Linking Mesoscale Spatial Variation in Methylmercury Production to Bioaccumulation in Tidal Marsh Food Webs.

Differences in sediment biogeochemistry among tidal marsh features with different hydrological and geomorphological characteristics, including marsh interiors, marsh edges, first-order channels, and third-order channels, can result in spatial variation in MeHg production and availability. To better understand the link between MeHg production in sediments and bioaccumulation in primary and secondary consumer invertebrates and fish, we characterized mesoscale spatial variation in sediment biogeochemistry and MeHg concentrations of sediments, water, and consumer tissues among marsh features. Our results indicated that marsh interiors had biogeochemical conditions, including greater concentrations of organic matter and sulfate reduction rates, that resulted in greater MeHg concentrations in sediments and surface water particulates from marsh interiors compared to other features. Tissue MeHg concentrations of consumers also differed among features, with greater concentrations from marsh edges and interiors compared to channels. This spatial mismatch of MeHg concentrations in sediments and water compared to those in consumers may have resulted from differences in behavior and physiology among consumers that influenced the spatial scale over which MeHg was integrated into tissues. Our results highlight the importance of sampling across a suite of marsh features and considering the behavioral and physiological traits of sentinel taxa for contaminant monitoring studies.

Competitive interactions with Aedes albopictus alter the nutrient content of Aedes aegypti.

Competition is often cited as a central force that affects the distribution and performance of organisms. Ecological stoichiometry is the balance of elements within animal bodies that can be affected by resource acquisition and processing, as well as by intra- or interspecific interactions. Though relatively underexplored for mosquitoes, stoichiometry may provide a wealth of information linking ecological interactions to body nutrient content, and potentially on to pathogen transmission. Detritus, which often varies in nutrient content, forms the base of the food web within the small aquatic habitats occupied by larval mosquitoes, and detrital nutrient content can alter mosquito growth, survival, and population growth. The invasive mosquitoes Aedes albopictus (Diptera: Culicidae) and Aedes aegypti (Diptera: Culicidae) interact as larvae in aquatic systems, often altering their adult populations. Herein, we investigated how different detritus combinations as well as how intra- and interspecific densities of Ae. albopictus and Ae. aegypti would affect coexistence; we also measured how nutrient composition (carbon and nitrogen) and stoichiometry (C:N) of adults would vary with those interactions. Ae. albopictus survival, population growth, and stoichiometry were not affected by intra- or interspecific competition; nutrient values did vary with detritus ratios. However, Ae. aegypti nutrient content and stoichiometry and survival were negatively affected within the lowest nutrient environments in the presence of Ae. albopictus, but in the highest nutrient environments, both species showed high survival rates and population growth. This is the first study to show that adult mosquito body nutrients can be altered by interspecific interactions, and as nutrient content in adults has been linked to pathogen transmission, it provides a novel role of competition in affecting disease dynamics.

Mapping Yellow fever epidemics as a potential indicator of the historical range of Aedes aegypti in the United States.

BACKGROUND: Yellow fever (YF) plagued the United States from the 1690s until 1905, resulting in thousands of deaths. Within the US, Aedes aegypti is the only YF vector and almost no data exists for the location of this species prior to the early 1900s. OBJECTIVES: To determine the historical range of Ae. aegypti we examined the occurrence of YF epidemics across time and space. We hypothesized that historically Ae. aegypti was driven by human population density, like its contemporary range suggests. METHODS: To test this hypothesis, we compiled a list of YF cases in the US, human population density, location, and the number of people infected. This data was mapped using ArcGIS and was analyzed using linear regression models to determine the relationship among variables. FINDINGS: The historic range was generally south of 40º latitude, from Texas in the west to Florida in the east, with concentrations along major waterways like the Mississippi River. Infected individuals and human population density were strongly correlated across the whole dataset as well as by decade. MAIN CONCLUSIONS: Although other factors likely affected the range of Ae. aegypti, we found that human population density was related to the number of people infected with historic YF infections.

Linking nutrient stoichiometry to Zika virus transmission in a mosquito.

