Diagnosis Of Hemophilia Research Articles

Simplifying the diagnosis of hemophilia

Simplifying the diagnosis of hemophilia

HEMOPHILIA C: A RARE CASE REPORT IN WOMAN

Factor XI deficiency (Hemophilia C) is a rare bleeding disorder that was first described in 1953 by Rosenthal et al. in patients who experienced severe bleeding after dental extractions. The estimated prevalence is about 1 in 1 million with increased prevalence among Ashkenazi Jews (8-9%). Patients are generally classified into three categories based on the factor XI levels: severe (<15-20% of normal), intermediate (20- 40%) and mild (>40%). Distinct from hemophilia A and B, FXI deficiency usually presents as post-traumatic bleeding and rarely manifests as spontaneous bleeding. To report a case of severe Hemophilia C in a 70-year-old woman. A 70-year-old woman was referred to Fundação Hemominas Juiz de Fora, Brazil due to gingivorrhagia and recurrent epistaxis. She reports having already received blood transfusions due to massive bleeding after surgeries, including cholecystectomy, cesarean section and hysterectomy. The patient is the sixth daughter of a seven children family. Her mother, three siblings and one nephew also have coagulation disorders, unknown Jewish descendancy. The laboratory study showed normal whole blood count, screening tests for coagulation disorders showed normal platelet count and an increase of activated partial thromboplastin time (aTTP). A plasma dosage of coagulation factors was performed, with results shown in Table 1. With the reduction of factor XI activity levels (3.59%), the increase of aTTP and the normality of other tests, the diagnosis of Hemophilia C was established. A family study was performed with heredogram, shown in Figure 1. Hemophilia C is a rare bleeding disorder with a wide variability in clinical presentation. Adequate diagnosis is essential to minimize severe hemorrhagic conditions, specially in surgical procedures. Family screening is recommended if a member has FXI deficiency and prevalence may vary in Brazil due to the wide miscegenation.

THE STUDY OF INFLUENCE OF PLATELET DYSFUNCTION ON CLINICAL PHENOTYPE OF HEMOPHILIA

Background: Hemophilia is an X-linked heritable coagulopathy with an overall prevalence of approximately 1 in 10,000 individuals. Hemophilias are rare X linked hereditary bleeding disorders. Platelets may be among the determinants of variability in bleeding phenotype. Objective: To evaluate the platelet function tests in patients with hemophilia, and to explore the influence of platelet dysfunction on hemophilia bleeding score. Patients and Methods: The study was conducted on 40 hemophilic patients and 20 normal persons as a control in outpatient clinics at Kafr El-Sheikh Governorate Hospitals and Al-Azhar University Hospitals (Al-Hussein and Sayed Galal) to evaluate the platelet function tests in patients with hemophilia, and to explore the influence of platelet dysfunction on hemophilia bleeding score. Results: The majority of cases (35 patients 87.5%) were type A and (5 patients 12.5%) were type B. As regard to hemophilia scoring system (HSS), 3 patients (7.5%) were type 1, 19 patients (47.5%) were type 2 and 18 patients (45%) were type 3. Bleeding from the knee occurred in the majority of patients (77.5%), from the elbow occurred in 32.5%, from the ankle occurred in 5%, from the vagina occurred in 15% and from the nose and the gum occurred in 7.5%. Platelets and maual platelet count showed insignificant difference between both groups. Platelets aggregation tests (ADP) test, collagen and restocetin agonists test) were significantly lower in cases group than control group. Prothrombin time (PT), international normalized ratio (INR), bleeding time (BT) showed insignificant differences between both group. On the other hands, activated partial thromboplastin time (APTT) significantly prolonged cases group than control group. No hemophilia C cases were detected in our study. Conclusion: There was a statistical significant relationship between bleeding phenotype in hemophilia B and platelet function. Diagnosis of hemophilia was confirmed by factor VIII assay for hemophilia A and factor IX assay for hemophilia B.

