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de Kovel MS, Escuriola-Ettingshausen C, Königs C, Ranta S, Fischer K. Bleeding phenotype according to factor level in 825 children with nonsevere hemophilia: data from the PedNet cohort. J Thromb Haemost 2024; 22:2460-2469. [PMID: 38866249 DOI: 10.1016/j.jtha.2024.05.030] [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: 02/01/2024] [Revised: 05/21/2024] [Accepted: 05/28/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Information on bleeding phenotype in nonsevere hemophilia may be used to determine target factor levels for prophylaxis or gene therapy in severe hemophilia. OBJECTIVES To assess the association between endogenous factor level and bleeding phenotype in children with nonsevere (factor [F]VIII/FIX activity 1%-25%) hemophilia A (HA) and B without prophylaxis. METHODS Data on annualized bleeding rate (ABR), annualized joint bleeding rate (AJBR), and onset of bleeding were extracted from the international PedNet cohort including children born since 2000. Mean ABR and AJBR were modeled and compared according to FVIII/FIX endogenous activity (1%-2%, 3%-5%, 6%-10%, 11%-15%, 16%-20%, and 21%-25%) using negative binomial regression. Onset of bleeding was analyzed using Kaplan-Meier survival curves. RESULTS Eight hundred twenty-five children (40% with moderate hemophilia; 87% with HA) with median follow-up of 7.4 years/child were included. The median age at onset of bleeding and median bleeding rates changed with increasing endogenous activity. From endogenous FVIII 1% to 2% to 21% to 25%, the age at onset of bleeding changed from a median of 1.4 to 14.2 years, ABR from 1.6 to 0.1/y, and AJBR from 0.5 to 0.0/y. From endogenous FIX 1% to 2% to 16% to 25%, the onset of bleeding changed from a median of 1.7 to 6.1 years, ABR from 0.5 to 0.1/y, and AJBR from 0.1 to 0.0/y. The negative correlation between AJBR and factor level was most strongly pronounced up to a factor level of 6% in HA and hemophilia B. CONCLUSION Endogenous factor activity of >5% was identified as a threshold to significantly lower joint bleeding rate, while FVIII levels >15% and FIX levels >10% were sufficient to achieve the goal of 0 bleeds in this pediatric cohort.
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Affiliation(s)
| | | | - Christoph Königs
- Goethe University Frankfurt, University Hospital, Department of Paediatrics and Adolescent Medicine, Clinical and Molecular Hemostasis, Frankfurt, Germany
| | - Susanna Ranta
- Pediatric Coagulation Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
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2
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Foppen W, van Leeuwen FHP, Timmer MA, Fischer K. The relevance of MRI findings in joints of persons with haemophilia: Insights from the last decade. Haemophilia 2024; 30:877-879. [PMID: 38812241 DOI: 10.1111/hae.15058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/29/2024] [Accepted: 05/20/2024] [Indexed: 05/31/2024]
Affiliation(s)
- Wouter Foppen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Flora H P van Leeuwen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Merel A Timmer
- Center for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Center for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Male C, Ay C, Crevenna R, Eichinger S, Feistritzer C, Füller R, Haushofer A, Kurringer A, Neumeister P, Puchner S, Rettl J, Schindl T, Schuster G, Schwarz R, Sohm M, Streif W, Thom K, Wagner B, Wissmann E, Zwiauer K, Pabinger I. [Treatment of haemophilia in Austria]. Wien Klin Wochenschr 2024; 136:75-102. [PMID: 38743098 DOI: 10.1007/s00508-024-02370-0] [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] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
This guideline is intended to provide practical guidance for the diagnosis and treatment of haemophilia in Austria. Few randomized controlled interventional trials are available addressing the treatment of haemophilia, therefore recommendations are usually based on low level of evidence and represent expert consensus.This guideline is based on the WFH guideline, published in 2020, and adapted according to the national circumstances and experience.It includes recommendations and suggestions for diagnosis and follow-up visits and pharmacological therapies for treatment and prophylaxis. Further topics comprise special aspects in children and adults with severe haemophilia, outcome measurement, and management of trauma, special bleedings and interventions, including dental procedures, inhibitors, management of haemophilia carriers, and psychosocial aspects.
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Affiliation(s)
- Christoph Male
- Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - Cihan Ay
- Abteilung für Hämatologie und Hämostaseologie, Universitätsklinik für Innere Medizin I, Medizinische Universität Wien, Wien, Österreich
| | - Richard Crevenna
- Universitätsklinik für Physikalische Medizin, Rehabilitation und Arbeitsmedizin, Medizinische Universität Wien, Wien, Österreich
| | - Sabine Eichinger
- Abteilung für Hämatologie und Hämostaseologie, Universitätsklinik für Innere Medizin I, Medizinische Universität Wien, Wien, Österreich
| | - Clemens Feistritzer
- Abteilung für Innere Medizin V - Hämatologie und Onkologie, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Robert Füller
- Österreichische Hämophilie Gesellschaft, Wien, Österreich
| | - Alexander Haushofer
- Institut für Medizinische und Chemische Labordiagnostik, Klinikum Wels-Grieskirchen, Wels-Grieskirchen, Österreich
| | - Andreas Kurringer
- Abteilung für Kinder- und Jugendheilkunde, Landeskrankenhaus Bregenz, Bregenz, Österreich
| | - Peter Neumeister
- Klinische Abteilung für Hämatologie, Medizinische Universität Graz, Graz, Österreich
| | - Stephan Puchner
- Klinische Abteilung für Orthopädie, Universitätsklinik für Orthopädie und Unfallchirurgie, Medizinische Universität Wien, Wien, Österreich
| | - Joachim Rettl
- Abteilung für Innere Medizin und Hämatologie und internistische Onkologie, Klinikum Klagenfurt, Klagenfurt, Österreich
| | - Thomas Schindl
- Österreichische Hämophilie Gesellschaft, Wien, Österreich
| | | | - Rudolf Schwarz
- Abteilung für Kinder- und Jugendheilkunde, Landesklinikum Amstetten, Universität Wien, Wien, Österreich
| | - Michael Sohm
- Universitätsklinik für Kinder- und Jugendheilkunde, Universitätsklinikum St. Pölten, St. Pölten, Österreich
| | - Werner Streif
- Department Kinder- und Jugendheilkunde, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Katharina Thom
- Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Barbara Wagner
- Universitätsklinik für Physikalische Medizin, Rehabilitation und Arbeitsmedizin, Medizinische Universität Wien, Wien, Österreich
| | - Eva Wissmann
- Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Karl Zwiauer
- Universitätsklinik für Kinder- und Jugendheilkunde, Universitätsklinikum St. Pölten, St. Pölten, Österreich
| | - Ingrid Pabinger
- Abteilung für Hämatologie und Hämostaseologie, Universitätsklinik für Innere Medizin I, Medizinische Universität Wien, Wien, Österreich
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4
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van Heel DA, Foppen W, Fischer K. Arthropathy on X-rays in 363 persons with hemophilia: long-term development, and impact of birth cohort and inhibitor status. Res Pract Thromb Haemost 2024; 8:102355. [PMID: 38496709 PMCID: PMC10941006 DOI: 10.1016/j.rpth.2024.102355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 01/13/2024] [Accepted: 02/09/2024] [Indexed: 03/19/2024] Open
Abstract
Background Arthropathy following repeated bleeding is common in persons with hemophilia. Since the introduction of prophylaxis, treatment has intensified and joint health has improved. However, data on the long-term development of arthropathy are still scant. Objectives To evaluate long-term arthropathy development since the introduction of prophylaxis according to birth cohort, hemophilia severity, and inhibitor status. Methods This single-center historic cohort study included persons with severe and moderate hemophilia A and hemophilia B born between 1935 and 2005. Arthropathy on X-rays was evaluated using the Pettersson score. Patient and joint characteristics were studied per birth cohort (<1970, 1970-1980, 1981-1990, and >1990) and compared according to hemophilia severity. The distribution of affected joints and cumulative incidence of arthropathy were analyzed. The association of Pettersson score with birth cohort and inhibitor characteristics was explored using multivariable regression analyses adjusted for age at evaluation. Results In total, 1064 X-rays of 363 patients were analyzed. Of persons with severe hemophilia (n = 317, 87.3%), 244 (77.0%) developed arthropathy. Prophylaxis was started at younger ages over time, from a median of 18 to 2.1 years, and concomitantly, arthropathy decreased in consecutive birth cohorts. Ankles were most commonly affected in 188 of 258 (72.9%) patients. Persons with moderate hemophilia (n = 46, 12.7%) had a lower risk of arthropathy (27/46 [58.7%]), but a reduction over time was less pronounced. In the multivariable analyses, birth cohort and age at evaluation were predictors for the development of arthropathy, while inhibitor status showed no association. Conclusion The development and severity of arthropathy have decreased over the past decades. However, patients have remained at risk for developing arthropathy, especially in their ankles.
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Affiliation(s)
- Dayna A.M. van Heel
- Center of Expertise for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Wouter Foppen
- Department of Radiology and Nuclear Medicine, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Kathelijn Fischer
- Center of Expertise for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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5
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van Vulpen LFD, Mastbergen SC, Foppen W, Fischer K, Lafeber FPJG, Schutgens REG. Towards Personalized Treatment in Haemophilia: The Role of Genetic Factors in Iron and Heme Control to Identify Patients at Risk for Haemophilic Arthropathy. J Pers Med 2024; 14:145. [PMID: 38392579 PMCID: PMC10890487 DOI: 10.3390/jpm14020145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/19/2024] [Accepted: 01/26/2024] [Indexed: 02/24/2024] Open
Abstract
The treatment landscape for haemophilia is changing rapidly, creating opportunities for personalized treatment. As major morbidity is still caused by haemophilic arthropathy, understanding the factors affecting joint damage and joint damage progression might lead to more individualized treatment regimens. We investigated the association of HFE mutations or HMOX1 polymorphisms affecting iron/heme handling with radiographic joint damage in 252 haemophilia patients (severe and moderate). Although iron levels and transferrin saturation were significantly increased in the 95 patients with an HFE mutation, neither carrying this mutation nor the HMOX1 polymorphism was associated with radiographic joint damage, and the same was true after adjustment for well-known factors associated with arthropathy. In conclusion, this study does not support the hypothesis that HFE mutations or HMOX1 polymorphisms can be used to predict the development of haemophilic arthropathy.