Food quality and quantity serve as the basis for cycling of key chemical elements in trophic interactions; yet the role of nutrient stoichiometry in shaping host-pathogen interactions is under appreciated. Most of the emergent mosquito-borne viruses affecting human health are transmitted by mosquitoes that inhabit container systems during their immature stages, where allochthonous input of detritus serves as the basal nutrients. Quantity and type of detritus (animal and plant) were manipulated in microcosms containing newly hatched Aedes aegypti mosquito larvae. Adult mosquitoes derived from these microcosms were allowed to ingest Zika virus-infected blood and then tested for disseminated infection, transmission, and total nutrients (percent carbon, percent nitrogen, ratio of carbon to nitrogen). Treatments lacking high-quality animal (insect) detritus significantly delayed development. Survivorship to adulthood was closely associated with the amount of insect detritus present. Insect detritus was positively correlated with percent nitrogen, which affected Zika virus infection. Disseminated infection and transmission decreased with increasing insect detritus and percent nitrogen. We provide the first definitive evidence linking nutrient stoichiometry to arbovirus infection and transmission in a mosquito using a model system of invasive Ae. aegypti and emergent Zika virus.

Population Pharmacokinetics of Enoxaparin in Pediatric Patients.

BACKGROUND: There are no studies evaluating the pharmacokinetics of enoxaparin in the hospitalized pediatric patient population. OBJECTIVE: To characterize the pharmacokinetics of enoxaparin in pediatric patients. METHODS: A retrospective review of inpatients 1 to 18 years of age admitted to our institution who received enoxaparin with anti-factor Xa activity level monitoring was performed. Demographic variables, enoxaparin dosing, and anti-factor Xa activity levels were collected. Population pharmacokinetic analysis was performed with bootstrap analysis. Simulation (n = 10 000) was performed to determine the percentage who achieved targeted anti-Xa levels at various doses. RESULTS: A total of 853 patients (male 52.1%, median age = 12.2 years; interquartile range [IQR] = 4.6-15.8 years) received a mean enoxaparin dose of 0.86 ± 0.31 mg/kg/dose. A median of 3 (IQR = 1-5) anti-factor Xa levels were sampled at 4.4 ± 1.3 hours after a dose, with a mean anti-factor Xa level of 0.52 ± 0.23 U/mL. A 1-compartment model best fit the data, and significant covariates included allometrically scaled weight, serum creatinine, and hematocrit on clearance, and platelets on volume of distribution. Simulations were run for patients both without and with reduced kidney function (creatinine clearance of ≤30 mL/min/1.73 m2). A dose of 1 mg/kg/dose every 12 hours had the highest probability (72.3%) of achieving an anti-Xa level within the target range (0.5-1 U/mL), whereas a dose reduction of ~30% achieved the same result in patients with reduced kidney function. CONCLUSIONS: Pediatric patients should initially be dosed at 1-mg/kg/dose subcutaneously every 12 hours for treatment of thromboembolism followed by anti-Xa activity monitoring. Dose reductions of ~30% for creatinine clearance ≤30 mL/min/1.73 m2 are required.

Improving evidence on anticoagulant therapies for venous thromboembolism in children: key challenges and opportunities.

Venous thromboembolism (VTE) is increasingly diagnosed in pediatric patients, and anticoagulant use in this population has become common, despite the absence of US Food and Drug Administration (FDA) approval for this indication. Guidelines for the use of anticoagulants in pediatrics are largely extrapolated from large randomized controlled trials (RCTs) in adults, smaller dose-finding and observational studies in children, and expert opinion. The recently FDA-approved direct oral anticoagulants (DOACs), such as dabigatran, rivaroxaban, apixaban, and edoxaban, provide potential advantages over oral vitamin K antagonists and subcutaneous low-molecular-weight heparins (LMWHs). However, key questions arise regarding their potential off-label clinical application in pediatric thromboembolic disease. In this Perspective, we provide background on the use of LMWHs such as enoxaparin as the mainstay of treatment of pediatric provoked VTE; identify key questions and challenges with regard to DOAC trials and future DOAC therapy in pediatric VTE; and discuss applicable lessons learned from the recent pilot/feasibility phase of a large multicenter RCT of anticoagulant duration in pediatric VTE. The challenges and lessons learned present opportunities to improve evidence for anticoagulant therapies in pediatric VTE through future clinical trials.

