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Warad DM, Chattha AJ, Rodriguez V. Oral Contraceptive Use in Obese Adolescents: A Cautionary Tale. J Pediatr Hematol Oncol 2021; 43:e1124-e1127. [PMID: 33448714 DOI: 10.1097/mph.0000000000002053] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 12/03/2020] [Indexed: 11/26/2022]
Abstract
Venous thromboembolism (VTE) is a life-threatening complication rarely encountered with the use of combined oral contraceptives (COCs). Obesity is an additional thrombosis risk factor that has been shown to further increase the risk of VTE with the use of COCs. We present 5 cases of obese adolescents (body mass index >30 kg/m2) who encountered thrombosis complications while on COCs. Although the absolute risk of VTE events in the setting of COCs is rare, caution should be observed when choosing hormonal therapy and safer COCs alternatives discussed with adolescents who are obese.
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Affiliation(s)
- Deepti M Warad
- Division of Pediatric Hematology-Oncology
- Special Coagulation Laboratory, Division of Hematopathology
| | - Asma J Chattha
- Department of Pediatric and Adolescent Medicine, Division of Pediatric and Adolescent Gynecology, Mayo Clinic, Rochester, MN
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2
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Devara J, Iyer VN, Warad DM, Brinjikji W, Aljobeh A, Lanzino G, Demirel N. Acute thrombosis of a giant perimedullary arteriovenous fistula in a pediatric HHT patient. Interv Neuroradiol 2021; 28:132-135. [PMID: 34053318 DOI: 10.1177/15910199211022499] [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] [Indexed: 11/15/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant hereditary disorder that results in arteriovenous malformations (AVMs) in the nose, mucocutaneous surfaces and visceral organs, including lung, brain, liver, bowel and rarely spinal cord. We describe a case of a young child with HHT who presented with acute paraparesis due to acute thrombosis of a spinal perimedullary arteriovenous fistula. Patient underwent coil embolization of spinal arteriovenous shunt with resolution of clinical symptoms. This case highlights the possibility of catastrophic complications in young children with HHT, the potential preventive role of screening for spinal AVMs in HHT and the importance of timely intervention.
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Affiliation(s)
- Janaki Devara
- Division of Pediatric Pulmonology, Mayo Clinic, Rochester, MN, USA
| | - Vivek N Iyer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Deepti M Warad
- Division of Pediatric Hematology Oncology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Nadir Demirel
- Division of Pediatric Pulmonology, Mayo Clinic, Rochester, MN, USA
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3
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Samuelson Bannow B, Warad DM, Jones CG, Pechauer SM, Curtis BR, Bougie DW, Sharma R, Grill DE, Redman MW, Khalighi PR, Leger RR, Pruthi RK, Chen D, Sabath DE, Aster RH, Garcia DA, Padmanabhan A. A prospective, blinded study of a PF4-dependent assay for HIT diagnosis. Blood 2021; 137:1082-1089. [PMID: 32898858 PMCID: PMC7907721 DOI: 10.1182/blood.2020008195] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [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: 07/14/2020] [Accepted: 08/23/2020] [Indexed: 12/22/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a life-threatening, prothrombotic, antibody-mediated disorder. To maximize the likelihood of recovery, early and accurate diagnosis is critical. Widely available HIT assays, such as the platelet factor 4 (PF4) heparin enzyme-linked immunosorbent assay (ELISA) lack specificity, and the gold-standard carbon 14-labeled serotonin release assay (SRA) is of limited value for early patient management because it is available only through reference laboratories. Recent studies have demonstrated that pathogenic HIT antibodies selectively activate PF4-treated platelets and that a technically simpler assay, the PF4-dependent P-selectin expression assay (PEA), may provide an option for rapid and conclusive results. Based upon predefined criteria that combined 4Ts scores and HIT ELISA results, 409 consecutive adults suspected of having HIT were classified as disease positive, negative, or indeterminate. Patients deemed HIT indeterminate were considered disease negative in the primary analysis and disease positive in a sensitivity analysis. The ability of PEA and SRA to identify patients judged to have HIT was compared using receiver operating characteristic curve statistics. Using these predefined criteria, the diagnostic accuracy of PEA was high (area under the curve [AUC], 0.94; 95% confidence interval [CI], 0.87-1.0) and similar to that of SRA (AUC, 0.91; 95% CI, 0.82-1.0). In sensitivity analysis, the AUCs of PEA and SRA were also similar at 0.88 (95% CI, 0.78-0.98) and 0.86 (95% CI, 0.77-0.96), respectively. The PEA, a technically simple nonradioactive assay that uses ∼20-fold fewer platelets compared with the SRA, had high accuracy for diagnosing HIT. Widespread use of the PEA may facilitate timely and more effective management of patients with suspected HIT.
