Thromboelastography testing in mice following blood collection from facial vein and cardiac puncture Blood collection is critical for mouse research studies particularly in hemostatic testing. Cardiac puncture; a standard effective method requires anesthesia and is a terminal procedure while facial vein technique allows multiple collections. Thromboelastography (TEG) is a global hemostasis test, provides a dynamic real-time picture of coagulation. However, TEG experiments in mice require large number of animals and may not allow pre/postinterventions assessment. In this study, we aimed to investigate the feasibility of facial vein sampling for TEG analysis as an alternative to cardiac puncture and examined the impact on coagulation results. Blood samples were obtained from a total of 10 C57BL/6 and CD-1 mice via cardiac puncture and a total of another eight mice of similar strains via facial vein sampling. We compared TEG parameters in both methods using descriptive statistics and the Student t test. Results show no significant difference in any of the TEG parameters between cardiac and facial vein blood indicating the two methods are comparable. Facial vein sampling provides a less costly alternative to cardiac puncture. It is a suitable blood collection method for pre/postinterventions or follow-up studies and it better addresses reduction and refinement goals in mouse studies. A larger study to evaluate the sex or strain and genetic background differences will be valuable. Correspondence to Dr Maha Othman, MD, MSc, PhD, Associate Professor, Department of Biomedical and Molecular Sciences, Queen's University, Boterell Hall, Room 513, Kingston, ON, Canada K7L 3N6. Tel: +1 613 533 6108; fax: +1 613 533 2022; e-mail: othman@queensu.ca Received 5 April, 2019 Revised 17 May, 2019 Accepted 26 June, 2019 Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Prolonged activated partial thromboplastin time due to plasma prekallikrein deficiency: a case study and literature review on its clinical significance Activated partial thromboplastin time is a test assessing the intrinsic and common pathways of the coagulation cascade. We presented an asymptomatic case with isolated activated partial thromboplastin time prolongation. After excluding coagulation factor deficiency and lupus anticoagulant, the patient was diagnosed with plasma prekallikrein (PPK) deficiency. We reviewed the literature regarding effects of PPK deficiency which could have both antithrombotic and prothrombotic effects. At the moment, research supports that PPK deficiency in healthy adults rarely causes bleeding as it is not a major contributor of hemastasis; whereas in adults with multiple comorbidities or with predominant systemic inflammation, effects of PPK deficiency remain debatable. Further research is needed to clarify impacts of PPK deficiency in clinical settings. Correspondence to Kehua Zhou, MD, DPT, Catholic Health System Internal Medicine Training Program, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA. E-mail: kehuazho@buffalo.edu Received 20 May, 2019 Revised 23 June, 2019 Accepted 26 June, 2019 Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Antithrombin concentrate during pregnancy in congenital antithrombin deficiency: a single-center experience Pregnancy carries a high risk of thromboembolic complications, especially in the postpartum period. This risk is particularly high in women with inherited thrombophilias, among these antithrombin deficiency seems to carry the highest risk. In this case, the use of low molecular weight heparin (LMWH) is recommended, while the use of antithrombin concentrate is controversial. We report our experience of seven pregnancies occurred in five women: two, with a personal and familiar history negative for venous thromboembolism, were treated with LMWH during pregnancy and antithrombin concentrate immediately before and after the delivery. The other three women had a personal and familiar history positive for venous thromboembolism and were treated with LMWH and antithrombin concentrate during all the pregnancy and the postpartum period. No thromboembolic or hemorrhagic complications were observed in both groups, demonstrating that our strategy could be safe and effective. Correspondence to Antonella Bruzzese, Hematology, Department of Translational and Precision Medicine, Sapienza University, Via Benevento 6, 00161 Rome, Italy. Tel: +39 06 857951; fax: +39 06 44241984; e-mail: bruzzese@bce.uniroma1.it Received 17 January, 2019 Revised 12 May, 2019 Accepted 4 June, 2019 Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Hemostasis-related gene polymorphisms and their epistatic relationship in women with idiopathic infertility A numerous factor can cause infertility, but around one of four reproductive failure cases remain unexplained and diagnosed as idiopathic infertility. In the past few decades, analysis of gene polymorphisms takes a significant place in pathogenesis of infertility. The aim of this study was to evaluate the possible role of hemostasis-related gene polymorphisms in unexplained infertility. The study includes 117 female patients with idiopathic infertility and 130 fertile women with at least one born child. Eight polymorphisms important for hemostasis (ITGB3 1565T>C, FV 1691G>A, FII 20210G>A, MTHFR 677C>T and 1298A>C, ATIII 786G>A, PAI-14G/5G and ACE I/D) were genotyped by real-time PCR system. The frequencies of alleles and genotypes of examined polymorphisms were analyzed in SPSS statistical program, whereas gene interactions were identified using the GMDR software. Examination of etiological factors