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Albahout KS, Yunus M, Mohammad YG, Almalki AF, Alduailej SK, Alanazi BZ. Correlation of Transfusion Dependence and Its Associated Sequelae to Hematological and Biochemical Parameters in Patients With Sickle Cell Disease and Beta Thalassemia Major in Khobar: A Retrospective Study. Cureus 2023; 15:e42151. [PMID: 37602131 PMCID: PMC10438923 DOI: 10.7759/cureus.42151] [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: 07/19/2023] [Indexed: 08/22/2023] Open
Abstract
Sickle cell disease (SCD) and beta thalassemia major (βTM) are multisystemic, genetically inherited diseases. They are caused by mutations of hemoglobin, which ultimately cause abnormal functioning of the red blood cells. The morbidity and mortality rates of these diseases are significant, as they may result in severe complications, some of which are quite fatal; hence, early diagnosis and treatment are crucial. The purpose of this study is to collect patients' data in terms of their manifestations and overall clinical picture and correlate them to the laboratory parameters with emphasis on their transfusion dependence and its sequelae in King Fahd Hospital of the University (KFHU), Al-Khobar, Saudi Arabia. After obtaining ethical approval from the institutional review board and in collaboration with the blood bank, patients' data were retrospectively collected from the hospital's database and categorized into two disease groups. Accordingly, data related to the biological and demographic information, clinical picture pattern, laboratory investigations, and therapeutic measures, with emphasis on blood transfusion as a treatment option, were gathered and analyzed. Eventually, the aforementioned data aspects were assessed for the probability of correlations, which were proven to be present to some level as an answer to our cohort study's question. Such findings, which will be depicted later in this study, might represent a ground for having a more comprehensive and extensive approach in terms of the general evaluation of patients with SCD and βTM based on the established level of correlation. During the course of conducting our research, we encountered some limitations, including the sample size and scarce data available during the process of data collection.
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Affiliation(s)
- Khaled S Albahout
- General Surgery, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Mohammed Yunus
- Pathology, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | | | - Adnan F Almalki
- Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | | | - Basel Z Alanazi
- Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
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2
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Thangamathesvaran L, Ong SS, Wang J, Lance E, Tekes A, Scott AW. EVALUATION OF MACULAR FLOW VOIDS ON OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY AS POTENTIAL BIOMARKERS FOR SILENT CEREBRAL INFARCTION IN SICKLE CELL DISEASE. Retina 2022; 42:340-347. [PMID: 34608107 DOI: 10.1097/iae.0000000000003309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine the relationship between macular microvascular abnormalities on optical coherence tomography angiography and silent cerebral infarctions (SCIs) on cerebral magnetic resonance imaging in sickle cell disease. METHODS Patients (age <18 years old) from our previous pediatric sickle cell disease study cohort who had prior optical coherence tomography angiography and brain magnetic resonance imaging were identified. Brain magnetic resonance imaging images were compared with macular optical coherence tomography angiography scans to identify macular vascular density differences between patients with SCI and without SCI. RESULTS Sixty-eight eyes from 34 patients who underwent optical coherence tomography angiography were evaluated, of whom 28 eyes from 14 patients met the inclusion criteria for this study. Eight patients (57%) with SCI and 6 patients (43%) without SCI were identified. The mean age (17 years in SCI and 16.3 years in non-SCI) was comparable between groups. There was no statistically significant difference in systemic complications. Deep capillary plexus vessel density was lower in the temporal quadrant in patients with SCI (49.3% vs. 53.7%, P = 0.014). CONCLUSION Patients with SCI were found to have lower vessel density in the deep capillary plexus compared with those without SCI. This finding suggests that deep capillary plexus vessel density may have utility as an imaging biomarker to predict the presence of SCI.
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Affiliation(s)
- Loka Thangamathesvaran
- Retina Division, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sally S Ong
- Department of Ophthalmology and Visual Science, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Jiangxia Wang
- Department of Biostatistics, Wilmer Biostats Center, Johns Hopkins University, Baltimore, Maryland
| | - Eboni Lance
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Aylin Tekes
- Department of Pediatric Radiology and Pediatric Neuroradiology, Russell Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adrienne W Scott
- Retina Division, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
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3
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Stroke and stroke prevention in sickle cell anemia in developed and selected developing countries. J Neurol Sci 2021; 427:117510. [PMID: 34077859 DOI: 10.1016/j.jns.2021.117510] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/22/2021] [Accepted: 05/24/2021] [Indexed: 02/02/2023]
Abstract
This comprehensive review provides an insight into the pathophysiology, epidemiology, evaluation, and treatment of sickle cell anemia (SCA)-related stroke in developed and developing countries. Vascular injury, hypercoagulability and vaso-occlusion play a role in the pathophysiology of stroke in SCA. Transcranial Doppler ultrasound (TCD) has lowered the incidence of ischemic stroke from 11% to 1% as TCD identifies children who are at risk for stroke, providing opportunities for interventions to reduce this risk. Whereas blood exchange is indicated in acute stroke, chronic transfusions (either simple or exchange on a monthly basis) are used for primary as well as secondary stroke prevention in developed countries. Children with abnormally high TCD velocities (≥ 200 cm/s) are at high risk of stroke and might benefit from hydroxyurea or hydroxycarbamide (HU) after a period of a successful transition from chronic transfusions. Hematopoietic stem cell transplant presents a cure for SCA. Gene therapy is currently investigated and may be offered to patients with SCA who had a stroke or who are at high risk of stroke if proven efficacious and safe. However, gene therapy is not likely to be implemented in low-income countries due to cost. Alternatively, HU is utilized for primary and secondary stroke prevention in developing countries. Further expansion of TCD implementation should be a priority in those settings.