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Affiliation(s)
| | - Deepti M Warad
- Department of Pediatric and Adolescent Medicine and
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | | | - Brian R Curtis
- Platelet and Neutrophil Immunology Laboratory, Versiti Wisconsin, Milwaukee, WI
| | | | - Ruchika Sharma
- Platelet and Neutrophil Immunology Laboratory, Versiti Wisconsin, Milwaukee, WI
| | - Diane E Grill
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | - Parisa R Khalighi
- Department of Obstetrics and Gynecology, University of Colorado, Denver, CO
| | - Rachel R Leger
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Rajiv K Pruthi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
- Department of Medicine, Mayo Clinic, Rochester, MN; and
| | - Dong Chen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Daniel E Sabath
- Department of Laboratory Medicine and
- Department of Medicine, University of Washington, Seattle, WA
| | | | - David A Garcia
- Department of Medicine, University of Washington, Seattle, WA
| | - Anand Padmanabhan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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4
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Wyatt KD, Freedman EB, Arteaga GM, Rodriguez V, Warad DM. Computer-based simulation to reduce EHR-related chemotherapy ordering errors. Cancer Med 2020; 9:8844-8851. [PMID: 33002331 PMCID: PMC7724293 DOI: 10.1002/cam4.3496] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/28/2020] [Accepted: 09/14/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The electronic health record (EHR) is a contributor to serious patient harm occurring within a sociotechnical system. Chemotherapy ordering is a high-risk task due to the complex nature of ordering workflows and potential detrimental effects if wrong chemotherapeutic doses are administered. Many chemotherapy ordering errors cannot be mitigated through systems-based changes due to the limited extent to which individual institutions are able to customize proprietary EHR software. We hypothesized that simulation-based training could improve providers' ability to identify and mitigate common chemotherapy ordering errors. METHODS Pediatric hematology/oncology providers voluntarily participated in simulations using an EHR testing ("Playground") environment. The number of safety risks identified and mitigated by each provider at baseline was recorded. Risks were reviewed one-on-one after initial simulations and at a group "lunch-and-learn" session. At three-month follow-up, repeat simulations assessed for improvements in error identification and mitigation, and providers were surveyed about prevention of real-life safety events. RESULTS The 8 participating providers identified and mitigated an average of 5.5 out of 10 safety risks during the initial simulation, compared 7.4 safety risks at the follow up simulation (p=0.030). Two of the providers (25%) reported preventing at least one real-world patient safety event in the clinical setting as a result of the initial training session. CONCLUSIONS Simulation-based training may reduce providers' susceptibility to chemotherapy ordering safety vulnerabilities within the EHR. This approach may be used when systems-based EHR improvements are not feasible due to limited ability to customize local instances of proprietary EHR software.
