[Haemophilia treatment centres in Germany]. / Register von Hämophilie-Zentren in Deutschland.

UNLABELLED: An adequate number of qualified haemophilia centres is an essential requirement for effective and cost-efficient haemophilia care. During a reassessment of the delivery of haemophilia care in Germany a broad range of criteria relating to structure and quality of the centres were defined and a questionnaire was developed. RESULTS: Of 137 doctors who received the questionnaire, 113 (82%) replied. Based on data related to diagnostic and treatment services, together with voluntary information from PEI forms (Paul Ehrlich Institut, Germany), 72 haemophilia centres were established. Three levels of haemophilia care were defined by the Medical Advisory Council of the German Haemophilia Society. This is in accordance with criteria defined by European working parties. 17 haemophilia centres were designated CCC (Comprehensive Care Centre), 24 were designated HTC (Haemophilia Treatment Centre) and 31 smallest centres were allocated the status HTR (Haemophilia Treatment Regional). In comparison to the survey in 2007, there was only slight variance in the CCC centres (+ 2 centres/-1 centre). From the previous HTC centres, 7 have withdrawn from this treatment level: 4 maintain treatment on the lower level HTR, and 3 centres had ceased treatment. On the HTR level of treatment, 6 of 29 (21%) had ceased to offer treatment. 9 had been able to increase the number of patients and were designated HTC. 5404 patients with haemophilia and 3047 with the severe form of haemophilia were reported. 67% were treated in CCC, 25% in haemophilia treatment centres and 8% in the 31 smallest centres. 13 of the adult CCC are situated in the department of internal medicine and 4 in the section of transfusion medicine. CONCLUSIONS: The survey and analysis of the haemophilia treatment centres in Germany show that the delivery of haemophilia care through 17 CCC, 24 HCT and 31 HTR appears to be adequately structured. But it is noticeable and alarming, however, that on both HTC and HTR levels of treatment, 32% and 21%, respectively, have left their treatment level. 9 centres (12.5%) have finished working in haemophilia care in the last four years. On the strength of these results, endeavours to maintain haemophilia centres must be intensified. A high level of effective care can be guaranteed only through continued existence of the centres.

The impact of a specific aqua-training for adult haemophilic patients--results of the WATERCISE study (WAT-QoL).

Sport is increasingly recommended for haemophilic patients due to physical and psychological benefits. 'WATERCISE' is a specific aqua-training programme for haemophiliacs in which endurance, strength, coordination and mobility are trained. In the WAT-QoL study benefits and risks of regular WATERCISE training sessions were investigated in terms of health-related quality of life (HRQoL), physical functioning (PF), orthopaedic joint status (OJS), bleeding frequency and factor consumption. Patients in the WATERCISE group attended an aqua-training programme once a week for 1 h over 12 months, patients in the control group did not. Patients were matched for clinical and demographic data. Information on clinical data, orthopaedic status, PF (HEP-Test-Q) and HRQoL were collected in both groups at baseline and at follow-up (6 and 12 months). Twenty-eight adult severely affected haemophilic patients (WATERCISE group: 10 haemophilia A (HA), 3 haemophilia B (HB) patients; control group: 12 HA and 3 HB patients) were enrolled (aged 40.68 ± 12.7 years). Baseline data (body mass indices, OJS, sportive activities, HRQoL and PF) were well distributed between groups. After 12 months the WATERCISE group reported a significantly better PF (M(W) = 65.22, SD = 11.3; M(C) = 52.5, SD = 15.0), especially for endurance (P < 0.004). Although always differently reported by the patients within the WATERCISE group, HRQoL did not prove to be significantly different between groups. WATERCISE seems to have a positive effect on the PF of patients suffering from haemophilia. These study findings need to be further investigated in a larger study group.

Inhibitor-immunology-study. Evaluation of inhibitor development in haemophilia B.

