1
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Johnson-Bishop L, Karakas C, Kralik SF, Cohen CT, Zobeck M, Park N, Rabin K, Pehlivan D, Bhar S. Cerebral Sinus Venous Thrombosis in Pediatric Acute Lymphoblastic Leukemia: Incidence, Clinical Characteristics, and Long-term Neurologic Outcomes. J Child Neurol 2024:8830738241282910. [PMID: 39324216 DOI: 10.1177/08830738241282910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
OBJECTIVE To describe the incidence, clinical characteristics, and long-term outcomes of cerebral sinus venous thrombosis in children with acute lymphoblastic leukemia. METHODS This was a retrospective cohort study comprising pediatric patients with newly diagnosed or first-relapse acute lymphoblastic leukemia who developed cerebral sinus venous thrombosis at Texas Children's Hospital from 2002 to 2019. RESULTS Nineteen cases (1.7%) with cerebral sinus venous thrombosis were identified in all pediatric patients with acute lymphoblastic leukemia (n = 1129). Increased risk of cerebral sinus venous thrombosis was observed with age >10 years (P = .006). Twelve cases (63%) occurred during the induction, 4 (21%) during maintenance, and 3 (16%) during the consolidation phases of leukemia therapy. Seizures (10/19) and headaches (9/19) were the most common presenting symptoms. After treatment with anticoagulation therapy, we observed full resolution of thrombosis in 10 (53%) and partial resolution in 8 patients (42%). Long-term neurologic outcomes at follow-up in the 14 patients who survived included normal neurologic examinations (n = 10), epilepsy (n = 3), and focal neurologic deficits (n = 2). The death occurred in 5 individuals. CONCLUSION Cerebral sinus venous thrombosis is a notable complication of pediatric acute lymphoblastic leukemia therapy. Older age (>10 years) was a risk factor for developing cerebral sinus venous thrombosis. Despite variable patient presentations and treatment durations, favorable clinical outcomes were observed in most patients after the treatment with anticoagulation for a minimum of 3 months.
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Affiliation(s)
- Lindsay Johnson-Bishop
- Department of Pediatrics, Division of Hematology and Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Cemal Karakas
- Division of Pediatric Neurology, Department of Neurology, Norton Children's Medical Group, University of Louisville, Louisville, KY, USA
| | - Stephen F Kralik
- Department of Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Clay T Cohen
- Department of Pediatrics, Division of Hematology and Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Mark Zobeck
- Department of Pediatrics, Division of Hematology and Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Nick Park
- Department of Pediatrics, Division of Hematology and Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Karen Rabin
- Department of Pediatrics, Division of Hematology and Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Davut Pehlivan
- Department of Pediatrics, Section of Pediatric Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, TX, USA
| | - Saleh Bhar
- Department of Pediatrics, Division of Hematology and Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatrics, Division of Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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2
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Weimar C, Beyer-Westendorf J, Bohmann FO, Hahn G, Halimeh S, Holzhauer S, Kalka C, Knoflach M, Koennecke HC, Masuhr F, Mono ML, Nowak-Göttl U, Scherret E, Schlamann M, Linnemann B. New recommendations on cerebral venous and dural sinus thrombosis from the German consensus-based (S2k) guideline. Neurol Res Pract 2024; 6:23. [PMID: 38637841 PMCID: PMC11027218 DOI: 10.1186/s42466-024-00320-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/20/2024] [Indexed: 04/20/2024] Open
Abstract
Over the last years, new evidence has accumulated on multiple aspects of diagnosis and management of cerebral venous and dural sinus thrombosis (CVT) including identification of new risk factors, studies on interventional treatment as well as treatment with direct oral anticoagulants. Based on the GRADE questions of the European Stroke Organization guideline on this topic, the new German guideline on CVT is a consensus between expert representatives of Austria, Germany and Switzerland. New recommendations include:• CVT occurring in the first weeks after SARS-CoV-2 vaccination with vector vaccines may be associated with severe thrombocytopenia, indicating the presence of a prothrombotic immunogenic cause (Vaccine-induced immune thrombotic thrombocytopenia; VITT).• D-dimer testing to rule out CVT cannot be recommended and should therefore not be routinely performed.• Thrombophilia screening is not generally recommended in patients with CVT. It should be considered in young patients, in spontaneous CVT, in recurrent thrombosis and/or in case of a positive family history of venous thromboembolism, and if a change in therapy results from a positive finding.• Patients with CVT should preferably be treated with low molecular weight heparine (LMWH) instead of unfractionated heparine in the acute phase.• On an individual basis, endovascular recanalization in a neurointerventional center may be considered for patients who deteriorate under adequate anticoagulation.• Despite the overall low level of evidence, surgical decompression should be performed in patients with CVT, parenchymal lesions (congestive edema and/or hemorrhage) and impending incarceration to prevent death.• Following the acute phase, oral anticoagulation with direct oral anticoagulants instead of vitamin K antagonists should be given for 3 to 12 months to enhance recanalization and prevent recurrent CVT as well as extracerebral venous thrombosis.• Women with previous CVT in connection with the use of combined hormonal contraceptives or pregnancy shall refrain from continuing or restarting contraception with oestrogen-progestagen combinations due to an increased risk of recurrence if anticoagulation is no longer used.• Women with previous CVT and without contraindications should receive LMWH prophylaxis during pregnancy and for at least 6 weeks post partum.Although the level of evidence supporting these recommendations is mostly low, evidence from deep venous thrombosis as well as current clinical experience can justify the new recommendations.This article is an abridged translation of the German guideline, which is available online.
