2022 Review of the 2019 American Society of Hematology Guidelines on Immune Thrombocytopenia.

The 2019 ASH guidelines for immune thrombocytopenia (ITP) included recommendations on management of adults (recommendations 1-9) and children (recommendations 10-21) with primary ITP (1). We describe here results of a review of the 2019 guidelines by a working group of experts requested by ASH to inform decision-making about the need for and timing of a guideline revision. An updated Medline and Embase search applied the same search terms as in the 2019 ASH guidelines, limited to systematic reviews and clinical trials, from May 2017 to July 2022. There were 193 studies identified, 102 underwent abstract review and 54 full review. Each study was assessed based on relevance to the previous recommendation with regards to the population, prioritized outcomes, new outcomes, and study design. Reviewers assessed if the data would change the strength or the directionality of the existing recommendation or merit development of a new recommendation. Based on this review, the ASH Committee on Quality endorsed a focused update on second-line management for adults with ITP. In addition, there will be continued annual monitoring and reviewing of the 2019 ASH guidelines on ITP in full to evaluate when there is sufficient new evidence to warrant additional revisions.

The latest insights into rare blood disorders: Diagnosis and treatment strategies.

Please visit https://bit.ly/AJHpodcast to complete the accredited learning activity and receive CME credit or NCPD contact hours. Because immune-mediated rare blood disorders are uncommon, healthcare providers often lack the knowledge and experience necessary to identify, diagnose, and treat them in accordance with best practices. As a result, there are significant gaps in care, including delays in diagnosis and suboptimal treatment. To ensure that more patients with these rare disorders are offered quality, evidence-based care, it is essential that healthcare providers possess up-to-date information about best practices and new developments in this area of medicine. In this activity, composed of three podcasts, an expert moderator will interview three expert faculty members about evidence-based guidelines for the diagnosis and treatment of acquired thrombotic thrombocytopenic purpura; developments in the diagnosis and treatment of cold agglutinin disease; and the challenges of achieving enduring remission in patients with immune thrombocytopenia.

The History of Extracorporeal Membrane Oxygenation and the Development of Extracorporeal Membrane Oxygenation Anticoagulation.

Extracorporeal membrane oxygenation (ECMO) was first started for humans in early 1970s by Robert Bartlett. Since its inception, there have been numerous challenges with extracorporeal circulation, such as coagulation and platelet activation, followed by consumption of coagulation factors and platelets, and biocompatibility of tubing, pump, and oxygenator. Unfractionated heparin (heparin hereafter) has historically been the defacto anticoagulant until recently. Also, coagulation monitoring was mainly based on bedside activated clotting time and activated partial thromboplastin time. In the past 50 years, the technology of ECMO has advanced tremendously, and thus, the survival rate has improved significantly. The indication for ECMO has also expanded. Among these are clinical conditions such as postcardiopulmonary bypass, sepsis, ECMO cardiopulmonary resuscitation, and even severe coronavirus disease 2019 (COVID-19). Not surprisingly, the number of ECMO cases has increased according to the Extracorporeal Life Support Organization Registry and prolonged ECMO support has become more prevalent. It is not uncommon for patients with COVID-19 to be on ECMO support for more than 1 year until recovery or lung transplant. With that being said, complications of bleeding, thrombosis, clot formation in the circuit, and intravascular hemolysis still remain and continue to be major challenges. Here, several clinical ECMO experts, including the "Father of ECMO"-Dr. Robert Bartlett, describe the history and advances of ECMO.

Iron Deficiency in Chronic Pediatric Heart Failure: Overall Assessment and Outcomes in Dilated Cardiomyopathy.

OBJECTIVE: To evaluate the frequency of iron status assessment in pediatric heart failure and the prevalence and adverse effects of absolute iron deficiency in dilated cardiomyopathy-induced heart failure. STUDY DESIGN: We retrospectively reviewed records of children with chronic heart failure at our center between 2010 and 2020. In children with dilated cardiomyopathy, we analyzed baseline cardiac function, hemoglobin level, and subsequent risk of composite adverse events (CAE), including death, heart transplant, ventricular assist device (VAD) placement, and transplant registry listing. Absolute iron deficiency and iron sufficiency were defined as transferrin saturations <20% and ≥30%, respectively; and indeterminant iron status as 20%-29%. RESULTS: Of 799 patients with chronic heart failure, 471 (59%) had no iron-related laboratory measurements. Of 68 children with dilated cardiomyopathy, baseline transferrin saturation, and quantitative left ventricular ejection fraction (LVEF), 33 (49%) and 14 (21%) were iron deficient and sufficient, respectively, and 21 (31%) indeterminant. LVEF was reduced to 23.6 ± 12.1% from 32.9 ± 16.8% in iron deficiency and sufficiency, respectively (P = .04), without a significant difference in hemoglobin. After stratification by New York Heart Association classification, in advanced class IV, hemoglobin was reduced to 10.9 ± 1.3 g/dL vs 12.7 ± 2.0 g/dL in iron deficiency and sufficiency, respectively (P = .01), without a significant difference in LVEF. CONCLUSIONS: In this single-center study, iron deficiency was not monitored in most children with chronic heart failure. In pediatric dilated cardiomyopathy-induced heart failure, absolute iron deficiency was prevalent and associated with clinically consequential and possibly correctable decreases in cardiac function and hemoglobin concentration.

