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Strauss AC, Marquardt N, Oldenburg J, Pieper CC, Attenberger U, Hmida J, Rommelspacher C, Koob S, Strauss AC. Self-conducted sonographic monitoring of the knee in patients with haemophilia-A feasibility study. Haemophilia 2024; 30:1025-1031. [PMID: 38825768 DOI: 10.1111/hae.15056] [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: 01/10/2024] [Revised: 03/30/2024] [Accepted: 04/16/2024] [Indexed: 06/04/2024]
Abstract
INTRODUCTION/AIM To evaluate whether patients with haemophilia (PwH) can be enabled to perform ultrasonography (US) of their knees without supervision according to the Haemophilia Early Arthropathy Detection with Ultrasound (HEAD-US) protocol and whether they would be able to recognize pathologies. METHODS Five PwH (mean age 29.6 years, range 20-48 years) were taught the use of a portable US device and the HEAD-US protocol. Subsequently, the patients performed US unsupervised at home three times a week for a total of 6 weeks with a reteaching after 2 weeks. All images were checked for mapping of the landmarks defined in the HEAD-US protocol by a radiologist. In a final test after the completion of the self-sonography period, participants were asked to identify scanning plane and potential pathology from US images of other PwH. RESULTS On the images of the self-performed scans, 82.7% of the possible anatomic landmarks could be identified and 67.5% of the requested images were unobjectionable, depicting 100% of the required landmarks. There was a highly significant improvement in image quality following reteaching after 2 weeks (74.80 ± 36.88% vs. 88.31 ± 19.87%, p < .001). In the final test, the participants identified the right scanning plane in 85.0% and they correctly identified pathology in 90.0% of images. CONCLUSION Appropriately trained PwH can perform the HEAD-US protocol of their knee with high quality and are capable to identify pathologic findings on these standardized images. Asynchronous tele-sonography could enable early therapy adjustment and thereby possibly reduce costs.
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Affiliation(s)
- Anna Christina Strauss
- Department of Diagnostic and Interventional Radiology, University of Bonn, Bonn, Germany
| | - Natascha Marquardt
- Institute for Experimental Haematology and Transfusion Medicine, University of Bonn, Bonn, Germany
| | - Johannes Oldenburg
- Institute for Experimental Haematology and Transfusion Medicine, University of Bonn, Bonn, Germany
| | - Claus Christian Pieper
- Department of Diagnostic and Interventional Radiology, University of Bonn, Bonn, Germany
| | - Ulrike Attenberger
- Department of Diagnostic and Interventional Radiology, University of Bonn, Bonn, Germany
| | - Jamil Hmida
- Department of Orthopaedics and Trauma Surgery, University of Bonn, Bonn, Germany
| | | | - Sebastian Koob
- Department of Orthopaedics and Trauma Surgery, University of Bonn, Bonn, Germany
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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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van Leeuwen FHP, Foppen W, de Jong PA, van Dijk WE, Blokzijl J, Fischer K, Timmer MA. Ultrasound in addition to clinical assessment of acute musculoskeletal complaints in bleeding disorders: impact on patient management. Res Pract Thromb Haemost 2024; 8:102372. [PMID: 38590365 PMCID: PMC10999475 DOI: 10.1016/j.rpth.2024.102372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/25/2024] [Accepted: 03/07/2024] [Indexed: 04/10/2024] Open
Abstract
Background Ultrasound is increasingly used for musculoskeletal assessment in hemophilia care. Objectives To evaluate the impact of point-of-care ultrasound added to clinical assessment for diagnosis and treatment of acute musculoskeletal episodes in a heterogeneous cohort of children and adults with hemophilia and von Willebrand disease (VWD). Methods This prospective cross-sectional study consecutively included children and adults with hemophilia or VWD who visited the outpatient clinic with acute musculoskeletal complaints between March 2020 and May 2023. For all episodes, initial diagnosis and treatment determined by clinical assessment were recorded on a case report form. Subsequently, a physiotherapist (M.A.T. and J.B.) with knowledge of the clinical diagnosis performed point-of-care ultrasound. After ultrasound, updated diagnosis and treatment were recorded. Diagnosis and treatment before and after ultrasound were compared, and proportions of change with 95% CIs were determined. Results We evaluated 77 episodes in 67 patients (median age, 24 years; IQR, 13-42 years). Before ultrasound, 37 joint bleeds, 13 muscle bleeds, and 27 other diagnoses were diagnosed. After ultrasound, 33 joint bleeds, 11 muscle bleeds, and 33 other diagnoses were confirmed. The diagnosis changed in 28 of 77 episodes (36%; 95% CI, 26%-48%). Nine joint bleeds and 2 muscle bleeds were missed by clinical assessment. Ultrasound findings changed treatment strategy in 30 of 77 episodes (39%; 95% CI, 28%-51%). Conclusion Ultrasound in addition to clinical assessment of acute musculoskeletal complaints in people with hemophilia and VWD has an impact on diagnosis (36%) and treatment (39%), which supports the use of ultrasound in acute musculoskeletal complaints in hemophilia and VWD.
