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Kuter DJ, Cataland SR, Broome CM, Neunert C. The latest insights into rare blood disorders: Diagnosis and treatment strategies. Am J Hematol 2024. [PMID: 38459819 DOI: 10.1002/ajh.27285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2024] [Indexed: 03/10/2024]
Abstract
Please visit https://bit.ly/AJHpodcast to complete the accredited learning activity and receive CME credit or NCPD contact hours. Because immune-mediated rare blood disorders are uncommon, healthcare providers often lack the knowledge and experience necessary to identify, diagnose, and treat them in accordance with best practices. As a result, there are significant gaps in care, including delays in diagnosis and suboptimal treatment. To ensure that more patients with these rare disorders are offered quality, evidence-based care, it is essential that healthcare providers possess up-to-date information about best practices and new developments in this area of medicine. In this activity, composed of three podcasts, an expert moderator will interview three expert faculty members about evidence-based guidelines for the diagnosis and treatment of acquired thrombotic thrombocytopenic purpura; developments in the diagnosis and treatment of cold agglutinin disease; and the challenges of achieving enduring remission in patients with immune thrombocytopenia.
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Affiliation(s)
- David J Kuter
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Spero R Cataland
- Division of Hematology, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - Catherine M Broome
- Division of Hematology Oncology, MedStar Georgetown University, Washington, DC, USA
| | - Cindy Neunert
- Pediatric Hematology, Columbia University Irving Medical Center, New York, New York, USA
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2
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Bartlett R, Arachichilage DJ, Chitlur M, Hui SKR, Neunert C, Doyle A, Retter A, Hunt BJ, Lim HS, Saini A, Renné T, Kostousov V, Teruya J. The History of Extracorporeal Membrane Oxygenation and the Development of Extracorporeal Membrane Oxygenation Anticoagulation. Semin Thromb Hemost 2024; 50:81-90. [PMID: 36750217 DOI: 10.1055/s-0043-1761488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) was first started for humans in early 1970s by Robert Bartlett. Since its inception, there have been numerous challenges with extracorporeal circulation, such as coagulation and platelet activation, followed by consumption of coagulation factors and platelets, and biocompatibility of tubing, pump, and oxygenator. Unfractionated heparin (heparin hereafter) has historically been the defacto anticoagulant until recently. Also, coagulation monitoring was mainly based on bedside activated clotting time and activated partial thromboplastin time. In the past 50 years, the technology of ECMO has advanced tremendously, and thus, the survival rate has improved significantly. The indication for ECMO has also expanded. Among these are clinical conditions such as postcardiopulmonary bypass, sepsis, ECMO cardiopulmonary resuscitation, and even severe coronavirus disease 2019 (COVID-19). Not surprisingly, the number of ECMO cases has increased according to the Extracorporeal Life Support Organization Registry and prolonged ECMO support has become more prevalent. It is not uncommon for patients with COVID-19 to be on ECMO support for more than 1 year until recovery or lung transplant. With that being said, complications of bleeding, thrombosis, clot formation in the circuit, and intravascular hemolysis still remain and continue to be major challenges. Here, several clinical ECMO experts, including the "Father of ECMO"-Dr. Robert Bartlett, describe the history and advances of ECMO.
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Affiliation(s)
- Robert Bartlett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Deepa J Arachichilage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Department of Haematology, Imperial College, Healthcare NHS Trust, London, United Kingdom
| | - Meera Chitlur
- Division of Hematology/Oncology, Central Michigan University School of Medicine, Children's Hospital of Michigan, Michigan
| | - Shiu-Ki Rocky Hui
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Cindy Neunert
- Columbia University Irving Medical Center, New York, New York
| | | | | | | | - Hoong Sern Lim
- University Hospitals Birmingham NHS Foundation Trust, United Kingdom
| | - Arun Saini
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- Center for Thrombosis and Hemostasis (CTH), Johannes Gutenberg University Medical Center, Mainz, Germany
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Vadim Kostousov
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Jun Teruya
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
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Phillips L, Richmond M, Neunert C, Jin Z, Brittenham GM. Iron Deficiency in Chronic Pediatric Heart Failure: Overall Assessment and Outcomes in Dilated Cardiomyopathy. J Pediatr 2023; 263:113721. [PMID: 37673205 DOI: 10.1016/j.jpeds.2023.113721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 08/15/2023] [Accepted: 08/30/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE To evaluate the frequency of iron status assessment in pediatric heart failure and the prevalence and adverse effects of absolute iron deficiency in dilated cardiomyopathy-induced heart failure. STUDY DESIGN We retrospectively reviewed records of children with chronic heart failure at our center between 2010 and 2020. In children with dilated cardiomyopathy, we analyzed baseline cardiac function, hemoglobin level, and subsequent risk of composite adverse events (CAE), including death, heart transplant, ventricular assist device (VAD) placement, and transplant registry listing. Absolute iron deficiency and iron sufficiency were defined as transferrin saturations <20% and ≥30%, respectively; and indeterminant iron status as 20%-29%. RESULTS Of 799 patients with chronic heart failure, 471 (59%) had no iron-related laboratory measurements. Of 68 children with dilated cardiomyopathy, baseline transferrin saturation, and quantitative left ventricular ejection fraction (LVEF), 33 (49%) and 14 (21%) were iron deficient and sufficient, respectively, and 21 (31%) indeterminant. LVEF was reduced to 23.6 ± 12.1% from 32.9 ± 16.8% in iron deficiency and sufficiency, respectively (P = .04), without a significant difference in hemoglobin. After stratification by New York Heart Association classification, in advanced class IV, hemoglobin was reduced to 10.9 ± 1.3 g/dL vs 12.7 ± 2.0 g/dL in iron deficiency and sufficiency, respectively (P = .01), without a significant difference in LVEF. CONCLUSIONS In this single-center study, iron deficiency was not monitored in most children with chronic heart failure. In pediatric dilated cardiomyopathy-induced heart failure, absolute iron deficiency was prevalent and associated with clinically consequential and possibly correctable decreases in cardiac function and hemoglobin concentration.
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Affiliation(s)
- Lia Phillips
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Irving Medical Center, New York, NY.
| | - Marc Richmond
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Cindy Neunert
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Irving Medical Center, New York, NY
| | - Zhezhen Jin
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY
| | - Gary M Brittenham
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Irving Medical Center, New York, NY
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Chen JK, Salerno DM, Law S, Freniere V, Neunert C. Anticoagulation Stability With Bivalirudin: Positioning the Horse Before the Cart. ASAIO J 2023; 69:e468-e469. [PMID: 37220194 DOI: 10.1097/mat.0000000000001992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Affiliation(s)
- Justin K Chen
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York
- Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - David M Salerno
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York
| | - Sabrina Law
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Victoria Freniere
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York
| | - Cindy Neunert
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
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Neunert C, Heitink-Polle KMJ, Lambert MP. A proposal for new definition (s) and management approach to paediatric refractory ITP: Reflections from the Intercontinental ITP Study Group. Br J Haematol 2023; 203:17-22. [PMID: 37641973 DOI: 10.1111/bjh.19072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/02/2023] [Indexed: 08/31/2023]
Abstract
Immune thrombocytopenia (ITP) in children is a relatively mild and self-limited disorder with the majority of children demonstrating normalization of platelet count by 12 months from diagnosis. Because of this, many children with ITP can be observed without the need for treatment. When needed, treatment with either intravenous immunoglobulin (IVIG) or corticosteroids is highly effective (>80% IVIG and >95% corticosteroids). For those children who require second-line therapies, response rates of >60% are seen with both the thrombopoietin-receptor agonists and rituximab. Despite this, some children will have 'refractory' ITP (rITP) with poor or transient responses to platelet-raising therapies. Here, we review the clinical features of rITP in children, outline proposed classifications and explore potential predictors for children with rITP.