UNLABELLED: The development of inhibitors in haemophilia B is one of the most important complications of replacement therapy, affecting mortality and morbidity. Inhibitor development is based on complex immunological factors, and to date, only little is known about its underlying mechanisms. Here, we present first results of the haemophilia B group of our Inhibitor-Immunology study. PATIENTS, METHODS: So far we have analysed 15 patients with haemophilia B. Four of them developed a high titre inhibitor; the remaining 11 had no inhibitor. We evaluated 9 SNPs in 8 genes (CD40, CTLA-4 , IL-1ß, IL-10, TLR2 , TLR4, TLR9, TNF-α). We compared the distribution of these alleles between inhibitor and non-inhibitor haemophilia B patients and between haemophilia B patients and a normal male control population. HLA typing was performed in all patients. Results, discussion: There appears to be a trend towards a skewed distribution of TLR 9, IL-10 and CTLA4 alleles in haemophilia B patients. Due to the limited number these differences are, however, not statistically significant. The t-test of all patients with inhibitor versus without inhibitor was significant for HLA-A*03 and DPB1*0401 and borderline for DRB1*0201.

Inhibitor-Immunology-Study. Different HLA-types seem to be involved in the inhibitor development in haemophilia A.

UNLABELLED: The development of inhibitors is one of the most important complications of replacement therapy in haemophilia, affecting mortality and morbidity. Inhibitor development is based on complex immunological factors. Cytokines and their receptors, T-cell receptors, and the Major Histocompatibility Complex may play important roles in the development of inhibitors. Earlier studies showed non significant associations between HLA class and inhibitor development. Later studies found an increased risk of inhibitor development if there was a combination between certain factor VIII mutations and HLA antigens. We performed HLA typing in 50 patients with haemophilia A in an effort to find associations with inhibitor development. RESULTS: 25 patients had developed an inhibitor (11 low titre, 14 high titre), and 25 never had. In logistic regression analysis, HLA-A 34, DRB1 0405, DRB1 1301 seemed to be involved in inhibitor development and HLA-A 30, B 13, B15, B 57, Cw 12, DQB1 0303, DPB1 0201 protection against inhibitor development. In our patients, the HLA-associations with inhibitor development were different from those in previous publications.

[Haemostatic aspects in clinical oncology]. / Hämostaseologische Aspekte in der Onkologie.

The clinical link between cancer and thrombosis has been recognized by Armand Trousseau in 1865. It has now become clear that clotting activation in malignancy not only plays an important role in the evolution of venous thromboembolism (VTE) or systemic coagulation disorders such as disseminated intravascular coagulation, but that multiple components of the haemostatic and fibrinolytic systems are directly involved in tumour progression. In particular, tissue factor (TF) appears to be involved in several pathways relevant to cancer growth and metastasis. Increasing evidence emerges that haemostatic perturbances in cancer patients are, at least in part, controlled by defined genetic events in molecular tumourigenesis including activating and inactivating mutations of oncogenes and tumour suppressor genes, respectively. Long-term therapy with low-molecular-weight heparin (LMWH) is considered as standard treatment for cancer-associated VTE. However, several experimental studies and clinical trials suggest that LMWH may also be beneficial as an adjunct in the treatment of patients with malignant disease. This article provides an overview on the significance, pathogenesis and treatment of cancer-related clotting disorders as well as on the cellular and molecular mechanisms, by which haemostatic components such as TF, platelets and fibrin(ogen) drive tumour progression.

Efficacy, safety and tolerability of recombinant factor VIII (REFACTO) in patients with haemophilia A: interim data from a postmarketing surveillance study in Germany and Austria.