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Affiliation(s)
- Flora Hendrica Pieternella van Leeuwen
- Department of Radiology and Nuclear Medicine, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Wouter Foppen
- Department of Radiology and Nuclear Medicine, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Pim A. de Jong
- Department of Radiology and Nuclear Medicine, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Wobke E.M. van Dijk
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Johan Blokzijl
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Merel A. Timmer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Manon-Jensen T, Tangada S, Bager C, Chowdary P, Klamroth R, von Drygalski A, Windyga J, Escobar M, Frederiksen P, Engl W, Ewenstein B, Karsdal M. Evaluation of collagen turnover biomarkers as an objective measure for efficacy of treatment with rurioctocog alfa pegol in patients with hemophilia A: a secondary analysis of a randomized controlled trial. J Thromb Haemost 2024; 22:90-100. [PMID: 37717853 DOI: 10.1016/j.jtha.2023.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Patients with hemophilia who have recurrent hemarthroses develop hemophilic arthropathy (HA). Regular prophylaxis with factor (F) VIII (FVIII) can reduce HA, but there is a need for objective outcome measures to evaluate treatment efficacy. OBJECTIVES Evaluate and assess collagen turnover biomarkers in patients with hemophilia A to determine the efficacy of rurioctocog alfa pegol treatment and understand their potential as tools for guiding treatment decisions and monitoring outcomes. METHODS Joint remodeling was assessed by analyzing serum levels of collagen remodeling products at baseline and months 3, 6, 9, and 12 in a 98 patient subset receiving pharmacokinetics-guided prophylaxis with rurioctocog alfa pegol, targeting FVIII trough levels of 1 to 3 International Units (IU)/dL or 8 to 12 IU/dL (PROPEL study, NCT0285960). RESULTS Basement membrane metabolism-related type 4 collagen remodeling products (C4M and PRO-C4) decreased after 3 months at all time points by up to 25% at 1 to 3 IU/dL (P = .049, P < .0001) and 8 to 12 IU/dL FVIII trough levels (P = .0002, P < .0001). Interstitial tissue metabolism-related type 3 (C3M) and 5 (PRO-C5) collagen remodeling products decreased after 3 months, by up to 19% at 1 to 3 IU/dL FVIII trough level (P = .0001, P = .009) and 23% at 8 to 12 IU/dL FVIII trough level (P = .0002, P = .001). An increase of up to 12% was seen for cartilage metabolism-related type 2 collagen product (PRO-C2, not C2M) after 6 months at both trough levels (P = .01, P = .005). When stratified by prior treatment, changes in C3M (P = .03) and C4M (P = .02) levels were observed between trough levels for prior on-demand treatment but not for prophylaxis prior to study entry. CONCLUSION Joint improvement measured by collagen remodeling biomarkers specific to the basement membrane, interstitial matrix, and cartilage was seen with pharmacokinetics-guided prophylaxis. These collagen remodeling biomarkers warrant further exploration as biomarkers to guide treatment toward improvement in HA.
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Affiliation(s)
| | - Srilatha Tangada
- Takeda Development Center Americas, Inc, Cambridge, Massachusetts, USA
| | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Robert Klamroth
- Vascular Medicine and Haemostaseology, Vivantes Klinikum im Friedrichschain, Berlin, Germany
| | - Annette von Drygalski
- Hemophilia and Thrombosis Treatment Center, UC San Diego Health, San Diego, California, USA
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Miguel Escobar
- University of Texas Health and Science Center at Houston, Houston, Texas, USA
| | | | - Werner Engl
- Baxalta Innovations GmbH, a Takeda company, Vienna, Austria
| | - Bruce Ewenstein
- Takeda Development Center Americas, Inc, Cambridge, Massachusetts, USA
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Barnes RFW, Aguero P, Hanacek C, Flores A, Steiner B, Bailey C, Quon DV, Kruse-Jarres R, von Drygalski A. Consistency of serial ultrasonographic joint tissue measurements by the Joint tissueActivity and Damage Exam (JADE) protocol in relation to hemophilic joint health parameters. BMC Musculoskelet Disord 2023; 24:299. [PMID: 37061676 PMCID: PMC10105411 DOI: 10.1186/s12891-023-06419-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 04/11/2023] [Indexed: 04/17/2023] Open
Abstract
OBJECTIVES The Joint tissueActivity and Damage Exam (JADE) is a point-of-care (POC) musculoskeletal ultrasound (MSKUS) protocol for non-radiologists to evaluate hemophilic arthopathy. Our aim was to determine the consistency of cross-sectional analyses of direct tissue measurements (JADE protocol) and clinical Hemophilia Joint Health Score [HJHS] and functional joint assessments (arc) at three clinic visits. METHODS We prospectively studied adults (n = 44) with hemophilia (A or B) of any severity and arthropathy at 3 North American sites. We assessed HJHS, total arc, and JADE parameters (bilateral elbows, ankles, and knees) at study entry, at ≈12-18 months, and at ≈24-36 months, and used MSKUS to evaluate painful episodes between study visits. JADE measurements included osteochondral alterations, cartilage thickness, and soft tissue expansion at sentinel positions. Associations between joint HJHS and total arc with each JADE variable were examined with random intercept models. RESULTS At each visit increasing HJHS and decreasing total arc were associated in the expected direction with increasing length of OAs and soft tissue expansion in all joints, and decreasing cartilage thickness in the knee. However, HJHS associations with cartilage thickness were U-shaped for elbow and ankle (i.e. cartilage thinning and thickening). Associations between total arc and cartilage thickness followed a similar curve. (Near) normal levels of both joint parameters (HJHS and total arc) were associated with normal ranges of cartilage thickness. JADE views were also helpful to detect hemarthrosis in association with joint pains. CONCLUSIONS POC MSKUS applying direct tissue measurements using the JADE protocol provided reproducible cross-sectional associations with joint health outcomes on three visits. These findings advance protocol validation and enable iterative adaptations resulting in JADE protocol version 2.
