57 articles found
Clotting factor replacement therapy has proven a highly effective means of treating haemophilia A and B. But treatment involves frequent and lifelong infusion of factor concentrates and is generally prophylactic rather than curative. It is also extremely expensive, associated with inhibitor formation and does not fully abolish the potential for spontaneous bleeding. Gene therapy offers a potential cure for haemophilia, with the possible continuous expression of a clotting factor gene following the administration of a viral vector carrying the appropriate gene. Recent clinical trials of gene therapy for haemophilia have proven positive in selected patients and new studies are underway.
Little is known about where, and from whom children with haemophilia receive support, as there is a paucity of psychosocial research on this topic. This paper, part of a larger study of living with haemophilia, discusses the importance of social support for boys with haemophilia.
This study examined the perception of the quality of life in a small group of boys (aged 8-15) who have severe haemophilia and have also developed inhibitors and their parents. The study design was a qualitative research methodology using a phenomenology theory approach in order to gain perspectives from participants in a series of semi-structured interviews. The study showed that inhibitor development had an impact on the perceived quality of life of these boys and their families and in so doing threatened the coping mechanisms that had worked effectively for them in the past. Although there is adequate awareness among haemophilia treaters of the psychosocial impact of inhibitor development on family life, this may not always be seen as a priority when managing these boys. The study also identified gaps in the published evidence as well as scope for future study.
The investigators behind the first gene therapy trial with adeno-associated virus 8 (AAV8) Factor IX appointed a patient ombudsperson to help ensure participants were able to give truly informed consent. The experiences and challenges of the ombudsperson, who met with the first six UK-based patients, are described. It was stressed to potential participants that altruism, rather than any expectation of clinical benefit, should be the primary motivation to taking part. At the same time a sober assessment of the potential risks to their safety needed to be made.
Intramuscular botulinum toxin-A (BtA) to produce neuromuscular blockade has been effective in treating spasticity in children with cerebral palsy (CP) [1-3]. The use of BtA in children with a combination of CP and haemophilia has not previously been reported. We report a case of a 2-year-old boy with severe haemophilia and CP who received intramuscular injections of BtA to reduce his spastic diplegia lower limb hypertonicity.
It is said that men have haemophilia and women are carriers, affected or unaffected. The terminology used is significant. Why it is that men are described as ‘having’ haemophilia and women with haemophilia are described as affected carriers? After all the men ‘carry’ the gene just as the women do and pass it on to their daughters. Likewise many women have Factor IX or Factor VIII levels that, if they were a man, would be categorised as mild or even in some cases moderate or severe haemophilia. Yet haemophilia is widely viewed as a condition affecting men with women as the passive vehicle for its transmission from generation to generation. There are many issues for women that are affected by this choice of terminology. Among them are their ability to access healthcare and their acknowledgement within healthcare systems throughout the world. Are women with the same factor level as men viewed in the same manner by healthcare professionals and do they acknowledge their own bleeding disorder as being the same as their male counterparts? How many women are unaware of their own bleeding disorder because they have only been viewed as ‘carriers’? Research into these issues is limited. This paper explores the aspects that affect women with haemophilia, from the definition in its historical context, obtaining a diagnosis, psychosocial elements, access to treatment, changing attitudes and acknowledgements within both the medical community and the wider community.
David Owen was Labour Health Minister 1974-76 and now sits as an independent social democrat in the House of Lords. Before entering Parliament he trained as a medical doctor at St Thomas’s Hospital, London, where he was Clinical Neurologist and Psychiatric Registrar. He has championed the NHS throughout its existence and is now a powerful advocate for its reinstatement to its original purpose. In this extract from his 2014 book The Health of the Nation, NHS in Peril, David Owen sets out the consequences of the 2012 Health and Social Care Act for the haemophilia community.
Adolescents experience important changes in their physical, emotional, social and behavioural development. It is known that adolescents wish to be accepted by their peers, strive for independence and are prone to experiment. The challenge for adolescents with haemophilia is the need for taking responsibility for managing their illness and learning to comply with recommended treatment. This study aimed to investigate the process of adherence to treatment in adolescents with haemophilia.
A case study is presented illustrating the everyday challenges faced by patients with haemophilia and inhibitors and how treatment with bypassing agents or just FEIBA prophylaxis can help to control bleeding and improve functional ability.
The World Federation of Hemophilia’s world congress in Melbourne offered haemophilia nurses from across the world an opportunity to meet and share knowledge and experience in a friendly and supportive setting.
A 73-year-old woman presented with recent onset significant spontaneous bruising. She also had a recent diagnosis of type 2 diabetes mellitus and was undergoing investigations for biochemical hyperthyroidism. A diagnosis of acquired haemophilia A was confirmed with laboratory testing in addition to thyrotoxic Graves’ disease. She had significant bruising of her left thigh and restricted mobility of the left leg. A significant left vastus lateralis haematoma was diagnosed by ultrasound scan. A course of FEIBA (Factor Eight Inhibitor Bypassing Activity) was commenced and physiotherapy input provided. Kinesio tape was applied to the thigh using a lymphatic drainage technique with the aim of reducing swelling and bruising. Eight days after the initial application of tape, bruising had significantly reduced and her range of movement had returned to normal. This case history demonstrates how Kinesio tape may be used as a useful adjunct to standard therapy.