Pseudotumor involving the distal femur – the rare presentation.

Pseudotumor is the rare presentation of hemophilia, and is the sign of severe disease. We present a case of 16 years old boy with no known comorbid who presented with pain and swelling around the right distal thigh for one month, his physical examination, laboratory investigation and imaging were suspicious of any malignant pathology. Biopsy was performed and specimen was sent for histopathology, that turned to be clotted blood with no atypical or malignant cells. On the basis of above findings provisional diagnosis of hemophilia was made serum levels of factor VIII were sent and that turned out to be 2.2%. Factor VIII concentrates was administered, swelling around the knee joint gradually subsided after the administration of factor VIII but there was no improvement of range of movement at knee joint.

Severe haemophilia A in a preterm girl with Turner syndrome: case report \u2013 a diagnostic and therapeutic challenge for a paediatrician (Part 2)

BackgroundHaemophilia A is an X-linked genetic condition which manifests itself mainly in male children in the first 2 years of life, during gross motor skill development. This disorder is rare in females. The clinical manifestation of severe haemophilia in preterm infants poses a great challenge to the therapeutic team. As extreme prematurity is linked to an increased risk of central nervous system or gastrointestinal bleeding, a well-informed and balanced treatment from the first days of life is crucial to prevent long-term damage.Haemophilia is most commonly caused by inheriting defective genes, and can also be linked to skewed X inactivation and Turner syndrome.The coincidental occurrence of haemophilia A and Turner syndrome is extremely rare, with only isolated cases described to date. Hence, a multidisciplinary approach is needed.Case presentationThe authors report on a preterm girl (gestational age 28 weeks) diagnosed with haemophilia and Turner syndrome. The first manifestation of haemophilia was prolonged bleeding from injection sites on the second day of life. Indeterminate aPTT and factor VIII level < 1% confirmed the diagnosis of haemophilia A. Dysmorphic features which did not match the typical clinical picture of haemophilia, the female sex, and a negative paternal family history led to the diagnosis of Turner syndrome. While in hospital, the girl received multiple doses of recombinant factor VIII in response to prolonged bleedings from the injection sites and from a nodule on the girl’s head, and before and after retinal laser photocoagulation. No central nervous system or abdominal cavity bleeding was observed. The substitutive therapy was complicated by the development of factor VIII inhibitor (anti-factor VIII (FVIII) antibodies). Treatment was continued with recombinant factor VIIa. This article aims at demonstrating the complexity of the diagnostics and treatment of a preterm child with two genetic disorders.ConclusionsHaemophilia should always be considered in the differential diagnosis of prolonged bleeding, even in patients with a negative family history. In the case of coinciding atypical phenotypic features, further diagnostics for another genetic disease are recommended. Infant care should follow current care standards, while considering certain individual features.

Genetic analysis of non-severe hemophilia A phenotype with A discrepancy between one-stage and chromogenic factor VIII activity assays

IntroductionThe diagnosis of hemophilia A (HA) is based on the measurement of factor VIII activity (VIII:C). About one-third of non-severe HA patients show a discrepancy of VIII:C measured by one-stage (VIII:C 1st) and chromogenic (VIII:C chr) assays. Different mutations in the F8 gene may cause the discrepancy in results of the FVIII activity assay.The aim of this study was to investigate F8 gene mutations in patients with assay discrepancies and to evaluate their impact on the results of VIII:C assays. MethodsMutation analysis was performed on 41 individuals with a discrepancy in VIII:C 1st and FVIII: C chr assays by direct sequencing. In addition, the effect of the variants on FVIII macromolecule structure was investigated by in silico and bioinformatics tools. ResultsGenetic analysis disclosed 22 different variants, of which 19 were identified for the first time to be involved in the phenotype of VIII:C discrepancy. Most of the variants related to the higher VIII:C 1st were found in A1, A2, A3 domains. The variant related to VIII:C chr > VIII:C 1st was located in the thrombin cleavage site. In silico analysis showed the effect of variants on FVIII macromolecule stability, which may be the possible mechanism causing the discrepancy. ConclusionOur data shed light on the impact of genetic defects on VIII:C assay and provided evidence that the consideration of these mutations may open a new window to the proper diagnosis and treatment monitoring of non-severe HA patients.

