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Ballmaier M, Germeshausen M, Schulze H, Andres O. THROMKIDplus Patient Registry and Biomaterial Banking for Children with Inherited Platelet Disorders. Hamostaseologie 2024; 44:298-303. [PMID: 37918839 DOI: 10.1055/a-2117-4639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023] Open
Abstract
Inherited platelet disorders (IPDs) represent a heterogeneous group of disorders that include both quantitative (thrombocytopenia or thrombocytosis) and qualitative (thrombocytopathy) defects. To gain better knowledge about the prevalence, pathogenesis, and clinical consequences of specific diseases, to improve diagnosis and treatment of patients with IPD, and to support translational research on a genetic, molecular, and physiological basis, the THROMKIDplus study group currently comprising 24 sites in Germany, Austria, and Switzerland decided to establish a patient registry with associated biomaterial banking for children. This registry is designed as a retrospective-prospective, multicenter observational study and supposed to launch in the second half of 2023. Blood smears, plasma, platelet pellets, and DNA of patients will be stored in certified biomaterial banks for future translational research projects. The main inclusion criteria are (1) diagnosis of or highly suspected IPD after assessment of a THROMKIDplus competence center and (2) patients aged 0 to 17 years. Initial and follow-up data on patient history, laboratory parameters, standardized documentation of bleeding tendency, and congenital defects are collected according to good clinical practice and current data protection acts by using the MARVIN platform, a broadly used data management system supported by the German Society for Pediatric Oncology Hematology (GPOH). The THROMKIDplus study group intends to enroll ∼200 patients retrospectively and an annual amount of ∼50 patients prospectively.
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Affiliation(s)
- Matthias Ballmaier
- Central Research Facility Cell Sorting, Hannover Medical School, Hannover, Germany
| | - Manuela Germeshausen
- Central Research Facility Cell Sorting, Hannover Medical School, Hannover, Germany
| | - Harald Schulze
- Institute for Experimental Biomedicine, University Hospital Würzburg, Würzburg, Germany
- Center of Inherited Blood Cell Disorders, University Hospital Würzburg, Würzburg, Germany
| | - Oliver Andres
- Center of Inherited Blood Cell Disorders, University Hospital Würzburg, Würzburg, Germany
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
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Alhaj D, Hagedorn N, Cuntz F, Reschke M, Schuldes J, Ruthenberg J, Bakchoul T, Greinacher A, Holzhauer S. ISTH bleeding assessment tool and platelet function analyzer in children with mild inherited platelet function disorders. Eur J Haematol 2024; 113:54-65. [PMID: 38549165 DOI: 10.1111/ejh.14198] [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: 10/15/2023] [Revised: 02/15/2024] [Accepted: 02/19/2024] [Indexed: 06/04/2024]
Abstract
OBJECTIVES To evaluate the diagnostic performance of platelet function analyzer (PFA) and The International Society on Thrombosis and Hemostasis bleeding-assessment-tool (ISTH-BAT) in detecting mild inherited platelet function disorders (IPFDs) in children with suspected bleeding disorders. METHODS Prospective single-center diagnostic study including consecutive patients <18 years with suspected bleeding disorder and performing a standardized workup for platelet function defects including ISTH-BAT, PFA, platelet aggregation testing, blood smear-based immunofluorescence, and next-generation sequencing-based genetic screening for IPFDs. RESULTS We studied 97 patients, of which 34 von Willebrand disease (VWD, 22 type-1, 11 type-2), 29 IPFDs (including delta-/alpha-storage pool disease, Glanzmann thrombasthenia, Hermansky-Pudlak syndrome) and 34 with no diagnosis. In a model combining PFA-adenosine diphosphate (ADP), PFA-epinephrine (EPI), and ISTH-BAT overall performance to diagnose IPFDs was low with area under the curves of 0.56 (95% CI 0.44, 0.69) compared with 0.84 (95% CI 0.76, 0.92) for VWD. Correlation of PFA-EPI/-ADP and ISTH-BAT was low with 0.25/0.39 Spearman's correlation coefficients. PFA were significantly prolonged in patients with VWD and Glanzmann thrombasthenia. ISTH-BAT-scores were only positive in severe bleeding disorders, but not in children with mild IPFDs or VWD. CONCLUSION Neither ISTH-BAT nor PFA or the combination of both help diagnosing mild IPFDs in children. PFA is suited to exclude severe IPFDs or VWD and is in this regard superior to ISTH-BAT in children.
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Affiliation(s)
- Dana Alhaj
- Department of Pediatric Hematology and Oncology, Charité University Medicine, Berlin, Germany
| | - Nikola Hagedorn
- Department of Pediatric Hematology and Oncology, Charité University Medicine, Berlin, Germany
| | - Franziska Cuntz
- Department of Pediatric Hematology and Oncology, Charité University Medicine, Berlin, Germany
| | - Madlen Reschke
- Department of Pediatric Hematology and Oncology, Charité University Medicine, Berlin, Germany
| | - Joerg Schuldes
- Department of Human Genetics, Labor Berlin, Berlin, Germany
| | - Juliane Ruthenberg
- Department of Pediatric Hematology and Oncology, Charité University Medicine, Berlin, Germany
| | - Tamam Bakchoul
- Institute for Clinical and Experimental Transfusion Medicine, Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany
| | - Andreas Greinacher
- Institute for Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Susanne Holzhauer
- Department of Pediatric Hematology and Oncology, Charité University Medicine, Berlin, Germany
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Edme E, Sola C, Cau-Diaz I, Sirvent N, Mollevi C, Biron-Andreani C, Theron A. Gingival bleeding is a useful clinical feature in the diagnosis of hereditary bleeding disorders in children. Eur J Pediatr 2024; 183:2215-2221. [PMID: 38386030 DOI: 10.1007/s00431-024-05487-6] [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: 12/18/2023] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 02/23/2024]
Abstract
The search for hereditary bleeding disorders (HBD) prior to invasive procedures in children is primarily based on personal and family bleeding history. Although several scores are available, they have only been evaluated in specific situations or in adults. Our monocentric retrospective study aimed to analyze the association between clinical history and four scores (HEMSTOP, PBQ, ISTH-BAT, TOSETTO) and the diagnosis of MHC in children referred to the University Hospital of Montpellier for hemostasis investigations. A total of 117 children were retrospectively included in the study. Of these, 57 (49%) were diagnosed with HBD, with 30 having primary bleeding disorders and 27 having coagulation disorders. The diagnosis of HBD was significantly associated with gingival bleeding, which was present in 30% of HBD patients. In our population, only the HEMSTOP score showed an association with the diagnosis of HBD, but it was positive in only 48% of patients. By including gingival bleeding as a factor, we modified the HEMSTOP score, which increased its sensitivity from 0.45 to 0.53. When examining primary bleeding disorders, the modified HEMSTOP score, with the inclusion of gingival bleeding, enables us to diagnose 63% of patients (see Fig. 1). Conclusion: Therefore, gingival bleeding should be considered a useful factor in bleeding history for HBD diagnosis. Adding this symptom to a screening score such as HEMSTOP improves its sensitivity. To confirm our findings, a prospective study is required. Trial registration: Study registration number: NCT05214300. What is Known: • Screening for hereditary bleeding disorder diseases is a necessity and a challenge in children. • Minor disorders of primary hemostasis are the most common, but often escape standard coagulation tests. What is New: • Gingival bleeding is a frequent symptom that is easy to investigate and may point to a primary hemostasis disorder. • Adding the gingival bleeding item to a routine screening score such as HEMSTOP improves sensitivity.
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Affiliation(s)
- Eleonore Edme
- Department of Pediatric Oncology and Hematology, Hôpital Arnaud de Villeneuve, Univ Montpellier, CHU Montpellier, 371 Av. du Doyen Gaston Giraud, 34090, Montpellier, France
| | - Chrystelle Sola
- Department of Pediatric Anesthesia, Univ Montpellier, CHU Montpellier, Montpellier, France
| | - Isabelle Cau-Diaz
- Department of Biological Hematology, Univ Montpellier, CHU Montpellier, Montpellier, France
- Hemophilia Treatment Center, Univ Montpellier, CHU Montpellier, Montpellier, France
| | - Nicolas Sirvent
- Department of Pediatric Oncology and Hematology, Hôpital Arnaud de Villeneuve, Univ Montpellier, CHU Montpellier, 371 Av. du Doyen Gaston Giraud, 34090, Montpellier, France
| | - Caroline Mollevi
- Institute Desbrest of Epidemiology and Public Health, Univ Montpellier, INSERM, CHU Montpellier, Montpellier, France
| | - Christine Biron-Andreani
- Department of Biological Hematology, Univ Montpellier, CHU Montpellier, Montpellier, France
- Hemophilia Treatment Center, Univ Montpellier, CHU Montpellier, Montpellier, France
| | - Alexandre Theron
- Department of Pediatric Oncology and Hematology, Hôpital Arnaud de Villeneuve, Univ Montpellier, CHU Montpellier, 371 Av. du Doyen Gaston Giraud, 34090, Montpellier, France.
- Hemophilia Treatment Center, Univ Montpellier, CHU Montpellier, Montpellier, France.
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Lauhasurayotin S, Moonla C, Ittiwut R, Ittiwut C, Songthawee N, Komvilaisak P, Natesirinilkul R, Sirachainan N, Rojnuckarin P, Sosothikul D, Suphapeetiporn K. Genetic variations of type 2 and type 3 von Willebrand diseases in Thailand. J Clin Pathol 2023:jcp-2023-209123. [PMID: 38053262 DOI: 10.1136/jcp-2023-209123] [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: 08/08/2023] [Accepted: 10/28/2023] [Indexed: 12/07/2023]
Abstract
AIMS Von Willebrand disease (VWD) is an inherited haemostatic disorder with a wide range of bleeding phenotypes based on von Willebrand factor (VWF) levels. Multiple assays including VWF gene analysis are employed to correctly diagnose VWD and its subtypes. However, data on VWF mutations among Southeast Asian populations are lacking. We, therefore, aimed to explore genetic variations in Thai patients with type 2 and type 3 VWD by whole exome sequencing (WES). METHODS In this multicentre study, Thai patients with type 2 and type 3 VWD, according to the definitions and VWF levels recommended by the international guidelines, were recruited. WES was performed using DNA extracted from peripheral blood in all cases. The novel variants were verified by Sanger sequencing. RESULTS Fifteen patients (73% females; median age at diagnosis 3.0 years) with type 2 (n=12) and type 3 VWD (n=3) from 14 families were enrolled. All patients harboured at least one VWF variant. Six missense (p.Arg1374Cys, p.Arg1374His, p.Arg1399Cys, p.Arg1597Trp, p.Ser1613Pro, p.Pro1648Arg) and one splice-site (c.3379+1G>A) variants in the VWF gene were formerly described. Notably, six VWF variants, including three missense (p.Met814Ile, p.Trp856Cys, p.Pro2032Leu), one deletion (c.2251delG) and two splice-site (c.7729+4A>C, c.8115+2delT) mutations were novelly identified. Compound heterozygosity contributed to type 2 and type 3 VWD phenotypes in two and one patients, respectively. CONCLUSIONS Type 2 and type 3 VWD in Thailand demonstrate the mutational variations among VWF exons/introns with several unique variants. The WES-based approach potentially provides helpful information to verify VWD diagnosis and facilitate genetic counselling in clinical practice.
