Hospital acquired venous thromboembolism in children is associated with significant morbidity/mortality. Prevention strategies include sequential compression devices and prophylactic anticoagulation ...but these interventions carry risk and are poorly studied in children.
Objectives were to evaluate primary thromboprophylaxis use in hospitalized children over time and the associated bleeding risk.
Retrospective study of hospitalized patients aged 10–18 years within the Pediatric Health Information System administrative database from January 2008–September 2015. Factors associated with thromboprophylaxis receipt and bleeding were identified using generalized linear mixed effects models.
Of 1,075,383 hospitalizations, 10,544 (1%) received prophylactic enoxaparin and 58,768 (5%) received mechanical compression. Mechanical thromboprophylaxis increased slightly over time (4.3% in 2008, 6.2% in 2015), enoxaparin use did not (0.8% in 2008, 1.2% in 2015). Patients aged 16–18 were more likely than younger children (10−12) to receive pharmacologic (adjusted odds ratio aOR 3.1, 95% confidence interval CI 2.9–3.3) or mechanical thromboprophylaxis (aOR 2.9, 95% CI 2.9–3). Patients on rehabilitation medical service were more likely to receive prophylactic enoxaparin (aOR 53, 95% CI 44.1–64.5). 5.6% (589/10,544) of patients receiving enoxaparin prophylaxis had bleeding. Thromboprophylaxis use by hospital varied with a range of 0.25–3.3% for enoxaparin and 2–26.2% for mechanical compression.
Thromboprophylaxis is infrequently utilized in hospitalized children. Pharmacologic prophylaxis with enoxaparin remains low and has not substantially increased over time. Significant variability exists across hospitals and services in the administration of both mechanical and pharmacologic thromboprophylaxis highlighting the need for further evidence to standardize practice.
•Hospital acquired pediatric venous thromboembolism (VTE) is a serious adverse event.•Use of mechanical compression devices or enoxaparin to prevent pediatric VTE not well understood•Significant variability exists in the implementation of thromboprophylaxis in children.•Bleeding risk similar using mechanical compression versus enoxaparin for thromboprophylaxis•Thromboprophylaxis needs further evaluation and implementation in pediatric patients.
Objective To describe the off-label use of antithrombin concentrate in tertiary care pediatric hospitals across the US. Study design This is a retrospective, multicenter, cohort study of 4210 ...admissions of children younger than 18 years of age who received antithrombin concentrate between 2002 and 2011 within the Pediatric Health Information System administrative database. An on-label admission was defined as an admission with an International Classification of Diseases diagnostic code for a primary hypercoagulable state; admissions without this code were classified as off-label. Results During the 10-year study period, off-label use of antithrombin concentrate increased 5-fold. Overall, 97% of study subjects received antithrombin off-label. Neonates younger than 30 days of age comprised the largest age group (45.7%) of use; 87% of patients had at least one complex chronic condition, with congenital heart/lung defects being the most prevalent primary diagnosis (36.3%). Extracorporeal membrane oxygenation was the most common procedure associated with antithrombin use (43.7%). Conclusions The off-label use of antithrombin concentrate is increasing rapidly, particularly in critically ill children receiving extracorporeal membrane oxygenation, with few parallel studies to substantiate its safety or efficacy. Further preclinical and controlled clinical studies are critical to expanding our knowledge of this drug. In the meantime, antithrombin concentrate should be used judiciously by clinicians and following guidelines instated by hospitals.
Background
Von Willebrand disease (VWD) is the most common inherited bleeding disorder and is caused by quantitative and qualitative defects in von Willebrand factor (VWF). The laboratory diagnosis ...of VWD in pediatric patients is complicated by VWF interassay and intra‐assay variability, stress‐induced elevations in VWF levels, and a lack of significant bleeding history with which to correlate test results.
Objective
Guidelines recommend repeat testing in patients with a high suspicion of VWD and unclear laboratory assay results; however, no studies have evaluated the utility of repeat VWF testing in pediatric patients.
Methods
This retrospective single‐center cohort study aimed to determine clinical variables associated with requiring more than one test to diagnose VWD and to establish a cutoff VWF value above which further testing is not informative.
