A single centre experience in circumcision of haemophilia patients: Izmir protocol

Use of crushed tranexamic acid tablets in water for paediatric patients with bleeding disorders

BACKGROUND

Ε-Aminocaproic acid oral solution (EACA OS) is the only commercially available antifibrinolytic for patients who cannot swallow tablets. Insurance denials and high costs remain barriers to its use.

OBJECTIVES

To determine the safety and efficacy of crushed tranexamic acid tablets in water (cTXAw) for children with bleeding disorders.

METHODS

We retrospectively reviewed records of children (<10 years) with bleeding disorders who received cTXAw or EACA OS from 1 December 2018, through 31 July 2022, at Mayo Clinic (Rochester, Minnesota). Bleeding outcomes were defined according to ISTH criteria.

RESULTS

Thirty-two patients were included (median age, 3 years; male, n = 23). Diagnoses were VWD (n = 17), haemophilia (n = 5), FVII deficiency (n = 3), inherited platelet disorder (n = 4), ITP (n = 2), and combined FV and FVII deficiencies (n = 1). Thirty-two courses of cTXAw (monotherapy 24/32; mean duration 6 days) and fifteen courses of EACA (monotherapy 12/15; mean duration 5 days) were administered. No surgical procedures (n = 28) were complicated by bleeding. Of the 19 bleeding events, 16 had effective haemostasis, two had no reported outcome, and one had no response. cTXAw and EACA were equally effective in preventing and treating bleeding (p value > .1). No patients had adverse effects. Eight of 19 patients (42%) who were initially prescribed EACA OS did not receive it because of cost or insurance denial. The estimated average wholesale price of one treatment was $94 for cTXAw and $905 for EACA OS.

CONCLUSIONS

CTXAw appears to be an effective, safe, and low-cost alternative option to EACA OS for young children with bleeding disorders.

Low dose prophylaxis and antifibrinolytics: Options to consider with proven benefits for persons with haemophilia

INTRODUCTION

Prophylaxis has become standard of care for persons with severe phenotype haemophilia (PWsH). However, 'standard prophylaxis' with either factor or non-factor therapies (emicizumab) is prohibitively expensive for much of the world. We sought to evaluate whether haemophilia care can be provided at a lower cost yet achieve good results using Lower dose/Lower frequency prophylaxis (LDP) and with increasing use of antifibrinolytics (Tranexamic acid and Epsilon amino caproic acid).

METHODS

We identified 12 studies that collectively included 335 PWsH using LDP. Additionally, we undertook a literature search regarding the benefits of antifibrinolytics in haemophilia care.

RESULTS

Identified studies show that LDP is far superior to no prophylaxis (On demand [OD] therapy) resulting in significant patient benefits. Patients on LDP showed (in comparison to patients OD) on average: 72% less total bleeds; 75% less joint bleeds; 91% less days lost from school; 77% less hospital admission days; and improved quality of life measures. These benefits come at similar or only slightly higher (< 2-fold greater) costs than OD therapy. Antifibrinolytics are effective adjunctive agents in managing bleeds (oral, nasal, intracranial, possibly other) and providing haemostasis for surgeries (particularly oral surgeries). Antifibrinolytics can substitute for more expensive factor concentrates or can reduce the use of such concentrates. There is evidence to show that antifibrinolytics may be used in conjunction with factor concentrates/emicizumab for more effective/less costly prophylaxis.

CONCLUSIONS

The use of LDP along with appropriate and increased use of antifibrinolytics offers less resourced countries good options for managing patients with haemophilia.

Systematic review of complications arising from male circumcision

Background

Neonatal male circumcision is the most common procedure performed on paediatric patients (Simpson et al., 2014) and one of the most common surgical procedures in the world (American Academy of Pediatrics, 2012).

Methods

A search was conducted for articles about complications arising from male circumcision surgeries by entering the term ‘male circumcision’ into PubMed on June 16, 2020. Six thousand six hundred forty‐one articles published from 1945 to 2020 were found. Seventy‐eight articles were ultimately selected for the systematic review.

Results

The 78 articles selected from the literature search were entered into one of three tables. The first table includes 15 articles pertaining to chart reviews and cohort studies and report complication rates. The second table reports specific complications from 51 case reports and case series, and the third table is a summary from 12 articles regarding physician questionnaires and society recommendations. Additionally, the 78 articles were used to compile a list of 47 specific complications arising from male circumcision surgeries.

Conclusions

Complications from neonatal male circumcisions are common and healthcare providers need to be better informed of the potential complications of the surgery so that they can more effectively counsel their patients about potential risks, likelihood of complications and what can be done to prevent them. While experienced providers who practice in sterile settings have better outcomes with fewer complications, encouraging parents to take into account who is performing their son's circumcision, what was their training, how clean is their practice and how much experience they have and reminding them they have the option to decline the procedure entirely allow the parents to get a more complete picture and play an essential role in the decision‐making process.