A proposal for new definition (s) and management approach to paediatric refractory ITP: Reflections from the Intercontinental ITP Study Group.

Immune thrombocytopenia (ITP) in children is a relatively mild and self-limited disorder with the majority of children demonstrating normalization of platelet count by 12 months from diagnosis. Because of this, many children with ITP can be observed without the need for treatment. When needed, treatment with either intravenous immunoglobulin (IVIG) or corticosteroids is highly effective (>80% IVIG and >95% corticosteroids). For those children who require second-line therapies, response rates of >60% are seen with both the thrombopoietin-receptor agonists and rituximab. Despite this, some children will have 'refractory' ITP (rITP) with poor or transient responses to platelet-raising therapies. Here, we review the clinical features of rITP in children, outline proposed classifications and explore potential predictors for children with rITP.

Bivalirudin Compared to Heparin as the Primary Anticoagulant in Pediatric Berlin Heart Recipients.

Bivalirudin has been used in increasing frequency as an alternative to unfractionated heparin (UFH) in pediatric recipients of Berlin Heart EXCOR ventricular assist devices (VAD). This single-center, retrospective review characterizes anticoagulant trends and outcomes in pediatric Berlin Heart VAD recipients implanted between September 1, 2013, and August 31, 2021, anticoagulated with either bivalirudin or UFH. Thirty-one patients were included; 65% who received bivalirudin and 35% who received UFH. The median age was 2.9 years, included 64.5% females, with 61.3% of patients diagnosed with dilated cardiomyopathy and 25.8% of patients with congenital heart disease. Therapeutic anticoagulation was achieved sooner in the bivalirudin group compared to UFH via anti-Xa monitoring (median 5.7 and 69.5 hours, respectively, p < 0.001). Bivalirudin had a greater number of therapeutic values comparatively to UFH (52% and 24%, respectively; p < 0.001) and a superior number of hours in the therapeutic range (67% and 32%, respectively; p < 0.001). Secondary outcomes were similar among the two groups, apart from greater chest tube output (UFH), more frequent events of elevated plasma-free hemoglobin (bivalirudin), and more frequent elevated inflammatory markers postimplant (bivalirudin). Prevalence of pump replacements secondary to significant clot burden and prevalence of stroke was comparable. In this patient cohort, bivalirudin demonstrated greater anticoagulation stability comparatively to UFH. Multicenter collaboration would be necessary to identify whether this further translates into improved patient outcomes.

The Changing Landscape of Anticoagulation in Pediatric Extracorporeal Membrane Oxygenation: Use of the Direct Thrombin Inhibitors.

Bleeding and thrombosis frequently occur in pediatric patients with extracorporeal membrane oxygenation (ECMO) therapy. Until now, most patients are anticoagulated with unfractionated heparin (UFH). However, heparin has many disadvantages, such as binding to other plasma proteins and endothelial cells in addition to antithrombin, causing an unpredictable response, challenging monitoring, development of heparin resistance, and risk of heparin-induced thrombocytopenia (HIT). Direct thrombin inhibitors (DTIs), such as bivalirudin and argatroban, might be a good alternative. This review will discuss the use of both UFH and DTIs in pediatric patients with ECMO therapy.

Case Report: The First Case Report of Visceral Leishmaniasis in Cambodia.

Leishmaniasis is considered a neglected tropical disease that is commonly found in Asia, Africa, South America, and Mediterranean countries. Visceral leishmaniasis (VL) is the most severe form of the disease and is almost universally fatal if left untreated. The symptoms of VL overlap with many infectious diseases, malignancies, and other blood disorders. The most common findings include fever, cytopenias, and splenomegaly. Given the nonspecific symptoms, the diagnosis requires detailed laboratory investigations, including bone marrow examination, that can be challenging in low- and middle-income countries. Diagnostic limitations likely lead to the underdiagnosis or delay in diagnosis of VL. We describe, to our knowledge, the first case report of VL in Cambodia in a child presenting with fever, anemia, and thrombocytopenia. The diagnosis required a liver biopsy and multiple bone marrow biopsies to visualize intracellular Leishmania spp. Our case illustrates the diagnostic challenges and the importance of timely diagnosis. This case also highlights the need for heightened awareness of the diagnostic findings of VL and improved reporting of tropical diseases.

