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Bosch A, Brunsvig Jarvis K, Brandão LR, Zou Y, Vincelli J, Amiri N, Avila L. The role of coagulation factors VIII, IX and XI in the prediction and mediation of recurrent thrombotic events in children with non-central venous catheter deep vein thrombosis. Thromb Res 2024; 236:228-235. [PMID: 38484629 DOI: 10.1016/j.thromres.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND The role of elevated coagulation factors VIII (FVIII), FIX, FXI for the prediction of recurrent thrombotic events in children after an index non-central venous catheter (non-CVC) related deep vein thrombosis (DVT) remains unclear. OBJECTIVE This study investigates the predictive role of FVIII, FIX, and FXI for recurrent thrombosis in children with index non-CVC DVTs, and the mediation effect of FVIII on chronic inflammation and recurrent thrombosis. METHODS Children aged 0-18 years diagnosed with an index non-CVC related DVT (1993-2020) were included in this single-center retrospective cohort study. Plasma levels of FVIII, FIX, FXI were measured cross-sectionally ≥30 days after the acute DVT. The association between the continuous variables FVIII, FIX, FXI and thrombosis recurrence was investigated using uni- and multivariable logistic regression, adjusting for age, sex, and chronic inflammation. Mediation analysis assessed the role of FVIII as a mediator between chronic inflammation and recurrent thrombosis. Ethics approval was obtained. RESULTS A total of 139 children with an index non-CVC related DVT were included. Thirty-eight (27 %) had a recurrent thrombosis at a median of 237 days (P25-P75 65-657 days) after the index DVT. In uni- and multivariable-analysis, FVIII, FIX or FXI did not predict thrombosis recurrence; However, chronic inflammation was an independent predictor. There was no evidence that FVIII mediated the effect of chronic inflammation on thrombosis recurrence. CONCLUSION We found no evidence that elevated FVIII, FIX or FXI predicted thrombosis recurrence, or evidence of a mediating role of FVIII. Underlying chronic inflammation predicted venous recurrent thrombotic events in this cohort.
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Affiliation(s)
- Alessandra Bosch
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada; University Children's Hospital Zurich, Department of Haematology, Zurich, Switzerland.
| | - Kirsten Brunsvig Jarvis
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada; Oslo University Hospital, Department of Pediatric Hematology and Oncology, Oslo, Norway
| | - Leonardo R Brandão
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yushu Zou
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Vincelli
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nour Amiri
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Laura Avila
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
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Albisetti M, Tartakovsky I, Halton J, Bomgaars L, Chalmers E, Mitchell LG, Luciani M, Nurmeev I, Gorbatikov K, Miede C, Brueckmann M, Brandão LR. Dabigatran for Treatment and Secondary Prevention of Venous Thromboembolism in Pediatric Congenital Heart Disease. J Am Heart Assoc 2024; 13:e028957. [PMID: 38348778 PMCID: PMC11010117 DOI: 10.1161/jaha.122.028957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/02/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Congenital heart disease (CHD) is common in children and associated with greater risk of thrombotic complications. Management of these complications with standard-of-care treatment is suboptimal for these children. METHODS AND RESULTS The effectiveness and safety of dabigatran were demonstrated in pivotal pediatric studies for the treatment of acute venous thromboembolism (VTE; NCT01895777) and secondary VTE prevention (NCT02197416). We report safety and efficacy outcomes from subgroup analyses of these studies for children with CHD (diagnosed according to local practice) and those without. In NCT01895777, 17/21 (81.0%) and 16/27 (59.3%) patients with CHD (including cyanotic) treated with dabigatran and standard of care, respectively, met the primary end point (complete thrombus resolution, freedom from recurrent VTE, and freedom from VTE-related death; odds ratio [OR], 0.34 [95% CI, 0.08-1.23]). In patients without CHD, 41.0% (n=64) versus 34.9% (n=22) achieved this end point with the respective treatments (OR, 0.77 [95% CI, 0.42-1.41]). Although numerical differences were observed, no heterogeneity in treatment effect of dabigatran on the composite primary end point was detected in patients with and without CHD (interaction P =0.2674). In NCT02197416, recurrent VTE at 12 months occurred in 0/17 patients with CHD versus 3/194 (1.5%) without. No patient with CHD experienced major or clinically relevant nonmajor bleeding events. CONCLUSIONS Data on favorable anticoagulant alternatives for the unmet needs of children with CHD are emerging, and our exploratory results suggest that dabigatran could be an appropriate treatment choice, although challenging sample size limitations in pediatric studies require cautious interpretation of findings. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01895777, NCT02197416.
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Affiliation(s)
- Manuela Albisetti
- Hematology Department University Children's Hospital Zürich Switzerland
| | | | - Jacqueline Halton
- Children's Hospital of Eastern Ontario University of Ottawa Ottawa Ontario Canada
| | - Lisa Bomgaars
- Department of Pediatrics Texas Children's Hospital, Baylor College of Medicine Houston TX USA
| | | | | | - Matteo Luciani
- Pediatric Hematology/Oncology Department Pediatric Hospital Bambino Gesù Rome Italy
| | - Ildar Nurmeev
- Pediatric Hospital, Republic of Tatarstan Kazan Medical University Kazan Russian Federation
| | - Kirill Gorbatikov
- Pediatric Cardiovascular Surgery Regional Hospital #1 Tyumen Region Russian Federation
| | | | - Martina Brueckmann
- Boehringer Ingelheim International GmbH Ingelheim Germany
- First Department of Medicine Faculty of Medicine Mannheim of the University of Heidelberg Mannheim Germany
| | - Leonardo R Brandão
- The Hospital for Sick Children University of Toronto Toronto Ontario Canada
- Dalla Lana School of Public Health University of Toronto Toronto Ontario Canada
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Bastas D, Brandão LR, Vincelli J, Wilson D, Perrem L, Guerra V, Wong G, Bentley RF, Tole S, Schneiderman JE, Amiri N, Williams S, Avila ML. Long-term outcomes of pulmonary embolism in children and adolescents. Blood 2024; 143:631-640. [PMID: 38134357 DOI: 10.1182/blood.2023021953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 12/24/2023] Open
Abstract
ABSTRACT Knowledge regarding the long-term consequences of pulmonary embolism (PE) in children is limited. This cohort study describes the long-term outcomes of PE in children who were followed-up at a single-center institution using a local protocol that included clinical evaluation, chest imaging, echocardiography, pulmonary function tests, and cardiopulmonary exercise tests at follow-up, starting 3 to 6 months after acute PE. Children objectively diagnosed with PE at age 0 to 18 years, who had ≥6 months of follow-up were included. Study outcomes consisted of PE resolution, PE recurrence, death, and functional outcomes (dyspnea, impaired pulmonary or cardiac function, impaired aerobic capacity, and post-PE syndrome). The frequency of outcomes was compared between patients with/without underlying conditions. In total, 150 patients were included; median age at PE was 16 years (25th-75th percentile, 14-17 years); 61% had underlying conditions. PE did not resolve in 29%, recurrence happened in 9%, and death in 5%. One-third of patients had at least 1 documented abnormal functional finding at follow-up (ventilatory impairments, 31%; impaired aerobic capacity, 31%; dyspnea, 26%; and abnormal diffusing capacity of the lungs to carbon monoxide, 22%). Most abnormalities were transient. When alternative explanations for the impairments were considered, the frequency of post-PE syndrome was lower, ranging between 0.7% and 8.5%. Patients with underlying conditions had significantly higher recurrence, more pulmonary function and ventilatory impairments, and poorer exercise capacity. Exercise intolerance was, in turn, most frequently because of deconditioning than to respiratory or cardiac limitation, highlighting the importance of physical activity promotion in children with PE.
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Affiliation(s)
- Denise Bastas
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leonardo R Brandão
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jennifer Vincelli
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - David Wilson
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Lucy Perrem
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Vitor Guerra
- Division of Cardiology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Gina Wong
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Robert F Bentley
- Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada
| | - Soumitra Tole
- Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital, London Health Sciences Centre, London, ON, Canada
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Jane E Schneiderman
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Nour Amiri
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Suzan Williams
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - M Laura Avila
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
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Longmuir PE, Chubbs Payne A, Beshara N, Brandão LR, Wright FV, Pohl D, Katz SL, McCormick A, De Laat D, Klaassen RJ, Johnston DL, Lougheed J, Roth J, McMillan HJ, Venkateswaran S, Sell E, Doja A, Boafo A, Macartney G, Matheson K, Feldman BM. Quick, Effective Screening Tasks Identify Children With Medical Conditions or Disabilities Needing Physical Literacy Support. Pediatr Exerc Sci 2024:1-11. [PMID: 38171358 DOI: 10.1123/pes.2023-0130] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/26/2023] [Accepted: 11/06/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE This study evaluated screening tasks able to identify children with medical conditions or disabilities who may benefit from physical literacy. METHOD Children completed ≤20 screening tasks during their clinic visit and then the Canadian Assessment of Physical Literacy (2nd edition) at a separate visit. Total Canadian Assessment of Physical Literacy scores <30th percentile were categorized as potentially needing physical literacy support. Receiver operator characteristic curves identified assessment cut points with 80% sensitivity and 40% specificity relative to total physical literacy scores. RESULTS 223 children (97 girls; 10.1 [2.6] y) participated. Physical activity adequacy, predilection, and physical competence achieved ≥80% sensitivity and ≥40% specificity in both data sets. Adequacy ≤ 6.5 had 86% to 100% sensitivity and 48% to 49% specificity. Daily screen time >4.9 hours combined with Adequacy ≤6.15 had 88% to 10% sensitivity and 53% to 56% specificity. CONCLUSIONS Activity adequacy, alone or with screen time, most effectively identified children likely to benefit from physical literacy support. Adequacy and screen time questionnaires are suitable for clinical use. Similar results regardless of diagnosis suggest physical competence deficits are not primary determinants of active lifestyles. Research to enhance screening specificity is required.
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Affiliation(s)
- Patricia E Longmuir
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON,Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON,Canada
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON,Canada
| | - Adam Chubbs Payne
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON,Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON,Canada
| | - Natalie Beshara
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON,Canada
| | - Leonardo R Brandão
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON,Canada
- Faculty of Medicine, University of Toronto, Toronto, ON,Canada
| | - F Virginia Wright
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON,Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON,Canada
| | - Daniela Pohl
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON,Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON,Canada
- Division of Neurology, Children's Hospital of Eastern Ontario, Ottawa, ON,Canada
| | - Sherri Lynne Katz
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON,Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON,Canada
- Division of Respirology, Children's Hospital of Eastern Ontario, Ottawa, ON,Canada
| | - Anna McCormick
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON,Canada
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON,Canada
- Division of Developmental Pediatrics and Rehabilitation Medicine, Children's Hospital of Eastern Ontario, Ottawa, ON,Canada
| | - Denise De Laat
- Division of Developmental Pediatrics and Rehabilitation Medicine, Children's Hospital of Eastern Ontario, Ottawa, ON,Canada
| | - Robert J Klaassen
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON,Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON,Canada
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, ON,Canada
| | - Donna L Johnston
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON,Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON,Canada
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, ON,Canada
| | - Jane Lougheed
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON,Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON,Canada
- Division of Cardiology, Children's Hospital of Eastern Ontario, Ottawa, ON,Canada
| | - Johannes Roth
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON,Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON,Canada
- Division of Dermatology and Rheumatology, Children's Hospital of Eastern Ontario, Ottawa, ON,Canada
| | - Hugh J McMillan
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON,Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON,Canada
- Division of Neurology, Children's Hospital of Eastern Ontario, Ottawa, ON,Canada
| | - Sunita Venkateswaran
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON,Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON,Canada
- Division of Neurology, Children's Hospital of Eastern Ontario, Ottawa, ON,Canada
| | - Erick Sell
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON,Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON,Canada
- Division of Neurology, Children's Hospital of Eastern Ontario, Ottawa, ON,Canada
| | - Asif Doja
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON,Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON,Canada
- Division of Neurology, Children's Hospital of Eastern Ontario, Ottawa, ON,Canada
| | - Addo Boafo
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON,Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON,Canada
- Division of Psychiatry, Children's Hospital of Eastern Ontario, Ottawa, ON,Canada
| | - Gail Macartney
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON,Canada
- Faculty of Nursing, University of Prince Edward Island, Charlottetown, PE,Canada
| | - Katherine Matheson
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON,Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON,Canada
- Division of Psychiatry, Children's Hospital of Eastern Ontario, Ottawa, ON,Canada
| | - Brian M Feldman
- Faculty of Medicine, University of Toronto, Toronto, ON,Canada
- Division of Rheumatology, Department of Pediatrics, and the Institute of Health Policy and Evaluation, The Hospital for Sick Children, Dalla Lana School of Public Health, University of Toronto, Toronto, ON,Canada
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Payne RM, Burns KM, Glatz AC, Male C, Donti A, Brandão LR, Balling G, VanderPluym CJ, Bu'Lock F, Kochilas LK, Stiller B, Cnota JF, Rahkonen O, Khan A, Adorisio R, Stoica S, May L, Burns JC, Saraiva JFK, McHugh KE, Kim JS, Rubio A, Chía-Vazquez NG, Meador MR, Dyme JL, Reedy AM, Ajavon-Hartmann T, Jarugula P, Carlson-Taneja LE, Mills D, Wheaton O, Monagle P. Apixaban for Prevention of Thromboembolism in Pediatric Heart Disease. J Am Coll Cardiol 2023; 82:2296-2309. [PMID: 38057072 DOI: 10.1016/j.jacc.2023.10.010] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Children with heart disease frequently require anticoagulation for thromboprophylaxis. Current standard of care (SOC), vitamin K antagonists or low-molecular-weight heparin, has significant disadvantages. OBJECTIVES The authors sought to describe safety, pharmacokinetics (PK), pharmacodynamics, and efficacy of apixaban, an oral, direct factor Xa inhibitor, for prevention of thromboembolism in children with congenital or acquired heart disease. METHODS Phase 2, open-label trial in children (ages, 28 days to <18 years) with heart disease requiring thromboprophylaxis. Randomization 2:1 apixaban or SOC for 1 year with intention-to-treat analysis. PRIMARY ENDPOINT a composite of adjudicated major or clinically relevant nonmajor bleeding. Secondary endpoints: PK, pharmacodynamics, quality of life, and exploration of efficacy. RESULTS From 2017 to 2021, 192 participants were randomized, 129 apixaban and 63 SOC. Diagnoses included single ventricle (74%), Kawasaki disease (14%), and other heart disease (12%). One apixaban participant (0.8%) and 3 with SOC (4.8%) had major or clinically relevant nonmajor bleeding (% difference -4.0 [95% CI: -12.8 to 0.8]). Apixaban incidence rate for all bleeding events was nearly twice the rate of SOC (100.0 vs 58.2 per 100 person-years), driven by 12 participants with ≥4 minor bleeding events. No thromboembolic events or deaths occurred in either arm. Apixaban pediatric PK steady-state exposures were consistent with adult levels. CONCLUSIONS In this pediatric multinational, randomized trial, bleeding and thromboembolism were infrequent on apixaban and SOC. Apixaban PK data correlated well with adult trials that demonstrated efficacy. These results support the use of apixaban as an alternative to SOC for thromboprophylaxis in pediatric heart disease. (A Study of the Safety and Pharmacokinetics of Apixaban Versus Vitamin K Antagonist [VKA] or Low Molecular Weight Heparin [LMWH] in Pediatric Subjects With Congenital or Acquired Heart Disease Requiring Anticoagulation; NCT02981472).
