60% of blood clots happen as a result of a hospital stay and many are preventable. Thrombosis Ireland & HSE have rolled out one million Blood Clot Alert Cards to all the Irish Public Acute Hospitals with the recommendation that they be used as part of their hospital VTE (venous thromboembolism) prevention strategy. All patients admitted should receive this card before discharge as their risk of getting a blood clot remains high for 90 days after they go home.

What is a blood clot?

A blood clot is made up of platelets and red blood cells that form a plug and a mesh of cross-linked fibrin protein, causing a blockage in a blood vessel. Blood clots do not discriminate between young, old, male or female. They can happen to anyone. They are very treatable if caught in time but can be potentially fatal if ignored or missed, so awareness can be lifesaving.

What increases your risk of getting a blood clot?

• A hospital stay – and the following 90 days once you’re home.
• Having active cancer or receiving cancer treatment.
• Being pregnant or having had a baby fewer than six weeks ago
• Becoming immobile (more than three days in bed/travel non-stop more than six hours/ in a leg cast

Risk may increase further if:

• You or a close relative had a blood clot
• You had surgery in the last 90 days
• You have thrombophilia (tendency to clot)
• You are on the oral contraceptive pill or HRT
• You have heart, lung or inflammatory disease
• You are over 60 years of age or are overweight
• You have varicose veins that become red and sore

Signs and symptoms of a blood clot:

• Swelling or pain in one leg, usually the calf, or arm
• warmth or redness in the leg or arm
• Shortness of breath or rapid breathing
• Chest pain (particularly when breathing deeply)
• Coughing or coughing up blood

If you have one or more of these symptoms, you may have a clot and need urgent treatment. Do not delay seeking medical advice.

Blood clots are preventable in many cases and very treatable if caught on time. Patients and carers need to be aware of the risks and the signs of a blood clot, in order to protect themselves and their loved ones, particularly in the 90 days after discharge from hospital.

Blood Clot Alert Card

The Blood Clot Alert Card is designed to be used as an information tool for patients admitted to our acute hospitals. It informs patients of their risk, the signs and the need to get medical attention fast. It also prompts them to request a VTE risk assessment from their doctor to assess if they need intervention to prevent blood clots while in hospital and when they go home.

It reminds them of the importance of walking and moving as much as possible to keep their blood flowing and the need to keep hydrated. Awareness about blood clots will save lives. Patients are entitled to be informed so they can be vigilant and proactive about their health.

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Multiple myeloma is the second most common blood cancer in Ireland and is diagnosed in approximately 250 patients per year in this country. The disease can be detected incidentally when an abnormal protein is found in the blood or urine, or the patient can experience symptoms, which raise the alarm that something is wrong.

Worldwide in 2020, patients with multiple myeloma are benefitting from the many new treatments that have become available for this disease over the last 15 years. This is translating into a better quality of life on treatment and longer survival for patients in Ireland.

Earlier detection, due to greater awareness of the disease and more sensitive tests, has also led to improvements for patients. However, this cancer typically follows a remitting and relapsing course, which means that patients need close monitoring and new treatments to be available to them when the disease re-emerges in their blood or bone marrow.

Aiming to personalise approach to treatment

Predicting when the disease might re-emerge and what treatment is best suited to a particular patient is one of the biggest challenges we face in treating this disease.

Along with new treatments, advanced testing techniques have also been developed worldwide in recent years with the aim of delivering a more personalised approach to treating this disease in individual patients.

One such test is “minimal residual disease” (MRD), which has emerged from several international clinical studies as an important predictor of remission times and survival in multiple myeloma. This test may also help doctors to decide which patients might benefit from certain types of treatment, particularly when combined with genetic tests of cancer cells.

At Beaumont Hospital and Royal College of Surgeons in Ireland (RCSI), in collaboration with several hospitals throughout Ireland, via the Blood Cancer Network Ireland and Cancer Trials Ireland, we are carrying out a research study looking at combination of MRD and genetic tests to try to identify how patients will respond to treatment, and learn more about predicting prognosis.

We hope that, in future, this will lead to a more personalised approach to the treatment of this disease for Irish patients.

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Developments in CAR-T therapy for multiple myeloma have lagged behind those for other forms of blood cancers, but that’s all changing.

Results from the first significant trials into CAR-T therapy for multiple myeloma, a bone marrow cancer, were published last year and offer fresh promise for patients who have few other options.