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Affiliation(s)
- Supanun Lauhasurayotin
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Integrative and Innovative Hematology/Oncology Research Unit, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chatphatai Moonla
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Rungnapa Ittiwut
- Center of Excellence for Medical Genomics, Medical Genomics Cluster, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Excellence Center for Genomics and Precision Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Chupong Ittiwut
- Center of Excellence for Medical Genomics, Medical Genomics Cluster, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Excellence Center for Genomics and Precision Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Natsaruth Songthawee
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Patcharee Komvilaisak
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | - Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ponlapat Rojnuckarin
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Darintr Sosothikul
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Integrative and Innovative Hematology/Oncology Research Unit, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kanya Suphapeetiporn
- Center of Excellence for Medical Genomics, Medical Genomics Cluster, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Excellence Center for Genomics and Precision Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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Doherty D, Grabell J, Christopherson PA, Montgomery RR, Coller BS, Lavin M, O'Donnell JS, James PD. Variability in International Society on Thrombosis and Haemostasis-Scientific and Standardization Committee endorsed Bleeding Assessment Tool (ISTH-BAT) score with normal aging in healthy females: contributory factors and clinical significance. J Thromb Haemost 2023; 21:880-886. [PMID: 36696194 PMCID: PMC11008594 DOI: 10.1016/j.jtha.2022.11.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Bleeding assessment tools are key screening tests used in the evaluation of patients with suspected inherited bleeding disorders. The International Society on Thrombosis and Haemostasis-Scientific and Standardization Committee endorsed Bleeding Assessment Tool (ISTH-BAT) has differing reference ranges for adult males (0-3), adult females (0-5), and children (0-2), reflecting differing bleeding symptoms and exposure to hemostatic challenges in these healthy population subgroups. Age is known to markedly impact bleeding score in individuals with von Willebrand disease. However, the influence of age on bleeding score in healthy adult controls is poorly understood. OBJECTIVES We aimed to assess variability in ISTH-BAT score with age among healthy control females. METHODS We used the legacy "Merging Project" dataset of normal healthy controls upon which current ISTH-BAT normal ranges are based. We included women, totaling 646 individuals. The normal range (middle 95th percentile) of total ISTH-BAT and grouped subdomain scores between age quartiles was assessed. RESULTS The normal range of ISTH-BAT scores increased with age, ranging from 0 to 4 in the youngest quartile (age range, 18-30) to 0 to 6 in the oldest (age range, 52-88). This increased variability with aging was related both to high menorrhagia domain scores in older women and an increase in postprocedural bleeding with accumulated exposure to hemostatic challenges. CONCLUSIONS Cumulatively, our data highlight that normal aging leads to increased variability in bleeding scores in healthy adult females. Further refinement of the ISTH-BAT with age-adjusted reference ranges may improve the sensitivity and specificity of the tool among females.
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Affiliation(s)
- Dearbhla Doherty
- National Coagulation Centre, St James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Julie Grabell
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Robert R Montgomery
- Blood Research Institute, Versiti, Milwaukee, WI, USA; Children's Research Institute, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Barry S Coller
- Allen and Frances Adler Laboratory of Blood and Vascular Biology, Rockefeller University, NY, USA
| | - Michelle Lavin
- National Coagulation Centre, St James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James S O'Donnell
- National Coagulation Centre, St James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; National Children's Research Centre, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
| | - Paula D James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
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Hemophilia and non-accidental head trauma in two siblings: lessons and legal implications. Childs Nerv Syst 2022; 38:2415-2423. [PMID: 36303077 DOI: 10.1007/s00381-022-05713-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/19/2022] [Indexed: 11/03/2022]
Abstract
Non-accidental head trauma (NAHT) is a common cause of traumatic brain injury in childhood, origin of profound and disabling neurological sequalae, and in the most disgraceful cases, ultimately death.Subdural hematoma (SDH) is the most common intracranial finding in NAHT. On the other hand, congenital bleeding disorders are a minor but a significant cause of ICH in the neonate and toddler. Not uncommonly, intracranial bleeding is the first sign of a severe inherited coagulation disorder. In the presence of an unexpected intracranial bleeding after a minor trauma or without a clear history of the related events, physicians and caregivers may be confronted to the dilemma of a possible child abuse. It must be bear in mind that physical abuse and bleeding disorders can co-exist in the same child.We report here the case of two siblings in whom a diagnosis of hemophilia coexisted with the presumption of a non-accidental head trauma. Child abuses were inflicted in both children with a spare time of 2 years. A diagnosis of mild hemophilia was prompted in the first sibling after initial NAHT, while inflicted trauma was evident in the second sibling after neuroimaging findings and concomitant lesions. Lessons from this case in co-existing bleeding disorders and inflicted trauma and legal implications derived will be discussed thereafter.The possibility of a bleeding disorder should be considered in all children presenting with unexplained bleeding at a critical site in the setting of suspected physical maltreatment, particularly intracranial hemorrhage (ICH).
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Anderst J, Carpenter SL, Abshire TC, Killough E, Mendonca EA, Downs SM, Wetmore C, Allen C, Dickens D, Harper J, Rogers ZR, Jain J, Warwick A, Yates A, Hord J, Lipton J, Wilson H, Kirkwood S, Haney SB, Asnes AG, Gavril AR, Girardet RG, Heavilin N, Gilmartin ABH, Laskey A, Messner SA, Mohr BA, Nienow SM, Rosado N, Idzerda SM, Legano LA, Raj A, Sirotnak AP, Forkey HC, Keeshin B, Matjasko J, Edward H, Chavdar M, Di Paola J, Leavey P, Graham D, Hastings C, Hijiya N, Hord J, Matthews D, Pace B, Velez MC, Wechsler D, Billett A, Stork L, Hooker R. Evaluation for Bleeding Disorders in Suspected Child Abuse. Pediatrics 2022; 150:189510. [PMID: 36180615 DOI: 10.1542/peds.2022-059276] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Bruising or bleeding in a child can raise the concern for child abuse. Assessing whether the findings are the result of trauma and/or whether the child has a bleeding disorder is critical. Many bleeding disorders are rare, and not every child with bruising/bleeding that may raise a concern for abuse requires an evaluation for bleeding disorders. However, in some instances, bleeding disorders can present in a manner similar to child abuse. Bleeding disorders cannot be ruled out solely on the basis of patient and family history, no matter how extensive. The history and clinical evaluation can be used to determine the necessity of an evaluation for a possible bleeding disorder, and prevalence and known clinical presentations of individual bleeding disorders can be used to guide the extent of laboratory testing. This clinical report provides guidance to pediatricians and other clinicians regarding the evaluation for bleeding disorders when child abuse is suspected.
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Affiliation(s)
- James Anderst
- Division of Child Adversity and Resilience, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - Shannon L Carpenter
- Division of Hematology/Oncology/BMT, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - Thomas C Abshire
- Senior Investigator Emeritus, Versiti Blood Research Institute, Department of Pediatrics, Medicine, and the CT SI of Southeast Wisconsin, Emeritus, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Emily Killough
- Division of Child Adversity and Resilience, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
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Carpenter SL, Abshire TC, Killough E, Anderst JD. Evaluating for Suspected Child Abuse: Conditions That Predispose to Bleeding. Pediatrics 2022; 150:189508. [PMID: 36120799 DOI: 10.1542/peds.2022-059277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Child abuse might be suspected when children present with cutaneous bruising, intracranial hemorrhage, or other manifestations of bleeding. In these cases, it is necessary to consider medical conditions that predispose to easy bleeding or bruising. When evaluating for the possibility of bleeding disorders and other conditions that predispose to hemorrhage, it is important for pediatricians to consider the child's presenting history, medical history, and physical examination findings before initiating a laboratory investigation. Many medical conditions can predispose to easy bleeding. Before ordering laboratory tests for a disease, it is useful to understand the biochemical basis and clinical presentation of the disorder, condition prevalence, and test characteristics. This technical report reviews the major medical conditions that predispose to bruising or bleeding and should be considered when evaluating for abusive injury.
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Affiliation(s)
- Shannon L Carpenter
- Division of Hematology/Oncology/BMT, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - Thomas C Abshire
- Senior Investigator Emeritus, Versiti Blood Research Institute, Department of Pediatrics, Medicine, and the CTSI of Southeast Wisconsin, Emeritus, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Emily Killough
- Division of Child Adversity and Resilience, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - James D Anderst
- Division of Child Adversity and Resilience, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
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Laoaroon N, Empremsilapa S, Sirachainan N. Pediatric standardized bleeding assessment tool for screening bleeding disorder in school-age children. Hematol Transfus Cell Ther 2022; 44:453-455. [PMID: 35110001 PMCID: PMC9477776 DOI: 10.1016/j.htct.2021.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 09/02/2021] [Accepted: 11/19/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Napat Laoaroon
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | - Nongnuch Sirachainan
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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Laboratory Assays of VWF Activity and Use of Desmopressin Trials in the Diagnosis of VWD: A Systematic Review and Meta-Analysis. Blood Adv 2022; 6:3735-3745. [PMID: 35192687 PMCID: PMC9631556 DOI: 10.1182/bloodadvances.2021005431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 02/02/2022] [Indexed: 11/20/2022] Open
Abstract
The findings of these reviews support VWF multimer analysis or VWF:CB/VWF:Ag to diagnose type 2 VWD. The reviews confirm that desmopressin trial is the test of choice to confirm increased VWF clearance in patients with suspected VWD type 1C.
von Willebrand Disease (VWD) is associated with significant morbidity because of excessive bleeding. Early diagnosis and treatment are important to prevent and treat these symptoms. We systematically reviewed the accuracy of any von Willebrand factor (VWF) activity assay in the diagnosis and classification of patients for VWD. We searched Cochrane Central, MEDLINE, and EMBASE for eligible studies. The risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 and the certainty of evidence using the GRADE framework. We pooled estimates of sensitivity and specificity. The review included 77 studies that evaluated the use of newer tests of VWF platelet binding activity (VWF:GPIbR, VWF:GPIbM) and VWF:RCo for the diagnosis of VWD (13 studies), VWF propeptide to VWF:Ag ratio, and desmopressin trial for the diagnosis of type 1C VWD (5 studies), VWF multimer analysis and VWF:CB/VWF:Ag ratio for the classification of type 2 VWD (11 studies), genetic testing and ristocetin-induced platelet aggregation to diagnose type 2B VWD (14 studies), genetic testing and FVIII:VWF binding to diagnose type 2N VWD (17 studies). Based on available diagnostic test accuracy, there appear to be comparable test accuracy results between newer tests of platelet binding activity of VWF function and VWF:RCo. The findings of these reviews support VWF multimer analysis or VWF:CB/VWF:Ag to diagnose type 2 VWD. The desmopressin trial test with 1- and 4-hour postinfusion blood work is the test of choice to confirm increased VWF clearance in patients with suspected VWD type 1C. Additionally, genetic testing is most useful in diagnosing type 2B VWD and has a role in the diagnostic algorithm of suspected type 2N VWD.
