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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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Meyer AD, Hughes TB, Rishmawi AR, Heard P, Shah S, Aune GJ. A cohort study on blood coagulation in childhood cancer survivors. Thromb Res 2023; 226:100-106. [PMID: 37141794 DOI: 10.1016/j.thromres.2023.04.025] [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: 09/05/2022] [Revised: 03/22/2023] [Accepted: 04/28/2023] [Indexed: 05/06/2023]
Abstract
Cancer survivors are at an increased risk of thromboembolism compared to the general pediatric population. Anticoagulant therapy decreases the risk of thromboembolism in cancer patients. We hypothesized that pediatric cancer survivors are in a chronically hypercoagulable state compared to healthy controls. Children who survived for more than five years from cancer diagnosis at the UT Health Science Center at San Antonio Cancer Survivorship Clinic were compared to healthy controls. The exclusion criteria were recent NSAID use or a history of coagulopathy. Coagulation analysis included platelet count, thrombin-antithrombin complexes (TAT), plasminogen activator inhibitor (PAI), routine coagulation assays, and thrombin generation with and without thrombomodulin. We enrolled 47 pediatric cancer survivors and 37 healthy controls. Platelet count was significantly lower in cancer survivors at a mean of 254 × 109/L (95%CI: 234-273 × 109/L) compared at 307 × 109/L (283-331 × 109/L) in healthy controls (p < 0.001), although not outside the normal range. Routine coagulation assays showed no differences, except for a significantly lower prothrombin time (PT) in cancer survivors (p < 0.004). Cancer survivors has significantly elevated biomarkers of the procoagulant state, such as TAT and PAI, compared to healthy controls (p < 0.001). A multiple logistic regression model controlling for age, BMI, gender, and race/ethnicity documented that a low platelet count, short prothrombin clot time, and higher procoagulant biomarkers (TAT and PAI) were significantly associated with past cancer therapy. Survivors of childhood cancer have a persistent procoagulant imbalance for more than five years after diagnosis. Further studies are needed to establish whether procoagulant imbalance increases the risk of thromboembolism in childhood cancer survivors.
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Affiliation(s)
- Andrew D Meyer
- Division of Critical Care, Department of Pediatrics, Long School of Medicine at The University of Texas Health Science Center, San Antonio, TX, United States of America.
| | - Tyler B Hughes
- Division of Critical Care, Department of Pediatrics, Long School of Medicine at The University of Texas Health Science Center, San Antonio, TX, United States of America.
| | - Anjana R Rishmawi
- Division of Critical Care, Department of Pediatrics, Long School of Medicine at The University of Texas Health Science Center, San Antonio, TX, United States of America
| | - Patty Heard
- Division of Critical Care, Department of Pediatrics, Long School of Medicine at The University of Texas Health Science Center, San Antonio, TX, United States of America.
| | - Shafqat Shah
- Division of Hematology/Oncology, Department of Pediatrics, Long School of Medicine at The University of Texas Health Science Center, San Antonio, TX, United States of America.
| | - Gregory J Aune
- Division of Hematology/Oncology, Department of Pediatrics, Long School of Medicine at The University of Texas Health Science Center, San Antonio, TX, United States of America; Greehey Children's Cancer Research Institute, San Antonio, TX, United States of America.
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Development and validation of a prediction model of catheter-related thrombosis in patients with cancer undergoing chemotherapy based on ultrasonography results and clinical information. J Thromb Thrombolysis 2022; 54:480-491. [PMID: 35972592 PMCID: PMC9553810 DOI: 10.1007/s11239-022-02693-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2022] [Indexed: 12/24/2022]
Abstract
Central venous catheters can be used conveniently to deliver medications and improve comfort in patients with cancer. However, they can cause major complications. The current study aimed to develop and validate an individualized nomogram for early prediction of the risk of catheter-related thrombosis (CRT) in patients with cancer receiving chemotherapy. In total, 647 patients were included in the analysis. They were randomly assigned to the training (n = 431) and validation (n = 216) cohorts. A nomogram for predicting the risk of CRT in the training cohort was developed based on logistic regression analysis results. The accuracy and discriminatory ability of the model were determined using area under the receiver operating characteristic curve (AUROC) values and calibration plots. Multivariate logistic regression analysis showed that body mass index, risk of cancer-related thrombosis, D-dimer level, and blood flow velocity were independent risk factors of CRT. The calibration plot showed an acceptable agreement between the predicted and actual probabilities of CRT. The AUROC values of the nomogram were 0.757 (95% confidence interval: 0.717-0.809) and 0.761 (95% confidence interval: 0.701-0.821) for the training and validation cohorts, respectively. Our model presents a novel, user-friendly tool for predicting the risk of CRT in patients with cancer receiving chemotherapy. Moreover, it can contribute to clinical decision-making.
