Browsing by Author "Miljic, Predrag (6604038486)"

Although various coagulation abnormalities occur in patients with Gaucher disease (GD), von Willebrand factor (vWF) deficiency has rarely been reported. A retrospective review of six treatment naïve cases with GD and concomitant vWF deficiency over a 12-year-period in a single center is presented. All patients had a personal history of prior hemorrhages. Based on both reduced level of vWF antigen (vWF:Ag, range 14-56%) and ristocetin cofactor activity (vWF:RCo, range 12-53%), with a vWF:RCo/Ag ratio >0.7, the diagnosis of type 1 von Willebrand disease was made in all six cases. During enzyme replacement therapy (ERT) of a 2-year duration all patients normalized their vWF:Ag levels. Based on the positive ERT effect on vWF:Ag levels, vWF deficiency was assumed to be acquired. It should be noted that beside vWF deficiency four patients with GD exhibited mild thrombocytopenia (range 81-131×109/L) and three had additional hemostatic defects (reduced collagen platelet aggregation, FV, FXI and FXII deficiencies). © 2013 Elsevier Inc.

Although various coagulation abnormalities occur in patients with Gaucher disease (GD), von Willebrand factor (vWF) deficiency has rarely been reported. A retrospective review of six treatment naïve cases with GD and concomitant vWF deficiency over a 12-year-period in a single center is presented. All patients had a personal history of prior hemorrhages. Based on both reduced level of vWF antigen (vWF:Ag, range 14-56%) and ristocetin cofactor activity (vWF:RCo, range 12-53%), with a vWF:RCo/Ag ratio >0.7, the diagnosis of type 1 von Willebrand disease was made in all six cases. During enzyme replacement therapy (ERT) of a 2-year duration all patients normalized their vWF:Ag levels. Based on the positive ERT effect on vWF:Ag levels, vWF deficiency was assumed to be acquired. It should be noted that beside vWF deficiency four patients with GD exhibited mild thrombocytopenia (range 81-131×109/L) and three had additional hemostatic defects (reduced collagen platelet aggregation, FV, FXI and FXII deficiencies). © 2013 Elsevier Inc.

Background Factor VIII (FVIII) products are usually dosed according to body weight (BW). This may lead to under-or over-dosing in underweight or obese patients, respectively. Objective This article evaluates the pharmacokinetics (PK) of recombinant FVIII concentrate, particularly recovery, in relation to body mass index (BMI) and other body composition descriptors. Materials and Methods Thirty-five previously treated adults with severe haemophilia A from five BMI categories (underweight, normal, overweight, obese class I and II/III) were included. PK was evaluated after 50 IU per kilogram of BW single-dose recombinant FVIII (turoctocog alfa). The body composition variable was based on measurements of weight, height, bioimpedance analysis, and dual-energy X-ray absorptiometry. A dosing model was derived to achieve similar peak FVIII activity levels across BMI categories. Results A statistically significant positive association between BMI and C 30min, IR 30min, and AUC 0-inf was observed; CL and V ss showed a significant negative association with BMI; t ½ was independent of BMI and other parameters. The dosing model introduced a correction factor 'M' for each BMI category, based on linear regression analysis of C 30min against BMI, which ranged from 0.55 for underweight to 0.39 for obese class II/III. This model achieved similar peak FVIII activity levels across BMI categories, estimating an average dose adjustment of +243.3 IU (underweight) to-1,489.6 IU (obese class II/III) to achieve similar C 30min. Conclusion BMI appears to be the best predictor of recombinant FVIII recovery; however, PK endpoints were also dependent on other body composition variables. The model demonstrated that dosing can be adjusted for individual BMI to achieve better FVIII predictability across BMI categories. © 2020 Georg Thieme Verlag KG Stuttgart New York.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an inherited adult-onset microangiopathy caused by missense mutations in the Notch3gene on chromosome 19. However, common vascular risk factors may additionally modify clinical expression and progression of the disease. The role of various prothrombotic factors has also been implied. We report a case of a middle-aged man with typical clinical, neuroimaging and histological features of CADASIL, but with notably prolonged activated partial thromboplastin time. Hematological investigations revealed severe clotting Factor XII deficiency. This case illustrates that the occurrence of vascular risk factors should not be overlooked in patients with CADASIL.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an inherited adult-onset microangiopathy caused by missense mutations in the Notch3gene on chromosome 19. However, common vascular risk factors may additionally modify clinical expression and progression of the disease. The role of various prothrombotic factors has also been implied. We report a case of a middle-aged man with typical clinical, neuroimaging and histological features of CADASIL, but with notably prolonged activated partial thromboplastin time. Hematological investigations revealed severe clotting Factor XII deficiency. This case illustrates that the occurrence of vascular risk factors should not be overlooked in patients with CADASIL.