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Affiliation(s)
- Kirk D. Wyatt
- Division of Pediatric Hematology/OncologyMayo ClinicRochesterMNUSA
| | | | | | | | - Deepti M. Warad
- Division of Pediatric Hematology/OncologyMayo ClinicRochesterMNUSA
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5
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Warad DM, Rao AN, Bjarnason H, Rodriguez V. Clinical Outcomes of May-Thurner Syndrome in Pediatric Patients: A Single Institutional Experience. TH Open 2020; 4:e189-e196. [PMID: 32844146 PMCID: PMC7440970 DOI: 10.1055/s-0040-1714694] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/25/2020] [Indexed: 01/01/2023] Open
Abstract
Introduction May-Thurner syndrome (MTS) is a vascular anatomic variant resulting in compression of the left common iliac vein by the right common iliac artery, affecting approximately 22% of the population. In adults, following acute deep vein thrombosis (DVT) of the iliofemoral veins, the incidence of postthrombotic syndrome (PTS) and recurrent DVT are high if treated with anticoagulation alone, warranting adjunctive treatment with thrombolysis and stent placement. However, there is paucity of literature documenting the course of treatment and associated outcomes in pediatric patients with MTS. Methods A retrospective chart review of pediatric patients (≤ 18 years of age) with radiologic confirmation of MTS with or without DVT evaluated and/or treated at our institution from January 1, 2005 through December 31, 2015 was conducted. Results Seventeen patients (4 male; 13 female) were identified. Median age was 15.4 years (range 8.8-17.1 years) with a median follow-up of 1.2 years (range 0.4-7.5 years). Thirteen (76.5%) patients presented with left lower extremity DVT. Management included catheter-directed thrombolysis ( n = 5), systemic thrombolysis ( n = 1), and mechanical thrombectomy ( n = 1). Fifteen patients were treated with anticoagulation including two patients with endovascular stents without DVT. Median duration of anticoagulation was 6.3 months (range 3.2-18.7 months). Ten patients (59%) underwent stent placements. Complete and partial thrombus resolution was noted in six patients each and no resolution in one patient. Four patients had recurrence/progression of thrombus ( n = 3 with stents) at a median time of 29 days (range 12-495 days). No bleeding complications were observed. Clinically documented or self-reported PTS was noted in 8 patients (62%). Conclusion There are no clear guidelines for MTS management in children and adolescents. In our cohort, thrombolysis, anticoagulation, or stent placements were not associated with bleeding risks, with recurrence/progression of DVT and signs and symptoms of PTS noted in 30 and 62%, respectively. Further studies are needed to determine a standardized treatment approach of the pediatric patient with MTS with or without thrombosis.
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Affiliation(s)
- Deepti M Warad
- Division of Pediatric Hematology-Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States.,Special Coagulation Laboratory, Division of Hematopathology, Mayo Clinic, Rochester, Minnesota, United States
| | - Amulya Nageswara Rao
- Division of Pediatric Hematology-Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Haraldur Bjarnason
- Division of Vascular and Interventional Radiology, Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology-Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States
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Wyatt KD, Rodriguez V, Youssef PE, Eckel LJ, Warad DM. Cerebral sinovenous thrombosis in pediatric hemolytic uremic syndrome. Res Pract Thromb Haemost 2020; 4:659-665. [PMID: 32548566 PMCID: PMC7292672 DOI: 10.1002/rth2.12329] [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: 12/17/2019] [Revised: 02/03/2020] [Accepted: 02/07/2020] [Indexed: 11/09/2022] Open
Abstract
Hemolytic uremic syndrome (HUS) may result in thrombotic central nervous system complications. We present a child with diarrhea-associated HUS who developed new-onset focal seizures secondary to cerebral sinovenous thrombosis (CSVT). Her CSVT was treated with low-molecular-weight heparin. The patient's seizures were controlled with levetiracetam, and her HUS was managed supportively with hemodialysis. Repeat imaging nearly 6 months following presentation and initiation of anticoagulation demonstrated cerebral sinus enlargement and persistent intraluminal webbing. Anticoagulation was discontinued after 6 months, and she did not experience long-term gross neurologic sequelae. CSVT is a complication of HUS that has not been previously described. In this report, we summarize the thrombotic central nervous system complications of pediatric HUS.