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Affiliation(s)
- Cindy Neunert
- Vagelos College of Physicians and Surgeons, Columbia University Medical School, New York, New York, USA
| | | | - Michele P Lambert
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at UPENN, Philadelphia, Pennsylvania, USA
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Freniere V, Salerno DM, Corbo H, Law S, McAllister J, Neunert C, Chen JK. Bivalirudin Compared to Heparin as the Primary Anticoagulant in Pediatric Berlin Heart Recipients. ASAIO J 2023; 69:e205-e211. [PMID: 36943709 DOI: 10.1097/mat.0000000000001921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
Bivalirudin has been used in increasing frequency as an alternative to unfractionated heparin (UFH) in pediatric recipients of Berlin Heart EXCOR ventricular assist devices (VAD). This single-center, retrospective review characterizes anticoagulant trends and outcomes in pediatric Berlin Heart VAD recipients implanted between September 1, 2013, and August 31, 2021, anticoagulated with either bivalirudin or UFH. Thirty-one patients were included; 65% who received bivalirudin and 35% who received UFH. The median age was 2.9 years, included 64.5% females, with 61.3% of patients diagnosed with dilated cardiomyopathy and 25.8% of patients with congenital heart disease. Therapeutic anticoagulation was achieved sooner in the bivalirudin group compared to UFH via anti-Xa monitoring (median 5.7 and 69.5 hours, respectively, p < 0.001). Bivalirudin had a greater number of therapeutic values comparatively to UFH (52% and 24%, respectively; p < 0.001) and a superior number of hours in the therapeutic range (67% and 32%, respectively; p < 0.001). Secondary outcomes were similar among the two groups, apart from greater chest tube output (UFH), more frequent events of elevated plasma-free hemoglobin (bivalirudin), and more frequent elevated inflammatory markers postimplant (bivalirudin). Prevalence of pump replacements secondary to significant clot burden and prevalence of stroke was comparable. In this patient cohort, bivalirudin demonstrated greater anticoagulation stability comparatively to UFH. Multicenter collaboration would be necessary to identify whether this further translates into improved patient outcomes.
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Affiliation(s)
| | - David M Salerno
- From the Department of Pharmacy, NewYork-Presbyterian Hospital
| | - Heather Corbo
- From the Department of Pharmacy, NewYork-Presbyterian Hospital
| | - Sabrina Law
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Jennie McAllister
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Cindy Neunert
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Justin K Chen
- From the Department of Pharmacy, NewYork-Presbyterian Hospital
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Lyvannak S, Sreynich K, Heng S, Thyl M, Chandna A, Chanpheaktra N, Pises N, Farrilend P, Jarzembowski J, Leventaki V, Davick J, Neunert C, Keller F, Kean LS, Camitta B, Tarlock K, Watkins B. Case Report: The First Case Report of Visceral Leishmaniasis in Cambodia. Am J Trop Med Hyg 2022; 107:336-338. [PMID: 35895585 PMCID: PMC9393436 DOI: 10.4269/ajtmh.22-0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/31/2022] [Indexed: 08/03/2023] Open
Abstract
Leishmaniasis is considered a neglected tropical disease that is commonly found in Asia, Africa, South America, and Mediterranean countries. Visceral leishmaniasis (VL) is the most severe form of the disease and is almost universally fatal if left untreated. The symptoms of VL overlap with many infectious diseases, malignancies, and other blood disorders. The most common findings include fever, cytopenias, and splenomegaly. Given the nonspecific symptoms, the diagnosis requires detailed laboratory investigations, including bone marrow examination, that can be challenging in low- and middle-income countries. Diagnostic limitations likely lead to the underdiagnosis or delay in diagnosis of VL. We describe, to our knowledge, the first case report of VL in Cambodia in a child presenting with fever, anemia, and thrombocytopenia. The diagnosis required a liver biopsy and multiple bone marrow biopsies to visualize intracellular Leishmania spp. Our case illustrates the diagnostic challenges and the importance of timely diagnosis. This case also highlights the need for heightened awareness of the diagnostic findings of VL and improved reporting of tropical diseases.
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Affiliation(s)
- Sam Lyvannak
- Angkor Hospital for Children, Siem Reap, Cambodia
| | | | - Sing Heng
- Angkor Hospital for Children, Siem Reap, Cambodia
| | - Miliya Thyl
- Angkor Hospital for Children, Siem Reap, Cambodia
| | - Arjun Chandna
- Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | | | - Ngeth Pises
- Angkor Hospital for Children, Siem Reap, Cambodia
| | | | | | | | | | | | - Frank Keller
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Leslie S. Kean
- Boston Children’s Hospital, Dana Farber Cancer Institute, Boston, Massachusetts
| | | | | | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
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Neunert C, Chitlur M, van Ommen CH. The Changing Landscape of Anticoagulation in Pediatric Extracorporeal Membrane Oxygenation: Use of the Direct Thrombin Inhibitors. Front Med (Lausanne) 2022; 9:887199. [PMID: 35872781 PMCID: PMC9299072 DOI: 10.3389/fmed.2022.887199] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/10/2022] [Indexed: 11/13/2022] Open
Abstract
Bleeding and thrombosis frequently occur in pediatric patients with extracorporeal membrane oxygenation (ECMO) therapy. Until now, most patients are anticoagulated with unfractionated heparin (UFH). However, heparin has many disadvantages, such as binding to other plasma proteins and endothelial cells in addition to antithrombin, causing an unpredictable response, challenging monitoring, development of heparin resistance, and risk of heparin-induced thrombocytopenia (HIT). Direct thrombin inhibitors (DTIs), such as bivalirudin and argatroban, might be a good alternative. This review will discuss the use of both UFH and DTIs in pediatric patients with ECMO therapy.