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Affiliation(s)
- Lize F D van Vulpen
- Centre for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Postbus 85500, 3508 GA Utrecht, The Netherlands
| | - Simon C Mastbergen
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, University Utrecht, 3508 GA Utrecht, The Netherlands
| | - Wouter Foppen
- Department of Radiology and Nuclear Medicine, Division of Imaging & Oncology, University Medical Center Utrecht, University Utrecht, 3508 GA Utrecht, The Netherlands
| | - Kathelijn Fischer
- Centre for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Postbus 85500, 3508 GA Utrecht, The Netherlands
| | - Floris P J G Lafeber
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, University Utrecht, 3508 GA Utrecht, The Netherlands
| | - Roger E G Schutgens
- Centre for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Postbus 85500, 3508 GA Utrecht, The Netherlands
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6
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van Bergen EDP, van Leeuwen FHP, Foppen W, Timmer MA, Schutgens REG, Mastbergen SC, Lafeber FPJG, de Jong PA, Fischer K, van Vulpen LFD. Subclinical synovial proliferation in patients with severe haemophilia A: The value of ultrasound screening and biochemical markers. Haemophilia 2023; 29:1580-1588. [PMID: 37694775 DOI: 10.1111/hae.14861] [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: 06/14/2023] [Revised: 08/24/2023] [Accepted: 08/30/2023] [Indexed: 09/12/2023]
Abstract
AIM Subclinical bleeding and inflammation play a role in progression of haemophilic arthropathy. Synovial proliferation is predictive of joint bleeding and its early detection may guide treatment changes and prevent arthropathy progression. This study evaluated the prevalence of active and inactive subclinical synovial proliferation and investigated potential biochemical blood/urine markers to identify patients with active subclinical synovial proliferation. METHODS This cross-sectional study included patients with severe haemophilia A born 1970-2006 who were evaluated during routine clinic visits. Patients with (a history of) inhibitors or recent joint bleeding were excluded. Elbows, knees and ankles were examined for subclinical synovial proliferation by ultrasound and physical examination. Active synovial proliferation was distinguished from inactive synovial proliferation using predefined criteria. Blood/urine biochemical markers (serum osteopontin, sVCAM-1, Coll2-1, COMP, CS846, TIMP, and urinary CTX-II) were compared individually and as combined indexes between patients with and without active synovial proliferation. RESULTS This cohort consisted of 79 patients with a median age of 31 years (range 16.5-50.8 years) with 62/79 (78%) of the patients using continuous prophylaxis. The annualized joint bleeding rate over the last 5 years was .6 (.2-1.1). Active (17/79, 22%) and inactive subclinical synovial proliferation (17/79, 22%) were both prevalent in this cohort. Biochemical markers were not correlated with active subclinical synovial proliferation. CONCLUSION Subclinical synovial proliferation, both active and inactive, was prevalent in patients with severe haemophilia A with access to prophylaxis and would be overlooked without routinely performed ultrasounds. Biochemical markers were unable to identify patients with active subclinical synovial proliferation.
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Affiliation(s)
- Eline D P van Bergen
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Flora H P van Leeuwen
- Department of Radiology & Nuclear Imaging, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Wouter Foppen
- Department of Radiology & Nuclear Imaging, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Merel A Timmer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Roger E G Schutgens
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Simon C Mastbergen
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Floris P J G Lafeber
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Pim A de Jong
- Department of Radiology & Nuclear Imaging, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Lize F D van Vulpen
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
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7
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van Leeuwen FHP, Timmer MA, de Jong PA, Fischer K, Foppen W. Screening for subclinical synovial proliferation in haemophilia: A systematic review and meta-analysis comparing physical examination and ultrasound. Haemophilia 2023; 29:445-455. [PMID: 36595617 DOI: 10.1111/hae.14737] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 11/29/2022] [Accepted: 12/14/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Ultrasound is increasingly used as addition to physical examination for detection of subclinical joint changes in haemophilia. However, the added value of ultrasound to physical examination for detecting synovial proliferation is not fully established. AIM To determine the diagnostic accuracy of swelling at physical examination for ultrasound-detected synovial proliferation in haemophilia. METHODS PubMed and EMBASE were searched up to 2 August 2022. Studies reporting original data on occurrence of swelling at physical examination and synovial proliferation on ultrasound of index joints in persons with haemophilia were included. Risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Diagnostic accuracy parameters of swelling at physical examination for ultrasound-detected synovial proliferation were determined. Summary sensitivity and specificity were calculated using a bivariate random-effects model. RESULTS Fifteen studies reporting on swelling at physical examination and synovial proliferation on ultrasound in 2890 joints of 627 patients were included. Prevalence of subclinical synovial proliferation ranged between 0% and 55%. Sensitivity of swelling was low [summary estimate .34; 95% confidence interval (CI) .24-.46], while specificity was high (summary estimate .97; CI .92-.99). Predictive values varied widely due to inter-study differences in prevalence of synovial proliferation. CONCLUSION Joint swelling has low sensitivity for presence of ultrasound-detected synovial proliferation in haemophilia, suggesting underestimation of synovial proliferation by physical examination alone. Consequently, ultrasound screening may generate important information on synovial changes which would otherwise remain undetected.
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Affiliation(s)
- Flora H P van Leeuwen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Merel A Timmer
- Center for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pim A de Jong
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Center for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wouter Foppen
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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8
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van Leeuwen FHP, van Bergen EPD, Timmer MA, van Vulpen LFD, Schutgens REG, de Jong PA, Fischer K, Foppen W. Magnetic resonance imaging evidence for subclinical joint bleeding in a Dutch population of people with severe hemophilia on prophylaxis. J Thromb Haemost 2023; 21:1156-1163. [PMID: 36758725 DOI: 10.1016/j.jtha.2023.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/31/2023] [Accepted: 01/31/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Previous studies suggest that subclinical bleeding occurs in persons with hemophilia. OBJECTIVES The aim of this study was to investigate whether patients with lifelong access to prophylaxis showed signs of previous subclinical bleeding on magnetic resonance imaging (MRI) in joints without a history of joint bleeding. METHODS This single-center cross-sectional study included persons with severe hemophilia A on prophylaxis, aged 16 to 33 years, with lifetime bleeding records available. Per participant, 1 index joint without a history of joint bleeding was evaluated with 3-Tesla MRI, including hemosiderin sensitive sequences. MRI scans were reviewed according to the International Prophylaxis Study Group (IPSG) additive MRI scale (range, 0-17/joint). Hemosiderin deposits with/without synovial hypertrophy were considered signs of previous subclinical bleeding. Additionally, physical examination was performed, followed by ultrasound examination according to the Hemophilia Early Arthropathy Detection with Ultrasound protocol. RESULTS In 43 patients with a median age of 23.5 years, 43 joints (16 elbows, 13 knees, 14 ankles) without reported bleeds were evaluated with MRI. The median IPSG MRI score was 1 (range, 0-9). Signs of previous subclinical bleeding were observed in 7 of 43 joints (16%; 95% CI, 7-30): 7 of 7 joints showed hemosiderin deposits, with concomitant synovial hypertrophy in 2 of 7 joints. MRI changes were accompanied by swelling and ultrasound-detected synovial hypertrophy in 1 ankle only. None of the other joints showed abnormalities at physical examination and ultrasound. CONCLUSION In this study, 16% of the joints without reported bleeds showed signs of previous subclinical bleeding, providing evidence for subclinical bleeding in people with severe hemophilia with lifelong access to prophylaxis.
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Affiliation(s)
- Flora H P van Leeuwen
- Department of Radiology and Nuclear Medicine, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Eline P D van Bergen
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Merel A Timmer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Lize F D van Vulpen
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roger E G Schutgens
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pim A de Jong
- Department of Radiology and Nuclear Medicine, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wouter Foppen
- Department of Radiology and Nuclear Medicine, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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9
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Kiialainen A, Niggli M, Kempton CL, Castaman G, Chang T, Paz‐Priel I, Adamkewicz JI, Levy GG. Effect of emicizumab prophylaxis on bone and joint health markers in people with haemophilia A without factor VIII inhibitors in the HAVEN 3 study. Haemophilia 2022; 28:1033-1043. [PMID: 35905294 PMCID: PMC9796488 DOI: 10.1111/hae.14642] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/13/2022] [Accepted: 07/13/2022] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Emicizumab prophylaxis significantly reduces bleeding events; however, the associated impact on bone/joint health is unknown. AIM To explore the effect of emicizumab prophylaxis on bone/joint health in people with haemophilia A (PwHA) without FVIII inhibitors enrolled in HAVEN 3 (NCT02847637). METHODS Haemophilia joint health scores (HJHS; v2.1) were evaluated at baseline and Weeks 49 and 97 in PwHA receiving emicizumab (n = 134), and at baseline and Weeks 49, 73 and 97 in PwHA who switched to emicizumab after 24 weeks of no prophylaxis (n = 17). Bone and joint biomarkers were measured in 117 PwHA at baseline and at Weeks 13, 25, 49 and 73. RESULTS HJHS was lower for PwHA who were previously on FVIII prophylaxis, aged <40 years or had no target joints at baseline compared with PwHA who were receiving no prophylaxis, aged ≥40 years or with target joints. Clinically significant mean (95% confidence interval) improvements from baseline of -2.13 (-3.96, -.29) in HJHS joint-specific domains were observed at Week 49 in PwHA with at least one target joint at study entry (n = 71); these changes were maintained through Week 97. Improvements in HJHS from baseline were also observed for PwHA aged 12-39 years. Biomarkers of bone resorption/formation, cartilage degradation/synthesis, and inflammation did not change significantly during emicizumab prophylaxis. CONCLUSIONS Clinically relevant improvements in HJHS were observed in younger PwHA and those with target joints after 48 weeks of emicizumab in HAVEN 3. Biomarkers of bone/joint health did not show significant changes during 72 weeks of emicizumab prophylaxis.