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Affiliation(s)
- Kirk D. Wyatt
- Division of Pediatric Hematology/OncologyDepartment of Pediatric and Adolescent MedicineMayo ClinicRochesterMinnesota
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology/OncologyDepartment of Pediatric and Adolescent MedicineMayo ClinicRochesterMinnesota
| | - Paul E. Youssef
- Division of Child and Adolescent NeurologyDepartment of NeurologyMayo ClinicRochesterMinnesota
| | - Laurence J. Eckel
- Division of NeuroradiologyDepartment of RadiologyMayo ClinicRochesterMinnesota
| | - Deepti M. Warad
- Division of Pediatric Hematology/OncologyDepartment of Pediatric and Adolescent MedicineMayo ClinicRochesterMinnesota
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7
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Nageswara Rao AA, Warad DM, Weaver AL, Schleck CD, Rodriguez V. Cross-Cultural Medical Care Training and Education: a National Survey of Pediatric Hematology/Oncology Fellows-in-Training and Fellowship Program Directors. J Cancer Educ 2019; 34:478-487. [PMID: 29380222 DOI: 10.1007/s13187-018-1326-8] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Pediatric hematologists/oncologists face complex situations such as breaking bad news, treatment/clinical trials discussions, and end-of-life/hospice care. With increasing diversity in patient and physician populations, cultural competency and sensitivity training covering different aspects of pediatric hematology/oncology (PDHO) care can help improve health care delivery and reduce disparities. Though it is considered a required component of fellowship training, there is no clearly defined curriculum meant specifically for PDHO fellows-in-training (PDHO-F). A national online survey of 356 PDHO-F and 67 PDHO program directors (PDHO-PD) was conducted to assess the educational experience, perceptions about identifying barriers including one's own biases and trainee comfort in delivering culturally sensitive care in various PDHO relevant clinical situations. One hundred and eleven (31.2%) PDHO-F and 27 (40.3%) PDHO-PD responded. 30.6% of PDHO-F "strongly agreed/agreed" they received comprehensive cross-cultural communication (CCC) training. The top two teaching methods were faculty role modeling and informal teaching. Majority of CCC training is in medical school or residency and only 10.8% of PDHO-F reported that most of their CCC training was in fellowship. In most clinical situations, there was a modest direct correlation between the fellow's level of agreement that they received comprehensive CCC training and their comfort level. Comfort level with some clinical situations was also significantly different based on year of training. Fellowship training programs should have CCC curricula which use experiential learning models and lay the foundation for promoting cultural awareness, self-reflection, and better patient-physician partnerships which can eventually adapt to and surmount the challenges unique to the physician's chosen field of practice.
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Affiliation(s)
- Amulya A Nageswara Rao
- Division of Pediatric Hematology/Oncology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Deepti M Warad
- Division of Pediatric Hematology/Oncology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
- Special Coagulation Laboratory, Division of Hematopathology, Mayo Clinic, Rochester, MN, USA
| | - Amy L Weaver
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Cathy D Schleck
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology/Oncology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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8
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Wyatt KD, Coon LM, Rusk DN, Rodriguez V, Warad DM. Case Report: Development of Factor VIII Inhibitor in a Patient with an Uncommon de novo Mutation in the Factor VIII Gene. Acta Haematol 2019; 141:129-134. [PMID: 30783064 DOI: 10.1159/000495559] [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: 08/13/2018] [Accepted: 11/15/2018] [Indexed: 11/19/2022]
Abstract
The development of factor VIII inhibitors remains a significant clinical challenge in the management of hemophilia A. We present a patient of mixed ethnicity with severe hemophilia A who was found to have a F8 gene hemizygous c.5815G>T mutation resulting in an Ala1939Ser substitution (Ala1920Ser in legacy nomenclature) and possible splice site change that has been reported in only 1 patient previously. He developed an inhibitor shortly after starting replacement recombinant factor VIII (Advate®; Baxalta, Bannockburn, IL, USA) and was successfully treated with immune tolerance therapy. Our report describes the second patient reported to have severe hemophilia due to this mutation and the only case of a factor VIII inhibitor associated with this mutation.