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Affiliation(s)
- Richard F W Barnes
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, 9333 Genesee Avenue, St 310, San Diego, CA, 92122, USA
| | - Peter Aguero
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, 9333 Genesee Avenue, St 310, San Diego, CA, 92122, USA
| | - Cris Hanacek
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, 9333 Genesee Avenue, St 310, San Diego, CA, 92122, USA
| | - Andres Flores
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, 9333 Genesee Avenue, St 310, San Diego, CA, 92122, USA
- Department of Physical Medicine and Rehabilitation, University of California San Diego, San Diego, CA, USA
| | - Bruno Steiner
- Washington Center for Bleeding Disorders, Seattle, WA, USA
| | - Cindy Bailey
- Orthopaedic Hemophilia Treatment Center at Orthopaedic Institute for Children Los Angeles, Los Angeles, CA, USA
| | - Doris V Quon
- Orthopaedic Hemophilia Treatment Center at Orthopaedic Institute for Children Los Angeles, Los Angeles, CA, USA
| | | | - Annette von Drygalski
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, 9333 Genesee Avenue, St 310, San Diego, CA, 92122, USA.
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6
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Tran DQ, Benson CC, Boice JA, Chitlur M, Dunn AL, Escobar MA, Gupta K, Johnsen JM, Jorgenson J, Martin SD, Martin S, Meeks SL, Narvaez AA, Quon DV, Reding MT, Reiss UM, Savage B, Schafer K, Steiner B, Thornburg C, Volland LM, von Drygalski A. Building the foundation for a community-generated national research blueprint for inherited bleeding disorders: research priorities to transform the care of people with hemophilia. Expert Rev Hematol 2023; 16:19-37. [PMID: 36920859 PMCID: PMC10020869 DOI: 10.1080/17474086.2023.2171981] [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: 12/05/2022] [Accepted: 01/19/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Decades of research have transformed hemophilia from severely limiting children's lives to a manageable disorder compatible with a full, active life, for many in high-income countries. The direction of future research will determine whether exciting developments truly advance health equity for all people with hemophilia (PWH). National Hemophilia Foundation (NHF) and American Thrombosis and Hemostasis Network conducted extensive inclusive all-stakeholder consultations to identify the priorities of people with inherited bleeding disorders and those who care for them. RESEARCH DESIGN AND METHODS Working group (WG) 1 of the NHF State of the Science Research Summit distilled the community-identified priorities for hemophilia A and B into concrete research questions and scored their feasibility, impact, and risk. RESULTS WG1 defined 63 top priority research questions concerning arthropathy/pain/bone health, inhibitors, diagnostics, gene therapy, the pediatric to adult transition of care, disparities faced by the community, and cardiovascular disease. This research has the potential to empower PWH to thrive despite lifelong comorbidities and achieve new standards of wellbeing, including psychosocial. CONCLUSIONS Collaborative research and care delivery will be key to capitalizing on current and horizon treatments and harnessing technical advances to improve diagnostics and testing, to advance health equity for all PWH.
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Affiliation(s)
- Duc Q. Tran
- Hemophilia of Georgia Center for Bleeding & Clotting Disorders of Emory, Emory University, Atlanta, Georgia, USA
| | - Craig C. Benson
- Sanofi ¬ Rare and Rare Blood Disorders Development, Cambridge, Massachusetts, USA
| | | | - Meera Chitlur
- Division of Hematology/Oncology, Central Michigan University College of Medicine, Detroit, Michigan, USA
| | - Amy L. Dunn
- Division of Hematology, Oncology and Bone Marrow Transplant, Nationwide Children’s Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Miguel A. Escobar
- Division of Hematology, UTHealth Houston McGovern Medical School, Gulf States Hemophilia and Thrombophilia Center, Houston, Texas, USA
| | - Kalpna Gupta
- Center for Bleeding and Clotting Disorders, Division Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
- Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, California, USA
| | - Jill M. Johnsen
- Bloodworks Northwest, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Washington Center for Bleeding Disorders, Seattle, Washington, USA
| | | | | | - Suzanne Martin
- Bleeding Disorders Association of South Carolina, Greenville, South Carolina, USA
| | - Shannon L. Meeks
- Hemophilia of Georgia Center for Bleeding & Clotting Disorders of Emory, Emory University, Atlanta, Georgia, USA
- Children’s Healthcare of Atlanta Inc Aflac Cancer and Blood Disorders Center, Atlanta, Georgia, USA
| | - Alfredo A Narvaez
- Louisiana Center for Bleeding & Clotting Disorders, Tulane University, New Orleans, Louisiana, USA
| | - Doris V. Quon
- Orthopaedic Hemophilia Treatment Center, Orthopaedic Hospital of Los Angeles, California, USA
| | - Mark T. Reding
- Center for Bleeding and Clotting Disorders, Division Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ulrike M. Reiss
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Brittany Savage
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - Kim Schafer
- Davis Hemostasis and Thrombosis Center, University of California Davis, Sacramento, California, USA
| | - Bruno Steiner
- Washington Center for Bleeding Disorders, Seattle, Washington, USA
| | - Courtney Thornburg
- Rady Children’s Hospital-San Diego, San Diego, California, USA
- UC San Diego, La Jolla, California, USA
| | | | - Annette von Drygalski
- Hemophilia & Thrombosis Treatment Center, University of California San Diego, California, USA
