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Élias A, Debourdeau P, Espitia O, Sevestre MA, Girard P, Mahé I, Sanchez O. [Translation into French and republication of: "Central venous catheter associated upper extremity deep vein thrombosis in cancer patients: Diagnosis and therapeutic management"]. Rev Med Interne 2024; 45:354-365. [PMID: 38823999 DOI: 10.1016/j.revmed.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 06/03/2024]
Abstract
Catheter-related thrombosis (CRT) is a relatively frequent and potentially fatal complication arising in patients with cancer who require a central catheter placement for intravenous treatment. In everyday practice, CRT remains a challenge for management; despite its frequency and its negative clinical impact, few data are available concerning diagnosis and treatment of CRT. In particular, no diagnostic studies or clinical trials have been published that included exclusively patients with cancer and a central venous catheter (CVC). For this reason, many questions regarding optimal management of CRT remain unanswered. Due to the paucity of high-grade evidence regarding CRT in cancer patients, guidelines are derived from upper extremity DVT studies for diagnosis, and from those for lower limb DVT for treatment. This article addresses the issues of diagnosis and management of CRT through a review of the available literature and makes a number of proposals based on the available evidence. In symptomatic patients, venous ultrasound is the most appropriate choice for first-line diagnostic imaging of CRT because it is noninvasive, and its diagnostic performance is high (which is not the case in asymptomatic patients). In the absence of direct comparative clinical trials, we suggest treating patients with CRT with a therapeutic dose of either a LMWH or a direct oral factor Xa inhibitor, with or without a loading dose. These anticoagulants should be given for a total of at least 3 months, including at least 1 month after catheter removal following initiation of therapy.
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Affiliation(s)
- A Élias
- Département de cardiologie et de médecine vasculaire, délégation recherche clinique et innovation, hôpital Sainte-Musse, centre hospitalier intercommunal de Toulon La Seyne-sur-Mer, 83000 Toulon, France; F-CRIN INNOVTE network, Saint-Étienne, France.
| | - P Debourdeau
- F-CRIN INNOVTE network, Saint-Étienne, France; Équipe mobile territoriale soins palliatifs, hôpital Joseph-Imbert, Arles, France
| | - O Espitia
- Service de médecine interne et vasculaire, Team III Vascular & Pulmonary Diseases, institut du thorax, CHU de Nantes, Nantes université, Inserm UMR 1087, CNRS UMR 6291, Nantes, France
| | - M-A Sevestre
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de médecine vasculaire, EA Chimère 7516, CHU d'Amiens, 80054 Amiens, France
| | - P Girard
- F-CRIN INNOVTE network, Saint-Étienne, France; Institut du thorax Curie-Montsouris, institut mutualiste Montsouris, 75014 Paris, France
| | - I Mahé
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de médecine interne, hôpital Louis-Mourier, AP-HP, Colombes, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France
| | - O Sanchez
- F-CRIN INNOVTE network, Saint-Étienne, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; Service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, AP-HP, 75015 Paris, France
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Ngo D, Chen J, Nguyen C, Choi K, Pullarkat V. Patterns of interventions for central venous catheter-associated deep vein thrombosis and outcomes in cancer patients. J Oncol Pharm Pract 2024:10781552231219995. [PMID: 38166462 DOI: 10.1177/10781552231219995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
PURPOSE This letter evaluated the impact of different management strategies, specifically the presence or absence of therapeutic anticoagulation, on clinical outcomes for central venous catheter (CVC)-associated deep vein thrombosis (DVT) in cancer patients. METHODS One-hundred ninety-eight adult cancer patients with a confirmed CVC-associated DVT diagnosis from February 2013 and February 2021 were included. RESULTS Incidence of symptomatic recurrent venous thromboembolism (VTE) was similar between patients who received therapeutic anticoagulation and those who did not (14% vs 16%, p = 0.807). In addition, therapeutic anticoagulation did not significantly alter the incidence of grade 3 and above bleeding events despite most patients having hematologic malignancies (9% vs 8%, p = 0.826). CONCLUSION AND RELEVANCE Therapeutic anticoagulation was not associated with a reduction in the incidence of recurrent VTE or increase the incidence of bleeding in adult cancer patients following a CVC-associated DVT diagnosis.