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Falanga A, Brenner B, Khorana AA, Francis C. Thrombotic complications in patients with cancer: Advances in pathogenesis, prevention, and treatment—A report from ICTHIC 2021. Res Pract Thromb Haemost 2022; 6:e12744. [PMID: 35794962 PMCID: PMC9248072 DOI: 10.1002/rth2.12744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/28/2022] [Accepted: 05/03/2022] [Indexed: 11/05/2022] Open
Abstract
Venous thromboembolism (VTE) is a common complication in cancer patients, resulting in deep vein thrombosis (DVT) or pulmonary embolism (PE), and is responsible for high morbidity and mortality. This article discusses evidence and future perspectives on pathogenesis and prevention and treatment of thrombotic complications in patients with cancer. In April 2021, international basic researchers and clinicians met for the virtual edition of the 10th International Conference on Thrombosis & Hemostasis Issues in Cancer. Pathogenic mechanisms, markers and scores for risk assessment, diagnosis and therapy issues, current prophylaxis recommendations, and special settings, such as palliative care, pediatrics, and COVID‐19 patients were discussed. Emerging areas of interest in cancer associated VTE are the role of immunotherapy, platelet activation markers, genetic alterations and real‐world systems‐based approaches to prevention and treatment.
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Affiliation(s)
- Anna Falanga
- Division of Immunohematology and Transfusion Medicine Hospital Papa Giovanni XXIII Bergamo Italy
- Department of Medicine and Surgery University of Milan Bicocca Milan Italy
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation Rambam Health Care Campus Haifa Israel
| | - Alok A. Khorana
- Taussig Cancer Institute Cleveland Clinic Lerner College of Medicine Cleveland Clinic Cleveland Ohio USA
| | - Charles W. Francis
- James P Wilmot Cancer Center and University of Rochester Rochester NY USA
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Cancer associated thrombosis in pediatric patients. Best Pract Res Clin Haematol 2022; 35:101352. [DOI: 10.1016/j.beha.2022.101352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/13/2022] [Indexed: 11/22/2022]
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Rodriguez V. Thrombosis Complications in Pediatric Acute Lymphoblastic Leukemia: Risk Factors, Management, and Prevention: Is There Any Role for Pharmacologic Prophylaxis? Front Pediatr 2022; 10:828702. [PMID: 35359904 PMCID: PMC8960248 DOI: 10.3389/fped.2022.828702] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/26/2022] [Indexed: 01/19/2023] Open
Abstract
Pediatric acute lymphoblastic leukemia (ALL) has achieved close to 90% cure rates through extensive collaborative and integrative molecular research, clinical studies, and advances in supportive care. Despite this high achievement, venous thromboembolic complications (VTE) remain one of the most common and potentially preventable therapy-associated adverse events in ALL. The majority of thromboses events involve the upper central venous system which is related to the use and location of central venous catheters (CVC). The reported rates of symptomatic and asymptomatic CVC-related VTE range from 2.6 to 36.7% and 5.9 to 43%, respectively. Thrombosis can negatively impact not only disease-free survival [e.g., therapy delays and/or interruption, omission of chemotherapy agents (e.g., asparaginase therapy)] but also can result in long-term adverse effects that can impair the quality of life of ALL survivors (e.g., post-thrombotic syndrome, central nervous system (CNS)-thrombosis related complications: seizures, neurocognitive deficits). In this review, will discuss thrombosis pathophysiology in pediatric ALL, risk factors, treatment, and prevention strategies. In addition, the recently published clinical efficacy and safety of direct oral anticoagulants (DOACs) use in thrombosis treatment, and their potential role in primary/secondary thrombosis prevention in pediatric patients with ALL will be discussed. Future clinical trials involving the use of these novel oral anticoagulants should be studied in ALL not only for primary thrombosis prevention but also in the treatment of thrombosis and its secondary prevention. These future research findings could potentially extrapolate to VTE prevention strategies in other pediatric cancer diagnoses and children considered at high risk for VTE.
