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Buxton B, Elliott K, Schwalm C. Direct oral anticoagulant use in hospitalized pediatric patients: Insights from nationwide data. Pediatr Blood Cancer 2024; 71:e31140. [PMID: 38956808 DOI: 10.1002/pbc.31140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 05/20/2024] [Accepted: 05/28/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have had significant impact on the management of venous thromboembolism (VTE) in adults, but these agents were not approved for use in pediatric patients until 2021. Our objective was to analyze the characteristics of pediatric patients treated with DOACs prior to and following U.S. Food and Drug Administration (FDA) approval for children and evaluate their impact on hospital outcomes. PROCEDURE We utilized the Epic Cosmos dataset (Cosmos), a de-identified dataset of over 220 million patients, to identify patients aged 1-18 years admitted with a first-occurrence diagnosis of VTE between January 1, 2017 and June 30, 2023. Patients were grouped by anticoagulation received (unfractionated heparin, low molecular weight heparin, and/or DOACs). RESULTS Among 5138 eligible patients, 18.1% received DOACs as all or part of their anticoagulation treatment, while 81.9% received heparin therapies alone. Patients treated with DOACs were older than patients treated with heparin monotherapy at 17.4 and 13.0 years, respectively. Non-DOAC patients were more likely to have chronic conditions and were less likely to have pulmonary embolism. Patients treated with DOACs demonstrated shorter overall length of stay and duration of intensive care unit (ICU) admission. CONCLUSIONS DOACs remain infrequently utilized in pediatric patients, especially in those under 13 years old. Initiation on heparin therapy and transition to DOACs remains common, with 80.6% of DOAC patients receiving heparin during their hospitalization. While DOAC monotherapy is not currently endorsed as first-line therapy for DVT or PE in children, it is being used clinically. Further research is needed to clarify the impact of DOAC use on patient adherence, VTE recurrence, and healthcare cost.
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Affiliation(s)
| | - Katharina Elliott
- Bronson Healthcare Group, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Carla Schwalm
- Bronson Healthcare Group, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
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Öncül Y, Akyay A, Özgen Ü. Thromboembolism in Children. Indian J Pediatr 2024; 91:696-701. [PMID: 37142860 DOI: 10.1007/s12098-023-04539-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 02/23/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVE To study pediatric patients who were diagnosed with thrombosis between January 2009 and March 2020. METHODS Patients were evaluated with respect to thrombophilic risk factors, localization of the thrombus, response to treatment, and recurrence rates during the last 11 y. RESULTS Among 84 patients, 59 (70%) had venous thrombosis and 20 (24%) had arterial thrombosis. The number of documented thrombosis amongst hospitalized children in authors' hospital has increased over the years. It has been observed that the annual incidence of thromboembolism has increased after 2014. Thirteen patients were recorded between 2009 and 2014 and 71 patients between 2015 and 2020 (until March 2020). Exact thrombosis localization could not be detected in 5 patients. The median age of patients was 8 ± 5.95 (range 0-18). Fourteen children (16.9%) had a history of familial thrombosis. Genetic and/or acquired risk factors were detected in 81 (96.4%) of the patients. Overall, 64 patients (76.1%) had acquired risk factors such as infection (20.2%), catheterization (13.1%), liver disease (11.9%), mastoiditis (8.3%), liver transplantation (6%), hypoxic-ischemic encephalopathy (4.8%), dehydration (3.6%), trauma (3.6%) and cancer (2.4%). As genetic risk factors, the most common genetic mutations were PAI-1 4G>5G, MTHFR C677T, and MTHFR A1298C mutations. Twenty-eight (41.2%) patients had at least one genetic thrombophilic mutation. At least one homozygous mutation in 37 patients (44%) and at least one heterozygous mutation in 55 patients (65.4%) were detected. CONCLUSIONS The annual incidence of thrombosis has increased over the years. Genetic predisposition and acquired risk factors play an important role in etiology, treatment, and follow-up in children with thromboembolism. Especially, genetic predisposition is common. Thrombophilic risk factors should be investigated and optimal therapeutic and prophylactic measures should be promptly taken in children with thrombosis.
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Affiliation(s)
- Yurday Öncül
- Department of Pediatric Hematology and Oncology, Inonu University School of Medicine, Malatya, Turkey.
| | - Arzu Akyay
- Department of Pediatric Hematology and Oncology, Inonu University School of Medicine, Malatya, Turkey
| | - Ünsal Özgen
- Department of Pediatric Hematology and Oncology, Inonu University School of Medicine, Malatya, Turkey
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Kelley-Quon LI, Acker SN, St Peter S, Goldin A, Yousef Y, Ricca RL, Mansfield SA, Sulkowski JP, Huerta CT, Lucas DJ, Rialon KL, Christison-Lagay E, Ham PB, Rentea RM, Beres AL, Kulaylat AN, Chang HL, Polites SF, Diesen DL, Gonzalez KW, Wakeman D, Baird R. Screening and Prophylaxis for Venous Thromboembolism in Pediatric Surgery: A Systematic Review. J Pediatr Surg 2024:S0022-3468(24)00345-2. [PMID: 38964986 DOI: 10.1016/j.jpedsurg.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 05/14/2024] [Accepted: 05/28/2024] [Indexed: 07/06/2024]
Abstract
OBJECTIVE The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee conducted a systematic review to describe the epidemiology of venous thromboembolism (VTE) in pediatric surgical and trauma patients and develop recommendations for screening and prophylaxis. METHODS The Medline (Ovid), Embase, Cochrane, and Web of Science databases were queried from January 2000 through December 2021. Search terms addressed the following topics: incidence, ultrasound screening, and mechanical and pharmacologic prophylaxis. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available literature. RESULTS One hundred twenty-four studies were included. The incidence of VTE in pediatric surgical populations is 0.29% (Range = 0.1%-0.48%) and directly correlates with surgery type, transfusion, prolonged anesthesia, malignancy, congenital heart disease, inflammatory bowel disease, infection, and female sex. The incidence of VTE in pediatric trauma populations is 0.25% (Range = 0.1%-0.8%) and directly correlates with injury severity, major surgery, central line placement, body mass index, spinal cord injury, and length-of-stay. Routine ultrasound screening for VTE is not recommended. Consider sequential compression devices in at-risk nonmobile, pediatric surgical patients when an appropriate sized device is available. Consider mechanical prophylaxis alone or with pharmacologic prophylaxis in adolescents >15 y and post-pubertal children <15 y with injury severity scores >25. When utilizing pharmacologic prophylaxis, low molecular weight heparin is superior to unfractionated heparin. CONCLUSIONS While VTE remains an infrequent complication in children, consideration of mechanical and pharmacologic prophylaxis is appropriate in certain populations. TYPE OF STUDY Systematic Review of level 2-4 studies. LEVEL OF EVIDENCE Level 3-4.
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Affiliation(s)
- Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
| | - Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine Aurora, CO, USA
| | - Shawn St Peter
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Adam Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Yasmine Yousef
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Canada
| | - Robert L Ricca
- Division of Pediatric Surgery, Prisma Health Upstate, University of South Carolina, Greenville, SC, USA
| | - Sara A Mansfield
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jason P Sulkowski
- Division of Pediatric Surgery, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA
| | - Carlos T Huerta
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA
| | - Donald J Lucas
- Department of Surgery, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Division of Pediatric Surgery, Naval Medical Center San Diego, CA, USA
| | - Kristy L Rialon
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Emily Christison-Lagay
- Division of Pediatric Surgery, Yale New Haven Children's Hospital, Yale School of Medicine, USA
| | - P Benson Ham
- Division of Pediatric Surgery, John R. Oishei Children's Hospital, University at Buffalo, Buffalo, NY, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Alana L Beres
- Division of Pediatric Surgery, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia PA, USA
| | - Afif N Kulaylat
- Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, PA, USA
| | - Henry L Chang
- Department of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | | | - Diana L Diesen
- Division of Pediatric Surgery, UT Southwestern, Dallas, TX, USA
| | | | - Derek Wakeman
- Division of Pediatric Surgery, University of Rochester, Rochester, NY, USA
| | - Robert Baird
- Division of Pediatric Surgery, BC Children's Hospital Vancouver Canada, University of British Columbia, Canada
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Zhou J, Zhu Y, Liu Y, Zhan H, Niu P, Chen H, Zhang J. Risk factors for venous thromboembolism in a single pediatric intensive care unit in China. Thromb J 2024; 22:26. [PMID: 38491391 PMCID: PMC10941433 DOI: 10.1186/s12959-024-00596-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/09/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Analyses of extensive, nationally representative databases indicate a rising prevalence of venous thromboembolism (VTE) among critically ill children. However, the majority of studies on childhood VTE have primarily concentrated on Caucasian populations in the United States and European countries. There is a lack of epidemiological studies on VTE in Chinese children. METHODS We conducted a retrospective cohort study of data from the Pediatric Intensive Care (PIC) database. Data were obtained and extracted by using Structured Query Language (SQL) and the administrative platform pgAdmin4 for PostgreSQL. Bivariate analyses were conducted in which categorical variables were analyzed by a chi-square test and continuous variables were analyzed by a Student's t-test. Separate multivariable logistic regressions were employed to investigate the associations between VTE and sociodemographic factors as well as clinical factors. RESULTS Our study included 12,881 pediatric patients from the PIC database, spanning the years 2010 to 2018. The incidence rate of pediatric VTE was 0.19% (24/12,881). The venous thrombotic locations were deep venous thrombosis extremities (n = 18), superior vena cava (n = 1), cerebral sinovenous (n = 1), and other deep venous thrombosis (n = 4). Univariate analysis showed that age, weight, shock, sepsis, cancer and vasopressor receipt were statistically significant risk factors for pediatric VTE (all p ≤ 0.05). After multivariable logistic regression analysis, only shock (aOR: 6.77, 95%CI: 1.33-34.73, p = 0.019) and admission for sepsis (aOR: 6.09, 95%CI: 1.76-21.09, p = 0.004) were statistically significant associated with pediatric VTE. CONCLUSIONS In conclusion, data obtained from the Pediatric Intensive Care (PIC) database revealed a prevalence of VTE in pediatric patients of 0.19%. The most common location for venous thrombi was deep venous thrombosis (DVT) in the extremities. We identified that shock and sepsis were statistically significant factors associated with pediatric VTE.
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Affiliation(s)
- Jintuo Zhou
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, China
| | - Yanting Zhu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, China
| | - Ying Liu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, China
| | - Hairong Zhan
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, China
| | - Peiguang Niu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, China
| | - Huajiao Chen
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, China.
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Athale U, Halton J, Gayowsky A, Chan AKC, Pole JD. Development and validation of thromboembolism diagnostic algorithms in children with cancer from real-world data. Pediatr Res 2024:10.1038/s41390-024-03082-x. [PMID: 38388822 DOI: 10.1038/s41390-024-03082-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 01/03/2024] [Accepted: 01/21/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE To evaluate the accuracy of diagnostic algorithms developed using the International Classification of Diseases (ICD-9-CM and ICD-10-CA) diagnostic codes and physician billing codes for thromboembolism (TE) from health administrative data compared to chart review diagnoses of TE in children with cancer. METHODS Using data linkage between the Pediatric Oncology Group of Ontario Network Information System (Ontario pediatric cancer registry) and various administrative data housed at ICES, eight algorithms were developed including a single reference to one of the billing codes, multiple references with varying time intervals, and combinations of various billing codes during primary cancer therapy for the whole cohort and, for early (<04/2002) and later (≥04/2002, solely ICD-10 codes) periods. Reference standard was chart review data from prior studies (from 1990 to 2016) among children (≤19 years) with cancer and radiologically confirmed TE. RESULTS Records of 2056 patients diagnosed with cancer at two participating sites during study period were reviewed; 112 had radiologically confirmed TE. The algorithm with addition of anticoagulation utilization codes was the best performing algorithm (sensitivity = 0.76;specificity = 0.85). With use of ICD-10 only codes, sensitivity of the same algorithm improved to 0.84 with specificity of 0.80. CONCLUSION This study provides a valid approach for ascertaining pediatric TE using real-world data. IMPACT Research in pediatric thrombosis, especially cancer-related thrombosis, is limited mainly due to small-sized studies. Real-world data provide ready access to large and diverse populations. However, there are no validated algorithms for identifying thrombosis in real-world data for children. An algorithm based on combination of thrombosis and anticoagulation utilization codes had 76% sensitivity and 85% specificity to identify diagnosis of thrombosis in children in administrative data. This study provides a valid approach for ascertaining pediatric thrombosis using real-world data and offers a good avenue to advance pediatric thrombosis research.
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Affiliation(s)
- Uma Athale
- Division of Hematology/Oncology, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada.
- Pediatrics, McMaster University, Hamilton, Ontario, Canada.