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4
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Stotesbury H, Kawadler JM, Saunders DE, Kirkham FJ. MRI detection of brain abnormality in sickle cell disease. Expert Rev Hematol 2021; 14:473-491. [PMID: 33612034 PMCID: PMC8315209 DOI: 10.1080/17474086.2021.1893687] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/18/2021] [Indexed: 02/08/2023]
Abstract
Introduction: Over the past decades, neuroimaging studies have clarified that a significant proportion of patients with sickle cell disease (SCD) have functionally significant brain abnormalities. Clinically, structural magnetic resonance imaging (MRI) sequences (T2, FLAIR, diffusion-weighted imaging) have been used by radiologists to diagnose chronic and acute cerebral infarction (both overt and clinically silent), while magnetic resonance angiography and venography have been used to diagnose arteriopathy and venous thrombosis. In research settings, imaging scientists are increasingly applying quantitative techniques to shine further light on underlying mechanisms.Areas covered: From a June 2020 PubMed search of 'magnetic' or 'MRI' and 'sickle' over the previous 5 years, we selected manuscripts on T1-based morphometric analysis, diffusion tensor imaging, arterial spin labeling, T2-oximetry, quantitative susceptibility, and connectivity.Expert Opinion: Quantitative MRI techniques are identifying structural and hemodynamic biomarkers associated with risk of neurological and neurocognitive complications. A growing body of evidence suggests that these biomarkers are sensitive to change with treatments, such as blood transfusion and hydroxyurea, indicating that they may hold promise as endpoints in future randomized clinical trials of novel approaches including hemoglobin F upregulation, reduction of polymerization, and gene therapy. With further validation, such techniques may eventually also improve neurological and neurocognitive risk stratification in this vulnerable population.
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Affiliation(s)
- Hanne Stotesbury
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Jamie Michelle Kawadler
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Dawn Elizabeth Saunders
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Fenella Jane Kirkham
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, UK
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5
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Optimisation of T2 and T2* sequences in MRI for better quantification of iron on transfused dependent sickle cell patients. Sci Rep 2021; 11:8513. [PMID: 33875765 PMCID: PMC8055987 DOI: 10.1038/s41598-021-88116-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 04/07/2021] [Indexed: 11/08/2022] Open
Abstract
This work aimed to investigate the effect of different shim techniques, voxel sizes, and repetition time (TR) on using theT2 and T2* sequences to determine their optimum settings to investigate the quantification of iron in transfused dependent sickle cell patients. The effect of each of these parameters was investigated on phantoms of different Gadolinium (Gd) concentrations, on 10 volunteers and 25 patients using a1 5T MRI Philips scanner. No significant difference between the three shim techniques was noticed in either T2 or T2* sequence measurements. Pixel sizes of 1 × 1 and 2 × 2 mm provided optimum results for T2 measurements. At 1 × 1 mm pixel size the T2* measurements experienced less error in measurements than the size of 2.5 × 2.5 mm used in the literature. Even though the slice thickness variation did not provide any changes in T2 measurements, the 12 mm provided optimum T2* measurements. TR variation did not yield significant changes on either T2 or T2* measurements. These results indicate that both T2 and T2* sequences can be further improved by providing more reliable measurements and reducing acquisition time.
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6
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Lagunju IA, Labaeka A, Ibeh JN, Orimadegun AE, Brown BJ, Sodeinde OO. Transcranial Doppler screening in Nigerian children with sickle cell disease: A 10-year longitudinal study on the SPPIBA cohort. Pediatr Blood Cancer 2021; 68:e28906. [PMID: 33522690 DOI: 10.1002/pbc.28906] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 12/30/2020] [Accepted: 12/31/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Primary stroke prevention programmes for children with sickle cell disease (SCD) have been shown to be feasible interventions in resource-poor countries. Different hydroxyurea (HU) regimens have been utilised in ameliorating the severity of SCD. OBJECTIVE To determine the long-term outcomes of the stroke prevention programme for children with SCD in Ibadan (SPPIBA), Nigeria. METHODS A longitudinal study of 396 children with haemoglobin SS disease who had been on the stroke prevention programme for a minimum period of 5 years. All enrollees had nonimaging TCD performed at baseline and thereafter 3-monthly or annually. Children with TCD velocities ≥170 cm/s were treated with HU by dose-escalation regimen. RESULTS The mean age at first TCD examination was 102 ± 46.7 months and the period of follow-up ranged from 5 to 10 years (mean = 7.2 ± 1.7). Time to significant decline in TCD velocities ranged from 5 to 35 months, (median = 10.0 months). The minimum dose of HU required to achieve significant decline in TCD velocities ranged from 15 to 31 mg/kg/day, mean 23.7 (±3.9). HU dose escalation beyond 20 mg/kg/day was required to attain significant reductions in the time-averaged mean of maximal velocities (TAMMV) in 69.1% of the cases. Two stroke events occurred giving a stroke incidence of 0.08 per 100 patient-years. CONCLUSION The majority of Nigerian children with SCD and elevated TCD velocities achieved significant decline in TAMMV within the first year of HU therapy but on higher doses of HU. It might be important to individualise HU doses for optimal outcomes in primary stroke prevention.