Identification and Validation of Hemophilia-Related Outcomes on Japanese Electronic Medical Record Database (Hemophilia-REAL V Study).

PurposeRoutinely collected data are useful for epidemiological study in hemophilia, but few studies validated the algorithm accuracy. We aimed to develop and validate algorithms to identify patients with hemophilia A and hemophilia A-related events.Patients and MethodsThis validation study compared data from medical chart reviews to a database of routinely collected health data, including claims data and discharge abstracts, and especially electronic medical records (EMR), at a single Japanese hospital (Kurashiki Central Hospital) using a stratified sampling method. Two physicians reviewed the charts for all patients at high risk for hemophilia A, and randomly sampled patients with moderate risk. Diagnostic accuracy was determined based on sensitivity, specificity, positive predictive value (PPV), and negative predictive value.ResultsThere were 1,033,845 eligible patients, of whom 31 had a diagnosis of hemophilia A. ICD-10 diagnosis code D66 in the EMR identified hemophilia A with a sensitivity of 93.5% (95% confidence interval: 78.6–99) and PPV of 61.7% (95% confidence interval: 46.4–75.5). The administration of ≥10,000 units/month of factor VIII products, as documented in the EMR, identified 81.3% of patients with prophylactic factor replacement therapy. The ICD-10 diagnosis code for intracranial bleeding in the EMR identified 75.0% of patients with intracranial bleeding, but those of gastrointestinal bleeding and major joint bleeding identified only 11.1% and 1.7%, respectively.ConclusionWe developed and validated algorithms to identify congenital hemophilia A and hemophilia A-related events. Hemophilia A could be identified with high sensitivity and PPV, but it was still challenging to identify hemophilia A-related events.

Severe Hemophilia A in a Patient with Sexual Differentiation Disorder: A Case Report

Hemophilia A is an inherited X-linked disease where the VIII Factor (FVIII) production is altered, causing hemorrhagic diathesis. It can be classified into mild, moderate or severe, depending on the levels of circulating FVIII. It is suffered by males with an incidence of 1 in 5000 live births. Women are carriers, and they transmit the mutation in 90% of the cases, whereas 10% are de novo mutations. Females are usually asymptomatic, showing normal or intermediate FVIII factor, although it is estimated that 1 in 100.000 carriers will show severe bleeding manifestations due to FVIII severe deficit. For this to occur, some of the following physiopathologic mechanisms should be present: 1) heterozygous compound mutations affecting both alleles of the FVIII; 2) Homozygous mutations; 3) Extreme lionization of all the normal X chromosomes; 4) Numerical or structural alterations of the X chromosomes, as in Turner´s syndrome; 5) Genetical mutation in a patient with XY genotype and female phenotype.The objective of this report is to describe the case of a girl with severe Hempohilia A and XY cariotype.Case report:A 2-year-old female patient presented to consultation, with no remarkable previous perinatal history nor family history of hematologic diseases, referred due to spontaneous hematomas and bleeding events of difficult medical management with a 4 ISTH score. Coagulation studies were performed, showing a FVIII level of less than 1%, with the rest of the blood parameters being normal. Coagulation studies of the mother showed FVIII levels of 30%, Von Willebrand antigen of 59% and ristocetin cofactor of 43%. The genetic analysis of both the child and mother informed a type I inversion of the 22 intron. A karyotype analysis of the patient is done. She is phenotypically a female, but she has a 46XY genotype. At present she is being studied to rule out if the sexual differentiation disorder is due to the lack of SRY gen (Swyer´s syndrome) or to insensitivity to androgens (Morris´syndrome).From the moment of the diagnosis, the patient started prophylaxis with recombinant FVIII factor, not showing complications.DiscussionThe severe manifestations of the X linked diseases are infrequent in females. Approximately 30% of the carriers of hemophilia have an activity of the FVIII of less than 40%, with the consequent risk of bleeding. The most common cause for this is the selective inactivation of the normal X chromosome, that usually occurs in a balanced and randomized fashion. The diagnosis of hemophilia is made based on the FVIII activity dosage, and is confirmed with the molecular study of the mutations of the gene. In asymptomatic carriers, the status of homozygous or heterozygous mutation must be determined.Similarly, it is important to know what is the patient´s karyotype, because although its frequency is low, the disease can be the result of a sexual differentiation disorder, as it is the case presented here, or a chromosomopathy. In both cases is important to follow up the patient interdisciplinary with endocrinology, to treat the hormonal disorders related to each situation.ConclusionIt is of paramount importance to obtain a complete clinical and molecular diagnosis, to perform a correct treatment and follow up, and also offer an adequate genetic counseling. DisclosuresNo relevant conflicts of interest to declare.