Introduction: Haemophilia causes joint, muscle and soft tissue bleeds, often leading to pain and disability. These effects can have a significant impact on patients’ well-being and quality of life. There is a need to better understand patient priorities and concerns so that haemophilia healthcare professionals can develop strategies to meet these needs with individuals and their families. Methods: The HaemophiliaLIVE ethnographic study enrolled 16 families from four comprehensive care centres in the UK. Each family received a kit consisting of video recording equipment, seven sealed envelopes each containing a “secret question” and pre-paid envelopes for secure return of the video memory cards. Video footage was recorded daily to examine the impact of haemophilia. Results: Over 30 hours of recorded footage was obtained from 10 families with children/young adults, two young adults, and three older men. Six participants had a current inhibitor. The key themes identified were impact on: family relationships, school, employment and travel. The older participants and those with inhibitors reported that pain was a major factor in their day-to-day lives, and also expressed fear about loss of mobility and pending surgery. Although parents expressed anger and sadness about their child’s haemophilia, those with haemophilia were generally positive about their life experiences. Many reported that their employers were understanding and made additional provision for their haemophilia. Conclusions: Haemophilia has a significant impact on patients and their families. This research provides insight on the support needs of individuals and families.
The Royal London Hospital is a major referral centre for children with inherited bleeding disorders (IBD). Dental caries and periodontal disease can be prevented, which is especially important in these children to avoid invasive treatment. For this reason a care pathway has been established, focusing on appropriate prevention advice and treatment A Paediatric Dental Specialist attends the monthly Paediatric Haematology clinics. Children are screened for untreated dental decay and preventive dental advice is given verbally along with a patient information leaflet. At the clinic, a letter is sent out to the patient’s general dental practitioner (GDP). Non-registered patients are directed to NHS Choices website to find a local NHS GDP. Liaison of GDPs with both haematology and hospital paediatric dental services is actively encouraged to support the provision of dental care within the primary care setting, particularly routine preventive care. Depending on the severity of the bleeding diathesis and the degree of invasive dental treatment required, the GDP may undertake simple treatment or, in more complex cases, may arrange a referral to the Royal London Dental Hospital. A consultation process takes place between paediatric dentist, paediatric haematologist and specialist nurse to determine the most appropriate haematological cover for each patient. This will depend on the severity of the bleeding disorder, the complexity of dental treatment and the need for local anaesthesia. The date of the dental visits and the haemostatic cover are requested via the electronic patient record so that it is accessible to all clinicians involved in their care without the need to retrieve their paper notes. This pathway encourages active involvement of the patients’ GDP and allows the patient to be treated as safely as possible in a timely manner. The care pathway has helped to formalise dental treatment for children with IBD and to improve every health care professional’s understanding of their role in this care.
Haemophilia care in South Africa faces a number of challenges and nurses can play a significant role in addressing these and raising standards of practice. This report considers those challenges and steps taken by the country as it has attempted to meet them. It also summarises the key themes that arose from a nursing workshop held in November 2013 as part of a MASAC symposium and facilitated by the authors.
The Latin American net of Prophylaxis and Immune Tolerance (RED LAPI) was established in 2010 and comprises a group of physicians dedicated to improving the diagnosis, treatment and quality of life of haemophilia patients in Latin America. The countries represented at RED LAPI are: Argentina, Chile, Uruguay, Venezuela, Colombia, Peru, Honduras, Guatemala, Paraguay, Dominican Republic, Bolivia, Ecuador and Panama. Analysis of the provision of care for haemophilia patients suggests a lack of consistent care both across and within Latin America countries. While some patients receive prophylaxis and immune tolerance induction (ITI), others are not even properly diagnosed, due to variation in patient’s health insurance. Few countries in Latin America have a national program that registers all patients’ information. Therefore, in many countries it is difficult to identify local, regional and national data regarding the number of diagnosed patients, type of hemophilia, severity, and the kind of treatment. With respect to patients with inhibitors, some countries rely on bypass agents for the treatment of bleeding episodes while a few are able to do ITI. This paper summarises available data obtained by a survey of RED LAPI members regarding the diagnosis and treatment of haemophilia in their countries, as well as the incidence of inhibitors and the treatments available to patients. Based on this analysis, the aim is to propose plans to improve the current situation of haemophilia patients in Latin America.
Clotting factor concentrates used in the treatment of haemophilia are now procured centrally in the UK by nationally organised competitive tendering to obtain the best product price while still preserving some degree of prescribing freedom. Inevitably, however, some patients are required to switch from one brand of factor VIII to another to fulfil contractual requirements. This process of switching patients from one product to another falls to staff at individual haemophilia centres, with haemophilia nurses in particular playing a key role. This article outlines the national procurement process and discusses how the switch can be managed quickly and smoothly, as well as providing practical guidance on selecting which patients may be asked to switch. Issues such as patient communication, managing potential patient anxiety and efficient stock management are also discussed.
