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Caru M, Dandekar S, Gordon B, Conroy DE, Barb ED, Doerksen SE, Smink GM, McKeone DJ, Shah NB, Greiner RJ, Schramm JW, Rao P, McGregor L, Schmitz KH. Implementing a behavioral physical activity program in children and adolescent survivors of childhood cancer: a pilot randomized controlled trial. J Behav Med 2024:10.1007/s10865-024-00497-z. [PMID: 38735024 DOI: 10.1007/s10865-024-00497-z] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/30/2024] [Indexed: 05/13/2024]
Abstract
Purpose We aimed to document the acceptability (enrollment rate) and feasibility (phone call delivery rate) of implementing a behavioral PA intervention over 12 weeks, in addition to documenting its effects on patient-reported outcomes and physical functioning. This study also describes the costs of carrying out a behavioral PA intervention. A total of 40 participants were randomized in a 1:1 ratio. The tailored behavioral PA intervention was developed based on the most recent PA guidelines in pediatric oncology and on the COM-B framework to enact PA behavior changes. The prescription (frequency, intensity, time and type (FITT)) was adjusted each week during the weekly support calls. The control group did not receive the intervention. 26 males and 14 females (13.6 years old on average and 2.9 years post-cancer treatment on average) participated in our study. The acceptability rate was 90.9% and the feasibility rate was > 85%. We found that 85% improved PA frequency, 80% improved PA intensity, 100% improved PA time, and 50.0% achieved the recommended PA guidelines. No adverse events were reported over the duration of the intervention. Physical function improved with longer 6-minute walk distances in the intervention group (465.8 ± 74.5 m) than in the control group (398.7 ± 92.9 m) (p = 0.016). PROs scores for all participants were within the limits of the normal range. The estimated cost per participant of carrying out this intervention was USD $126.57. Our 12-week behavioral PA intervention, based on the COM-B framework, was found to be acceptable, feasible and safe in childhood cancer survivors. This study is an important step in the right direction to make exercise standard practice in pediatric oncology.
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Affiliation(s)
- Maxime Caru
- Department of Pediatrics, Division of Hematology and Oncology, Pennsylvania State Health Children's Hospital, 500 University Drive, Hershey, PA, 17033, USA.
- Department of Public Health Sciences, Penn State University College of Medicine, Hershey, PA, USA.
| | - Smita Dandekar
- Department of Pediatrics, Division of Hematology and Oncology, Pennsylvania State Health Children's Hospital, 500 University Drive, Hershey, PA, 17033, USA
| | - Brett Gordon
- Department of Public Health Sciences, Penn State University College of Medicine, Hershey, PA, USA
| | - David E Conroy
- Department of Kinesiology, Penn State University, University Park, PA, USA
| | - Emily D Barb
- School of Kinesiology, Pennsylvania State University-Harrisburg, Middletown, PA, USA
| | - Shawna E Doerksen
- Division of Hematology and Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gayle M Smink
- Department of Pediatrics, Division of Hematology and Oncology, Pennsylvania State Health Children's Hospital, 500 University Drive, Hershey, PA, 17033, USA
| | - Daniel J McKeone