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Affiliation(s)
- C Weimar
- BDH Klinik Elzach und Institut für Medizinische Informatik, Biometrie und Epidemiologie, Universitätsklinikum Essen, Essen, Germany.
| | - J Beyer-Westendorf
- Department of Medicine I; Division "Thrombosis & Hemostasis ", Dresden University Hospital "Carl Gustav Caris; Technical University Dresden, Dresden, Germany
| | - F O Bohmann
- Department of Neurology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
| | - G Hahn
- Department of Pediatric Radiology, University Children`s Hospital Basel UKBB, Basel, Switzerland
| | - S Halimeh
- Universitätsklinikum Essen, gerinnungszentrum rhein-ruhr, Duisburg, Germany
| | - S Holzhauer
- Klinik für Pädiatrie mit Schwerpunkt Onkologie und Hämatologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - C Kalka
- Vascular Institute Central Switzerland, Aarau, Switzerland and University of Cologne, Cologne, Germany
| | - M Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - H-C Koennecke
- Klinik für Neurologie, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - F Masuhr
- Abteilung für Neurologie, Bundeswehrkrankenhaus Berlin, Berlin, Germany
| | - M-L Mono
- Abteilung für Neurologie, Stadtspital Triemli, Zürich, Switzerland
| | - U Nowak-Göttl
- Gerinnungszentrum UKSH (Campus Kiel und Lübeck), Institut für Klinische Chemie, Kiel, Germany
| | - E Scherret
- Klinik für Neurologie der Charité - , Universitätsmedizin Berlin, Berlin, Germany
| | - M Schlamann
- Sektion Neuroradiologie, Institut für Diagnostische und Interventionelle Radiologie, Klinikum der Universität zu Köln, Cologne, Germany
| | - B Linnemann
- Klinik für Kardiologie III - Angiologie, Universitätsmedizin Mainz, Mainz, Germany
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3
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Pelland-Marcotte MC, Kulkarni K, Tran TH, Stammers D, Gupta S, Sung L, Athale UH. Risk factors and clinical impact of thrombosis during induction chemotherapy for pediatric acute lymphoblastic leukemia: A report from CYP-C. Am J Hematol 2024; 99:274-283. [PMID: 38164978 DOI: 10.1002/ajh.27171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 11/08/2023] [Indexed: 01/03/2024]
Abstract
Thromboembolism (TE) is associated with reduced survival in pediatric acute lymphoblastic leukemia (ALL). It has been hypothesized that TE might signal leukemic aggressiveness. The objective was to determine risk factors for TE during ALL induction (TEind ) therapy and whether TEind is associated with treatment refractoriness. This retrospective cohort study using the population-based Cancer in Young People Canada (CYP-C) registry included children <15 years of age diagnosed with ALL (2000-2019) and treated at one of 12 Canadian pediatric centers outside of Ontario. Univariate and multivariable logistic regression models were used to determine risk factors for TEind and whether TEind predicted induction failure and ALL treatment intensification. The impact of TEind on overall and event-free survival was estimated using Cox proportional hazard regression models. The study included 2589 children, of which 45 (1.7%) developed a TEind . Age (<1 year and ≥10 years vs. 1-<10 years), T-cell phenotype, high-risk ALL, and central nervous system involvement were all associated with TEind in univariate analysis. Age and T-cell phenotype remained independent predictors of TEind in multivariable analysis. Induction failure occurred in 53 patients (2.1%). TEind was not associated with induction failure (OR: not estimable) or treatment intensification (adjusted OR [95% CI]: 0.66 [0.26-1.69]). TEind was independently associated with overall survival (adjusted HR [95% CI]: 2.54 [1.20-5.03]) but not event-free survival (adjusted HR [95% CI] 1.86 [0.98-3.51]). In this population-based study of children treated with contemporary chemotherapy protocols, TEind was associated with age and T-cell phenotype and mortality but did not predict induction failure.
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Affiliation(s)
| | - Ketan Kulkarni
- Division of Hematology-Oncology, Department of Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Thai Hoa Tran
- Division of Pediatric Hematology-Oncology, Charles-Bruneau Cancer Center, CHU Sainte-Justine, Montréal, Quebec, Canada
- Axis of Immune Diseases and Cancer, CHU Sainte-Justine Research Center, Montréal, Quebec, Canada
| | - David Stammers
- Division of Immunology, Hematology, Oncology& Palliative Care, Stollery's Children Hospital, Edmonton, Alberta, Canada
| | - Sumit Gupta
- Division of Hematology-Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - Lillian Sung
- Division of Hematology-Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - Uma H Athale
- Division of Haematology/Oncology, McMaster Children's Hospital, and Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Zhou Y, Jiang H, Wei H, Xiao X, Liu L, Ji X, Zhou C. Cerebral venous thrombosis in patients with autoimmune disease, hematonosis or coronavirus disease 2019: Many familiar faces and some strangers. CNS Neurosci Ther 2023; 29:2760-2774. [PMID: 37365966 PMCID: PMC10493677 DOI: 10.1111/cns.14321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/24/2023] [Accepted: 06/09/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Cerebral venous thrombosis, a rare stroke, is characterized by neurological dysfunction caused by bleeding and/or infarction resulting from venous sinus thrombosis, the so-called venous stroke. Current guidelines recommend anticoagulants as first-line therapy in the treatment of venous stroke. With complicated causes of cerebral venous thrombosis, treatment is difficult, especially when combined with autoimmune diseases, blood diseases, and even COVID-19. AIMS This review summarizes the pathophysiological mechanisms, epidemiology, diagnosis, treatment, and clinical prognosis of cerebral venous thrombosis combined with autoimmune diseases, blood diseases, or infectious diseases such as COVID-19. CONCLUSION A systematic understanding of particular risk factors that should not be neglected when unconventional cerebral venous thrombosis occurs and for a scientific understanding of pathophysiological mechanisms, clinical diagnosis, and treatment, thus contributing to knowledge on special types of venous stroke.
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Affiliation(s)
- Yifan Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
| | - Huimin Jiang
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
| | - Huimin Wei
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Engineering MedicineBeihang UniversityBeijingChina
| | - Xuechun Xiao
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Engineering MedicineBeihang UniversityBeijingChina
| | - Lu Liu
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xunming Ji
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
- Department of Neurosurgery, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Chen Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
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5
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Yamamoto M, Akane Y, Hamada R, Kabutoya H, Igarashi K, Kim S, Tsugawa T. Rivaroxaban for severe superior sagittal sinus thrombosis in a child with ALL. Int J Hematol 2023; 118:309-310. [PMID: 37450173 DOI: 10.1007/s12185-023-03640-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 07/04/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Masaki Yamamoto
- Department of Pediatrics, Sapporo Medical University School of Medicine, 291, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan.