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Affiliation(s)
- Kirk D Wyatt
- Division of Pediatric Hematology/Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Lea M Coon
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Dawn N Rusk
- Hemophilia Treatment Center, Department of Hematology/Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology/Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Deepti M Warad
- Division of Pediatric Hematology/Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA,
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9
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Cupit-Link MC, Nageswara Rao A, Warad DM, Rodriguez V, Khan S. EBV-PTLD, Adenovirus, and CMV in Pediatric Allogeneic Transplants With Alemtuzumab as Part of Pretransplant Conditioning: A Retrospective Single Center Study. J Pediatr Hematol Oncol 2018; 40:e473-e478. [PMID: 29620685 DOI: 10.1097/mph.0000000000001138] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The risk of viral infections and reactivation occurring in the setting of pediatric allogeneic hematopoietic stem cell transplantation is a concern in the pediatric patient, especially with the use of Alemtuzumab (Campath) as a conditioning agent. The purpose of this study was to determine the incidence of Epstein-Barr virus posttransplant lymphoproliferative disorder (EBV-PTLD), cytomegalovirus (CMV), and adenovirus among pediatric recipients of alemtuzumab at our institution. We found that EBV-PTLD occurred in 2.1% of transplants (1 matched unrelated donor [MUD] recipient), CMV reactivation occurred in 12.5% of transplants (4 MUD and 2 matched related donor [MRD] recipients) with disseminated CMV in 2.1% of cases (1 MRD recipient), and adenovirus infection occurred in 8.3% of the total transplants (2 MUD and 2 MRD recipients). Alemtuzumab continues to be used as a method of graft-versus-host disease and graft failure prevention among pediatric recipients of hematopoietic stem cell transplantation and seems to be safer than previously reported. At our institution, alemtuzumab has not increased the risk for EBV-PTLD, CMV infection, or adenovirus.
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Affiliation(s)
| | | | - Deepti M Warad
- Division of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, MN
| | | | - Shakila Khan
- Division of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, MN
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10
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Abstract
Rates of venous thromboembolism have increased in the adolescent population over the last two decades, likely due to advanced diagnostics, increased use of central venous catheters, chronic medical conditions, obesity, and oral contraceptive use. Of these factors, a modifiable risk factor for adolescents is obesity. Sedentary lifestyle and prolonged immobilization are additional prothrombotic risk factors that are often associated with obesity. With ever-increasing screen time, sedentary behavior has risen accordingly, especially among gamers. We present four cases of adolescents who developed life-threatening venous thromboembolic events in the setting of obesity, sedentary lifestyle and/or immobilization, and prolonged video game use.
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Affiliation(s)
- Mira A. Kohorst
- Division of Pediatric Hematology-Oncology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Deepti M. Warad
- Division of Pediatric Hematology-Oncology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN,Special Coagulation Laboratory Division of Hematopathology, Mayo Clinic, Rochester, MN
| | - Amulya A. Nageswara Rao
- Division of Pediatric Hematology-Oncology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology-Oncology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN
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Chen D, Uhl CB, Bryant SC, Krumwiede M, Barness RL, Olson MC, Gossman SC, Erdogan Damgard S, Gamb SI, Cummins LA, Charlesworth JE, Wood-Wentz CM, Salisbury JL, Plumhoff EA, Van Cott EM, He R, Warad DM, Pruthi RK, Heit JA, Nichols WL, White JG. Diagnostic laboratory standardization and validation of platelet transmission electron microscopy. Platelets 2018; 29:574-582. [PMID: 29863946 DOI: 10.1080/09537104.2018.1476682] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Platelet transmission electron microscopy (PTEM) is considered the gold standard test for assessing distinct ultrastructural abnormalities in inherited platelet disorders (IPDs). Nevertheless, PTEM remains mainly a research tool due to the lack of standardized procedures, a validated dense granule (DG) count reference range, and standardized image interpretation criteria. The aim of this study was to standardize and validate PTEM as a clinical laboratory test. Based on previously established methods, we optimized and standardized preanalytical, analytical, and postanalytical procedures for both whole mount (WM) and thin section (TS) PTEM. Mean number of DG/platelet (plt), percentage of plts without DG, platelet count (PC), mean platelet volume (MPV), immature platelet fraction (IPF), and plt light transmission aggregometry analyses were measured on blood samples from 113 healthy donors. Quantile regression was used to estimate the reference range for DG/plt, and linear regression was used to assess the association of DG/plt with other plt measurements. All PTEM procedures were standardized using commercially available materials and reagents. DG interpretation criteria were established based on previous publications and expert consensus, and resulted in improved operator agreement. Mean DG/plt was stable for 2 days after blood sample collection. The median within patient coefficient of variation for mean DG/plt was 22.2%; the mean DG/plt reference range (mid-95th %) was 1.2-4.0. Mean DG/plt was associated with IPF (p = .01, R2 = 0.06) but not age, sex, PC, MPV, or plt maximum aggregation or primary slope of aggregation (p > .17, R2 < 0.02). Baseline ultrastructural features were established for TS-PTEM. PTEM was validated using samples from patients with previously established diagnoses of IPDs. Standardization and validation of PTEM procedures and interpretation, and establishment of the normal mean DG/plt reference range and PTEM baseline ultrastructural features, will facilitate implementation of PTEM as a valid clinical laboratory test for evaluating ultrastructural abnormalities in IPDs.
