Who Progresses to Third-Line Therapies for Overactive Bladder? Trends From the AQUA Registry

INTRODUCTION

Overactive bladder (OAB) patients who do not achieve satisfactory results with second-line OAB medications should be offered third-line therapies (percutaneous tibial nerve stimulation, sacral neuromodulation, onabotulinumtoxinA bladder injection [BTX-A]). We aimed to determine which clinical factors affect progression from second- to third-line OAB therapy.

METHODS

Between 2014 and 2020, the AUA Quality Registry was queried for adult patients with idiopathic OAB. For the primary outcome, patient and provider factors associated with increased odds of progression from second- to third-line therapy were assessed. Secondary outcomes included median time for progression to third-line therapy and third-line therapy utilization across subgroups.

RESULTS

A total of 641,122 patients met inclusion criteria and were included in analysis. Of these, only 7487 (1.2%) received third-line therapy after receiving second-line therapy. On multivariate analysis, patients aged 65 to 79, women, White race, history of dual anticholinergic and β3 agonist therapy, metropolitan area, government insurance, and single specialty practice had the greatest odds of progressing to third-line therapy. Black and Asian race, male gender, and rural setting had lower odds of progressing to third-line therapy. BTX-A was the most common therapy overall (40% BTX-A, 32% sacral neuromodulation, 28% percutaneous tibial nerve stimulation). The median time of progression from second- to third-line therapy was 15.4 months (IQR 5.9, 32.4). Patients < 50 years old and women progressed fastest to third-line therapy.

CONCLUSIONS

Very few patients received third-line therapies, and the time to progression from second- to third-line therapies is > 1 year. The study findings highlight a potential need to improve third-line therapy implementation.

Factors Influencing Medication Selection for Management of Overactive Bladder: Trends and Insights From AUA Quality Registry

OBJECTIVE

To determine how a patient's demographics, including insurance type, race/ethnicity, gender, and age, may impact the choice of medication prescribed for overactive bladder (OAB).

METHODS

We queried the AUA Quality Registry for adults between 2014 and 2020 with a diagnosis of OAB for >1year, excluding neurogenic causes. Variables included age, race/ethnicity, gender, insurance type, medication first prescribed, year of prescription, provider metropolitan status, and provider practice type. Primary outcome was which factors were associated with increased odds of beta-3 prescription as first medication choice.

RESULTS

We found 1,453,566 patients with OAB, 641,122 (44.1%) with complete data. Of these, 112,021 (17.5%) were prescribed medication. On multivariate analysis, patients with Medicaid, Medicare, and other/self-pay insurance were less likely to receive a beta-3 vs an anticholinergic compared to private or military insurance. Compared to white patients, Asian, Black, and other races were less likely to receive a beta-3, as were patients outside of metropolitan areas. Age >50, prescriptions after 2014, and nonacademic settings were associated with increased odds of beta-3 prescription. There was no difference between genders.

CONCLUSION

Many nonclinical factors, including insurance type and race, may affect which medication is first prescribed for OAB. This is useful for practicing urologists and may help lower barriers to beta-3 prescription through policy change and advocacy.

Voided volume may not impact stone outcomes: Review of a large institutional nephrolithiasis cohort

Background

Urologic guidelines universally recommend increasing fluid intake for kidney stone prevention. Increased voided volume is thought to help reduce stone recurrence and severity, but supporting evidence is limited.

Patients and Methods

Nephrolithiasis outcomes and 24-h urine data for patients from the Registry for Stones of the Kidney and Ureter (ReSKU), a registry of nephrolithiasis patients collected between 2015 and 2020, were retrospectively analysed. Outcome was stone events, either an office visit where a patient reports symptomatic passage of stones or surgery for stone removal.

Results

We identified 450 stone patients with 24-h urine and kidney stone outcome data. There was no significant difference in 24-h voided volume between patients with one stone event and patients with two or more stone events. On multivariable logistic regression, after controlling for age, gender, BMI, and 24-h sodium and creatinine per kilogram, no significant associations were found between voided volume and stone events. There was a statistically significant negative correlation noted between voided volume and stone events in calcium oxalate dihydrate stone formers (Spearman R = -0.42, p = 0.04), but not others.

Conclusions

Twenty-four-hour voided volume was not associated with stone events in a large institutional cohort, and subset analysis reveals that some stone formers may benefit more from increased voided volume than others; identifying such patients represents a novel precision medicine opportunity.