| | - Yusuke Akane
- Department of Pediatrics, Sapporo Medical University School of Medicine, 291, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Ryo Hamada
- Department of Pediatrics, Sapporo Medical University School of Medicine, 291, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Hiroyuki Kabutoya
- Department of Pediatrics, Sapporo Medical University School of Medicine, 291, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Keita Igarashi
- Department of Pediatrics, Sapporo Medical University School of Medicine, 291, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Sangnyon Kim
- Department of Neurosurgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Takeshi Tsugawa
- Department of Pediatrics, Sapporo Medical University School of Medicine, 291, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
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6
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Pelland-Marcotte MC, Bouchard V, Bégin E, Bouhêlier È, Santiago R, Monagle P. Biomarkers in pediatric venous thromboembolism: a systematic review of the literature. J Thromb Haemost 2023; 21:1831-1848. [PMID: 36958517 DOI: 10.1016/j.jtha.2023.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/17/2023] [Accepted: 03/14/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Accurate prediction of the individual risk of venous thromboembolism (VTE) remains suboptimal in children, and biomarkers are currently not used to stratify the risk of VTE in children. OBJECTIVES This study aimed to assess which biological or radiological biomarkers may predict VTE or VTE complications in children. PATIENTS/METHODS A literature search was performed for peer-reviewed publications (1990-2022). We included studies addressing the use of biomarkers for patients aged 29 days to 18 years to predict VTE or its complications, including but not limited to TE-related death, VTE recurrence, or postthrombotic syndrome. Given the heterogeneity of the study designs, populations, and outcomes, no quantitative data synthesis was performed. RESULTS Forty studies were included, totaling 10,987 participants (median age: 4.7 years). Reports were often lacking critical methodological data, including blood collection method (68% of studies) and timepoints, laboratory testing technique (41%), or primary outcome definition (20%). Forty-six individual biomarkers were assessed for VTE prediction (32 studies, 9525 participants), including d-dimers, fibrinogen, platelet count, white blood cell count, and factor VIII. Albumin, C-reactive protein, d-dimers, factor VIII, and thrombin-antithrombin levels showed promising results for VTE prediction. In 9 studies (1606 participants), no biomarker was consistently predictive of postthrombotic syndrome, VTE persistence, or VTE recurrence in children. CONCLUSIONS Several candidate biomarkers were promising in the prediction of VTE in children. Still, discrepancies between different studies and the high risk of bias from the current literature prevent their widespread use in the clinical setting. Further prospective research in various pediatric subpopulations is required.
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Affiliation(s)
- Marie-Claude Pelland-Marcotte
- Division of Pediatric Hematology-Oncology, CHU de Québec - Centre Mère-Enfant Soleil, Quebec City, Quebec, Canada; Research Center of the CHU de Québec, Axe Reproduction, Santé de la Mère et de l'Enfant, Quebec City, Canada.
| | - Valérie Bouchard
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Evelyne Bégin
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Ève Bouhêlier
- Centre de recherche du CHU de Québec, Quebec City, Quebec, Canada
| | - Raoul Santiago
- Division of Pediatric Hematology-Oncology, CHU de Québec - Centre Mère-Enfant Soleil, Quebec City, Quebec, Canada; Research Center of the CHU de Québec, Axe Reproduction, Santé de la Mère et de l'Enfant, Quebec City, Canada
| | - Paul Monagle
- Department of Paediatrics, University of Melbourne, Murdoch Children's Research Institute, Department of Haematology, Royal Children's Hospital Melbourne, Kids Cancer Centre, Sydney Children's Hospital, Australia
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7
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Dhariwal N, Gollamudi VRM, Sangeetha KP, Parambil BC, Moulik NR, Dhamne C, Prasad M, Vora T, Chinnaswamy G, Kembhavi S, Subramanian PG, Gujral S, Banavali SD, Narula G. Pediatric cancer-associated thrombosis: Analysis from a tertiary care cancer center in India. Pediatr Blood Cancer 2023; 70:e30096. [PMID: 36401555 DOI: 10.1002/pbc.30096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 10/08/2022] [Accepted: 10/22/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND AIMS Thrombotic events (TEs) have been extensively studied in adult cancer patients, but data in children are limited. We prospectively analyzed pediatric cancer-associated thrombosis (PCAT) in children with malignancies. METHODS Children below 15 years of age with confirmed malignancies, treated at a large tertiary cancer center in India from July 2015 to March 2020 developing any TE were eligible. A standardized approach for detection and management was followed. Data were collected after informed consent. RESULTS Of 6132 eligible children, 150 (2.44%) had 152 TEs, with median age 8.5 years and male:female of 1.83:1. Most TEs occurred on chemotherapy: 111 (74.0%). The most common site was central nervous system (CNS) 59 (39.3%), followed by upper-limb venous system 37 (24.7%). Hemato-lymphoid (HL) malignancies were more prone to PCAT than solid tumors (ST) (incidence 3.23% vs. 1.58%; odds ratio [OR] = 2.06, 95% confidence interval [CI] [1.36-2.88]; p < .001). Malignancies associated with PCAT were acute lymphoblastic leukemia (ALL) 2.94%, acute myeloid leukemia (AML) 6.66%, and non-Hodgkin lymphomas 5.35%. Response imaging done in 106 (70.7%) children showed complete to partial resolution in almost 90% children. Death was attributable to TE in seven (4.66%) children. Age above 10 years (OR 2.33, 95% CI [1.59-3.41]; p < .001), AML (OR 4.62, 95% CI [1.98-10.74]; p = .0062), and non-Hodgkin lymphoma (OR 4.01, 95% CI [1.15-14.04]; p = .029) were significantly associated with TEs. In ALL, age more than 10 years (OR 1.86, 95% CI [1.06-3.24]; p < .03), T-ALL (OR 3.32, 95% CI [1.69-6.54]; p = .001), and intermediate-risk group (OR 4.97, 95% CI [1.12-22.02]; p = .035) were significantly associated with thrombosis. The 2-year event-free survival (EFS) for HL malignancies with PCAT was 55.3% versus 72.1% in those without PCAT (p = .05), overall survival (OS) being 84.6% versus 80.0% (p = .32). CONCLUSION Incidence of PCAT was 2.4%, and occurred predominantly in older children with hematolymphoid malignancies early in treatment. Most resolved completely with low molecular weight heparin (LMWH) and mortality was low. In hematolymphoid malignancies, PCAT reduce EFS, highlighting the need for prevention.