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Affiliation(s)
- IkeOluwa A Lagunju
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Adeyemi Labaeka
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Joy N Ibeh
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Adebola E Orimadegun
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Biobele J Brown
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Olugbemiro O Sodeinde
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Paediatrics, University College Hospital, Ibadan, Nigeria
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7
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Yuan S, Jordan LC, Davis LT, Cogswell PM, Lee CA, Patel NJ, Waddle SL, Juttukonda M, Sky Jones R, Griffin A, Donahue MJ. A cross-sectional, case-control study of intracranial arterial wall thickness and complete blood count measures in sickle cell disease. Br J Haematol 2020; 192:769-777. [PMID: 33326595 DOI: 10.1111/bjh.17262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/25/2020] [Accepted: 11/12/2020] [Indexed: 12/17/2022]
Abstract
In sickle cell disease (SCD), cerebral oxygen delivery is dependent on the cerebral vasculature's ability to increase blood flow and volume through relaxation of the smooth muscle that lines intracranial arteries. We hypothesised that anaemia extent and/or circulating markers of inflammation lead to concentric macrovascular arterial wall thickening, visible on intracranial vessel wall magnetic resonance imaging (VW-MRI). Adult and pediatric SCD (n = 69; age = 19.9 ± 8.6 years) participants and age- and sex-matched control participants (n = 38; age = 22.2 ± 8.9 years) underwent 3-Tesla VW-MRI; two raters measured basilar and bilateral supraclinoid internal carotid artery (ICA) wall thickness independently. Mean wall thickness was compared with demographic, cerebrovascular and haematological variables. Mean vessel wall thickness was elevated (P < 0·001) in SCD (1·07 ± 0·19 mm) compared to controls (0·97 ± 0·07 mm) after controlling for age and sex. Vessel wall thickness was higher in participants on chronic transfusions (P = 0·013). No significant relationship between vessel wall thickness and flow velocity, haematocrit, white blood cell count or platelet count was observed; however, trends (P < 0·10) for wall thickness increasing with decreasing haematocrit and increasing white blood cell count were noted. Findings are discussed in the context of how anaemia and circulating inflammatory markers may impact arterial wall morphology.
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Affiliation(s)
- Shuai Yuan
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lori C Jordan
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Larry T Davis
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Petrice M Cogswell
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Chelsea A Lee
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Niral J Patel
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Spencer L Waddle
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Meher Juttukonda
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - R Sky Jones
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Allison Griffin
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Manus J Donahue
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
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8
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Gilyard SN, Hamlin SL, Johnson JO, Herr KD. Imaging review of sickle cell disease for the emergency radiologist. Emerg Radiol 2020; 28:153-164. [PMID: 32734483 DOI: 10.1007/s10140-020-01828-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/21/2020] [Indexed: 02/08/2023]
Abstract
Sickle cell disease (SCD), one of the most common inherited genetic syndromes in the USA, is characterized by recurring episodes of acute illness and progressive multisystem organ injury. Individuals with SCD frequently present to the emergency department for a spectrum of complications, such as vaso-occlusive crises, infection, cholecystitis, and stroke. Imaging correlates for most of these presentations exist, positioning the emergency radiologist to play a pivotal role in facilitating patient care. Using a systems-based approach, we describe the acute and chronic imaging manifestations of SCD that an emergency radiologist can expect to encounter in most practice settings, highlighting the unique pathophysiology of this disorder that typically underlies the imaging findings.
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Affiliation(s)
- Shenise N Gilyard
- Emory University School of Medicine, Atlanta, USA. .,Division of Emergency and Trauma Imaging, Department of Radiology and Imaging Sciences, Emory University Hospital, 1364 Clifton Road NE Suite #D112, Atlanta, USA.
| | - Scott L Hamlin
- Emory University School of Medicine, Atlanta, USA.,Division of Emergency and Trauma Imaging, Department of Radiology and Imaging Sciences, Emory University Hospital, 1364 Clifton Road NE Suite #D112, Atlanta, USA
| | - Jamlik-Omari Johnson
- Emory University School of Medicine, Atlanta, USA.,Division of Emergency and Trauma Imaging, Department of Radiology and Imaging Sciences, Emory University Hospital, 1364 Clifton Road NE Suite #D112, Atlanta, USA
| | - Keith D Herr
- Emory University School of Medicine, Atlanta, USA.,Division of Emergency and Trauma Imaging, Department of Radiology and Imaging Sciences, Emory University Hospital, 1364 Clifton Road NE Suite #D112, Atlanta, USA
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9
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Abstract
The term "sickle cell disease" covers a group of genetic blood disorders caused by sickle hemoglobin (HbS) alone or in combination with other variants of the β‑globin locus. Sickle cell disease occurs frequently in sub-Saharan Africa, but is also common in Turkey, Greece, Sicily, the Middle East, India, and the Americas. Polymerization of deoxygenated sickle hemoglobin leads to decreased deformability of red blood cells. These altered erythrocytes can obstruct small blood vessels and cause acute episodes of pain, hemolytic anemia, and organ damage. Complications can vary between the different genotypes and it is important to be aware of the special features of the disease. Hydroxycarbamide has been shown to reduce the morbidity and mortality of patients with sickle cell disease. New drugs and novel treatment approaches such as gene therapy are currently being tested.
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Affiliation(s)
- L Distelmaier
- Klinik für Innere Medizin - Hämatologie, Onkologie und Palliativmedizin, Vivantes Klinikum Neukölln, Rudower Str. 48, 12351, Berlin, Deutschland. .,Klinik für Hämatologie, Universitätsklinikum Essen, Essen, Deutschland.