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[Interpretation of Chinese guideline on the diagnosis and management of von Willebrand disease (2022)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:13-15. [PMID: 35231986 PMCID: PMC8980658 DOI: 10.3760/cma.j.issn.0253-2727.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bleeding assessment tools in the diagnosis of VWD in adults and children: a systematic review and meta-analysis of test accuracy. Blood Adv 2021; 5:5023-5031. [PMID: 34597385 PMCID: PMC9153010 DOI: 10.1182/bloodadvances.2021004368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/14/2021] [Indexed: 12/29/2022] Open
Abstract
Von Willebrand disease (VWD) can be associated with significant morbidity. Patients with VWD can experience bruising, mucocutaneous bleeding, and bleeding after dental and surgical procedures. Early diagnosis and treatment are important to minimize the risk of these complications. Several bleeding assessment tools (BATs) have been used to quantify bleeding symptoms as a screening tool for VWD. We systematically reviewed diagnostic test accuracy results of BATs to screen patients for VWD. We searched Cochrane Central, MEDLINE, and EMBASE for eligible studies, reference lists of relevant reviews, registered trials, and relevant conference proceedings. Two investigators screened and abstracted data. Risk of bias was assessed using the revised tool for the quality assessment of diagnostic accuracy studies and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. We pooled estimates of sensitivity and specificity. The review included 7 cohort studies that evaluated the use of BATs to screen adult and pediatric patients for VWD. The pooled estimates for sensitivity and specificity were 75% (95% confidence interval, 66-83) and 54% (29-77), respectively. Certainty of evidence varied from moderate to high. This systematic review provides accuracy estimates for validated BATs as a screening modality for VWD. A BAT is a useful initial screening test to determine who needs specific blood testing. The pretest probability of VWD (often determined by the clinical setting/patient population), along with sensitivity and specificity estimates, will influence patient management.
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Bleeding Severity and Phenotype in 22q11.2 Deletion Syndrome-A Cross-Sectional Investigation. J Pediatr 2021; 235:220-225. [PMID: 33836185 DOI: 10.1016/j.jpeds.2021.03.071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 02/12/2021] [Accepted: 03/31/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To prospectively quantify bleeding severity and elaborate hemorrhagic symptoms in children with 22q11.2 deletion syndrome (22q11DS) using 2 validated bleeding assessment tools (BATs), namely the Pediatric Bleeding Questionnaire and the International Society on Thrombosis and Hemostasis BAT (ISTH-BAT). We also sought to compare subjects' bleeding scores to unaffected first-degree family members. STUDY DESIGN Children with 22q11DS and unaffected first-degree family members were recruited for the study. Two validated BATs were administered by a pediatric hematologist. Additional clinical and laboratory data were abstracted from patient medical records. Standard descriptive and nonparametric statistical methods were used. RESULTS In total, 29 eligible subjects and controls were assessed. Median age (range) of subjects and controls was 8 (5-17) years and 38 (9-56) years, respectively. In total, 17 of 29 subjects had a positive bleeding score on ISTH-BAT compared with 1 of 29 control patients (P < .0001). Median ISTH-BAT score in subjects was 3 (0-12), compared with 2 (0-6) in control patients (P = .022). Median Pediatric Bleeding Questionnaire score in subjects was 2 (-1 to 12). The most frequent bleeding symptoms reported in subjects with 22q11DS were epistaxis (69%) and bruising (52%). Eighteen subjects had been surgically challenged, and 6 were noted to have increased perioperative hemorrhage. CONCLUSIONS Children with 22q11DS have increased bleeding scores compared with their first-degree unaffected relatives. The majority of the bleeding symptoms described were mucocutaneous.
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Kaur D, Kerlin BA, Stanek JR, O'Brien SH. Use of electronic self-administered bleeding assessment tool in diagnosis of paediatric bleeding disorders. Haemophilia 2021; 27:710-716. [PMID: 34089545 DOI: 10.1111/hae.14349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 01/06/2023]
Abstract
INTRODUCTION In the era of electronic medical records, pen-and-paper-based physician-administered bleeding assessment tools (BAT) remain under-utilized in the clinical setting, as they are noted to be time-consuming. AIM The current study reviews the use of an electronic self-administered bleeding assessment tool (eBAT) prospectively in a paediatric haematology clinic and in comparison with a physician administered BAT (pBAT). MATERIALS AND METHODS This was reviewed and approved in the current form because the aims statement includes the method regarding comparison of 2 groups. So no additional section required. RESULTS A total of 94 BAT response pairs were available for analysis. The median time required for patients or parents to complete the eBAT was 8 min, with less than a third of the patients requiring over 10 min. The median bleeding scores noted in this study were 4 for both the BATs, with strong positive correlation between the eBAT and the physician administered bleeding questionnaire. The eBAT had a sensitivity of 93.8% (95% CI 82.8%-98.7%), a specificity of 34.8% (95% CI 21.4%-50.3%), a positive predictive value (PV) of 60.0% (95% CI 54.5%-65.2%) and a negative PV of 84.2% (95% CI 62.5%-94.5%) for identifying a bleeding disorder. CONCLUSIONS Findings indicate that eBAT is a valid and time-efficient screening tool for evaluating patients' bleeding symptoms, which can improve clinical applicability of BATs by reducing time for bleeding history review.
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Affiliation(s)
- Dominder Kaur
- Department of Paediatrics, Division of Paediatric Haematology/Oncology and Stem Cell Transplantation, Columbia University Medical Centre, New York, USA
| | - Bryce A Kerlin
- Division of Paediatric Haematology/Oncology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA.,Centre for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Joseph R Stanek
- Division of Paediatric Haematology/Oncology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Sarah H O'Brien
- Department of Paediatrics, Division of Paediatric Haematology/Oncology and Stem Cell Transplantation, Columbia University Medical Centre, New York, USA.,Centre for Innovation in Paediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
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15
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ASH ISTH NHF WFH 2021 guidelines on the diagnosis of von Willebrand disease. Blood Adv 2021; 5:280-300. [PMID: 33570651 DOI: 10.1182/bloodadvances.2020003265] [Citation(s) in RCA: 254] [Impact Index Per Article: 84.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/23/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND von Willebrand disease (VWD) is the most common inherited bleeding disorder known in humans. Accurate and timely diagnosis presents numerous challenges. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH), the International Society on Thrombosis and Haemostasis (ISTH), the National Hemophilia Foundation (NHF), and the World Federation of Hemophilia (WFH) are intended to support patients, clinicians, and other health care professionals in their decisions about VWD diagnosis. METHODS ASH, ISTH, NHF, and WFH established a multidisciplinary guideline panel that included 4 patient representatives and was balanced to minimize potential bias from conflicts of interest. The Outcomes and Implementation Research Unit at the University of Kansas Medical Center (KUMC) supported the guideline-development process, including performing or updating systematic evidence reviews up to 8 January 2020. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subsequently subject to public comment. RESULTS The panel agreed on 11 recommendations. CONCLUSIONS Key recommendations of these guidelines include the role of bleeding-assessment tools in the assessment of patients suspected of VWD, diagnostic assays and laboratory cutoffs for type 1 and type 2 VWD, how to approach a type 1 VWD patient with normalized levels over time, and the role of genetic testing vs phenotypic assays for types 2B and 2N. Future critical research priorities are also identified.
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Léguillier T, Favier R, Harroche A, Lasne D, Bachelot-Loza C, Borgel D, Boussaroque A, Pascreau T, Lallemant-Dudek P, Gkalea V, Haguet MC, Cormier-Daire V, Beaudeux JL, Monnot S, Lapillonne H, Baujat G, Forin V, Nivet-Antoine V. Assessing bleeding risk in 18 children with Osteogenesis imperfecta. Br J Haematol 2021; 192:785-788. [PMID: 33475155 DOI: 10.1111/bjh.17303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Teddy Léguillier
- Department of Clinical Biochemistry, Necker Enfants Malades Hospital, AP-HP, Paris, France.,INSERM UMR_S1140, Faculty of Pharmacy, Paris Descartes University, Paris, France
| | - Rémi Favier
- Department of Haematology, Reference Centre for Platelet Disorders, Armand Trousseau Hospital, AP-HP, Paris, France
| | - Annie Harroche
- Department of Haematology, Haemophilia Care Centre, Necker Enfants Malades Hospital, APHP, Paris, France
| | - Dominique Lasne
- Department of Haematology, Necker Enfants Malades Hospital, AP-HP, Paris, France.,INSERM UMR_S1176, Paris-Sud University, Paris-Saclay University, le Kremlin-Bicêtre, France
| | | | - Delphine Borgel
- Department of Haematology, Necker Enfants Malades Hospital, AP-HP, Paris, France.,INSERM UMR_S1176, Paris-Sud University, Paris-Saclay University, le Kremlin-Bicêtre, France
| | - Agathe Boussaroque
- Department of Clinical Biochemistry, Necker Enfants Malades Hospital, AP-HP, Paris, France.,INSERM UMR_S1140, Faculty of Pharmacy, Paris Descartes University, Paris, France
| | - Tiffany Pascreau
- Department of Haematology, Necker Enfants Malades Hospital, AP-HP, Paris, France.,INSERM UMR_S1176, Paris-Sud University, Paris-Saclay University, le Kremlin-Bicêtre, France
| | - Pauline Lallemant-Dudek
- Department of Paediatric Physical Therapy and Rehabilitation, Armand Trousseau Hospital, AP-HP, Paris, France
| | - Vasiliki Gkalea
- Department of Haematology, Reference Centre for Platelet Disorders, Armand Trousseau Hospital, AP-HP, Paris, France
| | - Marie-Clotilde Haguet
- Department of Clinical Biochemistry, Armand Trousseau Hospital, AP-HP, Paris, France
| | - Valérie Cormier-Daire
- Department of Medical Genetics, Necker Enfants Malades Hospital, AP-HP, Paris, France.,INSERM U1163, Imagine Institute, Paris Descartes University, Paris, France
| | - Jean-Louis Beaudeux
- Department of Clinical Biochemistry, Necker Enfants Malades Hospital, AP-HP, Paris, France.,INSERM UMR_S1139, Faculty of Pharmacy, Paris Descartes University, Paris, France
| | - Sophie Monnot
- Department of Medical Genetics, Necker Enfants Malades Hospital, AP-HP, Paris, France.,INSERM U1163, Imagine Institute, Paris Descartes University, Paris, France
| | - Hélène Lapillonne
- Department of Haematology, Reference Centre for Platelet Disorders, Armand Trousseau Hospital, AP-HP, Paris, France
| | - Geneviève Baujat
- Department of Medical Genetics, Necker Enfants Malades Hospital, AP-HP, Paris, France.,INSERM U1163, Imagine Institute, Paris Descartes University, Paris, France
| | - Véronique Forin
- Department of Paediatric Physical Therapy and Rehabilitation, Armand Trousseau Hospital, AP-HP, Paris, France
| | - Valérie Nivet-Antoine
- Department of Clinical Biochemistry, Necker Enfants Malades Hospital, AP-HP, Paris, France.,INSERM UMR_S1140, Faculty of Pharmacy, Paris Descartes University, Paris, France
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Kaufmann J, Adler M, Alberio L, Nagler M. Utility of the Platelet Function Analyzer in Patients with Suspected Platelet Function Disorders: Diagnostic Accuracy Study. TH OPEN 2020; 4:e427-e436. [PMID: 33376942 PMCID: PMC7755505 DOI: 10.1055/s-0040-1721502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/28/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction
The platelet function analyzer (PFA) is widely used as a screening tool for bleeding disorders in various settings. The diagnostic performance regarding platelet function disorders (PFDs), which are among the most common inherited bleeding disorders, is however still elusive. We aimed to assess the diagnostic value of PFA for PFD in clinical practice.