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Affiliation(s)
| | | | - Christine L. Kempton
- Hemophilia of Georgia Center for Bleeding & Clotting Disorders of EmoryEmory University School of MedicineAtlantaGeorgiaUSA
| | - Giancarlo Castaman
- Center for Bleeding Disorders and CoagulationCareggi University HospitalFlorenceItaly
| | - Tiffany Chang
- Genentech, Inc.South San FranciscoCaliforniaUSA,Graphite Bio, Inc.South San FranciscoCaliforniaUSA
| | - Ido Paz‐Priel
- Genentech, Inc.South San FranciscoCaliforniaUSA,Spark Therapeutics, Inc.PhiladelphiaPennsylvaniaUSA
| | | | - Gallia G. Levy
- Genentech, Inc.South San FranciscoCaliforniaUSA,Graphite Bio, Inc.South San FranciscoCaliforniaUSA
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10
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Rodriguez-Santana I, DasMahapatra P, Burke T, Hakimi Z, Bartelt-Hofer J, Nazir J, O’Hara J. Differential humanistic and economic burden of mild, moderate and severe haemophilia in european adults: a regression analysis of the CHESS II study. Orphanet J Rare Dis 2022; 17:148. [PMID: 35379282 PMCID: PMC8981861 DOI: 10.1186/s13023-022-02300-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/22/2022] [Indexed: 12/30/2022] Open
Abstract
Background The lifelong nature of haemophilia makes patient-centred and societal assessments of its impact important to clinical and policy decisions. Quantifying the humanistic and economic burden by severity is key to assessing the impact on healthcare systems. We analysed the annual direct medical (excluding factor replacement therapy costs) and non-medical costs as well as societal costs and health-related quality of life (HRQoL) of mild, moderate and severe disease among adults with haemophilia A or B without inhibitors in Europe. Participants in the CHESS II study reported their HRQoL, non-medical costs, and work impairment; physicians provided costs and consultation history from the medical chart. Descriptive statistics summarized patient characteristics, costs, and HRQoL scores. Regression models estimated differences in outcomes for moderate and severe versus mild disease, adjusting for age, body mass index, country, comorbidities, weight-adjusted factor consumption and education. Results The analytic sample included 707 patients with a mean age of 38 years; the majority of patients had haemophilia A (81%), and 47% had severe disease, followed by moderate (37%) and mild disease (16%). Patients with severe or moderate disease had on average higher direct costs, €3105 and €2469 respectively, versus mild disease. Societal costs were higher for patients with severe and moderate disease by €11,115 and €2825, respectively (all P < 0.01). HRQoL scores were also significantly worse for severe and moderate patients versus those with mild disease. Conclusion Severity of haemophilia is predictive of increasing economic and humanistic burden. The burden of moderate disease, as measured by direct costs and HRQoL, did not appear to be substantially different than that observed among patients with severe haemophilia. Supplementary information The online version contains supplementary material available at 10.1186/s13023-022-02300-1.
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11
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Rodriguez-Santana I, DasMahapatra P, Burke T, Hakimi Z, Bartelt-Hofer J, Nazir J, O’Hara J. Health-related quality of life, direct medical and societal costs among children with moderate or severe haemophilia in Europe: multivariable models of the CHESS-PAEDs study. Orphanet J Rare Dis 2022; 17:150. [PMID: 35379284 PMCID: PMC8981697 DOI: 10.1186/s13023-022-02301-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/22/2022] [Indexed: 11/17/2022] Open
Abstract
Background Haemophilia bears substantial humanistic and economic burden on children and their caregivers. Characterising the differential impact of severe versus moderate paediatric haemophilia is important for clinical and health policy decisions. We analysed health-related quality of life (HRQoL), annual direct medical (excluding factor treatment costs), non-medical and societal costs among children and adolescents with moderate and severe haemophilia A or B without inhibitors from the European CHESS-PAEDs study. Information was reported by physicians and caregivers; patients aged ≥ 8 years self-reported their HRQoL. Descriptive statistics summarised demographic and clinical characteristics, costs, and HRQoL scores (EQ-5D-Y). Regression models estimated differences in HRQoL and costs for moderate versus severe haemophilia adjusting for age, body mass index z-score, country, number of comorbidities, and weight-adjusted annual clotting factor consumption. Results The analytic sample comprised 794 patients with a mean age of 10.5 years; most had haemophilia A (79%) and 58% had severe haemophilia. Mean predicted direct medical costs in moderate patients were two-thirds of the predicted costs for severe disease (€3065 vs. €2047; p < 0.001; N = 794), while societal costs were more than half of the predicted costs for children with severe haemophilia (€6950 vs. €3666; p < 0.001; N = 220). Mean predicted HRQoL scores were 0.74 and 0.69 for moderate and severe disease, respectively (p < 0.05; N = 185). Conclusion Children with haemophilia and their caregivers displayed a significant economic and humanistic burden. While severe patients showed the highest direct medical and societal costs, and worse HRQoL, the burden of moderate haemophilia on its own was substantial and far from negligible. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02301-0.
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12
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Hoefnagels JW, Fischer K, Bos RAT, Driessens MHE, Schrijvers LH. A tailored intervention for illness acceptance improves adherence and quality of life in adults with haemophilia using prophylaxis. Haemophilia 2021; 27:e434-e440. [PMID: 33960588 PMCID: PMC8360197 DOI: 10.1111/hae.14320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 02/03/2021] [Accepted: 04/09/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Adherence to prophylactic treatment (prophylaxis) in persons with haemophilia is challenging and has been reported at only ±50%. Acceptance problems are one of the main reasons for non-adherence in haemophilia. An evidence-based intervention was developed based on an acceptance and commitment therapy (ACT) approach. AIM To evaluate a tailored intervention focused on illness acceptance in adults with haemophilia who were prescribed prophylaxis. METHODS A pre-post study was executed in adults with haemophilia who were prescribed prophylaxis. A series of 8 2-hour group trainings were held, including 3-8 participants/series. Adherence (VERITAS-Pro, optimum 0), health-related quality of life (HRQoL, SF-36, optimum 100) and illness perception (BIPQ, optimum 0) were measured at start, after six months and 12 months and analysed using Wilcoxon signed-rank test. RESULTS Twenty-four patients (median age 47 years, range 27-74) were included. After 12 months, adherence improved in 68% of patients, quality of life in 48% and illness perception in 31%. Adherence (total score) improved from 35 to 25 (P<0.01). HRQoL showed clinically relevant improvement in domains of social-functioning (P = 0.04), role-emotional, physical-functioning, role-physical and bodily pain. Illness perception improved statistically significant on domains of affect (P = 0.01), concern (P = 0.01) and understanding (P = 0.04). Patients evaluated the training useful, an eye-opener, a personal enrichment and insightful. CONCLUSION The tailored group intervention resulted in significant improvement of adherence, quality of life and illness perception. Based on our current experience, we have implemented it in clinical practice and collaborate with the patient association to make it available for all Dutch people with haemophilia.
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Affiliation(s)
| | - Kathelijn Fischer
- Van CreveldkliniekUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Ruud A. T. Bos
- Van CreveldkliniekUniversity Medical Center UtrechtUtrechtThe Netherlands
| | | | - Liesbeth H. Schrijvers
- Institute for Nursing StudiesUtrecht University of Applied SciencesUtrechtThe Netherlands
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13
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Sun J, Zhou X, Hu N. Factor VIII replacement prophylaxis in patients with hemophilia A transitioning to adults: a systematic literature review. Orphanet J Rare Dis 2021; 16:287. [PMID: 34174912 PMCID: PMC8236177 DOI: 10.1186/s13023-021-01919-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the advantages of prophylactic treatment for hemophilia, patients tend to discontinue or not adhere to it because of several challenges such as long-term use, high cost, young patients transitioning to adolescents, and switch to self-infusion or self-care. The goal of this systematic literature review is to emphasize adherence to and efficiency of prophylactic treatment in adults. METHODS A literature review was conducted in PubMed, Embase, and Cochrane databases until April 2021 according to PRISMA guidelines, and the protocol was registered with PROSPERO (CRD42020220085). Studies evaluating the efficacy of prophylaxis in enhancing the quality of life were included. RESULTS A total of 31 articles involving 2379 patients with hemophilia were included in this systematic review. Of these, 26 studies were observational, questionnaire-based studies, and 5 were randomized controlled trials. The majority of studies reported lower annualized bleeding rates in patients receiving prophylaxis compared with those receiving on-demand treatment or those who discontinued prophylaxis. Standard-dose prophylaxis was reported to be effective in most of the studies. In developing countries like China, data suggest that low doses were administered because of limited available resources. However, standard dose or individualized prophylaxis should be provided to prevent joint damage in the long term. Compared with adults, greater adherence to treatment was observed in patients aged < 16 years. CONCLUSION This systematic review emphasizes the importance of adherence to prophylaxis among young adults transitioning from childhood. In countries like China, low-dose prophylaxis can help in preventing joint bleeds in the short term, but in the long term, standard-dose therapy has shown high adherence among young adults and better joint health, in turn improving the quality of life.