- Department of Pediatrics, Division of Hematology and Oncology, Pennsylvania State Health Children's Hospital, 500 University Drive, Hershey, PA, 17033, USA
| | - Nidhi B Shah
- Department of Pediatrics, Division of Hematology and Oncology, Pennsylvania State Health Children's Hospital, 500 University Drive, Hershey, PA, 17033, USA
| | - Robert J Greiner
- Department of Pediatrics, Division of Hematology and Oncology, Pennsylvania State Health Children's Hospital, 500 University Drive, Hershey, PA, 17033, USA
| | - Joseph W Schramm
- Department of Pediatrics, Division of Hematology and Oncology, Pennsylvania State Health Children's Hospital, 500 University Drive, Hershey, PA, 17033, USA
| | - Pooja Rao
- Department of Pediatrics, Division of Hematology and Oncology, Pennsylvania State Health Children's Hospital, 500 University Drive, Hershey, PA, 17033, USA
| | - Lisa McGregor
- Department of Pediatrics, Division of Hematology and Oncology, Pennsylvania State Health Children's Hospital, 500 University Drive, Hershey, PA, 17033, USA
| | - Kathryn H Schmitz
- School of Kinesiology, Pennsylvania State University-Harrisburg, Middletown, PA, USA
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Yehya N, Booth TJ, Ardhanari GD, Thompson JM, Lam LKM, Till JE, Mai MV, Keim G, McKeone DJ, Halstead ES, Lahni P, Varisco BM, Zhou W, Carpenter EL, Christie JD, Mangalmurti NS. Inflammatory and tissue injury marker dynamics in pediatric acute respiratory distress syndrome. J Clin Invest 2024; 134:e177896. [PMID: 38573766 DOI: 10.1172/jci177896] [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: 11/22/2023] [Accepted: 03/27/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUNDThe molecular signature of pediatric acute respiratory distress syndrome (ARDS) is poorly described, and the degree to which hyperinflammation or specific tissue injury contributes to outcomes is unknown. Therefore, we profiled inflammation and tissue injury dynamics over the first 7 days of ARDS, and associated specific biomarkers with mortality, persistent ARDS, and persistent multiple organ dysfunction syndrome (MODS).METHODSIn a single-center prospective cohort of intubated pediatric patients with ARDS, we collected plasma on days 0, 3, and 7. Nineteen biomarkers reflecting inflammation, tissue injury, and damage-associated molecular patterns (DAMPs) were measured. We assessed the relationship between biomarkers and trajectories with mortality, persistent ARDS, or persistent MODS using multivariable mixed effect models.RESULTSIn 279 patients (64 [23%] nonsurvivors), hyperinflammatory cytokines, tissue injury markers, and DAMPs were higher in nonsurvivors. Survivors and nonsurvivors showed different biomarker trajectories. IL-1α, soluble tumor necrosis factor receptor 1, angiopoietin 2 (ANG2), and surfactant protein D increased in nonsurvivors, while DAMPs remained persistently elevated. ANG2 and procollagen type III N-terminal peptide were associated with persistent ARDS, whereas multiple cytokines, tissue injury markers, and DAMPs were associated with persistent MODS. Corticosteroid use did not impact the association of biomarker levels or trajectory with mortality.CONCLUSIONSPediatric ARDS survivors and nonsurvivors had distinct biomarker trajectories, with cytokines, endothelial and alveolar epithelial injury, and DAMPs elevated in nonsurvivors. Mortality markers overlapped with markers associated with persistent MODS, rather than persistent ARDS.FUNDINGNIH (K23HL-136688, R01-HL148054).