Self-completed measures of physical function and quality of life are increasingly being used in clinical practice yet little is known about how these measures correlate with joint scores in boys with severe haemophilia. In addition, it is not known whether currently used measures of functional outcome correlate with quality of life measures, which measure of physical function is most accurate and whether these measures are acceptable to a well treated contemporary cohort of boys.
The concentration of expertise in haemophilia treatment centres means that patients in most countries live a considerable distance from their treatment centre. Telephone support between regular clinic visits is common practice. This article describes the six principles that broadly outline nurses’ accountabilities when providing care over the telephone and discusses how they have been applied in practice with the Canadian Association of Nurses in Hemophilia Care (CANHC) telephone guidelines.
A broad scoping exercise was undertaken to assess and quantify haemophilia nursing care in Europe. A web-based survey in English was sent to known networks of haemophilia nurses working in Europe. This survey included questions concerning the haemophilia treatment centre, educational level, work activities, gaining knowledge/expertise and development in the future
The role of the nurse continues to develop, probably at greater speed than ever before. Would Florence Nightingale ever have dreamt of nurses who could manage whole episodes of patient care from diagnosis, through admission, requesting investigations, prescribing treatments and evaluating outcomes? She probably did – when she instigated the first nursing outcome measures looking at infection control. Nurses can and do, do most things. What is important is that they are appropriately trained and continue to develop skills, that are relevant both to them and the patients for whom they care. Assessing this ability, or competence, requires knowledge and skills in itself. In this paper we describe the process of defining competence in haemophilia nursing. Some of these competencies are transferable from other areas of nursing, others are haemophilia-specific. Together they provide a personal development framework for nurses who work within haemophilia as part or all of their role.
Aim: UK guidelines recommend regular assessment of joint status in children with haemophilia using a standardised tool performed by haemophilia physiotherapists. We surveyed UK physiotherapists working in haemophilia care regarding their current practice with respect to joint scoring. Methods: A survey was posted on SurveyMonkey and all haemophilia physiotherapists practising in the UK were invited to respond. Responses were analysed and discussed at a roundtable meeting attended by invited physiotherapists and specialist haemophilia nurses. Results: In all, responses were received from 29 of the estimated 37 physiotherapists in the UK who see haemophilia patients. Both the survey and subsequent discussion reflected agreement that joint scoring offers a valuable tool to clinicians, but that better ways of assessing joint health were needed. There was enthusiasm for combining joint scoring with systematic and validated patient-reported outcome measures. Conclusion: Greater understanding is needed of the relationship between joint scores and measures of physical function and quality of life.
The history of haemophilia care has been fraught with extreme successes and epic failures. The development of plasma-derived concentrates made prophylactic treatment and home care possible, but the unintended consequences were devastating for a generation and only abated with the emergence of recombinant products. Now with the arrival of longer-acting factor concentrates and the potential offered by gene therapy, further improvements in medical and social outcomes are possible. But these new treatment approaches raise challenging ethical and moral issues that society must be prepared to confront.
Assessment of health-related quality of life (HRQoL) in haemophilia is important in order to provide information for clinical decision-making and to verify the impact of haemophilia on patients and their partners. A cross-sectional single-centre study was performed to assess the health-related quality of life (HRQoL) and burden of the disease on partners of adult patients with haemophilia. Self-reported outcomes were completed by partners and patients (SF-36, VAS of Interference); partners also completed the Caregivers’ Burden Scale. A total of 108 of 150 eligible partners of adults with haemophilia (72%) participated. Mean age for partners was 44.7 years (range 20-79) and for patients 47.1 years (range 20-81). The majority of couples were married (65.7%). Couples reported being together a mean of 19.8 years and had, on average, 1.7 children. Partners of haemophilia patients across all severities reported lower HRQoL in the ‘emotional role’ domain of SF-36 (P=<0.041), with highest impairments observed among partners of moderately affected patients. Partners reported significantly less interference with daily life compared to patients (P<0.001). In general, partners reported low burden of haemophilia in the Caregivers’ Burden Scale; ‘emotional involvement’ was the greatest burden in the mild and moderate group; while in the severe group ‘general strain’ was the greatest burden. Partners of severe haemophilia patients on prophylaxis reported, in general, good HRQoL and low burden of the disease. Partners of moderate patients reported decreased HRQoL and higher burden. Our findings may be of importance for the care of the ageing person with haemophilia (PWH).
AAV-mediated gene therapy has the potential to be paradigm shifting as a treatment for haemophilia. A single administration of AAV vector can result in safe and consistent long-term expression of transgene (>5 years), reduction in spontaneous bleeding episodes, reduction in clotting factor usage and an improvement in quality of life. There is huge commercial interest in this approach, with the expectation that an AAV gene therapy product for haemophilia B will be licensed by 2020.
In recent decades, few disorders have benefited more from scientific research than haemophilia. Those living with the condition have witnessed improved standards of care resulting in dramatic improvements in quality of life. The Katharine Dormandy Haemophilia Centre and Thrombosis Unit has made a proud contribution to this improvement in care.