Molecular Diagnosis of Hemophilia B Leyden in Japanese Brothers Reveals Spontaneous Amelioration in Early Childhood with c. -35 G>A Onecut Binding Site Mutation

IntroductionHemophilia B is an X-linked inherited bleeding disorder which is caused by mutations in the F9 gene. Hemophilia B Leyden is a rare subtype of hemophilia B, which is caused by mutations within a 40-basepair region in the F9 promoter. Hemophilia B Leyden account for 1.9% of hemophilia B, Hemophilia B Leyden is characterized by low factor IX activity (FIX:C) during childhood and gradual increase in puberty. To date, more than 100 cases of hemophilia B Leyden and 21 distinct point mutations have been reported. However, the genotype-phenotype correlations have not yet been established. Nearly all reported hemophilia B Leyden cases are Caucasian. The first case of Japanese patient with Heophilia B was reported recently (Yamashita et al. Int J Hematol. 2017). There have been only two other reported cases of hemophilia B Leyden in Asia, one from Thailand (c. -19 T>C), the other from China (c. -21 T>A). Here, we report the distinct Japanese brother cases with hemophilia B Leyden. DNA sequencing analysis revealed HGVS (c. -35 G>A) ONECUT binding site mutation, which was the same as the first reported Japanese hemophilia B Leyden case. All three Japanese hemophilia B Leyden patients improved during early childhood.MethodsInformed consent was obtained from guardians. The study was approved by the Ethics Committee on Medical Research of Tokyo Medical University. DNA sequences were analyzed by direct sequencing.CasesA previously healthy six months old boy developed subcutaneous hematoma after vaccination. There was no family history of hemophilia. He was diagnosed as hemophilia B based on the results of APTT 54sec and FIX:C <1%. FIX:C increased with 4% at 1 year of age, 6% at 3 years of age and 9% at 7 years of age [Figure]. He has been free from major bleeding events.Younger brother of the above-mentioned proband was born at 39 weeks gestation with birth weight of 2988g. Although he had no symptoms, he underwent an examination at 1 month of age because of his family history. He was found to have hemophilia B with APTT 58sec and FIX:C <1%. FIX:C increased with 9% at 1 year of age and 13% at 4 years of age. He had bleeding episode of traumatic lip injury at 1 year of age.We identified a ONECUT binding site mutation (c.-35G>A) in the promoter region of FIX gene (F9) in both patients. Both of their parents were Japanese. This mutation was the same as that identified in the first Japanese case.DiscussionHere, we report Japanese brother cases with hemophilia B Leyden. Hemophilia B Leyden is caused by point mutation of proximal promoter region, which includes binding sites for three transcription factors, hepatic nuclear factor 4α (HNF4α), CCAAT enhancer-binding protein α (C/EBPα), and ONECUT1/2. Mutations in these transcription factor binding sites are postulated to disrupt transcriptional activation of F9 . Androgen receptor (AR) is also known to activates F9 transcription in the presence of androgen. It is thought that increased androgen secretion after puberty induce binding of AR to androgen receptor element (ARE) and activates transcription of F9 . In our brother cases with hemophilia B Leyden, FIX:C rose during early childhood, which was different from other hemophilia B Leyden, in which FIX:C rise in adolescence. It was thought that these phenomena might be associated with binding of ONECUT transcription factor to this site. Previously reported another Japanese hemophilia B Leyden patient also showed similar increase in FIX:C level during early childhood.ConclusionOur brother cases and previous report suggested that c. -35 G>A ONECUT binding site mutation might be associated with earlier rise of FIX:C level than other transcription factor binding sites mutation. We should be aware that hemophilia B Leyden is seen not only in Caucasian but also in Asian including Japanese. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Understanding Treatment and Care Utilization & Perceptions of Females with Hemophilia A or B in the Choice Project