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Affiliation(s)
- Nidhi Dhariwal
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Venkata Rama Mohan Gollamudi
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - K P Sangeetha
- Department of Medical Oncology, ESIC Bangalore, Bangalore, Karnataka, India
| | - Badira Cheriyalinkal Parambil
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Nirmalya Roy Moulik
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Chetan Dhamne
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Maya Prasad
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Tushar Vora
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Girish Chinnaswamy
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Seema Kembhavi
- Homi Bhabha National Institute, Mumbai, Maharashtra, India.,Department of Radiology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Papagudi G Subramanian
- Homi Bhabha National Institute, Mumbai, Maharashtra, India.,Hematopathology Laboratory, Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Sumeet Gujral
- Homi Bhabha National Institute, Mumbai, Maharashtra, India.,Hematopathology Laboratory, Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - S D Banavali
- Homi Bhabha National Institute, Mumbai, Maharashtra, India.,Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Gaurav Narula
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
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8
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Cerebral Sinovenous Thrombosis in Infants and Children: A Practical Approach to Management. Semin Pediatr Neurol 2022; 44:100993. [PMID: 36456034 DOI: 10.1016/j.spen.2022.100993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/27/2022] [Accepted: 08/29/2022] [Indexed: 11/23/2022]
Abstract
Cerebral sinovenous thrombosis (CSVT) is a rare, yet potentially devastating disorder, associated with acute complications and long-term neurologic sequelae. Consensus-based international pediatric CSVT treatment guidelines emphasize early clinical-radiologic recognition and prompt consideration for anticoagulation therapy. However, lack of clinical trials has precluded evidence-based patient selection, anticoagulant choice, optimal monitoring parameters and treatment duration. Consequently, uncertainties and controversies persist regarding anticoagulation practices in pediatric CSVT. This review focuses on commonly encountered issues that continue to pose questions and raise debates regarding anticoagulation therapy among pediatric neurologists and hematologists.
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9
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Skipper MT, Rank CU, Jarvis KB, Lynggaard LS, Andrés‐Jensen L, Quist‐Paulsen P, Semaskeviciene R, Hallböök H, Waitiovaara‐Kautto U, Ranta S, Trakymiene S, Abrahamsson J, Huttunen P, Albertsen BK, Schmiegelow K, Tuckuviene R. Cerebral sinovenous thrombosis and asparaginase re-exposure in patients aged 1-45 years with acute lymphoblastic leukaemia: A NOPHO ALL2008 study. EJHAEM 2022; 3:754-763. [PMID: 36051071 PMCID: PMC9422014 DOI: 10.1002/jha2.484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/06/2022] [Accepted: 05/11/2022] [Indexed: 11/22/2022]
Abstract
Cerebral sinovenous thrombosis (CSVT) is a serious complication during asparaginase therapy in patients with acute lymphoblastic leukaemia (ALL). We identified 46 patients with CSVT among 2651 patients (1‒45 years) treated according to the Nordic Society of Paediatric Haematology and Oncology (NOPHO) ALL2008 protocol between 2008 and 2018. CSVT cases were prospectively registered in the NOPHO database with retrospective updates. We examined the frequency of asparaginase re-exposure after CSVT, potential factors associated with asparaginase truncation, and sequelae after CSVT. This work was supported by the Danish Cancer Society and the Danish Childhood Cancer Foundation. The 2.5-year cumulative incidence of CSVT was 1.9% (95% confidence interval 1.4%-2.5%). The majority of patients (74%, n = 31) were re-exposed to asparaginase (with low-molecular-weight heparin coverage), one of whom had a second CSVT, without neurological sequelae. Patients re-exposed to asparaginase were earlier in ALL treatment and lacked more asparaginase doses than non-re-exposed patients at CSVT diagnosis (median 50 vs. 81 days, p = 0.03; mean 11.2 vs. 8.4 asparaginase doses, p = 0.04). No other examined factors had an impact on asparaginase re-exposure. At the last follow-up (median 4.5 years after CSVT), 61% of patients had normal neurological status, and 57% had complete recanalisation of CSVT, with no significant difference between patients re-exposed and non-re-exposed to asparaginase. Our results indicate that re-exposure to asparaginase is safe after CSVT during anticoagulation.
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Affiliation(s)
- Mette Tiedemann Skipper
- Department of Paediatrics and Adolescent MedicineAarhus University HospitalAarhusDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Cecilie Utke Rank
- Department of Paediatrics and Adolescent MedicineRigshospitalet University HospitalCopenhagenDenmark
| | | | - Line Stensig Lynggaard
- Department of Paediatrics and Adolescent MedicineAarhus University HospitalAarhusDenmark
| | - Liv Andrés‐Jensen
- Department of Paediatrics and Adolescent MedicineRigshospitalet University HospitalCopenhagenDenmark
| | | | - Ruta Semaskeviciene
- Oncology and Transfusion Medicine CentreVilnius University Hospital Santaros KlinikosVilniusLithuania
| | - Helene Hallböök
- Department of Medical SciencesUppsala UniversityUppsalaSweden
| | - Ulla Waitiovaara‐Kautto
- Department of HaematologyComprehensive Cancer CentreHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Susanna Ranta
- Astrid Lindgren Children's HospitalKarolinska University Hospital and Childhood Cancer Research UnitDepartment of Women's and Children's HealthKarolinska InstituteStockholmSweden
| | - Sonata Trakymiene
- Clinic of Children's DiseasesFaculty of MedicineVilnius UniversityVilnius University Hospital Santaros KlinikosVilniusLithuania
| | - Jonas Abrahamsson
- Department of PaediatricsInstitution of Clinical ScienceSahlgrenska Academy University of GothenburgGothenburgSweden
| | - Pasi Huttunen
- Department of Paediatric HaematologyOncology and SCTNew Children's HospitalHelsinki University HospitalHelsinkiFinland
| | - Birgitte Klug Albertsen
- Department of Paediatrics and Adolescent MedicineAarhus University HospitalAarhusDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent MedicineRigshospitalet University HospitalCopenhagenDenmark
| | - Ruta Tuckuviene
- Department of Paediatrics and Adolescent MedicineRigshospitalet University HospitalCopenhagenDenmark
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10
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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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11
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El-Khoury H, Saifi O, Haddad S, Chahrour M, Ghanem KM, Mubarak Y, Tamim H, Makki M, Zakka C, Chan AK, Mahfouz R, Tarek N, El-Solh H, Abboud MR, Saab R, Muwakkit SA. Treatment-induced cerebral sinus venous thrombosis in childhood acute lymphoblastic malignancies: New risk factors to consider. Pediatr Blood Cancer 2021; 68:e29210. [PMID: 34327817 DOI: 10.1002/pbc.29210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/16/2021] [Accepted: 06/04/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Cerebral sinus venous thrombosis (CSVT) is one of the many side effects encountered during acute lymphoblastic leukemia (ALL) therapy. Due to the rarity of cases, lack of data, and consensus management, no recommendations exist to target the population at risk. METHODS This is a retrospective chart review of 229 consecutive patients diagnosed with ALL with an age range of 1-21 years, treated at the Children's Cancer Center of Lebanon between October 2007 and February 2018. RESULTS The incidence of CSVT was 10.5%. Using univariate analysis, increased risk of CSVT was observed with male gender, age >10 years, T-cell immunophenotype, intermediate/high-risk disease, maximum triglyceride (TG) level of >615 mg/dl, presence of mediastinal mass, and larger body surface area (BSA). With multivariate analysis, the only statistically significant risk factors were maximum TG level, BSA, presence of mediastinal mass, and risk stratification (intermediate/high risk). CONCLUSION Our study was able to unveil TG level of >615 mg/dl, mediastinal mass, and a larger BSA as novel risk factors that have not been previously discussed in the literature.