Results
Of 811 patients evaluated for a suspected bleeding disorder, 22.2% were diagnosed with VWD, with ~70% diagnosed on the first test. Patients with VWD were younger (5.8 vs. 8.5 years, P = .002) and more likely to have a family history of VWD (38% vs. 22%, P < .001) than those without VWD. Univariate analysis failed to identify any clinical variables that correlated with needing multiple tests for a VWD diagnosis. A cutoff of 100 IU/dL for VWF antigen or activity on the first test yielded negative predictive values >95%.
Conclusions
We demonstrate that the majority of pediatric patients had diagnostic VWF values on the first set of testing. Pediatric patients without a family history of VWD and VWF levels >100 IU/dL may not need further testing to rule out the diagnosis of VWD.
Background
Recent pediatric immune thrombocytopenia (ITP) guidelines have significantly altered and are encouraging an observational approach for patients without significant bleeding regardless of ...their platelet count.
Procedure
This retrospective multicenter cohort study utilized the Pediatric Health Information Systems (PHIS) administrative database. Subjects were 6 months to 18 years of age, admitted to a PHIS hospital between January 1, 2008 and September 30, 2014, with a primary diagnosis code for ITP. International Classification of Disease, Ninth Revision, Clinical Modification Code (ICD‐9‐CM) discharge codes identified significant bleeding. Pharmaceutical billing codes identified the use of pharmacologic therapy for ITP. Clinical management during preguideline admissions (January 1, 2008 to August 31, 2011) was compared to postguideline admissions (September 1, 2011 to September 30, 2014).
Results
A total of 4,937 subjects met inclusion criteria with a mean age of 6.2 (SD 5) years; 93.4% (4,613/4,937) received pharmacologic treatment for ITP but only 14.2% (699/4,937) had ICD‐9‐CM codes for significant bleeding; 11.5% (570/4,937) of subjects were readmitted. In comparing pre‐ versus postguideline time periods, the proportion of subjects receiving ITP pharmacologic treatment did not change (92.9% vs. 94.1%; P = 0.26). A decrease was found in the proportion of bone marrows performed (9.7% vs. 6.4%; P < 0.001) and length of stay (2.3 vs. 2 days; P < 0.001). The proportion of ITP admissions from 2012 to 2014 was modestly decreased when compared to 2008–2010 (12.9 vs. 14.5/10,000 PHIS admissions, P < 0.001).
Conclusions
Despite guidelines and evidence that supports a watchful waiting approach for pediatric patients with ITP, a large proportion of inpatients without significant bleeding are still receiving pharmacologic therapy. Continued efforts are needed to address why inpatient U.S. practice patterns are so discrepant from current treatment guidelines.
With licensure of extended half‐life (EHL) factor products and the changing landscape of available hemophilia products, patients and providers have options for less treatment‐intense prophylaxis. The ...impact of these products in clinical practice to date remains understudied.
We aimed to quantify the use of EHL products in prophylaxis in the US using the ATHN‐dataset, a database of 145 ATHN‐affiliated hemophilia treatment centers (HTCs). Further, we aimed to quantify the impact of EHL on key hemophilia indicators including annualized bleed rates (ABRs), hemophilia joint health scores (HJHS) and quality of life (QOL) metrics. The use of EHL vs standard half‐life (SHL) products in severe hemophilia was compared between June 2018 and March 2019 using the ATHN‐dataset. A cohort of patients was also recruited from seven participating HTCs in order to compare ABR, HJHS and QOL between product classes.
By March 2019 the number of individuals with severe Hemophilia A (SHA) receiving EHLs remained relatively stable (28.4%), whereas the number of prescribed non‐factor products increased to 7.1%, with a diminishing majority of patients (64.0%) continuing to receive SHLs. The majority of patients with severe hemophilia B (SHB) received treatment with EHLs including 57.5% by March 2019. There was a trend toward lower ABR with use of EHLs in SHA and SHB, although this did not result in improved HJHS nor QOL.
EHL use in the United States in severe hemophilia continues to increase, although at a slower rate in SHA with the availability of non‐factor therapy. The impact of the EHL therapies in clinical practice should continue to be examined prospectively.