Background: Management of women with type 2B von Willebrand disease (VWD) during pregnancy is challenging because of dysfunctional von Willebrand factor (VWF) and the complexity resulting from discrepant VWF/factor VIII (VWF/FVIII) levels, impaired platelet-dependent VWF activity, progressive thrombocytopenia, and risks associated with the use of desmopressin. There is a lack of high-quality evidence to support clinical decision making. Objectives: In this study, we examined the current diagnostic and management approaches and outcomes in women with VWD during pregnancy. Methods: Data were collected via 3 avenues: literature review, an international registry, and an international survey on physicians’ practices for the management of pregnancy in women with VWD. The registry and survey were supported by the International Society on Thrombosis and Haemostasis. Results: Data on clinical and laboratory features, management and bleeding complications, and pregnancy outcomes of a total of 55 pregnancies from 49 women across the globe (literature: 35, registry: 20) and data reported by 112 physicians were analyzed. We describe the largest dataset on pregnancies in women with type 2B VWD available to date. The data highlight the following key issues: a) bleeding complications remain a concern in these patients, b) the target safe VWF level and the ideal monitoring approach are unknown, c) there is a wide range of hemostatic management practices in the type and timing of treatment, and d) physicians have diverse views on the mode of delivery and use of neuraxial anesthesia. Conclusion: We conclude that an international consensus and guidance are critically required for better care and improved outcomes in this patient cohort. © 2022

We report a treatment-naïve patient with Gaucher disease (GD) who experienced repeated bleeding after three neurosurgeries for a brain tumour, identified as an oligoastrocytoma. The patient had normal values on basic haemostatic tests: prothrombin time, 75-105%; activated partial thromboplastin time, 30.3-34 s; and mild thrombocytopaenia, 96-115 × 109cells/l. However, additional tests showed mild von Willebrand factor (vWF) deficiency (vWF antigen, 56%; vWF ristocetin cofactor, 49%; factor VIII [FVIII], 54%) and abnormal collagen-mediated platelet aggregation (0.45-0.55). Bleeding control was achieved after vWF/FVIII concentrate and platelet transfusions. This case raises questions about the safe platelet count and basic haemostatic tests for assessing bleeding risk in patients with GD prior to surgery. In patients with GD, a minimum haemostatic evaluation should include platelet count and basic haemostatic tests such as fibrinogen, prothrombin time, activated partial thromboplastin time as well as platelet function tests and assessing vWF and FVIII levels. Specific coagulation factors or platelet function deficiencies should be corrected with factor concentrates or platelet transfusions. © 2014 Informa UK Ltd.