| | - U Dührsen
- Klinik für Hämatologie, Universitätsklinikum Essen, Essen, Deutschland
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10
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Ismail WIM, Elnour M, Mustafa AEM. Evaluation of transcranial Doppler abnormalities in children with sickle cell disease in El-Obeid Specialized Children's Hospital. J Family Med Prim Care 2019; 8:1176-1181. [PMID: 31041270 PMCID: PMC6482797 DOI: 10.4103/jfmpc.jfmpc_112_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives: This study aims to evaluate transcranial Doppler abnormalities in children with sickle cell disease (SCD) in a specialized children's hospital in El-Obeid. Materials and Methods: This is a cross-sectional study done on 119 patients (2–18 years of age were included) who attended the sickle cell clinic in a specialized children's hospital in El-Obeid from December 2016 to February 2017; when patients do not have recent stroke symptoms, blood flow velocities were measured in both proximal internal carotid and middle cerebral arteries (MCAs) using non-imaging Doppler method, and time average mean velocities were recorded along with hemoglobin concentration and of the patients. Results: None of the study population had MCA velocity higher than 200 cm/s; also no high conditional velocity (170–199 cm/s) was recorded, so no patient was at high risk to develop stroke. About 20.1% of patients showed low velocities in one or both MCAs; 4.2% had abnormal MCAs’ interhemispheric ratio; 4.2% of study population showed absent flow in one of their MCAs, reflecting previous occlusion. About 4.2% had poor temporal window. It was difficult to measure the velocity in one of the four vessels in 5.9% of the patient due to uncooperativeness. There was statistically significant relationship between hemoglobin concentration and blood velocity in the left MCA. Conclusion: Despite the international recommendations, using transcranial Doppler ultrasonography (TCD) as a stroke screening tool in children with SCD in Sudan is still not a well-known practice. Successful strategies to improve TCD screening rates must be encouraged in all healthcare institutions.
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Affiliation(s)
| | - Mustafa Elnour
- Department of Radiology, Faculty of Medicine, University of Khartoum, Sudan
| | - Alam Eldin Musa Mustafa
- Department of Pediatrics, King Khalid University, Abha, Saudi Arabia.,Department of Pediatrics, University of Kordofan, Sudan
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11
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Lagunju I, Brown BJ, Oyinlade AO, Asinobi A, Ibeh J, Esione A, Sodeinde OO. Annual stroke incidence in Nigerian children with sickle cell disease and elevated TCD velocities treated with hydroxyurea. Pediatr Blood Cancer 2019; 66:e27252. [PMID: 29797633 DOI: 10.1002/pbc.27252] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/17/2018] [Accepted: 04/20/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND Elevated transcranial Doppler (TCD) velocities accurately predict stroke risk in children with sickle cell disease (SCD). Chronic blood transfusion, the gold standard for primary stroke prevention, is faced with numerous challenges in Africa. Hydroxyurea (HU) has been shown to reduce elevated TCD velocities in children with SCD. AIM To determine the effectiveness of HU in reducing the risk of primary stroke in a cohort of Nigerian children with SCD and elevated velocities treated with HU. METHODS Children with SCD and TCD velocities ≥170 cm/sec treated with HU were prospectively followed with 3-monthly TCD and neurological evaluations for ≥12 months to determine the incidence of primary stroke. RESULTS One hundred and four children, 53 males, and 51 females were enrolled into the study. Their ages ranged from 2 to 16 years with a mean of 6 years. At first TCD examination, velocities ranged from 173 to 260 cm/sec with conditional and abnormal risk velocities in 60 (57.7%) and 44 (42.3%) children, respectively. Follow up ranged from 1 to 8 years with a mean of 3.6 years. Mean TCD velocities showed a significant decline from 198.2 (standard deviation [SD] = 15.6) cm/sec to 169.3 (SD = 21.4) cm/sec (P < 0.001). One stroke event occurred in the cohort, giving a stroke incidence of 0.27/100 person years. CONCLUSION HU significantly reduces TCD velocities in Nigerian children with SCD and elevated TCD velocities, with a corresponding reduction in the incidence of primary stroke. HU may represent a potential alternative for primary stroke prevention in low and middle income countries where the burden of SCD resides.
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Affiliation(s)
- IkeOluwa Lagunju
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - B J Brown
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - A O Oyinlade
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - A Asinobi
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - J Ibeh
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - A Esione
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - O O Sodeinde
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria
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12
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Kalpatthi R, Novelli EM. Measuring success: utility of biomarkers in sickle cell disease clinical trials and care. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:482-492. [PMID: 30504349 PMCID: PMC6246014 DOI: 10.1182/asheducation-2018.1.482] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Progress in the care of sickle cell disease (SCD) has been hampered by the extreme complexity of the SCD phenotype despite its monogenic inheritance. While epidemiological studies have identified clinical biomarkers of disease severity, with a few exceptions, these have not been routinely incorporated in clinical care algorithms. Furthermore, existing biomarkers have been poorly apt at providing objective parameters to diagnose sickle cell crisis, the hallmark, acute complication of SCD. The repercussions of these diagnostic limitations are reflected in suboptimal care and scarcity of adequate outcome measures for clinical research. Recent progress in molecular and imaging diagnostics has heralded a new era of personalized medicine in SCD. Precision medicine strategies are particularly timely, since molecular therapeutics are finally on the horizon. This chapter will summarize the existing evidence and promising data on biomarkers for clinical care and research in SCD.