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Affiliation(s)
- Nadir Yehya
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas J Booth
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and
| | - Gnana D Ardhanari
- Division of Pediatric Cardiac Critical Care Medicine, Children's Heart Institute, Memorial Hermann Hospital, University of Texas Health McGovern Medical School, Houston, Texas, USA
| | - Jill M Thompson
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and
| | - L K Metthew Lam
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Department of Medicine and
| | - Jacob E Till
- Division of Hematology-Oncology, Department of Medicine, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark V Mai
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia, USA
| | - Garrett Keim
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel J McKeone
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and
| | - E Scott Halstead
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Patrick Lahni
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Brian M Varisco
- Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, Arkansas, USA
| | - Wanding Zhou
- Center for Computational and Genomic Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Erica L Carpenter
- Division of Hematology-Oncology, Department of Medicine, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Department of Medicine and
- Center for Translational Lung Biology and
- Center for Clinical Epidemiology and Biostatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nilam S Mangalmurti
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Department of Medicine and
- Center for Translational Lung Biology and
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Yehya N, Zinter MS, Thompson JM, Lim MJ, Hanudel MR, Alkhouli MF, Wong H, Alder MN, McKeone DJ, Halstead ES, Sinha P, Sapru A. Identification of molecular subphenotypes in two cohorts of paediatric ARDS. Thorax 2024; 79:128-134. [PMID: 37813544 PMCID: PMC10850835 DOI: 10.1136/thorax-2023-220130] [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] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Two subphenotypes of acute respiratory distress syndrome (ARDS), hypoinflammatory and hyperinflammatory, have been reported in adults and in a single paediatric cohort. The relevance of these subphenotypes in paediatrics requires further investigation. We aimed to identify subphenotypes in two large observational cohorts of paediatric ARDS and assess their congruence with prior descriptions. METHODS We performed latent class analysis (LCA) separately on two cohorts using biomarkers as inputs. Subphenotypes were compared on clinical characteristics and outcomes. Finally, we assessed overlap with adult cohorts using parsimonious classifiers. FINDINGS In two cohorts from the Children's Hospital of Philadelphia (n=333) and from a multicentre study based at the University of California San Francisco (n=293), LCA identified two subphenotypes defined by differential elevation of biomarkers reflecting inflammation and endotheliopathy. In both cohorts, hyperinflammatory subjects had greater illness severity, more sepsis and higher mortality (41% and 28% in hyperinflammatory vs 11% and 7% in hypoinflammatory). Both cohorts demonstrated overlap with adult subphenotypes when assessed using parsimonious classifiers. INTERPRETATION We identified hypoinflammatory and hyperinflammatory subphenotypes of paediatric ARDS from two separate cohorts with utility for prognostic and potentially predictive, enrichment. Future paediatric ARDS trials should identify and leverage biomarker-defined subphenotypes in their analysis.
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Affiliation(s)
- Nadir Yehya
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, USA
| | - Matt S Zinter
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Division of Allergy, Immunology, and Bone Marrow Transplantation, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Jill M Thompson
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, USA
| | - Michelle J Lim
- Department of Pediatrics, UC Davis, Davis, California, USA
| | - Mark R Hanudel
- Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
| | - Mustafa F Alkhouli
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Hector Wong
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Matthew N Alder
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Daniel J McKeone
- Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - E Scott Halstead
- Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Pratik Sinha
- Division of Clinical and Translational Research, Washington University School of Medicine, St. Louis, MO, USA
- Division of Critical Care, Department of Anesthesia, Washington University, St. Louis, MO, USA
| | - Anil Sapru
- Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
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Hahn TJ, McKeone DJ, Beal JW, Ericson JE, Halstead ES. Case Report: Successful avoidance of etoposide for primary hemophagocytic lymphohistiocytosis-induced multiple organ dysfunction syndrome using emapalumab. Front Pediatr 2024; 11:1340360. [PMID: 38304439 PMCID: PMC10830683 DOI: 10.3389/fped.2023.1340360] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 12/18/2023] [Indexed: 02/03/2024] Open
Abstract
We describe the case of an infant who presented with simple rhinovirus/enterovirus bronchiolitis whose condition worsened with rapid progression to multiple organ dysfunction syndrome (MODS). The patient was presumed to have either primary or secondary hemophagocytic lymphohistiocytosis (HLH), and treatment was initiated using dexamethasone, anakinra, and intravenous immunoglobulin to modulate the immune system. Due to the organ dysfunction, the use of etoposide was avoided and instead, emapalumab, an interferon gamma antagonist, was administered at a dose of 6 mg/kg. The patient's organ failure improved, and the levels of inflammatory markers decreased. The flow cytometry analysis revealed that cytotoxic cells lacked perforin expression, and subsequent genetic analysis confirmed homozygous pathogenic mutations in the perforin gene. This case highlights the potential avoidance of etoposide in cases of primary HLH, the possible benefit of an elevated initial dose of emapalumab, and the contribution offered by a multi-specialty team approach to complex diagnosis.
