Venous Thromboembolism in Children and Teenagers Admitted for Trauma: A 5-Year Nationwide Perspective

Venous thromboembolism (VTE) in pediatric trauma patients is under-investigated. The purpose of this study was to perform an evaluation of the risk factors for VTE after pediatric trauma, including readmissions across the United States. The Nationwide Readmissions Database for 2016-2020 was queried for all patients under the age of 18 years admitted for trauma. 276 670 patients were identified; 2063 (.8%) were diagnosed with VTE. Among those with VTE, 300 (15%) were identified during a readmission. Higher rates of VTE were seen in ages 15-17 years (n = 1,294, 1.3%, P < .001), penetrating injuries (n = 478, .9%, P < .001), and assault (n = 271, 2.7%, P < .001). The strongest risk factor for VTE was prolonged mechanical ventilation (OR 5.5 [4.9-6.3] P < .001). Our study found that a significant portion of post-traumatic VTE in children and teenagers occur during readmissions. A deeper understanding of the risk factors outlined here can guide enhanced clinical protocols, ensuring early detection and prevention of this complication.

Case Report: Initial Treatment Adjustments and Complications in Ovarian Cancer Patient With Inborn Error of Immunity

Background

Patients with inborn errors of immunity (IEI) have increased risk of developing cancers secondary to impaired anti-tumor immunity. Treatment of patients with IEI and cancer is challenging as chemotherapy can exacerbate infectious susceptibility. However, the literature on optimal cancer treatment in the setting of IEI is sparse.

Objectives

We present a patient with specific antibody deficiency with normal immunoglobins (SADNI), immune dysregulation (ID), and stage III ovarian carcinoma as an example of the need to modify conventional treatment in the context of malignancy, IEI, and ongoing infections.

Methods

This is a retrospective chart review of the patient’s clinical manifestations, laboratory evaluation and treatment course.

Results

Our patient is a female with SADNI and ID diagnosed with stage III ovarian carcinoma at 60 years of age. Her ID accounted for antinuclear antibody positive (ANA+) mixed connective tissue diseases, polyarthralgia, autoimmune neutropenia, asthma, autoimmune thyroiditis, and Celiac disease. Due to the lack of precedent in the literature, her treatment was modified with continuous input from infectious disease, allergy/immunology and oncology specialist using a multidisciplinary approach.

The patient completed debulking surgery and 6 cycles of chemotherapy. The dosing for immunoglobulin replacement therapy was increased for prophylaxis. Chemotherapy doses were lowered for all cycles preemptively for IEI. The therapy included carboplatin, paclitaxel, bevacizumab, and pegfilgrastim. The patient completed six-months of maintenance medication involving bevacizumab.

Her treatment course was complicated by Mycobacterium avium-complex (MAC) infection, elevated bilirubin and liver enzymes attributed to excessive immunoglobulin replacement therapy, and urinary tract infection (UTI) and incontinence.

Cancer genetic analysis revealed no targetable markers and primary immunodeficiency gene panel of 407 genes by Invitae was unrevealing. Lab tests revealed no evidence of Epstein-Barr Virus (EBV) infection. Post-chemotherapy imaging revealed no evidence of cancer for 1 year and 4 months, but the disease relapsed subsequently. The patient’s lung scarring requires vigilance.

Conclusions

Our patient with ovarian cancer and IEI required modified treatment and prevention of complications. In cases of IEI, optimal chemotherapy should be titrated to minimize immunosuppression yet treat cancer aggressively while decreasing the risk of infection with prophylactic antibiotics and prolonged post-treatment surveillance, including pulmonary evaluation.

RPE-lactate dissociation during extended cycling

This study examined the association of blood lactate concentration [La] and heart rate (HR) with ratings of perceived exertion (RPE) during 60 min of steady workload cycling. Physically active college-aged subjects (n = 14) completed an exhaustive cycling test to determine VO(2) (peak) and lactate threshold (2.5 mmol l(-1)). Subjects then cycled for 60 min at the power output associated with 2.5 mmol l(-1) [LA]. HR, [LA], RPE-overall, RPE-legs and RPE-chest were recorded at 5, 10, 20, 30, 40, 50 and 60 min. The 60-min trials were below maximal lactate steady state, with peak lactate concentration occurring at 20 min after which [LA] declined. The 20-min point was therefore considered pivotal, and data at other points were compared to this time point. Repeated measures ANOVA with simple contrasts (alpha = 0.05) showed (a) [LA] at 40, 50 and 60 min was significantly lower than at 20 min, (b) RPE-O and RPE-L were significantly greater at 30, 40, 50 and 60 min than at 20 min, (c) RPE-C was significantly greater at 40, 50 and 60 min than at 20 min, and (d) HR was significantly greater at 30, 40, 50 and 60 min than at 20 min. Significant (P < 0.05) positive correlations were found between HR and RPE-O (r = 0.43), RPE-L (r = 0.48) and RPE-C (r = 0.41) while correlations for [LA]-HR (r = 0.13) and [LA]-RPE (RPE-O: r = -0.11, RPE-L: r = 0.01, RPE-C: r = -0.06) were weak and non-significant. There is a dissociation of RPE and [LA] owing to RPE drift and lactate kinetics in longer duration sub-maximal exercise. Apparently, [LA] is not a strong RPE mediator during extended cycling.