Staff at the Katharine Dormandy Haemophilia Centre pioneered a systemic family therapy model for haemophilia, in which reviews combined medical care and family counselling. That approach has now been extended to specialised joint clinics such as in orthopaedics, women’s and genetic counselling. This multidisciplinary team approach enables specialist clinicians to focus on what they do best while the family therapy team manages the psychological, practical and family issues, and supports patients to make difficult decisions regarding their care.
The multidisciplinary team approach to providing comprehensive care is the cornerstone of the management of musculoskeletal issues in haemophilia. At the Royal Free the team takes a holistic approach to musculoskeletal disease management that is not just about assessment of a painful knee or having an operation. It recognises that patients sit on a spectrum of musculoskeletal disease severity that is dependent on age and the type of treatments available and the issues that may have been experienced with those treatments. The patient’s own goals sit at the heart of the team’s approach.
The development of registries through international collaboration has facilitated better understanding of the rare bleeding disorders. Such work has shown that rare bleeding disorders are heterogeneous and need to be studied singularly, and that heterozygous patients may bleed. There is a need to understand the minimum plasma coagulant activity level to prevent spontaneous bleeding. Moreover, due to the low prevalence of rare bleeding disorders, the management of this patient population remains a challenge. Data collection on clinical history, efficacy and side effects of treatment needs to be harmonised.
The HIV and hepatitis C epidemics of the 1980s represent the darkest days in the history of modern haemophilia care. The haemophilia centre at the Royal Free Hospital was at the forefront of research into the natural history of both diseases. This work led directly to the widespread use of recombinant products, as well as the establishment of combined haemophilia clinics with hepatologists and HIV physicians.
Advances in the understanding of haemophilia require effective collaboration, both at the national and international levels. Such collaborations are currently playing a major role in elucidating the natural history of acquired haemophilia, and also in clarifying the issue of product-related inhibitor development in previously untreated patients with haemophilia.
Use of recombinant clotting factor now represents the standard of care in haemophilia across the developed world. But the recombinant era would not have occurred without the isolation from plasma of factor VIII in sufficient quantities to allow characterisation and cloning. Much of this development work occurred at the Royal Free Hospital.
Modern haemophilia care based on good diagnosis and effective prophylaxis has allowed boys born with haemophilia to grow up leading essentially normal lives. Nevertheless, there remain challenges notably those posed by inhibitors and patient expectations. There is now a significant cohort of men in their 30s, 40s and 50s who have been looked after extremely well but many of whom now have significant ankle arthropathy because they played football, even when advised not to do so at a time when prophylaxis was limited or started late. The imminent era of longer-acting clotting factors and gene therapy will also impact on future patient expectations. Meeting and managing these challenges will be much enhanced by the development and maintenance of good relationships between the patient and the haemophilia team.
The issue of women with bleeding disorders was first reported by Professor von Willebrand in 1926, but it is only from around the mid 1990s that the issue has been fully recognised. Much of this is due to the vision and hard work of Professor Christine Lee and colleagues at the Katharine Dormandy Haemophilia Centre. This work has led to better diagnosis, better quality care and improved quality of life for women with bleeding disorders.
Patients with haemophilia have benefited hugely from the advances in basic science achieved over the past 50 years. The introduction of clotting factor concentrates opened the door to home treatment and the subsequent availability of plasma and then recombinant products heralded the prophylaxis era. As clinicians and patients begin to manage the introduction of longer-acting factor concentrates, there are also many novel therapies and approaches in development, many of which offer the potential to transform the lives for individuals with inherited bleeding disorders and their families.
The long-awaited results of the SIPPET (Survey of Inhibitors in Plasma-Products Exposed Toddlers) study were recently presented during a plenary session at the American Society of Hematology (ASH) conference in December 2015.
Pain is a phenomenon that accompanies a person with hemophilia (PWH) and many others with bleeding disorders from birth to death. Caregivers are not immune. For you cannot provide care, either as a loved one or a health care provider, and watch someone in pain without experiencing pain yourself
Pain is a major problem in haemophilia patients’ lives. The perspective of pain in such patients is unique and may be different from other chronic illnesses. This qualitative hermeneutic phenomenological study aims to describe and interpret pain experience of haemophilia patients. Participants were selected from a haemophilia clinic affiliated with Shiraz University of Medical Sciences, Shiraz, Iran. Taking the main theme, “pain: the voiceless scream in every moment of haemophilia life”, with two subthemes, “a life full of pain” and “describing complex pain quality”, data was collected using semi-structured in-depth interviews and field notes, and thematic analysis conducted using van Manen’s methodological framework for reflective hermeneutic interpretation. The findings indicated that pain always accompanied the lives of haemophilia patients. Participants experienced acute intense pains, accompanied by bleeding, which were described as “terrible”, “severe”, “intolerable” and “unbelievable”. As joints became damaged over time, participants experienced persistent pain that was “continuous” and “constant”. Participants also coped with ever-present pain in immobile joints, described as “intense”, “annoying” and “intolerable”. This qualitative study shows that pain is present throughout haemophilia patients’ lives and that they experience different kinds of pain, demonstrated through various descriptions. By understanding the experience of pain from the perspective of haemophilia patients, nurses and healthcare workers can provide high-quality care focused on their unique needs.