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Jacqueline Halton
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Anthony K C Chan
- Division of Hematology/Oncology, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada
- Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Jason D Pole
- Centre for Health Services Research, The University of Queensland, Queensland, Australia
- ICES, Toronto, Ontario, Canada
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Boulet M, Langlais T, Pelet S, Belzile É, Forsythe C. Incidence of venous thromboembolism in pediatric orthopedics: A systematic review. Orthop Traumatol Surg Res 2024:103830. [PMID: 38336248 DOI: 10.1016/j.otsr.2024.103830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/23/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUNDS Children undergoing orthopedic procedures often present numerous risk factors for thromboembolism. A recent survey, conducted by the Pediatric Orthopaedic Society of North America (POSNA), indicates that pediatric orthopedic surgeons are unaware of venous thromboembolism (VTE) prevention protocols and feel that certain procedures should require thromboprophylaxis. The aim of this systematic review was to properly assess the incidence of VTE in pediatric orthopedics. By using a thorough and broad search of the literature, the incidence according to different subspecialties of pediatric orthopedics was evaluated. METHODS A systematic review on VTE in pediatric orthopedics was conducted. Four databases were searched for articles reporting these events. Three major search concepts: "pediatrics", "orthopedic surgery/trauma" and "VTE complications" were used and broken down in MeSH, EmTree and their free vocabulary synonyms for proper literature review. Two independent authors screened 8467 titles and abstracts. Seventy articles reporting VTE in children treated by orthopedic surgeons were selected for data extraction. We reported median incidences by orthopedic subtypes and by study characteristics with a semi-quantitative review model. RESULTS The 70 articles yielded a total of 845,010 participants. Spine articles (33/70) provided 25,2% of the children included in the review. Trauma studies (16/70) accounted for 47.5% of the participants. The overall VTE median incidence was 0.16% [95% CI: 0.0-1.01%]. Musculoskeletal infections had a noticeably higher median incidence of 3.5% [CI: 0.0-13.8%]. Small variations were seen for the other subtypes: trauma, spine and elective surgeries. Subgroups by article characteristics did not differ significantly either. CONCLUSION Thrombotic complications are rare events in pediatric orthopedics, but knowledge epidemiologic is important because its potential severity. In this review, VTE median incidence for all orthopedic subtypes was around 0.16% [CI: 0.0-1.01%]. According to subspecialty assessment, musculoskeletal infections were associated with greater risk of VTE occurrence. LEVEL OF EVIDENCE III - Systematic review.
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Affiliation(s)
- Mathieu Boulet
- Department of Surgery, Division of Orthopaedic Surgery, CHU de Québec, Université Laval, Québec, QC, Canada
| | - Tristan Langlais
- Orthopaedic Paediatric Department, Children Hospital, CHU Purpan, Toulouse Universitary, Toulouse, France
| | - Stéphane Pelet
- Department of Surgery, Division of Orthopaedic Surgery, CHU de Québec, Université Laval, Québec, QC, Canada
| | - Étienne Belzile
- Department of Surgery, Division of Orthopaedic Surgery, CHU de Québec, Université Laval, Québec, QC, Canada
| | - Caroline Forsythe
- Department of Surgery, Division of Orthopaedic Surgery, CHU de Québec, Université Laval, Québec, QC, Canada.
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Spiezia L, Campello E, Tormene D, Simioni P. Venous Thromboembolism in Children: The Rivaroxaban Experience. Semin Thromb Hemost 2024. [PMID: 38181816 DOI: 10.1055/s-0043-1778106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
The incidence of venous thromboembolism (VTE) in the pediatric population has increased more than 10-fold in the last 20 years, as a consequence of the advancement of resuscitation and surgical techniques and the global increase in life expectancy of children suffering from chronic pathologies. Monitoring anticoagulant therapy to achieve outcomes within the target range in childhood VTE, parenteral administration of medications, and frequent blood tests in children are often cumbersome. Availability of safe and effective oral agents with pediatric data to support use would be of clear benefit. A physiologically based pharmacokinetic model was developed to estimate the appropriate dosing schedule for rivaroxaban in children. This incorporated growth/maturation and variability in anthropometrics (e.g., body height, weight, and body mass index), anatomy (e.g., organ weight), physiology (e.g., blood flow rates), metabolism and excretion. Rivaroxaban use in pediatric population underwent a complete investigational program, consisting mainly of one phase I pharmacokinetics/pharmacodynamics trial, three phase II trials, one phase III trial. The phase III trial enrolled 500 patients from birth to <18 years and documented the efficacy and safety of rivaroxaban regimens at dose equivalent to the adult 20 mg dose for the prevention of fatal or symptomatic nonfatal recurrent VTE and major bleeding versus heparin or vitamin K antagonists. Results were similar to those in rivaroxaban studies in adults. The efficacy and safety of rivaroxaban in children reported in the EINSTEIN JUNIOR trial provide further support to previous trials in adults (EINSTEIN Program), which demonstrate a favorable profile for the use of rivaroxaban for the management of VTE in challenging patient populations. Other clinical evidence contributing to the use of rivaroxaban among different risk groups in pediatric VTE population confirms the consistency with principal trial. Our review aims to describe the rationale for using rivaroxaban oral suspension in clinical practice and to summarize its multiple indications in each vascular bed (e.g., cerebral venous thrombosis, symptomatic or asymptomatic central venous catheter-associated thrombosis), etiology, and patients setting.
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Affiliation(s)
- Luca Spiezia
- General Internal Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padova University School of Medicine, Padova, Italy
| | - Elena Campello
- General Internal Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padova University School of Medicine, Padova, Italy
| | - Daniela Tormene
- General Internal Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padova University School of Medicine, Padova, Italy
| | - Paolo Simioni
- General Internal Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padova University School of Medicine, Padova, Italy
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Bashir DA, Cargill JC, Gowda S, Musick M, Coleman R, Chartan CA, Hensch L, Pezeshkmehr A, Qureshi AM, Sartain SE. Implementing a Pediatric Pulmonary Embolism Response Team Model: An Institutional Experience. Chest 2024; 165:192-201. [PMID: 38199732 DOI: 10.1016/j.chest.2023.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 01/12/2024] Open
Abstract
Pulmonary embolism is increasing in prevalence among pediatric patients; although still rare, it can create a significant risk for morbidity and death within the pediatric patient population. Pulmonary embolism presents in various ways depending on the patient, the size of the embolism, and the comorbidities. Treatment decisions are often driven by the severity of the presentation and hemodynamic effects; severe presentations require more invasive and aggressive treatment. We describe the development and implementation of a pediatric pulmonary embolism response team designed to facilitate rapid, multidisciplinary, data-driven treatment decisions and management.
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Affiliation(s)
- Dalia A Bashir
- Department of Pediatrics, Division of Critical Care Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX.
| | - Jamie C Cargill
- Department of Pediatrics, Division of Critical Care Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Srinath Gowda
- Division of Cardiology- Interventional Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Matthew Musick
- Department of Pediatrics, Division of Critical Care Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Ryan Coleman
- Department of Pediatrics, Division of Critical Care Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Corey A Chartan
- Department of Pediatrics, Division of Critical Care Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Lisa Hensch
- Department of Pathology & Immunology and Anesthesia, Division of Transfusion Medicine & Coagulation, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Amir Pezeshkmehr
- Department of Radiology, Division of Interventional Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Athar M Qureshi
- Division of Cardiology- Interventional Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Sarah E Sartain
- Division of Hematology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
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Havlicek EE, Goldman ZA, Faustino EVS, Ignjatovic V, Goldenberg NA, Sochet AA. Hospital-acquired venous thromboembolism during invasive mechanical ventilation in children: a single-center, retrospective cohort study. J Thromb Haemost 2023; 21:3145-3152. [PMID: 37423387 DOI: 10.1016/j.jtha.2023.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/01/2023] [Accepted: 06/29/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Invasive mechanical ventilation (IMV) has been independently associated with hospital-acquired venous thromboembolism (HA-VTE) among critically ill children, including extremity deep venous thrombosis and pulmonary embolism. OBJECTIVES We aimed to characterize the frequency and timing of HA-VTE following IMV exposure. METHODS This was a single-center, retrospective cohort study including children aged <18 years, hospitalized in a pediatric intensive care unit, undergoing mechanical ventilation for >24 hours from October 2020 through April 2022. Encounters with an existing tracheostomy or receiving treatment for HA-VTE prior to endotracheal intubation were excluded. The primary outcomes characterized clinically-relevant HA-VTE, including timing after intubation, location, and the presence of known hypercoagulability risk factors. Secondary outcomes were IMV exposure magnitude, defined by IMV duration and ventilator parameters (ie, volumetric, barometric, and oxygenation indices). RESULTS Of 170 consecutive, eligible encounters, 18 (10.6%) experienced HA-VTE at a median of 4 days (IQR, 1.4-6.4) following endotracheal intubation. Those with HA-VTE had an increased frequency of a prior venous thromboembolism (27.8% vs 8.6%, P = .027). No differences in frequency of other HA-VTE risk factors (ie, acute immobility, hematologic malignancy, sepsis, and COVID-19-related illness), presence of a concurrent central venous catheter, or the magnitude of IMV exposure were noted. CONCLUSION Children undergoing IMV experience HA-VTE at markedly higher rates than previously estimated in the general pediatric intensive care unit population after endotracheal intubation. While prospective validation is needed, these findings are an important step toward informing the development of risk-stratified thromboprophylaxis trials in critically ill children.
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Affiliation(s)
- Elizabeth E Havlicek
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, Florida, USA; Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.
| | - Zachary A Goldman
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | | | - Vera Ignjatovic
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA; Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Neil A Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA; Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA; Department of Medicine and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anthony A Sochet
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA; Department of Medicine and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Medicine, Division of Critical Care Medicine, Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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10
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Agarwal S, Abdelghani E, Stanek JR, Sankar A, Cua CL, Kerlin BA, Rodriguez V. Intracardiac thrombi in pediatrics: anticoagulation approach and treatment outcomes. Res Pract Thromb Haemost 2023; 7:102266. [PMID: 38193068 PMCID: PMC10772888 DOI: 10.1016/j.rpth.2023.102266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 10/26/2023] [Accepted: 10/31/2023] [Indexed: 01/10/2024] Open
Abstract
Background Intracardiac thrombi (ICT) are associated with significant morbidity and mortality. Anticoagulation is the first line of treatment and may be complemented by thrombectomy or thrombolysis. However, optimal anticoagulant duration remains ill-defined. High-risk features of ICT that may warrant long-term anticoagulation therapy have not been established. Objectives To describe anticoagulation duration and patterns of ICT resolution. To identify potential risk factors for persistent ICT despite anticoagulation. Methods A single-institution retrospective chart review identified patients diagnosed with ICT by echocardiogram between January 2014 and March 2022. Descriptive statistics and logistic regression were used. Results Fifty-one patients with ICT were identified. Median age at diagnosis was 9.2 years (IQR, 0.4-15.2). The most common underlying diagnoses were congenital heart disease (41%), infection (25%), and malignancy (24%). The majority of ICT were in the right atrium (n = 30). The median longest ICT dimension was 1.5 cm (range, 0.4-4.0). The median duration of anticoagulation was 4.3 months (IQR, 2.2-9.1). Among 48 patients who received anticoagulation as first-line treatment, 32 had partial or complete response with 3 to 6 months of anticoagulation, while remaining 16 patients had no response to anticoagulation. Patients with a central venous line had a delayed resolution of ICT [hazards ratio = 0.45 (95% CI, 0.22-0.93)]. Conclusion Our study demonstrates the wide variability in duration of anticoagulation for children with ICT. Majority of the individuals benefit from 3-to-6 month treatment; however, individuals with a central venous line may benefit from a longer course of anticoagulation. Further large-scale studies are recommended to validate our findings.
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Affiliation(s)
- Shreya Agarwal
- Division of Hematology, Department of Pediatrics, UCSF Benioff Children’s Hospital, San Francisco, California, USA
| | - Eman Abdelghani
- Pediatric Hematology, Indiana Hemophilia Treatment Center, Indianapolis, Indiana, USA
| | - Joseph R. Stanek
- Division of Hematology/Oncology/BMT, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Biostatistics Resource at Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Amanda Sankar
- Division of Hematology/Oncology/BMT, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Clifford L. Cua
- Division of Cardiology, Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Bryce A. Kerlin
- Division of Hematology/Oncology/BMT, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Center for Clinical and Translational Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Vilmarie Rodriguez
- Division of Hematology/Oncology/BMT, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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11
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He Y, Liu S, Su Y. Risk factors of deep vein thrombosis in children with osteomyelitis. Ann Med 2023; 55:2249011. [PMID: 37624766 PMCID: PMC10494723 DOI: 10.1080/07853890.2023.2249011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/08/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
OBJECTIVE To investigate the risk factors for deep vein thrombosis (DVT) in children with osteomyelitis and provide diagnostic and treatment strategies for the prevention, early detection and treatment of DVT. STUDY DESIGN The clinical data of nine children diagnosed with osteomyelitis and DVT between July 2012 and March 2021 were collected at our hospital, including age, sex, clinical manifestations, body temperature, coagulation function and other data, as well as the clinical data of 27 children diagnosed with osteomyelitis without DVT during the same period. Thirty-six children were divided into thrombus and thrombus-free groups. The clinical characteristics and risk factors for DVT in children with osteomyelitis were analysed. RESULTS Among the 36 children in this study, nine cases of thrombus formation mainly occurred in the femoral vein, popliteal vein and iliac vein, all near the infection site. The main clinical manifestations were lower extremity pain, swelling and pulmonary embolism in three cases. Among them, intensive care unit (ICU) admission, sepsis, higher D-dimer, higher body temperature during hospitalization, and pathogen culture showed that methicillin-resistant Staphylococcus aureus (MRSA) was associated with DVT. MRSA was the independent risk factor for DVT. CONCLUSIONS Admission to ICU, sepsis, higher D-dimer, higher body temperature during hospitalization, and MRSA are risk factors for thrombosis. MRSA is the independent risk factor for DVT. For patients with related risk factors, timely ultrasound examination of the infected site should be considered to achieve early detection and treatment.
