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Chu Y, Xu Y, Wang C, Yu X, Ma Q, Wang H. Treatment of thrombosis in KD Patients using tissue plasminogen activator: a single center study. Pediatr Rheumatol Online J 2022; 20:111. [PMID: 36471358 PMCID: PMC9720999 DOI: 10.1186/s12969-022-00767-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 11/05/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE The most severe complication associated with giant coronary aneurysm in children with Kawasaki disease is ischemic cardiomyopathy (ICM) caused by thrombosis. Addition of tissue plasminogen activator, Alteplase, in the treatment regimen can be an efficient thrombolytic therapy, and therefore can have a significantly positive impact on patients' quality of life in long term. METHODS Total four male KD patients with central thromboses in coronary aneurysm were treated in Pediatric Cardiology Department of Shengjing Hospital, China Medical University, from January 2020 to August 2021. These patients received thrombolytic treatments including Alteplase once + Heparin for 1 week followed by continuous oral Warfarin + Aspirin + Clopidogrel. RESULTS 4 young male KD patients had coronary aneurysm (CAA) complicated with total 7 occurrences of central thrombosis. These patients were given alteplase and heparin/oral Warfarin + Aspirin + Clopidogrel treatment. 9 days to 2 months later, thromboses were significantly dissolved. The treatment successfully diminished the thrombosis complication. CONCLUSION 1. Pediatric KD patients complicated with coronary aneurysm thrombosis are prone to recurrence of thrombosis. 2. In KD patients complicated with coronary aneurysm thrombosis, treatments described in Method can be used for treating either small thromboses formed less than 1 month with strong echo and convex lumen or large thromboses with mixed strong and weak echo. With these treatments, coronary artery blood flow can be improved or completely recovered. 3. Clinical experiences at our center in treating these KD patients suggest that Alteplase can be considered in thrombolytic treatment beyond the limitation of less than 12 h of thrombosis occurrence.
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Affiliation(s)
- Yanqiu Chu
- grid.412449.e0000 0000 9678 1884Pediatric department of shengjing hospital, China Medical University, 110004 shenyang, China
| | - Yunming Xu
- grid.412449.e0000 0000 9678 1884Pediatric department of shengjing hospital, China Medical University, 110004 shenyang, China
| | - Ce Wang
- grid.412449.e0000 0000 9678 1884Pediatric department of shengjing hospital, China Medical University, 110004 shenyang, China
| | - Xiaona Yu
- grid.412449.e0000 0000 9678 1884Ultrasonic department of shengjing hospital, China Medical University, 110004 shenyang, China
| | - Quanmei Ma
- grid.412449.e0000 0000 9678 1884Radiology department of shengjing hospital, China Medical University, 110004 shenyang, China
| | - Hong Wang
- Pediatric department of shengjing hospital, China Medical University, 110004, shenyang, China.
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Robinson C, Chanchlani R, Gayowsky A, Darling E, Seow H, Batthish M. Health care utilization and costs following Kawasaki disease. Paediatr Child Health 2022; 27:160-168. [PMID: 35712030 PMCID: PMC9191915 DOI: 10.1093/pch/pxab092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 11/23/2021] [Indexed: 12/17/2022] Open
Abstract
Objectives Kawasaki disease (KD) is a common childhood vasculitis with increasing incidence in Canada. Acute KD hospitalizations are associated with high health care costs. However, there is minimal health care utilization data following initial hospitalization. Our objective was to determine rates of health care utilization and costs following KD diagnosis. Methods We used population-based health administrative databases to identify all children (0 to 18 years) hospitalized for KD in Ontario between 1995 and 2018. Each case was matched to 100 nonexposed comparators by age, sex, and index year. Follow-up continued until death or March 2019. Our primary outcomes were rates of hospitalization, emergency department (ED), and outpatient physician visits. Our secondary outcomes were sector-specific and total health care costs. Results We compared 4,597 KD cases to 459,700 matched comparators. KD cases had higher rates of hospitalization (adjusted rate ratio 2.07, 95%CI 2.00 to 2.15), outpatient visits (1.30, 95%CI 1.28 to 1.33), and ED visits (1.22, 95%CI 1.18 to 1.26) throughout follow-up. Within 1 year post-discharge, 717 (15.6%) KD cases were re-hospitalized, 4,587 (99.8%) had ≥1 outpatient physician visit and 1,695 (45.5%) had ≥1 ED visit. KD cases had higher composite health care costs post-discharge (e.g., median cost within 1 year: $2466 CAD [KD cases] versus $234 [comparators]). Total health care costs for KD cases, respectively, were $13.9 million within 1 year post-discharge and $54.8 million throughout follow-up (versus $2.2 million and $23.9 million for an equivalent number of comparators). Conclusions Following diagnosis, KD cases had higher rates of health care utilization and costs versus nonexposed children. The rising incidence and costs associated with KD could place a significant burden on health care systems.
