/bloodadvances.2020002081] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/29/2020] [Indexed: 01/31/2023] Open
Abstract
Low von Willebrand factor (VWF) in adults is associated with significant bleeding, most notably heavy menstrual bleeding (HMB) and postpartum hemorrhage, although this has not been characterized in adolescents. The objectives of this analysis of a multicenter single arm observational cohort study in adolescents with low VWF-associated HMB were to describe the bleeding phenotype, HMB severity, and related complications. Eligibility criteria included postmenarchal females <21 years of age with HMB (Pictorial Blood Assessment Chart [PBAC] score >100) and low VWF (2 values of VWF activity ≥30 and ≤50 IU/dL). Patients diagnosed with other bleeding disorders were ineligible. Clinical phenotype data, including PBAC and Bleeding Assessment Tool (BAT) scores, laboratory data, and HMB management/outcome details, were extracted. Patient demographics and clinical characteristics were summarized as medians with minimum/maximum values or frequencies with percentages. Groups were compared using a Wilcoxon rank-sum test or Fisher's exact test. A total of 113 patients met inclusion criteria, and 2 were excluded. Ninety four percent had a significant bleeding phenotype (BAT score >2), with predominantly mucocutaneous bleeding (32%-44%), postprocedural/surgical bleeding (15%), and severe HMB (BAT HMB domain score ≥2; 90%). Bleeding complications included iron deficiency (60%), anemia (21%), transfusion (12%), and hospitalization (10%). Desmopressin challenge response in subjects tested was good and sustained. Several (48%) required combined therapy for HMB (hormonal/hemostatic), and one third did not show improvement despite therapy. Our results suggest that adolescent females with low VWF have a significant bleeding phenotype and resultant complications warranting a focus on prompt diagnosis, appropriate therapy, and prevention of complications.
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Affiliation(s)
- Lakshmi Srivaths
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Charles G Minard
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH
| | - Allison P Wheeler
- Department of Pediatrics, Vanderbilt University Medical Center, Vanderbilt, TN
| | - Eric Mullins
- Division of Hematology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital, Cincinnati, OH
| | - Mukta Sharma
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO
| | - Robert Sidonio
- Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, GA
| | - Shilpa Jain
- Department of Pediatrics, University of Buffalo, Buffalo, NY
| | - Ayesha Zia
- Department of Pediatrics, The University of Texas, Southwestern, Dallas, TX
| | - Margaret V Ragni
- Division of Hematology/Oncology, University of Pittsburgh, Pittsburgh, PA
| | - Roshni Kulkarni
- Department of Pediatrics and Human Development, Michigan State University, East Lansing, MI
| | - Jennifer E Dietrich
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX; and
| | - Peter A Kouides
- Department of Medicine, University of Rochester, Rochester, NY
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12
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Soucie JM, Miller CH, Dupervil B, Le B, Buckner TW. Occurrence rates of haemophilia among males in the United States based on surveillance conducted in specialized haemophilia treatment centres. Haemophilia 2020; 26:487-493. [PMID: 32329553 DOI: 10.1111/hae.13998] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/03/2020] [Accepted: 03/23/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Estimates of the size and characteristics of the US haemophilia population are needed for healthcare planning and resource needs assessment. A network of comprehensive haemophilia treatment centres (HTCs) located throughout the United States receives federal support for diagnosis and management of haemophilia and other rare bleeding disorders. AIM Estimate the incidence and prevalence of haemophilia among US males using the HTC network. METHODS During the period 2012-2018, de-identified surveillance data were collected on all males who visited an HTC that included year of birth, gender, race, Hispanic ethnicity, residence zip code, haemophilia type and severity. Data from all patients were used to calculate period prevalence by haemophilia type, severity and state of residence. Data from a subset of patients born 1995-2014 were used to estimate incidence rates over the 20-year period. RESULTS During the period, 21 748 males with haemophilia visited the HTCs resulting in an age-adjusted prevalence of 15.7 cases per 100 000 males (12 for haemophilia A and 3.7 for haemophilia B). Prevalence was higher among whites (15.1) than blacks (12.4) or Hispanics of either race (12.4). State-specific prevalence varied from 1.6 to 23.3 cases per 100 000. Based on 9587 males born during the index period, the average haemophilia incidence was 1 case per 4334 live male births. CONCLUSION Based on these data, we estimate that there are between 29 761 and 32 985 males with haemophilia living in the United States today, the majority of whom receive comprehensive care in specialized clinical centres.
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Affiliation(s)
- John Michael Soucie
- Division of Blood Disorders, Centers for Disease Control and Prevention, Atlanta, GA, USA.,Synergy America, Inc., Duluth, GA, USA
| | - Connie H Miller
- Division of Blood Disorders, Centers for Disease Control and Prevention, Atlanta, GA, USA.,Synergy America, Inc., Duluth, GA, USA
| | - Brandi Dupervil
- Division of Blood Disorders, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Binh Le
- Division of Blood Disorders, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Tyler W Buckner
- Division of Hematology, University of Colorado School of Medicine, Aurora, CO, USA
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13
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Eising HP, Sanders YV, de Meris J, Leebeek FWG, Meijer K. Women prefer proactive support from providers for treatment of heavy menstrual bleeding: A qualitative study in adult women with moderate or severe Von Willebrand disease. Haemophilia 2018; 24:950-956. [DOI: 10.1111/hae.13552] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2018] [Indexed: 12/24/2022]
Affiliation(s)
- H. P. Eising
- Department of Obstetrics and Gynaecology; Gelre Hospital; Apeldoorn The Netherlands
| | - Y. V. Sanders
- Division of Haemostasis and Thrombosis; Department of Haematology; Erasmus Medical Centre; University of Rotterdam; Rotterdam The Netherlands
| | - J. de Meris
- Netherlands Hemophilia Society; Leiden The Netherlands
| | - F. W. G. Leebeek
- Division of Haemostasis and Thrombosis; Department of Haematology; Erasmus Medical Centre; University of Rotterdam; Rotterdam The Netherlands
| | - K. Meijer
- Division of Haemostasis and Thrombosis; Department of Haematology; University Medical Centre Groningen; University of Groningen; Groningen The Netherlands
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