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Affiliation(s)
- Dat Ngo
- Department of Pharmacy, City of Hope, Duarte, CA, USA
| | - Jason Chen
- Department of Pharmacy, City of Hope, Duarte, CA, USA
| | - Chris Nguyen
- Department of Pharmacy, City of Hope, Duarte, CA, USA
| | - Kathy Choi
- Department of Pharmacy, City of Hope, Duarte, CA, USA
| | - Vinod Pullarkat
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
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Elias A, Debourdeau P, Espitia O, Sevestre MA, Girard P, Mahé I, Sanchez O. Central venous catheter associated upper extremity deep vein thrombosis in cancer patients: Diagnosis and therapeutic management. Arch Cardiovasc Dis 2024; 117:72-83. [PMID: 38065755 DOI: 10.1016/j.acvd.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 12/27/2023]
Abstract
Catheter-related thrombosis (CRT) is a relatively frequent and potentially fatal complication arising in patients with cancer who require a central catheter placement for intravenous treatment. In everyday practice, CRT remains a challenge for management; despite its frequency and its negative clinical impact, few data are available concerning diagnosis and treatment of CRT. In particular, no diagnostic studies or clinical trials have been published that included exclusively patients with cancer and a central venous catheter (CVC). For this reason, many questions regarding optimal management of CRT remain unanswered. Due to the paucity of high-grade evidence regarding CRT in cancer patients, guidelines are derived from upper extremity DVT studies for diagnosis, and from those for lower limb DVT for treatment. This article addresses the issues of diagnosis and management of CRT through a review of the available literature and makes a number of proposals based on the available evidence. In symptomatic patients, venous ultrasound is the most appropriate choice for first-line diagnostic imaging of CRT because it is noninvasive, and its diagnostic performance is high (which is not the case in asymptomatic patients). In the absence of direct comparative clinical trials, we suggest treating patients with CRT with a therapeutic dose of either a LMWH or a direct oral factor Xa inhibitor, with or without a loading dose. These anticoagulants should be given for a total of at least three months, including at least one month after catheter removal following initiation of therapy.
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Affiliation(s)
- Antoine Elias
- Département de Cardiologie et de Médecine Vasculaire, Délégation Recherche Clinique et Innovation, Centre Hospitalier Intercommunal Toulon La Seyne-sur-Mer, Toulon, France; F-CRIN INNOVTE network, Saint-Étienne, France.
| | - Philippe Debourdeau
- Équipe Mobile Territoriale Soins Palliatifs, Hôpital Joseph-Imbert d'Arles, Arles, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Olivier Espitia
- Service de Médecine Interne et Vasculaire, Nantes Université, CHU de Nantes, Institut du thorax, Inserm UMR 1087, CNRS UMR 6291, Team III Vascular & Pulmonary Diseases, Nantes, France
| | - Marie-Antoinette Sevestre
- Service de Médecine Vasculaire, EA Chimère 7516, CHU Amiens, 80054, Amiens, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Philippe Girard
- Institut du Thorax Curie-Montsouris, Institut Mutualiste Montsouris, Paris, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Isabelle Mahé
- Service de Médecine Interne, Hôpital Louis-Mourier, AP-HP, Colombes, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Olivier Sanchez
- Service de Pneumologie et de Soins Intensifs, AP-HP, Hôpital Européen Georges-Pompidou, Paris, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE network, Saint-Étienne, France
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Wu C, Zhang M, Gu W, Wang C, Zheng X, Zhang J, Zhang X, Lv S, He X, Shen X, Wei W, Wang G, Lu Y, Chen Q, Shan R, Wang L, Wu F, Shen T, Shao X, Cai J, Tao F, Cai H, Lu Q. Daily point-of-care ultrasound-assessment of central venous catheter-related thrombosis in critically ill patients: a prospective multicenter study. Intensive Care Med 2023; 49:401-410. [PMID: 36892598 DOI: 10.1007/s00134-023-07006-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/13/2023] [Indexed: 03/10/2023]