An open-label, multicentre, postmarketing surveillance study conducted in Germany and Austria with recombinant factor VIII (REFACTO) has enrolled 217 patients (mean age 26.3 years) from 38 haemophilia centres during the first 4.8 years. Most patients (188/217; 86.6%) had severe to moderately severe haemophilia A, of whom 153 completed sufficient diary information for the main efficacy analysis. These 153 patients experienced a median of 6.6 (interquartile range 1.4-18.6) bleeding episodes per year. Patients treated with prophylaxis experienced a median of 4.4 (1.1-9.3) bleeds per year, while patients treated on-demand experienced a median of 22.8 (11.3-29.0) bleeds per year. Overall, most physicians (41/43 [95.3%]) were 'very satisfied' or 'satisfied' with the efficacy of REFACTO in the treatment of bleeding episodes. A total of 137 non-serious adverse events have been reported in 52/217 patients (24.0%) to date. In addition, 129 serious adverse events in 87 patients (40%) were reported, including 41 cases of 'less than expected therapeutic effect' (LETE). Of these, 39 LETE cases were reported in one centre; however, patients in this centre experienced considerably fewer bleeding episodes per year than patients outside this centre. Overall, six patients (2.8%) have developed de novo inhibitors, three of which were considered high titre. Four of these patients were at high risk (0-50 exposure days [ED]) of inhibitor formation, one was at intermediate risk (51-100 ED) and one was at low risk (>100 ED). These results emphasize the benefit of postmarketing surveillance and, overall, this study confirms the efficacy, safety and tolerability of REFACTO in the treatment of patients with haemophilia A.

Experimental metastasis and primary tumor growth in mice with hemophilia A.

During experimental lung metastasis, tumor cells adhere to the pulmonary microvasculature and activate coagulation via surface-expressed tissue factor (TF), leading to local fibrin deposition and platelet aggregation. While interventional studies have demonstrated great efficacy of anticoagulants and antiplatelet agents in inhibiting metastasis, no information is available on how tumor biology may be affected by congenital bleeding disorders such as hemophilia A. We therefore used a syngeneic model to study experimental metastasis and primary tumor growth in factor VIII (FVIII)-deficient mice. By conventional reverse transcription-polymerase chain reaction, flow cytometry, and one-stage clotting assays, we demonstrated constitutive expression of TF mRNA, antigen, and procoagulant activity in the murine B16F10 melanoma cell line. In hemophilic mice, B16F10 lung metastasis was significantly (P < 0.001) enhanced by a single dose of human FVIII (100 U kg(-1)), suggesting that FVIII played a critical role during the early blood-borne phase of the metastatic cascade. In contrast, lung seeding was significantly (P < 0.05) reduced by lepirudin, a direct thrombin inhibitor, suggesting that thrombin generation contributed to pulmonary metastasis even in the absence of FVIII. Consistent with this finding, intravenous injection of B16F10 cell-evoked laboratory changes of a hemolytic thrombotic microangiopathy and consumptive coagulopathy in both hemophilic and non-hemophilic mice. Subcutaneous implantation of B16F10 cells into mice with hemophilia A gave rise to primary tumors in an exponential growth pattern similar to that observed in non-hemophilic mice. Although TF expression by B16F10 cells may promote thrombin-dependent metastasis in mice with hemophilia A, amplification of coagulation by host FVIII appears to be necessary for maximum lung seeding.

Non-overt disseminated intravascular coagulation in patients during treatment with antithymocyte globulin for unrelated allogeneic hematopoietic stem cell transplantation.

We assessed the effect of rabbit antithymocyte globulin manufactured by Fresenius (ATG-F) on the hemostatic system in patients (n=12) with various hematological malignancies undergoing hematopoietic stem cell transplantation (HSCT) from HLA-matched unrelated donors. For this purpose, we monitored different parameters of coagulation before, during and after the administration of ATG-F. As a control group, we recruited patients (n=10) undergoing HSCT from their HLA-identical siblings who did not receive ATG-F as part of their preparative regimens. At 24 and 48 h after ATG-F treatment had been initiated, we found a temporary rise in D-Dimer, tissue factor, soluble thrombomodulin and thrombin-antithrombin III complex levels and a significant decrease of platelet counts in patients treated with ATG-F as compared to the control group. No differences between the two groups could be detected with regard to global coagulation tests as well as the incidence of bleeding manifestations, thromboembolic complications or the development of vascular-occlusive-disease of the liver. This temporary state of a stressed but compensated coagulation system under ATG-F therapy can be addressed as nonovert disseminated intravascular coagulation (DIC). The effect was independent from the different conditioning regimens and eased off after cessation of ATG-F. We conclude that ATG-F can induce nonovert DIC in patients receiving antithymocyte globulin as part of their conditioning regimen for HSCT.