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Affiliation(s)
- Dong Chen
- a Division of Hematopathology , Mayo Clinic , Rochester , Minnesota , USA
| | - Cindy B Uhl
- b Electron Microscope Core Facility , Mayo Clinic , Rochester , Minnesota , USA
| | - Sandra C Bryant
- c Division of Biomedical Statistics and Informatics , Mayo Clinic , Rochester , Minnesota , USA
| | - Marcy Krumwiede
- d Departments of Laboratory Medicine, Pathology, and Pediatrics , University of Minnesota School of Medicine , Minneapolis , Minnesota , USA
| | - Ryan L Barness
- b Electron Microscope Core Facility , Mayo Clinic , Rochester , Minnesota , USA
| | - Mary C Olson
- b Electron Microscope Core Facility , Mayo Clinic , Rochester , Minnesota , USA
| | - Susan C Gossman
- b Electron Microscope Core Facility , Mayo Clinic , Rochester , Minnesota , USA
| | | | - Scott I Gamb
- b Electron Microscope Core Facility , Mayo Clinic , Rochester , Minnesota , USA
| | - Lisa A Cummins
- b Electron Microscope Core Facility , Mayo Clinic , Rochester , Minnesota , USA
| | - Jon E Charlesworth
- b Electron Microscope Core Facility , Mayo Clinic , Rochester , Minnesota , USA
| | - Christina M Wood-Wentz
- c Division of Biomedical Statistics and Informatics , Mayo Clinic , Rochester , Minnesota , USA
| | - Jeffrey L Salisbury
- b Electron Microscope Core Facility , Mayo Clinic , Rochester , Minnesota , USA
| | | | - Elizabeth M Van Cott
- e Department of Pathology , Massachusetts General Hospital, Harvard Medical School , Boston , Massachusetts , USA
| | - Rong He
- a Division of Hematopathology , Mayo Clinic , Rochester , Minnesota , USA
| | - Deepti M Warad
- a Division of Hematopathology , Mayo Clinic , Rochester , Minnesota , USA
| | - Rajiv K Pruthi
- a Division of Hematopathology , Mayo Clinic , Rochester , Minnesota , USA
| | - John A Heit
- a Division of Hematopathology , Mayo Clinic , Rochester , Minnesota , USA
| | - William L Nichols
- a Division of Hematopathology , Mayo Clinic , Rochester , Minnesota , USA
| | - James G White
- d Departments of Laboratory Medicine, Pathology, and Pediatrics , University of Minnesota School of Medicine , Minneapolis , Minnesota , USA
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Botero JP, Chen D, Majerus JA, Coon LM, He R, Warad DM, Pruthi RK, Nichols WL. Hermansky-Pudlak syndrome subtype 5 (HPS-5) novel mutation in a 65 year-old with oculocutaneous hypopigmentation and mild bleeding diathesis: The importance of recognizing a subtle phenotype. Platelets 2017; 29:91-94. [DOI: 10.1080/09537104.2017.1361019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | - Dong Chen
- Special Coagulation Laboratory, Mayo Clinic, Rochester, MN, USA
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Lea M. Coon
- Special Coagulation Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Rong He
- Special Coagulation Laboratory, Mayo Clinic, Rochester, MN, USA
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Deepti M. Warad
- Special Coagulation Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Rajiv K. Pruthi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Special Coagulation Laboratory, Mayo Clinic, Rochester, MN, USA
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - William L. Nichols
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Special Coagulation Laboratory, Mayo Clinic, Rochester, MN, USA
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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13
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Kohorst MA, Warad DM, Matsumoto JM, Heimbach JK, El-Youssef M, Arndt CAS, Rodriguez V, Nageswara Rao AA. Management of pediatric hepatocellular carcinoma: A multimodal approach. Pediatr Transplant 2017. [PMID: 28631359 DOI: 10.1111/petr.13007] [Citation(s) in RCA: 5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
HCC is rare in the pediatric population, but is the second most common liver malignancy in children. Survival rates for primary unresectable HCC have been dismal. The objective of this study was to describe our experience with a multimodal approach for the management of unresectable HCC in two adolescent patients and to review the literature. Both patients are currently alive with no recurrence at 51 and 29 months post-transplant. Multimodality treatment involving chemotherapy with doxorubicin, cisplatin, and sorafenib; TACE; timely liver transplantation; and post-transplant therapy with sorafenib and mTOR inhibitors may help improve outcomes and prolong survival in pediatric patients with unresectable HCC.