Jean St-Louis MD, FRCPC 1,2| Audrey Abad BSc 3| Sharon Funk DPT 4|Merlyn Tilak MPT 5| Stephen Classey PT 6| Nichan Zourikian BSc, PT 7|Paul McLaughlin PT, MSc, MCSP 8| Sébastien Lobet PT, PhD 9|Grace Hernandez PT10| Stacie Akins PT11| Anna J. Wells PT, MSc, MCSP, SRP12|Marilyn Manco-Johnson MD4| Judy John MD5| Steve Austin MBBS BMedSci FRACP FRCPA6| Pratima Chowdary MD8| Cedric Hermans MD9| Diane Nugent MD10|Nihal Bakeer MD11| Sarah Mangles MD, MBBS, MD (Res), FRCP, FRCPath12|Pamela Hilliard BSc, PT3| Victor S. Blanchette MB, BChir (Cantab), FRCPC13,14|Brian M. Feldman MD, MSc, FRCPC15,161Department of Hematology, CHU Sainte-Justine and Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada2Department of Medicine, Université de Montréal, Montréal, Québec, Canada3Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada4Hemophilia and Thrombosis Center, University of Colorado, Denver, Colorado, USA5Department of Physical Medicine & Rehabilitation, Christian Medical College, Vellore, India6Haemostasis and Thrombosis Centre, St Thomas’ Hospital, London, UK7Pediatric/Adult Comprehensive Hemostasis Center, CHU Sainte-Justine, Montréal, Québec, Canada8Katharine Dormandy Haemophilia and Thrombosis Centre, The Royal Free Hospital, London, UK9Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint- Luc, Brussels, Belgium10The Center for Inherited Blood Disorders (CIBD), Orange County, California, USA11Indiana Hemophilia & Thrombosis Center, Indianapolis, Indiana, USA12Haemophilia, Haemostasis & Thrombosis Centre, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK13Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada14Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada15Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada16Department of Pediatrics, Faculty of Medicine, Institute of Health Policy, Management and Evaluation, The Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada The authors regret a technical error in the graph-generating software resulted in an inaccurate visual representation for the moderate group in Figure 1. The bar graphs were not representative of the actual data obtained in the moderate hemophilia group. The correct bar graphs for the moderate group should display a Median HJHS total score of 27.5 in those 30 to 40 years; 29.5 in those 41 to 50 years, and 29.0 in those > 50 years. This corrected figure does not alter the original data, analysis, or conclusions.[Formula presented] The authors would like to apologise for any inconvenience caused. © 2023

The authors regret the affiliation of Clinical Pathology Department, Faculty of Medicine, Mansoura University, Egypt was omitted for Maha Othman. This has been corrected and added as below. The authors would like to apologise for any inconvenience caused. © 2023

Severe congenital protein C deficiency (SCPCD) is rare and there is currently substantial variation in the management of this condition. A joint project by three Scientific and Standardization Committees of the ISTH: Plasma Coagulation Inhibitors, Pediatric/Neonatal Thrombosis and Hemostasis, and Women’s Health Issues in Thrombosis and Hemostasis, was developed to review the current evidence and help guide on diagnosis and management of SCPCD. We provide a summary of the clinical presentations, differential diagnoses, appropriate investigations to confirm the diagnosis, approaches for management of the acute situation, and options for long-term management including subsequent pregnancies. We finally provide a set of recommendations to help in this regard. © 2022 The Authors. Journal of Thrombosis and Haemostasis published by Wiley Periodicals LLC on behalf of International Society on Thrombosis and Haemostasis.

There is a paucity of data on the effects of enzyme replacement therapy (ERT) on the coagulation abnormalities and platelet function of patients with Gaucher's disease (GDPs) and much of this data are controversial. This study investigates the haemostatic parameters in treatment-nave GDPs and the effects of ERT. 31 Serbian treatment-nave type 1 GDPs (M/F 17/14; median age 49 years, splenectomized 9/31) were studied. The complete blood count, prothrombin time (PT), activated partial tromboplastin time (aPTT) and coagulation factors were measured using the standard methods. Platelet aggregation was assessed with a whole-blood aggregometer. Splenic volumes were assessed using computer tomography. Twenty-one patients were treated with ERT (Imiglucerase). The haemostatic parameters were assessed after 6, 12 and 24 months (ERT 6, 12, 24). Initially bleeding episodes were registered in 10/31 GDPs. Median platelet count was 108×10 9/L; 22/31 GDPs were thrombocytopenic. The PT and aPTT values were abnormal in 16/31 and 13/31 GDPs, respectively. Platelet aggregation abnormalities were recorded in 19/31GDPs. Median platelet aggregation was reduced in response to adenosine-diphosphate 5mol/L (ADP 5 0.46) and collagen 5mol/L (Col5 0.47). Splenic volume inversely correlated with the platelet count and a reduced response to arachidonic acid (AA), Col5 and ADP5 (p<0.05). The splenectomized GDPs had a significantly lower platelet aggregation to Col 10 (p<0.05). Bleeding GDPs had a significantly lower platelet count, higher chitotriosidase levels and a greater splenic volume compared to non-bleeding patients (p<0.01). ERT: The number of bleeding GDPs had significantly decreased by ERT 6 (1/10; p<0.01). The platelet count had significantly increased by ERT 6 (ERT 6 180×10 9/L, p<0.01). The PT increased significantly from ERT0 to ERT 24 (PT0 65%, PT 24 81%; p<0.05). The von Willebrand factor had increased significantly by ERT 6 and ERT 24 (ERT0 56%, ERT 6 70%, ERT 12 70%, ERT 24 86%; p<0.01). The number of GDPs with abnormal platelet aggregation had decreased significantly by ERT 6 (10/19; p<0.05). Platelet aggregation on ADP 10 and AA significantly increased by ERT 6 (ADP 10: ERT 0 0.75, ERT 6 0.8 p<0.01; AA: ERT0 0.7, ERT 6 0.8 p<0.05). In conclusion, platelet dysfunction and coagulation abnormalities were found in a considerable number of our GDPs. The absence of severe bleeding episodes suggests that the haemostatic system is sufficiently balanced and therefore the exact mechanism of the etiology of these abnormalities need to be fully clarified. ERT resulted in the cessation of bleeding and marked increase in platelet count, PT, vWF and platelet aggregation. © 2012 Informa UK Ltd. All rights reserved.