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Affiliation(s)
- Yunjian He
- Orthopedics Department, Children’s Hospital of Chongqing Medical University, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Jiangxi Hospital Affiliated Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Shaoshan Liu
- Orthopedics Department, Children’s Hospital of Chongqing Medical University, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Jiangxi Hospital Affiliated Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Yuxi Su
- Orthopedics Department, Children’s Hospital of Chongqing Medical University, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Jiangxi Hospital Affiliated Children’s Hospital of Chongqing Medical University, Chongqing, China
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12
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Bram R, Bram J, Beaman A, Lee A, Lu M, Yheulon C, Tabak B, Woo R. High Rates of Pediatric Venous Thromboembolism After Elective Laparoscopic Splenectomy Suggest Need for Perioperative Prophylaxis. J Surg Res 2023; 289:135-140. [PMID: 37119614 DOI: 10.1016/j.jss.2023.03.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/20/2023] [Accepted: 03/26/2023] [Indexed: 05/01/2023]
Abstract
INTRODUCTION In adult populations, postoperative venous thromboembolism (VTE) is a reported complication of up to 8% of elective laparoscopic splenectomy (LS) cases. VTE is a rare event in the pediatric population, affecting less than 1% of all pediatric surgical patients. We hypothesized that pediatric patients are at a higher risk of postoperative VTE after undergoing elective LS relative to other laparoscopic procedures and may warrant prophylactic treatment. MATERIALS AND METHODS We queried the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database from 2012 to 2020. Patients were identified using the Current Procedural Terminology code 38120 and only elective cases were analyzed. RESULTS The incidence of VTE in all pediatric patients undergoing surgery in the American College of Surgeons NSQIP-P database was 0.13%. The incidence of VTE in pediatric patients undergoing elective laparoscopic abdominopelvic procedures was 0.17%. There were seven total cases of VTE (0.41%) in pediatric patients undergoing elective LS, more than twice the rate of the general population (P = 0.001). Eighty percent of pediatric patients undergoing elective LS had an underlying hematological disorder. CONCLUSIONS By analyzing the NSQIP-P database, we evaluated the largest cohort of pediatric patients undergoing elective LS to date. We identified a higher incidence of VTE following this procedure relative to the rate of VTE in the overall population in the NSQIP-P database, as well as those undergoing elective laparoscopic abdominopelvic operations. The relatively higher incidence of VTE after elective LS is likely due to the presence of underlying hematological conditions. Given the low incidence of complications associated with pharmacologic VTE prophylaxis, the results of this study suggest that further research is warranted to establish the efficacy of perioperative pharmacological VTE prophylaxis in pediatric patients undergoing elective LS.
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Affiliation(s)
- Ryan Bram
- Tripler Army Medical Center, Honolulu Hawaii.
| | - Jason Bram
- The Fu Foundational School of Engineering, Columbia University, New York, New York
| | | | - Anson Lee
- John A. Burns School of Medicine, Honolulu, Hawaii
| | - Michelle Lu
- John A. Burns School of Medicine, Honolulu, Hawaii
| | - Christopher Yheulon
- Tripler Army Medical Center, Honolulu Hawaii; Emory University School of Medicine, Atlanta, Georgia
| | | | - Russell Woo
- Kapi'olani Medical Center for Women & Children, Honolulu, Hawaii
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13
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Wright J, Qamar F, McLaughlin M, Jodeh DS, Amankwah E, Mosha M, Halsey J, Binitie O, Metts J, Goldenberg N, Rottgers SA. The Incidence of Thromboembolic Events During Hospitalizations Following Surgical Resection of Lower Extremity Sarcomas in Children: Utilizing the Pediatric Health Information System Database. J Pediatr Orthop 2023; 43:268-272. [PMID: 36693390 DOI: 10.1097/bpo.0000000000002357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a frequent occurrence during treatment for adults with sarcoma. The incidence and underlying risk factors of postsurgical VTE in children and adolescents undergoing resection of sarcoma are unknown. METHODS Using International Classification of Disease revision-9 diagnostic and procedure codes, the Pediatric Health Information System database was queried for patients aged 18 years and younger, discharged from 2004 to 2015 with a diagnosis of lower extremity malignant neoplasm who had a tumor resection or amputation performed during the encounter. Malignant neoplasms of the pelvic bones and soft tissues were categorized as "pelvis tumors", whereas malignant neoplasms of bone and soft tissues of the lower limbs were categorized as "lower limb tumors". Hospitalizations were evaluated for the occurrence of VTE. Demographic characteristics (age at admission, sex, race, and race/ethnicity) and incidence of VTE were reported. RESULTS There were 2400 patients identified. Of these, 19 experienced VTE (0.79%) during their surgical hospitalization encounter. By anatomic group, the rate of VTE was 1.4% (CI: 0.5%-3.2%) for tumors in the pelvis and 0.6% (CI: 0.3%-1.0%) in lower limb tumors. Categorizing by age, the incidence of VTE was 1.2% in patients aged zero to 5, 0.3% in patients 6 to 13, and 1.2% in patients 14 to 18 years old. (Table 1). The extremely low rate of VTE occurrence precluded further analysis of risk factors. CONCLUSIONS In this analysis, postsurgical VTE during hospitalization after pelvic and lower extremity sarcoma resection was an uncommon event in children and adolescents. There seemed to be an increased incidence of postsurgical VTE in pelvic tumors when compared with lower limb tumors, however, the rarity of all events precluded formal statistical analysis. A more robust data set would be required to determine if there are subsets of children and adolescents with sarcoma at higher risk of VTE that could benefit from thromboprophylaxis in the postoperative setting. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Joshua Wright
- Division of Plastic and Reconstructive Surgery, Department of Surgery
| | - Fatima Qamar
- Division of Plastic and Reconstructive Surgery, Department of Surgery
| | - Mariel McLaughlin
- Department of Plastic and Reconstructive Surgery, University of South Florida Morsani College of Medicine
| | - Diana S Jodeh
- Division of Plastic and Reconstructive Surgery, Department of Surgery
| | - Ernest Amankwah
- Data Coordinating Center for Pediatric Multicenter Studies, Institute for Clinical and Translational Research
| | - Maua Mosha
- Data Coordinating Center for Pediatric Multicenter Studies, Institute for Clinical and Translational Research
| | - Jordan Halsey
- Division of Plastic and Reconstructive Surgery, Department of Surgery
- Department of Plastic and Reconstructive Surgery, University of South Florida Morsani College of Medicine
| | - Odion Binitie
- Department of Sarcoma, Moffitt Cancer Center, Tampa, FL
| | - Jonathan Metts
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital
| | - Neil Goldenberg
- Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg
- Divisions of Hematology, Departments of Pediatrics and Medicine
| | - S Alex Rottgers
- Division of Plastic and Reconstructive Surgery, Department of Surgery
- Department of Plastic and Reconstructive Surgery, University of South Florida Morsani College of Medicine
- Division of Pediatric Plastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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14
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Sochet AA, Havlicek EE, Faustino EVS, Goldenberg NA. Mechanical Ventilation and Hospital-Acquired Venous Thromboembolism Among Critically Ill Children. Hosp Pediatr 2022; 12:1099-1109. [PMID: 36349533 DOI: 10.1542/hpeds.2022-006697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To estimate the occurrence of, and evaluate associations between, hospital-acquired venous thromboembolism (HA-VTE) and invasive mechanical ventilation (MV) among children hospitalized in the PICU. METHODS We performed a multicenter, retrospective cohort study comparing HA-VTE frequencies among subjects <18 years of age hospitalized in the PICU from January 2018 through December 2019 among 47 participating centers, via the Pediatric Health Information Systems registry. We excluded perinatal encounters, those with VTE present at admission, and those with observational status. The primary outcome was the proportion of HA-VTE events before hospital discharge, including extremity deep venous thrombosis, pulmonary embolism, and organ-specific deep venous thrombosis. The HA-VTE frequencies were compared using χ2 tests. The association between HA-VTE and MV was investigated via multivariable logistic regression, adjusting for previously described VTE risk factors. RESULTS Of the 205 231 PICU encounters identified for study, 70 829 (34.5%) underwent MV. The occurrence of HA-VTE was 2.2% and was greater among children who received, versus did not receive, MV (4.4% versus 1.1%, P < .001). Multivariable logistic regression revealed significant association between MV and HA-VTE (odds ratio 2.51, 95% confidence interval 2.33-2.69; P < .001). CONCLUSIONS In this multicenter, retrospective, registry-based cohort study, HA-VTE were diagnosed in 2.2% of critically-ill children, and after adjustment for central venous catheterization, MV independently increased the risk of HA-VTE 2.5-fold. These findings warrant prospective validation to inform the design of future risk-stratified clinical trials of thromboprophylaxis in critically-ill children.
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Affiliation(s)
- Anthony Alexander Sochet
- Divisions of Critical Care Medicine.,Department of Pediatrics, University of South Florida College of Medicine, Tampa, Florida.,Departments of Anesthesiology.,Critical Care Medicine, Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | | | | | - Neil Andrew Goldenberg
- Hematology, Department of Medicine, Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Critical Care Medicine, Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Departments of Medicine.,Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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15
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Lazaruc TI, Bodescu Amancei Ionescu L, Lupu VV, Muntean (Duicu) C, Bogos RA, Ivanov A, Scurtu G, Starcea IM, Miron IC, Mocanu MA. Thrombosis in Chronic Kidney Disease in Children. Diagnostics (Basel) 2022; 12:diagnostics12122931. [PMID: 36552938 PMCID: PMC9777211 DOI: 10.3390/diagnostics12122931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/04/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022] Open
Abstract
Venous thromboembolism (VTE) in children is a rare condition. An increased incidence has been observed in the last few years due to several factors, such as increased survival in chronic conditions, especially chronic kidney disease (CKD), use of catheters, and increased sensitivity of diagnostic tools. VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE). VTE in children is associated with a two to six times higher mortality risk and a 5-10% prevalence of post-thrombotic syndrome. Overall, 5% of VTE episodes in children are associated with chronic kidney disease. The etiology of VTE in chronic kidney disease covers a wide range of pathologies. Various types of thrombotic complications may occur during long-term use of a chronic dialysis catheter. VTE occurs in 3% of children with nephrotic syndrome (NS). The risks for VTE and arterial thromboembolism (ATE) were particularly high in the first 6 months after the onset of NS. Other causes of VTE are graft rejection due to thrombosis of vascular anastomoses after kidney transplantation (3%) and autoimmune diseases (lupus nephritis, antiphospholipid syndrome). In this state-of-the-art overview, we have reviewed the physiologic and pathologic mechanisms underlying pediatric thrombosis and updated current diagnostic and treatment options, emphasizing personal experience as well.
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Affiliation(s)
- Tudor Ilie Lazaruc
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Lavinia Bodescu Amancei Ionescu
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Vasile Valeriu Lupu
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Carmen Muntean (Duicu)
- Department of Pediatrics I, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540088 Targu Mures, Romania
| | - Roxana Alexandra Bogos
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary’s Emergency Children Hospital, 700309 Iasi, Romania
| | - Anca Ivanov
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Georgiana Scurtu
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Iuliana Magdalena Starcea
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary’s Emergency Children Hospital, 700309 Iasi, Romania
- Correspondence: ; Tel.: +40-726-704-612
| | - Ingrith Crenguta Miron
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Maria Adriana Mocanu
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary’s Emergency Children Hospital, 700309 Iasi, Romania
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16
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Sochet AA, Morrison JM, Jaffray J, Godiwala N, Wilson HP, Thornburg CD, Bhat RV, Zia A, Lawrence C, Kudchadkar SR, Hamblin F, Russell CJ, Streiff MB, Spyropoulos AC, Amankwah EK, Goldenberg NA. Enoxaparin Thromboprophylaxis in Children Hospitalized for COVID-19: A Phase 2 Trial. Pediatrics 2022; 150:e2022056726. [PMID: 35484817 DOI: 10.1542/peds.2022-056726] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Evidence regarding the safety and efficacy of anticoagulant thromboprophylaxis among pediatric patients hospitalized for coronavirus disease 2019 (COVID-19) is limited. We sought to evaluate safety, dose-finding, and preliminary efficacy of twice-daily enoxaparin as primary thromboprophylaxis among children hospitalized for symptomatic COVID-19, including primary respiratory infection and multisystem inflammatory syndrome in children (MISC). METHODS We performed a phase 2, multicenter, prospective, open-label, single-arm clinical trial of twice-daily enoxaparin (initial dose: 0.5mg/kg per dose; max: 60mg; target anti-Xa activity: 0.20-0.49IU/mL) as primary thromboprophylaxis for children <18 years of age hospitalized for symptomatic COVID-19. Study endpoints included: cumulative incidence of International Society of Thrombosis and Haemostasis-defined clinically relevant bleeding; enoxaparin dose-requirements; and cumulative incidence of venous thromboembolism within 30-days of hospital discharge. Descriptive statistics summarized endpoint estimates that were further evaluated by participant age (±12 years) and clinical presentation. RESULTS Forty children were enrolled and 38 met analyses criteria. None experienced clinically relevant bleeding. Median (interquartile range) dose to achieve target anti-Xa levels was 0.5 mg/kg (0.48-0.54). Dose-requirement did not differ by age (0.5 [0.46-0.52] mg/kg for age ≥12 years versus 0.52 [0.49-0.55] mg/kg for age <12 years, P = .51) but was greater for participants with MISC (0.52 [0.5-0.61] mg/kg) as compared with primary COVID-19 (0.48 [0.39-0.51] mg/kg, P = .010). Two children (5.3%) developed central-venous catheter-related venous thromboembolism. No serious adverse events were related to trial intervention. CONCLUSIONS Among children hospitalized for COVID-19, thromboprophylaxis with twice-daily enoxaparin appears safe and warrants further investigation to assess efficacy.