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Aguero P, Barnes RF, Flores A, von Drygalski A. Teleguidance for Patient Self-Imaging of Hemophilic Joints Using Mobile Ultrasound Devices: A Pilot Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:701-712. [PMID: 35984090 DOI: 10.1002/jum.16084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/16/2022] [Accepted: 07/31/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Teleguidance on portable devices opens the possibility of joint self-imaging in persons with hemophilia (PWH). AIMS Determine the feasibility of patient self-imaging with/without teleguidance. METHODS Adult PWH received ultrasound teaching including 11 views for hemarthrosis detection in ankles, elbows, and knees. The patients acquired five randomly selected views with the Butterfly/IQ probe without assistance at 2, 6-8 weeks, and 3-4 months later, followed by teleguidance. Image acquisition was timed, patients identified anatomic landmarks, and image quality was graded. Questionnaires assessed the imaging experience. Hemophilia Joint Health Score (HJHS) indicated arthropathy status. RESULTS Of 132 PWH, 10 (median age 52 years) opted for study inclusion. Most had severe Hemophilia A, were white/non-Hispanic, with at least a high school degree and, overall, similar to the other 122 PWH. At 2 and 6 weeks after training, ~80% images were acquired correctly compared with 53% at 12 weeks. Accuracy of landmark recognition was ~55%. With teleguidance, all images were acquired correctly, with near-perfect image quality (P ≤ .01 compared with the 3-4 month time point). Median HJHS of scanned joints was 11.5 at each time point, demonstrating a similar spectrum of arthropathic changes. Median time of image acquisition was fast, and similar with or without teleguidance (median 01:04 [mm:ss] vs median 01:02), but differed slightly between arthropathic and non-arthropathic joints. Study participants and the imaging facilitator rated that it was easy to navigate mobile technology and acquire images with teleguidance. CONCLUSION Mobile ultrasound with teleguidance for joint self-imaging is feasible and warrants further exploration.
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Affiliation(s)
- Peter Aguero
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Richard Fw Barnes
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Andres Flores
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Annette von Drygalski
- Department of Medicine, University of California San Diego, La Jolla, California, USA
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8
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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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9
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Gallastegui N, Steiner BUK, Aguero P, Bailey C, Kruse-Jarres R, Quon DV, Hanacek C, Volland LM, Barnes RFW, von Drygalski A. The role of point-of-Care Musculoskeletal Ultrasound for Routine Joint evaluation and management in the Hemophilia Clinic - A Real World Experience. BMC Musculoskelet Disord 2022; 23:1111. [PMID: 36539778 PMCID: PMC9768915 DOI: 10.1186/s12891-022-06042-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The use of musculoskeletal ultrasound (MSKUS) for point-of-care (POC) evaluation of hemophilic arthropathy is growing rapidly. However, the extent to which MSKUS influences clinical treatment decisions is unknown. METHODS We conducted a three-year, prospective, multi-center study at three hemophilia treatment centers in the United States to evaluate the utilization of POC-MSKUS for routine clinical decision-making in adult persons with hemophilic arthropathy. Bilateral elbows, knees and ankles were assessed clinically [Hemophilia Joint Health Score (HJHS)] and with POC-MSKUS by the Joint TissueActivity and Damage Exam (JADE) protocol at baseline and approximately annually for two additional times. Treatment decisions, including physical therapy (PT) and "medical" (joint injections/aspirations, referrals to orthopedics, changes/adjustments of hemostatic plans, and use of oral anti-inflammatory medications) were recorded in relation to POC-MSKUS. RESULTS Forty-four persons [median age 37 years (IQR 29, 51)], mostly with severe Hemophilia A on clotting factor prophylaxis, completed 129 visits, yielding 792 joint exams by POC-MSKUS and HJHS [median at baseline 27 (IQR 18, 42)] over a median follow up of 584 days (range: 363 to 1072). Among 157 management decisions, 70% were related to PT plans (n = 110) and 30% were "medical". Point-of-care MSKUS influenced 47/110 (43%) PT plans, mostly informing treatment of specific arthropathic joints (45/47 plans) in patients with high HJHS. Physical therapy plans influenced by POC-MSKUS directed more manual therapy/therapeutic exercises, while plans based on physical exam were focused more on global exercises and wellness. Treatment decisions were mostly based on the identification of specific musculoskeletal abnormalities visualized by POC-MSKUS. Of note 20/47 (43%) POC-MSKUS plans included de-escalation strategies, thereby reducing exercise intensity, mostly for joint instability and subclinical hemarthroses. Point-of-care MSKUS also informed 68% (32/47) of "medical" decisions, surprisingly mostly for injections/aspirations and referrals to orthopedics, and not for adjustments of hemostatic treatment. Although not formally studied, ultrasound images were used frequently for patient education. CONCLUSION Routine joint evaluations with POC-MSKUS resulted in few changes regarding medical management decisions but had a profound effect on the formulation of PT plans. Based on these findings, new studies are essential to determine the benefit of MSKUS-informed management plans on joint health outcomes.