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Affiliation(s)
- Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, No. 1838 North Guangzhou Avenue, Guangzhou, 510515, China.
| | - Xuan Zhou
- Department of Hematology, Nanfang Hospital, Southern Medical University, No. 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Nan Hu
- Medical Affairs, Pharmaceuticals, Bayer Healthcare Company Ltd, Beijing, 100020, China
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14
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Lobet S, Timmer M, Königs C, Stephensen D, McLaughlin P, Duport G, Hermans C, Mancuso ME. The Role of Physiotherapy in the New Treatment Landscape for Haemophilia. J Clin Med 2021; 10:jcm10132822. [PMID: 34206923 PMCID: PMC8267623 DOI: 10.3390/jcm10132822] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/16/2021] [Accepted: 06/23/2021] [Indexed: 12/21/2022] Open
Abstract
The physiotherapist plays an essential role for people with haemophilia, an inherited bleeding disease responsible for musculoskeletal complications. Yet, with the advent of new and advanced therapies, the medical landscape is changing, and physiotherapy must adapt alongside. This paper considers whether there will still be a need for physiotherapy in the era of advanced therapies, and discusses ways in which services should evolve to complement emerging treatment paradigms for haemostasis in people with haemophilia. Ultimately, physiotherapy will remain an important element of care, even for people with little joint damage and low risks in the era of the new mild phenotype. However, competencies will need to evolve, and physiotherapists in both primary care and specialist treatment centres should work with haematology colleagues to develop more sensitive tools for detecting early joint changes. Physiotherapists will also play a crucial role in counselling and physically coaching, monitoring the musculoskeletal status of people with haemophilia who have transitioned to new treatments.
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Affiliation(s)
- Sébastien Lobet
- Hemostasis and Thrombosis Unit, Division of Hematology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium;
- Neuromusculoskeletal Lab (NMSK), Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 53, 1200 Brussels, Belgium
- Secteur de Kinésithérapie, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium
- Correspondence:
| | - Merel Timmer
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, 3584 Utrecht, The Netherlands;
| | - Christoph Königs
- Department of Paediatrics and Adolescent Medicine, Haemophilia Treatment Centre, Goethe University, 60323 Frankfurt, Germany;
| | - David Stephensen
- Kent Haemophilia Centre, East Kent Hospitals University NHS Trust, Canterbury CT1 3NG, UK;
- Haemophilia Centre, Royal London Hospital, Barts Health NHS Trust, London E1 1BB, UK
| | - Paul McLaughlin
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London NW3 2QG, UK;
| | - Gaetan Duport
- Association Française des Hemophiles, 75739 Paris, France;
| | - Cédric Hermans
- Hemostasis and Thrombosis Unit, Division of Hematology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium;
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy;
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15
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Marchesini E, Morfini M, Valentino L. Recent Advances in the Treatment of Hemophilia: A Review. Biologics 2021; 15:221-235. [PMID: 34163136 PMCID: PMC8214539 DOI: 10.2147/btt.s252580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/10/2021] [Indexed: 01/19/2023]
Abstract
Progress in hemophilia therapy has been remarkable in the first 20 years of the third millennium, but the innovation began with the description the fractionation of plasma in 1946. The first concentrates followed the discovery of FVIII in the cryoprecipitate of frozen plasma and FIX in the supernatant in the early 1960s, which led to the initial attempts at replacement therapy. Unfortunately, the lack of screening methods for viral pathogens resulted in people with hemophilia (PWH) receiving concentrates contaminated by hepatitis A virus, hepatitis C virus, and human immunodeficiency virus, as these concentrates were made from large industrial pools of plasma derived from thousands of donors. Fortunately, by 1985, viral screening methods and proper virucidal techniques were developed that made concentrates safe. Increasingly pure products followed the introduction of chromatography steps with monoclonal antibodies in the production process. The problem of immunogenicity of exogenously administered concentrates has not yet had a complete solution. The development of alloantibodies against FVIII in about 25-35% of PWH is the most serious adverse effect of replacement therapy. The next major advance followed the cloning of the F8 gene and later the F9 genes, which paved the way to produce concentrates of factors obtained by the recombinant DNA technology. The injected FVIII and FIX molecules had a relatively short circulating half-life in the plasma of people with hemophilia A and B, approximately 12 and 18 hours, respectively. The ability to prolong the plasma half-life and extend the interval between injections followed the application of methods to conjugate the factor molecule with the fragment crystallizable of IgG1 or albumin or by adding polyethylene glycol, which has led to an increase in the half-life of concentrates, especially for rFIX. The next frontier in hemophilia therapy is the application of durable and potentially curative therapies such as with gene addition therapy. Experiments in hemophilia B have demonstrated durable responses. Unfortunately, the results with gene therapy for hemophilia A have not been as remarkable and the durability must still be demonstrated. Nonetheless, the long-term safety, predictability, durability, and efficacy of gene therapy for hemophilia A and B remain an open question. At present, only healthy adult PWH have been enrolled in gene therapy clinical trials. The application of gene therapy to children and those with pre-existing antibodies against the delivery vector must also be studied before this therapy becomes widespread.
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Affiliation(s)
- Emanuela Marchesini
- Hemophilia Centre, SC Vascular and Emergency Department, University of Perugia, Perugia, Italy
| | - Massimo Morfini
- Italian Association of Haemophilia Centres (AICE), Naples, Italy
| | - Leonard Valentino
- National Hemophilia Foundation, New York, NY, USA
- Rush University, Chicago, IL, USA
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16
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MRI predicts 5-year joint bleeding and development of arthropathy on radiographs in hemophilia. Blood Adv 2021; 4:113-121. [PMID: 31917842 DOI: 10.1182/bloodadvances.2019001238] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 12/11/2019] [Indexed: 01/01/2023] Open
Abstract
Magnetic resonance imaging (MRI) is considered as the reference standard to assess early joint changes in hemophilia. However, the clinical relevance of MRI findings is still unknown. The aim of this prospective study was to assess the predictive value of MRI for 5-year joint bleeding and progression of arthropathy in patients with hemophilia. Both knees and ankles of patients with hemophilia and absent or limited arthropathy on radiographs were assessed by using MRI and radiographs. MRI scans were scored according to the International Prophylaxis Study Group MRI score for hemophilic arthropathy. Patients were followed up for 5 years, including assessment of joint bleeding and repeated radiographic assessment. Associations between baseline MRI findings with 5-year bleeding and progression of arthropathy were expressed as odds ratios (OR), adjusted for severity of disease and joint bleeding history. Baseline assessment included 104 joints of 26 patients with hemophilia (median age, 21 years). Four ankles with severe joint changes were excluded. Follow-up was available for 96 (92%) of 104 joints. During 5 years of follow-up, bleeding was reported for 36% of joints. Five-year bleeding was significantly increased in joints with synovial hypertrophy at 80% vs 27% in joints without synovial hypertrophy (OR, 10.1; 95% confidence interval, 3.4-31.3). In joints with normal baseline radiographs, any osteochondral or synovial changes on MRI were associated with radiographic changes 5 years later (positive predictive value, 75%; negative predictive value, 98%). Joints with synovial hypertrophy on MRI had a significantly higher chance of 5-year bleeding. All MRI changes, except effusion, were strong predictors for development of arthropathy on radiographs.
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17
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Gooding R, Thachil J, Alamelu J, Motwani J, Chowdary P. Asymptomatic Joint Bleeding and Joint Health in Hemophilia: A Review of Variables, Methods, and Biomarkers. J Blood Med 2021; 12:209-220. [PMID: 33833602 PMCID: PMC8023018 DOI: 10.2147/jbm.s304597] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/19/2021] [Indexed: 12/14/2022] Open
Abstract
Joint health is a key contributor to quality of life in patients with hemophilia. However, variables that impact long-term joint outcomes have not been comprehensively defined. A systematic literature search identified publications relating to joint health in patients with hemophilia. Studies clearly show that early, sustained prophylaxis with factor replacements improves long-term joint outcomes. However, a subset of patients appear to develop arthropathy despite maintaining excellent bleeding outcomes, which suggests possible recurrent asymptomatic bleeding into the joints in these patients. Furthermore, limited data are available on how long-acting factor VIII and factor IX replacement therapies could impact long-term joint outcomes. Many variables were identified as potential indicators that a patient may develop hemophilic arthropathy, including genetic mutations, endogenous factor VIII and IX levels, bone health, and physical activity levels. Tools for the diagnosis and monitoring of hemophilic arthropathy are critical to detect early joint damage, so that management can be adjusted accordingly. Imaging techniques, particularly magnetic resonance imaging, can detect synovial changes, a strong predictor for the future development of hemophilic arthropathy. In addition, several biomarkers associated with cartilage and bone formation, vascularization, and angiogenesis could potentially identify the onset and progression of early joint damage. Since the development of hemophilic arthropathy is complex, a comprehensive therapeutic approach is necessary for the effective prevention of arthropathy in patients with hemophilia.