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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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Howie C, Erker C, Crooks B, Moorehead P, Kulkarni K. Incidence and risk factors of venous thrombotic events in pediatric patients with CNS tumors compared with non-CNS cancer: A population-based cohort study. Thromb Res 2021; 200:51-55. [PMID: 33540292 DOI: 10.1016/j.thromres.2021.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a well-recognized complication in pediatric cancer patients. It has been demonstrated that the incidence of VTE in pediatric patients with central nervous system (CNS) tumors is lower than that of patients with other cancers. Risk factors for developing cancer-related thrombosis are numerous and can include patient, disease, or treatment-related influences. The present study was designed to assess the VTE incidence in a pediatric oncology population, and to investigate whether intensity of treatment has similar associated with risk of VTE development in patients with and without CNS tumors. METHODS A retrospective population-based cohort study of pediatric oncology patients in Atlantic Canada was conducted. Data collected from medical records included demographics, cancer type, treatment, presence of central venous catheters (CVC), and presence of thrombosis. Treatment intensity was assessed using the intensity of treatment rating scale (ITR-3). Study period was from January 2000 to December 2017. SPSS version 24 was used for statistical analysis. RESULTS Of 1262 patients with pediatric cancer, 247 (19.6%) had CNS tumors. VTE occurred in significantly fewer (n = 5, 2%) patients with CNS tumors compared with patients with non-CNS cancers (n = 79, 7.8%) (p = 0.001). The ITR-3 scores did not differ significantly between the CNS and non-CNS groups (p = 0.638). In a multivariate logistic regression analysis, ITR-3 score was associated with VTE (odds ratio [OR]: 1.48, 95% CI: 1.2-1.9), while presence of CNS tumor was protective (OR: 0.26, 95% CI: 0.1-0.6). CONCLUSIONS We demonstrate that pediatric patients with CNS tumors experience a significantly lower incidence of VTE compared with patients with non-CNS cancer. An increase in the ITR-3 rating significantly increased the odds of developing VTE.
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Affiliation(s)
- Chelsea Howie
- Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Craig Erker
- Division of Hematology/Oncology, Department of Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Bruce Crooks
- Division of Hematology/Oncology, Department of Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Paul Moorehead
- Pediatric Hematology/Oncology, Janeway Children's Health and Rehabilitation Centre, St. John's, NL, Canada; Faculty of Medicine, Memorial University, St. John's, NL, Canada; Janeway Pediatric Research Unit, Memorial University, St. John's, NL, Canada
| | - Ketan Kulkarni
- Division of Hematology/Oncology, Department of Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada.
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Pediatric CNS Tumor Patients Have Significantly Lower Requirement of Tissue Plasminogen Activator for Episodes of Central Venous Catheter Dysfunction Compared With Other Pediatric Oncology Patients: Results of a Population-based Cohort Study. J Pediatr Hematol Oncol 2020; 42:e623-e626. [PMID: 31725547 DOI: 10.1097/mph.0000000000001670] [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] [Indexed: 11/25/2022]
Abstract
PURPOSE Central venous catheters (CVCs) are an important component of care delivery in pediatric oncology patients. However, CVC dysfunction is a common problem. Tissue plasminogen activator (tPA) is often administered to re-establish function, however, specific experience in pediatric patients with central nervous system (CNS) tumors is lacking. The goal of this study was to investigate the CVC experience and use of tPA for episodes of CVC dysfunction in pediatric patients with CNS tumors in comparison with other patients. METHODS Medical records of all pediatric oncology patients from the 4 Atlantic provinces in Canada (Nova Scotia, New Brunswick, Prince Edward Island, and Newfoundland and Labrador) were reviewed. Data collected included demographics, treatment, details of CVCs along with CVC dysfunction, and tPA use. RESULTS The cohort consisted of 1152 pediatric oncology patients, 222 (19.3%) of whom had CNS tumors. CVC dysfunction requiring tPA administration occurred in 12 (5.4%) of patients with CNS tumors compared with 182 (19.6%) of patients with non-CNS tumors (P=0.0001). Multivariate logistic regression analysis showed that administration of tPA for CVC dysfunction was 2.5 times more likely in patients with non-CNS tumors than those with CNS tumors (P=0.012; 95% confidence interval, 1.3-4.9). CONCLUSIONS Our study showed that pediatric patients with CNS tumors require significantly less frequent administration of tPA for episodes of CVC dysfunction than patients with non-CNS tumors after adjusting for confounding factors. Hypotheses for this include: potential biologic differences of tumors, the role of the blood-brain barrier, or systematic differences in intensity of treatments.
