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Sharathkumar A, Wendt L, Ortman C, Srinivasan R, Chute CG, Chrischilles E, Takemoto CM. COVID-19 outcomes in persons with hemophilia: results from a US-based national COVID-19 surveillance registry. J Thromb Haemost 2024; 22:61-75. [PMID: 37182697 PMCID: PMC10181864 DOI: 10.1016/j.jtha.2023.04.040] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/29/2023] [Accepted: 04/25/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Hypercoagulable state contributing to thrombotic complications worsens COVID-19 severity and outcomes, whereas anticoagulation improves outcomes by alleviating hypercoagulability. OBJECTIVES To examine whether hemophilia, an inherent hypocoagulable condition, offers protection against COVID-19 severity and reduces venous thromboembolism (VTE) risk in persons with hemophilia (PwH). METHODS A 1:3 propensity score-matched retrospective cohort study used national COVID-19 registry data (January 2020 through January 2022) to compare outcomes between 300 male PwH and 900 matched controls without hemophilia. RESULTS Analyses of PwH demonstrated that known risk factors (older age, heart failure, hypertension, cancer/malignancy, dementia, and renal and liver disease) contributed to severe COVID-19 and/or 30-day all-cause mortality. Non-central nervous system bleeding was an additional risk factor for poor outcomes in PwH. Odds of developing VTE with COVID-19 in PwH were associated with pre-COVID VTE diagnosis (odds ratio [OR], 51.9; 95% CI, 12.8-266; p < .001), anticoagulation therapy (OR, 12.7; 95% CI, 3.01-48.6; p < .001), and pulmonary disease (OR, 16.1; 95% CI, 10.4-25.4; p < .001). Thirty-day all-cause mortality (OR, 1.27; 95% CI, 0.75-2.11; p = .3) and VTE events (OR, 1.32; 95% CI, 0.64-2.73; p = .4) were not significantly different between the matched cohorts; however, hospitalizations (OR, 1.58; 95% CI, 1.20-2.10; p = .001) and non-central nervous system bleeding events (OR, 4.78; 95% CI, 2.98-7.48; p < .001) were increased in PwH. In multivariate analyses, hemophilia did not reduce adverse outcomes (OR, 1.32; 95% CI, 0.74-2.31; p = .2) or VTE (OR, 1.14; 95% CI, 0.44-2.67; p = .8) but increased bleeding risk (OR, 4.70; 95% CI, 2.98-7.48; p < .001). CONCLUSION After adjusting for patient characteristics/comorbidities, hemophilia increased bleeding risk with COVID-19 but did not protect against severe disease and VTE.
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Affiliation(s)
- Anjali Sharathkumar
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.
| | - Linder Wendt
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, Iowa, USA
| | - Chris Ortman
- Department of Bioinformatics, University of Iowa, Iowa City, Iowa, USA; Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Ragha Srinivasan
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - Elizabeth Chrischilles
- Department of Bioinformatics, University of Iowa, Iowa City, Iowa, USA; Department of Epidemiology, School of Public Health, University of Iowa, Iowa, USA
| | - Clifford M Takemoto
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Zheng Y, Yang W, Estepp J, Pei D, Cheng C, Takemoto CM, Inaba H, Jeha S, Pui CH, Relling MV, Karol SE. Genomic analysis of venous thrombosis in children with acute lymphoblastic leukemia from diverse ancestries. Haematologica 2024; 109:53-59. [PMID: 37408475 PMCID: PMC10772501 DOI: 10.3324/haematol.2022.281582] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 06/29/2023] [Indexed: 07/07/2023] Open
Abstract
Venous thrombosis is a common adverse effect of modern therapy for acute lymphoblastic leukemia (ALL). Prior studies to identify risks of thrombosis in pediatric ALL have been limited by genetic screens of pre-identified genetic variants or genome- wide association studies (GWAS) in ancestrally uniform populations. To address this, we performed a retrospective cohort evaluation of thrombosis risk in 1,005 children treated for newly diagnosed ALL. Genetic risk factors were comprehensively evaluated from genome-wide single nucleotide polymorphism (SNP) arrays and were evaluated using Cox regression adjusting for identified clinical risk factors and genetic ancestry. The cumulative incidence of thrombosis was 7.8%. In multivariate analysis, older age, T-lineage ALL, and non-O blood group were associated with increased thrombosis while non-low-risk treatment and higher presenting white blood cell count trended toward increased thrombosis. No SNP reached genome-wide significance. The SNP most strongly associated with thrombosis was rs2874964 near RFXAP (G risk allele; P=4x10-7; hazard ratio [HR] =2.8). In patients of non-European ancestry, rs55689276 near the α globin cluster (P=1.28x10-6; HR=27) was most strongly associated with thrombosis. Among GWAS catalogue SNP reported to be associated with thrombosis, rs2519093 (T risk allele, P=4.8x10-4; HR=2.1), an intronic variant in ABO, was most strongly associated with risk in this cohort. Classic thrombophilia risks were not associated with thrombosis. Our study confirms known clinical risk features associated with thrombosis risk in children with ALL. In this ancestrally diverse cohort, genetic risks linked to thrombosis risk aggregated in erythrocyte-related SNP, suggesting the critical role of this tissue in thrombosis risk.
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Affiliation(s)
| | | | - Jeremie Estepp
- Departments of Global Pediatric Medicine; Departments of Hematology
| | | | | | | | - Hiroto Inaba
- Departments of Oncology. St. Jude Children's Research Hospital, Memphis, TN
| | - Sima Jeha
- Departments of Global Pediatric Medicine; Departments of Oncology. St. Jude Children's Research Hospital, Memphis, TN
| | - Ching-Hon Pui
- Departments of Oncology. St. Jude Children's Research Hospital, Memphis, TN
| | | | - Seth E Karol
- Departments of Oncology. St. Jude Children's Research Hospital, Memphis, TN.
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Jesudas R, Takemoto CM. Where have all the platelets gone? HIT, DIC, or something else? Hematology Am Soc Hematol Educ Program 2023; 2023:43-50. [PMID: 38066886 PMCID: PMC10727081 DOI: 10.1182/hematology.2023000465] [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] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Thrombocytopenia in ill children is common; accurately diagnosing the underlying etiology is challenging and essential for appropriate management. Triggers for accelerated consumption of platelets are numerous; common downstream mechanisms of clearance include platelet trapping in microvascular thrombi, phagocytosis, and platelet activation. Thrombocytopenia with microangiopathic hemolytic anemia (MAHA) is frequently due to disseminated intravascular coagulation. Thrombotic microangiopathy (TMA) is a subgroup of MAHA. Specific TMA syndromes include thrombotic thrombocytopenic purpura, complement-mediated TMA (CM-TMA), and Shiga toxin-mediated hemolytic uremic syndrome. Isolated thrombocytopenia is characteristic of immune thrombocytopenia; however, concomitant cytopenias are frequent in critically ill patients, making the diagnosis difficult. Immune thrombocytopenia with large vessel thrombosis is a feature of heparin-induced thrombocytopenia and antiphospholipid antibody syndrome. In addition, thrombocytopenia is common with macrophage activation, which is characteristic of hemophagocytic lymphohistiocytosis. While thrombocytopenia in ill patients can be driven by hypoproliferative processes such as myelosuppression and/or bone marrow failure, this review will focus on consumptive thrombocytopenia due to immune and nonimmune causes.
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Heitzer AM, Rashkin SR, Trpchevska A, Longoria JN, Rampersaud E, Olufadi Y, Wang WC, Raches D, Potter B, Steinberg MH, King AA, Kang G, Takemoto CM, Hankins JS. Catechol-O-methyltransferase gene (COMT) is associated with neurocognitive functioning in patients with sickle cell disease. Curr Res Transl Med 2023; 72:103433. [PMID: 38244277 DOI: 10.1016/j.retram.2023.103433] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/26/2023] [Accepted: 11/19/2023] [Indexed: 01/22/2024]
Abstract
PURPOSE Neurocognitive impairment is a common and debilitating complication of sickle cell disease (SCD) resulting from a combination of biological and environmental factors. The catechol-O-methyltransferase (COMT) gene modulates levels of dopamine availability in the prefrontal cortex. COMT has repeatedly been implicated in the perception of pain stimuli and frequency of pain crises in patients with SCD and is known to be associated with neurocognitive functioning in the general population. The current study aimed to examine the associations of genetic variants in COMT and neurocognitive functioning in patients with SCD. PATIENTS AND METHODS The Sickle Cell Clinical Research and Intervention Program (SCCRIP) longitudinal cohort was used as a discovery cohort (n = 166). The genotypes for 5 SNPs (rs6269, rs4633, rs4818, rs4680, and rs165599) in COMT were extracted from whole genome sequencing data and analyzed using a dominant model. A polygenic score for COMT (PGSCOMT) integrating these 5 SNPs was analyzed as a continuous variable. The Cooperative Study of Sickle Cell Disease (CSSCD, n = 156) and the Silent Cerebral Infarction Transfusion (SIT, n = 114) Trial were used as 2 independent replication cohorts. Due to previously reported sex differences, all analyses were conducted separately in males and females. The Benjamini and Hochberg approach was used to calculate false discovery rate adjusted p-value (q-value). RESULTS In SCCRIP, 1 out of 5 SNPs (rs165599) was associated with IQ at q<0.05 in males but not females, and 2 other SNPs (rs4633 and rs4680) were marginally associated with sustained attention at p<0.05 in males only but did not maintain at q<0.05. PGSCOMT was negatively associated with IQ and sustained attention at p<0.05 in males only. Using 3 cohorts' data, 4 out of 5 SNPs (rs6269, rs4633, rs4680, rs165599) were associated with IQ (minimum q-value = 0.0036) at q<0.05 among male participants but not female participants. The PGSCOMT was negatively associated with IQ performance among males but not females across all cohorts. CONCLUSION Select COMT SNPs are associated with neurocognitive abilities in males with SCD. By identifying genetic predictors of neurocognitive performance in SCD, it may be possible to risk-stratify patients from a young age to guide implementation of early interventions.
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Affiliation(s)
- Andrew M Heitzer
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN, United States.
| | - Sara R Rashkin
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Ana Trpchevska
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Jennifer N Longoria
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Evadnie Rampersaud
- Center for Applied Bioinformatics, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Yunusa Olufadi
- Biostatistics Department, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Winfred C Wang
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Darcy Raches
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Brian Potter
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Martin H Steinberg
- Department of Medicine, Boston University Chobanian & Avidesian School of Medicine, Boston, MA, United States
| | - Allison A King
- Program in Occupational Therapy and Departments of Pediatrics and Medicine, Washington University, St. Louis, MO, United States
| | - Guolian Kang
- Biostatistics Department, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Clifford M Takemoto
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Jane S Hankins
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN, United States; Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
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Smeltzer MP, Reeves SL, Cooper WO, Attell BK, Strouse JJ, Takemoto CM, Kanter J, Latta K, Plaxco AP, Davis RL, Hatch D, Reyes C, Dombkowski K, Snyder A, Paulukonis S, Singh A, Kayle M. Common data model for sickle cell disease surveillance: considerations and implications. JAMIA Open 2023; 6:ooad036. [PMID: 37252051 PMCID: PMC10224800 DOI: 10.1093/jamiaopen/ooad036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 02/10/2023] [Accepted: 05/23/2023] [Indexed: 05/31/2023] Open
Abstract
Objective Population-level data on sickle cell disease (SCD) are sparse in the United States. The Centers for Disease Control and Prevention (CDC) is addressing the need for SCD surveillance through state-level Sickle Cell Data Collection Programs (SCDC). The SCDC developed a pilot common informatics infrastructure to standardize processes across states. Materials and Methods We describe the process for establishing and maintaining the proposed common informatics infrastructure for a rare disease, starting with a common data model and identify key data elements for public health SCD reporting. Results The proposed model is constructed to allow pooling of table shells across states for comparison. Core Surveillance Data reports are compiled based on aggregate data provided by states to CDC annually. Discussion and Conclusion We successfully implemented a pilot SCDC common informatics infrastructure to strengthen our distributed data network and provide a blueprint for similar initiatives in other rare diseases.