A Novel Standardized Morbidity and Mortality Process to Promote Discourse, Improve Education, and Facilitate Practice Change: The M-PROVE Model

INTRODUCTION

The morbidity and mortality conference is essential to medical education and quality improvement. Ideally, the conference is inclusive, judgment-free, and focused on practice improvement. In reality, it may not meet these goals. We reimagined the process by standardizing presentations and creating an oversight committee to improve the perceived value of the conference and identify opportunities for improvement. This study evaluates the subjective impact of the redesigned process at our institution and provides a blueprint for our reproducible model.

METHODS

We created a faculty and resident committee to review all submitted cases, implemented a standardized presentation template and moderating structure, and tracked quality improvement measures from proposed improvement initiatives. Attitudes toward the conference, including perceived quality/relevance, identification of potential systems changes, inclusiveness, and educational value, were assessed among faculty and trainees using pre- and postintervention Likert-style surveys.

RESULTS

Of 45 eligible department members, 41 (91%) completed the preintervention and 36 (80%) completed the postintervention survey. We found a statistically significant improvement in all questions between pre- and postintervention surveys except on the question about the conference environment being nonthreatening, which also improved but was not statistically significant. The overall average answer improved on the postintervention survey compared to the preintervention survey (3.36 vs 4.20, P < .001). These trends were similar regardless of attendee role and gender.

CONCLUSIONS

Redesigning and standardizing the morbidity and mortality conference with greater attention to education, inclusion, systems change, and quality improvement improves the attitudes of conference attendees and increases the perceived value of the conference.

61 STROKE MIMIC CASE REPORT: A YOUNG PATIENT WITH COVID-19 REFERRED TO NEUROVASCULAR CLINIC SUBSEQUENTLY DIAGNOSED WITH SYSTEMIC ARTERIAL EMBOLI

Background

An independent 44 year-old is reviewed at Neurovascular Clinic with a suspected high-risk Transient-Ischaemic-Attack (TIA). He had a recent diagnosis of COVID-19. Investigations revealed multiple systemic arterial emboli responsible for his symptoms, rather than a cerebrovascular cause.

Methods

The patient attended our Neurovascular Clinic following a virtual Stroke Consultant telephone assessment 3 days previously, when he had been referred from his GP with a brief episode of left arm weakness. This was felt to be a high-risk TIA event. He had tested COVID-19 positive with mild flu-like symptoms 4 days prior to this event. He described sudden onset weakness involving the left forearm and wrist which became ‘floppy’. Symptoms had fully resolved within one hour. His only reported vascular risk factor was controlled essential hypertension. He was a life-long non-smoker with no family history of stroke. On examination his left arm felt significantly colder than the right. His radial pulses bilaterally were palpable with good volume. Blood pressure was satisfactory in both arms. No other focal neurology was found.

Results

Computed-Tomography (CT) angiogram of the left arm revealed an occlusion of the ulnar artery in the antecubital fossa, dilated aortic root, splenic infarcts and probable pulmonary emboli. CT pulmonary angiogram revealed large bilateral volume pulmonary emboli within both main pulmonary arteries extending into all lobar branches of both pulmonary arteries. A Patent Foramen Ovale was not seen on bubble-contrast transthoracic echocardiogram. Diffusion-weighted Magnetic-Resonance-Imaging (MRI) Brain was normal. Anticoagulation with Apixaban for 6 months was commenced for provoked emboli following consultation with our trust haematologist.

Conclusion

This case of a so-called “stroke mimic” highlights a pitfall of virtual assessment for neurovascular patients and the need for assessing in person those who we should have a higher suspicion for alternative pathology, especially in those who were recently COVID-19 positive given documented pro-thrombotic tendencies.

A case of prenatally diagnosed prune belly syndrome variant and congenital pouch colon in the United States: A case report

