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Altuwayjiri A, AlDarwish A, Alshuraim R. An Evaluation of the Appropriateness of Initial Enoxaparin Dosing Among Pediatric Patients. Cureus 2023; 15:e48830. [PMID: 38106767 PMCID: PMC10722443 DOI: 10.7759/cureus.48830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 12/19/2023] Open
Abstract
Background Enoxaparin is a low molecular weight heparin that irreversibly inactivates factor Xa leading to the inhibition of clot formation. Despite the non-FDA approval in pediatrics, enoxaparin is recommended with an initial dose of 1.5mg/kg/q12hrs for patients aged ≤ 2 months and 1mg/kg/q12hrs for patients > 2 months, targeting therapeutic anti-Xa with a range of 0.5 to 1 units/mL. Due to more rapid clearance in pediatrics, our study aims to assess the need for initial higher doses than recommended by the guideline to reach the target anti-Xa level. Methods A retrospective chart review of all pediatric patients under all specialties who were treated with enoxaparin either in inpatient or outpatient settings between February 2021 and June 2022 at children's specialized hospital and meet the inclusion criteria, including age ≤ 15 years old and treated with enoxaparin with initial dose according to the American College of Chest Physicians (CHEST) guideline, while patients who received prophylaxis doses did not have anti-Xa levels or creatinine clearance < 30 mL/min/1.73m2 were excluded. Demographic data, laboratory data, and enoxaparin dosing were all collected to assess whether the initial enoxaparin dose will result in a therapeutic level as a primary endpoint and secondary endpoints including the average enoxaparin dose required to achieve the therapeutic level and to report any side effects. All data were entered and analyzed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 25, Armonk, NY), and all categorical variables were reported as frequency and percentage while continuous variables expressed as mean ± SD and the study was approved by our research center institutional review board (IRB). Results Thirty patients were included in the study (17 males), 10 patients were aged ≤ 2 months, four were between 3 and 12 months and 16 were > 12 months, most of the patients received enoxaparin for deep vein thrombosis. In the majority of patients (76.7%), the initial dose failed to achieve the target anti-Xa while a mean dose of 2 mg/kg/q12hrs in patients ≤ 2 months, 1.7mg/kg/q12hrs in patients 3-12 months and 1.3 mg/kg/q12hrs in patients > 12 months was sufficient to reach the target level. After achieving a therapeutic anti-Xa level, only one patient experienced major bleeding while four patients experienced minor bleeding, no edema or thrombocytopenia were reported. Conclusion In conclusion, initiating enoxaparin according to the recommended dose by the guideline failed to achieve target anti-Xa in the majority of patients which necessitates starting enoxaparin with initial higher doses according to the patient's age to provide more prompt achievement of target anti-Xa.
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Affiliation(s)
| | | | - Renad Alshuraim
- Pharmaceutical Services Department, King Saud Medical City, Riyadh, SAU
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Haftmann RJ, Pineda EM, Hall BA, Wilson MD, Mateev SN. Comparison of Time Within Therapeutic Range Using Anti-Factor Xa Versus Activated Partial Thromboplastin Time Monitoring of Unfractionated Heparin in Children. J Pediatr Pharmacol Ther 2023; 28:228-234. [PMID: 37303766 PMCID: PMC10249978 DOI: 10.5863/1551-6776-28.3.228] [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: 04/13/2022] [Accepted: 07/19/2022] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To compare unfractionated heparin (UFH) monitoring using time in therapeutic range of activated partial thromboplastin time (aPTT) versus anti-factor Xa activity (anti-Xa) in children. METHODS This retrospective chart review, with data between October 2015 and October 2019, included pediatric patients younger than 18 years on therapeutic UFH infusion with aPTT or anti-Xa monitoring. Patients receiving extracorporeal membrane oxygenation, dialysis, concomitant anticoagulants, prophylactic UFH, no stated goal, and UFH administered for less than 12 hours were excluded. The primary outcome compared the percentage of time in therapeutic range between aPTT and anti-Xa. Secondary outcomes included time to first therapeutic value, UFH infusion rates, mean rate adjustments, and adverse events. RESULTS A total of 65 patients were included, with 33 aPTT patients and 32 anti-Xa patients, representing 39 UFH orders in each group. Baseline characteristics were similar between groups, with an overall mean age of 1.4 years and mean weight of 6.7 kg. The anti-Xa cohort demonstrated a statistically significantly higher percentage of time in therapeutic range compared with the aPTT group (50.3% vs 26.9%, p = 0.002). The anti-Xa group also demonstrated a trend toward decreased time to first therapeutic value compared with aPTT (14 vs 23.2 hours, p = 0.12). Two patients in each group experienced new or worsening thrombosis. Six patients in the aPTT cohort experienced bleeding. CONCLUSIONS This study demonstrated greater time was spent within therapeutic range for children receiving UFH monitored with anti-Xa compared with aPTT. Future studies should assess clinical outcomes in a larger population.
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Affiliation(s)
- Richard J. Haftmann
- Department of Pharmacy Services (RJH, BAH), University of California, Davis Health, Sacramento, CA
| | - Erika May Pineda
- Department of Pharmacy Services (EMP), Children's Hospital of Philadelphia, Philadelphia, PA
| | - Brent A. Hall
- Department of Pharmacy Services (RJH, BAH), University of California, Davis Health, Sacramento, CA
| | - Machelle D. Wilson
- Department of Public Health Sciences (MDW), Division of Biostatistics, Clinical and Translational Science Center, University of California, Davis Health, Sacramento, CA
| | - Stephanie N. Mateev
- Department of Pediatrics, Division of Pediatric Critical Care (SNM), University of California, Davis Health, Sacramento, CA
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3
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Chandika P, Tennakoon P, Kim TH, Kim SC, Je JY, Kim JI, Lee B, Ryu B, Kang HW, Kim HW, Kim YM, Kim CS, Choi IW, Park WS, Yi M, Jung WK. Marine Biological Macromolecules and Chemically Modified Macromolecules; Potential Anticoagulants. Mar Drugs 2022; 20:md20100654. [PMID: 36286477 PMCID: PMC9604568 DOI: 10.3390/md20100654] [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: 09/27/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 11/07/2022] Open
Abstract
Coagulation is a potential defense mechanism that involves activating a series of zymogens to convert soluble fibrinogen to insoluble fibrin clots to prevent bleeding and hemorrhagic complications. To prevent the extra formation and diffusion of clots, the counterbalance inhibitory mechanism is activated at levels of the coagulation pathway. Contrariwise, this system can evade normal control due to either inherited or acquired defects or aging which leads to unusual clots formation. The abnormal formations and deposition of excess fibrin trigger serious arterial and cardiovascular diseases. Although heparin and heparin-based anticoagulants are a widely prescribed class of anticoagulants, the clinical use of heparin has limitations due to the unpredictable anticoagulation, risk of bleeding, and other complications. Hence, significant interest has been established over the years to investigate alternative therapeutic anticoagulants from natural sources, especially from marine sources with good safety and potency due to their unique chemical structure and biological activity. This review summarizes the coagulation cascade and potential macromolecular anticoagulants derived from marine flora and fauna.