Patients who participated in the trials, including a few from Ireland, all had an advanced stage of the disease, and had already undergone multiple other treatment cycles.

“We’re aware of patients getting very good responses, but unfortunately, those are not sustained beyond six to 12 months,” explains Professor Paul Browne, Professor of Haematology at Trinity College Dublin.

Waiting for mature results, but it’s a positive start

The second generation of trials addressing issues of durability are ongoing. These studies are also assessing whether outcomes could be improved by bringing CAR-T therapy forward in a patient’s myeloma experience, rather than waiting until they are at an advanced stage.

“In principal, that sounds like an appealing idea, but we’re going to have to wait for mature results,” continues Browne.

Initial signs are promising but, realistically, it will be years rather than months before there is any talk of mass roll out and licencing.

It’s worth remembering though that, as research gathers momentum, more patients will have the opportunity to access the therapy through trials.

Browne is hopeful that some may even be conducted in Ireland. Infrastructure and funding are already in place to start treating patients who have other forms of blood cancer with CAR-T therapy in the country in the very near future.

“Trials are our aim,” confirms Browne. “We have a very good track record of delivering stem cell therapy. We have a very attractive system with an integrated approach working with partners, and some seed funding.”

While great leaps have been made in advancing CAR-T therapy to treat multiple myeloma, it takes significant time to accumulate the evidence needed to progress further.

The journey continues, but it does so with great hope.

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The long-cherished hope of seeing gene therapy and a possible functional cure for haemophilia is now visible on the horizon.

A person with haemophilia B has a deficiency in coagulation Factor IX. In normal individuals without haemophilia, the Factor IX level is typically between 50% and 150%. In severe haemophilia, it is usually less than 1%.

Gene therapy involves an intravenous infusion of a modified human Factor IX gene, carried within an attenuated virus known as an adeno associated virus (AAV). This delivery system is known as a vector. AAV virus does not cause illness. In this case it is acting as a delivery system for the FIX gene. The vector travels to the liver where the FIX gene is released, and these liver cells then start producing factor IX.

Three individuals undergoing clinical trials

On World Haemophilia Day in April 2019, the Irish Haemophilia Society highlighted the fact that clinical trials of gene therapy for both haemophilia A and haemophilia B (the rarer form) were underway globally. We are working with the haemophilia clinicians to provide the opportunity for some people with haemophilia in Ireland to participate in some of these clinical trials.

The long-cherished hope of seeing gene therapy and a possible functional cure for haemophilia is now visible on the horizon.

In March this year, we announced that the first Irish person with haemophilia B had been treated with gene therapy as part of a clinical trial. Since then, the number of people treated has been increased to three. All three individuals are reported to be doing well.

Findings so far

In the earlier dose finding study, FIX levels six months post infusion ranged from 33% to 57%. This changed the individual from having severe haemophilia to mild haemophilia or even normal. It is also our hope that people with haemophilia in Ireland will have an opportunity to participate in Factor VIII Gene Therapy clinical trials (for haemophilia A) in 2021.

Gene therapy could be licenced in the near future

Gene therapy for haemophilia has been on the horizon for over 20 years. It is now close to becoming a licenced therapy. It is anticipated that the first Factor VIII gene therapy will be licenced later this year and the first Factor IX gene therapy will be licenced in 2021.

When licenced, these therapies will initially be options only for adults with severe haemophilia. (As the liver in a child continues to develop, there is significant turnover of liver cells so the current gene therapies in clinical trials would not be suitable for children as the liver cells producing the factor would be lost as the child’s liver cells changed).

A functional cure for haemophilia?

The current therapies in clinical trials are also one-off therapies as the person will develop antibodies to the AAV, thereby preventing retreatment. Work is ongoing to allow retreatment in the future. For most of the clinical trials, individuals with pre-existing AAV antibodies are also excluded. The Factor IX trial here is an exception as, with this particular vector, those with pre-existing antibodies can be included without damaging the effectiveness.

Questions remain regarding the range of factor expression we will see and the duration of expression, but the long-cherished hope of seeing gene therapy and a possible functional cure for haemophilia is now visible on the horizon.

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A novel class of drugs holds promise for patients with diffuse large B-cell lymphoma who don’t respond to first line treatment or relapse.  

Diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma and over 800 people are diagnosed with it in Ireland each year.

However, a third of patients don’t respond to first line treatment or relapse and the options for them are limited.

