Prospective evaluation of the clinical utility of quantitative bleeding severity assessment in patients referred for hemostatic evaluation

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1 Journal of Thrombosis and Haemostasis, 9: 8 DOI:./j x ORIGINAL ARTICLE Prospective evaluation of the clinical utility of quantitative bleeding severity assessment in patients referred for hemostatic evaluation A. TOSETTO,* G. CASTAMAN,* I. PLUG, F. RODEGHIERO* and J. EIKENBOOMà *Department of Hematology, San Bortolo Hospital, Vicenza, Italy; Department of Clinical Epidemiology; and àdepartment of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands To cite this article: Tosetto A, Castaman G, Plug I, Rodeghiero F, Eikenboom J. Prospective evaluation of the clinical utility of quantitative bleeding severity assessment in patients referred for hemostatic evaluation. J Thromb Haemost ; 9: 8. Summary. Background: Quantitative bleeding assessment tools (BATs) have been used to describe the severity of the bleeding phenotype in patients with von Willebrand disease. Objectives: To evaluate the clinical usefulness of a BAT for the diagnosis of mild bleeding disorders (MBDs) in previously undiagnosed patients. Methods: We prospectively assessed 5 patients who were consecutively referred for evaluation of bleeding symptoms (n = 7), abnormal laboratory clotting test results (n = 5) or family investigation (n =9)attwo second-level centers. The bleeding history was assessed by a young investigator who administered the BAT instrument, and also by a senior physician who independently evaluated the patient and made the final diagnoses. Sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) were computed for a predefined bleeding score (BS) cut-off (BS of > ). Receiver operating characteristic curves were used to establish a diagnostic prediction rule. Results: Assuming the prevalence of MBD in the general population to be %, a normal BS ( ) had a very high NPV (99.%). The PPVs in patients referred for hemostatic or family evaluation at second-level clinics were estimated to be 7.% and 77.5% (assuming MDB prevalences of % and 5%, respectively, in these settings). Measurement of BS in addition to activated partial thromboplastin time significantly increased the diagnostic efficiency of the BAT instrument (NPV of 99.6%). Conclusions: BAT use improves the evaluation of patients with suspected MBD, and we propose its use in a clinical prediction guide based on BAT and activated partial thromboplastin time for the exclusion of patients with suspected MBD in a lowprevalence setting. Correspondence: Alberto Tosetto, Department of Hematology, S. Bortolo Hospital, 6 Vicenza, Italy. Tel.: ; fax: tosetto@hemato.ven.it Received 9 vember, accepted 8 March Keywords: blood coagulation disorders, diagnosis, epidemiology. Introduction Patients with mild bleeding disorders (MBDs) usually exhibit a mild to moderate bleeding tendency that is most often characterized by mucocutaneous bleeding after trauma or invasive procedures []. In contrast to patients with severe bleeding disorders, MBD patients neither experience major bleeding nor have increased mortality. netheless, their quality of life can be impaired [], and as they can bleed, particularly after surgery, they may require blood-derived products to control this. In the general population, the most frequent MBDs are von Willebrand disease (VWD) and platelet function disorders, each of which has an estimated frequency of up to % [,]. For these reasons, the diagnosis of MBD in patients presenting with minor bleeding symptoms is frequently pursued, at least in affluent societies. Physicians are often asked to exclude an MBD, particularly in patients requiring invasive procedures or elective surgery who have abnormal clotting screening test results. Unfortunately, most patients with an MBD do not show a definitive bleeding history, and are difficult to distinguish from normal subjects [5 7]. For this reason, more quantitative bleeding assessment tools (BATs) have been proposed to reduce interobserver variability and improve the diagnostic criteria for MBD [8]. The use of BATs has been mainly limited to the diagnosis of type VWD, which is a useful model for mild to moderate bleeding disorders [9], but they could also be potentially useful for the diagnosis of platelet function disorders []. The clinical usefulness of a BAT in daily clinical practice is, however, unknown, as very few data are available on the use of a BAT in consecutive patients referred for the evaluation of bleeding disorders. In this study, we evaluated the diagnostic utility of a standardized BAT in a prospective study on patients referred for the evaluation of abnormal bleeding or laboratory test results at two second-level hemostasis centers. Ó International Society on Thrombosis and Haemostasis