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Affiliation(s)
- Ram Kalpatthi
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Children’s Hospital of Pittsburgh, Pittsburgh, PA; and
| | - Enrico M. Novelli
- Division of Hematology/Oncology and UPMC Heart, Lung and Blood Vascular Medicine Institute, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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13
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Dowling MM, Quinn CT, Ramaciotti C, Kanter J, Osunkwo I, Inusa B, Iyer R, Kwiatkowski JL, Johnson C, Rhodes M, Owen W, Strouse JJ, Panepinto JA, Neumayr L, Sarnaik S, Plumb PA, Dlamini N, Kirkham F, Hynan LS. Increased prevalence of potential right-to-left shunting in children with sickle cell anaemia and stroke. Br J Haematol 2016; 176:300-308. [PMID: 27766637 DOI: 10.1111/bjh.14391] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 08/03/2016] [Indexed: 01/28/2023]
Abstract
'Paradoxical' embolization via intracardiac or intrapulmonary right-to-left shunts (RLS) is an established cause of stroke. Hypercoagulable states and increased right heart pressure, which both occur in sickle cell anaemia (SCA), predispose to paradoxical embolization. We hypothesized that children with SCA and overt stroke (SCA + stroke) have an increased prevalence of potential RLS. We performed contrasted transthoracic echocardiograms on 147 children (aged 2-19 years) with SCA + stroke) mean age 12·7 ± 4·8 years, 54·4% male) and a control group without SCA or stroke (n = 123; mean age 12·1 ± 4·9 years, 53·3% male). RLS was defined as any potential RLS detected by any method, including intrapulmonary shunting. Echocardiograms were masked and adjudicated centrally. The prevalence of potential RLS was significantly higher in the SCA+stroke group than controls (45·6% vs. 23·6%, P < 0·001). The odds ratio for potential RLS in the SCA + stroke group was 2·7 (95% confidence interval: 1·6-4·6) vs controls. In post hoc analyses, the SCA + stroke group had a higher prevalence of intrapulmonary (23·8% vs. 5·7%, P < 0·001) but not intracardiac shunting (21·8% vs. 18·7%, P = 0·533). SCA patients with potential RLS were more likely to report headache at stroke onset than those without. Intrapulmonary and intracardiac shunting may be an overlooked, independent and potentially modifiable risk factor for stroke in SCA.
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Affiliation(s)
- Michael M Dowling
- Departments of Pediatrics and Neurology & Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Charles T Quinn
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Claudio Ramaciotti
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Julie Kanter
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Ifeyinwa Osunkwo
- The Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA
| | - Baba Inusa
- Haematology, Evelina Children's Hospital, Guy's and St. Thomas NHS Trust, London, UK
| | - Rathi Iyer
- University of Mississippi Medical Center, Jackson, MS, USA
| | - Janet L Kwiatkowski
- Division of Hematology, Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Melissa Rhodes
- Pediatric Hematology/Oncology, University of Mississippi Medical Center, Jackson, MS, USA
| | - William Owen
- Children's Cancer and Blood Disorders Center, Children's Hospital of the King's Daughters, Norfolk, VA, USA
| | - John J Strouse
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Julie A Panepinto
- Department of Pediatrics, Hematology/Oncology, Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Lynne Neumayr
- Department of Hematology Oncology, UCSF Benioff Children's Hospital, Oakland, CA, USA
| | - Sharada Sarnaik
- Department of Pediatrics, Division of Hematology & Oncology, Wayne State University, Detroit, MI, USA
| | - Patricia A Plumb
- Department of Neurology & Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Nomazulu Dlamini
- Department of Paediatric Neurology, Evelina Children's Hospital, London, UK
| | - Fenella Kirkham
- Developmental Neurosciences, UCL Institute of Child Health, London, UK
| | - Linda S Hynan
- Departments of Clinical Science (Biostatistics) and Psychiatry, UT Southwestern Medical Center, Dallas, TX, USA
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Castilla-Rodríguez I, Cela E, Vallejo-Torres L, Valcárcel-Nazco C, Dulín E, Espada M, Rausell D, Mar J, Serrano-Aguilar P. Cost-effectiveness analysis of newborn screening for sickle-cell disease in Spain. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1179572] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Iván Castilla-Rodríguez
- Departamento de Ingeniería Informática y de Sistemas, Universidad de La Laguna, La Laguna, Spain
- Centre for Biomedical Research of the Canary Islands (CIBICAN), S/C de Tenerife, Spain
| | - Elena Cela
- Pediatric Hematology Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Laura Vallejo-Torres
- Centre for Biomedical Research of the Canary Islands (CIBICAN), S/C de Tenerife, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Spain
| | - Cristina Valcárcel-Nazco
- Centre for Biomedical Research of the Canary Islands (CIBICAN), S/C de Tenerife, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Spain
- Canary Islands Foundation for Health Research (FUNCANIS), S/C de Tenerife, Spain
| | - Elena Dulín
- Newborn Screening Laboratory, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Dolores Rausell
- Clinical Pathology Laboratory, Metabolic Disorders Unit, Hospital Universitario La Fe, Valencia, Spain
| | - Javier Mar
- Health Services Research on Chronic Patients Network (REDISSEC), Spain
- Clinical Management Service, Alto Deba Hospital, Mondragón, Spain
| | - Pedro Serrano-Aguilar
- Centre for Biomedical Research of the Canary Islands (CIBICAN), S/C de Tenerife, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Spain
- HTA Unit of the Canary Islands Health Service (SESCS), S/C de Tenerife, Spain
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15
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Central nervous system complications and management in sickle cell disease. Blood 2016; 127:829-38. [DOI: 10.1182/blood-2015-09-618579] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 12/25/2015] [Indexed: 02/07/2023] Open
Abstract
Abstract
With advances in brain imaging and completion of randomized clinical trials (RCTs) for primary and secondary stroke prevention, the natural history of central nervous system (CNS) complications in sickle cell disease (SCD) is evolving. In order of current prevalence, the primary CNS complications include silent cerebral infarcts (39% by 18 years), headache (both acute and chronic: 36% in children with sickle cell anemia [SCA]), ischemic stroke (as low as 1% in children with SCA with effective screening and prophylaxis, but ∼11% in children with SCA without screening), and hemorrhagic stroke in children and adults with SCA (3% and 10%, respectively). In high-income countries, RCTs (Stroke Prevention in Sickle Cell Anemia [STOP], STOP II) have demonstrated that regular blood transfusion therapy (typically monthly) achieves primary stroke prevention in children with SCA and high transcranial Doppler (TCD) velocities; after at least a year, hydroxycarbamide may be substituted (TCD With Transfusions Changing to Hydroxyurea [TWiTCH]). Also in high-income countries, RCTs have demonstrated that regular blood transfusion is the optimal current therapy for secondary prevention of infarcts for children with SCA and strokes (Stroke With Transfusions Changing to Hydroxyurea [SWiTCH]) or silent cerebral infarcts (Silent Infarct Transfusion [SIT] Trial). For adults with SCD, CNS complications continue to be a major cause of morbidity and mortality, with no evidence-based strategy for prevention.