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Affiliation(s)
- Habib El-Khoury
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Omran Saifi
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Salame Haddad
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Mohamad Chahrour
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Khaled M Ghanem
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Yaacoub Mubarak
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani Tamim
- Department of Pediatrics, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Maha Makki
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - Cyril Zakka
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Anthony K Chan
- Department of Pediatrics, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Rami Mahfouz
- Molecular Diagnostics Laboratory, Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nidale Tarek
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hassan El-Solh
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Miguel R Abboud
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Raya Saab
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Samar A Muwakkit
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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12
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Endothelial dysfunction and thromboembolism in children, adolescents, and young adults with acute lymphoblastic leukemia. Leukemia 2021; 36:361-369. [PMID: 34389803 DOI: 10.1038/s41375-021-01383-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 07/22/2021] [Accepted: 08/04/2021] [Indexed: 02/06/2023]
Abstract
Endothelial dysfunction has not previously been investigated as a thrombogenic risk factor among patients with acute lymphoblastic leukemia (ALL), known to be at high risk of thromboembolism. We retrospectively explored the association between three circulating biomarkers of endothelial dysfunction (thrombomodulin, syndecan-1, VEGFR-1) measured in prospectively collected blood samples and risk of thromboembolism in 55 cases and 165 time-matched controls, treated according to the NOPHO ALL2008 protocol. In age-, sex-, and risk group-adjusted analysis, increasing levels of thrombomodulin and VEGFR-1 were independently associated with increased odds of developing thromboembolism (OR 1.37 per 1 ng/mL [95% CI 1.20‒1.56, P < 0.0001] and OR 1.21 per 100 pg/mL [95% CI 1.02‒1.21, P = 0.005], respectively). These associations remained significant when including only samples drawn >30 days before thromboembolic diagnosis. Thrombomodulin levels were on average 3.2 ng/mL (95% CI 2.6-8.2 ng/mL) higher in samples with measurable asparaginase activity (P < 0.0001). Among single nucleotide variants located in or neighboring coding genes for the three biomarkers, none were significantly associated with odds of thromboembolism. If results are validated in another cohort, thrombomodulin and VEGFR-1 could serve as predictive biomarkers, identifying patients in need of preemptive antithrombotic prophylaxis.
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13
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Pelland‐Marcotte M, Kulkarni K, Athale UH, Pole JD, Brandão LR, Sung L. Thrombosis is associated with worse survival in children with acute lymphoblastic leukemia: A report from CYP-C. Am J Hematol 2021; 96:796-804. [PMID: 33848369 DOI: 10.1002/ajh.26193] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 01/19/2023]
Abstract
There are conflicting data about whether the development of cancer-associated thrombo-embolism (TE) negatively impacts survival in children. The objective was to determine whether TE during treatment was associated with overall survival (OS) and event-free survival (EFS) in children with acute lymphoblastic leukemia (ALL). We performed a population-based retrospective cohort study using the Cancer in Young People-Canada registry. Children <15 years of age were diagnosed with de novo ALL (2000-2016). The primary exposure variable was radiologically-confirmed thrombo-embolism requiring medical intervention. Multivariable Cox regression models were used to determine the impact of thrombo-embolism on survival, where TE was time-dependent. We included 2006 children (median age: 4 years, 88.5% precursor B-cell ALL). Thrombo-embolism occurred in 113 patients (5.6%), at a median time of 107 days (interquartile range: 35-184 days) after ALL diagnosis. Among standard/low-risk patients, 41/1165 (3.5%) developed TE while among high/very high-risk patients, 72/841 (8.6%) developed TE. Patients with TE had a significantly worse OS (adjusted HR [aHR] of death: 2.61, 95% CI: 1.62-4.22, p < 0.001) and EFS (aHR of an event [death, relapse, second malignancy]: 2.03, 95% CI: 1.35-3.05, p = 0.001), compared with patients without TE. No statistically significant difference was seen in standard/low risk ALL for OS and EFS, but TE was associated with a significantly lower OS and EFS in children with high/very high-risk ALL (aHR of death: 2.90, 95% CI: 1.79-4.72, p < 0.001; aHR of an event: 2.02, 95% CI: 1.30-3.12, p = 0.002). Thus, TE led to a statistically significant reduction in OS and EFS in children with high risk/very high-risk leukemia.
