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Aygun B, Lane A, Smart LR, Santos B, Tshilolo L, Williams TN, Olupot-Olupot P, Stuber SE, Tomlinson G, Latham T, Ware RE. Hydroxyurea dose optimisation for children with sickle cell anaemia in sub-Saharan Africa (REACH): extended follow-up of a multicentre, open-label, phase 1/2 trial. Lancet Haematol 2024; 11:e425-e435. [PMID: 38701812 DOI: 10.1016/s2352-3026(24)00078-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Realizing Effectiveness Across Continents with Hydroxyurea (REACH) is an open-label non-randomised trial of hydroxyurea (hydroxycarbamide) in children with sickle cell anaemia in sub-Saharan Africa. The short-term results of REACH on safety, feasibility, and effectiveness of hydroxyurea were published previously. In this paper we report results from extended hydroxyurea treatment in the REACH cohort up to 8 years. METHODS In this open-label, non-randomised, phase 1/2 trial, participants were recruited from four clinical sites in Kilifi, Kenya; Mbale, Uganda; Luanda, Angola; and Kinshasa, Democratic Republic of Congo. Eligible children were 1-10 years old with documented haemoglobin SS or haemoglobin Sβ zero thalassaemia, weighing at least 10 kg. Participants received fixed-dose hydroxyurea of 17.5 (±2.5) mg/kg per day for 6 months (fixed-dose phase), followed by 6 months of dose escalation (2·5-5·0 mg/kg increments every 8 weeks) as tolerated, up to 20-35 mg/kg per day (maximum tolerated dose; MTD), defined as mild myelosuppression. After the MTD was reached, hydroxyurea dosing was optimised for each participant on the basis of changes in bodyweight and laboratory values over time (MTD with optimisation phase). After completion of the first 12 months, children with an acceptable toxicity profile and favourable responses were given the opportunity to continue hydroxyurea until the age of 18 years. The safety and feasibility results after 3 years has been reported previously. Here, haematological responses, clinical events, and toxicity rates were compared across the dosing phases (fixed-dose hydroxyurea vs MTD with optimisation phase) as protocol-specified outcomes. REACH is registered on ClinicalTrials.gov (NCT01966731) and is ongoing. FINDINGS We enrolled 635 children between July 4, 2014, and Nov 11, 2016. 606 children were given hydroxyurea and 522 (86%; 266 [51%] boys and 256 [49%] girls) received treatment for a median of 93 months (IQR 84-97) with 4340 patient-years of treatment. The current (Oct 5, 2023) mean dose is 28·2 (SD 5·2) mg/kg per day with an increased mean haemoglobin concentration (7·3 [SD 1·1] g/dL at baseline to 8·5 [1·5] g/dL) and mean fetal haemoglobin level (10·9% [SD 6·8] to 23·3% [9·5]) and decreased absolute neutrophil count (6·8 [3·0] × 109 cells per L to 3·6 [2·2] × 109 cells per L). Incidence rate ratios (IRR) comparing MTD with fixed-dose hydroxyurea indicate decreased vaso-occlusive episodes (0·60; 95% CI 0·52-0·70; p<0·0001), acute chest syndrome events (0·21; 0·13-0·33; p<0·0001), recurrent stroke events (0·27; 0·07-1·06; p=0·061), malaria infections (0·58; 0·46-0·72; p<0·0001), non-malarial infections (0·52; 0·46-0·58; p<0·0001), serious adverse events (0·42; 0·27-0·67; p<0·0001), and death (0·70; 0·25-1·97; p=0·50). Dose-limiting toxicity rates were similar between the fixed-dose (24·1 per 100 patient-years) and MTD phases (23·2 per 100 patient-years; 0·97; 0·70-1·35; p=0·86). Grade 3 and 4 adverse events were infrequent (18·5 per 100 patient-years) and included malaria infection, non-malarial infections, vaso-occlusive pain, and acute chest syndrome. Serious adverse events were uncommon (3·6 per 100 patient-years) and included malaria infections, parvovirus-associated anaemia, sepsis, and stroke, with no treatment-related deaths. INTERPRETATION Hydroxyurea dose escalation to MTD with dose optimisation significantly improved clinical responses and treatment outcomes, without increasing toxicities in children with sickle cell anaemia in sub-Saharan Africa. FUNDING US National Heart, Lung, and Blood Institute and Cincinnati Children's Research Foundation.
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Affiliation(s)
- Banu Aygun
- Northwell Health, Department of Pediatrics, New Hyde Park, NY, USA; Division of Hematology, Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA.
| | - Adam Lane
- Division of Hematology, Cincinnati Children's Hospital, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Luke R Smart
- Division of Hematology, Cincinnati Children's Hospital, Cincinnati, OH, USA; Global Health Center, Cincinnati Children's Hospital, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Brígida Santos
- Department of Pediatrics, Hospital Pediátrico David Bernardino, Luanda, Angola
| | - Léon Tshilolo
- Department of Pediatrics, Centre Hospitalier Monkole, Kinshasa, Democratic Republic of Congo
| | - Thomas N Williams
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya; Department of Surgery and Cancer, Institute of Global Health Innovation, Imperial College, London, UK
| | - Peter Olupot-Olupot
- Mbale Clinical Research Institute, Mbale, Uganda; Mbale Regional Referral and Teaching Hospital, Busitema University, Mbale Uganda
| | - Susan E Stuber
- Division of Hematology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - George Tomlinson
- Department of Medicine, University Health Network and Mt Sinai Hospital, Toronto, ON, Canada; The Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Teresa Latham
- Division of Hematology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Russell E Ware
- Division of Hematology, Cincinnati Children's Hospital, Cincinnati, OH, USA; Global Health Center, Cincinnati Children's Hospital, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Galadanci NA, Kanter J. Long-term data from the REACH study testing hydroxyurea to treat sickle cell anaemia in children in sub-Saharan Africa. Lancet Haematol 2024; 11:e393-e395. [PMID: 38701813 DOI: 10.1016/s2352-3026(24)00096-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 05/05/2024]
Affiliation(s)
- Najibah A Galadanci
- Division of Hematology and Oncology, UAB School of Medicine, University of Alabama, Birmingham, AL 35233, USA
| | - Julie Kanter
- Division of Hematology and Oncology, UAB School of Medicine, University of Alabama, Birmingham, AL 35233, USA.
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Sun H, Ma B, Jin C, Li Z, Song X, Bu Y, Liu T, Han X, Yang X, Yang K, Xu D, Zhang J, Li Y. Global, Regional, and National Burdens of Stroke in Children and Adolescents From 1990 to 2019: A Population-Based Study. Stroke 2024; 55:1543-1553. [PMID: 38591228 DOI: 10.1161/strokeaha.123.044827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 03/11/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Stroke is one of the leading causes of death among children, yet evidence on stroke incidence and prognosis in this population is largely neglected worldwide. The aim of this study was to estimate the latest burden of childhood stroke, as well as trends, risk factors, and inequalities from 1990 to 2019, at the global, regional, and national levels. METHODS The Global Burden of Disease 2019 study was utilized to evaluate the prevalence, incidence, years lived with disability, years of life lost (YLLs), and average annual percentage changes in stroke among populations aged 0 to 19 years from 1990 to 2019. RESULTS The global age-standardized incidence of stroke increased (average annual percentage change, 0.15% [95% uncertainty interval, 0.09%-0.21%]), while YLLs decreased substantially (average annual percentage change, -3.33% [95% uncertainty interval, -3.38% to -3.28%]) among children and adolescents between 1990 and 2019. Ischemic stroke accounted for 70% of incident cases, and intracerebral hemorrhage accounted for 63% of YLLs. Children under 5 years of age had the highest incidence of ischemic stroke, while adolescents aged 15 to 19 years had the highest incidence of hemorrhagic stroke. In 2019, low-income and middle-income countries were responsible for 84% of incident cases and 93% of YLLs due to childhood stroke. High-sociodemographic index countries had a reduction in YLLs due to stroke that was more than twice as fast as that of low-income and middle-income. CONCLUSIONS Globally, the burden of childhood stroke continues to increase, especially among females, children aged <5 years, and low-sociodemographic index countries, such as sub-Saharan Africa. The burden of childhood stroke is likely undergoing a significant transition from being fatal to causing disability. Global public health policies and the deployment of health resources need to respond rapidly and actively to this shift.
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Affiliation(s)
- Hao Sun
- Department of Clinical Epidemiology and Evidence-Based Medicine (H.S., B.M.), The First Hospital of China Medical University, Shenyang
| | - Bing Ma
- Department of Clinical Epidemiology and Evidence-Based Medicine (H.S., B.M.), The First Hospital of China Medical University, Shenyang
| | - Chenye Jin
- Department of Rheumatology and Immunology (C.J.), The First Hospital of China Medical University, Shenyang
| | - Zhenning Li
- Department of Oromaxillofacial-Head and Neck Surgery, School and Hospital of Stomatology, Liaoning Province Key Laboratory of Oral Disease (Z.L.)
| | - Xinying Song
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang (X.S.)
| | - Yifan Bu
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center, Boston, MA (Y.B.)
| | - Tingting Liu
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China (T.L.)
| | - Xu Han
- Department of Obstetrics (X.H.), The First Hospital of China Medical University, Shenyang
| | - Xue Yang
- Department of Endocrinology and Metabolism, The Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Disease (X.Y., K.Y., Y.L.), The First Hospital of China Medical University, Shenyang
| | - Kaijie Yang
- Department of Endocrinology and Metabolism, The Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Disease (X.Y., K.Y., Y.L.), The First Hospital of China Medical University, Shenyang
| | - Dongchu Xu
- Harvard Medical School, Boston, MA (D.X.)
| | - Jing Zhang
- School of Public Health, Shenzhen University Medical School, China (J.Z.)
| | - Yongze Li
- Department of Endocrinology and Metabolism, The Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Disease (X.Y., K.Y., Y.L.), The First Hospital of China Medical University, Shenyang
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Abdullahi SU, Sunusi S, Aminu H, Umar R, Abba MS, Jibir BW, Sani S, Gambo S, Bello-Manga H, Galadanci NA, Covert Greene B, Kassim AA, Jordan LC, Aliyu MH, Rodeghier M, DeBaun MR, Volanakis EJ. Transcranial doppler velocity in iron-deficient Nigerian children with sickle cell anemia. Am J Hematol 2024; 99:797-799. [PMID: 38323371 DOI: 10.1002/ajh.27230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 12/26/2023] [Accepted: 12/30/2023] [Indexed: 02/08/2024]
Abstract
Oral iron supplementation in iron deficient children with sickle cell anemia and normal transcranial Doppler ultrasound (TCD) velocities does not reduce arterial flow in the middle cerebral artery.