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Affiliation(s)
- Cindy Neunert
- Department of Pediatrics, Columbia University Medical Center, New York, NY, United States
| | - Meera Chitlur
- Division of Hematology, Oncology, Carmen and Ann Adams Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, MI, United States
- *Correspondence: Cornelia Heleen van Ommen,
| | - Cornelia Heleen van Ommen
- Department of Pediatric Hematology and Oncology, Erasmus Medical Center University Medical Center Sophia Children’s Hospital, Rotterdam, Netherlands
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Hillier K, Rothman JA, Klaassen RJ, Neunert C, Rose MJ, Grace RF, Lambert MP. SARS-CoV-2 vaccination in pediatric patients with immune thrombocytopenia. Pediatr Blood Cancer 2022; 69:e29760. [PMID: 35561101 PMCID: PMC9347939 DOI: 10.1002/pbc.29760] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/12/2022] [Accepted: 04/18/2022] [Indexed: 11/12/2022]
Affiliation(s)
- Kirsty Hillier
- Department of PediatricsDivision of Pediatric Hematology‐OncologyHassenfeld Children's Hospital at NYU Langone HealthNYU Grossman School of MedicineNew YorkNew YorkUSA
| | - Jennifer A. Rothman
- Department of PediatricsDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Robert J. Klaassen
- Division of Hematology/Oncology, Department of PediatricsChildren's Hospital of Eastern Ontario Research InstituteOttawaOntarioCanada
| | - Cindy Neunert
- Division of Hematology/Oncology/Stem Cell Transplant, Department of PediatricsColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Melissa J. Rose
- Nationwide Children's and The Ohio State University Wexner Medical CenterColumbusOhioUSA
| | - Rachael F. Grace
- Pediatric Hematology/OncologyDana‐Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical SchoolBostonMassachusettsUSA
| | - Michele P. Lambert
- Division of HematologyThe Children's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA,Department of PediatricsPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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Shimano KA, Grace RF, Despotovic JM, Neufeld EJ, Klaassen RJ, Bennett CM, Ma C, London WB, Neunert C. Phase 3 randomised trial of eltrombopag versus standard first-line pharmacological management for newly diagnosed immune thrombocytopaenia (ITP) in children: study protocol. BMJ Open 2021; 11:e044885. [PMID: 34452956 PMCID: PMC8404450 DOI: 10.1136/bmjopen-2020-044885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Immune thrombocytopaenia (ITP) is an acquired disorder of low platelets and risk of bleeding. Although many children can be observed until spontaneous remission, others require treatment due to bleeding or impact on health-related quality of life. Standard first-line therapies for those who need intervention include corticosteroids, intravenous immunoglobulin and anti-D globulin, though response to these agents may be only transient. Eltrombopag is an oral thrombopoietin receptor agonist approved for children with chronic ITP who have had an insufficient response to corticosteroids, intravenous immunoglobulin or splenectomy. This protocol paper describes an ongoing open-label, randomised trial comparing eltrombopag to standard first-line management in children with newly diagnosed ITP. METHODS AND ANALYSIS Randomised treatment assignment is 2:1 for eltrombopag versus standard first-line management and is stratified by age and by prior treatment. The primary endpoint of the study is platelet response, defined as ≥3 of 4 weeks with platelets >50×109/L during weeks 6-12 of therapy. Secondary outcomes include number of rescue therapies needed during the first 12 weeks, proportion of patients who do not need ongoing treatment at 12 weeks and 6 months, proportion of patients with a treatment response at 1 year, and number of second-line therapies used in weeks 13-52, as well as changes in regulatory T cells, iron studies, bleeding, health-related quality of life and fatigue. A planned sample size of up to 162 randomised paediatric patients will be enrolled over 2 years at 20 sites. ETHICS AND DISSEMINATION The study has been approved by the centralised Baylor University Institutional Review Board. The results are expected to be published in 2023. TRIAL REGISTRATION NUMBER NCT03939637.
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Affiliation(s)
- Kristin A Shimano
- UCSF Benioff Children's Hospital, San Francisco, California, USA
- Pediatrics, UCSF, San Francisco, California, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Jenny M Despotovic
- Texas Children's Hospital, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| | - Ellis J Neufeld
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - Carolyn M Bennett
- Pediatrics, Emory University, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Clement Ma
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Wendy B London
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Biostatistics, Harvard Medical School, Boston, Massachusetts, USA
| | - Cindy Neunert
- Pediatrics, Columbia University Medical School, New York, New York, USA
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Shimano KA, Neunert C, Bussel JB, Klaassen RJ, Bhat R, Pastore YD, Lambert MP, Bennett CM, Despotovic JM, Forbes P, Grace RF. Quality of life is an important indication for second-line treatment in children with immune thrombocytopenia. Pediatr Blood Cancer 2021; 68:e29023. [PMID: 33764667 DOI: 10.1002/pbc.29023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND The decision to initiate second-line treatment in children with immune thrombocytopenia (ITP) is complex and involves many different factors. METHODS In this prospective, observational, longitudinal cohort study of 120 children from 21 centers, the factors contributing to the decision to start second-line treatments for ITP were captured. At study entry, clinicians were given a curated list of 12 potential reasons the patient required a second-line treatment. Clinicians selected all that applied and ranked the top three reasons. RESULTS Quality of life (QOL) was the most frequently cited reason for starting a second-line therapy. Clinicians chose it as a reason to treat in 88/120 (73%) patients, as among the top three reasons in 68/120 (57%), and as the top reason in 32/120 (27%). Additional factors ranked as the top reason to start second-line treatment included severity of bleeding (22/120, 18%), frequency of bleeding (19/120, 16%), and severity of thrombocytopenia (18/120, 15%). Patients for whom QOL (p = .006) or sports participation (p = .02) were ranked reasons were more likely to have chronic ITP, whereas those for whom severity (p = .003) or frequency (p = .005) of bleeding were ranked reasons were more likely to have newly diagnosed or persistent ITP. Parental anxiety, though rarely the primary impetus for treatment, was frequently cited (70/120, 58%) as a contributing factor. CONCLUSION Perceived QOL is the most frequently selected reason pediatric patients start second-line therapies for ITP. It is critical that studies of treatments for childhood ITP include assessments of their effects on QOL.
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Affiliation(s)
| | - Cindy Neunert
- Columbia University Medical Center, New York, New York, USA
| | | | | | - Rukhmi Bhat
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Michele P Lambert
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Carolyn M Bennett
- Emory University School of Medicine, Children's Healthcare of Atlanta, Aflac Cancer and Blood Disorders Center, Atlanta, Georgia, USA
| | - Jenny M Despotovic
- Texas Children's Hematology Center, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Forbes
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, Massachusetts, USA
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12
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Davis L, Yao Y, Jin Z, Moscoso S, Neunert C, Broglie L, Hall M, Bhatia M, George D, Garvin JH, Satwani P. Length of Stay and Health Care Utilization Among Pediatric Autologous Hematopoietic Cell Transplantation Recipients. Transplant Cell Ther 2021; 27:613.e1-613.e7. [PMID: 33831624 DOI: 10.1016/j.jtct.2021.03.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/19/2021] [Accepted: 03/22/2021] [Indexed: 11/28/2022]
Abstract
Autologous hematopoietic cell transplantation (autoHCT) has become a critical component in the treatment of pediatric malignancies, allowing for high-dose chemotherapy to be given safely and with greater efficacy in a subset of children at high risk for relapse. Risk factors associated with hospital length of stay (LOS) in adults undergoing autoHCT have been studied extensively; however, there is a paucity of studies describing risk factors associated with LOS and health care cost in children undergoing autoHCT. This study sought to identify factors influencing LOS and cost in pediatric autoHCT. We assessed LOS from autologous stem cell infusion from day 0 (D0) in 100 autoHCT admissions in 73 patients with malignant disease between 2007 and 2019. We evaluated demographic, pre-transplantation, post-transplantation, and socioeconomic variables to identify potential risk factors associated with LOS and cost. AutoHCT cost data were provided by the Pediatric Health Information System database. Indications for autoHCT included neuroblastoma (35.6%), brain tumor (27.4%), and relapsed lymphoma (24.7%). The median patient age was 4.88 years (range, 0.72 to 22 years), with 71% age <12 years, and the cohort was 63% male, 77% white, and 41% Hispanic. The median LOS from D0 was 19 days (range, 13 to 100 days). On multivariable analysis, age >12 years compared with 2 to 12 years (estimate, -8.9 days; 95% confidence interval [CI], -15.1 to -2.8; P = .004) and complete remission/very good partial response disease status (estimate, -5.0 days; 95% CI, -9.6 to -0.4 days; P = .031) were associated with a significantly decreased median LOS, whereas Hispanic ethnicity (estimate, +6.8 days; 95% CI, 1.1 to 12.6 days; P = .019), >5 days of fever (estimate, +7.3 days; 95% CI, 1.4 to 13.2 days; P = .015), and pediatric intensive care unit (PICU) LOS (estimate, +14.9 days; 95% CI, 1.8 to 28.0 days; P = .025) were associated with a significant increase in median LOS. The median cost per transplantation admission was $96,850 (range, $39,833 to $587,321). Multivariable analysis showed that age >12 years (estimate, -$6,776; 95% CI, -$71,787 to -$11,402; P = .007) or <2 years (estimate, -$32,426; 95% CI, -$53,507 to -$11,345; P = .003), and complete remission/very good partial response disease status (estimate, -$20,266; 95% CI, -$40,211 to -$322; P = .046) were associated with significantly decreased median cost, whereas >5 days of fever (estimate, +$58,886; 95% CI, $30,667 to $87,105; P < .001) and PICU admission (estimate, +$102,458; 95% CI, $23,843 to $181,076; P = .011) were associated with significantly increased median cost. In summary, fever and PICU stay were found to be risk factors for increased LOS and cost. Age <12 years and Hispanic ethnicity were risk factors for increased LOS, whereas age <2 years and >12 years and female sex were associated with decreased cost. Further investigation to determine specific factors influencing LOS and cost is warranted to identify potentially modifiable risks within these patient populations.