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Affiliation(s)
- R Mark Payne
- Riley Hospital for Children, Wells Center for Pediatric Research, Department of Pediatrics, Division of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, USA.
| | - Kristin M Burns
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Andrew C Glatz
- Division of Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Christoph Male
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Andrea Donti
- IRCCS- Azienda Ospedaliera-Universitaria, Ospedale di S. Orsola, Bologna, Italy
| | - Leonardo R Brandão
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada; Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Gunter Balling
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Christina J VanderPluym
- Heart Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Frances Bu'Lock
- East Midlands Congenital Heart Centre and University of Leicester, University Hospitals of Leicester NHS Trust, Leicester, England
| | - Lazaros K Kochilas
- Children's Healthcare of Atlanta and the Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Brigitte Stiller
- Department of Congenital Heart Defects and Pediatric Cardiology, University Heart Centre, Medical Center-University of Freiburg, Freiburg, Germany
| | - James F Cnota
- Heart Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Otto Rahkonen
- New Children's Hospital, Helsinki University Central Hospital, Department of Pediatric Cardiology, Helsinki, Finland
| | - Asra Khan
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Rachele Adorisio
- Heart Failure, Transplant and Mechanical Assist Devices, Bambino Gesù Hospital and Research Institute, Rome, Italy
| | - Serban Stoica
- Bristol Children's Hospital and the Heart Institute, Bristol, United Kingdom
| | - Lindsay May
- University of Utah: Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Jane C Burns
- Rady Children's Hospital San Diego, University of California-San Diego, La Jolla, California, USA
| | | | - Kimberly E McHugh
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John S Kim
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Agustin Rubio
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Nadia G Chía-Vazquez
- Pediatric Cardiology Department, Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico
| | - Marcie R Meador
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Joshua L Dyme
- Bristol Myers Squibb, Inc, Lawrence Township, New Jersey, USA
| | - Alison M Reedy
- Bristol Myers Squibb, Inc, Lawrence Township, New Jersey, USA
| | | | | | | | - Donna Mills
- Bristol Myers Squibb, Inc, Lawrence Township, New Jersey, USA
| | | | - Paul Monagle
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Haematology Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Haematology, Royal Children's Hospital, Melbourne, Victoria, Australia; Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
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Sayyid RK, Klaassen Z, Berlin A, Roy S, Brandão LR, Bernardino R, Chavarriaga J, Jiang DM, Spratt DE, Fleshner NE, Wallis CJD. Poly(adenosine diphosphate-ribose) polymerase inhibitor combinations in first-line metastatic castrate-resistant prostate cancer setting: a systematic review and meta-analysis. BJU Int 2023; 132:619-630. [PMID: 37461140 DOI: 10.1111/bju.16130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
OBJECTIVES To compare radiographic progression-free survival (rPFS), overall survival (OS), and treatment-emergent adverse events (TEAEs) among patients with metastatic castrate-resistant prostate cancer (mCRPC) receiving a combination of first-line poly(adenosine diphosphate-ribose) polymerase inhibitors (PARPi) plus androgen receptor axis-targeted agents (ARAT) vs placebo/ARAT. MATERIALS AND METHODS We conducted a systematic review/meta-analysis of all published Phase III randomised controlled trials using EMBASE, MEDLINE, and Cochrane (inception until 6 June 2023). Published full-text manuscripts and conference abstracts were inclusion eligible. Study selection/data extraction were independently performed by two authors. The Cochrane Risk-of-Bias 2 Tool was used, and certainty of evidence assessed using the Grading of Recommendations, Assessment, Development, and Evaluations framework. Pooled hazard ratios (HRs) and relative risks, with corresponding confidence intervals (CIs), were generated using random-effects models. RESULTS Three trials were identified: PROpel, MAGNITUDE, and TALAPRO-2. Compared to placebo/ARAT, the PARPi/ARAT combination was associated with a 35% rPFS improvement in the overall cohort (HR 0.65, 95% CI 0.56-0.76), with 68%, 45%, and 26% improvements in the BReast CAncer gene 1/gene 2 (BRCA1/2)-mutated (BRCA1/2m; P < 0.001), homologous recombination repair-mutated (HRRm; P < 0.001), and non-HRRm cohorts (P = 0.003), respectively. OS data maturity ranged from 31% to 48%, with overall cohort OS data unavailable from MAGNITUDE. The PROpel/TALAPRO-2 pooled analysis demonstrated a 16% OS improvement in the overall cohort (HR 0.84, 95 CI 0.72-0.98; P = 0.02). OS in the HRRm (HR 0.76, 95% CI 0.61-0.95) and the BRCA1/2m cohorts (HR 0.53, 95% CI 0.18-1.56) were improved, with a higher effect magnitude compared to the overall cohort. This combination was associated with a 45% relative risk increase in Grade ≥3 TEAEs, including 6.22-fold for Grade ≥3 anaemia (31.9% vs 4.9%). CONCLUSIONS The addition of PARPi to ARAT in the first-line mCRPC setting is associated with rPFS benefits across subgroups, with the greatest magnitude of benefit in BRCA1/2m patients. OS benefits remain inconsistent irrespective of HRRm status, with significant increases in Grade ≥3 TEAEs, particularly anaemia. Currently, we suggest this combined approach be selectively offered to HRRm patients, preferentially BRCA1/2m.
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Affiliation(s)
- Rashid K Sayyid
- Division of Urologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Zachary Klaassen
- Section of Urology, Department of Surgery, Augusta University, Augusta, GA, USA
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Soumyajit Roy
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL, USA
| | | | - Rui Bernardino
- Division of Urologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Julian Chavarriaga
- Division of Urologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Di Maria Jiang
- Division of Medical Oncology, Department of Medicine, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals, Case Western Reserve University, Cleveland, OH, USA
| | - Neil E Fleshner
- Division of Urologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Christopher J D Wallis
- Division of Urologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Surgery, Urology, Mount Sinai Health System, Toronto, ON, Canada
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7
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Avila ML, Bentley RF, Bastas D, Brandão LR, Schneiderman JE, Ward L, Wong G, Stephens S, Liu K, Thomas S. Unraveling the pathophysiology of lower-limb postthrombotic syndrome in adolescents: a proof-of-concept study. Blood Adv 2023; 7:2784-2793. [PMID: 36763520 PMCID: PMC10275697 DOI: 10.1182/bloodadvances.2022009599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/07/2023] [Accepted: 02/07/2023] [Indexed: 02/11/2023] Open
Abstract
A better understanding of the pathophysiology of pediatric postthrombotic syndrome (PTS) is needed to develop strategies to treat this condition. We investigated calf pump function, exercise capacity, balance in power output, and changes in limb muscle oxygen saturation (SmO2) and fluid content during exercise in 10 pediatric patients with unilateral lower-limb PTS, and in age- and sex-matched controls (1:1-1:2 ratio). Outcomes were investigated using bioimpedance spectroscopy, torque-sensing pedals, and near-infrared spectroscopy during incremental- and constant-load cycling tests. The median age at participation was 17 years (25th-75th percentile, 15-18 years); 68% of participants were females. The median CAPTSure score in the affected leg of affected participants was 35 points (25th-75th percentile, 24-46 points), indicating moderate/severe PTS; 20% of patients had a history of central venous catheter-related thrombosis. Increasing PTS severity was associated with higher calf pump venous volume and higher ejection volume, leading to compensated calf pump performance. We found no evidence of PTS impact on exercise capacity. Leg contribution to power output was similar in affected and unaffected legs. However, the PTS-affected legs showed lower SmO2 during active cycling and recovery with increasing PTS severity, indicating impaired microvascular function in the muscle. These findings suggest that PTS severity is associated with impaired blood flow, presumably from elevated venous pressure during and after exercise. The fact that microvascular function is impaired in young patients with PTS underscores the relevance of developing strategies to mitigate the effects of this chronic vascular disease to minimize its deleterious effects as children grow older.
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Affiliation(s)
- M. Laura Avila
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Robert F. Bentley
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Denise Bastas
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leonardo R. Brandão
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jane E. Schneiderman
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Clinical Research Services, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leigh Ward
- School of Chemistry and Molecular Biosciences, The University of Queensland, St. Lucia, Brisbane, Australia
| | - Gina Wong
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Samantha Stephens
- Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Kuan Liu
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Scott Thomas
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
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8
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Bastas D, Brandão LR, Vincelli J, Schneiderman JE, Cunningham J, Avila ML. Physical Activity for Children with Deep Vein Thrombosis and Pulmonary Embolism on Anticoagulation: A Scoping Review. Res Pract Thromb Haemost 2023; 7:100094. [PMID: 37063770 PMCID: PMC10099307 DOI: 10.1016/j.rpth.2023.100094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/18/2023] [Accepted: 02/09/2023] [Indexed: 03/03/2023] Open
Abstract
Context There are no clear pediatric guidelines on the return to physical activity following deep vein thrombosis (DVT) or pulmonary embolism (PE), particularly while being treated with anticoagulation. Objective This scoping review aimed to examine the current literature on physical activity beyond simple ambulation for patients with DVT/PE being treated with anticoagulation. Data Sources An electronic search for articles in MEDLINE, Epub Ahead of Print, In-Process, and Other Non-Indexed Citations, Daily (1946 to April 4, 2022), and Embase+Embase Classic (1946 to 2022, week 13) was conducted. Study Selection (1) Patients of any age with DVT/PE, treated with anticoagulation; (2) studies of any design providing information on physical activity (ie, sport, exercise) while on anticoagulation; and (3) studies in English. Data Extraction Data from eligible studies obtained included the study design, population, disease characteristics, and information on physical activity participation. Results A total of 26 eligible studies were included. Only 2 studies were specific to children. Studies recommend a gradual return to participation in noncontact or low-risk activities after the first 3-4 weeks of anticoagulation, with close monitoring of symptoms. Participation in contact sports and activities is typically delayed until after anticoagulants are discontinued. However, personalized anticoagulation with intermittent dosing schedules has been proposed for athletes after the first 3 months of anticoagulation treatment. Conclusions Physical activity participation guidelines for children with DVT/PE being treated with anticoagulation are needed, and the evidence currently available is limited. Largely based on evidence from adult patients, we present evidence-informed options to facilitate clinician recommendations for returning to activity.
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Affiliation(s)
- Denise Bastas
- Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Leonardo R. Brandão
- Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jennifer Vincelli
- Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jane E. Schneiderman
- Clinical Research Services, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jessie Cunningham
- SickKids Hospital Library, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - M. Laura Avila
- Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Correspondence M. Laura Avila, Division of Paediatrics, Haematology/Oncology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada. @didascalias_TO
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9
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Minford A, Brandão LR, Othman M, Male C, Abdul-Kadir R, Monagle P, Mumford AD, Adcock D, Dahlbäck B, Miljic P, DeSancho MT, Teruya J. Corrigendum to Diagnosis and management of severe congenital protein C deficiency (SCPCD): Communication from the SSC of the ISTH [J Thromb Haemost. 2022 Jul;20(7):1735-1743]. J Thromb Haemost 2023; 21:1069. [PMID: 36732161 DOI: 10.1016/j.jtha.2023.01.019] [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] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Adrian Minford
- Department of Paediatrics, Bradford Royal Infirmary, West Yorkshire, UK
| | - Leonardo R Brandão
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Maha Othman
- School of Medicine, Queen's University, Kingston, ON, Canada; School of Baccalaureate Nursing, St. Lawrence College, Kingston, ON, Canada; Clinical Pathology Department, Faculty of Medicine, Mansoura University, Egypt
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Rezan Abdul-Kadir
- Katharine Dormandy Haemophilia and Thrombosis Centre and Department of Obstetrics and Gynaecology, The Royal Free NHS Foundation Hospital, London, London, UK; Institute for Women's Health, University College London, London, UK
| | - Paul Monagle
- Kids Cancer Centre, Department of Haematology, Sydney Children's Hospital, Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Dorothy Adcock
- Laboratory Corporation of America, Burlington, North Carolina, USA
| | - Björn Dahlbäck
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Predrag Miljic
- Faculty of Medicine, Clinic of Hematology, Clinical Center of Serbia, University in Belgrade, Belgrade, Serbia
| | - Maria T DeSancho
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Jun Teruya
- Departments of Pathology & Immunology, Pediatrics, and Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
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10
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Bastas D, Brandão LR, Allen DD, Vincelli J, Amiri N, Abdul-Samad K, Liu K, Stephens S, Avila ML. Functional impact of pediatric postthrombotic syndrome. J Thromb Haemost 2023; 21:896-904. [PMID: 36739234 DOI: 10.1016/j.jtha.2023.01.004] [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] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/09/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
BACKGROUND Postthrombotic syndrome (PTS) is the most common complication of deep vein thrombosis (DVT) in children. OBJECTIVES We aimed to assess the impact of pediatric PTS on functioning as assessed by movement ability, mobility, functional disability, and physical activity levels in children after diagnosis of limb DVT. METHODS Patients aged 8-21 years in follow-up care after objectively documented limb DVT were prospectively recruited in this cross-sectional study. Measures of functioning (outcomes) included self-reported questionnaires that assessed: 1) movement ability, measured with the Movement Ability Measure-Computer Adaptive Test version; 2) mobility, evaluated with the Computer Adaptive Test version of the Patient-Reported Outcomes Measurement Information System Pediatric Physical Functioning, Mobility domain; 3) functional disability, evaluated with the Functional Disability Inventory; and 4) physical activity levels, evaluated with the Godin Leisure-Time Exercise Questionnaire. The main predictor was PTS severity, which was assessed using the index for the Clinical Assessment of PTS in children. The association between PTS and outcomes was analyzed using linear models. RESULTS Eighty-seven patients (median age, 16 years; 25th-75th percentile, 15-18 years; 56% boys) were enrolled. Adjusted for age, sex, and underlying condition, increasing PTS severity was associated with lower current movement ability, a wider gap between current vs preferred movement ability, lower mobility, and slightly higher functional disability scores. There was a nonsignificant effect of PTS severity on moderate-strenuous physical activity. CONCLUSION In children, increased PTS severity is associated with lower movement ability and impaired mobility. Reducing the gap between the patients' current vs preferred movement ability is a relevant aspect of PTS management in children.
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Affiliation(s)
- Denise Bastas
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada; Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Leonardo R Brandão
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Diane D Allen
- Graduate Program in Physical Therapy, University of California, San Francisco/San Francisco State University, USA
| | - Jennifer Vincelli
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nour Amiri
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada; Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Karem Abdul-Samad
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kuan Liu
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Samantha Stephens
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - M Laura Avila
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada; Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
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11
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Kumar R, Sun LR, Rodriguez V, Sankar A, Sharma M, Meoded A, Brandão LR, Goldenberg NA. Hemostatic and Thrombotic Considerations in the Diagnosis and Management of Childhood Arterial Ischemic Stroke: A Narrative Review. Semin Pediatr Neurol 2022; 43:101003. [PMID: 36344025 DOI: 10.1016/j.spen.2022.101003] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/12/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
Although rare in children, arterial ischemic stroke (AIS) is associated with increased mortality and neurological morbidity. The incidence of AIS after the neonatal period is approximately 1-2/100,000/year, with an estimated mortality of 3-7%. A significant proportion of children surviving AIS experience life-long neurological deficits including hemiparesis, epilepsy, and cognitive delays. The low incidence of childhood AIS coupled with atypical clinical-presentation and lack of awareness contribute to delay in diagnosis and consequently, the early initiation of treatment. While randomized-clinical trials have demonstrated the efficacy and safety of reperfusion therapies including thrombolysis and endovascular thrombectomy in appropriately-selected adult patients, similar data for children are unavailable. Consequently, clinical decisions surrounding reperfusion therapy in childhood AIS are either extrapolated from adult data or based on local experience. The etiology of childhood AIS is multifactorial, often occurring in the setting of both acquired and congenital risk-factors including thrombophilia. While multiple studies have investigated the association of thrombophilia with incident childhood AIS, its impact on stroke recurrence and therefore duration and intensity of antithrombotic therapy is less clear. Despite these limitations, a significant progress has been made over the last decade in the management of childhood AIS. This progress can be attributed to international consortiums, and in selected cohorts to federally-funded clinical trials. In this narrative review, the authors have systematically appraised the literature and summarize the hemostatic and thrombotic considerations in the diagnosis and management of childhood AIS focusing on the evidence supporting reperfusion therapies, relevance of thrombophilia testing, and duration and drug choices for secondary-prophylaxis.
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Affiliation(s)
- Riten Kumar
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Lisa R Sun
- Division of Pediatric Neurology, Johns Hopkins School of Medicine, Baltimore, MD; Division of Cerebrovascular Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Amanda Sankar
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Mukta Sharma
- Division of Hematology, Children's Mercy Hospital, Kansas City, MO
| | - Avner Meoded
- Edward B. Singleton, Department of Radiology, Texas Children's Hospital, Houston, TX
| | - Leonardo R Brandão
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON; Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Neil A Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL; Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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12
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Gariépy-Assal L, Dubois J, Zwicker K, Pincivy A, Powell J, Zhang Y, Breakey V, Price V, Brandão LR, Carcao M, Kleiber N. Defining vascular anomaly phenotypes in children based on a systematic literature search: A critical step in developing a single severity score for interventional clinical trials. Pediatr Blood Cancer 2022; 69:e29869. [PMID: 35731233 DOI: 10.1002/pbc.29869] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 05/18/2022] [Accepted: 06/16/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Genetically targeted drugs in vascular anomalies (VA) are used despite the absence of a validated severity score. The aim of this study was to evaluate the feasibility of grouping phenotypic VA clinical characteristics into a single severity score. METHODS A systematic literature review including children treated with sirolimus accompanied by a detailed description of phenotype and management was conducted. Demographic data and clinical features were extracted to define distinct categories of phenotypes. RESULTS Children with VA display two main phenotypes regardless of VA subtype, which may overlap. A systemic phenotype results from direct invasion and compression of vital structures generally leading to hospitalization and aggressive management in infancy. A functional phenotype is associated with chronic pain and disability manifesting mainly during early adolescence and managed in the outpatient setting. CONCLUSION The two distinct phenotypes described could be the basis for developing a unified scoring system for VA severity assessment.
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Affiliation(s)
- Laurence Gariépy-Assal
- Pediatric Residency Program, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada
| | - Josée Dubois
- Department of Radiology, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada.,Vascular Anomaly Team, CHU Sainte-Justine, Université de Montréal, Canada.,Vascular Anomalies Canada, Anomalies Vasculaires, Montréal, Quebec, Canada.,Research Center, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada
| | - Kelley Zwicker
- Vascular Anomalies Canada, Anomalies Vasculaires, Montréal, Quebec, Canada.,Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Alix Pincivy
- Library, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada
| | - Julie Powell
- Vascular Anomaly Team, CHU Sainte-Justine, Université de Montréal, Canada.,Vascular Anomalies Canada, Anomalies Vasculaires, Montréal, Quebec, Canada.,Division of Dermatology, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada
| | - Yang Zhang
- Canadian Economic Analysis Department, Bank of Canada, Ottawa, Ontario, Canada
| | - Vicky Breakey
- Vascular Anomalies Canada, Anomalies Vasculaires, Montréal, Quebec, Canada.,Division of Pediatric Hematology/Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Victoria Price
- Vascular Anomalies Canada, Anomalies Vasculaires, Montréal, Quebec, Canada.,Division of Pediatric Hematology-Oncology, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Leonardo R Brandão
- Vascular Anomalies Canada, Anomalies Vasculaires, Montréal, Quebec, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Division of Haematology/Oncology, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Manuel Carcao
- Vascular Anomalies Canada, Anomalies Vasculaires, Montréal, Quebec, Canada.,Division of Haematology/Oncology, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Niina Kleiber
- Vascular Anomaly Team, CHU Sainte-Justine, Université de Montréal, Canada.,Vascular Anomalies Canada, Anomalies Vasculaires, Montréal, Quebec, Canada.,Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada.,Research Center, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada.,Department of Pharmacology and Physiology, Université de Montréal, Montréal, Quebec, Canada
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13
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Woods GM, Raffini L, Brandão LR, Jaffray J, Branchford BR, Ng CJ, Sartain SE, Pak J, Male C, Zia A, Rizzi M, Sirachainan N, Faustino EVS, Carpenter SL, Goldenberg NA. Practical considerations and consensus opinion for children's hospital-based inpatient hemostasis and thrombosis (HAT) consultative services: Communication from the ISTH SSC Subcommittee on Pediatric/Neonatal Thrombosis and Hemostasis. J Thromb Haemost 2022; 20:2151-2158. [PMID: 35748322 DOI: 10.1111/jth.15798] [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: 03/25/2022] [Revised: 05/26/2022] [Accepted: 06/19/2022] [Indexed: 11/29/2022]
Abstract
Caring for children and adolescents with disorders of hemostasis and thrombosis (HAT) has become more specialized and requires a unique skill set that many providers are not able to obtain in standard pediatric hematology/oncology/bone marrow transplant fellowship training programs. The influx of numerous therapeutic advances and increasing medical complexity has expanded the need for experienced HAT providers and subspecialty collaboration in the inpatient setting due to the nuances in the management of patients with HAT complications and concerns. While there are data highlighting the benefits of an inpatient hemostasis, thrombosis, and anticoagulation management service in adult hospitals, there are limited pediatric data supporting such programs. In this article, we summarize the current practices of various pediatric institutions in the inpatient management of HAT patients and provide a consensus opinion for the development of a pediatric inpatient HAT service at tertiary care referral centers.
