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Geng Y, Meng C, Gao T, Li S, Bi L, Wang Y, Zhang P. Efficacy and Safety of Direct Oral Anticoagulants in Pediatric Venous Thromboembolism: A Systematic Review and Meta-Analysis. Indian J Pediatr 2023:10.1007/s12098-023-04952-8. [PMID: 38117441 DOI: 10.1007/s12098-023-04952-8] [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: 03/08/2023] [Accepted: 10/05/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVES To assess the efficacy and safety of direct oral anticoagulants (DOACs) in comparison to standard-of-care (SOC) anticoagulants in the management and prophylaxis of thromboembolic events in pediatric populations. METHODS A comprehensive search of electronic databases was conducted to identify relevant studies published between January 1, 2015, and December 18, 2022. A meta-analysis was undertaken to evaluate the effect of DOACs on clinically significant endpoints, employing trial-level data with harmonized endpoint definitions. The primary outcome was venous thromboembolism (VTE). Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. The study was registered with INPLASY (2022120065). RESULTS Three studies encompassing 934 subjects were included. The incidence of VTE was reduced in patients administered DOACs compared to those on SOC anticoagulants (OR 0.41 [95% CI 0.19-0.93], I² = 0%, P = 0.03). No significant differences were observed between the DOAC and SOC groups in all-cause mortality (OR 0.50 [95% CI 0.07-3.59], I² = 0%, P = 0.35) or serious adverse events (OR 0.75 [95% CI 0.50-1.12], I² = 0%, P = 0.16). The risk of major bleeding (OR 0.50 [95% CI 0.13-1.87], I² = 44%, P = 0.30) and clinically relevant non-major bleeding (OR 1.23 [95% CI 0.50-3.00], I² = 0%, P = 0.65) exhibited no significant differences between the groups. CONCLUSIONS DOACs are associated with a reduced risk of VTE in pediatric patients without increasing the risk of bleeding, all-cause mortality, or serious adverse events when compared to SOC anticoagulants. DOACs may be an alternative for the treatment and prevention of thromboembolic events in the pediatrics.
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Affiliation(s)
- Yu Geng
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, NO. 168 Litang Road, Changping District, Beijing, 102218, P. R. China
| | - Chang Meng
- Department of Emergency, Emergency General Hospital, Beijing, China
| | - Tong Gao
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, NO. 168 Litang Road, Changping District, Beijing, 102218, P. R. China
| | - Siyuan Li
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, NO. 168 Litang Road, Changping District, Beijing, 102218, P. R. China
| | - Lei Bi
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, NO. 168 Litang Road, Changping District, Beijing, 102218, P. R. China
| | - Yintang Wang
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, NO. 168 Litang Road, Changping District, Beijing, 102218, P. R. China.
| | - Ping Zhang
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, NO. 168 Litang Road, Changping District, Beijing, 102218, P. R. China.
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Timing of Central Venous Line Insertion During Induction in Children With Acute Lymphoblastic Leukemia. J Pediatr Hematol Oncol 2023; 45:25-28. [PMID: 36598960 DOI: 10.1097/mph.0000000000002600] [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: 01/14/2022] [Accepted: 10/29/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE Central venous lines (CVL) in children with acute lymphoblastic leukemia (ALL) provide comfortable administration of intensive chemotherapy and blood sampling. The optimal time for the insertion of CVL in patients with ALL during induction therapy is controversial. This study aimed to investigate the frequency of CVL-related complications in children with ALL concerning the time of CVL insertion. PATIENTS AND METHODS We reviewed the records of 52 pediatric ALL patients with CVL. CVL placement before or on treatment day 15 was defined as "early insertion", and after treatment day 15 was defined as "late insertion". Demographics, preoperative blood counts, type of central line, time of CVL placement, CVL-related complications, and blood counts during complications were all noted. All the data were collected from those with the first catheter use. RESULTS CVL was placed ≤15 days in 26 patients (50%) and after 15 days in 26 patients (50%). Regarding the infection rates, no statistical difference was found between early and late CVL-inserted groups ( P =n.s.). Five patients developed thrombosis, and risk was found to be similar between early and late CVL-inserted groups ( P =n.s.). Catheter-related mechanical complications were recorded in 7 patients (3 in early and 4 in late CVL-inserted group, ( P =n.s.). CONCLUSION The present study showed no relation between the timing of CVL placement during induction therapy and the occurrence of infection and thrombosis. Our results suggest that CVL can be placed safely at the time of diagnosis or early induction treatment to provide a comfortable administration of chemotherapy and decrease painful blood samplings.
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Daei M, Abbasi G, Khalili H, Heidari Z. Direct oral anticoagulants toxicity in children: an overview and practical guide. Expert Opin Drug Saf 2022; 21:1183-1192. [PMID: 35924671 DOI: 10.1080/14740338.2022.2110236] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION By increasing use of direct oral anticoagulants (DOACs) in adults and children, gradual increase in the number of intentional or unintentional DOAC poisonings among children is suspected in the near future. Hence, clinicians and pharmacists need to be familiar with the clinical features and management of DOAC-toxicity among pediatric population. AREAS COVERED This article provides an overview and practical guide to DOAC-toxicity in pediatrics according to the available clinical evidence. EXPERT OPINION Based on limited available data, accidental pediatric ingestion of DOACs can be managed by supportive care in most cases. However, serious toxicity may occur following massive overdose, in presence of underlying disorders (renal or hepatic dysfunction) and concurrent anticoagulant therapy. Activated charcoal is recommended for known recent ingestion of DOACs (within 2-4 hours) to reduce the gastrointestinal absorption. Supportive interventions including local hemostatic measures and volume resuscitation are the cornerstone of management of bleeding. Vitamin K and fresh frozen plasma are ineffective for DOAC reversal and thus are not recommended. Currently, safety and efficacy data regarding the use of specific reversal agents (including idarucizumab and andexanet alfa) and 3-factor or 4-factor prothrombin complex concentrate (PCC) or activated PCC (aPCC) among children with DOAC-associated bleeding are lacking.