There has been considerable interest in CAR-T therapy in recent years. The treatment, which involves programming a patient’s immune system to target the cancer by re-infusing genetically edited T cells, certainly holds great promise, but it isn’t suitable for everyone. It’s challenging and extremely expensive.

Dr Brian Bird, Consultant Medical Oncologist at Bon Secours Health System, is keen to highlight other, potentially more accessible, new treatments.

“There are more options for elderly people who don’t respond to first line chemotherapy or where a transplant hasn’t worked or isn’t an option. The one that’s going to be most relevant to the greatest number of people are antibody-drug conjugates,” he confirms.

Treatment options

As it currently stands, the first line treatment for most DLBCL patients is a combination of chemotherapy drugs known as R-CHOP.

For patients who don’t respond or relapse, the next option is an autologous hematopoietic stem cell transplant followed by high dose chemotherapy.

Transplants are lengthy, risky and not generally considered for anyone over 70.

“Of the third of people who relapse, only half of those will be fit to start a transplant and only half of those will be cured. That leaves us with an unserved population,” confirms Dr Bird.

For this “unserved population” there are few alternatives, which is why trials currently taking place into antibody-drug conjugates (ADCs) are so exciting.

This novel treatment combines powerful cancer drugs with an antibody that allows them to be delivered directly to cancer cells, which limits damage to healthy cells.

Benefits of antibody-drug conjugate

ADCs are already licensed for use in the US and EU but not reimbursed in Ireland and Dr Bird believes they could bring fresh hope to forgotten patients with DLBCL in Ireland.

“It seems to be well tolerated in frail and elderly patients with co-morbidities. I don’t think it’s a cure for the majority of patients, but it’s a very helpful drug in terms of prolongation of life,” confirms Dr Bird.

Other research is taking place into therapies, such as cell signal blockers, other antibodies, bispecific antibodies, and checkpoint inhibitors, that have already been used to successfully treat other lymphomas.

However, Dr Bird is hopeful that the phase three trial currently taking place into the efficacy of ADCs in first line DLBCL will mean that patients in Ireland could benefit within the next few years.

“I do think that drugs like this are important advances in this population and would be optimistic that it may move into earlier lines of treatment, should the clinical trials be positive” he concludes.

Veeva no- M-IE-00000106
Date of preparation- June 2020

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Hospital-acquired venous thromboembolism (HA-VTE) is the leading cause of preventable hospital deaths.

Venous thromboembolism: Acute and chronic morbidity & mortality

Venous thromboembolism (VTE), which comprises primarily of pulmonary embolism (PE) and deep vein thrombosis (DVT), has an annual incidence of approximately one in 1,000.

VTE is recognised as being a leading cause of cardiovascular mortality worldwide. Among survivors, a substantial burden of chronic morbidity has been reported.

Well-known chronic complications of VTE include a potentially life-threatening pulmonary vascular disease called chronic thromboembolic pulmonary hypertension, and post-thrombotic syndrome; a disorder characterised by chronic pain, swelling and ulceration of limbs affected by deep vein thrombosis.

Recent data pertaining to a range of other newly described ‘post-PE’ syndromes has also been reported, suggesting that a substantial burden of chronic morbidity associated with this condition exists, which has likely been under-appreciated until recently.

This chronic morbidity associated with VTE is a major contributor to healthcare resource utilisation globally as well as a major negative influence on patient quality of life.

Hospital-acquired VTE

A number of risk factors have been identified as being associated with an increased risk of VTE.

Major surgery, active cancer, prolonged immobilisation with medical illness and traumatic injury with limb fracture are amongst the most clinically significant VTE risk factors encountered in clinical practice. Other risk factors include pregnancy, oestrogen therapy and long-haul travel.

However, while VTE may arise for different reasons in different people, the majority of all these VTE events occur during admission to hospital.

This is likely because multiple transient VTE risk factors frequently arise among hospital in-patients (such as immobility, acute infection/inflammation, major surgery etc.).

Crucially, while VTE is common in hospitals, high-quality data has consistently demonstrated that the majority of these VTE events are preventable, provided appropriate steps to reduce VTE risk are taken.

Effective VTE prevention strategies consist primarily of the use of validated clinical risk assessment tools (to identify high-risk patients) followed by the appropriate use of pharmacological thromboprophylaxis with anticoagulant medicines to reduce the chance of blood clotting during these high-risk periods.