2 A. Tosetto et al Materials and methods Patients In this cross-sectional study, we consecutively enrolled all patients referred for hemostatic evaluation at two hemostasis services (Vicenza General Hospital, Italy, and Leiden University Medical Center, The Netherlands) over a 7-month period. Patients were considered to be eligible if they were referred by their general practitioner or another caring physician for evaluation of: (i) bleeding symptoms; (ii) abnormal laboratory test results (prothrombin time [PT] or activated partial thromboplastin time [APTT] prolongation); or (iii) family study, the patient being the first-degree relative of a patient with a known bleeding disorder. Patients were considered to be not eligible if they were older than 8 years, were taking vitamin K antagonists or receiving antiplatelet therapy, were pregnant, or had thrombocytopenia (< platelets L ) ) or lupus anticoagulant. All patients, or their parents, gave informed consent. BAT For the present investigation, we used a condensed version of the BAT developed for the European MCMDM- VWD study [], retaining in the questionnaire only those questions relevant for computation of the MCMDM- VWD bleeding score, as previouslydescribed bybowman[]. The BAT used inthestudy is presented in Fig.. The bleeding score (BS) was computed according to the MCMDM- VWD study criteria []. Study protocol All eligible patients underwent a two-step evaluation. In the first step, the patient was interviewed by a young investigator, who administered the condensed questionnaire and computed the BS. The young investigator was blinded to the reason for referral of the patient; a parent was interviewed, or helped in the interview, if the patient age was <8 years of age. In the second step, a senior investigator (G.C., J.E., A.T.), who was expert in the diagnosis of bleeding disorders and blinded to the results of the first step, evaluated the patient, ordered additional laboratory investigations if deemed necessary, and offered a final diagnosis on the basis of their clinical expertise and judgement. This latter diagnosis was considered to be the ÔtrueÕ (reference) diagnosis, and was not disputed on the basis of the results of the first step. To avoid any possible influence on the patient of the interview with the senior investigator, the young investigator always collected the data before the senior investigator. On the basis of a preliminary chart review of patients referred at the Vicenza Hemophilia and Thrombosis Patient ID: Prospective validation of a bleeding score Date of recruitment: Sex: Date of birth: Epistaxis Oral cavity Surgery Muscle hematoma or trivial (less than 5) > 5 or more than Packing or Cauterization or Antifibrinolytics Reported at least one Surgical hemostasis or Antifibrinolytics bleeding in at least surgeries t done or no bleeding in surgery Reported in <5% of all surgeries Reported in >5% of all surgeries, no intervention Surgical hemostasis or Antifibrinolytics Never Post-trauma no therapy Spontaneous no therapy Desmopressin or Replacement therapy Surgical intervention or Blood transf Cutaneous Gl bleeding Menorrhagia Hemarthrosis or trivial (< cm) > cm and no trauma Associated with ulcer, portal hypertension, hemorrhoids, angiodysplasia Spontaneous Surgical hemostasis or Blood transfusion or Replacement therapy or Desmopressin or Antifibrinolytics Antifibrinolytics or pill use Curettage or Iron therapy ther -apy or Desmopressin or Hysterectomy Never Post-trauma no therapy Spontaneous no therapy desmopressin or Replacement therapy surgical intervention or blood transfusion Bleeding from minor wounds Tooth extraction Post-partum hemorrhage CNS bleeding or trivial (less than 5) > 5 or more than 5 Surgical hemostasis bleeding in at least extractions t done or no bleeding in extraction Reported in <5% of all procedures Reported in >5% of all procedures, no intervention Resuturing or Packing bleeding in at least deliveries deliveries or no bleeding in delivery Curettage or Iron therapy or Antifibrinolytics Hysterectomy Never - - Subdural, any intervention Intracerebral, any intervention Total assigned score: Fig.. Condensed bleeding assessment tool used in the study. CNS, central nervous system; GI, gastrointestinal. Ó International Society on Thrombosis and Haemostasis