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Affiliation(s)
- Laurie Davis
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Yujing Yao
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Zhezhen Jin
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Susana Moscoso
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Cindy Neunert
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Larisa Broglie
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Monica Bhatia
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Diane George
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - James H Garvin
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Prakash Satwani
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Department of Pediatrics, Columbia University Medical Center, New York, New York.
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13
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Jonat B, Gorelik M, Boneparth A, Geneslaw AS, Zachariah P, Shah A, Broglie L, Duran J, Morel KD, Zorrilla M, Svoboda L, Johnson C, Cheng J, Garzon MC, Silver WG, Gross Margolis K, Neunert C, Lytrivi I, Milner J, Kernie SG, Cheung EW. Multisystem Inflammatory Syndrome in Children Associated With Coronavirus Disease 2019 in a Children's Hospital in New York City: Patient Characteristics and an Institutional Protocol for Evaluation, Management, and Follow-Up. Pediatr Crit Care Med 2021; 22:e178-e191. [PMID: 33003176 PMCID: PMC7924927 DOI: 10.1097/pcc.0000000000002598] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The disease caused by severe acute respiratory syndrome coronavirus 2, known as coronavirus disease 2019, has resulted in a global pandemic. Reports are emerging of a new severe hyperinflammatory syndrome related to coronavirus disease 2019 in children and adolescents. The Centers for Disease Control and Prevention has designated this disease multisystem inflammatory syndrome in children. Our objective was to develop a clinical inpatient protocol for the evaluation, management, and follow-up of patients with this syndrome. DATA SOURCES The protocol was developed by a multidisciplinary team based on relevant literature related to coronavirus disease 2019, multisystem inflammatory syndrome in children, and related inflammatory syndromes, as well as our experience caring for children with multisystem inflammatory syndrome in children. Data were obtained on patients with multisystem inflammatory syndrome in children at our institution from the pre-protocol and post-protocol periods. DATA SYNTHESIS Our protocol was developed in order to identify cases of multisystem inflammatory syndrome in children with high sensitivity, stratify risk to guide treatment, recognize co-infectious or co-inflammatory processes, mitigate coronary artery abnormalities, and manage hyperinflammatory shock. Key elements of evaluation include case identification using broad clinical characteristics and comprehensive laboratory and imaging investigations. Treatment centers around glucocorticoids and IV immunoglobulin with biologic immunomodulators as adjuncts. Multidisciplinary follow-up after discharge is indicated to manage continued outpatient therapy and evaluate for disease sequelae. In nearly 2 months, we admitted 54 patients with multisystem inflammatory syndrome in children, all of whom survived without the need for invasive ventilatory or mechanical circulatory support. After institution of this protocol, patients received earlier treatment and had shorter lengths of hospital stay. CONCLUSIONS This report provides guidance to clinicians on evaluation, management, and follow-up of patients with a novel hyperinflammatory syndrome related to coronavirus disease 2019 known as multisystem inflammatory syndrome in children. It is based on the relevant literature and our experience. Instituting such a protocol during a global pandemic is feasible and is associated with patients receiving treatment and returning home more quickly.
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Affiliation(s)
- Brian Jonat
- Department of Pediatrics, Division of Critical Care and Hospital Medicine, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Mark Gorelik
- Department of Pediatrics, Division of Allergy, Immunology, and Rheumatology, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Alexis Boneparth
- Department of Pediatrics, Division of Allergy, Immunology, and Rheumatology, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Andrew S Geneslaw
- Department of Pediatrics, Division of Critical Care and Hospital Medicine, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Philip Zachariah
- Department of Pediatrics, Division of Infectious Diseases, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Amee Shah
- Department of Pediatrics, Division of Cardiology, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Larisa Broglie
- Department of Pediatrics, Division of Hematology, Oncology, and Stem Cell Transplantation, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Juan Duran
- Department of Neurology, Division of Child Neurology, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Kimberly D Morel
- Department of Dermatology, Division of Pediatric Dermatology, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
- Department of Pediatrics, Division of Pediatric Dermatology, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Maria Zorrilla
- Department of Pharmacy, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Leanne Svoboda
- Department of Pharmacy, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Candace Johnson
- Department of Pediatrics, Division of Infectious Diseases, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Jennifer Cheng
- Department of Pharmacy, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Maria C Garzon
- Department of Dermatology, Division of Pediatric Dermatology, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
- Department of Pediatrics, Division of Pediatric Dermatology, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Wendy G Silver
- Department of Neurology, Division of Child Neurology, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Kara Gross Margolis
- Department of Pediatrics, Division of Gastroenterology, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Cindy Neunert
- Department of Pediatrics, Division of Hematology, Oncology, and Stem Cell Transplantation, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Irene Lytrivi
- Department of Pediatrics, Division of Cardiology, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Joshua Milner
- Department of Pediatrics, Division of Allergy, Immunology, and Rheumatology, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Steven G Kernie
- Department of Pediatrics, Division of Critical Care and Hospital Medicine, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | - Eva W Cheung
- Department of Pediatrics, Division of Critical Care and Hospital Medicine, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
- Department of Pediatrics, Division of Cardiology, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
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14
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Davis LM, Yao Y, Jin Z, Moscoso S, Neunert C, Broglie L, Bhatia M, George D, Garvin J, Satwani P. Risk Factors Associated with Length of Stay (LOS) and Cost of Pediatric Autologous Hematopoietic Cell Transplantation (AutoHCT). Transplant Cell Ther 2021. [DOI: 10.1016/s2666-6367(21)00402-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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15
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Affiliation(s)
- Allison Remiker
- Division of Pediatric Hematology, Oncology, Neuro-Oncology, and Stem Cell Transplantation, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Cindy Neunert
- Division of Pediatric Hematology/Oncology/Stem Cell Transplantation, Columbia University Medical Center, New York, NY, USA.