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Affiliation(s)
- Matthew P Smeltzer
- Corresponding Author: Matthew P. Smeltzer, PhD, MStat, Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, 222 Robison Hall, Memphis, TN 38152, USA;
| | - Sarah L Reeves
- Department of Pediatrics, Susan B Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor, Michigan, USA
| | - William O Cooper
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Brandon K Attell
- Georgia Health Policy Center, Georgia State University, Atlanta, Georgia, USA
| | - John J Strouse
- Department of Hematology, Duke University, Durham, North Carolina, USA
| | - Clifford M Takemoto
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Julie Kanter
- Division of Hematology-Oncology, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Krista Latta
- Department of Pediatrics, Susan B Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Allison P Plaxco
- Division of Epidemiology, Biostatistics, and Environmental Health School of Public Health, University of Memphis, Memphis, Tennessee, USA
| | - Robert L Davis
- Department of Bioinformatics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Daniel Hatch
- Duke University School of Nursing, Durham, North Carolina, USA
| | - Camila Reyes
- Duke Office of Clinical Research, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kevin Dombkowski
- Department of Pediatrics, Susan B Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Angela Snyder
- Georgia Health Policy Center, Georgia State University, Atlanta, Georgia, USA
| | - Susan Paulukonis
- Tracking California, Public Health Institute, Oakland, California, USA
| | - Ashima Singh
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mariam Kayle
- Duke University School of Nursing, Durham, North Carolina, USA
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Christakopoulos GE, Walker KN, Smith J, Takemoto CM, Zheng Y, Pui CH, Ribeiro RC, Wang L, Pounds SB, Rubnitz JE, Inaba H. Clinical characteristics and outcomes of children with newly diagnosed acute myeloid leukemia and hyperleukocytosis managed with different cytoreductive methods. Cancer 2023; 129:1873-1884. [PMID: 36943896 PMCID: PMC10824268 DOI: 10.1002/cncr.34751] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 01/31/2023] [Accepted: 02/09/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Hyperleukocytosis in patients with acute myeloid leukemia (AML) has been associated with worse outcomes. For cytoreduction, leukapheresis has been used but its clinical utility is unknown, and low-dose cytarabine (LD-cytarabine) is used as an alternative method. METHODS Children with newly diagnosed AML treated between 1997 and 2017 in institutional protocols were studied. Hyperleukocytosis was defined as a leukocyte count of ≥100 × 109 /L at diagnosis. Clinical characteristics, early complications, survival data, and effects of cytoreductive methods were reviewed. Among 324 children with newly diagnosed AML, 49 (15.1%) presented with hyperleukocytosis. Initial management of hyperleukocytosis included leukapheresis or exchange transfusion (n = 16, considered as one group), LD-cytarabine (n = 18), hydroxyurea (n = 1), and no leukoreduction (n = 14). RESULTS Compared with patients who received leukapheresis, the percentage decrease in leukocyte counts following intervention was greater among those who received LD-cytarabine (48% vs. 75%; p = .02), with longer median time from diagnosis to initiation of protocol therapy (28.1 vs. 95.2 hours; p < .001). The incidence of infection was higher in patients (38%) who had leukapheresis than those who receive LD-cytarabine (0%) or leukoreduction with protocol therapy (14%) (p = .008). No differences were noted in the outcomes among the intervention groups. Although patients with hyperleukocytosis had higher incidences of pulmonary and metabolic complications than did those without, no early deaths occurred, and the complete remission, event-free survival, overall survival rates, and outcomes of both groups were similar. CONCLUSION LD-cytarabine treatment appears to be a safe and effective means of cytoreduction for children with AML and hyperleukocytosis.
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Affiliation(s)
| | - Kendra N. Walker
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
- Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jesse Smith
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Clifford M. Takemoto
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Yan Zheng
- Department of Pathology, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Raul C. Ribeiro
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Lei Wang
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Stanley B. Pounds
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Jeffrey E. Rubnitz
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Hiroto Inaba
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
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Takemoto CM. Pediatric stroke and thrombophilia-To test or not to test? Pediatr Blood Cancer 2023:e30449. [PMID: 37243904 DOI: 10.1002/pbc.30449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 05/11/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Clifford M Takemoto
- Clinical Division of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Snyder K, Takemoto CM. Introduction: The changing role of the pediatric hematologist/oncologist in the care of people with vascular anomalies. Pediatr Blood Cancer 2022; 69 Suppl 3:e29614. [PMID: 35471737 DOI: 10.1002/pbc.29614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Kristen Snyder
- Comprehensive Vascular Anomalies Program, Solid Tumor Program, Children's Hospital of Philadelphia, Division of Oncology, Philadelphia, Pennsylvania, USA
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Morris SA, Crews KR, Hayden RT, Takemoto CM, Yang W, Baker DK, Broeckel U, Relling MV, Haidar CE. Incorporating G6PD genotyping to identify patients with G6PD deficiency. Pharmacogenet Genomics 2022; 32:87-93. [PMID: 34693927 PMCID: PMC8976699 DOI: 10.1097/fpc.0000000000000456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Indexed: 11/25/2022]
Abstract
Glucose-6-phosphate-dehydrogenase (G6PD) deficiency is a common X-linked enzyme disorder associated with hemolytic anemia after exposure to fava beans or certain medications. Activity testing is the gold standard for detecting G6PD deficiency; however, this test is affected by various hematologic parameters. Clinical G6PD genotyping is now included in pharmacogenetic arrays and clinical sequencing efforts and may be reconciled with activity results. Patients (n = 1391) enrolled on an institutional pharmacogenetic testing protocol underwent clinical G6PD genotyping for 164 G6PD variants. An algorithm accounting for known interferences with the activity assay is proposed. We developed clinical decision support alerts to inform prescribers when high-risk medications were prescribed, warning of gene-drug interactions and recommending therapy alteration. Of 1391 patients with genotype results, 1334 (95.9%) patients were predicted to have normal G6PD activity, 30 (2.1%) were predicted to have variable G6PD activity and 27 (2%) were predicted to have deficient G6PD activity. Of the 417 patients with a normal genotype and an activity result, 415 (99.5%) had a concordant normal G6PD phenotype. Of the 21 patients with a deficient genotype and an activity result, 18 (85.7%) had a concordant deficient activity result. Genotyping reassigned phenotype in five patients with discordant genotype and activity results: three switched from normal to deficient, and two switched from deficient to normal. G6PD activity and genotyping are two independent testing methods that can be used in conjunction to assign a more informed G6PD phenotype than either method alone.
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Affiliation(s)
- Sarah A. Morris
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
| | - Kristine R. Crews
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
| | - Randall T. Hayden
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN
| | | | - Wenjian Yang
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
| | - Donald K. Baker
- Department of Information Sciences, St. Jude Children’s Research Hospital, Memphis, TN
| | - Ulrich Broeckel
- RPRD Diagnostics LLC, Milwaukee, WI
- Department of Pediatrics, Section of Genomic Pediatrics, and Genomic Sciences and Precision Medicine Center, Medical College of Wisconsin, Milwaukee, WI
| | - Mary V. Relling
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
| | - Cyrine E. Haidar
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
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Sharathkumar AA, Faustino EVS, Takemoto CM. How we approach thrombosis risk in children with COVID-19 infection and MIS-C. Pediatr Blood Cancer 2021; 68:e29049. [PMID: 33955167 PMCID: PMC8206673 DOI: 10.1002/pbc.29049] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/04/2021] [Accepted: 03/22/2021] [Indexed: 01/08/2023]
Abstract
Thrombosis within the microvasculature and medium to large vessels is a serious and common complication among critically ill individuals with coronavirus disease 2019 (COVID-19). While children are markedly less likely to develop severe disease than adults, they remain at risk for thrombosis during acute infection and with the post-acute inflammatory illness termed multisystem inflammatory syndrome in children. Significant knowledge deficits in understanding COVID-19-associated coagulopathy and thrombotic risk pose clinical challenges for pediatric providers who must incorporate expert opinion and personal experience to manage individual patients. We discuss clinical scenarios to provide framework for characterizing thrombosis risk and thromboprophylaxis in children with COVID-19.
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Affiliation(s)
- Anjali A. Sharathkumar
- Stead Family Department of Pediatrics, Carver College of MedicineUniversity of IowaIowa CityIowaUSA
| | - E. Vincent S. Faustino
- Section of Pediatric Critical Care Medicine, Department of PediatricsYale School of MedicineNew HavenConnecticutUSA
| | - Clifford M. Takemoto
- Division of Clinical HematologySt. Jude Children's Research HospitalMemphisTennesseeUSA
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Casella JF, Barton BA, Kanter J, Black LV, Majumdar S, Inati A, Wali Y, Drachtman RA, Abboud MR, Kilinc Y, Fuh BR, Al-Khabori MK, Takemoto CM, Salman E, Sarnaik SA, Shah N, Morris CR, Keates-Baleeiro J, Raj A, Alvarez OA, Hsu LL, Thompson AA, Sisler IY, Pace BS, Noronha SA, Lasky JL, de Julian EC, Godder K, Thornburg CD, Kamberos NL, Nuss R, Marsh AM, Owen WC, Schaefer A, Tebbi CK, Chantrain CF, Cohen DE, Karakas Z, Piccone CM, George A, Fixler JM, Singleton TC, Moulton T, Quinn CT, de Castro Lobo CL, Almomen AM, Goyal-Khemka M, Maes P, Emanuele M, Gorney RT, Padgett CS, Parsley E, Kronsberg SS, Kato GJ, Gladwin MT. Effect of Poloxamer 188 vs Placebo on Painful Vaso-Occlusive Episodes in Children and Adults With Sickle Cell Disease: A Randomized Clinical Trial. JAMA 2021; 325:1513-1523. [PMID: 33877274 PMCID: PMC8058640 DOI: 10.1001/jama.2021.3414] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Although effective agents are available to prevent painful vaso-occlusive episodes of sickle cell disease (SCD), there are no disease-modifying therapies for ongoing painful vaso-occlusive episodes; treatment remains supportive. A previous phase 3 trial of poloxamer 188 reported shortened duration of painful vaso-occlusive episodes in SCD, particularly in children and participants treated with hydroxyurea. OBJECTIVE To reassess the efficacy of poloxamer 188 for vaso-occlusive episodes. DESIGN, SETTING, AND PARTICIPANTS Phase 3, randomized, double-blind, placebo-controlled, multicenter, international trial conducted from May 2013 to February 2016 that included 66 hospitals in 12 countries and 60 cities; 388 individuals with SCD (hemoglobin SS, SC, S-β0 thalassemia, or S-β+ thalassemia disease) aged 4 to 65 years with acute moderate to severe pain typical of painful vaso-occlusive episodes requiring hospitalization were included. INTERVENTIONS A 1-hour 100-mg/kg loading dose of poloxamer 188 intravenously followed by a 12-hour to 48-hour 30-mg/kg/h continuous infusion (n = 194) or placebo (n = 194). MAIN OUTCOMES AND MEASURES Time in hours from randomization to the last dose of parenteral opioids among all participants and among those younger than 16 years as a separate subgroup. RESULTS Of 437 participants assessed for eligibility, 388 were randomized (mean age, 15.2 years; 176 [45.4%] female), the primary outcome was available for 384 (99.0%), 15-day follow-up contacts were available for 357 (92.0%), and 30-day follow-up contacts were available for 368 (94.8%). There was no significant difference between the groups for the mean time to last dose of parenteral opioids (81.8 h for the poloxamer 188 group vs 77.8 h for the placebo group; difference, 4.0 h [95% CI, -7.8 to 15.7]; geometric mean ratio, 1.2 [95% CI, 1.0-1.5]; P = .09). Based on a significant interaction of age and treatment (P = .01), there was a treatment difference in time from randomization to last administration of parenteral opioids for participants younger than 16 years (88.7 h in the poloxamer 188 group vs 71.9 h in the placebo group; difference, 16.8 h [95% CI, 1.7-32.0]; geometric mean ratio, 1.4 [95% CI, 1.1-1.8]; P = .008). Adverse events that were more common in the poloxamer 188 group than the placebo group included hyperbilirubinemia (12.7% vs 5.2%); those more common in the placebo group included hypoxia (12.0% vs 5.3%). CONCLUSIONS AND RELEVANCE Among children and adults with SCD, poloxamer 188 did not significantly shorten time to last dose of parenteral opioids during vaso-occlusive episodes. These findings do not support the use of poloxamer 188 for vaso-occlusive episodes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01737814.