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Affiliation(s)
- Pathum Chandika
- Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan 48513, Korea
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, Korea
| | - Pipuni Tennakoon
- Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan 48513, Korea
- Major of Biomedical Engineering, Division of Smart Healthcare and New-Senior Healthcare Innovation Center (BK21 Plus), Pukyong National University, Busan 48513, Korea
| | - Tae-Hee Kim
- Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan 48513, Korea
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, Korea
| | - Se-Chang Kim
- Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan 48513, Korea
- Major of Biomedical Engineering, Division of Smart Healthcare and New-Senior Healthcare Innovation Center (BK21 Plus), Pukyong National University, Busan 48513, Korea
| | - Jae-Young Je
- Major of Human Bioconvergence, Division of Smart Healthcare, Pukyong National University, Busan 48513, Korea
| | - Jae-Il Kim
- Major of Food Science and Nutrition, Pukyong National University, Busan 48513, Korea
| | - Bonggi Lee
- Major of Food Science and Nutrition, Pukyong National University, Busan 48513, Korea
| | - BoMi Ryu
- Major of Food Science and Nutrition, Pukyong National University, Busan 48513, Korea
| | - Hyun Wook Kang
- Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan 48513, Korea
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, Korea
- Major of Biomedical Engineering, Division of Smart Healthcare and New-Senior Healthcare Innovation Center (BK21 Plus), Pukyong National University, Busan 48513, Korea
| | - Hyun-Woo Kim
- Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan 48513, Korea
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, Korea
- Department of Marine Biology, Pukyong National University, Busan 48513, Korea
| | - Young-Mog Kim
- Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan 48513, Korea
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, Korea
- Major of Food Science and Technology, Pukyong National University, Busan 48513, Korea
| | - Chang Su Kim
- Department of Orthopedic Surgery, Kosin University Gospel Hospital, Busan 49267, Korea
| | - Il-Whan Choi
- Department of Microbiology, College of Medicine, Inje University, Busan 47392, Korea
| | - Won Sun Park
- Department of Physiology, Institute of Medical Sciences, School of Medicine, Kangwon National University, Chuncheon 24341, Korea
| | - Myunggi Yi
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, Korea
- Major of Biomedical Engineering, Division of Smart Healthcare and New-Senior Healthcare Innovation Center (BK21 Plus), Pukyong National University, Busan 48513, Korea
| | - Won-Kyo Jung
- Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan 48513, Korea
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, Korea
- Major of Biomedical Engineering, Division of Smart Healthcare and New-Senior Healthcare Innovation Center (BK21 Plus), Pukyong National University, Busan 48513, Korea
- Correspondence:
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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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5
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Hansen R, Meade S, Beattie RM, Auth MK, Croft N, Davies P, Devadason D, Doherty C, Epstein J, Howarth L, Kiparissi F, Muhammed R, Shivamurthy V, Spray C, Stanton MP, Torrente F, Urs A, Wilson D, Irving PM, Samaan M, Kammermeier J. Adaptations to the current ECCO/ESPGHAN guidelines on the management of paediatric acute severe colitis in the context of the COVID-19 pandemic: a RAND appropriateness panel. Gut 2021; 70:1044-1052. [PMID: 32873696 PMCID: PMC7470179 DOI: 10.1136/gutjnl-2020-322449] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/04/2020] [Accepted: 08/18/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Paediatric acute severe colitis (ASC) management during the novel SARS-CoV-2/COVID-19 pandemic is challenging due to reliance on immunosuppression and the potential for surgery. We aimed to provide COVID-19-specific guidance using the European Crohn's and Colitis Organisation/European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines for comparison. DESIGN We convened a RAND appropriateness panel comprising 14 paediatric gastroenterologists and paediatric experts in surgery, rheumatology, respiratory and infectious diseases. Panellists rated the appropriateness of interventions for ASC in the context of the COVID-19 pandemic. Results were discussed at a moderated meeting prior to a second survey. RESULTS Panellists recommended patients with ASC have a SARS-CoV-2 swab and expedited biological screening on admission and should be isolated. A positive swab should trigger discussion with a COVID-19 specialist. Sigmoidoscopy was recommended prior to escalation to second-line therapy or colectomy. Methylprednisolone was considered appropriate first-line management in all, including those with symptomatic COVID-19. Thromboprophylaxis was also recommended in all. In patients requiring second-line therapy, infliximab was considered appropriate irrespective of SARS-CoV-2 status. Delaying colectomy due to SARS-CoV-2 infection was considered inappropriate. Corticosteroid tapering over 8-10 weeks was deemed appropriate for all. After successful corticosteroid rescue, thiopurine maintenance was rated appropriate in patients with negative SARS-CoV-2 swab and asymptomatic patients with positive swab but uncertain in symptomatic COVID-19. CONCLUSION Our COVID-19-specific adaptations to paediatric ASC guidelines using a RAND panel generally support existing recommendations, particularly the use of corticosteroids and escalation to infliximab, irrespective of SARS-CoV-2 status. Consideration of routine prophylactic anticoagulation was recommended.