Population pharmacokinetics of human antithrombin concentrate in paediatric patients.

AIMS: Antithrombin is increasingly used in paediatric patients, yet there are few age-specific pharmacokinetic data to guide dosing. We aimed to describe the pharmacokinetic profile of human (plasma-derived) antithrombin concentrate in paediatric patients. METHODS: A 5-year retrospective review was performed of patients <19 years of age admitted to our institution who received antithrombin concentrate, were not on mechanical circulatory support and had baseline (predose) and postdose plasma antithrombin activity levels available for analysis. Demographic and laboratory variables, antithrombin dosing information and data on the use of continuous infusion unfractionated heparin were collected. Population pharmacokinetic analysis was performed with bootstrap analysis. The model developed was tested against a validation dataset from a cohort of similar patients, and a predictive value was calculated. RESULTS: A total 184 patients met the study criteria {46.7% male, median age [years] 0.35 [interquartile range (IQR) 0.07-3.9]}. A median of two antithrombin doses (IQR 1-4) were given to patients (at a dose of 46.3 ± 13.6 units kg-1 ), with median of three (IQR 2-7) postdose levels per patient. Continuous infusion unfractionated heparin was administered in 87.5% of patients, at a mean dose of 34.1 ± 22.7 units kg-1 h-1 . A one-compartment exponential error model best fit the data, and significant covariates included allometrically scaled weight on clearance and volume of distribution, unfractionated heparin dose on clearance, and baseline antithrombin activity level on volume of distribution. The model resulted in a median -1.75% prediction error (IQR -11.75% to 6.5%) when applied to the validation dataset (n = 30). CONCLUSIONS: Antithrombin pharmacokinetics are significantly influenced by the concurrent use of unfractionated heparin and baseline antithrombin activity.

Enoxaparin Population Pharmacokinetics in the First Year of Life.

AIMS: Enoxaparin dosing requirements in the first year of life can be highly variable. Characterization of pharmacokinetics in this patient population can assist in dosing. METHODS: Patients less than 1 year postnatal age who received enoxaparin and had an anti-factor Xa activity level drawn as inpatients were identified through the pharmacy database over a 5-year period. Patients on renal replacement therapy or with hyperbilirubinemia were excluded. Data collection included demographic variables, indication for enoxaparin, enoxaparin doses, anti-factor Xa activity levels, serum creatinine, hemoglobin, hematocrit, platelet count, and urine output over the previous 24 hours. Population pharmacokinetic analysis was performed with NONMEM. RESULTS: A total of 182 patients [male 50%, median 100 days postnatal age (range: 4-353 days)] met the study criteria. Patients received median 22 doses (range: 1-526) at a mean starting dose of 1.38 ± 0.43 mg/kg with median 5 (range: 1-56) anti-factor Xa activity levels measured. A 1-compartment proportional and additive error model best fits the data. Allometrically scaled weight significantly decreased the objective function value, as did serum creatinine on clearance, and postmenstrual age (PMA) on volume of distribution. When evaluated graphically, dosing based on PMA appeared to have less variability as compared to postnatal age-based dosing. CONCLUSIONS: Dosing of enoxaparin in infants younger than 1 year should incorporate PMA.

Association of outcomes and anti-Xa levels in the treatment of pediatric venous thromboembolism.

