Talk:Hereditary hemorrhagic telangiectasia

For

For some reason, this condition has been reported to respond to sirolimus[1]. Enter the trials. JFW | T@lk 04:57, 7 February 2006 (UTC)

Loeys-Dietz syndrome, a hereditary aneurysmatic condition, has also been linked to abnormal TGF signalling[2]. JFW | T@lk 22:58, 23 August 2006 (UTC)

Redirection Wrong

Osler Weber Rendu should redirect to this page.

Currently Rendu Osler Weber and Rendu Weber Osler redirect here. —The preceding unsigned comment was added by 200.88.105.250 (talk) 13:50, 17 March 2007 (UTC).

I don't know how to add it, but I searched for Osler-Weber-Rendu and got nothing. Does anyone know how to add a redirect? 24.99.86.24 (talk) 03:13, 14 January 2009 (UTC)

Differences in clinical expression

The different genetic variants have differing clinical expressions: doi:10.1111/j.1538-7836.2007.02531.x JFW | T@lk 09:43, 10 June 2007 (UTC)

Osler

Is this Osler's original paper: http://qjmed.oxfordjournals.org/cgi/reprint/os1/1/53 JFW | T@lk 22:23, 22 May 2008 (UTC)

No, it was 1901. This is about the eponym: doi:10.1016/S0140-6736(03)14696-X JFW | T@lk 19:33, 22 June 2008 (UTC)

Liver

doi:10.1111/j.1365-2036.2008.03775.x HHT does the liver. JFW | T@lk 19:31, 22 June 2008 (UTC)

Bevacizumab

http://content.nejm.org/cgi/content/short/360/20/2143 is an early report of anti-VEGF treatment, with interesting results. Might be notable. JFW | T@lk 09:04, 14 May 2009 (UTC)

Mechanism

http://www.jci.org/articles/view/39482 - real-time AVM formation studied in animal model of AKT1 mutation. JFW | T@lk 23:07, 1 October 2009 (UTC)

Reviews for expansion

Some sources that might be useful for an eventual expansion:

• J Thromb Haemost 2010 (doi:10.1111/j.1538-7836.2010.03860.x - French)
• CMAJ 2009 (doi:10.1503/cmaj.081739 - Canadian)
• Eur J Hum Genet 2009 (doi:10.1038/ejhg.2009.35 - British)

I might do some work here soon. JFW | T@lk 09:32, 4 July 2010 (UTC)

Have just discovered the 2009 J Med Genet consensus guideline. I shall be quoting from this when it comes to diagnosis and treatment. JFW | T@lk 20:34, 18 July 2010 (UTC)

Updating

I've started updating the article from a number of sources. For the backbone I'm using Govani & Shovlin, which is readable, free and comprehensive, but for the diagnosis and treatment I shall have to source much of what I write to the Canadian 2006 consensus guidelines. I might supplement particular sections with the ERJ and Liver Int reviews (already cited). If there are still gaps in the content I might dip into textbooks, but currently there is plently for MEDRS available.

Sections:

•  Done Signs & symptoms
•  Done Genetics
•  Done Pathogenesis - will be mostly from Govani, but may use NEJM 1995 too
  • Actually, Dupuis is very good on this. Now this section needs an image!
•  Done Diagnosis - to cover the clinical and genetic diagnosis
•  Done Criteria - expand to include Govani's mention of those not meeting criteria but having strong family history
•  Done Treatment - need a source from an ENT perspective
•  Done Epidemiology - age at diagnosis, international distribution & should include prognosis
•  Done History

As always, any help is appreciated, but I'm going to do the usual and keep on working on this until it is a GA candidate. JFW | T@lk 09:57, 19 July 2010 (UTC)

HHT is clearly in the air, what with the Lancet case report this week (doi:10.1016/S0140-6736(10)60811-2), which reminded me to find a source for platypnea in pAVMs. JFW | T@lk 22:33, 24 July 2010 (UTC)