Circumcision in Hemophilia: A Multicenter Experience

BACKGROUND

Hemophiliac patients and their families have social pressure to undergo circumcision, despite the potential complications. The objective of this study was to report our experience in the circumcision of hemophilia patients.

MATERIALS AND METHODS

We included 35 patients with hemophilia who had circumcision in 3 centers from January 2010 to August 2019. Their age ranged between 0.3 months and 8 years. Hemophilia a was classified as mild (n=3), moderate (n=4), and severe (n=28). Patients received 2 doses of factor VIII concentrate 50μ/kg, 1 hour before the procedure and 12 hours after it.

RESULTS

Four neonates were diagnosed with hemophilia after circumcision because of prolonged bleeding. Two patients with severe hemophilia A had bleeding after hospital discharge (6.5%). They received additional factor concentrate, and 1 patient had an extra stitch. Two patients had wound gaping (6.5%), and 1 patient had a wound infection (3.2%).

CONCLUSION

Hemophilia is not an absolute contraindication for circumcision. Circumcision of hemophilic children should be performed under appropriate conditions in hemophilia centers. Bleeding is not frequent but could be serious.

Haemostatic efficacy of single-dose factor administration in neonates with severe haemophilia undergoing circumcision

INTRODUCTION

Perioperative management of children with haemophilia undergoing surgery is a complex and understudied topic. Circumcision is the most common procedure performed in the neonatal period, and guidelines to prevent bleeding complications from circumcision are lacking. Treatment protocols vary widely, and many centres treat patients with factor products for up to two weeks after circumcision. There is an unmet need for studies evaluating optimal factor replacement therapy around the time of circumcision in neonates with severe haemophilia.

AIM

To determine the efficacy of a single dose of factor replacement before circumcision to prevent bleeding complications in neonates with severe haemophilia.

METHODS

We conducted a retrospective chart review of male infants born between January 2000 and June 2019. Male neonates with severe haemophilia diagnosed at the Iowa Hemophilia and Thrombosis Center (n = 22) and healthy newborn controls who underwent circumcision at the University of Iowa Hospitals were included. Data were collected from the electronic medical record. Neonates with severe haemophilia were separated into two groups-those pretreated with one dose of factor replacement before circumcision and those without pretreatment.

RESULTS

We observed that neonates with severe haemophilia pretreated with a single dose of factor VIII or factor IX replacement had significantly reduced bleeding complications, shorter hospital stay and required less therapeutic intervention compared with untreated patients. Importantly, pretreated patients had outcomes similar to healthy controls.

CONCLUSIONS

Our results demonstrate that a single dose of factor replacement before circumcision is effective to prevent bleeding in neonates with severe haemophilia.

Fibrin glue for local haemostasis in haemophilia surgery

INTRODUCTION

Local fibrin glue (FG) appears to be a useful local haemostatic agent for severe haemorrhage in people with haemophilia (PWH) undergoing surgical procedures.

AIM

To evaluate the role of local FG in PWH.

METHODS

A review of the literature on the topic has been performed.

RESULTS

Local FG is not always necessary to achieve haemostasis in all surgical procedures performed in PWH. However, it could be a good adjunct therapy, primarily when a surgical field will bleed more than expected (e.g. patients with inhibitors), and also for circumcisions, dental extractions, and surgical treatment of pseudotumours.

CONCLUSIONS

Although correct surgical haemostasis can typically be achieved by the infusion of factor concentrate at the adequate dose, my recommendation for surgeons is always to have local FG by their side. Local FG appears to be an effective adjunctive therapy for cases in which bleeding is likely (e.g. patients with inhibitors), and for circumcisions, oral surgery, and treatment of pseudotumours. Through the use of local FG, the doses of factor concentrate necessary to prevent bleeding could be reduced, providing considerable cost savings.

Circumcision in hemophilia using low quantity of factor concentrates: experience from Dakar, Senegal

Background

Circumcision in hemophiliacs is a delicate surgery because of bleeding risks that could be avoided by adequate substitution of coagulation factor. This practice is very challenging in countries where anti hemophilic treatment is inaccessible. The study aimed to evaluate a circumcision protocol in hemophilia A using low quantities of factor concentrates.

Methods

This prospective study included 26 hemophiliacs A who underwent circumcision in 2014. Medical treatment protocol using low quantity of factor concentrates was drafted by physicians of the Hemophilia Treatment Center and the surgical protocol by experienced surgeons. Assessment criteria were: number of hospitalization days, number of exposure days to factor concentrates, delay to healing and occurrence of bleeding events.