Background: Prune belly syndrome (PBS) and congenital pouch colon (CPC) are rare congenital syndromes with a low incidence in the United States (U.S.) with most CPC cases being from India. In this case report, we describe, to the best of our knowledge, the first PBS variant and CPC patient in the U.S. Case Presentation: A 30-year-old G2P0010 woman was referred to a tertiary center after an 18-week ultrasound showed a fetal abdominal mass. A prenatal MRI showed a dilated loop of bowel containing a mixture of urine and meconium, oligohydramnios, and a protuberant abdominal wall. Born at 37 weeks, the child’s physical exam was notable for a distended abdomen with thin abdominal musculature, non-palpable bilateral testes, no anal opening, and flat buttocks. Intra-operatively, a dilated cecum/ascending colon was noted with an abrupt change in caliber at the transverse colon, bilateral enlarged ureters, a left testis at the internal ring and no visualized right testis. A colostomy and mucous fistula were created 5 cm from the sigmoid pouch. Conclusion: While most reported cases of CPC undergo single stage repair (one operation) at 1 day of life, our patient underwent the first procedure of a staged repair at 16 hours of life given his clinical instability at the time as well as his unknown urological anatomy in the setting of urinary obstruction. This case demonstrates the importance of fetal imaging, multidisciplinary approach at a tertiary care center, and reinforces a staged repair when necessary.

Autologous haematopoietic stem cell transplantation as a first-line disease-modifying therapy in patients with 'aggressive' multiple sclerosis

BACKGROUND

Autologous haematopoietic stem cell transplantation (AHSCT) is an effective treatment for patients with multiple sclerosis (MS) who have highly active disease, despite the use of standard disease-modifying therapies (DMTs). However, the optimal time for offering AHSCT to patients with 'aggressive' MS is yet to be established.

OBJECTIVES

The objective was to explore the safety and efficacy of AHSCT as a first-line DMT in patients with 'aggressive' MS.

METHODS

All patients with 'aggressive' MS who received AHSCT as a first-line DMT in five European and North American centres were retrospectively evaluated.

RESULTS

Twenty patients were identified. The median interval between diagnosis and AHSCT was 5 (1-20) months. All had multiple poor prognostic markers with a median pre-transplant Expanded Disability Status Scale (EDSS) score of 5.0 (1.5-9.5). After a median follow-up of 30 (12-118) months, the median EDSS score improved to 2.0 (0-6.5, p < 0.0001). No patient had further relapses. Three had residual magnetic resonance imaging (MRI) disease activities in the first 6 months post-transplant, but no further new or enhancing lesions were observed in subsequent scans.

CONCLUSION

AHSCT is safe and effective as a first-line DMT in inducing rapid and sustained remission in patients with 'aggressive' MS.

1088 Heart Rate Variability During Sleep in Adults With and Without a History of Depression and the Influence of Antidepressant Use

Introduction

Individuals with depression have an increased risk for cardiovascular disease. While lower daytime HRV may be one mechanism of this association, it is less clear whether HRV during sleep (sHRV) differs between adults with and without depression. Examining sHRV is an important measure to test given evidence that nocturnal differences in physiology are strong predictors of cardiovascular disease.

Methods

118 adults who completed psychiatric interviews between the ages of 21-60 y (T1) returned 18.7 ± 4.5 years later for a re-evaluation of their mental health and assessment of sleep (T2). 71 participants were diagnosed with Major Depressive Disorder (MDD) at either T1 or T2, while 47 participants were free from depression at both time points. At T2, participants underwent an overnight polysomnogram with concurrent assessment of electrocardiography. The primary measures of sHRV were root mean square of successive differences (RMSSD) values during rapid eye movement (REM) sleep and non-REM (NREM) sleep stages N2 and N3. Lower values of RMSSD suggest lower parasympathetic activity. RMSSD values were natural log-transformed prior to analysis. Differences in RMSSD between depressive groups were examined using analysis of covariance (ANCOVA), adjusting for age, body mass index, gender, race, and antihypertensive medication use. Additional ANCOVA models adjusted for antidepressant use.

Results

Participants with current or a history of MDD had lower RMSSD values during REM sleep (P=.01) and a trend toward lower values during NREM (P=.06) compared to those without MDD. Antidepressant use was significantly associated with lower RMSSD during both REM (P=.002) and NREM sleep (P&lt;.001). Depression history was no longer associated with RMSSD during NREM or REM sleep following adjustment for antidepressant use (P&gt;.40).

Conclusion

These data indicate that adults with MDD exhibit lower parasympathetic activity during sleep compared to those without MDD. These associations were modified by antidepressant use, suggesting that antidepressants may partially explain the association between depression and sHRV. Future studies investigating the influence of specific antidepressants for modifying nocturnal physiology may help to better understand the link between depression and cardiovascular disease risk.

Support

This study was funded by National Institutes of Health (NIH) grants R01 HL104607 and K23 HL118318.

Cumulative live birth rates following a 'freeze-all' strategy: a population-based study

STUDY QUESTION

What is the cumulative live birth rate following a ‘freeze-all’ strategy compared with a ‘fresh-transfer’ strategy?

