Management of Urgent Bleeding in Patients with Hemophilia A: Focus on the Use of Emicizumab.

Management of patients with hemophilia A (HA) requires the knowledge and experience of specialized health care professionals. However, these patients may need to be attended in emergencies, outside the referral hospital, where health care professionals do not know about hemophilia and/or new innovative treatments. This study aimed to develop a simple and practical algorithm that could be used in emergency situations by nonspecialized treaters in HA and bleeding with or without factor VIII (FVIII) inhibitors under emicizumab prophylaxis. A group of experts agreed on a simple algorithm, easy to operate, adapted from previous international guidelines, and based on their clinical experience. The proposed algorithm starts with identifying the patient, confirming the diagnosis of HA, prophylaxis with emicizumab, and/or use of other treatments. After stabilizing the patient and stratifying the bleeding risk, the patient is managed according to the presence/absence of FVIII inhibitors. Patients without FVIII inhibitors should receive FVIII concentrate. Dose and follow-up depend on bleeding localization and severity. Patients with FVIII inhibitors should preferably receive recombinant activated factor VII as bypass agent. A basic coagulation assay, FVIII assessment, and FVIII inhibitors detection assays are necessary in an emergency. However, these tests should be interpreted with caution and appropriately chosen, as emicizumab may alter the results. The management of patients with HA is challenging in emergency situations, especially if they are treated with new agents. Nonspecialized in coagulopathies health care professionals have limited understanding of the disease, highlighting the need for an algorithm to assist them in making informed decisions.

Origin of the frameshift codons 41/42 (-TCTT) mutation in the first cases described in the Spanish population.

Thalassemias are hereditary anemias. In beta-thalassemia (beta-thal), beta-globin synthesis is either deficient or absent. A high incidence of beta-thal is found in populations of Mediterranean and African origin. Smaller, but significant concentrations of beta-thal are present throughout the Middle East, India, Pakistan and China, while sporadic cases have been reported in most ethnic groups. Over 200 beta-thal mutations have been described so far. But each population group displays its own mutations. In Spain, as in other countries of the Mediterranean region, the most often seen mutations are codon 39 (C > T); IVS-I-1 (G > A); IVS-I-6 (T > C) and IVS-I-110 (G > A). However, a large number of rarer alleles have been observed both in Spain and other populations. The frameshift codons (FSC) 41/CD42 (-TCTT) mutation is a rather common allele in individuals of Chinese origin, but rare in the Mediterranean region, although, it has been recorded in East Asian populations. We describe the first eight Spanish patients displaying the FSC 41/42 mutation. This mutation was initially detected with a real-time polymerase chain reaction (PCR) method on a LightCycle, using a probe designed to detect mutations in codons 37 and 39, and subsequently specifically characterized by automatic sequencing. The haplotype found in our patients suggested that this mutation has not arisen independently in our population but must be taken into account when identifying most beta-thal mutations.

Paraneoplastic hyperamylasaemia in association with multiple myeloma.

Marked hyperamylasaemia associated with an amylase-producing multiple myeloma appears to be a fairly unusual phenomenon. The present report describes a fatal case of multiple myeloma associated with paraneoplastic hyperamylasaemia without evidence of pancreatic or salivary gland involvement. Serum and urine amylase levels paralleled the myeloma response to chemotherapy and disease progression. The importance of paraneoplastic hyperamylasaemia as a useful myeloma marker to monitor disease progression and treatment response is emphasized. Conventional chemotherapy at diagnosis and salvage treatment with bortezomib at relapse failed to achieve a long-term response and to decrease the serum amylase to a normal level.