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Affiliation(s)
| | | | - Julie Jaffray
- Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Nihal Godiwala
- Department of Pediatrics, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Hope P Wilson
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham, Alabama
| | - Courtney D Thornburg
- Department of Pediatrics, University of California San Diego, La Jolla, California Division of Hematology and Oncology, Rady Children's Hospital San Diego, San Diego, California
| | - Rukhmi V Bhat
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ayesha Zia
- Department of Pediatrics, The University of Texas Southwestern, Dallas, Texas
| | | | - Sapna R Kudchadkar
- Critical Care Medicine
- Pediatrics
- Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Christopher J Russell
- Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Alex C Spyropoulos
- Department of Medicine, Zucker School of Medicine at Hofstra and Northwell and Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Ernest K Amankwah
- Departments of Anesthesia
- Pediatrics
- Oncology, Johns Hopkins All Children's Institute for Clinical and Translational Research
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17
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Pedersen LH, Villadsen GB, Hellfritzsch M, Hvas AM. Prophylaxis of Venous Thromboembolism in Children: A Systematic Review. Semin Thromb Hemost 2022; 48:413-421. [PMID: 35772401 DOI: 10.1055/s-0042-1748151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Venous thromboembolism (VTE) in children is a rare but serious event. Current guidance on pharmacological thromboprophylaxis in children is mostly based on adult studies and expert opinions. The aim of this systematic review was to examine under which conditions children (age ≤ 18 years) would benefit from pharmacological thromboprophylaxis with low molecular weight heparin or unfractionated heparin. Eligible studies included children, who did not receive pharmacological thromboprophylaxis as comparator, and VTE events were radiologically verified. MEDLINE and Embase were searched up to October 3, 2021. Ten studies were included presenting data for 976 children receiving pharmacological thromboprophylaxis. We divided the studies into three categories based on the population studied: children in the intensive care unit (n = 2), children with fractures and/or undergoing surgery (n = 5), and children with systemic disease (n = 3). A lower incidence of VTE was found when pharmacological thromboprophylaxis was used compared with no prophylaxis in children in intensive care unit with central venous catheter and mechanical ventilation (7/27 vs. 13/24), children in the intensive care unit admitted after trauma with a very high risk of VTE based on several risk factors (0/21 vs. 13/96), and children with acute lymphoblastic leukemia treated with L-asparaginase concomitant with steroid and presence of central venous catheter (0/82 vs. 8/121). Pharmacological thromboprophylaxis was not associated with an increased bleeding risk. In conclusion, pharmacological thromboprophylaxis in children is sparsely investigated. Only children with several risk factors for VTE are likely to benefit from pharmacological thromboprophylaxis.
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Affiliation(s)
| | | | | | - Anne-Mette Hvas
- Faculty of Health, Aarhus University, Aarhus, Denmark.,Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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18
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Olivieri M. Hemostaseology in Pediatrics. Hamostaseologie 2022; 42:101-102. [PMID: 35488162 DOI: 10.1055/a-1804-2517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Martin Olivieri
- Paediatric Thrombosis and Haemostasis Unit, Paediatric Haemophilia Center, Dr. von Hauner Children's Hospital, LMU Clinic, Munich, Germany
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19
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Male C. Anticoagulation in Pediatric Patients. Hamostaseologie 2022; 42:46-53. [PMID: 35042258 DOI: 10.1055/a-1703-0821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Special aspects of anticoagulation in children include the different epidemiology of thrombosis, developmental changes in the coagulation system, age-dependent pharmacokinetics of anticoagulants, risk of bleeding, and practical hurdles to anticoagulation. The classical anticoagulants so far used in children have several limitations, resulting in the need for regular monitoring. The pharmacological properties of direct oral anticoagulants (DOACs) and the special challenges of anticoagulation in children make the DOACs particularly attractive for children. All DOACs have pediatric development programs, targeting various indications for prevention and treatment of thrombosis. Child-appropriate formulations have been developed, age-specific dosing information generated, and safety and efficacy evaluated in ongoing phase 3 trials. Rivaroxaban and dabigatran have already been authorized for children for treatment of acute venous thrombosis and for extended secondary prevention. Their safety and efficacy have been demonstrated comparable to that of standard-of-care anticoagulants, without need for monitoring. Further studies are ongoing, which are expected to lead to pediatric authorizations of DOACs for primary venous thromboembolic event prevention in some high-risk settings. More real-life data will be necessary from postmarketing studies and registries to complement the evidence base for DOAC use in children, particularly in the youngest age groups and special disease populations.
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Affiliation(s)
- Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
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20
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Predictors of venous thromboembolism among infants in children's hospitals in the United States: a retrospective Pediatric Health Information Study. J Perinatol 2022; 42:103-109. [PMID: 34657144 PMCID: PMC8520347 DOI: 10.1038/s41372-021-01232-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/02/2021] [Accepted: 10/01/2021] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Examine: (1) Prevalence of diagnosed venous thromboembolism (VTE) in infants <6 months discharged from U.S. NICUs; (2) Associations between sociodemographic and clinical factors and VTE; (3) Secondary outcomes related to VTE. STUDY DESIGN Multivariable logistic regressions examined associations between VTE and sociodemographic and clinical factors among infants <6 months discharged from Pediatric Health Information System (PHIS) NICUs between 2016 and 2019. RESULTS Of 201,033 infants, 2720 (1.35%) had diagnosed VTE. Birthweight 300-1000 g (aOR 3.14, 95% CI 2.54-3.88), 1000-1500 g (aOR 1.77, 95% CI 1.40-2.42) versus 2500-3999 g, and public (aOR 1.18, 95% CI 1.02-1.37) versus private insurance were associated with increased odds of VTE, as were CVC, TPN, mechanical ventilation, infection, ECMO, and surgery. All types of central lines (non-tunneled and tunneled CVCs, PICCs, and umbilical catheters) had higher odds of VTE than not having that type of line. CVCs in upper versus lower extremities had higher odds of VTE. CONCLUSION Infants with risk factors may require monitoring for VTE. Results may inform VTE prevention.
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Kalff H, Cario H, Holzhauer S. Iron deficiency anemia and thrombosis risk in children-revisiting an old hypothesis. Front Pediatr 2022; 10:926925. [PMID: 35979407 PMCID: PMC9376258 DOI: 10.3389/fped.2022.926925] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
Iron deficiency anemia has a high prevalence in children and has repeatedly been implicated as a risk factor for arterial and venous thrombosis. As an effective therapy for iron deficiency anemia is available, understanding the association between this form of anemia and the potentially severe thrombosis phenotype is of major clinical interest. Recent findings shed light on pathophysiology of hypercoagulability resulting from iron-restricted erythropoiesis. Specifically, an animal model of induced iron deficiency allowed identifying multiple mechanisms, by which iron deficiency anemia results in increased thrombus formation and thrombus progression both in arterial and venous thrombosis. These findings complement and support conclusions derived from clinical data. The purpose of this mini review is to summarize current evidence on the association of iron deficiency anemia and thrombosis. We want to increase the awareness of iron deficiency as a risk factor for thrombosis in the pediatric population. We discuss how novel pathophysiological concepts can be translated into the clinical settings and suggest clinical studies on prevention and treatment strategies in high-risk patient groups.
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Affiliation(s)
- Hannah Kalff
- Department of Pediatric Hematology and Oncology, Charité University Medicine, Berlin, Germany
| | - Holger Cario
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Susanne Holzhauer
- Department of Pediatric Hematology and Oncology, Charité University Medicine, Berlin, Germany
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22
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Ishikawa T, Nakajima Y, Omae T, Ogiwara K, Nogami K. Comprehensive coagulation and fibrinolytic potential in the acute phase of pediatric patients with idiopathic nephrotic syndrome evaluated by whole blood-based rotational thromboelastometry. Pediatr Nephrol 2022; 37:1605-1614. [PMID: 34997323 PMCID: PMC8741554 DOI: 10.1007/s00467-021-05366-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/09/2021] [Accepted: 11/09/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Venous thromboembolism is a rare, serious complication of idiopathic nephrotic syndrome (INS) in childhood. The mechanisms responsible for the hypercoagulable state in the acute phase of INS are poorly understood, however. This study aimed to assess overall coagulation and fibrinolytic function in pediatric patients with INS. METHODS Global coagulation and fibrinolysis were examined in whole blood samples from 22 children with initial onset INS (initial-group), 22 children with relapsed INS (relapse-group), and 15 control pediatric patients using rotational thromboelastometry (ROTEM®). In the initial-group, blood samples were obtained before (week 0) and 1-4 weeks after initiation of corticosteroid therapy. EXTEM and FIBTEM were used to assess coagulation and fibrinolysis, respectively. Clot time (CT), clot formation time (CFT), maximum clot firmness (MCF), and α-angle were determined as coagulation parameters, and lysis index at 30 and 60 min (LI30 and LI60, respectively) were assessed as fibrinolytic parameters. RESULTS CT was significantly shortened, and MCF and α-angle were significantly greater than controls at week 0 and week 1 both in the initial-group and the relapse-group. MCF correlated with serum albumin (r = 0.70, p < 0.001) and fibrinogen level (r = 0.68, p < 0.001). The fibrinolytic parameters (LI30 and LI60) in the initial-group were stable and higher than those in controls at all time points (p < 0.01). CONCLUSIONS We have shown that the hypofibrinolytic defect did not improve with effective NS treatment at the early 4-week time-point. Additionally, a likely pre-thrombotic state was evident in the period before initial onset and 1 week after corticosteroid therapy in pediatric INS.
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Affiliation(s)
- Tomoaki Ishikawa
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522 Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522 Japan ,Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara Japan
| | - Takashi Omae
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522 Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522 Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
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23
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Jindal AK, Ahluwalia J, Suku R, Suri D, Nuytemans K, Ortel TL, Pericak-Vance MA, Vance JM, Singh S. Successful Management of Catastrophic Thrombotic Storm in a Young Boy: A Case Report From Northern India. J Pediatr Hematol Oncol 2021; 43:e1132-e1135. [PMID: 33560088 DOI: 10.1097/mph.0000000000002069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/02/2020] [Indexed: 11/26/2022]
Abstract
Thrombotic storm is a rare clinical entity characterized by acute to subacute thrombosis developing at multiple sites over a few days to a few weeks. An 11-year-old boy presented with headache and facial nerve palsy. He was found to have cortical sinus venous thrombosis and was initiated on low molecular weight heparin, but rapidly progressed with thromboses involving the pulmonary arteries and deep veins of the legs. Thereafter managed on high-dose unfractionated heparin, he eventually stabilized after a hospital stay of 34 days. Genetic analysis showed potentially pathogenic variants in the factor V and stabilin-2 genes.
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Affiliation(s)
| | - Jasmina Ahluwalia
- Department of Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajiv Suku
- Department of Paediatrics, Allergy Immunology Unit
| | - Deepti Suri
- Department of Paediatrics, Allergy Immunology Unit
| | - Karen Nuytemans
- John P. Hussman Institute for Human Genomics and Dr John T. Macdonald Foundation Department of Human Genomics, University of Miami Miller School of Medicine, Miami, FL
| | - Thomas L Ortel
- Division of Hematology, Duke University Medical Center, Duke Hemostasis and Thrombosis Center, Durham, NC
| | - Margaret A Pericak-Vance
- John P. Hussman Institute for Human Genomics and Dr John T. Macdonald Foundation Department of Human Genomics, University of Miami Miller School of Medicine, Miami, FL
| | - Jeffery M Vance
- John P. Hussman Institute for Human Genomics and Dr John T. Macdonald Foundation Department of Human Genomics, University of Miami Miller School of Medicine, Miami, FL
| | - Surjit Singh
- Department of Paediatrics, Allergy Immunology Unit
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24
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Panagopoulos D, Karydakis P, Noutsos G, Themistocleous M. Venous Thromboembolism Risk and Thromboprophylaxis in Pediatric Neurosurgery and Spinal Injury: Current Trends and Literature Review. Semin Thromb Hemost 2021; 48:318-322. [PMID: 34624914 DOI: 10.1055/s-0041-1733959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Although the entities of venous thromboembolism (VTE), deep venous thrombosis, pulmonary embolus, and thromboprophylaxis in adult patients undergoing brain tumor and spine surgery, traumatic brain injury and elective neurosurgical procedures are widely elucidated, the same is not valid when pediatric patients are under consideration. An attempt to review the peculiarities of these patients through a comprehensive bibliographic review is undertaken. We performed a narrative summary of the relevant literature dedicated to pediatric patients, centered on traumatic brain injury, the general incidence of thromboembolic disease in this patient population, the role of low molecular weight heparin (LMWH) in the treatment and prophylaxis of VTE, and its role in elective neurosurgical procedures, including spinal operations. Additionally, the risk of deep venous thrombosis in elective neurosurgical procedures is reviewed. Due to inherent limitations of the current studies, particularly a restricted number of patients, our data are underpowered to give a definitive protocol and guidelines for all the affected patients. Our current conclusions, based only on pediatric patients, argue that there is limited risk of VTE in pediatric patients suffering from brain tumors and that the possibility of VTE is very low in children undergoing elective neurosurgical procedures. There is no consensus regarding the exact incidence of VTE in traumatic brain injury patients. LMWH seems to be a safe and effective choice for the "at risk" pediatric patient population defined as being older than 15 years, venous catheterization, nonaccidental trauma, increased length of hospital stays, orthopaedic (including spinal) surgery, and cranial surgery.