Phase 3 randomised trial of eltrombopag versus standard first-line pharmacological management for newly diagnosed immune thrombocytopaenia (ITP) in children: study protocol.

INTRODUCTION: Immune thrombocytopaenia (ITP) is an acquired disorder of low platelets and risk of bleeding. Although many children can be observed until spontaneous remission, others require treatment due to bleeding or impact on health-related quality of life. Standard first-line therapies for those who need intervention include corticosteroids, intravenous immunoglobulin and anti-D globulin, though response to these agents may be only transient. Eltrombopag is an oral thrombopoietin receptor agonist approved for children with chronic ITP who have had an insufficient response to corticosteroids, intravenous immunoglobulin or splenectomy. This protocol paper describes an ongoing open-label, randomised trial comparing eltrombopag to standard first-line management in children with newly diagnosed ITP. METHODS AND ANALYSIS: Randomised treatment assignment is 2:1 for eltrombopag versus standard first-line management and is stratified by age and by prior treatment. The primary endpoint of the study is platelet response, defined as ≥3 of 4 weeks with platelets >50×109/L during weeks 6-12 of therapy. Secondary outcomes include number of rescue therapies needed during the first 12 weeks, proportion of patients who do not need ongoing treatment at 12 weeks and 6 months, proportion of patients with a treatment response at 1 year, and number of second-line therapies used in weeks 13-52, as well as changes in regulatory T cells, iron studies, bleeding, health-related quality of life and fatigue. A planned sample size of up to 162 randomised paediatric patients will be enrolled over 2 years at 20 sites. ETHICS AND DISSEMINATION: The study has been approved by the centralised Baylor University Institutional Review Board. The results are expected to be published in 2023. TRIAL REGISTRATION NUMBER: NCT03939637.

Multisystem Inflammatory Syndrome Associated with COVID-19 Anti-thrombosis Guideline of Care for Children by Action.

With growing number of pediatric cases of COVID-19, a unique hyper-inflammatory syndrome, linked to SARS-CoV-2 infection, has emerged in children referred to as multisystem inflammatory syndrome in children (MIS-C). This Kawasaki Disease (KD)-like illness has been described across the world. This syndrome shares features of KD, toxic shock syndrome, and macrophage activation syndrome and is associated with significantly elevated inflammatory markers. Everyday there are new data emerging improving the care of these patients. The Advanced Cardiac Therapies Improving Outcomes Network (ACTION) is a collaborative network designed to improve the outcomes of pediatric patients with end-stage heart failure and involves centers from across North America. The committee gathered information concerning COVID-19 anticoagulation practices at various centers and harmonized the data to formulate a set of recommendations.

Length of Stay and Health Care Utilization Among Pediatric Autologous Hematopoietic Cell Transplantation Recipients.

Autologous hematopoietic cell transplantation (autoHCT) has become a critical component in the treatment of pediatric malignancies, allowing for high-dose chemotherapy to be given safely and with greater efficacy in a subset of children at high risk for relapse. Risk factors associated with hospital length of stay (LOS) in adults undergoing autoHCT have been studied extensively; however, there is a paucity of studies describing risk factors associated with LOS and health care cost in children undergoing autoHCT. This study sought to identify factors influencing LOS and cost in pediatric autoHCT. We assessed LOS from autologous stem cell infusion from day 0 (D0) in 100 autoHCT admissions in 73 patients with malignant disease between 2007 and 2019. We evaluated demographic, pre-transplantation, post-transplantation, and socioeconomic variables to identify potential risk factors associated with LOS and cost. AutoHCT cost data were provided by the Pediatric Health Information System database. Indications for autoHCT included neuroblastoma (35.6%), brain tumor (27.4%), and relapsed lymphoma (24.7%). The median patient age was 4.88 years (range, 0.72 to 22 years), with 71% age <12 years, and the cohort was 63% male, 77% white, and 41% Hispanic. The median LOS from D0 was 19 days (range, 13 to 100 days). On multivariable analysis, age >12 years compared with 2 to 12 years (estimate, -8.9 days; 95% confidence interval [CI], -15.1 to -2.8; P = .004) and complete remission/very good partial response disease status (estimate, -5.0 days; 95% CI, -9.6 to -0.4 days; P = .031) were associated with a significantly decreased median LOS, whereas Hispanic ethnicity (estimate, +6.8 days; 95% CI, 1.1 to 12.6 days; P = .019), >5 days of fever (estimate, +7.3 days; 95% CI, 1.4 to 13.2 days; P = .015), and pediatric intensive care unit (PICU) LOS (estimate, +14.9 days; 95% CI, 1.8 to 28.0 days; P = .025) were associated with a significant increase in median LOS. The median cost per transplantation admission was $96,850 (range, $39,833 to $587,321). Multivariable analysis showed that age >12 years (estimate, -$6,776; 95% CI, -$71,787 to -$11,402; P = .007) or <2 years (estimate, -$32,426; 95% CI, -$53,507 to -$11,345; P = .003), and complete remission/very good partial response disease status (estimate, -$20,266; 95% CI, -$40,211 to -$322; P = .046) were associated with significantly decreased median cost, whereas >5 days of fever (estimate, +$58,886; 95% CI, $30,667 to $87,105; P < .001) and PICU admission (estimate, +$102,458; 95% CI, $23,843 to $181,076; P = .011) were associated with significantly increased median cost. In summary, fever and PICU stay were found to be risk factors for increased LOS and cost. Age <12 years and Hispanic ethnicity were risk factors for increased LOS, whereas age <2 years and >12 years and female sex were associated with decreased cost. Further investigation to determine specific factors influencing LOS and cost is warranted to identify potentially modifiable risks within these patient populations.