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Affiliation(s)
- Richard Gooding
- Leicester Haemophilia Centre, Haemostasis & Thrombosis Unit, Leicester Royal Infirmary, Leicester, UK
| | - Jecko Thachil
- Haematology Department, Manchester Royal Infirmary, Manchester, UK
| | - Jayanthi Alamelu
- Haemophilia Department, Evelina Children's Hospital - St Thomas' Hospital, London, UK
| | - Jayashree Motwani
- Haemophilia Comprehensive Care Centre, Birmingham Children's Hospital, Birmingham, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia Centre, Royal Free Hospital, London, UK
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18
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Hoefnagels JW, Versloot O, Schrijvers LH, van der Net J, Leebeek FWG, Gouw SC, Fischer K. Sports participation is not associated with adherence to prophylaxis in Dutch patients with haemophilia. Haemophilia 2021; 27:e402-e405. [PMID: 33556987 DOI: 10.1111/hae.14244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 12/01/2022]
Affiliation(s)
| | - Olav Versloot
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Liesbeth H Schrijvers
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands.,Nursing Department, Utrecht University of Applied Sciences, Utrecht, The Netherlands
| | - Janjaap van der Net
- Center for Child Development, Exercise and Physical Literacy, University Children's Hospital, UMC Utrecht, Utrecht, The Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Samantha C Gouw
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
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19
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Hoefnagels JW, Fischer K, Bos RAT, Driessens MHE, Meijer SLA, Schutgens REG, Schrijvers LH. A feasibility study on two tailored interventions to improve adherence in adults with haemophilia. Pilot Feasibility Stud 2020; 6:189. [PMID: 33292771 PMCID: PMC7708110 DOI: 10.1186/s40814-020-00723-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 11/03/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Haemophilia is a congenital bleeding disorder mainly affecting males. To prevent bleeding, patients need to perform regular intravenous injections (prophylaxis) throughout life. Non-adherence often occurs. Problems with acceptance or self-management appear to be the main reasons for non-adherence in haemophilia. The aim of this study was to test the feasibility and effects of two interventions focussed on acceptance (face-to-face) and self-management (online). METHODS Patients with severe haemophilia and acceptance or self-management problems were eligible. The face-to-face group intervention was based on Acceptance and Commitment Therapy (ACT) (8 sessions/6 months, target N = 8 participants). The online intervention was based on a successful online programme in rheumatoid arthritis (5-8 modules/2 months, target N = 8). Both interventions were designed according to the MRC framework in collaboration with the patient society and experts. We compared adherence (VERITAS-Pro, optimum 0), quality of life (SF-36, optimum 100) and illness perception (BIPQ, optimum 0) before start (T0) and after 2 months (T2). Feasibility criteria were as follows: completion of training by > 50% of participants and ability to collect at least 80% of outcome parameters. RESULTS The face-to-face intervention was feasible (89% enrolment and recruitment, 100% retention). One hundred percent of the outcome parameters was collected. Results were promising: although adherence (VERITAS-Pro) was stable (from 64 to 62 points), quality of life (SF-36) showed a clinically relevant improvement (> 5 points) in five of eight domains. Illness perception (BIPQ) showed a clinically relevant increase from 47 to 39 points. Patient evaluation was positive. The online intervention, however, was infeasible: enrolment was only 20% (6/30). Only three patients signed informed consent (recruitment 10%), and none completed more than one module (retention 0%). Consequently, the online intervention was terminated. CONCLUSION The face-to-face acceptance intervention was considered feasible with promising results. Unfortunately, the online intervention was infeasible and therefore terminated. These findings suggest that adapting effective interventions to other settings does not guarantee success, despite the use of established methodology and patient participation. Population differences (only male participants, congenital disease) could be an explanation for failure of the online intervention in haemophilia despite success in rheumatoid arthritis. TRIAL REGISTRATION NL55883.041.16.
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Affiliation(s)
- J W Hoefnagels
- Division Internal Medicine and Dermatology, Van Creveldkliniek, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - K Fischer
- Division Internal Medicine and Dermatology, Van Creveldkliniek, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, The Netherlands
| | - R A T Bos
- Division Internal Medicine and Dermatology, Van Creveldkliniek, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, The Netherlands
| | - M H E Driessens
- Netherlands Haemophilia Patient Society (NVHP), Nijkerk, The Netherlands
| | - S L A Meijer
- Netherlands Haemophilia Patient Society (NVHP), Nijkerk, The Netherlands
| | - R E G Schutgens
- Division Internal Medicine and Dermatology, Van Creveldkliniek, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, The Netherlands
| | - L H Schrijvers
- Division Internal Medicine and Dermatology, Van Creveldkliniek, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, The Netherlands
- Utrecht University of Applied Sciences, Utrecht, The Netherlands
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20
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Hoefnagels JW, Schrijvers LH, Fischer K. Adherence to prophylaxis and bleeding in children: Significant drop during puberty but no correlation with bleeding. Haemophilia 2020; 26:e240-e243. [PMID: 32478933 DOI: 10.1111/hae.14051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/04/2020] [Accepted: 05/11/2020] [Indexed: 12/01/2022]
Affiliation(s)
| | | | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
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21
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Rayment R, Chalmers E, Forsyth K, Gooding R, Kelly AM, Shapiro S, Talks K, Tunstall O, Biss T. Guidelines on the use of prophylactic factor replacement for children and adults with Haemophilia A and B. Br J Haematol 2020; 190:684-695. [PMID: 32390158 DOI: 10.1111/bjh.16704] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/04/2020] [Accepted: 04/08/2020] [Indexed: 01/19/2023]
Affiliation(s)
| | | | | | | | - Anne M Kelly
- Cambridge University Hospitals NHS foundation Trust, Cambridge, UK
| | - Susan Shapiro
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kate Talks
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Oliver Tunstall
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Tina Biss
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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22
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Miesbach W, Kittler S, Bauhofer A, Königs C, Becker T, Nemes L, Staus A, Schüttrumpf J. Long-term analysis of the benefit of prophylaxis for adult patients with severe or moderate haemophilia A. Haemophilia 2020; 26:467-477. [PMID: 32293085 DOI: 10.1111/hae.13988] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/02/2020] [Accepted: 03/16/2020] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Prophylaxis with factor VIII (FVIII) concentrates in children with haemophilia A (HA) is current standard of care. The benefit of prophylactic treatment for adult HA patients is not commonly accepted. AIM To investigate the benefit of prophylaxis over on-demand treatment in adult and elderly patients with severe or non-severe HA in a real-life setting. METHODS Data from 163 patients comprising 1202 patient-years were evaluated for 7.5 (±5.3) years. The effects on the annual bleeding rate (ABR, including spontaneous and traumatic bleeds) of treatment with a plasma-derived FVIII concentrate, the patient's age and disease severity were investigated. The effect of changing the treatment from on demand to continuous prophylaxis on the patients' ABRs was further analysed. RESULTS Prophylaxis had the greatest effect on the ABRs of patients of any age with severe or non-severe HA. The difference in ABR of all patients treated on demand (median 31.4; interquartile range (IQR) 27.6; N = 83) compared with those treated prophylactically (median 1.3; IQR 3.6; N = 122) was statistically significant (P < .05), even for patients with non-severe HA (median 8.4; IQR 15.5; N = 11) vs median 1.5; IQR 4.2 (N = 17), P < .05). Patients, aged up to 88 years, switching from on demand to continuous prophylaxis showed the lowest median ABR (1.1; N = 51) after their regimen change. CONCLUSION Any (even low-frequency) prophylaxis results in lower ABR than on-demand treatment. Patients switching to prophylaxis benefitted the most, irrespective of age or HA severity. Prophylactic treatment-even tertiary-is the regimen of choice for patients of any age, including elderly patients, with severe or non-severe HA.
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Affiliation(s)
- Wolfgang Miesbach
- Haemophilia Centre, Medical Clinic 2, Institute of Transfusion Medicine, University Hospital Frankfurt, Frankfurt/Main, Germany
| | | | | | - Christoph Königs
- Haemophilia Centre, Department of Paediatrics, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | | | - László Nemes
- National Haemophilia Centre and Haemostasis Department, Medical Centre, Hungarian Defence Forces, Budapest, Hungary
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Fischer K, Ljung R. WITHDRAWN: Primary prophylaxis in haemophilia care: Guideline update 2016. Blood Cells Mol Dis 2020; 80:102172. [PMID: 28363466 DOI: 10.1016/j.bcmd.2017.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 03/08/2017] [Accepted: 03/13/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Kathelijn Fischer
- Van Creveld kliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rolf Ljung
- Lund University, Dept. of Clinical Sciences Lund, Paediatrics, Lund, Sweden; Skåne University Hospital, Department of Paediatrics and Malmö Centre for Thrombosis and Haemostasis, Malmö, Sweden.
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24
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Gouw SC, Timmer MA, Srivastava A, de Kleijn P, Hilliard P, Peters M, Blanchette V, Fischer K. Measurement of joint health in persons with haemophilia: A systematic review of the measurement properties of haemophilia-specific instruments. Haemophilia 2019; 25:e1-e10. [PMID: 30427100 PMCID: PMC7379965 DOI: 10.1111/hae.13631] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 04/20/2018] [Accepted: 05/04/2018] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Accurate assessment of joint health in persons with haemophilia is crucial. Several haemophilia-specific measurement tools are available, but an overview of the measurement properties is lacking. AIM To provide an overview of the measurement properties of haemophilia-specific measurement tools to assess clinical joint health. METHODS MEDLINE and EMBASE were searched for reports on reliability, validity or responsiveness of the World Federation of Haemophilia Orthopedic Joint Score (WFH), Colorado Physical Examination Score (CPE), joint examination score by Petrini (PJS) and Hemophilia Joint Health Score (HJHS). Methodological quality of the studies was assessed using an adapted COSMIN checklist. RESULTS The search yielded 2905 unique hits, and 98 papers were included. The methodological quality of the included studies was limited. The HJHS was studied most extensively, which yielded limited evidence for good internal consistency and structural validity, moderate evidence for hypothesis testing in adults and conflicting evidence for hypothesis testing in children. Reliability, measurement error and responsiveness were rated unknown due to low COSMIN scores. For the CPE and PJS, we found limited to moderate evidence for good responsiveness and conflicting evidence for hypothesis testing. CONCLUSION Only patchy evidence is available on the quality of measurement properties of all haemophilia-specific joint health scores. Although significant gaps in the evidence for all instruments remain, measurement properties of the HJHS were most extensively studied and show no drawbacks for use in clinical practice. This review forms the basis for further research aimed at the assessment of measurement properties of measurement tools to assess joint health.
