Sarah H. O'Brien

The ASH Choosing Wisely® Campaign: five hematologic tests and treatments to question

Choosing Wisely® is a medical stewardship and quality improvement initiative led by the American Board of Internal Medicine Foundation in collaboration with leading medical societies in the United States. The ASH is an active participant in the Choosing Wisely® project. Using an iterative process and an evidence-based method, ASH has identified 5 tests and treatments that in some circumstances are not well supported by evidence and which in certain cases involve a risk of adverse events and financial costs with low likelihood of benefit. The ASH Choosing Wisely® recommendations focus on avoiding liberal RBC transfusion, avoiding thrombophilia testing in adults in the setting of transient major thrombosis risk factors, avoiding inferior vena cava filter usage except in specified circumstances, avoiding the use of plasma or prothrombin complex concentrate in the nonemergent reversal of vitamin K antagonists, and limiting routine computed tomography surveillance after curative-intent treatment of non-Hodgkin lymphoma. We recommend that clinicians carefully consider anticipated benefits of the identified tests and treatments before performing them.

Pediatric Venous Thromboembolism in the United States: A Tertiary Care Complication of Chronic Diseases

Pediatric venous thromboembolism (VTE) is an increasingly common problem. We hypothesized that VTE occurs most commonly in tertiary care settings and that the pattern of associated illnesses may have changed from earlier reports.

Effect of injury severity on the incidence and utilization-related outcomes of venous thromboembolism in pediatric trauma inpatients.

Objective: The objective of this study was to generate national estimates of the effect of injury severity on the occurrence rate and associated resource utilization-related outcomes of venous thromboembolism (VTE) between pediatric and adolescent trauma inpatients in the United States. Data Source: 2003 Healthcare Cost and Utilization Project Kids’ Inpatient Database, the largest all-payer pediatric (age ≤20 yrs) inpatient care database in the United States. Measurements and Main Results: VTE was identified in 2.7 per 1000 pediatric trauma discharges. Although injury severity is strongly associated with an increased risk of VTE, the occurrence rate is low even among critically injured patients (<2%). However, VTE has a significant and an independent impact on the length of stay and hospitalization costs in the critical care setting. Conclusions: VTE increases both the length of stay and hospitalization costs independent of injury severity, demonstrating the need to consider thromboprophylaxis in the critically injured population. However, the low overall occurrence rate of VTE in young trauma patients, even in the intensive care unit, highlights the need for additional studies of risk factors and the potential risks of prophylactic anticoagulation, so that thromboprophylaxis can be more directly targeted to the children at highest risk.

In the absence of a central venous catheter, risk of venous thromboembolism is low in critically injured children, adolescents, and young adults: evidence from the National Trauma Data Bank.

Objective: To describe the incidence and risk factors of venous thromboembolism in a large sample of critical care pediatric, adolescent, and young adult trauma patients. Data Source: The National Trauma Data Bank—the largest and most complete aggregation of trauma registry data in the United States. Setting: Seven hundred eighty-four level I to level IV trauma centers. Patients: Patients ≤21 yrs of age who spent at least 1 day in a critical care unit during a trauma admission between 2001 and 2005. Measurements and Main Results: To characterize differences between patients with and without venous thromboembolism, we extracted variables regarding patient demographics, injury pattern and severity, procedures, total length of stay, and intensive care unit and ventilator days. Odds ratios for predictors of venous thromboembolism were estimated with a logistic regression model. Among the 135,032 critical care patients analyzed, venous thromboembolism was uncommon (6 per 1,000 discharges). Placement of a central venous catheter was a significant predictor of venous thromboembolism (odds ratio = 2.24; p < .0001) when populations were analyzed collectively. When we narrowed our focus to injuries associated with venous thromboembolism, such as lower-extremity fractures, the effects of central venous catheter were of even greater magnitude, particularly in adolescents and young adults. The risk of venous thromboembolism in critical care patients without a central venous catheter was <1% even in adolescents/young adults. Conclusions: Venous thromboembolism is rare in young critical care trauma patients, even older adolescents. The absence of published data on both the baseline risk of venous thromboembolism in pediatric critical care patients and the efficacy and safety of venous thromboembolism prophylaxis preclude the ability to make definitive recommendations for the use of venous thromboembolism prophylaxis in this setting. Our results, however, suggest that venous thromboembolism prophylaxis may need to be considered only in critically injured adolescents and young adults with a continuing need for central venous access.

FondaKIDS: A prospective pharmacokinetic and safety study of fondaparinux in children between 1 and 18 years of age†

The incidence of thromboembolic disease is increasing in children. New anticoagulants have been licensed in adults and need to be studied in children. This report describes the first prospective study of fondaparinux in children.

Iron deficiency and fatigue in adolescent females with heavy menstrual bleeding.

Iron deficiency and fatigue are common problems in adolescent females. Heavy menstrual bleeding (HMB) is associated with both iron deficiency and fatigue. The aim of this study was to define baseline ferritin values and fatigue symptoms in a population of young females with excessive menstrual blood loss, as compared to healthy controls. The study population included 11 to 17‐year‐old menstruating females presenting to an Adolescent Gynaecology Clinic, Menorrhagia Clinic or Sports Medicine clinic. To evaluate the degree and effects of menstrual blood loss, we utilized the Ruta Menorrhagia Severity Score. We investigated the symptoms of fatigue using the Fatigue Severity Scale. We evaluated possible predictors of ferritin level (age, body mass index, fatigue scores and Menorrhagia Severity Score) using generalized linear models. A total of 48 adolescents with HMB and 102 healthy adolescents completed the study. Iron deficiency and elevated fatigue scores were common findings in young women with HMB. Both fatigue severity scores and menorrhagia severity scores were significantly higher in young women with HMB as compared to healthy controls. In adolescents with HMB, 87.5% had ferritin levels ≤40 ng mL−1, and 29.2% had ferritin levels ≤15 ng mL−1. Our generalized linear models did not identify any significant univariate relationships between ferritin levels and patient age, body mass index, fatigue score or menorrhagia score. Iron deficiency and symptoms of fatigue are common findings in young women with HMB. Fatigue severity scores are significantly higher in young women with HMB as compared to healthy controls.