Methods
Comprehensive clinical and laboratory data of all consecutive patients referred to a specialized outpatient between January 2012 and March 2017 with a suspected bleeding disorder were prospectively recorded. The diagnostic work-up was performed according to a prespecified protocol following current guidelines and platelet function was tested using light transmission aggregometry as well as flow cytometry.
Results
Five hundred and fifty-five patients were included (median age 43.7 years; interquartile range [IQR] 29.3, 61.7; 66.9% female). Possible PFD was diagnosed in 64 patients (11.5%) and confirmed PFD in 54 patients (9.7%). In patients with confirmed PFD, median closure times were 107 seconds (ADP or adenosine diphosphate; IQR 89, 130) and 169 seconds (EPI; IQR 121, 211). In patients without bleeding disorders, PFA closure times were 96 seconds (ADP; IQR 83, 109) and 137 seconds (EPI; IQR 116, 158). The sensitivity was 19.5% in case of PFA ADP (95%CI 12.6, 30.0; specificity 86.4%; 95% CI 82.4, 89.8), and 44.3% in case of PFA EPI (95% CI 34.9, 53.9; specificity 75.6%; 95% CI 70.8, 79.9).
Conclusion
The diagnostic performance of PFA for PFD was moderate to poor. Our results do not support the utilization of PFA for screening of PFD in clinical practice.
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Affiliation(s)
- Jonas Kaufmann
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Marcel Adler
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland.,Division of Hematology and Central Hematology Laboratory, CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Central Hematology Laboratory, CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Michael Nagler
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland.,University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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18
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Jain S, Zhang S, Acosta M, Malone K, Kouides P, Zia A. Prospective evaluation of ISTH-BAT as a predictor of bleeding disorder in adolescents presenting with heavy menstrual bleeding in a multidisciplinary hematology clinic. J Thromb Haemost 2020; 18:2542-2550. [PMID: 32654321 DOI: 10.1111/jth.14997] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/30/2020] [Accepted: 07/02/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) can be the first manifestation of an undiagnosed bleeding disorder (BD). Identifying a BD can be challenging in the adolescent age group. The utility of bleeding assessment tools (BAT) remains elusive in this population. AIM We evaluated the ability of the International Society on Thrombosis and Haemostasis-BAT (ISTH-BAT) in predicting a BD in adolescents referred for HMB to a multidisciplinary hematology clinic. METHODS Two hundred adolescents with HMB underwent a standardized evaluation for BD. The clinical characteristics, laboratory data, and bleeding scores (BS) assessed using ISTH-BAT were prospectively collected. Comparisons were made between patients based on the diagnosis of BD receiver operating characteristic (ROC) curve analyses of ISTH-BAT were performed to assess its value for predicting BD. RESULTS Overall, 33% (n = 67) of adolescents were diagnosed with a BD. The mean ISTH-BAT BS was higher in BD as compared to those without (4.1 versus 3.1, P < .0001), but the mean menorrhagia-specific scores did not differ (2.9 in both groups). The ISTH-BAT demonstrated a modest discriminative ability as a screening tool to identify BD in girls with HMB with an area under the curve (AUC) of 0.71. The ROC analysis demonstrated that with increasing BS, the sensitivity decreased, but the specificity increased. At BS = 3, sensitivity was 88%, specificity 31%, and accuracy 50%; at BS = 5, sensitivity was 37%, specificity 94%, and accuracy was 75%. There was no change thereafter. CONCLUSION In adolescents with HMB, an ISTH-BAT BS of >4 instead of the established cut-off of >2 in children is highly specific in predicting a BD.
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Affiliation(s)
- Shilpa Jain
- Division of Pediatric Hematology-Oncology, John R. Oishei Children's Hospital, University at Buffalo, Buffalo, NY, USA
- Western New York BloodCare, Buffalo, NY, USA
| | - Song Zhang
- Department of Population and Data Sciences, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Kendra Malone
- Division of Hematology/Oncology, Department(s) of Pediatrics, Children's Medical Center, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Peter Kouides
- Mary M. Gooley Hemophilia Center, University of Rochester School of Medicine, Rochester, NY, USA
| | - Ayesha Zia
- Division of Hematology/Oncology, Department(s) of Pediatrics, Children's Medical Center, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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19
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Srivastava A. Diagnosis of haemophilia and other inherited bleeding disorders ‐ Is a new paradigm needed? Haemophilia 2020; 27 Suppl 3:14-20. [DOI: 10.1111/hae.14042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Alok Srivastava
- Department of Haematology Christian Medical College Vellore India
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20
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Fogarty H, Doherty D, O'Donnell JS. New developments in von Willebrand disease. Br J Haematol 2020; 191:329-339. [PMID: 32394456 DOI: 10.1111/bjh.16681] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 12/19/2022]
Abstract
Von Willebrand disease (VWD) constitutes the most common inherited human bleeding disorder. It is associated with a mucocutaneous bleeding phenotype that can significantly impact upon quality of life. Despite its prevalence and associated morbidity, the diagnosis and subclassification of VWD continue to pose significant clinical challenges. This is in part attributable to the fact that plasma von Willebrand factor (VWF) levels vary over a wide range in the normal population, together with the multiple different physiological functions played by VWF in vivo. Over recent years, substantial progress has been achieved in elucidating the biological roles of VWF. Significant advances have also been made into defining the pathophysiological mechanisms underpinning both quantitative and qualitative VWD. In particular, several new laboratory assays have been developed that enable more precise assessment of specific aspects of VWF activity. In the present review, we discuss these recent developments in the field of VWD diagnosis, and consider how these advances can impact upon clinical diagnostic algorithms for use in routine clinical practice. In addition, we review some important recent advances pertaining to the various treatment options available for managing patients with VWD.
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Affiliation(s)
- Helen Fogarty
- 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
| | - Dearbhla Doherty
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James S O'Donnell
- 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.,National Children's Research Centre, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
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21
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Belen Apak FB, Ümit EG, Zengin Y, Sezgin Evim M, Ünal E, Özbaş HM, Acıpayam C. Assessment of Patients with von Willebrand Disease with ISTH/BAT and PBQ Scores. Turk J Haematol 2020; 37:57-58. [PMID: 31718118 PMCID: PMC7057742 DOI: 10.4274/tjh.galenos.2019.2019.0446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Fatma Burcu Belen Apak
- Başkent University Faculty of Medicine, Department of Pediatric Hematology Oncology, Ankara, Turkey
| | - Elif Gülsüm Ümit
- Trakya University Faculty of Medicine, Department of Hematology, Edirne, Turkey
| | - Yağmur Zengin
- Başkent University Faculty of Medicine, Department of Biostatistics, Ankara, Turkey
| | - Melike Sezgin Evim
- Uludağ University Faculty of Medicine, Department of Pediatric Hematology Oncology, Bursa, Turkey
| | - Ekrem Ünal
- Erciyes University Faculty of Medicine, Department of Pediatric Hematology Oncology, Kayseri, Turkey
| | - Hasan Mücahit Özbaş
- Giresun University Faculty of Medicine, Department of Hematology, Giresun, Turkey
| | - Can Acıpayam
- Kahramanmaraş Sütçü İmam University Faculty of Medicine, Department of Pediatric Hematology and Oncology, Kahramanmaraş, Turkey
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22
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Abe K, Dupervil B, O’Brien SH, Oakley M, Kulkarni R, Gill JC, Byams V, Soucie MJ. Higher rates of bleeding and use of treatment products among young boys compared to girls with von Willebrand disease. Am J Hematol 2020; 95:10-17. [PMID: 31612544 PMCID: PMC9125340 DOI: 10.1002/ajh.25656] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 10/02/2019] [Accepted: 10/04/2019] [Indexed: 01/25/2023]
Abstract
There are limited observational studies among children diagnosed with von Willebrand Disease (VWD). We analyzed differences in bleeding characteristics by sex and type of VWD using the largest reported surveillance database of children with VWD (n = 2712), ages 2 to 12 years old. We found that the mean ages of first bleed and diagnosis were lowest among children with type 3 VWD. It was even lower among boys than girls among all VWD types, with statistically significant difference among children with type 1 or type 3 VWD. Children with type 3 VWD also reported higher proportions of ever having a bleed compared to other VWD types, with statistically higher proportions of boys compared to girls reporting ever having a bleed with type 1 and type 2 VWD. A similar pattern was observed with the use of treatment product, showing higher usage among type 3 VWD, and among boys than girls with type 1 and type 2 VWD. While there were no differences in life quality or in well-being status by sex, children with type 3 VWD showed a greater need for mobility assistance compared to children with type 1 and type 2 VWD. In an adjusted analysis among children with type 1 VWD, boys showed a significant association of ever bleeding [hazard ratio 1.4; P-value <.001)] compared to girls. Understanding phenotypic bleeding characteristics, well-being status, treatment, and higher risk groups for bleeding among pre-adolescent children with VWD will aid physicians in efforts to educate families about bleeding symptoms.
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Affiliation(s)
- Karon Abe
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Brandi Dupervil
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sarah H. O’Brien
- Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Meredith Oakley
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Roshni Kulkarni
- Centers for Bleeding and Clotting Disorders, Department of Pediatrics and Human Development, Michigan State University, East Lansing, Michigan
| | - Joan Cox Gill
- Bloodcenter of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Vanessa Byams
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Michael J. Soucie
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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23
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Doshi BS, Rogers RS, Whitworth HB, Stabnick EA, Britton J, Butler RB, Obstfeld AE, Witmer CM. Utility of repeat testing in the evaluation for von Willebrand disease in pediatric patients. J Thromb Haemost 2019; 17:1838-1847. [PMID: 31350816 DOI: 10.1111/jth.14591] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/23/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Von Willebrand disease (VWD) is the most common inherited bleeding disorder and is caused by quantitative and qualitative defects in von Willebrand factor (VWF). The laboratory diagnosis of VWD in pediatric patients is complicated by VWF interassay and intra-assay variability, stress-induced elevations in VWF levels, and a lack of significant bleeding history with which to correlate test results. OBJECTIVE Guidelines recommend repeat testing in patients with a high suspicion of VWD and unclear laboratory assay results; however, no studies have evaluated the utility of repeat VWF testing in pediatric patients. METHODS This retrospective single-center cohort study aimed to determine clinical variables associated with requiring more than one test to diagnose VWD and to establish a cutoff VWF value above which further testing is not informative. RESULTS Of 811 patients evaluated for a suspected bleeding disorder, 22.2% were diagnosed with VWD, with ~70% diagnosed on the first test. Patients with VWD were younger (5.8 vs. 8.5 years, P = .002) and more likely to have a family history of VWD (38% vs. 22%, P < .001) than those without VWD. Univariate analysis failed to identify any clinical variables that correlated with needing multiple tests for a VWD diagnosis. A cutoff of 100 IU/dL for VWF antigen or activity on the first test yielded negative predictive values >95%. CONCLUSIONS We demonstrate that the majority of pediatric patients had diagnostic VWF values on the first set of testing. Pediatric patients without a family history of VWD and VWF levels >100 IU/dL may not need further testing to rule out the diagnosis of VWD.