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16
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Grace RF, Klaassen RJ, Shimano KA, Lambert MP, Grimes A, Bussel JB, Breakey VR, Pastore YD, Black V, Overholt K, Bhat R, Forbes PW, Neunert C. Fatigue in children and adolescents with immune thrombocytopenia. Br J Haematol 2020; 191:98-106. [PMID: 32501532 DOI: 10.1111/bjh.16751] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/22/2020] [Accepted: 04/23/2020] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP), an acquired autoimmune disorder of low platelets and risk of bleeding, has a substantial impact on health-related quality of life (HRQoL). Patients with ITP often report significant fatigue, although the pathophysiology of this is poorly understood. In this observational cohort of 120 children receiving second-line therapies for ITP, we assessed reports of fatigue using the Hockenberry Fatigue Scale. Children and adolescents with ITP reported a similarly high level of fatigue with 54% (29/54) of children and 62% (26/42) of adolescents reporting moderate-to-severe fatigue. There was no correlation between fatigue and age or gender. Adolescents with newly diagnosed and persistent ITP had higher mean fatigue scores than those with chronic ITP (P = 0·03). Fatigue significantly improved in children and adolescents by 1 month after starting second-line treatments, and this improvement continued to be present at 12 months after starting treatment. Fatigue scores at all time-points correlated with general HRQoL using the Kids ITP Tool, but did not correlate with bleeding symptoms, platelet count, or platelet response to treatment. Fatigue is common in children and adolescents with ITP and may benefit from ITP-directed treatment even in the absence of bleeding symptoms.
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Affiliation(s)
- Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, MA, USA
| | - Robert J Klaassen
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Kristin A Shimano
- Division of Allergy/Immunology/Bone Marrow Transplant, UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Michele P Lambert
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Amanda Grimes
- Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, TX, USA
| | | | | | | | - Vandy Black
- Division of Pediatric Hematology/Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Kathleen Overholt
- Riley Hospital at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rukhmi Bhat
- Ann and Robert H. Lurie Childrens Hospital of Chicago, Chicago, IL, USA
| | - Peter W Forbes
- Clinical Research Center, Boston Children's Hospital, Boston, MA, USA
| | - Cindy Neunert
- Columbia University Medical School, New York, NY, USA
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17
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Grace RF, Shimano KA, Bhat R, Neunert C, Bussel JB, Klaassen RJ, Lambert MP, Rothman JA, Breakey VR, Hege K, Bennett CM, Rose MJ, Haley KM, Buchanan GR, Geddis A, Lorenzana A, Jeng M, Pastore YD, Crary SE, Neier M, Neufeld EJ, Neu N, Forbes PW, Despotovic JM. Second-line treatments in children with immune thrombocytopenia: Effect on platelet count and patient-centered outcomes. Am J Hematol 2019; 94:741-750. [PMID: 30945320 DOI: 10.1002/ajh.25479] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 04/01/2019] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder with isolated thrombocytopenia and hemorrhagic risk. While many children with ITP can be safely observed, treatments are often needed for various reasons, including to decrease bleeding, or to improve health related quality of life (HRQoL). There are a number of available second-line treatments, including rituximab, thrombopoietin-receptor agonists, oral immunosuppressive agents, and splenectomy, but data comparing treatment outcomes are lacking. ICON1 is a prospective, multi-center, observational study of 120 children starting second-line treatments for ITP designed to compare treatment outcomes including platelet count, bleeding, and HRQoL utilizing the Kids ITP Tool (KIT). While all treatments resulted in increased platelet counts, romiplostim had the most pronounced effect at 6 months (P = .04). Only patients on romiplostim and rituximab had a significant reduction in both skin-related (84% to 48%, P = .01 and 81% to 43%, P = .004) and non-skin-related bleeding symptoms (58% to 14%, P = .0001 and 54% to 17%, P = .0006) after 1 month of treatment. HRQoL significantly improved on all treatments. However, only patients treated with eltrombopag had a median improvement in KIT scores at 1 month that met the minimal important difference (MID). Bleeding, platelet count, and HRQoL improved in each treatment group, but the extent and timing of the effect varied among treatments. These results are hypothesis generating and help to improve our understanding of the effect of each treatment on specific patient outcomes. Combined with future randomized trials, these findings will help clinicians select the optimal second-line treatment for an individual child with ITP.
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Affiliation(s)
- Rachael F. Grace
- Division of Hematology/OncologyDana‐Farber/Boston Children's Cancer and Blood Disorder Center Boston Massachusetts
| | - Kristin A. Shimano
- Division of Pediatric Allergy, Immunology, and Bone Marrow TransplantationUCSF Benioff Children's Hospital San Francisco California
| | - Rukhmi Bhat
- Center for Cancer & Blood Disorders, Ann and Robert H. Lurie Childrens Hospital of ChicagoFeinberg School of Medicine, Northwestern University Chicago Illinois
| | - Cindy Neunert
- Division of Hematology, Oncology, and Stem Cell TransplantColumbia University Medical School New York New York
| | - James B. Bussel
- Department of PediatricsWeill Cornell Medicine New York New York
| | - Robert J. Klaassen
- Division of Hematology/OncologyChildren's Hospital of Eastern Ontario Ottawa Ontario Canada
| | - Michele P. Lambert
- Division of HematologyThe Children's Hospital of Philadelphia Philadelphia Pennsylvania
| | - Jennifer A. Rothman
- Division of Pediatric Hematology/OncologyDuke University Medical Center Durham North Carolina
| | - Vicky R. Breakey
- Division of Pediatric Hematology/OncologyMcMaster University Hamilton Ontario Canada
| | - Kerry Hege
- Division of Pediatric Hematology/Oncology, Riley Hospital at IU HealthIndiana University School of Medicine Indianapolis Indiana
| | - Carolyn M. Bennett
- Division of Hematology/Oncology, Aflac Cancer and Blood Disorders CenterEmory University School of Medicine, Children's Healthcare of Atlanta Atlanta Georgia
| | - Melissa J. Rose
- Division of Hematology, Oncology, and Bone Marrow Transplant, Nationwide Children's HospitalThe Ohio State University College of Medicine Columbus Ohio
| | - Kristina M. Haley
- Division of Pediatric HematologyOregon Health & Science University Portland Oregon
| | - George R. Buchanan
- Division of Hematology‐OncologyUniversity of Texas Southwestern Medical Center Dallas Texas
| | - Amy Geddis
- Division of Pediatric Hematology/OncologyUniversity of Washington, Seattle Children's Hospital Seattle Washington
| | - Adonis Lorenzana
- Division of Pediatric Hematology/OncologySt. John Ascension Hospital Detroit Michigan
| | - Michael Jeng
- Department of PediatricsStanford School of Medicine Palo Alto California
| | - Yves D. Pastore
- Division of Hematology/OncologyCHU Sainte‐Justine Montreal Québec Canada
| | - Shelley E. Crary
- Department of PediatricsUniversity of Arkansas for Medical Sciences Little Rock Arkansas
| | - Michelle Neier
- Division of Pediatric Hematology/OncologyGoryeb Children's Hospital Morristown New Jersey
| | - Ellis J. Neufeld
- Division of HematologySt. Jude Children's Research Hospital Memphis Tennessee
| | - Nolan Neu
- Division of Hematology/OncologyDana‐Farber/Boston Children's Cancer and Blood Disorder Center Boston Massachusetts
| | - Peter W. Forbes
- Clinical Research CenterBoston Children's Hospital Boston Massachusetts
| | - Jenny M. Despotovic
- Department of PediatricsHematology/Oncology Section, Baylor College of Medicine Houston Texas
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18
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Saleem R, Rogers ZR, Neunert C, George JN. Maintenance rituximab for relapsing thrombotic thrombocytopenic purpura: a case report. Transfusion 2018; 59:921-926. [DOI: 10.1111/trf.15093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/09/2018] [Accepted: 10/26/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Rabia Saleem
- Department of Internal Medicine, College of Medicine, Department of Biostatistics & Epidemiology, College of Public HealthUniversity of Oklahoma Health Sciences Center Oklahoma City Oklahoma
| | - Zora R. Rogers
- Division of Hematology/Oncology, Department of PediatricsThe University of Texas Southwestern Medical Center Dallas Texas
| | - Cindy Neunert
- Hematology Division, Department of PediatricsNew York‐Presbyterian Hospital, Columbia University College of Physicians & Surgeons New York New York
| | - James N. George
- Department of Internal Medicine, College of Medicine, Department of Biostatistics & Epidemiology, College of Public HealthUniversity of Oklahoma Health Sciences Center Oklahoma City Oklahoma
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19