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Affiliation(s)
- Gary M Woods
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Leslie Raffini
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leonardo R Brandão
- Department of Paediatrics, Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Julie Jaffray
- Department of Pediatrics, Division of Hematology/Oncology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Brian R Branchford
- Department of Pediatrics, Division of Hematology/Oncology/Bone Marrow Transplant at Children's Wisconsin, Medical College of Wisconsin, and Versiti Comprehensive Center for Blood Disorders, Wauwatosa, Wisconsin, USA
| | - Christopher J Ng
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sarah E Sartain
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Jennifer Pak
- Department of Pharmacy, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Ayesha Zia
- Department of Pediatrics, Children's Medical Center, University of Texas Southwestern, Dallas, Texas, USA
| | - Mattia Rizzi
- Pediatric Hematology-Oncology Unit, Division of Pediatrics, Department "Woman-Mother-Child", Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Shannon L Carpenter
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Neil A Goldenberg
- Department of Pediatrics, Johns Hopkins All Children's Hospital, Johns Hopkins University, St. Petersburg, Florida, USA
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14
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Mitchell LG, Röshammar D, Huang F, Albisetti M, Brandão LR, Bomgaars L, Chalmers E, Halton J, Luciani M, Joseph D, Tartakovsky I, Gropper S, Brueckmann M. Anticoagulant Effects of Dabigatran on Coagulation Laboratory Parameters in Pediatric Patients: Combined Data from Five Pediatric Clinical Trials. Thromb Haemost 2022; 122:1573-1583. [PMID: 35909257 PMCID: PMC9420551 DOI: 10.1055/s-0042-1744542] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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] [Indexed: 11/05/2022]
Abstract
Background
Dabigatran etexilate, a direct oral thrombin inhibitor, is approved to treat venous thromboembolism (VTE) in both adults and children.
Objectives
This population analysis characterized relationships between dabigatran total plasma concentrations and coagulation laboratory parameters (activated partial thromboplastin time [aPTT]; diluted thrombin time [dTT]; ecarin clotting time [ECT]).
Methods
Data from three phase 2a and one single-arm and one randomized, comparative phase 2b/3 pediatric studies (measurements: aPTT 2,925 [
N
= 358]; dTT 2,348 [
N
= 324]; ECT 2,929 [
N
= 357]) were compared with adult data (5,740 aPTT, 3,472 dTT, 3,817 ECT measurements;
N
= 1,978). Population models were fitted using nonlinear mixed-effects modeling. Covariates (e.g., sex, age) were assessed on baseline and drug-effect parameters, using a stepwise covariate model-building procedure.
Results
Overall, relationships between dabigatran, aPTT, dTT, and ECT were similar in children and adults. For children aged <6 months, a higher proportion of baseline samples were outside or close to the upper aPTT and ECT adult ranges. No age-related differences were detected for dTT. With increasing dabigatran concentration, aPTT rose nonlinearly (half the maximum effect at 368 ng/mL dabigatran) while dTT and ECT increased linearly (0.37 and 0.73% change per ng/mL dabigatran, respectively). Mean baseline aPTT (45 vs. 36 seconds) and ECT (40 vs. 36 seconds) were slightly increased for those aged <6 months versus older children.
Conclusion
The similar relationships of laboratory parameters observed across pediatric age groups suggests that developmental changes in the hemostatic system may have little effect on response to dabigatran.
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Affiliation(s)
- Lesley G Mitchell
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Fenglei Huang
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, United States
| | - Manuela Albisetti
- Hematology Department, University Children's Hospital, Zürich, Switzerland
| | - Leonardo R Brandão
- Division of Hematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Bomgaars
- Department of Pediatrics, Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas, United States
| | - Elizabeth Chalmers
- The Glasgow Children's Haemophilia Unit, Royal Hospital for Children, Glasgow, Scotland, United Kingdom
| | - Jacqueline Halton
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Matteo Luciani
- Pediatric Hematology/Oncology Department, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - David Joseph
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, United States
| | - Igor Tartakovsky
- Therapeutic Area Cardiovascular Medicine, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Savion Gropper
- Therapeutic Area Inflammation Medicine, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Martina Brueckmann
- Therapeutic Area Cardiovascular Medicine, Boehringer Ingelheim International GmbH, Ingelheim, Germany.,Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim, Germany
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15
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Bastas D, Vincelli J, De R, Benia E, Gairdner S, Brandão LR, Avila L. Impact of deep vein thrombosis on adolescent athletes: Navigating an invisible disability. Res Pract Thromb Haemost 2022; 6:e12779. [PMID: 35919876 PMCID: PMC9336208 DOI: 10.1002/rth2.12779] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/01/2022] [Accepted: 07/09/2022] [Indexed: 11/12/2022] Open
Abstract
Background Injury in adolescent athletes that threatens their sport participation can result in a sense of identity loss during critical years for identity development, creating the potential for significant mental health challenges. The specific effect of deep vein thrombosis (DVT) in this vulnerable population has not been characterized. Purpose To describe the impact of DVT diagnosis, treatment, and long-term complications on the mental well-being of athletes who sustained a DVT during adolescence and to identify strategies to improve the quality of care for these patients. Methods Using a qualitative study design, athletes with a history of DVT during adolescence and their parents were recruited to participate in semistructured interviews. Interviews were transcribed and analyzed using thematic analysis. Participants were recruited until reaching thematic saturation. Results In total, 19 participants (12 athletes, 7 parents) were recruited. Athletes were mainly males (67%), median age at time of DVT was 15 years (range, 12-18 years), and median age at study participation was 19 years (range, 16-34 years). Thematic analysis revealed four main themes: Theme 1: DVT posed a threat to sport participation; Theme 2: at a personal level, there were significant mental health challenges; Theme 3: at a societal level, DVT is an invisible disability; and Theme 4: physical, psychological, and transition support are important to improve the care of these patients. Conclusion Deep vein thrombosis threatens an athlete's participation in sport, resulting in a significant and complex impact on their mental well-being. Heightened awareness and a multidisciplinary approach are needed to help young athletes navigate the consequences of DVT.
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Affiliation(s)
- Denise Bastas
- Division of Haematology/Oncology The Hospital for Sick Children Toronto Ontario Canada.,Child Health Evaluative Sciences, Research Institute The Hospital for Sick Children Toronto Ontario Canada
| | - Jennifer Vincelli
- Division of Haematology/Oncology The Hospital for Sick Children Toronto Ontario Canada
| | - Riddhita De
- Division of Haematology/Oncology The Hospital for Sick Children Toronto Ontario Canada.,Child Health Evaluative Sciences, Research Institute The Hospital for Sick Children Toronto Ontario Canada
| | - Eliana Benia
- Division of Haematology/Oncology The Hospital for Sick Children Toronto Ontario Canada
| | - Sarah Gairdner
- Faculty of Kinesiology and Physical Education University of Toronto Toronto Ontario Canada
| | - Leonardo R Brandão
- Division of Haematology/Oncology The Hospital for Sick Children Toronto Ontario Canada.,Dalla Lana School of Public Health University of Toronto Toronto Ontario Canada
| | - Laura Avila
- Division of Haematology/Oncology The Hospital for Sick Children Toronto Ontario Canada.,Child Health Evaluative Sciences, Research Institute The Hospital for Sick Children Toronto Ontario Canada.,Dalla Lana School of Public Health University of Toronto Toronto Ontario Canada
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16
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Minford A, Brandão LR, Othman M, Male C, Abdul-Kadir R, Monagle P, Mumford AD, Adcock D, Dahlbäck B, Miljic P, DeSancho MT, Teruya J. Diagnosis and management of severe congenital protein C deficiency (SCPCD): Communication from the SSC of the ISTH. J Thromb Haemost 2022; 20:1735-1743. [PMID: 35570324 DOI: 10.1111/jth.15732] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 02/04/2023]
Abstract
Severe congenital protein C deficiency (SCPCD) is rare and there is currently substantial variation in the management of this condition. A joint project by three Scientific and Standardization Committees of the ISTH: Plasma Coagulation Inhibitors, Pediatric/Neonatal Thrombosis and Hemostasis, and Women's Health Issues in Thrombosis and Hemostasis, was developed to review the current evidence and help guide on diagnosis and management of SCPCD. We provide a summary of the clinical presentations, differential diagnoses, appropriate investigations to confirm the diagnosis, approaches for management of the acute situation, and options for long-term management including subsequent pregnancies. We finally provide a set of recommendations to help in this regard.
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Affiliation(s)
- Adrian Minford
- Department of Paediatrics, Bradford Royal Infirmary, West Yorkshire, UK
| | - Leonardo R Brandão
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Maha Othman
- School of Medicine, Queen's University, Kingston, ON, Canada
- School of Baccalaureate Nursing, St. Lawrence College, Kingston, ON, Canada
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Rezan Abdul-Kadir
- Katharine Dormandy Haemophilia and Thrombosis Centre and Department of Obstetrics and Gynaecology, The Royal Free NHS Foundation Hospital, London, London, UK
- Institute for Women's Health, University College London, London, UK
| | - Paul Monagle
- Kids Cancer Centre, Department of Haematology, Sydney Children's Hospital, Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Dorothy Adcock
- Laboratory Corporation of America, Burlington, North Carolina, USA
| | - Björn Dahlbäck
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Predrag Miljic
- Faculty of Medicine, Clinic of Hematology, Clinical Center of Serbia, University in Belgrade, Belgrade, Serbia
| | - Maria T DeSancho
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Jun Teruya
- Departments of Pathology & Immunology, Pediatrics, and Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
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17
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Avila ML, Amiri N, Zavareh ZT, Al‐Saoud SA, Sabapathy C, Vincelli J, Moharir M, Silverman E, Williams S, Brandão LR, Levy D. Characterization of recurrent thrombosis in pediatric antiphospholipid syndrome. Am J Hematol 2022; 97:E268-E270. [PMID: 35389524 DOI: 10.1002/ajh.26565] [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] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/01/2022] [Accepted: 04/05/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Maria Laura Avila
- Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
- Child Health Evaluative Sciences Research Institute, The Hospital for Sick Children Toronto Ontario Canada
- Dalla Lana School of Public Health University of Toronto Toronto Ontario Canada
| | - Nour Amiri
- Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
- Child Health Evaluative Sciences Research Institute, The Hospital for Sick Children Toronto Ontario Canada
| | - Zahra Tofighi Zavareh
- Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
- Child Health Evaluative Sciences Research Institute, The Hospital for Sick Children Toronto Ontario Canada
| | - Sima Abu Al‐Saoud
- Faculty of Medicine, Department of Pediatrics Makassed Hospital, Al‐Quds University East Jerusalem Palestine
| | - Christine Sabapathy
- Department of Paediatrics McGill University Health Centre Montreal Quebec Canada
| | - Jennifer Vincelli
- Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
| | | | - Earl Silverman
- Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
| | - Suzan Williams
- Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
| | - Leonardo R. Brandão
- Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
- Child Health Evaluative Sciences Research Institute, The Hospital for Sick Children Toronto Ontario Canada
- Dalla Lana School of Public Health University of Toronto Toronto Ontario Canada
| | - Deborah Levy
- Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
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18
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Betensky M, Kulkarni K, Rizzi M, Jones S, Brandão LR, Faustino EVS, Goldenberg NA, Sharathkumar A. Recommendations for standardized definitions, clinical assessment, and future research in pediatric clinically unsuspected venous thromboembolism: Communication from the ISTH SSC subcommittee on pediatric and neonatal thrombosis and hemostasis. J Thromb Haemost 2022; 20:1729-1734. [PMID: 35570328 PMCID: PMC9324216 DOI: 10.1111/jth.15731] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/07/2022] [Accepted: 04/11/2022] [Indexed: 11/28/2022]
Abstract
Clinically unsuspected venous thromboembolism (VTE) in children is defined as a VTE diagnosed via imaging test performed for surveillance (i.e., with an intent to identify clinically silent VTEs) or incidentally found (most often via imaging performed for evaluation of regional pathology unrelated to VTE) in the absence of any VTE-associated signs or symptoms. Our understanding of the clinical significance of these events in children is limited by a paucity of data on the epidemiology and outcomes of this complication. There is an urgent need for further research in this area to inform optimal management. Recognizing this knowledge gap, this Task Force has previously published a systematic review of the literature in this topic. We now provide guidance recommendations for standardization of definitions and identify future research needs on clinically unsuspected VTE in children. These recommendations will serve to enhance the quantity and quality of evidence on the topic and facilitate the design and execution of cooperative observational studies, and interventional trials of risk-stratified management approaches aimed at preventing and optimizing long-term outcomes of clinically unsuspected VTE in children.
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Affiliation(s)
- Marisol Betensky
- Department of PediatricsDivision of HematologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Institute of Clinical and Translational ResearchJohns Hopkins All Children’s HospitalSt. PetersburgFloridaUSA
| | - Ketan Kulkarni
- Department of PediatricsDivision of Hematology‐OncologyIWK Health CentreHalifaxNSCanada
| | - Mattia Rizzi
- Pediatric Hematology/Oncology UnitDepartment of Woman‐Mother‐ChildUniversity Hospital CHUVLausanneSwitzerland
| | - Sophie Jones
- Department of NursingThe University of MelbourneMelbourneVic.Australia
- Department of Clinical HaematologyThe Royal Children's HospitalMelbourneVic.Australia
| | - Leonardo R. Brandão
- Division of Haematology/OncologyDepartment of PediatricsThe Hospital for Sick ChildrenTorontoONCanada
- Dalla Lana School of Public HealthUniversity of TorontoTorontoONCanada
| | | | - Neil A. Goldenberg
- Institute of Clinical and Translational ResearchJohns Hopkins All Children’s HospitalSt. PetersburgFloridaUSA
- Department of Medicine and PediatricsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Anjali Sharathkumar
- Stead Family Department of PediatricsUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
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19
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Goldenberg NA, Brandão LR, Male C. Anticoagulant Therapy for 6 Weeks vs 3 Months and Recurrence and Bleeding in Patients Younger Than 21 Years With Provoked Venous Thromboembolism-Reply. JAMA 2022; 327:1709-1710. [PMID: 35503347 DOI: 10.1001/jama.2022.3729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Neil A Goldenberg
- Johns Hopkins University, Johns Hopkins All Children's Institute for Clinical and Translational Research, St Petersburg, Florida
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20
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Proulx C, Floh A, Jeewa A, Pulcine E, Muthusami P, Brandão LR, Honjo O, Vargas C, Maurich A, Mazwi M. Successful Pediatric Mechanical Thrombectomy for HeartMate 3-Related Intracranial Thromboembolism. World J Pediatr Congenit Heart Surg 2022; 13:242-244. [PMID: 35238712 PMCID: PMC8894621 DOI: 10.1177/21501351221075840] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Thromboembolic events post left ventricular assist devices (LVAD) implantation remain a major cause of morbidity and mortality. Mechanical thrombectomy for the treatment of pediatric intracranial thromboembolic events have been reported in LVADs, but never following HeartMate 3 (HM3) implantation. We present the case of an 8-year-old, 26.5 kg male with dilated cardiomyopathy and decompensated heart failure who presented with extensive intracranial thromboembolism in the early postoperative period following HM3 implantation and underwent successful mechanical thrombectomy with a favorable neurological outcome.