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Affiliation(s)
- Shehu Umar Abdullahi
- Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Surayya Sunusi
- Department of Pediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria
- Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Hauwa Aminu
- Department of Pediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Rashida Umar
- Department of Pediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria
| | | | | | - Saifuddeen Sani
- Department of Pediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Safiya Gambo
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Halima Bello-Manga
- Department of Hematology and Blood Transfusion, Barau-Dikko Teaching Hospital, Kaduna, Nigeria
| | - Najibah A Galadanci
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brittany Covert Greene
- Department of Pediatrics, Vanderbilt-Meharry-Matthew Walker Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adetola A Kassim
- Department of Hematology and Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Lori C Jordan
- Department of Pediatrics, Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Muktar H Aliyu
- Vanderbilt Institute for Global Health, Nashville, Tennessee, USA
| | | | - Michael R DeBaun
- Department of Pediatrics, Vanderbilt-Meharry-Matthew Walker Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Emmanuel J Volanakis
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Drown L, Osei M, Thapa A, Boudreaux C, Archer N, Bukhman G, Adler AJ. Models of care for sickle cell disease in low-income and lower-middle-income countries: a scoping review. Lancet Haematol 2024; 11:e299-e308. [PMID: 38432241 DOI: 10.1016/s2352-3026(24)00007-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 03/05/2024]
Abstract
Sickle cell disease has a growing global burden falling primarily on low-income countries (LICs) and lower-middle-income countries (LMICs) where comprehensive care is often insufficient, particularly in rural areas. Integrated care models might be beneficial for improving access to care in areas with human resource and infrastructure constraints. As part of the Centre for Integration Science's ongoing efforts to define, systematise, and implement integrated care delivery models for non-communicable diseases (NCDs), this Review explores models of care for sickle cell disease in LICs and LMICs. We identified 99 models from 136 studies, primarily done in tertiary, urban facilities in LMICs. Except for two models of integrated care for concurrent treatment of other conditions, sickle cell disease care was mostly provided in specialised clinics, which are low in number and accessibility. The scarcity of published evidence of models of care for sickle cell disease and integrated care in rural settings of LICs and LMICs shows a need to implement more integrated models to improve access, particularly in rural areas. PEN-Plus, a model of decentralised, integrated care for severe chronic non-communicable diseases, provides an approach to service integration that could fill gaps in access to comprehensive sickle cell disease care in LICs and LMICs.
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Affiliation(s)
- Laura Drown
- Center for Integration Science in Global Health Equity, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Miriam Osei
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ada Thapa
- Center for Integration Science in Global Health Equity, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Chantelle Boudreaux
- Center for Integration Science in Global Health Equity, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Natasha Archer
- Harvard Medical School, Harvard University, Boston, MA, USA; Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | - Gene Bukhman
- Center for Integration Science in Global Health Equity, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Program in Global Noncommunicable Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Alma J Adler
- Center for Integration Science in Global Health Equity, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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Ogu UO, Mukhopadhyay A, Patel K, Nelson MN, Strahan KS, Wu L, Smeltzer MP, Ataga KI. Hydroxyurea at escalated dose versus fixed low-dose hydroxyurea in adults with sickle cell disease. Eur J Haematol 2024; 112:466-474. [PMID: 38019026 PMCID: PMC10922392 DOI: 10.1111/ejh.14138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 11/30/2023]
Abstract
Hydroxyurea reduces the frequency of vaso-occlusive complications, increases hemoglobin, and decreases mortality in sickle cell disease (SCD). Although current guidelines recommend escalation to maximum tolerated dose (MTD), the use of fixed low-dose hydroxyurea is common in low-resource countries. We conducted a systematic review and meta-analysis to evaluate the efficacy of escalated doses versus fixed low-dose of hydroxyurea in adults with SCD. Nine studies were included in the quantitative synthesis, four evaluating fixed low-dose and five evaluating escalated doses of hydroxyurea. Average daily doses of hydroxyurea in the fixed low-dose and escalated dose studies were ~10 and 22 mg/kg, respectively. There was no difference in the estimate of vaso-occlusive crisis rate between escalated and fixed low-dose studies (p = .73). The mean difference in hemoglobin from baseline to follow-up was greater for fixed low-dose than escalated dose studies (1.07 g/dL vs. 0.54 g/dL, p = .01). No difference was seen in the mean estimate of fetal hemoglobin. Despite limited eligible studies and substantial heterogeneity of effect between the studies for several outcomes, there appears to be clinical equipoise regarding the most appropriate hydroxyurea dosing regimen in adults with SCD. Controlled studies of hydroxyurea at MTD versus fixed low-dose in adults with SCD are required.
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Affiliation(s)
- Ugochi O. Ogu
- Center for Sickle Cell Disease, University of Tennessee Health Science Center, Memphis, TN
- Division of Hematology/Oncology, University of Tennessee Health Science Center, Memphis, TN
| | - Ayesha Mukhopadhyay
- Division of Epidemiology, Biostatistics and Environmental Health, School of Public Health, University of Memphis, Memphis, TN
| | - Kruti Patel
- Division of Hematology/Oncology, University of Tennessee Health Science Center, Memphis, TN
| | - Marquita N. Nelson
- Center for Sickle Cell Disease, University of Tennessee Health Science Center, Memphis, TN
- Division of Hematology/Oncology, University of Tennessee Health Science Center, Memphis, TN
| | - KayLee S. Strahan
- Northwest Campus Library, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Lin Wu
- Research and Learning Services, Health Science Library, University of Tennessee Health Science Center, Memphis, TN
| | - Matthew P. Smeltzer
- Division of Epidemiology, Biostatistics and Environmental Health, School of Public Health, University of Memphis, Memphis, TN
| | - Kenneth I. Ataga
- Center for Sickle Cell Disease, University of Tennessee Health Science Center, Memphis, TN
- Division of Hematology/Oncology, University of Tennessee Health Science Center, Memphis, TN
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Lugthart S, Ginete C, Kuona P, Brito M, Inusa BPD. An update review of new therapies in sickle cell disease: the prospects for drug combinations. Expert Opin Pharmacother 2024; 25:157-170. [PMID: 38344818 DOI: 10.1080/14656566.2024.2317336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/07/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Sickle cell disease (SCD) is an inherited disorder characterised by polymerisation of deoxygenated haemoglobin S and microvascular obstruction. The cardinal feature is generalised pain referred to as vaso-occlusive crises (VOC), multi-organ damage and premature death. SCD is the most prevalent inherited life-threatening disorders in the world and over 85% of world's 400,000 annual births occur low-and-middle-income countries. Hydroxyurea remained the only approved disease modifying therapy (1998) until the FDA approved L-glutamine (2017), Crizanlizumab and Voxelotor (2019) and gene therapies (Exa-cel and Lovo-cel, 2023). AREAS COVERED Clinical trials performed in the last 10 years (November 2013 - November 2023) were selected for the review. They were divided according to the mechanisms of drug action. The following pubmed central search terms [sickle cell disease] or [sickle cell anaemia] Hydroxycarbamide/ Hydroxyurea, L-Glutamine, Voxelotor, Crizanlizumab, Mitapivat, Etavopivat, gene therapy, haematopoietic stem cell transplantation, and combination therapy. EXPERT OPINION We recommend future trials of combination therapies for specific complications such as VOCs, chronic pain and renal impairment as well as personalised medicine approach based on phenotype and patient characteristics. Following recent approval of gene therapy for SCD, the challenge is addressing the role of shared decision-making with families, global access and affordability.
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Affiliation(s)
- Sanne Lugthart
- Haematology department, University Hospitals of Bristol and Weston Foundation Trust, Bristol, UK
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Catarina Ginete
- Health and Technology Research Center, Escola Superior de Tecnologia da Saúde de Lisboa, Instituto Politécnico de Lisboa, Portugal
| | - Patience Kuona
- Child, Adolescent and Women's Health Department, University of Zimbabwe Faculty of Medicine and Health Sciences, Harare, Zimbabwe
| | - Miguel Brito
- Health and Technology Research Center, Escola Superior de Tecnologia da Saúde de Lisboa, Instituto Politécnico de Lisboa, Portugal
| | - Baba Psalm Duniya Inusa
- Paediatric Haematology, Evelina London, Guy's and St Thomas NHS Foundation Trust, London
- Women's and Children Academic health, Life Sciences and Medicine, King's College London, London
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Bello-Manga H, Haliru L, Ahmed K, Ige S, Musa H, Muhammad-Idris ZK, Monday B, Sani AM, Bonnet K, Schlundt DG, Varughese T, Tabari AM, DeBaun MR, Baumann AA, King AA. Barriers and facilitators to a task-shifted stroke prevention program for children with sickle cell anemia in a community hospital: a qualitative study. Implement Sci Commun 2024; 5:10. [PMID: 38225633 PMCID: PMC10790401 DOI: 10.1186/s43058-023-00534-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 11/21/2023] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Children with sickle cell anemia (SCA) are at high risk for stroke. Protocols for stroke prevention including blood transfusions, screening for abnormal non-imaging transcranial Doppler (TCD) measurements, and hydroxyurea therapy are difficult to implement in low-resource environments like Nigeria. This study aimed to examine the contextual factors around TCD screening in a community hospital in Nigeria using qualitative interviews and focus groups. METHODS We conducted a descriptive qualitative study in a community hospital in Kaduna, Nigeria, using focus groups and interviews. Interview guides and analysis were informed by the Consolidated Framework for Implementation Research (CFIR) framework and the Theory of Planned Behavior. Transcripts were coded and analyzed using an iterative deductive (CFIR)/Inductive (transcribed quotes) qualitative methodology. RESULTS We conducted two focus groups and five interviews with health care workers (nurses and doctors) and hospital administrators, respectively. Themes identified key elements of the inner setting (clinic characteristics, resource availability, implementation climate, and tension for change), characteristics of individuals (normative, control, and behavioral beliefs), and the implementation process (engage, implement, and adopt), as well as factors that were influenced by external context, caregiver needs, team function, and intervention characteristics. Task shifting, which is already being used, was viewed by providers and administrators as a necessary strategy to implement TCD screening in a clinic environment that is overstressed and under-resourced, a community stressed by poverty, and a nation with an underperforming health system. CONCLUSION Task shifting provides a viable option to improve health care by making more efficient use of already available human resources while rapidly expanding the human resource pool and building capacity for TCD screening of children with SCD that is more sustainable. TRIAL REGISTRATION NCT05434000.