SUMMARY ANSWER

The ‘freeze-all’ strategy resulted in a similar cumulative live birth rate as the ‘fresh-transfer’ strategy among high responders (>15 oocytes retrieved) but did not benefit normal (10–15 oocytes) and suboptimal responders (<10 oocytes).

WHAT IS KNOWN ALREADY

Frozen-thawed embryo transfer is associated with a decreased risk of adverse obstetric and perinatal outcomes compared with fresh embryo transfer. It is unclear whether the ‘freeze-all’ strategy should be offered to all women undergoing ART treatment.

STUDY DESIGN, SIZE, DURATION

A population-based retrospective cohort study using data collected by the Victorian Assisted Reproductive Treatment Authority. This study included 14 331 women undergoing their first stimulated ART cycle with at least one oocyte fertilised between 1 July 2009 and 30 June 2014 in Victoria, Australia. Demographic characteristics, type of ART procedures and resulting pregnancy and birth outcomes were recorded for the stimulated cycle and associated thaw cycles until 30 June 2016, or until a live birth was achieved, or until all embryos from the stimulated cycle had been used.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women were grouped by whether they had undergone the ‘freeze-all’ strategy (n = 1028) where all embryos were cryopreserved for future transfer, or the ‘fresh-transfer’ strategy (n = 13 303) where selected embryo(s) were transferred in the stimulated cycle, and remaining embryo(s) were cryopreserved for future use. A discrete-time survival model was used to evaluate the cumulative live birth rate following ‘freeze-all’ and ‘fresh-transfer’ strategy.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1028 women undergoing ‘freeze-all’ strategy and 13 303 women undergoing ‘fresh-transfer’ strategy had 1788 and 22 334 embryo transfer cycles resulting in 452 and 5126 live births, respectively. Most women (61.3%) in the ‘freeze-all’ group had more than 15 oocytes retrieved in the stimulated cycle compared with 18.1% of women in the ‘fresh-transfer’ group (P < 0.001). For high responders (>15 oocytes), the cumulative live birth rate in the ‘freeze-all’ group was similar to the ‘fresh-transfer’ group (56.8% vs. 56.2%, adjusted hazard ratio (AHR) 0.90, 95% CI 0.77–1.04). However, the likelihood of a live birth was lower in the ‘freeze-all’ group compared with the ‘fresh-transfer’ group among normal responders (10–15 oocytes) (33.2% vs. 46.3%, AHR 0.62, 95% CI 0.46–0.83) and suboptimal responders (<10 oocytes) (14.6% vs. 28.0%, AHR 0.67, 95% CI 0.14–1.01). During the minimum follow-up time of 2 years, 34.1%, 24.4% and 8.4% of suboptimal, normal and high responders, respectively, in the ‘freeze-all’ group did not return for any embryo transfer after the stimulated cycle, whereas all women in the ‘fresh-transfer’ group had at least one embryo transferred in the stimulated cycle.

LIMITATIONS REASONS FOR CAUTION

A limitation of this population-based study is the lack of information available on clinic-specific protocols for the ‘freeze-all’ strategy and the potential impact of these on outcomes. Data were not available on whether the ‘freeze-all’ strategy was used to prevent ovarian hyperstimulation syndrome (OHSS).

WIDER IMPLICATIONS OF THE FINDINGS

This study presents population-based evidence on clinical efficacy associated with a ‘freeze-all’ and ‘fresh-transfer’ strategy. The ‘freeze-all’ strategy may benefit some subgroups of patients, including women who are high responders and those who are at risk of OHSS, but should not be offered universally. Clinicians should consider the potential impact of electively deferring embryo transfer on treatment discontinuation in choosing the optimal embryo transfer strategy for couples undergoing ART treatment.

STUDY FUNDING/COMPETING INTEREST(S)

No specific funding was received to undertake this study. There is no conflict of interest, except that M.B. is a shareholder in Genea Ltd.