Abstract
PURPOSE Central venous catheter (CVC)-related thrombosis (CRT) is a known complication in critically ill patients. However, its clinical significance remains unclear. The objective of the study was to evaluate the occurrence and evolution of CRT from CVC insertion to removal. METHODS A prospective multicenter study was conducted in 28 intensive care units (ICUs). Duplex ultrasound was performed daily from CVC insertion until at least 3 days after CVC removal or before patient discharge from the ICU to detect CRT and to follow its progression. CRT diameter and length were measured and diameter > 7 mm was considered extensive. RESULTS The study included 1262 patients. The incidence of CRT was 16.9% (95% confidence interval 14.8-18.9%). CRT was most commonly found in the internal jugular vein. The median time from CVC insertion to CRT onset was 4 (2-7) days, and 12% of CRTs occurred on the first day and 82% within 7 days of CVC insertion. CRT diameters > 5 mm and > 7 mm were found in 48% and 30% of thromboses. Over a 7-day follow-up, CRT diameter remained stable when the CVC was in place, whereas it gradually decreased after CVC removal. The ICU length of stay was longer in patients with CRT than in those without CRT, and the mortality was not different. CONCLUSION CRT is a frequent complication. It can occur as soon as the CVC is placed and mostly during the first week following catheterization. Half of the thromboses are small but one-third are extensive. They are often non-progressive and may be resolved after CVC removal.
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Affiliation(s)
- Chunshuang Wu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China
- Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, China
| | - Mao Zhang
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China
- Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, China
| | - Wenjie Gu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China
- Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, China
| | - Caimu Wang
- The First Hospital of Ninghai, Ningbo, China
| | | | | | | | - Shijin Lv
- The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Xuwei He
- Lishui People's Hospital, Lishui, China
| | - Xiaoyuan Shen
- The First People's Hospital of Xiaoshan District, Hangzhou, China
| | | | | | - Yingru Lu
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | | | - Renfei Shan
- Taizhou Hospital of Zhejiang Province, Taizhou, China
| | - Lingcong Wang
- The First Affiliated Hospital of Zhejiang, Chinese Medical University, Hangzhou, China
| | - Feng Wu
- Zhejiang Quhua Hospital, Quzhou, China
| | - Ting Shen
- Yuyao People's Hospital of Zhejiang Province, Ningbo, China
| | - Xuebo Shao
- The First People's Hospital of Fuyang, Hangzhou, Hangzhou, China
| | - Jiming Cai
- The Second Hospital of Jiaxing, Jiaxing, China
| | - Fuzheng Tao
- Taizhou Integrated Chinese and Western Medicine Hospital, Taizhou, China
| | | | - Qin Lu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China.
- Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, China.
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Koethe Y, Bochnakova T, Kaufman CS. Upper Extremity Deep Venous Thrombosis: Etiologies, Diagnosis, and Updates in Therapeutic Strategies. Semin Intervent Radiol 2022; 39:475-482. [PMID: 36561939 PMCID: PMC9767760 DOI: 10.1055/s-0042-1757937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Upper extremity deep vein thrombosis (UEDVT) is responsible for 4 to 10% of all deep vein thrombosis (DVT). Untreated UEDVT can lead to significant disability secondary to the postthrombotic syndrome. To date, there are no randomized trials specifically comparing different therapeutic strategies. Ultimately, optimal management of UEDVT depends on the underlying etiology, patient symptoms, and degree of thrombosis, with supporting evidence primarily extrapolated from lower extremity DVT data. This article will review the classification, presentation, and diagnosis of both primary and secondary UEDVT. In addition, it will discuss updates in clinical guidelines, anticoagulation, endovascular and surgical treatment strategies.