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Affiliation(s)
- Bhavya S Doshi
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel S Rogers
- Biostatistical and Data Management Core, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hilary B Whitworth
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Emily A Stabnick
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jessica Britton
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Regina B Butler
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Amrom E Obstfeld
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Char M Witmer
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania
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24
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Zia A, Jain S, Kouides P, Zhang S, Gao A, Salas N, Lau M, Wilson E, DeSimone N, Sarode R. Bleeding disorders in adolescents with heavy menstrual bleeding in a multicenter prospective US cohort. Haematologica 2019; 105:1969-1976. [PMID: 31624107 PMCID: PMC7327636 DOI: 10.3324/haematol.2019.225656] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 10/14/2019] [Indexed: 12/03/2022] Open
Abstract
Heavy menstrual bleeding is common in adolescents. The frequency and predictors of bleeding disorders in adolescents, especially with anovulatory bleeding, are unknown. Adolescents referred for heavy menstrual bleeding underwent an evaluation of menstrual bleeding patterns, and bleeding disorders determined a priori. The primary outcome was the diagnosis of a bleeding disorder. Two groups were compared: anovulatory and ovulatory bleeding. Multivariable logistic regression analysis of baseline characteristics and predictors was performed. Kaplan Meier curves were constructed for the time from the first bleed to bleeding disorder diagnosis. In 200 adolescents, a bleeding disorder was diagnosed in 33% (n=67): low von Willebrand factor levels in 16%, von Willebrand disease in 11%, and qualitative platelet dysfunction in 4.5%. The prevalence of bleeding disorder was similar between ovulatory and anovulatory groups (31% vs. 36%; P=0.45). Predictors of bleeding disorder included: younger age at first bleed (OR: 0.83; 95%CI: 0.73, 0.96), Hispanic ethnicity (OR: 2.48; 95%CI: 1.13, 5.05), non-presentation to emergency department for heavy bleeding (OR: 0.14; 95%CI: 0.05, 0.38), and International Society on Thrombosis and Haemostasis (ISTH) Bleeding Assessment Tool score ≥4 (OR: 8.27; 95%CI: 2.60, 26.44). Time from onset of the first bleed to diagnosis was two years in the anovulatory, and six years in the ovulatory cohort (log-rank test, P<0.001). There is a high prevalence of bleeding disorders in adolescents with heavy periods, irrespective of the bleeding pattern. Among bleeding disorders, the prevalence of qualitative platelet dysfunction is lower than previously reported.
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Affiliation(s)
- Ayesha Zia
- The University of Texas Southwestern Medical Center, Dallas, TX .,Department of Pediatrics, Children's Medical Center, Dallas, TX.,Division of Hematology/Oncology, Children's Medical Center, Dallas, TX.,Children's Medical Center, Dallas, TX
| | - Shilpa Jain
- Hemophilia Center of Western New York, John R. Oishei Children's Hospital of Buffalo, Division of Pediatric Hematology-Oncology, Buffalo, NJ
| | - Peter Kouides
- Mary M. Gooley Hemophilia Center, University of Rochester School of Medicine, Rochester, MN
| | - Song Zhang
- The University of Texas Southwestern Medical Center, Dallas, TX.,Department of Data and Population Sciences, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Ang Gao
- The University of Texas Southwestern Medical Center, Dallas, TX.,Department of Data and Population Sciences, The University of Texas Southwestern Medical Center, Dallas, TX
| | | | - May Lau
- The University of Texas Southwestern Medical Center, Dallas, TX.,Division of Hematology/Oncology, Children's Medical Center, Dallas, TX.,Division of Adolescent Medicine, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Ellen Wilson
- The University of Texas Southwestern Medical Center, Dallas, TX.,Children's Medical Center, Dallas, TX.,Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Nicole DeSimone
- The University of Texas Southwestern Medical Center, Dallas, TX.,Department of Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ravi Sarode
- The University of Texas Southwestern Medical Center, Dallas, TX.,Department of Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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25
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Hemostasis in Critical Illness: Better Tools, Better Answers! Pediatr Crit Care Med 2019; 20:986-987. [PMID: 31580272 DOI: 10.1097/pcc.0000000000002024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Hussein HK, Nicolson P, Fordwor K, Lowe GC. Mild bleeding disorders: what every clinician should know. Br J Hosp Med (Lond) 2019; 78:684-710. [PMID: 29240509 DOI: 10.12968/hmed.2017.78.12.684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patients with mild bleeding disorders are under-recognized and frequently present to general physicians. The underlying reasons for bleeding are multifactorial. There is little evidence to guide diagnostic and management decision making in patients with mild bleeding disorders. This article outlines different types of mild bleeding disorders, with a particular focus on bleeding associated with low levels of von Willebrand factor and mild platelet defects. It gives practical, evidence-based advice on the investigation and management of patients with a suspected or known mild bleeding disorder, considering the scenarios of an acute bleed, stable outpatient, peri-surgical management and thrombosis. Patients with a mild bleeding disorder have variable bleeding because of the interplay of genetic and environmental factors. The clinical history remains of utmost importance in their general management. Liaison with a specialist centre, multidisciplinary assessment and a careful judgement of the balance of risk in each individual circumstance is required to safely manage these patients.
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Affiliation(s)
- H K Hussein
- Specialty Registrar in Clinical Haematology, Department of Clinical Haematology, Queen Elizabeth Hospital, Birmingham
| | - Plr Nicolson
- Specialty Registrar in Clinical Haematology and BHF Clinical Research Training Fellow, Department of Clinical Haematology, Queen Elizabeth Hospital, Birmingham, and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT
| | - K Fordwor
- Core Medical Trainee, Department of Medicine, Chelsea and Westminster Hospital, London
| | - G C Lowe
- Consultant Haematologist, Department of Clinical Haematology, Queen Elizabeth Hospital, Birmingham
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Adler M, Kaufmann J, Alberio L, Nagler M. Diagnostic utility of the ISTH bleeding assessment tool in patients with suspected platelet function disorders. J Thromb Haemost 2019; 17:1104-1112. [PMID: 31021046 PMCID: PMC6852182 DOI: 10.1111/jth.14454] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 04/11/2019] [Indexed: 01/09/2023]
Abstract
Essentials The utility of bleeding assessment tools regarding platelet function disorders is still elusive. We studied consecutive patients in a prospective cohort study in a tertiary hospital. Substantially higher scorings were observed in patients with platelet function disorders. Bleeding assessment tools might provide a useful screening tool. BACKGROUND Bleeding assessment tools (BATs) have been widely implemented in the evaluation of patients with suspected bleeding disorders. However, diagnostic BAT utility regarding platelet function disorders is still elusive. AIM We aimed to assess the diagnostic value of the International Society on Thrombosis and Haemostasis BAT (ISTH-BAT) for platelet function disorders in clinical practice. METHODS The clinical characteristics and laboratory data of all consecutive patients with a suspected bleeding disorder referred between January 2012 and March 2017 to an outpatient unit of a university hospital were prospectively collected. The diagnostic evaluation was performed according to current recommendations following a prespecified protocol and platelet function was tested using light transmission aggregometry as well as flow cytometry. RESULTS Five hundred and fifty-five patients were assessed; 66.9% were female, median age was 43.7 years (interquartile range [IQR] 29.3, 61.7). Confirmed platelet function disorder was diagnosed in 54 patients (9.7%), possible platelet function disorder in 64 patients (11.5%), and other disorders in 170 patients (30.6%). Median scoring of the ISTH-BAT was 2 in patients without a bleeding disorder (IQR 1, 3), 4 in patients with a possible platelet function disorder (2, 7), and 7 in patients with confirmed platelet function disorder (5, 9). Area under the receiver operating characteristic curve (the area under the curve [AUC]) was 0.75 (95% CI 0.70, 0.80). CONCLUSIONS Presence of a platelet function disorder was associated with substantially higher BAT scorings compared to patients without. Our data suggest that the ISTH-BAT provides a useful screening tool for patients with suspected platelet function disorders.
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Affiliation(s)
- Marcel Adler
- Department of Haematology and Central Haematology Laboratory, InselspitalBern University Hospital and University of BernBernSwitzerland
- Division of Haematology and Central Hematology LaboratoryCHUVLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Jonas Kaufmann
- Department of Haematology and Central Haematology Laboratory, InselspitalBern University Hospital and University of BernBernSwitzerland
| | - Lorenzo Alberio
- Division of Haematology and Central Hematology LaboratoryCHUVLausanne University Hospital and University of LausanneLausanneSwitzerland
- Faculty of Biology and MedicineUniversity of LausanneLausanneSwitzerland
| | - Michael Nagler
- Department of Haematology and Central Haematology Laboratory, InselspitalBern University Hospital and University of BernBernSwitzerland
- University Institute of Clinical ChemistryUniversity of BernBernSwitzerland
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Bui J, Martyres D, James PD, Grabell J, Wu J, Steele M, Silva M, Rand ML, Blanchette VS, Barrowman N, Klaassen RJ. Validation of the school age self-administered pediatric bleeding questionnaire (Self-PBQ) in children aged 8-12 years. Pediatr Blood Cancer 2019; 66:e27709. [PMID: 30900820 PMCID: PMC7643750 DOI: 10.1002/pbc.27709] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 02/05/2019] [Accepted: 02/21/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND In the pediatric population, pathologic bleeding is often challenging to identify. The pediatric bleeding questionnaire (PBQ) was developed as a screening tool for von Willebrand disease (VWD) but was designed to be self-completed by children above 12 years of age. The study objective was to determine whether a modified Self-PBQ could be completed by 8- to 12-year-old children with adult assistance. PROCEDURE The initial phase involved seven children who underwent cognitive debriefing to identify problems in the questionnaire, resulting in modifications to wording and response options. In phase 2, children completed the modified Self-PBQ independently or with assistance from their parent at five Canadian treatment centers. Parents filled out the Self-PBQ separately to serve as a comparison. Bleeding scores derived from the child self-report were compared to those of the parent proxy. RESULTS Twenty-nine out of 31 patient/parent pairs successfully completed the Self-PBQ. Child and parent scores demonstrated a high level of agreement with an intraclass correlation (ICC) of 0.825. In the age subgroup analysis, the ICC was 0.834 and 0.824 for the 8- to 9-year-old and 10- to 12-year-old groups, respectively. The ICC was also determined in children with type 1 VWD (ICC = 0.829) versus those with more severe bleeding disorders (ICC = 0.802). Thus, age and disease severity had no significant effect on degree of agreement. CONCLUSIONS Our study shows that agreement was maintained even in younger children aged 8-9 years and in children with varying bleeding phenotypes. This supports the administration of the modified Self-PBQ to 8- to 12-year-old children.
