[Therapy of inherited diseases of platelet function. Interdisciplinary S2K guideline of the Permanent Paediatric Committee of the Society of Thrombosis and Haemostasis Research (GTH e. V.)]. / Therapie hereditärer Thrombozytopathien. Interdisziplinäre S2K-Leitlinie der Ständigen Kommission Pädiatrie der Gesellschaft für Thrombose- und Hämostaseforschung e. V.

Inherited disorders of platelet function are a heterogeneous group. For optimal prevention and management of bleeding, classification and diagnosis of the underlying defect are highly recommended. An interdisciplinary guideline for a diagnostic approach has been published (AWMF # 086-003 S2K; Hämostaseologie 2014; 34: 201-212). Underlying platelet disorder, platelet count, age and clinical situation modify treatment. Exclusive transfusion of platelet concentrates may be inappropriate as potentially adverse effects can outweigh its benefit. A stepwise and individually adjusted approach for restitution and maintenance of haemostasis is recommended. Administration of antifibrinolytics is generally endorsed, but is of particular use in Quebec disease. Restricted to older children, desmopressin is favourable in storage pool disease and unclassified platelet disorders. Although licensed only for patients with Glanzmann thrombasthenia and alloantibodies, in clinical practice rFVIIa is widely used in inherited platelet disorders with severe bleeding tendency. This guideline aims at presenting the best available advice for the management of patients with inherited platelet function disorders.

[Diagnosis of inherited diseases of platelet function. Interdisciplinary S2K guideline of the Permanent Paediatric Committee of the Society of Thrombosis and Haemostasis Research (GTH e. V.)]. / Diagnose angeborener Störungen der Thrombozytenfunktion. Interdisziplinäre S2K-Leitlinie der Ständigen Kommission Pädiatrie der Gesellschaft für Thrombose- und Hämostaseforschung e. V.

Congenital disorders of platelet function are a heterogeneous group of disorders that are often not detected until bleeding occurs. In clinical settings only a few methods have proven to be useful for identification and classification of inherited platelet disorders. For a rational diagnostic approach, a stepwise algorithm is recommended. Patient history and clinical investigation are mandatory. Von Willebrand disease and other coagulation disorders should always be ruled out prior to specific platelet testing. Platelet count, size, volume (MPV) and morphology may guide further investigations. The PFA-100® CT is suited for screening for severe platelet defects. Platelet aggregometry allows assessment of multiple aspects of platelet function. Flow cytometry enables diagnosis of thrombasthenia Glanzmann, Bernard-Soulier syndrome and storage pool defects. Molecular genetics may confirm a putative diagnosis or pave the way for identifying new defects. We present an unabridged version of the interdisciplinary guideline.

[Inhibitor development against FVIII in previously treated patients with haemophilia A. A retrospective data collection]. / Inhibitorentwicklung bei FVIII-Präparaten in vorbehandelten Patienten mit Hämophilie A. Eine retrospektive Datenerhebung.

UNLABELLED: In a retrospective study 118 haemophilia A patients from two treatment centres (Berlin and Muenster) were evaluated with respect to safety, i. e. inhibitor development, and efficacy of bleeding control of recombinant FVIII products. During approx. 57 thousand injections with more than 87 million I.U. rFVIII no de novo inhibitor was observed in patients previously treated with pFVIII after switch to a recombinant product. A total of 75 thousand injections with more than 111 million I.U. FVIII had been applied during the investigation period of 14 years. Before as well as after switch of the product type bleeding episodes could be controlled with one to two injections per bleed. CONCLUSION: According to our results equal safety and efficacy of plasma derived and recombinant FVIII products can be assumed.

[Haemophilia A and haemophilia B. Are there relevant clinical differences?]. / Hämophilie A und Hämophilie B. Gibt es relevante klinische Unterschiede?