BACKGROUND: There are few data in the pediatric population evaluating the relationship between measured anti-Xa levels during enoxaparin therapy and thrombotic outcomes. OBJECTIVE: To determine whether there is a difference in outcomes in children who receive enoxaparin with mean anti-Xa levels between 0.45 and 0.79 unit/ml (low therapeutic range) versus between 0.80 and 1.05 unit/ml (high therapeutic range) throughout their course of their treatment. METHODS: We retrospectively identified subjects with uncomplicated venous thromboembolism treated with enoxaparin. RESULTS: Of 69 patients with any response to therapy, 48 (70%) had mean anti-Xa levels in the low therapeutic range and 21 (30%) had mean anti-Xa levels in the high therapeutic range. Of 20 patients with no documented response to therapy, 13 (65%) had mean anti-Xa levels in the low therapeutic range and 7 (35%) had mean anti-Xa levels in the high therapeutic range. Forty-eight (79%) of the 61 patients with low-range mean anti-Xa level had any response to therapy. Twenty-one (75%) of the 28 patients with high-range mean anti-Xa level had any response to therapy. Chi-square test (P = 0.080) and logistic regression (OR = 1.23, P = 0.70) demonstrated no significant association between mean anti-Xa range (lower vs. upper) and therapy response. CONCLUSIONS: There was no statistically significant difference between low-range versus high-range mean anti-Xa levels and thrombus resolution. Empiric clinical practices of targeting anti-Xa levels in the higher therapeutic range to achieve better outcomes may not be warranted.

Pediatric Acquired von Willebrand Syndrome in Cardiopulmonary Disorders: Do Laboratory Abnormalities Predict Bleeding Risk?

There are conflicting reports on whether or not laboratory abnormalities in pediatric acquired von Willebrand syndrome (AVWS) predict bleeding manifestations in patients with cardiopulmonary disorders (CPD). We retrospectively reviewed charts of patients with AVWS and CPD (n=16) seen at Texas Children's Hospital from 2003 to 2012. The most common CPD were valve stenoses, ventricular septal defects, and pulmonary hypertension. All patients had loss of high molecular weight multimers. Fifteen (94%) patients presented with bleeding symptoms, with menorrhagia and epistaxis being the most common. Von Willebrand ristocetin cofactor activity (VWF:RCo), as well as the use of anticoagulant or antiplatelet medication, did not predict bleeding manifestations (P=0.70 and 0.84, respectively). VWF:RCo/VWF antigen (Ag) ratio of <0.7 was significantly associated with presence of bleeding symptoms. All patients who had complete repair of their cardiac defect experienced normalization of VWF multimers and VWF:RCo/Ag ratio, as well as bleeding symptom resolution. We conclude that increased bleeding risk is associated with low VWF:RCo/Ag ratio in pediatric AVWS due to CPD. However, other laboratory abnormalities such as VWF:RCo level and qualitative multimer analysis, do not appear to predict bleeding. Future studies exploring quantification of multimer loss may be helpful in further assessing bleeding risk associations.

Oviposition preference and offspring performance in container breeding mosquitoes: evaluating the effects of organic compounds and laboratory colonisation.

The preference-performance hypothesis predicts that organisms lacking parental care should oviposit in habitats that optimize offspring performance. We investigated preference-performance relationships for the Asian tiger mosquito (Aedes albopictus Skuse) and the southern house mosquito (Culex quinquefasciatus Say) (Diptera:Culicidae), two medically important container-breeding species, in response to an organic chemical blend mimicking decaying plant matter. Additionally, we evaluated the effects of long-term laboratory colonization of Cx. quinquefasciatus by using wild and laboratory strains.Oviposition bioassays were conducted by releasing gravid mosquitoes into field enclosures with automobile tires containing low and high concentrations of the chemical blend, and water controls. The offspring were then reared in water collected from the tires in which they were deposited.Aedes albopictus and wild Cx. quinquefasciatus laid more eggs in the chemical blend than water controls but did not differentiate between the low and high concentrations. Conversely, laboratory Cx. quinquefasciatus only preferred the high concentration to the low concentration. No statistical associations between oviposition preference and larval survival were found, as the chemical blend did not affect survivorship of either species.The oviposition preference for the chemical blend over water controls suggests that both species oviposit in the best available resource environment, but further studies are needed before conclusions regarding preference-performance relationships can be drawn.We found that long-term laboratory colonization affects oviposition behavior in Cx. quinquefasciatus, suggesting that behavioral studies on laboratory strains are not always applicable to wild populations.

A Statewide Survey for Container-Breeding Mosquitoes in Mississippi.