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Li B, Zhu X, Ward CM, Starlard-Davenport A, Takezaki M, Berry A, Ward A, Wilder C, Neunert C, Kutlar A, Pace BS. MIR-144-mediated NRF2 gene silencing inhibits fetal hemoglobin expression in sickle cell disease. Exp Hematol 2018; 70:85-96.e5. [PMID: 30412705 DOI: 10.1016/j.exphem.2018.11.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 11/01/2018] [Indexed: 12/30/2022]
Abstract
Inherited genetic modifiers and pharmacologic agents that enhance fetal hemoglobin (HbF) expression reverse the clinical severity of sickle cell disease (SCD). Recent efforts to develop novel strategies of HbF induction include discovery of molecular targets that regulate γ-globin gene transcription and translation. The purpose of this study was to perform genome-wide microRNA (miRNA) analysis to identify genes associated with HbF expression in patients with SCD. We isolated RNA from purified reticulocytes for microarray-based miRNA expression profiling. Using samples from patients with contrasting HbF levels, we observed an eightfold upregulation of miR-144-3p (miR-144) and miR-144-5p in the low-HbF group compared with those with high HbF. Additional analysis by reverse transcription quantitative polymerase chain reaction confirmed individual miR-144 expression levels of subjects in the two groups. Subsequent functional studies in normal and sickle erythroid progenitors showed NRF2 gene silencing by miR-144 and concomitant repression of γ-globin transcription; by contrast, treatment with miR-144 antagomir reversed its silencing effects in a dose-dependent manner. Because NRF2 regulates reactive oxygen species levels, additional studies investigated mechanisms of HbF regulation using a hemin-induced oxidative stress model. Treatment of KU812 cells with hemin produced an increase in NRF2 expression and HbF induction that reversed with miR-144 pretreatment. Chromatin immunoprecipitation assay confirmed NRF2 binding to the γ-globin antioxidant response element, which was inhibited by miR-144 mimic treatment. The genome-wide miRNA microarray and primary erythroid progenitor data support a miR-144/NRF2-mediated mechanism of γ-globin gene regulation in SCD.
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Affiliation(s)
- Biaoru Li
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - Xingguo Zhu
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - Christina M Ward
- Department of Biochemistry and Molecular Biology, Boston University, Boston, MA, USA
| | - Athena Starlard-Davenport
- Department of Genetics, Genomics and Informatics, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Mayuko Takezaki
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - Amber Berry
- Medical College of Georgia, Augusta, GA, USA
| | - Alexander Ward
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - Caroline Wilder
- Department of Otolaryngology, Augusta University, Augusta, GA, USA
| | - Cindy Neunert
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - Abdullah Kutlar
- Department of Medicine, Augusta University, Augusta, GA, USA
| | - Betty S Pace
- Department of Pediatrics, Augusta University, Augusta, GA, USA; Department of Biochemistry and Molecular Biology, Augusta University, Augusta, GA, USA.
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20
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Grace RF, Despotovic JM, Bennett CM, Bussel JB, Neier M, Neunert C, Crary SE, Pastore YD, Klaassen RJ, Rothman JA, Hege K, Breakey VR, Rose MJ, Shimano KA, Buchanan GR, Geddis A, Haley KM, Lorenzana A, Thompson A, Jeng M, Neufeld EJ, Brown T, Forbes PW, Lambert MP. Physician decision making in selection of second-line treatments in immune thrombocytopenia in children. Am J Hematol 2018; 93:882-888. [PMID: 29659042 DOI: 10.1002/ajh.25110] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 04/02/2018] [Accepted: 04/06/2018] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is an acquired autoimmune bleeding disorder which presents with isolated thrombocytopenia and risk of hemorrhage. While most children with ITP promptly recover with or without drug therapy, ITP is persistent or chronic in others. When needed, how to select second-line therapies is not clear. ICON1, conducted within the Pediatric ITP Consortium of North America (ICON), is a prospective, observational, longitudinal cohort study of 120 children from 21 centers starting second-line treatments for ITP which examined treatment decisions. Treating physicians reported reasons for selecting therapies, ranking the top three. In a propensity weighted model, the most important factors were patient/parental preference (53%) and treatment-related factors: side effect profile (58%), long-term toxicity (54%), ease of administration (46%), possibility of remission (45%), and perceived efficacy (30%). Physician, health system, and clinical factors rarely influenced decision-making. Patient/parent preferences were selected as reasons more often in chronic ITP (85.7%) than in newly diagnosed (0%) or persistent ITP (14.3%, P = .003). Splenectomy and rituximab were chosen for the possibility of inducing long-term remission (P < .001). Oral agents, such as eltrombopag and immunosuppressants, were chosen for ease of administration and expected adherence (P < .001). Physicians chose rituximab in patients with lower expected adherence (P = .017). Treatment choice showed some physician and treatment center bias. This study illustrates the complexity and many factors involved in decision-making in selecting second-line ITP treatments, given the absence of comparative trials. It highlights shared decision-making and the need for well-conducted, comparative effectiveness studies to allow for informed discussion between patients and clinicians.
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Affiliation(s)
- Rachael F. Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorder Center; Boston Massachusetts
| | - Jenny M. Despotovic
- Texas Children's Hematology Center, Baylor College of Medicine; Houston Texas
| | - Carolyn M. Bennett
- Emory University School of Medicine; Children's Healthcare of Atlanta, Aflac Cancer and Blood Disorders Center; Atlanta Georgia
| | | | | | - Cindy Neunert
- Columbia University Medical School; New York New York
| | - Shelley E. Crary
- University of Arkansas for Medical Sciences; Little Rock Arkansas
| | | | | | | | - Kerry Hege
- Riley Hospital at IU Health, Indiana University School of Medicine; Indianapolis Indiana
| | | | - Melissa J. Rose
- Nationwide Children's Hospital, The Ohio State University College of Medicine; Columbus Ohio
| | | | | | - Amy Geddis
- University of Washington, Seattle Children's Hospital; Seattle Washington
| | | | | | - Alexis Thompson
- Ann and Robert H. Lurie Childrens Hospital of Chicago, Northwestern University, Feinberg School of Medicine; Chicago Illinois
| | - Michael Jeng
- Stanford School of Medicine; Palo Alto California
| | | | - Travis Brown
- Dana-Farber/Boston Children's Cancer and Blood Disorder Center; Boston Massachusetts
| | - Peter W. Forbes
- Boston Children's Hospital, Clinical Research Center; Boston Massachusetts
| | - Michele P. Lambert
- Division of Hematology; The Children's Hospital of Philadelphia; Philadelphia Pennsylvania
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21
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Bennett CM, Neunert C, Grace RF, Buchanan G, Imbach P, Vesely SK, Kuhne T. Predictors of remission in children with newly diagnosed immune thrombocytopenia: Data from the Intercontinental Cooperative ITP Study Group Registry II participants. Pediatr Blood Cancer 2018; 65. [PMID: 28792679 DOI: 10.1002/pbc.26736] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 06/12/2017] [Accepted: 07/02/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) during childhood spontaneously remits in up to 80% of children. Predictors of remission are not well understood. PROCEDURE We analyzed data from Intercontinental Cooperative ITP Study Group (ICIS) Registry II, a large prospective cohort of children with ITP, to investigate factors that might predict remission. RESULTS In ICIS Registry II, 705 patients had data collected through 12 months following diagnosis, with 383 patients having data available at 24 months as well. Younger age and pharmacologic treatment at diagnosis were significantly associated with disease resolution at 12 and 24 months (P < 0.0001 for both) as was bleeding at diagnosis (P < 0.0001 and P = 0.0213, respectively). Gender and platelet count at diagnosis were not significantly correlated with remission. In the multivariable analysis, remission at 12 months was associated with younger age, higher bleeding grade at diagnosis, and treatment with a combination of intravenous immunoglobulin (IVIG) and corticosteroids at diagnosis. Only younger age and treatment with IVIG and steroids in combination at diagnosis were associated with remission at 24 months. Patients <1 year of age had the highest odds of achieving remission at both 12 months (OR 4.7, 95% CI: 2.0-10.6) and 24 months (OR 7.0, 95% CI: 2.3-20.8). CONCLUSIONS Younger age, bleeding severity at diagnosis, and initial treatment with a combination of corticosteroids and IVIG are associated with remission at 12 months in the ICIS Registry II. Patients <1 year of age have the highest likelihood of remission. The relationship of bleeding and treatment at diagnosis requires further study to clarify whether these are independent predictors of remission.