HHT is definitely in the air! NEJM (clinical problem solving) in June: doi:10.1056/NEJMcps0901416 JFW | T@lk 19:04, 29 July 2010 (UTC)

Some people kindly pointed me to the identity of F.M. Hanes. PMC 2242304 has him as a professor of medicine at Duke. Rather appropriate that most early genetic linkage work was done there! JFW | T@lk 20:27, 29 July 2010 (UTC)

Quandary

I'm having trouble with the inclusion of the following reference:

Lebrin, Franck (2010). "Thalidomide stimulates vessel maturation and reduces epistaxis in individuals with hereditary hemorrhagic telangiectasia". Nature Medicine. 16 (4): 420–428. doi:10.1038/nm.2131. PMID 20364125. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)

On the one hand, it is a very interesting paper with both experimental and clinical data showing that thalidomide markedly reduces bleeding and telangiectasia formation. At the same time, it is not technically a WP:MEDRS and needs to remain in the incubator unless there is a secondary source to support its actual relevance to patients. Thalidomide is toxic (it can cause polyneuropathy and thrombosis) and has a lugubrious teratogenic history; acceptance in the HHT community may take a while.

There is more secondary sourcing about bevacizumab, but again this is still experimental and probably does not warrant inclusion on this page. It is not mentioned in the 2009 guideline, for instance. JFW | T@lk 06:51, 26 July 2010 (UTC)

Finishing touches before GAC

I have now expanded the entire article. I've left a number of items uncovered, which could of course be developed if deemed important by others or reviewers.

• The first is migraine - it is reported in people with CAVMs as well as PAVMs and may have something to do with shunt phenomena, but its exact place in HHT is unclear and I don't recall reading anything about the symptoms responding to embolisation of PAVMs. (Added: doi:10.1159/000134011 is a review that provides some context.)
• The second is PAH. I've mentioned it as an aside on two occasions, and the link with TGF signalling is more than simply interesting, but its diagnosis and treatment are a whole separate chapter that is best dealt with in the mother article on PAH; Faughan's ERJ 2009 article has a lot of material on it, but then this appeared in a theme issue about PAH and it is probably not representative. Govani & Shovlin have some nifty content (including sample L&R heart catheter data) on the subject (but their institution is the national referral centre for PAH in the UK).
• The third is spinal AVMs. I've mentioned it in passing, but even the Guideline regards it as so uncommon that it cannot make recommendations other than concerning the mode of imaging.
• The fourth is the thrombotic diathesis and immunodeficiency alluded to by Govani & Shovlin.

Very keen to hear if anyone has strong feelings about these matters. I've emailed Dr Faughnan to enquire when JMG will be printing the Guideline, which was formulated in 2006 but only submitted in 2009. JFW | T@lk 20:41, 29 July 2010 (UTC)

GA Review

This review is transcluded from Talk:Hereditary hemorrhagic telangiectasia/GA1. The edit link for this section can be used to add comments to the review.

Reviewer: WhatamIdoing (talk) 16:56, 27 August 2010 (UTC)

GA review – see WP:WIAGA for criteria

1. Is it reasonably well written?

   A. Prose quality:

   (1) I'm not sure about British English (style I've presumed), but in American English, word geeks often recommend restricting the word "where" to expressions of physical location. For example, "This is particularly done in lesions where the feeding blood vessel is 3 mm or larger," would be expressed as something like "This is particularly done in lesions whose feeding blood vessel is 3 mm or larger." Also, in AmEng, "side effects" is not hyphenated. I don't know what the BrEng standard is.

   (2) "coils are deployed that obstruct the blood flow through the lesion and allow it to regress": Is "it" blood, or the AVM, or the coils?

   (3) "Surgery has now essentially been abandoned due to the success of embolotherapy": I thought that embolotherapy was technically a form of surgery? Does this refer to something like surgical excision of the AVM?