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Affiliation(s)
- Maryam Daei
- Faculty of Pharmacy, Alborz University of Medical Sciences, Alborz, Iran
| | - Golnaz Abbasi
- Faculty of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hossein Khalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Zinat Heidari
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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Motta SE, Zaytseva P, Fioretta ES, Lintas V, Breymann C, Hoerstrup SP, Emmert MY. Endothelial Progenitor Cell-Based in vitro Pre-Endothelialization of Human Cell-Derived Biomimetic Regenerative Matrices for Next-Generation Transcatheter Heart Valves Applications. Front Bioeng Biotechnol 2022; 10:867877. [PMID: 35433657 PMCID: PMC9008229 DOI: 10.3389/fbioe.2022.867877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/14/2022] [Indexed: 01/22/2023] Open
Abstract
Hemocompatibility of cardiovascular implants represents a major clinical challenge and, to date, optimal antithrombotic properties are lacking. Next-generation tissue-engineered heart valves (TEHVs) made from human-cell-derived tissue-engineered extracellular matrices (hTEMs) demonstrated their recellularization capacity in vivo and may represent promising candidates to avoid antithrombotic therapy. To further enhance their hemocompatibility, we tested hTEMs pre-endothelialization potential using human-blood-derived endothelial-colony-forming cells (ECFCs) and umbilical vein cells (control), cultured under static and dynamic orbital conditions, with either FBS or hPL. ECFCs performance was assessed via scratch assay, thereby recapitulating the surface damages occurring in transcatheter valves during crimping procedures. Our study demonstrated: feasibility to form a confluent and functional endothelium on hTEMs with expression of endothelium-specific markers; ECFCs migration and confluency restoration after crimping tests; hPL-induced formation of neo-microvessel-like structures; feasibility to pre-endothelialize hTEMs-based TEHVs and ECFCs retention on their surface after crimping. Our findings may stimulate new avenues towards next-generation pre-endothelialized implants with enhanced hemocompatibility, being beneficial for selected high-risk patients.
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Affiliation(s)
- Sarah E. Motta
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
- Wyss Translational Center Zurich, University and ETH Zurich, Zurich, Switzerland
| | - Polina Zaytseva
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Emanuela S. Fioretta
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Valentina Lintas
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Christian Breymann
- Department of Obstetrics and Gynaecology, University Hospital Zurich, Obstetric Research, Feto- Maternal Haematology Research Group, Zurich, Switzerland
| | - Simon P. Hoerstrup
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
- Wyss Translational Center Zurich, University and ETH Zurich, Zurich, Switzerland
| | - Maximilian Y. Emmert
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
- Wyss Translational Center Zurich, University and ETH Zurich, Zurich, Switzerland
- Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- *Correspondence: Maximilian Y. Emmert,
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Kapur S, Gilmore M, Macartney C, Thompson A. How to use a coagulation screen. Arch Dis Child Educ Pract Ed 2022; 107:45-49. [PMID: 33637579 DOI: 10.1136/archdischild-2020-320925] [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] [Accepted: 02/08/2021] [Indexed: 11/04/2022]
Abstract
A coagulation screen is an important screening test when investigating a child who presents with easy bruising or bleeding. Interpretation of a coagulation screen can be challenging for clinicians. Evolution of the haemostasis system during childhood means normal ranges vary with age and needs to be interpreted alongside the clinical information. It is essential to consider preanalytical variables when interpreting a coagulation screen, and the reason for the investigation must always be considered. It is important that the sample is taken under optimal conditions, including sample technique, use of the correct bottle and prompt transport to the laboratory. An abnormal coagulation screen may indicate an underlying congenital bleeding disorder or an acquired bleeding disorder, or may be due to sampling error. Limitations of the coagulation screen are essential to be aware of, as some children with normal coagulation screen results may have bleeding disorders. Conversely, an abnormal coagulation screen does not always indicate a bleeding disorder.
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Affiliation(s)
- Sarah Kapur
- Children's Haematology Unit, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Mark Gilmore
- Neonatal Intensive Care, Royal Maternity Hospital, Belfast, UK
| | - Christine Macartney
- Children's Haematology Unit, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Andrew Thompson
- General Paediatics, Royal Belfast Children's Hospital, Belfast, UK
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6
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Male C. Anticoagulation in Pediatric Patients. Hamostaseologie 2022; 42:46-53. [PMID: 35042258 DOI: 10.1055/a-1703-0821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Special aspects of anticoagulation in children include the different epidemiology of thrombosis, developmental changes in the coagulation system, age-dependent pharmacokinetics of anticoagulants, risk of bleeding, and practical hurdles to anticoagulation. The classical anticoagulants so far used in children have several limitations, resulting in the need for regular monitoring. The pharmacological properties of direct oral anticoagulants (DOACs) and the special challenges of anticoagulation in children make the DOACs particularly attractive for children. All DOACs have pediatric development programs, targeting various indications for prevention and treatment of thrombosis. Child-appropriate formulations have been developed, age-specific dosing information generated, and safety and efficacy evaluated in ongoing phase 3 trials. Rivaroxaban and dabigatran have already been authorized for children for treatment of acute venous thrombosis and for extended secondary prevention. Their safety and efficacy have been demonstrated comparable to that of standard-of-care anticoagulants, without need for monitoring. Further studies are ongoing, which are expected to lead to pediatric authorizations of DOACs for primary venous thromboembolic event prevention in some high-risk settings. More real-life data will be necessary from postmarketing studies and registries to complement the evidence base for DOAC use in children, particularly in the youngest age groups and special disease populations.