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Affiliation(s)
| | - Ketan Kulkarni
- Division of Hematology‐Oncology, Department of Pediatrics IWK Health Centre Halifax Nova Scotia Canada
| | - Uma H. Athale
- Division of Haematology/Oncology, McMaster Children's Hospital, and Department of Pediatrics McMaster University Hamilton Ontario Canada
| | - Jason D. Pole
- Centre for Health Services Research University of Queensland Herston Queensland Australia
| | - Leonardo R. Brandão
- Division of Haematology/Oncology, Department of Paediatrics SickKids Hospital Toronto Ontario Canada
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning Toronto Ontario Canada
- Dalla Lana School of Public Health, University of Toronto Toronto Ontario Canada
| | - Lillian Sung
- Division of Haematology/Oncology, Department of Paediatrics SickKids Hospital Toronto Ontario Canada
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning Toronto Ontario Canada
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14
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Koganesawa M, Matsuno R, Sugishita Y, Kaneko R, Kawabata N, Fujita S, Akiyama K, Toyama D, Yamamoto S. Anticoagulation treatment and prophylactic edoxaban for cerebral sinus venous thrombosis in an adolescent with acute lymphoblastic leukemia. SAGE Open Med Case Rep 2021; 9:2050313X211013225. [PMID: 34017593 PMCID: PMC8114254 DOI: 10.1177/2050313x211013225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 04/07/2021] [Indexed: 01/19/2023] Open
Abstract
Pediatric acute lymphoblastic leukemia regimens include large L-asparaginase dosages and steroids, which are associated with an increased risk of venous thromboemboli in adolescents and young adults. Herein, we report the case of an 18-year-old male with acute lymphoblastic leukemia, who was treated with the pediatric regimen, in which edoxaban was employed as a prophylaxis against cerebral sinus venous thrombosis. The event happened on day 20 of induction therapy, when brain magnetic resonance imaging demonstrated a cerebral sinus venous thrombosis in the superior sagittal sinus. Anticoagulation therapy was initiated, and the patient's symptoms disappeared 3 days later. The induction therapy was restarted after an interruption of 16 days, and the consolidation therapies, which included L-asparaginase and steroids, were completed. Edoxaban was administered as a prophylaxis during the consolidation therapy. There were no further adverse events. Edoxaban could be an effective prophylaxis for coagulation complications in adolescents and young adults with acute lymphoblastic leukemia.
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Affiliation(s)
- Masaya Koganesawa
- Department of Pediatrics, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Ryosuke Matsuno
- Department of Pediatrics, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Yumiko Sugishita
- Department of Pediatrics, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Ryota Kaneko
- Department of Pediatrics, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Naoko Kawabata
- Department of Pediatrics, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Sachio Fujita
- Department of Pediatrics, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Kosuke Akiyama
- Department of Pediatrics, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Daisuke Toyama
- Department of Pediatrics, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Shohei Yamamoto
- Department of Pediatrics, Showa University Fujigaoka Hospital, Yokohama, Japan
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15
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Ferro JM, Infante J. Cerebrovascular manifestations in hematological diseases: an update. J Neurol 2021; 268:3480-3492. [PMID: 33586004 PMCID: PMC8357668 DOI: 10.1007/s00415-021-10441-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 01/31/2021] [Accepted: 02/01/2021] [Indexed: 01/04/2023]
Abstract
Patients with hematological diseases often experience cerebrovascular complications including ischemic stroke, intracerebral and subarachnoid hemorrhage, microbleeds, posterior reversible encephalopathy syndrome, and dural sinus and cerebral vein thrombosis (CVT). In this update, we will review recent advances in the management of cerebrovascular diseases in the context of myeloproliferative neoplasms, leukemias, lymphomas, multiple myeloma, POEMS, paroxysmal nocturnal hemoglobinuria (PNH), thrombotic thrombocytopenic purpura (TTP), and sickle-cell disease. In acute ischemic stroke associated with hematological diseases, thrombectomy can in general be applied if there is a large vessel occlusion. Intravenous thrombolysis can be used in myeloproliferative neoplasms and sickle-cell anemia, but in other diseases, a case-by-case evaluation of the bleeding risks is mandatory. Patients with sickle-cell disease and acute stroke need very often to be transfused. In PNH, acute ischemic stroke patients must be anticoagulated. Most patients with CVT can be treated with low-molecular weight heparin (LMWH) acutely, even those with leukemias. Prevention of recurrence of cerebral thrombotic events depends on the control of the underlying disease, combined in some conditions with antithrombotic drugs. The recent introduction of specific monoclonal antibodies in the treatment of PHN and TTP has dramatically reduced the risk of arterial and venous thrombosis.
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Affiliation(s)
- José M Ferro
- Serviço de Neurologia, Departamento de Neurociências e Saúde Mental, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal. .,Faculdade de Medicina, Universidade de Lisboa, Hospital de Santa Maria, Neurology, 6th Floor, Avenida Professor Egas Moniz s/n, 1649-035, Lisbon, Portugal.
| | - Joana Infante
- Serviço de Hematologia e Transplantação de Medula, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
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16
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Anastasopoulou S, Heyman M, Eriksson MA, Niinimäki R, Taskinen M, Mikkel S, Vaitkeviciene GE, Johannsdottir IM, Myrberg IH, Jonsson OG, Als-Nielsen B, Schmiegelow K, Banerjee J, Ranta S, Harila-Saari A. Seizures during treatment of childhood acute lymphoblastic leukemia: A population-based cohort study. Eur J Paediatr Neurol 2020; 27:72-77. [PMID: 32340855 DOI: 10.1016/j.ejpn.2020.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 03/18/2020] [Accepted: 04/11/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Seizures are common in children with acute lymphoblastic leukemia (ALL). As ALL survival rates are improving, the challenge to minimize treatment related side effects and late sequelae rises. Here, we studied the frequency, timing, etiology and risk factors of seizures in ALL patients. METHODS The study included children aged 1-17.9 years at diagnosis of B-cell-precursor and T cell ALL who were treated according to the Nordic Society of Pediatric Hematology and Oncology (NOPHO) ALL2008 protocol between 2008 and 2015. Detailed patient data were acquired from the NOPHO ALL2008 registry and by review of medical records. RESULTS Seizures occurred in 81/1464 (5.5%) patients. The cumulative incidence of seizures at one months was 1.7% (95% CI: 1.2-2.5) and at one year 5.3% (95% CI 4.2-6.5%). Patients aged 10-17.9 years, those with T cell immunophenotype, CNS involvement, or high-risk induction with dexamethasone had higher risk for seizures in univariable analyses. Only age remained a risk factor in multivariable analyses (the cumulative incidence of seizures for patients 10-17.9 years old at one year was 9.0% (95% CI: 6.2-12.9)). Of the 81 patients with seizures, 43 had posterior reversible encephalopathy syndrome (PRES), 15 had isolated seizures, nine had sinus venous thrombosis (SVT), three had stroke-like syndrome, and 11 had other neurotoxicities. Epilepsy diagnosis was reported in totally 11 ALL survivors at last follow up. CONCLUSION Seizures are relatively common in ALL patients and occur most often in patients with PRES, SVT, or as an isolated symptom. Older children have higher risk of seizures.