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Affiliation(s)
- N Gallastegui
- grid.266100.30000 0001 2107 4242Department of Medicine, Division of Hematology/Oncology, University of California San Diego, CA San Diego, USA ,grid.261331.40000 0001 2285 7943Department of Medicine, Division of Hematology, The Ohio State University, OH Columbus, USA
| | - BUK Steiner
- Washington Center for Bleeding Disorders, WA Seattle, USA
| | - P Aguero
- grid.266100.30000 0001 2107 4242Department of Medicine, Division of Hematology/Oncology, University of California San Diego, CA San Diego, USA
| | - C Bailey
- grid.489149.90000 0004 5900 1331The Orthopaedic Hemophilia Treatment Center, Orthopaedic Institute for Children, Los Angeles California, USA
| | - R Kruse-Jarres
- Washington Center for Bleeding Disorders, WA Seattle, USA
| | - DV Quon
- grid.489149.90000 0004 5900 1331The Orthopaedic Hemophilia Treatment Center, Orthopaedic Institute for Children, Los Angeles California, USA
| | - C Hanacek
- grid.266100.30000 0001 2107 4242Department of Medicine, Division of Hematology/Oncology, University of California San Diego, CA San Diego, USA ,Department of General Medical Education, KPC Health. Hemet, CA, USA 1810 Cannon Drive, Suite 1150E, OH Columbus, USA
| | - LM Volland
- grid.266100.30000 0001 2107 4242Department of Medicine, Division of Hematology/Oncology, University of California San Diego, CA San Diego, USA ,grid.422264.40000 0004 0542 3790National Hemophilia Foundation, NYC NY, USA
| | - RFW Barnes
- grid.266100.30000 0001 2107 4242Department of Medicine, Division of Hematology/Oncology, University of California San Diego, CA San Diego, USA
| | - A von Drygalski
- grid.266100.30000 0001 2107 4242Department of Medicine, Division of Hematology/Oncology, University of California San Diego, CA San Diego, USA
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10
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Gopal S, Barnes RFW, Volland LM, Page D, von Drygalski A. Patient-derived assessment tool using musculoskeletal ultrasound for validation of haemarthrosis. Haemophilia 2022; 28:842-848. [PMID: 35654082 DOI: 10.1111/hae.14591] [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: 01/24/2022] [Revised: 04/05/2022] [Accepted: 05/02/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Haemophilia patients experience painful joint episodes which may or may not be associated with haemarthrosis. We sought to validate a questionnaire developed by the Canadian Haemophilia Society using point-of-care musculoskeletal ultrasound (POC MSKUS) to confirm haemarthrosis. METHODS The questionnaire comprised of 20 questions (10 each associated with haemarthrosis and arthritis pain) and was administered to adult haemophilia patients reporting to the Haemophilia Treatment Centre (University of California San Diego). We confirmed the presence (or absence) of haemarthrosis using POC MSKUS [Joint Activity and Damage Exam (JADE)]. We fitted univariate and multivariate generalized estimating equations to identify symptoms associated with haemarthrosis. RESULTS We evaluated 79 painful episodes in 32 patients [median age = 38 years (range 21-74)]. POC MSKUS detected haemarthrosis in 36 (46%) episodes. The strongest predictor for haemarthrosis pain was 'like a balloon swelling with water' (odds ratio [OR] 2.88 [CI .68;12.10]); 'no feeling of sponginess with movement' (OR .24[CI .07;.76]) was the strongest for arthritic pain. We identified four questions with the strongest OR for differentiating haemarthrosis pain from arthritic pain to develop an algorithm for haemarthrosis prediction. Answering these questions in "yes/no" fashion yielded estimates of the probability of haemarthrosis CONCLUSION: Objective diagnosis of haemarthrosis by MSKUS facilitated the development of a symptom-based prediction tool for diagnosis of haemarthrosis. The tool requires further validation and will be particularly helpful in situations where MSKUS is not readily available.