The transition to self-regulated learning for first-year dental students: threshold concepts

Research shows that when students arrive at university they are often not prepared for independent learning. New students enter a period of transition during their first year, which is often characterised by emotional destabilisation, as they move towards becoming more self-regulating in their new learning environment. In this small-scale qualitative study, data from an in-depth pair interview were triangulated with data from a questionnaire, to explore participants' experiences of self-regulated learning in the first year of a Dental Surgery course. Five threshold concepts relating to learning in transition emerged from the analysis of the data. These concepts were as follows: learning how to learn using a range of self-chosen sources instead of a single textbook, learning how to organise incoming information without guidance, distinguishing between main ideas and detail during revision, coping with a heavy workload, and knowing what to expect from examinations and coursework. Strong emotions (feeling confused, overwhelmed and scared) were associated with negotiating these threshold concepts. However, the study illustrates how the participants adopted new cognitive and metacognitive strategies to become more self-regulating over time. The findings of the study suggest that lecturers, tutors, study advisers and peers all have an important role to play in explicitly guiding first-year students as they grapple with troublesome threshold concepts relating to self-regulated learning. Furthermore, structural changes to the content-heavy, lecture-based curricula often associated with first-year Medical and Dental courses would help ease students' transition to independent learning, which may make an impact on student attainment.

Australia-wide assessment of perfluoroalkyl substances (PFASs) in landfill leachates

Leachate from 27 landfills was analysed for nine perfluoroalkyl substances (PFASs). Five PFASs were detected ubiquitously, with perfluorohexanoate (PFHxA) the predominant PFAS (mean 1700ng/L; range 73-25,000ng/L). Despite the complexity of landfill-specific factors, some general trends in PFAS concentrations were observed. Mean concentrations of eight PFASs were higher in operating landfills (or landfill cells) accepting primarily municipal waste, compared to closed municipal landfills. Landfills accepting primarily construction and demolition wastes produced leachate that had higher mean PFAS concentrations than municipal landfills. Younger landfills appeared to have a higher burden of waste containing PFASs (or their precursors), as significant relationships (p<0.05) were observed between selected PFAS concentrations and landfill age. Increasing pH and total organic carbon (TOC) in leachate were associated with increased concentrations of several PFASs. Eight landfills discharged leachate to wastewater treatment plants (WWTPs). Estimated masses of PFASs discharged reached a maximum of 62g annually (PFHxA), with a national estimate reaching 31kg (PFHxA) annually. The practise of treating leachate at WWTPs allows redistribution of PFASs between the solid and liquid waste streams, although the contribution of leachate to the total load of PFASs entering WWTPs is minor compared to domestic waste water sources.

Normal range of bleeding scores for the ISTH-BAT: adult and pediatric data from the merging project

Bleeding Assessment Tools (BATs) have been developed to aid in the standardized evaluation of bleeding symptoms. The Vicenza Bleeding Questionnaire (BQ), published in 2005, established a common framework and scoring key that has undergone subsequent modification over the years, culminating in the publication of the ISTH-BAT in 2010. Understanding the normal range of bleeding scores is critical when assessing the utility of a BAT. Within the context of The Merging Project, a bioinformatics system was created to facilitate the merging of legacy data derived from four different (but all Vicenza-based) BATs; the MCMDM1-VWD BQ, the Condensed MCMDM-1VWD BQ, the Pediatric Bleeding Questionnaire and the ISTH-BAT. Data from 1040 normal adults and 328 children were included in the final analysis, which showed that the normal range is 0-3 for adult males, 0-5 for adult females and 0-2 in children for both males and females. Therefore, the cut-off for a positive or abnormal BS is ≥4 in adult males, ≥6 in adult females and ≥3 in children. This information can now be used to objectively assess bleeding symptoms as normal or abnormal in future studies.

A report from the 16th Annual IGPA Conference (December 9-11, 2013 - Brussels, Belgium)

The 16th annual International Generic Pharmaceutical Alliance (IGPA) conference brought together approximately 200 attendees representing 35 nations. The IGPA consists of generic industry associations from the United States (GPhA), Canada (CGPA), Europe (EGA), Jordan (JAPM), South Africa (NAPM), and Japan (JGA), in addition to observer member organizations from Brazil (PróGenéricos), Mexico (AMEGI) and Taiwan (TGPA). Conference attendees listened to industry experts and participating organization representatives present some of the key issues affecting the generic industry. Nick Haggar (President, EGA) welcomed attendees by highlighting the impact that IGPA and its member alliance associations have on healthcare around the world. The 2-day conference reviewed the trends in 11 different markets, the ongoing trade negotiations between numerous countries and the role generic associations in their respective countries can have in increasing patient access to affordable high-quality medicines.