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Affiliation(s)
- James F. Casella
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Julie Kanter
- Medical University of South Carolina, Charleston
- University of Alabama at Birmingham, Birmingham
| | - L. Vandy Black
- Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana
- University of Florida College of Medicine, Gainesville
| | - Suvankar Majumdar
- University of Mississippi Medical Center, Jackson
- Children’s National Hospital, Washington, DC
| | - Adlette Inati
- Lebanese American University, Byblos and Beirut, Lebanon
- Nini Hospital, Tripoli, Lebanon
| | | | | | | | - Yurdanur Kilinc
- Çukurova University Medical Faculty Balcali Hospital, University of Çukurova, Adana, Turkey
| | - Beng R. Fuh
- East Carolina University, Greenville, North Carolina
| | | | - Clifford M. Takemoto
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Emad Salman
- Golisano Children’s Hospital of Southwest Florida, Ft Myers
| | - Sharada A. Sarnaik
- Wayne State University School of Medicine, Detroit, Michigan
- Children’s Hospital of Michigan, Detroit
| | - Nirmish Shah
- Duke University School of Medicine, Durham, North Carolina
| | - Claudia R. Morris
- Emory University School of Medicine, Atlanta, Georgia
- Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - Ashok Raj
- University of Louisville/Norton Children’s Hospital, Louisville, Kentucky
| | | | | | - Alexis A. Thompson
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Evanston, Illinois
| | - India Y. Sisler
- Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond
| | | | - Suzie A. Noronha
- University of Rochester School of Medicine and Dentistry, Golisano Children’s Hospital at University of Rochester Medical Center, Rochester, New York
| | - Joseph L. Lasky
- Harbor-UCLA Medical Center, Torrance, California
- Cure 4 The Kids Foundation, Las Vegas, Nevada
| | - Elena Cela de Julian
- Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Courtney Dawn Thornburg
- Rady Children’s Hospital - San Diego, San Diego, California
- UC San Diego School of Medicine, La Jolla, California
| | - Natalie L. Kamberos
- University of Iowa Children’s Hospital, Iowa City
- Loyola University Medical Center, Maywood, Illinois
| | - Rachelle Nuss
- Children’s Hospital Colorado, University of Colorado, Aurora
| | - Anne M. Marsh
- UCSF Benioff Children’s Hospital Oakland (UBCHO), Oakland, California
- University of Wisconsin–Madison, Madison
| | - William C. Owen
- Children’s Hospital of the King’s Daughters, Norfolk, Virginia
| | - Anne Schaefer
- Joe DiMaggio Children’s Hospital, Hollywood, Florida
| | | | | | - Debra E. Cohen
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Studer Family Children’s Hospital Ascension Sacred Heart, University of Florida, Pensacola
| | - Zeynep Karakas
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Connie M. Piccone
- Rainbow Babies and Children’s Hospital, Cleveland, Ohio
- Carle Foundation Hospital, Urbana, Illinois
| | - Alex George
- Baylor College of Medicine, Houston, Texas
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jason M. Fixler
- The Herman and Walter Samuelson Children’s Hospital at Sinai, Baltimore, Maryland
| | - Tammuella C. Singleton
- Tulane University, New Orleans, Louisiana
- Mississippi Center for Advanced Medicine, Slidell, Louisiana
| | - Thomas Moulton
- Bronx-Lebanon Hospital, Bronx, New York City, New York
- Bayer Pharmaceuticals, Whippany, New Jersey
| | | | | | - Abdulkareem M. Almomen
- Blood and Cancer Center, King Khalid University Hospital (KKUH), King Saud University Medical City, Riyadh, Saudi Arabia
| | - Meenakshi Goyal-Khemka
- Phoenix Children’s Hospital, Phoenix, Arizona
- Rutgers Cancer Institute of New Jersey, New Brunswick
| | - Philip Maes
- University Hospital of Antwerp (UZA), Edegem, Belgium
| | - Marty Emanuele
- Visgenx, San Diego, California
- Mast Therapeutics Inc, San Diego, California
| | | | - Claire S. Padgett
- Mast Therapeutics Inc, San Diego, California
- Sanifit Therapeutics, San Diego, California
| | - Ed Parsley
- Mast Therapeutics Inc, San Diego, California
- Biotechnology, San Diego, California
| | | | - Gregory J. Kato
- CSL Behring, King of Prussia, Pennsylvania
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mark T. Gladwin
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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12
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Darbari I, Jacobs E, Gordon O, Weiss D, Winship K, Casella JF, Strouse JJ, Takemoto CM. Correlates of successful transition in young adults with sickle cell disease. Pediatr Blood Cancer 2019; 66:e27939. [PMID: 31429531 DOI: 10.1002/pbc.27939] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 03/27/2019] [Revised: 07/07/2019] [Accepted: 07/08/2019] [Indexed: 12/19/2022]
Abstract
The transition period from pediatric care to adult care for patients with sickle cell disease (SCD) is associated with increased mortality and morbidity. Identification of risk factors for unsuccessful transition may aid in developing strategies to improve the transition process and health outcomes in this population. We examined factors associated with unsuccessful transition from pediatric to adult care for patients with SCD at the Johns Hopkins Hospital. We found that public insurance and increased hospitalization rates were associated with poor transition to adult care. The findings provide possible areas of intervention.
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Affiliation(s)
- Isha Darbari
- Division of Pediatric Hematology, Department of Pediatrics, The Johns Hopkins University, Baltimore, Maryland
| | - Emily Jacobs
- Division of Pediatric Hematology, Department of Pediatrics, The Johns Hopkins University, Baltimore, Maryland
| | - Olivia Gordon
- Division of Pediatric Hematology, Department of Pediatrics, The Johns Hopkins University, Baltimore, Maryland
| | - Diane Weiss
- Division of Pediatric Hematology, Department of Pediatrics, The Johns Hopkins University, Baltimore, Maryland
| | - Kim Winship
- Division of Pediatric Hematology, Department of Pediatrics, The Johns Hopkins University, Baltimore, Maryland
| | - James F Casella
- Division of Pediatric Hematology, Department of Pediatrics, The Johns Hopkins University, Baltimore, Maryland
| | - John J Strouse
- Division of Hematology, Duke University School of Medicine, Durham, North Carolina
| | - Clifford M Takemoto
- Division of Pediatric Hematology, Department of Pediatrics, The Johns Hopkins University, Baltimore, Maryland.,Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee
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13
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Goel R, Patel EU, Cushing MM, Frank SM, Ness PM, Takemoto CM, Vasovic LV, Sheth S, Nellis ME, Shaz B, Tobian AAR. Association of Perioperative Red Blood Cell Transfusions With Venous Thromboembolism in a North American Registry. JAMA Surg 2019; 153:826-833. [PMID: 29898202 DOI: 10.1001/jamasurg.2018.1565] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Importance Increasing evidence supports the role of red blood cells (RBCs) in physiological hemostasis and pathologic thrombosis. Red blood cells are commonly transfused in the perioperative period; however, their association with postoperative thrombotic events remains unclear. Objective To examine the association between perioperative RBC transfusions and postoperative venous thromboembolism (VTE) within 30 days of surgery. Design, Setting, and Participants This analysis used prospectively collected registry data from the American College of Surgery National Surgical Quality Improvement Program (ACS-NSQIP) database, a validated registry of 525 teaching and nonteaching hospitals in North America. Participants included patients in the ACS-NSQIP registry who underwent a surgical procedure from January 1 through December 31, 2014. Data were analyzed from July 1, 2016, through March 15, 2018. Main Outcomes and Measures Risk-adjusted odds ratios (aORs) were estimated using multivariable logistic regression. The primary outcome was the development of postoperative VTE (deep venous thrombosis [DVT] and pulmonary embolism [PE]) within 30 days of surgery that warranted therapeutic intervention; DVT and PE were also examined separately as secondary outcomes. Subgroup analyses were performed by surgical subtypes. Propensity score matching was performed for sensitivity analyses. Results Of 750 937 patients (56.8% women; median age, 58 years; interquartile range, 44-69 years), 47 410 (6.3%) received at least 1 perioperative RBC transfusion. Postoperative VTE occurred in 6309 patients (0.8%) (DVT in 4336 [0.6%]; PE in 2514 [0.3%]; both DVT and PE in 541 [0.1%]). Perioperative RBC transfusion was associated with higher odds of VTE (aOR, 2.1; 95% CI, 2.0-2.3), DVT (aOR, 2.2; 95% CI, 2.1-2.4), and PE (aOR, 1.9; 95% CI, 1.7-2.1), independent of various putative risk factors. A significant dose-response effect was observed with increased odds of VTE as the number of intraoperative and/or postoperative RBC transfusion events increased (aOR, 2.1 [95% CI, 2.0-2.3] for 1 event; 3.1 [95% CI, 1.7-5.7] for 2 events; and 4.5 [95% CI, 1.0-19.4] for ≥3 events vs no intraoperative or postoperative RBC transfusion; P < .001 for trend). In subgroup analyses, the association between any perioperative RBC transfusion and postoperative VTE remained statistically significant across all surgical subspecialties analyzed. The association between any perioperative RBC transfusion and the development of postoperative VTE also remained robust after 1:1 propensity score matching (47 142 matched pairs; matched OR, 1.9; 95% CI, 1.8-2.1). Conclusions and Relevance The results of this study suggest that perioperative RBC transfusions may be significantly associated with the development of new or progressive postoperative VTE, independent of several putative confounders. These findings, if validated, should reinforce the importance of rigorous perioperative management of blood transfusion practices.
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Affiliation(s)
- Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, New York Presbyterian Hospital, Weill Cornell Medicine, New York.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, New York Presbyterian Hospital, Weill Cornell Medicine, New York
| | - Eshan U Patel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Melissa M Cushing
- Division of Transfusion Medicine, Department of Pathology, New York Presbyterian Hospital, Weill Cornell Medicine, New York
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Paul M Ness
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Clifford M Takemoto
- Division of Pediatric Hematology, Johns Hopkins University, Baltimore, Maryland
| | - Ljiljana V Vasovic
- Division of Transfusion Medicine, Department of Pathology, New York Presbyterian Hospital, Weill Cornell Medicine, New York
| | - Sujit Sheth
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, New York Presbyterian Hospital, Weill Cornell Medicine, New York
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, New York Presbyterian Hospital, Weill Cornell Medicine, New York
| | | | - Aaron A R Tobian
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
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14
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Goel R, Patel EU, White JL, Chappidi MR, Ness PM, Cushing MM, Takemoto CM, Shaz BH, Frank SM, Tobian AAR. Factors associated with red blood cell, platelet, and plasma transfusions among inpatient hospitalizations: a nationally representative study in the United States. Transfusion 2018; 59:500-507. [PMID: 30548491 DOI: 10.1111/trf.15088] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 10/19/2018] [Accepted: 10/22/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Demographic and hospital-level factors associated with red blood cell (RBC), plasma, and platelet transfusions in hospitalized patients across the U.S. are not well characterized. METHODS We conducted a retrospective analysis of the National Inpatient Sample (2014). The unit of analysis was a hospitalization; sampling weights were applied to generate nationally-representative estimates. The primary outcome was having ≥ 1 RBC transfusion procedure; plasma and platelet transfusions were similarly assessed as secondary outcomes. For each component, factors associated with transfusion were measured using adjusted prevalence ratios (adjPR) and 95% confidence intervals (95% CI) estimated by multivariable Poisson regression. RESULTS The prevalence of RBC, plasma, and platelet transfusion was 5.8%, 0.9%, and 0.7%, respectively. RBC transfusions were associated with older age (≥ 65 vs. < 18 years; adjPR = 1.80; 95% CI = 1.66-1.96), female sex (adjPR = 1.13; 95% CI = 1.12-1.14), minority race/ethnic status, and hospitalizations in rural hospitals compared to urban teaching hospitals. Prevalence of RBC transfusion was lower among hospitalizations in the Midwest compared to the Northeast (adjPR = 0.73; 95% CI = 0.67-0.80). All components were more likely to be transfused in patients with a primary hematologic diagnosis, patients with a higher number of total diagnoses, patients who experienced a higher number of other procedures, and patients who eventually died in the hospital. In contrast to RBC transfusions, prevalence of platelet transfusion was greater in urban teaching hospitals (vs. rural; adjPR = 1.71; 95% CI = 1.49-1.98) and lower in blacks (vs. whites; adjPR = 0.80; 95% CI = 0.76-0.85). CONCLUSIONS Nationally, there is heterogeneity in factors associated with transfusion between each blood component, including by hospital type and location. This variability presents patient blood management programs with potential opportunities to reduce transfusions.