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Affiliation(s)
- Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
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Östlund ÅKM, Fläring U, Larsson P, Kaiser S, Vermin L, Frisk T, Dahlberg A, Berner J, Norberg Å, Andersson A. Incidence of venous thromboembolic events not related to vascular catheters in a prospective cohort of critically ill children. Eur J Pediatr 2022; 181:3031-3038. [PMID: 35652985 PMCID: PMC9352609 DOI: 10.1007/s00431-022-04487-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 04/20/2022] [Accepted: 04/23/2022] [Indexed: 12/29/2022]
Abstract
UNLABELLED The risk for venous thromboembolism (VTE) is considered to be low in the general paediatric intensive care unit (PICU) population, and pharmacological thromboprophylaxis is not routinely used. PICU patients considered at high-risk of VTE could possibly benefit from pharmacological thromboprophylaxis, but the incidence of VTE in this group of patients is unclear. This was an observational, prospective study at a tertiary multi-disciplinary paediatric hospital. We used comprehensive ultrasonography screening for VTE in critically ill children with multiple risk factors for VTE. Patients admitted to PICU ≥ 72 h and with ≥ two risk factors for VTE were included. Patients receiving pharmacological thromboprophylaxis during their entire PICU stay were excluded. The primary outcome of the study was VTEs not related to the use of a CVC. Ultrasonography screening of the great veins was performed at PICU discharge. Seventy patients with median (interquartile range) 3 (2-4) risk factors for VTE were evaluated. Median age was 0.3 years (0.03-4.3) and median PICU length of stay 9 days (5-17). Regarding the primary outcome, no symptomatic VTEs occurred and no asymptomatic VTEs were found on ultrasonography screening, resulting in an incidence of VTEs not related to a vascular catheter of 0% (95% CI: 0-5.1%). CONCLUSION Our results indicate that VTEs not related to a vascular catheter are a rare event even in a selected group of severely ill small children considered to be at high risk of VTE. WHAT IS KNOWN • Children in the PICU often have several risk factors for venous thromboembolism (VTE). • The incidence of VTE in PICU patients is highly uncertain, and there are no evidence-based guidelines regarding VTE prophylaxis. WHAT IS NEW • This study found an incidence of VTEs not related to a vascular catheter of 0% (95% CI: 0-5.1%). • This indicates that such VTE events are rare even in PICU patients with multiple risk factors for VTE.
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Affiliation(s)
- Åsa K M Östlund
- Department of Paediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
| | - Urban Fläring
- Department of Paediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Larsson
- Department of Paediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Sylvie Kaiser
- Department of Paediatric Radiology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Lena Vermin
- Department of Paediatric Radiology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Tony Frisk
- Department of Children's Health, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Ann Dahlberg
- Department of Paediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Berner
- Department of Paediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Åke Norberg
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Andersson
- Department of Paediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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8
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Male C, Monagle P, Albisetti M, Brandão LR, Young G. Direct Oral Anticoagulants: Overcoming the Challenges of Managing Venous Thromboembolism in Children. J Pediatr 2022; 240:14-23. [PMID: 34687696 DOI: 10.1016/j.jpeds.2021.09.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Christoph Male
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria.
| | - Paul Monagle
- Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia; Australia and Kids Cancer Centre, Sydney Children's Hospital, Sydney, Australia
| | - Manuela Albisetti
- Division of Hematology, University Children's Hospital of Zurich, Zurich, Switzerland
| | - Leonardo R Brandão
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Guy Young
- Children's Hospital Los Angeles, University of Southern California, Keck School of Medicine, Los Angeles, CA
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9
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Tran VL, Parsons S, Varela CR. The Trilogy of SARS-CoV-2 in Pediatrics (Part 3): Thrombosis, Anticoagulant, and Antiplatelet Considerations. J Pediatr Pharmacol Ther 2021; 26:565-576. [PMID: 34421405 DOI: 10.5863/1551-6776-26.6.565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/06/2021] [Indexed: 12/20/2022]
Abstract
The hypercoagulable state induced by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) affects all patients regardless of age. The incidence of venous thromboembolism in pediatric patients with SARS-CoV-2-related illnesses is not well established. Although deep vein thrombosis is rare in children in the absence of risk factors, coagulopathy and the development of thromboses have been described in pediatric patients with acute COVID-19 and multisystem inflammatory syndrome. This comprehensive review provides a detailed overview of SARS-CoV-2-associated coagulopathy as well as strategies for optimizing the evaluation, management, and prevention of thrombosis in pediatric patients.