The experience of living in a non-metropolitan area and parenting a child with haemophilia is relatively unknown. Using Interpretive Phenomenological Analysis (IPA), the following study explored the experiences of seven parents, from which four themes emerged: ‘bearing the brunt of diagnosis’ captures the impact of the diagnosis; ‘if you can’t help me, who can?’ reveals experiences with the health system; ‘tackling the challenge of treatment’ encompasses difficulties in adhering to the treatment regime; ‘I need you to understand’ reflects desires for others support and understanding. These themes should be considered when developing support systems and interventions for parents living in non-metropolitan areas.
Prophylactic coagulation factor replacement is increasingly the treatment modality of choice for people with haemophilia (PWH). Currently available recombinant factor products require reconstitution from a lyophilised powder and diluent, and a range of infusion systems is available to assist in this process. This study aimed to understand the properties of a reconstitution/infusion system that are most important to PWH and carers of children with haemophilia (CWH), and to assess two available systems produced by Novo Nordisk for the reconstitution and infusion of activated recombinant factor VII and recombinant factor VIII: the original infusion system and the newer MixPro® system. Both were tested by a group of 67 PWH or carers of CWH who were naïve to them. Participants rated the performance of each system against 18 predefined parameters using the 7-point Likert scale, and ranked the importance of these parameters to the design of an infusion system. They also directly compared the performance of the two systems and provided qualitative feedback. Overall, MixPro® was preferred to the original system by 94% of study participants. This was reflected in the performance scores for individual parameters, with scores in 16/18 parameters being significantly higher for MixPro® (p<0.05) than the original system. Low contamination risk was seen as the most important criterion in the design and choice of an infusion system, with 97% regarding MixPro® as the superior system in this category. The MixPro® system was perceived as being quick, easy to use, convenient and portable. It is hoped that these findings may help guide the future design of infusion systems for PWH.
Haematuria is not uncommon in people with haemophilia and is mainly caused by spontaneous haemorrhage or trauma. The frequency and clinical significance of urinary schistosomiasis in the aetiology of haematuria among haemophiliacs in schistosomiasis endemic countries such as Nigeria have not been previously studied. We retrospectively analysed the clinical and laboratory data of 45 haemophiliacs with haematuria in Nigeria with the aim of determining the frequency of urinary schistosomiasis and other causes of haematuria among haemophiliacs, the haematological profiles of haemophiliacs with haematuria and the severity of schistosomal haematuria relative to non-schistosomal haematuria. Haematuria was due to spontaneous haemorrhage in 23 (51.1%) patients, trauma in 14 (31.1%) patients and schistosomiasis in 8 (17.8%) patients. There were no significant differences in mean values of haematological parameters between patients with spontaneous and traumatic haematuria. However, compared to patients with spontaneous and traumatic haematuria, patients with schistosomal haematuria had significantly lower mean Hb concentration (8.5 vs.11 and 11.5g/dl; p<0.05) and significantly higher mean eosinophil count (0.42 vs. 0.21 and 0.2×109/l; p<0.05). This study revealed that schistosomiasis was responsible for 17.8% of cases of haematuria in northern Nigerian haemophiliacs. Schistosomal haematuria was severe and caused significant anaemia in contradistinction to spontaneous and traumatic haematuria that were mild and did not cause significant anaemia. A superimposed pro-haemorrhagic host-parasite relationship was responsible for the severe haematuria seen in haemophiliacs with schistosomiasis, a situation that would potentially increase their risk of iron deficiency and its attendant consequences including childhood cognitive impairment. Haemophiliacs with haematuria in schistosomiasis endemic countries should be investigated by urinalysis for early detection and treatment. Haemophiliacs who present with haematuria in association with eosinophilia should evoke the strongest clinical suspicion for schistosomiasis. Parents of haemophiliacs should be counselled on how to protect their children from exposures to infected waters
Haemophilia is a rare blood clotting disorder. Characteristic features of the condition include extemporaneous and post-traumatic subcutaneous bleeding and mucosal haemorrhages. Genetic deficiency of coagulation factor VIII is the instrumental factor leading to haemophilia A, while deficiency of factor IX leads to haemophilia B. The most common and identified treatment modality for haemophilia A is administration of recombinant or plasma-derived factor VIII concentrate, in order to raise the levels of the deficient factor VIII. Tranexamic acid is also used as an anti-fibrinolytic agent that inhibits plasminogen activators present in oral secretion and stabilises the clot. Administration of factor IX is required in cases of haemophilia B. These treatment modalities lead to the increased longevity and quality of life of the patient. Dental conditions and treatments are more complicated and uncertain in patients with haemophilia due to bleeding risk, thus restorative dental care is of paramount importance for the patient with haemophilia. The fear of bleeding during treatment procedures is the primary cause of lack of proper dental care of people with haemophilia in countries with limited health care resources. This case report highlights the significance of clinical examination and investigation, and the importance of proper interaction between a haematologist and the periodontist for correct multidisciplinary and uneventful management of periodontal health of a patient with haemophilia.
