From August 7-9, Mayo Medical Laboratories will be hosting its 15th Bleeding and Thrombosing Diseases Conference in Rochester, Minn. The conference includes presentations from several faculty at Mayo Clinic from the Division of Hematology, Department of Internal Medicine and the Division of Hematopathology, Department of Laboratory Medicine and Pathology.
For those that are unable to attend this year's conference in person, we will be blogging updates, photos and videos throughout the conference.
On Twitter, follow the conversation using #2013BTConf.
Posted on Aug. 9 at 2:15 p.m.
Another great Mayo Clinic conference is in the books
Dr. Nichols shot a quick (71-seconds) wrap-up video for this year's conference. Thank you to our attendees, faculty and exhibitors. Also, thanks to all of you following along with our blog.
Posted on Aug. 9 at 12:40 p.m.
Panel Discussion: Question and Answer Session with Morning Presenters
Posted on Aug. 9 at 12:25 p.m.
Thrombotic and Hemostatic Disorders in Pregnancy by Dr. Aneel Ashrani
Dr. Ashrani began his presentation by outlining the burden of pregnancy and thrombosis:
- Incidence of deep vein thrombosis 70-180/100,000 women
- Incidence of pulmonary embolism: 9-65/100,000 women
- Incidence goes up with each trimester
- Greatest Risk at delivery and continues up to 4-6 weeks post partum
- Cesarean delivery (4 – 6x higher risk)
He then went on to discuss therapeutic options and anticoagulant choices for women with bleeding disorders during pregnancy.
Posted on Aug. 9 at 11:50 a.m.
Evaluating Children for Bleeding Symptoms and Disorders by Dr. Vilmarie Rodriguez
Dr. Rodriguez’s presentation detailed the:
- Diagnostic approach to evaluating a child for a bleeding disorder.
- Key features of the clinical history and PE assessment of a child with a bleeding disorder.
- Tests and applications in the management of a child with a bleeding disorder.
Specifically, she mentioned these important points related to screening for bleeding disorders in pediatrics:
- It lacks hemostatic challenges.
- Mild bleeding symptoms occur in patients with or without bleeding disorders.
- Severity is influenced by patient/parent background (i.e. education, personality, experiences).
Posted on Aug. 9 at 11:25 a.m.
Venous Thromboembolism: Selected Updates by Dr. Aneel Ashrani
Dr. Ashrani’s presentation on highlighted:
- Newer agents for treatment of venous thromboembolism (VTE)
- Alternative strategies for secondary VTE prevention
- Post thrombotic syndrome and the role of graduated compression stockings
He also offered the following take home points on new anticoagulants:
- Newer oral anticoagulants are at least as effective and safe (if not safer) compared to warfarin tor the treatment of acute VTE
- Rivaroxaban is approved for the acute VTE therapy
- Fixed daily dose
- Minimal drug and food interactions
- No anticoagulant lab monitoring
- Lack of antidote to reverse its anticoagulant effects
- Relative long half-life
Posted on Aug. 9 at 9:55 a.m.
Clinical and Laboratory Update on New Anticoagulants by Dr. John Heit
Dr. Heit's presentation gave a detailed update on Novel Oral Anticoagulants (NOACs). Specifically discussed were targets, drug interactions, trials and outcomes, and laboratory testing for:
- Dabigatran Etexilate
Posted on Aug. 8 at 5:15 p.m.
Honoring the Career of Whyte G. Owen, Ph.D.
Thursday afternoon at this year's conference was a Hemostasis Mini-Symposium, which honored the career of Whyte G. Owen, Ph.D.
Whyte Owen was born in New Orleans, La.,on May 12, 1943. In 1972, he received a Ph.D. degree in biochemistry from the University of North Carolina, under the direction of Robert H. Wagner, with a dissertation on the structure of factor VIII. After post-doctoral training at Washington University, where he studied prothrombinase, he served on the faculties of the University of Iowa departments of biochemistry and pathology until he moved in 1985 to the Mayo Clinic in Rochester, MN.