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10
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Kim S, Klugman J, Norell S, Kenefake A, Komos L, Jain D, Corcoran M, Montero C, Kreppel A, Sales J, Porto I, Wang J, Hsu LL, Erwin K. Improving VTE prophylaxis adherence among hospitalized adolescents using Human-Centered Design. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2021. [DOI: 10.1177/25160435211036784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background/problem statement Venous thromboembolism (VTE) is the leading cause of preventable hospital mortality in the United States; however, compliance with VTE prophylaxis is poor. Most materials for education about VTE prophylaxis are oriented toward adults rather than adolescents, for whom VTE risks are lower and prophylaxis indications differ. We hypothesized that educational materials for adolescents could improve compliance with VTE prophylaxis, reduce nurse burden for initiating and maintaining VTE prevention practices, and reduce practice variation by standardizing the conversation between clinicians and patients. Methods A multidisciplinary team including physicians, nurses, quality experts, communication designers, service designers, and medical students applied a human-centered design (HCD) process to define, iteratively prototype, and test education tools for nurses assigned to adolescents. We piloted a suite of six educational tools for adolescent VTE prophylaxis to fit into the existing hospital workflow. Results An in-room poster was selected after 85% of nurses responded favorably to this intervention. Adolescent adherence with Intermittent Pneumatic Compression Device increased from 69% to 79%, attaining the benchmark goal of 78%. Staff reported greater confidence in educating adolescent patients after the intervention: 62% of nurses and 72% of residents. Conclusion An HCD process helped nurses improve VTE prophylaxis for adolescents with an in-room poster and messaging strategy. Engaging staff in the design increased receptivity and adoption. The piloted materials also helped to create an environment of shared priority among the clinicians.
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Affiliation(s)
- Soobin Kim
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jessie Klugman
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Sarah Norell
- Institute for Healthcare Delivery Design, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Alexandra Kenefake
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Laurel Komos
- Institute for Healthcare Delivery Design, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Divya Jain
- Institute for Healthcare Delivery Design, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Moire Corcoran
- Institute for Healthcare Delivery Design, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Carlos Montero
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Andrew Kreppel
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jocelyn Sales
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Isabel Porto
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jenny Wang
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Lewis L. Hsu
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kim Erwin
- Institute for Healthcare Delivery Design, University of Illinois at Chicago, Chicago, Illinois, USA
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11
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Branstetter JW, Kiskaddon AL, King MA, Coalter C, Grubbs KM, Fly H, Male C, Brandão L, Goldenberg NA. Efficacy and Safety of Non-Vitamin K Antagonist Oral Anticoagulants in Pediatric Venous Thromboembolism Treatment and Thromboprophylaxis: A Systematic Review of the Literature. Semin Thromb Hemost 2021; 47:643-653. [PMID: 33971679 DOI: 10.1055/s-0041-1725944] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Venous thromboembolism (VTE) in children can lead to significant morbidity and mortality. Traditionally, treatment for thrombotic events in pediatric patients has been limited mainly to unfractionated heparin, low-molecular-weight heparin (LMWH), or vitamin K antagonists. Since the first non-vitamin K antagonist oral anticoagulant (NOAC) was approved for adult use, these agents have gained popularity for a variety of indications. This is largely due to their ease of administration, favorable pharmacokinetic and pharmacodynamic profile, decreased food interactions, and decreased need for therapeutic drug monitoring. Treating and preventing VTE with traditional anticoagulants in pediatric patients presents many challenges. This systematic review evaluated the current literature regarding pediatric NOAC trials. Additionally, based on an up-to-date query of clinicaltrials.gov, we detail current ongoing and as-yet unpublished clinical trials, study outcomes, and projected completion dates. Published pediatric NOAC trials have included 1,007 total children to date and have ranged from phase 1 to 4, with "indications" including both thromboembolism prophylaxis and VTE treatment. Three recent phase 3 trials, specifically involving rivaroxaban and dabigatran, have shown the agents to be at least as effective as traditional anticoagulants for acute and/or extended VTE treatment, with low frequency of recurrent thrombosis and clinically significant bleeding rates. Additionally, specially developed and tested pediatric formulations have allowed for accurate and reliable dosing, oral administration, stable pharmacokinetics and pharmacodynamics, and fewer drug or food interactions. Ongoing trials, anticipated for completion in the next few years, will reveal important information with regard to thromboembolism prophylaxis in special pediatric subpopulations and settings.
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Affiliation(s)
| | - Amy L Kiskaddon
- Department of Pharmacy, The Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, Florida
| | - Madeleine A King
- Department of Pharmacy, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Carli Coalter
- College of Pharmacy, Union University, Jackson, Tennessee
| | - Kimberly M Grubbs
- Department of Pharmacy, Medical University of South Carolina, Charleston, South Carolina
| | - Hunter Fly
- Department of Pharmacy, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Austria
| | - Leonardo Brandão
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Neil A Goldenberg
- Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, Florida.,Thrombosis Program, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Department of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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12
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Marano M, Pisani M, Zampini G, Pontrelli G, Roversi M. Acute Exposure to European Viper Bite in Children: Advocating for a Pediatric Approach. Toxins (Basel) 2021; 13:toxins13050330. [PMID: 34063282 PMCID: PMC8170888 DOI: 10.3390/toxins13050330] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 11/16/2022] Open
Abstract
Viper bite is an uncommon but serious cause of envenoming in Europe, especially in children. Our study aim is to better describe and analyze the clinical course and treatment of viper bite envenoming in a pediatric population. We retrospectively reviewed 24 cases of pediatric viper bites that were admitted to the Pediatric Emergency Department and the Pediatric Intensive Care Unit of the Bambino Gesù Children Hospital in Rome between 2000 and 2020. Epidemiological characteristics of the children, localization of the bite, clinical and laboratory findings, and treatment approaches were evaluated. The median age of the patients was 4.2 years, with male predominance. Most cases of viper bite occurred in the late summer. Most patients required admission to the ward for prolonged observation. The most common presenting signs were pain, local oedema, and swelling. Patients with a high severity score also had a significantly higher white blood cell count and an increase of INR, LDH, and CRP levels. No fatality was reported. Viper bite envenomation is a rare pediatric medical emergency in Italy but may sometimes be severe. A new pediatric severity score may be implemented in the screening of children with viper bites to favor a selective and prompt administration of antivenom.
