COVID-19 outcomes in a large pediatric hematology-oncology center in Houston, Texas.

An understanding of the behavior of SARS-CoV-2 in pediatric hematology-oncology patients is essential to the optimal management of these patients during the COVID-19 pandemic. This study describes the characteristics and outcomes of COVID-19 disease in children with cancer or hematologic disorders treated at a large children's hospital. A retrospective cohort study was conducted at Texas Children's Cancer and Hematology Center from January 1, 2020 to September 30, 2020. All patients with a primary hematology-oncology diagnosis and SARS-CoV-2 positivity by reverse transcription polymerase chain reaction were identified. Clinical and laboratory data were obtained from the medical record. Descriptive analyses were performed to evaluate COVID-19-related outcomes and risk factors for severe disease in this population. We identified 109 patients with COVID-19 disease, including 52 hematology, 51 oncology, and 6 HSCT patients; median age was 10.3 years (IQR 4.4-15.9), and 58.7% were male. Seventy-four percent of the patients were managed in the outpatient setting. Patients with sickle cell disease were more likely to require hospitalization. ICU care was needed in 8% (n = 9) of the entire cohort, and mechanical ventilation was required in 6.4% (6 oncology patients, 1 hematology patient). COVID-19 contributed to the deaths of two cancer patients. No deaths occurred in hematology or HSCT patients. In conclusion, the risk of severe COVID-19 complications is slightly higher in pediatric hematology-oncology patients than in the general pediatric population but lower than initially feared. For most asymptomatic patients, primary disease management may continue as planned, but treatment decisions must be individualized.

An outpatient Urgent Care Bay within a pediatric cancer and hematology center.

Time-sensitive medical care is essential for pediatric patients undergoing treatment for a hematologic or oncologic condition. Such patients commonly experience acute symptoms related to routine childhood illness and/or their underlying disease or therapy. An Urgent Care Bay (UCB) staffed by a designated nurse and medical provider was established within Texas Children's Cancer Center Outpatient Clinic to provide time-sensitive, same-day diagnostic and therapeutic medical care during clinic hours for patients with acute, non-life-threatening symptoms. The number of patients seen in UCB, chief complaint, underlying diagnosis, and disposition was reviewed. To establish timeliness of care, the authors reviewed the time of referral to the UCB provider or nurse, time of arrival to UCB, time evaluated by providers, and time of initiation of treatment. The addition of an UCB to Texas Children's Cancer Center Outpatient Clinic has shown to allow for rapid assessment and initiation of treatment while avoiding unnecessary emergency room care.

Lupus anticoagulant assays: questions answered and to be answered.

CONTEXT: Lupus anticoagulants are antibodies with heterogenous specificities to phospholipids. They have been associated with clinical syndromes consisting of thrombosis and recurrent fetal loss. OBJECTIVE: To address questions about the laboratory assay aspects of lupus anticoagulants. This review is intended for clinicians managing lupus anticoagulant testing in clinical laboratories. DATA SOURCES: Published literature on lupus anticoagulants, with emphasis on laboratory assay methods. CONCLUSIONS: Although there are published criteria for confirming the presence of a lupus anticoagulant, there is no consensus on assay methods for lupus anticoagulant testing. The mixing study is a useful screening test for lupus anticoagulants, but it may have limited utility. Clinical context may necessitate the performance of factor assays in addition to lupus anticoagulant testing to rule out factor deficiency or factor-specific inhibitor. Additionally, the presence of different anticoagulants may affect the reliability of lupus anticoagulant assays. Lupus anticoagulants are an independent risk factor for thrombosis. It may be useful to use different assays when there is clinical suspicion for a lupus anticoagulant. When testing for lupus anticoagulants, clinicians must carefully consider the clinical context because factor assays may also be indicated.

Increased pulmonary artery pressures among adolescents with sickle cell disease.

The prevalence of pulmonary hypertension (PHT) among adolescents with sickle cell disease (SCD) is unknown. A tricuspid regurgitant (TR) jet peak velocity of 2.5 m/s or more is a screening test for PHT. The authors retrospectively reviewed echocardiograms and clinical data of adolescents followed at the Texas Children's Sickle Cell Center. Of 80 evaluable adolescents with SCD and echocardiogram data, 21 (26%) had a TR jet velocity of 2.5 m/s or more. Of these 21 patients with PHT, 12 (57%) had an echocardiogram performed during an inpatient stay for vaso-occlusive crisis (n = 6), acute chest syndrome (n = 4), fever (n = 1), or seizures (n = 1), and 9 (43%) had an echocardiogram performed as an outpatient in a baseline state of health. Elevation of pulmonary artery pressures was common in this adolescent cohort, but clinical symptoms were rare. Prospective study is warranted to determine the prevalence and course of elevated pulmonary artery pressures in this age group.

The role of bone marrow evaluation in the staging of patients with otherwise localized, low-risk neuroblastoma.

BACKGROUND: Bone marrow aspirations and biopsies are standard staging procedures for neuroblastoma because the tumor frequently metastasizes to the bone marrow. The presence of bone marrow metastases indicates stage 4 or 4S neuroblastoma by International Neuroblastoma Staging System (INSS) criteria; these stages are also associated with other metastatic sites of disease. We questioned whether bone marrow studies changed the staging or treatment of children with localized, completely resected tumors if there was no other evidence of metastatic spread. If stage of disease rarely changed with bone marrow results, it might be possible to avoid this procedure in a subset of patients with neuroblastoma. PROCEDURE: The staging studies of patients with INSS stage 1 (n = 29), 4 (n = 60), and 4S (n = 13) neuroblastoma from two institutions were reviewed. RESULTS: There were no patients upstaged from stage 1 to 4 or 4S by bone marrow metastases alone. Fifty-nine of 60 stage 4 patients had other sites of metastases on imaging studies, the remaining patient had an unresectable primary tumor and marrow disease. All subjects with stage 4S disease had liver metastases. CONCLUSIONS: Bone marrow studies did not contribute data that changed the stage of patients who had surgically resectable tumors and no evidence of metastatic spread on imaging studies. When present, metastatic spread to the marrow was associated with advanced local tumors or other sites of metastatic disease. Given the relatively small size of our study population, further studies are warranted that investigate the utility of bone marrow studies for patients who otherwise have INSS stage 1 neuroblastoma.

Outcomes for children with gallbladder abnormalities and sickle cell disease.

OBJECTIVE: To determine whether elective cholecystectomy is justifiable in children with sickle cell disease (SCD), gallbladder abnormalities, and minimal clinical symptoms. STUDY DESIGN: A retrospective review comparing clinical presentations and abdominal ultrasound results with outcomes in 146 children with SCD. RESULTS: Ultrasound examination showed sludge or stones in 83 of 146 children (57%). This was found during a diagnostic ultrasound in 59 patients (71%) and during a screening ultrasound in 24 asymptomatic patients (29%). Fifty-four (65%) children with a positive ultrasound underwent cholecystectomy; 13 of these were initially asymptomatic patients who had subsequent development of clinical symptoms. Of the patients with cholecystectomy, 93% had histopathologic evidence of cholecystitis. Perioperative complications were rare, and there were no episodes of postoperative acute chest syndrome. Children who underwent elective surgery had an average 12-days-shorter overall hospital stay than those who underwent emergent surgery (4 vs 16 days, P <.001). CONCLUSIONS: Elective laparoscopic cholecystectomy may be safely performed in children with SCD. Surgery should be strongly considered at the time of gallstone diagnosis before symptoms or complications develop. Histopathologic chronic cholecystitis does not correlate with clinical symptoms.