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Affiliation(s)
- Catherine Proulx
- Department of Critical Care Medicine, 7979The Hospital for Sick Children, Toronto, Canada
| | - Alejandro Floh
- Department of Critical Care Medicine, 7979The Hospital for Sick Children, Toronto, Canada.,Division of Cardiology, 7979The Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, 12366University of Toronto, Toronto, Canada
| | - Aamir Jeewa
- Division of Cardiology, 7979The Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, 12366University of Toronto, Toronto, Canada
| | - Elizabeth Pulcine
- Division of Neurology, 7979The Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, 12366University of Toronto, Toronto, Canada
| | - Prakash Muthusami
- Department of Diagnostic Imaging, 7979The Hospital for Sick Children, Toronto, Canada
| | - Leonardo R Brandão
- Division of Haematology/Oncology, 7979The Hospital for Sick Children, Toronto, Canada
| | - Osami Honjo
- Division of Cardiovascular Surgery, 7979The Hospital for Sick Children, Toronto, Canada.,Department of Surgery, 12366University of Toronto, Toronto, Canada
| | - Carolina Vargas
- Division of Neurology, 7979The Hospital for Sick Children, Toronto, Canada
| | - Andrea Maurich
- Division of Cardiology, 7979The Hospital for Sick Children, Toronto, Canada
| | - Mjaye Mazwi
- Department of Critical Care Medicine, 7979The Hospital for Sick Children, Toronto, Canada.,Division of Cardiology, 7979The Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, 12366University of Toronto, Toronto, Canada
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21
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Ross C, Kumar R, Pelland-Marcotte MC, Mehta S, Kleinman ME, Thiagarajan RR, Ghbeis MB, VanderPluym CJ, Friedman KG, Porras D, Fynn-Thompson F, Goldhaber SZ, Brandão LR. Acute Management of High-Risk and Intermediate-Risk Pulmonary Embolism in Children: A Review. Chest 2022; 161:791-802. [PMID: 34587483 PMCID: PMC8941619 DOI: 10.1016/j.chest.2021.09.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 06/21/2021] [Revised: 09/09/2021] [Accepted: 09/20/2021] [Indexed: 10/20/2022] Open
Abstract
Severe forms of pulmonary embolism (PE) in children, althought rare, cause significant morbidity and mortality. We review the pathophysiologic features of severe (high-risk and intermediate-risk) PE and suggest novel pediatric-specific risk stratifications and an acute treatment algorithm to expedite emergent decision-making. We defined pediatric high-risk PE as causing cardiopulmonary arrest, sustained hypotension, or normotension with signs or symptoms of shock. Rapid primary reperfusion should be pursued with either surgical embolectomy or systemic thrombolysis in conjunction with a heparin infusion and supportive care as appropriate. We defined pediatric intermediate-risk PE as a lack of systemic hypotension or compensated shock, but with evidence of right ventricular strain by imaging, myocardial necrosis by elevated cardiac troponin levels, or both. The decision to pursue primary reperfusion in this group is complex and should be reserved for patients with more severe disease; anticoagulation alone also may be appropriate in these patients. If primary reperfusion is pursued, catheter-based therapies may be beneficial. Acute management of severe PE in children may include systemic thrombolysis, surgical embolectomy, catheter-based therapies, or anticoagulation alone and may depend on patient and institutional factors. Pediatric emergency and intensive care physicians should be familiar with the risks and benefits of each therapy to expedite care. PE response teams also may have added benefit in streamlining care during these critical events.
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Affiliation(s)
- Catherine Ross
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Riten Kumar
- Harvard Medical School, Boston, MA,Department of Pediatrics, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
| | | | - Shivani Mehta
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA,College of Osteopathic Medicine, New York Institute of Technology, Old Westbury, NY
| | - Monica E. Kleinman
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Ravi R. Thiagarajan
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Muhammad B. Ghbeis
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Christina J. VanderPluym
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Kevin G. Friedman
- Department of Pediatric Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Diego Porras
- Division of Invasive Cardiology, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Samuel Z. Goldhaber
- Harvard Medical School, Boston, MA,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Leonardo R. Brandão
- Department of Paediatrics, Haematology/Oncology Division, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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22
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Faustino EVS, Karam O, Parker RI, Hanson SJ, Brandão LR, Monagle P. Coagulation Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference. Pediatrics 2022; 149:S79-S83. [PMID: 34970670 DOI: 10.1542/peds.2021-052888l] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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] [Accepted: 09/24/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Previous criteria for coagulation dysfunction in critically ill children were based mainly on expert opinion. OBJECTIVE To evaluate current evidence regarding coagulation tests associated with adverse outcomes in children to inform criteria for coagulation dysfunction during critical illness. DATA SOURCES Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020 by using a combination of medical subject heading terms and text words to define concepts of coagulation dysfunction, pediatric critical illness, and outcomes of interest. STUDY SELECTION Studies were included if critically ill children with coagulation dysfunction were evaluated, if performance characteristics of assessment and/or scoring tools to screen for coagulation dysfunction were evaluated, and if outcomes related to mortality or functional status, organ-specific outcomes, or other patient-centered outcomes were assessed. DATA EXTRACTION Data were abstracted from each eligible study into a standard data extraction form, along with risk of bias assessment, by a task force member. RESULTS The systematic review supports the presence of at least 2 of the following criteria reflecting coagulation dysfunction in the absence of liver dysfunction: platelet count <100 000 cells per μL, international normalized ratio >1.5, fibrinogen level <150 mg/dL, and D-dimer value above 10 times the upper limit of normal, or above the assay's upper limit of detection if this limit is below 10 times the upper limit of normal. LIMITATIONS The proposed criteria for coagulation dysfunction are limited by the available evidence and will require future validation. CONCLUSIONS Validation of the proposed criteria and identified scientific priorities will enhance our understanding of coagulation dysfunction in critically ill children.
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Affiliation(s)
- E Vincent S Faustino
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, School of Medicine, Yale University, New Haven, Connecticut
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Robert I Parker
- Hematology/Oncology, Department of Pediatrics (Emeritus), Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Sheila J Hanson
- Critical Care Section, Department of Pediatrics, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, Wisconsin
| | - Leonardo R Brandão
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Paul Monagle
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Department of Clinical Haematology, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Kids Cancer Centre, Sydney Children's Hospital, Randwick, New South Wales, Australia
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23
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Male C, Monagle P, Albisetti M, Brandão LR, Young G. Direct Oral Anticoagulants: Overcoming the Challenges of Managing Venous Thromboembolism in Children. J Pediatr 2022; 240:14-23. [PMID: 34687696 DOI: 10.1016/j.jpeds.2021.09.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 03/10/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Christoph Male
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria.
| | - Paul Monagle
- Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia; Australia and Kids Cancer Centre, Sydney Children's Hospital, Sydney, Australia
| | - Manuela Albisetti
- Division of Hematology, University Children's Hospital of Zurich, Zurich, Switzerland
| | - Leonardo R Brandão
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Guy Young
- Children's Hospital Los Angeles, University of Southern California, Keck School of Medicine, Los Angeles, CA
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24
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Bembea MM, Agus M, Akcan-Arikan A, Alexander P, Basu R, Bennett TD, Bohn D, Brandão LR, Brown AM, Carcillo JA, Checchia P, Cholette J, Cheifetz IM, Cornell T, Doctor A, Eckerle M, Erickson S, Farris RW, Faustino EVS, Fitzgerald JC, Fuhrman DY, Giuliano JS, Guilliams K, Gaies M, Gorga SM, Hall M, Hanson SJ, Hartman M, Hassinger AB, Irving SY, Jeffries H, Jouvet P, Kannan S, Karam O, Khemani RG, Niranjan K, Lacroix J, Laussen P, Leclerc F, Lee JH, Leteurtre S, Lobner K, McKiernan PJ, Menon K, Monagle P, Muszynski JA, Odetola F, Parker R, Pathan N, Pierce RW, Pineda J, Prince JM, Robinson KA, Rowan CM, Ryerson LM, Sanchez-Pinto LN, Schlapbach LJ, Selewski DT, Shekerdemian LS, Simon D, Smith LS, Squires JE, Squires RH, Sutherland SM, Ouellette Y, Spaeder MC, Srinivasan V, Steiner ME, Tasker RC, Thiagarajan R, Thomas N, Tissieres P, Traube C, Tucci M, Typpo KV, Wainwright MS, Ward SL, Watson RS, Weiss S, Whitney J, Willson D, Wynn JL, Yeyha N, Zimmerman JJ. Pediatric Organ Dysfunction Information Update Mandate (PODIUM) Contemporary Organ Dysfunction Criteria: Executive Summary. Pediatrics 2022; 149:S1-S12. [PMID: 34970673 PMCID: PMC9599725 DOI: 10.1542/peds.2021-052888b] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [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] [Accepted: 09/24/2021] [Indexed: 01/20/2023] Open
Abstract
Prior criteria for organ dysfunction in critically ill children were based mainly on expert opinion. We convened the Pediatric Organ Dysfunction Information Update Mandate (PODIUM) expert panel to summarize data characterizing single and multiple organ dysfunction and to derive contemporary criteria for pediatric organ dysfunction. The panel was composed of 88 members representing 47 institutions and 7 countries. We conducted systematic reviews of the literature to derive evidence-based criteria for single organ dysfunction for neurologic, cardiovascular, respiratory, gastrointestinal, acute liver, renal, hematologic, coagulation, endocrine, endothelial, and immune system dysfunction. We searched PubMed and Embase from January 1992 to January 2020. Study identification was accomplished using a combination of medical subject headings terms and keywords related to concepts of pediatric organ dysfunction. Electronic searches were performed by medical librarians. Studies were eligible for inclusion if the authors reported original data collected in critically ill children; evaluated performance characteristics of scoring tools or clinical assessments for organ dysfunction; and assessed a patient-centered, clinically meaningful outcome. Data were abstracted from each included study into an electronic data extraction form. Risk of bias was assessed using the Quality in Prognosis Studies tool. Consensus was achieved for a final set of 43 criteria for pediatric organ dysfunction through iterative voting and discussion. Although the PODIUM criteria for organ dysfunction were limited by available evidence and will require validation, they provide a contemporary foundation for researchers to identify and study single and multiple organ dysfunction in critically ill children.
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Affiliation(s)
- Melania M. Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael Agus
- Division of Medical Critical Care, Boston Children’s Hospital, Harvard Medical School, Boston Children’s Hospital, Boston, MA
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Sections of Critical Care and Nephrology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Peta Alexander
- Department of Cardiology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Rajit Basu
- Division of Pediatric Critical Care, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Tellen D. Bennett
- Sections of Informatics and Data Science and Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Desmond Bohn
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto
| | - Leonardo R. Brandão
- Division of Hematology-Oncology, Department of Paediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ann-Marie Brown
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Paul Checchia
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children’s Hospital and Baylor College of Medicine, Houston, TX
| | - Jill Cholette
- Department of Pediatrics, University of Rochester Golisano Children’s Hospital, Rochester, NY
| | - Ira M. Cheifetz
- Department of Pediatrics, Rainbow Babies and Children’s Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Timothy Cornell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA
| | - Allan Doctor
- University of Maryland School of Medicine, Center for Blood Oxygen Transport and Hemostasis
| | - Michelle Eckerle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati OH USA and Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati OH
| | - Simon Erickson
- Department of Paediatric Critical Care; Perth Children’s Hospital and University of Western Australia; Perth, Western Australia, Australia
| | - Reid W.D. Farris
- Department of Pediatrics, University of Washington and Seattle Children’s Hospital; Seattle, WA
| | - E. Vincent S. Faustino
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Yale School of Medicine, New Haven CT
| | - Julie C. Fitzgerald
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Dana Y. Fuhrman
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - John S. Giuliano
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Kristin Guilliams
- Department of Neurology, Division of Pediatric and Development Neurology, Department of Pediatrics, Division of Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, MI
| | - Michael Gaies
- Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | | | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | - Sheila J. Hanson
- Department of Pediatrics, Critical Care Section, Medical College of Wisconsin/Children’s Wisconsin, Milwaukee, WI
| | - Mary Hartman
- Department of Pediatrics, Washington University, St. Louis, MO
| | - Amanda B. Hassinger
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children’s Hospital, Buffalo, NY
| | - Sharon Y. Irving
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Howard Jeffries
- Department of Pediatrics, University of Washington School of Medicine, Seattle WA
| | - Philippe Jouvet
- Department of Paediatrics; Sainte-Justine Hospital and University of Montreal; Montreal, Québec, Canada
| | - Sujatha Kannan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children’s Hospital of Richmond at VCU, Richmond, VA
| | - Robinder G. Khemani
- Department of Anesthesiology and Critical Care Medicine; Children’s Hospital Los Angeles and University of Southern California Keck School of Medicine; Los Angeles, CA
| | - Kissoon Niranjan
- Division of Critical Care, Department of Pediatrics, University of British Columbia and BC Children’s Hospital
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Centre Hospitalier Universitaire de Sainte-Justine, Université de Montreal, Canada
| | - Peter Laussen
- Department of Cardiology, Boston Children’s Hospital and Department of Anesthesia, Harvard Medical School, Boston, MA
| | - Francis Leclerc
- Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France
| | - Jan Hau Lee
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, and, Duke-NUS Medical School, Singapore
| | - Stephane Leteurtre
- Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France
| | - Katie Lobner
- Welch Medical Library, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Patrick J. McKiernan
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Kusum Menon
- Division of Pediatric Critical Care, Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Paul Monagle
- Department of Clinical Haematology, Royal Children’s Hospital, Victoria, Australia, and Haematology Research, Murdoch Children’s Research Institute, Victoria, Australia
| | - Jennifer A. Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | | | - Robert Parker
- Department of Pediatrics (Emeritus), Hematology/Oncology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge; Clinical Research Associate, Kings College, Cambridge, UK
| | - Richard W. Pierce
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Jose Pineda
- Department of Anesthesiology and Critical Care Medicine; Children’s Hospital Los Angeles and University of Southern California Keck School of Medicine; Los Angeles, CA
| | - Jose M. Prince
- Department of Surgery and Pediatrics, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Karen A. Robinson
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Courtney M. Rowan
- Department of Pediatrics, Division of Pediatric Critical Care; Indiana University School of Medicine and Riley Hospital for Children; Indianapolis, IN
| | | | - L. Nelson Sanchez-Pinto
- Departments of Pediatrics (Critical Care) and Preventive Medicine (Health & Biomedical Informatics), Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Luregn J Schlapbach
- Pediatric and Neonatal Intensive Care Unit, Children`s Research Center, University Children`s Hospital Zurich, Zurich, Switzerland
| | - David T. Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Lara S. Shekerdemian
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children’s Hospital and Baylor College of Medicine, Houston, TX
| | - Dennis Simon
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Lincoln S. Smith
- Department of Pediatrics, University of Washington and Seattle Children’s Hospital; Seattle, WA
| | - James E. Squires
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Robert H. Squires
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Scott M. Sutherland
- Department of Pediatrics, Division of Nephrology, Stanford University School of Medicine, Stanford, CA
| | - Yves Ouellette
- Division of Critical Care Medicine, Department of Pediatrics, Mayo Clinic, Rochester, MN
| | | | - Vijay Srinivasan
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Marie E. Steiner
- Department of Pediatrics, Critical Care Medicine & Hematology, University of Minnesota, Minneapolis, MN
| | - Robert C. Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston MA
| | - Ravi Thiagarajan
- Department of Cardiology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Neal Thomas
- Department of Pediatrics and Public Health Science, Division of Pediatric Critical Care Medicine; Penn State Hershey Children’s Hospital; Hershey, PA
| | - Pierre Tissieres
- Pediatric Intensive Care, AP-HP Paris Saclay University, Le Kremlin-Bicêtre, France
| | - Chani Traube
- Department of Pediatrics, Division of Critical Care Medicine, Weill Cornell Medical College, NY
| | - Marisa Tucci
- Division of Pediatric Critical Care Medicine, Centre Hospitalier Universitaire de Sainte-Justine, Université de Montreal, Canada
| | - Katri V. Typpo
- Department of Pediatrics and the Steele Children’s Research Center, University of Arizona College of Medicine, Tucson, AZ
| | - Mark S. Wainwright
- Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle, WA
| | - Shan L. Ward
- Department of Pediatrics, Division of Critical Care, UCSF Benioff Children’s Hospitals, San Francisco and Oakland, CA
| | - R. Scott Watson
- Department of Pediatrics, University of Washington and Seattle Children’s Hospital; Seattle, WA
| | - Scott Weiss
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jane Whitney
- Division of Medical Critical Care, Boston Children’s Hospital, Harvard Medical School, Boston Children’s Hospital, Boston, MA
| | - Doug Willson
- Division of Pediatric Critical Care Medicine, Children’s Hospital of Richmond at VCU, Richmond, VA
| | - James L. Wynn
- Department of Pediatrics and Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Nadir Yeyha
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jerry J. Zimmerman
- Department of Pediatrics, Seattle Children’s Hospital, Seattle Children’s Research Institute, University of Washington School of Medicine, Seattle, WA
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Avila L, Amiri N, De R, Vincelli J, Pullenayegum E, Brandão LR. Compression garments for the management of pediatric post-thrombotic syndrome: A prospective longitudinal study. J Thromb Haemost 2021; 19:3073-3079. [PMID: 34418289 DOI: 10.1111/jth.15507] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/11/2021] [Accepted: 08/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Graduated compression garments (CG) are a standard form of management of post-thrombotic syndrome (PTS) in adults, but data in children are lacking. OBJECTIVES We aimed to study the attitudes toward CG and change in PTS severity score in children who were prescribed CG for PTS management. METHODS Children with PTS were enrolled in this longitudinal prospective study at the time of CG prescription. PTS severity was measured at baseline and follow-up using CAPTSure© ; attitude toward CG was registered at follow-up. RESULTS Forty-five patients were enrolled (median age 13 years, 25th-75th percentile 8-15 years; 53% male patients); 71% were prescribed socks and 29% sleeves; pressure was 15-20 mmHg in 84% of CG. Median baseline PTS CAPTSure© score was 31 points (25th-75th percentile 21-45 points). At follow-up, 49% of patients found CG helpful, 27% found CG not helpful, and 16% did not buy or wear the CG. Eight percent of enrolled patients did not return for study follow-up. Ninety-five percent of the children who found CG helpful wore them for ≥3 days/week. Hours of CG wear at the time of follow-up were associated with lower PTS scores at follow-up in a non-linear manner (e.g., wearing 12 vs. 0 h/day was associated with a 16-point reduction in PTS scores at follow-up, 95% CI -29 to -2 points). CONCLUSION Nearly half the patients who were prescribed CG found them helpful. We observed non-linear improvement in PTS severity with the use of low-pressure CG for 8-12 h/day and ≥3 days/week, providing guidance in their prescription.