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Affiliation(s)
- Stavroula Anastasopoulou
- Karolinska Institutet, Department of Women's and Children's Health, Stockholm, Sweden; Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden.
| | - Mats Heyman
- Karolinska Institutet, Department of Women's and Children's Health, Stockholm, Sweden; Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Mats A Eriksson
- Karolinska Institutet, Department of Women's and Children's Health, Stockholm, Sweden; Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Riitta Niinimäki
- Oulu University Hospital, Department of Children and Adolescents, and University of Oulu, PEDEGO Research Unit, Oulu, Finland
| | - Mervi Taskinen
- Division of Pediatric Hematology and Oncology and Stem Cell Transplantation, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Sirje Mikkel
- University of Tartu, Department of Hematology and Oncology, Tartu, Estonia
| | - Goda E Vaitkeviciene
- Children's Hospital, Affiliation of Vilnius University Hospital Santaros Klinikos and Vilnius University, Lithuania
| | | | - Ida Hed Myrberg
- Karolinska Institutet, Department of Women's and Children's Health, Stockholm, Sweden
| | | | - Bodil Als-Nielsen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Denmark
| | - Joanna Banerjee
- Division of Pediatric Hematology and Oncology and Stem Cell Transplantation, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Susanna Ranta
- Karolinska Institutet, Department of Women's and Children's Health, Stockholm, Sweden; Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Arja Harila-Saari
- University of Uppsala, Department of Women's and Children's Health, Uppsala, Sweden
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17
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Garg A, Kashyap R, Lal H, Mishra P. Cerebral Sinus Venous Thrombosis in Indian Pediatric Patients With Acute Lymphoblastic Leukemia: Incidence, Risk Factors, and Outcome. Indian J Med Paediatr Oncol 2020. [DOI: 10.4103/ijmpo.ijmpo_206_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
AbstractCerebral sinus venous Thrombosis (CSVT) is a rare complication of acute lymphoblastic leukemia (ALL) treatment, with an incidence rate ranging from 1.1% to 2.9%. Steroids and L-asparaginase (LASP) are the major risk factors.The aim of this study was to find the incidence rate and risk factors for CSVT in our patients. Ninety-two pediatric ALL diagnosed and treated with ALL-Berlin–Frankfurt–Munster-95 protocol over a period of 5 years (2013–2017) were the subject of the study. Six (6.5%) patients developed CSVT during their therapy and were further analyzed.Six (five males and one female) patients had a CSVT event. The mean age at presentation was 13.5 ± 4.1 years. CSVT event occurred during the induction/re-induction phase of chemotherapy. The superior sagittal sinus was the most frequent site of thrombosis. The timing of CSVT was related to using of LASP and steroids. High-risk disease was associated with an increased risk of thrombosis. Infection and dehydration were other important risk factors. No association was observed between the risk of CSVT and age, sex, immunophenotype, and white blood cell count. All the patients were treated with low-molecular-weight heparin and one patient developed heparin-induced thrombocytopenia. No death occurred due to CSVT.The Incidence of CSVT was 6.5% in our study which is significantly high but comparable with studies from other Asian countries. It is, therefore, important to be vigilant for the detection of CSVT during treatment of ALL and initiate the appropriate treatment to prevent adverse events.
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Affiliation(s)
- Akanksha Garg
- Department of Hematology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rajesh Kashyap
- Department of Hematology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Hira Lal
- Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prabhakar Mishra
- Department of Biostatistics and Health Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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18
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Xian Z, Chen Y, Chen L, Lu Q, Huang G, Qin Q, Zeng J, Liang Z. A clinical research on the potential pathogenesis of somatic cancer related cerebral venous sinus thrombosis. Medicine (Baltimore) 2019; 98:e15134. [PMID: 31083150 PMCID: PMC6531122 DOI: 10.1097/md.0000000000015134] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
To investigate the pathogenesis of somatic solid cancer-related cerebral venous sinus thrombosis (CVST).A total of 174 patients with CVST were recruited from the hospital between January 2006 and December 2017 and divided into two groups: (1) somatic cancer-related CVST group, defined as active somatic solid cancer patients with acute CVST; (2) cancer group (CG), defined as active somatic solid cancer patients without CVST. The cancer group patients were age and gender-matched somatic cancer-related CVST group patients. In addition, the types and amount distribution of cancer in cancer group were also matched with somatic cancer-related CVST group patients.Compared to cancer group patients, somatic cancer-related CVST group patients had more intracranial metastasis, a higher platelet count, higher plasma D-dimer, carcinoembryonic antigen (CEA) and cancer antigen (CA) 125 levels, a greater platelet to lymphocyte ratio (PLR), and a greater platelet to neutrophil ratio (PNR). The risk for CVST in somatic cancer-related CVST group patients increased independently by 0.7% (odds ratio [OR] 1.007; 95% confidence interval [CI] 1.000, 1.015; P = .047) with a 1 ng/ml increase in D-dimer levels, by 4.6% (OR 1.046; 95% CI 1.011, 1.083; P = .010) with a 1 U/ml increase in CEA, by 2.7% (OR 1.027; 95% CI 1.003, 1.051; P = .025) with a 1 U/ml increase in CA125, and by 10.6% (OR 1.106; 95% CI 1.002, 1.220; P = .045) with a 1 unit increase in PNR.It was suggested that together impacts of elevated plasma D-dimer, CA125, CEA levels, and a greater PNR may lead to hypercoagulability and to trigger the development of cancer-related CVST.