UNLABELLED: Haemophilia B (HB) was described in 1952 as a single disease for the first time. In comparison to haemophilia A (HA) the bleeding tendency seemed to be less severe. The aim of this study was to investigate this hypothesis in all patients with HA and HB treated in the haemophilia care center of the Vivantes Klinikum. PATIENTS, METHODS: All patients with severe HA and HB treated at the haemophilia care center were included. We evaluated the regimen of replacement therapy and factor concentrate consumption within the last 5 years (1/2004 to 12/2008). Intracerebral bleeds were analysed over the whole life span of the included patients. RESULTS: 111/181 patients with HA had the severe form and 12/34 patients severe HB. 4/12 patients with severe HB had a history of intracerebral bleeding in comparison to 5/111 patients with severe HA. 2/8 adult patients with severe HB used a prophylactic treatment with factor concentrates (mean consumption 1289 IU factor IX/kg BW/year) in contrast to 60/95 adult patients with HA (mean consumption 2109 IU factor VIII /kg BW/year). CONCLUSION: The data suggest a milder bleeding type of patients with severe HB in comparison to patients with severe HA but may be patients with severe HB are at higher risk for intracerebral bleeds.

Bridging with enoxaparin using a half-therapeutic dose regimen: safety and efficacy.

BACKGROUND: Low molecular weight heparin is widely used during the interruption of long-term oral anticoagulation in patients undergoing surgery. The optimal dose is still a matter of debate. The 8th ACCP Guidelines primarily recommend therapeutic-dose or low-dose low molecular weight heparin after stratification of the thromboembolic risk. We investigated the efficacy and safety of a standardized bridging therapy with enoxaparin in a half-therapeutic dose in patients with a target INR of 2,0 to 3,0. PATIENTS AND METHODS: In our prospective registry we studied 198 consecutive patients receiving oral anticoagulant therapy with phenprocoumon and a planned surgery. Phenprocoumon was stopped 7 days before surgery and after reaching an INR less than 2,0 all patients received enoxaparin in a half-therapeutic dose (1 x 1 mg / kg body weight (bw)/day) until the day before surgery. Enoxaparin was continued with the same dose split into 2 x 0,5 mg / kg bw / day after the procedure. Phenprocoumon was resumed within day 1 to 14 after surgery depending on the bleeding risk as determined by the surgeon. All patients were followed up for 28 days after surgery. RESULTS: Major surgery was performed in 148 patients (75 %). 175 patients (88 % of the total) had an intermediate thromboembolic risk. On average, enoxaparin was administered for 19,5 days. One patient (0,5 %) experienced arterial thrombosis after surgery, and one patient (0,5 %) required a second surgical intervention due to severe bleeding. CONCLUSIONS: In patients receiving oral anticoagulant therapy with a target INR of 2,0-3,0 and at an intermediate risk of thromboembolic events who require interruption of oral anticoagulant therapy a half therapeutic dose of enoxaparin seems to be safe and effective for bridging.

Successful angiographic embolization of recurrent elbow and knee joint bleeds in seven patients with severe haemophilia.

In haemophilic joints with high-grade arthropathy, bleeds occur that do not respond to replacement therapy of the deficient coagulation factor. The reason may be pathologically reactive angiogenesis in chronic synovitis. Seven patients with severe haemophilia A or haemophilia B experienced recurrent massive bleeds of one elbow joint or knee joint in the absence of trauma. After initial application of factor VIII or IX (fVIII/fIX; 50 IU kg(-1) bodyweight), there was only slow and never complete relief of symptoms. Despite intensive secondary prophylaxis maintaining the plasma level of factor concentrate at minimum 50%, new massive bleeds at the same location occurred. Vascular bleeding was suspected. Angiography of the arteries was performed via the femoral artery. Vessels identified as potential bleeding sources were embolized with embolization fluid (ONYX) in eight joints (six elbow and two knee joints). Under low-dose prophylactic treatment (15 IU fVIII or fIX per kg bodyweight for three times per week), no recurrent severe bleed unresponsive to coagulation factor replacement occurred after a mean observation time of 16 months after embolization. The consumption of factor concentrate decreased to one-third of the amount consumed before embolization. In conclusion, angiographic embolization with a non-adhesive liquid embolic agent might be considered as a promising therapeutic and coagulation factor saving option in joint bleeds not responding to replacement of coagulation factor to normal levels.