The need to prepare children and young people with haemophilia for long-term care in the adult sector has long been accepted and is reflected in many national health care policies. Ideally, transition should be an individualised age- and development-appropriate process, through which each young person is empowered to self-manage, with support from their families and multidisciplinary team (MDT). It is widely recognised that young people who are not engaged in self-management frequently become nonadherent to therapy. For those with haemophilia, this can have a life-long impact on joint health and quality of life. In practice, anecdotal reports from individuals suggest that the transition process is often poorly planned, leaving them feeling lost and unsupported by the healthcare professionals who, until this point, have been core members of their support network. Rarely are the views of young people or their families sought regarding the outcome of their transition process. For those with less severe disease or rarer bleeding disorders, and for girls at the menarche, transition is often not addressed at all. This literature review forms the first part of a project that seeks to identify the outcome measures that can be used to drive a nurse-led initiative improvement in transition for young people with bleeding disorders, through changes in both working practices among health professionals and in the underpinning system, which enables them to put such changes into practice.
Hypertension is a well-known risk factor for ischaemic heart disease and cerebrovascular events. Globally, there is a drive to try to reduce salt intake. In an older population, where hypertension is likely to have a high prevalence, are health care professionals aware of the sodium content in replacement factor?
Risk factors for falls in the general population are frequently identified in patients with haemophilia. Screening for fall risk can help prevent significant injury in populations with high rates of falls and associated complications. We aimed to describe the rates of falls, injurious falls, near falls, and activity restriction due to fear of falling in a population of adults with haemophilia, an inherited bleeding disorder. Subjects completed a questionnaire inquiring about fall history over the previous 12 months at study onset (time 1) and again approximately 12 months later (time 2). In all, 75 patients with haemophilia between the ages of 18 and 85 participated. The annual fall rate was 33% at time 1, and 23% at time 2. 13% of subjects reported recurrent falls. The annual fall injury rate was 15% at time 1, and 16% at time 2. 63 % of subjects reported near falls at time 1, and 49% at time 2. 16% of subjects reported activity restriction due to fear of falling at time 1, and 21% at time 2. Rates of falls, recurrent falls, and fall-related injury in haemophilia patients in this study are similar to or higher than those found in community-dwelling adults aged 65 years and older, although our subjects were younger on average. These high rates were reported across all disease severities. Near falls were common among all subjects and rates of activity restriction were generally lower than those reported in older adults living in the community. Results should be replicated. Haemophilia patients should be questioned about fall history and further research into optimal fall risk prevention in this population is warranted.
Services for people with haemophilia in Uganda are poor, resulting in a very low number of confirmed diagnoses. Over the past year, the Haemophilia Foundation of Uganda (HFU) has engaged in a concerted and coordinated media campaign focusing on radio, television and social media promoting the message that haemophilia results in painful shortened lives but is a treatable condition if appropriate services are in place. At the end of 2015, this awareness campaign culminated in a patient-screening day, along with a patient information camp. In advance of the patient testing day, a team from London’s Great Ormond Street Hospital ran an educational workshop for staff from Mulago Hospital. The team also attended the testing day, taking clinical histories from those attending, and ran workshop sessions at the patient meeting. The physician-training day attracted obstetricians, paediatricians, nurses, dentists, physiotherapists, midwives and pharmacists. Delegates understood that to develop a haemophilia service in Uganda required capacity building, and awareness raising, initially at a central level but gradually moving out to the regions. Physicians in Uganda have now embarked on a journey to providing haemophilia care. The next steps are to build political engagement and to continue raising awareness among the population.
Since 2005, the Novo Nordisk Haemophilia Foundation (NNHF; www.nnhf.org) has worked in collaboration with local partners and internationally renowned experts to improve access to haemophilia care. The NNHF has identified three areas on which to focus its activities in order to create impact where it is most needed: capacity building, diagnosis and registry, and education and empowerment. Underpinning these focus areas are targeted awareness creation activities and the development of strategic partnerships, which enable and facilitate local impact creation through empowered community advocates and authority engagement. NNHF supports fellowships, local development projects, and recognises extraordinary achievements via the annual ‘NNHF Project of the Year Award’ and the ‘NNHF Community Award’. Raising awareness of haemophilia in Uganda was the NNHF global fundraiser in 2015. This article summarises how the donations raised were used to establish diagnosis and education for a better future for Uganda’s haemophilia patients.
People with haemophilia may neglect their oral hygiene due to the fear of bleeding during brushing, leading to an increase in dental caries, gingivitis and periodontitis in this group. The available literature shows very few studies on the oral health status of children with haemophilia. The aim of the current study, therefore, was to assess the oral health status of children with haemophilia in comparison with healthy children. Data were collected from a study and control groups of haemophilic and healthy children aged 6-16 years. All children were examined under standardised conditions by a single qualified examiner and Plaque Index (PI), Modified Gingival Index (MGI) and permanent decayed, missing, and filled teeth (DMFT) and primary dmft index were recorded. A questionnaire distributed to the parents was analysed using Chi-Square and Kruskal-Wallis test, and showed a significant difference in GMI and DMFT and dmft scores between the study and control groups, a lower level of parental education level in the study group, a difference in the frequency of tooth brushing between the two groups, and a statistically higher frequency of sugar consumption among the children with haemophilia. The study concluded that children with haemophilia have poor oral health status compared to healthy children. Parental education levels, beliefs and attitude towards dental health have an impact on the child’s overall dental health. This indicates a need for early intervention by dental services as a preventive measure for children with haemophilia.