Women are increasingly encouraged to participate in making decisions about hormone replacement therapy (HRT). In postmenopausal women with severe vasomotor symptoms, HRT can significantly improve the quality of life. However, the use of HRT may also increase the risk of venous thromboembolism (VTE), the risk which depends of both treatment-related and patient-related factors. This review summarizes some important points about the selection of the safest hormonal replacement modality in women with a history of VTE and management of VTE risks in postmenopausal women wishing to take HRT. © 2016 Elsevier Ltd

Introduction: Turoctocog alfa is a recombinant factor VIII (FVIII) molecule, approved for treatment and prophylaxis of bleeding in patients with haemophilia A. In the guardian 1 (adolescents/adults) and guardian 3 (children) phase 3 trials, turoctocog alfa demonstrated a favourable efficacy and safety profile. Guardian 1 or 3 completers could enrol in the guardian 2 extension. Final guardian 2 results are reported here. Aim: Investigate long-term safety and efficacy of turoctocog alfa administered for prophylaxis and treatment of bleeds. Methods: In this phase 3b open-label trial, previously treated males of all ages with severe haemophilia A received prophylaxis regimens of turoctocog alfa or on-demand treatment of bleeds. The primary safety endpoint was frequency of FVIII inhibitor development. Efficacy endpoints included annualized bleeding rate (ABR) during prophylaxis, haemostatic response in treatment of bleeds and number of injections required to treat bleeds. Results: Overall, 213 patients were dosed with turoctocog alfa; 207 patients received prophylaxis; 19 received on-demand treatment. No FVIII inhibitors (≥0.6 BU) were reported. For all patients on prophylaxis, overall median ABR was 1.37 bleeds/y; success rate for treatment of bleeds was 90.2%; and 88.2% of bleeds were controlled with 1-2 injections of turoctocog alfa. For the on-demand regimen, overall median ABR was 30.44 bleeds/y; success rate for treatment of bleeds was 96.7%; and 94.9% of bleeds were controlled with 1-2 injections of turoctocog alfa. Conclusion: Extended use of turoctocog alfa is safe and effective for prevention and treatment of bleeding episodes in previously treated patients with haemophilia A across all ages. © 2018 The Authors. Haemophilia Published by John Wiley & Sons Ltd.

Chronic exposure to high glucocorticoid levels in Cushing's syndrome (CS) is often associated with alterations in the hemostatic system and the expression of prothrombotic phenotypes. Increased frequency of both atherothrombotic and venous thromboembolic events (VTE) has been reported in patients with CS. In general, cardiovascular complications in these patients cause a five-fold increase in mortality compared to the normal population. Although numerous abnormalities in the hemostatic system have been detected in patients with CS, the underlying mechanisms of the prothrombotic state are not fully elucidated. High levels of factor VIII and von Willebrand factor, with evidence of enhanced thrombin generation and decreased fibrinolytic activity, have been documented in several studies. However, it is not clear to what extent these changes contribute to the shift of hemostatic balance towards the hypercoagulable state and expression of thrombophilic phenotypes. Thrombosis is usually a multicausal disease, and all three components of the so-called Virchow triad, namely 1) vascular abnormalities and endothelial dysfunction, 2) hypercoagulability and 3) stasis, may play a variable role in the pathogenesis of the prothrombotic state in CS patients. Larger studies are needed to establish strategies for prevention of cardiovascular complications in patients with Cushing's syndrome.