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Affiliation(s)
- Marco Marano
- Pediatric Intensive Care Unit, Pediatric Clinical Toxicology Center, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.M.); (G.Z.)
| | - Mara Pisani
- Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Giorgio Zampini
- Pediatric Intensive Care Unit, Pediatric Clinical Toxicology Center, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.M.); (G.Z.)
| | - Giuseppe Pontrelli
- Clinical Trial Unit, Academic Department of Pediatrics, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Marco Roversi
- Clinical Trial Unit, Academic Department of Pediatrics, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
- Correspondence:
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Faustino EVS, Raffini LJ, Hanson SJ, Cholette JM, Pinto MG, Li S, Kandil SB, Nellis ME, Shabanova V, Silva CT, Tala JA, McPartland T, Spinella PC. Age-Dependent Heterogeneity in the Efficacy of Prophylaxis With Enoxaparin Against Catheter-Associated Thrombosis in Critically Ill Children: A Post Hoc Analysis of a Bayesian Phase 2b Randomized Clinical Trial. Crit Care Med 2021; 49:e369-e380. [PMID: 33566465 PMCID: PMC7979442 DOI: 10.1097/ccm.0000000000004848] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES We explored the age-dependent heterogeneity in the efficacy of prophylaxis with enoxaparin against central venous catheter-associated deep venous thrombosis in critically ill children. DESIGN Post hoc analysis of a Bayesian phase 2b randomized clinical trial. SETTING Seven PICUs. PATIENTS Children less than 18 years old with newly inserted central venous catheter. INTERVENTIONS Enoxaparin started less than 24 hours after insertion of central venous catheter and adjusted to anti-Xa level of 0.2-0.5 international units/mL versus usual care. MEASUREMENTS AND MAIN RESULTS Of 51 children randomized, 24 were infants less than 1 year old. Risk ratios of central venous catheter-associated deep venous thrombosis with prophylaxis with enoxaparin were 0.98 (95% credible interval, 0.37-2.44) in infants and 0.24 (95% credible interval, 0.04-0.82) in older children greater than or equal to 1 year old. Infants and older children achieved anti-Xa level greater than or equal to 0.2 international units/mL at comparable times. While central venous catheter was in situ, endogenous thrombin potential, a measure of thrombin generation, was 223.21 nM.min (95% CI, 8.78-437.64 nM.min) lower in infants. Factor VIII activity, a driver of thrombin generation, was also lower in infants by 45.1% (95% CI, 15.7-74.4%). Median minimum platelet count while central venous catheter was in situ was higher in infants by 39 × 103/mm3 (interquartile range, 17-61 × 103/mm3). Central venous catheter:vein ratio was not statistically different. Prophylaxis with enoxaparin was less efficacious against central venous catheter-associated deep venous thrombosis at lower factor VIII activity and at higher platelet count. CONCLUSIONS The relatively lesser contribution of thrombin generation on central venous catheter-associated thrombus formation in critically ill infants potentially explains the age-dependent heterogeneity in the efficacy of prophylaxis with enoxaparin.
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Affiliation(s)
| | - Leslie J Raffini
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Sheila J Hanson
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Jill M Cholette
- Department of Pediatrics, University of Rochester Golisano Children's Hospital, Rochester, NY
| | - Matthew G Pinto
- Department of Pediatrics, New York Medical College, Maria Fareri Children's Hospital, Valhalla, NY
| | - Simon Li
- Department of Pediatrics, New York Medical College, Maria Fareri Children's Hospital, Valhalla, NY
| | - Sarah B Kandil
- Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Marianne E Nellis
- Department of Pediatrics, NY Presbyterian Hospital/Weill Cornell Medicine, New York, NY
| | | | - Cicero T Silva
- Department of Diagnostic Radiology, Yale School of Medicine, New Haven, CT
| | - Joana A Tala
- Pediatric Intensive Care Unit, Yale-New Haven Children's Hospital, New Haven, CT
| | - Tara McPartland
- Yale Center for Clinical Investigation, Yale School of Medicine, New Haven, CT
| | - Philip C Spinella
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
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14
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Sadiq MW, Ukrani RD, Arif A, Akbar I, Altaf S, Moiz B. Risk Assessment and Outcome of Venous Thromboembolism in Pediatric Population in an Academic Care Center of a Low-Middle Income Country. Clin Appl Thromb Hemost 2021; 27:1076029621995895. [PMID: 33605153 PMCID: PMC7897837 DOI: 10.1177/1076029621995895] [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] [Indexed: 11/16/2022] Open
Abstract
Venous thromboembolism (VTE) is a recognized complication of hospital stay in young patients in many developed countries, but such an information is largely unavailable from a low middle-income country (LMIC). This study aimed at identifying the frequency, risk factors, treatment options and outcome of deep venous thrombosis/pulmonary embolism (DVT/PE) in pediatric population in a tertiary care center from a LMIC. International classification of disease, ninth revision (ICD-9) was used to identify VTE in patients aged 0-18 years during January 2011 to September 2019. In-house computerized system was used to collect data for demographics, clinical and laboratory details. SPSS version 19 was used to analyzed data. The study was approved by Institutional ethical review committee (3872-Pat-ERC-15). During the study period, 134617 pediatric patients were hospitalized, DVT/PE was observed in 77 unique patients (47 males and 30 females) with a median (IQR) age of 14 (5-16) years equivalent to 5.9 VTE events /10,000 hospital admissions. Malignancy, community acquired infections and autoimmune diseases were the predominant risk factors (75%) in adolescent age-group while surgery for congenital heart anomalies was the primary reason (71%) in infants. Overall, lower extremity thrombosis was the most frequent (51%) followed by pulmonary embolism (25%). and upper extremity thrombosis (24%). Enoxaparin and unfractionated heparin were mainly used to treat VTE and all-cause mortality was 13% in the cohort studied. We observed substantial VTE events in pediatric patients during their hospital stay in a tertiary care center of a low-middle income country.