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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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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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Gaunt T, D'Arco F, Smets AM, McHugh K, Shelmerdine SC. Emergency imaging in paediatric oncology: a pictorial review. Insights Imaging 2019; 10:120. [PMID: 31853747 PMCID: PMC6920284 DOI: 10.1186/s13244-019-0796-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 09/25/2019] [Indexed: 11/12/2022] Open
Abstract
Despite the decline in mortality rates over the last 20 years, cancer remains one of the leading causes of death in children worldwide. Early recognition and treatment for acute oncological emergencies are vital in preventing mortality and poor outcomes, such as irreversible end-organ damage and a compromised quality of life.Imaging plays a pivotal and adjunctive role to clinical examination, and a high level of interpretative acumen by the radiologist can make the difference between life and death. In contrast to adults, the most accessible cross-sectional imaging tool in children typically involves ultrasound. The excellent soft tissue differentiation allows for careful delineation of malignant masses and along with colour Doppler imaging, thromboses and large haematomas can be easily identified. Neurological imaging, particularly in older children is an exception. Here, computed tomography (CT) is required for acute intracranial pathologies, with magnetic resonance imaging (MRI) providing more definitive results later.This review is divided into a 'body systems' format covering a range of pathologies including neurological complications (brainstem herniation, hydrocephalus, spinal cord compression), thoracic complications (airway obstruction, superior vena cava syndrome, cardiac tamponade), intra-abdominal complications (bowel obstruction and perforation, hydronephrosis, abdominal compartment syndrome) and haematological-related emergencies (thrombosis, infection, massive haemorrhage). Within each subsection, we highlight pertinent clinical and imaging considerations.The overall objective of this pictorial review is to illustrate how primary childhood malignancies may present with life-threatening complications, and emphasise the need for imminent patient management.
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Affiliation(s)
- Trevor Gaunt
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Felice D'Arco
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Anne M Smets
- Academic Medical Center, PO Box 22700, Amsterdam, 1100 DE, The Netherlands
| | - Kieran McHugh
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Susan C Shelmerdine
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
- UCL Great Ormond Street Institute of Child Health, London, UK.
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Central Venous Catheter-associated Venous Thromboembolism in Children With Hematologic Malignancy. J Pediatr Hematol Oncol 2018; 40:e519-e524. [PMID: 29863581 DOI: 10.1097/mph.0000000000001229] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
In pediatric oncology, the diagnosis of a hematologic malignancy and presence of a central venous catheter (CVC) have been identified as significant risk factors for the development of a venous thromboembolism (VTE). There remain little data regarding CVC factors associated with CVC-related VTE. Using the VTE and oncology database in a quaternary care center, a retrospective cohort study was conducted in children below 18 years old with hematologic cancer from November 5, 2012 to April 4, 2016. Patient, CVC factors, and VTE occurrence were analyzed to identify significant patient and CVC factors associated with the development of clinically identified CVC-related VTE. Utilizing the χ, Mann-Whitney, and the Fisher exact tests, patient factors were compared across VTE yes/no groups. Of the 198 study patients, 22 VTE cases were identified. Eighteen VTE events were CVC-associated, occurring in 9% of study population. Peripherally inserted central catheter lines and older ages were associated with VTE. The use of tissue-plasminogen activator for CVC occlusion was associated with decreased VTE rates, suggesting a protective potential.
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Madenci AL, Weil BR, Liu Q, Murphy AJ, Gibson TM, Yasui Y, Leisenring WM, Howell RM, Tinkle CL, Nekhlyudov L, Diller LR, Armstrong GT, Oeffinger KC, Weldon CB. Long-Term Risk of Venous Thromboembolism in Survivors of Childhood Cancer: A Report From the Childhood Cancer Survivor Study. J Clin Oncol 2018; 36:JCO2018784595. [PMID: 30216123 DOI: 10.1200/jco.2018.78.4595] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose To estimate the incidence of late-occurring venous thromboembolism (VTE) among survivors of childhood cancer and to identify risk factors for VTE to facilitate diagnosis and prevention. Methods The Childhood Cancer Survivor Study is a multi-institutional cohort of 24,355 5-year childhood cancer survivors (diagnosed between 1970 and 1999; median age at last follow-up, 28.7 years [range, 5.6 to 58.9 years]; median follow-up since diagnosis, 21.3 years [range, 5.0 to 39.2 years]) and 5,051 sibling participants. The primary end point was self-reported late (≥ 5 years after cancer diagnosis) VTE. Rate ratios (RRs) were estimated with multivariable piecewise exponential models. Results Late VTE incidence among survivors and siblings was 1.1 and 0.5 events per 1,000 person-years, respectively (RR, 2.2; 95% CI, 1.7 to 2.8), with 2.5 excess events per 100 survivors over 35 years. Among survivors, risk factors for VTE were female sex (RR, 1.3; 95% CI, 1.1 to 1.6), cisplatin (reference none; 1 to 199 mg/m2: RR, 3.0 [95% CI, 1.4 to 6.5]; 200 to 399 mg/m2: RR, 1.9 [95% CI, 1.0 to 3.6]; ≥ 400 mg/m2: RR, 2.0 [95% CI, 1.2 to 3.3]), l-asparaginase (RR, 1.3; 95% CI, 1.0 to 1.7), obesity or underweight (reference body mass index [BMI] 18.5 to 24.9 kg/m2; BMI ≥ 30.0 kg/m2: RR, 1.6 [95% CI, 1.2 to 2.0]; BMI < 18.5 kg/m2: RR, 2.4 [95% CI, 1.7 to 3.4]), and late cancer recurrence or subsequent malignant neoplasm (RR, 4.6; 95% CI, 3.6 to 5.8). Among lower-extremity osteosarcoma survivors, limb salvage (reference amputation; RR, 3.1; 95% CI, 1.2 to 7.5) and cisplatin 200 to 399 or ≥ 400 mg/m2 (reference none; RR, 4.0 [95% CI, 1.1 to 14.6] and 2.9 [95% CI, 1.1 to 8.0], respectively) were independently associated with late VTE. VTE was associated with increased risk for nonexternal cause late mortality (RR, 1.9; 95% CI, 1.6 to 2.3). Conclusion Childhood cancer survivors are at increased risk for VTE across their lifespan and a diagnosis of VTE increases mortality risk. Interventions that target potentially modifiable comorbidities, such as obesity, warrant consideration, with prophylaxis for high-risk survivors, including those treated with cisplatin and limb-sparing approaches.