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Affiliation(s)
- Yilun Koethe
- Dotter Department of Interventional Radiology, Oregon Health & Sciences University, Portland, Oregon
| | - Teodora Bochnakova
- Dotter Department of Interventional Radiology, Oregon Health & Sciences University, Portland, Oregon
| | - Claire S. Kaufman
- Dotter Department of Interventional Radiology, Oregon Health & Sciences University, Portland, Oregon
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Catheter-related thrombosis (CRT) in patients with solid tumors: a narrative review and clinical guidance for daily care. Support Care Cancer 2022; 30:8577-8588. [PMID: 35932317 DOI: 10.1007/s00520-022-07297-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 07/24/2022] [Indexed: 10/16/2022]
Abstract
Central venous access devices (CVADs) including central venous catheters and peripherally inserted central catheters (PICCs) are essential in the treatment of cancer. Catheter-related thrombosis (CRT) is the most frequent non-infectious complication associated with the use of central lines. The development of CRT may cause to delays in oncologic treatment and increase morbidity leading to potentially life-threatening complications. Several local and systemic risk factors are associated with the development of CRT and should be taken into account to prevent CRT by standardizing appropriate catheter placement and maintenance. The use of primary pharmacological thromboprophylaxis in order to avoid CRT is not routinely recommended, although it can be considered in selected cases. Recommendations for the management of established CRT are based on the extrapolation of anticoagulation for lower limb venous thrombosis. The present review summarizes the current evidence and recommendations for the prevention and management of CRT and identifies areas that require further research.
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Lipe DN, Qdaisat A, Rajha E, Al-Breiki A, Cruz Carreras MT, Chaftari P, Yeung SCJ, Rice TW. Characteristics and predictors of venous thrombosis recurrence in patients with cancer and catheter-related thrombosis. Res Pract Thromb Haemost 2022; 6:e12761. [PMID: 36000091 PMCID: PMC9391569 DOI: 10.1002/rth2.12761] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 05/23/2022] [Accepted: 06/05/2022] [Indexed: 11/16/2022] Open
Abstract
Background Central venous catheters raise the risk of catheter‐related thrombosis (CRT) in patients with cancer, typically affecting the upper extremity. Management of CRT involves catheter removal and anticoagulation. However, robust evidence is lacking on the optimal timing of anticoagulation relative to catheter removal. Objectives Our goal is to provide a better understanding of the factors that increase the risk of recurrent venous thromboembolism (VTE) in these patients. Patients and Methods We conducted a retrospective chart review of all consecutive patients with cancer in our hospital affected by CRT between January 1, 2015, and December 31, 2017. We measured recurrence of VTE as thrombosis in any vascular bed or pulmonary embolism, for up to 2 years after diagnosis. Logistic and competing risk regression analyses were used to determine the association between different clinical factors and any VTE recurrence in patients with cancer and CRT. Results Of the 257 individuals meeting the inclusion criteria, 80.2% had their catheter removed; of these, 50.5% did not receive anticoagulation before the removal. Patients who did not receive anticoagulation before the removal had increased 3‐month and 1‐year risks of recurrent VTE (odds ratio, 5.07 [95% confidence interval [CI], 1.53–23.18]; and hazard ratio, 3.47 [95% CI, 1.34–9.01]), respectively. Conclusions Our study supports the use of anticoagulants before catheter removal in patients with CRT. Randomized clinical trials are recommended to establish stronger evidence pertaining to the long‐term risk of VTE recurrence and the effect of catheter reinsertion.