The current widely accepted stratification defined by age and previous thrombosis in patients with essential thrombocythemia (ET) probably deserves deeper analysis. The aim of our study was to identify additional factors at the time of diagnosis, which have an impact on the thrombosis prediction. We conducted a study of 244 consecutive ET patients with median follow-up of 83 months. We analyzed the influence of age, gender, laboratory parameters, history of previous thrombosis, spleen size, JAK2 mutation as well as cardiovascular (CV) risk factors including arterial hypertension, diabetes, active tobacco use and hyperlipidemia in the terms of thrombosis. The most important predictors of thrombosis in multivariate Cox regression model were the presence of CV risk factors (p = 0.004) and previous thrombosis (p = 0.038). Accordingly, we assigned risk scores based on multivariable analysis–derived hazard ratios (HR) to the presence of 1 CV risk factor (HR = 3.5; 1 point), >1 CV risk factors (HR = 8.3; 2 points) and previous thrombosis (HR = 2.0; 1 point). A final three-tiered prognostic model for thrombosis prediction was developed as low (score 0), intermediate (score 1 or 2) and high risk (score 3) (p < 0.001). The hazard of thrombosis was 3.8 % in low-risk group, 16.7 % in the intermediate-risk group and 60 % in the high-risk group (p < 0.001). Patients with thrombotic complications during the follow-up had a significantly shorter survival (p = 0.018). The new score based on CV risk factors and previous thrombotic events allows a better patient selection within prognostic-risk groups and improved identification of the high-risk patients for thrombosis. © 2014, Springer Science+Business Media New York.

The current widely accepted stratification defined by age and previous thrombosis in patients with essential thrombocythemia (ET) probably deserves deeper analysis. The aim of our study was to identify additional factors at the time of diagnosis, which have an impact on the thrombosis prediction. We conducted a study of 244 consecutive ET patients with median follow-up of 83 months. We analyzed the influence of age, gender, laboratory parameters, history of previous thrombosis, spleen size, JAK2 mutation as well as cardiovascular (CV) risk factors including arterial hypertension, diabetes, active tobacco use and hyperlipidemia in the terms of thrombosis. The most important predictors of thrombosis in multivariate Cox regression model were the presence of CV risk factors (p = 0.004) and previous thrombosis (p = 0.038). Accordingly, we assigned risk scores based on multivariable analysis–derived hazard ratios (HR) to the presence of 1 CV risk factor (HR = 3.5; 1 point), >1 CV risk factors (HR = 8.3; 2 points) and previous thrombosis (HR = 2.0; 1 point). A final three-tiered prognostic model for thrombosis prediction was developed as low (score 0), intermediate (score 1 or 2) and high risk (score 3) (p < 0.001). The hazard of thrombosis was 3.8 % in low-risk group, 16.7 % in the intermediate-risk group and 60 % in the high-risk group (p < 0.001). Patients with thrombotic complications during the follow-up had a significantly shorter survival (p = 0.018). The new score based on CV risk factors and previous thrombotic events allows a better patient selection within prognostic-risk groups and improved identification of the high-risk patients for thrombosis. © 2014, Springer Science+Business Media New York.