Immune thrombocytopenia: A review of upfront treatment strategies.

Immune thrombocytopenia (ITP), resulting from antibody-mediated platelet destruction combined with impaired platelet production, is a rare cause of thrombocytopenia in both children and adults. The decision to treat newly diagnosed patients is based on several factors, including the desire to increase platelet count to prevent bleeding, induce remission, and improve health-related quality of life (HRQoL). At present, standard first-line therapy is corticosteroids. While this treatment does increase the platelet count in many patients, a high percentage still relapse after discontinuation of therapy. For this reason, alteration or intensification of first-line therapy that results in superior long-term remission rates is desirable. The objective of this review is to outline different upfront strategies for newly diagnosed patients with ITP in an effort to potentially enhance remission rates and prevent relapse, taking into account an assessment of the risks and benefits of each approach. We primarily focus on adults with ITP, highlighting pediatric data and practice when applicable.

Quality of life is an important indication for second-line treatment in children with immune thrombocytopenia.

BACKGROUND: The decision to initiate second-line treatment in children with immune thrombocytopenia (ITP) is complex and involves many different factors. METHODS: In this prospective, observational, longitudinal cohort study of 120 children from 21 centers, the factors contributing to the decision to start second-line treatments for ITP were captured. At study entry, clinicians were given a curated list of 12 potential reasons the patient required a second-line treatment. Clinicians selected all that applied and ranked the top three reasons. RESULTS: Quality of life (QOL) was the most frequently cited reason for starting a second-line therapy. Clinicians chose it as a reason to treat in 88/120 (73%) patients, as among the top three reasons in 68/120 (57%), and as the top reason in 32/120 (27%). Additional factors ranked as the top reason to start second-line treatment included severity of bleeding (22/120, 18%), frequency of bleeding (19/120, 16%), and severity of thrombocytopenia (18/120, 15%). Patients for whom QOL (p = .006) or sports participation (p = .02) were ranked reasons were more likely to have chronic ITP, whereas those for whom severity (p = .003) or frequency (p = .005) of bleeding were ranked reasons were more likely to have newly diagnosed or persistent ITP. Parental anxiety, though rarely the primary impetus for treatment, was frequently cited (70/120, 58%) as a contributing factor. CONCLUSION: Perceived QOL is the most frequently selected reason pediatric patients start second-line therapies for ITP. It is critical that studies of treatments for childhood ITP include assessments of their effects on QOL.

Antifactor Xa Monitoring and Hematologic Complications of Pediatric Extracorporeal Membrane Oxygenation.

Hemorrhagic and thrombotic complications are a significant source of morbidity and mortality for pediatric patients on extracorporeal membrane oxygenation (ECMO). Optimal anticoagulation therapies and monitoring strategies remain unknown. In 2013, our institution changed the anticoagulation monitoring protocol from activated clotting time (ACT) to antifactor Xa (anti-Xa) levels. We conducted a retrospective review of patients who received anticoagulation management directed by ACT results (n = 96) or anti-Xa levels (n = 72) between January 2010 and March 2016. Hemorrhagic complications occurred in 25% of the ACT group and 39% of the anti-Xa group (p = 0.054). Thrombotic complications were observed in 12.5% of the ACT group and 14% of the anti-Xa group (p = 0.8). There was a greater incidence of extracorporeal cardiopulmonary resuscitations (E-CPR; 36% vs. 15%; p = 0.005) in the anti-Xa group as compared with the ACT group. Secondary analysis showed no difference in transfusion requirements for red blood cells (ml/kg; p = 0.32) or platelets (ml/kg; p = 0.32). There was no difference in average heparin infusion rates (unit/kg/hr) per cannulation (p = 0.17) between the groups. Management of anticoagulation based on anti-Xa levels appears to be as effective as management based on ACT results.