Container-breeding mosquitoes are important in public health due to outbreaks of Zika, chikungunya, and dengue viruses. This paper documents the distribution of container-breeding mosquito species in Mississippi, with special emphasis on the genus Aedes. Five sites in each of the 82 Mississippi counties were sampled monthly between May 1 and August 31, 2016, and 50,109 mosquitoes in 14 species were collected. The most prevalent and widely distributed species found was Ae. albopictus, being found in all 82 counties, especially during July. A recent invasive, Ae. japonicus, seems to be spreading rapidly in Mississippi since first being discovered in the state in 2011. The most abundant Culex species collected were Cx. quinquefasciatus (found statewide), Cx. salinarius (almost exclusively in the southern portion of the state), and Cx. restuans (mostly central and southern Mississippi). Another relatively recent invasive species, Cx. coronator, was found in 20 counties, predominantly in the southern one-third of the state during late summer. Co-occurrence data of mosquito species found in the artificial containers were also documented and analyzed. Lastly, even though we sampled extensively in 410 sites across Mississippi, no larval Ae. aegypti were found. These data represent the first modern statewide survey of container species in Mississippi, and as such, allows for better public health readiness for emerging diseases and design of more effective vector control programs.

Interspecific Interactions Between Adult Aedes albopictus and Culex quinquefasciatus (Diptera: Culicidae).

Single and mixed species densities of adult Aedes albopictus and Culex quinquefasciatus were manipulated to determine if different combinations affected their egg laying preference or mortality rates. Oviposition was measured in environments that contained containers of different surface areas (small cups vs. larger bowls), and the number of eggs (Aedes) and egg rafts or larvae (Culex) deposited by each species was examined with respect to intra- and interspecific density treatment levels. Mixed species densities did not have an effect on survivorship, but single species densities did affect longevity, with higher densities leading to shorter life spans in Cx. quinquefasciatus: Cx. quinquefasciatus lived longer than Ae. albopictus overall. There was no significant effect of density combinations on oviposition patterns in either species, but Cx. quinquefasciatus laid more rafts in bowls compared with cups. There is little evidence of adult interactions between these species; however, future experimental work is necessary to more fully characterize the possible effects of adult interactions on these species.

Validation Study of the Composite Score to Identify Von Willebrand Disease in Children.

BACKGROUND: The diagnosis of type 1 von Willebrand disease (VWD) presents a diagnostic challenge in children. In fact, 25% or more of children with VWD may be diagnosed only after they experience postoperative bleeding. We previously described a 4-variable composite score that has 92.5% sensitivity and 95% specificity for diagnosing VWD in children with known VWD when 2 of 4 criteria are positive: (1) Tosetto bleeding score ≥ 1; (2) family history of VWD; (3) personal history of iron deficiency anemia; and/or (4) positive James early bleeding score. The purpose of this study was to prospectively validate a composite score of ≥ 2 for identifying children with VWD. PROCEDURE: Children without a previously diagnosed bleeding disorder presenting for hematology evaluation were enrolled. Sensitivity, specificity, positive, and negative predictive value of the composite score was determined. RESULTS: A total of 193 subjects were enrolled from 12 participating centers were included in the analysis. Forty-seven children had type 1 VWD, including 11 with von Willebrand Ristocetin Cofactor (VWF):RCo < 30 IU/dL, 14 subjects with a VWF:RCo 30 to 39 IU/dL, and 22 with a VWF:RCo 40 to 49 IU/dL. Including all 4 variables, a composite score of ≥ 2 had a sensitivity of 63.6% to 76.0%, specificity of 33.5% to 35.1%, negative predictive value of 76.9% to 93.8%, and positive predictive value of 5.5% to 25%. CONCLUSIONS: The negative predictive value of the composite score was robust, especially at lower VWF:RCo suggesting that VWD testing could be eliminated in nearly a third of children referred for VWD testing.

Antithrombin Concentrate Use in Children Receiving Unfractionated Heparin for Acute Thrombosis.