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Affiliation(s)
- Laura Avila
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Nour Amiri
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Riddhita De
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Eleanor Pullenayegum
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Leonardo R Brandão
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Ostertag-Hill CA, Cameron DB, Brandão LR, John PR, Kim HB, Fishman SJ. A large and complex saccular external jugular vein aneurysm in an adolescent girl. Journal of Pediatric Surgery Case Reports 2021. [DOI: 10.1016/j.epsc.2021.102051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Pulcine E, Seed M, Brandão LR, Slim M, Palasamudram S, Shroff M, Moharir M, deVeber G, Dlamini N. Hemorrhagic transformation and stroke recurrence in children with cardiac disease receiving antithrombotic therapy for secondary stroke prevention. J Thromb Haemost 2021; 19:2428-2439. [PMID: 34152075 DOI: 10.1111/jth.15428] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 05/20/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Antithrombotic therapy is currently recommended for stroke prevention in pediatric cardioembolic stroke where the recurrence risk is high; however, safety concerns remain. The primary objective of this study was to evaluate clinical and radiographic predictors of hemorrhagic transformation and stroke recurrence in children with cardiac disease to ascertain the safety and failure rates for secondary stroke prevention. METHODS This was a single-center, retrospective analysis of a prospectively enrolled cohort of children with radiologically confirmed cardioembolic stroke from January 2003 to December 2017 treated with institutional guidelines. RESULTS Eighty-two children met inclusion criteria (male 44 [54%]; neonates 23 [28%]; median age 0.43 years [0.08-4.23]). Hemorrhagic transformation occurred in 20 (24%) with the majority (75% of 20) being petechial and asymptomatic. One death (1%) was reported from hemorrhagic transformation. Four children (5%) had major extracranial hemorrhage. Most (95%) received antithrombic therapy, with anticoagulation being favored (82%). Greater stroke volume was associated with hemorrhagic transformation using the pediatric Alberta Stroke Program Early CT Score (6.1 ± 3.3 vs. 3.5 ± 2.3; p = .006). Stroke recurred in 11 (13%) children at a median 32 days (5.5-93) from the index event and the majority (90%) were on treatment at the time of recurrence. Children with univentricular physiology were less likely to have hemorrhagic transformation (RR 0.31; 95% CI 0.09-0.96, p = .04); however, they had higher rates of recurrent stroke before final palliative repair. CONCLUSIONS In spite of the 24% hemorrhagic transformation rate, antithrombotic therapy has a positive risk-balance in certain cardioembolic stroke subgroups, particularly in those with single-ventricle physiology, when accounting for stroke volume.
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Affiliation(s)
- Elizabeth Pulcine
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mike Seed
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leonardo R Brandão
- Division of Haematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Mahmoud Slim
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sunitha Palasamudram
- Division of Diagnostic Imaging, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Manohar Shroff
- Division of Diagnostic Imaging, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mahendranath Moharir
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Gabrielle deVeber
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Nomazulu Dlamini
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
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Avila L, Amiri N, Pullenayegum E, Sealey VA, De R, Williams S, Vincelli J, Brandão LR. Diagnostic value of D-dimers for limb deep vein thrombosis in children: A prospective study. Am J Hematol 2021; 96:954-960. [PMID: 33930198 DOI: 10.1002/ajh.26212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 04/24/2021] [Accepted: 04/28/2021] [Indexed: 01/01/2023]
Abstract
The present study sought to evaluate the discriminative and predictive ability of D-dimer for pediatric limb DVT. Children aged 28 days-18 years requiring imaging to rule out limb DVT, as per the treating clinical team, were enrolled in the study. The outcome was ultrasound proven DVT. The D-dimer levels were obtained around the time of imaging. Receiver operating characteristic (ROC) curves and logistic regression models were used for data analyses. In total, 296 patients were enrolled between 2017-2020; 204 patients were diagnosed with DVT (DVT[+]). Median D-dimer levels were 2.3 μg/ml FEU (25th-75th percentile 0.9-3.9) among DVT(+) and 1.9 μg/ml FEU (25th-75th percentile 0.8-4.0) among DVT(-) patients (p = 0.60). The area under the ROC curve (AUC) was 0.52 (95% confidence interval [CI] 0.45-0.59). The odds ratio for D-dimer levels was 1.00 (95% CI 0.99-1.01), holding confounders constant. In a sub-group exploratory analysis including 23 patients with no underlying conditions or co-morbidities, the AUC curve was 0.90 (95% CI 0.76-1.00). In conclusion, in this prospective cohort study of consecutive children with suspected limb DVT, D-dimer levels had poor discriminative and predictive ability for DVT. However, D-dimer levels showed better discriminative and predictive ability for DVT in an exploratory sample of patients with no underlying conditions or co-morbidities at the time of diagnosis.
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Affiliation(s)
- Laura Avila
- The Hospital for Sick Children Toronto Ontario Canada
| | - Nour Amiri
- The Hospital for Sick Children Toronto Ontario Canada
| | | | | | - Riddhita De
- The Hospital for Sick Children Toronto Ontario Canada
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Pelland‐Marcotte M, Kulkarni K, Athale UH, Pole JD, Brandão LR, Sung L. Thrombosis is associated with worse survival in children with acute lymphoblastic leukemia: A report from CYP-C. Am J Hematol 2021; 96:796-804. [PMID: 33848369 DOI: 10.1002/ajh.26193] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 01/19/2023]
Abstract
There are conflicting data about whether the development of cancer-associated thrombo-embolism (TE) negatively impacts survival in children. The objective was to determine whether TE during treatment was associated with overall survival (OS) and event-free survival (EFS) in children with acute lymphoblastic leukemia (ALL). We performed a population-based retrospective cohort study using the Cancer in Young People-Canada registry. Children <15 years of age were diagnosed with de novo ALL (2000-2016). The primary exposure variable was radiologically-confirmed thrombo-embolism requiring medical intervention. Multivariable Cox regression models were used to determine the impact of thrombo-embolism on survival, where TE was time-dependent. We included 2006 children (median age: 4 years, 88.5% precursor B-cell ALL). Thrombo-embolism occurred in 113 patients (5.6%), at a median time of 107 days (interquartile range: 35-184 days) after ALL diagnosis. Among standard/low-risk patients, 41/1165 (3.5%) developed TE while among high/very high-risk patients, 72/841 (8.6%) developed TE. Patients with TE had a significantly worse OS (adjusted HR [aHR] of death: 2.61, 95% CI: 1.62-4.22, p < 0.001) and EFS (aHR of an event [death, relapse, second malignancy]: 2.03, 95% CI: 1.35-3.05, p = 0.001), compared with patients without TE. No statistically significant difference was seen in standard/low risk ALL for OS and EFS, but TE was associated with a significantly lower OS and EFS in children with high/very high-risk ALL (aHR of death: 2.90, 95% CI: 1.79-4.72, p < 0.001; aHR of an event: 2.02, 95% CI: 1.30-3.12, p = 0.002). Thus, TE led to a statistically significant reduction in OS and EFS in children with high risk/very high-risk leukemia.
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Affiliation(s)
| | - Ketan Kulkarni
- Division of Hematology‐Oncology, Department of Pediatrics IWK Health Centre Halifax Nova Scotia Canada
| | - Uma H. Athale
- Division of Haematology/Oncology, McMaster Children's Hospital, and Department of Pediatrics McMaster University Hamilton Ontario Canada
| | - Jason D. Pole
- Centre for Health Services Research University of Queensland Herston Queensland Australia
| | - Leonardo R. Brandão
- Division of Haematology/Oncology, Department of Paediatrics SickKids Hospital Toronto Ontario Canada
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning Toronto Ontario Canada
- Dalla Lana School of Public Health, University of Toronto Toronto Ontario Canada
| | - Lillian Sung
- Division of Haematology/Oncology, Department of Paediatrics SickKids Hospital Toronto Ontario Canada
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning Toronto Ontario Canada
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Avila L, Cullinan N, White M, Gaballah M, Cahill AM, Warad D, Rodriguez V, Tarango C, Hoppmann A, Nelson S, Kuhn T, Biss T, Weiss A, Temple M, Amaral JG, Amiri N, Xavier AC, Renzi S, Brandão LR. Pediatric May-Thurner Syndrome-Systematic review and individual patient data meta-analysis. J Thromb Haemost 2021; 19:1283-1293. [PMID: 33651481 PMCID: PMC8126469 DOI: 10.1111/jth.15284] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 01/08/2021] [Accepted: 02/25/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND The outcomes of deep vein thrombosis (DVT) in children with May-Thurner Syndrome (MTS) remain unclear. OBJECTIVES This systematic review and patient-level meta-analysis aims to describe the outcomes of children with MTS presenting with DVT. METHODS A systematic review of the published literature was performed. Data related to patients <18 years diagnosed with MTS and DVT was extracted. Risk of bias was assessed using the Murad criteria. Outcomes included vessel patency post-treatment, DVT recurrence, and post-thrombotic syndrome (PTS). Predictive and explanatory models were developed for these outcomes. RESULTS In total, 109 cases were identified (age range 4-17 years; 77 females) in 28 studies; 75% of patients had ≥1 additional risk factor for DVT. PTS was seen in 61% of patients, DVT recurrence in 38%, and complete vessel patency post-treatment in 65%. The models developed to predict and explain PTS performed poorly overall. Recurrent thrombosis (adjusted for age and patency) predicted PTS (odds ratio [OR] 3.36, 95% confidence interval [CI] 1.28-8.82). DVT management strategies (adjusted for age and DVT characteristics) predicted vessel patency (OR 2.10, 95% CI 1.43-3.08). Lack of complete vessel patency (adjusted for age and thrombophilia) predicted recurrent DVT (OR 2.70, 95% CI 1.09-6.67). Sensitivity analyses showed the same direction of effects for all outcomes. CONCLUSIONS PTS and DVT recurrence occur frequently in pediatric MTS. PTS prediction is complex and it was not possible to identify early predictors to guide clinical practice. Use of imaging-guided therapy and thrombus burden predicted venous patency, and lack of patency predicted DVT recurrence.
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Affiliation(s)
- Laura Avila
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Michael White
- Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Marian Gaballah
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Anne Marie Cahill
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | - Cristina Tarango
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Centre, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Anna Hoppmann
- Children’s of Alabama, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Stephen Nelson
- Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
| | - Tomas Kuhn
- University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Tina Biss
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | - Michael Temple
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - João G. Amaral
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nour Amiri
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ana C. Xavier
- Children’s of Alabama, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Samuele Renzi
- The Hospital for Sick Children, Toronto, Ontario, Canada
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Röshammar D, Huang F, Albisetti M, Bomgaars L, Chalmers E, Luciani M, Halton J, Mitchell LG, Bergstrand M, Ibrahim MMA, Joseph D, Tartakovsky I, Gropper S, Brueckmann M, Brandão LR. Pharmacokinetic modeling and simulation support for age- and weight-adjusted dosing of dabigatran etexilate in children with venous thromboembolism. J Thromb Haemost 2021; 19:1259-1270. [PMID: 33636042 PMCID: PMC8251571 DOI: 10.1111/jth.15277] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Dabigatran etexilate (DE), a direct oral thrombin inhibitor, has been evaluated in children with venous thromboembolism (VTE) using oral solution, pellets, or capsules. OBJECTIVES This study evaluated DE pharmacokinetics (PK) in children with VTE and the appropriateness of a DE pediatric age- and weight-based dosing algorithm. PATIENTS/METHODS A population PK model was fitted to data from four single-arm and one randomized, comparative pediatric VTE studies (358 children aged birth to <18 years; 2748 PK observations) and one healthy-adult study (32 males aged <40 years; 1523 PK observations) using nonlinear mixed-effects modeling. A stepwise, covariate, model-building procedure evaluated the influence of covariates (e.g., age, body weight, body surface area [BSA]-normalized renal function, and sex). The final model was used to evaluate the pediatric dosing algorithm, with simulations comparing pediatric trough exposure with reference exposure defined for the pediatric studies. RESULTS The population PK of dabigatran was adequately described by a two-compartment model with first-order elimination and absorption. Age, weight, BSA-normalized renal function, and sex were statistically significant covariates (all P < .05). Apparent clearance increased with age (independently of body weight), diminished with decreasing BSA-normalized renal function, and was lower in females than males. All disposition parameters increased with body weight escalation (allometric scaling). Simulations confirmed that for all DE formulations, the final pediatric dosing algorithms achieved reference exposure without dose adjustment. CONCLUSIONS Using a population PK model of DE for children with VTE, simulations showed that the final dosing algorithms were appropriate for all DE formulations; no dose titration was needed.
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Affiliation(s)
| | - Fenglei Huang
- Translational Medicine and Clinical PharmacologyBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldConnecticutUSA
| | - Manuela Albisetti
- Hematology DepartmentUniversity Children’s HospitalZürichSwitzerland
| | - Lisa Bomgaars
- Department of PediatricsTexas Children’s Cancer CenterBaylor College of MedicineHoustonTexasUSA
| | - Elizabeth Chalmers
- Department of HaematologyRoyal Hospital for Children, GlasgowScotlandUnited Kingdom
| | - Matteo Luciani
- Pediatric Hematology/Oncology DepartmentPediatric Hospital Bambino GesùRomeItaly
| | - Jacqueline Halton
- Department of Pediatrics, Children’s Hospital of Eastern OntarioUniversity of OttawaOttawaOntarioCanada
| | - Lesley G. Mitchell
- Katz Group Centre for ResearchUniversity of AlbertaEdmontonAlbertaCanada
| | | | | | - David Joseph
- Translational Medicine and Clinical PharmacologyBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldConnecticutUSA
| | - Igor Tartakovsky
- Therapeutic Area Cardiovascular MedicineBoehringer Ingelheim International GmbHIngelheimGermany
| | - Savion Gropper
- Therapeutic Area Inflammation MedicineBoehringer Ingelheim International GmbHIngelheimGermany
| | - Martina Brueckmann
- Therapeutic Area Cardiovascular MedicineBoehringer Ingelheim International GmbHIngelheimGermany
- Faculty of Medicine Mannheim of the University of HeidelbergMannheimGermany
| | - Leonardo R. Brandão
- Department of PaediatricsThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
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Do J, Blais A, Feldman B, Brandão LR, Lougheed J, Pohl D, Klaassen RJ, Johnston DL, De Laat D, Roth J, Katz SL, McCormick A, Wright FV, Macartney G, McMillan HJ, Venkateswaran S, Sell E, Doja A, Matheson K, Boafo A, Longmuir PE. Characterization of physical literacy in children with chronic medical conditions compared with healthy controls: a cross-sectional study. Appl Physiol Nutr Metab 2021; 46:1073-1082. [PMID: 33689492 DOI: 10.1139/apnm-2020-0957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 11/22/2022]
Abstract
To determine the physical literacy, defined as the capability for a physically active lifestyle, of children with medical conditions compared with healthy peers, this multicenter cross-sectional study recruited children with medical conditions from cardiology, neurology (including concussion), rheumatology, mental health, respirology, oncology, hematology, and rehabilitation (including cerebral palsy) clinics. Participants aged 8-12 years (N = 130; mean age: 10.0 ± 1.44 years; 44% female) were randomly matched to 3 healthy peers from a normative database, based on age, gender, and month of testing. Total physical literacy was assessed by the Canadian Assessment of Physical Literacy, a validated assessment of physical literacy measuring physical competence, daily behaviour, knowledge/understanding, and motivation/confidence. Total physical literacy mean scores (/100) did not differ (t(498) = -0.67; p = 0.44) between participants (61.0 ± 14.2) and matched healthy peers (62.0 ± 10.7). Children with medical conditions had lower mean physical competence scores (/30; -6.5 [-7.44 to -5.51]; p < 0.001) but higher mean motivation/confidence scores (/30; 2.6 [1.67 to 3.63]; p < 0.001). Mean daily behaviour and knowledge/understanding scores did not differ from matches (/30; 1.8 [0.26 to 3.33]; p = 0.02;/10; -0.04 [-0.38 to 0.30]; p = 0.81; respectively). Children with medical conditions are motivated to be physically active but demonstrate impaired movement skills and fitness, suggesting the need for targeted interventions to improve their physical competence. Novelty: Physical literacy in children with diverse chronic medical conditions is similar to healthy peers. Children with medical conditions have lower physical competence than healthy peers, but higher motivation and confidence. Physical competence (motor skill, fitness) interventions, rather than motivation or education, are needed for these youth.