Multisystem Inflammatory Syndrome in Children Associated With Coronavirus Disease 2019 in a Children's Hospital in New York City: Patient Characteristics and an Institutional Protocol for Evaluation, Management, and Follow-Up.

OBJECTIVES: The disease caused by severe acute respiratory syndrome coronavirus 2, known as coronavirus disease 2019, has resulted in a global pandemic. Reports are emerging of a new severe hyperinflammatory syndrome related to coronavirus disease 2019 in children and adolescents. The Centers for Disease Control and Prevention has designated this disease multisystem inflammatory syndrome in children. Our objective was to develop a clinical inpatient protocol for the evaluation, management, and follow-up of patients with this syndrome. DATA SOURCES: The protocol was developed by a multidisciplinary team based on relevant literature related to coronavirus disease 2019, multisystem inflammatory syndrome in children, and related inflammatory syndromes, as well as our experience caring for children with multisystem inflammatory syndrome in children. Data were obtained on patients with multisystem inflammatory syndrome in children at our institution from the pre-protocol and post-protocol periods. DATA SYNTHESIS: Our protocol was developed in order to identify cases of multisystem inflammatory syndrome in children with high sensitivity, stratify risk to guide treatment, recognize co-infectious or co-inflammatory processes, mitigate coronary artery abnormalities, and manage hyperinflammatory shock. Key elements of evaluation include case identification using broad clinical characteristics and comprehensive laboratory and imaging investigations. Treatment centers around glucocorticoids and IV immunoglobulin with biologic immunomodulators as adjuncts. Multidisciplinary follow-up after discharge is indicated to manage continued outpatient therapy and evaluate for disease sequelae. In nearly 2 months, we admitted 54 patients with multisystem inflammatory syndrome in children, all of whom survived without the need for invasive ventilatory or mechanical circulatory support. After institution of this protocol, patients received earlier treatment and had shorter lengths of hospital stay. CONCLUSIONS: This report provides guidance to clinicians on evaluation, management, and follow-up of patients with a novel hyperinflammatory syndrome related to coronavirus disease 2019 known as multisystem inflammatory syndrome in children. It is based on the relevant literature and our experience. Instituting such a protocol during a global pandemic is feasible and is associated with patients receiving treatment and returning home more quickly.

Immune Thrombocytopenia (ITP): Current Limitations in Patient Management.

Primary immune thrombocytopenia (ITP) is an acquired autoimmune disorder characterized by isolated thrombocytopenia caused by increased platelet destruction and impaired platelet production. First-line therapies include corticosteroids, intravenous immunoglobulin, and anti-D immunoglobulin. For patients who are refractory to these therapies, those who become corticosteroid dependent, or relapse following treatment with corticosteroid, options include splenectomy, rituximab, and thrombopoietin-receptor agonists, alongside a variety of additional immunosuppressive and experimental therapies. Despite recent advances in the management of ITP, many areas need further research. Although it is recognized that an assessment of patient-reported outcomes in ITP is valuable to understand and guide treatment, these measures are not routinely measured in the clinical setting. Consequently, although corticosteroids are first-line therapies for both children and adults, there are no data to suggest that corticosteroids improve health-related quality of life or other patient-related outcomes in either children or adults. In fact, long courses of corticosteroids, in either children or adults, may have a negative impact on a patient's health-related quality of life, secondary to the impact on sleep disturbance, weight gain, and mental health. In adults, additional therapies may be needed to treat overt hemorrhage, but unfortunately the results are transient for the majority of patients. Therefore, there is a need to recognize the limitations of current existing therapies and evaluate new approaches, such as individualized treatment based on the probability of response and the size of effect on the patient's most bothersome symptoms and risk of adverse effects or complications. Finally, a validated screening tool that identifies clinically significant patient-reported outcomes in routine clinical practice would help both patients and physicians to effectively follow a patient's health beyond simply treating the laboratory findings and physical symptoms of ITP. The goal of this narrative review is to discuss management of newly diagnosed and refractory patients with ITP, with a focus on the limitations of current therapies from the patient's perspective.