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Affiliation(s)
- Jessica Bui
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | | | - Paula D. James
- Department of Medicine, Queen’s University, Kingston, Canada
| | | | - John Wu
- Division of Hematology/Oncology, British Columbia Children’s Hospital, Vancouver, Canada
| | - MacGregor Steele
- Section of Pediatric Hematology, Alberta Children’s Hospital, Calgary, Canada
| | | | - Margaret L. Rand
- Division of Hematology/Oncology and Translational Medicine, The Hospital for Sick Children; Departments of Laboratory Medicine & Pathobiology, Biochemistry, and Pediatrics, University of Toronto, Toronto, Canada
| | - Victor S. Blanchette
- Division of Hematology/Oncology, Department of Pediatrics, University of Toronto, Hospital for Sick Children, Toronto, Canada
| | - Nick Barrowman
- Department of Pediatrics, University of Ottawa, Ottawa, Canada
| | - Robert J. Klaassen
- Department of Pediatrics, Division of Hematology/Oncology, Children’s Hospital of Eastern Ontario, Ottawa, Canada
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29
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Thromboelastometry as a diagnostic tool in mild bleeding disorders: A prospective cohort study. Eur J Anaesthesiol 2019; 36:457-465. [PMID: 30950901 DOI: 10.1097/eja.0000000000000985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Major guidelines emphasise the potential of visco-elastic methods to overcome the limitations of conventional laboratory assays in the peri-operative setting. Their sensitivity regarding mild bleeding disorders (MBDs), the most common bleeding disorders in the general population, is however unknown. OBJECTIVE The aim of this study was to investigate the sensitivity of thromboelastometry for diagnosis of MBD. DESIGN A single-centre prospective cohort study. SETTING Haematology outpatient unit of a tertiary general hospital in Central Switzerland. PATIENTS All consecutive patients referred over a 32-month period with a suspected bleeding disorder were included and thromboelastometry was conducted using a ROTEM delta (EXTEM, INTEM and FIBTEM). Diagnostic work-up was performed according to current guidelines including the ISTH bleeding assessment tool (ISTH BAT). MAIN OUTCOME MEASURES Distribution of clotting time (CT) and maximum clot firmness (MCF) results in relation to the presence of MBD. RESULTS Two hundred and seventeen patients were assessed; the median [IQR] age was 39 years [28 to 57]; 151 patients were women (70%). MBD was diagnosed in 97 patients (45%), no MBD was found in 100 patients (46%) and a systemic disorder recognised in 20 patients (9%). Presence of MBD was not associated with a significant difference in thromboelastometry variables (0.2 s in CT EXTEM, 95% CI -2.3 to 2.7; -0.2 mm in MCF EXTEM, 95% CI -1.8 to 1.5; -0.7 s in CT INTEM, 95% CI -12.6 to 11.2; 0.6 mm in MCF INTEM, 95% CI -1.2 to 1.3; 0.8 mm in MCF FIBTEM, 95% CI -1.6 to 1.4) and most results were within the established reference ranges. CONCLUSION Our data did not support the use of thromboelastometry as a diagnostic tool in patients with MBD.
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30
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Bleeding Disorders in Adolescents with Heavy Menstrual Bleeding: The Queensland Statewide Paediatric and Adolescent Gynaecology Service. J Pediatr Adolesc Gynecol 2019; 32:122-127. [PMID: 30472382 DOI: 10.1016/j.jpag.2018.11.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/09/2018] [Accepted: 11/12/2018] [Indexed: 01/28/2023]
Abstract
STUDY OBJECTIVE Heavy menstrual bleeding (HMB) is a common gynecological complaint among young women with up to 40% having experienced HMB. Bleeding disorders are increasingly being recognized in adolescents and young adults with HMB. The aim of this study was to determine the prevalence of bleeding disorders in adolescents with HMB, among patients who presented to the Queensland Statewide Paediatric and Adolescent Gynaecology Service between July 2007 and July 2017. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: The study was a retrospective review of 124 female adolescents aged 8 to 18 years with HMB who presented to the Queensland Paediatric and Adolescent Gynaecology Service, Brisbane, Australia. The primary outcome measure was diagnosis of a bleeding disorder, with secondary outcomes including iron deficiency and/or anemia and treatment modalities. RESULTS Screening for bleeding disorders was performed in 77/124 (62.1%) of patients with HMB. Twenty-seven adolescents were diagnosed with a bleeding disorder, giving a prevalence of 27/124 (21.7%) in those with HMB, and 27/77 (35%) with HMB who were screened. Of these 35%, von Willebrand disease was the most common bleeding disorder, found in 14/27 (51.6%), followed by inherited platelet function disorders diagnosed in 9/27 (33.3%), thrombocytopenia (inherited or acquired) in 3/27 (11.1%), and Factor IX deficiency in 1/27 (3.7%). Iron deficiency and/or anemia was diagnosed in 53/107 (49.5%) of patients with HMB who were screened for this, and 19/27 (70.3%) of those diagnosed with a bleeding disorder. CONCLUSION Adolescents with HMB who present to a tertiary pediatric and adolescent gynecology service should be screened for bleeding disorders, because of the considerably high prevalence in this at-risk population.
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31
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Nessle CN, Ghosal S, Mathews C, Taylor D, Myers J, Raj A, Panigrahi A. Weak correlation of bleeding scores to platelet electron microscopy: A retrospective chart review of pediatric patients with delta-storage pool disorder. Pediatr Blood Cancer 2019; 66:e27505. [PMID: 30345617 DOI: 10.1002/pbc.27505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 09/11/2018] [Accepted: 09/24/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Delta granule storage pool deficiency (δ-SPD) is a rare platelet disorder in which a deficiency of platelet granules leads to poor aggregation, resulting in varying clinical bleeding phenotypes. Children with δ-SPD have variable laboratory results, making the proper diagnosis and evaluation controversial. OBJECTIVES To describe the demographic and laboratory trends of this population and to assess the value of electron microscopy in diagnostic evaluation and its correlation to bleeding symptoms. METHODS We performed a retrospective review of 109 pediatric patients diagnosed with δ-SPD. We collected demographic information and bleeding scores using a validated bleeding assessment tool. A descriptive and exploratory analysis was performed. RESULTS The majority of patients were female, with an average age at diagnosis of 11.61 years. Females were diagnosed at a significantly older age presenting most often with menorrhagia, while males presented most commonly with epistaxis. The majority showed normal lumiaggregometry, the mean platelet electron microscopy (PEM) value was 2.37, and the mean bleeding score was 6. Bleeding assessment tool and PEM had a significantly weak correlation. CONCLUSIONS Patients with more dense granules per platelet had higher bleeding scores than those with fewer dense granules per platelet. The current body of evidence does not favor the use of PEM in routine clinical practice, and results are difficult to interpret. In patients with severe mucocutaneous bleeding symptoms and normal platelet aggregation studies, consideration should be given to an alternative diagnosis and further evaluation is warranted.
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Affiliation(s)
- C N Nessle
- Department of Pediatrics, University of Louisville, Louisville, Kentucky
| | - S Ghosal
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, Kentucky
| | - C Mathews
- Department of Pediatrics, University of Louisville, Louisville, Kentucky
| | - D Taylor
- Department of Pediatrics, University of Louisville, Louisville, Kentucky
| | - J Myers
- Department of Pediatrics, University of Louisville, Louisville, Kentucky.,Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, Kentucky
| | - A Raj
- Department of Pediatrics, University of Louisville, Louisville, Kentucky.,Department of Pediatric Hematology Oncology, University of Louisville, Louisville, Kentucky
| | - A Panigrahi
- Department of Pediatric Hematology Oncology, University of California-Davis, Davis, California
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32
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Mezzano D, Quiroga T. Diagnostic challenges of inherited mild bleeding disorders: a bait for poorly explored clinical and basic research. J Thromb Haemost 2019; 17:257-270. [PMID: 30562407 DOI: 10.1111/jth.14363] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Indexed: 01/10/2023]
Abstract
The best-known inherited mild bleeding disorders (MBDs), i.e. type 1 von Willebrand disease (VWD), platelet function disorders (PFDs), and mild to moderate clotting factor deficiencies, are characterized clinically by mucocutaneous bleeding, and, although they are highly prevalent, still pose difficult diagnostic problems. These include establishing the pathological nature of bleeding, and the uncertainties surrounding the clinical relevance of laboratory results. Furthermore, the high frequency of bleeding symptoms in the normal population and the subjective appraisal of symptoms by patients or parents makes elucidating the pathological nature of bleeding difficult. Standardized bleeding assessment tools and semiquantitative bleeding scores (BSs) help to discriminate normal from abnormal bleeding. However, as most MBDs have similar bleeding patterns, for example, bleeding sites, frequency, and severity, BSs are of little help for diagnosing specific diseases. Global tests of primary hemostasis (bleeding time; PFA-100/200) lack sensitivity and, like BSs, are not disease-specific. Problems with the diagnosis of type 1 VWD and PFD include assay standardization, uncertain definition of von Willebrand factor cut-off levels, and the lack of universal diagnostic criteria for PFD. Regarding clotting factor deficiencies, the bleeding thresholds of some coagulation factors, such as factor VII and FXI, are highly variable, and may lead to misinterpretation of the clinical relevance of mild to moderate deficiencies. Remarkably, a large proportion of MBDs remain undiagnosed even after comprehensive and repeated laboratory testing. These are tentatively considered to represent bleeding of undefined cause, with clinical features indistinguishable from those of classical MBD; the pathogenesis of this is probably multifactorial, and unveiling these mechanisms should constitute a fertile source of translational research.
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Affiliation(s)
- D Mezzano
- Department of Hematology-Oncology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - T Quiroga
- Clinical Laboratory, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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33
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Gresele P, Bury L, Mezzasoma AM, Falcinelli E. Platelet function assays in diagnosis: an update. Expert Rev Hematol 2019; 12:29-46. [DOI: 10.1080/17474086.2019.1562333] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Loredana Bury
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Anna Maria Mezzasoma
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Emanuela Falcinelli
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
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Abstract
Abnormal uterine bleeding is common in adolescents and is thought to affect 9% to 14% of women in their reproductive years. Certain unique aspects of underlying inherited or acquired blood disorders exacerbate the "expected" hormonal imbalance at this age, thereby increasing the morbidity of the underlying problem. A multifactorial etiology demands a collaborative approach between hematologists and gynecologists or adolescent medicine physicians to effectively manage abnormal uterine bleeding in young women with blood disorders.
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Affiliation(s)
- Kathryn E Dickerson
- Division of Hematology/Oncology, The University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Neethu M Menon
- Pediatric Hematology Oncology, Division of Hematology/Oncology, The University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Ayesha Zia
- Division of Hematology/Oncology, The University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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35
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Stokhuijzen E, Rand ML, Cnossen MH, Biss TT, James PD, Suijker MH, Peters M, van der Lee JH, Peters B, Meijer AB, Blanchette VS, Fijnvandraat K. Identifying Children with HEreditary Coagulation disorders (iCHEC): a protocol for a prospective cohort study. BMJ Open 2018; 8:e020686. [PMID: 29724741 PMCID: PMC5942417 DOI: 10.1136/bmjopen-2017-020686] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION It is challenging to obtain a reliable bleeding history in children who are referred for a suspected inherited bleeding disorder. Bleeding symptoms may be subtle as children face fewer haemostatic challenges compared with adults. In order to standardise bleeding histories, questionnaires have been developed, called bleeding assessment tools (BATs). Although it has been shown that high bleeding scores are associated with the presence of a mucocutaneous bleeding disorder, these BATs lack sensitivity, efficiency and flexibility in the paediatric setting. We developed a new BAT (the iCHEC (identifying Children with HEreditary Coagulation disorders) BAT) to improve on these characteristics. We aim to evaluate the diagnostic accuracy of the iCHEC BAT as a screening tool for children who are suspected for having a bleeding disorder. METHODS AND ANALYSIS This is a prospective cohort study. Children (age 0-18 years) suspected for a bleeding disorder who present at tertiary haematology clinics, and/or their parents/guardians, will be asked to complete the iCHEC BAT. Sensitivity was increased by inclusion of paediatric-specific bleeding symptoms and novel qualitative questions per bleeding symptom. Efficiency was improved by developing a self-administered (online) version of the questionnaire. Flexibility for changes in the bleeding phenotype of developing children was improved by including questions that define when the bleeding symptoms occurred in the past. The diagnostic accuracy of the specific bleeding items will be evaluated by receiver operator characteristic curves, using classification based on the results from laboratory assessment as the reference standard. Analysis of the discriminative power of individual bleeding symptoms will be assessed. ETHICS AND DISSEMINATION The study has been approved by the medical ethics committees of all participating centres in the Netherlands, Canada and the UK. All paediatric subjects and/or their parents/guardians will provide written informed consent. Study results will be submitted for publication in peer-reviewed journals.