Interleukin-8 in Hodgkin's disease. Preferential expression by reactive cells and association with neutrophil density.

Hodgkin's disease (HD) shows rare neoplastic Hodgkin and Reed-Sternberg cells embedded in an abundant reactive infiltrate containing, among other cell types, neutrophilic granulocytes. Interleukin (IL)-8 is chemotactic for neutrophils. The expression of IL-8 was tested by in situ hybridization with 35S-labeled IL-8-specific RNA probes on 38 cases of HD. Reactive lesions, non-Hodgkin's lymphomas of B and T phenotype, and Langerhans cell histiocytosis served as controls. IL-8 expression was observed in Hodgkin and Reed-Sternberg cells in 3 of 33 cases of classical HD and in reactive cells in 20 of 33 HD cases as evidenced by combined isotopic in situ hybridization and immunohistology for the demonstration of cell-type-characteristic antigens or enzyme histochemistry for chloroacetate esterase. IL-8-positive cells were more numerous in cases of nodular sclerosing HD as compared with the mixed cellularity histotype (P = 0.01). The number of IL-8-positive cells and the density of neutrophils were positively correlated (P < 0. 01). In 5 cases of lymphocyte-predominant HD, IL-8 expression was not displayed. Non-Hodgkin's lymphoma cases contained IL-8 transcripts only in 1 of 23 cases in sparse reactive cells. In 4 of 7 cases of Langerhans cell histiocytosis, IL-8-specific signals were displayed in S100-negative cells. In conclusion, IL-8 expression in HD is largely confined to reactive cells and associated with infiltration by neutrophils. Elaboration of other cytokines by Hodgkin and Reed-Sternberg cells and reactive cells may explain the frequent expression of this cytokine in HD, particularly in the nodular sclerosing type.

Frequent expression of IL-7 gene transcripts in tumor cells of classical Hodgkin's disease.

Interleukin-7 (IL-7) is a pleiotropic cytokine acting mainly on cells of the hematolymphoid system. In vitro studies have shown enhanced proliferation of acute lymphoblastic leukemia cells in response to IL-7. On the other hand, tumor cell lines transfected with a functioning IL-7 gene and subsequently transplanted into mice resulted in a prominent inflammatory infiltrate and reduced tumorigeneicity. These data suggest an important role of this cytokine in the pathophysiology of lymphoid neoplasms. Because little is known about the in vivo expression of this cytokine in various neoplastic and nonneoplastic lesions of the lymphoid system, we examined frozen and paraffin-embedded tissue samples of normal, reactive, and malignant lymphoid lesions using in situ hybridization with a 35S-labeled RNA probe specific for IL-7. Tumor cells of nodular sclerosing and mixed cellularity type of Hodgkin's disease displayed IL-7-specific signals in 24 of 31 cases. Among reactive lesions, only thymic tissue showed labeling within both cortex and medulla (4 of 7 cases), whereas in tonsils clear-cut IL-7-specific signals could not be found. Tissues infiltrated by B-type chronic lymphocytic leukemia or T- or B-type lymphoblastic lymphoma showed cytokine-specific signals in only one case of lymphoblastic lymphoma in rare reactive cells. In conjunction with the finding of elevated levels of IL-7 in the serum of many patients with Hodgkin's disease, our data suggest an important role of this cytokine in the pathogenesis of Hodgkin's disease. The prominent reactive infiltrate observed in most cases of Hodgkin's disease could be a consequence of elevated local levels of this cytokine as similar infiltrates are also observed in tumors in mice resulting from injection of tumor cell lines transfected with a functioning IL-7 gene.