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Affiliation(s)
| | | | - Georgios Noutsos
- Department of Anesthesiology, Pediatric Hospital of Athens, "Agia Sophia," Athens, Greece
| | - Marios Themistocleous
- Department of Neurosurgery, Pediatric Hospital of Athens, "Agia Sophia," Athens, Greece
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25
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Aardoom MA, Klomberg RCW, Kemos P, Ruemmele FM, van Ommen CH(H, de Ridder L, Croft NM. The Incidence and Characteristics of Venous Thromboembolisms in Paediatric-Onset Inflammatory Bowel Disease: A Prospective International Cohort Study Based on the PIBD-SETQuality Safety Registry. J Crohns Colitis 2021; 16:695-707. [PMID: 34599822 PMCID: PMC9228884 DOI: 10.1093/ecco-jcc/jjab171] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS Guidelines regarding thromboprophylaxis for venous thromboembolisms [VTEs] in children with inflammatory bowel disease [IBD] are based on limited paediatric evidence. We aimed to prospectively assess the incidence of VTEs in paediatric-onset IBD [PIBD], characterize PIBD patients with a VTE and identify potential IBD-related risk factors. METHODS From October 2016 to September 2020, paediatric gastroenterologists prospectively replied to the international Safety Registry, monthly indicating whether they had observed a VTE case in a patient <19 years with IBD. IBD details [type, Paris classification, clinical and biochemical disease activity, treatment] and VTE details [type, location, treatment, outcome] were collected. To estimate VTE incidence, participants annually reported the number of PIBD patients, data source and catchment area of their centre. A systematic literature review and meta-analysis was performed to calculate the VTE incidence in the general paediatric population. RESULTS Participation of 129 PIBD centres resulted in coverage of 24 802 PIBD patients. Twenty cases of VTE were identified [30% Crohn's disease]. The incidence of VTEs was 3.72 (95% confidence interval [CI] 2.27-5.74) per 10 000 person-years, 14-fold higher than in the general paediatric population (0.27 [95% CI 0.18-0.38], p < 0.001). Cerebral sinus venous thrombosis was most frequently reported [50%]. All but one patient had active IBD, 45% were using steroids and 45% were hospitalized. No patient received thromboprophylaxis, whereas according to current PIBD guidelines, this was recommended in 4/20 patients. CONCLUSION There is an increased risk of VTEs in the PIBD population compared to the general paediatric population. Awareness of VTE occurrence and prevention should be extended to all PIBD patients with active disease, especially those hospitalized.
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Affiliation(s)
| | | | - Polychronis Kemos
- Paediatric Gastroenterology, Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Frank M Ruemmele
- Department of Paediatric Gastroenterology, Université Paris Descartes, Sorbonne Paris Cité, APHP, Hôpital Necker Enfants Malades, Paris, France
| | | | - C H (Heleen) van Ommen
- Department of Paediatric Haematology, Erasmus Medical Centre – Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Lissy de Ridder
- Corresponding author: Dr Lissy de Ridder, MD PhD, Erasmus Medical Center – Sophia Children’s Hospital, Department of Paediatric Gastroenterology, Room SP-2430, PO Box 2040, 3000 CA Rotterdam, the Netherlands. Tel: 0031650001782;
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26
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Implementation of automatic data extraction from an enterprise database warehouse (EDW) for validating pediatric VTE decision rule: a prospective observational study in a critical care population. J Thromb Thrombolysis 2021; 50:782-789. [PMID: 32529550 DOI: 10.1007/s11239-020-02158-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Multiple clinical risk prediction tools for hospital acquired venous thromboembolism (HA-VTE) have been developed. The objectives of this study were to develop and assess the feasibility of data extraction from Electronic Medical Records (EMR) from an enterprise database warehouse (EDW) and to test the validity of a previously developed Pediatric Clot Decision Rule (PCDR). This single-center prospective observational cohort study was conducted between March 2016 and March 2017 and included eligible patients admitted to the intensive care units. Risk score was calculated using the PCDR tool. Sensitivity, specificity, positive and negative predicted value (PPV and NPV) were calculated based on a cut-point of 3. A total of 2822 children were eligible for analysis and 5.1% (95% CI 4.2-6.2) children had a PCDR score of 3. Children with PCDR score of ≥ 3 had a 3 times higher odd of developing VTE compared to those with scores < 3 (OR 3.1; 95% CI 1.93-4.80; p < 0.001). The model performance showed that at the cutoff point of ≥ 3, both the specificity and sensitivity of the PCDR in predicting VTE was 69% and NPV of 98%. We successfully demonstrated using our EDW to populate a research database using an automatic data import. A PCDR score of ≥ 3 was associated with VTE. Collaboration through large registries will be useful in informing practices and guidelines for rare disorders such as pediatric VTE.
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27
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García-Boyano M, Caballero-Caballero JM, García Fernández de Villalta M, Gutiérrez Alvariño M, Blanco Bañares MJ, Climent Alcalá FJ. Risk factors determining central venous access device-associated deep vein thrombosis resolution in children: a retrospective study. Eur J Pediatr 2021; 180:1907-1914. [PMID: 33555427 DOI: 10.1007/s00431-021-03985-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/29/2021] [Accepted: 02/04/2021] [Indexed: 11/25/2022]
Abstract
The risk factors associated with the probability of central venous access device (CVAD)-associated deep vein thrombosis (DVT) resolution have been hardly evaluated in children. Current guidelines suggest anticoagulation for a maximum of 3 months in patients with provoked DVT if the provoking factor is resolved. To know if the thrombus will resolve after anticoagulant therapy will help to choose whether to initiate and/or continue this treatment or not. We did a retrospective study of 85 pediatric patients (45 girls, 40 boys) with CVAD-associated DVT to examine the risk factors associated with lack of thrombus resolution in the first 6 months after diagnosis. Sixty-two children had their thrombosis resolved after a median of 50 days (p25-p75 25-97) since diagnosis. In multivariate analysis, variables significantly associated with no resolution were total occlusion (OR 12.50, 95% CI 2.99-52.14, p=.001), location in upper extremity, head, and neck veins (OR 17.70, 95% CI 1.64-191.43, p=.018); collateral circulation in the first 45 days after diagnosis (OR 33.55, 95% CI 2.42-464.71, p=.009); and having between 0 and 3 prothrombotic risk factors at diagnosis (OR 6.20, 95% CI 1.21-31.75, p=.029).Conclusion: CVAD-associated DVT resolution in children in the first 6 months since diagnosis was significantly lower if the thrombosis was occlusive, if it was located in the upper extremity, head, and neck veins; if collateral circulation was seen on ultrasound in the first 45 days; and/or when the patient showed less prothrombotic risk factors at diagnosis. What is Known: • The risk factors associated with central venous access device-associated deep vein thrombosis resolution have been hardly evaluated in children. • Current guidelines suggest anticoagulation for a maximum of 3 months in provoked vein thrombosis if the provoking factor is resolved. What is New: • Thrombus resolution was lower if it was occlusive, located in the upper extremity veins, if collateral circulation was seen, and with less prothrombotic risk factors at diagnosis. • To know if the thrombus will resolve after anticoagulation will help to choose whether to initiate and/or continue it or not.
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28
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Sochet AA, Kiskaddon A, Betensky M, Goldenberg N. Venous Thromboembolism among Critically Ill Children: A Narrative Review. Semin Thromb Hemost 2021; 47:631-642. [PMID: 34058768 DOI: 10.1055/s-0041-1722847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Venous thromboembolism (VTE) is a leading cause of morbidity and mortality among hospitalized patients, including children. In recent years, it has become clear that hospitalization and critical illness bestow an increased VTE risk in pediatrics and relate to mortality and life-limiting comorbidities. For critically ill children, reported rates of VTE vary by study sampling techniques, presence of inherited or acquired thrombophilia, acute and chronic immobility, underlying illness prompting hospitalization, and clinical factors related to illness severity such as central venous catheterization, length of stay, mechanical ventilation, and patient age. Accordingly, critically ill children with new signs of venous congestion, acute inflammation, or unexplained acute organ dysfunction should be routinely evaluated for VTE. This narrative review summarizes recent and historical literature regarding risk factors, prevention, presentation, treatment, and outcomes of VTE in critically ill children. In addition, we identify knowledge gaps and priorities for future collaborative research on this vital condition. Special attention is given to the clinical trial opportunities, challenges, and ongoing efforts in thromboprophylaxis in critically ill children, including those hospitalized for disease related to novel coronavirus (COVID-19) and multisystem inflammatory disease in children.
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Affiliation(s)
- Anthony A Sochet
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Pediatric Critical Care Medicine, Department of Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Amy Kiskaddon
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Marisol Betensky
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Thrombosis Program, Johns Hopkins All Children's Cancer and Blood Disorder Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Neil Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Thrombosis Program, Johns Hopkins All Children's Cancer and Blood Disorder Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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29
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Morrison JM, Betensky M, Kiskaddon AL, Goldenberg NA. Venous Thromboembolism among Noncritically Ill Hospitalized Children: Key Considerations for the Pediatric Hospital Medicine Specialist. Semin Thromb Hemost 2021; 48:434-445. [PMID: 33962474 DOI: 10.1055/s-0041-1729170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Venous thromboembolism (VTE) is a leading cause of morbidity and preventable harm among noncritically ill hospitalized children. Several clinical factors relevant to the noncritically ill hospitalized child significantly increase the risk of VTE including the presence of central venous catheters, systemic inflammation, and prolonged immobilization. Although risk mitigation strategies have been described, the diagnosis, treatment, and prevention of VTE require standardization of institutional practices combined with multidisciplinary collaboration among pediatric hospitalists, hematologists, and other care providers. In this narrative review, we summarize the epidemiology of VTE, risk models identifying high-risk conditions associated with VTE, and prevention and treatment strategies. We further describe successful quality improvement efforts implementing institutional VTE risk stratification and thromboprophylaxis procedures. Finally, we highlight unique challenges facing pediatric hospital medicine specialists in the era of the COVID-19 pandemic, including caring for adults admitted to pediatric hospital units, and describe future research opportunities for VTE in the noncritically ill hospitalized child.
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Affiliation(s)
- John M Morrison
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Pediatric Hospital Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Marisol Betensky
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Pediatric Hematology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Amy L Kiskaddon
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Neil A Goldenberg
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Pediatric Hematology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
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Graham RT, Coven SL, Stanek JR, Folta A, Hollingsworth EW, Finlay JL, Kumar R. Venous thromboembolism in children with central nervous system tumors: Comparison of an institutional cohort to a national administrative database. Pediatr Blood Cancer 2021; 68:e28846. [PMID: 33340265 DOI: 10.1002/pbc.28846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/23/2020] [Accepted: 11/26/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND Central nervous system (CNS) tumors are the second most common malignancy of childhood, and published data on venous thromboembolism (VTE) rate and risk factors for these patients are outdated or incomplete. Here, we determine the cumulative incidence and risk factors for VTE in this population. PROCEDURE VTE diagnosis and associated clinical risk factors were abstracted and analyzed for two cohorts of children (0-21 years) diagnosed with CNS tumors between January 1, 2010 to September 30, 2018. The first study was a retrospective single institution cohort study. The initial observations were confirmed across multiple pediatric hospitals using the Pediatric Health Information System (PHIS) administrative database. RESULTS The single-institution cohort included 338 patients aged 3 days to 20.9 years (median age, 8.6 years); VTE developed in eight (2.4%) patients. The PHIS cohort included 17 634 patients aged from 0 to 21.9 years (median: 9.5 years); VTE developed in 354 (2.0%) patients. Univariate analysis for the single-institution cohort identified central venous catheter (CVC) placement as a risk factor for VTE (odds ratio [OR] 8.40, 95% confidence interval [CI] 1.43-49.41, P = .0186). Multivariable analysis of the PHIS dataset identified CVC placement (OR 1.97, 95% CI 1.57-2.46; P < .0001), obesity (OR 2.96, 95% CI 1.21-7.26; P = .0177), and more than one hospital admission (OR 3.54, 95% CI 2.69-4.64; P < .0001) as significant predictors of VTE. VTE diagnosis was not associated with increased mortality in either cohort. CONCLUSIONS The VTE rate in children with CNS tumors is low (2%). CVC placement was identified as a modifiable risk factor in both cohorts.