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Affiliation(s)
- Richard Hansen
- Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, UK
| | - Susanna Meade
- Department of Gastroenterology, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - R Mark Beattie
- Department of Paediatric Gastroenterology, Southampton Children's Hospital, Southampton, UK
| | - Marcus Kh Auth
- Department of Paediatric Gastroenterology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Nick Croft
- Blizard Institute, Queen Mary's University of London, Barts and the London School of Medicine, London, UK
- Department of Paediatric Gastroenterology, Royal London Children's Hospital, Barts Health NHS Trust, London, UK
| | - Philip Davies
- Department of Paediatric Respiratory Medicine, Royal Hospital for Children, Glasgow, UK
| | - David Devadason
- Department of Paediatric Gastroenterology, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Conor Doherty
- Department of Paediatric Infectious Diseases and Immunology, Royal Hospital for Children, Glasgow, UK
| | - Jenny Epstein
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Lucy Howarth
- Department of Paediatric Gastroenterology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Fevronia Kiparissi
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children, London, UK
| | - Rafeeq Muhammed
- Department of Paediatric Gastroenterology, Birmingham Children's Hospital, Birmingham, West Midlands, UK
| | - Vinay Shivamurthy
- Department of Paediatric Rheumatology, Evelina London Children's Hospital, London, UK
| | - Christine Spray
- Department of Paediatric Gastroenterology, Hepatology & Nutrition, Bristol Royal Hospital for Children, Bristol, UK
| | - Michael P Stanton
- Department of Paediatric Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Franco Torrente
- Department of Paediatric Gastroenterology, Addenbrookes Hospital, Cambridge, UK
| | - Arun Urs
- Department of Paediatric Gastroenterology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - David Wilson
- Child Life and Health, University of Edinburgh, Edinburgh, UK
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, UK
| | - Peter M Irving
- Department of Gastroenterology, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Mark Samaan
- Department of Gastroenterology, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Jochen Kammermeier
- Department of Paediatric Gastroenterology, Evelina London Children's Hospital, London, UK
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6
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Robinson V, Achey MA, Nag UP, Reed CR, Pahl KS, Greenberg RG, Clark RH, Tracy ET. Thrombosis in infants in the neonatal intensive care unit: Analysis of a large national database. J Thromb Haemost 2021; 19:400-407. [PMID: 33075167 DOI: 10.1111/jth.15144] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 10/11/2020] [Accepted: 10/13/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Thrombosis in the neonatal population is rare, but increasing. Its incidence and management are not well understood. OBJECTIVES To investigate the incidence, associated factors, and management of thrombosis in the neonatal intensive care unit (NICU) population. PATIENTS/METHODS We performed a retrospective cohort study of infants admitted to a Pediatrix Medical Group-affiliated NICU from 1997 through 2015. We determined the prevalence of venous and arterial thrombosis, and assessed demographic characteristics and known risk factors. Categorical variables were compared with the Pearson χ2 test and continuous variables with Wilcoxon rank-sum tests. Stepwise logistic regression was used to identify associated factors. The primary outcome was incidence of thrombosis. Secondary analyses investigated correlations between clinical and demographic characteristics and thrombosis. RESULTS Among 1 158 755 infants, we identified 2367 (0.20%) diagnosed with thrombosis. In a multivariable regression analysis, prematurity, male sex, congenital heart disease, sepsis, ventilator support, vasopressor receipt, central venous catheter, invasive procedures, and receipt of erythropoietin were associated with increased risk of thrombosis, while Black race and Hispanic ethnicity were associated with reduced risk. The majority of infants diagnosed with thrombosis (73%) received no anticoagulation, but anticoagulant use in infants with thrombosis was higher than those without (27% versus 0.2%, P < .001). Thrombosis in infants was associated with higher mortality (11% versus 2%, P < .001) and longer hospital stays (57 days, [interquartile range (IQR) 28--100] versus 10 days, [IQR 6--22], P < .001). CONCLUSIONS In the largest national study to date, we found that thrombosis in NICU patients is associated with prematurity, low birth weight, sepsis, and invasive procedures.
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Affiliation(s)
| | | | - Uttara P Nag
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Kristy S Pahl
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Rachel G Greenberg
- Division of Neonatology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Elisabeth T Tracy
- Division of Pediatric Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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8
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In vitro and in silico analysis of dual-function peptides derived from casein hydrolysate. FOOD SCIENCE AND HUMAN WELLNESS 2021. [DOI: 10.1016/j.fshw.2020.08.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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9
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New options for anticoagulation in congenital and pediatric acquired heart disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2020.101301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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10
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Damle B, Jen F, Sherman N, Jani D, Sweeney K. Population Pharmacokinetic Analysis of Dalteparin in Pediatric Patients With Venous Thromboembolism. J Clin Pharmacol 2020; 61:172-180. [PMID: 32827160 PMCID: PMC7818112 DOI: 10.1002/jcph.1716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 07/23/2020] [Indexed: 11/29/2022]
Abstract
This article describes the population pharmacokinetics (PK) of dalteparin in pediatric patients with venous thromboembolism (VTE). A prospective multicenter open‐label study was conducted in children who required anticoagulation for the treatment of VTE. The study population included children with and without cancer. The goal was to describe the pharmacokinetics of dalteparin using anti‐Xa as a surrogate marker and to determine the dose required to achieve therapeutic anti‐Xa levels (0.5‐1.0 IU/mL). The anti‐Xa data were supplemented with 2 published studies and analyzed using population pharmacokinetic approaches. The pharmacokinetics of dalteparin following subcutaneous injection in pediatric patients was described by a 1‐compartment model with linear absorption and elimination. Body weight was added as a covariate on both CL/F and Vd/F as a power function with fixed exponents of 0.75 and 1.0, respectively. The estimates of CL/F and Vd/F in the full model were 929 mL/h and 7180 mL, respectively, for a reference female patient aged 12 years with body weight of 43 kg. Body weight‐normalized CL/F decreased with age. Cancer status and sex did not have significant effects on CL/F and Vd/F. Simulations were conducted to select starting doses of dalteparin that would rapidly achieve therapeutic anti‐Xa levels. These simulations suggested that the recommended starting doses of dalteparin administered subcutaneously in pediatric patients of different age cohort groups for treatment of VTE were 150 IU/kg every 12 hours (1 month to <2 years), 125 IU/kg every 12 hours (≥2 to <8 years), and 100 IU/kg every 12 hours (≥8 to <19 years).