Exacerbation of antiphospholipid antibody syndrome after treatment of localized cancer: a report of two cases.

Patients with malignancy often present with a variety of coagulation abnormalities which may ultimately lead to recurrent arterial and venous thromboses. Recently the presence of antiphospholipid antibodies in cancer patients has been proposed as one of the potential mechanisms promoting hypercoagulability. Here we report two consecutive patients with localized tumors, one suffering from breast cancer and another presenting with colorectal cancer, who experienced dramatic exacerbation of the antiphospholipid antibody syndrome (APAS) within 4 weeks after surgery. In the first patient who had also received one course of adjuvant chemotherapy, major ischemic stroke and recurrent venous thromboembolism were paralleled by the development of ulcerative livedoid vasculitis and pancytopenia, constituting the diagnosis of systemic lupus erythematosus with secondary APAS. In the second patient, progressive thrombotic occlusion of the superior and inferior vena cava was associated with bilateral pulmonary embolism, acute renal failure, and disabling soft tissue edema. Although not fulfilling the classic criteria of "catastrophic" APAS, the clinical features were life threatening and appeared to be refractory to oral anticoagulation with phenprocoumon. In addition, a diagnosis of Trousseau's syndrome was unlikely due to missing evidence of gross metastatic disease. Besides a suggested treatment strategy comprising high doses of low-molecular-weight heparin, potential pathogenic mechanisms are discussed in consideration of a recently proposed "thrombotic storm," which may cause multiple thromboses after an initial provocation in patients with known hypercoagulability.

Platelet function testing in apheresis products: flow cytometric, resonance thrombographic (RTG) and rotational thrombelastographic (roTEG) analyses.

During storage of platelet concentrates, quality control of the units is mandatory. This includes the important testing of the hemostatic function of platelets. So far, mostly platelet aggregation analyses have been performed. In this study, new approaches were tested to evaluate the applicability of modern techniques for quality monitoring. Plateletpheresis was performed with two different cell separators (AMICUS cell separator, Fenwal, Baxter Healthcare, Deerfield, USA; COBE Spectra, COBE BCT, Lakewood, USA). In each procedure split products (n = 22) were prepared and stored for 1-2 days (n = 22) or 3 5 days (n = 22). Platelet hemostatic capacity was tested by applying flow cytometry. platelet aggregation (platelet-rich-plasma [PRP]+agonist), resonance thrombography (RTG; PRP, no agonist) and rotational thrombelastography (roTEG; PRP+agonist). Flow cytometric analyses did not reveal significant changes in structural (CD41a. CD42b) or activation-dependent antigens (CD62p, CD63, LIBS, RIBS). Also, differences in the data from the flow cytometric reactivity tests were not significant between the two groups. In platelet aggregation assays, shape change (p = 0.8), maximum aggregation (p = 0.4), and maximum gradient (p = 0.8) did not show significant differences between the two groups. In the RTG test, differences between r-time (reaction time; p = 0.4), and f-time (clot formation time [fibrin influence]; p = 0.3), and in roTEG r-time (coagulation time; p = 0.1) and k-time (clot formation time; p = 1.0) were not significant. P-time (clot formation time [platelet influence]) and M (maximum amplitude) in RTG, and k-time and MA (maximum amplitude) in roTEG showed a slight decrease in platelet function (p < or = 0.05). We conclude that platelet function is well maintained during storage. This is reflected by the results of immunological and platelet function assays. Rotational thrombelastography (in the case of PRP) and especially resonance thrombography represent promising methods for quality control of platelet concentrates and rapidly provide information about the status of platelet function and the whole clotting process.