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Affiliation(s)
- Srila Gopal
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Richard F W Barnes
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Lena M Volland
- Department of Medicine, University of California San Diego, La Jolla, California, USA.,National Haemophilia Foundation, New York, New York, USA
| | - David Page
- Canadian Haemophilia Society, Montreal, QC, Canada
| | - Annette von Drygalski
- Department of Medicine, University of California San Diego, La Jolla, California, USA.,Department of Molecular Medicine, The Scripps Research Institute, La Jolla, California, USA
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11
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Donners AAMT, Rademaker CMA, Bevers LAH, Huitema ADR, Schutgens REG, Egberts TCG, Fischer K. Pharmacokinetics and Associated Efficacy of Emicizumab in Humans: A Systematic Review. Clin Pharmacokinet 2021; 60:1395-1406. [PMID: 34389928 PMCID: PMC8585815 DOI: 10.1007/s40262-021-01042-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Emicizumab is an effective new treatment option for people with hemophilia A (PwHA). The approved dosing regimens are based on body weight, without the necessity for laboratory monitoring. This assumes a clear dose-concentration-response relationship, with acceptable variability due to factors other than body weight. To investigate this assumption, a systematic review on the pharmacokinetics (PK) and associated efficacy of emicizumab in humans was conducted. METHODS The EMBASE, Pubmed and CENTRAL databases were systematically searched to November 2020 to identify studies on the PK data of emicizumab in humans. Data on the study, population, PK and efficacy (annualized bleeding rate of treated [joint] bleeds) were extracted and synthesized, and exposure effects modeling was performed using non-linear least squares regression in a maximum effect (Emax) model. RESULTS The 15 included studies reported on data for 140 volunteers and 467 PwHA, including children (0 to <12 years) and adolescents and adults (≥12 years), both with and without factor VIII (FVIII) inhibitors. Emicizumab demonstrated dose-linear PK. The interindividual variability of trough concentrations was moderate (32%) and was similar across various subgroups, such as FVIII inhibitor status, age group and dosing interval. The control of bleeds did not further improve above emicizumab concentrations of 30 µg/mL, potentially enabling lower dosing in a substantial proportion of PwHA. CONCLUSION This review supports body weight-based dosing, although individualized monitoring of emicizumab concentrations may allow for more cost-effective dosing.
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Affiliation(s)
- Anouk A M T Donners
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, D.00.204, Postbus 85500, 3508 GA, Utrecht, The Netherlands.
| | - Carin M A Rademaker
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, D.00.204, Postbus 85500, 3508 GA, Utrecht, The Netherlands
| | - Lisanne A H Bevers
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, D.00.204, Postbus 85500, 3508 GA, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, D.00.204, Postbus 85500, 3508 GA, Utrecht, The Netherlands
- Department of Pharmacy and Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Roger E G Schutgens
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Toine C G Egberts
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, D.00.204, Postbus 85500, 3508 GA, Utrecht, The Netherlands
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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12
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Bakeer N, Dover S, Babyn P, Feldman BM, von Drygalski A, Doria AS, Ignas DM, Abad A, Bailey C, Beggs I, Chang EY, Dunn A, Funk S, Gibikote S, Goddard N, Hilliard P, Keshava SN, Kruse-Jarres R, Li Y, Lobet S, Manco-Johnson M, Martinoli C, O'Donnell JS, Papakonstantinou O, Pergantou H, Poonnoose P, Querol F, Srivastava A, Steiner B, Strike K, Timmer M, Tyrrell PN, Vidarsson L, Blanchette VS. Musculoskeletal ultrasound in hemophilia: Results and recommendations from a global survey and consensus meeting. Res Pract Thromb Haemost 2021; 5:e12531. [PMID: 34268464 PMCID: PMC8271584 DOI: 10.1002/rth2.12531] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/18/2021] [Accepted: 04/24/2021] [Indexed: 01/19/2023] Open
Abstract
Introduction For persons with hemophilia, optimization of joint outcomes is an important unmet need. The aim of this initiative was to determine use of ultrasound in evaluating arthropathy in persons with hemophilia, and to move toward consensus among hemophilia care providers regarding the preferred ultrasound protocols for global adaptation. Methods A global survey of hemophilia treatment centers was conducted that focused on understanding how and why ultrasound was being used and endeavored to move toward consensus definitions of both point‐of‐care musculoskeletal ultrasound (POC‐MSKUS) and full diagnostic ultrasound, terminology to describe structures being assessed by ultrasound, and how these assessments should be interpreted. Next, an in‐person meeting of an international group of hemophilia health care professionals and patient representatives was held, with the objective of achieving consensus regarding the acquisition and interpretation of POC‐MSKUS and full diagnostic ultrasound for use in the assessment of musculoskeletal (MSK) pathologies in persons with hemophilia. Results The recommendations were that clear definitions of the types of ultrasound examinations should be adopted and that a standardized ultrasound scoring/measurement system should be developed, tested, and implemented. The scoring/measurement system should be tiered to allow for a range of complexity yet maintain the ability for comparison across levels. Conclusion Ultrasound is an evolving technology increasingly used for the assessment of MSK outcomes in persons with hemophilia. As adoption increases globally for clinical care and research, it will become increasingly important to establish clear guidelines for image acquisition, interpretation, and reporting to ensure accuracy, consistency, and comparability across groups.