3 Bleeding score for the diagnosis of bleeding disorders 5 Center, we estimated that 5% of patients had been diagnosed as having an MBD. We therefore aimed at consecutively enrolling at least patients to identify a sufficient number of affected patients (n > 5). Laboratory investigations Per protocol, the minimal screening panel in patients considered by the senior investigator as worthy of further investigations was as follows: PT, APTT, fibrinogen, and platelet count. These investigations were always performed in patients referred for evaluation of abnormal laboratory test results. Other specific tests (von Willebrand factor antigen or ristocetin cofactor, Platelet Function Analyzer [PFA-, Siemens Healthcare Diagnostics Products, Marburg, Germany] closure time or bleeding time; measurement of specific clotting factors; impedance aggregometry) were performed by each local laboratory according to the local standards and upon request of the senior physician. All reported laboratory values were measured at the time of evaluation, in the investigatorsõ laboratories. Criteria for an abnormal bleeding history Per protocol, and based on the findings of the European MCMDM- VWD Study, we prespecified that all subjects with BS of > had an abnormal bleeding history []. As a secondary analysis, we evaluated the sensitivity and specificity of BS of > []. Diagnoses Per protocol, senior physicians classified subjects either as having no disease, an MBD (i.e. platelet function disease, VWD, mild hemophilia, or factor XI deficiency), or an alternative diagnosis (senile purpura, asymptomatic factor deficiency [e.g. FXII deficiency], or Rendu Weber Osler disease), on the basis of their clinical findings and the local laboratory results. As patients classified as having an Ôalternative diagnosisõ do not have an appreciable risk of surgical bleeding (the reason why subjects were investigated), they were pooled in the normal group for subsequent analyses. Statistics Differences between subgroups were tested with the exact Fisher or median test, for qualitative or quantitative variables, respectively. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under the receiver operating characteristic (ROC) curve were computed according to Pepe []. PPV and NPV were computed under the hypothesis of a different prevalence, to simulate different clinical scenarios. The following prevalences were chosen: %, to account for screening in a general-population setting (assuming such a prevalence for VWD and platelet function disorders [,]); % for prevalence of MBD in a second-level clinic; and 5% for expected prevalence of an autosomal dominant MBD within a family [5]. Multivariate logistic regression was used to identify predictors of the presence of MBD in enrolled patients, by contrasting patients with a diagnosis of MBD with subjects receiving another diagnosis. We finally used the c-statistic to test whether addition of BS could actually improve the identification of subjects with MBD and guide the clinician towards the request for further investigations. The c-statistic tests the null hypothesis that the areas under the ROC curves of two diagnostic tests are the same. All computations were performed with the Stata software package (version ; Statacorp, College Station, TX, USA) [6]. Results Patients Two hundred and fifteen patients were enrolled in the study, 7 being referred for evaluation of abnormal clotting test results, 5 for the presence of bleeding symptoms, and 9 for family investigation (Table ). There were 7 pediatric (< years) patients; the mean BS in pediatric cases was lower than, but non-statistically different from, that in the adult cases (.7 vs..78, P =.96 by median test). Subjects referred for evaluation of an abnormal clotting test result were younger and had a longer APTT ratio than subjects referred for bleeding symptoms or family investigation. After exclusion of patients with Rendu Weber Osler disease (in whom the diagnosis was based Table Characteristics of evaluated subjects, by type of referral Reason for referral Abnormal clotting test result (n = 7) Bleeding symptoms (n = 5) Family investigation (n = 9) P* Male/female ratio 5/6 7/68 7/.7 Age (years), median (range) (5 69) 8 (5 79) 5 ( 7).8 Pediatric (< years) (%) 8/5 (5) 8/87 (7) /8 (). Blood group O/non-O (%) /5 (8) 6/79 (5) /7 (5). PT ratio, median (range)à.8 (.8.9).5 (.9.8). (.95.). APTT ratio, median (range)à. (.7 5.).7 (.7.5). (.97.9). APTT, activated partial thromboplastin time; PT, prothrombin time. *Test differences between referral subgroups. P =.6 when comparing patients referred for abnormal clotting tests and those with bleeding symptoms. àpt and APTT ratios as measured at the time of evaluation, in the investigatorsõ laboratories. Ó International Society on Thrombosis and Haemostasis