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Meier ER, Fasano RM, Estrada M, He J, Luban NLC, McCarter R. Early Reticulocytosis and Anemia Are Associated with Abnormal and Conditional Transcranial Doppler Velocities in Children with Sickle Cell Anemia. J Pediatr 2016; 169:227-31.e1. [PMID: 26593107 DOI: 10.1016/j.jpeds.2015.10.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 08/28/2015] [Accepted: 10/08/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To improve prediction of sickle cell anemia severity at an early age, we evaluated whether absolute reticulocyte count (ARC) or hemoglobin (Hb) levels during early infancy (2-6 months of age) in patients with sickle cell anemia predict the risk of later developing an abnormal (abTCD) or conditional (cdTCD) Transcranial Doppler (TCD). STUDY DESIGN We used chart review to identify 121 consecutive patients who underwent TCD screening and had steady state ARC and Hb levels recorded between 2 and 6 months of age. Cox regression analysis was used to determine the relationship between ARC, Hb levels, and risk of developing cdTCD/abTCD over time. RESULTS Mean ARC in early infancy was highest and mean Hb lowest in those children with abTCDs and cdTCDs. Cox regression analysis revealed that those subjects with an ARC ≥200 K/μL in early infancy had nearly 3 times the risk of having an abTCD/cdTCD than the group with an ARC <200 K/μL, and patients with a Hb <8.5 g/dL had 2.7 times the risk of having an abTCD/cdTCD. CONCLUSIONS These data suggest that both elevated ARC and low baseline Hb during early infancy are associated with an increased risk of developing a cdTCD or abTCD later in childhood.
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Affiliation(s)
- Emily Riehm Meier
- Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, DC; Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Ross M Fasano
- Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, DC; Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Monica Estrada
- Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, DC
| | - Jianping He
- Division of Biostatistics and Study Methodology, Children's National Medical Center, Washington, DC
| | - Naomi L C Luban
- Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, DC; Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Robert McCarter
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC; Division of Biostatistics and Study Methodology, Children's National Medical Center, Washington, DC
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Overlapping biological mechanisms underlying sickle cell disease, stress, and depression: a stress-vulnerability framework. Harv Rev Psychiatry 2014; 22:205-15. [PMID: 24887328 DOI: 10.1097/hrp.0000000000000022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
After participating in this activity, learners should be better able to:1. Evaluate the overlap between sickle cell disease (SCD) and depression.2. Identify sources of psychological stress and biological vulnerabilities toward developing depression in patients with SCD.3. Assess the potential mechanisms underlying SCD, stress, and depression.Depression is a common co-occurring disorder in persons with sickle-cell disease (SCD). Individuals with this chronic illness may be particularly vulnerable to depression. In addition to risk factors for depression specifically related to SCD, these individuals typically experience further psychological stress due to multiple risk factors in their environment. To date, however, little research has focused on the co-occurring biological mechanisms across these conditions and how those mechanisms may interact to produce depressive symptoms. In this review we use a stress-vulnerability framework to describe the sources of psychological stress and the SCD factors that increase the risk of depression. We suggest that several biological factors, such as nitric oxide and cytokines, may play an important role in co-occurring stress, SCD, and depression. The interaction of these factors may be of particular importance for understanding the comorbidity of SCD and depression. Implications for current treatment and future research are discussed.
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Abstract
At least 25% of individuals with sickle cell disease will have a neurological complication over their lifetime, often as early as in childhood. Neuroradiological findings in patients with sickle cell disease are common and include acute territorial infarction, silent ischaemia and intracranial haemorrhage. Imaging abnormalities are typically, but not always, manifestations of the underlying vasculopathy. Coexisting acute and chronic pathology may pose challenges to interpretation.