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Affiliation(s)
- Nihal Bakeer
- Indiana Hemophilia & Thrombosis Center Indianapolis IN USA
| | - Saunya Dover
- Child Health Evaluative Sciences, Research Institute The Hospital for Sick Children Toronto ON Canada
| | - Paul Babyn
- Department of Medical Imaging University of Saskatchewan and Saskatchewan Health Authority Saskatoon City Hospital SK Canada
| | - Brian M Feldman
- Child Health Evaluative Sciences, Research Institute The Hospital for Sick Children Toronto ON Canada.,Department of Pediatrics Faculty of Medicine University of Toronto Toronto ON Canada.,Institute of Health Policy, Management and Evaluation The Dalla Lana School of Public Health University of Toronto Toronto ON Canada.,Division of Rheumatology The Hospital for Sick Children Toronto ON Canada
| | | | - Andrea S Doria
- Department of Medical Imaging University of Toronto The Hospital for Sick Children Toronto ON Canada
| | - Danial M Ignas
- Child Health Evaluative Sciences, Research Institute The Hospital for Sick Children Toronto ON Canada
| | - Audrey Abad
- Child Health Evaluative Sciences, Research Institute The Hospital for Sick Children Toronto ON Canada
| | - Cindy Bailey
- Los Angeles Orthopaedic Treatment Centre Los Angeles CA USA
| | - Ian Beggs
- Department of Radiology Royal Infirmary of Edinburgh NHS Lothian Edinburgh UK
| | - Eric Y Chang
- University of California San Diego Medical Center San Diego CA USA
| | - Amy Dunn
- Division of Pediatric Hematology, Oncology & Marrow Transplant Department of Pediatrics Nationwide Children's Hospital The Ohio State University College of Medicine Columbus OH USA
| | - Sharon Funk
- Hemophilia and Thrombosis Center University of Colorado Anschutz Medical Campus Aurora CO USA
| | - Sridhar Gibikote
- Division of Clinical Radiology Christian Medical College Vellore India
| | - Nicholas Goddard
- Katherine Dormandy Haemophilia Centre Royal Free Hospital London UK
| | - Pamela Hilliard
- Child Health Evaluative Sciences, Research Institute The Hospital for Sick Children Toronto ON Canada
| | | | - Rebecca Kruse-Jarres
- University of Washington and Washington Center for Bleeding Disorders Seattle WA USA
| | - Yingjia Li
- Ultrasound Department Manfang Hospital Guangzhou China
| | - Sébastien Lobet
- Haemostasis and Thrombosis Unit Division of Haematology Cliniques Universitaires Saint-Luc Brussels Belgium
| | - Marilyn Manco-Johnson
- Hemophilia & Thrombosis Center Department of Pediatrics University of Colorado Anschutz Medical Center Aurora CO USA
| | - Carlo Martinoli
- Department of Health Sciences (DISSAL) Università di Genova IRCCS Ospedale Policlinico San Martino Genova Italy
| | - James S O'Donnell
- Irish Centre for Vascular Biology Royal College of Surgeons in Ireland Dublin Ireland
| | | | - Helen Pergantou
- Pediatric Hemophilia Centre/Haemostatis and Thrombosis Unit Aghia Sophia Children's Hospital Athens Greece
| | - Pradeep Poonnoose
- Department of Orthopedics Unit 2 Christian Medical College Vellore India
| | - Felipe Querol
- Haemostasis and Thrombosis Unit Hospital LA FE Universidad de Valencia Valencia Spain
| | - Alok Srivastava
- Department of Hematology Christian Medical College Vellore India
| | - Bruno Steiner
- Department of Rehabilitation Medicine Physical Therapy and MSKUS Program Washington Center for Bleeding Disorders University of Washington Seattle WA USA
| | - Karen Strike
- School of Rehabilitation Science Faculty of Health Science Hamilton Niagara Regional Hemophilia Program Hamilton Health Sciences McMaster University Hamilton ON Canada
| | - Merel Timmer
- van Creveldkliniek University Medical Center Utrecht Utrecht The Netherlands
| | - Pascal N Tyrrell
- Department of Medical Imaging Institute of Medical Science Toronto ON Canada.,Department of Statistical Sciences University of Toronto Toronto ON Canada
| | - Logi Vidarsson
- Diagnostic Imaging The Hospital for Sick Children Toronto ON Canada
| | - Victor S Blanchette
- Department of Pediatrics Division of Hematology/Oncology University of Toronto The Hospital for Sick Children Toronto ON Canada
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13
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Gopal S, Barnes RFW, Cooke EJ, Zhou JY, Levin I, Emery P, Hughes TH, Karsdal MA, Manon-Jensen T, von Drygalski A. Systemic vascular basement membrane markers linked to synovial vascular remodeling are biomarkers of hemarthrosis in patients with hemophilia. J Thromb Haemost 2021; 19:1200-1211. [PMID: 33587779 DOI: 10.1111/jth.15268] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/29/2021] [Accepted: 02/09/2021] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Interstitial, cartilage, and bone collagens have been proposed as biomarkers of joint deterioration in hemophilic arthropathy. The role of basement membrane (type IV and VIII) collagens as biomarkers of endothelial turnover in relation to acute joint bleeding is not understood. METHODS Thirty-one adult patients with hemophilia were studied prospectively for 3 years with musculoskeletal ultrasound/power Doppler (MSKUS/PD) during pain-free intervals and painful events for joint bleed status, synovial vascular flow, and 10 plasma markers of collagen turnover. Joint health was determined using Hemophilia Joint Health Scores and Pettersson scores. In animal studies, bleeding was induced in factor VIII-/- mice by knee joint injury. Synovial vascular remodeling was assessed using MSKUS/PD and histology. Murine plasma samples were analyzed for type IV collagen turnover markers. RESULTS Ninety-one patient visits were compiled. Twenty-five were due to acute painful episodes, with 16 confirmed hemarthroses. Type IV collagen turnover markers (PRO-C4 and C4M), and a type VIII collagen synthesis marker (PRO-C8), were transiently elevated during acute hemarthrosis. Hemarthrosis was accompanied by increased synovial microvascular flow (MSKUS/PD), and levels of type IV collagen markers correlated with PD signals in the joint. In factor VIII-deficient mice, plasma levels of type IV collagen turnover markers correlated negatively with synovial αSMA staining, indicating that reduced type IV collagen turnover was associated with thicker vessels. CONCLUSIONS Our findings suggest that basement membrane turnover markers, closely linked to synovial vascular remodeling, may be systemic biomarkers of acute hemarthrosis. Vascular instability during neovascularization may be involved in the dynamics of hemarthrosis.