4 6 A. Tosetto et al Table Diagnoses given by the senior physicians, by type of referral Reason for referral on physical examination alone), a full laboratory evaluation (including von Willebrand factor assay and platelet aggregation) was ordered by the senior investigator in 89/99 (9%) of cases referred for the evaluation of bleeding symptoms, and in 8/85 (96%) of those with BS of >. Diagnoses Abnormal clotting test (n = 7) Table reports the frequency of specific diagnoses by type of referral. In total, 56 patients were classified as having MBD and 59 as not having MBD. MBD was more frequently (%) diagnosed in patients referred for family investigation, but there was no difference in MBD prevalence for patients referred for bleeding symptoms or abnormal clotting test results (6% vs. 7%, respectively, P =.98). Diagnostic utility of a quantitative BS Bleeding symptoms (n = 5) Family investigation (n = 9) VWD 6 Mild hemophilia Platelet function defect FXI deficiency Total number of patients (7) 7 (6) 7 () with MBD (%) Senile purpura Asymptomatic clotting defect 7 Rendu Weber Osler disease 6 rmal subjects 68 Total number of patients without bleeding disorder (%) 59 (8) 78 (7) (56) MBD, mild bleeding disorder; VWD, von Willebrand disease. On the basis of the presence or absence of MBD, the sensitivity, specificity and PPV or NPV were computed (Table ). In a low-prevalence scenario (MBD prevalence of %), a normal BS ( ) showed a very high NPV (above 99%), essentially ruling out MBD in patients with a normal BS from the general population. Conversely, the PPV was acceptable in patients referred for hemostatic evaluation at secondary-level clinics or for family evaluation (7.% and 77.5%, for MDB prevalences of % and 5%, respectively). The area under the ROC curve was significantly greater with a cut-off for BS of > than with a cut-off for BS of > (.69 vs..6, P =.). We finally evaluated the additive value of including the BS in a diagnostic pathway directed at identifying MBD. In a logistic regression model that included age, gender, blood group, PT, APTT, and BS, only an abnormal APTT ratio (defined as an APTT ratio of >.) and an abnormal BS (> ) were significantly and independently associated with the presence of MBD(oddsratio[OR].andOR 6.6,respectively;P <. for both variables). These results did not materially change after exclusion of patients with FXI deficiency (OR. and OR.6, respectively; P <. for both variables). Addition of the BS significantly increased the area under the ROC curve of a prediction model based on the presence of an abnormal APTT alone (from.6 to.7, P =.). Following this finding, we tested the diagnostic efficiency of a hypothetical diagnostic scenario in which patients referred for evaluation of bleeding symptoms or laboratory abnormalities were referred for further clinical assessment if they had a BS of > or an APTT ratio of >., despite having a normal BS (Fig. ). In this scenario, a ÔnegativeÕ screening had an NPV of 99.6% under low-prevalence conditions(prevalence%), whichincreasedto99.8% whenabs of > was considered as a cut-off for abnormal bleeding. Discussion In this study, we assessed the clinical utility of a quantitative BAT in outpatients referred to a second-level clinic for the possible presence of an MBD. Few studies have prospectively addressed the usefulness of the bleeding history in the identification of MBD [6], an otherwise relevant topic, as the usual screening tests (PT, APTT, and bleeding time) have a very low predictive power for screening purposes [7,8]. The main strengths of the study are the use of a well-described BAT that has been extensively used in patients with type VWD [], the prospective enrolment of consecutive patients at two hemostasis centers, and the design of the study, which allows a blinded evaluation of enrolled patients. Table Sensitivity and specificity of an abnormal bleeding score (BS) for the diagnosis of a mild bleeding disorder PPV% Prevalence NPV% Prevalence Type of referral Sensitivity Specificity 5 5 Abnormal clotting test results Bleeding symptoms Abnormal clotting test results * 8. or bleeding symptoms Family investigation NPV, negative predictive value; PPV, positive predictive value. PPVs and NPVs are reported on the assumption of different prevalences (depending on clinical setting); for subjects referred for family investigation, PPVs and NPVs are reported only for a prevalence of 5% (assumed on the basis of autosomal dominant model). *99., based on a cut-off for abnormal BS of > (instead of > ); 87.6, based on a cut-off for abnormal BS of > (instead of > ). Ó International Society on Thrombosis and Haemostasis