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Affiliation(s)
- Richard T Graham
- Division of Neuro-Oncology, Department of Pediatrics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Scott L Coven
- Department of Pediatrics, Indiana University, Riley Children's Hospital, Indianapolis, Indiana
| | - Joseph R Stanek
- Division of Hematology/Oncology, Department of Pediatrics, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio
| | - Ashley Folta
- Division of Hematology/Oncology, Department of Pediatrics, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio
| | - Ethan W Hollingsworth
- Medical Scientist Training Program, University of California, Irvine, California
- Department of Anatomy and Neurobiology, University of California, Irvine, California
| | - Jonathan L Finlay
- Division of Hematology/Oncology, Department of Pediatrics, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio
| | - Riten Kumar
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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31
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Is There Value in Venous Thromboembolism Chemoprophylaxis After Pediatric Scoliosis Surgery? A 28-Year Single Center Study. J Pediatr Orthop 2021; 41:138-142. [PMID: 33448726 DOI: 10.1097/bpo.0000000000001746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND With a recognized increase in the incidence of venous thromboembolism (VTE) in children, especially in those with complex, chronic conditions, it is important for patient safety and risk management to identify subgroups that would benefit from prophylactic treatment. The aim of our study was to assess whether scoliosis surgery in children was associated with an increased incidence of VTE, including deep venous thrombosis (DVT) and pulmonary embolism, and if chemoprophylaxis is warranted. METHODS We reviewed our institution's Pediatric Orthopaedic Spine Database (1992-2019) to identify patients who had a symptomatic VTE postoperatively. RESULTS There were 1471 patients (1035 female, 436 male) with a mean age at surgery of 12.1±3.2 years (range, 1 to 18 y) underwent posterior spinal fusion and instrumentation (2131 procedures). No patients were given pharmacological VTE prophylaxis, and no routine screening for VTE was performed. Two patients had a lower extremity DVT (0.13%) within 6 months following surgery, (range, 55 to 161 d). Neither patient had a subsequent pulmonary embolism. They were 9 and 17 years of age with a diagnosis of neuromuscular scoliosis (1 each postpolio and myelodysplasia). One affected patient had a central venous line inserted perioperatively, a known risk factor for thromboembolism. All DVTs were treated with appropriately dosed anticoagulants. None had a family history of hypercoagulation. CONCLUSIONS The risk of symptomatic VTE is extraordinarily low after pediatric spinal deformity surgery. Mechanical prophylaxis is sufficient in most cases. Further multi-center studies may help identify patient specific risk factors.
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Jaffray J, Branchford B, Goldenberg N, Malvar J, Croteau SE, Silvey M, Fargo JH, Cooper JD, Bakeer N, Sposto R, Ji L, Zakai NA, Faustino EVS, Stillings A, Krava E, Young G, Mahajerin A. Development of a Risk Model for Pediatric Hospital-Acquired Thrombosis: A Report from the Children's Hospital-Acquired Thrombosis Consortium. J Pediatr 2021; 228:252-259.e1. [PMID: 32920105 PMCID: PMC7752847 DOI: 10.1016/j.jpeds.2020.09.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To identify pertinent clinical variables discernible on the day of hospital admission that can be used to assess risk for hospital-acquired venous thromboembolism (HA-VTE) in children. STUDY DESIGN The Children's Hospital-Acquired Thrombosis Registry is a multi-institutional registry for all hospitalized participants aged 0-21 years diagnosed with a HA-VTE and non-VTE controls. A risk assessment model (RAM) for the development of HA-VTE using demographic and clinical VTE risk factors present at hospital admission was derived using weighted logistic regression and the least absolute shrinkage and selection (Lasso) procedure. The models were internally validated using 5-fold cross-validation. Discrimination and calibration were assessed using area under the receiver operating characteristic curve and Hosmer-Lemeshow goodness of fit, respectively. RESULTS Clinical data from 728 cases with HA-VTE and 839 non-VTE controls, admitted between January 2012 and December 2016, were abstracted. Statistically significant RAM elements included age <1 year and 10-22 years, cancer, congenital heart disease, other high-risk conditions (inflammatory/autoimmune disease, blood-related disorder, protein-losing state, total parental nutrition dependence, thrombophilia/personal history of VTE), recent hospitalization, immobility, platelet count >350 K/μL, central venous catheter, recent surgery, steroids, and mechanical ventilation. The area under the receiver operating characteristic curve was 0.78 (95% CI 0.76-0.80). CONCLUSIONS Once externally validated, this RAM will identify those who are at low-risk as well as the greatest-risk groups of hospitalized children for investigation of prophylactic strategies in future clinical trials.
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Affiliation(s)
- Julie Jaffray
- Children's Hospital Los Angeles, Los Angeles, CA; University of Southern California Keck School of Medicine, Los Angeles, CA.
| | - Brian Branchford
- Children's Hospital Colorado, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| | - Neil Goldenberg
- Johns Hopkins All Children's Hospital, Baltimore, MD; Department of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Stacy E Croteau
- Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | | | | | | | - Nihal Bakeer
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN
| | - Richard Sposto
- University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Lingyun Ji
- University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Neil A Zakai
- Department of Medicine, Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont Burlington, Burlington, VT
| | | | | | - Emily Krava
- Children's Hospital Los Angeles, Los Angeles, CA
| | - Guy Young
- Children's Hospital Los Angeles, Los Angeles, CA; University of Southern California Keck School of Medicine, Los Angeles, CA
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Campos LR, Petroli M, Sztajnbok FR, da Costa ES, Brandão LR, Land MGP. Risk factors for the development of hospital-acquired pediatric venous thromboembolism-Dealing with potentially causal and confounding risk factors using a directed acyclic graph (DAG) analysis. PLoS One 2020; 15:e0242311. [PMID: 33186402 PMCID: PMC7665816 DOI: 10.1371/journal.pone.0242311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 11/01/2020] [Indexed: 11/27/2022] Open
Abstract
Introduction Hospital-acquired venous thromboembolism (HA-VTE) in children comprises multiple risk factors that should not be evaluated separately due to collinearity and multiple cause and effect relationships. This is one of the first case-control study of pediatric HA-VTE risk factors using a Directed Acyclic Graph (DAG) analysis. Material and methods Retrospective, case-control study with 22 cases of objectively confirmed HA-VTE and 76 controls matched by age, sex, unit of admission, and period of hospitalization. Descriptive statistics were used to define distributions of continuous variables, frequencies, and proportions of categorical variables, comparing cases and controls. Due to many potential risk factors of HA-VTE, a directed acyclic graph (DAG) model was created to identify confounding, reduce bias, and increase precision on the analysis. The final model consisted of a DAG-informed conditional logistic regression. Results In the initial conventional univariable model, the following variables were selected as potential risk factors for HA-VTE: length of stay (LOS, days), immobility, ICU admission in the last 30 days, LOS in ICU, infection, central venous catheter (CVC), number of CVCs placed, L-asparaginase, heart failure, liver failure, and nephrotic syndrome. The final model using the set of variables selected by DAG analysis revealed LOS (OR = 1.106, 95%CI = 1.021–1.198, p = 0.013), L-asparaginase (OR = 26.463, 95%CI = 1.609–435.342, p = 0.022), and nephrotic syndrome (OR = 29.127, 95%CI = 1.044–812.508, p = 0.004) as independent risk factors for HA-VTE. Conclusion The DAG-based approach was useful to clarify the influence of confounders and multiple causalities of HA-VTE. Interestingly, CVC placement—a known thrombotic risk factor highlighted in several studies—was considered a confounder, while LOS, L-asparaginase use and nephrotic syndrome were confirmed as risk factors to HA-VTE. Large confidence intervals are related to the sample size; however, the results were significant.
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Affiliation(s)
- Leonardo Rodrigues Campos
- Department of Pediatrics, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Pediatrics, Division of Pediatric Rheumatology, Hospital Universitário Antônio Pedro, Universidade Federal Fluminense, Niterói - Rio de Janeiro, Brazil
| | - Maurício Petroli
- Department of Pediatrics, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Pediatrics, Faculty of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Flavio Roberto Sztajnbok
- Department of Pediatrics, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Pediatrics, Faculty of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Pediatrics, Division of Pediatric Rheumatology, Hospital Universitário Pedro Ernesto, Rio de Janeiro, Brazil
| | - Elaine Sobral da Costa
- Department of Pediatrics, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Pediatrics, Faculty of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leonardo Rodrigues Brandão
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Gerardin Poirot Land
- Department of Pediatrics, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Pediatrics, Faculty of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Abstract
BACKGROUND Deep vein thrombosis (DVT) can occasionally be secondary to mechanical compressions, such as in May-Thurner syndrome. To our knowledge, no cases of DVT associated with mechanical compression by fecal impaction in a pediatric patient have been previously reported. CASE PRESENTATION An 18-year-old developmentally delayed female presented to the emergency department with swelling involving her left lower extremity. Cross-sectional imaging revealed a significant stool burden in the rectosigmoid colon compressing the left external iliac vein and causing secondary thrombosis. Thrombectomy successfully alleviated the clot burden. CONCLUSION This case underscores the potentially serious implications of severe fecal impaction in the pediatric and adolescent populations.
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Soret J, Debray D, Fontbrune FSD, Kiladjian JJ, Saadoun D, Latour RPD, Valla D, Hernandez-Gea V, Hillaire S, Dutheil D, Plessier A, Bureau C, De Raucourt E. Risk factors for vascular liver diseases: Vascular liver diseases: position papers from the francophone network for vascular liver diseases, the French Association for the Study of the Liver (AFEF), and ERN-rare liver. Clin Res Hepatol Gastroenterol 2020; 44:410-419. [PMID: 32651075 DOI: 10.1016/j.clinre.2020.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/03/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Juliette Soret
- Center of Clinical Investigation, Saint-Louis Hospital APHP, 1, avenue Claude Vellefaux, 75010 Paris, France; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France.
| | - Dominique Debray
- Pediatric hepatology Unit, Necker Hospital APHP, 149, rue de Sèvres, 75015 Paris, France; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - Flore Sicre de Fontbrune
- Service d'hématologie, French referral centre for Aplastic anemia and PNH and filière de santé maladies rares immunohématologiques, Saint-Louis Hospital APHP, ERN eurobloodnet, 75010 Paris, France
| | - Jean-Jacques Kiladjian
- Center of Clinical Investigation, Saint-Louis Hospital APHP, 1, avenue Claude Vellefaux, 75010 Paris, France; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - David Saadoun
- Departement of Internal Medecine, Médecine interne, La Pitié Salpêtrière Hospital APHP, CMR maladies auto_immunes systémiques rares ; CMR maladies auto inflammatoires et amylose, ERN RITA, 47-83, boulevard de l'Hôpital, 75651 Paris, France
| | - Régis Peffault de Latour
- Service d'hématologie, French referral centre for Aplastic anemia and PNH and filière de santé maladies rares immunohématologiques, Saint-Louis Hospital APHP, ERN eurobloodnet, 75010 Paris, France
| | - Dominique Valla
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Department of Hepatology, Beaujon Hospital AP-HP, 100, boulevard du Général Leclerc, 92118 Clichy, France; Reference center of vascular liver diseases, European Reference Network (ERN) Rare-Liver
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Unit, Liver Unit. IMDIM. CIBERehd, Hospital Clinic, Barcelona, Spain
| | - Sophie Hillaire
- Department of Internal Medicine, Foch Hospital, 40, rue Worth, 92150 Suresnes, France
| | - Danielle Dutheil
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Association of patients with vascular liver diseases (AMVF), Beaujon Hospital, Department of Hepatology, 100, boulevard du Général-Leclerc, 92118 Clichy, France
| | - Aurélie Plessier
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Department of Hepatology, Beaujon Hospital AP-HP, 100, boulevard du Général Leclerc, 92118 Clichy, France; Reference center of vascular liver diseases, European Reference Network (ERN) Rare-Liver
| | - Christophe Bureau
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Department of Gastroenterology and Hepatology, Rangueil Hospital, University Hospital of Toulouse, 1, avenue du Professeur Jean-Poulhès, 31400 Toulouse, France
| | - Emmanuelle De Raucourt
- Department of Laboratory Hematology, Beaujon Hospital AP-HP, 100, boulevard du Général Leclerc, 92118 Clichy, France; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Reference center of vascular liver diseases, European Reference Network (ERN) Rare-Liver
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Bitsadze V, Nalli C, Khizroeva J, Lini D, Andreoli L, Lojacono A, Fazzi E, Shoenfeld Y, Tincani A, Makatsariya A. "APS pregnancy - The offspring". Lupus 2020; 29:1336-1345. [PMID: 32752918 DOI: 10.1177/0961203320947154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Antiphospholipid antibody syndrome (APS) is an autoimmune disease that affects women in childbearing age. In recent years, great improvements were achieved in the management of pregnancies in these women. Prematurity could be an issue in these pregnancies, mainly due to the direct pathogenic effect of antiphospholipid antibodies (aPL) on the placental surface. Maternal IgG aPL can cross the placenta and theoretically interact with the growing fetus; it could reach the fetal brain because of the incompleteness of the fetal blood-brain barrier: whether this can have an effect on brain development is still debated. Neonatal thrombosis episodes have been described in children positive for aPL, not always associated with maternal antibody positivity, suggesting the hypothesis of a possible aPL de novo synthesis in fetus and neonates. METHODS A keyword-based literature search was conducted. We also described a case of neonatal catastrophic antiphospholipid syndrome (CAPS). RESULTS Offspring of patients with APS are generally healthy but the occurrence of neonatal thrombosis or minor neurological disorders were reported. CONCLUSIONS The limited number of the available data on this sensitive issue supports the need for further studies. Clinical follow-up of children of mothers with APS seems to be important to exclude, in the neonatal period, the occurrence of aPL associated pathological events such as thrombosis, and in the long-term, impairment in learning skills or behavioral problems.