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Affiliation(s)
- Bharat Damle
- Clinical Pharmacology, Pfizer Inc., New York, New York, USA
| | - Frank Jen
- Clinical Pharmacology, Pfizer Inc., New York, New York, USA
| | - Nancy Sherman
- Global Product Development, Pfizer Inc., New York, New York, USA
| | - Darshana Jani
- Clinical Pharmacology, Pfizer Inc., Cambridge, Massachusetts, USA
| | - Kevin Sweeney
- Clinical Pharmacology, Pfizer Inc., Groton, Connecticut, USA
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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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12
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Safdar OY, Rajab RH, Alghanemi RG, Tantawi GA, Alsulami NA, Alsayed AA, Habiballah AK. Bilateral Pulmonary Embolism in a 12-Year-Old Girl with Steroid-Resistant Nephrotic Syndrome. CHILDREN 2020; 7:children7060062. [PMID: 32549197 PMCID: PMC7346196 DOI: 10.3390/children7060062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 05/23/2020] [Accepted: 06/11/2020] [Indexed: 11/18/2022]
Abstract
Nephrotic syndrome is the most common glomerular disease among children. Although most cases respond to steroid therapy, approximately 10–20% of patients exhibit resistance to conventional steroid therapy and are labeled as steroid-resistant. Such patients are at risk of complications, including infection, thrombosis, and chronic kidney disease. Nephrotic syndrome is considered a thrombogenic condition. Pulmonary embolism is associated with high mortality, and early treatment is essential for the survival of patients. Here, we report the case of a 12-year-old girl with late steroid resistance who developed bilateral pulmonary embolism.
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Affiliation(s)
- Osama Y. Safdar
- Pediatric Nephrology Center of Excellence, Pediatric Department, Faculty of Medicine, King Abdulaziz University, Jeddah 21414, Saudi Arabia
- Correspondence:
| | - Rahaf H. Rajab
- Faculty of Medicine, King Abdulaziz University, Jeddah 21414, Saudi Arabia; (R.H.R.); (R.G.A.); (G.A.T.); (N.A.A.); (A.A.A.); (A.K.H.)
| | - Rand G. Alghanemi
- Faculty of Medicine, King Abdulaziz University, Jeddah 21414, Saudi Arabia; (R.H.R.); (R.G.A.); (G.A.T.); (N.A.A.); (A.A.A.); (A.K.H.)
| | - Gazal A. Tantawi
- Faculty of Medicine, King Abdulaziz University, Jeddah 21414, Saudi Arabia; (R.H.R.); (R.G.A.); (G.A.T.); (N.A.A.); (A.A.A.); (A.K.H.)
| | - Noora A. Alsulami
- Faculty of Medicine, King Abdulaziz University, Jeddah 21414, Saudi Arabia; (R.H.R.); (R.G.A.); (G.A.T.); (N.A.A.); (A.A.A.); (A.K.H.)
| | - Aeshah A. Alsayed
- Faculty of Medicine, King Abdulaziz University, Jeddah 21414, Saudi Arabia; (R.H.R.); (R.G.A.); (G.A.T.); (N.A.A.); (A.A.A.); (A.K.H.)
| | - Abdullah K. Habiballah
- Faculty of Medicine, King Abdulaziz University, Jeddah 21414, Saudi Arabia; (R.H.R.); (R.G.A.); (G.A.T.); (N.A.A.); (A.A.A.); (A.K.H.)
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13
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Culbert MH, Hamidi M, Zeeshan M, Hanna K, Romero A, Joseph B, O'Keeffe T. Retrospective Analysis of Low-Molecular-Weight Heparin and Unfractionated Heparin in Pediatric Trauma Patients: A Comparative Analysis. J Surg Res 2020; 249:121-129. [DOI: 10.1016/j.jss.2019.11.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/28/2019] [Accepted: 11/03/2019] [Indexed: 11/28/2022]
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14
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Zhang T, Liu Q, Ren Y. Design, synthesis and biological activity evaluation of novel methyl substituted benzimidazole derivatives. Tetrahedron 2020. [DOI: 10.1016/j.tet.2020.131027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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15
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Samuel R, Dixon A, Kretschmar P, Fletcher M, Warrier R. Is This Working "Well" for Pediatrics? The Diagnosis and Treatment of Thromboembolic Disease in a Patient With Protein C Deficiency. Clin Pediatr (Phila) 2020; 59:95-98. [PMID: 31603001 DOI: 10.1177/0009922819881208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | - Rajasekharan Warrier
- Ochsner Children's Hospital, New Orleans, LA, USA.,Ochsner Clinical School of University of Queensland, New Orleans, LA, USA
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16
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Delayed branch retinal artery occlusion in infectious endocarditis. J Formos Med Assoc 2019; 119:1232-1233. [PMID: 31685405 DOI: 10.1016/j.jfma.2019.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 09/22/2019] [Accepted: 10/16/2019] [Indexed: 11/23/2022] Open
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17
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A multi-national trial of a direct oral anticoagulant in children with cardiac disease: Design and rationale of the Safety of ApiXaban On Pediatric Heart disease On the preventioN of Embolism (SAXOPHONE) study. Am Heart J 2019; 217:52-63. [PMID: 31493728 DOI: 10.1016/j.ahj.2019.08.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 08/01/2019] [Indexed: 12/16/2022]
Abstract
Anticoagulation in children is problematic for multiple reasons. Currently used anticoagulants have significant disadvantages and may negatively affect quality of life (QOL). This manuscript describes the design, rationale, and methods of a prospective, randomized, open label phase II multi-national clinical trial of a direct oral anticoagulant (DOAC), apixaban, in children and infants with congenital and acquired heart disease. This trial is designed to gather preliminary safety and pharmacokinetics (PK) data, as well as generate data on QOL of individuals taking apixaban compared to the standard of care (SOC) anticoagulants vitamin K antagonists (VKA) or low molecular weight heparin (LMWH). A key issue this trial seeks to address is the practice of using therapeutics tested in adult trials in the pediatric population without robust pediatric safety or efficacy data. Pediatric heart diseases are not common, and specific diagnoses often meet the criteria of a rare disease; thus, statistical efficacy may be difficult to achieve. This trial will provide valuable PK and safety data intended to inform clinical practice for anticoagulation in pediatric heart diseases, a setting in which a fully powered phase III clinical trial is not feasible. A second consideration this trial addresses is that metrics besides efficacy, such as QOL, have not been traditionally used as endpoints in regulated anticoagulation studies yet may add substantial weight to the clinical decision for use of a DOAC in place of VKA or LMWH. This study examines QOL related to both heart disease and anticoagulation among children randomized to either SOC or apixaban. There are considerable strengths and benefits to conducting a clinical trial in pediatric rare disease populations via an industry-academic collaboration. The SAXOPHONE study represents a collaboration between Bristol-Myers Squibb (BMS)/Pfizer Alliance, and the National Heart, Lung, and Blood Institute's (NHLBI) Pediatric Heart Network (PHN) and may be an attractive model for future pediatric drug trials.