has shown that family history is a significant factor in assessing individual risk for infertility. The alleles and genotypes frequency of FV 1691G>A and FII 20210G>A polymorphisms were statistically different between control and patient group leading to a greater risk for infertility. The analysis of epistatic relationship between examined hemostasis-related gene polymorphisms identified more complex high-risk genotypes associated with infertility. Our results suggest that positive family history could be important predictive factor for fertility problems, pointing to the potential hereditary basis of this condition. Polymorphisms FVL and FII prothrombin are independent risk factors for idiopathic infertility, whereas multilocus interactions approach should be taken into consideration for the future research. Correspondence to Jelena Velickovic, PhD, Institute of Forensic Medicine, Faculty of Medicine, University of Belgrade, Deligradska 31a, 11000 Belgrade, Serbia. Tel: +381 11 3617931; fax: +381 11 3617931; e-mail: djurovic_j@yahoo.com Received 22 January, 2019 Revised 22 January, 2019 Accepted 10 June, 2019 Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (www.bloodcoagulation.com). Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Development of an inhibitor in a child with severe hemophilia B: treatment with immunosuppression and an extended desensitization protocol Development of neutralizing alloantibodies in hemophilia B is a less common, but clinically challenging phenomenon. Novel therapeutics for hemophilia B have recently been developed and reports of clinical experience with these agents outside of clinical trials are needed. We report development of an inhibitor in a child with severe hemophilia B, and subsequent immune tolerance induction using an extended desensitization protocol with the addition of immunosuppression. This case highlights successful management of a rare complication in a rare bleeding disorder and the need for additional investigation into this infrequent and clinically challenging occurrence. Correspondence to Jonathan C. Roberts, MD, Bleeding & Clotting Disorders Institute, 9128 N Lindbergh Dr, Peoria, IL 61615, USA. Tel: +1 309 692 5337; fax: +1 309 693 3913; e-mail: jroberts@ilbcdi.org Received 4 February, 2019 Revised 17 April, 2019 Accepted 4 June, 2019 Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Rare clotting factor deficiency among Sudanese children Rare clotting factor (F) deficiency is a deficiency of one or more of coagulation factors other than FVIII, FIX and vonWillebrand (FI, FII, FV, FV + FVIII, FVII, FIX, FX, FXI and FXIII) that cause bleeding disorders and are inherited as autosomal recessive. Descriptive study was conducted in Hemophilia Centre, Khartoum, Sudan. The medical files of pediatric patients presented to the center were reviewed retrospectively. Forty-seven patients (male : female ratio = 1.2 : 1) were included. The majority (93.6%) have parental history of consanguinity and around one third (31.9%) have family history of bleeding disorder. FV deficiency was the most common deficient factor (36.2%) followed by FI deficiency (23.4%) and FX111 deficiency (21.3%). Bruising (46.8%) and epistaxis (25.5%) were the most common presenting complains. FV deficiency mainly presented with cutaneous ecchymosis (47.1%). FI deficiency presented with umbilical bleeding (45.5%) and FXIII presented with cutaneous ecchymosis (50%). Rare clotting factor deficiency is an existing disease in Sudan with the male : female ratio was 1.2 : 1. FV deficiency, FI deficiency, FXIII deficiency were the common deficiency encountered. Correspondence to Ishag Adam, MD, PhD, Faculty of Medicine, University of Khartoum, PO Box 102, Khartoum, Sudan. Tel: +249 912168988; fax: +249 183771211; e-mail: ishagadam@hotmail.com Received 12 February, 2019 Revised 29 April, 2019 Accepted 4 June, 2019 Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

The predictive value of stress hyperglycemia on thrombus burden in nondiabetic patients with ST-segment elevation myocardial infarction It is established that hyperglycemia directly effects the platelet functions and fibrin structure. In this study, we aimed to investigate the predictive value of hyperglycemia on thrombus burden in nondiabetic patients with ST-segment elevation myocardial infarction (STEMI) who underwent to primer percutaneous coronary intervention (PPCI). We enrolled 619 nondiabetic patients with STEMI who received PPCI. Patients were divided two groups according to thrombus burden. Stress hyperglycemia was determined as blood glucose concentration more than 180 mg/dl and angiographic coronary thrombus burden was scored based on thrombolysis in myocardial infarction thrombus grades. Patients with thrombus grades 4 were defined as large thrombus burden (LTB), patients with thrombus burden less than thrombus grades 4 were defined as small thrombus burden. A total of 68 (11.0%) STEMI patients had stress hyperglycemia, while 223 (36.0%) patients had LTB. Sex, the prevalence of hypertension, smoking, and dyslipidemia were not different between the thrombus burden groups (P > 0.05 for all parameters). Compared with the patients with small thrombus burden, the patients with LTB were had significantly higher admission blood glucose concentrations (135 ± 39.1 mg/dl vs. 145.9 ± 43.1, P = 0.002, respectively). The multivariate logistic regression analysis demonstrated that stress hyperglycemia is an independent predictor of LTB (odds ratio: 3.025, confidence interval 1.200–7.622, P = 0.019). Admission hyperglycemia is associated with the LTB which cause