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McEvoy MT, Stuckert AJ, Castellanos MI, Gilbert MM, Pfeiffer T, Prudowsky Z, Rios X, Airewele G, Okcu MF, Powers JM. Management of nutritional iron deficiency anemia for young children in the emergency department. Pediatr Blood Cancer 2023; 70:e30181. [PMID: 36579803 DOI: 10.1002/pbc.30181] [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: 08/23/2022] [Revised: 12/01/2022] [Accepted: 12/06/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Guidelines for young children with nutritional iron deficiency anemia (IDA) presenting to the emergency department (ED) are lacking, leading to variability in care. We aimed to standardize management of these patients through the development and implementation of an evidence-based algorithm using quality improvement methodology. PROCEDURE Baseline data of the target population (n = 42; 60% male; median age 22.5 months, median hemoglobin 5.3 g/dl) identified variability across four key measures of clinical management: laboratory evaluation, therapy choice, therapy administration, and patient disposition. Literature review and consensus from pediatric hematology providers informed a draft algorithm that was refined in an iterative multidisciplinary process. From September 2020 to June 2021, we aimed to increase IDA management per the algorithm by ≥20% relative to baseline for the four key outcome measures using sequential Plan-Do-Study-Act (PDSA) cycles. Process measures focusing on provider communication/documentation and balancing measures involving efficiency and therapy-related adverse events were assessed concurrently. RESULTS Thirty-five patients were evaluated among four PDSA cycles and shared similar characteristics as the baseline population. Improvements of ≥20% above baseline adherence levels or 100% adherence were achieved for all outcome measure across four PDSA cycles. Adherence to recommended laboratory evaluation improved from 43 (baseline) to 71%, therapy choice from 78 to 100%, therapy administration from 50 to 83%, and disposition from 85 to 100%. ED length of stay remained stable. CONCLUSIONS Implementation of a standardized algorithm for young children with nutritional IDA in the ED increased adherence to evidence-based patient care.
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Affiliation(s)
- Matthew T McEvoy
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Austin J Stuckert
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Maria I Castellanos
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA.,UCSF Benioff Children's Hospitals, Department of Pediatrics, San Francisco/Oakland, California, USA
| | - Megan M Gilbert
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Thomas Pfeiffer
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA.,St. Louis Children's Hospital, Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Zachary Prudowsky
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Xavier Rios
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Gladstone Airewele
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - M Fatih Okcu
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Jacquelyn M Powers
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
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Arabzade A, Zhao Y, Varadharajan S, Chen HC, Jessa S, Rivas B, Stuckert AJ, Solis M, Kardian A, Tlais D, Golbourn BJ, Stanton ACJ, Chan YS, Olson C, Karlin KL, Kong K, Kupp R, Hu B, Injac SG, Ngo M, Wang PR, De León LA, Sahm F, Kawauchi D, Pfister SM, Lin CY, Hodges HC, Singh I, Westbrook TF, Chintagumpala MM, Blaney SM, Parsons DW, Pajtler KW, Agnihotri S, Gilbertson RJ, Yi J, Jabado N, Kleinman CL, Bertrand KC, Deneen B, Mack SC. ZFTA-RELA Dictates Oncogenic Transcriptional Programs to Drive Aggressive Supratentorial Ependymoma. Cancer Discov 2021; 11:2200-2215. [PMID: 33741710 PMCID: PMC8418998 DOI: 10.1158/2159-8290.cd-20-1066] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 01/05/2021] [Accepted: 03/16/2021] [Indexed: 01/10/2023]
Abstract
More than 60% of supratentorial ependymomas harbor a ZFTA-RELA (ZRfus) gene fusion (formerly C11orf95-RELA). To study the biology of ZRfus, we developed an autochthonous mouse tumor model using in utero electroporation (IUE) of the embryonic mouse brain. Integrative epigenomic and transcriptomic mapping was performed on IUE-driven ZRfus tumors by CUT&RUN, chromatin immunoprecipitation sequencing, assay for transposase-accessible chromatin sequencing, and RNA sequencing and compared with human ZRfus-driven ependymoma. In addition to direct canonical NFκB pathway activation, ZRfus dictates a neoplastic transcriptional program and binds to thousands of unique sites across the genome that are enriched with PLAGL family transcription factor (TF) motifs. ZRfus activates gene expression programs through recruitment of transcriptional coactivators (Brd4, Ep300, Cbp, Pol2) that are amenable to pharmacologic inhibition. Downstream ZRfus target genes converge on developmental programs marked by PLAGL TF proteins, and activate neoplastic programs enriched in Mapk, focal adhesion, and gene imprinting networks. SIGNIFICANCE: Ependymomas are aggressive brain tumors. Although drivers of supratentorial ependymoma (ZFTA- and YAP1-associated gene fusions) have been discovered, their functions remain unclear. Our study investigates the biology of ZFTA-RELA-driven ependymoma, specifically mechanisms of transcriptional deregulation and direct downstream gene networks that may be leveraged for potential therapeutic testing.This article is highlighted in the In This Issue feature, p. 2113.