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Affiliation(s)
- Halima Bello-Manga
- Department of Haematology and Blood Transfusion, Barau Dikko Teaching Hospital/Kaduna State University, Kaduna, Nigeria.
| | - Lawal Haliru
- Department of Paediatrics, Barau Dikko Teaching Hospital/Kaduna State University, Kaduna, Nigeria
| | - Kudirat Ahmed
- Department of Paediatrics, Barau Dikko Teaching Hospital/Kaduna State University, Kaduna, Nigeria
| | - Samuel Ige
- Yusuf Dantsoho Memorial Hospital, Kaduna State Ministry of Health, Kaduna, Nigeria
| | - Hayatu Musa
- Department of Library and Information Science, Ahmadu Bello University, Zaria, Nigeria
| | | | - Binshak Monday
- Department of Library and Information Science, Ahmadu Bello University, Zaria, Nigeria
| | | | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - David G Schlundt
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Taniya Varughese
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Abdulkadir M Tabari
- Department of Radiology, Barau Dikko Teaching Hospital/Kaduna State University, Kaduna, Nigeria
| | - Michael R DeBaun
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University of School of Medicine, Nashville, TN, USA
| | - Ana A Baumann
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Allison A King
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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Booth N, Ngwube A, Appavu B, Shah S, Abruzzo T. Reversal of Cerebral Arteriopathy Post-Hematopoietic Stem Cell Transplant for Sickle Cell Disease. Pediatrics 2024; 153:e2023062643. [PMID: 38263886 DOI: 10.1542/peds.2023-062643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2023] [Indexed: 01/25/2024] Open
Abstract
Sickle cell disease (SCD) is a chronic hematologic disorder which causes progressive cerebral arteriopathy beginning in childhood. As a result, arterial ischemic stroke is a major cause of morbidity and mortality in SCD, and SCD is a leading cause of childhood stroke worldwide. Allogenic hematopoietic stem cell transplant (HSCT) may be curative for individuals with SCD. Long-term outcomes and effects are currently being studied. In this report, we describe a child with SCD who presented with arterial ischemic stroke at 6 years of age and was found to have a severe form of cerebral large vessel arteriopathy by catheter-directed angiography. The patient initially underwent revascularization surgery by indirect superficial temporal artery to middle cerebral artery bypass, and 1 year later, he underwent curative HSCT. Approximately 3 years after HSCT, repeat catheter-directed angiography revealed a striking reversal of cerebral large vessel arteriopathy. This article reveals a previously unrecognized and potentially beneficial effect of HSCT that may ameliorate cerebral large vessel arteriopathy and improve cerebrovascular health for children with SCD.
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Affiliation(s)
- Natalie Booth
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St Petersburg, FL
| | - Alexander Ngwube
- Center for Cancer and Blood Disorders
- Department of Child Health, College of Medicine, University of Arizona, Phoenix, Arizona
| | | | - Sanjay Shah
- Center for Cancer and Blood Disorders
- Department of Child Health, College of Medicine, University of Arizona, Phoenix, Arizona
| | - Todd Abruzzo
- Radiology, Phoenix Children's Hospital, Phoenix, Arizona
- Department of Child Health, College of Medicine, University of Arizona, Phoenix, Arizona
- College of Medicine, Mayo Clinic, Phoenix, Arizona
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10
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Kirton A, Jordan LC. Stroke in Children: Key Advances in the Field and the Next 20 Years. Stroke 2024; 55:182-185. [PMID: 38134252 DOI: 10.1161/strokeaha.123.044250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Affiliation(s)
- Adam Kirton
- Departments of Pediatrics and Clinical Neurosciences, Alberta Children's Hospital Research Institute, University of Calgary, Canada (A.K.). Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN (L.C.J.)
| | - Lori C Jordan
- Departments of Pediatrics and Clinical Neurosciences, Alberta Children's Hospital Research Institute, University of Calgary, Canada (A.K.). Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN (L.C.J.)
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11
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Ataga KI. The challenge of clinical end points in sickle cell disease. Blood 2023; 142:2047-2054. [PMID: 37890140 PMCID: PMC10733825 DOI: 10.1182/blood.2023021220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 10/05/2023] [Accepted: 10/08/2023] [Indexed: 10/29/2023] Open
Abstract
As most patients with sickle cell disease (SCD) do not have access to curative therapies, the availability of drug therapies that can modify disease severity remains highly desirable. Despite an increased understanding of the pathophysiology of SCD, only 4 drugs are approved by the US Food and Drugs Administration. Most drug trials in SCD have involved the use of acute pain episodes as the primary clinical end point. These studies have typically been to prevent or shorten the duration of such episodes. To date, no drug has received regulatory approval for shortening the duration of acute vaso-occlusive complications, likely highlighting the complex pathophysiology of acute pain episodes. Trials to prevent acute pain episodes have largely evaluated those episodes requiring health care use as a surrogate end point. However, with differences in culture and health care practices among countries, health care use may not reliably predict clinically important effects on acute pain episodes. This article discusses issues related to the use of health care use as the primary end point for prevention trials of acute pain episodes and highlights the importance of evaluating patient-reported outcomes as well as other SCD-related complications as outcome measures.
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Affiliation(s)
- Kenneth I. Ataga
- Center for Sickle Cell Disease, University of Tennessee Health Science Center, Memphis, TN
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12
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Rai P, Ataga KI. Using disease-modifying therapies in sickle cell disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:519-531. [PMID: 38066905 PMCID: PMC10727073 DOI: 10.1182/hematology.2023000485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
As curative therapy using allogeneic hematopoietic stem cell transplantation as well as gene therapy and gene editing remains inaccessible to most patients with sickle cell disease, the availability of drug therapies that are safe, efficacious, and affordable is highly desirable. Increasing progress is being made in developing drug therapies based on our understanding of disease pathophysiology. Four drugs, hydroxyurea, L-glutamine, crizanlizumab, and voxelotor, are currently approved by the US Food and Drug Administration, with multiple others at various stages of testing. With the limited efficacy of individual agents, combinations of agents will likely be required for optimal outcomes.
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Affiliation(s)
- Parul Rai
- Department of Hematology, St Jude Children's Research Hospital, Memphis, TN
| | - Kenneth I Ataga
- Center for Sickle Cell Disease, University of Tennessee Health Science Center, Memphis, TN
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13
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Klein LJ, Abdullahi SU, Gambo S, Stallings VA, Acra S, Rodeghier M, DeBaun MR. Risk factors in underweight older children with sickle cell anemia: a comparison of low- to high-income countries. Blood Adv 2023; 7:6923-6930. [PMID: 37756514 PMCID: PMC10685159 DOI: 10.1182/bloodadvances.2023009711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/25/2023] [Accepted: 09/10/2023] [Indexed: 09/29/2023] Open
Abstract
Previously, we demonstrated that older children with sickle cell anemia (SCA) living in Nigeria are at increased risk of death if they are underweight (weight-for-age z score < -1). We now conducted a cross-sectional study in low- and high-income settings to determine the risk factors for being underweight a in children aged 5 to 12 years with SCA. The children from low- and high-income settings were eligible participants for the Primary Prevention of Stroke in Children with Sickle Cell Disease in Nigeria (SPRING; N = 928) and the Silent Cerebral Infarct (SIT, North America/Europe; N = 1093) trials, respectively. The median age in the SPRING and SIT cohorts was 8.1 and 8.5 years, respectively (P < .001). A total of 87.9% (n = 816) of participants in the SPRING trial (low-income) met the study criteria for being underweight (weight-for-age z score < -1), and 22.7% (n = 211) for severely underweight (weight-for-age z score < -3), significantly higher than the SIT (high-income) cohort at 25.7% underweight (n = 281) and 0.7% severely underweight (n = 8; P < .001 for both comparisons). In the combined cohort, older age (odds ratio [OR], 1.24; P < .001) and lower hemoglobin level (OR, 0.67; P < .001) were associated with being underweight. Age and hemoglobin level remained statistically significant in separate models for the SPRING and SIT cohorts. Older age and lower hemoglobin levels in children aged 5 to 12 years with SCA are associated with being underweight in low- and high-income settings.
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Affiliation(s)
- Lauren Jane Klein
- D. Brent Polk Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN
| | - Shehu Umar Abdullahi
- Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Safiya Gambo
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Virginia A. Stallings
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Sari Acra
- D. Brent Polk Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | | | - Michael R. DeBaun
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN
- Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN
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14
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Adamkiewicz TV, Yee MEM, Thomas S, Tunali A, Lai KW, Omole FS, Lane PA, Yildirim I. Pneumococcal infections in children with sickle cell disease before and after pneumococcal conjugate vaccines. Blood Adv 2023; 7:6751-6761. [PMID: 37698500 PMCID: PMC10660014 DOI: 10.1182/bloodadvances.2022009643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 07/13/2023] [Accepted: 07/13/2023] [Indexed: 09/13/2023] Open
Abstract
Children with sickle cell disease (SCD) are at increased risk of invasive pneumococcal disease (IPD). Over 25 years, the Georgia Emerging Infections Program/Centers for Disease Control and Prevention Active Bacterial Core Surveillance network identified 104 IPD episodes among 3707 children with hemoglobin SS (HbSS) or HbSC aged <10 years, representing 6% of IPD in Black or African American children residing in Metropolitan Atlanta (reference population). Children with IPD and HbSS/SC were older than those with IPD in the reference population (P < .001). From 1994-1999 to 2010-2018, IPD declined by 87% in children with HbSS aged 0 to 4 years, and by 80% in those aged 5 to 9 years. However, IPD incidence rate ratios when comparing children with SCD with the reference population increased from 20.2 to 29.2 over these periods. Among children with HbSS and IPD, death declined from 14% to 3% after 2002, and meningitis declined from 16% to 8%. Penicillin resistance was more prevalent in children with SCD before 7-valent pneumococcal conjugate vaccine (PCV7) licensure. After 2010, all IPD serotypes were not included in the 13-valent PCV (PCV13). Within 3 years of vaccination, the effectiveness of the 23-valent pneumococcal polysaccharide vaccine (PPSV23) against non-PCV13 serotypes included in PPSV23 plus 15A/15C was 92% (95% confidence interval, 40.8- 99.0, P = .014; indirect-cohort effect adjusted for age and hydroxyurea). PPSV23 would cover 62% of non-PCV13 serotype IPD in children with SCD, whereas PCV15, PCV20, and PCV21/V116 (in development) could cover 16%, 51%, and 92%, respectively. Although less frequent, IPD remains a life-threatening risk in children with SCD. Effective vaccines with broader coverage could benefit these children.