Wider access to modern treatment of haemophilia has led to a growing interest in the family’s role in management. An increasing amount of research has sought to understand the psychosocial impact of living with a child with haemophilia. Understanding how such demands affect parents and families who live with the daily threat of bleeding can help health professionals to provide effective support. A literature review was undertaken with the aim of summarising the key findings from studies published since 2000. The literature review describes many common themes from observational studies that were generally consistent with those emerging from interviews of parents of children with haemophilia. Few intervention studies were identified. Overall, this evidence shows that raising a child with haemophilia can be challenging for parents and the family. Quality of life is impaired in the parents of a child with haemophilia and that many aspects of life are affected. However, providing care can also be rewarding and programmes of support, education and appropriate treatment evidently improve the well-being of parents and families.
Haemophilia and associated bleeding disorders are chronic conditions that require easy, accessible, and reliable venous access for treatment. Peripheral venous access is traditionally the first option considered for prophylaxis. The initial introduction of prophylaxis to a child is during the first two years of life, and peripheral access can be problematic. Central venous catheters (CVC), for example port-a-caths, are widely used among this group; however, these devices require surgical insertion and are not without their own complications. Data were collected on venous access methods used at the paediatric centre at the Evelina London Children’s Hospital, where 242 children are registered at the comprehensive care centre, 48 of whom have a severe bleeding disorder. Of these 48, 27 have a CVC currently (PICC n=1, port-a-cath n=25, Hickman line n=1) and 3 have an arteriovenous fistula (AVF). Patient 1 is a 12-year-old boy with severe haemophilia A and an intracranial haemorrhage at the age of 9 months. He remains on prophylaxis and had an AVF created 5 years ago following repeated port-a-cath infections and poor venous access. Patient 2 is a 7 year old boy with severe haemophilia B and an inhibitor, who has also had repeated port-a-cath infections. An AVF was constructed 2 years ago. Patient 3 is a 12-year-old girl with type III von Willebrand disease and an inhibitor. Due to need for regular factor treatment in the context of poor venous access, an AVF was formed. We have had a 100% success rate with all three AVFs at a follow-up period of 8-69 months. Our experience suggests AVF is a viable option of venous access in patients with haemophilia and other bleeding disorders, especially so for children with repeated CVC infections or poor peripheral venous access. However, this is not a straightforward option and further evidence on long-term use based on multicentre research will be beneficial in managing AVF in this group of patients.
There is little evidence on which to define the best treatment for the prevention of bleeding in people with congenital bleeding disorders undergoing surgery. As a result, treatment regimens are frequently based on local protocols developed by expert clinicians and information from uncontrolled observational studies. This article summarises the Cochrane Cystic Fibrosis and Genetic Disorders Group systematic review on ‘Treatment for preventing bleeding in people with haemophilia or other congenital bleeding disorders (CBDs) undergoing surgery’.
An integrated model of specialised-delivered care is widely accepted as the standard of care for people with haemophilia in the UK. Assessment of available evidence on patient outcomes confirms this approach. But leading the specialist care for this group of patients does not require a medical qualification. Specialist nursing is well established within the haemophilia service and offers perhaps the greatest resource as health services cope with cost constraints on the specialist provision of services.
Consensus evidence-based guidelines regarding prophylactic treatment for circumcision in patients with haemophilia are lacking. In this study, we retrospectively examined the results of circumcision of 40 consecutive neonates with haemophilia, diagnosed after delivery. Our protocol included application of a single dose of factor replacement prior to the procedure and 3 days’ oral treatment with tranexamic acid. Only 3/40 neonates with haemophilia experienced mild post-circumcision bleeding. No major or any life-threatening bleeds were encountered. As the therapy administered was minimal and the procedure simple and feasible, we concluded that circumcision in neonates with haemophilia should be performed according to family’s and physician’s discretion. Avoidance of circumcising male babies with haemophilia due to fear of bleeding complications is not supported by the results shown within our patient cohort.
Haemophilia caregivers face limitations in their life leading to perceived burden. This single-centre study investigates the impact of burden on caregivers’ health-related quality of life (HRQoL). Methods: Questionnaires for caregivers comprised demographic data, HRQoL (EQ-5D, SF-36) and caregiver burden (IOF: Impact on Family Scale). Children were also asked about their HRQoL (EQ-5D, Haemo-QoL Short Form). Results: 20 consecutive parent/child dyads participated. 80% were mothers (mean age of 39.80±6.2 years) with 1-3 haemophilic children aged 8-17 years and 2.5±1.2 children <18 years living in the household. Mothers did most childcare (80%), 50% worked part-time, and 55% reported that haemophilia had an economic impact on their family. 80% of boys had haemophilia A; 60% were severely affected. Most received home treatment (85%) and prophylaxis (80%). Caregivers’ and boys’ HRQoL was similarly good (EQ-5Dparents M=0.90±0.1 vs. EQ-5Dchild M=0.81±0.3); by contrast, boys reported better values in the EQ-VAS (Mchild=90.25±10.0 vs. Mparents=82.16±14.8). Caregivers reported highest impairments in the dimensions ‘vitality’ (M=60.00±20.5) and ‘emotional role’ (M=70.37±42.6) of the SF-36. In the IOF, caregivers reported highest impairments in the dimension ‘negative impact’ (M=60.08±20.7). Caregivers reporting high burden had significantly worse HRQoL in the domains ‘bodily pain’ (p<.028) and ‘social functioning’ (p<0.024) of the SF-36. Caregivers who reported that haemophilia had an economic impact on their family and those with a chronic disease showed significant higher impairments in caregiver burden and their HRQoL. Conclusions: The perceived burden of haemophilia has a direct impact on caregivers’ HRQoL. Further studies with haemophilia-specific instruments are needed to verify these findings.