5 Bleeding score for the diagnosis of bleeding disorders 7 Patients referred for bleeding symptoms or abnormal laboratory test results (n = 76) Specificity: 6.% n = 97 BS >? APTT ratio >.? (n = 7) Yes (n = 9) Yes (n = 5) n = 79 Sensitivity: 76.9% Fig.. Derivation of a clinical prediction guide in patients referred for evaluation of bleeding symptoms or abnormal laboratory test results. APTT, activated partial thromboplastin time; BS, bleeding score. As expected, we observed that the prevalence of MBD was strongly dependent on the type of referral of patients. Among subjects not referred for family study, 9/76 subjects were diagnosed as having an MBD (%), most of them (/9, 56%) having a disorder of primary hemostasis (platelet function disorder or type VWD). In contrast, in subjects referred for family investigation, the prevalence of MBD was close to that expected for autosomal dominant disorders (7/9, %) [5]. These wide differences in the prevalence of MBD are important when evaluating the diagnostic efficiency of the BAT used in the present study. In clinical practice, a BAT could be used both to exclude an MBD in unselected subjects (hence negating further clinical or laboratory testing) and to identify patients who are likely to have an MBD (who may benefit from specific treatment). To attain the first goal, the BAT should have a high sensitivity (and NPV), whereas a high specificity (and PPV) is required for the second goal. For the exclusion of MBD in an unselected population, it could be estimated that about one patient in every 5 (NPV of 99.%) could be falsely considered as being normal when his or her BS is below or equal to. With a less stringent criterion (and hence increasing sensitivity), i.e. by considering as abnormal those subjects with a BS of > (instead of, as prespecified in our study protocol), only one patient in every 67 (NPV of 99.%) would have been misclassified as normal when in fact having an MBD (Table ). We subsequently tested the hypothesis that the BAT could be incorporated into a clinical prediction guide (CPG) including additional tests, and for this purpose we examined, using logistic regression and ROC analysis, whether additional tests could be useful to identify patients with MBD. Only an abnormal APTT ratio was found to be associated with MBD, and the observed marked increase in the c-statistic supports the combination of these two tests as a screening strategy for MBD. As reported in Fig., a CPG considering those individuals with a BS of > or an abnormal APTT ratio as possible MBD patients would misclassify one patient in every 5 (NPV of 99.6%); alternatively, if based on a BS cut-off of >, it would misclassify one patient in every 5 (NPV of 99.8%). These and the preceding values could, however, be considered to represent a worst-case scenario, if we assuming the MBD prevalence to be as high as %. In an unselected population (e.g. before surgical procedures), the NPV could actually be higher, assuming a lower prevalence for more severe forms of MBD. Therefore, although the present findings need to be supported by additional studies, a CPG based on two rapid, inexpensive and standardized investigations (BAT and APTT) could be cost-effective and potentially negate the need for additional testing or referral to second-level hemostasis centers. For a positive diagnosis of MBD, this study suggests that about one-fourth of patients referred to a second-level clinic for family investigation or abnormal hemostatic screening test results (PT, APTT, fibrinogen) may have MBD. In these patients, a complete laboratory investigation should be considered to be mandatory in the presence of an abnormal BS, given the high PPV in such a setting (7.