Background: The CHOICE Project was conducted in partnership between the US Centers for Disease Control and Prevention (CDC) and Hemophilia Federation of America, a non-profit, community-based organization, to survey persons with bleeding disorders (PWBD), male and female, in the US. Participants in the CHOICE Project included both PWBD receiving care at federally-funded hemophilia treatment centers (HTC) and those who do not receive care at HTCs (non-HTC PWBD). The ExPAND Project was derived to analyze a portion of the CHOICE data set related to males and females with a single diagnosis of hemophilia A or hemophilia B (PWH, HTC and non-HTC).Objective: To retrospectively analyze treatment and healthcare utilization and perceptions among female PWH (FWH) in the CHOICE data set to better understand gaps in FWH healthcare and how those gaps can be addressed.Methods: Demographic and clinical information was collected through CHOICE by survey in the US from 04/2013-07/2015 among adults (≥18 years) and caregivers of children with bleeding disorders. Participants were recruited to take a 20-minute survey in English or Spanish, online or on paper. Non-HTC PWBD were solicited specifically but others were not excluded from participation. Participants' status as non-HTC PWBD was determined using an algorithm based on responses to a specific survey question. Both females diagnosed with a bleeding disorder and undiagnosed females with bleeding disorder symptoms and/or children with a bleeding disorder could participate. Because participants were not required to respond to every survey questions, data for females with hemophilia A or B are combined in some instance to afford a sufficient n for analysis. Descriptive analysis of participants reporting hemophilia diagnosis was performed.Results: Of the 719 eligible surveys, 576 PWH were identified as having a single diagnosis of hemophilia A or hemophilia B. Of the 576 PWH, FWH accounted for 20% (n=113); of FWH, 61% reported mild hemophilia A and 56% mild hemophilia B. FWH ethnicity was 13% Hispanic and race: 59% White, 4% Black/African American, 0% Asian, 4% other; 71% reported having commercial health insurance; 46% were employed full-time, 5% permanently disabled (Table 1). Of FWH, 77% use recombinant FVIII, 20% plasma-derived FVIII containing vWF, 11% hormonal contraceptives. Of FWH using factor products, 23% use it to prevent bleeds, 20% use it on a regular schedule, 57% infuse at home, and 77% self-infuse. Over 81% of FWH reported ever having had a bleed and in the prior 12 months 59% reported having a joint bleed and 46% a bleed in another location. Over 63% of FWH reported receiving care for their hemophilia at least once per year and 23% receive care only prior to a medical procedure. In the prior 12 months, due to their hemophilia 14% were admitted to a hospital and 28% visited an ER. For usual care, 40% visit an HTC, 29% a doctor's office, 10% ER (Table 2). For FWH, general satisfaction with care for their hemophilia was 2.9 out of 5 for all ages, with FWH ages 18-34 reporting 1.8 out of 5 (Table 3).Conclusions: Preliminary data from CHOICE offers new insights in the treatment and healthcare utilization among FWH. As FWH in their reproductive years (18-34) had the lowest satisfaction score, there is further need to understand the disease/treatment paradigm for this group. Additional data for FWH of different race/ethnicity is also needed to properly assess these population. This sample does not necessarily represent all PWBD, as targeted outreach in some regions may have led to over-representation of some participant characteristics. [Display omitted] DisclosuresMorales Arias:Bioverativ: Employment. Cyhaniuk:HFA: Employment.