Central venous catheters (CVCs) account for the largest proportion of thrombotic events in pediatric patients. Questions remain regarding adequate treatment and prevention methods. We surveyed ...pediatric hematology/oncology specialists, using hypothetical cases to assess management strategies for acute CVC thrombosis and secondary prevention. Survey respondents varied in the use of the thrombophilia evaluation (33.3%, 41/123) and duration of treatment (6 weeks: 54.1%, 66/122). Secondary CVC prophylaxis was utilized by 36.6% (45/123) of respondents and by 24.4% (30/123) but only if there was a documented thrombophilia. This heterogeneity highlights the need for clinical studies to address these important clinical questions.
Previous research suggests that individuals with 22q11.2 deletion syndrome (DS) have an increased risk of bleeding following cardiac surgery. However, current guidelines for management of patients ...with 22q11.2DS do not provide specific recommendations for perioperative management. This study sought to identify specific risk factors for bleeding in this patient population. Examine the factors determining bleeding and transfusion requirements in patients with 22q11.2DS undergoing cardiac surgery. This was a single center review of patients who underwent cardiac surgery at the Children's Hospital of Philadelphia from 2000 to 2016. Data was extracted from the medical record. Frequency of bleeding events, laboratory values, and transfusion requirements were compared. We included 226 patients with 22q11.2DS and 506 controls. Bleeding events were identified in 13 patients with 22q11.2DS (5.8%) and 27 controls (5.3%). Platelet counts were lower among patients with 22q11.2DS than in control patients, but not statistically different comparing bleeding to not bleeding. Patients with 22q11.2DS received more transfusions (regardless of bleeding status). However, multivariate analysis showed only procedure type was associated with increased risk of bleeding (
= .012). The overall risk of bleeding when undergoing cardiac surgery is not different in patients with 22q11.2DS compared to non-deleted patients. Though platelet counts were lower in patients with 22q11.2DS, only procedure type was significantly associated with an increased risk of bleeding.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Venous thromboembolism (VTE) is rare in healthy children, but is an increasing problem in children with underlying medical conditions. Pediatric VTE encompasses a highly heterogenous population, with ...variation in age, thrombosis location, and underlying medical comorbidities. Evidence from pediatric clinical trials to guide treatment of VTE is lacking so treatment is often extrapolated from adult trials and expert consensus opinion. Aspects unique to children include developmental hemostasis and the major role of central venous access devices. There is an absence of information regarding the optimal target levels of anticoagulation for neonates and infants and lack of suitable drug formulations. Anticoagulants, primarily low-molecular-weight heparin and warfarin, are used to treat children with symptomatic VTE. These drugs have significant limitations, including the need for subcutaneous injections and frequent monitoring. Randomized clinical trials of direct oral anticoagulants in pediatric VTE are ongoing, with results anticipated soon. These trials will provide new evidence and options for therapy that have the potential to improve care. International collaborative registries offer the ability to study outcomes of rare subgroups of pediatric VTE (eg, renal vein thrombosis), and will be important to ultimately guide therapy in a more disease-specific manner.
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A complete blood cell count (CBC) is a frequent test sent to aid in the diagnostic evaluation of ill patients. Not uncommonly hematologic abnormalities may be the first sign of an underlying systemic ...disorder. The astute clinician needs to understand how systemic disease can affect the CBC to direct further diagnostic investigations. This article focuses on the 2 most common acquired anemias including iron deficiency and anemia of inflammation as well as disseminated intravascular coagulation.
Children with sickle cell disease (SCD) are at risk of complications from viral infections, including SARS‐CoV‐2. We present the clinical characteristics and outcomes of pediatric patients with SCD ...from the Pediatric COVID‐19 United States Registry who developed acute COVID‐19 due to SARS‐CoV‐2 infection (n = 259) or multisystem inflammatory syndrome in children (MIS‐C; n = 4). Nearly half of hospitalized children with SCD and SARS‐CoV‐2 infection required supplemental oxygen, though children with SCD had fewer intensive care (ICU) admissions compared to the general pediatric and immunocompromised populations. All registry patients with both SCD and MIS‐C required ICU admission. Children with SCD are at risk of severe disease with SARS‐CoV‐2 infection, highlighting the importance of vaccination in this vulnerable population.
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