Elevated FVIII levels in hereditary hemorrhagic telangiectasia: Implications for clinical management

Objectives

The objective of this study was twofold: to determine the prevalence of arterial and venous thromboembolic events in the Norwegian Hereditary Hemorrhagic Telangiectasia (HHT) population, and to explore potential factors linked to such events, with particular emphasis on FVIII.

Methods

Patients with an HHT diagnosis attending the Otorhinolaryngology Department at Oslo University Hospital-Rikshospitalet were included consecutively between April 2021 and November 2022. We recorded the participants' medical history with an emphasis on thromboembolic events. Measurements of blood constituents, including FVIII, FIX, vWF, hemoglobin, iron, ferritin, and CRP were performed.

Results

One hundred and thirty-four patients were included in the study. The total prevalence of thromboembolic events among the participants was 23.1%. FVIII levels were high (>150 IU/dL) in the majority of HHT patients (n = 84) (68.3%) and were significantly associated with thromboembolic events (p < .001), as was age. Of the patients with high FVIII levels, 28 (33%) had experienced a thromboembolic event. Furthermore, FVIII levels were measured consecutively in 51 patients and were found to fluctuate above or below 150 IU/dL in 25% of these cases.

Conclusion

Thromboembolic events are highly prevalent in the Norwegian HHT population and are significantly associated with FVIII levels. FVIII levels can fluctuate, and measurements should be repeated in HHT patients to assess the risk of thromboembolic events.

Level of Evidence

4.

The Mayo, Cushing, and Osler Influence on A. L. Rhoton: A Historical Vignette of the Interconnectedness Between Highly Influential Neurosurgery Leaders over 100 Years

The careers of the Mayo brothers, Harvey Cushing, and Sir William Osler greatly shaped medical and surgical practice in the late 19th century and early 20th century and created a legacy to influence decades of physicians to follow. Additionally, these individuals were instrumental in the founding of neurosurgery as a distinct surgical specialty. Alongside these great men, Dr. Albert L. Rhoton Jr., revolutionized neurosurgical practice through his study of neuroanatomy and development of microsurgical technique in the second half of the 20th century. This review of the interactions and relationships between the Mayo brothers, Cushing, and Osler and their influences on Rhoton highlights the 100-year-long interconnectedness shared between these giants in the history of neurosurgery.

Sir William Osler's fatal trip to Scotland: "Mrs M" and the University Grants Committee

On 23 September 1919, Sir William Osler, after a telephone call from his friend Dyson Perrins, went to Glasgow where he saw a 40-year-old woman, Bethia Fulton Martin, in consultation with three local physicians. Osler called it "one of those remarkable Erythema cases (all sorts of skin lesions and three months on and off consolidation of both lower lobes)." Mrs Martin died 114 days later; her death certificate listed "angioneurotic oedema with chronic nephritis" and "tuberculous enlargement of the mediastinal lymph nodes." Osler died 18 days before Mrs Martin of complications from a respiratory infection acquired on his way home from Scotland. We discuss factors that possibly prompted Osler to go to Scotland, including his role with the newly formed University Grants Committee, and the differential diagnosis of the case, which is mainly between systemic lupus erythematosus and Henoch-Schönlein purpura.

The problem of comparing nurse practitioner practice with medical practice

Comparing the practice of nurse practitioners to medical practice began almost 50 years ago and continues to this day. This comparison is curious since the founders of this movement did not indicate that these advanced practice nurses were to be interchangeable with physicians. Nevertheless, substantial literature indicates that nurse practitioners perform equally or better when measured against physician practice standards. This paper compares the ontology and epistemology of both professions and concludes that the philosophical foundations are so different that comparisons are illogical.

The principles and practice of death: The Oslerian conflicted conception of dying

Sir William Osler espoused a particularly idealized medical life that included the patient in the physician's worldview. Disease is not considered a monolith, only a reflection of one's broader health. Death, too, is configured as a part of one's being, not as a thing apart from life. The wholesomeness that characterized Osler's practice is well known-however, his long discussions and thoughts on death have not been sufficiently analyzed. His clinical views have been hinted at and numerous medical historians have noted that Osler's worldview on death was avant-garde for its time, one in which he described finality not as a time of suffering and anguish, but as "singularly free from mental distress." This essay contends with this simple view. This straightforward understanding becomes complicated when delving into such primary resources as Osler's Study on Dying cards, his writings on other medical conditions, and personal reflections following the personal losses of his sons Edward Revere Osler and Paul Revere Osler. This essay contends that the loss and the death he imagines is not one of peace, but rather, of horror and terror. Furthermore, the primary sources show Osler not as the paragon of flawless clinical acumen and reasoning, but a man of personal beliefs that were in conflict with views he espoused more publicly. The essay therefore reconceptualizes the common understanding of a stoic Osler, determines how death prefigures into Oslerian thought, and challenges the idea of an Oslerian simple death.

TIMolol nasal spray as a treatment for epistaxis in hereditary hemorrhagic telangiectasia (HHT) - study protocol of the prospective, randomized, double-blind, controlled cross-over TIM-HHT trial

BACKGROUND

Hereditary hemorrhagic telangiectasia (HHT) is an inherited orphan disease, in which the absence of capillary beds between arterioles and venules lead to arteriovenous shunts. Epistaxis is the core symptom. Several case reports have described the nonselective beta-adrenergic receptor antagonist timolol as a successful treatment method of nosebleeds due in HHT patients.