Results

Mean age was 9.6 years (1–30). Hemophiliacs patients were classified as severe (n = 8), moderate (n = 9) and mild form (n = 9). Mean number of exposure days to factor VIII concentrates was 6.9 days (5–12) in children and 10.75 days (7–16) in adults (p = 0.0049); mean number of hospitalization days was 3.68 days (2–10) in children and 13.5 days (13–15) in adults (p = 0.0000); delay to healing was 26.47 days (20–35) in children and 25.25 days (22–30) in adults (p = 0.697); five haemophiliacs (19.2%) presented bleeding events after the circumcision. The mean amount of FIII concentrates used per patient was 1743 IU (810–2340).

Conclusion

The study shows treatment protocol using low quantity of factor concentrates is efficient in hemophilia patients who underwent circumcision.

Tranexamic acid--an old drug still going strong and making a revival

Experience with tranexamic acid, an indirect fibrinolytic inhibitor, started as soon as it was released from Shosuke Okamoto's lab in the early 1960s. It was first prescribed to females with heavy menstrual blood loss and to patients with hereditary bleeding disorders. Soon the indications were widened to elective surgery because of its blood saving effects. Contraindications are few, most important is ongoing venous or arterial thrombosis and allergy to tranexamic acid, and the doses has to be reduced in renal insufficiency. In randomized controlled trials, however, patients with other risk factors are excluded as well (patients with history of cardiovascular disease, thromboembolism, bleeding diathesis, renal failure with creatinine >250μmol/L, pregnancy, and patients on treatment with anticoagulants). Recent meta-analyses of several randomized controlled trials in orthopedic arthroplasty have shown that tranexamic acid reduces peri- and postoperative blood loss, blood transfusion requirements and reoperations caused by bleedings. In general, the preoperative dose was 10-15mg/kg i.v. (or 1g), followed or not, by one or two doses, some as continuous infusion i.v. To validate relationship between dose and effect more data are needed. No evidence was found of increased thromboembolic accidents or other adverse events in the patients on tranexamic acid compared to the control groups. In major cardiac surgery tranexamic acid has been used in a large number of controlled trials with various dosing schemes in which the highest dosages seem to be associated with neurotoxicity; therefore a maximum total dose of 100mg/kg especially in patients over 50years of age is recommended by ISMICS (International Society for Minimally Invasive Cardiothoracic Surgery). Other indications for tranexamic acid are reviewed here as well. In recent years the extensive trial in severe trauma with massive bleedings using tranexamic acid was presented, CRASH-2 (Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage) comprising more than 20,000 patients. It showed that the survival was increased when tranexamic acid was given early after the accident compared to placebo; further studies are taking place is this field to get more information. Of utmost importance is the ongoing WOMAN (World Maternal Antifibrinolytic) a randomized, double-blind, placebo controlled trial among 15,000 with clinical diagnosis of postpartum haemorrhage bearing in mind that each year a large number of women in low and middle income countries, die from causes related to childbirth. In summary, we consider tranexamic acid is a drug of great value to reduce almost any kind of bleeding, it is cheap and convenient to use and has principally few contraindications. It may be added, that tranexamic acid is included in the WHOs list of essential medicines.

Surgical interventions in childhood rare factor deficiencies: a single-center experience from Turkey

Congenital rare factor deficiencies may present in infancy by life-threatening bleedings or may not show any symptoms until adulthood. It is reported more commonly in countries having consanguineous marriages. Data regarding surgical interventions of rare congenital factor deficiencies are based on case reports and records of guidelines. There are no well documented and separately prepared directories related to pre-surgical and prophylactic approaches of surgical interventions of these deficiencies. Our retrospective study consisted of 171 rare factor deficiencies that were followed up in our clinic, and of whom 61 had 88 surgical interventions between 1990 and 2012. Of these patients, 45 were having factor VII deficiency, and factor V, X, XI, XIII and fibrinogen deficiencies were present in five, four, three, two and two patients, respectively. In 23 patients, factor coagulant activities were under 5% (37.7%), in 15 it was between 5 and 30% (24.6%), and in 23 between 30 and 50% (37.7%). Twenty-eight were symptomatic and 33 were asymptomatic. Information of 51 (83.6%) male and 10 (16.4%) female patients with an age range of 5-25 years (13 ± 5.27), whose age at presentation ranged between 3 weeks and 18 years (7 ± 4.66), were retrieved from patient records and from the records contained in the data-processing environment introduced in 2005. The rate of familial consanguinity was 49.2%. Of the surgical interventions, 24 (27.3%) were major, 24 (27.3%) were minor and 40 (45.4%) were circumcision. We used fresh frozen plasma in 32, recombinant factor (rF)VIIa in 20, prothrombin complex concentrate in five and fibrinogen in three patients during surgical interventions. In 18 patients, antifibrinolytic agents were also used. In 27 patients, surgical interventions were applied without any replacement therapy. No additional doses were required after surgical prophylaxis doses. Thrombotic events were not observed. Antibody occurrence was not detected in these patients. In our study, we evaluated preparation for surgical procedures, factor replacement therapy before surgical intervention and postoperative follow-up in patients with rare coagulation factor deficiency.