Cognitive change and neuroimaging following immunoablative therapy and hematopoietic stem cell transplantation in multiple sclerosis: A pilot study

BACKGROUND

Individuals with MS undergoing immunoablative therapy and hematopoietic stem cell transplantation (HSCT) show substantial decrease in brain volume over 2.4 months, presumably from chemotoxic effects, although other mechanisms have also been postulated.

OBJECTIVE

We examined whether volume loss was accompanied by a concomitant decrease in cognition. White and gray matter volumes, and the effect of stem cell dosage were considered.

METHODS

Seven individuals with rapidly progressing MS and poor prognosis underwent high dose immunosuppression and autologous HSCT. Neuropsychological testing and MRI scans were performed at baseline, 2 and 24 months post-procedure.

RESULTS

Cognitive impairment was noted at all times in most participants. Median decline of 1.39% in total brain volume was noted 2 months post-HSCT. By 24 months a further decline of 1.65% was noted. At 2 months significant decline was observed for areas of executive functioning. At 24 months almost no significant declines were noted. No significant correlations were found between cognitive decline and change in imaging variables or stem cell dosage.

CONCLUSIONS

Cognition changed in the early period following treatment but with little apparent relationship to volume changes. With temporal distance from the HSCT procedure, cognition returned to baseline levels. With the caution of a very small sample, preliminary results suggest that immunoablation and HSCT may have no lasting deleterious effects on cognition.

The genetics of Canadian type 3 von Willebrand disease: further evidence for co-dominant inheritance of mutant alleles

BACKGROUND

Type 3 von Willebrand disease (VWD) is the most severe form of the disease and is classically inherited in an autosomal recessive fashion.

OBJECTIVES

The aim of the current study was to investigate the molecular pathogenesis of a Canadian cohort of type 3 VWD patients.

PATIENTS AND METHODS

Thirty-four families comprised of 100 individuals were investigated. Phenotypic data, including bleeding scores (BS), von Willebrand factor (VWF) laboratory values and anti-VWF inhibitor status were included as well as sequence analysis.

RESULTS

We identified 31 different mutations (20 novel): 8 frameshift, 5 splice site, 9 nonsense, 1 gene conversion, 6 missense and 2 partial gene deletion mutations. The majority of mutations identified were in the propeptide (42%); index cases (IC) with these mutations exhibited more severe bleeding (BS = 22) than those with mutations elsewhere in VWF (BS = 13). Sixty-two out of 68 (91%) mutant alleles were identified. Twenty-nine IC (85%) had a VWF null genotype identified; 17 homozygous, 12 compound heterozygous. In five IC (15%), two mutant VWF alleles were not identified to explain the type 3 VWD phenotype. In four ICs only one mutant VWF allele was identified and in one IC no mutant VWF alleles were identified.

CONCLUSIONS

We have investigated the molecular pathogenesis of a Canadian cohort of type 3 VWD patients. Obligate carriers are not phenotypically silent in the Canadian population; 48% have been diagnosed with type 1 VWD. In approximately 50% of families in this study the inheritance pattern for type 3 VWD is co-dominant and not recessive.

A prospective evaluation of the prevalence of symptomatic von Willebrand disease (VWD) in a pediatric primary care population

The prevalence of von Willebrand disease (VWD) is reported as approximately 1%; however, these estimates were not based on individuals with significant symptoms. Four thousand five hundred ninety-two unselected parents/children were asked: "Does your child have a problem with bleeding/bruising?"; 223 (5%) answered yes, 41 of whom were administered the validated Pediatric Bleeding Questionnaire and had VWF testing. Five were diagnosed with VWD (three type 1, one type 2A, one type 2B). The prevalence of bleeding/bruising in a general pediatric population is 5%; the prevalence of symptomatic VWD at the level of pediatric primary care is at least 1 in 1,000.

Quantitation of bleeding symptoms in children with von Willebrand disease: use of a standardized pediatric bleeding questionnaire

SUMMARY BACKGROUND

Excessive bruising and mucocutaneous bleeding are frequent presenting symptoms in childhood. A detailed bleeding history can distinguish children who may have an inherited bleeding disorder from those who are normal. There is a lack of standardization of such history taking in pediatric practise.

OBJECTIVES

To assess the performance of a Pediatric Bleeding Questionnaire (PBQ), an adaptation of a standardized adult bleeding questionnaire and score that includes pediatric-specific bleeding symptoms, in a cohort of children with von Willebrand disease (VWD).

PATIENTS/METHODS

Bleeding scores were determined by interview, for children with a previous diagnosis of VWD and a control group of unaffected siblings.

