Paula D. James

ISTH/SSC bleeding assessment tool: a standardized questionnaire and a proposal for a new bleeding score for inherited bleeding disorders

F . RODEGHIERO,* A . TOSETTO,* T . ABSH IRE , D . M . A R NO L D , B . COLLE R ,§ P . J AMES ,– C. NEUNER T** and D . L I LL ICRAP ON BEHALF OF THE I STH/SSC JOINT VWF AND PER INATAL/ PED IA TR I C HEMOSTA S IS SUB CO MMI TTEES WO RKI NG GRO U P 1 *Department of Cell Therapy and Hematology, San Bortolo Hospital, Vicenza, Italy; Blood Center of Wisconsin, Milwaukee, WI, USA; Michael G DeGroote School of Medicine, Department of Medicine, McMaster University and Canadian Blood Services, Hamilton, Canada; §Allen and Frances Adler Laboratory of Blood and Vascular Diseases, The Rockefeller University New York, NY, USA; –Department of Medicine, Queen s University, Kingston, Canada; **Department of Pediatric Hematology/Oncology, UT Southwestern Medical Center, Dallas, TX, USA; and Department of Pathology and Molecular Medicine, Richardson Laboratory Queen s University, Kingston, Canada

ISTH/SSC bleeding assessment tool

F . RODEGHIERO,* A . TOSETTO,* T . ABSH IRE , D . M . A R NO L D , B . COLLE R ,§ P . J AMES ,– C. NEUNER T** and D . L I LL ICRAP ON BEHALF OF THE I STH/SSC JOINT VWF AND PER INATAL/ PED IA TR I C HEMOSTA S IS SUB CO MMI TTEES WO RKI NG GRO U P 1 *Department of Cell Therapy and Hematology, San Bortolo Hospital, Vicenza, Italy; Blood Center of Wisconsin, Milwaukee, WI, USA; Michael G DeGroote School of Medicine, Department of Medicine, McMaster University and Canadian Blood Services, Hamilton, Canada; §Allen and Frances Adler Laboratory of Blood and Vascular Diseases, The Rockefeller University New York, NY, USA; –Department of Medicine, Queen s University, Kingston, Canada; **Department of Pediatric Hematology/Oncology, UT Southwestern Medical Center, Dallas, TX, USA; and Department of Pathology and Molecular Medicine, Richardson Laboratory Queen s University, Kingston, Canada

Generation and validation of the Condensed MCMDM-1VWD Bleeding Questionnaire for von Willebrand disease

Summary.  Background: Given the challenges involved in obtaining accurate bleeding histories, attempts at standardization have occurred and the value of quantifying hemorrhagic symptoms has been recognized. Patients/methods: An extensive validated bleeding questionnaire (MCMDM‐1VWD) was condensed by eliminating all details that did not directly affect the bleeding score (BS) and the correlation between the two versions was tested. Additionally, the diagnostic utility of the condensed version was prospectively tested. Results: Data on 259 individuals who were administered the questionnaire are presented here; 217 being prospectively investigated for von Willebrand disease (VWD) (group 1) and 42 previously known to have type 1, 2 or 3 VWD (group 2). Of the 217 prospectively investigated, 35 had positive BS (≥4) and 182 had negative scores. Seven individuals (all with positive BS) had laboratory results consistent with type 1 VWD. This results in a sensitivity of 100% and a specificity of 87%. The positive predictive value is 0.20 and the negative predictive value is 1. The correlation between the full MCMDM‐1VWD and condensed versions is excellent (Spearman’s 0.97, P < 0.001, linear regression r2 = 96.4). Inter‐observer reliability for the condensed version is reasonable (Spearman’s 0.72, P < 0.001 and intra‐class correlation coefficient 0.805, P < 0.001). There was a significant difference in BS between subtypes of VWD, with type 3 >> type 2 >> type 1 VWD (anovaP < 0.001). There is a strong inverse relationship between VWF:Ag level and BS (Spearman’s −0.411, P < 0.001). Conclusions: The Condensed MCMDM‐1VWD Bleeding Questionnaire is an efficient, effective tool in the evaluation of patients for VWD.