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18
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High-dose heparin is associated with higher bleeding and thrombosis rates in pediatric patients following cardiac surgery. J Thorac Cardiovasc Surg 2019; 158:1199-1206. [DOI: 10.1016/j.jtcvs.2019.06.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/04/2019] [Accepted: 06/08/2019] [Indexed: 12/16/2022]
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19
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Affiliation(s)
- S Jinks
- Great Ormond Hospital NHS Foundation Trust, London, UK
| | - A Arana
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
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20
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Tu M, Liu H, Cheng S, Mao F, Chen H, Fan F, Lu W, Du M. Identification and characterization of a novel casein anticoagulant peptide derived from in vivo digestion. Food Funct 2019; 10:2552-2559. [DOI: 10.1039/c8fo02546k] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A novel anticoagulant casein peptide has been identified by in vivo digestion.
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Affiliation(s)
- Maolin Tu
- Department of Food Science and Engineering
- School of Chemistry and Chemical Engineering
- Harbin Institute of Technology
- Harbin 150001
- China
| | - Hanxiong Liu
- School of Food Science and Technology
- National Engineering Research Center of Seafood
- Dalian Polytechnic University
- Dalian 116034
- China
| | - Shuzhen Cheng
- School of Food Science and Technology
- National Engineering Research Center of Seafood
- Dalian Polytechnic University
- Dalian 116034
- China
| | - Fengjiao Mao
- School of Food Science and Technology
- National Engineering Research Center of Seafood
- Dalian Polytechnic University
- Dalian 116034
- China
| | - Hui Chen
- School of Food Science and Technology
- National Engineering Research Center of Seafood
- Dalian Polytechnic University
- Dalian 116034
- China
| | - Fengjiao Fan
- Department of Food Science and Engineering
- School of Chemistry and Chemical Engineering
- Harbin Institute of Technology
- Harbin 150001
- China
| | - Weihong Lu
- Department of Food Science and Engineering
- School of Chemistry and Chemical Engineering
- Harbin Institute of Technology
- Harbin 150001
- China
| | - Ming Du
- Department of Food Science and Engineering
- School of Chemistry and Chemical Engineering
- Harbin Institute of Technology
- Harbin 150001
- China
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21
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Pollak U. Heparin-induced thrombocytopenia complicating extracorporeal membrane oxygenation support in pediatric patients: review of the literature and alternative anticoagulants. Perfusion 2018; 33:7-17. [PMID: 29788841 DOI: 10.1177/0267659118766723] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a prothrombotic, immune-mediated complication of unfractionated heparin (UFH) and low molecular weight heparin therapy. HIT is characterized by moderate thrombocytopenia 5-10 days after initial heparin exposure, detection of platelet-activating anti-platelet factor 4/heparin antibodies and an increased risk of venous and arterial thrombosis. Extracorporeal membrane oxygenation (ECMO) is a form of mechanical circulatory support used in critically ill patients with respiratory or cardiac failure. Systemic anticoagulation is used to alleviate the thrombotic complications that may occur when blood is exposed to artificial surfaces within the ECMO circuit. Therefore, when HIT complicates patients on ECMO support, it is associated with a high thrombotic morbidity and mortality. The following article reviews the current knowledge in pediatric HIT, especially in ECMO patients, and the alternative anticoagulation options in the presence of HIT.
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Affiliation(s)
- Uri Pollak
- 1 Pediatric Cardiac Intensive Care Unit, The Edmond J Safra International Congenital Heart Center; The Edmond and Lily Safra Children's Hospital; The Chaim Sheba Medical Center, Tel Hashomer, Israel.,2 Pediatric Cardiology, The Edmond J Safra International Congenital Heart Center; The Edmond and Lily Safra Children's Hospital; The Chaim Sheba Medical Center, Tel Hashomer, Israel.,3 ECMO service, The Edmond J Safra International Congenital Heart Center; The Edmond and Lily Safra Children's Hospital; The Chaim Sheba Medical Center, Tel Hashomer, Israel.,4 The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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22
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Hypercoagulation and Pediatric Inflammatory Bowel Disease: A Case Report. J Pediatr Gastroenterol Nutr 2018; 66:e112-e114. [PMID: 29287018 DOI: 10.1097/mpg.0000000000001884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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23
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Li QQ, Yang YX, Qv JW, Hu G, Hu YJ, Xia ZN, Yang FQ. Investigation of Interactions between Thrombin and Ten Phenolic Compounds by Affinity Capillary Electrophoresis and Molecular Docking. JOURNAL OF ANALYTICAL METHODS IN CHEMISTRY 2018; 2018:4707609. [PMID: 29744232 PMCID: PMC5884136 DOI: 10.1155/2018/4707609] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/30/2017] [Accepted: 12/31/2017] [Indexed: 06/08/2023]
Abstract
Thrombin plays a vital role in blood coagulation, which is a key process involved in thrombosis by promoting platelet aggregation and converting fibrinogen to form the fibrin clot. In the receptor concept, drugs produce their therapeutic effects via interactions with the targets. Therefore, investigation of interaction between thrombin and small molecules is important to find out the potential thrombin inhibitor. In this study, affinity capillary electrophoresis (ACE) and in silico molecular docking methods were developed to study the interaction between thrombin and ten phenolic compounds (p-hydroxybenzoic acid, protocatechuic acid, vanillic acid, gallic acid, catechin, epicatechin, dihydroquercetin, naringenin, apigenin, and baicalein). The ACE results showed that gallic acids and six flavonoid compounds had relative strong interactions with thrombin. In addition, the docking results indicated that all of optimal conformations of the six flavonoid compounds were positioned into the thrombin activity centre and had interaction with the HIS57 or SER195 which was the key residue to bind thrombin inhibitors such as argatroban. Herein, these six flavonoid compounds might have the potential of thrombin inhibition activity. In addition, the developed method in this study can be further applied to study the interactions of other molecules with thrombin.