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Affiliation(s)
- Viktoria Bitsadze
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Cecilia Nalli
- Rheumatology and Immunology Unit, ASST Spedali Civili, Brescia, Italy
| | - Jamilya Khizroeva
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Daniele Lini
- Rheumatology and Immunology Unit, ASST Spedali Civili, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Immunology Unit, ASST Spedali Civili, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Andrea Lojacono
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Obstetric and Gynecology Unit, ASST Spedali Civili, Brescia, Italy
| | - Elisa Fazzi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Child Neurology and Psychiatry Unit, ASST Spedali Civili, Brescia, Italy
| | - Yehuda Shoenfeld
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia.,Department of Medicine 'B', The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Angela Tincani
- Rheumatology and Immunology Unit, ASST Spedali Civili, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,I.M. Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Alexander Makatsariya
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
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Barg AA, Kenet G. Cancer-associated thrombosis in pediatric patients. Thromb Res 2020; 191 Suppl 1:S22-S25. [PMID: 32736773 DOI: 10.1016/s0049-3848(20)30392-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/30/2019] [Accepted: 01/07/2020] [Indexed: 12/21/2022]
Abstract
Childhood malignancy and especially acute lymphoblastic leukemia are increasingly associated with thromboembolism. The etiology of pediatric cancer associated thrombosis is multifactorial and may reflect a tumor mass effect, tumor thrombi, alterations of the hemostatic system, treatment-related hazards (e.g. procoagulant changes induced by chemotherapy), presence of central venous lines and comorbidities (e.g. inherited thrombophilia). With over 80% cure rates of childhood cancer, strategies for prevention as well as for early diagnosis and optimal treatment of thromboembolism in children with malignancies are of major importance. While the use of therapeutic low molecular weight heparin prevails, prospective studies regarding guidelines for treatment or prevention are currently lacking. This review will address the epidemiology, etiology and risk factors for thrombosis, describe the presently available evidence associated with current therapy, and offer a glimpse into future treatment options.
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Affiliation(s)
- Assaf Arie Barg
- The Israeli National Hemophilia Center and Thrombosis Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Israel
| | - Gili Kenet
- The Israeli National Hemophilia Center and Thrombosis Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Israel.
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Shen X, Wile R, Young G. FondaKIDS III: A long-term retrospective cohort study of fondaparinux for treatment of venous thromboembolism in children. Pediatr Blood Cancer 2020; 67:e28295. [PMID: 32307822 DOI: 10.1002/pbc.28295] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 03/03/2020] [Accepted: 03/15/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND The incidence of venous thromboembolism (VTE) and use of anticoagulation are rising in children, but treatment options remain limited. As a newer anticoagulant, fondaparinux may be a safe and effective alternative with the benefit of once-daily dosing, but there is relatively little data supporting its use. PROCEDURE This retrospective cohort study describes the long-term dosing, efficacy, and safety of fondaparinux for treatment of VTE in children at a single institution. The study included children <18 years old treated with fondaparinux for VTE between 2008 and 2018. Descriptive statistics were used to present the findings. RESULTS A total of 277 patients were identified and analyzed in this study. Seventy-six percent of patients reached therapeutic levels with 0 or 1 dose adjustments over a median treatment duration of 93 days. Of the patients included in the efficacy analysis, 91% of patients had improvement in their clot status, including 69% (160/233) with complete resolution and 22% (53/233) with partial resolution. Twenty-six patients (11%) had VTE recurrence, but only seven (3%) of the new thrombi developed while on fondaparinux. Major bleeding occurred in seven patients (2.5%), primarily in patients with underlying medical conditions with increased bleeding risk. Minor bleeding occurred in 53 patients (19%). CONCLUSIONS This study demonstrates the stable long-term pediatric dosing of fondaparinux with similar efficacy and safety when compared to other anticoagulants. Given its advantages, fondaparinux can be considered a reasonable alternative for treatment of VTE in children.
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Affiliation(s)
- Xiaofan Shen
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California
| | - Rachel Wile
- Department of Integrative Biology and Physiology, University of California, Los Angeles, California
| | - Guy Young
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine, University of Southern California, Los Angeles, California
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Bosch A, Albisetti M. Management of Venous Thromboembolism in Children: Current Recommendations and Therapeutic Options. Ther Clin Risk Manag 2020; 16:673-679. [PMID: 32801724 PMCID: PMC7395688 DOI: 10.2147/tcrm.s218622] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/05/2020] [Indexed: 11/25/2022] Open
Abstract
Venous thromboembolism has an increasing significance in the pediatric patient population. Due to the lack of well-designed pediatric clinical trials, recommendations for the treatment of venous thromboembolic events in children have low evidence and are mainly extrapolated from adult guidelines. This review summarizes and compares recommendations for the treatment of several venous thromboembolic events in children from CHEST, ASH, and the UK guidelines.
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Affiliation(s)
- Alessandra Bosch
- Division of Hematology, University Children's Hospital, Zurich, Switzerland
| | - Manuela Albisetti
- Division of Hematology, University Children's Hospital, Zurich, Switzerland
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Abstract
Background: Thrombosis, well known as a condition of the elderly, is occurring in the otherwise healthy adolescent population. Immobility is a significant risk factor for venous thromboembolism (VTE), and adolescents who play video games are immobile for extended periods of time. Some are presenting with VTE. When other risk factors such as obesity are present, the risk of VTE formation increases. We provide a review of published case reports regarding gaming and thrombosis. Methods: We searched PubMed, Scopus, Web of Science, and EBSCO for articles published through July 2019, using the keywords “computer game thrombosis,” “computer game pulmonary embolism,” “computer game deep vein thrombosis,” “video game thrombosis,” “video game pulmonary embolism,” and “video game deep vein thrombosis.” Results: Of the 26 articles we identified, we included 12 articles in our review that report a total of 15 cases, of which 2 resulted in fatalities. Modifiable risk factors included cigarette use, being overweight, birth control use, and prolonged immobility. Anticoagulation was the principal treatment modality in patients presenting with gaming thrombosis. Conclusion: We strongly encourage screening gamers for possible VTEs if clinically warranted.
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Prophylaxis for Pediatric Venous Thromboembolism: Current Status and Changes Across Pediatric Orthopaedic Society of North America From 2011. J Am Acad Orthop Surg 2020; 28:388-394. [PMID: 32011545 DOI: 10.5435/jaaos-d-19-00578] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Pediatric venous thromboembolism (VTE) is a concern for orthopaedic surgeons. We sought to query the Pediatric Orthopaedic Society of North America (POSNA) members on current VTE prophylaxis practice and compare those results with those of a previous survey (2011). METHODS A 35-question survey was emailed to all active and candidate POSNA members. The survey consisted of questions on personal and practice demographics; knowledge and implementation of various VTE prophylaxis protocols, mechanical and chemical VTE prophylaxis agents, and risk factors; and utilization of scenarios VTE prophylaxis agents for various clinical scenarios. One- and two-way frequency tables were constructed comparing results from the current survey and those of the 2011 survey. RESULTS Two hundred thirty-nine surveys were completed (18% respondent rate), with most respondents from an academic/university practice reporting one or two partners (>60%). Half were in practice ≥15 years, and >90% reported an almost exclusive pediatric practice. One-third of the respondents reported familiarity with their institution-defined VTE prophylaxis protocol, and 20% were aware of an institutionally driven age at which all patients receive VTE prophylaxis. The most frequently recognized risk factors to guide VTE prophylaxis were oral contraceptive use, positive family history, and obesity. Respondents indicated a similar frequency of use of a VTE prophylaxis agent (either mechanical or chemical) for spinal fusion, hip reconstruction, and trauma (60% to 65%), with lower frequency for neuromuscular surgery (34%) (P < 0.001). One hundred thirty-seven respondents had a patient sustain a deep vein thrombosis, and 66 had a patient sustain a pulmonary embolism. Compared with responses from 2011, only 20 more respondents reported familiarity with their institution VTE prophylaxis protocol (75 versus 55). In 2018, aspirin was used more frequently than in 2011 (52% versus 19%; P < 0.0001) and enoxaparin was used less frequently (20% versus 41%; P < 0.0001). DISCUSSION Over the past 7 years since the first POSNA survey on VTE prophylaxis, most POSNA members are still unaware of their institution specific VTE prophylaxis protocol. Most respondents agree that either mechanical or chemical VTE prophylaxis should be used for spinal fusion, hip reconstruction, and trauma. The use of aspirin as an agent of chemical VTE prophylaxis has increased since 2011. LEVEL OF EVIDENCE Level IV. Type of evidence: therapeutic.
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Mets EJ, McLynn RP, Grauer JN. Venous thromboembolism in children undergoing surgery: incidence, risk factors and related adverse events. WORLD JOURNAL OF PEDIATRIC SURGERY 2020; 3:e000084. [DOI: 10.1136/wjps-2019-000084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 02/07/2023] Open
Abstract
BackgroundAlthough less common in adults, venous thromboembolism (VTE) in children is a highly morbid, preventable adverse event. While VTE has been well studied among pediatric hospitalized and trauma patients, limited work has been done to examine postoperative VTE in children undergoing surgery.MethodsUsing data from National Surgical Quality Improvement Project Pediatric database (NSQIP-P) from 2012 to 2016, a retrospective cohort analysis was performed to determine the incidence of, and risk factors for, VTE in children undergoing surgery. Additionally, the relationships between VTE and other postoperative adverse outcomes were evaluated.ResultsOf 361 384 pediatric surgical patients, 378 (0.10%) were identified as experiencing postoperative VTE. After controlling for patient and surgical factors, we found that American Society of Anesthesiologists (ASA) class of II or greater, aged 16–18 years, non-elective surgery, general surgery (compared with several other surgical specialties), cardiothoracic surgery (compared with general surgery) and longer operative time were significantly associated with VTE in pediatric patients (p<0.001 for each comparison). Furthermore, a majority of adverse events were found to be associated with increased risk of subsequent VTE (p<0.001).ConclusionIn a large pediatric surgical population, an incidence of postoperative VTE of 0.10% was observed. Defined patient and surgical factors, and perioperative adverse events were found to be associated with such VTE events.
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Goel R, Josephson CD, Patel EU, Petersen MR, Makhani S, Frank SM, Ness PM, Bloch EM, Gehrie EA, Lokhandwala PM, Nellis MM, Karam O, Shaz BH, Patel RM, Tobian AAR. Perioperative Transfusions and Venous Thromboembolism. Pediatrics 2020; 145:e20192351. [PMID: 32198293 PMCID: PMC7111487 DOI: 10.1542/peds.2019-2351] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/03/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Annual incidence of venous thromboembolism (VTE) including postoperative VTE in hospitalized children is rising significantly. A growing body of evidence supports the role of red blood cells (RBCs) in pathologic thrombosis. In this study, we examined the association of perioperative RBC transfusion with postoperative VTE in pediatric patients. METHODS The pediatric databases of the American College of Surgeons' National Surgical Quality Improvement Project from 2012 to 2017 were used. Multivariable logistic regression was used to examine the association between perioperative RBC transfusion status and the development of new or progressive VTE within 30 days of surgery. The analyses were age stratified, as follows: neonates (≤28 days), infants (>28 days and <1 year), and children (≥1 year). RESULTS In this study, we included 20 492 neonates, 79 744 infants, and 382 862 children. Postoperative development of VTE was reported in 99 (0.48%) neonates, 147 (0.2%) infants, and 374 (0.1%) children. In all age groups, development of VTE was significantly more common among patients with a perioperative RBC transfusion than patients without a perioperative RBC transfusion (neonates: adjusted odds ratio [aOR] = 4.1, 95% confidence interval [CI] = 2.5-6.7; infants: aOR = 2.4, 95% CI = 1.7-3.6; children: aOR = 2.2, 95% CI = 1.7-2.9). Among children who received an intra- or postoperative transfusion, the weight-based volume of RBCs (mL/kg) transfused was associated with postoperative VTE in a dose-dependent manner: second tertile (odds ratio = 2.3, 95% CI = 1.3-4.1) and third tertile (odds ratio = 4.1, 95% CI = 2.3-7.4) versus first tertile. CONCLUSIONS Perioperative RBC transfusions are independently associated with development of new or progressive postoperative VTE in children, infants, and neonates. These findings need further validation in prospective studies and emphasize the need for evidence-based perioperative pediatric blood transfusion decisions.