[Complicated antiphospholid antibody syndrome]. / Kompliziertes Antiphospholipidantikörper-Syndrom - Eine interdisziplinäre Herausforderung -

HISTORY AND CLINICAL FINDINGS: A 51-year-old female patient suffered from recurrent ischemic strokes and venous thromboembolism although treated with ASS and phenprocoumon, which mainly occurred after diagnosis and treatment of an invasive-ductal mamma carcinoma. The severely ill patient presented with right-sided hemiparesis and dysarthria, a swollen leg, a painful necrotic-ulcerative lesion at the left-lateral ankle and a systolic heart murmur. INVESTIGATIONS: Laboratory data revealed a haemoglobin of 8,4 g/dl, a leucocyte count of 3,1 x 10 (9)/l and a platelet count of 87 x 10 (9)/l. C-reactive protein, ESR and plasma fibrinogen were markedly increased. Levels of antinuclear, IgG-anticardiolipin and anti-doublestranded-DNA antibodies were excessively elevated. A test for lupus anticoagulant was strongly positive. Sonographic examinations showed deep vein thrombosis and significant mitral valve regurgitation. Suspected pulmonary embolism was demonstrated by CT scan. We diagnosed systemic lupus erythematosus with secondary antiphospholipid antibody syndrome (APAS). TREATMENT AND COURSE: Phenprocoumon was stopped and full-dose anticoagulation with low-molecular-weight heparin initiated. Additional immunosuppressive therapy consisted of cyclophosphamide, azathioprin and prednisone resulting in prevention of further thromboembolism and significant improvement of clinical symptoms. The observed severe interference of LA with the prothrombin time after cessation of phenprocoumon (INR 3,6; FII activity 81 %) suggested that the effect of oral anticoagulation had been overestimated in the past. CONCLUSION: APAS may present as an acute and life-threatening disorder. In this case interdisciplinary co-operation and a highly individualised treatment strategy are mandatory.

Enhanced platelet aggregation with TRAP-6 and collagen in platelet aggregometry in patients with venous thromboembolism.

The role of platelet hyperaggregability as a possible risk factor for venous thromboembolism is not well defined. Some authors described enhanced maximal platelet aggregation in platelet aggregometry as a contributing factor for arterial and venous thrombosis. This syndrome has been termed "sticky-platelet syndrome" (SPS). The diagnosis of SPS is based on the demonstration of platelet hyperaggregability in aggregometry after stimulation with epinephrine (EPI) and/or adenosine diphosphate (ADP). We investigated platelet hyperaggregability in platelet-rich plasma (PRP) of patients (n = 34) with unexplained venous thromboembolism in comparison to healthy individuals (n = 53). For analysis, platelet aggregometry was performed and the influence of epinephrine, adenosine diphosphate, collagen (Coll) and thrombin receptor-activated peptide (TRAP-6) as agonist were determined. Compared to the control group, patients with venous thromboembolism showed an enhanced maximal platelet aggregation with low concentrations of TRAP-6 (2 microM) and collagen (0.05 microM). In contrast, we could not detect an increased platelet aggregation with EPI or ADP. Our results indicate that platelet hyperaggregability may represent an independent risk factor in patients with otherwise unexplained venous thromboembolism. In our study, low concentrations of TRAP-6 and collagen are superior to EPI and ADP to define platelet hyperreactivity in platelet aggregometry.

[Thrombophilia factors as inducers of retinal vascular occlusion]. / Thrombophiliefaktoren als Auslöser retinaler Gefässverschlüsse.

PURPOSE: Thrombophilic abnormalities and defects in the anticoagulant system, such as protein C or protein S deficiency, activated protein C resistance and factor V Leiden mutation, may produce retinal vascular occlusions. PATIENTS: Blood samples from 66 consecutive retinal vascular occlusion patients were obtained and analysed for protein C resistance and fibrinolysis activity. Other thrombophilic and standard laboratory coagulant tests were also carried out. RESULTS: An increased activity of factor VIII was found in 72% of the collective. Furthermore, 24% of all patients and 32% of patients younger than 45 years old were resistant to activated protein C. Nevertheless only one patient showed a homozygous factor V Leiden mutation. CONCLUSION: Thrombophilic activity in cases of protein C resistance or factor V Leiden mutation may result in severe thrombotic manifestations in ocular vessels. Compared to the elderly, younger people showed a higher activated protein C resistance which seems be one of the most common causes for retinal vascular occlusion in this age group.