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Affiliation(s)
- Arin L Madenci
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Brent R Weil
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Qi Liu
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Andrew J Murphy
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Todd M Gibson
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Yutaka Yasui
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Wendy M Leisenring
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Rebecca M Howell
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Christopher L Tinkle
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Larissa Nekhlyudov
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Lisa R Diller
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Gregory T Armstrong
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Kevin C Oeffinger
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Christopher B Weldon
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
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17
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MacLean J, MacDonald T, Digout C, Smith N, Rigby K, Kulkarni K. Need for tissue plasminogen activator for central venous catheter dysfunction is significantly associated with thrombosis in pediatric cancer patients. Pediatr Blood Cancer 2018. [PMID: 29537717 DOI: 10.1002/pbc.27015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Central venous catheter (CVC) dysfunction is a common complication among pediatric cancer patients. Tissue plasminogen activator (tPA) is administered to resolve CVC dysfunction. The present study was designed to determine risk factors associated with requirement of tPA for CVC dysfunction and to assess the clinical impact of CVC dysfunction in terms of CVC loss and venous thrombotic events (VTE). PROCEDURE Case records of all pediatric patients with cancer from the Maritimes, Canada were reviewed following ethics approval. Data regarding demographics, clinical diagnosis, CVC dysfunction, characteristics of CVCs, and VTE were pooled from multiple data sources. RESULTS Seven hundred and forty-one patients required ≥1 CVC. 26.3% of patients required tPA for ≥1 episodes of CVC dysfunction. Requirement of one or more doses of tPA for episodes of CVC dysfunction increased the odds of VTE by two times (95% confidence interval, 1.1-3.6). Patients that required ≥1 doses of tPA required significantly more CVCs (2.05 ± 1.29 per individual patient, 55% of the patients needed >1 CVCs) as compared to the remainder (1.52 ± 0.95 per individual patient, 32% needed >1 CVCs) (P = 0.0001). Multivariate analysis revealed age > 10 years, diagnosis of sarcoma, and tunneled line were independently associated with tPA requirement. CONCLUSION We determined independent risk factors associated with requirement of tPA for CVC dysfunction. Requirement of tPA for CVC dysfunction was associated with significantly increased risk of VTE and requirement of more CVCs. These observations can assist in identification of patients at increased risk of CVC dysfunction and inform approaches to reduce CVC loss and VTE.
