The immune thrombocytopenic purpura (ITP) bleeding score: assessment of bleeding in patients with ITP

Abstract

This pilot study used an immune thrombocytopenic purpura (ITP)-specific bleeding score, the ITP Bleeding Scale (IBLS) to analyse the correlation of clinical and laboratory platelet variables with bleeding. MethodsA prospective Institutional Review Board-approved study was conducted on 100 visits for 65 consenting patients with ITP (30 on one and 35 on two visits) from December 2004 to December 2005. The patients were primarily adults with chronic ITP; a minority were children or adults with acute ITP.The IBLS (Table I) comprised 11 grades from 0 (none) to 2 (marked bleeding) assessed at nine anatomical sites by history over the previous week (Hx). In addition, two of these sites, skin and oral, were also assessed by physical examination (PE). The 'worst ever' bleeding experienced at each site was graded using the same system. Blood counts were analysed by using the Bayer-ADVIA TM 120 (Giacomini et al, 2001). Large platelets (20-60 fl) were examined as they were reported to be more haemostatically active (Karpatkin, 1978;Michel et al, 2005). Analysis focused on the six grades with most bleeding -skin and oral (Hx and PE), epistaxis and gynaecological (GYN) (Hx). Insufficient haemorrhages occurred at the other sites to enable inclusion in the analysis. Means, medians, ranges, the Kruskal-Wallis, Fisher's exact and chi-squared tests, and the Kappa statistic to establish inter-observer reliability (for 63/100 visits) were calculated. P-values <0AE05 were considered significant. ResultsThe median age was 31AE5 years; 20 patients were under 18 and eight over 65 years. Forty-two were female, 23 of reproductive age and assessed for GYN bleeding on 36 visits. Eighty-eight per cent had chronic ITP (median duration 6 years) and 40% were splenectomised. No correlation between IBLS and age, sex, duration of ITP or splenectomy status was found.The IBLS grades on the 100 study visits are presented in Tables II-IV. Seventy-two per cent of grade 1 haemorrhages occured in the skin. Grade 2 bleeding was more heterogeneous (28% skin, 46% oral, 13% GYN and 10% epistaxis). Patients with more skin bleeding also had more oral bleeding (PE and Hx, all P-values <0AE026).The median platelet count for all visits was 39AE5 · 10 9 /l (range: 6-623 · 10 9 /l). Twenty-five visits had a platelet count £ 20 · 10 9 /l and 46 visits had a platelet SummaryA method for objective quantification of bleeding symptoms in immune thrombocytopenic purpura (ITP) has not been established. The ITP Bleeding Scale (IBLS) is a novel bleeding assessment system comprising 11 site-specific grades. Implementation of the IBLS on 100 patient visits revealed that although platelet count and large platelet count correlated well with bleeding symptoms overall, this relationship disappeared in marked thrombocytopenia. The IBLS is a useful clinical tool for monitoring bleeding and may be used to aid the development of laboratory parameters that correlate with underlying bleeding propensity in thrombocytopenia.

Severe hemorrhage in children with newly diagnosed immune thrombocytopenic purpura

“…Several grading or scoring instruments for hemorrhage in thrombocytopenic subjects have been described. [31][32][33][34][35] A method already reported when the ICIS Registry II was being designed was that of Bolton-Maggs and Moon. 20 Since then, more quantitative measurement instruments that assess bleeding in different anatomic sites have been developed.…”

“…20 Since then, more quantitative measurement instruments that assess bleeding in different anatomic sites have been developed. 31,34 When BoltonMaggs and Moon 20 applied their scoring severity method to a cohort of newly diagnosed ITP patients in the United Kingdom, they defined 3% of the children as having severe hemorrhage. As validation of this scoring method, the frequency of severe hemorrhage in our ICIS Registry II ITP patients was virtually identical, For personal use only.…”

Comparison of two dosing schedules for subcutaneous injections of low-dose anti-CD20 veltuzumab in relapsed immune thrombocytopenia

“…Patients could be recruited irrespectively of whether they had or had not undergone splenectomy and in all stages of their disease (newly-diagnosed, <3 months; persistent, 3-12 months; or chronic, >1 year). 9 Using the ITP Bleeding Scale (IBLS) with bleeding at any anatomic site graded as 0 (none), 1 (mild), or marked (2), 10 patients with marked bleeding were excluded, as were patients with other significant cytopenias (patients with Evans syndrome, etc.). Patients had to be off ITP medications, except for prednisone ≤20 mg/day and danazol, which were allowed if the patients were continuing on stable doses.…”

Intracranial hemorrhage (ICH) in children with immune thrombocytopenia (ITP): study of 40 cases

“…Head trauma and no bleeding other than petechiae and ecchymosis 9 (23) 1 (1) No head trauma but bleeding other than petechiae and ecchymosis 20 (51) 35 (44) No head trauma and no bleeding other than petechiae and ecchymosis 6 (15) 44 (55) GI indicates gastrointestinal; U, urinary; and GYN, gynecological/vaginal. *Data for bleeding symptoms, NSAID use, and head trauma were considered negative if no specific response was provided on the questionnaire.…”