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Affiliation(s)
- Thomas V. Adamkiewicz
- Department of Family Medicine, Morehouse School of Medicine, Atlanta, GA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Marianne E. M. Yee
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Stepy Thomas
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Georgia Emerging Infections Program, Atlanta, GA
- Atlanta Veterans Administration Health System, Decatur, GA
| | - Amy Tunali
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Atlanta Veterans Administration Health System, Decatur, GA
| | - Kristina W. Lai
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
- University of California, Davis, CA
| | - Folashade S. Omole
- Department of Family Medicine, Morehouse School of Medicine, Atlanta, GA
| | - Peter A. Lane
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Inci Yildirim
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT
- Yale Center for Infection and Immunity, Yale Institute of Global Health, New Haven, CT
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15
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Green NS, Rosano C, Bangirana P, Opoka R, Munube D, Kasirye P, Kawooya M, Lubowa SK, Mupere E, Conroy A, Minja FJ, Boehme AK, Kang MS, Honig LS, Idro R. Neurofilament light chain: A potential biomarker for cerebrovascular disease in children with sickle cell anaemia. Br J Haematol 2023; 203:460-467. [PMID: 37581299 PMCID: PMC10615726 DOI: 10.1111/bjh.19036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/23/2023] [Accepted: 08/01/2023] [Indexed: 08/16/2023]
Abstract
Cerebrovascular injury frequently occurs in children with sickle cell anaemia (SCA). Limited access to magnetic resonance imaging and angiography (MRI-MRA) in sub-Saharan Africa impedes detection of clinically unapparent cerebrovascular injury. Blood-based brain biomarkers of cerebral infarcts have been identified in non-SCA adults. Using plasma samples from a well-characterized cross-sectional sample of Ugandan children with SCA, we explored relationships between biomarker levels and MRI-detected cerebral infarcts and transcranial Doppler (TCD) arterial velocity. Testing was performed using a 4-plex panel of brain injury biomarkers, including neurofilament light chain (NfL), a central nervous system neuron-specific protein. Mean biomarker levels from the SCA group (n = 81) were similar to those from non-SCA sibling controls (n = 54). Within the SCA group, NfL levels were significantly higher in those with MRI-detected infarcts compared to no infarcts, and higher with elevated TCD velocity versus normal velocity. Elevated NfL remained strongly associated with MRI-detected infarcts after adjusting for sex and age. All non-SCA controls and SCA participants lacking MRI-detected infarcts had low NfL levels. These data suggest potential utility of plasma-based NfL levels to identify children with SCA cerebrovascular injury. Replication and prospective studies are needed to confirm these novel findings and the clinical utility of NfL versus MRI imaging.
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Affiliation(s)
- Nancy S Green
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
| | - Caterina Rosano
- Department of Epidemiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
| | - Robert Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Deogratias Munube
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Philip Kasirye
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Michael Kawooya
- Department of Radiology, Makerere University College of Health Sciences, Kampala, Uganda
- Ernest Cook Ultrasound Research and Education Institute (ECUREI), Mengo Hospital, Kampala, Uganda
| | - Samson K Lubowa
- Department of Radiology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ezekiel Mupere
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrea Conroy
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Frank J Minja
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Amelia K Boehme
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA
| | - Min Suk Kang
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA
| | - Lawrence S Honig
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
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16
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Jacob SA, Talati R, Kanter J. The evolving treatment landscape for children with sickle cell disease. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:797-808. [PMID: 37858508 DOI: 10.1016/s2352-4642(23)00201-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 10/21/2023]
Abstract
Sickle cell disease is the most common inherited pathological haemoglobinopathy. Over the past 30 years, disease-related morbidity and mortality have improved in high-income countries due to advances in preventive care and treatments. Established disease-modifying therapies, such as hydroxyurea (hydrocarbamide), are continuing to have an important role in the treatment of sickle cell disease, and newer agents also show promise. In the past 5 years, the US Food and Drug Administration approved three additional sickle cell disease-modifying medications, and new gene therapies have been developed as an alternative curative treatment to haematopoietic stem-cell transplantation. In this Review, we discuss the current treatment landscape for paediatric sickle cell disease and emerging innovations in care. We also review the need for close, long-term management for children receiving newer therapies and the importance of ongoing investment in people with sickle cell disease in low-income and middle-income countries.
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Affiliation(s)
- Seethal A Jacob
- Division of Pediatric Hematology Oncology, Riley Hospital for Children, Indianapolis, IN, USA
| | - Ravi Talati
- Division of Pediatric Hematology, Oncology & Blood/Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Julie Kanter
- Lifespan Comprehensive Sickle Cell Center, University of Alabama, Birmingham, AL, USA.
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17
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Du M, Mi D, Liu M, Liu J. Global trends and regional differences in disease burden of stroke among children: a trend analysis based on the global burden of disease study 2019. BMC Public Health 2023; 23:2120. [PMID: 37891500 PMCID: PMC10612321 DOI: 10.1186/s12889-023-17046-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/22/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Stroke is a major cause of acute neurological symptoms in children with significant long-term neurological sequelae. However, data of diseases burden on stroke among children was lack. We aimed to be dedicated to analyze and compare global trends as well as regional and sociodemographic differences in stroke prevalence, incidence, mortality and disability-adjusted life-years (DALYs) among children aged 0 ~ 14 years. METHOD We obtained data on annual number of incident strokes, prevalent strokes, deaths, and DALYs, age-standardized incidence rates (ASIRs), prevalence rates (ASPRs), mortality rates (ASMRs) and DALY rates (ASDRs) of stroke among individuals aged 14 years and younger during 1990-2019 from the 2019 Global Burden of Disease Study. To quantify the temporal trends, we calculated changes (%) in number, and used joinpoint regression analysis to identify the average annual percentage changes (AAPCs) of age standardized rates. RESULT Globally, the incident strokes and prevalent strokes increased by 18.51% and 31.97%, respectively, but DALYs due to stroke and deaths due to stroke decreased by 60.18% and 65.03%, respectively, from 1990 to 2019. During the same period, ASIR increased by 0.21% (95%CI: 0.17, 0.24) from 18.02 to 100,000 population in 1990 to 19.11 per 100,000 in 2019; ASPR increased by 0.66% (95%CI: 0.36, 0.96) from 68.88 to 100,000 population in 1990 to 81.35 per 100,000 in 2019; while ASMR (AAPC= -3.94; 95%CI: -4.07, -3.81) and ASDR (AAPC= -3.50; 95%CI: -3.64, -3.36) both decreased. In 2019, the highest age standardized incidence, prevalence, mortality, and DALY rates all occurred in low sociodemographic index (SDI) regions. The greatest increase of age standardized incidence rate (AAPC = 0.21; 95%CI: 0.18, 0.25) and prevalence rate (AAPC = 1.15; 95%CI: 0.34, 1.96) both were in high SDI regions. Eastern Sub-Saharan Africa had the highest ASIR and ASPR in 2019, and Oceania had the highest ASMR and ASDR in 2019 across 21 GBD regions. High-income North America had the largest increase in ASIR (AAPC = 0.63; 95%CI: 0.59, 0.66) and ASPR (AAPC = 1.58; 95%CI: 0.54, 2.63). Against the overall decreasing trend of ASMR, an increasing trend of ASMR was found in Zimbabwe (AAPC = 0.91; 95%CI: 0.44, 1.37) and Botswana (AAPC = 0.74; 95%CI: 0.02, 1.47). CONCLUSION The overall increasing stroke incidence and prevalence indicated that prevention and management of stroke among younger population should be critical in the future. Despite stroke mortality with falling trend worldwide, specific countries or territories present worrying increase in stroke mortality. Without urgent implementation of effective primary prevention strategies, the stroke burden of children will probably continue to grow across the world, particularly in high-SDI countries.
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Affiliation(s)
- Min Du
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, No.38, Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Donghua Mi
- Beijing Tiantan Hospital, China National Clinical Research Center for Neurological Diseases, Capital Medical University, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100871, China
| | - Min Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, No.38, Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Jue Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, No.38, Xueyuan Road, Haidian District, Beijing, 100191, China.
- Institute for Global Health and Development, Peking University, No.5, Yiheyuan Road, Haidian District, Beijing, 100871, China.
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18
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Abdullahi SU, Gambo S, Murtala HA, Kabir H, Shamsu KA, Gwarzo G, Acra S, Stallings VA, Rodeghier M, DeBaun MR, Klein LJ. Feasibility trial for the management of severe acute malnutrition in older children with sickle cell anemia in Nigeria. Blood Adv 2023; 7:6024-6034. [PMID: 37428866 PMCID: PMC10582275 DOI: 10.1182/bloodadvances.2023010789] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/12/2023] Open
Abstract
Children with sickle cell anemia (SCA) living in Nigeria are at an increased risk of malnutrition, which contributes to increased morbidity and mortality. However, evidence-based guidelines for managing malnutrition in children with SCA are lacking. To address this gap, we conducted a multicenter, randomized controlled feasibility trial to assess the feasibility and safety of treating children with SCA aged from 5 to 12 years and having uncomplicated severe acute malnutrition (body mass index z score of <-3.0). Children with SCA and uncomplicated severe acute malnutrition were randomly allocated to receive supplemental ready-to-use therapeutic food (RUTF) with or without moderate-dose hydroxyurea therapy (20 mg/kg per day). Over a 6-month enrollment period, 3190 children aged from 5 to 12 years with SCA were evaluated for eligibility, and 110 of 111 children who were eligible were enrolled. During the 12-week trial, no participants withdrew or missed visits. One participant died of unrelated causes. Adherence was high for hydroxyurea (94%, based on pill counts) and RUTF (100%, based on the number of empty sachets returned). No refeeding syndrome event or hydroxyurea-related myelosuppression occurred. At the end of the trial, the mean change in body mass index z score was 0.49 (standard deviation = 0.53), and 39% of participants improved their body mass index z score to ≥-3.0. Our findings demonstrate the feasibility, safety, and potential of outpatient treatment for uncomplicated severe acute malnutrition in children with SCA aged from 5 to 12 years in a low-resource setting. However, RUTF sharing with household and community members potentially confounded the response to malnutrition treatment. This trial was registered at clinicaltrials.gov as #NCT03634488.
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Affiliation(s)
- Shehu U. Abdullahi
- Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Safiya Gambo
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Hassan Adam Murtala
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Halima Kabir
- Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Khadija A. Shamsu
- Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Garba Gwarzo
- Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Sari Acra
- Department of Pediatrics, D. Brent Polk Division of Pediatric Gastroenterology, Hepatology, and Nutrition at Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Virginia A. Stallings
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | | | - Michael R. DeBaun
- Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN
| | - Lauren J. Klein
- Department of Pediatrics, D. Brent Polk Division of Pediatric Gastroenterology, Hepatology, and Nutrition at Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN
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19
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Arji EE, Eze UJ, Ezenwaka GO, Kennedy N. Evidence-based interventions for reducing sickle cell disease-associated morbidity and mortality in sub-Saharan Africa: A scoping review. SAGE Open Med 2023; 11:20503121231197866. [PMID: 37719166 PMCID: PMC10504846 DOI: 10.1177/20503121231197866] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 08/11/2023] [Indexed: 09/19/2023] Open
Abstract
Objective Sickle cell disease is a lifelong illness affecting millions of people globally, but predominantly burdensome in sub-Saharan Africa, where most affected children do not live to adulthood, despite available evidence-based interventions that reduce the disease burden in high-income countries. Method We reviewed studies evaluating evidence-based interventions that decrease sickle cell disease-related morbidity and mortality among children living in sub-Saharan Africa. We used the Joanna Briggs scoping review methodological framework and grouped identified evidence-based interventions into preventative pharmacotherapeutic agents, newborn screening and comprehensive healthcare, disease-modifying agents, nutritional supplementation, systemic treatment, supportive agents and patient/carer/population education. Results We included 36 studies: 18 randomized controlled trials, 11 observational studies, 5 before-and-after studies and 2 economic evaluation studies, with most of the studies performed in West African countries. Included studies suggest evidence-based interventions effectively to reduce the common morbidities associated with sickle cell disease such as stroke, vaso-occlusive crisis, acute chest syndrome, severe anaemia and malaria infection. Evidence-based interventions also improve survival among study participants. Specifically, our review shows hydroxyurea increases haemoglobin and foetal haemoglobin levels, a finding with practical implications given the challenges with blood transfusion in this setting. The feasibility of implementing individual interventions is hampered by challenges such as affordability, accessibility and the availability of financial and human resources. Conclusion Our review suggests that regular use of low-dose hydroxyurea therapy, sulphadoxine-pyrimethamine chemoprophylaxis, L-arginine and Omega-3 fatty acid supplementation and establishment of specialist stand-alone sickle cell clinics could reduce the sickle cell disease-associated morbidity and mortality in sub-Saharan Africa countries.