Large retroperitoneal hematoma in a patient with haemophilia B

A spontaneous retroperitoneal hematoma is very rare and quite a challenging entity, more so when its presentation mimics other more common causes of acute abdomen, as in this interesting case. Here, patient presented with acute abdomen with polyarthralgia with flank ecchymosis (Grey Turner’s sign) with flank mass which lead us in the direction of acute pancreatitis. However, past history of recurrent bleeding episodes and positive family history along with blood investigations revealing an isolated prolongation of activated partial thromboplastin time tickled our brains with the differentials of coagulation disorders. Computed tomography showed large retroperitoneal hematoma. After initial resuscitation in the emergency room he was managed conservatively with fresh frozen plasma, cryoprecipitate and blood transfusions. On detailed evaluation, coagulation workup showed deficient coagulation factor IX levels leading us to the diagnosis of haemophilia B. Now, the patient is doing good on regular follow up.

Incidental diagnosis of haemophilia: A case report of three cases following voluntary medical male circumcision in South Africa

Introduction: Since 2007, over 15.2 million Voluntary Medical Male Circumcisions (VMMCs) have been performed in 14 sub-Saharan African countries for partial prevention of transmission of HIV. In South Africa, close to 4 million VMMCs have been conducted since the onset of the national VMMC program in 2010. Within this context, the occurrence of notifiable adverse events related to peri-operative bleeding occurs commonly. The ability to screen, diagnose, and manage these cases appropriately will mitigate associated adverse events. Aim: In this paper, we describe three cases of prolonged bleeding after VMMC procedure and propose program measures. Methods: Descriptive haemophilia case accrual at three sites implementing a PEPFAR- funded VMMC program. The cases were recruited consecutively over a 17-month period (May 2017 to September 2018). Standard laboratory tests were used to confirm diagnosis. Written assent and informed consent were obtained from each subject and their respective guardians. Results: A total number of 31 severe or moderate adverse events were reported of whom three 16-year-old clients from three different provinces in South Africa were diagnosed with Haemophilia post VMMC services during July 2018. Two clients were diagnosed with Haemophilia A and one client was diagnosed with Haemophilia B. Conclusions: Greater emphasis on training and placement of qualified health care workers for peri-operative screening as well as a high index of suspicion for pre-operative diagnosis and appropriate referral for bleeding disorders is highly recommended. Clinical VMMC protocols guiding post-operative wound management, adverse event management, active client follow-up and care need to be reinforced, with rigorous reporting. Keywords: Prolonged bleeding; Adverse events; Haemophilia; Screening; Bleeding disorders; Incidental diagnosis.

Identification of Novel miRNAs in the F8 Gene Via Bioinformatics Tools.

Background: Hemophilia A is an X-linked bleeding disorder resulting in a deficiency of plasma clotting factor VIII and caused by mutations in the FVIII gene (F8 gene). MicroRNAs (miRNAs) in body fluids are promising biomarker candidates for Hemophilia A, due to their stability in body fluids and accessibility by non- or minimally-invasive procedures. Therefore; Advances in miRNA analysis methods resulted in a wide range of publications on miRNAs as putative biomarkers.Objective: Here we tried to scan the F8 gene region to predict a novel miRNA and identify it as a regulator of the F8 gene.Materials and Methods: To this aim, the ability to express novel miRNAs in F8 locus was assessed via reliable bioinformatics databases such as SSCprofiler, RNAfold, miREval, FOMmiR, MaturBayes, miRFIND, UCSC genome browser, Deep Sequencing, and miRBase.Results: Data analysis from the relevant databases offers one stem-loop structure that is predicted to express a novel miRNAConclusions: The diagnosis of Hemophilia A with the help of these types of biomarkers is a non-invasive procedure that has been demonstrated to have a significant role in the early diagnosis of the disease. Hopefully, the proposed candidate sequence will be confirmed in vitro and become a non-invasive biomarker in the near future

