Musculoskeletal evaluation in severe haemophilia A patients from Latin America

There is a paucity of literature on haemophilia treatment in Latin American countries, a region characterized by rapidly improving systems of care, but with substantial disparities in treatment between countries. The aim of this study was to evaluate the musculoskeletal status of haemophilia patients from Latin America and to examine the relationship between musculoskeletal status and treatment practices across countries. The Committee of Latin America on the Therapeutics of Inhibitor Groups conducted a survey of its member country representatives on key aspects of haemophilia treatment in 10 countries. Musculoskeletal status of patients was obtained during routine comprehensive evaluations between March 2009 and March 2011. Eligible patients had severe haemophilia A (factor VIII <1%) without inhibitors (<0.6 BU mL−1) and were ≥5 years of age. Musculoskeletal status was compared between three groups of countries, based primarily on differences in the availability of long‐term prophylaxis. Overall, 143 patients (5–66 years of age) were enrolled from nine countries. In countries where long‐term prophylaxis had been available for at least 10 years (Group A), patients aged 5–10 years had significantly better mean World Federation of Hemophilia clinical scores, fewer target joints and fewer affected joints than patients from countries where long‐term prophylaxis has been available for about 5 years (Group B) or was not available (Group C). In Latin America, the musculoskeletal status of patients with severe haemophilia without inhibitors has improved significantly in association with the provision of long‐term prophylaxis. As more countries in Latin America institute this practice, further improvements are anticipated

Resumo: Estabelecimento da cultura de células endoteliais progenitoras circulantes a partir do sangue periférico. PECIBES, supl.1, 44, 2015

As células endoteliais exercem grande variedade de funções como manutenção do tônus vascular, hemostasia, participação na resposta inflamatória e na angiogênse. A ativação, lesão ou disfunção endotelial dessas células podem contribuir em diversos mecanismos fisiopatológicos de doenças como aterosclerose, diabetes e a anemia falciforme (AF). As células endoteliais progenitoras circulantes ou como serão denominadas neste estudo _ Blood Outgrowth Endothelial Cells (BOECs) _ são células endoteliais com características de células endoteliais maduras. As BOECs, assim como as Células Endoteliais Progenitoras precoces (CEPs), podem ser isoladas do sangue periférico por meio de cultura in vitro, e ambas células estão presentes em baixo número dentre as células mononucleares (0,1-0,01%). Diversos estudos indicam as BOECs como candidatas à regeneração vascular, biomaterial na terapia gênica e modelo no estudo fisiopatológico de doença vascular. Assim, o objetivo deste trabalho foi estabelecer a cultura de BOEC para servir como modelo de estudo in vitro do sistema endotelial de pacientes com AF. Participaram da pesquisa pacientes com diagnóstico de anemia falciforme (N=15) e indivíduos saudáveis (N=14) com padrão eletroforético e índices hematológicos normais. O estabelecimento da cultura de células BOECs foi baseado no protocolo de Lin et al. (2000). Apartir do sangue periférico foi isolada uma camada de células momonucleares e estas foram cultivadas em meio específico para células endoteliais. As culturas positivas para BOECs (N=13) apresentaram na primeira semana da cultura o surgimento de CEPs, com o formato de spindle-shaped que desapareceram ao longo da cultura; as primeiras colônias de BOECs surgiram em torno de 9 a 21 dias de cultura, com a morfologia característica de células endoteliais maduras, denominada de cobblestone. Após três passagens das células, obteve-se uma quantidade suficiente de células para fazer a caracterização destas por citometria de fluxo utilizando marcadores específicos (CD31, CD105, CD146, KDR, CD144). Esta pesquisa confirmou a possibilidade de se estabelecer a cultura de BOECs de pacientes com AF e de indivíduos saudáveis. O estabelecimento da cultura foi complexa, de longa duração e com 50% de sucesso de estabelecer culturas positivas para BOECs. No entanto, as BOECs possuem vantagens a serem utilizadas em estudos por possuírem alta capacidade proliferativa, fenótipo de célula endotelial madura estável por várias passagens durante o cultivo e a possibilidade de utilizar tratamentos com drogas. Diante do estabelecimento da cultura de BOECs de pacientes com AF e das características destas células, sugere-se que as BOECs podem ser utilizadas como modelo de estudo in vitro da anemia falciforme, isto é, na ausência de vaso-oclusão e inflamação crônica presentes na doença