His discovery, of the association of factor VIII with a larger carrier protein, led to the elucidation of the phenotype of von Willebrand disease and launched his career in hemostasis research. He has been broadly involved in laboratory and clinical aspects of hemostasis, including the mechanism of heparin, interactions of thrombin with endothelium, and the co-discovery, with Charles T. Esmon, of thrombomodulin, control of plasminogen activation, and the physiologic significance of calcium in the regulation of hemostasis.
Highlights of Curriculum Vitae and Publications
- Published more than 122 peer-reviewed publications and 20 invited contributions.
- Earned his Bachelor of Science in zoology in 1964 and a Master of Science in physiology in 1967 from Louisiana State University in Baton Rouge, La.
- Earned his Ph.D. in biochemistry in 1972 from the University of North Carolina – Chapel Hill.
- Served his Post-Doc in biochemistry from 1972-74 at Washington University, St. Louis, Mo.
- Joined the faculty of the University of Iowa in Iowa City, Iowa in the department of biochemistry and pathology (1974-1985), serving as an Assistant Professor and then Professor.
- Dr. Owen joined Mayo Clinic in Rochester, Minn. as a Consultant and a member of the faculty, Hematology Research Section & Biochemistry/Molecular Biology (1985-2012). He achieved the academic rank of Professor and then Professor Emeritus (November 2012)
- Dr. Own also served as a Visiting Professor between 1994-2010 at the University of the West Indies, Mona (Kingston) Jamaica and St. Augustine, Trinidad and Tobago.
Posted on Aug. 8 at 3:20 p.m.
The Role of the Protein C Pathway in the Control of Coagulation and Inflammation by Dr. Charles T. Esmon
Dr. Esmon, Oklahoma Medical Research Foundation, delivered one of the key presentations at this year’s conference. He is a pioneer in the identification and understanding of the role of the protein C pathway in hemostasis and contributed new information about its role in the inflammation process.
Key topics included:
- Anticoagulation activation complex
- Thrombin-TM complex
- The role of EPCR as a substrate presenting molecule
- Histones and polyphosphates released from inflammatory leukocytes can impact protein C pathway functions, contributing to thrombosis and tissue injury
Throughout his presentation, Dr. Esmon reviewed several critical research studies that have greatly increased our knowledge of the role of the protein C pathway.
Posted on Aug. 8 at 3:20 p.m.
Plasminogen Activator Inhibitor-1 Deficiency: A Cause of Abnormal Bleeding and Much More by Dr. William P. Fay
Dr. Fay's presentation focus on the following key aspects of plasminogen activator inhibitor-1 deficiency:
- PAI-1 regulates hemostasis and thrombosis
- Healthy people can have undetectable plasma PAI-1 activity
- The clinical presentation of PAI-1 deficiency include
- Epistaxis, subcutaneous and excessive menstrual
- Delayed bleeding: Post-trauma and post-surgical
- PAI-1 deficiency is a rare bleeding disorder
- Pharmacological inhibition of PAI-1 may prove useful not only in inhibiting thrombosis, but also in inhibiting adverse vascular remodeling
Posted on Aug. 8 at 2:45 p.m.
Factor VIII: The Forbidden Fruit by Dr. John S. (Pete) Lollar of Emory University
Dr. Lollar's presentation offered the following take-away points:
- FVIII antibody epitopes are structurally and functionally complex.
- Modification of fVIII antibody epitopes or T cell epitopes to reduce immunogenicity does not seem feasible.
- Antigenic differences between human and porcine fVIII can be exploited therapeutically.
- High expression elements in porcine fVIII potentially can be exploited for gene therapy purposes and in conventional fVIII manufacture.
Posted on Aug. 8 at 1:15 p.m.
Coagulation Factor Inhibitors – Clinical and Laboratory Aspects by Dr. Rajiv Pruthi
Dr. Pruthi's presentation detailed:
- Drugs like Heparin and direct thrombin inhibitors
- Ethylenediaminetetraacetic acid (EDTA)
- Specific factor inhibitors: FVIII, FIX, Factor V Factor XI
- Non-specific inhibitors: Lupus anticoagulants and Global inhibitors like monoclonal protein and LPD
- Unusual inhibitors: Factor XIII inhibitors
Reptiles, Leeches and Coagulation by Dr. Mrinal Patnaik
During his presentation, Dr. Patnaik discussed:
- An Introduction to herpetology (the study of reptiles and amphibians).