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Affiliation(s)
- Ruchika Goel
- Department of Pathology, Johns Hopkins University, Baltimore, MD, United States.,Division of Hematology/Oncology, Simmons Cancer Institute at SIU School of Medicine, Springfield, IL, United States
| | - Eshan U Patel
- Department of Pathology, Johns Hopkins University, Baltimore, MD, United States
| | - Jodie L White
- Department of Pathology, Johns Hopkins University, Baltimore, MD, United States
| | - Meera R Chappidi
- Department of Pathology, Johns Hopkins University, Baltimore, MD, United States
| | - Paul M Ness
- Department of Pathology, Johns Hopkins University, Baltimore, MD, United States
| | - Melissa M Cushing
- Department of Pathology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, United States
| | - Clifford M Takemoto
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, United States
| | - Beth H Shaz
- New York Blood Center, New York, NY, United States
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University, Baltimore, MD, United States
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15
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Ronda J, Nord A, Arrington-Sanders R, Naik R, Takemoto CM, Baskin J, Lanzkron S, Pecker LH. Challenges in the management of the transgender patient with sickle cell disease. Am J Hematol 2018; 93:E360-E362. [PMID: 30094866 DOI: 10.1002/ajh.25242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 08/02/2018] [Accepted: 08/03/2018] [Indexed: 01/24/2023]
Affiliation(s)
- Jocelyn Ronda
- Johns Hopkins Medicine; Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine; Baltimore Maryland
| | - Anne Nord
- Children's Hospital Los Angeles; Department of Pediatrics, Division of Pediatric Hematology; Los Angeles California
| | - Renata Arrington-Sanders
- Johns Hopkins Medicine; Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine; Baltimore Maryland
| | - Rakhi Naik
- Johns Hopkins Medicine, Department of Medicine, Division of Hematology; Baltimore Maryland
| | - Clifford M. Takemoto
- Johns Hopkins Medicine, Department of Pediatrics, Division of Pediatric Hematology; Baltimore Maryland
| | - Jacquelyn Baskin
- Children's Hospital Los Angeles; Department of Pediatrics, Division of Pediatric Hematology; Los Angeles California
| | - Sophie Lanzkron
- Johns Hopkins Medicine, Department of Medicine, Division of Hematology; Baltimore Maryland
| | - Lydia H. Pecker
- Johns Hopkins Medicine, Department of Pediatrics, Division of Pediatric Hematology; Baltimore Maryland
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16
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Thimm MA, Rhee D, Takemoto CM, Karnsakul W, Cuffari C, Guerrerio AL, Garcia A, Gearhart J, Huisman TAGM, Hwang M. Diagnosis of congenital and acquired focal lesions in the neck, abdomen, and pelvis with contrast-enhanced ultrasound: a pictorial essay. Eur J Pediatr 2018; 177:1459-1470. [PMID: 29971555 DOI: 10.1007/s00431-018-3197-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 04/07/2018] [Revised: 05/30/2018] [Accepted: 06/19/2018] [Indexed: 01/17/2023]
Abstract
UNLABELLED Contrast-enhanced ultrasound (CEUS) is a versatile imaging modality that improves the diagnostic potential of conventional ultrasound. It allows for portable imaging at the bedside. In this paper, we illustrate how CEUS can be used in evaluating several focal lesions in the pediatric population, including liver hemangioma, telangiectasias, splenic hamartomas, and bladder lesions. We describe the ultrasound findings and contrast enhancement patterns associated with these lesions. Findings are correlated with MRI, CT, and/or pathology when available. This paper demonstrates the value of CEUS in improving characterization of many focal lesions in the pediatric population. CONCLUSION CEUS is a valuable bedside technique for use in the pediatric population to evaluate focal lesions in various organs, and will allow for safe, more efficient diagnostic imaging. What is Known: • CEUS offers many advantages over CT and MRI and is underutilized in the United States. • It is only FDA approved for vesicoureteral reflux and liver in the pediatric population. However, off label uses are well described. What is New: • This pictorial essay describes ultrasound findings and contrast enhancement patterns associated with liver hemangioma, liver telangiectasia, splenic hamartoma, hemorrhagic ovarian cyst, urachal remnant, spinning top urethras, and kaposiform hemangioendothelioma. • We demonstrate the utility of CEUS in expanding the diagnostic potential of conventional ultrasound.
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Affiliation(s)
- Matthew A Thimm
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel Rhee
- Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Clifford M Takemoto
- Division of Pediatric Hematology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Wikrom Karnsakul
- Division of Pediatric Gastroenterology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Carmen Cuffari
- Division of Pediatric Gastroenterology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Anthony L Guerrerio
- Division of Pediatric Gastroenterology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Alejandro Garcia
- Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - John Gearhart
- Division of Pediatric Urology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Thierry A G M Huisman
- Division of Pediatric Radiology and Pediatric Neuroradiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Misun Hwang
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA. .,Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
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17
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Zheng G, Streiff MB, Allison D, Takemoto CM, Salimian K, Morris P, Jani J, McCord R, Kickler TS. A novel diagnostic algorithm for heparin-induced thrombocytopenia. Int J Lab Hematol 2018; 40:527-532. [PMID: 29756276 DOI: 10.1111/ijlh.12853] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 02/05/2018] [Accepted: 04/08/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION While diagnostic algorithm using PF4-heparin enzyme-linked immunosorbent assay (ELISA) optical density (OD), and heparin neutralization assay (HNA), or 4T score have been proposed to replace serotonin-release assay (SRA) for heparin-induced thrombocytopenia (HIT), their performance against SRA is unclear. In this study, we proposed and validated the performance of a new algorithm combining PF4-heparin ELISA optical density (OD), HNA and 4T score against SRA for HIT diagnosis. METHODS Heparin neutralization assays were performed on specimens submitted for HIT testing with positive PF4-heparin ELISA from December 2015 to September 2017, which were separated into a "training" and a "validation" data set. 4T scores were calculated for ELISA positive cases. RESULTS A total of 123 consecutive unique patient samples had positive PF4-heparin ELISA with also HNA data, SRA data, and 4T scores available. Compared to SRA, a "laboratory criteria" (ELISA OD ≥ 1.4 and HNA ≥ 70%) had a sensitivity of 88% (14/16) and specificity of 91% (42/46), and a "combined criteria" (4T score = 8, or 4T score = 6 or 7 and ELISA OD ≥ 1.0, or 4T score = 4 or 5 and ELISA OD ≥ 2.0) had a sensitivity of 75% (12/16) and specificity of 98% (45/46) in the training data set. Laboratory and combined criteria had 90% (56/62) concordance rate. Importantly, for these concordant cases, the diagnostic specificity is 100% (46/46). Based on the data, a novel diagnostic algorithm combining these 2 criteria was proposed and validated prospectively. CONCLUSION A novel algorithm has high diagnostic accuracy and potentially could eliminate the need for SRA testing in at least 90% patients with suspected HIT.
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Affiliation(s)
- G Zheng
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - M B Streiff
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - D Allison
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - C M Takemoto
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - K Salimian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - P Morris
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J Jani
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - R McCord
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - T S Kickler
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Palam LR, Mali RS, Ramdas B, Srivatsan SN, Visconte V, Tiu RV, Vanhaesebroeck B, Roers A, Gerbaulet A, Xu M, Janga SC, Takemoto CM, Paczesny S, Kapur R. Loss of epigenetic regulator TET2 and oncogenic KIT regulate myeloid cell transformation via PI3K pathway. JCI Insight 2018; 3:94679. [PMID: 29467326 DOI: 10.1172/jci.insight.94679] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 04/21/2017] [Accepted: 01/18/2018] [Indexed: 01/08/2023] Open
Abstract
Mutations in KIT and TET2 are associated with myeloid malignancies. We show that loss of TET2-induced PI3K activation and -increased proliferation is rescued by targeting the p110α/δ subunits of PI3K. RNA-Seq revealed a hyperactive c-Myc signature in Tet2-/- cells, which is normalized by inhibiting PI3K signaling. Loss of TET2 impairs the maturation of myeloid lineage-derived mast cells by dysregulating the expression of Mitf and Cebpa, which is restored by low-dose ascorbic acid and 5-azacytidine. Utilizing a mouse model in which the loss of TET2 precedes the expression of oncogenic Kit, similar to the human disease, results in the development of a non-mast cell lineage neoplasm (AHNMD), which is responsive to PI3K inhibition. Thus, therapeutic approaches involving hypomethylating agents, ascorbic acid, and isoform-specific PI3K inhibitors are likely to be useful for treating patients with TET2 and KIT mutations.
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Affiliation(s)
- Lakshmi Reddy Palam
- Department of Pediatrics, Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Raghuveer Singh Mali
- Department of Pediatrics, Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Baskar Ramdas
- Department of Pediatrics, Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Valeria Visconte
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ramon V Tiu
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Axel Roers
- Institute for Immunology, Dresden, Germany
| | | | - Mingjiang Xu
- Sylvester Comprehensive Cancer Center, Department of Biochemistry & Molecular Biology, University of Miami School of Medicine, Miami, Florida, USA
| | - Sarath Chandra Janga
- School of Informatics and Computing, Indiana University & Purdue University, Indianapolis, Indiana, USA.,Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Clifford M Takemoto
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sophie Paczesny
- Department of Pediatrics, Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Reuben Kapur
- Department of Pediatrics, Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Biochemistry and Molecular Biology and.,Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Yang W, Xu R, Porras JL, Takemoto CM, Khalid S, Garzon-Muvdi T, Caplan JM, Colby GP, Coon AL, Tamargo RJ, Huang J, Ahn ES. Effectiveness of surgical revascularization for stroke prevention in pediatric patients with sickle cell disease and moyamoya syndrome. J Neurosurg Pediatr 2017; 20:232-238. [PMID: 28686127 DOI: 10.3171/2017.1.peds16576] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [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] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Sickle cell disease (SCD) in combination with moyamoya syndrome (MMS) represents a rare complication of SCD, with potentially devastating neurological outcomes. The effectiveness of surgical revascularization in this patient population is currently unclear. The authors' aim was to determine the effectiveness of surgical intervention in their series of SCD-MMS patients by comparing stroke recurrence in those undergoing revascularization and those undergoing conservative transfusion therapy. METHODS The authors performed a retrospective chart review of patients with MMS who were seen at the Johns Hopkins Medical Institution between 1990 and 2013. Pediatric patients (age < 18 years) with confirmed diagnoses of SCD and MMS were included. Intracranial stroke occurrence during the follow-up period was compared between surgically and conservatively managed patients. RESULTS A total of 15 pediatric SCD-MMS patients (28 affected hemispheres) were included in this study, and all were African American. Seven patients (12 hemispheres) were treated with indirect surgical revascularization. The average age at MMS diagnosis was 9.0 ± 4.0 years, and 9 patients (60.0%) were female. Fourteen patients (93.3%) had strokes before diagnosis of MMS, with an average age at first stroke of 6.6 ± 3.9 years. During an average follow-up period of 11.6 years, 4 patients in the conservative treatment group experienced strokes in 5 hemispheres, whereas no patient undergoing the revascularization procedure had any strokes at follow-up (p = 0.029). Three patients experienced immediate postoperative transient ischemic attacks, but all recovered without subsequent strokes. CONCLUSIONS Indirect revascularization is suggested as a safe and effective alternative to the best medical therapy alone in patients with SCD-MMS. High-risk patients managed on a regimen of chronic transfusion should be considered for indirect revascularization to maximize the effect of stroke prevention.
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Affiliation(s)
| | | | | | - Clifford M Takemoto
- Division of Pediatric Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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20
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Zheng G, Streiff MB, Takemoto CM, Bynum J, Gelwan E, Jani J, Judge D, Kickler TS. The Clinical Utility of the Heparin Neutralization Assay in the Diagnosis of Heparin-Induced Thrombocytopenia. Clin Appl Thromb Hemost 2017; 24:749-754. [PMID: 28774196 DOI: 10.1177/1076029617721013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) remains diagnostically challenging. Immunoassays including PF4/heparin enzyme-linked immunosorbent assay (ELISA) have high sensitivity but low specificity. Whether the heparin neutralization assay (HNA) improves the diagnostic accuracy of the PF4/heparin ELISA for HIT is uncertain. In this study, to assess its clinical utility and evaluate whether it improves the diagnostic accuracy for HIT, we implemented HNA in conjunction with PF4/heparin ELISA over a 1-year period. A total of 1194 patient samples were submitted to the laboratory for testing from December 2015 to November 2016. Heparin neutralization assay alone is a poor predictor for HIT, but it has high negative predictive value (NPV): Cases with %inhibition <70% are always negative for serotonin release assay. It improves the diagnostic positive predictive value (PPV) of ELISA without compromising sensitivity: ELISA optical density (OD) ≥1.4 alone has a sensitivity of 88% (14/16) and a PPV of 61% (14/23); with HNA %inhibition ≥70%, the sensitivity remains 88% (14/16) and PPV is 82% (14/17). 4Ts score correlates with ELISA OD and predicts HIT; the predictive accuracy of 4Ts score is further improved by HNA. Interestingly, HNA %inhibition of <70% correlates with low 4Ts scores. Based on its high NPV, HNA has the potential to facilitate more timely and accurate HIT diagnosis.