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Affiliation(s)
- Amir Arabzade
- Department of Chemical and Biomolecular Engineering, Rice University, Houston, Texas
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Texas Children's Cancer and Hematology Centers, Dan L. Duncan Cancer Center, Houston, Texas
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
| | - Yanhua Zhao
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Texas Children's Cancer and Hematology Centers, Dan L. Duncan Cancer Center, Houston, Texas
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
| | - Srinidhi Varadharajan
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Texas Children's Cancer and Hematology Centers, Dan L. Duncan Cancer Center, Houston, Texas
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
| | - Hsiao-Chi Chen
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Texas Children's Cancer and Hematology Centers, Dan L. Duncan Cancer Center, Houston, Texas
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
- Cancer and Cell Biology Program, Baylor College of Medicine, Dan L. Duncan Cancer Center, Houston, Texas
| | - Selin Jessa
- Quantitative Life Sciences, McGill University, Montreal, Quebec, Canada
| | - Bryan Rivas
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Texas Children's Cancer and Hematology Centers, Dan L. Duncan Cancer Center, Houston, Texas
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
| | - Austin J Stuckert
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Texas Children's Cancer and Hematology Centers, Dan L. Duncan Cancer Center, Houston, Texas
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
| | - Minerva Solis
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Texas Children's Cancer and Hematology Centers, Dan L. Duncan Cancer Center, Houston, Texas
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
- Cancer and Cell Biology Program, Baylor College of Medicine, Dan L. Duncan Cancer Center, Houston, Texas
| | - Alisha Kardian
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Texas Children's Cancer and Hematology Centers, Dan L. Duncan Cancer Center, Houston, Texas
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
- Cancer and Cell Biology Program, Baylor College of Medicine, Dan L. Duncan Cancer Center, Houston, Texas
| | - Dana Tlais
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Texas Children's Cancer and Hematology Centers, Dan L. Duncan Cancer Center, Houston, Texas
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
| | - Brian J Golbourn
- Department of Neurological Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ann-Catherine J Stanton
- Department of Neurological Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Yuen San Chan
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
- Department of Molecular and Cellular Biology and Center for Precision Environmental Health, Baylor College of Medicine, Houston, Texas
- Department of Bioengineering, Rice University, Houston, Texas
- Center for Cancer Epigenetics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Calla Olson
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
- Department of Biochemistry and Molecular Biology, Houston, Texas
| | - Kristen L Karlin
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
- Department of Biochemistry and Molecular Biology, Houston, Texas
| | - Kathleen Kong
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
| | - Robert Kupp
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Cambridge, England
- Department of Oncology, University of Cambridge, Hutchison/MRC Research Centre, Cambridge Biomedical Campus, Cambridge, England
| | - Baoli Hu
- Department of Neurological Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sarah G Injac
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Texas Children's Cancer and Hematology Centers, Dan L. Duncan Cancer Center, Houston, Texas
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
| | - Madeline Ngo
- Department of Chemical and Biomolecular Engineering, Rice University, Houston, Texas
| | - Peter R Wang
- Department of Chemical and Biomolecular Engineering, Rice University, Houston, Texas
| | - Luz A De León
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Texas Children's Cancer and Hematology Centers, Dan L. Duncan Cancer Center, Houston, Texas
| | - Felix Sahm
- Hopp-Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Neuropathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Daisuke Kawauchi
- Hopp-Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Biochemistry and Cellular Biology, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan
| | - Stefan M Pfister
- Hopp-Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Department of Pediatric Neurooncology, German Cancer Research Center (DKFZ) and German Cancer Consortium (DKTK), Heidelberg, Germany
- Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Charles Y Lin
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - H Courtney Hodges
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
- Department of Molecular and Cellular Biology and Center for Precision Environmental Health, Baylor College of Medicine, Houston, Texas
- Department of Bioengineering, Rice University, Houston, Texas
- Center for Cancer Epigenetics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Irtisha Singh
- Department of Molecular and Cellular Medicine, College of Medicine, Texas A&M University Health Science Center, Bryan, Texas
| | - Thomas F Westbrook
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
- Department of Biochemistry and Molecular Biology, Houston, Texas
| | - Murali M Chintagumpala
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Texas Children's Cancer and Hematology Centers, Dan L. Duncan Cancer Center, Houston, Texas
| | - Susan M Blaney
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Texas Children's Cancer and Hematology Centers, Dan L. Duncan Cancer Center, Houston, Texas
| | - Donald W Parsons
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Texas Children's Cancer and Hematology Centers, Dan L. Duncan Cancer Center, Houston, Texas
| | - Kristian W Pajtler
- Hopp-Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Department of Pediatric Neurooncology, German Cancer Research Center (DKFZ) and German Cancer Consortium (DKTK), Heidelberg, Germany
- Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Sameer Agnihotri
- Department of Neurological Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Richard J Gilbertson
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Cambridge, England
- Department of Oncology, University of Cambridge, Hutchison/MRC Research Centre, Cambridge Biomedical Campus, Cambridge, England
| | - Joanna Yi
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Texas Children's Cancer and Hematology Centers, Dan L. Duncan Cancer Center, Houston, Texas
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
| | - Nada Jabado
- Quantitative Life Sciences, McGill University, Montreal, Quebec, Canada
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada
| | - Claudia L Kleinman
- Quantitative Life Sciences, McGill University, Montreal, Quebec, Canada
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada
- Lady Davis Research Institute, Jewish General Hospital, Quebec, Canada
| | - Kelsey C Bertrand
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Texas Children's Cancer and Hematology Centers, Dan L. Duncan Cancer Center, Houston, Texas.
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
| | - Benjamin Deneen
- Cancer and Cell Biology Program, Baylor College of Medicine, Dan L. Duncan Cancer Center, Houston, Texas.
- Program in Developmental Biology, Baylor College of Medicine, Houston, Texas
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Stephen C Mack
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Texas Children's Cancer and Hematology Centers, Dan L. Duncan Cancer Center, Houston, Texas.
- Therapeutic Innovation Center at Baylor College of Medicine, Houston, Texas
- Cancer and Cell Biology Program, Baylor College of Medicine, Dan L. Duncan Cancer Center, Houston, Texas
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