- An overview of snake envenomation syndromes, including: acute flaccid paralysis, rhabdomyolysis, thrombotic microangiopathy, systemic coagulopathy, acute renal injury, and local tissue damage.
- The relationship of snake venoms and coagulation.
- Leeches of medicinal value, which in 1905 provided the first anticoagulant for humans and are still in use today in some applications.
- Contribution of these animals in coagulation testing and drug development.
Posted on Aug. 8 at 10:55 a.m.
DIC (ICF) and Laboratory/Clinical Evaluation by Dr. Rajiv Pruthi
During his presentation, Dr. Pruthi detailed the pathophysiology, diagnosis/laboratory assessment (overt and non-overt scoring system), and management of disseminated intravascular coagulation (DIC).
Diagnosis of DIC (ICF) is based on the clinical scenario/laboratory data. However, DIC (ICF) is a dynamic situation and no single test is diagnostic. The laboratory abnormalities in decreasing order of frequency are:
- Elevated fibrin degredation products
- Prolonged PT
- Prolonged aPTT
- Low fibrinogen
Posted on Aug. 8 at 10:15 a.m.
Issues and Updates in Anti-Phospholipid Antibody Serologic Testing by Dr. Melissa Snyder
Among the Anti-Phospholipid Syndrome topics discussed by Dr. Snyder were:
- Antibody Nomenclature and Subsets
- Challenges in Antibody Testing
- Antibody Testing Guidelines
- Frequency of Positive Results
Dr. Synder also discussed the design of an algorithmic approach to anti-phospholipid testing beginning with anti-CL IgG and IgM testing.
Posted on Aug. 8 at 9:25 a.m.
Lupus Anticoagulants, Antiphospholipid Antibodies and Syndrome: Overview and Update by Dr. Thomas Ortel of Duke University Medical Center
During his presentation, Dr. Ortel:
- Reviewed the clinical manifestations of APS.
- Identified and explained the diagnostic laboratory tests and strategies used for APS.
- Reviewed therapeutic management of patients with antiphospholipid antibodies and APS.
Posted on Aug. 7 at 4:30 p.m.
Heparin-Induced Thrombocytopenia (HIT) – Laboratory and Clinical Diagnosis and Management by Dr. Thomas Ortel of Duke University Medical Center
- Clinical assessment remains the most important aspect to make an accurate diagnosis of HIT.
- Laboratory testing helps confirm (or refute) the diagnosis of HIT, but many patients may have positive results in the heparin/PF4 antibody ELISA and not have HIT
- We have several anticoagulant options for patients with HIT, but overall outcomes for these patients remain poor.
Posted on Aug. 7 at 3:30 p.m.
TTP (Thrombotic Thrombocytopenic Purpura): Clinical and Laboratory Update by Dr. Michelle Elliott
- Dr. Elliott presented a detailed review of Thrombotic Thrombocytopenic Purpura (TTP).
- TTP is defined by systemic platelet rich microvascular thrombi, which manifests as consumptive thrombocytopenia, mechanical red cell fragmentation or end-organ ischemia.
- TTP has long been studied dating back to its discovery in 1924.
- Rapid fulminant of a clinical course for TTP is essential illustrated by the fact that prior to use of plasma exchange, the mortality rate was greater than 90%. In comparison, current outcomes improved with a mortality rate between 10-20%.
- Diagnosis in current clinical practice is based on the “Triad”: microangiopathic hemolytic anemia, thrombocytopenia and the absence of an alternative explanation.
Posted on Aug. 7 at 3:10 p.m.
Hereditary Platelet Disorders: Laboratory Testing Update by Dr. Dong Chen
Dr. Chen's presentation provided a detailed view of the spectrum of platelet testing. Below are the four main areas of focus:
- Pre-analytical activities for platelet lab testing should focus on a patient's personal and family bleeding history.
- Platelet morphology testing options available to providers are peripheral blood CBC and peripheral blood smear.
- Common platelet functional tests include platelet aggregation and platelet function analysis (PFA-100).