Local fibrin glue and chitosan-based dressings in haemophilia surgery

Fibrin glue and chitosan-based dressings (CBDs) could be useful local haemostatic agents for severe haemorrhage in persons with haemophilia undergoing surgical procedures. The aim of the present study was to clarify the role of fibrin glue and CBDs in persons with haemophilia. A review of the most recent literature on the topic was performed. Local fibrin glue and CBDs are not always necessary to achieve haemostasis in all surgical procedures performed in persons with haemophilia. However, they could be good adjunct therapies, mainly when a surgical field or a surgical wound potentially will bleed more than expected (i.e. patients with inhibitors), and also circumcisions, dental extractions, and some orthopaedic procedures (mainly the surgical removal of pseudotumours). Although a correct surgical haemostasis can be usually achieved by the infusion of factor concentrate at the right dose, my recommendation for surgeons is always to have fibrin glue and CBDs by their side. CBDs could be better haemostatic dressings for control of haemorrhage than current standards of care. To clarify the real value of fibrin glue and CBDs in surgery of haemophilia in specific situations new well designed prospective comparative studies should be carried out.

Circumcision in males with bleeding disorders

Introduction

Male circumcision practice is an invasive procedure that is using worldwide. It makes challenges to haemostatic system and its possible haemorrhagic side effects are more serious in bleeding individuals than normal subjects. In most cases, it can be complete controlled using infusion of appropriate amount of coagulation factors before and post circumcision.

Aim

We aim to documentation type of coagulation therapy and post circumcision practice haemorrhagic presentation among 463 bleeder males of both common and rare bleeding disorders in north eastern part of country.

Methods

We retrospectively gathered information using evaluation medical records in 3 major hospitals during last 15 years and list of patients with bleeding disorders that obtained from haemophilia center. Also a call phone established for each bleeder person to complete data and updating of them. The survey took time from Sep 2009 – Mar 2011. The designed question form included data on doing circumcision or not, types of treatment before and post the procedure and occurrence of bleeding episodes after the surgery.

Results

Overall among 424 cases with various common and rare bleeding disorders who had circumcised, 239 cases (56.3%) had passed the procedure with bleeding experience (indication of undiagnosed cases who underwent circumcision or inadequacy of coagulation therapy), while 185 cases (43.7%) had passed it successfully and without noticeable bleeding experience. The types of coagulation therapy in each group have been cited.

Conclusion

The circumcision practice in unequipped medical center for bleeder ones may make challenges for them and medical services. Also it needed supervision of expert haematologist for

Risk of bleeding and inhibitor development after circumcision of previously untreated or minimally treated severe hemophilia A children

BACKGROUND

Surgery and intensive factor VIII (FVIII) replacement may be risk factors for development of inhibitors.

OBJECTIVE

To evaluate time and rate of inhibitor development postcircumcision over 12-month period, and to assess bleeding of children with severe hemophilia A after low-dose FVIII replacement and local hemostasis.

PATIENTS AND METHODS

Sixty-one previously untreated patients (PUPs) or minimally treated patients (MTPs) with severe hemophilia A less than 36 months were enrolled; 25 underwent circumcision during the 18-month enrollment period, and 36 matched patients were not circumcised. All patients were treated on demand with plasma-derived FVIII, and all were inhibitor negative at the time of enrollment. Intron 22 inversion was analyzed. A potent hemostatic agent (gelatin sponge) was applied on the site of surgery, and then dressed with gauze. Two doses of FVIII concentrate (25 U/kg) were given, 1 hour before circumcision and 1 hour before removal of dressing. The inhibitor was determined every 8 exposure days (EDs).

RESULTS

None of the patients had bleeding or infection, except one who had minimal transient bleeding 8 days after surgery, and was treated easily by a single dose of FVIII (50 U/kg). After a median of 16 EDs, high-titer inhibitors developed in seven patients: three patients in the circumcised group (12%) in contrast to four patients (11.1%) in the noncircumcised group.

CONCLUSION

Two doses factor concentrate and gelatin sponge application were generally enough to prevent bleeding after circumcision of severe hemophilia A. Circumcision and low-dose FVIII protocol were not an additional risk for development of high-titer inhibitor.