   (4) Under treatment, is "(high-flow arteriovenous fistulae)" the type of lesion that causes more problems than average, or is it one of the problems that is caused by problematic lesions?

   B. MoS compliance:  Yes

   This article complies with all applicable MoS pages from the GA requirements (lead, layout, words).

2. Is it factually accurate and verifiable?

   A. References to sources:

   B. Citation of reliable sources where necessary:

   C. No original research:

3. Is it broad in its coverage?

   A. Major aspects:  Yes

   B. Focused:  Yes

4. Is it neutral?

   Fair representation without bias:  Yes

5. Is it stable?

   No edit wars, etc:  Yes

6. Does it contain images to illustrate the topic?

   A. Images are copyright tagged, and non-free images have fair use rationales:  Yes

   B. Images are provided where possible and appropriate, with suitable captions:  Yes

7. Overall:

   Pass or Fail:

Aside from my notes above, what's left is the tedious step of making sure that whatever JFW (and others) claim is in a given source is actually there. This will take a while (probably several days), and—given the reputation of most of the editors involved—is unlikely to find any problems. WhatamIdoing (talk) 18:59, 27 August 2010 (UTC)

Thanks for the hard work, WhatamIdoing. Hope the sources do back up everything I've said, given that I carried them around with me for a few weeks while doing this. I'm also shocked at how many spelling mistakes I made. After working on the same content for a while, one tends to skim over the sentences that look most familiar. Thanks for fixing them. I will now address the four concerns in the A/prose quality section:

1. I work in the UK and write BE, but I did not want to change the spelling standard. Thanks for identifying these slips, and please correct me where I have strayed. I will hunt down the examples and change them.
2. You are correct that it's the AVM wot is meant to regress; I will fix it
3. Will clarify that this it is surgery by craniotomy that was abandoned
4. Will clarify that high-flow AVFs are the kind of lesions that cause more trouble

Looking forward to the finishing touches. JFW | T@lk 21:20, 28 August 2010 (UTC)

I've still got three papers to go (including the enormous one), but here's my current list of possible discrepancies. (NB that these complaints may represent deficiencies in my search strategies, not actual problems):

1. "Often contrast-enhanced computed tomography (CT angiography) is used to identify lung lesions; this modality has a sensitivity of over 97%."

   Govani[1] seems to favor non-contrast CT; Faughnan[5] only claims >90% sensitivity.

2. "(epistaxis), which happen frequently from childhood and affect about 90% of people with HHT"

   Dupuis[2] says more than 95%.

3. "Lesions on the skin and in the mouth bleed less often but may be considered cosmetically displeasing; they affect about 80%"

   Neither the "bleed less often" nor the "cosmetically displeasing" claims seem to be in Govani[1] or Dupuis[2]

4. "In Haut Jura, this has been shown to be the result of a particular ACVRL1 mutation (named c.1112dupG or c.1112_1113insG).[2]"

   Dupuis[2] does not contain this much detail (e.g., searching for "Jura" produces no results). This may well be both True™ and verifiable, but it does not seem to be in the named source.

5. "In 2000, an international meeting on the Caribbean island of Curaçao formulated the now widely used Curaçao criteria.[7][15]"

   It looks like the meeting itself may have been in 1997.

6. I don't have Young's 1967 paper[18], and I'm concerned that it may not directly support a claim that it is useful for HHT. WhatamIdoing (talk) 01:27, 1 September 2010 (UTC)

You're being very thorough! Thanks for double-checking this.

1. Govani is alone in suggesting non-contrast, hence left this out. Faughnan was talking about contrast echo, but I agree that they give no exact sensitivity for CTA.
2. Agree that Dupuis' figure ought to be quoted explicitly
3. Agree that no source states this explicitly, but few people like blood vessels in their face - I will happily remove this if you don't think I should state the obvious.
4. I wasn't sure whether to quote an additional primary source to link the statements in both papers; doi:10.1038/ejhg.2008.3 is the relevant reference. It is cited as such by Dupuis-Girod, but with omission of Haut-Jura as the authors clearly presume we are not interested in French geography.
5. The paper does not state when the meeting took place. I should probably remove the year until we can verify this.
6. I only cited the paper as evidence that the procedure exists and was described by Young. You are quite correct that it was described in atrophic rhinitis. Do you think I should change it?