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Affiliation(s)
- Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
- Departments of Internal Medicine and Pediatrics, School of Medicine, Southern Illinois University and Mississippi Valley Regional Blood Center, Springfield, Illinois
| | - Cassandra D Josephson
- Department of Pathology, School of Medicine, Emory University and
- Department of Pediatrics, Children's Healthcare of Atlanta and School of Medicine, Emory University, Atlanta, Georgia
| | - Eshan U Patel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Molly R Petersen
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Sarah Makhani
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Steven M Frank
- Department of Anesthesiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Paul M Ness
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Evan M Bloch
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Eric A Gehrie
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Parvez M Lokhandwala
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Marianne M Nellis
- Department of Pediatrics, Weill Cornell Medicine, New York, New York
| | - Oliver Karam
- Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia; and
| | | | - Ravi M Patel
- Department of Pediatrics, Children's Healthcare of Atlanta and School of Medicine, Emory University, Atlanta, Georgia
| | - Aaron A R Tobian
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
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Odent T, de Courtivron B, Gruel Y. Thrombotic risk in children undergoing orthopedic surgery. Orthop Traumatol Surg Res 2020; 106:S109-S114. [PMID: 31859250 DOI: 10.1016/j.otsr.2019.05.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 02/02/2023]
Abstract
Children are physiologically protected against venous thromboembolism (VTE). Specific triggering events or contributing factors have been identified in the majority of reported cases, which differs from the adult pathology where 50% of the thromboses are considered "idiopathic". This is a rare disease in children with an estimated frequency of less than 1/1000. The risk is highest in neonates, then decreases and increases again around 13 years to reach the same level as adults at 16 years. The risk of VTE is clearly higher in certain situations: significant trauma, prolonged immobilization, central venous catheter, stay in intensive care unit, inherited thrombophilia, cancer, obesity, oral contraceptives, etc. Thromboprophylaxis should not be used systematically, even in adolescents. Proper hydration and early mobilization form the basis of mechanical thromboprophylaxis. A prescription is only given after careful analysis of the child's risk factors and the orthopedic context. Thrombotic risk assessment scores - which are based on expert opinion and large VTE registers but have not been evaluated in clinical studies - are currently the most reliable method to evaluate the thrombotic risk in children and to prescribe thromboprophylaxis. Low-molecular weight heparin are the most commonly used thromboprophylaxis agents in children, with good tolerance and efficacy.
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Affiliation(s)
- Thierry Odent
- Service de chirurgie orthopédique pédiatrique, université François Rabelais de Tours, PRES Centre-Val de Loire Université, hôpital Gatien-de-Clocheville, CHRU de Tours, 49, boulevard Béranger, 37044 Tours cedex 9, France.
| | - Benoît de Courtivron
- Service de chirurgie orthopédique pédiatrique, université François Rabelais de Tours, PRES Centre-Val de Loire Université, hôpital Gatien-de-Clocheville, CHRU de Tours, 49, boulevard Béranger, 37044 Tours cedex 9, France
| | - Yves Gruel
- Service d'Hématologie-Hémostase, université François Rabelais de Tours, PRES Centre-Val de Loire Université, hôpital Trousseau, CHRU de Tours, 37044 Tours cedex 9, France
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Filippova OA, Vakhlova IV, Tsaur GA, Kuznetsov NN, Abolina TB. The role of thrombophilia genes in the clinical implementation of arterial and venous thrombosis in newborns. BIO WEB OF CONFERENCES 2020. [DOI: 10.1051/bioconf/20202202021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The article considers the analysis results of the occurrence frequency of genotypes and alleles of plasma, platelet and fibrinolytic hemostasis in full-term newborns with arterial and venous thrombosis of various localization. Gene polymorphisms were studied by real-time PCR in human DNA samples obtained from buccal epithelium and venous blood lymphocytes. The control group was a group of healthy full-term newborns from families without a thrombophilic history. Predictors of arterial and venous thrombosis in children are such as polymorphism of the plasminogen activator inhibitor gene PAI-1-675 4G/4G (OR=5,6 [2,3-13,8]), combinations of polymorphisms PAI-1-675 4G/4G + factor VII G10976A G/G (OR=5,8 [1,7-19,1]), combinations of polymorphisms PAI-1 -675 4G/4G + factor VII G10976A G/G + factor XIII Val34Leu G/G (% AR=61), fibrinogen FGB -455 G/A (OR=3,75 [1,4-9,4]) and integrin alpha 2 ITGA2 807 T/T (OR=15,56 [1,9-126,7]). Thus, the study of polymorphisms of the plasminogen activator inhibitor, fibrinogen, integrin alpha 2 can serve as one of the criteria for identifying a high-risk group for the development of arterial and venous thrombosis in newborns and should be taken into account when evaluating individual thrombophilia risk.
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Park ES, Choi HS, Lee KS, Kim SW, Lee JM. Venous Thromboembolism in Children and Young Adults in Korea: Analysis of the Korean Health Insurance Review and Assessment Service Database. J Korean Med Sci 2019; 34:e316. [PMID: 31858756 PMCID: PMC6926097 DOI: 10.3346/jkms.2019.34.e316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 10/28/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is very rare in childhood. Nevertheless, its incidence has increased recently. This study aimed to identify risk factors for developing thrombosis in childhood cancers and other childhood diseases through the Korean Health Insurance Review and Assessment Service database. METHODS Data were extracted from the Korean Health Insurance Review and Assessment Service database. Children and young adults from 1 month to 29 years of age were eligible, and 21,747 cases of VTE between January 2008 and December 2016 were identified. RESULTS The VTE incidence was high in children younger than 1 year of age. After 1 year of age, its incidence decreased rapidly and gradually increased. The VTE incidence for children between 0 and 1 year of age was 10.23-fold higher than that for those between 1 and 5 years of age. Annual VTE incidence increased by year. The age-standardized annual incidence rates were 9.98 per 100,000 population in 2008 and 22.53 per 100,000 population in 2016. The age-standardized annual incidence rate increased 2.25-fold during the 8 years. The lower extremity was the most common site of venous thrombosis. CONCLUSION The incidence of VTE in a population younger than 30 years was 13.11 per 100,000 persons in Korea. We found a bimodal age distribution of the VTE incidence with peaks at infancy and again after 16 years. The incidence of portal vein thrombosis was high in infants, and infection and malignancy were the most common comorbidities in patients with VTE.
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Affiliation(s)
- Eun Sil Park
- Department of Pediatrics, College of Medicine, Gyeongsang National University, Jinju, Korea
| | - Hyoung Soo Choi
- Department of Pediatrics, Seoul National University Bundang Hospital, College of Medicine, Seoul National University, Seongnam, Korea
| | - Kyeong Soo Lee
- Department of Preventive Medicine and Public Health, College of Medicine, Yeungnam University, Daegu, Korea
| | - Sang Won Kim
- Medical Research Center, College of Medicine, Yeungnam University, Daegu, Korea
| | - Jae Min Lee
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu, Korea.
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Venous thromboembolism in childhood: where is Brazil after 20 years? Hematol Transfus Cell Ther 2019; 42:62-69. [PMID: 31582342 PMCID: PMC7031103 DOI: 10.1016/j.htct.2019.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 10/11/2018] [Accepted: 01/31/2019] [Indexed: 12/12/2022] Open
Abstract
Due to the longer survival of critically ill children, venous thromboembolism is a problem which is becoming increasingly recognized in pediatric practice. In the last decades, several international studies have been published, shedding a light upon the epidemiology of this disease during childhood. These data show peculiarities in the clinical presentation and the significant morbidity and mortality. The new "epidemic of thrombosis" in pediatric hospitals points toward the urgent need for specific treatment and prevention protocols targeting this population. In Brazil, knowledge regarding this disease remains scarce. The lack of epidemiological data impacts both the clinical care and the design of specific public policies in the field. Thus, a national registry of pediatric venous thromboembolism is relevant to the proposal of an appropriate plan of action to create a qualified net of assistance. The improvement in educational initiatives related to the field of Pediatric Hemostasis is also very important. In this review, we have updated the epidemiological, clinical and therapeutic aspects of the disease, as well as the prevention strategies.
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Abstract
An increase in the incidence of deep vein thrombosis (DVT) has been reported in pediatric patients over the past decade. The presence of central venous line (CVL) is a major contributing risk factor with conflicting data on the relative risk of DVT with various types of central lines. We aimed to assess the incidence of and identify potential risk factors for DVT overall and with different types of CVL individually. A retrospective chart review of pediatric patients with a CVL placed at Cleveland Clinic Children's from 2011 to 2016 was conducted. Data collected included demographics, potential risk factors, CVL characteristics and related thrombotic events. The study cohort consisted of 376 CVLs in 325 patients between 0 and 26 years of age. There were 1.6 thrombi per 10,000 line-days (95% confidence interval: 1.0, 2.5), and the overall incidence of DVT was 5.1%. The incidence of DVT was highest with tunneled catheters (5/16=31%) versus with peripherally inserted central catheters (4/111=3.6%) or with ports (10/249=4%, P<0.001), and whereas there were overarching significant risk factors for CVL-associated thrombi, these risk factors differed in significance when analyzed by the CVL type. The study supports the need for continued improvement in pediatric hospital practices for early identification of patients at a higher thrombosis risk.
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Carson JH, Smith LE, Pandiyan P, Yagnik PJ. A Pediatric Diabetic Ketoacidosis Patient with Multisystem Complications and a Prolonged Course. Kans J Med 2019; 12:89-90. [PMID: 31489106 PMCID: PMC6710026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 02/05/2019] [Indexed: 10/26/2022] Open
Affiliation(s)
- John Henry Carson
- Internal Medicine/Pediatrics Residency Progam, University of Kansas School of Medicine-Wichita
| | - Lindall E. Smith
- Department of Pediatrics, University of Kansas School of Medicine-Wichita
| | - Poornima Pandiyan
- Department of Pediatrics, University of Kansas School of Medicine-Wichita
| | - Priyank J. Yagnik
- Department of Pediatrics, University of Kansas School of Medicine-Wichita
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Woods GM, Boulet SL, Texter K, Yates AR, Kerlin BA. Venous thromboembolism in chronic pediatric heart disease is associated with substantial health care burden and expenditures. Res Pract Thromb Haemost 2019; 3:372-382. [PMID: 31294324 PMCID: PMC6611372 DOI: 10.1002/rth2.12205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 03/13/2019] [Indexed: 01/19/2023] Open
Abstract
ABSTRACT Background: Venous thromboembolism (VTE) is a complication in children with chronic pediatric heart disease (CPHD). The influence of acute VTE risk factors and the health care burden associated with VTE in CPHD is unknown.Methods: Children <18 years of age with a CPHD diagnostic code were identified from the 2003-2013 MarketScan Commercial Databases. VTE diagnoses were identified either concomitantly with initial CPHD diagnoses or during a 6-month follow-up. The associations between demographic and clinical characteristics and VTE among children with CPHD, stratified by recent cardiac surgery, were assessed by multivariable logistic regression models. Estimates of health care utilization were compared using Wilcoxon rank-sum tests.Results: VTE events occurred in 957 of 120 884 children with CPHD (0.8%). In-hospital mortality was significantly higher in children with VTE. Single-ventricle physiology had the highest VTE rate (2.3%). All comorbid conditions were significantly associated with VTE, but the prevalence was highest in children with recent cardiac (11.1%) or noncardiac surgery (7.8%). The magnitude of association between noncardiac comorbidities and acquired acute cardiovascular conditions and VTE were larger for children without a recent cardiac surgery. Children with VTE had significantly higher health care utilization.Conclusions: VTE in CPHD is associated with significantly increased health care resource utilization and in-hospital mortality. All of the comorbid conditions examined were significantly associated with VTE, but a recent surgical procedure, especially cardiac surgery, conferred the highest VTE risk. Although confounding inherently limits observational studies, these findings provide practical information about the health care costs among patients with CPHD and VTE.
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Affiliation(s)
- Gary M. Woods
- Division of Hematology/Oncology/BMTChildren's Healthcare of AtlantaAtlantaGeorgia
- Department of PediatricsEmory University School of MedicineAtlantaGeorgia
| | - Sheree L. Boulet
- Department of Gynecology and ObstetricsEmory University School of MedicineAtlantaGeorgia
| | - Karen Texter
- Division of CardiologyNationwide Children's HospitalColumbusOhio
- Department of PediatricsCollege of MedicineThe Ohio State UniversityColumbusOhio
| | - Andrew R. Yates
- Division of CardiologyNationwide Children's HospitalColumbusOhio
- Department of PediatricsCollege of MedicineThe Ohio State UniversityColumbusOhio
| | - Bryce A. Kerlin
- Department of PediatricsCollege of MedicineThe Ohio State UniversityColumbusOhio
- Division of Hematology/Oncology/BMTNationwide Children's HospitalColumbusOhio
- Center for Clinical & Translational ResearchThe Research Institute at Nationwide Children's HospitalColumbusOhio
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