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Affiliation(s)
- Carolyn M Bennett
- Department of Pediatrics, Children's Healthcare of Atlanta, Aflac Cancer and Blood Disorder Center, Emory University School of Medicine, Atlanta, Georgia
| | - Cindy Neunert
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Rachael F Grace
- Department of Pediatric Hematology/Oncology, Dana-Farber Boston Children's Cancer and Blood Disorder Center, Boston, Massachusetts
| | - George Buchanan
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Paul Imbach
- Prof. Emeritus of the Medical Faculty, University of Basel, Switzerland
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Thomas Kuhne
- Division of Oncology/Hematology, University Children's Hospital, Basel, Switzerland
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Abstract
Immune thrombocytopenia (ITP) is a rare, acquired autoimmune condition characterized by a low platelet count and an increased risk of bleeding. Although many children and adults with ITP will not need therapy beyond historic first-line treatments of observation, steroids, intravenous immunoglobulin (IVIG), and anti-D globulin, others will have an indication for second-line treatment. Selecting a second-line therapy depends on the reason for treatment, which can vary from bleeding to implications for health-related quality of life (HRQoL) to likelihood of remission and patient preference with regard to adverse effects, route of administration, and cost. Published studies of these treatments are limited by lack of comparative trials, in addition to inconsistent outcome measures, definitions, and efficacy endpoints. This article provides an up-to-date comparison of the second-line treatments, highlighting important outcome measures including bleeding, HRQoL, fatigue, and platelet counts, which influence treatment selection in a shared decision-making model.
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Affiliation(s)
- Rachael F Grace
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, MA; and
| | - Cindy Neunert
- Division of Pediatric Hematology/Oncology/Stem Cell Transplantation, Columbia University Medical Center, New York, NY
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23
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Neunert C, Despotovic J, Haley K, Lambert MP, Nottage K, Shimano K, Bennett C, Klaassen R, Stine K, Thompson A, Pastore Y, Brown T, Forbes PW, Grace RF. Thrombopoietin Receptor Agonist Use in Children: Data From the Pediatric ITP Consortium of North America ICON2 Study. Pediatr Blood Cancer 2016; 63:1407-13. [PMID: 27135461 PMCID: PMC5718620 DOI: 10.1002/pbc.26003] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 03/04/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Data on second-line treatment options for pediatric patients with immune thrombocytopenia (ITP) are limited. Thrombopoietin receptor agonists (TPO-RA) provide a nonimmunosuppressive option for children who require an increased platelet count. PROCEDURE We performed a multicenter retrospective study of pediatric ITP patients followed at ITP Consortium of North America (ICON) sites to characterize TPO-RA use. RESULTS Seventy-nine children had a total of 87 treatments (28 eltrombopag, 43 romiplostim, and eight trialed on both). The majority had primary ITP (82%) and most (60.8%) had chronic ITP. However, 22% had persistent ITP and 18% had newly diagnosed ITP. During the first 3 months of treatment, 89% achieved a platelet count ≥ 50 × 10(9) /l (86% romiplostim, 81% eltrombopag, P = 0.26) at least once in the absence of rescue therapy. The average time to a response was 6.4 weeks for romiplostim and 7.0 weeks for eltrombopag (P = 0.83). Only 40% of patients demonstrated a stable response with consistent dosing over time. An intermittent response with constant dose titration was seen in 15%, and an initial response that waned to no response was seen in 13%. Significant adverse events were minimal with the exception of two patients with thrombotic events and one who developed a neutralizing antibody. CONCLUSIONS Our results demonstrate that TPO-RA agents are being used in children with ITP of varying duration and severity. The response was similar to clinical trials, but the sustainability of response varied. Future studies need to focus on the ideal timing and rationale for these medications in pediatric patients.
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Affiliation(s)
- Cindy Neunert
- Division of Pediatric Hematology/Oncology/Stem Cell Transplantation, Columbia University Medical Center, New York, NY
| | - Jenny Despotovic
- Texas Children’s Hematology Center, Baylor College of Medicine, Houston, TX
| | - Kristina Haley
- Division of Pediatric Hematology/Oncology, Oregon Health and Sciences University, Portland, OR
| | - Michele P. Lambert
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Kristin Shimano
- Division of Pediatric Hematology/Oncology, University of California San Francisco, San Francisco, CA
| | - Carolyn Bennett
- Aflac Cancer Center and Blood Disorders Service, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, GA
| | - Robert Klaassen
- Division of Pediatric Hematology/Oncology, University of Ottawa, Ottawa, Ontario
| | - Kimo Stine
- Division of Pediatric Hematology/Oncology, University of Arkansas for Medical Sciences at Arkansas Children’s Hospital, Little Rock, AR
| | - Alexis Thompson
- Division of Hematology/Oncology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Yves Pastore
- CHU Ste-Justine, Montreal University, Montreal, Quebec
| | - Travis Brown
- Clinical Research Center, Boston Children’s Hospital, Boston, MA
| | - Peter W. Forbes
- Clinical Research Center, Boston Children’s Hospital, Boston, MA
| | - Rachael F. Grace
- Clinical Research Center, Boston Children’s Hospital, Boston, MA
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Witmer CM, Lambert MP, O'Brien SH, Neunert C. Multicenter Cohort Study Comparing U.S. Management of Inpatient Pediatric Immune Thrombocytopenia to Current Treatment Guidelines. Pediatr Blood Cancer 2016; 63:1227-31. [PMID: 26929009 DOI: 10.1002/pbc.25961] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 02/04/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Recent pediatric immune thrombocytopenia (ITP) guidelines have significantly altered and are encouraging an observational approach for patients without significant bleeding regardless of their platelet count. PROCEDURE This retrospective multicenter cohort study utilized the Pediatric Health Information Systems (PHIS) administrative database. Subjects were 6 months to 18 years of age, admitted to a PHIS hospital between January 1, 2008 and September 30, 2014, with a primary diagnosis code for ITP. International Classification of Disease, Ninth Revision, Clinical Modification Code (ICD-9-CM) discharge codes identified significant bleeding. Pharmaceutical billing codes identified the use of pharmacologic therapy for ITP. Clinical management during preguideline admissions (January 1, 2008 to August 31, 2011) was compared to postguideline admissions (September 1, 2011 to September 30, 2014). RESULTS A total of 4,937 subjects met inclusion criteria with a mean age of 6.2 (SD 5) years; 93.4% (4,613/4,937) received pharmacologic treatment for ITP but only 14.2% (699/4,937) had ICD-9-CM codes for significant bleeding; 11.5% (570/4,937) of subjects were readmitted. In comparing pre- versus postguideline time periods, the proportion of subjects receiving ITP pharmacologic treatment did not change (92.9% vs. 94.1%; P = 0.26). A decrease was found in the proportion of bone marrows performed (9.7% vs. 6.4%; P < 0.001) and length of stay (2.3 vs. 2 days; P < 0.001). The proportion of ITP admissions from 2012 to 2014 was modestly decreased when compared to 2008-2010 (12.9 vs. 14.5/10,000 PHIS admissions, P < 0.001). CONCLUSIONS Despite guidelines and evidence that supports a watchful waiting approach for pediatric patients with ITP, a large proportion of inpatients without significant bleeding are still receiving pharmacologic therapy. Continued efforts are needed to address why inpatient U.S. practice patterns are so discrepant from current treatment guidelines.