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Affiliation(s)
- Cal Robinson
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada,Division of Nephrology, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Rahul Chanchlani
- Division of Nephrology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada,ICES McMaster, Hamilton, Ontario, Canada
| | | | - Elizabeth Darling
- McMaster Midwifery Research Centre, McMaster University, Hamilton, Ontario, Canada
| | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Michelle Batthish
- Correspondence: Michelle Batthish, Division of Rheumatology, Department of Pediatrics, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4K1, Canada. Telephone 905-521-2100, fax 905-521-4968, e-mail
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Assessing Health Care Utilization and Compliance in Kawasaki Disease. J Pediatr 2021; 234:181-186.e1. [PMID: 33753117 DOI: 10.1016/j.jpeds.2021.03.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 02/13/2021] [Accepted: 03/10/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To characterize health care utilization and costs associated with care after diagnosis of Kawasaki disease including adherence to guidelines for echocardiograms. STUDY DESIGN We analyzed children hospitalized for Kawasaki disease using 2015-2017 national Truven MarketScan commercial claims data. The mean 90-day prehospitalization utilization and costs were quantified and compared with the 90 days posthospitalization via Wilcoxon 2-sample test. Adherence to echocardiogram guidelines was examined using multivariable logistic regression to identify factors associated with adherence. RESULTS The mean total payments 90 days prior to hospitalization ($2090; n = 360) were significantly lower than those after discharge ($3778), though out of pocket costs were higher ($400 vs $270) (P < .0001). There was an increase in office visits, medical procedures, and echocardiograms after discharge. A majority of health care utilization before hospitalization occurred in the 7 days immediately prior to the date of admission; 51% obtained an echocardiogram within the first 2 weeks, and 14% were completely adherent with recommendations. Children with greater utilization prior to admission were more likely to adhere to American Heart Association guidelines for follow-up echocardiograms (OR 1.03, 95% CI 1.01-1.06). CONCLUSIONS Outpatient health care expenditure nearly doubles after Kawasaki disease hospital discharge when compared with prehospitalization, suggesting the financial ramifications of this diagnosis persist beyond costs incurred during hospitalization. A significant portion of patients do not receive guideline recommended follow-up echocardiograms. This issue should be explored in more detail given the morbidity and mortality associated with this diagnosis.
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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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Clark NA, Richardson T, Schuster JE, Parthiban A, Puls HT. Variations in Sedated Echocardiography and Association With Repeat Echocardiography in Nonrefractory Kawasaki Disease. Hosp Pediatr 2020; 11:36-43. [PMID: 33288673 DOI: 10.1542/hpeds.2020-0145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Echocardiography performed under sedation allows for better coronary artery visualization in children with Kawasaki disease. We sought to describe hospital-level variability in the percentage of sedated echocardiography (SE) among children with nonrefractory Kawasaki disease (NRKD) and then test its association with repeat echocardiography, length of stay (LOS), and costs. METHODS We identified children in the Pediatric Health Information System <36 months of age hospitalized with NRKD from March 2010 to February 2017. Hospital-level percentage of SE was the primary outcome. Secondary outcomes were repeat echocardiography during the same hospitalization, LOS, and costs. We used χ2 and Wilcoxon rank tests to compare differences in repeat echocardiography between SE and nonsedated echocardiography. Pearson correlation was used to test associations between SE and repeat echocardiography, LOS, and costs. RESULTS There were 2887 NRKD hospitalizations from 40 children's hospitals. Initial SE varied from 0.0% to 87.0% (median 5.9%; interquartile range 1.4%-21.1%). Of initial echocardiographies, 22.4% were sedated and 10.1% of all hospitalizations had a repeat echocardiography. Use of SE at the hospital level was associated with a lower likelihood for repeat echocardiography (r = -0.32; 95% confidence interval -0.58 to -0.01; P = .042). Absolute risk reduction was 3.5% and the number needed to sedate was 29. Initial SE was not associated with LOS or hospital-level costs but was associated with increased patient-level costs. CONCLUSIONS Significant variation exists in the use of SE for children <36 months of age with NRKD at children's hospitals. Our results suggest that determination of SE should not be driven by concern for repeat echocardiography or LOS considerations.