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Affiliation(s)
- Samantha C. Gouw
- Department of Pediatric HematologyAcademic Medical CenterAmsterdamThe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterAmsterdamThe Netherlands
| | - Merel A. Timmer
- Van Creveldkliniek, Department of HematologyUniversity Medical CenterUtrechtThe Netherlands
| | - Alok Srivastava
- Department of HematologyChristian Medical CollegeVelloreIndia
| | - Piet de Kleijn
- Van Creveldkliniek, Department of HematologyUniversity Medical CenterUtrechtThe Netherlands
- Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf MagnusUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Pamela Hilliard
- Department of RehabilitationHospital for Sick ChildrenTorontoOntarioCanada
| | - Marjolein Peters
- Department of Pediatric HematologyAcademic Medical CenterAmsterdamThe Netherlands
| | - Victor Blanchette
- Department of Paediatrics, Division of Hematology/Oncology, Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Kathelijn Fischer
- Van Creveldkliniek, Department of HematologyUniversity Medical CenterUtrechtThe Netherlands
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25
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Attempting to remedy sub-optimal medication adherence in haemophilia: The rationale for repeated ultrasound visualisations of the patient's joint status. Blood Rev 2018; 33:106-116. [PMID: 30146094 DOI: 10.1016/j.blre.2018.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 07/14/2018] [Accepted: 08/17/2018] [Indexed: 01/01/2023]
Abstract
Haemophilia is marked by joint bleeding (haemarthrosis) leading to cartilage damage (arthropathy). Lifelong prophylaxis-initiated after the first bleeding episode-leads to a dramatic decrease in arthropathy in haemophilia patients. However, adherence to continuous intravenous administrations of factor VIII (FVIII) or FIX products is challenging, and patients potentially suffer from breakthrough bleedings while on prophylaxis. Newer FVIII/FIX products with enhanced convenience attributes and/or easier infusion procedures are intended to improve adherence. However, pharmacokinetic data should be harmonised with information from individual attitudes and treatment needs, to tailor intravenous dosing and scheduling in patients who receive extended half-life products. Nor is there sound evidence as to how subcutaneous non-FVIII/FIX replacement approaches (concizumab; emicizumab; fitusiran) or single intravenous injections of adeno-associated viral vectors (when employing gene therapy) will revolutionize adherence in haemophilia. In rheumatoid arthritis, repeated ultrasound examination of a patient's major joints is a valuable tool to educate patients and parents to understand the disease and provide an objective framework for clinicians to acknowledge patient's adherence. Joint ultrasound examination in haemophilia significantly correlates with cartilage damage, effusion, and synovial hypertrophy evaluated by magnetic resonance imaging. Furthermore, in patients with haemophilia undergoing prophylaxis with an extended half-life product for a ≈ 2.8 year period, a significant continued improvement in joint health is detected at the physical examination. This provides the rationale for studies on repeated ultrasound examinations of joint status to attempt to remedy sub-optimal medication adherence and help identify which approach is most suited on which occasion and for which patient.
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Pulles AE, Mastbergen SC, Foppen W, Schutgens REG, Lafeber FPJG, van Vulpen LFD. The combination of urinary CTX-II and serum CS-846: Promising biochemical markers to predict radiographic progression of haemophilic arthropathy-An exploratory study. Haemophilia 2018; 24:e278-e280. [DOI: 10.1111/hae.13554] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A. E. Pulles
- Department of Rheumatology & Clinical Immunology; University Medical Center Utrecht; Utrecht University; Utrecht The Netherlands
- Van Creveldkliniek; University Medical Center Utrecht; Utrecht University; Utrecht The Netherlands
| | - S. C. Mastbergen
- Department of Rheumatology & Clinical Immunology; University Medical Center Utrecht; Utrecht University; Utrecht The Netherlands
| | - W. Foppen
- Department of Radiology; University Medical Center Utrecht; Utrecht University; Utrecht The Netherlands
| | - R. E. G. Schutgens
- Van Creveldkliniek; University Medical Center Utrecht; Utrecht University; Utrecht The Netherlands
| | - F. P. J. G. Lafeber
- Department of Rheumatology & Clinical Immunology; University Medical Center Utrecht; Utrecht University; Utrecht The Netherlands
| | - L. F. D. van Vulpen
- Van Creveldkliniek; University Medical Center Utrecht; Utrecht University; Utrecht The Netherlands
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27
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O'Hara J, Sima CS, Frimpter J, Paliargues F, Chu P, Presch I. Long-term outcomes from prophylactic or episodic treatment of haemophilia A: A systematic review. Haemophilia 2018; 24:e301-e311. [PMID: 30004613 DOI: 10.1111/hae.13546] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2018] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Evaluating treatment success in patients with haemophilia A (HA) remains a vigorous debate, especially concerning the interpretation of results from clinical and observational research. The benefits of short-term prophylaxis are well established, but long-term outcomes, particularly related to humanistic and economic burden, are not as well understood. AIM We conducted a systematic literature review to evaluate the association of episodic or prophylactic bleed control with long-term clinical, humanistic and economic outcomes. METHODS Studies published in English between 1 January 2006 and 15 December 2016 were included. Participants had HA (with or without inhibitors), received prophylactic or episodic treatment and had at least 4 years of treatment or follow-up. Results were analysed qualitatively with descriptive findings. RESULTS A total of 2091 records were screened, resulting in 19 studies from 20 publications for inclusion. Most studies included children (84%), were limited to patients with severe disease (74%) and were conducted in Europe or North America (89%). Ten studies (53%) included patients with inhibitors. Median study follow-up ranged from 5 to 19 years. Long-term bleeding and haemarthrosis outcomes were consistently better for patients receiving prophylaxis, who also required fewer hospitalizations or surgeries. Health-related quality of life, functionality and productivity were generally more favourable in patients receiving prophylaxis. Quantitative comparisons were not feasible due to the lack of consistency in endpoint collection and reporting among studies. CONCLUSION This systematic review confirmed that the benefits of prophylactic treatment on short-term outcomes translate to broader long-term clinical, humanistic and economic benefits. Better harmonization of data collection and outcome assessments across both registries and clinical studies is needed to allow for effective comparisons across studies and across data sources.
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Affiliation(s)
- J O'Hara
- University of Chester, Chester, UK
| | - C S Sima
- Genentech, Inc., San Francisco, CA, USA
| | - J Frimpter
- Health Interactions, Inc., San Francisco, CA, USA
| | | | - P Chu
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - I Presch
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
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Rodriguez-Merchan EC, Valentino LA. Increased bone resorption in hemophilia. Blood Rev 2018; 33:6-10. [PMID: 29857920 DOI: 10.1016/j.blre.2018.05.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 05/07/2018] [Accepted: 05/24/2018] [Indexed: 12/31/2022]
Abstract
In patients with hemophilia, osteoporosis is frequently observed for which the etiology remains unclear. The aim of this paper is to review the available experimental evidence indicating the presence of this disorder in patients with hemophilia, explore the potential mechanisms which may lead to reduced bone mineral density (BMD) and speculate on useful interventions to circumvent it. A narrative review of the English literature up to April 2018 was performed. The available evidence demonstrates an increased rate of bone resorption and an excess of osteoporosis among patients with hemophilia. FVIII and FIX may act through at least two pathways: promoting bone formation by a thrombin-mediated mitogenic effect on osteoblasts and by cytokine-mediated osteoclast activity. Another potential indirect mechanism mediated through the RANK-RANKL pathway has been suggested but remains controversial. The role of confounders such as lack of activity and immobility must be considered.
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29
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Timmer MA, Gouw SC, Feldman BM, Zwagemaker A, de Kleijn P, Pisters MF, Schutgens REG, Blanchette V, Srivastava A, David JA, Fischer K, van der Net J. Measuring activities and participation in persons with haemophilia: A systematic review of commonly used instruments. Haemophilia 2017; 24:e33-e49. [DOI: 10.1111/hae.13367] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2017] [Indexed: 11/30/2022]
Affiliation(s)
- M. A. Timmer
- Van Creveldkliniek; University Medical Center Utrecht; Utrecht University; The Netherlands
- Physical Therapy Research; Department of Rehabilitation; Physical Therapy Science and Sport; Brain Center Rudolf Magnus; Utrecht University; The Netherlands
| | - S. C. Gouw
- Department of Pediatric Hematology; Academic Medical Center; Amsterdam The Netherlands
| | - B. M. Feldman
- Division of Rheumatology; Department of Paediatrics; The Hospital for Sick Children; Institute of Health Policy, Management and Evaluation; Dalla Lana School of Public Health; University of Toronto; Toronto ON Canada
| | - A. Zwagemaker
- Department of Pediatric Hematology; Academic Medical Center; Amsterdam The Netherlands
| | - P. de Kleijn
- Van Creveldkliniek; University Medical Center Utrecht; Utrecht University; The Netherlands
- Physical Therapy Research; Department of Rehabilitation; Physical Therapy Science and Sport; Brain Center Rudolf Magnus; Utrecht University; The Netherlands
| | - M. F. Pisters
- Physical Therapy Research; Department of Rehabilitation; Physical Therapy Science and Sport; Brain Center Rudolf Magnus; Utrecht University; The Netherlands
- Center for Physical Therapy Research and Innovation in Primary Care; Julius Health Care Centers; Utrecht The Netherlands
| | - R. E. G. Schutgens
- Van Creveldkliniek; University Medical Center Utrecht; Utrecht University; The Netherlands
| | - V. Blanchette
- Department of Pediatrics; Division of Hematology/Oncology Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - A. Srivastava
- Department of Haematology; Christian Medical College; Vellore India
| | - J. A. David
- Department of Physical Medicine and Rehabilitation; Christian Medical College; Vellore India
| | - K. Fischer
- Van Creveldkliniek; University Medical Center Utrecht; Utrecht University; The Netherlands
| | - J. van der Net
- Department of Child Development and Exercise; University Medical Center Utrecht and Children's Hospital; Utrecht University The Netherlands
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30
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van Galen K, Timmer M, de Kleijn P, Fischer K, Foppen W, Schutgens R, Eikenboom J, Meijer K, Cnossen M, Fijnvandraat K, van der Bom J, Larosvan Gorkom B, Leebeek F, Mauser-Bunschoten E. Joint assessment in von Willebrand disease. Thromb Haemost 2017; 117:1465-1470. [DOI: 10.1160/th16-12-0967] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 04/10/2017] [Indexed: 11/05/2022]
Abstract
SummaryAssessment of clinical outcome after joint bleeding is essential to identify joint damage and optimise treatment, to prevent disability. However, disease-specific tools to assess the musculoskeletal status in patients with von Willebrand disease (VWD) are lacking. We aimed to determine validity and reliability of the Haemophilia Joint Health Score (HJHS) and Haemophilia Activities List (HAL) in patients with Von Willebrand disease (VWD). Ninety-six patients with VWD were included (mean age 46 years) of whom 27 had more than five documented joint bleeds. The HJHS was performed in all patients and all patients completed the HAL and Impact on Participation and Autonomy (IPA) questionnaires. Health-related quality of life (SF36) results were obtained from the prior ‘Willebrand in the Netherlands’ study. Joint X-rays of knees, elbows and ankles were scored according to Pettersson (PS). Internal consistency of the HJHS (Cronbach’s α (α)=0.75) and HAL (α=0.89) were good. Inter-observer agreement of the HJHS was good (ICC 0.84; Limits of Agreement ± 10.3). The HJHS showed acceptable correlation with the X-ray PS (Spearman’s r (rs)>0.60 all joints) and HAL (rs=0.71). The HAL also showed acceptable correlation with the SF36 physical functioning (rs=0.65) and IPA (rs=0.69). Hypothesis testing showed adequate discriminative power of both instruments: in patients with a history of >5 versus ≤ 5 joint bleeds (median HJHS 10 vs 2 (p<0.01); median HAL 77 vs 98 (p<0.01)), independent from age. In conclusion, both the HJHS and HAL are feasible to assess clinical outcome after joint bleeds in VWD.