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Affiliation(s)
- Jessica MacLean
- Division of Hematology/Oncology, Department of Pediatrics, IWK Health Centre, Halifax, Canada
| | - Tamara MacDonald
- Division of Hematology/Oncology, Department of Pediatrics, IWK Health Centre, Halifax, Canada
| | - Carol Digout
- Division of Hematology/Oncology, Department of Pediatrics, IWK Health Centre, Halifax, Canada
| | - Nadine Smith
- Division of Hematology/Oncology, Department of Pediatrics, IWK Health Centre, Halifax, Canada
| | - Krista Rigby
- Division of Hematology/Oncology, Department of Pediatrics, IWK Health Centre, Halifax, Canada
| | - Ketan Kulkarni
- Division of Hematology/Oncology, Department of Pediatrics, IWK Health Centre, Halifax, Canada
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18
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Athale UH, Mizrahi T, Laverdière C, Nayiager T, Delva YL, Foster G, Thabane L, David M, Leclerc JM, Chan AKC. Impact of baseline clinical and laboratory features on the risk of thrombosis in children with acute lymphoblastic leukemia: A prospective evaluation. Pediatr Blood Cancer 2018; 65:e26938. [PMID: 29334169 DOI: 10.1002/pbc.26938] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 11/03/2017] [Accepted: 11/20/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Children with acute lymphoblastic leukemia (ALL) have increased risk of thromboembolism (TE). However, the predictors of ALL-associated TE are as yet uncertain. OBJECTIVE This exploratory, prospective cohort study evaluated the effects of clinical (age, gender, ALL risk group) and laboratory variables (hematological parameters, ABO blood group, inherited and acquired prothrombotic defects [PDs]) at diagnosis on the development of symptomatic TE (sTE) in children (aged 1 to ≤18) treated on the Dana-Farber Cancer Institute ALL 05-001 study. PROCEDURES Samples collected prior to the start of ALL therapy were evaluated for genetic and acquired PDs (proteins C and S, antithrombin, procoagulant factors VIII (FVIII:C), IX, XI and von Willebrand factor antigen levels, gene polymorphisms of factor V G1691A, prothrombin gene G20210A and methylene tetrahydrofolate reductase C677T, anticardiolipin antibodies, fasting lipoprotein(a), and homocysteine). RESULTS Of 131 enrolled patients (mean age [range] 6.4 [1-17] years) 70 were male patients and 20 patients (15%) developed sTE. Acquired or inherited PD had no impact on the risk of sTE. Multivariable analyses identified older age (odds ratio [OR] 1.13; 95% confidence interval [CI]: 1.01, 1.26) and non-O blood group (OR 3.64, 95% CI: 1.06, 12.51) as independent predictors for development of sTE. Patients with circulating blasts had higher odds of developing sTE (OR 6.66; 95% CI: 0.82, 53.85). CONCLUSION Older age, non-O blood group, and presence of circulating blasts, but not PDs, predicted the risk of sTE during ALL therapy. We recommend evaluation of these novel risk factors in the development of ALL-associated TE. If confirmed, these easily accessible variables at diagnosis can help develop a risk-prediction model for ALL-associated TE.
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Affiliation(s)
- Uma H Athale
- Division of Pediatric Hematology/Oncology, McMaster Children's Hospital, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - T Mizrahi
- Division of Hematology/Oncology, Department of Pediatrics, CHU Ste-Justine, University of Montréal, Montréal, Canada
| | - C Laverdière
- Division of Hematology/Oncology, Department of Pediatrics, CHU Ste-Justine, University of Montréal, Montréal, Canada
| | - T Nayiager
- Division of Pediatric Hematology/Oncology, McMaster Children's Hospital, Hamilton, ON, Canada
| | - Y-L Delva
- Division of Hematology/Oncology, Department of Pediatrics, CHU Ste-Justine, University of Montréal, Montréal, Canada
| | - G Foster
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Biostatistics Unit, St Joseph's HealthCare, Hamilton, ON, Canada
| | - L Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Biostatistics Unit, St Joseph's HealthCare, Hamilton, ON, Canada.,Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - M David
- Division of Hematology/Oncology, Department of Pediatrics, CHU Ste-Justine, University of Montréal, Montréal, Canada
| | - J-M Leclerc
- Division of Hematology/Oncology, Department of Pediatrics, CHU Ste-Justine, University of Montréal, Montréal, Canada
| | - A K C Chan
- Division of Pediatric Hematology/Oncology, McMaster Children's Hospital, Hamilton, ON, Canada.,Department of Pediatrics, McMaster University, Hamilton, ON, Canada
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19
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Branchford BR, Carpenter SL. The Role of Inflammation in Venous Thromboembolism. Front Pediatr 2018; 6:142. [PMID: 29876337 PMCID: PMC5974100 DOI: 10.3389/fped.2018.00142] [Citation(s) in RCA: 220] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 04/27/2018] [Indexed: 12/12/2022] Open
Abstract
Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT), and pulmonary embolism (PE), is becoming increasingly recognized as a cause of morbidity and mortality in pediatrics, particularly among hospitalized children. Furthermore, evidence is accumulating that suggests the inflammatory response may be a cause, as well as consequence, of VTE, but current anticoagulation treatment regimens are not designed to inhibit inflammation. In fact, many established clinical VTE risk factors such as surgery, obesity, cystic fibrosis, sepsis, systemic infection, cancer, inflammatory bowel disease, and lupus likely modulate thrombosis through inflammatory mediators. Unlike other traumatic mechanisms of thrombosis involving vascular transection and subsequent exposure of subendothelial collagen and other procoagulant extracellular matrix materials, inflammation of the vessel wall may initiate thrombosis on an intact vein. Activation of endothelial cells, platelets, and leukocytes with subsequent formation of microparticles can trigger the coagulation system through the induction of tissue factor (TF). Identification of biomarkers to evaluate VTE risk could be of great use to the clinician caring for a patient with inflammatory disease to guide decisions regarding the risk:benefit ratio of various types of potential thromboprophylaxis strategies, or suggest a role for anti-inflammatory therapy. Unfortunately, no such validated inflammatory scoring system yet exists, though research in this area is ongoing. Elevation of C-reactive protein, IL-6, IL-8, and TNF-alpha during a response to systemic inflammation have been associated with increased VTE risk. Consequent platelet activation enhances the prothrombotic state, leading to VTE development, particularly in patients with other risk factors, most notably central venous catheters.