RESULTS

Bleeding scores were obtained for 100 children with VWD, median age 10.9 years (range, 0.8-17.8 years), and 21 unaffected siblings. Median bleeding score in children with VWD was 7.0 (range, 0-29) and in the control group was 0 (range, -1-2). Bleeding score varied within and between each VWD type: definite type 1, n = 40, median, 9.0 (range, 2-18); possible type 1, n = 38, median, 2.0 (0-15); type 2, n = 6, median, 14.0 (3-17); and type 3, n = 16, median, 12.0 (4-29). Bleeding scores in affected children correlated with age (Spearman's correlation coefficient, 0.35; P = 0.0004). The most frequent clinically significant bleeding symptoms were surgical bleeding, bleeding after tooth extraction and menorrhagia. Post-circumcision bleeding, cephalohematoma, macroscopic hematuria and umbilical stump bleeding were clinically significant in 32% (of circumcised males), 4%, 4% and 3% of children, respectively.

CONCLUSIONS

The PBQ provides a standardized quantitation of bleeding severity in children with VWD.

Generation and validation of the Condensed MCMDM-1VWD Bleeding Questionnaire for von Willebrand disease

BACKGROUND

Given the challenges involved in obtaining accurate bleeding histories, attempts at standardization have occurred and the value of quantifying hemorrhagic symptoms has been recognized.

PATIENTS/METHODS

An extensive validated bleeding questionnaire (MCMDM-1VWD) was condensed by eliminating all details that did not directly affect the bleeding score (BS) and the correlation between the two versions was tested. Additionally, the diagnostic utility of the condensed version was prospectively tested.

RESULTS

Data on 259 individuals who were administered the questionnaire are presented here; 217 being prospectively investigated for von Willebrand disease (VWD) (group 1) and 42 previously known to have type 1, 2 or 3 VWD (group 2). Of the 217 prospectively investigated, 35 had positive BS (> or =4) and 182 had negative scores. Seven individuals (all with positive BS) had laboratory results consistent with type 1 VWD. This results in a sensitivity of 100% and a specificity of 87%. The positive predictive value is 0.20 and the negative predictive value is 1. The correlation between the full MCMDM-1VWD and condensed versions is excellent (Spearman's 0.97, P < 0.001, linear regression r(2) = 96.4). Inter-observer reliability for the condensed version is reasonable (Spearman's 0.72, P < 0.001 and intra-class correlation coefficient 0.805, P < 0.001). There was a significant difference in BS between subtypes of VWD, with type 3 >> type 2 >> type 1 VWD (anova P < 0.001). There is a strong inverse relationship between VWF:Ag level and BS (Spearman's -0.411, P < 0.001).

CONCLUSIONS

The Condensed MCMDM-1VWD Bleeding Questionnaire is an efficient, effective tool in the evaluation of patients for VWD.

The effect of exercise on von Willebrand factor and ADAMTS-13 in individuals with type 1 and type 2B von Willebrand disease

BACKGROUND

The effect of exercise on von Willebrand factor (VWF) and ADAMTS-13 levels in individuals with von Willebrand disease (VWD) has never been reported.

OBJECTIVES

The aim was to quantify the effect of a standardized exercise protocol on individuals with type 1 and type 2B VWD.

PATIENTS/METHODS

Thirty individuals from three groups (10 controls, 11 with type 1 VWD and 9 with type 2B VWD) completed the Standard Bruce Protocol Treadmill Test. A bleeding questionnaire was administered and blood tests were performed pre- and immediately postexercise. The groups were well matched for age, gender and body mass index (BMI).

RESULTS

There was a correlation in all groups between the metabolic equivalents (METS) achieved and the degree of change of VWF and FVIII:C levels (P < 0.002, Pearson's correlation). There was a significant postexercise increase in VWF:Ag, VWF:RCo, FVIII:C and activated VWF levels in both the control group and in the type 2B VWD group, but not in the type 1 VWD group. Specific to the type 2B VWD group was an increase in the percentage of high molecular weight multimers (P = 0.022), a decrease in the mean platelet count compared with the other groups (P < 0.001) and an increase in the ADAMTS-13 level (P = 0.001).

CONCLUSIONS

There are significant differences in the effects of exercise on individuals with type 1 and type 2B VWD compared with controls. Further clinical studies are necessary to evaluate exercise as a therapeutic option in VWD.