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Affiliation(s)
| | - Troy Richardson
- Divisions of Hospital Medicine.,Children's Hospital Association, Lenexa, Kansas
| | | | - Anitha Parthiban
- Cardiology, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri; and
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Abstract
Kawasaki disease (KD) is a vasculitis syndrome of unknown etiology, affecting medium-sized vessels and occurring primarily in young children. It is a self-limited illness classically presenting with fever, conjunctivitis, mucocutaneous lesions, and cervical adenopathy. However, vasculitis of coronary arteries with aneurysm formation may occur, leading to morbidity and rarely mortality. Prompt diagnosis of KD is essential as early treatment with intravenous immune globulin (IVIG) decreases the occurrence and severity of coronary vasculitis. This article reviews the clinical characteristics of KD, laboratory assessment, echocardiogram findings, and recommended initial medical therapy. Complications of KD are discussed, including KD refractory to IVIG, the presence of shock or macrophage activation syndrome (MAS), and short/long-term cardiac sequelae. The medical management of these complications is reviewed. Although improved treatment of KD has resulted in a decrease of coronary artery vasculitis over the past 3 decades, KD remains the most common cause of acquired heart disease in children. [Pediatr Ann. 2019;48(10):e400-e405.].
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Hester GZ, Watson D, Nickel AJ, Ryan N, Jepson B, Gray J, Bergmann KR. Identifying Patients With Kawasaki Disease Safe for Early Discharge: Development of a Risk Prediction Model at a US Children's Hospital. Hosp Pediatr 2019; 9:749-756. [PMID: 31501220 DOI: 10.1542/hpeds.2019-0049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To develop a model to predict risk of intravenous immunoglobulin (IVIg) nonresponse in patients with Kawasaki disease (KD) to assist in early discharge decision-making. METHODS Retrospective cohort study of 430 patients 0 to 18 years old discharged from a US children's hospital January 1, 2010, through July 31, 2017 with a diagnosis of KD. IVIg nonresponse was defined as at least 1 of the following: temperature ≥38.0°C between 36 hours and 7 days after initial IVIg dose, receipt of a second IVIg dose after a temperature ≥38.0°C at least 20 hours after initial IVIg dose, or readmission within 7 days with administration of a second IVIg dose. Backward stepwise logistic regression was used to select a predictive model. RESULTS IVIg nonresponse occurred in 19% (81 of 430) of patients. We identified a multivariate model (which included white blood cell count, hemoglobin level, platelet count, aspartate aminotransferase level, sodium level, albumin level, temperature within 6 hours of first IVIg dose, and incomplete KD) with good predictive ability (optimism-adjusted concordance index: 0.700) for IVIg nonresponse. Stratifying into 2 groups by a predictive probability cutoff of 0.10, we identified 26% of patients at low risk for IVIg nonresponse, with a sensitivity and specificity of 90% and 30%, respectively, and a negative predictive value of 93%. CONCLUSIONS We developed a model with good predictive value for identifying risk of IVIg nonresponse in patients with KD at a US children's hospital. Patients at lower risk may be considered for early discharge by using shared decision-making. Our model may be used to inform implementation of electronic health record tools and future risk prediction research.