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Affiliation(s)
- Gang Zheng
- 1 Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael B Streiff
- 2 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Clifford M Takemoto
- 3 Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer Bynum
- 1 Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elise Gelwan
- 1 Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jayesh Jani
- 1 Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Danielle Judge
- 1 Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thomas S Kickler
- 1 Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,2 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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21
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Hampton K, Chowdary P, Dunkley S, Ehrenforth S, Jacobsen L, Neff A, Santagostino E, Sathar J, Takedani H, Takemoto CM, Négrier C. First report on the safety and efficacy of an extended half-life glycoPEGylated recombinant FVIII for major surgery in severe haemophilia A. Haemophilia 2017; 23:689-696. [PMID: 28470862 DOI: 10.1111/hae.13246] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND N8-GP (turoctocog alfa pegol) is an extended half-life glycoPEGylated recombinant factor VIII (FVIII) product developed for the prevention and treatment of bleeds in haemophilia A patients. AIM This is a planned interim analysis of pathfinder™3, an international, open-label, Phase 3 trial evaluating the efficacy and safety (including immunogenicity) of N8-GP administered before, during and after major surgery in severe haemophilia A patients aged ≥12 years. METHODS Sixteen patients who underwent 18 major surgical procedures (including synovectomy, joint replacement and ankle arthrodesis) were included here. Postoperative assessments were conducted daily for days 1-6, and once for days 7-14. Primary endpoint was N8-GP haemostatic efficacy, assessed after completion of surgery using a four-point scale ('excellent', 'good', 'moderate', 'none'). RESULTS Haemostasis was successful (rated 'excellent' or 'good') on completion of surgery in 17 (94.4%) procedures and rated as 'moderate' (5.6%) for one surgery in a patient with multiple comorbidities who needed an intraoperative N8-GP dose (20.7 IU kg-1 ). In the postoperative period, three bleeds occurred (one during days 1-6; two during days 7-14); all were successfully treated with N8-GP. Mean N8-GP consumption on day of surgery was 80.0 IU kg-1 ; patients received a mean of 1.7 doses (median: 2, range: 1-3). No safety concerns were identified. CONCLUSION The data showed that N8-GP was effective and well tolerated for the prevention and treatment of bleeds during major surgery; such FVIII products with extended half-lives may modify current treatment schedules, enabling fewer infusions and earlier patient discharge.
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Affiliation(s)
- K Hampton
- Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
| | - P Chowdary
- KD Haemophilia Centre and Thrombosis Unit, Royal Free Hospital, London, UK
| | - S Dunkley
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown,Sydney, New South Wales, Australia
| | | | | | - A Neff
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Santagostino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Ca' Granda Foundation, Maggiore Hospital Policlinico, Milan, Italy
| | - J Sathar
- Department of Haematology, Ampang Hospital, Selangor, Malaysia
| | - H Takedani
- Department of Joint Surgery, Research Hospital, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - C M Takemoto
- Division of Pediatric Hematology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - C Négrier
- Hemostasis and Thrombosis Unit, Louis Pradel Hospital, Université Claude Bernard, Lyon, France
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22
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Abstract
Pediatric hospital acquired venous thromboembolism (HA-VTE) is an increasing problem with an estimated increase from 5.3 events per 10,000 pediatric hospital admissions in the early 1990s to a current estimate of 30-58 events per 10,000 pediatric hospital admissions. Pediatric HA-VTE is associated with significant morbidity and mortality. The etiology is multifactorial but central venous catheters remain the predominant risk factor. Additional HA-VTE risk factors include both acquired (recent surgery, immobility, inflammation, and critical illness) and inherited risk factors. Questions remain regarding the most effective method to assess for HA-VTE risk in hospitalized pediatric patients and what preventative strategies should be implemented. While several risk-assessment models have been published in pediatric patients, these studies have limited power due to small sample size and require prospective validation. Potential thromboprophylactic measures include mechanical and pharmacologic methods both of which have associated harms, the most significant of which is bleeding from anticoagulation. Standard anticoagulation options in pediatric patients currently include unfractionated heparin, low molecular weight heparin, or warfarin all of which pose a monitoring burden. Ongoing pediatric studies with direct oral anticoagulants could potentially revolutionize the prevention and treatment of pediatric thrombosis with the possibility of a convenient route of administration and no requirement for monitoring. Further studies assessing clinical outcomes of venous thromboembolism (VTE) prevention strategies are critical to evaluate the effectiveness and harm of prophylactic interventions in children. Despite HA-VTE prevention efforts, thrombotic events can still occur, and it is important that clinicians have a high clinical suspicion to ensure prompt diagnosis and treatment to prevent further associated harms.
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Affiliation(s)
- Char M Witmer
- Department of Pediatrics, Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Clifford M Takemoto
- Pediatric Hematology, The Johns Hopkins University, Baltimore, MD, United States
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23
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Stieglitz E, Taylor-Weiner AN, Chang TY, Gelston LC, Wang YD, Mazor T, Esquivel E, Yu A, Seepo S, Olsen SR, Rosenberg M, Archambeault SL, Abusin G, Beckman K, Brown PA, Briones M, Carcamo B, Cooper T, Dahl GV, Emanuel PD, Fluchel MN, Goyal RK, Hayashi RJ, Hitzler J, Hugge C, Liu YL, Messinger YH, Mahoney DH, Monteleone P, Nemecek ER, Roehrs PA, Schore RJ, Stine KC, Takemoto CM, Toretsky JA, Costello JF, Olshen AB, Stewart C, Li Y, Ma J, Gerbing RB, Alonzo TA, Getz G, Gruber TA, Golub TR, Stegmaier K, Loh ML. Corrigendum: The genomic landscape of juvenile myelomonocytic leukemia. Nat Genet 2016; 48:101. [PMID: 26711114 DOI: 10.1038/ng0116-101a] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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24
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Goel R, King KE, Takemoto CM, Ness PM, Tobian AAR. Prognostic risk-stratified score for predicting mortality in hospitalized patients with thrombotic thrombocytopenic purpura: nationally representative data from 2007 to 2012. Transfusion 2016; 56:1451-8. [PMID: 27079482 DOI: 10.1111/trf.13586] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 02/12/2016] [Accepted: 02/13/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Despite proven efficacy and increased availability of therapeutic plasma exchange (TPE), mortality for patients with thrombotic thrombocytopenic purpura (TTP) remains high with a limited understanding of those at highest risk of death. STUDY DESIGN AND METHODS This study utilized the Nationwide Inpatient Sample (2007-2012) to derive a prognostic score for mortality in hospitalized TTP patients. Odds ratios of death with various putative risk factors adjusted for age, sex, and race were calculated (adjOR). Weighted mean of adjOR estimates were incorporated in a risk-stratified score. RESULTS Among 8203 hospitalizations with TTP as primary admission diagnosis who underwent TPE, 613 deaths were identified (all-cause mortality, 7.5%; median time-to-death, 9 days; interquartile range, 4-14 days). In multivariable logistic regression, arterial thrombosis (adjOR 6.7, 95% confidence interval [CI], 1.1-40.9), intracranial hemorrhage (adjOR, 6.1; 95% CI, 1.6-23.2), age at least 60 years (adjOR, 3.5; 95% CI, 2.1-5.6), renal failure (adjOR, 2.6; 95% CI, 1.5-4.5), ischemic stroke (adjOR, 2.4; 95% CI, 1.2-5.0), platelet (PLT) transfusions (adjOR, 2.2; 95% CI, 1.2-4.1), and myocardial infarction (adjOR, 2.3; 95% CI, 1.2-4.6) were significant independent predictors of mortality in TTP patients who underwent TPE. A prognostic weighted mortality prediction scoring system incorporating arterial thrombosis, intracranial hemorrhage, age, renal failure, ischemic stroke, PLT transfusion, and myocardial infarction showed very good discrimination and was predictive of 78.6% deaths. CONCLUSIONS Early and targeted therapy for high-risk individuals should be used to guide management of TTP patients for improved survival outcomes.
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Affiliation(s)
- Ruchika Goel
- Division of Pediatric Hematology.,Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Karen E King
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | | | - Paul M Ness
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Aaron A R Tobian
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
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25
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Stieglitz E, Taylor-Weiner AN, Chang TY, Gelston LC, Wang YD, Mazor T, Esquivel E, Yu A, Seepo S, Olsen S, Rosenberg M, Archambeault SL, Abusin G, Beckman K, Brown PA, Briones M, Carcamo B, Cooper T, Dahl GV, Emanuel PD, Fluchel MN, Goyal RK, Hayashi RJ, Hitzler J, Hugge C, Liu YL, Messinger YH, Mahoney DH, Monteleone P, Nemecek ER, Roehrs PA, Schore RJ, Stine KC, Takemoto CM, Toretsky JA, Costello JF, Olshen AB, Stewart C, Li Y, Ma J, Gerbing RB, Alonzo TA, Getz G, Gruber T, Golub T, Stegmaier K, Loh ML. The genomic landscape of juvenile myelomonocytic leukemia. Nat Genet 2015; 47:1326-1333. [PMID: 26457647 PMCID: PMC4626387 DOI: 10.1038/ng.3400] [Citation(s) in RCA: 194] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 08/17/2015] [Indexed: 12/16/2022]
Abstract
Juvenile myelomonocytic leukemia (JMML) is a myeloproliferative neoplasm (MPN) of childhood with a poor prognosis. Mutations in NF1, NRAS, KRAS, PTPN11 and CBL occur in 85% of patients, yet there are currently no risk stratification algorithms capable of predicting which patients will be refractory to conventional treatment and therefore be candidates for experimental therapies. In addition, there have been few other molecular pathways identified aside from the Ras/MAPK pathway to serve as the basis for such novel therapeutic strategies. We therefore sought to genomically characterize serial samples from patients at diagnosis through relapse and transformation to acute myeloid leukemia in order to expand our knowledge of the mutational spectrum in JMML. We identified recurrent mutations in genes involved in signal transduction, gene splicing, the polycomb repressive complex 2 (PRC2) and transcription. Importantly, the number of somatic alterations present at diagnosis appears to be the major determinant of outcome.