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Affiliation(s)
- Timothy J. Hahn
- Division of Pediatric Rheumatology, Department of Pediatrics, Penn State University College of Medicine, Hershey, PA, United States
- Dysregulated Immune Response Team (DIRT), Department of Pediatrics, Penn State University College of Medicine, Hershey, PA, United States
| | - Daniel J. McKeone
- Dysregulated Immune Response Team (DIRT), Department of Pediatrics, Penn State University College of Medicine, Hershey, PA, United States
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Penn State University College of Medicine, Hershey, PA, United States
| | - James W. Beal
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State University College of Medicine, Hershey, PA, United States
| | - Jessica E. Ericson
- Dysregulated Immune Response Team (DIRT), Department of Pediatrics, Penn State University College of Medicine, Hershey, PA, United States
- Division of Pediatric Infectious Disease, Department of Pediatrics, Penn State University College of Medicine, Hershey, PA, United States
| | - E. Scott Halstead
- Dysregulated Immune Response Team (DIRT), Department of Pediatrics, Penn State University College of Medicine, Hershey, PA, United States
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State University College of Medicine, Hershey, PA, United States
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Caru M, Alberts NM, Freeman MC, Dandekar SC, Rao P, McKeone DJ, Brown VI, McGregor LM, Schmitz KH. Chronic pain in children and adolescents diagnosed with cancer: the challenge of mitigating the pain and the potential of integrating exercise into pain management. Support Care Cancer 2023; 31:228. [PMID: 36952029 DOI: 10.1007/s00520-023-07695-6] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 03/16/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Pain is one of the most common and distressing symptoms experienced by children and adolescents diagnosed with cancer. It is vital that children and adolescents receive adequate pain management early on in their cancer treatments to mitigate pain and cancer-related symptoms. Exercise training shows particular promise in the management of acute and chronic pain among children and adolescents diagnosed with cancer. METHODS This position paper comes to outline the challenge of mitigating pain in children and adolescents diagnosed with cancer, and the potential benefits of integrating exercise training to the management of chronic pain in this population in need. RESULTS Integrating exercise training into the care and pain management of children and adolescents diagnosed with cancer who have chronic pain would have the advantage of addressing several shortcomings of pain medication. Pain medication aims to temporarily manage or reduce pain; it does not have the potential to directly improve a patient's physical condition in the way that exercise training can. The current paucity of data available on the use of exercise training as a complementary treatment to pain medications to reduce chronic pain in children and adolescents diagnosed with cancer allows only for hypotheses on the effectiveness of this pain management modality. CONCLUSION More research on this important topic is necessary and mitigating pain effectively while also reducing the use of opioid pain medication is an important goal shared by patients, their families, clinicians, and researchers alike. Future research in this area has great potential to inform clinical care, clinical care guidelines, and policy-making decisions for pain management in children and adolescents diagnosed with cancer who experience chronic pain.
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Affiliation(s)
- Maxime Caru
- Division of Hematology and Oncology, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA.
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.