Will fix anything else that comes up when you read the Guideline. It still hasn't appeared in print. JFW | T@lk 20:27, 1 September 2010 (UTC)

1. I'm entirely satisfied with your response.
2. That's fine.
3. I accept the inclusion of the cosmetic issue; it does not require an inline source. Do the sources say that the skin lesions bleed less frequently than mucocutaneous lesions? I couldn't find it, and "more" is a "statistic" at some level.
4. I don't think we need to worry about it. It's verifiable, and not one of the five items on the GA list, so I'm happy. If someone decides to fuss about it some day, they'll find the answer here.
5. Your solution looks fine.
6. I'm waffling. That Young's is/could be used is supported by that lengthy guideline, so we don't really "need" it. But if the reader wants to find out what the procedure is, then the source might be handy. (Should that be a redlink?)

From the guideline, the only think I couldn't find "Liver scans may be useful if someone is suspected of HHT, but does not meet the criteria (see below) unless liver lesions can be demonstrated.[7]" However, I strongly suspect the problem is that my eyes are about to close on me, not that it's not in there somewhere.

I've fixed a couple of trivial ENGVAR-type issues. I think this article is in great shape, and I'm happy to pass it (but tomorrow, when I'm awake enough to follow the directions.  ;-) WhatamIdoing (talk) 04:59, 4 September 2010 (UTC)

More review

doi:10.1016/j.blre.2010.07.001 is Shovlin's review in Blood Rev 2010. Shall read. JFW | T@lk 22:22, 19 May 2011 (UTC)

doi:10.1097/GIM.0b013e3182136d32 is a GeneTests review from Genet Med (2011). JFW | T@lk 21:00, 26 May 2013 (UTC)

Another review

Am FP http://www.aafp.org/afp/2010/1001/p785.html --Doc James (talk · contribs · email) 01:29, 4 December 2011 (UTC)

Not too bad, but bases itself on lots of slightly outdated sources. Also makes no reference to the international consensus guidelines. JFW | T@lk 10:41, 4 December 2011 (UTC)

Clinical trials

Cytoscape55 (talk · contribs) added the following content:

“ Because HHT is most likely due to abnormally increased angiogenesis, several studies have investigated the potential therapeutic effect in HHT patients of approved angiogenesis inhibitors. Bevacizumab (Avastin) is a humanized monoclonal VEGF antibody that prevents endothelial cell proliferation and angiogenesis and is licensed to treat various cancers. Bevacizumab has been used off-label in the treatment of HHT-associated complications since 2008. In 2012, a study published in JAMA reported that bevacizumab infusion (5 mg per kg, every 14 days for a total of 6 injections) in 25 HHT patients followed up for 6 months after the beginning of the treatment, was associated with a decrease in cardiac output and reduced duration and number of episodes of epistaxis

Thalidomide, an anti-nausea and sedative drug associated with anti-angiogenic properties, was reported to induce vessel maturation in an experimental mouse model of HHT and to reduce the severity and frequency of nosebleeds in the majority of a group of 7 HHT patients. The blood hemoglobin levels of these treated patients rose as a result of reduced hemorrhage and enhanced blood vessel stabilization.