adverse cardiac outcomes. Hyperglycemia may play a role on thrombus development. Correspondence to Serhat Sigirci, Cardiologist, Department of Cardiology, Sisli Hamidiye Etfal Training and Research Hospital, Sisli, 34377 Istanbul, Turkey. Tel: +00 90 555 636 8034; fax: +00 90 212 224 0772; e-mail: serhatsigirci@gmail.com Received 26 March, 2019 Revised 29 May, 2019 Accepted 10 June, 2019 Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Thrombopoietin receptor agonists as second-line therapy in splenectomy-eligible persistent immune thrombocytopenia: a case series Thrombopoietin receptor agonists (TPO-RA) are currently approved to treat chronic immune thrombocytopenia (ITP) but there is increasing interest in considering these drugs earlier during the course of the disease. We present six patients with primary ITP resistant to corticosteroids and intravenous immunoglobulins, who received TPO-RA in the persistent phase and then underwent splenectomy in the chronic phase. Eltrombopag was administered as a second-line therapy in four patients, whereas two patients received romiplostim. Five out of six patients rapidly reached response or complete response (four and one, respectively) and steroid suspension. In one case, remission was obtained with steroid and TPO-RA. No significant side effects were reported. After splenectomy, complete response and response was reached in four and two patients, respectively. One relapse was recorded, rescued by steroid and eltrombopag. Postsplenectomy complication was registered in one patient (grade 4 intra-abdominal bleeding). TPO-RA could be a valuable choice in ITP patients in persistent phase candidates to splenectomy. Correspondence to Fabrizio Vianello, MD, Department of Medicine, Haematology and Immunology Unit, University of Padova, Padua, Italy. Tel: +39 049 821 2176; fax: +39 049 821 1853; e-mail: fabrizio.vianello@unipd.it Received 12 April, 2019 Revised 20 May, 2019 Accepted 24 May, 2019 Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Measuring high on-treatment platelet reactivity in clinical practice should we use a panel of platelet function tests? High on-treatment platelet reactivity (HPR) on P2Y12-inhibitors in patients treated with dual antiplatelet therapy is strongly associated with adverse ischaemic events. Studies have shown conflicting results with regard to the correlation and agreement between the different tests. Several assays are available to establish HPR. A composite advice based on more than one test might be a better way to identify HPR patients. To compare HPR rates and agreement between individual platelet function tests and a panel of three tests In our large percutaneous coronary intervention centre, all patients who suffered a stent thrombosis were invited back to a dedicated clinic. Platelet function testing was performed in all patients and matched control patients. HPR rates were compared between individual tests and with a composite comprised of three tests. A total of 242 patients were included, of whom in 193 patients all tests were available. HPR rates ranged from 14.6% [VerifyNow cut-off >235 platelet reactivity units (PRU)] to 49.7% (Vasodilator-Stimulated Phosphoprotein Assay). HPR according to the composite advice (≥2 out of 3 tests indicating HPR) was present in 29.8% of patients. The best correlation with the composite advice was observed with light transmittance aggregometry (kappa = 0.78) and VerifyNow (lower cut-off >208 PRU; kappa = 0.68). VerifyNow with cut-off more than 235 PRU identified the smallest proportion of patients with HPR, whereas Vasodilator-Stimulated Phosphoprotein Assay seemed to ‘over-identify’ HPR. In this real life patient cohort, a large variability was observed between four different platelet function tests. The use of a composite advice based on three tests is a promising alternative. Correspondence to Jurriën M. ten Berg, MD, PhD, MSc, FESC, FACC, Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands. Tel: +088 320 3000; fax: +31 30 6034420; e-mail: j.ten.berg@antoniusziekenhuis.nl Received 16 April, 2019 Revised 28 May, 2019 Accepted 10 June, 2019 Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Limitations of prophylactic treatment in patients with hemophilia Prophylaxis with factor VIII concentrates is the cornerstone of treatment for severe hemophilia A. In children, early onset of primary and secondary prophylaxis is the gold standard in most of countries with adequate financial resources. In adults, it is reasonable to continue the prophylactic treatment initiated during childhood to preserve joint functionality. Adults with advanced hemophilic arthropathy can also benefit from tertiary prophylaxis, showing reductions in bleeding episodes, target joints and missed days from work. The long-term evolution of hemophilic patients usually depends on how successfully prophylaxis can prevent bleeding in both children and adults. For prophylaxis to be efficient it is essential to consider the resources available (factor concentrate use and trough levels) and the patient's bleeding phenotype and clinical situation (levels of activity required, presence of chronic synovitis and arthropathy), and to define the annual number of bleeds (particularly into joints) acceptable for each patient. Correspondence to María Fernanda López Fernández, MD, PhD, Hemostasis and Thrombosis Unit, Department of Hematology and Transfusion, Integrated Health Management Directorship, A Coruña, Spain. E-mail: mflopezfer@gmail.com Received 24 June, 2018 Revised 18 March, 2019 Accepted 20 March, 2019 Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.