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Affiliation(s)
- Eva Stokhuijzen
- Pediatric Hematology, Academic Medical Center - Emma Children’s Hospital, Amsterdam, The Netherlands
- Department of Plasma Proteins, Sanquin Research, Amsterdam, The Netherlands
| | - Margaret L Rand
- Division of Hematology/Oncology and Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Departments of Laboratory Medicine & Pathobiology, Biochemistry, and Pediatrics, University of Toronto, Ontario, Canada
| | - Marjon H Cnossen
- Department of Pediatric Hematology, Erasmus University Medical Center - Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Tina T Biss
- Department of Haematology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Paula D James
- Department of Medicine, Division of Hematology, Queens University, Kingston General Hospital, Kingston, Canada
| | - Monique H Suijker
- Pediatric Hematology, Academic Medical Center - Emma Children’s Hospital, Amsterdam, The Netherlands
| | - Marjolein Peters
- Pediatric Hematology, Academic Medical Center - Emma Children’s Hospital, Amsterdam, The Netherlands
| | - Johanna H van der Lee
- Academic Medical Center - Pediatric Clinical Research Office, Woman-Child Center, Amsterdam, The Netherlands
| | - Bram Peters
- Pediatric Hematology, Academic Medical Center - Emma Children’s Hospital, Amsterdam, The Netherlands
| | - Alexander B Meijer
- Department of Plasma Proteins, Sanquin Research, Amsterdam, The Netherlands
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Victor S Blanchette
- Department of Pediatrics, University of Toronto, Toronto, Canada
- Division of Hematology/Oncology, Hospital for Sick Children, Toronto, Canada
| | - Karin Fijnvandraat
- Pediatric Hematology, Academic Medical Center - Emma Children’s Hospital, Amsterdam, The Netherlands
- Department of Plasma Proteins, Sanquin Research, Amsterdam, The Netherlands
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36
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Stokhuijzen E, Segbefia CI, Biss TT, Clark DS, James PD, Riddel J, Blanchette VS, Rand ML. Severity and Features of Epistaxis in Children with a Mucocutaneous Bleeding Disorder. J Pediatr 2018; 193:183-189.e2. [PMID: 29198540 DOI: 10.1016/j.jpeds.2017.09.082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/14/2017] [Accepted: 09/28/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To use standardized bleeding questionnaires to compare the severity and patterns of epistaxis in children with a mucocutaneous bleeding disorder and control children. STUDY DESIGN The epistaxis sections of the Pediatric Bleeding Questionnaire (PBQ) administered to pediatric patients with von Willebrand disease or a platelet function disorder and healthy control children were reviewed. Scores and features of epistaxis (frequency, duration, onset, site, seasonal correlation, and need for medical/surgical intervention) were recorded. A PBQ epistaxis score ≥2 was defined as clinically significant. The Katsanis epistaxis scoring system was administered to eligible patients, ie, with ≥5 episodes of epistaxis per year. RESULTS PBQ epistaxis scores were obtained for 66 patients, median age 12 years (range 0.6-18.3 years), and 56 control children. The median PBQ epistaxis score in patients was 2 vs 0 in control children (P <.0001). All of the features of epistaxis, except spontaneous onset, occurred in a significantly greater proportion of patients than control children with epistaxis. A total of 50% of the patients were graded as having severe epistaxis by the Katsanis epistaxis scoring system, and 30 of these (91%) had a clinically significant PBQ epistaxis score. CONCLUSION Standardized bleeding questionnaires are useful in the assessment of epistaxis severity and pattern and may help to distinguish children with and without a mucocutaneous bleeding disorder.
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Affiliation(s)
- Eva Stokhuijzen
- Department of Pediatric Hematology, Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Catherine I Segbefia
- Department of Child Health, School of Medicine and Dentistry, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Tina T Biss
- Department of Haematology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Dewi S Clark
- Department of Respirology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Paula D James
- Departments of Medicine and Pathology & Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - Jim Riddel
- Department of Medicine-Hematology-Oncology, University of California, San Francisco, San Francisco, CA
| | - Victor S Blanchette
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Margaret L Rand
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada; Departments of Laboratory Medicine & Pathobiology and Biochemistry, University of Toronto, Toronto, Ontario, Canada.
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Pathare A, Al Omrani S, Al Hajri F, Al Obaidani N, Al Balushi B, Al Falahi K. Bleeding score in Type 1 von Willebrand disease patients using the ISTH-BAT questionnaire. Int J Lab Hematol 2017; 40:175-180. [PMID: 29115727 DOI: 10.1111/ijlh.12761] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 10/05/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Bleeding assessment tools have evolved in the last decade to standardize the assessment of the severity of bleeding symptom in a consistent way. In 2010, the International Society on Thrombosis and Hemostasis-Bleeding Assessment Tool (ISTH-BAT) was developed and validated. AIMS Our aim was to administer ISTH-BAT questionnaire to the Omani patients with type 1 VWD and obtain the bleeding score (BS). We also studied the severity of their bleeding symptoms and correlated it with the BS as well as with the laboratory parameters. METHODS Forty-eight type I VWD index cases and 52 normal subjects were interviewed and the ISTH-BAT questionnaire administered. The BS was calculated based on a history of bleeding symptoms from 12 different sites according to the standard ISTH-BAT questionnaire. Laboratory parameters were obtained from patient's medical records. RESULTS The mean age of this cohort was 27 years (range, 6-49) with 60% being females. The median time to administer this questionnaire was 10 minutes with an interquartile range (IQR) from 8 to 17 minutes. Overall, the median BS was 7 (IQR; 2,11) although individual scores ranged between 0 and 36. The BS was negatively correlated with VWF: Ag, VWF: RCo, and VWF: CB and the Spearman's correlation coefficient "rho" was, respectively, -0.15, -0.08, and -0.22. CONCLUSION The ISTH-BAT BS is designed to reflect the severity of bleeding. Our results demonstrate the inherent variability of this bleeding pattern. We also found that the ISTH-BAT BS significantly correlated with VWF: Ag and VWF: CB.
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Affiliation(s)
- A Pathare
- Department of Haematology, College of Medicine & Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman
| | - S Al Omrani
- Department of Haematology, College of Medicine & Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman
| | - F Al Hajri
- Department of Haematology, College of Medicine & Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman
| | - N Al Obaidani
- Department of Haematology, College of Medicine & Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman
| | - B Al Balushi
- Department of Haematology, College of Medicine & Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman
| | - K Al Falahi
- Department of Haematology, College of Medicine & Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman
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Casey LJ, Tuttle A, Grabell J, Hopman W, Moorehead PC, Blanchette VS, Wu JK, Steele M, Klaassen RJ, Silva M, Rand ML, James PD. Generation and optimization of the self-administered pediatric bleeding questionnaire and its validation as a screening tool for von Willebrand disease. Pediatr Blood Cancer 2017; 64. [PMID: 28453185 DOI: 10.1002/pbc.26588] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 03/05/2017] [Accepted: 03/06/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Our objective was to generate, optimize, and validate a self-administered pediatric bleeding questionnaire (Self-PBQ) as a screening tool for von Willebrand disease (VWD) in children referred to the hematology clinic for the first time. STUDY DESIGN The Self-PBQ was generated by combining the validated expert-administered PBQ and the International Society on Thrombosis and Hemostasis (ISTH) bleeding assessment tool (BAT). Medical terminology was translated into lay language requiring a grade 4 reading level. In Phase 1, the Self-PBQ was optimized and the level of agreement between the Self-PBQ and the expert-administered PBQ was determined. Phase 2 established the normal range of bleeding scores (BSs) of the Self-PBQ. Phase 3 examined the Self-PBQ as a screening tool for first-time referrals to the hematology clinic. RESULTS The Self-PBQ is a reliable surrogate for the expert-administered PBQ with an excellent intraclass correlation (ICC) of 0.917. The Self-PBQ was scored with the PBQ and the ISTH-BAT scoring systems, for which its normal BS ranges are -1 to 2 or 0 to 2, respectively. A positive Self-PBQ BS (≥3) had a sensitivity of 78%, a specificity of 37%, a positive predictive value of 0.18, and a negative predictive value of 0.91 for identifying VWD in children being investigated by a hematologist for a bleeding disorder. CONCLUSION The Self-PBQ generates comparable BSs to the expert-administered PBQ and is a reliable, reasonably sensitive screening tool to incorporate into the assessment of children presenting to a hematologist for the investigation of an inherited bleeding disorder.
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Affiliation(s)
| | | | | | | | - Paul C Moorehead
- Janeway Children's Health and Rehabilitation Centre, St. John's, Canada.,Discipline of Pediatrics, Faculty of Medicine, Memorial University, St. John's, Canada
| | - Victor S Blanchette
- Division of Hematology/Oncology, Department of Pediatrics, University of Toronto, Hospital for Sick Children, Toronto, Canada
| | - John K Wu
- British Columbia Children's Hospital, Vancouver, Canada
| | | | | | | | - Margaret L Rand
- Division of Hematology/Oncology and Program in Experimental Medicine, The Hospital for Sick Children.,Departments of Laboratory Medicine & Pathobiology, Biochemistry and Pediatrics, University of Toronto, Toronto, Canada
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Perez Botero J, Warad DM, He R, Uhl CB, Tian S, Otteson GE, Barness RL, Olson MC, Gossman SC, Charlesworth JE, Nichols WL, Pruthi RK, Chen D. Comprehensive Platelet Phenotypic Laboratory Testing and Bleeding History Scoring for Diagnosis of Suspected Hereditary Platelet Disorders. Am J Clin Pathol 2017; 148:23-32. [DOI: 10.1093/ajcp/aqx038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Bowman ML, James PD. Controversies in the diagnosis of Type 1 von Willebrand disease. Int J Lab Hematol 2017; 39 Suppl 1:61-68. [DOI: 10.1111/ijlh.12653] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 02/08/2017] [Indexed: 11/25/2022]
Affiliation(s)
- M. L. Bowman
- Department of Medicine; Queen's University; Kingston ON Canada
| | - P. D. James
- Department of Medicine; Queen's University; Kingston ON Canada
- Department of Pathology and Molecular Medicine; Queen's University; Kingston ON Canada
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Gresele P, Falcinelli E, Bury L. Inherited platelet function disorders. Diagnostic approach and management. Hamostaseologie 2016; 36:265-278. [PMID: 27484722 DOI: 10.5482/hamo-16-02-0002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 07/16/2016] [Indexed: 12/25/2022] Open
Abstract
Inherited platelet function disorders (IPFDs) make up a significant proportion of congenital bleeding diatheses, but they remain poorly understood and often difficult to diagnose. Therefore, a rational diagnostic approach, based on a standardized sequence of laboratory tests, with consecutive steps of increasing level of complexity, plays a crucial role in the diagnosis of most IPFDs. In this review we discuss a diagnostic approach through platelet phenotyping and genotyping and we give an overview of the options for the management of bleeding in these disorders and an account of the few systematic studies on the bleeding risk associated with invasive procedures and its treatment.