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Affiliation(s)
- Qiao-Qiao Li
- School of Chemistry and Chemical Engineering, Chongqing University, Chongqing 401331, China
| | - Yu-Xiu Yang
- School of Chemistry and Chemical Engineering, Chongqing University, Chongqing 401331, China
| | - Jing-Wen Qv
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, China
| | - Guang Hu
- School of Pharmacy and Bioengineering, Chongqing University of Technology, Chongqing 400054, China
| | - Yuan-Jia Hu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, China
| | - Zhi-Ning Xia
- School of Chemistry and Chemical Engineering, Chongqing University, Chongqing 401331, China
| | - Feng-Qing Yang
- School of Chemistry and Chemical Engineering, Chongqing University, Chongqing 401331, China
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24
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Tullius BP, Athale U, van Ommen CH, Chan AKC, Palumbo JS, Balagtas JMS. The identification of at-risk patients and prevention of venous thromboembolism in pediatric cancer: guidance from the SSC of the ISTH. J Thromb Haemost 2018; 16:175-180. [PMID: 29178421 DOI: 10.1111/jth.13895] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Indexed: 01/19/2023]
Affiliation(s)
- B P Tullius
- Division of Pediatric Hematology/Oncology and BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - U Athale
- Pediatrics, McMaster University and Division of Paediatric Hematology/Oncology, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - C H van Ommen
- Department of Pediatric Hematology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - A K C Chan
- Pediatrics, McMaster University and Division of Paediatric Hematology/Oncology, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - J S Palumbo
- Division of Pediatric Hematology, University of Cincinnati, Cincinnati, OH, USA
| | - J M S Balagtas
- Division of Pediatric Hematology/Oncology, Stanford University, Stanford, CA, USA
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25
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Kulhari A, Dorn E, Pace J, Alambyan V, Chen S, Wu OC, Rizvi M, Hammond A, Ramos-Estebanez C. Acute Ischemic Pediatric Stroke Management: An Extended Window for Mechanical Thrombectomy? Front Neurol 2017; 8:634. [PMID: 29238322 PMCID: PMC5712569 DOI: 10.3389/fneur.2017.00634] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 11/13/2017] [Indexed: 11/26/2022] Open
Abstract
Ischemic stroke is a rare condition to afflict the pediatric population. Congenital cardiomyopathy represents one of several possible etiologies in children. We report a 9-year-old boy who developed right middle cerebral artery stroke secondary to primary restrictive cardiomyopathy. In the absence of pediatric guidelines, the child met adult criteria for mechanical thrombectomy given the small core infarct and large penumbra. The literature suggests children may benefit from mechanical thrombectomy in carefully selected cases. Our patient exemplifies specific circumstances in which acute stroke therapy with thrombolysis and thrombectomy may be safe.
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Affiliation(s)
- Ashish Kulhari
- Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.,Department of Neurological Surgery, Neurological Institute, University Hospitals, Cleveland, OH, United States
| | - Elizabeth Dorn
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH, United States
| | - Jonathan Pace
- Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.,Department of Neurological Surgery, Neurological Institute, University Hospitals, Cleveland, OH, United States
| | - Vilakshan Alambyan
- Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.,Department of Neurological Surgery, Neurological Institute, University Hospitals, Cleveland, OH, United States
| | - Stephanie Chen
- Department of Physiology, Case Western Reserve University, Cleveland, OH, United States
| | - Osmond C Wu
- Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.,Department of Neurological Surgery, Neurological Institute, University Hospitals, Cleveland, OH, United States
| | - Macym Rizvi
- Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.,Department of Neurological Surgery, Neurological Institute, University Hospitals, Cleveland, OH, United States
| | - Anthony Hammond
- Department of Emergency Medicine, University Hospitals, Cleveland, OH, United States
| | - Ciro Ramos-Estebanez
- Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.,Department of Neurological Surgery, Neurological Institute, University Hospitals, Cleveland, OH, United States
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26
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Hinsley K, Evans-Langhorst M, Porter C, Chandler S, VanderPluym C, Triedman J, Bezzerides VJ. Low molecular weight heparin as an anticoagulation strategy for left-sided ablation procedures. CONGENIT HEART DIS 2017; 13:222-225. [DOI: 10.1111/chd.12551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 10/16/2017] [Accepted: 10/28/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Karen Hinsley
- Department of Cardiology; Boston Children's Hospital; Boston Massachusetts, USA
| | | | - Courtney Porter
- Department of Cardiology; Boston Children's Hospital; Boston Massachusetts, USA
| | - Stephanie Chandler
- Department of Cardiology; Boston Children's Hospital; Boston Massachusetts, USA
| | | | - John Triedman
- Department of Cardiology; Boston Children's Hospital; Boston Massachusetts, USA
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27
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Association Between Hematologic and Inflammatory Markers and 31 Thrombotic and Hemorrhagic Events in Berlin Heart Excor Patients. Pediatr Cardiol 2017; 38:770-777. [PMID: 28184979 DOI: 10.1007/s00246-017-1578-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 01/20/2017] [Indexed: 10/20/2022]
Abstract
Bleeding and thrombotic events remain a significant cause of morbidity in pediatric patients supported with ventricular assist devices (VADs). The objective of this study is to identify the association between markers of anticoagulation and bleeding and thrombosis events during Berlin Heart ExCor support. A retrospective, single-center analysis of 9 patients supported with the Berlin Heart ExCor was performed. Inflammatory and anticoagulation parameters including C-reactive protein, fibrinogen, partial thromboplastin time (PTT), and platelet count were measured at 48 and 24 h before and after bleeding or thrombosis events. Patients served as their own controls, and the same parameters were measured during a control period where subjects did not experience either event. All patients received the anticoagulation regimen proposed by Berlin Heart. A total of 31 bleeding or thrombotic events were identified and matched to 18 control events. Patient with predominantly thrombotic events tended to weigh less than those with bleeding events (Δ7.7 kg, p < 0.001). PTT levels were higher before and after bleeding (Δ17.36, p = 0.002) and thrombosis (Δ8.75, p < 0.001) events relative to control. Heparin dose decreased after a thrombosis event (Δ-5.67, p = 0.097), and this decrease was significantly different from control (p = 0.032). Non-collinearity between heparin dose and PTT should prompt further inflammatory and hematological investigation. In addition, heavier patients were more prone to bleeding complications. The role of inflammation in the development of thrombus or hemorrhages in the pediatric VAD population needs to be studied further.