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Affiliation(s)
| | | | - Aiman Arif
- 72591Medical College, The Aga Khan University, Karachi, Pakistan
| | - Inaara Akbar
- 72591Medical College, The Aga Khan University, Karachi, Pakistan
| | - Sadaf Altaf
- Department of Oncology, 72591Aga Khan University, Karachi, Pakistan
| | - Bushra Moiz
- Department of Pathology and Laboratory Medicine, 72591Aga Khan University, Karachi, Pakistan
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15
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Affiliation(s)
- Jamie Shoag
- Holtz Children's Hospital, Jackson Memorial Medical Center, Miami, FL.,Division of Pediatric Hematology-Oncology, University of Miami-Miller School of Medicine, Miami, FL
| | - Joanna A Davis
- University of Miami - Hemophilia Treatment Center, Miami, FL
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16
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Diagnosis and management of cerebral venous sinus thrombosis in children: a single-center retrospective analysis. Childs Nerv Syst 2021; 37:153-160. [PMID: 33156360 DOI: 10.1007/s00381-020-04958-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/29/2020] [Indexed: 01/14/2023]
Abstract
PURPOSE Cerebral venous thrombosis (CVT) is a rare disease in children, characterized by partial or total occlusion of blood flow in the cerebral venous system. The aim of this study is to describe clinical presentation, neuroimaging features, therapeutic management, and outcome of children with CVT. METHODS We retrospectively analyzed the data, including clinical manifestations, laboratory data, neurological findings, and treatment of children with radiologically confirmed CVT, admitted between January 2010 and March 2020 to our hospital. Cases of CVT complicating brain surgery were excluded. RESULTS We enrolled 24 children with CVT. Infection was the main etiology (58.3%), followed by trauma in 16.7% of cases. In the remaining 25% of cases, the cause was identified only in one patient presenting a thrombophilic factor. The most frequent site of thrombosis was the superficial venous system (86.8%), with multiple localizations disclosed in 79% of patients. All children received anticoagulant therapy with low molecular weight heparin (LMWH). One patient died for systemic complications of an underlying disease. No patient developed hemorrhagic events during the therapy, lasting from 35 to 360 days (mean 86 days). In all but one surviving patients (22 out of 24), recanalization of the sinus was observed at AngioMRI performed during follow-up. No neurological complications of CVT were recorded (mean follow-up: 1.5 year). CONCLUSIONS CVT may present with subtle and unspecific clinical manifestations in children. High level of suspicion should be kept in trauma and sinusitis. Anticoagulation treatment is safe and effective and should be promptly started to improve outcome.
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17
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Kaufmann MR, Camilon PR, Levi JR, Devaiah AK. Predicting Anticoagulation Need for Otogenic Intracranial Sinus Thrombosis: A Machine Learning Approach. J Neurol Surg B Skull Base 2020; 82:233-243. [PMID: 33777638 DOI: 10.1055/s-0040-1713105] [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: 11/19/2019] [Accepted: 04/15/2020] [Indexed: 10/23/2022] Open
Abstract
Objective The role of anticoagulation (AC) in the management of otogenic cerebral venous sinus thrombosis (OCVST) remains controversial. Our study aims to better define when AC is used in OCVST. Methods MEDLINE, EMBASE, and The Cochrane Library were searched from inception to February 14, 2019 for English and English-translated articles. References cited in publications meeting search criteria were searched. Titles and abstracts were screened and identified in the literature search, assessing baseline risk of bias on extracted data with the methodological index for nonrandomized studies (MINORS) scale. Random effects meta-regression followed by random forest machine learning analysis across 16 moderator variables between AC and nonanticoagulated (NAC) cohorts was conducted. Results A total of 92% of treated patients were free of neurologic symptoms at the last follow-up (mean 29.64 months). Four percent of AC and 14% of NAC patients remained symptomatic (mean 18.72 and 47.10 months). 3.5% of AC patients experienced postoperative wound hematomas. AC and NAC recanalization rates were 81% (34/42) and 63% (five-eights), respectively. OCVST was correlated with cholesteatoma and intracranial abscess. Among the analyzed covariates, intracranial abscess was most predictive of AC and cholesteatoma was most predictive of NAC. Comorbid intracranial abscess and cholesteatoma were predictive of AC. Conclusion The present study is the first to utilize machine learning algorithms in approaching OCVST. Our findings support the therapeutic use of AC in the management of OCVST when complicated by thrombophilia, intracranial abscess, and cholesteatoma. Patients with intracranial abscess and cholesteatoma may benefit from AC and surgery. Patients with cholesteatoma can be managed with NAC and surgery.