EP447 - Improving and accelerating clinical molecular diagnosis of severe hemophilia A with optical genome mapping technology

eP447 - Improving and accelerating clinical molecular diagnosis of severe hemophilia A with optical genome mapping technology

Prospective observational study on the clinical behaviour of dental implants in patients with haemophilia. Preliminary results

Haemophilia is a recessive congenital hereditary haemorrhagic disorder characterised by the decrease in, or absence of, the functional activity of factor VIII (Haemophilia A) or factor IX (Haemophilia B). The haematological medical treatment for these patients is systemic replacement therapy with factor VIII or factor IX concentrates. Dental implants are considered the gold standard for the replacement of missing teeth. There is no evidence or safe protocol for their use in patients with haemophilia. The objective of this study was to evaluate the clinical osseointegration and the incidence of postoperative bleeding in patients with haemophilia. The patients included in this study were over 18 years old with a diagnosis of haemophilia. A surgical implant protocol was implemented, supported by systemic and local haemostatic measures. Age, type of haemophilia, pre- and post-factor levels, gingival index, surgical duration, oedema, and pain were recorded for each case. In the event of haemorrhage, the bleeding index was determined. At four months, the success of the implant was evaluated using the absence of pain, suppuration, and clinical mobility as parameters. Fifteen surgeries were performed and 21 implants were placed in 10 patients. All the implants were successful in terms of the evaluated parameters. Among the 15 surgeries performed, bleeding was detected in three. The preliminary results found in this study seem to establish that the proposed surgical implant and haemostatic protocol is a predictable treatment for the placement of dental implants in patients with haemophilia.

Challenges of antithrombotic therapy in the management of cardiovascular disease in patients with inherited bleeding disorders: A single-centre experience.

Cardiovascular events in patients with inherited bleeding disorders are challenging to manage. The risk of bleeding secondary to antithrombotic treatment must be balanced against the risk of thrombosis secondary to haemostatic therapy. Patients with inherited bleeding disorders with coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI) or atrial fibrillation (AF) from a single centre (2010-2018) are included. A total of 11 patients undergoing CABG (n=3), PCI (n=5) or with AF (n=3) and a diagnosis of haemophilia A (n=8), haemophilia B (n=1), factor XI deficiency (n=1) and von Willebrand disease (n=1) managed by a multidisciplinary team are reported. In patients undergoing CABG, factor levels were normalized for 7-10days with trough levels of 70-80% with severe patients continuing high-dose factor prophylaxis (trough 20-30%) three weeks post-operatively with daily aspirin. In a patient with mild haemophilia A and an inhibitor, recombinant factor VIIa dosing was monitored with thromboelastometry. For PCI, a 3rd-generation drug-eluting stent with one month of dual antiplatelet therapy in addition to high-dose prophylaxis as needed was preferred. Patients with AF and severe haemophilia did not receive antithrombotic treatment, and a thrombin generation assay was used to guide heparin dosing in mild haemophilia. Our experience demonstrates the importance of interdisciplinary communication to identify strategies that decrease the risk of bleeding and thrombosis. The use of extended, increased intensity prophylaxis facilitated antiplatelet therapy. Global assays may help balance the intensity of haemostatic and antithrombotic treatment.

Case Report: Identification of a de novo Missense Mutation in the F8 Gene, p.(Phe690Leu)/c.2070C > A, Causing Hemophilia A: A Case Report.