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Affiliation(s)
- Emmanuel Emenike Arji
- School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, UK
| | - Ujunwa Justina Eze
- Department of Family Medicine, WellSpan Good Samaritan Hospital, Lebanon, PA, USA
| | - Gloria Oluchukwu Ezenwaka
- Department of Paediatrics, Enugu State University Teaching Hospital, Parklane, Enugu, Enugu State, Nigeria
| | - Neil Kennedy
- School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, UK
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20
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Namazzi R, Opoka R, Conroy AL, Datta D, Tagoola A, Bond C, Goings MJ, Ryu MS, Cusick SE, Krebs NF, Jang JH, Tu W, Ware RE, John CC. Zinc for infection prevention in children with sickle cell anemia: a randomized double-blind placebo-controlled trial. Blood Adv 2023; 7:3023-3031. [PMID: 36735400 PMCID: PMC10331409 DOI: 10.1182/bloodadvances.2022008539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 01/17/2023] [Accepted: 01/21/2023] [Indexed: 02/04/2023] Open
Abstract
Data from small clinical trials in the United States and India suggest zinc supplementation reduces infection in adolescents and adults with sickle cell anemia (SCA), but no studies of zinc supplementation for infection prevention have been conducted in children with SCA living in Africa. We conducted a randomized double-blind placebo-controlled trial to assess zinc supplementation for prevention of severe or invasive infections in Ugandan children 1.00-4.99 years with SCA. Of 252 enrolled participants, 124 were assigned zinc (10 mg) and 126 assigned placebo once daily for 12 months. The primary outcome was incidence of protocol-defined severe or invasive infections. Infection incidence did not differ between treatment arms (282 vs. 270 severe or invasive infections per 100 person-years, respectively, incidence rate ratio of 1.04 [95% confidence interval (CI), 0.81, 1.32, p=0.78]), adjusting for hydroxyurea treatment. There was also no difference between treatment arms in incidence of serious adverse events or SCA-related events. Children receiving zinc had increased serum levels after 12-months, but at study exit, 41% remained zinc deficient (<65 μg/dL). In post-hoc analysis, occurrence of stroke or death was lower in the zinc treatment arm (adjusted hazard ratio (95% CI), 0.22 (0.05, 1.00); p=0.05). Daily 10 mg zinc supplementation for 12 months did not prevent severe or invasive infections in Ugandan children with SCA, but many supplemented children remained zinc deficient. Optimal zinc dosing and the role of zinc in preventing stroke or death in SCA warrant further investigation. This trial was registered at clinicaltrials.gov as #NCT03528434.
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Affiliation(s)
- Ruth Namazzi
- Department of Pediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
| | - Robert Opoka
- Department of Pediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
| | - Andrea L. Conroy
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Abner Tagoola
- Department of Pediatrics, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Caitlin Bond
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Michael J. Goings
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Moon-Suhn Ryu
- Department of Food and Nutrition, Yonsei University, Seoul, Republic of Korea
| | - Sarah E. Cusick
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Nancy F. Krebs
- Department of Pediatrics, University of Colorado, Aurora, CO
| | - Jeong Hoon Jang
- Underwood International College and Department of Applied Statistics, Yonsei University, Seoul, Republic of Korea
| | - Wanzhu Tu
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN
| | - Russell E. Ware
- Division of Hematology and Global Health Center, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Chandy C. John
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
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21
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Bello-Manga H, Haliru L, Ahmed K, Ige S, Musa H, Muhammad-Idris ZK, Monday B, Sani AM, Bonnet K, Schlundt DG, Varughese T, Tabari AM, DeBaun MR, Baumann AA, King AA. Barriers and Facilitators to a Task-Shifted Stroke Prevention Program for Children with Sickle Cell Anemia in a Community Hospital: A Qualitative Study. RESEARCH SQUARE 2023:rs.3.rs-2985921. [PMID: 37461538 PMCID: PMC10350163 DOI: 10.21203/rs.3.rs-2985921/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
Background Children with sickle cell anemia (SCA) are at high risk for stroke. Protocols for stroke prevention including blood transfusions, screening for abnormal non-imaging transcranial Doppler (TCD) measurements, and hydroxyurea therapy are difficult to implement in low-resource environments like Nigeria. This study aimed to examine the contextual factors around TCD screening in a community hospital in Nigeria using qualitative interviews and focus groups. Methods We conducted focus groups with health care providers and interviews with administrative leadership of the community hospital. Interview guides and analysis were informed by the Consolidated Framework for Implementation Research (CFIR) framework. Transcripts were coded and analyzed using an iterative deductive (CFIR)/Inductive (transcribed quotes) qualitative methodology. Results We conducted two focus groups and five interviews with health care workers (nurses and doctors) and hospital administrators, respectively. Themes identified key elements of the inner setting (clinic characteristics, resource availability, implementation climate, and tension for change), characteristics of individuals (normative, control, and behavioral beliefs), and the implementation process (engage, implement, and adopt), as well as factors that were influenced by external context, caregiver needs, team function, and intervention characteristics. Task shifting, which is already being used, was viewed by providers and administrators as a necessary strategy to implement TCD screening in a clinic environment that is overstressed and under-resourced, a community stressed by poverty, and a nation with an underperforming health system. Conclusion Task shifting provides a viable option to improve health care by making more efficient use of already available human resources while rapidly expanding the human resource pool and building capacity that is more sustainable. Trial registration NCT05434000.
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Affiliation(s)
| | | | | | - Samuel Ige
- Yusuf Dantsoho Memorial Hospital, Ministry of Health, Kaduna
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22
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Smart LR, Charles M, McElhinney KE, Dong M, Power-Hays A, Howard T, Vinks AA, Ambrose EE, Ware RE. Hydroxyurea pharmacokinetics and precision dosing in low-resource settings. Front Mol Biosci 2023; 10:1130206. [PMID: 37325474 PMCID: PMC10267409 DOI: 10.3389/fmolb.2023.1130206] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 05/22/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction: Hydroxyurea is effective disease-modifying treatment for sickle cell anemia (SCA). Escalation to maximum tolerated dose (MTD) achieves superior benefits without additional toxicities, but requires dose adjustments with serial monitoring. Pharmacokinetic (PK)-guided dosing can predict a personalized optimal dose, which approximates MTD and requires fewer clinical visits, laboratory assessments, and dose adjustments. However, PK-guided dosing requires complex analytical techniques unavailable in low-resource settings. Simplified hydroxyurea PK analysis could optimize dosing and increase access to treatment. Methods: Concentrated stock solutions of reagents for chemical detection of serum hydroxyurea using HPLC were prepared and stored at -80C. On the day of analysis, hydroxyurea was serially diluted in human serum, then spiked with N-methylurea as an internal standard and analyzed using two commercial HPLC machines: 1) standard benchtop Agilent with 449 nm detector and 5 micron C18 column; and 2) portable PolyLC with 415 nm detector and 3.5 micron C18 column. After validation in the United States, the portable HPLC and chemicals were transported to Tanzania. Results: A calibration curve using hydroxyurea 2-fold dilutions ranging from 0 to 1000 µM was plotted against the hydroxyurea:N-methylurea ratio. In the United States, both HPLC systems yielded calibration curves with R2 > 0.99. Hydroxyurea prepared at known concentrations confirmed accuracy and precision within 10%-20% of the actual values. Both HPLC systems measured hydroxyurea with <10% variance from the prepared concentrations, and paired analysis of samples on both machines documented <15% variance. Serial measurements of 300 and 100 μM concentrations using the PolyLC system were precise with 2.5% coefficient of variance. After transport to Tanzania with setup and training, the modified PolyLC HPLC system produced similar calibration curves with R2 > 0.99. Conclusion: Increasing access to hydroxyurea for people with SCA requires an approach that eases financial and logistical barriers while optimizing safety and benefits, especially in low-resource settings. We successfully modified a portable HPLC instrument to quantify hydroxyurea, validated its precision and accuracy, and confirmed capacity building and knowledge transfer to Tanzania. HPLC measurement of serum hydroxyurea is now feasible in low-resource settings using available laboratory infrastructure. PK-guided dosing of hydroxyurea will be tested prospectively to achieve optimal treatment responses.
