57 Background: Pediatric acute lymphoblastic leukemia (ALL) protocols currently include steroids during induction therapy, which may lead to hyperglycemia. Published pediatric and adult leukemia data demonstrate increased rates of infection and mortality associated with hyperglycemia. Presently, there are no accepted recommendations for how to track blood glucose (BG) levels, so hyperglycemia may go undetected. A random review of 20 patients diagnosed with ALL during a 4-month period in 2014 at Texas Children’s Cancer Center (TXCCC) demonstrated that only 40% had BG checked throughout induction. The SMART aim of this quality improvement project was to increase BG screening rates to > 95% during first week of treatment and induction days 8, 15, 22 and 29 for patients with newly diagnosed ALL at TXCCC in a 15-month period. Methods: PDSA cycle 1 involved sticker reminders on treatment roadmaps by days that required a BG check. PDSA cycle 2 entailed reminder flyers in patient care areas and no further roadmap stickers. Primary outcome measure was the percentage of successful occurrences for BG checks on days 8, 15, 22, 29. Secondary outcome measure was the percentage of patients who needed insulin therapy. Results: TXCCC had 97 new ALL patients during March 2015 to May 2016. Providers obtained 333 of 372 possible BG checks (90%) on days 8, 15, 22, 29. Thirty-nine percent of patients developed hyperglycemia ≥ 200 mg/dL. Eighteen percent patients required insulin therapy. Eighty-nine percent of patients had their peak blood glucose by day 8, and 82% of patients who required insulin were started on insulin prior to day 8. Conclusions: We improved hyperglycemia screening rates for TXCCC ALL patients in induction from 40% to 90% by implementing reminder processes for providers. The roadmap stickers were replaced with reminder flyers for sustainability. Because the peak BG was reached by 89% of patients by day 8 of therapy, our efforts are now being directed at improving screening and interventions prior to day 8. Our goal is to standardize BG screening and hyperglycemia intervention algorithms to decrease both the time-to-initiation for insulin and readmission rate for symptomatic hyperglycemia for ALL patients at TXCCC.
Heterozygous mutations in Factor V Leiden (FVL) or prothrombin G20210A
(PT-G20210A) are relatively common; the presence of
double-heterozygosity for these mutations is rare but may be as high as
5% in patients with deep vein thrombosis (DVT). Antiphospholipid
syndrome (APS) is a rare autoimmune disorder and commonly presents in
adolescents and young adults. This report describes the diagnosis,
treatment, and outcome for acute presentation of extensive lower
extremity DVT and saddle pulmonary embolism (PE) in a previously healthy
17-year-old male found to have multiple genetic risk factors including
double-heterozygosity for FVL/PT-G20210A and concurrent APS, which is
rare and not well-described.
Sinusoidal obstruction syndrome (SOS) of the liver is a complication of chemotherapy most often encountered with hematopoietic stem cell transplant due to high-dose conditioning regimens, but it can also occur with regimens outside of the transplant setting. Mild-to-moderate SOS is a well-described 6-thioguanine toxicity; however, it has rarely been reported as secondary to 6-mercaptopurine, a related thiopurine. This report details a case of a 10-year-old male with T-cell acute lymphoblastic leukemia who developed severe SOS during maintenance therapy with 6-mercaptopurine, and a review of the related literature.
Objectives: Sickle cell disease (SCD) is well recognized as a
hypercoagulable state, however venous thromboembolism (VTE) risk factors
in children remain largely unknown. In this study, we aim to describe
the clinical characteristics, outcomes and recurrence of hospital
acquired VTE in patients younger than 21 years of age. Study
Design/Methods: Data were extracted from electronic medical records
over a 10-year period (2011-2021). Data regarding sickle cell genotype,
demographics, reason for admission, location of thrombus, presence of
central venous catheter (CVC), intensive care unit (ICU) admission,
presence of thrombophilia risk factors, resolution of VTE, mortality,
and bleeding outcomes on anticoagulation were collected. Recurrence of
VTE at 1 and 5 years was assessed. Descriptive statistics were used as
indicated. Results: We identified a total of 21 VTE events over
the ten-year study period. Six of these events occurred in those younger
than 12 years of age. Fifteen (71%) VTE events occurred in the HbSS or
HbSβThal genotypes compared to 8 (29%) in HbSC.
Eleven (52%) patients were admitted with acute chest syndrome (ACS).
Most VTE events were associated with ICU admissions (n=13, 62%) and
presence of central venous catheter (n=12, 57%). Major bleeding on
anticoagulation occurred in 10%.All patients had resolution of index
VTE at 12 weeks. Recurrence rate for VTE at 5 years was 13%. One
patient died from the VTE event. Conclusions: Our study
highlights that VTE can complicate SCD in children and young adults.
Hospital acquired VTE were most associated with ICU admission, CVC, and
ACS, but larger studies are indicated to validate our findings.
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