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Affiliation(s)
- Jeffrey Do
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Angelica Blais
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Brian Feldman
- Division of Rheumatology, The Hospital for Sick Children, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Leonardo R Brandão
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jane Lougheed
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Division of Cardiology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Daniela Pohl
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Division of Neurology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Robert J Klaassen
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Donna L Johnston
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Denise De Laat
- Division of Developmental Pediatrics and Rehabilitation Medicine, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Johannes Roth
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Division of Dermatology and Rheumatology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sherri Lynne Katz
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Division of Respirology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Anna McCormick
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Division of Developmental Pediatrics and Rehabilitation Medicine, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - F Virginia Wright
- Holland Bloorview Children's Rehab Hospital, Toronto, ON, Canada.,Department of Physical Therapy, University of Toronto, Ottawa, ON, Canada
| | - Gail Macartney
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada.,Faculty of Nursing, University of Prince Edward Island, Charlottetown, PEI, Canada
| | - Hugh J McMillan
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Division of Neurology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sunita Venkateswaran
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Division of Neurology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Erick Sell
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Division of Neurology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Asif Doja
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Division of Neurology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Katherine Matheson
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Division of Psychiatry, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Addo Boafo
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Division of Psychiatry, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Patricia E Longmuir
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
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Low T, Jegatheeswaran A, Devlin PJ, Chahal N, Brandão LR, McCrindle BW. Bleeding risk associated with combination thromboprophylaxis therapy is low for patients with coronary artery aneurysms after Kawasaki disease. Int J Cardiol 2020; 321:6-11. [PMID: 32697954 DOI: 10.1016/j.ijcard.2020.07.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 03/31/2020] [Revised: 06/04/2020] [Accepted: 07/13/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Kawasaki disease (KD) may lead to coronary artery aneurysms (CAA) with potential for thrombosis. We aimed to determine the bleeding risk during thromboprophylaxis regimens with dual and triple therapy. METHODS KD patients with medium to large CAAs receiving combination thromboprophylaxis therapy (dual or triple therapy with acetylsalicylic acid (ASA), clopidogrel, low molecular weight heparin (LMWH) or warfarin) were reviewed (1979-2017). Treatment periods <30 days were excluded. Bleeding events were classified using the Bleeding Academic Research Consortium (BARC) Score. The incidence of bleeding events per patient year of exposure was determined for each regimen. RESULTS n = 98 of 3022 KD (23 females:75 males) were included. Median age at diagnosis was 2.6 years (IQR: 0.6-6.2), median maximum CAA z-score was 18.0 (range: 5-65.5, IQR: 10.8-28.0, m = 6) and median follow-up duration was 6.5 years (IQR: 2.5-20.2). The incidence of type ≥2 bleeds per patient-year for each regimen was 0 (ASA + clopidogrel+LMWH), 0.03 (ASA + clopidogrel), 0.06 (ASA + warfarin), 0.06 (ASA + clopidogrel+warfarin), and 0.1 (ASA + LMWH) in ascending order. 31 bleeding events requiring medical attention (type ≥2) occurred in 30 patients (median age 7.8 years). Of the 17 type ≥2 bleeds on warfarin with an International Normalised Ratio (INR) available, 13 occurred with an INR >3. For patients receiving triple therapy (dual antiplatelet with anticoagulant), there were 57 bleeding events over 20 treatment periods. CONCLUSIONS The overall bleeding risk was low in KD patients receiving combination thromboprophylaxis, and not significantly different across all regimens. Type ≥2 bleeding events that occurred on warfarin were most frequently associated with high INR values.
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Affiliation(s)
- Tisiana Low
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada; Division of Cardiology, Department of Paediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Anusha Jegatheeswaran
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada; Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Paul J Devlin
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Nita Chahal
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada; Division of Cardiology, Department of Paediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leonardo R Brandão
- Division of Hematology/Oncology, Department of Paediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Brian W McCrindle
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada; Division of Cardiology, Department of Paediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada.
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Halton J, Brandão LR, Luciani M, Bomgaars L, Chalmers E, Mitchell LG, Nurmeev I, Sharathkumar A, Svirin P, Gorbatikov K, Tartakovsky I, Simetzberger M, Huang F, Sun Z, Kreuzer J, Gropper S, Reilly P, Brueckmann M, Albisetti M. Dabigatran etexilate for the treatment of acute venous thromboembolism in children (DIVERSITY): a randomised, controlled, open-label, phase 2b/3, non-inferiority trial. Lancet Haematol 2020; 8:e22-e33. [PMID: 33290737 DOI: 10.1016/s2352-3026(20)30368-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/29/2020] [Accepted: 11/04/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Dabigatran etexilate is a direct oral anticoagulant with potential to overcome the limitations of standard of care in children with venous thromboembolism. The aims of this clinical trial were to study the appropriateness of a paediatric dabigatran dosing algorithm, and the efficacy and safety of dabigatran dosed according to that algorithm versus standard of care in treating children with venous thromboembolism. METHODS DIVERSITY is a randomised, controlled, open-label, parallel-group, phase 2b/3 non-inferiority trial done in 65 centres in 26 countries. Standard of care (low-molecular-weight heparins, unfractionated heparin, vitamin K antagonists or fondaparinux) was compared with a paediatric oral dabigatran dosing regimen (an age-adjusted and weight-adjusted nomogram) in children younger than 18 years with acute venous thromboembolism initially treated (5-21 days) with parenteral anticoagulation, requiring anticoagulation therapy for at least 3 months. Patients were randomised 1:2 (standard of care:dabigatran) and stratified by age (12 to <18 years, 2 to <12 years, and birth to <2 years) via interactive response technology. The primary composite efficacy endpoint (intention-to-treat analysis) was the proportion of children with complete thrombus resolution, and freedom from recurrent venous thromboembolism and venous thromboembolism-related death. A non-inferiority margin of absolute differences of 20% was used. Secondary endpoints included safety (determined by major bleeding events [time-to-event analysis on the treated set]), and pharmacokinetic-pharmacodynamic relationships (descriptive analyses). This trial is registered with ClinicalTrials.gov, NCT01895777 and is completed. FINDINGS 328 children were enrolled between Feb 18, 2014, and Nov 14, 2019. 267 were randomly assigned (90 [34%] to standard of care and 177 [66%] to dabigatran) and included in the analyses. Median exposure to standard of care was 85·0 days (IQR 80·0-90·0) and to dabigatran was 84·5 days (78·0-89·0). Similar proportions of children treated with standard of care and dabigatran met the composite efficacy endpoint (38 [42%] of 90 vs 81 [46%] of 177; Mantel-Haenszel weighted difference, -0·04; 90% CI -0·14 to 0·07; p<0·0001 for non-inferiority). On-treatment bleeding events were reported in 22 (24%) of 90 children receiving standard of care and 38 (22%) of 176 children receiving dabigatran (hazard ratio [HR] 1·15, 95% CI 0·68 to 1·94; p=0·61); major bleeding events were similar between the groups (two [2%] of 90 and four [2%] of 176; HR 0·94, 95% CI 0·17 to 5·16; p=0·95). Pharmacokinetic-pharmacodynamic curves showed a linear relationship between total dabigatran plasma concentration and diluted thrombin time and ecarin clotting time, and a non-linear relationship with activated partial thromboplastin time; curves were similar to those for adults. Serious adverse events were reported for 18 (20%) of 90 children receiving standard of care and 22 (13%) of 176 children receiving dabigatran. The most common severe adverse events were vascular disorders (standard of care three [3%] of 90, dabigatran two [1%] of 176), and gastrointestinal disorders (standard of care two [2%] of 90 and dabigatran five [3%] of 176). One on-treatment death occurred in the standard of care group (retroperitoneal bleeding, not considered treatment related by the study investigators). INTERPRETATION An age-adjusted and weight-adjusted dabigatran dosing algorithm was appropriate in children aged birth to less than 18 years with venous thromboembolism. Dabigatran was non-inferior to standard of care in terms of efficacy, with similar pharmacokinetic-pharmacodynamic relationships as those seen in adults, and might be a suitable alternative to standard of care. FUNDING Boehringer Ingelheim.
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Affiliation(s)
- Jacqueline Halton
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | | | - Matteo Luciani
- Pediatric Hematology/Oncology Department, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - Lisa Bomgaars
- Department of Pediatrics, Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX, USA
| | | | - Lesley G Mitchell
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Ildar Nurmeev
- Pediatric Hospital, Republic of Tatarstan, Kazan Medical University, Kazan, Russian Federation
| | - Anjali Sharathkumar
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Pavel Svirin
- Pediatric Hematology Department, Municipal Children's Hospital "Morozovskaya", Moscow, Russian Federation
| | - Kirill Gorbatikov
- Pediatric Cardiovascular Surgery, Regional hospital #1, Tyumen region, Russia
| | - Igor Tartakovsky
- Therapeutic Area Cardiovascular Medicine, Boehringer Ingelheim International, Ingelheim am Rhein, Germany
| | | | - Fenglei Huang
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
| | - Zhichao Sun
- Biostatistics and Data Sciences, Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
| | | | - Savion Gropper
- Therapeutic Area Inflammation Medicine, Boehringer Ingelheim International, Ingelheim, Germany
| | - Paul Reilly
- Therapeutic Area Cardiovascular Medicine, Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
| | - Martina Brueckmann
- Therapeutic Area Cardiovascular Medicine, Boehringer Ingelheim International Pharma, Ingelheim, Germany; Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Manuela Albisetti
- Hematology Department, University Children's Hospital, Zurich, Switzerland.
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Avila L, Amiri N, Yenson P, Khan S, Zavareh ZT, Chan AKC, Williams S, Brandão LR. Heparin-Induced Thrombocytopenia in a Pediatric Population: Implications for Clinical Probability Scores and Testing. J Pediatr 2020; 226:167-172.e2. [PMID: 32640269 DOI: 10.1016/j.jpeds.2020.06.081] [Citation(s) in RCA: 3] [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: 04/13/2020] [Revised: 06/23/2020] [Accepted: 06/25/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To determine the applicability of the 4Ts score and the Heparin-Induced Thrombocytopenia (HIT) Expert Probability (HEP) score in children with suspected HIT and to estimate the number of children potentially at risk of HIT. STUDY DESIGN We retrospectively estimated 4Ts and HEP scores in a cohort of 50 children referred for laboratory screening with enzyme immunoassay. In addition, minor modifications were introduced to the 4Ts score (modified 4Ts score) to adapt it for use in the pediatric setting. All patients with positive enzyme immunoassays were tested with serotonin release assay. We also extracted the number of patients started on heparins in a similar period of time. RESULTS The median age at the time of testing was 4 years (25th-75th percentile, 8.7 months to 13.5 years); 78% of patients had low and 22% had intermediate risk pretest probability scores using the original 4Ts score; 86% had low risk and 14% had intermediate risk scores using the modified 4Ts score; 54% of children had a HEP score of ≥2. Six patients (12%) had a positive (≥0.40 optical density units) enzyme immunoassay, but none had a positive serotonin release assay. Based on anticoagulation dose, there were 1-2 new daily potentially high-risk exposures to heparinoids at our institution. CONCLUSIONS The modified 4Ts and original 4Ts scores may be more adequate than the HEP score to determine HIT pretest probability in children. Despite the number of patients potentially at risk, HIT is rare in pediatrics.
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Affiliation(s)
- Laura Avila
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nour Amiri
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul Yenson
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shirin Khan
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; G. Raymond Chang School of Continuing Education, Ryerson University, Toronto, Ontario, Canada
| | - Zahra Tofighi Zavareh
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; G. Raymond Chang School of Continuing Education, Ryerson University, Toronto, Ontario, Canada
| | - Anthony K C Chan
- Division of Hematology/Oncology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Suzan Williams
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Leonardo R Brandão
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Abstract
Vascular anomalies, comprised of vascular tumors and malformations, are frequently associated with coagulopathy. Recognition of and familiarity with these vascular anomaly-associated hematologic abnormalities prior to surgery or interventional procedures is essential for pre-operative pre-operative planning. Complicated coagulopathies present within the framework of either Kasabach-Merritt phenomenon (KMP) or localized intravascular coagulopathy (LIC), and their management benefits from the expertise of a hematologist for optimal intra- and peri‑operative care. Furthermore, with the recent broadening of understanding of vascular anomalies and the addition of new classification sub-groups, distinctions of these two classic coagulopathy phenotypes have been recognized. This review summarizes the main features of these coagulopathies, described according to their vascular anomaly type, highlighting clinical aspects relevant to surgical management.
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Affiliation(s)
- Kiersten W Ricci
- Hemangioma and Vascular Malformation Center, Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 7015, Cincinnati 45229, OH, United States.
| | - Leonardo R Brandão
- The Hospital for Sick Children, Division of Haematology-Oncology, Toronto, Ontario, Canada
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Engel ER, Nguyen ATH, Amankwah EK, Albisetti M, Brandão LR, Goldenberg NA, Betensky M. Predictors of postthrombotic syndrome in pediatric thrombosis: A systematic review and meta-analysis of the literature. J Thromb Haemost 2020; 18:2601-2612. [PMID: 32614496 DOI: 10.1111/jth.14984] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/28/2020] [Accepted: 06/22/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Postthrombotic syndrome (PTS) is a significant complication of pediatric deep venous thrombosis (DVT). There is a gap in the understanding of the risk factors associated with the development of pediatric PTS preventing the early identification of those patients at greatest risk, and the development of risk-stratified interventions. OBJECTIVES To conduct a systematic review and meta-analysis of the literature on prognostic factors for PTS development in pediatric patients. METHODS A systematic search of MEDLINE, EMBASE, and the Cochrane Library from 1960 to December 2018 was performed. Eligible studies reported at least one prognostic factor for PTS development in patients < 21 years of age with a radiographically confirmed DVT. To be included in the meta-analysis, prognostic factors had to be reported in at least three published studies. RESULTS AND CONCLUSIONS Twelve studies (n = 1160 patients) met criteria for inclusion. Ninety-three percent of patients with an extremity DVT (n = 1076) were assessed for PTS. PTS developed in 40% (n = 434) of these patients. Central venous catheter-associated DVT (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.08-2.98), complete veno-occlusion (OR, 1.89; 95% CI, 1.04-3.46), and incomplete DVT resolution (OR, 2.07; 95% CI, 1.4-3.07) were identified as candidate prognostic factors for pediatric PTS. These findings should be interpreted in the context of the heterogeneity of the included studies and the limitations of current pediatric PTS assessment tools. Further, the predictive value of these prognostic factors will need to be validated in future collaborative prospective multicenter studies that maximize the homogeneity of pediatric DVT patients.
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Affiliation(s)
- Elissa R Engel
- Department of Pediatrics, University of South Florida, Tampa, FL, USA
| | - Anh Thy H Nguyen
- Epidemiology and Biostatistics Unit, Johns Hopkins All Children's Health Informatics, St. Petersburg, FL, USA
| | - Ernest K Amankwah
- Epidemiology and Biostatistics Unit, Johns Hopkins All Children's Health Informatics, St. Petersburg, FL, USA
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, FL, USA
| | - Manuela Albisetti
- Hematology Department, University Children's Hospital, Zürich, Switzerland
| | - Leonardo R Brandão
- Division of Pediatric Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Neil A Goldenberg
- Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, FL, USA
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marisol Betensky
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins All Children's Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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Sun LR, Linds A, Sharma M, Rafay M, Vadivelu S, Lee S, Brandão LR, Appavu B, Estepp JH, Hukin J, Hassanein SMA, Chan A, Beslow LA. Cancer and Tumor-Associated Childhood Stroke: Results From the International Pediatric Stroke Study. Pediatr Neurol 2020; 111:59-65. [PMID: 32951663 DOI: 10.1016/j.pediatrneurol.2020.06.002] [Citation(s) in RCA: 4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND The prevalence of cancer among children with stroke is unknown. This study sought to evaluate cancer- and tumor-associated childhood ischemic stroke in a multinational pediatric stroke registry. METHODS Children aged 29 days to less than 19 years with arterial ischemic stroke or cerebral sinovenous thrombosis enrolled in the International Pediatric Stroke Study between January 2003 and June 2019 were included. Data including stroke treatment and recurrence were compared between subjects with and without cancer using Wilcoxon rank sum and chi-square tests. RESULTS Cancer or tumor was present in 99 of 2968 children (3.3%) with arterial ischemic stroke and 64 of 596 children (10.7%) with cerebral sinovenous thrombosis. Among children in whom cancer type was identified, 42 of 88 arterial ischemic stroke cases (48%) had brain tumors and 35 (40%) had hematologic malignancies; 45 of 58 cerebral sinovenous thrombosis cases (78%) had hematologic malignancies and eight (14%) had brain tumors. Of 54 cancer-associated arterial ischemic stroke cases with a known cause, 34 (63%) were due to arteriopathy and nine (17%) were due to cardioembolism. Of 46 cancer-associated cerebral sinovenous thrombosis cases with a known cause, 41 (89%) were related to chemotherapy-induced or other prothrombotic states. Children with cancer were less likely than children without cancer to receive antithrombotic therapy for arterial ischemic stroke (58% vs 80%, P = 0.007) and anticoagulation for cerebral sinovenous thrombosis (71% vs 87%, P = 0.046). Recurrent arterial ischemic stroke (5% vs 2%, P = 0.04) and cerebral sinovenous thrombosis (5% vs 1%, P = 0.006) were more common among children with cancer. CONCLUSIONS Cancer is an important risk factor for incident and recurrent childhood stroke. Stroke prevention strategies for children with cancer are needed.