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Affiliation(s)
- Brian R Branchford
- University of Colorado Hemophilia and Thrombosis Center, Pediatric Hematology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
| | - Shannon L Carpenter
- Kansas City Regional Hemophilia Treatment Center, Pediatric Hematology, UMKC School of Medicine and Children's Mercy Hospital, Kansas, CO, United States
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20
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Santos BB, Heineck I, Negretto GW. USE OF WARFARIN IN PEDIATRICS: CLINICAL AND PHARMACOLOGICAL CHARACTERISTICS. ACTA ACUST UNITED AC 2017; 35:375-382. [PMID: 28977131 PMCID: PMC5737260 DOI: 10.1590/1984-0462/;2017;35;4;00008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 02/06/2017] [Indexed: 11/22/2022]
Abstract
Objective: To describe how children respond to oral anticoagulation with warfarin, verifying the influence of age, clinical condition, route of administration of warfarin and use of total parenteral nutrition (TPN), as well as to describe risk factors for the occurrence of thrombotic events (TE) in childhood. Methods: A retrospective descriptive study including all patients ≤18 years old for whom warfarin was prescribed in a university hospital. Patients were divided according to clinical condition, age, route of medication administration and use of TPN. Data was collected from the patients’ medical records and the analysis considered the risk factors for TE already described in the literature, the time and the dose required in order to reach the first International Normalized Ratio (INR) in the target and the adverse events in this period. After reaching the INR, the maintenance of anticoagulation was verified by the prescribed dose and INR tests. Results: Twenty-nine patients were included in the study. The major risk factor for TE was the use of a central venous catheter in 89.6% of the patients. Patients with short bowel syndrome and total parenteral nutrition required significantly higher doses (p≤0.05) to achieve and maintain the INR in the target. Patients ≤1 year old needed longer periods and required an increased dose of anticoagulation and maintenance than older patients. The mean number of INR examinations below the target was 48.2% in the groups studied. Conclusions: The observed complexity of anticoagulant therapy reinforces the need to develop protocols that guide clinical practice.
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Affiliation(s)
| | - Isabela Heineck
- Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
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21
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Cooper JD, Costello AG, Shaw PH. A Comparison of Extremity Thrombosis Rates in Adolescent and Young Adult Versus Younger Pediatric Oncology Patients at a Children's Hospital. J Adolesc Young Adult Oncol 2017; 6:62-66. [DOI: 10.1089/jayao.2016.0044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- James D. Cooper
- Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Aimee G. Costello
- Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Peter H. Shaw
- Department of Oncology, Johns Hopkins School of Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
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22
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Venous thrombosis in children and adolescents with Hodgkin lymphoma in Sweden. Thromb Res 2017; 152:64-68. [PMID: 28249199 DOI: 10.1016/j.thromres.2017.02.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 01/30/2017] [Accepted: 02/14/2017] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Pediatric patients with Hodgkin lymphoma (HL) have several risk factors for venous thromboembolism (VTE). Although these patients are occasionally treated with thromboprophylaxis, no guidelines are implemented in Sweden. Scarce data from adult patients indicate an increased risk of VTE, but pediatric data is largely missing. Given the favorable overall survival of HL, there should reasonably be more focus on preventing complications. MATERIALS AND METHODS We conducted a retrospective cohort study, including all patients registered in the Childhood Cancer Registry under the age of 18years diagnosed with HL between January 2005 and December 2015 in Sweden. RESULTS Data was retrieved from the medical records of all 163 patients (100%) at six Swedish pediatric cancer centers. The incidence of VTE was 7.7% (symptomatic VTE 3.9%). The median follow-up was 3.4years (range 0.3-10.5). Only five patients (3.1%) were treated with thromboprophylaxis. All VTE events occurred in the older age category (11-17years) and all but one (92.7%) had a mediastinal mass. While the VTE did not significantly affect the treatment of HL, it caused increased morbidity and 2/12 developed a post-thrombotic syndrome. No significant risk factors for VTE were identified. CONCLUSIONS VTE is a relatively common complication of HL and its treatment, causing increased acute and long-term morbidity. However, due to limited number of events we could not demonstrate risk-factors for VTE that would identify patients who might benefit from thromboprophylaxis.