% and 77.5%, respectively, for patients referred for abnormal bleeding test results and family investigation). Our study has some limitations. First, as there is no reference standard for the diagnosis of MBD, we relied on the diagnoses given by senior investigators working in experienced centers, following consensus guidelines when available [9]. tably, these expert clinicians classified patients who were referred for evaluation of bleeding symptoms or with an abnormal BS (> ) but with no laboratory abnormalities as Ônormal subjectsõ. These patients have been previously identified as patients with unexplained mucocutaneous bleeding [], and were conservatively classified as normal subjects, given the uncertain clinical relevance of these subjects. Although a predefined set of investigations was not prespecified in our study protocol, the expert clinicians requested a complete hemostatic evaluation (including von Willebrand factor and platelet function assays) in 8/85 (96%) of those referred for evaluation of bleeding symptoms who had a ÔblindedÕ BS of >. As a specific diagnosis was reached in 6% of patients referred for evaluation of bleeding symptoms (Table ), the expected misclassification rate would be ([85)8].6)/ 85 =.9% or lower. This would change our specificity estimates from.8 to.8 in the group referred for evaluation, and so would not materially affect our conclusions. A classification bias could be excluded in the groups referred for evaluation of abnormal bleeding test results or for family investigation, because, in these patients, the expert clinicians always sought for the diagnosis of a specific defect. Second, the intraindividual and interindividual variability of diagnoses made by expert clinicians has never been formally Ó International Society on Thrombosis and Haemostasis

6 8 A. Tosetto et al assessed, and this may have introduced some random (but nondifferential) classification bias. Third, the lack of a central core laboratory may have introduced a further source of classification bias. Fourth, we could blind only the young, and not the expert, clinician as to the reason for patient referral. Finally, the inclusion in this study of young subjects, with a shorter exposure to hemostatic challenges and, consequently, a lower BS, may have reduced the sensitivity and NPV of an abnormal BS in this setting, as has been recently reported []. Although this conservatively affects our main study findings, it should be kept in mind that a detailed laboratory investigation is always required to exclude with confidence the presence of an MBD in a very young subject. On the other hand, a retrospective study on patients diagnosed with type VWD suggests that the bleeding risk in patients with an MBD and a negative BS could possibly be low [], and so the need for a detailed investigation in subjects with a normal BS should be balanced against the procedural bleeding risk. To summarize, we found that the addition of a standardized BAT is valuable for assessment of MBD based on laboratory screening alone. A normal BS could reasonably exclude the presence of an MBD in an unselected population, especially when coupled with a normal APTT. In contrast, an abnormal BS always calls for a more detailed hemostatic evaluation, particularly in patients referred for abnormal laboratory or family investigation. On the basis of these findings and the recent availability of a consensus ISTH BAT for inherited bleeding disorders (largely based on the BAT used for this work) [], we encourage the use of a standardized BAT in the prospective evaluation of patients referred for hemostatic evaluation. Acknowledgements We thank F. Scognamiglio and A. Cappelletti for their valuable work in collecting clinical data of enrolled patients. Disclosure of Conflict of Interests The authors state that they have no conflict of interest. References Rodeghiero F, Tosetto A, Castaman G. How to estimate bleeding risk in mild bleeding disorders. J Thromb Haemost 7; 5 (Suppl. ): de Wee EM, Mauser-Bunschoten EP, van der BoJ, Degenaar- Dujardin ME, Eikenboom JC, Fijnvandraat K, de Goede-Bolder A, Laros-van Gorkom B, Meijer K, Raat H, Leebeek FW, Win Study Group. Health related quality of life among adult patients with moderate and severe von Willebrand disease. JThrombHaemost; 8:9 9. 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Rodeghiero F, Tosetto A, Abshire T, Arnold DM, Coller B, James P, Neunert C, Lillicrap D; Group ft. ISTH/SSC bleeding assessment tool: a standardized questionnaire and a proposal for a new bleeding score for inherited bleeding disorders. J Thromb Haemost ; 8:6 5. Ó International Society on Thrombosis and Haemostasis