Simpson, Pippa

Abstract Standard treatment of catheter-associated upper extremity deep vein thrombosis (UE-DVT) is anticoagulation, although catheters are often removed for this indication. The optimal time for catheter removal and whether the act and/or timing of catheter removal is associated with pulmonary embolism (PE) remain unknown. A retrospective cohort study was performed at 8 participating institutions through the Venous thromboEmbolism Network US. Patients with hematologic malignancies and central venous catheter (CVC)–associated UE-DVT were included from 1 January 2010 through 31 December 2016. The primary outcome was objectively confirmed PE within 7 days of UE-DVT diagnosis in anticoagulated patients comparing early (≤48 hours) vs delayed (>48 hours) catheter removal. A total of 626 patients were included, among whom 480 were treated with anticoagulation. Among anticoagulated patients, 255 underwent early CVC removal, while 225 had delayed or no CVC removal; 146 patients received no anticoagulation, among whom 116 underwent CVC removal alone. PE within 7 days occurred in 2 patients (0.78%) with early removal compared with 1 patient (0.44%) with delayed or no CVC removal (P > .9). PE or any cause of death within 7 days occurred in 3 patients in both the early removal (1.18%) and delayed/no removal (1.33%) groups (P > .9). In patients treated with CVC removal only (no anticoagulation), there were no PEs but 3 deaths within 7 days. In patients with hematological malignancy and CVC-associated UE-DVT, early removal of CVCs was not associated with an increased risk of PE compared with delayed or no removal.

Background: Standard treatment for catheter-associated upper extremity deep vein thrombosis (UEDVT) is anticoagulation. If catheter removal is otherwise indicated, it is unknown if catheter removal close to the time of initiation of anticoagulation is associated with a higher incidence of pulmonary embolization. Methods: A multicenter retrospective cohort study was performed at 8 participating institutions through the Venous thromboEmbolism Network US (VENUS). ICD-9/10 codes were used to identify patients with hematologic malignancies and upper extremity deep vein thrombosis (UEDVT) from 1/1/2010 through 12/31/2016. Identified patients underwent medical record review to verify diagnostic codes and determine if a catheter was associated with the upper extremity DVT and assess for outcomes. Patients were excluded if the UEDVT was not catheter provoked or if there were associated lower extremity DVT and/or pulmonary emboli. The anticoagulant start and finish date as well as the timing of the catheter removal, total follow up, and death were recorded. Patients started on anticoagulation at the time of their diagnosis were divided into two groups: 1) anticoagulation with delayed (> 48 hrs) or no catheter removal and 2) anticoagulation with early catheter removal (< 48 hrs). Outcomes were also assessed in patients with no anticoagulation initiation but catheter removal as the only treatment. The primary outcome was clinically identified pulmonary emboli within 7 days and the secondary outcome was pulmonary emboli or death from any cause within 7 days. Baseline characteristics were compared between groups using Χ2 for categorical variables, 2-tailed t-tests for continuous variables, and Wilcoxon rank-sum for nonparametric continuous variables. Fisher's exact test was used to evaluate the primary and secondary outcomes. Results: 663 patients with hematologic malignancies and isolated catheter-associated UEDVT underwent chart review. 512 patients were treated with anticoagulation of which 312 underwent early catheter removal while 200 had delayed or no catheter removal (Figure 1). 151 patients received no anticoagulation and 119 underwent catheter removal alone as the treatment for the DVT. Among patients who were treated with anticoagulation, the mean age was 52.6 years and 44% were male; age and sex did not differ between patients with early vs. delayed or no catheter removal (Table 1). Type of hematologic malignancy, type of central catheter, and DVT location were significantly different between groups. Patients with PICC lines were more likely to have early catheter removal (71% vs. 49%). The median platelet count was not significantly different among patients treated with anticoagulation, but was lower in patients treated with catheter removal only. Most patients were initially treated with low molecular weight heparins (LMWH) and anticoagulation treatment did not differ between groups. Pulmonary emboli within 7 days occurred in 2 patients (0.64%) with early catheter removal compared to 1 patient (0.5%) with delayed or no removal (p=1.0). Pulmonary emboli or any cause death within 7 days occurred in 3 patients (1.0%) with early removal compared to 3 patients (1.5%) with delayed or no removal (p=0.68). In patients treated with catheter removal only (no anticoagulation), there were no pulmonary emboli within 7 days and 3 deaths. All 3 patients with pulmonary emboli within 7 days had PICC lines and leukemia/MDS and the sites of most proximal DVT involvement were brachiocephalic veins (2 patients) and subclavian vein (1 patient). Conclusions: In patients with hematological malignancy and catheter-associated UEDVT, removal of catheters within 48 hours was not associated with increased risk of pulmonary emboli compared to delayed or no removal. Disclosures Billett: Albert Einstein College of Medicine: Patents & Royalties: Patent application pending for NETs AI software. Gaddh:Pfizer: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Hema Biologics: Membership on an entity's Board of Directors or advisory committees; Pharmacyclics LLC: Membership on an entity's Board of Directors or advisory committees. Oo:Medical Education Speakers Network: Honoraria; Janssen and Janssen: Other: Research: site co-investigator . Jaglal:NOVARTIS: Consultancy. Streiff:Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Daiichi-Sankyo: Consultancy, Honoraria; Bayer: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Portola: Consultancy, Honoraria; Roche: Research Funding. Baumann Kreuziger:Vaccine Injury Compensation Program: Consultancy; CSL Behring: Consultancy.