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Affiliation(s)
- Lisa R Sun
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland; Division of Cerebrovascular Neurology, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland.
| | - Alexandra Linds
- Division of Neurology, Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mukta Sharma
- Division of Hematology Oncology, Children's Mercy, University of Missouri Kansas City, Kansas City, Missouri
| | - Mubeen Rafay
- Section of Pediatric Neurology, Department of Pediatrics and Child Health, Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sudhakar Vadivelu
- Division of Neurosurgery, Department of Neurosurgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Neurosurgery, Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Leonardo R Brandão
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Brian Appavu
- Department of Child Health and Neurology, University of Arizona College of Medicine - Phoenix Barrow Neurologic Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Jeremie H Estepp
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee; Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Juliette Hukin
- Division of Neurology, Department of Pediatrics, Children's and Women's Health Centre, Vancouver, British Columbia, Canada; Division of Oncology, Department of Pediatrics, Children's and Women's Health Centre, Vancouver, British Columbia, Canada
| | - Sahar M A Hassanein
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Anthony Chan
- Department of Paediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
BACKGROUND The prevalence of children diagnosed with thrombotic events has been increasing in the last decades. The most common thrombosis risk factor in neonates, infants and children is the placement of a central venous catheter (CVC). It is unknown if anticoagulation prophylaxis with low molecular weight heparin (LMWH) decreases CVC-related thrombosis in children. This is an update of the Cochrane Review published in 2014. OBJECTIVES To determine the effect of LMWH prophylaxis on the incidence of CVC-related thrombosis and major and minor bleeding complications in children. Further objectives were to determine the effect of LMWH on occlusion of CVCs, number of days of CVC patency, episodes of catheter-related bloodstream infection (CRBSI), other side effects of LMWH (allergic reactions, abnormal coagulation profile, heparin-induced thrombocytopaenia and osteoporosis) and mortality during therapy. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 7 May 2019. We undertook reference checking of identified trials to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-randomised trials comparing LMWH to no prophylaxis (placebo or no treatment), or low-dose unfractionated heparin (UFH) either as continuous infusion or flushes (low-dose UFH aims to ensure the patency of the central line but has no systemic anticoagulation activity), given to prevent CVC-related thrombotic events in children. We selected studies conducted in children aged 0 to 18 years. DATA COLLECTION AND ANALYSIS Two review authors independently identified eligible studies, which were assessed for study methodology including bias, and extracted unadjusted data where available. In the data analysis step, all outcomes were analysed as binary or dichotomous outcomes. The effects of interventions were summarised with risk ratios (RR) and their respective 95% confidence intervals (CI). We assessed the certainty of evidence for each outcome using the GRADE approach. MAIN RESULTS One additional study was included for this update bringing the total to two included studies (with 1135 participants). Both studies were open-label RCTs comparing LMWH with low-dose UFH to prevent CVC-related thrombosis in children. We identified no studies comparing LMWH with placebo or no treatment. Meta-analysis found insufficient evidence of an effect of LMWH prophylaxis in reducing the incidence of CVC-related thrombosis in children with CVC, compared to low-dose UFH (RR 0.68, 95% CI 0.27 to 1.75; 2 studies; 787 participants; low-certainty evidence). One study (158 participants) reported symptomatic and asymptomatic CVC-related thrombosis separately and detected no evidence of a difference between LMWH and low-dose UFH (RR 1.03, 95% CI 0.21 to 4.93; low-certainty evidence; RR 1.17, 95% CI 0.45 to 3.08; low-certainty evidence; for symptomatic and asymptomatic participants respectively). There was insufficient evidence to determine whether LMWH impacts the risk of major bleeding (RR 0.27, 95% CI 0.05 to 1.67; 2 studies; 813 participants; low-certainty evidence); or minor bleeding. One study reported minor bleeding in 53.3% of participants in the LMWH arm and in 44.7% of participants in the low-dose UFH arm (RR 1.20, 95% CI 0.91 to 1.58; 1 study; 158 participants; very low-certainty evidence), and the other study reported no minor bleeding in either group (RR: not estimable). Mortality during the study period was reported in one study, where two deaths occurred during the study period. Both were unrelated to thrombotic events and occurred in the low-dose UFH arm. The second study did not report mortality during therapy per arm but showed similar 5-year overall survival (low-certainty evidence). No additional adverse effects were reported. Other pre-specified outcomes (including CVC occlusion, patency and CRBSI) were not reported. AUTHORS' CONCLUSIONS Pooling data from two RCTs did not provide evidence to support the use of prophylactic LWMH for preventing CVC-related thrombosis in children (low-certainty evidence). Evidence was also insufficient to confirm or exclude a difference in the incidence of major and minor bleeding complications in the LMWH prophylaxis group compared to low-dose UFH (low and very low certainty respectively). No evidence of a clear difference in overall mortality was seen. Studies did not report on the outcomes catheter occlusion, days of catheter patency, episodes of CRBSI and other side effects of LMWH (allergic reactions, abnormal coagulation profile, heparin-induced thrombocytopaenia and osteoporosis). The certainty of the evidence was downgraded due to risk of bias of the included studies, imprecision and inconsistency, preventing conclusions in regards to the efficacy of LMWH prophylaxis to prevent CVC-related thrombosis in children.
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Affiliation(s)
| | - Nour Amiri
- Division of Haematology-Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Maria L Avila
- Division of Haematology-Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Leonardo R Brandão
- Division of Haematology-Oncology, The Hospital for Sick Children, Toronto, Canada
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Abstract
BACKGROUND The role of cardiac catheterization in pediatrics has progressed significantly over the last two decades, evolving from a primary diagnostic tool to a primary treatment modality in children with congenital heart disease. Vascular complications, particularly arterial thrombosis, are among the most common unwanted post-cardiac catheterization events. In 1974, unfractionated heparin proved to be superior to placebo in decreasing the incidence of arterial thrombosis in pediatric patients. However, the optimal dose of unfractionated heparin to be utilized in this setting remains a matter of controversy. This is an update of the review first published in 2014. OBJECTIVES To evaluate the use of low-dose (< 100 units/kg) versus high-dose (≥ 100 units/kg) unfractionated heparin administered as an intravenous bolus at the time of initiation of cardiac catheterization (that is, immediately after arterial puncture), with or without subsequent heparin maintenance doses, for the prevention of post-procedural arterial thrombosis in children. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 15 October 2019. We planned to undertake reference checking of identified trials to identify additional studies. No language restrictions were applied. SELECTION CRITERIA We included randomized or quasi-randomized trials that compared low dose to high dose unfractionated heparin administered prior to cardiac catheterization. We selected studies conducted in children aged 0 to 18 years. DATA COLLECTION AND ANALYSIS The first screening of potentially eligible studies was conducted by one of the authors (MLA). The second screening, risk of bias assessment and data extraction were independently conducted by two authors (MLA, LRB). Outcomes (thrombotic events, bleeding complications, other complications) were treated as dichotomous variables. The effect measures used were risk ratio (RR), risk difference (RD) and number needed to treat (NNT), with 95% confidence intervals (CI). We assessed the certainty of evidence for each outcome using the GRADE approach. MAIN RESULTS We identified no new studies for inclusion in this review. In total, two studies with a total of 492 participants were included. We had concerns about risk of bias for one of the two studies. The certainty of the evidence for our key outcomes was downgraded to moderate due to risk of bias concerns and imprecision. The confidence interval for the risk of arterial thrombotic events was compatible with benefits of either high or low unfractionated heparin dose regimens (RR low-dose versus high-dose 1.06, 95% CI 0.58 to 1.92). Only one of the studies reported the frequency of bleeding events and found no clear difference in the incidence of major or minor bleeding events between arms (RR low-dose versus high-dose 2.96, 95% CI 0.12 to 71.34 for major bleeding events; RR low-dose versus high-dose 1.38, 95% CI 0.46 to 4.13 for minor bleeding). This study also reported on the incidence of deep vein thrombosis when comparing the high versus low dose of heparin and reported a non-significant difference (RR low-dose versus high-dose 0.34, 95% CI 0.01 to 8.28). The other study lacked information about bleeding. Additional side effects of heparin other than bleeding events were not reported in either of the studies. AUTHORS' CONCLUSIONS Due to the limitations of the current evidence, small number of included studies, and lack of details reported in one study, we are unable to determine the effects of different dosing regimens of unfractionated heparin for the prevention of vascular thrombosis during cardiac catheterization in children. Further adequately powered, randomized clinical trials are needed.
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Affiliation(s)
- Maria L Avila
- The Hospital for Sick ChildrenDivision of Haematology‐Oncology555 University AvenueTorontoONCanadaM5G 1X8
| | - Prakeshkumar S Shah
- University of Toronto Mount Sinai HospitalDepartment of Paediatrics and Institute of Health Policy, Management and Evaluation600 University AvenueTorontoONCanadaM5G 1XB
| | - Leonardo R Brandão
- The Hospital for Sick ChildrenDivision of Haematology‐Oncology555 University AvenueTorontoONCanadaM5G 1X8
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Avila ML, Feldman BM, Pullenayegum E, Lumia C, Montoya MI, Vincelli J, Williams S, Brandão LR. Post-thrombotic syndrome in children: Measurement properties of CAPTSure, a new diagnostic tool. Res Pract Thromb Haemost 2019; 3:652-657. [PMID: 31624784 PMCID: PMC6781925 DOI: 10.1002/rth2.12251] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 07/22/2019] [Accepted: 07/26/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND CAPTsure (Clinical Assessment of PTS) is a new tool for diagnosis and severity rating of pediatric postthrombotic syndrome (PTS). Our objective was to test the reliability, measurement error, and minimal detectable change of CAPTSure. METHODS Children aged newborn to 18 years who sustained upper extremity or lower extremity deep vein thrombosis (DVT) were enrolled ≥ 6 months after DVT diagnosis. Patients were assessed by 2 raters to determine the reliability of the clinician assessment component (CC) of CAPTSure. Patients/proxies completed CAPTSure at baseline and approximately 2 weeks later to assess test-retest reliability of the symptoms component (SC). RESULTS Of 148 patients enrolled in the study; 30 had sustained either bilateral or both upper and lower extremity DVT. Hence, 178 extremities were assessed for PTS signs (86 upper extremity, 92 lower extremity). Intraclass correlation coefficient (ICC) for the CC was 0.89 (95% confidence interval [CI], 0.84-0.93) for upper extremity and 0.88 (95% CI, 0.83-0.92) for lower extremity. Nonclinicians performed 59% of measurements. Ninety-eight patients completed the SC at baseline and follow-up, for a total of 60 upper extremity and 61 lower extremity assessments. ICC for the SC was 0.89 (95% CI, 0.84-0.93) for upper extremity and 0.92 (0.87-0.95) for lower extremity. ICC for CAPTSure was 0.92 (95% CI, 0.87-0.95) for upper extremity and 0.93 (95% CI, 0.88-0.95) for lower extremity assessment. Measurement error ranged between 1.7 and 4.3 of 100 points. A change of approximately 11 of 100 points in CAPTSure score would be required to be confident that there was a change in PTS severity. CONCLUSION CAPTSure has excellent reliability and a small measurement error, even when applied by nonhematologists.
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Affiliation(s)
- Maria Laura Avila
- Department of PediatricsThe Hospital for Sick ChildrenTorontoONCanada
- Child Health Evaluative SciencesThe Hospital for Sick ChildrenTorontoONCanada
| | - Brian M. Feldman
- Department of PediatricsThe Hospital for Sick ChildrenTorontoONCanada
- Child Health Evaluative SciencesThe Hospital for Sick ChildrenTorontoONCanada
- Institute of Health Policy, Management and EvaluationDalla Lana School of Public HealthUniversity of TorontoTorontoONCanada
| | | | - Celeste Lumia
- Department of PediatricsThe Hospital for Sick ChildrenTorontoONCanada
| | | | - Jennifer Vincelli
- Department of PediatricsThe Hospital for Sick ChildrenTorontoONCanada
| | - Suzan Williams
- Department of PediatricsThe Hospital for Sick ChildrenTorontoONCanada
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Tole S, Price V, Pope E, Powell J, David M, Zwicker K, Kendrick V, Malic C, John PR, Somers GR, Dubois J, Brandão LR. Abnormal hemostasis in children with vascular anomalies, part I: Thrombocytopenias among different vascular anomalies. Thromb Res 2019; 196:626-634. [PMID: 31221393 DOI: 10.1016/j.thromres.2019.06.004] [Citation(s) in RCA: 2] [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] [Received: 04/09/2019] [Revised: 05/31/2019] [Accepted: 06/09/2019] [Indexed: 12/18/2022]
Abstract
Long before the classification of vascular anomalies from the International Society for the Study of Vascular Anomalies (ISSVA) provided a framework to differentiate vascular anomalies, otherwise known as vascular birthmarks, it was recognized that patients with such lesions can present with acute life-threatening hemostatic and/or thrombotic complications, as well as chronic long-standing bleeding or thrombotic issues. Scenarios such as a rapidly growing vascular lesion with severe acute thrombocytopenia, a visceral hemorrhagic lesion, a lesion associated with repetitive and painful superficial thrombosis, and cases of unprovoked or post-procedural fatal pulmonary embolism highlight the wide spectrum of manifestations of abnormal coagulation in patients with vascular anomalies. The separation of vascular anomalies into two distinct groups, vascular tumors and vascular malformations, was followed by the characterization that their respective coagulopathies were due to either a derangement of platelets or to a disequilibrium of the patient's coagulation/fibrinolytic process. This configuration of coagulopathies will be the foundation for this two-chapter review series. In the initial review, coagulopathies where thrombocytopenia is the main feature will be characterized, whereas the second review will focus on vascular malformations that have a coagulation disorder secondary to some degree of coagulation consumption and/or fibrinolytic pathway derangement.
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Affiliation(s)
- Soumitra Tole
- Department of Paediatrics, Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Victoria Price
- Department of Paediatrics, Division of Haematology-Oncology, IWK Health Centre, Dalhousie University, Halifax, NS, Canada
| | - Elena Pope
- Department of Paediatrics, Section of Dermatology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Julie Powell
- Department of Pediatrics, Division of Dermatology, Sainte-Justine University Hospital Center, University of Montreal, Montreal, QC, Canada
| | - Michèle David
- Department of Pediatrics, Division of Hematology, Sainte-Justine University Hospital Center, University of Montreal, Montreal, QC, Canada
| | - Kelley Zwicker
- Department of Paediatrics, Division of Community Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Victoria Kendrick
- Department of Pediatrics, Division of Community Pediatrics, Calgary, AB, Canada
| | - Claudia Malic
- Division of Plastic Surgery, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Philip R John
- Department of Diagnostic Imaging, Division of Interventional Radiology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Gino R Somers
- Department of Paediatric Laboratory Medicine, Division of Pathology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Josée Dubois
- Department of Medical Imaging, CHU Sainte-Justine Mother and Child University Hospital Center, University of Montreal, Montreal, QC, Canada
| | - Leonardo R Brandão
- Department of Paediatrics, Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.
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Manlhiot C, McCrindle BW, Williams S, Menjak IB, O'Shea S, Chan AK, Brandão LR. Characterization of Post-Thrombotic Syndrome in Children with Cardiac Disease. J Pediatr 2019; 207:42-48. [PMID: 30528575 DOI: 10.1016/j.jpeds.2018.10.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 09/21/2018] [Accepted: 10/26/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To assess the validity of existing clinical scales assessing the presence of physical and functional abnormalities for diagnosing post-thrombotic syndrome (PTS) in children, including specific evaluation of use in children with congenital heart disease (CHD). STUDY DESIGN One hundred children aged >2 years (average age, 6 years), including 33 with CHD and previously proven extremity deep vein thrombosis (DVT), 37 with CHD and no previous DVT, and 30 healthy siblings, were blindly assessed for PTS using the modified Villalta Scale (MVS). All patients aged <6 years underwent neurodevelopmental testing and an age-appropriate quality of life assessment. RESULTS The MVS identified mild PTS in 20 children and moderate PTS in 1 child (including 14 of 33 [42%] in the CHD/DVT group, 5 of 37 [14%] in the CHD/no DVT group, and 2 of 30 controls [7%]). The diagnosis of PTS was confirmed clinically in 14 patients, all of whom had previous thrombosis and 1 of whom was MVS-negative. MVS had an accuracy of 91% and performed reasonably well as a screening tool but poorly as a diagnostic tool. MVS reliability was acceptable. Children with PTS had similar quality of life as those without PTS but had higher rates of neurodevelopmental delays in gross motor skills (70% vs 24%; P = .02) and problem-solving indicators (60% vs 15%; P = .008). CONCLUSIONS Using the MVS scale for PTS screening in children with CHD is feasible and reliable, and the scale has good correlation with a clinical diagnosis of PTS despite a high prevalence of false-positive findings. Further research is needed to determine the clinical relevance of PTS in this population.
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Affiliation(s)
- Cedric Manlhiot
- Labatt Family Heart Centre, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada.
| | - Brian W McCrindle
- Labatt Family Heart Centre, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Suzan Williams
- Division of Haematology/Oncology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ines B Menjak
- Labatt Family Heart Centre, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sunita O'Shea
- Labatt Family Heart Centre, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Anthony K Chan
- Division of Haematology/Oncology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leonardo R Brandão
- Division of Haematology/Oncology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
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Pelland-Marcotte MC, Tucker C, Klaassen A, Avila ML, Amid A, Amiri N, Williams S, Halton J, Brandão LR. Outcomes and risk factors of massive and submassive pulmonary embolism in children: a retrospective cohort study. The Lancet Haematology 2019; 6:e144-e153. [DOI: 10.1016/s2352-3026(18)30224-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/03/2018] [Accepted: 12/10/2018] [Indexed: 01/13/2023]
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Kubitza D, Willmann S, Becka M, Thelen K, Young G, Brandão LR, Monagle P, Male C, Chan A, Kennet G, Martinelli I, Saracco P, Lensing AWA. Exploratory evaluation of pharmacodynamics, pharmacokinetics and safety of rivaroxaban in children and adolescents: an EINSTEIN-Jr phase I study. Thromb J 2018; 16:31. [PMID: 30534007 PMCID: PMC6278122 DOI: 10.1186/s12959-018-0186-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 10/29/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The EINSTEIN-Jr program will evaluate rivaroxaban for the treatment of venous thromboembolism (VTE) in children, targeting exposures similar to the 20 mg once-daily dose for adults. METHODS This was a multinational, single-dose, open-label, phase I study to describe the pharmacodynamics (PD), pharmacokinetics (PK) and safety of a single bodyweight-adjusted rivaroxaban dose in children aged 0.5-18 years. Children who had completed treatment for a venous thromboembolic event were enrolled into four age groups (0.5-2 years, 2-6 years, 6-12 years and 12-18 years) receiving rivaroxaban doses equivalent to 10 mg or 20 mg (either as a tablet or oral suspension). Blood samples for PK and PD analyses were collected within specified time windows. RESULTS Fifty-nine children were evaluated. In all age groups, PD parameters (prothrombin time, activated partial thromboplastin time and anti-Factor Xa activity) showed a linear relationship versus rivaroxaban plasma concentrations and were in line with previously acquired adult data, as well as in vitro spiking experiments. The rivaroxaban pediatric physiologically based pharmacokinetic model, used to predict the doses for the individual body weight groups, was confirmed. No episodes of bleeding were reported, and treatment-emergent adverse events occurred in four children and all resolved during the study. CONCLUSIONS Bodyweight-adjusted, single-dose rivaroxaban had predictable PK/PD profiles in children across all age groups from 0.5 to 18 years. The PD assessments based on prothrombin time and activated partial thromboplastin time demonstrated that the anticoagulant effect of rivaroxaban was not affected by developmental hemostasis in children. TRIAL REGISTRATION ClinicalTrials.gov number, NCT01145859.