As most instances of HA-VTE are preventable, deaths associated with HA-VTE are also likely to be preventable in many cases.

The implementation of standardised VTE prevention strategies in other countries, including the UK, has been proven to reduce VTE-related mortality in hospitals.

Recently, the HSE has made a concerted effort to address the major risk posed by HA-VTE in Irish hospitals.

Guidelines for prevention of HA-VTE in Ireland have been published and a HA-VTE national key performance indicator has been introduced for all Irish hospitals to drive VTE quality improvement initiatives.

VTE prevention in the era of COVID-19

COVID-19 is posing challenges across our healthcare system. At an early stage of the pandemic, derangements of blood coagulation were identified as being hallmarks of this infection and as being indicators of poor outcome.

Moreover, very high rates of thrombosis have been reported, which are associated with COVID-19, and appear to occur despite standard VTE prevention practices.

Clinical trials to determine the optimal prevention strategy are awaited but, in the interim, adherence to existing evidence-based guidelines for VTE prevention and maintaining a high level of vigilance in our approach to VTE prevention is vital.

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The pandemic has had a dramatic effect on the lives of people worldwide, but we must adapt and continue the vital work we are doing in the blood health sector.

Patients with blood cancers would be expected to be at increased risk of severe sequelae from COVID-19 infection due to their age profile, their underlying condition and their treatment.

Thus, Irish healthcare professionals have had to take unprecedented steps to protect patients with blood cancers from the effects of infection by COVID-19.

Many patients are being monitored remotely by phone or video consultation to reduce risk of exposure. Decisions about whether to proceed with strongly immunosuppressive therapy or to delay treatment with careful monitoring have been carefully made.

Each individual case is carefully considered, using a multidisciplinary approach, national and international guidelines and taking into account experience from other countries.

Testing for white blood cell abnormalities in COVID-19 patients

The unsung heroes in the fight against COVID-19 are our hospital laboratory staff.

Despite the stressful circumstances, the hospital laboratory staff continue to perform the molecular testing for COVID-19, provide excellent 24-hour laboratory cover, generate rapid blood test results and provide blood products for COVID-19 patients with severe bleeding problems.

We must adapt and continue the vital work we are doing in the blood health sector.

In my laboratory, white blood cell abnormalities distinctive to COVID-19 infection can be detected by microscopy in about 70% of COVID-19 positive patients and may aid in the early detection of this viral infection.

Hope for chemotherapy-resistant patients, despite COVID-19

Myeloma is a cancer of plasma cells in the bone marrow, which usually presents with severe bone and/or kidney disease.

This year, we have seen patients with advanced, chemotherapy-resistant myeloma, enter complete remission using an oral therapy targeting BCL2 protein.

Targeting BCL2 and similar proteins offers great hope for many other patients with blood cancers in the future.

Hodgkin lymphoma is a cancer of lymph nodes with a generally excellent response to combination chemotherapy. However, a minority of patients are resistant.

An ongoing study is researching using a combination of chemotherapy and an antibody-drug conjugate as initial therapy for Hodgkin lymphoma. This study is a BCNI and the European Organisation for Research and Treatment of Cancer (EORTC) collaboration.

There is an antibody-drug conjugate that specifically targets the Hodgkin cancer cell and its combination with chemotherapy promises to improve the prognosis of this lymphoma even further.

Blood conditions must not be overlooked

Haemophilia is a hereditary disorder affecting males, who are at risk of severe bleeding due to low levels of clotting factors.

Traditional treatment includes replacement of the missing clotting factor by intravenous infusion. However, in the recent past, gene therapy offers the hope of long-term cure for such patients.

In a ground-breaking development, three Irish patients with haemophilia B have entered an international clinical trial, which uses a viral vector to deliver gene therapy. The first Irish patient received the gene therapy in March of this year.

Based on earlier studies, it is expected that the effects of a single gene therapy may last for many years or even a lifetime.

Women may overlook symptoms of bleeding disorders

Heavy periods or heavy menstrual bleeding (HMB) affect many women and, in one fifth of cases, may be due to an underlying bleeding disorder. With early diagnosis, HMB may be effectively treated, significantly improving quality of life.

Recognition of bleeding disorders is essential to reduce the risk of future bleeding at operations or childbirth.

A new Health Research Board funded public awareness campaign “Know Your Flow”, which was launched this year, seeking to educate women about heavy periods and their impact as well as signs of an underlying bleeding disorder.

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