[Perioperative treatment of a patient with hereditary angioedema (HAE) in a case of a young patient with osteosynthesis from a femoral fracture]. / Die perioperative Behandlung von Patienten mit hereditärem Angioödem (HAE) am Beispiel eines Jugendlichen mit Osteosynthese einer Oberschenkelfraktur.

The following case report describes hereditary angioedema (HAE) in a juvenile male patient presenting with femoral fracture. The clinical characteristics, pathophysiological changes, diagnostics and management of anaesthesia for patients with hereditary angioedema will be discussed. Hereditary angioedema (HAE) is a rare autosomal dominant disorder, which is caused by congenital deficiency of functional C1-inhibitor (C1-INH). Patients are suffering from episodic and painless edema of the skin (face and limbs) and mucous membranes of the respiratory and gastrointestinal tracts (the latter causing abdominal cramps due to edema of the intestine). Life-threatening airway obstruction may occur when patients develop laryngeal edema. It is important to differentiate HAE from the more frequent allergic angioedema because of differences in the pharmacological treatment of acute attacks of HAE. C1-INH-concentrate is effective in both treatment of acute attacks and prevention of edema, especially in children, juveniles and young women.

Biocompatibility of a new cell separator studied by flow cytometry: analyses of platelet antigens during apheresis and storage.

BACKGROUND: Alterations of platelet antigens are known to occur during cytapheresis and storage. These changes have been shown to be dependent on the biomaterials, techniques, and devices used. In this study, the influence of a new cell separator (AMICUS) and storage container (PL-2410) on platelet glycoproteins was analyzed. STUDY DESIGN AND METHODS: During plateletpheresis and storage, the levels of platelet glycoproteins and binding of fibrinogen were determined by flow cytometry. RESULTS: During apheresis, mean channel fluorescence intensity of CD41 a did not change significantly (p = 0.06). A small increase was evident in CD42b mean channel fluorescence intensity, which rose from a baseline level of 178.6 +/- 68.3 to 231.5 +/- 97.9 at the end of the procedure (p<0.05); in CD62p-positive platelets, which increased from 2.0 +/- 0.9 percent to 9.9 +/- 3.9 percent (p<0.05); in CD63-positive platelets, which increased from 1.7 +/- 0.7 percent to 7.9 +/- 2.6 percent (p<0.05); and in the binding of fibrinogen, which increased from 1.9 +/- 0.8 percent positive platelets to 10.5 +/- 2.6 percent (p<0.05). During storage, the mean channel fluorescence intensity of CD41a and CD42b, the percentage of CD62p- and CD63-positive platelets, and the binding of fibrinogen to platelets showed no significant change. CONCLUSION: These studies show that alterations in platelet antigens and platelet activation occur to a small degree during apheresis and storage. These findings demonstrate generally good biocompatibility of this new cell separator.

[Intraoperative coagulation activity--a defined group of trauma surgery patients]. / Intraoperative Gerinnungsaktivierung--Untersuchungen an einem definierten Patientengut der Unfallchirurgie.

Analyses of blood coagulation in a defined group of patients before, during, and after trauma-surgery confirms an intraoperative trigger-mechanism, that causes postoperative thromboembolic complications. They also proof the correlation between extent of tissue-lesion and extent of triggering, this was previously presumed from the postoperative incidence of thromboembolic complications. Apart from the usual blood coagulation tests the following parameters where analysed: Factor VIII: C, Ristocetin-Co-factor, Factor Xa, AT III, TAT, Reptilase-time, tPA, D-dimers, and FPA. Simultaneously, it was shown, that a preoperative prophylaxis of thrombosis can prevent an intraoperative increase of Factor Xa, that plays a key role in postoperative thromboembolic complication. The increased intraoperative turnover of coagulation factors, which is necessary for physiologic blood coagulation, is not prevented.