Five hematologic tests and treatments to question

Choosing Wisely(®) is a medical stewardship initiative led by the American Board of Internal Medicine Foundation in collaboration with professional medical societies in the United States. The American Society of Hematology (ASH) released its first Choosing Wisely(®) list in 2013. Using the same evidence-based methodology as in 2013, ASH has identified 5 additional tests and treatments that should be questioned by clinicians and patients under specific, indicated circumstances. The ASH 2014 Choosing Wisely(®) recommendations include: (1) do not anticoagulate for more than 3 months in patients experiencing a first venous thromboembolic event in the setting of major, transient risk factors for venous thromboembolism; (2) do not routinely transfuse for chronic anemia or uncomplicated pain crises in patients with sickle cell disease; (3) do not perform baseline or surveillance computed tomography scans in patients with asymptomatic, early-stage chronic lymphocytic leukemia; (4) do not test or treat for heparin-induced thrombocytopenia if the clinical pretest probability of heparin-induced thrombocytopenia is low; and (5) do not treat patients with immune thrombocytopenia unless they are bleeding or have very low platelet counts.

The ASH Choosing Wisely®campaign: five hematologic tests and treatments to question

Choosing Wisely® is a medical stewardship and quality improvement initiative led by the American Board of Internal Medicine Foundation in collaboration with leading medical societies in the United States. The ASH is an active participant in the Choosing Wisely® project. Using an iterative process and an evidence-based method, ASH has identified 5 tests and treatments that in some circumstances are not well supported by evidence and which in certain cases involve a risk of adverse events and financial costs with low likelihood of benefit. The ASH Choosing Wisely® recommendations focus on avoiding liberal RBC transfusion, avoiding thrombophilia testing in adults in the setting of transient major thrombosis risk factors, avoiding inferior vena cava filter usage except in specified circumstances, avoiding the use of plasma or prothrombin complex concentrate in the nonemergent reversal of vitamin K antagonists, and limiting routine computed tomography surveillance after curative-intent treatment of non-Hodgkin lymphoma. We recommend that clinicians carefully consider anticipated benefits of the identified tests and treatments before performing them.

A multinational study of thromboprophylaxis practice in critically ill children.

Objectives:Although critically ill children are at increased risk for developing deep venous thrombosis, there are few pediatric studies establishing the prevalence of thrombosis or the efficacy of thromboprophylaxis. We tested the hypothesis that thromboprophylaxis is infrequently used in critically ill children even for those in whom it is indicated. Design:Prospective multinational cross-sectional study over four study dates in 2012. Setting:Fifty-nine PICUs in Australia, Canada, New Zealand, Portugal, Singapore, Spain, and the United States. Patients:All patients less than 18 years old in the PICU during the study dates and times were included in the study, unless the patients were 1) boarding in the unit waiting for a bed outside the PICU or 2) receiving therapeutic anticoagulation. Interventions:None. Measurements and Main Results:Of 2,484 children in the study, 2,159 (86.9%) had greater than or equal to 1 risk factor for thrombosis. Only 308 children (12.4%) were receiving pharmacologic thromboprophylaxis (e.g., aspirin, low-molecular-weight heparin, or unfractionated heparin). Of 430 children indicated to receive pharmacologic thromboprophylaxis based on consensus recommendations, only 149 (34.7%) were receiving it. Mechanical thromboprophylaxis was used in 156 of 655 children (23.8%) 8 years old or older, the youngest age for that device. Using nonlinear mixed effects model, presence of cyanotic congenital heart disease (odds ratio, 7.35; p < 0.001) and spinal cord injury (odds ratio, 8.85; p = 0.008) strongly predicted the use of pharmacologic and mechanical thromboprophylaxis, respectively. Conclusions:Thromboprophylaxis is infrequently used in critically ill children. This is true even for children at high risk of thrombosis where consensus guidelines recommend pharmacologic thromboprophylaxis.

Increased use of enoxaparin in pediatric trauma patients

PURPOSE Venous thromboembolism (VTE) in pediatric trauma patients has been reported from 0.7 to 4.2 patients per 1000 admissions. There are no clear guidelines for prophylactic anticoagulation in children. The purpose of this study was to examine the use of enoxaparin in pediatric trauma patients. METHODS The Pediatric Health Information System database was queried from 2001 to 2008 for patients 0 to 18 years with a primary diagnosis of trauma based on International Classification of Diseases, Ninth Revision, codes. Patients who received enoxaparin and/or diagnosed with VTE were identified using pharmacy and International Classification of Diseases, Ninth Revision, codes. Logistic regression was used to identify patient and hospital characteristics associated with VTE and enoxaparin use. RESULTS Among 260,078 pediatric trauma patients, 3195 were prescribed enoxaparin (1.23%), 2915 (1.12%) of whom were given enoxaparin without a diagnosis of VTE. The incidence of VTE remained stable (0.23%-0.28%), whereas the use of enoxaparin increased (0.75%-1.54%), especially in patients without VTE (0.65%-1.43%). Venous thromboembolism was significantly associated with pelvic fractures, intensive care unit stay, and central venous catheters (P = .017, P < .001, P < .001). CONCLUSIONS Despite a stable VTE incidence, the use of enoxaparin significantly increased in pediatric trauma patients, suggesting that use of pharmacologic thromboprophylaxis is increasing in pediatric trauma centers.