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Affiliation(s)
- Luke R Smart
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Global Health Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Mwesige Charles
- Department of Laboratory Sciences, Bugando Medical Centre, Mwanza, Tanzania
| | - Kathryn E McElhinney
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Min Dong
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Alexandra Power-Hays
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Global Health Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Thad Howard
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Alexander A Vinks
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Emmanuela E Ambrose
- Department of Paediatrics and Child Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
- Department of Paediatrics and Child Health Bugando Medical Centre, Mwanza, Tanzania
| | - Russell E Ware
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Global Health Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
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23
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Boma PM, Panda J, Ngoy Mande JP, Bonnechère B. Rehabilitation: a key service, yet highly underused, in the management of young patients with sickle cell disease after stroke in DR of Congo. Front Neurol 2023; 14:1104101. [PMID: 37292134 PMCID: PMC10244556 DOI: 10.3389/fneur.2023.1104101] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 05/02/2023] [Indexed: 06/10/2023] Open
Affiliation(s)
- Paul Muteb Boma
- Reference Centre for Sickle Cell Disease of Lubumbashi, Institut de Recherche en Science de la Santé, Lubumbashi, Democratic Republic of Congo
| | - Jules Panda
- Reference Centre for Sickle Cell Disease of Lubumbashi, Institut de Recherche en Science de la Santé, Lubumbashi, Democratic Republic of Congo
- Department of Surgery, Faculty of Medicine, University of Lubumbashi, Lubumbashi, Democratic Republic of Congo
| | - Jean Paul Ngoy Mande
- Department of Neurology and Psychiatry, Faculty of Medicine, University of Lubumbashi, Lubumbashi, Democratic Republic of Congo
| | - Bruno Bonnechère
- REVAL Rehabilitation Research Center, Faculty of Rehabilitation Sciences, University of Hasselt, Hasselt, Belgium
- Technology-Supported and Data-Driven Rehabilitation, Data Science Institute, University of Hasselt, Hasselt, Belgium
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24
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Alakbarzade V, Maduakor C, Khan U, Khandanpour N, Rhodes E, Pereira AC. Cerebrovascular disease in sickle cell disease. Pract Neurol 2023; 23:131-138. [PMID: 36123118 DOI: 10.1136/pn-2022-003440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 11/04/2022]
Abstract
Sickle cell disease (SCD) is the most common type of hereditary anaemia and genetic disorder worldwide. Cerebrovascular disease is one of its most devastating complications, with consequent increased morbidity and mortality. Current guidelines suggest that children and adults with SCD who develop acute ischaemic stroke should be transfused without delay. Those with acute ischaemic stroke aged over 18 years who present within 4.5 hours of symptom onset should be considered for intravenous thrombolysis; older patients with conventional vascular risk factors are the most likely to benefit. Endovascular thrombectomy should be considered carefully in adults with SCD as there are few data to guide how the prevalence of cerebral vasculopathy may confound the expected benefits or risks of intervention. We present a practical approach to cerebrovascular disease in sickle cell patients based on the available evidence and our experience.
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Affiliation(s)
- Vafa Alakbarzade
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Chinedu Maduakor
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Usman Khan
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Nader Khandanpour
- Department of Neuroradiology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Elizabeth Rhodes
- Department of Haematology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Anthony C Pereira
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
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25
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Ambrose EE, Latham TS, Songoro P, Charles M, Lane AC, Stuber SE, Makubi AN, Ware RE, Smart LR. Hydroxyurea with dose escalation for primary stroke risk reduction in children with sickle cell anaemia in Tanzania (SPHERE): an open-label, phase 2 trial. Lancet Haematol 2023; 10:e261-e271. [PMID: 36870358 PMCID: PMC10132280 DOI: 10.1016/s2352-3026(22)00405-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/10/2022] [Accepted: 12/12/2022] [Indexed: 03/05/2023]
Abstract
BACKGROUND Transcranial Doppler screening with chronic transfusions reduces stroke risk in children with sickle cell anaemia but is not feasible in low-resource settings. Hydroxyurea is an alternative treatment to decrease stroke risk. We aimed to estimate stroke risk in children with sickle cell anaemia in Tanzania and to determine the efficacy of hydroxyurea to decrease and prevent stroke. METHODS We did an open-label, phase 2 trial (SPHERE) at Bugando Medical Centre, Mwanza, Tanzania. Children aged 2-16 years with a diagnosis of sickle cell anaemia confirmed by haemoglobin electrophoresis were eligible for enrolment. Participants had transcranial Doppler ultrasound screening by a local examiner. Participants with elevated Doppler velocities, either conditional (170-199 cm/s) or abnormal (≥200 cm/s), received oral hydroxyurea starting at 20 mg/kg once daily and escalated every 8 weeks by 5 mg/kg per day to the maximum tolerated dose. Participants with normal Doppler velocities (<170 cm/s) received usual care from the sickle cell anaemia clinic and were rescreened after 12 months to determine whether they qualified for treatment on trial. The primary endpoint was change in transcranial Doppler velocity from the baseline visit to after 12 months of hydroxyurea treatment, analysed in all patients who had paired baseline and follow-up measurements collected after 12 months of treatment. Safety was analysed in the per-protocol population (all participants who received study treatment). This study is registered with ClinicalTrials.gov, NCT03948867. FINDINGS Between April 24, 2019, and April 9, 2020, 202 children were enrolled and had transcranial Doppler screening. Sickle cell anaemia was confirmed by DNA-based testing in 196 participants (mean age 6·8 years [SD 3·5], 103 [53%] were female, and 93 [47%] were male). At the baseline screening, 47 (24%) of 196 participants had elevated transcranial Doppler velocities (43 [22%] conditional, four [2%] abnormal); 45 initiated hydroxyurea at a mean dose of 20·2 mg/kg per day (SD 1·4) with escalation to a mean dose of 27·4 mg/kg per day (5·1) after 12 months. Treatment response was analysed after 12 months (± 1 month; median 11 months, IQR 11-12) and 24 months (±3 months; median 22 months, 22-22). Transcranial Doppler velocities decreased to a mean of 149 cm/s (SD 27) compared with 182 cm/s (12) at baseline, which was significantly lower than baseline (p<0·0001), with an average decline of 35 cm/s (SD 23) after 12 months of treatment in 42 participants with paired results available at baseline and 12 months. No clinical strokes occurred, and 35 (83%) of 42 participants reverted to normal transcranial Doppler velocities. Clinical adverse events were mild, and dose-limiting toxicities were uncommon. The most common grade 3 adverse events were malaria (12 [29%] episodes in 45 patients) and sepsis (13 [32%] episodes). There were three serious adverse events, none of which were treatment-related, and no treatment-related deaths occurred. INTERPRETATION Children with sickle cell anaemia in Tanzania have a high baseline stroke risk. Hydroxyurea at the maximum tolerated dose significantly lowers transcranial Doppler velocities and reduces primary stroke risk. Transcranial Doppler screening plus hydroxyurea at the maximum tolerated dose is an effective stroke prevention strategy, supporting wider hydroxyurea access for patients with sickle cell anaemia across sub-Saharan Africa. FUNDING American Society of Hematology, National Institutes of Health, Cincinnati Children's Research Foundation.
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Affiliation(s)
- Emmanuela E Ambrose
- Department of Paediatrics and Child Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania; Department of Paediatrics and Child Health, Bugando Medical Centre, Mwanza, Tanzania
| | - Teresa S Latham
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Primrose Songoro
- Department of Paediatrics and Child Health, Bugando Medical Centre, Mwanza, Tanzania
| | - Mwesige Charles
- Department of Laboratory Science, Bugando Medical Centre, Mwanza, Tanzania
| | - Adam C Lane
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Susan E Stuber
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Global Health Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Abel N Makubi
- Department of Internal Medicine, Bugando Medical Centre, Mwanza, Tanzania
| | - Russell E Ware
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Global Health Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Luke R Smart
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Global Health Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.
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26
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Fox C. Pediatric Ischemic Stroke. Continuum (Minneap Minn) 2023; 29:566-583. [PMID: 37039410 DOI: 10.1212/con.0000000000001239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Pediatric cerebrovascular disease is one of the leading causes of death and disability in children. Survivors of childhood stroke and their families are often left to cope with long-lasting sequelae, such as barriers to school reentry and long-term challenges in attaining independence as adults. Because childhood stroke is rare and providers may not be familiar with the disorder, this article reviews the risk factors, acute management, and sequelae of ischemic stroke in children. LATEST DEVELOPMENTS High-quality evidence has resulted in an organized approach to emergent treatment of ischemic stroke in adults, but most front-line providers are less prepared for emergent stroke management in children. The level of evidence for reperfusion therapies in children remains low but is growing. Thrombolysis and thrombectomy are sometimes considered for hyperacute treatment of stroke in children. Readiness for pediatric stroke at regional centers should include an organized approach to pediatric stroke triage and management based on extrapolation from adult stroke trials, expert consensus, and emerging pediatric studies. ESSENTIAL POINTS This review provides up-to-date information about ischemic stroke risk factors and management in children. Preparation for rapid stroke diagnosis and management in children may improve outcomes.
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27
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Tonin FS, Ginete C, Ferreira J, Delgadinho M, Santos B, Fernandez-Llimos F, Brito M. Efficacy and safety of pharmacological interventions for managing sickle cell disease complications in children and adolescents: Systematic review with network meta-analysis. Pediatr Blood Cancer 2023; 70:e30294. [PMID: 36916826 DOI: 10.1002/pbc.30294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 03/16/2023]
Abstract
This study aimed to synthesize the evidence on the effects of disease-modifying agents for managing sickle cell disease (SCD) in children and adolescents by means of a systematic review with network meta-analyses, surface under the cumulative ranking curve (SUCRA) and stochastic multicriteria acceptability analyses (SMAA) (CRD42022328471). Eightteen randomized controlled trials (hydroxyurea [n = 7], l-arginine [n = 3], antiplatelets [n = 2], immunotherapy/monoclonal antibodies [n = 2], sulfates [n = 2], docosahexaenoic acid [n = 1], niprisan [n = 1]) were analyzed. SUCRA and SMAA demonstrated that hydroxyurea at higher doses (30 mg/kg/day) or at fixed doses (20 mg/kg/day) and immunotherapy/monoclonal antibodies are more effective for preventing vaso-occlusive crisis (i.e., lower probabilities of incidence of this event; 14, 25, and 30%, respectively), acute chest syndrome (probabilities ranging from 8 to 30%), and needing of transfusions (11-31%), while l-arginine (100-200 mg/kg) and placebo were more prone to these events. Therapies were overall considered safe; however, antiplatelets and sulfates may lead to more severe adverse events. Although the evidence was graded as insufficient and weak, hydroxyurea remains the standard of care for this population, especially if a maximum tolerated dose schedule is considered.