| | - Nicole M Alberts
- Department of Psychology, Concordia University, Montréal, QC, Canada
| | - Michelle C Freeman
- Division of Complex and Palliative Care, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Smita C Dandekar
- Division of Hematology and Oncology, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Pooja Rao
- Division of Hematology and Oncology, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Daniel J McKeone
- Division of Hematology and Oncology, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Valerie I Brown
- Division of Hematology and Oncology, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Lisa M McGregor
- Division of Hematology and Oncology, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Kathryn H Schmitz
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
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Rangarajan HG, Stanek JR, Abdel-Azim H, Modi A, Haight A, McKinney CM, McKeone DJ, Buchbinder DK, Katsanis E, Abusin GA, Ahmed I, Law J, Silva JG, Mallhi KK, Burroughs LM, Shah N, Shaw PJ, Greiner R, Shenoy S, Pulsipher MA, Abu-Arja R. Hematopoietic Cell Transplantation for Congenital Dyserythropoietic Anemia. A Report from the Pediatric Transplant and Cellular Therapy Consortium (PTCTC). Transplant Cell Ther 2022; 28:329.e1-329.e9. [DOI: 10.1016/j.jtct.2022.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 11/25/2022]
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Gardner MM, Kirschen MP, Wong HR, McKeone DJ, Halstead ES, Thompson J, Himebauch AS, Topjian AA, Yehya N. Biomarkers associated with mortality in pediatric patients with cardiac arrest and acute respiratory distress syndrome. Resuscitation 2022; 170:184-193. [PMID: 34871756 PMCID: PMC8799511 DOI: 10.1016/j.resuscitation.2021.11.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/16/2021] [Accepted: 11/26/2021] [Indexed: 01/03/2023]
Abstract
AIMS To identify plasma biomarkers associated with cardiac arrest in a cohort of children with acute respiratory distress syndrome (ARDS), and to assess the association of these biomarkers with mortality in children with cardiac arrest and ARDS (ARDS + CA). METHODS This was a secondary analysis of a single-center prospective cohort study of children with ARDS from 2014-2019 with 17 biomarkers measured. Clinical characteristics and biomarkers were compared between subjects with ARDS + CA and ARDS with univariate analysis. In a sub-cohort of ARDS + CA subjects, the association between biomarker levels and mortality was tested using univariate and bivariate logistic regression. RESULTS Biomarkers were measured in 333 subjects: 301 with ARDS (median age 5.3 years, 55.5% male) and 32 ARDS + CA (median age 8 years, 53.1% male). More arrests (69%) occurred out-of-hospital with a median CPR duration of 11 (IQR 5.5, 25) minutes. ARDS severity, PRISM III score, vasoactive-ionotropic score and extrapulmonary organ failures were worse in the ARDS + CA versus ARDS group. Eight biomarkers were elevated in the ARDS + CA versus ARDS cohort: sRAGE, nucleosomes, SP-D, CCL22, IL-6, HSP70, IL-8, and MIP-1b. sRAGE, SP-D, and CCL22 remained elevated when the cohorts were matched for illness severity. When controlling for severity of ARDS and cardiac arrest characteristics, sRAGE, IL-6 and granzyme B were associated with mortality in the ARDS + CA group. CONCLUSION sRAGE, IL-6 and granzyme B were associated with cardiac arrest mortality when controlling for illness severity. sRAGE was consistently higher in the ARDS + CA cohort compared to ARDS and retained independent association with mortality.
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Affiliation(s)
- Monique M. Gardner
- Division of Cardiac Critical Care Medicine, Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia Pennsylvania
| | - Matthew P. Kirschen
- Division of Critical Care Medicine, Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia Pennsylvania
| | - Hector R. Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Daniel J. McKeone
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - E. Scott Halstead
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Jill Thompson
- Division of Critical Care Medicine, Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia Pennsylvania
| | - Adam S. Himebauch
- Division of Critical Care Medicine, Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia Pennsylvania
| | - Alexis A. Topjian
- Division of Critical Care Medicine, Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia Pennsylvania
| | - Nadir Yehya
- Division of Critical Care Medicine, Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia Pennsylvania,Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA
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Hackett G, Munir F, Shapiro T, Greiner R, McKeone DJ, Aluquin VPR. Pulmonary arterial hypertension in pediatric patients undergoing high-dose carboplatin/thiotepa and stem cell transplant. Pulm Circ 2021; 11:20458940211050469. [PMID: 34646500 PMCID: PMC8504246 DOI: 10.1177/20458940211050469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 09/13/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Gretchen Hackett
