Hemoglobin concentration and body mass index are determinants of plasma von Willebrand factor and factor VIII levels.

BACKGROUND: Von Willebrand Disease (VWD) is the most common inherited bleeding disorder. VWD is characterized by an abnormal quantity or quality of von Willebrand Factor (VWF). Anemia is often found at presentation for a bleeding disorder evaluation due to chronic blood loss. OBJECTIVES/HYPOTHESIS: We hypothesized that anemia is associated with elevations in both VWF and factor VIII (FVIII) over baseline. We also hypothesized that obesity would be associated with increased levels of VWF. METHODS: We conducted a single-center review of the electronic health record for patients that had proximal von Willebrand profiles and Hb data. RESULTS: We identified 4552 unique subjects with VWF studies and a CBC within 24 h. We found that decreasing hemoglobin inversely correlated with VWF antigen, VWF ristocetin cofactor activity, and FVIII activity. We also found that obesity and Black race were independently associated with increased VWF antigen, activity, and FVIII activity. Hb, race, and body mass index (BMI) continued to be determinants of VWF and FVIII levels in multivariable analysis. CONCLUSION: Our study demonstrates that anemia, race, and BMI were found to be associated with elevation of VWF antigen, VWF activity, and FVIII levels. As many individuals with anemia present for evaluation for a bleeding disorder, these variables need to be considered. KEY POINTS: - Anemia was found to be associated with elevation of VWF antigen, VWF activity and FVIII levels. - Testing von Willebrand factor at times of anemia may mask a diagnosis of von Willebrand Disease.

Sustained reductions in time to antibiotic delivery in febrile immunocompromised children: results of a quality improvement collaborative.

BACKGROUND: Timely delivery of antibiotics to febrile immunocompromised (F&I) paediatric patients in the emergency department (ED) and outpatient clinic reduces morbidity and mortality. OBJECTIVE: The aim of this quality improvement initiative was to increase the percentage of F&I patients who received antibiotics within goal in the clinic and ED from 25% to 90%. METHODS: Using the Model of Improvement, we performed Plan-Do-Study-Act cycles to design, test and implement high-reliability interventions to decrease time to antibiotics. Pre-arrival interventions were tested and implemented, followed by post-arrival interventions in the ED. Many processes were spread successfully to the outpatient clinic. The Chronic Care Model was used, in addition to active family engagement, to inform and improve processes. RESULTS: The study period was from January 2010 to January 2015. Pre-arrival planning improved our F&I time to antibiotics in the ED from 137 to 88 min. This was sustained until October 2012, when further interventions including a pre-arrival huddle decreased the median time to <50 min. Implementation of the various processes to the clinic delivery system increased the mean percentage of patients receiving antibiotics within 60 min to >90%. In September 2014, we implemented a rapid response team to improve reliable venous access in the ED, which increased our mean percentage of patients receiving timely antibiotics to its highest rate (95%). CONCLUSIONS: This stepwise approach with pre-arrival planning using the Chronic Care Model, followed by standardisation of processes, created a sustainable improvement of timely antibiotic delivery in F&I patients.