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Affiliation(s)
- Elliot Stieglitz
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | | | - Tiffany Y Chang
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Laura C Gelston
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Yong-Dong Wang
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - Tali Mazor
- Department of Neurological Surgery, University of California, San Francisco, CA
| | - Emilio Esquivel
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Ariel Yu
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Sara Seepo
- Broad Institute of MIT and Harvard, Cambridge, MA
| | - Scott Olsen
- Hartwell Center for Bioinformatics and Biotechnology, St. Jude Children's Research Hospital, Memphis, TN
| | | | - Sophie L Archambeault
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Ghada Abusin
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Kyle Beckman
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Patrick A Brown
- Department of Pediatrics, The Johns Hopkins Hospital, Baltimore, MA
| | - Michael Briones
- Department of Pediatrics, Emory University School of Medicine, Aflac Cancer and Blood Disorder Center, Atlanta, GA
| | | | - Todd Cooper
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
| | - Gary V Dahl
- Department of Pediatrics, Stanford School of Medicine, Stanford, CA
| | - Peter D Emanuel
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Mark N Fluchel
- Department of Pediatric Hematology Oncology, University of Utah, Salt Lake City, UT
| | - Rakesh K Goyal
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Robert J Hayashi
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Johann Hitzler
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christopher Hugge
- Pediatric Hematology Oncology, SSM Cardinal Glennon Children's Medical Center, Saint Louis, MO
| | - Y Lucy Liu
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Yoav H Messinger
- Division of Pediatric Hematology Oncology, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN
| | - Donald H Mahoney
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Philip Monteleone
- Pediatric Hematology Oncology, Pediatric Specialists of Lehigh Valley Hospital, Bethlehem, PA
| | - Eneida R Nemecek
- Pediatric Bone Marrow Transplant Program, Oregon Health & Science University, Portland, OR
| | - Philip A Roehrs
- Department of Pediatrics, University of North Carolina at Chapel Hill, NC
| | - Reuven J Schore
- Division of Pediatric Oncology, Children's National Medical Center, Washington, DC
| | - Kimo C Stine
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | | | - Jeffrey A Toretsky
- Department of Pediatrics, Georgetown University, Washington, DC.,Department of Oncology, Georgetown University, Washington, DC
| | - Joseph F Costello
- Department of Neurological Surgery, University of California, San Francisco, CA
| | - Adam B Olshen
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
| | - Chip Stewart
- Broad Institute of MIT and Harvard, Cambridge, MA
| | - Yongjin Li
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - Jing Ma
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN
| | - Robert B Gerbing
- Department of Statistics, Children's Oncology Group, Monrovia, CA
| | - Todd A Alonzo
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Gad Getz
- Broad Institute of MIT and Harvard, Cambridge, MA.,Harvard Medical School, Boston, MA.,Department of Pathology and Cancer Center, Massachusetts General Hospital, Boston, MA
| | - Tanja Gruber
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN.,Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Todd Golub
- Broad Institute of MIT and Harvard, Cambridge, MA.,Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA.,Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Kimberly Stegmaier
- Broad Institute of MIT and Harvard, Cambridge, MA.,Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA.,Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Mignon L Loh
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA.,Department of Pediatrics, Benioff Children's Hospital, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
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26
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Arlikar SJ, Atchison CM, Amankwah EK, Ayala IA, Barrett LA, Branchford BR, Streiff MB, Takemoto CM, Goldenberg NA. Development of a new risk score for hospital-associated venous thromboembolism in critically-ill children not undergoing cardiothoracic surgery. Thromb Res 2015; 136:717-22. [DOI: 10.1016/j.thromres.2015.04.036] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 03/24/2015] [Accepted: 04/27/2015] [Indexed: 10/23/2022]
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Trucco M, Lehmann CU, Mollenkopf N, Streiff MB, Takemoto CM. Retrospective cohort study comparing activated partial thromboplastin time versus anti-factor Xa activity nomograms for therapeutic unfractionated heparin monitoring in pediatrics. J Thromb Haemost 2015; 13:788-94. [PMID: 25740425 DOI: 10.1111/jth.12890] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [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: 07/16/2014] [Accepted: 03/01/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Unfractionated heparin (UFH) is widely used to treat thromboembolic disease, but monitoring in children is challenging. Both activated partial thromboplastin time (aPTT) and anti-factor Xa activity (anti-Xa) are utilized, but a comparison of dosing nomograms has not been reported in pediatrics. OBJECTIVE To compare the performance of aPTT and anti-Xa for UFH monitoring in pediatric patients. DESIGN/METHODS A retrospective cohort study was conducted in patients ≤ 21 years old treated with UFH at Johns Hopkins Hospital from January 2009 to May 2011. For monitoring, an aPTT nomogram was used for the initial 15 months, and an anti-Xa nomogram was used for the subsequent 12 months. Clinical characteristics, laboratory data and outcomes were analyzed. RESULTS Thirty-four patients were monitored with aPTT and 26 patients with anti-Xa. There was no significant difference in median time to therapeutic range (11.6 h aPTT, 95%CI = 6.0-17.0; 9.9 h anti-Xa, 95%CI = 7.3-20.7) or per cent of patients achieving therapeutic measurements at 24 (79% aPTT, 95%CI = 62-91; 73% anti-Xa, 95%CI = 52-88) and 48 h (88% aPTT, 95%CI = 73-97; 96% anti-Xa, 95%CI = 80-100). However, anti-Xa measurements were more frequently therapeutic than aPTT (74% [95%CI = 69-78] vs. 54% [95%CI = 50-59]). Variance between anti-Xa and aPTT measurements was high (R(2) = 0.236). No significant difference was seen in bleeding incidence (9% aPTT, 95%CI = 2-24; 15% anti-Xa, 95%CI = 4-35). CONCLUSION The time to achieve therapeutic measures and bleeding outcomes were not significantly different between anti-Xa and aPTT nomograms. However, a small study size limits the power to detect clinically relevant differences. The results warrant larger prospective studies of UFH monitoring in children with thromboembolic disease.
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Affiliation(s)
- M Trucco
- Division of Pediatric Hematology, The Johns Hopkins University, Baltimore, MD, USA
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28
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Hayashi M, Strouse JJ, Veltri MA, Curtis BR, Takemoto CM. Immune thrombocytopenia due to Trimethoprim-Sulfamethoxazole; under-recognized adverse drug reaction in children? Pediatr Blood Cancer 2015; 62:922-3. [PMID: 25683320 PMCID: PMC4559584 DOI: 10.1002/pbc.25430] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/22/2014] [Indexed: 12/13/2022]
Affiliation(s)
- Masanori Hayashi
- Department of Pediatrics, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John J. Strouse
- Department of Pediatrics, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael A. Veltri
- Department of Pharmacy, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Brian R. Curtis
- Platelet and Neutrophil Immunology Lab BloodCenter of Wisconsin, Milwaukee, WI
| | - Clifford M. Takemoto
- Department of Pediatrics, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD
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29
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Abstract
BACKGROUND Asthma and iron deficiency are common conditions. Whether iron status affects the risk of asthma is unclear. OBJECTIVE To determine the relationship between iron status and asthma, lung function, and pulmonary inflammation. METHODS Relationships between measures of iron status (serum ferritin, serum soluble transferrin receptor (sTfR), and sTfR/log10ferritin (sTfR-F Index)) and asthma, lung function, and pulmonary inflammation were examined in women 20-49 years in the National Health and Nutrition Examination Survey. Logistic, linear, and quadratic regression models accounting for the survey design of NHANES were used to evaluate associations between iron status and asthma-related outcomes and were adjusted for race/ethnicity, age, smoking status, income, and BMI. RESULTS Approximately 16% reported a lifetime history of asthma, 9% reported current asthma, and 5% reported a recent asthma episode/attack (n = 2906). Increased ferritin (iron stores) was associated with decreased odds of lifetime asthma, current asthma, and asthma attacks/episodes in the range of ferritin linearly correlated with iron stores (20-300ng/ml). The highest quintile of ferritin (>76 ng/ml) was also associated with a decreased odds of asthma. Ferritin levels were not associated with FEV1. Increased values of the sTfR-F Index and sTfR, indicating lower body iron and higher tissue iron need, respectively, were associated with decreased FEV1, but neither was associated with asthma. None of the iron indices were associated with FeNO. CONCLUSION In US women, higher iron stores were inversely associated with asthma and lower body iron and higher tissue iron need were associated with lower lung function. Together, these findings suggest that iron status may play a role in asthma and lung function in US women.
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Affiliation(s)
- Emily P. Brigham
- Johns Hopkins University School of Medicine, Division of Pulmonary and Critical Care Medicine, Baltimore, Maryland, United States of America
| | - Meredith C. McCormack
- Johns Hopkins University School of Medicine, Division of Pulmonary and Critical Care Medicine, Baltimore, Maryland, United States of America
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Clifford M. Takemoto
- Johns Hopkins University School of Medicine, Division of Pediatric Hematology, Baltimore, Maryland, United States of America
| | - Elizabeth C. Matsui
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Johns Hopkins University School of Medicine, Division of Pediatric Allergy and Immunology, Baltimore, Maryland, United States of America
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Oh SY, Brandal S, Kapur R, Zhu Z, Takemoto CM. Global microRNA expression is essential for murine mast cell development in vivo. Exp Hematol 2014; 42:919-23.e1. [PMID: 25201754 DOI: 10.1016/j.exphem.2014.07.266] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 07/16/2014] [Accepted: 07/24/2014] [Indexed: 11/26/2022]
Abstract
MicroRNAs (miRNAs) are small, noncoding RNAs that have been shown to play a critical role in normal physiology and disease, such as hematopoietic development and cancer. However, their role in mast-cell function and development is poorly understood. The major objective of this study was to determine how global miRNA expression affects mast-cell physiology. The RNase III endonuclease, Dicer, is required for the processing of pre-miRNAs into mature miRNAs. To investigate the effect of global miRNA depletion on mast cells in vivo, we generated a mast-cell-specific knock out of Dicer in mice. Transgenic mice (Mcpt5-Cre) that express Cre selectively in connective tissue mast cells were crossed with mice carrying the floxed conditional Dicer allele (Dicer fl/fl). Mcpt5-Cre × Dicer fl/fl mice with homozygous Dicer gene deletion in mast cells were found to have a profound mast-cell deficiency with near complete loss of peritoneal, gastrointestinal, and skin mast cells. We examined the in vivo functional consequence of mast-cell-specific Dicer deletion using an immunoglobulin-E-dependent passive systemic anaphylaxis murine model. Immunoglobulin-E-sensitized wild type Mcpt5-Cre × Dicer +/+ and heterozygous Mcpt5-Cre × Dicer fl/+ mice show marked hypothermia with antigen; however, homozygous Mcpt5-Cre × Dicer fl/fl mice were completely unresponsive to antigen challenge. These studies suggest a critical role for Dicer and miRNA expression for establishment of tissue compartments of functional mast cells in vivo.
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Affiliation(s)
- Sun Young Oh
- Division of Allergy and Clinical Immunology, Johns Hopkins Allergy and Asthma Center, Baltimore, MD, USA
| | - Stephanie Brandal
- Division of Pediatric Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Reuben Kapur
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Cancer Research Institute, Indianapolis, IN, USA
| | - Zhou Zhu
- Division of Allergy and Clinical Immunology, Johns Hopkins Allergy and Asthma Center, Baltimore, MD, USA; Section of Allergy and Clinical Immunology, Yale School of Medicine, New Haven, CT, USA
| | - Clifford M Takemoto
- Division of Pediatric Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Takemoto CM, Sohi S, Desai K, Bharaj R, Khanna A, McFarland S, Klaus S, Irshad A, Goldenberg NA, Strouse JJ, Streiff MB. Hospital-associated venous thromboembolism in children: incidence and clinical characteristics. J Pediatr 2014; 164:332-8. [PMID: 24332452 DOI: 10.1016/j.jpeds.2013.10.025] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [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: 05/03/2013] [Revised: 09/09/2013] [Accepted: 10/09/2013] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine incidence and clinical characteristics of hospital-associated venous thromboembolism (VTE) in pediatric patients. STUDY DESIGN A retrospective analysis of patients with hospital-associated VTE at the Johns Hopkins Hospital from 1994 to 2009 was performed. Clinical characteristics of patients aged 21 years and younger who developed VTE symptoms after 2 days of hospitalization or <90 days after hospital discharge were examined. International Classification of Diseases, Ninth Revision codes were used to categorize patients with complex chronic medical conditions and trauma. RESULTS There were 270 episodes of hospital-associated VTE in 90,485 admissions (rate 30 per 10,000 admissions). Young adults (18-21 years) and adolescents (14-17 years) had significantly increased rates of VTE compared with children (2-9 years) (incidence rate ratio [IRR] 7.7, 95% CI 5.1-12.0; IRR 4.3, 95% CI 2.7-6.8, respectively). A central venous catheter (CVC) was present in 50% of patients, and a surgical procedure was performed in 45% of patients before VTE diagnosis. For patients without a CVC, trauma was the most common admitting diagnosis. CVC-related VTE was diagnosed most frequently in infants (<1 year old) and in patients with malignancy. Renal and cardiac diseases were associated with the highest rates of VTE (51 and 48 per 10,000, respectively). Rates were significantly higher among those with ≥ 4 medical conditions compared with those with 1 medical condition (IRR 4.0, 95% CI 1.4-8.9). CONCLUSION Older age and multiple medical conditions were associated with increased rates of hospital-associated VTE. These data can contribute to the design of future clinical trials to prevent hospital-associated VTE in high-risk children.