Background: Inherited antithrombin (AT) deficiency is a rare autosomal dominant disorder, caused by mutations in the SERPINC1 gene. The most common clinical presentation in AT deficient patients includes venous thrombosis and pulmonary embolism, while the association of AT deficiency and its effect on the development of pregnancy complications has been less studied. The aim of our research was to evaluate the effect of AT deficiency types, determined by genotyping, on pregnancy outcomes. Methods: A retrospective cohort study included 28 women with AT deficiency, and their 64 pregnancies were analyzed. Results: With regard to live birth rate, a significant difference was observed among women who were carriers of different SERPINC1 mutations, as the rate varied from 100% in cases of type I to the extremely low rate of 8% for women with type II HBS (AT Budapest 3) in the homozygous variant, P = 0.0005. All pregnancies from the type I group, even untreated ones, resulted in live births. In women with AT Budapest 3 in homozygous variant the overall live birth rate increased to 28.5% in the treated pregnancies. In this group the highest incidence of fetal death was observed of 62%; repeated fetal losses in 30%; fetal growth restriction in 22% and placental abruption in 7% of all pregnancies. Conclusion: Our study results indicate a difference between type I and type II AT deficiency. The risk of pregnancy related VTE was equally present in both groups, except for AT Budapest 3 in the heterozygous variant, while adverse pregnancy outcomes were strictly related to type II, especially AT Budapest 3 in the homozygous variant. © 2018 Elsevier Ltd

Background: Thrombosis is a major global disease burden with almost 60% of cases related to underlying heredity and most cases still idiopathic. Synonymous single nucleotide polymorphisms (sSNPs) are considered silent and phenotypically neutral. Our previous study revealed a novel synonymous FII c.1824C>T variant as a potential risk factor for pregnancy loss, but it has not yet been associated with thrombotic diseases. Methods: To determine the frequency of the FII c.1824C>T variant we have sequenced patients' DNA. Prothrombin RNA expression was measured by quantitative PCR. Functional analyses included routine hemostasis tests, western blotting and ELISA to determine prothrombin levels in plasma, and global hemostasis assays for thrombin and fibrin generation in carriers of the FII c.1824C>T variant. Scanning electron microscopy was used to examine the structure of fibrin clots. Results: Frequency of the FII c.1824C>T variant was significantly increased in patients with venous thromboembolism and cerebrovascular insult. Examination in vitro demonstrated increased expression of prothrombin mRNA in FII c.1824T transfected cells. Our ex vivo study of FII c.1824C>T carriers showed that the presence of this variant was associated with hyperprothrombinemia, hypofibrinolysis, and formation of densely packed fibrin clots resistant to fibrinolysis. Conclusion: Our data indicate that FII c.1824C>T, although a synonymous variant, leads to the development of a prothrombotic phenotype and could represent a new prothrombotic risk factor. As a silent variant, FII c.1824C>T would probably be overlooked during genetic screening, and our results show that it could not be detected in routine laboratory tests. © 2020 American Association for Clinical Chemistry. All rights reserved.

Introduction Thrombotic events (TE) appear to be more common in acute promyelocytic leukemia (APL) than in other acute leukemias, with reported prevalence ranging from 2 to10-15%. Materials and Methods We retrospectively analyzed the data on TE appearance in 63 APL patients. Results TE occured in 13 (20.6%) cases, four arterial (6.3%) and nine venous (14.3%). TE were more frequently diagnosed after initiation of weekly D-dimer monitoring (7 TE during 20 months vs 6 during 76 months, P = 0.032). Patients with and without venous thrombosis were significantly different regarding female/male ratio (P = 0.046), PT (P = 0.022), aPTT (P = 0.044), ISTH DIC score (P = 0.001), bcr3 (P = 0.02) and FLT3-ITD (P = 0.028) mutation. The most significant risk factor for venous TE occurrence in multivariate analysis was FLT3-ITD mutation (P = 0.034). PAI-1 4G/4G polymorphism was five times more frequent in patients with venous TE than without it (P = 0.05). Regarding risk factors for arterial TE we failed to identify any. Conclusions We have demonstrated that APL-related TE rate is higher than previously reported and that weekly D-dimer monitoring might help to identify patients with silent thrombosis. Moreover, our study suggests a possible relationship between venous TE occurrence and several laboratory findings (PT, aPTT, ISTH DIC score, bcr3 isoform, FLT3-ITD mutation and PAI 4G/4G). Prophylactic use of heparin might be considered in patients with ISTH DIC score < 5, bcr3 isoform, FLT3-ITD mutation and PAI 4G/4G. © 2014 Elsevier Ltd.