”

I am aware of experimental work with bevacizumab and thalidomide, but none of the aforementioned sources is a WP:MEDRS-compatible secondary source. Even recent reviews (i.e. the ones I used in the writing of much of the article) don't spend much time on them. I would much prefer trying to identify a good secondary source to discuss these experimental treatments, either in the "Treatment" section or in a new section to be called "Research directions". JFW | T@lk 20:36, 26 May 2013 (UTC)

doi:10.1016/j.blre.2010.07.001 is a good secondary source in Blood Rev (already mentioned above) which discusses both treatments. For some obscure reason, bevacizumab is consistently spelled "Bevazicimub". If I find the time I will work the conclusions from this article into this entry. JFW | T@lk 20:43, 26 May 2013 (UTC)

Cytoscape55 (talk · contribs) disagrees that the mentioned sources in the above section "Clinical trials" are not WP:MEDRS-compatible. All citations are peer-reviewed scientific articles and thus represent "reliable, third-party, published sources and accurately reflect current medical knowledge". I agree, however, that this section is not accurately named and could be incorporated in the "Treatment" section. I would suggest to rename it "Experimental treatments" and make it a sub-section of the "Treatment" section. Please advice. — Preceding unsigned comment added by Cytoscape55 (talk • contribs)

I think you're misunderstanding the purpose of MEDRS. If secondary sources are available, these are vastly preferable over small case series (these were not even randomised controlled trials, because HHT is too rare to have properly designed RCTs). You will notice that the best medical articles on Wikipedia are built almost entirely on secondary sources. JFW | T@lk 22:48, 26 May 2013 (UTC)

The goal of the section is not to conclude that the 2 mentioned drugs are effective treatments (a conclusion that, I agree, you only reach after RCT), but rather to report promising pre-clinical and clinical data published in high-profile scientific journals, e.g., JAMA (impact factor: 30) and Nat Med (impact factor: 22). I think it is a reliable and important information for the reader. In that context, I agree that referring to "clinical trials" could be misleading. Would you agree to maintain the section under another title? — Preceding unsigned comment added by Cytoscape55 (talk • contribs) 23:53, 26 May 2013 (UTC)

Primary research remains primary research, even in journals as prominent as JAMA and NEJM. Secondary sources really trump primary sources, even if they refer to bevacizumab as "bevazicimub". JFW | T@lk 17:40, 27 May 2013 (UTC)

This discussion is not going anywhere. You are clearly getting confused between primary research (first report of a specific set of data) and primary source ("one in which the authors directly participated in the research or documented their personal experiences"). Further, a review article of the literature is not necessary a secondary source. The author of the review paper can cite its own research. The review is in this case a primary source. Read and understand WP:MEDRS before using it to block correctly referenced information. — Preceding unsigned comment added by 108.14.187.81 (talk) 22:56, 27 May 2013 (UTC)

I presume you are the same editor, just editing from an IP account. I know perfectly well what I mean by a primary source. I am not delighted that the content has been reinserted without discussion, but at least it now prominently features some secondary sources (Shovlin's review and the Franchini review). JFW | T@lk 22:23, 29 May 2013 (UTC)

The new addition can stand, but I have removed a source that is of historical interest only. JFW | T@lk 23:43, 30 May 2013 (UTC)

References

Review

Br J Haem doi:10.1111/bjh.13606. To be used for updates. JFW | T@lk 09:49, 28 July 2015 (UTC)

Neuroradiology doi:10.1016/j.neurad.2016.02.005 JFW | T@lk 08:52, 27 June 2016 (UTC)

doi:10.1017/S0022215115000365 Evidence-based management of epistaxis in hereditary haemorrhagic telangiectasia JFW | T@lk 10:24, 4 January 2017 (UTC)

AV Malformation Redundancy

AV Malformation is already covered in considerable detail here. Can we reduce it's redundancy on this page? — Preceding unsigned comment added by Iiibalesiii (talk • contribs) 20:08, 4 March 2017 (UTC)

Second international guidelines

doi:10.7326/M20-1443 Annals JFW | T@lk 13:47, 9 September 2020 (UTC)

doi:10.1016/j.ejmg.2021.104370 - European framework. JFW | T@lk 16:37, 9 February 2022 (UTC)