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Affiliation(s)
- Matthew R Kaufmann
- Boston University School of Medicine, Boston, Massachusetts, United States
| | - Philip Ryan Camilon
- Boston University School of Medicine, Boston, Massachusetts, United States.,Department of Otolaryngology, Boston University, Boston, Massachusetts, United States
| | - Jessica R Levi
- Boston University School of Medicine, Boston, Massachusetts, United States.,Department of Otolaryngology, Boston University, Boston, Massachusetts, United States
| | - Anand K Devaiah
- Boston University School of Medicine, Boston, Massachusetts, United States.,Department of Otolaryngology, Boston University, Boston, Massachusetts, United States.,Department of Neurological Surgery and Ophthalmology, Boston, Massachusetts, United States.,Institute for Health System Innovation and Policy, Boston University, Boston, Massachusetts, United States
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18
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Eghbali A, Rahimi Afzal R, Sheikhbeygloo R, Eghbali A, Taherkhanchi B, Bagheri B. Dabigatran versus Warfarin for the Treatment of Pediatric Thromboembolism: A Pilot Randomized Trial. PHARMACEUTICAL SCIENCES 2020. [DOI: 10.34172/ps.2020.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Aziz Eghbali
- Aliasghar Clinical Research Development Center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Roya Sheikhbeygloo
- Department of Pediatrics, Arak University of Medical Sciences, Arak, Iran
| | - Aygin Eghbali
- Aliasghar Clinical Research Development Center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Bahador Bagheri
- Cancer Research Center, Semnan University of Medical Sciences, Semnan, Iran
- Department of Pharmacology, Semnan University of Medical Sciences, Semnan, Iran
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19
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Lassandro G, Palmieri VV, Palladino V, Amoruso A, Faienza MF, Giordano P. Venous Thromboembolism in Children: From Diagnosis to Management. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17144993. [PMID: 32664502 PMCID: PMC7400059 DOI: 10.3390/ijerph17144993] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/24/2020] [Accepted: 07/07/2020] [Indexed: 02/07/2023]
Abstract
Venous thromboembolism (VTE) in children is a rare occurrence, although in recent decades we have seen an increase due to several factors, such as the rise in survival of subjects with chronic conditions, the use of catheters, and the increased sensitivity of diagnostic tools. Besides inherited thrombophilia, acquired conditions such as cardiovascular diseases, infections, chronic disorders, obesity and malignancy are also common risk factors for paediatric VTE. The treatment of paediatric VTE consists of the use of heparins and/or vitamin K antagonists to prevent dissemination, embolization, and secondary VTE. Randomized clinical trials of direct oral anticoagulants in paediatric VTE are ongoing, with the aim to improve the compliance and the care of patients. We reviewed the physiological and pathological mechanisms underlying paediatric thrombosis and updated the current diagnosis and treatment options.
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20
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Abstract
Warfarin is the most commonly prescribed anticoagulant for children in the outpatient setting in Australia. Pediatric patients likely have different challenges to warfarin adherence compared with their adult counterparts; however, little is known about warfarin adherence among this population. This study aimed to understand warfarin adherence among community-based pediatric patients by using an online survey design. The survey instrument incorporated parent or patient self-reported warfarin doses missed in the preceding month, a validated warfarin adherence assessment tool, the 13-item Self-Efficacy for Appropriate Medication use Scale (SEAMS-13), and an open-ended question asking about the challenges of warfarin adherence. The indication of warfarin administration and patient's time in therapeutic range were obtained from medical records. The study recruited outpatients managed by a tertiary pediatric hospital who had previously consented to participate in warfarin research. In total, 53 families were contacted with 43 responses (81% response rate) and 41 completed surveys. The median age of the children from participating families was 10.6 years (range, 4.1 to 18.9 y). The majority of these children (n=42) used warfarin prophylactically and only 1 child used it to treat deep venous thrombosis. The time in therapeutic range achievement of this cohort was 64.4% (95% confidence interval, 58.7-70.2). The mean SEAMS-13 score was 33.5 (95% confidence interval, 31.75-35.37) and the total missed doses was 2.5%. Participants also identified barriers and enablers of warfarin adherence. This study was the first of its kind and thus it provides baseline data for future research. The warfarin adherence of this cohort was likely optimized because of frequent clinical contact and access to self-testing. Future studies are required to examine the different approaches aiming to improve the anticoagulant adherence after the emergence of direct oral anticoagulants with a wider therapeutic index and minimal monitoring that could contribute to less clinical contact.
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21
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Kawasaki Disease: Complex Long-term Issues for Pediatric and Adult Cardiologists. Can J Cardiol 2020; 36:1566-1568. [PMID: 32407965 DOI: 10.1016/j.cjca.2020.04.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 11/21/2022] Open
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Audu CO, Wakefield TW, Coleman DM. Pediatric deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2019; 7:452-462. [DOI: 10.1016/j.jvsv.2018.12.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 12/16/2018] [Indexed: 12/14/2022]
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Faria C, Antunes H, Pontes T, Antunes A, Martins S, Carvalho S. Deep venous thrombosis of lower limbs in adolescents: a study in a tertiary hospital. Int J Adolesc Med Health 2019; 33:/j/ijamh.ahead-of-print/ijamh-2018-0137/ijamh-2018-0137.xml. [PMID: 30707683 DOI: 10.1515/ijamh-2018-0137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/23/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) - which includes deep venous thrombosis (DVT) and pulmonary embolism (PE) - has been increasingly recognized in the pediatric population. The estimated incidence is 0.07-0.14 cases per 10,000 children. Most cases are associated with two or more risk factors. Medium and long-term complications include recurrence and post-thrombotic syndrome (PTS). OBJECTIVE To characterize the adolescent population with the diagnosis of DVT of lower limbs in a tertiary hospital, regarding its clinical presentation, associated risk factors, treatment and outcome. METHODS Retrospective analysis of adolescents with the diagnosis of DVT of lower limbs in our hospital for a period of 7 years. RESULTS Eight patients were identified; seven were females; median age was 15 years. The main symptoms were local pain and edema. Left lower limb was affected in six patients. PE occurred in two cases. Positive family history of venous thromboembolism was found in five patients. Seven patients had at least two identifiable risk factors. Combined oral contraceptive pill use was the most common (seven patients). Factor V Leiden mutation was found in three patients and protein C deficiency in one. Iliac vein compression syndrome was diagnosed in one patient. The median time for discharge was 8 days. Election treatment was enoxaparin followed by warfarin, for a median period of 10.9 months. Three patients developed PTS. CONCLUSIONS Although uncommon, VTE is an emerging reality in adolescents, particularly in females using oral contraceptive pills. Appropriated prevention strategies and treatment are required as most orientations are extrapolated from adults.