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Affiliation(s)
| | - David Watson
- Children's Research Institute, Children's Minnesota, Minneapolis, Minnesota
| | - Amanda J Nickel
- Children's Research Institute, Children's Minnesota, Minneapolis, Minnesota
| | | | - Bryan Jepson
- Pediatric Residency Program, University of Minnesota, Minneapolis, Minnesota; and
| | - James Gray
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Min DE, Kim DH, Han MY, Cha SH, Yoon KL. High antistreptolysin O titer is associated with coronary artery lesions in patients with Kawasaki disease. KOREAN JOURNAL OF PEDIATRICS 2019; 62:235-239. [PMID: 30404429 PMCID: PMC6584233 DOI: 10.3345/kjp.2018.06989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/29/2018] [Accepted: 11/06/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE In Kawasaki disease (KD) patients, coronary artery complications, incomplete and refractory types occur more frequently in patients with streptococcal or other bacterial/viral infections. Recently, we observed a higher incidence of coronary lesions in KD patients with high anti-streptolysin O (ASO) titer. Therefore, we hypothesized that KD patients diagnosed with concurrent streptococcal infection have poor prognosis, with respect to treatment response and development of coronary artery lesions. METHODS A retrospective review was performed in 723 patients with KD who were admitted to 2 major hospitals between June 2010 and September 2017. RESULTS Among 723 patients with KD, 11 initially showed an elevated ASO titer (>320 IU/mL) or elevated follow-up ASO titer after treatment. Of these patients, 5 showed no response to the first intravenous immunoglobulin treatment, 3 had abnormalities of the coronary arteries. This is a significantly higher proportion of patients with a high ASO titer (n=3, 27.3%) than those with a normal ASO titer (n=53, 7.4%; P=0.047). A severe clinical course was seen in 81.8% of patients in the high ASO group versus 14.5% of patients in the normal ASO group. CONCLUSION It is not certain whether acute streptococcal infection may cause KD, but this study revealed that KD with high ASO titers showed higher rates of severe clinical course. It may be helpful to analyze concurrent streptococcal infection in patients with a severe clinical course.
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Affiliation(s)
- Dong Eun Min
- Department of Pediatrics,, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Do Hee Kim
- Department of Pediatrics,, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Mi Young Han
- Department of Pediatrics,, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Sung Ho Cha
- Department of Pediatrics,, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Kyung Lim Yoon
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, Seoul, Korea
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Prevalence and risk factors for venous thromboembolism in children with sickle cell disease: an administrative database study. Blood Adv 2019; 2:285-291. [PMID: 29431623 DOI: 10.1182/bloodadvances.2017012336] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 01/04/2018] [Indexed: 11/20/2022] Open
Abstract
A hypercoagulable state resulting in increased venous thromboembolism (VTE) has been described in adults with sickle cell disease (SCD), but similar data for children are lacking. The objective of this retrospective cohort study was to describe the rate of VTE and risk factors associated with VTE in children with SCD across tertiary-care children's hospitals in the United States between the years 2009 and 2015. We used the Pediatric Health Information System database to investigate all pediatric patients with SCD admitted to 1 of 48 participating institutions between 1 January 2009 and 30 September 2015. International Classification of Disease, Ninth Edition, Clinical Modification codes were used to identify index thromboembolic events and chronic medical conditions known to be associated with VTE. Billing codes were used to identify central venous line (CVL) placement and pharmaceutical billing codes to identify estrogen containing oral-contraceptive use. Logistic regression analysis was used to study the association among unique patient characteristics, VTE, and death. 10 454 eligible subjects with SCD were identified. Median age (±interquartile range) of study cohort was 10 (±11) years. 181 subjects (1.7%) developed an index venous thromboembolic event during the study period. Median age at VTE diagnosis was 15.9 (±7.4) years. On multivariable logistic regression analysis, CVL placement, chronic renal disease, history of stroke, female sex, length of hospitalization, intensive care unit utilization, and older age were associated with VTE. After adjusting for other variables, VTE was independently associated with death. In summary, VTE can occur in pediatric patients with SCD. CVL placement is a modifiable risk factor for VTE development.
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Abstract
"Resistant" Kawasaki disease is defined by the American Heart Association as failure to respond within 36 h following the first dose of intravenous immunoglobulin. The optimal management of resistant Kawasaki disease remains uncertain, the outcomes are potentially serious, and the cost of some treatments is considerable. We review the current evidence to guide treatment of resistant Kawasaki disease. Given the relative rarity, there are few trial data, and studies tend to be small and methodologically heterogeneous, making interpretation difficult and limiting generalisability. The literature on resistant Kawasaki disease should be interpreted with reference to current expert consensus guidelines.
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