BACKGROUND:The American Academy of Pediatrics (AAP) introduced revised return-to-care recommendations for mildly ill children in 2009 that were added to national standards in 2011. Child care directors' practices in a state without clear emphasis on return-to-care guidelines are unknown. We investigated director return-to-care practices just before the release of recently revised AAP guidelines.METHODS:A telephone survey with 5 vignettes of mild illness (cold symptoms, conjunctivitis, vomiting/diarrhea, fever, and ringworm) was administered to randomly sampled directors in metropolitan Milwaukee, Wisconsin. Directors were asked about return-to-care criteria for each illness. Questions for return-to-care criteria were open-ended; multiple responses were allowed. Answers were compared with AAP return-to-care recommendations.RESULTS:A total of 305 directors participated. Based on director responses to vignettes, the percentage of correct responses regarding return-to-child care management compared with AAP return-to-care recommendations was low: fever (0%); conjunctivitis (0%); diarrhea (1.6%); cold symptoms (12%); ringworm (21%); and vomiting (80%). Two illnesses (conjunctivitis and cold symptoms) would require the child to have an urgent medical evaluation or treatment not recommended by the AAP, as follows: Conjunctivitis—antibiotics for 24 hours (62%), physician visit (49%), any antibiotic treatment (6%), and symptom resolution (4%); and Cold Symptoms—physician visit (45.6%), antibiotics (10%), and symptom resolution (25%).CONCLUSIONS:Directors’ self-reported return-to-child care practices differed substantially before the release of revised AAP return-to-care recommendations. Active adoption of AAP return-to-child care guidelines would decrease the need for unnecessary urgent medical evaluation and treatment as well as unnecessary exclusion of a child from child care.

OBJECTIVE:No study has evaluated the association between state endorsement of American Academy of Pediatrics (AAP) and American Public Health Association (APHA) national guidelines and unnecessary exclusion decisions. We sought to determine the rate of unnecessary exclusion decisions by child care directors in a state that endorses AAP/APHA guidelines and to identify factors that are associated with higher unnecessary exclusion decisions.METHODS:A telephone survey was administered to directors in metropolitan Milwaukee, Wisconsin. Directors were randomly sampled from a list of 971 registered centers. Director, center, and neighborhood characteristics were obtained. Directors reported whether immediate exclusion was indicated for 5 vignettes that featured children with mild illness that do not require exclusion by AAP/APHA guidelines. Weighted data were summarized by using descriptive statistics. Regression analysis was used to identify factors that were associated with directors' exclusion decisions.RESULTS:A total of 305 directors completed the survey. Overall, directors would unnecessarily exclude 57% of children. More than 62% had never heard of the AAP/APHA guidelines. Regression analysis showed fewer exclusions among more experienced compared with less experienced directors, among larger centers compared with smaller centers, and among centers that were located in areas with a higher percentage of female heads of household. Centers with ≤10% children on state-assisted tuition excluded more.CONCLUSIONS:High rates of inappropriate exclusion persist despite state endorsement of AAP/APHA guidelines. Focused initial and ongoing training of directors regarding AAP/APHA guidelines may help to reduce high rates of unnecessary exclusions.