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Affiliation(s)
- S C Thust
- 1 St Thomas Hospital, Guy's and St Thomas' Hospitals NHS Foundation Trust, Radiology Department, London, UK
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20
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Childhood arterial ischaemic stroke incidence, presenting features, and risk factors: a prospective population-based study. Lancet Neurol 2014; 13:35-43. [DOI: 10.1016/s1474-4422(13)70290-4] [Citation(s) in RCA: 240] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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21
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Connes P, Verlhac S, Bernaudin F. Advances in understanding the pathogenesis of cerebrovascular vasculopathy in sickle cell anaemia. Br J Haematol 2013; 161:484-98. [DOI: 10.1111/bjh.12300] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Philippe Connes
- UMR Inserm 665; Academic Hospital of Pointe à Pitre; Pointe à Pitre Guadeloupe
- Laboratory ACTES EA3596; Department of Physiology; University of Antilles-Guyane; Pointe à Pitre Guadeloupe
- Laboratory of Excellence GR-Ex “The red cell: from genesis to death”; PRES Sorbonne Paris Cité; Paris France
| | - Suzanne Verlhac
- Medical Imaging; Centre Hospitalier Intercommunal; Creteil France
| | - Françoise Bernaudin
- Department of Paediatrics; Referral Centre for Sickle Cell Disease; Centre Hospitalier Intercommunal; Creteil France
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22
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Daak AA, Ghebremeskel K, Hassan Z, Attallah B, Azan HH, Elbashir MI, Crawford M. Effect of omega-3 (n-3) fatty acid supplementation in patients with sickle cell anemia: randomized, double-blind, placebo-controlled trial. Am J Clin Nutr 2013; 97:37-44. [PMID: 23193009 DOI: 10.3945/ajcn.112.036319] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Blood cell aggregation and adherence to vascular endothelium and inflammation play a central role in vaso-occlusive crisis in sickle cell disease. The antiaggregatory, antiadhesive, antiinflammatory, and vasodilatory omega-3 (n-3) fatty acids (DHA and EPA) are significantly reduced in patients with the disease. OBJECTIVE The aim was to investigate the therapeutic potential of omega-3 fatty acids for patients with homozygous sickle cell disease in a randomized, placebo-controlled, double-blind trial. DESIGN One hundred forty patients recruited from a single center in Sudan were randomly assigned and received, daily, 1 (age 2-4 y), 2 (age 5-10 y), 3 (age 11-16 y), or 4 (age ≥17 y) omega-3 capsules containing 277.8 mg DHA and 39.0 mg EPA or placebo for 1 y. Of these patients, 128 were followed up and the data were obtained. The primary and secondary endpoints-rates of clinical vaso-occlusive crisis and hemolytic events, blood transfusion rate, school attendance, and blood count-were analyzed by intention-to-treat analysis (n = 140). RESULTS Omega-3 treatment reduced the median rate of clinical vaso-occlusive events (0 compared with 1.0 per year, P < 0.0001), severe anemia (3.2% compared with 16.4%; P < 0.05), blood transfusion (4.5% compared with 16.4%; P < 0.05), white blood cell count (14.4 ± 3.3 compared with 15.6 ± 4.0 ×10(3)/μL; P < 0.05), and the OR of the inability to attend school at least once during the study period because of illness related to the disease to 0.4 (95% CI: 0.2, 0.9; P < 0.05). CONCLUSION The findings of this trial, which need to be verified in a large multicenter study, suggest that omega-3 fatty acids can be an effective, safe, and affordable therapy for sickle cell anemia. This trial was registered with Current Controlled Trials as ISRCTN80844630.
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Affiliation(s)
- Ahmed A Daak
- Faculty of Life Sciences and Computing, London Metropolitan University, London, United Kingdom
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23
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Lagunju IA, Brown BJ. Adverse neurological outcomes in Nigerian children with sickle cell disease. Int J Hematol 2012; 96:710-8. [PMID: 23129067 DOI: 10.1007/s12185-012-1204-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 10/10/2012] [Accepted: 10/10/2012] [Indexed: 11/30/2022]
Abstract
Sickle cell disease (SCD) is reported to be the most common genetic disorder affecting Nigerians. Children with SCD are at a high risk of neurological morbidity. The main objective of this study was to determine the pattern of adverse neurological outcomes among a cohort of Nigerian children with SCD. All children with SCD seen in the Department of Paediatrics, University College Hospital, Ibadan, Nigeria, over a period of 2 years were carefully evaluated for symptoms and signs of neurological complications, defined as clinical outcomes referable to the central nervous system. Of the 214 children evaluated, 187 were diagnosed with Hb SS disease and 27 with Hb SC disease. Neurological complications were identified in 78 (36.4 %) of the cases. The most common complications were headache (17.8 %), seizure (9.3 %) and stroke (8.4 %). Other less frequent complications included bacterial meningitis (2.8 %), spontaneous visual loss (1.4 %), paraplegia (0.9 %) and transient ischaemic attacks (0.9 %). Neurological complications occurred more frequently in children with sickle cell anaemia than in those with Hb SC disease (P = 0.002, 95 % CI 1.450-82.870). Adverse neurological events are common in Nigerian children with SCD, with a significantly higher risk in Hb SS than Hb SC disease. Stroke represents a major underlying cause of symptomatic epilepsy in SCD. Institution of primary preventive measures for stroke in SCD will significantly reduce the burden of stroke and epilepsy associated with SCD in Nigeria.
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Affiliation(s)
- I A Lagunju
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria.
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24
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Islam MS, Anoop P. Current concepts in the management of stroke in children with sickle cell disease. Childs Nerv Syst 2011; 27:1037-43. [PMID: 21258808 DOI: 10.1007/s00381-011-1394-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 01/07/2011] [Indexed: 11/30/2022]
Abstract
Stroke is the most significant complication of sickle cell disease (SCD) in children with the potential for major morbidity and mortality. The recent two decades have witnessed tremendous advancements in understanding the pathophysiology of stroke, risk stratification of children and the role of timely preventative interventions. The aetiopathogenesis, types of stroke and specific risk factors are reviewed here with special emphasis on the role of transcranial Doppler ultrasonogram in the early identification of at-risk children. Published studies on primary and secondary prevention of stroke in children with SCD are analysed with respect to the levels of evidence, in favour of preventative and therapeutic strategies. The roles of the neurologist and the neurosurgeon are highlighted.
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Affiliation(s)
- M S Islam
- Department of Haematology, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, England, UK.