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Affiliation(s)
- Mira A Kohorst
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Mayo Clinic, Rochester, MN, USA
| | - Deepti M Warad
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Mounif El-Youssef
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Carola A S Arndt
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Mayo Clinic, Rochester, MN, USA
| | - Vilmarie Rodriguez
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Mayo Clinic, Rochester, MN, USA
| | - Amulya A Nageswara Rao
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Mayo Clinic, Rochester, MN, USA
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Perez Botero J, Warad DM, He R, Uhl CB, Tian S, Otteson GE, Barness RL, Olson MC, Gossman SC, Charlesworth JE, Nichols WL, Pruthi RK, Chen D. Comprehensive Platelet Phenotypic Laboratory Testing and Bleeding History Scoring for Diagnosis of Suspected Hereditary Platelet Disorders. Am J Clin Pathol 2017; 148:23-32. [DOI: 10.1093/ajcp/aqx038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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15
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Cupit-Link MC, Nageswara Rao A, Warad DM, Rodriguez V. Lemierre Syndrome: A Retrospective Study of the Role of Anticoagulation and Thrombosis Outcomes. Acta Haematol 2016; 137:59-65. [PMID: 28006761 DOI: 10.1159/000452855] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [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: 10/13/2016] [Accepted: 10/16/2016] [Indexed: 11/19/2022]
Abstract
Lemierre syndrome (LS) is a multisystemic infection beginning in the oropharynx and leading to thrombosis of the internal jugular vein (IJV) with septic emboli and potential thrombotic extension to the central nervous system. Although patient outcomes have improved with early initiation of antimicrobial therapies, there is no consensus regarding the role of anticoagulation in LS. To better define the role of anticoagulation therapy in LS and determine whether anticoagulation improves thrombosis outcomes, we conducted a retrospective chart review of pediatric and adult patients diagnosed with LS and managed at our institution from January 1998 to December 2014. Eighteen patients (9 females and 9 males) were included in this analysis, 6 of whom received ≥4 weeks of anticoagulation therapy (median 23.1 weeks, range 6.9-32.9 weeks). Six patients were in the pediatric age group (<18 years). All patients received broad-spectrum antibiotics. All patients had improvement in their thrombi by 3 months (nonanticoagulated patient group: complete response [CR], n = 9; partial response [PR], n = 3; anticoagulated patient group: CR, n = 2; PR, n = 4). No patient developed recurrent thrombosis or progression during the follow-up period, regardless of anticoagulation status. Our study suggests that anticoagulation in LS may not affect thrombosis outcomes.
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16
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Elwood K, Laack N, Warad DM, Keating G, Eckel L, Nageswara Rao AA. Injury to insult: infarction after radiotherapy in the treatment of pediatric brain tumor. Pediatr Neurol 2015; 52:552-3. [PMID: 25724372 DOI: 10.1016/j.pediatrneurol.2015.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 01/19/2015] [Accepted: 01/22/2015] [Indexed: 11/15/2022]
Affiliation(s)
- Kendra Elwood
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nadia Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Deepti M Warad
- Division of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, Minnesota
| | - Gesina Keating
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Laurence Eckel
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
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