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Affiliation(s)
- Paolo Gresele
- Paolo Gresele, MD, PhD, Division of Internal and Cardiovascular Medicine Department of Medicine, University of Perugia, Via E. dal Pozzo, 06126 Perugia, Italy, Tel. +39/07 55 78 39 89, Fax +39/07 55 71 60 83, E-Mail:
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Boender J, Kruip MJHA, Leebeek FWG. A diagnostic approach to mild bleeding disorders. J Thromb Haemost 2016; 14:1507-16. [PMID: 27208505 DOI: 10.1111/jth.13368] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Indexed: 01/02/2023]
Abstract
Mild inherited bleeding disorders are relatively common in the general population. Despite recent advances in diagnostic approaches, mild inherited bleeding disorders still pose a significant diagnostic challenge. Hemorrhagic diathesis can be caused by disorders in primary hemostasis (von Willebrand disease, inherited platelet function disorders), secondary hemostasis (hemophilia A and B, other (rare) coagulant factor deficiencies) and fibrinolysis, and in connective tissue or vascular formation. This review summarizes the currently available diagnostic methods for mild bleeding disorders and their pitfalls, from structured patient history to highly specialized laboratory diagnosis. A comprehensive framework for a diagnostic approach to mild inherited bleeding disorders is proposed.
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Affiliation(s)
- J Boender
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - M J H A Kruip
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - F W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
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Preoperative hemostatic assessment: a new and simple bleeding questionnaire. Can J Anaesth 2016; 63:1007-15. [PMID: 27369959 DOI: 10.1007/s12630-016-0688-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 03/10/2016] [Accepted: 06/16/2016] [Indexed: 10/21/2022] Open
Abstract
PURPOSE Current recommendations for the assessment of the risk of perioperative bleeding limit coagulation testing to patients with a personal and/or family history of bleeding. As no simple preoperative screening questionnaire is currently available, we assessed the performance of a novel screening questionnaire for its ability to detect bleeding disorders. METHODS A dichotomized, seven-point questionnaire named HEMSTOP (Hematoma, hEmorrhage, Menorrhagia, Surgery, Tooth extraction, Obstetrics, Parents) was applied to three groups of subjects: patients referred to hemostasis specialists for bleeding symptoms for whom any kind of perioperative hemostatic precautions were subsequently recommended (n = 38); patients referred to hemostasis specialists for whom precautions were not required (n = 75); healthy volunteers (n = 70). We calculated the sensitivity and specificity of HEMSTOP scores and compared them with the discriminative performances of standard blood coagulation assays (prothrombin time, activated partial thromboplastin time). RESULTS Patients requiring perioperative hemostatic precautions had greater median [interquartile range] HEMSTOP scores (2 [2-3]) than patients not requiring precautions (1 [1-2]) and healthy controls (0 [0-0]); P < 0.001. A HEMSTOP score ≥ 2 had a specificity of 98.6% [95% confidence interval (CI), 92.3 to 100] and a sensitivity of 89.5% (95% CI, 75.2 to 97.1). The 26.3% (95% CI, 13.4 to 43.1) sensitivity of the standard coagulation times was much lower. CONCLUSION The HEMSTOP score discriminates patients at an elevated risk for bleeding with recommended perioperative precautions from those without such recommendations as well as from healthy participants. Further evaluation of the HEMSTOP score is required for a better evaluation of its definitive usefulness to predict the risk of perioperative bleeding.
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Rashid A, Moiz B, Karim F, Shaikh MS, Mansoori H, Raheem A. Use of ISTH bleeding assessment tool to predict inherited platelet dysfunction in resource constrained settings. Scandinavian Journal of Clinical and Laboratory Investigation 2016; 76:373-8. [DOI: 10.1080/00365513.2016.1183260] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Anila Rashid
- Department of Pathology & Laboratory Medicine, the Aga Khan University Hospital, Karachi, Pakistan
| | - Bushra Moiz
- Department of Pathology & Laboratory Medicine, the Aga Khan University Hospital, Karachi, Pakistan
| | - Farheen Karim
- Department of Pathology & Laboratory Medicine, the Aga Khan University Hospital, Karachi, Pakistan
| | - Muhammad Shariq Shaikh
- Department of Pathology & Laboratory Medicine, the Aga Khan University Hospital, Karachi, Pakistan
| | - Huma Mansoori
- Department of Pathology & Laboratory Medicine, the Aga Khan University Hospital, Karachi, Pakistan
| | - Ahmed Raheem
- Department of Pathology & Laboratory Medicine, the Aga Khan University Hospital, Karachi, Pakistan
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Challenges of diagnosing and managing the adolescent with heavy menstrual bleeding. Thromb Res 2016; 143:91-100. [PMID: 27208978 DOI: 10.1016/j.thromres.2016.05.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/26/2016] [Accepted: 05/01/2016] [Indexed: 11/20/2022]
Abstract
Unpredictable, prolonged or heavy menstrual bleeding (HMB) may be expected for many adolescents soon after menarche. A decade of clinical experience and research has now established firmly that bleeding disorders (BD) are common in adolescents with HMB. Despite these advances, many questions remain, and several aspects of the diagnosis and management of BDs in adolescents are not supported by rigorous clinical trials. In this overview, four major areas will be discussed. First, we will discuss the frequency of BDs in young women with HMB. Up to 20% of older females with HMB are thought to have an underlying BD. Estimates from retrospective studies in adolescents suggest a prevalence that varies anywhere from 10 to 62%. Prospective studies with uniform hemostatic evaluation are needed to answer this question definitively. Second, we will review existing tools that help screen and diagnose adolescents with HMB with an underlying BD. Although identification of an underlying BD in older women with HMB is relatively straight forward, uncertainties remain for adolescents. Heavy menstrual bleeding in this age group may have different pathophysiological underpinnings than those in older women and may often be disregarded as anovulatory. There is an urgent need to develop novel tools, and evaluate existing diagnostic strategies in adolescents. Third, we will discuss the optimal medical management of HMB in young adolescents. As direct evidence is largely lacking, these areas are also subject to extrapolation from older women. Lastly, an important area- prediction, and management of future bleeding in those adolescents who are diagnosed with a mild BD-will be discussed. Throughout, areas of controversy and opportunities for further research are highlighted.
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Kurnik K, Bidlingmaier C, Hütker S, Olivieri M. [Haemostatic disorders in children]. Hamostaseologie 2016; 36:109-25. [PMID: 26988657 DOI: 10.5482/hamo-15-04-0016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 03/04/2016] [Indexed: 12/28/2022] Open
Abstract
Haemorrhagic and thrombotic events occur in both children and adults. The underlying causes are congenital or acquired disorders. In contrast to haemorrhagic disorders, inherited thrombotic disorders nearly exclusively in association with additional external risk factors lead to thrombotic events predominantly during the newborn period and adolescence. It is necessary to be aware of age-specific properties of coagulation in order to correctly interpret clinical and laboratory findings and to provide optimal care for children with haemorrhagic and thrombotic complications.
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Affiliation(s)
- Karin Kurnik
- Priv.-Doz. Dr. med. Karin Kurnik, Kinderklinik im Dr. von Haunerschen Kinderspital Klinikum der Universität München, Lindwurmstr. 4, 80337 München,
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Zia A, Lau M, Journeycake J, Sarode R, Marshall J, De Simone N, Wilson E, Winborn A, Kouides P. Developing a multidisciplinary Young Women's Blood Disorders Program: a single-centre approach with guidance for other centres. Haemophilia 2016; 22:199-207. [DOI: 10.1111/hae.12836] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2015] [Indexed: 11/29/2022]
Affiliation(s)
- A. Zia
- Department of Pediatrics; The University of Texas Southwestern Medical Center; Dallas TX USA
- Division of Hematology/Oncology; The University of Texas Southwestern Medical Center; Dallas TX USA
- Children's Medical Center; Dallas TX USA
| | - M. Lau
- Department of Pediatrics; The University of Texas Southwestern Medical Center; Dallas TX USA
- Children's Medical Center; Dallas TX USA
| | - J. Journeycake
- Department of Pediatrics; The University of Texas Southwestern Medical Center; Dallas TX USA
- Division of Hematology/Oncology; The University of Texas Southwestern Medical Center; Dallas TX USA
- Children's Medical Center; Dallas TX USA
| | - R. Sarode
- Department of Pathology; The University of Texas Southwestern Medical Center; Dallas TX USA
| | | | - N. De Simone
- Department of Pathology; The University of Texas Southwestern Medical Center; Dallas TX USA
| | - E. Wilson
- Department of Obstetrics and Gynecology; The University of Texas Southwestern Medical Center; Dallas TX USA
| | - A. Winborn
- Children's Medical Center; Dallas TX USA
| | - P. Kouides
- Mary M. Gooley Hemophilia Center; University of Rochester School of Medicine; Rochester NY USA
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Guay J, Faraoni D, Bonhomme F, Borel Derlon A, Lasne D. Ability of hemostatic assessment to detect bleeding disorders and to predict abnormal surgical blood loss in children: a systematic review and meta-analysis. Paediatr Anaesth 2015; 25:1216-26. [PMID: 26467201 DOI: 10.1111/pan.12723] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Systematic preoperative coagulation testing is still widely used in children scheduled for surgery, although current guidelines recommend that a bleeding history should be the first choice for hemostatic assessment. We performed a systematic review with meta-analysis to evaluate the pertinence of bleeding questionnaire and screening laboratory testing to detect bleeding disorders (BDs) in children and to predict abnormal surgical blood loss. METHODS A search was conducted in PubMed, EMBASE, MEDLINE(R), Cochrane Central Register of Controlled Trials, Health technology Assessment, and all EBM Reviews (Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA, and NHSEED and EBM Reviews) up to October 22, 2013. Prospective trials containing 20 children or more and any tests evaluating either the ability of the test to detect a congenital BD or the ability of the test to predict increased surgical blood loss were retained. The quality of the study was judged with the Cochrane Collaboration Tool and two investigators extracted data independently. Data were combined to calculate the pooled diagnostic odds ratio (DOR) and their 95% confidence intervals (CI 95%). I(2) statistics were used to assess statistics heterogeneity. RESULTS Data could be extracted from 16 studies. Best results for detecting a congenital abnormality at potential risk for increased surgical blood loss were obtained with the PFA-100 (DOR = 113.0; 95% CI, 22.6-566.2; I(2) = 0%) in two studies, followed by the bleeding time in two other studies (DOR = 110.7; 95% CI, 24.4-502.3; I(2) = 0%). With a high amount of heterogeneity, questionnaires showed disappointing performances (DOR = 7.9; 95% CI: 3.5-17.5; I(2) = 72.6%). CONCLUSION Current evidence does not identify a tool that adequately predicts BDs and/or abnormal surgical blood loss in children. Questionnaires currently available do not perform well. In the setting of a pediatric coagulation clinic, the PFA-100 has the highest chance of detecting a BD. This meta-analysis highlights the weakness of the literature regarding the prediction of perioperative bleeding due to congenital hemostatic disorders in children.
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Affiliation(s)
- Joanne Guay
- Department of Anesthesiology, University of Sherbrooke, Sherbrooke, QC, Canada
| | - David Faraoni
- Department of Anesthesiology, Peri-operative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Fanny Bonhomme
- Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Annie Borel Derlon
- Reference Centre for Hemophilia and von Willebrand Disease, University Hospital of Caen, Caen, France
| | - Dominique Lasne
- Department of Biological Hematology, AP-HP Hôpital Necker-Enfants Malades, INSERM UMR_S 765, Paris Descartes University, Sorbonne Paris Cité, Paris, France
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