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Affiliation(s)
| | - Sajeet Sohi
- Division of Pediatric Hematology, Johns Hopkins University, Baltimore, MD
| | - Kruti Desai
- Division of Pediatric Hematology, Johns Hopkins University, Baltimore, MD
| | - Raman Bharaj
- Division of Pediatric Hematology, Johns Hopkins University, Baltimore, MD
| | - Anuj Khanna
- Division of Pediatric Hematology, Johns Hopkins University, Baltimore, MD
| | - Susan McFarland
- Division of Quality and Safety, Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Sybil Klaus
- Division of Quality and Safety, Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Alia Irshad
- Division of Quality and Safety, Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Neil A Goldenberg
- Division of Pediatric Hematology, Johns Hopkins University, Baltimore, MD; Pediatric Thrombosis Program, All Children's Hospital-Johns Hopkins Medicine, St. Petersburg, FL
| | - John J Strouse
- Division of Pediatric Hematology, Johns Hopkins University, Baltimore, MD; Division of Adult Hematology, The Johns Hopkins Hospital, Baltimore, MD
| | - Michael B Streiff
- Division of Adult Hematology, The Johns Hopkins Hospital, Baltimore, MD
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Takemoto CM, Streiff MB, Shermock KM, Kraus PS, Chen J, Jani J, Kickler T. Activated partial thromboplastin time and anti-xa measurements in heparin monitoring: biochemical basis for discordance. Am J Clin Pathol 2013; 139:450-6. [PMID: 23525615 DOI: 10.1309/ajcps6ow6dynognh] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
We examined the concordance of heparin levels measured by a chromogenic anti-Xa assay and the activated partial thromboplastin time (APTT) during unfractionated heparin therapy (UFH) and the biochemical basis for differences between these measures. We also investigated the endogenous thrombin potential (ETP) as a possible measure of anticoagulation. Paired measures of anti-Xa and APTT were performed on 569 samples from 149 patients on UFH. The anti-Xa values and the APTT were concordant in only 54% of measurements. One hundred twelve samples from 59 patients on UFH were assayed for APTT, anti-Xa, factor II, factor VIII, and ETP. Supratherapeutic APTT values but therapeutic anti-Xa results had decreased factor II activity. Subtherapeutic APTT but therapeutic anti-Xa values had high factor VIII activity. ETP correlated with anticoagulation status and UFH dose. In conclusion, factor II and VIII activity contributes to discordance between APTT and anti-Xa results. ETP measurements may provide an additional assessment of anticoagulation status.
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Affiliation(s)
- Clifford M. Takemoto
- Department of Pediatric Hematology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael B. Streiff
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kenneth M. Shermock
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pharmacy, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Peggy S. Kraus
- Department of Pharmacy, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Junnan Chen
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jayesh Jani
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Thomas Kickler
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
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Darbari DS, Desai D, Arnaldez F, Desai K, Kallen J, Strouse J, Streiff MB, Hong K, Takemoto CM. Safety and efficacy of catheter directed thrombolysis in children with deep venous thrombosis. Br J Haematol 2012; 159:376-8. [PMID: 22934795 DOI: 10.1111/bjh.12025] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
The incidence of venous thromboembolism (VTE) is increasing in the pediatric population. Individuals with cystic fibrosis (CF) have an increased risk of thrombosis due to central venous catheters (CVCs), as well as acquired thrombophilia secondary to inflammation, or deficiencies of anticoagulant proteins due to vitamin K deficiency and/or liver dysfunction. CVC-associated thrombosis commonly results in line occlusion, but may develop into serious life-threatening conditions such as deep venous thrombosis (DVT), superior vena cava syndrome or pulmonary embolism (PE). Post-thrombotic syndrome (PTS) may be a long complication. Local occlusion of the catheter tip may be managed with instillation of thrombolytics (such as tPA) within the lumen of the catheter; however, CVC-associated thrombosis involving the proximal veins is most often is treated with systemic anticoagulation. Initial treatment with heparin is a standard approach, but thrombolytic therapy, which may carry higher bleeding risks, should be considered for life and limb threatening episodes of VTE. Recommended duration of anticoagulation with low molecular weight heparin (LMWH) or warfarin ranges from 3 to 6 months for major removable thrombotic risks; longer anticoagulation is considered for recurrent thrombosis, major persistent thrombophilia, or the continued presence of a major risk factor such as a CVC. While CVCs are the most common risk for development of VTE in children, studies have not demonstrated a clear benefit with routine use of systemic thromboprophylaxis. The incidence and risk factors of VTE in CF patients will be reviewed and principles of diagnosis and management will be summarized.
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Affiliation(s)
- Clifford M Takemoto
- Division of Pediatric Hematology, The Johns Hopkins University, Baltimore, Maryland, USA.
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Romano AA, Allanson JE, Dahlgren J, Gelb BD, Hall B, Pierpont ME, Roberts AE, Robinson W, Takemoto CM, Noonan JA. Noonan syndrome: clinical features, diagnosis, and management guidelines. Pediatrics 2010; 126:746-59. [PMID: 20876176 DOI: 10.1542/peds.2009-3207] [Citation(s) in RCA: 359] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Noonan syndrome (NS) is a common, clinically and genetically heterogeneous condition characterized by distinctive facial features, short stature, chest deformity, congenital heart disease, and other comorbidities. Gene mutations identified in individuals with the NS phenotype are involved in the Ras/MAPK (mitogen-activated protein kinase) signal transduction pathway and currently explain ∼61% of NS cases. Thus, NS frequently remains a clinical diagnosis. Because of the variability in presentation and the need for multidisciplinary care, it is essential that the condition be identified and managed comprehensively. The Noonan Syndrome Support Group (NSSG) is a nonprofit organization committed to providing support, current information, and understanding to those affected by NS. The NSSG convened a conference of health care providers, all involved in various aspects of NS, to develop these guidelines for use by pediatricians in the diagnosis and management of individuals with NS and to provide updated genetic findings.
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Affiliation(s)
- Alicia A Romano
- Department of Pediatrics, Munger Pavilion, Room 123, New York Medical College, Valhalla, NY 10595, USA.
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Takemoto CM, Brandal S, Jegga AG, Lee YN, Shahlaee A, Ying Y, Dekoter R, McDevitt MA. PU.1 positively regulates GATA-1 expression in mast cells. J Immunol 2010; 184:4349-61. [PMID: 20304827 DOI: 10.4049/jimmunol.0900927] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Coexpression of PU.1 and GATA-1 is required for proper specification of the mast cell lineage; however, in the myeloid and erythroid lineages, PU.1 and GATA-1 are functionally antagonistic. In this study, we report a transcriptional network in which PU.1 positively regulates GATA-1 expression in mast cell development. We isolated a variant mRNA isoform of GATA-1 in murine mast cells that is significantly upregulated during mast cell differentiation. This isoform contains an alternatively spliced first exon (IB) that is distinct from the first exon (IE) incorporated in the major erythroid mRNA transcript. In contrast to erythroid and megakaryocyte cells, in mast cells we show that PU.1 and GATA-2 predominantly occupy potential cis-regulatory elements in the IB exon region in vivo. Using reporter assays, we identify an enhancer flanking the IB exon that is activated by PU.1. Furthermore, we observe that in PU.1(-/-) fetal liver cells, low levels of the IE GATA-1 isoform is expressed, but the variant IB isoform is absent. Reintroduction of PU.1 restores variant IB isoform and upregulates total GATA-1 protein expression, which is concurrent with mast cell differentiation. Our results are consistent with a transcriptional hierarchy in which PU.1, possibly in concert with GATA-2, activates GATA-1 expression in mast cells in a pathway distinct from that seen in the erythroid and megakaryocytic lineages.
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Affiliation(s)
- Clifford M Takemoto
- Division of Pediatric Hematology, The Johns Hopkins University, Baltimore, MD 21205, USA.
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Zhang L, Oh SY, Wu X, Oh MH, Wu F, Schroeder JT, Takemoto CM, Zheng T, Zhu Z. SHP-1 deficient mast cells are hyperresponsive to stimulation and critical in initiating allergic inflammation in the lung. J Immunol 2009; 184:1180-90. [PMID: 20042576 DOI: 10.4049/jimmunol.0901972] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Phosphatase Src homology region 2 domain-containing phosphatase 1 (SHP-1)-deficient mice display an allergic asthma phenotype that is largely IL-13 and STAT6 dependent. The cell types responsible for the Th2 phenotype have not been identified. We hypothesized that SHP-1 deficiency leads to mast cell dysregulation and increased production and release of mediators and Th2 cytokines, leading to the allergic asthma phenotype. We examined SHP-1 regulation of mast cell differentiation, survival, and functional responses to stimulation using bone marrow-derived mast cells from viable motheaten (mev) mice. We assessed pulmonary phenotypical changes in mev mice on the mast cell-deficient Kit(W-Sh) genetic background. The results showed that SHP-1 deficiency led to increased differentiation and survival, but reduced proliferation, of mast cells. SHP-1-deficient mast cells produced and released increased amounts of mediators and Th2 cytokines IL-4 and -13 spontaneously and in response to H(2)O(2), LPS, and Fc epsilonI cross-linking, involving c-Kit-dependent and -independent processes. The Fc epsilonRI signaling led to binding of SHP-1 to linker for activation of T cells 2 and enhanced linker for activation of T cells 2 phosphorylation in mev bone marrow-derived mast cells. Furthermore, the number of mast cells in the lung tissue of mev mice was increased and mast cell production and release of Th2 cytokines were distinctly increased upon Fc epsilonRI stimulation. When backcrossed to the Kit(W-Sh) background, mev mice had markedly reduced pulmonary inflammation and Th2 cytokine production. These findings demonstrate that SHP-1 is a critical regulator of mast cell development and function and that SHP-1-deficient mast cells are able to produce increased Th2 cytokines and initiate allergic inflammatory responses in the lung.
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Affiliation(s)
- Li Zhang
- Division of Allergy and Clinical Immunology, The Johns Hopkins Asthma and Allergy Center, Baltimore, MD 21224, USA
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39
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Affiliation(s)
- Clifford M Takemoto
- Pediatric Hematology, The Johns Hopkins University, Baltimore, Maryland, USA.
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41
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Strouse JJ, Takemoto CM, Keefer JR, Kato GJ, Casella JF. Corticosteroids and increased risk of readmission after acute chest syndrome in children with sickle cell disease. Pediatr Blood Cancer 2008; 50:1006-12. [PMID: 17849474 PMCID: PMC2757656 DOI: 10.1002/pbc.21336] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [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] [Indexed: 01/13/2023]
Abstract
BACKGROUND Acute chest syndrome (ACS) is a frequent cause of hospitalization and mortality in children with sickle cell disease. Transfusion is often required to prevent respiratory failure and treatment with dexamethasone may reduce the length of admission and the need for transfusions. We performed a retrospective cohort study to evaluate risk factors for readmission and prolonged hospitalization after different treatments for ACS. PROCEDURE We identified patients <22 years of age hospitalized with ACS at Johns Hopkins Hospital from January 1998 to April 2004 using the hospitals discharge database and by reviewing dictated summaries. RESULTS We identified 65 patients with 129 episodes of ACS (mean age 12.5 years, range 1.2-21.9 years). Thirty-nine episodes were treated with corticosteroids and 51 with transfusions. Patients were readmitted within 14 days after 23 episodes (18%). Readmission was strongly associated with report of an inhaler or nebulizer at home [odds ratio (OR) 6.0, P < 0.05], diastolic BP at 48 hr (OR 1.8 per 10 mm increase, P<0.01), corticosteroids (OR 20, P < 0.005), or transfusion (OR 0.03, P < 0.05). Treatment with corticosteroids alone (P < 0.05) and older age (P < 0.001) were associated with longer hospitalization. CONCLUSIONS These results demonstrate a greatly elevated independent risk of readmission after ACS in children with asthma and after treatment with corticosteroids and a protective effect of transfusion. Although dexamethasone has documented efficacy for reducing the duration of ACS, the substantial risk of readmission for pain should limit its use.
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Affiliation(s)
- John J Strouse
- Division of Pediatric Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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42
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Gamper CJ, Takemoto CM, Schowinsky J, Borowitz MJ, Horwitz MS, Strouse JJ. Lymphadenopathy as the primary manifestation of malignant transformation in two patients with severe congenital neutropenia. Pediatr Blood Cancer 2008; 50:1072-5. [PMID: 18213714 DOI: 10.1002/pbc.21485] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We present the cases of two patients with severe congenital neutropenia (SCN) who both developed generalized adenopathy. Although both had recent histories that placed infection high on the differential of causes for the adenopathy, biopsies demonstrated acute myeloid leukemia (AML) as the etiology. The risk of malignant transformation in SCN is known to be significantly elevated, and these cases illustrate the need for physicians of such patients to keep myelodysplastic syndrome (MDS) and AML high on the differential when patients manifest atypical symptoms.