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Affiliation(s)
- Ziqiang Xian
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory Base of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-cerebrovascular Diseases, Nanning, 530021, Guangxi
| | - Yicong Chen
- Department of Neurology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, Guangdong, P.R. China
| | - Li Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory Base of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-cerebrovascular Diseases, Nanning, 530021, Guangxi
| | - Qiuhong Lu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory Base of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-cerebrovascular Diseases, Nanning, 530021, Guangxi
| | - Gelun Huang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory Base of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-cerebrovascular Diseases, Nanning, 530021, Guangxi
| | - Qixiong Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory Base of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-cerebrovascular Diseases, Nanning, 530021, Guangxi
| | - Jinsheng Zeng
- Department of Neurology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, Guangdong, P.R. China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory Base of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-cerebrovascular Diseases, Nanning, 530021, Guangxi
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19
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Klaassen ILM, Lauw MN, Fiocco M, van der Sluis IM, Pieters R, Middeldorp S, van de Wetering MD, de Groot‐Kruseman HA, van Ommen CH. Venous thromboembolism in a large cohort of children with acute lymphoblastic leukemia: Risk factors and effect on prognosis. Res Pract Thromb Haemost 2019; 3:234-241. [PMID: 31011707 PMCID: PMC6462738 DOI: 10.1002/rth2.12182] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 11/15/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is relatively common in children with acute lymphoblastic leukemia (ALL). Thrombotic risk factors in ALL are asparaginase and steroids. However, within the ALL populations treated on the same regimen, it is less clear which other risk factors play a role. Furthermore, few data are available on the effect of VTE on ALL outcomes. METHODS In 778 children (1-18 years) with newly diagnosed precursor-B-lineage or T-lineage ALL, treated in the Dutch Childhood Oncology Group (DCOG) ALL-10 protocol in the Netherlands (October 2004 to April 2013), we conducted a nested case control study with 59 VTE cases and 118 controls to identify risk factors for VTE. RESULTS Fifty-nine of 778 ALL patients developed VTE (7.6%), with cerebral venous sinus thrombosis (CVST) in 26 of 59 patients (44.1%). VTE occurred during induction treatment in 59.3% (n = 35) and in 40.7% (n = 24) during medium risk intensification. Conditional multivariable logistic regression analysis showed that age and ALL subtype were significantly associated with VTE (age ≥7 years: OR 2.72, 95% CI 1.33-5.57; ALL subtype T-ALL: OR 2.95, 95% CI 1.02-8.57). A multivariable Cox model showed no association between the occurrence of VTE and event free survival. In CVST patients, permanent disability was present in 34.6%. CONCLUSION Within this large pediatric ALL cohort, we demonstrated a high morbidity in CVST patients. Age ≥7 years at diagnosis and T-ALL subtype were the main risk factors for VTE, and should be considered in preventive strategies.
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Affiliation(s)
- Irene L. M. Klaassen
- Department of Pediatric HematologyAcademic Medical CenterAmsterdamthe Netherlands
- Department of Vascular MedicineAcademic Medical CenterAmsterdamthe Netherlands
| | - Mandy N. Lauw
- Department of Vascular MedicineAcademic Medical CenterAmsterdamthe Netherlands
- Department of HematologyAcademic Medical CenterAmsterdamthe Netherlands
| | - Marta Fiocco
- Medical StatisticsDepartment of Biomedical Data SciencesLeiden University Medical CenterLeidenthe Netherlands
- Mathematical Institute Leiden UniversityLeidenthe Netherlands
- Dutch Childhood Oncology GroupThe Haguethe Netherlands
| | - Inge M. van der Sluis
- Department of Pediatric Oncology/HematologyErasmus MC‐Sophia Children's HospitalRotterdamthe Netherlands
- Princess Máxima Center for Pediatric OncologyUtrechtthe Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric OncologyUtrechtthe Netherlands
| | - Saskia Middeldorp
- Department of Vascular MedicineAcademic Medical CenterAmsterdamthe Netherlands
| | | | | | - C. Heleen van Ommen
- Department of Pediatric Oncology/HematologyErasmus MC‐Sophia Children's HospitalRotterdamthe Netherlands
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Sibson KR, Biss TT, Furness CL, Grainger JD, Hough RE, Macartney C, Payne JH, Chalmers EA. BSH Guideline: management of thrombotic and haemostatic issues in paediatric malignancy. Br J Haematol 2018; 180:511-525. [DOI: 10.1111/bjh.15112] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 10/28/2017] [Accepted: 11/07/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Keith R. Sibson
- Department of Haematology; Great Ormond Street Hospital; London UK
| | - Tina T. Biss
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust; Newcastle Upon Tyne UK
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Schmiegelow K, Müller K, Mogensen SS, Mogensen PR, Wolthers BO, Stoltze UK, Tuckuviene R, Frandsen T. Non-infectious chemotherapy-associated acute toxicities during childhood acute lymphoblastic leukemia therapy. F1000Res 2017; 6:444. [PMID: 28413626 PMCID: PMC5389408 DOI: 10.12688/f1000research.10768.1] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2017] [Indexed: 01/19/2023] Open
Abstract
During chemotherapy for childhood acute lymphoblastic leukemia, all organs can be affected by severe acute side effects, the most common being opportunistic infections, mucositis, central or peripheral neuropathy (or both), bone toxicities (including osteonecrosis), thromboembolism, sinusoidal obstruction syndrome, endocrinopathies (especially steroid-induced adrenal insufficiency and hyperglycemia), high-dose methotrexate-induced nephrotoxicity, asparaginase-associated hypersensitivity, pancreatitis, and hyperlipidemia. Few of the non-infectious acute toxicities are associated with clinically useful risk factors, and across study groups there has been wide diversity in toxicity definitions, capture strategies, and reporting, thus hampering meaningful comparisons of toxicity incidences for different leukemia protocols. Since treatment of acute lymphoblastic leukemia now yields 5-year overall survival rates above 90%, there is a need for strategies for assessing the burden of toxicities in the overall evaluation of anti-leukemic therapy programs.
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Affiliation(s)
- Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Klaus Müller
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Signe Sloth Mogensen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Pernille Rudebeck Mogensen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Diabetes and Metabolism, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Benjamin Ole Wolthers
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ulrik Kristoffer Stoltze
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ruta Tuckuviene
- Department of Pediatrics, Aalborg University Hospital, Aalborg, Denmark
| | - Thomas Frandsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
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