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Affiliation(s)
- Fernanda S Tonin
- H&TRC - Health & Technology Research Center, ESTeSL - Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
| | - Catarina Ginete
- H&TRC - Health & Technology Research Center, ESTeSL - Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
| | - Joana Ferreira
- H&TRC - Health & Technology Research Center, ESTeSL - Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
| | - Mariana Delgadinho
- H&TRC - Health & Technology Research Center, ESTeSL - Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
| | - Brígida Santos
- Centro de Investigação em Saúde de Angola (CISA), Bengo, Angola.,Hospital Pediátrico David Bernardino (HPDB), Luanda, Angola
| | - Fernando Fernandez-Llimos
- CINTESIS@RISE, Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - Miguel Brito
- H&TRC - Health & Technology Research Center, ESTeSL - Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
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28
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Hydroxyurea and stroke prevention in sickle cell anaemia: the challenge of application in sub-Saharan Africa. Lancet Haematol 2023; 10:e237-e238. [PMID: 36870359 DOI: 10.1016/s2352-3026(23)00003-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 03/06/2023]
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29
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Quinn CT. Hydroxyurea: how much is enough? Blood 2023; 141:813-814. [PMID: 36821183 DOI: 10.1182/blood.2022018790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
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30
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Abdullahi SU, Sunusi S, Abba MS, Sani S, Inuwa HA, Gambo S, Gambo A, Musa B, Covert Greene BV, Kassim AA, Rodeghier M, Hussaini N, Ciobanu M, Aliyu MH, Jordan LC, DeBaun MR. Hydroxyurea for secondary stroke prevention in children with sickle cell anemia in Nigeria: a randomized controlled trial. Blood 2023; 141:825-834. [PMID: 36322937 PMCID: PMC10023719 DOI: 10.1182/blood.2022016620] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 09/29/2022] [Accepted: 10/18/2022] [Indexed: 11/07/2022] Open
Abstract
We tested the hypothesis that fixed oral moderate-dose hydroxyurea (20 mg/kg per day) for initial treatment of secondary stroke prevention results in an 80% relative risk reduction of stroke or death when compared with fixed oral low-dose hydroxyurea (10 mg/kg per day) in a phase 3 double-blind, parallel-group, randomized controlled trial in children with sickle cell anemia (SCA) living in Nigeria. A total of 101 participants were randomly allocated to low-dose (n = 49) and moderate-dose (n = 52) hydroxyurea treatment groups. The median participant follow-up was 1.6 years (interquartile range, 1.0-2.3), with a planned minimum follow-up of 3.0 years. A total of 6 recurrent strokes and 2 deaths vs 5 recurrent strokes and 3 deaths occurred in the low- and moderate-dose groups, respectively. The incidence rate ratio (IRR) of the primary outcome measure of stroke or death in the low- and moderate-dose hydroxyurea treatment groups was 0.98 (95% confidence interval [CI], 0.32-3.00; P = .97). The trial was stopped early owing to no clinical difference in the incidence rates of the primary outcome measure. The incidence rates of recurrent strokes were 7.1 and 6.0 per 100 person-years in the low- and moderate-dose groups, respectively, (IRR, 1.18; 95% CI, 0.30-4.88; P = .74). As a measure of adherence to the oral hydroxyurea therapy, the median percent of returned pills was 3.0% and 2.6% in the low- and moderate-dose groups, respectively. No participant had hydroxyurea therapy stopped for myelosuppression. For children with SCA in low-income settings without access to regular blood transfusion therapy, initial low-dose hydroxyurea is a minimum known efficacious dose for secondary stroke prevention.
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Affiliation(s)
- Shehu U. Abdullahi
- Department of Pediatrics, Bayero University and Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Surayya Sunusi
- Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | | | - Saifuddeen Sani
- Department of Administration, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Hauwau Aminu Inuwa
- Department of Internal Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Safiya Gambo
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Awwal Gambo
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Bilya Musa
- Department of Administration, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Brittany V. Covert Greene
- Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN
| | - Adetola A. Kassim
- Department of Hematology and Oncology, Vanderbilt School of Medicine, Vanderbilt University, Nashville, TN
| | | | - Nafiu Hussaini
- Department of Mathematical Sciences, Bayero University, Kano, Nigeria
| | - Mariana Ciobanu
- Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN
| | - Muktar H. Aliyu
- Vanderbilt Institute for Global Health, Vanderbilt University and Vanderbilt University Medical Center, Nashville, TN
| | - Lori C. Jordan
- Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN
| | - Michael R. DeBaun
- Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN
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Odame I. Sickle cell disease in children: an update of the evidence in low- and middle-income settings. Arch Dis Child 2023; 108:108-114. [PMID: 35705370 DOI: 10.1136/archdischild-2021-323633] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/15/2022] [Indexed: 01/24/2023]
Abstract
Sickle cell disease (SCD), one of the most common monogenetic diseases in the world, is associated with multisystemic complications that begin in childhood. Most of the babies homozygous for the sickle haemoglobin gene are born in sub-Saharan Africa. Over the years, progress has been made with early diagnosis through newborn screening, penicillin prophylaxis, pneumococcal immunisation, transcranial Doppler (TCD) screening, hydroxyurea therapy and chronic blood transfusions with remarkably improved survival and quality of life of children with SCD. However, wide disparities in outcomes exist between high-income countries (HICs) where over 90% survive to adulthood, and low-income and middle-income countries (LMICs) where less than half achieve that milestone. Even in HICs, racial inequities pose barriers to accessing specialised care and receiving treatment for acute pain episodes. Better understanding of SCD pathophysiology is being exploited to develop new disease-modifying drugs and gene therapy approaches to further improve outcomes. Bone marrow transplantation is established as a curative treatment for SCD, but it is largely unavailable in LMICs. To bridge the disparity and inequity gaps, innovative approaches are needed in LMICs. Validated and more affordable, easy-to-use point-of-care tests offer opportunities to link early diagnosis with immunisation programmes and healthcare encounters. Widespread use of hydroxyurea therapy-a relatively affordable and effective disease-modifying drug-in LMICs would help improve survival and quality of life. Integration of SCD treatment into primary care linked to district level/provincial hospitals that are supported with evidence-based guidelines will help extend needed interventions to many more patients living in LMICs.
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Affiliation(s)
- Isaac Odame
- Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada .,University of Toronto, Toronto, Ontario, Canada
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Ambrose EE, Kidenya BR, Charles M, Ndunguru J, Jonathan A, Makani J, Minja IK, Ruggajo P, Balandya E. Outcomes of Hydroxyurea Accessed via Various Means and Barriers Affecting Its Usage Among Children with Sickle Cell Anaemia in North-Western Tanzania. J Blood Med 2023; 14:37-47. [PMID: 36712580 PMCID: PMC9875573 DOI: 10.2147/jbm.s380901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 12/05/2022] [Indexed: 01/22/2023] Open
Abstract
Purpose To assess clinical and haematological outcomes of Hydroxyurea accessed via various access means and uncover the barriers to its utilization in children with Sickle cell anaemia (SCA), North-western Tanzania. Patients and Methods A retrospective study was conducted between October 2020 and April 2021 at Bugando Medical Centre (BMC) through review of medical files to compare the clinical and haematological outcomes among children with SCA at baseline and followed up retrospectively for at least one year of hydroxyurea utilization, accessed via cash, insurance and projects. Subsequently, a cross-sectional survey was conducted among parents and caregivers to ascertain the barriers to access of hydroxyurea via the various means. The p-values <0.05 were considered statistically significant. Results We identified 87 children with SCA who were on hydroxyurea for at least one year. The median age at baseline (before hydroxyurea) was 99 [78-151] months, and 52/87 (59.8%) were male. Compared to baseline, there was a significant reduction in proportion of patients reporting vaso-occlusive crisis, admissions and blood transfusions, a significant increase in Haemoglobin and mean corpuscular volume, conversely a significant reduction in absolute neutrophil and reticulocytes to both insurance and project participants. There was no significant change in most of these parameters among patients who accessed hydroxyurea via cash. Further, a total of 24/87 (27.6%) participants reported different barriers to access of hydroxyurea, where 10/24 (41.7%) reported hydroxyurea to be very expensive, 10/24 (41.7%) reported insurance challenges, and 4/21 (16.6%) reported unavailability of the drug. Conclusion The paediatric patients utilizing hydroxyurea accessed via insurance and projects, but not cash, experienced significant improvement in the clinical and haematological outcomes. Several barriers for access to hydroxyurea were observed which appeared to impact these outcomes. These findings call for concerted efforts to improve the sustainable access to hydroxyurea among all patients with SCA.
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Affiliation(s)
- Emmanuela E Ambrose
- Department of Paediatrics and Child Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania,Correspondence: Emmanuela E Ambrose, Department of Paediatrics and Child Health, Catholic University of Health and Allied Sciences, P.O. Box 1464, Mwanza, Tanzania, Tel +255789733833, Fax +255282500799, Email
| | - Benson R Kidenya
- Department of Biochemistry and Molecular Biology, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Mwesige Charles
- Department of Laboratory Services, Bugando Medical Centre, Mwanza, Tanzania
| | - Joyce Ndunguru
- Department of Haematology and Blood Transfusion, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Agnes Jonathan
- Department of Haematology and Blood Transfusion, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Julie Makani
- Department of Haematology and Blood Transfusion, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Irene K Minja
- Department of Haematology and Blood Transfusion, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania,Department of Restorative Dentistry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Paschal Ruggajo
- Department of Haematology and Blood Transfusion, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania,Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Emmanuel Balandya
- Department of Haematology and Blood Transfusion, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania,Department of Physiology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Asare EV. Acute pain episodes, acute chest syndrome, and pulmonary thromboembolism in pregnancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:388-407. [PMID: 36485167 PMCID: PMC9821602 DOI: 10.1182/hematology.2022000376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Pregnancy in women with sickle cell disease (SCD) is a life-threatening condition. In both high- and low-income countries, there is an 11-fold increased risk of maternal death and a 4-fold increased risk of perinatal death. We highlight the epidemiology of SCD-specific and obstetric complications commonly seen during pregnancy in SCD and propose definitions for acute pain and acute chest syndrome (ACS) episodes during pregnancy. We conducted a systematic review of the recent obstetric and hematology literature using full research articles published within the last 5 years that reported outcomes in pregnant women with SCD. The prevalence of acute pain episodes during pregnancy ranged between 4% and 75%. The prevalence of ACS episodes during pregnancy ranged between 4% and 13%. The estimated prevalence of pulmonary thromboembolism in women with SCD during pregnancy is approximately 0.5 to 1%. ACS is the most common cause of death and is often preceded by acute pain episodes. The most crucial time to develop these complications in pregnancy is during the third trimester and postpartum period. In a pooled analysis from studies in low- and middle-income settings, maternal death in women with SCD is approximately 2393 and 4300 deaths per 100 000 live births with and without multidisciplinary care, respectively. In comparison, in the US and northern Europe, the general maternal mortality rate is approximately 23.8 and 8 deaths per 100 000 live births, respectively. A multidisciplinary SCD obstetrics care approach reduces maternal and perinatal morbidity and mortality in low- and middle-income countries.