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Kuijlaars IAR, Timmer MA, de Kleijn P, Pisters MF, Fischer K. Monitoring joint health in haemophilia: Factors associated with deterioration. Haemophilia 2017; 23:934-940. [PMID: 28873289 DOI: 10.1111/hae.13327] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Joint bleeds in patients with haemophilia may result in haemophilic arthropathy. Monitoring joint health is essential for identifying early signs of deterioration and allows timely adjustment of treatment. AIM The aim was to describe changes in joint health over 5-10 years follow-up and identify factors associated with joint health deterioration in patients with haemophilia. METHODS A post hoc analysis was performed from previous cohort studies in patients with moderate/severe haemophilia, ≥16 years. Joint health of ankles, knees and elbows was measured with the Haemophilia Joint Health Score (HJHS) from 2006-2008 (T0) to 2011-2016 (T1). Analyses were performed on patient level (ΔHJHS-total) and joint level (ΔHJHS-joint). Deterioration was defined as ΔHJHS-total ≥4 and ΔHJHS-joint ≥2. RESULTS Sixty-two patients (median age 25, 73% severe haemophilia, median [interquartile range] 0.0 [0.0;2.0] joint bleeds between T0 to T1) were included. After median 8 years, HJHS-total deteriorated in 37% and HJHS-joint in 17%. Ankle joints (31%) showed deterioration more often than elbows (19%) and knees (3%). Deterioration of HJHS-total was only associated with severe haemophilia. Deterioration of HJHS-joint was weakly associated with a lower HJHS at baseline and more self-reported limitations in activities, and strongly with more joint bleeds between T0 and T1 and presence of synovitis. CONCLUSION In 37% of patients with moderate/severe haemophilia and low joint bleeding rates, joint health deteriorated over 5-10 years. Ankle and elbow joints showed deterioration most frequently. Factors found in this study help to identify which joints need frequent monitoring in patients with haemophilia with access to early prophylaxis.
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Affiliation(s)
- I A R Kuijlaars
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands.,Physical Therapy Sciences, Program in Clinical Health Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M A Timmer
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands.,Physical Therapy Sciences, Program in Clinical Health Sciences, University Medical Center Utrecht, Utrecht, The Netherlands.,Physical Therapy Research, Department of Rehabilitation, Physiotherapy Science & Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P de Kleijn
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands.,Physical Therapy Research, Department of Rehabilitation, Physiotherapy Science & Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M F Pisters
- Physical Therapy Sciences, Program in Clinical Health Sciences, University Medical Center Utrecht, Utrecht, The Netherlands.,Physical Therapy Research, Department of Rehabilitation, Physiotherapy Science & Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands.,Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, The Netherlands
| | - K Fischer
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
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Fischer K, Ljung R. Primary prophylaxis in haemophilia care: Guideline update 2016. Blood Cells Mol Dis 2017; 67:81-85. [DOI: 10.1016/j.bcmd.2017.02.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/15/2017] [Indexed: 10/20/2022]
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van Galen KPM, de Kleijn P, Foppen W, Eikenboom J, Meijer K, Schutgens REG, Fischer K, Cnossen MH, de Meris J, Fijnvandraat K, van der Bom JG, Laros-van Gorkom BAP, Leebeek FWG, Mauser-Bunschoten EP. Long-term impact of joint bleeds in von Willebrand disease: a nested case-control study. Haematologica 2017; 102:1486-1493. [PMID: 28572165 PMCID: PMC5685243 DOI: 10.3324/haematol.2017.168617] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 05/30/2017] [Indexed: 11/11/2022] Open
Abstract
Patients with severe von Willebrand disease (VWD) may develop arthropathy after joint bleeds. Information on its prevalence and severity is limited. We aimed to assess the occurrence and severity of arthropathy in VWD and its impact on daily life. VWD patients with and without verified joint bleeds were matched for age, sex and Factor VIII level or von Willebrand Factor activity in a nested case-control study within the Willebrand in the Netherlands study. Assessments included the Hemophilia Joint Health Score (0–124), Pettersson score (0–13 per joint X-ray), Hemophilia Activity List score (0–100), joint pain (Visual Analog Scale 0–10), and the Impact on Participation and Autonomy questionnaire (0–20). Arthropathy was defined as a Hemophilia Joint Health Score of 10 or higher, or a Pettersson score over 3 of at least one joint. We included 48 patients with verified joint bleeds (cases) and 48 controls: 60% males, mean age 46 years (range 18–80), median von Willebrand Factor activity 5 versus 8 IU/dL and Factor VIII 24 versus 36 IU/dL. Arthropathy occurred in 40% of the cases versus 10% of the controls (P<0.01). The cases reported more functional limitations compared to the controls (median Hemophilia Activity List score: 88 vs. 100, P<0.01). Arthropathy was related to joint pain and less social participation (Visual Analog Scale>3: 13 of 19 vs. 3 of 28, P<0.01, and median score on the participation questionnaire 6.1 vs. 0.9, P<0.01). In conclusion, arthropathy occurs in 40% of VWD patients after joint bleeds and is associated with pain, radiological abnormalities, functional limitations, and less social participation (Dutch trial register: NTR4548).
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Affiliation(s)
| | - Piet de Kleijn
- Van Creveldkliniek and Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Centre Utrecht, the Netherlands
| | - Wouter Foppen
- Department of Radiology, University Medical Center Utrecht, the Netherlands
| | - Jeroen Eikenboom
- Department of Thrombosis and Hemostasis and Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, the Netherlands
| | - Karina Meijer
- Department of Hematology, University of Groningen, University Medical Center Groningen, the Netherlands
| | | | - Kathelijn Fischer
- Van Creveldkliniek and Julius Center Department of Epidemiology, University Medical Center Utrecht, the Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Joke de Meris
- Dutch Society of Haemophilia Patients, Leiden, the Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Academisch Medisch Centrum, Emma Children's Hospital, Amsterdam, the Netherlands
| | - Johanna G van der Bom
- Jon J van Rood Center for Clinical Transfusion Medicine, Sanquin Research, Leiden, and Department of Clinical Epidemiology, Leiden University Medical Center, the Netherlands
| | | | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
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Lissitchkov T, Rusen L, Georgiev P, Windyga J, Klamroth R, Gercheva L, Nemes L, Tiede A, Bichler J, Knaub S, Belyanskaya L, Walter O, Pasi KJ. PK-guided personalized prophylaxis with Nuwiq®(human-cl rhFVIII) in adults with severe haemophilia A. Haemophilia 2017; 23:697-704. [DOI: 10.1111/hae.13251] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2017] [Indexed: 11/27/2022]
Affiliation(s)
- T. Lissitchkov
- Department of Clinical Haematology in Haemorrhagic Diathesis and Anaemia; Specialized Hospital for Active Treatment “Joan Pavel”; Sofia Bulgaria
| | | | - P. Georgiev
- Clinic of Haematology; University Multiprofile Hospital for Active Treatment “Sveti Georgi” and Medical University; Plovdiv Bulgaria
| | - J. Windyga
- Department of Disorders of Haemostasis and Internal Medicine; Institute of Haematology and Transfusion Medicine; Warsaw Poland
| | - R. Klamroth
- Department for Internal Medicine, Vascular Medicine and Haemostaseology; Vivantes Klinikum im Friedrichshain; Berlin Germany
| | - L. Gercheva
- Clinic of Clinical Haematology; Multiple Hospital for Active Treatment “Sveta Marina”; Varna Bulgaria
| | - L. Nemes
- Medical Centre; Hungarian Defence Forces; National Haemophilia Centre; Budapest Hungary
| | - A. Tiede
- Clinic for Haematology, Haemostaseology, Oncology and Stem Cell Transplantation; Hannover Medical School; Hannover Germany
| | | | - S. Knaub
- Octapharma AG; Lachen Switzerland
| | | | | | - K. J. Pasi
- The Royal London Hospital; Barts and the London School of Medicine and Dentistry; London UK
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Mizrahi T, St-Louis J, Young NL, Ménard F, Zourikian N, Dubé E, Rivard GE. Adherence to treatment regimen and bleeding rates in a prospective cohort of youth and young adults on low-dose daily prophylaxis for severe hemophilia A. BMC HEMATOLOGY 2016; 16:26. [PMID: 27833753 PMCID: PMC5101823 DOI: 10.1186/s12878-016-0067-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 10/31/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND When availability and/or affordability of anti-hemophilic factor concentrates are limited, optimal prophylaxis regimens in severe hemophilia A (HA) remain to be determined. In selected situations, low-dose daily prophylaxis (LDDP) may be an effective and economical option. The goal of our study was to evaluate if subjects on a LDDP regimen could achieve adherence and good clinical outcome. METHODS Seventeen subjects (age between 15.2 and 28.4) on LDDP suffering from severe/moderate HA were followed prospectively for 2 to 3 years as part of a health-related quality of life (HRQoL) study. Bleeding and treatments data were collected using electronic diaries and validated every three months. The SF-36 questionnaire was administered at the beginning of the study and then every 6 months until the end of the study. RESULTS The subjects (mean age 22.0, median 21.9, standard deviation 4.06), were all from a single centre and on LDDP for at least 12 months as part of their routine care before entering the study. Fifteen subjects were prescribed a daily dose of 500 IU factor VIII (FVIII) and 2 subjects received 1000 IU FVIII per day, resulting into a median dose of 7.1 IU/kg/day (ranging from 4 to 13 IU/kg/day) and of 2591 IU/kg/year. Median adherence (the percentage of the prescribed daily dose received) was 84 % (mean 80 %, range 57 % to 94 %) throughout the study. Seventy-six bleeds in the 6 index joints and 51 other types of bleeds were observed throughout the study. The median annualized bleeding rate in joints (ABRjoints) was 0.7 and the median annualized bleeding rate for all bleeds (ABRall) was 1.6. The Physical Component and Mental Component Summary scores of SF-36, and the Hemophilia Joint Health Score were not significantly different over the course of the study (respective medians of 49.8, 52.4 and 16.0 at entry; vs. 52.5, 51.5 and 16.0 upon exit). CONCLUSIONS This prospective longitudinal study in youth and young adults shows that LDDP may be associated with low ABRs, adequate adherence and HRQoL comparable to previously reported.