- Division of Pediatric Cardiology, Penn State Hershey Children's Hospital, Hershey, PA, USA
| | - Farrah Munir
- Division of Pediatric Cardiology, Penn State Hershey Children's Hospital, Hershey, PA, USA
| | - Teresa Shapiro
- Division of Pediatric Hematology and Oncology, Penn State Hershey Children's Hospital, Hershey, PA, USA
| | - Robert Greiner
- Division of Pediatric Hematology and Oncology, Penn State Hershey Children's Hospital, Hershey, PA, USA
| | - Daniel J McKeone
- Division of Pediatric Hematology and Oncology, Penn State Hershey Children's Hospital, Hershey, PA, USA
| | - Vincent P R Aluquin
- Division of Pediatric Cardiology, Penn State Hershey Children's Hospital, Hershey, PA, USA
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McKeone DJ, DeMartini TKM, Kavanagh RP, Halstead ES. Case Report: Rapid Recognition and Immune Modulation of Secondary HLH Due to Disseminated HSV Infection. Front Pediatr 2021; 9:681055. [PMID: 34277520 PMCID: PMC8282902 DOI: 10.3389/fped.2021.681055] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/26/2021] [Indexed: 11/23/2022] Open
Abstract
We describe the case of a newborn who presented with multiple organ dysfunction syndrome (MODS) and hyperferritinemia, who eventually met criteria for hemophagocytic lymphohistiocytosis (HLH) due to disseminated herpes simplex virus 1 (HSV-1). While the cytokine storm abated after administration of multiple immune modulatory therapies including dexamethasone, etoposide, intravenous immune globulin, anakinra, as well as the interferon gamma antagonist emapalumab, multiple organ dysfunction syndrome progressed. Care was withdrawn after 5 days. Subsequent genetic testing did not reveal any mutations associated with familial HLH. This case highlights that even with appropriate antiviral treatment and immune suppression, disseminated HSV is often fatal. Further study is warranted to determine whether early immune modulatory therapy including interferon gamma blockade can interrupt the HLH inflammatory cascade and prevent progression of MODS.
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Affiliation(s)
- Daniel J McKeone
- Penn State University College of Medicine, Hershey, PA, United States
| | | | - Robert P Kavanagh
- Penn State University College of Medicine, Hershey, PA, United States
| | - E Scott Halstead
- Penn State University College of Medicine, Hershey, PA, United States
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Lutzkanin K, McKeone DJ, Greiner R, Andreae DA. A Novel Mutation in Chronic Granulomatous Disease: Treating the Family, Not Just the Patient. Front Pediatr 2019; 7:107. [PMID: 30984725 PMCID: PMC6447646 DOI: 10.3389/fped.2019.00107] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/06/2019] [Indexed: 11/13/2022] Open
Abstract
Chronic Granulomatous Disease (CGD) is caused by genetic defects in the phagocyte NADPH oxidase leading to potentially severe infections with catalase positive micro-organisms. With the innate immune system being affected this disease usually presents before the age of 5 years with infections involving the skin, lung, liver or lymphnodes. Infections with specific catalase positive organisms, especially Burkholderia cepacia, Serratia, Nocardia and Chromobacterium violaceum prompt a workup for CGD in affected patients. In addition, a family history of CGD also warrants testing. The pattern of inheritance of CGD varies across geographic regions of the world and societies, with X-linked inheritance being most prevalent in the United States and Europe. Affected patients require life-long therapy with prophylactic antibiotics, antifungals, and possibly interferon-gamma. Hematopoietic Stem Cell Transplantation is the only curative therapy known to date. Identification, diagnosis and management of patients with CGD usually involves a multi-specialty team including Pediatrics, Immunology, Infectious Diseases, Hematology/Oncology and often also Pulmonology and GI/Hepatology. Frequent follow up is paramount for good outcomes; infections have to be recognized and treated promptly and often preemptively. This is challenging for most patients and their families but presents a significant barrier for patients with limited access to care, limited resources or other challenging social situations. This case report describes the difficulties of managing a family with a novel mutation and multiple affected family members in different custody arrangements. It highlights the importance of close contact and communication with the family in deciding on management and treatment options. Educating the family and patient is critical to avoid complications of the disease and allow shared decision making that ultimately leads to better outcomes.
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Affiliation(s)
- Kristen Lutzkanin
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Daniel J McKeone
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Robert Greiner
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Doerthe Adriana Andreae
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
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