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Affiliation(s)
- Demis N Lipe
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Aiham Qdaisat
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Eva Rajha
- Department of Emergency Medicine Baylor College of Medicine Houston Texas USA
| | - Aisha Al-Breiki
- Department of Emergency Medicine Sultan Qaboos University Hospital Muscat Oman
| | - Maria T Cruz Carreras
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Patrick Chaftari
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Sai-Ching J Yeung
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas USA
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EHA Guidelines on Management of Antithrombotic Treatments in Thrombocytopenic Patients With Cancer. Hemasphere 2022; 6:e750. [PMID: 35924068 PMCID: PMC9281983 DOI: 10.1097/hs9.0000000000000750] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/01/2022] [Indexed: 01/19/2023] Open
Abstract
In cancer patients, thrombocytopenia can result from bone marrow infiltration or from anticancer medications and represents an important limitation for the use of antithrombotic treatments, including anticoagulant, antiplatelet, and fibrinolytic agents. These drugs are often required for prevention or treatment of cancer-associated thrombosis or for cardioembolic prevention in atrial fibrillation in an increasingly older cancer population. Data indicate that cancer remains an independent risk factor for thrombosis even in case of thrombocytopenia, since mild-to-moderate thrombocytopenia does not protect against arterial or venous thrombosis. In addition, cancer patients are at increased risk of antithrombotic drug-associated bleeding, further complicated by thrombocytopenia and acquired hemostatic defects. Furthermore, some anticancer treatments are associated with increased thrombotic risk and may generate interactions affecting the effectiveness or safety of antithrombotic drugs. In this complex scenario, the European Hematology Association in collaboration with the European Society of Cardiology has produced this scientific document to provide a clinical practice guideline to help clinicians in the management of patients with cancer and thrombocytopenia. The Guidelines focus on adult patients with active cancer and a clear indication for anticoagulation, single or dual antiplatelet therapy, their combination, or reperfusion therapy, who have concurrent thrombocytopenia because of either malignancy or anticancer medications. The level of evidence and the strength of the recommendations were discussed according to a Delphi procedure and graded according to the Oxford Centre for Evidence-Based Medicine.
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[Chinese expert consensus on the diagnosis and treatment of venous thromboembolism after hematopoietic stem cell transplantation (2022)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:184-196. [PMID: 35405775 PMCID: PMC9072068 DOI: 10.3760/cma.j.issn.0253-2727.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Jaffray J, Baumann Kreuziger L, Branchford B, Wee CP, Faustino EVS, Zakai NA, Croteau SE, Silvey M, Fargo JH, Cooper JD, Bakeer N, Stillings A, Krava E, Young G, Goldenberg NA. Symptomatic pulmonary embolus after catheter removal in children with catheter related thrombosis: A report from the CHAT Consortium. J Thromb Haemost 2022; 20:133-137. [PMID: 34623749 DOI: 10.1111/jth.15548] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/06/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Appropriate timing of central venous catheter (CVC) removal, in relation to start of anticoagulation, in children after the diagnosis of a CVC-related thrombosis (CRT) is not well established. OBJECTIVES This retrospective cohort study evaluated the incidence of symptomatic pulmonary embolism (PE) after CVC removal using data from the multi-institutional Children's Hospital-Acquired Thrombosis (CHAT) Consortium Registry. PATIENTS/METHODS The CHAT Registry consists of data from children aged 0-21 years with a hospital-acquired venous thromboembolism. Eligible subjects were those with CRT diagnosed <3 days after CVC removal. Subjects were excluded if the CRT was due to a failed CVC insertion. Subjects were divided into three groups: those with CVC removal without anticoagulation, those with CVC removal <48 h after starting anticoagulation, and those with CVC removal ≥48 h after starting anticoagulation. RESULTS A total of 687 CRT events from 663 subjects were included. A majority of CRT events were in subjects with peripherally inserted central catheters (62.3%, n = 428). For the 611 CRT events in which the CVC was removed, there was only one case of symptomatic PE (0.16%), which occurred <48 h after initiation of anticoagulation. CONCLUSIONS While current guidelines suggest anticoagulation before CVC removal in the setting of a CRT to prevent embolization, CVC removal is not associated with symptomatic PE regardless of duration of anticoagulation before CVC removal.
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Affiliation(s)
- Julie Jaffray
- Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | | | | | - Choo Phei Wee
- Children's Hospital Los Angeles, Los Angeles, California, USA
| | | | - Neil A Zakai
- Department of Medicine and Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Stacy E Croteau
- Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - James D Cooper
- Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nihal Bakeer
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - Amy Stillings
- Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Emily Krava
- Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Guy Young
- Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Neil A Goldenberg
- Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Data Coordinating Center, Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, Florida, USA
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