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Affiliation(s)
- Eugenia Vicky Asare
- Ghana Institute of Clinical Genetics, Korle-Bu, Accra, Ghana
- Department of Haematology, Korle-Bu Teaching Hospital, Accra, Ghana
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Abstract
BACKGROUND Sickle cell disease (SCD) is one of the most common inherited diseases worldwide. It is associated with lifelong morbidity and a reduced life expectancy. Hydroxyurea (hydroxycarbamide), an oral chemotherapeutic drug, ameliorates some of the clinical problems of SCD, in particular that of pain, by raising foetal haemoglobin (HbF). This is an update of a previously published Cochrane Review. OBJECTIVES The aims of this review are to determine through a review of randomised or quasi-randomised studies whether the use of hydroxyurea in people with SCD alters the pattern of acute events, including pain; prevents, delays or reverses organ dysfunction; alters mortality and quality of life; or is associated with adverse effects. In addition, we hoped to assess whether the response to hydroxyurea in SCD varies with the type of SCD, age of the individual, duration and dose of treatment, and healthcare setting. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Haemoglobinopathies Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also searched online trial registries. The date of the most recent search was 17 February 2022. SELECTION CRITERIA Randomised and quasi-randomised controlled trials (RCTs and quasi-RCTs), of one month or longer, comparing hydroxyurea with placebo or standard therapy in people with SCD. DATA COLLECTION AND ANALYSIS Authors independently assessed studies for inclusion, carried out data extraction, assessed the risk of bias and assessed the quality of the evidence using GRADE. MAIN RESULTS We included nine RCTs recruiting 1104 adults and children with SCD (haemoglobin SS (HbSS), haemoglobin SC (HbSC) or haemoglobin Sβºthalassaemia (HbSβºthal) genotypes). Studies lasted from six to 30 months. We judged the quality of the evidence for the first two comparisons below as moderate to low as the studies contributing to these comparisons were mostly large and well-designed (and at low risk of bias); however, the evidence was limited and imprecise for some outcomes such as quality of life, deaths during the studies and adverse events, and the results are applicable only to individuals with HbSS and HbSβºthal genotypes. We judged the quality of the evidence for the third and fourth comparisons to be very low due to the limited number of participants, the lack of statistical power (both studies were terminated early with approximately only 20% of their target sample size recruited) and the lack of applicability to all age groups and genotypes. Hydroxyurea versus placebo Five studies (784 adults and children with HbSS or HbSβºthal) compared hydroxyurea to placebo; four recruited individuals with only severe disease and one recruited individuals with all disease severities. Hydroxyurea probably improves pain alteration (using measures such as pain crisis frequency, duration, intensity, hospital admissions and opoid use) and life-threatening illness, but we found no difference in death rates (10 deaths occurred during the studies, but the rates did not differ by treatment group) (all moderate-quality evidence). Hydroxyurea may improve measures of HbF (low-quality evidence) and probably decreases neutrophil counts (moderate-quality evidence). There were no consistent differences in terms of quality of life and adverse events (including serious or life-threatening events) (low-quality evidence). There were fewer occurrences of acute chest syndrome and blood transfusions in the hydroxyurea groups. Hydroxyurea and phlebotomy versus transfusion and chelation Two studies (254 children with HbSS or HbSβºthal also with risk of primary or secondary stroke) contributed to this comparison. There were no consistent differences in terms of pain alteration, death or adverse events (low-quality evidence) or life-threatening illness (moderate-quality evidence). Hydroxyurea with phlebotomy probably increased HbF and decreased neutrophil counts (moderate-quality evidence), but there were more occurrences of acute chest syndrome and infections. Quality of life was not reported. In the primary prevention study, no strokes occurred in either treatment group but in the secondary prevention study, seven strokes occurred in the hydroxyurea and phlebotomy group (none in the transfusion and chelation group) and the study was terminated early. Hydroxyurea versus observation One study (22 children with HbSS or HbSβºthal also at risk of stoke) compared hydroxyurea to observation. Pain alteration and quality of life were not reported. There were no differences in life-threatening illness, death (no deaths reported in either group) or adverse events (very low-quality evidence). We are uncertain if hydroxyurea improves HbF or decreases neutrophil counts (very low-quality evidence). Treatment regimens with and without hydroxyurea One study (44 adults and children with HbSC) compared treatment regimens with and without hydroxyurea. Pain alteration, life-threatening illness and quality of life were not reported. There were no differences in death rates (no deaths reported in either group), adverse events or neutrophil levels (very low-quality evidence). We are uncertain if hydroxyurea improves HbF (very low-quality evidence). AUTHORS' CONCLUSIONS There is evidence to suggest that hydroxyurea may be effective in decreasing the frequency of pain episodes and other acute complications in adults and children with sickle cell anaemia of HbSS or HbSβºthal genotypes and in preventing life-threatening neurological events in those with sickle cell anaemia at risk of primary stroke by maintaining transcranial Doppler velocities. However, there is still insufficient evidence on the long-term benefits of hydroxyurea, particularly with regard to preventing chronic complications of SCD, or recommending a standard dose or dose escalation to maximum tolerated dose. There is also insufficient evidence about the long-term risks of hydroxyurea, including its effects on fertility and reproduction. Evidence is also limited on the effects of hydroxyurea on individuals with the HbSC genotype. Future studies should be designed to address such uncertainties.
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Affiliation(s)
- Angela E Rankine-Mullings
- Sickle Cell Unit, Caribbean Institute for Health Research, University of the West Indies, Kingston, Jamaica
| | - Sarah J Nevitt
- Department of Health Data Science, University of Liverpool, Liverpool, UK
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Prophylactic Hydroxyurea Treatment Is Associated with Improved Cerebral Hemodynamics as a Surrogate Marker of Stroke Risk in Sickle Cell Disease: A Retrospective Comparative Analysis. J Clin Med 2022; 11:jcm11123491. [PMID: 35743561 PMCID: PMC9225168 DOI: 10.3390/jcm11123491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/10/2022] [Accepted: 06/15/2022] [Indexed: 11/21/2022] Open
Abstract
Sickle cell disease (SCD) increases the incidence of childhood stroke eighty-fold. Stroke risk can be estimated by measurement of the blood velocity through the middle cerebral artery (MCA) using transcranial doppler ultrasound (TCD). A high MCA blood velocity indicates increased stroke risk due to cerebral vasculopathy, and first-line treatment to prevent primary or recurrent strokes in high-risk children with SCD has classically been chronic blood transfusions. Research has more recently shown that many of these patients may safely transition from transfusions to oral hydroxyurea (HU) treatment while maintaining a decreased risk of stroke. However, the effect on stroke risk of truly prophylactic HU treatment beginning in infancy, prior to the onset of cerebral vasculopathy, is less well understood. Our retrospective study aimed to document the long-term effects of HU treatment compared with no HU treatment in children with SCD, using TCD measurements as our primary outcome and a surrogate marker of stroke risk. Our results showed that when accounting for age-related variability and duration of treatment, prophylactic HU treatment was independently associated with lower TCD MCA velocities compared with no HU treatment, providing further evidence supporting its early initiation for patients with SCD.
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Dua M, Bello-Manga H, Carroll YM, Galadanci AA, Ibrahim UA, King AA, Olanrewaju A, Estepp JH. Strategies to increase access to basic sickle cell disease care in low- and middle-income countries. Expert Rev Hematol 2022; 15:333-344. [PMID: 35400264 PMCID: PMC9442799 DOI: 10.1080/17474086.2022.2063116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 04/04/2022] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Sickle cell disease (SCD) is the most common hemoglobinopathy in the world. Over 90% of those born with SCD live in low- and middle-income countries (LMICs), yet individuals in these settings have much poorer outcomes compared to those in high-income countries. AREAS COVERED This manuscript provides an in-depth review of the cornerstones of basic SCD care, the barriers to implementing these in LMICs, and strategies to increase access in these regions. Publications in English language, peer-reviewed, and edited from 2000 to 2021 were identified on PubMed. Google search was used for gray literature. EXPERT OPINION Outcomes for patients with SCD in high-income countries have improved over the last few decades due to the implementation of universal newborn screening programs and use of routine antimicrobial prophylaxis, increase in therapeutic and curative options, and the adoption of specific measures to decrease risk of stroke. This success has not translated to LMICs due to several reasons including resource constraints. A combination of several strategies is needed to increase access to basic SCD care for patients in these settings.
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Affiliation(s)
- Meghna Dua
- Department of Global Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Halima Bello-Manga
- Department of Hematology and Blood Transfusion, Barau Dikko Teaching Hospital/Kaduna State University, Nigeria
| | - Yvonne M. Carroll
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | | | | | - Allison A. King
- in Occupational Therapy, Departments of Pediatrics, Medicine and Surgery, Washington University School of MedicineProgram , St. Louis, USA
| | - Ayobami Olanrewaju
- Department of Global Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Jeremie H. Estepp
- Department of Global Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
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Bello-Manga H, Haliru L, Ahmed KA, Tabari AM, Farouk BU, Bahago GY, Kazaure AS, Muhammad AS, Gwarzo SA, Baumann AA, DeBaun MR, King AA. Primary Prevention of Stroke in Children with Sickle Cell Anemia in Nigeria: Protocol for a Mixed-Methods Implementation Study in a Community Hospital (Preprint). JMIR Res Protoc 2022; 11:e37927. [PMID: 35700018 PMCID: PMC9496111 DOI: 10.2196/37927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/15/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Halima Bello-Manga
- Department of Hematology and Blood Transfusion, Barau Dikko Teaching Hospital/Kaduna State University, Kaduna, Nigeria
| | - Lawal Haliru
- Department of Pediatrics, Barau Dikko Teaching Hospital/Kaduna State University, Kaduna, Nigeria
| | - Kudrat Abdulkareem Ahmed
- Department of Pediatrics, Barau Dikko Teaching Hospital/Kaduna State University, Kaduna, Nigeria
| | - Abdulkadir Musa Tabari
- Department of Radiology, Barau Dikko Teaching Hospital/Kaduna State University, Kaduna, Nigeria
| | - Bilkisu Usman Farouk
- Department of Radiology, Barau Dikko Teaching Hospital/Kaduna State University, Kaduna, Nigeria
| | - Gloria Yimi Bahago
- Department of Nursing Services, Haematology Unit, Barau Dikko Teaching Hospital, Kaduna, Nigeria
| | - Aisha Shuaibu Kazaure
- Department of Pharmaceutical Services, Barau Dikko Teaching Hopsital, Kaduna, Nigeria
| | | | | | - Ana A Baumann
- Department of Surgery, Washington University in St. Louis, St. Louis, MO, United States
| | - Michael R DeBaun
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Allison A King
- Program in Occupational Therapy, Department of Medicine, Pediatrics, Surgery, and Education, Washington University School of Medicine, St. Louis, MO, United States
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Debaun MR. PRIMARY STROKE PREVENTION IN CHILDREN WITH SICKLE CELL ANEMIA LIVING IN AFRICA: THE FALSE CHOICE BETWEEN PATIENT-ORIENTED RESEARCH AND HUMANITARIAN SERVICE-PART II. TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION 2022; 132:236-248. [PMID: 36196180 PMCID: PMC9480538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
In the United States, primary stroke prevention in children with sickle cell anemia (SCA) is the standard of care and includes annual transcranial Doppler ultrasound to detect elevated velocities. For children with velocities ≥200 cm/sec, initial monthly blood transfusion therapy for at least a year, followed by the option of hydroxyurea therapy, results in a significant decline in the stroke rate. In Africa, no prior strategy exists for primary stroke prevention because regular blood transfusion therapy is not feasible. We completed a randomized controlled trial for primary stroke prevention using initial low- and moderate-dose hydroxyurea as an alternative to blood transfusion therapy. The trial results demonstrated equal primary stroke prevention efficacy with both doses. After the trial, we provided a state-supported stroke screening service and treatment for over 20,000 children in Kano, Nigeria. We will review the strategies implemented to conduct clinical research and provide humanitarian assistance to children with SCA in Nigeria.
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