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Affiliation(s)
- Char M Witmer
- Divisions of Hematology, Departments of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michele P Lambert
- Divisions of Hematology, Departments of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Cindy Neunert
- Division of Pediatric Hematology, Oncology/Bone Marrow Transplant, Columbia University, New York, New York
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Neunert C, Farah R, Yacobovich J, Neufeld E. Refractory autoimmune disease: an overview of when first-line therapy is not enough. Semin Hematol 2016; 53 Suppl 1:S35-8. [PMID: 27312162 DOI: 10.1053/j.seminhematol.2016.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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26
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Neunert C, Arnold DM. Severe bleeding events in adults and children with primary immune thrombocytopenia: a systematic review: reply. J Thromb Haemost 2015; 13:1522-3. [PMID: 26017732 DOI: 10.1111/jth.13019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- C Neunert
- Department of Pediatrics and Cancer Center, Georgia Regents University, Augusta, GA, USA
| | - D M Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- Canadian Blood Services, Hamilton, ON, Canada
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Neunert C, Noroozi N, Norman G, Buchanan GR, Goy J, Nazi I, Kelton JG, Arnold DM. Severe bleeding events in adults and children with primary immune thrombocytopenia: a systematic review. J Thromb Haemost 2015; 13:457-64. [PMID: 25495497 PMCID: PMC4991942 DOI: 10.1111/jth.12813] [Citation(s) in RCA: 187] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND The burden of severe bleeding in adults and children with immune thrombocytopenia (ITP) has not been established. OBJECTIVES To describe the frequency and severity of bleeding events in patients with ITP, and the methods used to measure bleeding in ITP studies. PATIENTS/METHODS We performed a systematic review of all prospective ITP studies that enrolled 20 or more patients. Two reviewers searched Medline, Embase, CINAHL and the Cochrane registry up to May 2014. Overall weighted proportions were estimated using a random effects model. Measurement properties of bleeding assessment tools were evaluated. RESULTS We identified 118 studies that reported bleeding (n = 10 908 patients). Weighted proportions for intracerebral hemorrhage (ICH) were 1.4% for adults (95% confidence interval [CI], 0.9-2.1%) and 0.4% for children (95% CI, 0.2-0.7%; P < 0.01), most of whom had chronic ITP. The weighted proportion for severe (non-ICH) bleeding was 9.6% for adults (95% CI, 4.1-17.1%) and 20.2% for children (95% CI, 10.0-32.9%; P < 0.01) with newly-diagnosed or chronic ITP. Methods of reporting and definitions of severe bleeding were highly variable in primary studies. Two bleeding assessment tools (Buchanan 2002 for children; Page 2007 for adults) demonstrated adequate inter-rater reliability and validity in independent assessments. CONCLUSIONS ICH was more common in adults and tended to occur during chronic ITP; other severe bleeds were more common in children and occurred at all stages of disease. Reporting of non-ICH bleeding was variable across studies. Further attention to ITP-specific bleeding measurement in clinical trials is needed to improve standardization of this important outcome for patients.
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Affiliation(s)
- C Neunert
- Department of Pediatrics and Cancer Center, Georgia Regents University, Augusta, GA, USA
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28
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Hussain S, Nichols F, Bowman L, Xu H, Neunert C. Implementation of transcranial Doppler ultrasonography screening and primary stroke prevention in urban and rural sickle cell disease populations. Pediatr Blood Cancer 2015; 62:219-223. [PMID: 25381872 DOI: 10.1002/pbc.25306] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 09/18/2014] [Indexed: 11/06/2022]
Abstract
BACKGROUND Transcranial Doppler (TCD) ultrasonography identifies children with sickle cell disease (SCD) at increased risk of stroke. Initiation of chronic transfusions as primary stroke prevention in children with abnormal TCD significantly reduces stroke risk. Here, we report the results describing the implementation of TCD screening and primary stroke prevention in both urban and rural clinical practices. PROCEDURE Retrospective chart review identified children ages 2-16 years with Hgb SS or Sß0 -thalassemia and no history of stroke followed in either the local urban or rural SCD clinics at Georgia Regents University. We defined standard of care (SOC) as having one TCD performed annually between January 2010 and December 2012 starting at age 2 years. RESULTS A total of 195 patients were included in the evaluation of SOC screening, overall 41% achieved SOC. There was no difference in SOC between the two clinics (35% urban and 47.4% rural). The majority of patients with abnormal TCDs are on chronic transfusions (83%), and none have experienced a stroke. Monitoring of effects of transfusion was difficult with 38% and 31% of rural patients lacking documentation of Hgb S% and ferritin levels, respectively, in the past year. CONCLUSIONS We report here data describing primary stroke prophylaxis in rural patients. SOC rates are similar between the two clinical settings. While implementation of primary stroke prevention in rural patients was difficult, rural TCD screening is feasible and can achieve SOC equal to that in an urban setting. This suggests that barriers exist in provided primary stroke prevention to all patients. Pediatr Blood Cancer 2015;62:219-223. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
- Samiya Hussain
- Medical College of Georgia, Georgia Regents University, Augusta, Georgia
| | - Fenwick Nichols
- Department of Neurology, Georgia Regents University, Augusta, Georgia
| | - Latanya Bowman
- Sickle Cell Center, Georgia Regents University, Augusta, Georgia
| | - Hongyan Xu
- Department of Biostatistics and Epidemiology, Georgia Regents University, Augusta, Georgia
| | - Cindy Neunert
- Cancer Center, Georgia Regents University, Augusta, Georgia.,Department of Pediatrics, Georgia Regents University, Augusta, Georgia
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Neunert C. Idiopathic thrombocytopenic purpura: advances in management. Clin Adv Hematol Oncol 2011; 9:404-406. [PMID: 21685870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Cindy Neunert
- Department of Pediatrics, University of Texas, Southwestern Medical Center at Dallas, Dallas, TX, USA
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Rodeghiero F, Tosetto A, Abshire T, Arnold DM, Coller B, James P, Neunert C, Lillicrap D. ISTH/SSC bleeding assessment tool: a standardized questionnaire and a proposal for a new bleeding score for inherited bleeding disorders. J Thromb Haemost 2010; 8:2063-5. [PMID: 20626619 DOI: 10.1111/j.1538-7836.2010.03975.x] [Citation(s) in RCA: 497] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- F Rodeghiero
- Department of Cell Therapy and Hematology, San Bortolo Hospital, Vicenza, Italy.
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