Evaluation of the diagnostic utility for von Willebrand disease of a pediatric bleeding questionnaire

1 Warkentin TE, Greinacher A, Koster A, Lincoff AM. American College of Chest Physicians. Treatment and prevention of heparininduced thrombocytopenia: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).Chest 2008 ; 133 (6 Suppl.): 340S–80S. 2 Greinacher A, Warkentin TE. Recognition, treatment, and prevention of heparin-induced thrombocytopenia: review and update. Thromb Res 2006; 118: 165–76. 3 Francis JL. A critical evaluation of assays for detecting antibodies to the heparin-PF4 complex. Semin Thromb Hemost 2004; 30: 359– 68. 4 de Larrañaga G, Martinuzzo M, Bocassi A, Fressart MM, Forastiero R. Heparin-platelet factor 4 induced antibodies in patients with either autoimmune or alloimmune antiphospholipid antibodies. Thromb Haemost 2002; 88: 371–3. 5 Martin-Toutain I, Piette JC, Diemert MC, Faucher C, Jobic L, Ankri A. High prevalence of antibodies to platelet factor 4 heparin in patients with antiphospholipid antibodies in absence of heparin-induced thrombocytopenia. Lupus 2007; 16: 79–83. 6 Jang IK, Marcie JH. When heparin promote thrombosis: review of heparin-induced thrombocytopenia. Circulation 2005; 111: 2671–83. 7 Price EA, Hayward CPM, Moffat KA, More JC, Waerkentin TE. Laboratory testing for heparin-induced thrombocytopenia is inconsistent in North America: a survey of North American specialized coagulation laboratories. Thromb Haemost 2007; 98: 1357–61. 8 Zandecki M, Genevieve F, Gerard J, Godon A. Spurious counts and spurious results on haematology analysers: a review. Part I: platelets. Int J Lab Hematol 2007; 29: 4–20. 9 Bartels PC, Schoorl M, Lombarts AJ. Screening for EDTA-dependent deviations in platelet counts and abnormalities in platelet distribution histograms in pseudothrombocytopenia. Scand J Clin Lab Invest 1997; 57: 629–36. 10 Amiral J, Bridey F, Dreyfus M, Vissoc AM, Fressinaud E, Wolf M, Meyer D. Platelet factor 4 complexed to heparin is the target for antibodies generated in heparin-induced thrombocytopenia. Thromb Haemost 1992; 68: 95–6. 11 Chong BH, Burgess J, Ismail F. The clinical usefulness of the platelet aggregation test for the diagnosis of heparin-induced thrombocytopenia. Thromb Haemost 1993; 69: 344–50. 12 Schwarzinger I, Speiser W, Lubenow N, Greinacher A, Panzer S. Heparin-platelet factor (PF) 4 antibodies in patients with pseudothrombocytopenia: coincidence or association?ThrombHaemost 2000; 84: 1123–4.

Use of a quantitative pediatric bleeding questionnaire to assess mucocutaneous bleeding symptoms in children with a platelet function disorder