Rates of obesity are rising in the general population. People with haemophilia are at high risk for being overweight or obese, and may benefit from physical activity-based interventions. The school setting is an ideal environment to implement physical activity based interventions as it greatly influences the first two decades of life. However, there is a lack of knowledge about the benefits of exercise for managing haemophilia, as well as possible restriction of physical activity by parents or carers due to a fear of increasing the number of bleeding episodes. Furthermore, schools and teachers may be uncertain of how to integrate physical activity for children with bleeding disorders. This article summarises the Cochrane Metabolic and Endocrine Disorders Group systematic review on ‘school-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18 and considers published literature about the role of physical activity within haemophilia.
We predicted that haemophilia would create a prohaemorrhagic host-parasite relationship, which would make haemophiliacs very vulnerable to haemorrhagic effects of intestinal helminths in tropical countries like Nigeria. If our prediction is correct, the frequency and risks of gastrointestinal haemorrhage and iron deficiency will be higher among haemophiliacs infected by helminths in comparison with uninfected haemophiliacs. Frequency of gastrointestinal haemorrhages and iron deficiency among haemophiliacs with and without intestinal helminth infections were retrospectively obtained and analysed, and their relative risk determined by regression analysis. Haemophiliacs with intestinal helminths had significantly higher frequencies of gastrointestinal haemorrhage (73.3% vs. 18.5%, p<0.05) and iron deficiency (60% vs. 22.2%, p<0.05) in comparison with haemophiliacs without intestinal helminths. Haemophiliacs with intestinal helminths had significantly elevated relative risks (RR) of gastrointestinal haemorrhage (RR=3.4, CI95%: 2.4- 4.3, p=0.007) and iron deficiency (RR=2.5, CI95%: 1.7-3.3, p=0.009). These results showed that helminth infections were associated with increased risks of gastrointestinal haemorrhage and iron deficiency in haemophiliacs. This is thought to be due to a pro-haemorrhagic host-parasite relationship resulting from host haemostatic abnormality, coupled with the concurrent manipulation of the host haemostatic system by anticoagulants produced by some of the parasites. Haemophiliacs in tropical countries should be regularly screened and treated for intestinal helminths.
The benefits of regular activity and exercise are well established, yet a third of the population of the European Union does not achieve the recommended levels of activity. For patients with haemophilia, some activity can cause bleeding into joints, leading to potential joint damage, whereas other activities can protect the joint from bleeds and further destruction. This study investigates the understanding and experience of exercise and activity in people with haemophilia (PWH). We conducted semi-structured interviews with six men with severe haemophilia using a consecutive sampling framework and Interpretative Phenomenological Analysis (IPA). We identified five themes: • “I don’t think about haemophilia, I’ve just got to deal with it” A level of acceptance of awareness of their condition, but they do not want it to rule their lives. • “I don’t let my limitations hold me back” Striving to find activities they can participate in, despite joint impairment. • ”The worst thing anyone can do is stop being active” Belief that activity helps to strengthen joints, gives confidence and improves both body and mind. • ”The best thing they did was to not wrap me up in cotton wool” Knowledge of haemophilia, how to treat and recognise bleeds, and finding activities to suit their bodies. • “Time constraints at home” Common barriers to exercise, as in the general population. Our findings provide clinicians with insight into understanding the barriers to exercise and activity in men with severe haemophilia. This can help clinicians to offer the most appropriate support and allow PWH to find an activity or exercise that suits them. Our findings demonstrate that even those with severe haemophilia wish to remain active and do not want to let their limitations prevent them from exercising. Findings also indicate that being given the education and freedom to make independent decisions about exercise and activities are valued. This suggests that clinicians need to provide a therapeutic environment where their patients can feel safe to make sensible choices about types and level of activity.
The terms ‘nurse-led service’ and ‘nurse-led care’ are often used, but are frequently not well defined. As health care delivery evolves across the world and struggles to cope with changes in medical care and with the rising number of people living longer with long term conditions, it is frequently suggested that more care should be delivered and coordinated by nurses who have the most day-to-day contact with affected individuals and their families. This paper addresses the notion of modern ‘nurse-led’ care in the 21st century, with a focus on haemophilia. Haemophilia is one specialty in which totally nurse-led and delivered care could become a reality, there is already evidence from both developing and developed countries of nurses providing excellent and innovative haemophilia care.