Comparison of Time Within Therapeutic Range Using Anti-Factor Xa Versus Activated Partial Thromboplastin Time Monitoring of Unfractionated Heparin in Children.

OBJECTIVE: To compare unfractionated heparin (UFH) monitoring using time in therapeutic range of activated partial thromboplastin time (aPTT) versus anti-factor Xa activity (anti-Xa) in children. METHODS: This retrospective chart review, with data between October 2015 and October 2019, included pediatric patients younger than 18 years on therapeutic UFH infusion with aPTT or anti-Xa monitoring. Patients receiving extracorporeal membrane oxygenation, dialysis, concomitant anticoagulants, prophylactic UFH, no stated goal, and UFH administered for less than 12 hours were excluded. The primary outcome compared the percentage of time in therapeutic range between aPTT and anti-Xa. Secondary outcomes included time to first therapeutic value, UFH infusion rates, mean rate adjustments, and adverse events. RESULTS: A total of 65 patients were included, with 33 aPTT patients and 32 anti-Xa patients, representing 39 UFH orders in each group. Baseline characteristics were similar between groups, with an overall mean age of 1.4 years and mean weight of 6.7 kg. The anti-Xa cohort demonstrated a statistically significantly higher percentage of time in therapeutic range compared with the aPTT group (50.3% vs 26.9%, p = 0.002). The anti-Xa group also demonstrated a trend toward decreased time to first therapeutic value compared with aPTT (14 vs 23.2 hours, p = 0.12). Two patients in each group experienced new or worsening thrombosis. Six patients in the aPTT cohort experienced bleeding. CONCLUSIONS: This study demonstrated greater time was spent within therapeutic range for children receiving UFH monitored with anti-Xa compared with aPTT. Future studies should assess clinical outcomes in a larger population.

Infectious diseases pre-transplant evaluation improves vaccination rates for liver transplant candidates.

Immunization rates in pre-liver transplant patients have been historically below rates for immunocompetent patients. At Cleveland Clinic, an infectious diseases (ID) consult is required for all patients during the liver transplant evaluation and may beneficially impact vaccination rates. The goal of this study was to evaluate pre-transplant vaccination rates in pre-liver transplant candidates. This single-center, retrospective chart review included adults transplanted between January 1, 2013, and December 31, 2016. Prior to transplant, rates of vaccination and/or documented seropositivity were 35% for hepatitis B vaccine, 92% for hepatitis A vaccine, 57% for pneumococcal conjugate vaccine, 62% for pneumococcal polysaccharide vaccine, and 77% for influenza vaccine. Vaccination rates were higher than to previously reported. Rates were also higher for several vaccines compared to transplant candidates for other organs without ID consult. With ongoing ID consult requirements for liver transplant candidates, combined with standardization of vaccine recommendations via technology, and increased multi-disciplinary collaboration, vaccination rates should improve further.

Insulin Glargine Dose and Weight Changes in Underweight, Normal Weight, and Overweight Children Newly Diagnosed with Type 1 Diabetes Mellitus.

STUDY OBJECTIVE: Newly diagnosed pediatric patients with type 1 diabetes mellitus (T1D) can be underweight, overweight, or normal weight at presentation. Study objectives were to determine if, across weight categories, admission body weight (ABW)-based initial insulin glargine dosing resulted in similar fasting blood glucose responses on day of discharge, how initial ABW-based doses differed from doses at outpatient follow-up, and whether an ideal body weight (IBW) would provide a better estimate of body weight after discharge. DESIGN: Retrospective chart review. SETTING: Urban tertiary academic medical center. PATIENTS: Eighty-one pediatric patients newly diagnosed with T1D who started therapy with subcutaneous insulin glargine between October 2014 and October 2016; patients were categorized by weight using body mass index (BMI) percentiles (underweight, normal weight, or overweight/obese). MEASUREMENTS AND MAIN RESULTS: Data on patient parameters from hospitalization to outpatient physician follow-up were collected. The McLaren, Moore, and BMI IBW methods were used to calculate IBW for each patient; these IBWs were compared with weights at outpatient follow-up. Initial insulin glargine doses were similar among all weight groups: median (range) 0.299 (0.227-0.4), 0.297 (0.204-0.421), and 0.291 (0.194-0.394) units/kg/dose, respectively, for the underweight, normal weight, and overweight/obese groups. No significant differences in discharge fasting glucose level or insulin glargine dose change from admission to first outpatient follow-up visit were noted. Underweight patients gained significantly more weight within 60 days after discharge compared with normal and overweight/obese patients, (median 16.3% vs 7.7% and 5.7%, respectively; p=0.002), aligning closest with the McLaren IBW. ABW was the best estimate of weight at outpatient follow-up in the overweight/obese patient group. CONCLUSION: For children who presented underweight, the McLaren IBW method was the best predictor of outpatient dose and body weight, whereas ABW was the best estimate in overweight and obese patients. Further investigation of the role of IBW- or ABW-based dosing methods in underweight pediatric patients with T1D may assist in optimal dosing.