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Ko RH, Thornburg CD. Venous Thromboembolism in Children with Cancer and Blood Disorders. Front Pediatr 2017; 5:12. [PMID: 28220143 PMCID: PMC5292750 DOI: 10.3389/fped.2017.00012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/18/2017] [Indexed: 01/19/2023] Open
Abstract
Venous thromboembolism (VTE) in children is multifactorial and most often related to a combination of inherited and acquired thrombophilias. Children with cancer and blood disorders are often at risk for VTE due to disease-related factors such as inflammation and abnormal blood flow and treatment-related factors such as central venous catheters and surgery. We will review risk factors for VTE in children with leukemia, lymphoma, and solid tumors. We will also review risk factors for VTE in children with blood disorders with specific focus on sickle cell anemia and hemophilia. We will present the available evidence and clinical guidelines for prevention and treatment of VTE in these populations.
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Affiliation(s)
| | - Courtney D Thornburg
- Hemophilia and Thrombosis Treatment Center, Rady Children's Hospital San Diego , San Diego, CA , USA
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Venous Thromboembolic Disease in Children and Adolescents. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:149-165. [DOI: 10.1007/5584_2016_113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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25
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Kero A, Madanat-Harjuoja L, Järvelä L, Malila N, Matomäki J, Lähteenmäki P. Cardiovascular medication after cancer at a young age in Finland: A nationwide registry linkage study. Int J Cancer 2015; 139:683-90. [DOI: 10.1002/ijc.29943] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 11/18/2015] [Indexed: 12/23/2022]
Affiliation(s)
- A.E. Kero
- Department of Pediatric and Adolescent Medicine; Turku University Hospital and Turku University; Turku Finland
| | - L.M. Madanat-Harjuoja
- Department of Pediatrics; University of Helsinki and Helsinki University Hospital; Helsinki Finland
- Finnish Cancer Registry; Helsinki Finland
| | - L.S. Järvelä
- Department of Pediatric and Adolescent Medicine; Turku University Hospital and Turku University; Turku Finland
| | - N. Malila
- Finnish Cancer Registry; Helsinki Finland
- School of Health Sciences; University of Tampere; Tampere Finland
| | - J. Matomäki
- Turku Clinical Research Center, Turku University Hospital; Finland
| | - P.M. Lähteenmäki
- Department of Pediatric and Adolescent Medicine; Turku University Hospital and Turku University; Turku Finland
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Humes DJ, Nordenskjöld A, Walker AJ, West J, Ludvigsson JF. Risk of venous thromboembolism in children after general surgery. J Pediatr Surg 2015; 50:1870-3. [PMID: 26078211 DOI: 10.1016/j.jpedsurg.2015.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 04/23/2015] [Accepted: 05/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE The purpose of the study was to determine absolute and relative rates of venous thromboembolism (VTE) following general surgical procedures in children compared to the general population. METHODS We analyzed data from all patients under the age of 18years in the Clinical Practice Research Datalink, linked to Hospital Episode Statistics from England (2001-2011) undergoing a general surgical procedure and population controls. Crude rates of VTE and adjusted hazard ratios were calculated using Cox regression. RESULTS We identified 15,637 children who had a surgical procedure with 161,594 controls. Six children undergoing surgery had a VTE diagnosed in the year after compared to five children in the population cohort. The overall rate of VTE following surgery was 0.4 per 1000 person years (pyrs) (95% confidence interval [CI] 0.15-0.88) compared to 0.04 per 1000 pyrs (95% CI 0.02-0.09) in the population cohort. This represented a 9 fold increase in risk compared to the population cohort (adjusted hazard ratio [HR] 8.80; 95% CI 2.59-29.94). CONCLUSIONS Children are at increased risk for VTE following general surgical procedures compared to the general population however the absolute risk is small and given this the benefits of thromboprophylaxis need to be balanced against the risk of complications following its use.
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Affiliation(s)
- David J Humes
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building 2, City Hospital, Nottingham, UK, NG5 1 PB; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 17177, Stockholm, Sweden.
| | - Agneta Nordenskjöld
- Unit of Paediatric Surgery, Department of Women's and Children's Health, Karolinska Institutet, 17177 Stockholm, Sweden.
| | - Alex J Walker
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building 2, City Hospital, Nottingham, UK, NG5 1 PB.
| | - Joe West
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building 2, City Hospital, Nottingham, UK, NG5 1 PB.
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 17177, Stockholm, Sweden; Department of Paediatrics, Örebro University Hospital, 70185 Örebro, Sweden.
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