- Esoteric Testing examples are platelet flow cytometry, platelet transmission electron microscopy and genotyping studies.
Posted on Aug. 7 at 2:10 p.m.
Von Willebrand Disease: Laboratory and Clinical Update by Dr. William Nichols
During his presentation, Dr. Nichols:
- Described the recommendations for initial clinical evaluation for VWD or similar bleeding disorder.
- Discussed recommended initial and supplemental laboratory testing for VWD including evolving newer methods.
- Emphasized the role of pre-analytical variables of the patient and sample that can impact test results.
- Outlined the important aspects of the revised (2006) classification of VWD along with several examples of typical test results.
- Reviewed a list of the categories of medical disorders that may cause acquired von Willebrand syndrome (AVWS) or acquired VWF abnormality (AVWA).
Posted on Aug. 7 at 1:45 p.m.
Lunch in the park
Over the lunch hour, the conference attendees had lunch in Central Park in beautiful downtown Rochester, Minn. At the sun-filled picnic, attendees and faculty continued the conversation and discussed the morning sessions.
Posted on Aug. 7 at 12:15 p.m.
This morning's speakers took questions from the conference attendees.
Posted on Aug. 7 at 11:10 a.m.
Dr. Paula Santrach now on stage to present Point of Care Hemostasis Testing: Current Approaches
- Point-of-care testing
- The Good - Rapid turnaround time, easy to use in general and accessible.
- The Not so Good - Comparability to laboratory methods, cost and oversight issues.
True clinical utility depends on facilitation of clinical workflow, facilitation of clinical decision-making, improved patient outcomes and it is not something you should do just because you can.
Examples of current usages of point of care testing include Warfarin anticoagulation monitoring, Heparin anticoagulation monitoring, Transfusion decision-making, and Anti-platelet therapy assessment.
Posted on Aug. 7 at 10:30 a.m.
Dr. Bill Nichols is now presenting Evaluation of Unexplained Prolonged APTT and/or PT
- Prolonged clotting time mechanisms include coagulation factor deficiency(ies), coagulation inhibition, both or neither (spurious).
- Remember the mnemonic "SICKFAIL" for pathophysicalogic classification: Spurious, Inhibitors, Congenital/Hereditary factor deficiencies, Vitamin K deficiency, Factor deficiencies (acquired), Anticoagulants, Intravascular coagulation and fibrinolysis, and Liver disease.
Posted on Aug. 7 at 9:30 a.m.
Pre-analytical Variables and Issues in Coagulation Testing by Layna Cardel, MT (ASCP), Education Specialist, Special Coagulation Laboratory
- Pre-analytical variables that are in our control and should always be considered when encountering unexpected results are patient identification, sample collection, sample transport, sample processing and sample storage.
Adhering to the guidelines for specimen collection, transport, processing and storage will minimize the effect of these variables.
Awareness of potential patient variables and knowledge of assay performance can bring attention to suspicious results.
Discrepant/unexpected results may be an indication of possible error.
Posted on Aug. 7 at 8:47 a.m.
C. Christopher Hook, is presenting The Hemostatic History: The Most Important Test
- Dr. Hook is reviewing a number of patient cases, providing clinical history and discuss the process of diagnosis.
- Emphasizing the importance of Hemostatic History and discussing the key aspects to consider.
- Reviewing medications with the patient is a critical activity.
- Thrombosis history components include age of onset, location, documentation, type, drugs, family history, smoking history and others.
Posted on Aug. 7 at 8:15 a.m.
Dr. Rajiv Pruthi is presenting Hemostasis 101: Basic Refresher and Update.
Posted on Aug. 7 at 8:12 a.m.
We are ready to go and the podium is ready for Dr. Rajiv Pruthi's presentation: Hemostasis 101: Basic Refresher and Update.
Posted on Aug. 5 at 1 p.m.
Dr. William Nichols previews the 2013 Mayo Clinic conference, which will provide reviews and updates about laboratory and clinical aspects of bleeding and thrombosing disorders. Didactic presentations will be supplemented with panel discussions and case presentations. The conference will be held in Rochester, Minn. from Aug. 7-9.