OBJECTIVE: To characterize features of antithrombin concentrate (ATC) use in children receiving unfractionated heparin (UFH) therapy for acute thrombosis. STUDY DESIGN: All pediatric patients at Texas Children's Hospital who received ATC in the context of UFH therapy for acute thrombosis during February 2011 to May 2013 were analyzed. RESULTS: Fifty-one children received ATC during UFH therapy for acute thrombosis. Median age was 3 months (IQR 1 to 18 months). Clinical indications included venous (53%), arterial (37%), venous and arterial (6%), and intracardiac (4%) thrombosis. Median baseline antithrombin (AT) level was 61% and UFH dose was 26 U/kg/h. The median dose of ATC was 49.9 IU/kg (IQR 32.6 to 50.0 IU/kg). Although most patients (86%) did not undergo a change in UFH dose, there was a significant increase in both AT and anti-factor Xa level after the first dose of ATC (P < .001 for both). There was no correlation between ATC dose or increment in AT level above baseline and the achievement of targeted anticoagulation by anti-factor X activity level. Adverse bleeding events occurred in 10% of patients. CONCLUSIONS: There was a significant change in AT and anti-factor Xa activity level after a single dose of ATC despite little to no change in dose of UFH. ATC appears to facilitate anticoagulation with UFH in some children with acute thrombosis but the degree of response is variable and dependent on factors identified in this study. Bleeding and other theoretical risks must be carefully considered.

Declines in polybrominated diphenyl ether contamination of San Francisco Bay following production phase-outs and bans.

California has implemented unique consumer product flammability standards. Polybrominated diphenyl ether (PBDE) flame retardants were once widely incorporated into products to meet these standards, but concerns regarding toxicity and accumulation in humans and biota led to nationwide phase-outs and state bans. A decade of PBDE monitoring in San Francisco Bay has resulted in a data set that covers periods during and after PBDE use and consists of hundreds of measurements of water, sediment, and biota. While PBDEs remain widely detected in biota, levels have declined by nearly half in sport fish and 74-95% in bivalves and bird eggs. Concentrations of BDE-47 in sediment have dropped by over one-third from 2002 to 2012; in water, a decline is not yet evident. The dominant congener in sediment, DecaBDE component BDE-209, showed no temporal trend. U.S. production of DecaBDE ended in 2013; future monitoring may reveal declines. Overall, the data indicate that reduced production can result in relatively rapid reductions in the concentrations of some hydrophobic contaminants in biota and sediment, particularly when implemented after only a few decades of heavy use. Recent changes to California's flammability standards may lessen the use of other flame retardants and similarly reduce Bay contamination.

Mosquito Larvae in Tires from Mississippi, United States: The Efficacy of Abiotic and Biotic Parameters in Predicting Spatial and Temporal Patterns of Mosquito Populations and Communities.

Container systems, including discarded vehicle tires, which support populations of mosquitoes, have been of interest for understanding the variables that produce biting adults that serve as both nuisances and as public health threats. We sampled tires in six sites at three times in 2012 across the state of Mississippi to understand the biotic and abiotic variables responsible for explaining patterns of larvae of common species, species richness, and total abundance of mosquitoes. From 498 tires sampled, we collected >58,000 immatures representing 16 species, with the most common species including Aedes albopictus (Skuse), Culex quinquefasciatus (L.), Orthopodomyia signifera (Coquillett), Aedes triseriatus (Say), Toxorhynchites rutilus septentrionalis (Coquillett), and Culex territans (Walker) accounting for ∼97% of all larvae. We also documented 32 new county records for resident species and recent arrivals in the state, including Aedes japonicus japonicus (Theobald) and Culex coronator (Dyar & Knab). Cluster analysis, which was used to associate sites and time periods based on similar mosquito composition, did reveal patterns across the state; however, there also were more general patterns between species and genera and environmental factors. Broadly, Aedes was often associated with factors related to detritus, whereas Culex was frequently associated with habitat variables (e.g., tire size and water volume) and microorganisms. Some Culex did lack factors connecting variation in early and late instars, suggesting differences between environmental determinants of oviposition and survival. General patterns between the tire environment and mosquito larvae do appear to exist, especially at the generic level, and point to inherent differences between genera that may aid in predicting vector locations and populations.

Age-related differences in urinary 11-dehydroxythromboxane B2 between infants, children, and adolescents: another example of developmental hemostasis?