OBJECTIVE

TIM-HHT is a single-site, prospective, randomized, placebo-controlled, double-blind, cross-over study to investigate whether the efficacy of standard laser treatment of epistaxis in HHT patients can be increased by the additional use of timolol nasal spray (1 mg/d).

METHODS

Twenty patients will be randomly allocated to one of two treatment sequences. Primary outcome is the severity of epistaxis determined by the Epistaxis Severity Score (ESS). Secondary outcomes are subjective satisfaction, quality of life, as well as the hemoglobin, ferritin, and transferrin levels of the participating patients. Safety outcome is assessed by means of pulse, blood pressure, and adverse events.

CONCLUSION

TIM-HHT will evaluate the efficacy and safety of timolol as an additional treatment of epistaxis in HHT patients in a three-month trial period. Benzalkonium chloride is used as a placebo, which has no documented positive effect on the nasal mucosa and hence on epistaxis in HHT patients (in contrast to saline).

TRIAL REGISTRATION

German Clinical Trials Register (DRKS), DRKS00020994. Registered on 10 March 2020.

Why William Osler Matters

William Osler has been largely forgotten, but his abiding wisdom speaks loudly to a profession consumed in burnout & uncertainty.

Sir William Osler, eugenics, racism, and the Komagata Maru incident

A recent critic levels two new charges against Sir William Osler: (1) that in 1912 he was a vice president of the First International Eugenics Congress; and (2) that in 1914 he asserted Canada should remain a "a white man's country." Osler was indeed among the 31 vice presidents of the First International Eugenics Congress, but he did nothing further in this area. Osler indeed asserted that Canada should remain a "white man's country," but his context was the Komagata Maru incident during which most Canadians felt the same way about 376 passengers from the Punjab Province of British India who sought to defy Canadian immigration law. There is little or no indication of racism elsewhere in Osler's deeds and writings, and the idea that race is largely a social construct emerged only after his death. Advocates for racial equality should view Osler not as an adversary but rather as an ally in today's battles for global justice and also for human survival.

Lessons of the month 3: Gone but not forgotten - Osler - a reminder of the syndrome not bearing his name

Streptococcus pneumoniae is the most frequently implicated microbial agent in community acquired bacterial pneumonia and meningitis. It is also responsible for between 1 and 3% of cases of native valve infective endocarditis, with mortality rates up to 60%. Osler first described the association between pneumococcal pneumonia, endocarditis, and meningitis secondary to bacteria that he described as 'micrococci', subsequently elucidated to be S pneumoniae by Robert Austrian, and the syndrome bears his name. We report a case of fulminant pneumococcal native aortic valve endocarditis and perforation in a young male patient with chronic alcoholism and splenectomy who exhibited poor compliance to pneumococcal prophylaxis.

The centenary of 'The Old Humanities and the New Science,' the last public address of Sir William Osler (1849-1919)

On 16 May 1919, Sir William Osler (1849-1919) gave what would be his last public address, 'The Old Humanities and the New Science,' to the Classical Association of which he was president. British educators were locked in a struggle between classics teachers, who wished to preserve their dominance in public schools and universities, and science teachers, who wanted more time in the curriculum. Osler had supported the science teachers' position three years earlier in his presidential address to the Association of Public School Science Masters. What could he now say to the classicists without making enemies? He gently chided both groups, but he was less concerned that day with the curricular dispute than with the question whether 'Science … can rule without invoking ruin.' He averred that 'there must be a very different civilization or there will be no civilization at all.' He invoked the Hippocratic ideal of 'philanthropia and philotechnia' (love of humanity and love of science of technology) not just for medicine, but for all of humankind.

Patients Are Our Teachers

In the patient-physician encounter, physicians hone their skills while alleviating the patient's suffering. Both benefit. Leaning on the work of Hippocrates, Darwin, and William Osler, the authors sketch out the case for honoring patients as indispensable teachers of the art and science of medicine. They argue that this tradition of Hippocratic medicine both anticipates modern precision medicine and reawakens a focus on public health medicine, each a benefit to the patients and communities served by physicians. A community that compromises the learning relationship of physician to patient and population undermines quality of care.

Integrative medicine selects best practice from public health and biomedicine

The meaning of terms Integrated and Integrative are described variously by an amalgam of latest scientific advances with ancient healing systems, of complementary medicine and biomedicine, and sexually transmitted infections and HIV/AIDS. It means seamless good quality care between hospital and primary care. They provoke approval mostly from patients and disapproval mostly from advocates of science and evidence-based medicine. The Institute of Applied Dermatology in Kasaragod, Kerala, India has championed a mix of Biomedicine, Yoga and herbals from Ayurvedic medicine, partly based on publications from the Department of Dermatology of the University of Oxford. In Oxford dermatology, acceptance of value of integrative medicine (IM) is demonstrated, especially in wound healing and the skin's blood supply. This has long featured in the university's research program. A variety of approaches to the practice of medicine are illustrated with reference to Osler, Garrod, and Doll. IM is believed to underlie contemporarily best practice. Particular emphasis is given to the control of heat, pain, redness, and swelling, all manifestations of inflammation, and the importance of emotion as a stimulus or inhibitor carried by neural pathways. These may explain some unbelievable Asian practices and one of the many roles of Yoga. The concept of Integrative is expanded to include care of the earth and nutrition, the hazards of climate change, Gardens for Health, do (k) no (w) harm as a key to good practice.