is a common complication following splenectomy in patients with malignant haematological diseases. Eur J Haematol 2006; 77: 203–9. 11 van t Riet M, Burger JW, van Muiswinkel JM, Kazemier G, Schipperus MR, Bonjer HJ. Diagnosis and treatment of portal vein thrombosis following splenectomy. Br J Surg 2000; 87: 1229–33. 12 Winslow ER, Brunt LM, Drebin JA, Soper NJ, Klingensmith ME. Portal vein thrombosis after splenectomy.Am J Surg 2002; 184: 631–5. 13 Parker HH III, Bynoe RP, Nottingham JM. Thrombosis of the portal venous system after splenectomy for trauma. J Trauma 2003; 54: 193– 6. 14 Peacock AJ. Pulmonary hypertension after splenectomy: a consequence of loss of the splenic filter or is there something more? Thorax 2005; 60: 983–4. 15 Bisharat N, Omari H, Lavi I, Raz R. Risk of infection and death among post-splenectomy patients. J Infect 2001; 43: 182–6. 16 Cullingford GL, Watkins DN, Watts AD, Mallon DF. Severe late postsplenectomy infection. Br J Surg 1991; 78: 716–21. 17 Ejstrud P, Kristensen B, Hansen JB, Madsen KM, Schonheyder HC, Sorensen HT. Risk and patterns of bacteraemia after splenectomy: a population-based study. Scand J Infect Dis 2000; 32: 521–5. 18 Schwartz PE, Sterioff S, Mucha P, Melton LJ III, Offord KP. Postsplenectomy sepsis andmortality in adults. JAMA 1982; 248: 2279–83. 19 Mellemkjoer L, Olsen JH, Linet MS, Gridley G, McLaughlin JK. Cancer risk after splenectomy. Cancer 1995; 75: 577–83. 20 Frank L Epidemiology. When an entire country is a cohort. Science 2000; 287: 2398–9. 21 Wiseman J, Brown CV, Weng J, Salim A, Rhee P, Demetriades D. Splenectomy for trauma increases the rate of early postoperative infections. Am Surg 2006; 72: 947–50. 22 Boxer MA, Braun J, Ellman L. Thromboembolic risk of postsplenectomy thrombocytosis. Arch Surg 1978; 113: 808–9. 23 Cappellini MD, Robbiolo L, Bottasso BM, Coppola R, Fiorelli G, Mannucci AP. Venous thromboembolism and hypercoagulability in splenectomized patients with thalassaemia intermedia. Br J Haematol 2000; 111: 467–73. 24 Sorensen HT, Mellemkjaer L, Steffensen FH, Olsen JH, Nielsen GL. The risk of a diagnosis of cancer after primary deep venous thrombosis or pulmonary embolism. N Engl J Med 1998; 338: 1169– 73. 25 KniffinWD. Jr, Baron JA, Barrett J, Birkmeyer JD, Anderson FA Jr. The epidemiology of diagnosed pulmonary embolism and deep venous thrombosis in the elderly. Arch Intern Med 1994; 154: 861–6. 26 Larsen TB, Johnsen SP, Moller CI, Larsen H, Sorensen HT. A review of medical records and discharge summary data found moderate to high predictive values of discharge diagnoses of venous thromboembolism during pregnancy and postpartum. J Clin Epidemiol 2005; 58: 316–9. 27 Goldhaber SZ. Pulmonary embolism. Lancet 2004; 363: 1295–305. 28 Kyrle PA, Eichinger S. Deep vein thrombosis.Lancet 2005; 365: 1163– 74. 29 Sorensen HT, Horvath-Puho E, Pedersen L, Baron JA, Prandoni P. Venous thromboembolism and subsequent hospitalisation due to acute arterial cardiovascular events: a 20-year cohort study. Lancet 2007; 370: 1773–9. 30 Schmidt LM, Foli-Andersen NJ, Rasmussen HM, Wille-Jorgensen PA. Thrombo-prophylaxis in Danish surgical departments. Status 2005 and 25 years development. Ugeskr Laeger 2008; 170: 947– 51.

Normal range of bleeding scores for the ISTH-BAT: adult and pediatric data from the merging project.

Bleeding Assessment Tools (BATs) have been developed to aid in the standardized evaluation of bleeding symptoms. The Vicenza Bleeding Questionnaire (BQ), published in 2005, established a common framework and scoring key that has undergone subsequent modification over the years, culminating in the publication of the ISTH‐BAT in 2010. Understanding the normal range of bleeding scores is critical when assessing the utility of a BAT. Within the context of The Merging Project, a bioinformatics system was created to facilitate the merging of legacy data derived from four different (but all Vicenza‐based) BATs; the MCMDM1‐VWD BQ, the Condensed MCMDM‐1VWD BQ, the Pediatric Bleeding Questionnaire and the ISTH‐BAT. Data from 1040 normal adults and 328 children were included in the final analysis, which showed that the normal range is 0–3 for adult males, 0–5 for adult females and 0–2 in children for both males and females. Therefore, the cut‐off for a positive or abnormal BS is ≥4 in adult males, ≥6 in adult females and ≥3 in children. This information can now be used to objectively assess bleeding symptoms as normal or abnormal in future studies.

The C-type lectin receptor CLEC4M binds, internalizes and clears von Willebrand factor and contributes to the variation in plasma von Willebrand factor levels

Genetic variation in or near the C-type lectin domain family 4 member M (CLEC4M) has been associated with plasma levels of von Willebrand factor (VWF) in healthy individuals. CLEC4M is a lectin receptor with a polymorphic extracellular neck region possessing a variable number of tandem repeats (VNTR). A total of 491 participants (318 patients with type 1 von Willebrand disease [VWD] and 173 unaffected family members) were genotyped for the CLEC4M VNTR polymorphism. Family-based association analysis on kindreds with type 1 VWD demonstrated an excess transmission of VNTR 6 to unaffected individuals (P = .0096) and an association of this allele with increased VWF:RCo (P = .029). CLEC4M-Fc bound to VWF. Immunofluorescence and enzyme-linked immunosorbent assay demonstrated that HEK 293 cells transfected with CLEC4M bound and internalized VWF. Cells expressing 4 or 9 copies of the CLEC4M neck region VNTR showed reduced interaction with VWF relative to CLEC4M with 7 VNTR (CLEC4M 4%-60% reduction, P < .001; CLEC4M 9%-45% reduction, P = .006). Mice expressing CLEC4M after hydrodynamic liver transfer have a 46% decrease in plasma levels of VWF (P = .0094). CLEC4M binds to and internalizes VWF, and polymorphisms in the CLEC4M gene contribute to variable plasma levels of VWF.