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Affiliation(s)
- Christopher J Gamper
- Division of Pediatric Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Abstract
Acquired inhibitors of coagulation factors, particularly to factor V (FV) and thrombin, after topical bovine thrombin exposure may result in clinically important coagulopathies. While bovine thrombin is commonly used in pediatric patients for surgical hemostasis, the reported cases of acquired inhibitors in children are few. We report two cases of children who developed factor inhibitors after bovine thrombin exposure. One child developed a FV inhibitor at 3 months of age after exposure to bovine thrombin during cardiac surgery. The inhibitor resolved with intravenous immunoglobulin (IVIG) and steroids. The other child developed concomitant FV and bovine thrombin inhibitors after cardiac surgery at age 11 years. The presence of these inhibitors complicated post-operative anti-coagulation management, but the inhibitors were transient. In addition to these two cases, we identified all the pediatric patients with bovine thrombin-induced inhibitors who were reported in the world's literature, and reviewed their clinical characteristics. These cases underscore the fact that bovine thrombin can be antigenic in infants and children and can result in significant coagulopathies.
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Affiliation(s)
- William J Savage
- Division of Pediatric Hematology, The Johns Hopkins University, Baltimore, Maryland 21205, USA
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Khan JU, Takemoto CM, Casella JF, Streiff MB, Nwankwo IJ, Kim HS. Catheter-directed thrombolysis of inferior vena cava thrombosis in a 13-day-old neonate and review of literature. Cardiovasc Intervent Radiol 2007; 31 Suppl 2:S153-60. [PMID: 18004620 DOI: 10.1007/s00270-007-9229-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2007] [Revised: 09/28/2007] [Accepted: 10/16/2007] [Indexed: 10/22/2022]
Abstract
Complete inferior vena cava thrombosis (IVC) in neonates is uncommon, but may cause significant morbidity. A 13-day-old neonate suffered IVC thrombosis secondary to antithrombin III deficiency, possibly contributed to by a mutation in the methyl tetrahydrofolate reductase gene. Catheter-directed thrombolysis (CDT) with recombinant tissue plasminogen activator (rt-PA, Alteplase) was used successfully to treat extensive venous thrombosis in this neonate without complications. We also review the literature on CDT for treatment of IVC thrombosis in critically ill neonates and infants.
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Affiliation(s)
- Jawad U Khan
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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Shahlaee AH, Brandal S, Lee YN, Jie C, Takemoto CM. Distinct and shared transcriptomes are regulated by microphthalmia-associated transcription factor isoforms in mast cells. J Immunol 2007; 178:378-88. [PMID: 17182576 PMCID: PMC2605087 DOI: 10.4049/jimmunol.178.1.378] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The Microphthalmia-associated transcription factor (Mitf) is an essential basic helix-loop-helix leucine zipper transcription factor for mast cell development. Mice deficient in Mitf harbor a severe mast cell deficiency, and Mitf-mutant mast cells cultured ex vivo display a number of functional defects. Therefore, an understanding of the genetic program regulated by Mitf may provide important insights into mast cell differentiation. Multiple, distinct isoforms of Mitf have been identified in a variety of cell types; we found that Mitf-a, Mitf-e, and Mitf-mc were the major isoforms expressed in mast cells. To determine the physiologic function of Mitf in mast cells, we restored expression of these isoforms in primary mast cells from Mitf(-/-) mice. We found that these isoforms restored granular morphology and integrin-mediated migration. By microarray analysis, proteases, signaling molecules, cell surface receptor, and transporters comprised the largest groups of genes up-regulated by all isoforms. Furthermore, we found that isoforms also regulated distinct genes sets, suggesting separable biological activities. This work defines the transcriptome regulated by Mitf in mast cells and supports its role as master regulator of mast cell differentiation. Expression of multiple isoforms of this transcription factor may provide for redundancy of biological activities while also allowing diversity of function.
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Affiliation(s)
- Amir H Shahlaee
- Division of Pediatric Hematology, Johns Hopkins University, Baltimore, MD 21205, USA.
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Takemoto CM, Yoon YJ, Fisher DE. The identification and functional characterization of a novel mast cell isoform of the microphthalmia-associated transcription factor. J Biol Chem 2002; 277:30244-52. [PMID: 12039954 DOI: 10.1074/jbc.m201441200] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.0] [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] [Indexed: 11/06/2022] Open
Abstract
The microphthalmia-associated transcription factor (Mitf) is critical for mast cell development based on the severe mast cell deficiency seen in Mitf mutant mice. Mitf also is important for the development of melanocytes, osteoclasts, and retinal pigment epithelium. The lineage-restricted phenotypes of Mitf mutations correlate with tissue-restricted expression of Mitf, a feature due in part to the presence of several distinct Mitf isoforms. We report the identification and characterization of a novel mast cell isoform, Mitf-mc. This isoform arises from alternative splicing of a novel 5'-exon onto the common body of the gene and is predicted to encode a unique 43-amino acid sequence at its amino terminus. It is specifically expressed in mast cells. The mast cell isoform functions differently from the melanocyte isoform in its ability to activate cell type-specific Mitf gene targets. Mitf-mc functions only on a mast cell target promoter and fails to activate a melanocyte target promoter despite binding to its E-box element. Moreover, Mitf-mc heterodimerizes with a closely related transcription factor, Tfe3, and dominantly inhibits the ability of Tfe3 to transactivate a melanocyte-specific promoter. These studies identify a new isoform of Mitf with tissue-specific features that may underlie key aspects of the mast cell phenotype of Mitf mutations.
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Affiliation(s)
- Clifford M Takemoto
- Division of Pediatric Hematology, The Johns Hopkins University, Baltimore, Maryland 21205, USA.
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Weilbaecher KN, Motyckova G, Huber WE, Takemoto CM, Hemesath TJ, Xu Y, Hershey CL, Dowland NR, Wells AG, Fisher DE. Linkage of M-CSF signaling to Mitf, TFE3, and the osteoclast defect in Mitf(mi/mi) mice. Mol Cell 2001; 8:749-58. [PMID: 11684011 DOI: 10.1016/s1097-2765(01)00360-4] [Citation(s) in RCA: 128] [Impact Index Per Article: 5.6] [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] [Indexed: 11/26/2022]
Abstract
Osteoclasts are multinucleated hematopoietic cells essential for bone resorption. Macrophage colony-stimulating factor (M-CSF) is critical for osteoclast development and function, although its nuclear targets in osteoclasts are largely unknown. Mitf and TFE3 are two closely related helix-loop-helix (HLH) transcription factors previously implicated in osteoclast development and function. We demonstrate that cultured Mitf(mi/mi) osteoclasts are immature, mononuclear, express low levels of TRAP, and fail to mature upon M-CSF stimulation. In addition, M-CSF induces phosphorylation of Mitf and TFE3 via a conserved MAPK consensus site, thereby triggering their recruitment of the coactivator p300. Furthermore, an unphosphorylatable mutant at the MAPK consensus serine is specifically deficient in formation of multinucleated osteoclasts, mimicking the defect in Mitf(mi/mi) mice. These results identify a signaling pathway that appears to coordinate cytokine signaling with the expression of genes vital to osteoclast development.
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Affiliation(s)
- K N Weilbaecher
- Department of Adult Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA
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Wu M, Hemesath TJ, Takemoto CM, Horstmann MA, Wells AG, Price ER, Fisher DZ, Fisher DE. c-Kit triggers dual phosphorylations, which couple activation and degradation of the essential melanocyte factor Mi. Genes Dev 2000. [DOI: 10.1101/gad.14.3.301] [Citation(s) in RCA: 246] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Microphthalmia (Mi) is a bHLHZip transcription factor that is essential for melanocyte development and postnatal function. It is thought to regulate both differentiated features of melanocytes such as pigmentation as well as proliferation/survival, based on phenotypes of mutant mouse alleles. Mi activity is controlled by at least two signaling pathways. Melanocyte-stimulating hormone (MSH) promotes transcription of the Mi gene through cAMP elevation, resulting in sustained Mi up-regulation over many hours. c-Kit signaling up-regulates Mi function through MAP kinase phosphorylation of Mi, thereby recruiting the p300 transcriptional coactivator. The current study reveals that c-Kit signaling triggers two phosphorylation events on Mi, which up-regulate transactivation potential yet simultaneously target Mi for ubiquitin-dependent proteolysis. The specific activation/degradation signals derive from MAPK/ERK targeting of serine 73, whereas serine 409 serves as a substrate for p90 Rsk-1. An unphosphorylatable double mutant at these two residues is at once profoundly stable and transcriptionally inert. These c-Kit-induced phosphorylations couple transactivation to proteasome-mediated degradation. c-Kit signaling thus triggers short-lived Mi activation and net Mi degradation, in contrast to the profoundly increased Mi expression after MSH signaling, potentially explaining the functional diversity of this transcription factor in regulating proliferation, survival, and differentiation in melanocytes.
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Wu M, Hemesath TJ, Takemoto CM, Horstmann MA, Wells AG, Price ER, Fisher DZ, Fisher DE. c-Kit triggers dual phosphorylations, which couple activation and degradation of the essential melanocyte factor Mi. Genes Dev 2000; 14:301-12. [PMID: 10673502 PMCID: PMC316361] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Microphthalmia (Mi) is a bHLHZip transcription factor that is essential for melanocyte development and postnatal function. It is thought to regulate both differentiated features of melanocytes such as pigmentation as well as proliferation/survival, based on phenotypes of mutant mouse alleles. Mi activity is controlled by at least two signaling pathways. Melanocyte-stimulating hormone (MSH) promotes transcription of the Mi gene through cAMP elevation, resulting in sustained Mi up-regulation over many hours. c-Kit signaling up-regulates Mi function through MAP kinase phosphorylation of Mi, thereby recruiting the p300 transcriptional coactivator. The current study reveals that c-Kit signaling triggers two phosphorylation events on Mi, which up-regulate transactivation potential yet simultaneously target Mi for ubiquitin-dependent proteolysis. The specific activation/degradation signals derive from MAPK/ERK targeting of serine 73, whereas serine 409 serves as a substrate for p90 Rsk-1. An unphosphorylatable double mutant at these two residues is at once profoundly stable and transcriptionally inert. These c-Kit-induced phosphorylations couple transactivation to proteasome-mediated degradation. c-Kit signaling thus triggers short-lived Mi activation and net Mi degradation, in contrast to the profoundly increased Mi expression after MSH signaling, potentially explaining the functional diversity of this transcription factor in regulating proliferation, survival, and differentiation in melanocytes.
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Affiliation(s)
- M Wu
- Division of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts 02115, USA
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Price ER, Horstmann MA, Wells AG, Weilbaecher KN, Takemoto CM, Landis MW, Fisher DE. alpha-Melanocyte-stimulating hormone signaling regulates expression of microphthalmia, a gene deficient in Waardenburg syndrome. J Biol Chem 1998; 273:33042-7. [PMID: 9830058 DOI: 10.1074/jbc.273.49.33042] [Citation(s) in RCA: 188] [Impact Index Per Article: 7.2] [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: 11/06/2022] Open
Abstract
The pituitary peptide alpha-melanocyte-stimulating hormone (alpha-MSH) stimulates melanocytes to up-regulate cAMP, but the downstream targets of cAMP are not well understood mechanistically. One consequence of alpha-MSH stimulation is increased melanization attributable to induction of pigmentation enzymes, including tyrosinase, which catalyzes a rate-limiting step in melanin synthesis. The tyrosinase promoter is a principle target of the melanocyte transcription factor Microphthalmia (Mi), a factor for which deficiency in humans causes Waardenburg syndrome II. We show here that both alpha-MSH and forskolin, a drug that increases cAMP, stimulate a rapid increase in Mi mRNA and protein levels in both melanoma cell lines and primary melanocytes. This up-regulation requires a cAMP-responsive element within the Mi promoter, and the pathway leading to Mi stimulation is subject to tight homeostatic regulation. Although cAMP signaling is ubiquitous, the Mi promoter was seen to be cAMP-responsive in melanocytes but not in nonmelanocytes. Moreover, dominant negative interference with Mi impeded successful alpha-MSH stimulation of tyrosinase. The regulation of Mi expression via alpha-MSH thus provides a direct mechanistic link to pigmentation. In addition, because the human melanocyte and deafness condition Waardenburg syndrome is sometimes caused by haploinsufficiency of Mi, its modulation by alpha-MSH suggests therapeutic strategies targeted at up-regulating the remaining wild type Mi allele.
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Affiliation(s)
- E R Price
- Department of Pediatric Hematology/Oncology, Dana Farber Cancer Research Institute and Harvard Medical School, Boston, Massachusetts 02115, USA
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