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Affiliation(s)
- Terry Mizrahi
- CHU Sainte-Justine, University of Montreal, 3175, chemin de la Côte-Ste-Catherine, H3T 1C5 Montreal, Quebec Canada
| | - Jean St-Louis
- CHU Sainte-Justine, University of Montreal, 3175, chemin de la Côte-Ste-Catherine, H3T 1C5 Montreal, Quebec Canada
| | | | - Francine Ménard
- CHU Sainte-Justine, University of Montreal, 3175, chemin de la Côte-Ste-Catherine, H3T 1C5 Montreal, Quebec Canada
| | - Nichan Zourikian
- CHU Sainte-Justine, University of Montreal, 3175, chemin de la Côte-Ste-Catherine, H3T 1C5 Montreal, Quebec Canada
| | - Evemie Dubé
- CHU Sainte-Justine, University of Montreal, 3175, chemin de la Côte-Ste-Catherine, H3T 1C5 Montreal, Quebec Canada
| | - Georges E Rivard
- CHU Sainte-Justine, University of Montreal, 3175, chemin de la Côte-Ste-Catherine, H3T 1C5 Montreal, Quebec Canada
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Fischer K, Poonnoose P, Dunn AL, Babyn P, Manco-Johnson MJ, David JA, van der Net J, Feldman B, Berger K, Carcao M, de Kleijn P, Silva M, Hilliard P, Doria A, Srivastava A, Blanchette V. Choosing outcome assessment tools in haemophilia care and research: a multidisciplinary perspective. Haemophilia 2016; 23:11-24. [DOI: 10.1111/hae.13088] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2016] [Indexed: 01/23/2023]
Affiliation(s)
- K. Fischer
- Van Creveldkliniek; University Medical Center Utrecht; Utrecht The Netherlands
| | - P. Poonnoose
- Department of Orthopaedics; Christian Medical College; Vellore Tamil Nadu India
| | - A. L. Dunn
- Division of Hematology and Oncology; Nationwide Children's Hospital and The Ohio State University; Columbus OH USA
| | - P. Babyn
- Department of Medical Imaging; University of Saskatchewan and Saskatoon Health Region Royal University Hospital; Saskatoon SK Canada
| | - M. J. Manco-Johnson
- Section of Hematology/Oncology/Bone Marrow Transplantation; Department of Pediatrics; University of Colorado Anschutz Medical Campus and Children's Hospital; Aurora CO USA
| | - J. A. David
- Department of PMR; Christian Medical College; Vellore Tamil Nadu India
| | - J. van der Net
- Child Health Services; Child Development and Exercise Center; University Medical Center and Children's Hospital; Utrecht The Netherlands
| | - B. Feldman
- Division of Rheumatology; Department of Paediatrics and Child Health Evaluative Sciences; Research Institute; Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - K. Berger
- Division of Haematology/Oncology; University Hospital of Munich; Munich Germany
| | - M. Carcao
- Division of Haematology/Oncology; Department of Paediatrics and Child Health Evaluative Sciences; Research Institute; Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - P. de Kleijn
- Department of Rehabilitation, Nursing Science and Sports, and Van Creveldkliniek; University Medical Center Utrecht; Utrecht The Netherlands
| | - M. Silva
- Department of Orthopaedic Surgery; Orthopaedic Institute for Children; David Geffen School of Medicine at UCLA; Los Angeles CA USA
| | - P. Hilliard
- Department of Rehabilitation; Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - A. Doria
- Department of Diagnostic Imaging; Research Institute; Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - A. Srivastava
- Department of Haematology; Christian Medical College; Vellore Tamil Nadu India
| | - V. Blanchette
- Division of Haematology/Oncology; Department of Paediatrics and Child Health Evaluative Sciences; Research Institute; Hospital for Sick Children; University of Toronto; Toronto ON Canada
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Fischer K, Lewandowski D, Janssen MP. Modelling lifelong effects of different prophylactic treatment strategies for severe haemophilia A. Haemophilia 2016; 22:e375-82. [PMID: 27353496 DOI: 10.1111/hae.13019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lifelong prophylactic replacement therapy with clotting factor concentrates is recommended for severe haemophilia. The prophylactic dose determines both clinical outcome and treatment cost. In the absence of clinical studies, computer simulation was used to explore lifelong effects and clotting factor consumption for various prophylactic dose levels, and optimize strategies for switching between prophylactic and on-demand treatment. DESIGN AND METHODS Individual patients' lifetime joint bleeds, radiological arthropathy (Pettersson score, 0-78) and consumption were simulated for each treatment strategy. Treatment effectiveness (expressed as % of patients maintaining a lifetime Pettersson score ≤14) and clotting factor consumption were modelled for lifelong prophylaxis at dose levels 1000-4500 IU kg(-1) year(-1) , for on-demand treatment and for switching strategies. Treatment efficiency (consumption per unit of effectiveness) was used to compare strategies. RESULTS Compared to lifelong on-demand treatment, lifelong prophylaxis at 1000 IU kg(-1) year(-1) increased effectiveness from 21 to 36%, at an additional consumption of 0.9 × 10(6) IU kg(-1) . For lifelong prophylaxis, each additional 1000 IU kg(-1) year(-1) resulted in a proportional increase in consumption by ±5 × 10(6) IU kg(-1) but a less than proportional reduction in arthropathy by ±50%; consequently, increasing consumption progressively diminished treatment efficiency. Switching strategies slightly reduce effectiveness and consumption. Optimum switching criteria were similar across prophylactic dose levels. CONCLUSION According to the simulation model, low-dose prophylaxis (1000 IU kg(-1) year(-1) ) improved outcome at a limited increase in consumption compared to on-demand treatment. Increasing prophylactic dose further improved health outcomes, but at decreasing efficiency. Optimal prophylactic dose should therefore be selected balancing acceptable health impact and available budget.
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Affiliation(s)
- K Fischer
- Julius Center for Health Sciences and Primary care, University Medical Center Utrecht, Utrecht, The Netherlands. .,Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - D Lewandowski
- Julius Center for Health Sciences and Primary care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M P Janssen
- Julius Center for Health Sciences and Primary care, University Medical Center Utrecht, Utrecht, The Netherlands.,Research Division, Transfusion Technology Assessment Department, Sanquin Blood Supply Foundation, Amsterdam, The Netherlands
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Schrijvers LH, Beijlevelt-van der Zande M, Peters M, Lock J, Cnossen MH, Schuurmans MJ, Fischer K. Adherence to prophylaxis and bleeding outcome in haemophilia: a multicentre study. Br J Haematol 2016; 174:454-60. [PMID: 27098446 DOI: 10.1111/bjh.14072] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 01/29/2016] [Indexed: 12/20/2022]
Abstract
Prevention of bleeding and joint damage in severe haemophilia is dependent on adherence to prophylactic replacement therapy. The aim of this study was to assess adherence to prophylaxis, including associations with age, bleeding and clotting factor consumption (CFC). In three Dutch haemophilia centres, semi-structured interviews about adherence to prophylaxis in the previous 2 weeks were conducted with patients or parents of a child with haemophilia. Patients were classified, according to pre-specified definitions, as adherent, sub-optimally adherent or non-adherent based on missing, timing, and dose of infusions. Association of annual bleeding rates, mean CFC, person performing the infusion (parents verus patients) with adherence categories were analysed. Overall, 241 patients with haemophilia using prophylaxis were studied. Parents were more adherent (66%; n = 48/73) than patients (43%; n = 72/168). Sub-optimal adherence occurred in 29% of parents and 37% of patients and was characterized by changes in timing of infusion (mostly from morning to evening), while missing <6% of infusions. Non-adherence occurred less often: in 5% of parents and 20% of patients. Reduced adherence was associated with lower CFC, but not with joint bleeding. In conclusion, non-adherence in haemophilia was relatively rare, yet 1/3 of patients struggled to administer prophylaxis at the appropriate time of day.
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Affiliation(s)
| | | | - Marjolein Peters
- Haemophilia Treatment Centre, Emma Children's' Hospital- Academical Medical Centre, Amsterdam, the Netherlands
| | - Janske Lock
- Department of Paediatric Haematology, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marjon H Cnossen
- Department of Paediatric Haematology, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marieke J Schuurmans
- Nursing Science, Faculty of Health Care, University of Applied Science, Utrecht, the Netherlands.,Nursing Science, University Medical Centre, Utrecht, the Netherlands
| | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Centre, Utrecht, the Netherlands.,Julius Centre for Health Sciences and Primary Care, University Medical Centre, Utrecht, the Netherlands
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