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Affiliation(s)
- Catarina Faria
- Sete Fontes - São Victor, Pediatrics Departement, Hospital of Braga, 4710-243 Braga, Portugal
- Unit of Adolescent Medicine, Department of Pediatrics, Hospital of Braga, Braga, Portugal
| | - Henedina Antunes
- Unit of Adolescent Medicine, Department of Pediatrics, Hospital of Braga, Braga, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, ICVS/3B's-PT Government Associate Laboratory, University of Minho, Braga/Guimarães, Portugal
| | - Teresa Pontes
- Unit of Adolescent Medicine, Department of Pediatrics, Hospital of Braga, Braga, Portugal
| | - Ana Antunes
- Unit of Adolescent Medicine, Department of Pediatrics, Hospital of Braga, Braga, Portugal
| | - Sofia Martins
- Unit of Adolescent Medicine, Department of Pediatrics, Hospital of Braga, Braga, Portugal
| | - Susana Carvalho
- Unit of Adolescent Medicine, Department of Pediatrics, Hospital of Braga, Braga, Portugal
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Male C, Thom K, O'Brien SH. Direct oral anticoagulants: What will be their role in children? Thromb Res 2019; 173:178-185. [DOI: 10.1016/j.thromres.2018.06.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/16/2018] [Accepted: 06/26/2018] [Indexed: 01/01/2023]
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Monagle P. Slow progress. How do we shift the paradigm of thinking in pediatric thrombosis and anticoagulation? Thromb Res 2019; 173:186-190. [DOI: 10.1016/j.thromres.2018.07.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 07/02/2018] [Accepted: 07/11/2018] [Indexed: 11/28/2022]
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Monagle P, Newall F. Management of thrombosis in children and neonates: practical use of anticoagulants in children. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:399-404. [PMID: 30504338 PMCID: PMC6245972 DOI: 10.1182/asheducation-2018.1.399] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Venous thrombosis (VTE) in children and neonates presents numerous management challenges. Although increasing in frequency, VTE in children and neonates is still uncommon compared with adults. The epidemiology of VTE is vastly different in neonates vs children vs adolescents vs adults. In reality, pediatric thrombosis should be viewed as a multitude of rare diseases (eg, renal vein thrombosis, spontaneous thrombosis, catheter-related thrombosis, cerebral sinovenous thrombosis), all requiring different approaches to diagnosis and with different short- and long-term consequences, but linked by the use of common therapeutic agents. Further, children have fundamentally different physiology in terms of blood flow, developmental hemostasis, and, likely, endothelial function. The American Society of Hematology 2017 Guidelines for Management of Venous Thromboembolism: Treatment of Pediatric VTE provides up-to-date evidence-based guidelines related to treatment. Therefore, this article will focus on the practical use of therapeutic agents in the management of pediatric VTE, especially unfractionated heparin, low-molecular-weight heparin, and oral vitamin K antagonists, as the most common anticoagulants used in children. Direct oral anticoagulants (DOACs) remain in clinical trials in children and should not be used outside of formal trials for the foreseeable future.
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Affiliation(s)
- Paul Monagle
- Department of Clinical Haematology, Royal Children’s Hospital, Haematology Research Murdoch Children’s Research Institute, Department of Paediatrics, University of Melbourne, and
| | - Fiona Newall
- Department of Clinical Haematology, Royal Children’s Hospital, Haematology Research Murdoch Children’s Research Institute, School of Nursing, University of Melbourne, Melbourne, VIC, Australia
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Pirmohamed M. Warfarin: The End or the End of One Size Fits All Therapy? J Pers Med 2018; 8:jpm8030022. [PMID: 29958440 PMCID: PMC6163581 DOI: 10.3390/jpm8030022] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/24/2018] [Accepted: 06/25/2018] [Indexed: 12/21/2022] Open
Abstract
Oral anticoagulants are required for both treatment and prophylaxis in many different diseases. Clinicians and patients now have a choice of oral anticoagulants, including the vitamin K antagonists (of which warfarin is the most widely used and is used as the exemplar in this paper), and direct oral anticoagulants (DOACs: dabigatran, apixaban, rivaroxaban, and edoxaban). This paper explores the recent advances and controversies in oral anticoagulation. While some commentators may favour a complete switchover to DOACs, this paper argues that warfarin still has a place in therapy, and a stratified approach that enables the correct choice of both drug and dose would improve both patient outcomes and affordability.
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Affiliation(s)
- Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool L69 3GL, UK.
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