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Affiliation(s)
- Srila Gopal
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Richard F W Barnes
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Esther J Cooke
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Jenny Y Zhou
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Ilana Levin
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Pamela Emery
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Tudor H Hughes
- Department of Radiology, University of California San Diego, La Jolla, California, USA
| | | | | | - Annette von Drygalski
- Department of Medicine, University of California San Diego, La Jolla, California, USA
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, California, USA
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14
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von Drygalski A, Pasta G, de la Corte-Rodriguez H. Ultrasound and patient self-imaging in hemophilia. Haemophilia 2020; 27:e298-e301. [PMID: 33236460 DOI: 10.1111/hae.14208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/16/2020] [Accepted: 11/03/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Annette von Drygalski
- Division of Hematology/Oncology, Department of Medicine, University of California San Diego, San Diego, CA, USA.,Department of Experimental Medicine, The Scripps Research Institute, La Jolla, CA, USA
| | - Gianluigi Pasta
- Department of Orthopaedics and Traumatology, Fondazione Policlinico IRCCS San Matteo, University of Pavia, Pavia, Italy
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15
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Ignas DM, Doria AS, von Drygalski A, Blanchette VS, Chang EY, Dover S, Fischer K, Gibikote S, Keshava SN, Querol F, Abad A, Babyn P. Use of ultrasound for assessment of musculoskeletal disease in persons with haemophilia: Results of an International Prophylaxis Study Group global survey. Haemophilia 2020; 26:685-693. [PMID: 32441402 DOI: 10.1111/hae.14006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 03/30/2020] [Indexed: 12/18/2022]
Abstract
AIM The objective of this survey was to understand the global trends of imaging assessments in persons with haemophilia, focusing on point-of-care ultrasound (POCUS). Insights into the barriers impeding its widespread proliferation as a frontline imaging modality were obtained. METHODS The survey opened in September of 2017 and closed in May of 2018. Haemophilia Treatment Centres (HTCs) treating both paediatric/adult patients were the population of interest. A REDCap survey of 25 questions was disseminated to 232 clinical staff in 26 countries. RESULTS The majority of respondents (88.3%, 91/103) reported that POCUS is most useful to confirm or rule out a presumed acute joint bleed. European HTCs reported the highest routine use of POCUS at 59.5% (22/37) followed by HTCs in the "Other" countries of the world at 46.7% (7/15) and North American HTCs at 43.9% (25/57). At the time of the survey, physiotherapists were identified as the clinical staff who perform POCUS 52.8% (28/53) of the time, in contrast with nurses/nurse practitioners who represent only 5.7% (3/53) of users. The greatest perceived barriers to the implementation of POCUS are the lack of trained healthcare professionals who can perform POCUS at 69.2% (74/107) and the overall time commitment required at 68.2% (73/107). CONCLUSION Despite POCUS being used in 49.5% (54/109) of sampled HTCs, it is still utilized almost 30% less globally than full diagnostic ultrasound. A list of barriers has been identified to inform HTCs which challenges they will likely need to overcome should they choose to incorporate this imaging modality into their practice.
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Affiliation(s)
- Danial M Ignas
- Child Health Evaluative Sciences Program, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Andrea S Doria
- Department of Medical Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Annette von Drygalski
- Hemophilia and Thrombosis Treatment Center, Department of Medicine, Division of Hematology/Oncology, University of California, San Diego, CA, USA
| | - Victor S Blanchette
- Child Health Evaluative Sciences Program, The Hospital for Sick Children Research Institute, Toronto, ON, Canada.,Department of Pediatrics, Division of Hematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Eric Y Chang
- Radiology Service, VA San Diego Healthcare System, University of California, San Diego, San Diego, CA, USA
| | - Saunya Dover
- Child Health Evaluative Sciences Program, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Center, Utrecht, The Netherlands
| | - Sridhar Gibikote
- Department of Radiology, Christian Medical College, Vellore, India
| | | | - Felipe Querol
- Haemostasis and Thrombosis Unit, Hospital LA FE, Universidad de Valencia, Valencia, Spain
| | - Audrey Abad
- Child Health Evaluative Sciences Program, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Paul Babyn
- Department of Medical Imaging, University of Saskatchewan and Saskatchewan Health Authority Saskatoon City Hospital, Saskatoon, SK, Canada
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16
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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: 10] [Impact Index Per Article: 2.5] [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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17
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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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