The prevalence of symptomatic von Willebrand disease in primary care practice

The adjusted HR for the development of PTS in thrombophilic as compared with non-thrombophilic patients was 1.23 (95% CI, 0.92–1.64; P = 0.15). In comparison to non-carriers of thrombophilia, the adjusted HR for the development of PTS was 0.42 (95% CI, 0.20–0.88; P = 0.02) in carriers of FVL, 0.81 (0.36–1.37) in carriers of lupus anticoagulant, 0.96 (0.29–3.82) in carriers of protein C deficiency, 1.08 (0.29–2.70) in carriers of protein S deficiency, and 1.33 (0.68–2.58) in carriers of the prothrombin gene mutation. Neither of the two patients with antithrombin deficiency developed PTS. In the subgroup of the 85 patients with FVL, PTS developed in 11 of the 50 patients (22.0%) with involvement of the popliteal vein only, and in 18 of the 35 (51.4%; P = 0.01) with more proximal thrombosis location, irrespective of the modality of clinical presentation (idiopathic or secondary to risk factors). The main limitation of our investigation lies in the failure to assess the role of other thrombophilic abnormalities such as hyperhomocysteinemia and increased levels of factors VIII, IX or XI. Nevertheless, based on our results the PTS rate in carriers of the most common thrombophilic abnormalities who develop an episode of proximal DVT does not seem to exceed that expected in non-carriers, and is likely to be even diminished by the carriage of FVL, most probably because of the more distal location of the thrombotic episode in carriers as compared with non-carriers of this abnormality [3,8]. The main implication of our study results is that awareness of a thrombophilic status should not influence the strategy that is commonly recommended for prevention of late post-thrombotic sequelae in patients with proximal DVT. Disclosure of Conflict of Interests

Genetic linkage and association analysis in type 1 von Willebrand disease: results from the Canadian type 1 VWD study.

Summary.  Background: von Willebrand disease (VWD) is the most common bleeding disorder known in humans, with type 1 VWD representing the majority of cases. Unlike the other variant forms of VWD, type 1 disease represents a complex genetic trait, influenced by both genetic and environmental factors. Aim: To evaluate the contribution of the von Willebrand factor (VWF) and ABO blood group loci to the type 1 VWD phenotype, and to assess the potential for locus heterogeneity in this condition, we have performed genetic linkage and association studies on a large, unselected type 1 VWD population. Method: We initially collected samples from 194 Canadian type 1 VWD families for analysis. After the exclusion of families found to have either type 2 or type 3 VWD, and pedigrees with samples from single generations, linkage and association analysis was performed on 155 type 1 VWD families. Results and conclusion: The linkage study has shown a low heterogeneity LOD score of 2.13 with the proportion of families linked to the VWF gene estimated to be 0.41. Linkage was not detected to the ABO locus in this type 1 VWD population. In the family‐based association test, significant association was found between the type 1 VWD phenotype, the quantitative traits, VWF:Ag, VWF:RCo, and FVIII:C and the ABO ‘O’ and ‘A’ alleles and the VWF codon 1584 variant. There was also weak association with the −1185 promoter polymorphism and VWF:Ag, VWF:RCo, and FVIII:C plasma levels. These studies provide further evidence to support the role for genetic loci other than VWF and ABO in the pathogenesis of type 1 VWD.

The evolution and value of bleeding assessment tools

Summary.  A personal history of excessive mucocutaneous bleeding is a key component in the diagnosis of a number of mild bleeding disorders, including von Willebrand disease (VWD), platelet function disorders (PFD), and coagulation factor deficiencies. However, the evaluation of hemorrhagic symptoms is a well‐recognized challenge for both patients and physicians, because the reporting and interpretation of bleeding symptoms is subjective. As a result, bleeding assessment tools (BATs) have been developed and studied in a variety of clinical settings. This work has been pioneered by a group of Italian researchers, and the resultant ‘Vicenza Bleeding Questionnaire’ stands as the original BAT. In this review, we will discuss the modifications of the Vicenza Bleeding Questionnaire that have taken place over the years, as well as the validation studies that have been published. Other BATs that have been developed and published will be reviewed, as will the special situations of assessing pediatric bleeding as well as menorrhagia. Lastly, the clinical utility of BATs will be discussed including remaining challenges and future directions for the field.