Hemophilia A is an X-linked recessive bleeding disorder caused by various types of pathological defects in the factor VIII gene (F8/FVIII). Preimplantation genetic testing for monogenic disease (PGT-M) is a powerful tool to tackle the transmission of monogenic inherited disorders from generation to generation. In our case, a mutation in F8 had passed through female carriers in a hemophilia A family and resulted in two male patients with hemophilia A. To identify the etiological genetic variants of F8, next-generation sequencing (NGS) was used for chromosome copy number variation detection, Sanger sequencing to verify mutation sites, single nucleotide polymorphism (SNP) for site amplification, and sequencing to validate the genetic linkage. Finally, a novel missense mutation, p. (Phe690Leu)/c.2070C > A, occurring in exon 13 of F8, was screened out as a pathogenic mutation. Following this, an F8 normal euploid blastocyst was transferred. At the 18th week, the pregnant mother underwent amniocentesis, NGS, Sanger sequencing, and SNP typing that further confirmed that the fetus had a healthy genotype. After delivery, a neonatal blood sample was sent for FVIII concentration detection, and the result established that the FVIII protein was rescued to a nearly average level. We first identified a new type of pathogenic mutation in F8, which has not been previously reported, selected a genetically healthy progeny for an affected family, and provided valuable knowledge of the diagnosis and treatment of hemophilia A.

Development of a Specific Monoclonal Antibody to Detect Male Cells Expressing the RPS4Y1 Protein.

Hemophilia is an X-linked recessive bleeding disorder. In pregnant women carrier of hemophilia, the fetal sex can be determined by non-invasive analysis of fetal DNA circulating in the maternal blood. However, in case of a male fetus, conventional invasive procedures are required for the diagnosis of hemophilia. Fetal cells, circulating in the maternal bloodstream, are an ideal target for a safe non-invasive prenatal diagnosis. Nevertheless, the small number of cells and the lack of specific fetal markers have been the most limiting factors for their isolation. We aimed to develop monoclonal antibodies (mAbs) against the ribosomal protein RPS4Y1 expressed in male cells. By Western blotting, immunoprecipitation and immunofluorescence analyses performed on cell lysates from male human hepatoma (HepG2) and female human embryonic kidney (HEK293) we developed and characterized a specific monoclonal antibody against the native form of the male RPS4Y1 protein that can distinguish male from female cells. The availability of the RPS4Y1-targeting monoclonal antibody should facilitate the development of novel methods for the reliable isolation of male fetal cells from the maternal blood and their future use for non-invasive prenatal diagnosis of X-linked inherited disease such as hemophilia.

Hemophilia B: Genes in Hemophilia B, Diagnosis, and Treament Approach Using Adeno-Associated Virus Vectors

Background: Hemophilia B is a hemorrhage disorder inherited based on the X-linked inheritance pattern. Diagnosis of this disease can include such as fetal DNA test. Adeno-associated virus (AAV) delivery vehicles can be used for treating hemophilia B. In this study, the author reports the progress in a study of hemophilia B focused on genetic inheritance and treatment of the disease with AAV delivery vehicles as objectives of this study. Methods: The author searched Google, ScienceDirect and the PubMed Database at NCBI for articles on hemophilia B and treatment of hemophilia B with AAV vectors . Results: Mutations in the F9 gene result in hemophilia B. Diagnosis of hemophilia B can include such as fetal DNA and cell-free fetal DNA tests. Currently, an additional plasma-derived or recombinant factor IX are drugs for treating this disease. Unfortunately, this approach can permanently not recover patients with hemophilia B. Therefore, it needs another approach for treating this disease such as AAV vectors. Research results in animal model have demonstrated great promise for treatment of hemophilia B with these vectors. Conclusions: Hemophilia B is inherited according to X-linked pattern. To detect this disorder, cell-free fetal DNA test, for example, can be used. Adeno-associated virus vectors are a helpful tool for treatment of hemophilia B.

Safety first: Tracking adverse events associated with new therapies for people with hemophilia

Safety first: Tracking adverse events associated with new therapies for people with hemophilia