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Affiliation(s)
- Dagmar Kubitza
- Bayer AG, Global Drug Discovery – Clinical Sciences, Clinical Pharmacology Cardiovascular, Aprather Weg 18a, Gebäude 429, 42113 Wuppertal, Germany
| | - Stefan Willmann
- Bayer AG, Global Drug Discovery – Clinical Sciences, Clinical Pharmacology Cardiovascular, Aprather Weg 18a, Gebäude 429, 42113 Wuppertal, Germany
| | - Michael Becka
- Research and Clinical Sciences, Bayer AG, Wuppertal, Germany
| | - Kirstin Thelen
- Bayer AG, Global Drug Discovery – Clinical Sciences, Clinical Pharmacology Cardiovascular, Aprather Weg 18a, Gebäude 429, 42113 Wuppertal, Germany
| | - Guy Young
- Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA USA
| | - Leonardo R. Brandão
- Department of Paediatrics, Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Paul Monagle
- Department of Haematology Royal Children’s Hospital, Department of Paediatrics, University of Melbourne, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Christoph Male
- Thrombosis & Haemostasis Unit, Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Anthony Chan
- McMaster Children’s Hospital/Hamilton Health Sciences Foundation Pediatric Thrombosis and Hemostasis, Hamilton, Canada
| | - Gili Kennet
- National Hemophilia Center & Thrombosis Institute, Sheba Medical Center, Ramat Gan, Israel
| | - Ida Martinelli
- A.Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Saracco
- Pediatric Hematology, University Hospital Città della Salute e della Scienza, Torino, Italy
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Monagle P, Cuello CA, Augustine C, Bonduel M, Brandão LR, Capman T, Chan AKC, Hanson S, Male C, Meerpohl J, Newall F, O'Brien SH, Raffini L, van Ommen H, Wiernikowski J, Williams S, Bhatt M, Riva JJ, Roldan Y, Schwab N, Mustafa RA, Vesely SK. American Society of Hematology 2018 Guidelines for management of venous thromboembolism: treatment of pediatric venous thromboembolism. Blood Adv 2018; 2:3292-3316. [PMID: 30482766 PMCID: PMC6258911 DOI: 10.1182/bloodadvances.2018024786] [Citation(s) in RCA: 216] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 09/24/2018] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Despite an increasing incidence of venous thromboembolism (VTE) in pediatric patients in tertiary care settings, relatively few pediatric physicians have experience with antithrombotic interventions. OBJECTIVE These guidelines of the American Society of Hematology (ASH), based on the best available evidence, are intended to support patients, clinicians, and other health care professionals in their decisions about management of pediatric VTE. METHODS ASH formed a multidisciplinary guideline panel that included 2 patient representatives and was balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including updating or performing systematic evidence reviews (up to April of 2017). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 30 recommendations, covering symptomatic and asymptomatic deep vein thrombosis, with specific focus on management of central venous access device-associated VTE. The panel also addressed renal and portal vein thrombosis, cerebral sino venous thrombosis, and homozygous protein C deficiency. CONCLUSIONS Although the panel offered many recommendations, additional research is required. Priorities include understanding the natural history of asymptomatic thrombosis, determining subgroup boundaries that enable risk stratification of children for escalation of treatment, and appropriate study of newer anticoagulant agents in children.
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Affiliation(s)
- Paul Monagle
- Department of Clinical Haematology, Royal Children's Hospital, University of Melbourne and Murdoch Children's Research Institute, VIC, Australia
| | - Carlos A Cuello
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Tecnologico de Monterrey School of Medicine, Monterrey, Mexico
| | | | - Mariana Bonduel
- Department of Hematology/Oncology, Hospital de Pediatria "Prof. Dr. Juan P. Garrahan," Buenos Aires, Argentina
| | - Leonardo R Brandão
- Division of Haematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Anthony K C Chan
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Sheila Hanson
- Department of Pediatrics, Medical College of Wisconsin and Critical Care Section, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Christoph Male
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Joerg Meerpohl
- Department of Medical Biometry and Statistics, Institute of Medical Biometry and Medical Informatics, University of Freiburg and University Medical Center Freiburg, Freiburg, Germany
| | - Fiona Newall
- Department of Clinical Haematology and
- Department of Nursing Research, Royal Children's Hospital, University of Melbourne, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Leslie Raffini
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Heleen van Ommen
- Department of Pediatric Hematology, Sophia Children's Hospital Erasmus MC, Rotterdam, The Netherlands
| | - John Wiernikowski
- Division of Hematology/Oncology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - Suzan Williams
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Meha Bhatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - John J Riva
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Yetiani Roldan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Nicole Schwab
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Division of Nephrology and Hypertension, Department of Medicine, University of Kansas Medical Center, Kansas City, KS; and
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Luciani M, Albisetti M, Biss B, Bomgaars L, Brueckmann M, Chalmers E, Gropper S, Halton JML, Harper R, Huang F, Manastirski I, Mitchell LG, Tartakovsky I, Wang B, Brandão LR. Phase 3, single-arm, multicenter study of dabigatran etexilate for secondary prevention of venous thromboembolism in children: Rationale and design. Res Pract Thromb Haemost 2018; 2:580-590. [PMID: 30046763 PMCID: PMC6046601 DOI: 10.1002/rth2.12093] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 02/18/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Anticoagulant therapy for venous thromboembolism (VTE) in children is largely based on treatment recommendations for adults. However, differences in both physiology (ie, renal maturation and drug excretion) and developmental hemostasis must be considered when treating children, as such differences could affect dose appropriateness, safety and efficacy. OBJECTIVES To address these concerns, a study was designed to evaluate the safety of dabigatran etexilate in children requiring secondary thrombus prevention in whom an initial VTE was associated with an identified risk factor that persisted after the acute VTE treatment period. We report herein the rationale and design of the study. PATIENTS/METHODS This phase 3, open-label, single-arm, multicenter, multinational, prospective cohort study will be conducted in ≥100 children aged 0 to <18 years at ~100 specialist sites worldwide. Children will be treated with dabigatran etexilate for 12 months, or for a shorter duration if their identified VTE risk factor resolves, as per current American College of Chest Physicians recommendations. A nomogram will be used to determine starting doses for each patient. RESULTS The primary outcomes of the study will be VTE recurrence, bleeding events, overall mortality, and VTE-related mortality. Secondary outcomes will include occurrence of post-thrombotic syndrome, the pharmacokinetics of dabigatran, and the need for dose adjustments during treatment. Data on adverse events during the study will also be collected. CONCLUSION This study will evaluate the safety of dabigatran etexilate for the secondary prevention of VTE in children, in addition to providing further data to guide pediatric dosing with dabigatran.
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Affiliation(s)
- Matteo Luciani
- OncoHematology DepartmentBambino Gesù Children's HospitalRomeItaly
| | - Manuela Albisetti
- Hematology DepartmentUniversity Children's HospitalZürichSwitzerland
| | - Branislav Biss
- Department of Clinical DevelopmentBoehringer Ingelheim RCV GmbH & Co. KGViennaAustria
| | - Lisa Bomgaars
- Texas Children's Cancer CenterBaylor College of MedicineHoustonTXUSA
| | - Martina Brueckmann
- Clinical Development and Medical AffairsBoehringer Ingelheim Pharma GmbH & Co. KGIngelheimGermany
- Faculty of Medicine MannheimUniversity of HeidelbergMannheimGermany
| | | | - Savion Gropper
- Clinical Development and Medical AffairsBoehringer Ingelheim Pharma GmbH & Co. KGIngelheimGermany
| | | | - Ruth Harper
- Boehringer Ingelheim LtdBracknellBerkshireUK
| | - Fenglei Huang
- Translational Medicine and Clinical PharmacologyBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldCTUSA
| | - Ivan Manastirski
- Department of Clinical DevelopmentBoehringer Ingelheim RCV GmbH & Co. KGViennaAustria
| | | | - Igor Tartakovsky
- Clinical Development and Medical AffairsBoehringer Ingelheim Pharma GmbH & Co. KGIngelheimGermany
| | - Bushi Wang
- Biostatistics and Data SciencesBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldCTUSA
| | - Leonardo R. Brandão
- Department of PediatricsDivision of Hematology/OncologyThe Hospital for Sick ChildrenUniversity of TorontoTorontoONCanada
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Avila ML, Feldman BM, Williams S, Ward LC, Montoya MI, Stinson J, Kiss A, Vincelli J, Lumia C, Brandão LR. Assessment of limb edema in pediatric post-thrombotic syndrome. Res Pract Thromb Haemost 2018; 2:591-595. [PMID: 30046764 PMCID: PMC6046586 DOI: 10.1002/rth2.12082] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/12/2018] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Pediatric tools for diagnosis of post-thrombotic syndrome (PTS) include the assessment of limb edema as a symptom (patient/proxy-reported) and as a sign. However, it is unclear whether these two approaches refer to the same clinical aspect of PTS. This could result in overestimation of disease severity. We sought to evaluate the correlation among different techniques to assess limb edema as a sign and as a symptom in children who sustained upper extremity (UE) or lower extremity (LE) deep vein thrombosis (DVT) and were, therefore, at risk of PTS. METHODS Limb edema was cross-sectionally measured as a symptom (ie, patient- or proxy-reported) and as a sign (ie, clinician-assessed limb circumference difference, limb volume ratio, bioimpedance spectroscopy ratio (BIS), and durometry ratio) in 140 children at risk of PTS (n = 70 UE-DVT, n = 70 LE-DVT). Item-item correlations were estimated using Pearson or Spearman correlation coefficients, as appropriate, and separately for the UE and LE groups. RESULTS In the UE-DVT group, proxy-reported swelling correlated weakly to moderately with circumference difference and with volume ratio, but not with BIS ratio. In the LE-DVT group, proxy-reported swelling correlated moderately with thigh circumference difference and volume ratio, and patient-reported swelling correlated moderately with BIS ratio. CONCLUSION Our findings suggest that patient/proxy-reported and clinician-assessed limb edema measure slightly different aspects of PTS, justifying their inclusion in pediatric PTS tools. In addition, proxy-reported swelling was in closer agreement with clinician-assessed total limb size (ie, observed edema), and patient-reported swelling in the LE seemed to reflect limb fluid content (ie, perceived edema).
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Affiliation(s)
- Maria L. Avila
- Department of PediatricsThe Hospital for Sick ChildrenTorontoONCanada
| | - Brian M. Feldman
- Department of PediatricsThe Hospital for Sick ChildrenTorontoONCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoONCanada
- Child Health Evaluative SciencesThe Hospital for Sick ChildrenUniversity of TorontoTorontoONCanada
| | - Suzan Williams
- Department of PediatricsThe Hospital for Sick ChildrenTorontoONCanada
| | - Leigh C. Ward
- School of Chemistry and Molecular BiosciencesThe University of QueenslandSt. Lucia, BrisbaneAustralia
| | | | - Jennifer Stinson
- Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoONCanada
- Child Health Evaluative SciencesThe Hospital for Sick ChildrenUniversity of TorontoTorontoONCanada
- Lawrence S. Bloomberg Faculty of NursingUniversity of TorontoTorontoONCanada
| | - Alex Kiss
- Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoONCanada
- Department of Research Design and BiostatisticsSunnybrook Health Sciences CentreTorontoONCanada
| | - Jennifer Vincelli
- Department of PediatricsThe Hospital for Sick ChildrenTorontoONCanada
| | - Celeste Lumia
- Department of PediatricsThe Hospital for Sick ChildrenTorontoONCanada
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Albisetti M, Biss B, Bomgaars L, Brandão LR, Brueckmann M, Chalmers E, Gropper S, Harper R, Huang F, Luciani M, Manastirski I, Mitchell LG, Tartakovsky I, Wang B, Halton JML. Design and rationale for the DIVERSITY study: An open-label, randomized study of dabigatran etexilate for pediatric venous thromboembolism. Res Pract Thromb Haemost 2018; 2:347-356. [PMID: 30046738 PMCID: PMC6055566 DOI: 10.1002/rth2.12086] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 01/26/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The current standard of care (SOC) for pediatric venous thromboembolism (VTE) comprises unfractionated heparin (UFH), or low-molecular-weight heparin (LMWH) followed by LMWH or vitamin K antagonists, all of which have limitations. Dabigatran etexilate (DE) has demonstrated efficacy and safety for adult VTE and has the potential to overcome some of the limitations of the current SOC. Pediatric trials are needed to establish dosing in children and to confirm that results obtained in adults are applicable in the pediatric setting. OBJECTIVES To describe the design and rationale of a planned phase IIb/III trial that will evaluate a proposed dosing algorithm for DE and assess the safety and efficacy of DE versus SOC for pediatric VTE treatment. PATIENTS/METHODS An open-label, randomized, parallel-group noninferiority study will be conducted in approximately 180 patients aged 0 to <18 years with VTE, who have received initial UFH or LMWH treatment and who are expected to require ≥3 months of anticoagulation therapy. Patients will receive DE or SOC for 3 months. DE will be administered twice daily as capsules, pellets, or an oral liquid formulation according to patient age. Initial doses will be calculated using a proposed dosing algorithm. RESULTS There will be two coprimary endpoints: a composite efficacy endpoint comprising the proportion of patients with complete thrombus resolution, freedom from recurrent VTE and VTE-related mortality, and a safety endpoint: freedom from major bleeding events. CONCLUSION Findings will provide valuable information regarding the efficacy and safety of DE for the treatment of pediatric VTE. ClinicalTrials.gov registration number: NCT01895777.
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Affiliation(s)
- Manuela Albisetti
- Hematology DepartmentUniversity Children's HospitalZürichSwitzerland
| | - Branislav Biss
- Department of Clinical DevelopmentBoehringer Ingelheim RCV GmbH & Co. KGViennaAustria
| | - Lisa Bomgaars
- Department for PediatricsBaylor College of MedicineHoustonTXUSA
| | - Leonardo R. Brandão
- Department of PediatricsDivision of Hematology/OncologyUniversity of TorontoThe Hospital for Sick ChildrenTorontoONCanada
| | - Martina Brueckmann
- Clinical Development and Medical AffairsBoehringer Ingelheim Pharma GmbH& Co. KGIngelheimGermany
- Faculty of Medicine MannheimUniversity of HeidelbergMannheimGermany
| | | | - Savion Gropper
- Clinical Development and Medical AffairsBoehringer Ingelheim Pharma GmbH& Co. KGIngelheimGermany
| | - Ruth Harper
- Boehringer Ingelheim LtdBracknellBerkshireUK
| | - Fenglei Huang
- Translational Medicine and Clinical PharmacologyBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldCTUSA
| | - Matteo Luciani
- OncoHematology DepartmentBambino Gesù Children's HospitalRomeItaly
| | - Ivan Manastirski
- Department of Clinical DevelopmentBoehringer Ingelheim RCV GmbH & Co. KGViennaAustria
| | | | - Igor Tartakovsky
- Clinical Development and Medical AffairsBoehringer Ingelheim Pharma GmbH& Co. KGIngelheimGermany
| | - Bushi Wang
- Biostatistics and Data SciencesBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldCTUSA
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50
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Avila ML, Stinson J, Lumia C, Williams S, Montoya MI, Feldman BM, Brandão LR. Characteristics of pain, other symptoms and function in pediatric post-thrombotic syndrome. Res Pract Thromb Haemost 2018; 2:334-338. [PMID: 30046736 PMCID: PMC6055484 DOI: 10.1002/rth2.12099] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 02/28/2018] [Indexed: 01/04/2023] Open
Abstract
ESSENTIALS BACKGROUND Symptoms and function in pediatric post-thrombotic syndrome (PTS) remain poorly characterized. METHODS The present cross-sectional study describes the characteristics of pain, other symptoms, and impaired function in pediatric PTS in a cohort of children with history of upper or lower limb deep vein thrombosis and PTS diagnosis. The frequency of clinical findings was compared between patients with and without pain, and between patients with upper and lower extremity PTS. RESULTS Seventy-eight children were included in the study. The most common PTS symptoms were pain, tired limb and heaviness. Symptoms were usually reported to occur at mid-day or later and were typically triggered by exercise. Half the patients reported impaired endurance. Pain was reported by 45% of patients and was usually mild-moderate. Heaviness, tightness, tired limb, paresthesia, self-reported limb edema, and impaired endurance were most common in patients with than in patients without pain. Conversely, activity and participation scores, skin redness, and clinician-assessed limb edema did not differ between patients with and without pain. Lastly, there was no difference in pain intensity or frequency of paresthesia, swelling, heaviness, or impaired endurance when comparing the upper and lower extremities. CONCLUSION Tired limb, heaviness, pain, and impaired endurance were the most frequent clinical findings in pediatric PTS. Frequency of symptoms and pain intensity did not differ between upper and lower extremities. Pain was associated with the presence of other symptoms and impaired function, but not with activity limitation and participation restriction. Better tools are needed to measure these two latter aspects of health.
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Affiliation(s)
- Maria L. Avila
- Department of PediatricsThe Hospital for Sick ChildrenTorontoONCanada
| | - Jennifer Stinson
- Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoONCanada
- Child Health Evaluative SciencesThe Hospital for Sick ChildrenUniversity of TorontoTorontoONCanada
- Lawrence S. Bloomberg Faculty of NursingUniversity of TorontoTorontoONCanada
| | - Celeste Lumia
- Department of PediatricsThe Hospital for Sick ChildrenTorontoONCanada
| | - Suzan Williams
- Department of PediatricsThe Hospital for Sick ChildrenTorontoONCanada
| | | | - Brian M. Feldman
- Department of PediatricsThe Hospital for Sick ChildrenTorontoONCanada
- Child Health Evaluative SciencesThe Hospital for Sick ChildrenUniversity of TorontoTorontoONCanada
- Lawrence S. Bloomberg Faculty of NursingUniversity of TorontoTorontoONCanada
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