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28
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Rahawi KW, Higgins KL, Noda C, Stultz JS. Effect of Plasmapheresis on the Anti-Factor Xa Activity of Enoxaparin in an Obese Adolescent Patient. Pharmacotherapy 2017; 37:e16-e20. [PMID: 28152224 DOI: 10.1002/phar.1907] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
To our knowledge, the effect of plasmapheresis on the anti-factor Xa activity of enoxaparin has never been reported. We describe a 13-year-old, obese (92-kg) girl who was treated with enoxaparin for a pulmonary embolism while receiving plasmapheresis for suspected autoimmune encephalitis and who experienced clinically significant reductions in anti-factor Xa activity after plasmapheresis. She received five courses of plasmapheresis, with the final two administered during treatment with enoxaparin. Her anti-factor Xa concentrations were highly variable, and we hypothesized that plasmapheresis was affecting these levels. To test this hypothesis, anti-factor Xa concentrations were measured before and immediately after the patient's last plasmapheresis treatment, and then again 2 days after plasmapheresis. The rate of anti-factor Xa activity decline was 0.28 IU/mL/hour with plasmapheresis and only 0.088 IU/mL/hour on the day without plasmapheresis, representing a greater than 3-fold difference. The changes in anti-factor Xa activity due to plasmapheresis altered the final enoxaparin dosage required to remain in the therapeutic range of 0.5-1 IU/mL (0.98 mg/kg/dose while receiving plasmapheresis vs 0.69 mg/kg/dose without plasmapheresis). Our patient's data suggest that plasmapheresis can significantly alter enoxaparin's anticoagulant effect as measured by anti-factor Xa concentrations, which could cause a decreased anticoagulant effect during plasmapheresis and an increased risk of bleeding on plasmapheresis discontinuation. If concurrent enoxaparin-based anticoagulation and plasmapheresis are necessary, close monitoring of anti-factor Xa levels is advisable. Dose escalations and reductions of enoxaparin may be necessary when initiating and discontinuing plasmapheresis, respectively.
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Affiliation(s)
- Kassim W Rahawi
- Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Kristi L Higgins
- Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Cady Noda
- Virginia Commonwealth University School of Pharmacy, Richmond, Virginia.,Department of Pharmacy Services, Virginia Commonwealth University Health, Richmond, Virginia
| | - Jeremy S Stultz
- Virginia Commonwealth University Health, Richmond, Virginia.,Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
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29
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Olivieri M, Kurnik K, Hoffmann F, Reiter K, Bidlingmaier C, Kuhlencordt P, Treitl M. Ultrasound Assisted Endovascular Thrombolysis in Adolescents: 2 Case Reports. Pediatrics 2016; 138:peds.2016-0022. [PMID: 27283015 DOI: 10.1542/peds.2016-0022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2016] [Indexed: 11/24/2022] Open
Abstract
Descending iliofemoral thrombosis in children is a rare event. Anticoagulation therapy with low-molecular-weight-heparin is standard of care. However, patency cannot be achieved in all cases, increasing the risk for rethrombosis and postthrombotic syndrome. To reduce the risk of venous valve failure in adults, local catheter-directed thrombolysis is used to reopen vessels. Two adolescent girls (17 and 15 years old) presented with acute descending iliofemoral thrombosis of the left common iliac, external, and common femoral veins. Anticoagulation with enoxaparin was started until insertion of an EkoSonic Mach 4e catheter for ultrasound-assisted local thrombolysis with recombinant tissue plasminogen activator and administration of unfractionated heparin. Success was monitored by increases in D-dimer levels and ultrasound findings. After 24 hours respectively 48 hours, complete recanalization was obtained. No complication occurred except minimal local bleeding. Screening for hereditary thrombophilia revealed a heterozygous antithrombin mutation in 1 girl (ie, the 15-year-old). May-Thurner syndrome was identified in both girls, necessitating stenting of the left common iliac veins and continuation of anticoagulation therapy with enoxaparin and acetylsalicylic acid. No rethrombosis or complications occurred during the follow-up period. Ultrasound-assisted catheter-directed local thrombolysis with the EkoSonic Mach 4e system was effective in achieving immediate recanalization of the occluded veins and should be considered in children experiencing descending iliofemoral thrombosis. The fast recanalization might reduce the incidence of postthrombotic syndrome. May-Thurner syndrome is regularly found in these patients, and if present, requires stenting of the common iliac vein to avoid early reocclusion. However, long-term patency of iliac vein stenting in children remains to be examined.
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Affiliation(s)
| | | | - Florian Hoffmann
- Pediatric Intensive Care Unit, Dr von Hauner Children's Hospital, Ludwig-Maximilians-Universität Munich, Munich, Germany; and
| | - Karl Reiter
- Pediatric Intensive Care Unit, Dr von Hauner Children's Hospital, Ludwig-Maximilians-Universität Munich, Munich, Germany; and
| | | | - Peter Kuhlencordt
- Division of Vascular Medicine, Medical Clinic and Policlinic IV, and
| | - Marcus Treitl
- Institute for Clinical Radiology, Ludwig-Maximilians-Universität Munich, Munich, Germany
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30
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von Vajna E, Alam R, So TY. Current Clinical Trials on the Use of Direct Oral Anticoagulants in the Pediatric Population. Cardiol Ther 2016; 5:19-41. [PMID: 26739579 PMCID: PMC4906081 DOI: 10.1007/s40119-015-0054-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Indexed: 01/22/2023] Open
Abstract
Common treatment options for deep vein thrombosis and venous thromboembolism in the pediatric population include unfractionated heparin, low molecular weight heparin, and warfarin. Other alternatives are bivalirudin, argatroban, and fondaparinux. Warfarin is the only approved oral option, but an oral agent without frequent monitoring would be optimal for pediatric patients. Thus, there is an increasing need for new anticoagulation options in this population. None of the current direct oral anticoagulants have FDA-approved indications and dosing in children. The two classes of DOACs and the drugs they are comprised of are factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) and direct thrombin inhibitor (dabigatran). Off-label usage of these agents is largely based on adult doses. By far, rivaroxaban and dabigatran have the most published data and ongoing trials in pediatric patients compared to edoxaban and apixaban. After evaluating the current literature available on these agents, it is, however, still too early to make any definitive recommendations on their usage in this special population.