Resumo: Estabelecimento da cultura de células endoteliais progenitoras circulantes a partir do sangue periférico. PECIBES, supl.1, 44, 2015

As células endoteliais exercem grande variedade de funções como manutenção do tônus vascular, hemostasia, participação na resposta inflamatória e na angiogênse. A ativação, lesão ou disfunção endotelial dessas células podem contribuir em diversos mecanismos fisiopatológicos de doenças como aterosclerose, diabetes e a anemia falciforme (AF). As células endoteliais progenitoras circulantes ou como serão denominadas neste estudo _ Blood Outgrowth Endothelial Cells (BOECs) _ são células endoteliais com características de células endoteliais maduras. As BOECs, assim como as Células Endoteliais Progenitoras precoces (CEPs), podem ser isoladas do sangue periférico por meio de cultura in vitro, e ambas células estão presentes em baixo número dentre as células mononucleares (0,1-0,01%). Diversos estudos indicam as BOECs como candidatas à regeneração vascular, biomaterial na terapia gênica e modelo no estudo fisiopatológico de doença vascular. Assim, o objetivo deste trabalho foi estabelecer a cultura de BOEC para servir como modelo de estudo in vitro do sistema endotelial de pacientes com AF. Participaram da pesquisa pacientes com diagnóstico de anemia falciforme (N=15) e indivíduos saudáveis (N=14) com padrão eletroforético e índices hematológicos normais. O estabelecimento da cultura de células BOECs foi baseado no protocolo de Lin et al. (2000). Apartir do sangue periférico foi isolada uma camada de células momonucleares e estas foram cultivadas em meio específico para células endoteliais. As culturas positivas para BOECs (N=13) apresentaram na primeira semana da cultura o surgimento de CEPs, com o formato de spindle-shaped que desapareceram ao longo da cultura; as primeiras colônias de BOECs surgiram em torno de 9 a 21 dias de cultura, com a morfologia característica de células endoteliais maduras, denominada de cobblestone. Após três passagens das células, obteve-se uma quantidade suficiente de células para fazer a caracterização destas por citometria de fluxo utilizando marcadores específicos (CD31, CD105, CD146, KDR, CD144). Esta pesquisa confirmou a possibilidade de se estabelecer a cultura de BOECs de pacientes com AF e de indivíduos saudáveis. O estabelecimento da cultura foi complexa, de longa duração e com 50% de sucesso de estabelecer culturas positivas para BOECs. No entanto, as BOECs possuem vantagens a serem utilizadas em estudos por possuírem alta capacidade proliferativa, fenótipo de célula endotelial madura estável por várias passagens durante o cultivo e a possibilidade de utilizar tratamentos com drogas. Diante do estabelecimento da cultura de BOECs de pacientes com AF e das características destas células, sugere-se que as BOECs podem ser utilizadas como modelo de estudo in vitro da anemia falciforme, isto é, na ausência de vaso-oclusão e inflamação crônica presentes na doença

Molecular Genetic Testing Of Hemostasis And Thrombosis In Developing Countries: Achievements, Hopes, And Challenges.

In today's developing world, how do we define a developing country? What level of effort and resources is invested in diagnosis, patient care, and research in those countries that we define to be developing? In particular, what is the situation with respect to molecular genetic testing in these countries? How much has been achieved to date, and what are the challenges to further achievements? This article describes the current status, challenges, and future hopes with respect to molecular genetic testing in hemostasis and thrombosis from the perspective of experts from three countries: Brazil, Colombia, and Iran. These individuals have lived and practiced genetic testing in their countries and have also had the experience to work and/or interact with the developed world to enable an appreciation of the difference.34569-7

Key issues in inhibitor management in patients with haemophilia

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Heat Treatment Of Samples Improve The Performance Of The Nijmegen-bethesda Assay In Hemophilia A Patients Undergoing Immune Tolerance Induction.