Our study was developed to ascertain reference ranges of 11-dehydrothromboxane B2 (11-dhTXB2) in the urine of healthy pediatric subjects. Urine samples were analyzed using the AspirinWorks™ assay that measures levels of 11-dehydrothromboxane B2. 128 individuals (2 months to 18 years) were identified as healthy and not receiving aspirin. When adjusted as picograms/milligrams urine creatinine, there was a negative correlation between age and level of 11-dehydrothromboxane B2 (P = 0.0001). This study confirms a negative correlation between age and level of urinary 11-dehydrothromboxane B2 and provides a set of age-specific reference ranges.

Catheter-directed thrombolysis for severe pulmonary embolism in pediatric patients.

BACKGROUND: Catheter-directed thrombolytic (CDT) therapies for severe pulmonary embolism (PE) have been shown to be effective and safe when compared with systemic thrombolysis in adults. Pediatric studies assessing efficacy and safety of CDT for PE are lacking. Hence, our aim was to review CDT as a therapy for pediatric PE. METHODS: We retrospectively reviewed charts of patients aged <18 years, who underwent CDT for main or major branch pulmonary artery occlusion associated with hypotension or right ventricular dysfunction secondary to PE during a 3-year period, in our tertiary care academic Pediatric Intensive Care Unit. RESULTS: Six CDT interventions were performed on 5 patients with PE (median age: 16.5 years). All patients presented with chest pain and dyspnea. The predisposing factors for thrombogenesis differed in all patients, and all had multiple risk factors. Five of six procedures (83%) were accompanied by ultrasound agitation with EKOS endowave infusion system (ultrasound-accelerated CDT [UCDT]), whereas 1 had CDT without ultrasound agitation. Complete resolution of PE occurred in 4 instances (67%) at 24 hr, whereas in 2 cases (33%), there was partial resolution. One patient with complete resolution underwent another successful UCDT after 4 months for recurrence. Clinical parameters (heart rate, respiratory rate, blood pressure, and oxygen saturations) and echocardiographic findings improved after treatment in all the patients. Median duration of hospital stay was 9 days with no mortality and treatment-related complications. All patients were discharged with long-term anticoagulation. CONCLUSIONS: Our case series is the first that describes CDT/UCDT as an effective and safe therapy for pediatric patients with severe PE. CDT is known to accelerate fibrinolysis via focused delivery of thrombolytic agent to the thrombus site. For carefully selected patients, CDT/UCDT provides a useful treatment option for severe PE irrespective of the etiology, predisposing conditions, and associated comorbidities.

Evaluation of weight-based dosing of unfractionated heparin in obese children.

OBJECTIVE: To determine whether pediatric patients with obesity receiving weight-based dosages of unfractionated heparin (UFH) exhibit an enhanced response when dosed by actual body weight compared with nonobese patients as assessed primarily by the frequency of supratherapeutic anticoagulation. Secondary measures included UFH doses associated with therapeutic anticoagulation. STUDY DESIGN: This single-institution retrospective case-matched study included children with and without obesity, matched on a 1:1 basis, who received a weight-based continuous infusion of UFH. Therapeutic monitoring values were defined for activated partial thromboplastin time (aPTT) level (70-101 seconds) and anti-activated factor X (Xa) level (0.35-0.7 U/mL). RESULTS: The study included 50 children. The percentage of patients with supratherapeutic anticoagulation at any point in the study, as measured by either aPTT or anti-Xa level, was similar in the obese and nonobese groups (76% vs 72%; P = 1.0). However, compared with patients without obesity, those with obesity received a lower mean starting dose (17.4 vs 20.2 U/kg/hour; P = .013) and a lower mean maintenance dose (19.1 vs 24.3 U/kg/hour; P = .033) to achieve stable therapeutic monitoring test values. There was no difference in mean initial post-UFH aPTT between the 2 groups, but the mean initial anti-Xa level was higher in the obese group (0.45 vs 0.29 U/mL; P = .045). CONCLUSION: Compared with children without obesity, those with obesity who received actual body weight-based continuous UFH infusions did not exhibit a higher frequency of supratherapeutic anticoagulation, but did require lower dosages to achieve comparable anticoagulation. Our results highlight recognized discrepancies between aPTT and anti-Xa monitoring assays.