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Affiliation(s)
- Erika von Vajna
- Department of Pharmacy, Moses H. Cone Memorial Hospital, Greensboro, NC, USA
| | - Ruhaniyah Alam
- University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Tsz-Yin So
- Department of Pharmacy, Moses H. Cone Memorial Hospital, Greensboro, NC, USA.
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31
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Venous Thromboembolic Disease in Children and Adolescents. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:149-165. [DOI: 10.1007/5584_2016_113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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32
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Singh RR, Gupte-Singh KR, Wilson JP, Moffett BS. Adherence to Anticoagulant Therapy in Pediatric Patients Hospitalized With Pulmonary Embolism or Deep Vein Thrombosis. Clin Appl Thromb Hemost 2015; 22:260-4. [DOI: 10.1177/1076029615601493] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: The American College of Chest Physicians recommends anticoagulant therapy for at least 3 months in children hospitalized for venous thromboembolism. The objectives of the study were to evaluate the medication utilization patterns and predictors of adherence to anticoagulant therapy in pediatric population. Methods: Texas Medicaid medical and prescription claims from September 1, 2007 to December 12, 2012 were extracted for children (<18 years) hospitalized for pulmonary embolism (PE) or deep vein thrombosis (DVT). The index date was defined as the date of the first prescription of an anticoagulant given within 14 days of discharge. Proportion of days covered (≥80% vs <80%) was used to assess adherence to anticoagulants while controlling for demographics, cause of hospitalization, history of nonsteroidal anti-inflammatory drug use, anticoagulant use, malignancy, drug type, and Charlson comorbidity index (CCI). Key Findings: The patients (n = 60) had a mean (± standard deviation [SD]) age of 14.2 (±4.8) years, were primarily female (56.7%), African American (55.0%), enoxaparin users (58.3%), and had a mean (±SD) CCI of 18.3 (±37.7). The mean (±SD) adherence rates for warfarin and enoxaparin were 85.5% (±22.7%) and 78.7% (±27.8%), respectively. Overall, 66.7% were adherent (≥80%) to anticoagulant therapy. Logistic regression showed that increasing age was significantly associated with adherence to anticoagulant therapy, after controlling for other covariates (odds ratio = 1.5, 95% confidence interval = 1.13-1.85). Conclusion: Nearly one-third of the pediatric patients on anticoagulant therapy after discharge from PE or DVT were still nonadherent. Further research is needed to highlight the factors responsible for nonadherence in pediatric patients.
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Affiliation(s)
- Rakesh R. Singh
- Health Outcomes and Pharmacy Practice Division, Center for Pharmacoeconomic Studies, The University of Texas at Austin, Austin, TX, USA
| | - Komal R. Gupte-Singh
- Health Outcomes and Pharmacy Practice Division, Center for Pharmacoeconomic Studies, The University of Texas at Austin, Austin, TX, USA
| | - James P. Wilson
- Health Outcomes and Pharmacy Practice Division, Center for Pharmacoeconomic Studies, The University of Texas at Austin, Austin, TX, USA
| | - Brady S. Moffett
- Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
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Warad D, Rao AN, Mullikin T, Graner K, Shaughnessy WJ, Pruthi RK, Rodriguez V. A retrospective analysis of outcomes of dalteparin use in pediatric patients: a single institution experience. Thromb Res 2015; 136:229-33. [PMID: 26026634 DOI: 10.1016/j.thromres.2015.05.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 04/11/2015] [Accepted: 05/20/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dalteparin is a commonly used low molecular weight heparin (LMWH) with extensive safety data in adults. With distinct advantages of once daily dosing and relative safety in renal impairment, it has been used off-label in pediatric practice; however, age-based dosing guidelines, safety and efficacy data in children are evolving. OBJECTIVES To report our institutional experience with the use of dalteparin in the treatment and prophylaxis of venous thromboembolism (VTE) in pediatric patients. PATIENTS/METHODS Retrospective chart review of all children (0-18years) that received dalteparin from December 1, 2000 through December 31, 2011. Doses per unit body weight per day (units/kg/day) were calculated for age-based group comparisons. RESULTS Of 166 patients identified, 116 (70%) received prophylactic doses while 50 (30%) received therapeutic doses of dalteparin. Infants (<1year) required significantly higher weight-based dosing to achieve therapeutic anti-Xa levels compared to children (1-10years) or adolescents (>10-18years) (mean dose units/kg/day; 396.6 versus 236.7 and 178.8 respectively, p<0.0001). Overall response rate, including complete and partial thrombus resolution, was 83%. Bleeding complications were minor and the rates were similar in therapeutic and prophylaxis patients. No significant differences in dosing or bleeding events were noted based on obesity or malignancy. CONCLUSIONS In our experience, dalteparin is effective for prophylaxis and therapy of VTE in pediatric patients. Dosing should be customized in an age-based manner with close monitoring of anti-Xa activity in order to achieve optimal levels, prevent bleeding complications, and to allow full benefit of prevention or therapy of thrombotic complications.
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Affiliation(s)
- Deepti Warad
- Division of Pediatric Hematology-Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States; Special Coagulation Laboratory, Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, United States.
| | - Amulya Nageswara Rao
- Division of Pediatric Hematology-Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Trey Mullikin
- Mayo Medical School, Mayo Clinic, Rochester, Minnesota, United States
| | - Kevin Graner
- Mayo Pharmacy Services, Mayo Clinic, Rochester, Minnesota, United States
| | | | - Rajiv K Pruthi
- Special Coagulation Laboratory, Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, United States
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology-Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States
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