Nijmegen-Bethesda assay is the gold standard to assess inhibitory antibodies against factor (F) VIII. This method has some limitations, including high coefficient of variation and possible interference of residual endogenous or exogenous factor VIII. Heat-treatment of samples at 56°C for 30min could be a strategy to improve the sensitivity of this test. The aim of this study was to compare inhibitor quantification in hemophilia patients with and without inhibitor performed in previously heated and non-heated samples. A total of 109 analyses from 46 patients with severe hemophilia A were performed. Patients were divided into three groups: 20 patients with no history of inhibitor, recently and not recently exposed to FVIII (group I), 21 patients with history of inhibitor not exposed to FVIII (group II), and 5 patients (68 samples) undergoing an immune tolerance induction (ITI) protocol (group III). For patients with no history of inhibitor, heat-treatment did not modify the results (p=0.24). However, differences in inhibitor levels between heated and non-heated samples were observed in patients with history of inhibitor (group II, p<0.05) and in patients in ITI (group III, p<0.001). In 11 samples, inhibitor quantification shifted from negative to positive. Additionally, a longitudinal evaluation of each ITI patient showed similar trend line for the results of heated and non-heated samples. In this study, we demonstrated that heating samples increase sensitivity of Nijmegen-Bethesda assay, with no shift from negative to positive results in patients with no history of inhibitor. Furthermore, this procedure has an important role to patients undergoing an ITI protocol.1361280-128

Extended half-life recombinant factor VIII treatment of hemophilia A in Brazil: an expert consensus statement

Introduction: Treatment of hemophilia A in Brazil is offered to all patients at no cost. However, several unmet medical needs exist. Method: In this study, we applied the Delphi method to discuss with seven hemophilia A specialists the challenges that patients and the health system face regarding hemophilia A treatment and opportunities for improvement. Results: A consensus was obtained regarding the number of weekly infusions and patient adherence to treatment. The bleeding profile, unfavourable pharmacokinetics (PKs), low adherence and high daily activity were patient profiles that would benefit from using the extended half-life (EHL) recombinant factor VIII (rFVIII). The advantages of treatment with the EHL rFVIII were the lower number of infusions per week, which could increase patient adherence and decrease the risk of bleeds, due to a more constant plasma level, a lower value. Additionally, the EHL rFVIII could improve quality of life, especially in patients with high daily activity, such as adolescents and young adults. The panelists mentioned that EHL rFVIII, if available, could be offered first to the priority group (adolescents between 12 and 19 years old), followed by adults (20 to 64 years old) and elderly people (over 65 years old). Conclusion: In summary, the EHL rFVIII offers the optimal prophylaxis by decreasing the dose frequency, increasing the treatment adherence and improving the QoL, without compromising safety and efficacy

Intermittent low platelet counts hampering diagnosis of X-linked thrombocytopenia in children: report of two unrelated cases and a novel mutation in the gene coding for the Wiskott-Aldrich syndrome protein

Abstract Background Thrombocytopenia can occur in different circumstances during childhood and although immune thrombocytopenia is its most frequent cause, it is important to consider other conditions, especially when there is a persistent or recurrent low platelet count. We report two cases of intermittent thrombocytopenia, previously misdiagnosed as immune thrombocytopenia. Cases presentation Both cases described were boys who presented with an intermittent pattern of thrombocytopenia, with a persistently low mean platelet volume. In both patients, peripheral blood smear revealed small platelets and flow cytometry showed low expression of Wiskott-Aldrich syndrome protein (WASP) in leucocytes. Molecular analysis of the first case identified a mutation in exon 2 of the gene coding for WASP, leading to a p.Thr45Met amino acid change and confirming the diagnosis of X-linked thrombocytopenia. In the second case, a novel missense mutation in exon 2 of the gene coding for WASP was detected, which resulted in a p.Pro58Leu amino acid change. Conclusion These two rare presentations of thrombocytopenia highlight the importance of evaluating the peripheral blood smear in the presence of recurrent or persistent thrombocytopenia and show that failing to do so can lead to misdiagnoses. Since thrombocytopenia may be found in pediatric outpatient clinic, increased awareness among general pediatricians will help to improve the differential diagnosis of this condition