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Abstract
PURPOSE Stroke and subclinical "silent infarcts" are major causes of morbidity in children with Sickle Cell Disease (SCD). Ischemic strokes are more common in younger children while hemorrhagic strokes are more frequent in adults. The goal of neuroimaging in acute stroke is to document whether the stroke is ischemic or hemorrhagic, to assess the extent of parenchymal abnormalities and to determine the presence of other cerebrovascular lesions. Computed Tomography (CT) is the primary modality for the assessment of acute stroke patients because of its 24/7 availability and ability to exclude hemorrhagic causes. Magnetic resonance imaging (MRI) and MR angiography (MRA) are recommended to determine precisely extent of infarction and detect cerebrovascular abnormalities. The goal of neuroimaging in patients with hemorrhagic stroke is to identify an arteriovenous malformation or aneurysm(s) amenable to surgery or catheter intervention.The risk of first stroke is very high in asymptomatic children with intracranial arterial mean velocities over 200 cm/s on transcranial Doppler (TCD) examination. The risk can be substantially reduced if chronic blood transfusions are timely implemented. Large cerebral vessel disease detected by TCD can be confirmed or excluded by MRI/MRA. Those with evidence of parenchymal and/or cerebrovascular lesions should be followed by preventive therapy. In patients with neurologic symptoms and negative MRI/MRA findings Positron Emission Tomography or single photon emission CT is recommended. There are no specific neuroimaging findings that suggest that blood transfusions can be safely halted in children with SCD.
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28
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Sidani CA, Ballourah W, El Dassouki M, Muwakkit S, Dabbous I, Dahoui H, Al-Kutoubi A, Abboud MR. Venous sinus thrombosis leading to stroke in a patient with sickle cell disease on hydroxyurea and high hemoglobin levels: treatment with thrombolysis. Am J Hematol 2008; 83:818-20. [PMID: 18756541 DOI: 10.1002/ajh.21261] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
A 21-year-old man with homozygous sickle cell disease maintained on hydroxyurea for 1 year developed thrombosis of the superior sagittal, right transverse, and right sigmoid dural sinuses with a large venous infarct. He was successfully treated with endovascular thrombolysis. Investigation did not reveal any inherited or acquired hypercoagulable state. This patient however had consistently elevated hemoglobin levels both at the time of the initial event and on follow up. One year later he developed symptomatic avascular necrosis of the right hip. High hemoglobin levels resulting from hydroxyurea therapy may have contributed to development of complications in this patient.
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Affiliation(s)
- Charif A Sidani
- Department of Radiology, American University of Beirut Medical Center, Beirut, Lebanon
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29
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Shet AS, Hoffmann TJ, Jirouskova M, Janczak CA, Stevens JRM, Adamson A, Mohandas N, Manci EA, Cynober T, Coller BS. Morphological and functional platelet abnormalities in Berkeley sickle cell mice. Blood Cells Mol Dis 2008; 41:109-18. [PMID: 18374611 DOI: 10.1016/j.bcmd.2008.01.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2008] [Accepted: 01/24/2008] [Indexed: 11/27/2022]
Abstract
Berkeley sickle cell mice are used as animal models of human sickle cell disease but there are no reports of platelet studies in this model. Since humans with sickle cell disease have platelet abnormalities, we studied platelet morphology and function in Berkeley mice (SS). We observed elevated mean platelet forward angle light scatter (FSC) values (an indirect measure of platelet volume) in SS compared to wild type (WT) (37+/-3.2 vs. 27+/-1.4, mean+/-SD; p<0.001), in association with moderate thrombocytopenia (505+/-49 x 10(3)/microl vs. 1151+/-162 x 10(3)/microl; p<0.001). Despite having marked splenomegaly, SS mice had elevated levels of Howell-Jolly bodies and "pocked" erythrocytes (p<0.001 for both) suggesting splenic dysfunction. SS mice also had elevated numbers of thiazole orange positive platelets (5+/-1% vs. 1+/-1%; p<0.001), normal to low plasma thrombopoietin levels, normal plasma glycocalicin levels, normal levels of platelet recovery, and near normal platelet life spans. Platelets from SS mice bound more fibrinogen and antibody to P-selectin following activation with a threshold concentration of a protease activated receptor (PAR)-4 peptide compared to WT mice. Enlarged platelets are associated with a predisposition to arterial thrombosis in humans and some humans with SCD have been reported to have large platelets. Thus, additional studies are needed to assess whether large platelets contribute either to pulmonary hypertension or the large vessel arterial occlusion that produces stroke in some children with sickle cell disease.
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Affiliation(s)
- Arun S Shet
- The Laboratory of Blood and Vascular Biology, Rockefeller University, 1230 York Avenue, New York, NY 10065, USA
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Wood KC, Hsu LL, Gladwin MT. Sickle cell disease vasculopathy: a state of nitric oxide resistance. Free Radic Biol Med 2008; 44:1506-28. [PMID: 18261470 DOI: 10.1016/j.freeradbiomed.2008.01.008] [Citation(s) in RCA: 156] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2007] [Revised: 11/21/2007] [Accepted: 01/11/2008] [Indexed: 12/31/2022]
Abstract
Sickle cell disease (SCD) is a hereditary hemoglobinopathy characterized by microvascular vaso-occlusion with erythrocytes containing polymerized sickle (S) hemoglobin, erythrocyte hemolysis, vasculopathy, and both acute and chronic multiorgan injury. It is associated with steady state increases in plasma cell-free hemoglobin and overproduction of reactive oxygen species (ROS). Hereditary and acquired hemolytic conditions release into plasma hemoglobin and other erythrocyte components that scavenge endothelium-derived NO and metabolize its precursor arginine, impairing NO homeostasis. Overproduction of ROS, such as superoxide, by enzymatic (xanthine oxidase, NADPH oxidase, uncoupled eNOS) and nonenzymatic pathways (Fenton chemistry), promotes intravascular oxidant stress that can likewise disrupt NO homeostasis. The synergistic bioinactivation of NO by dioxygenation and oxidation reactions with cell-free plasma hemoglobin and ROS, respectively, is discussed as a mechanism for NO resistance in SCD vasculopathy. Human physiological and transgenic animal studies provide experimental evidence of cardiovascular and pulmonary resistance to NO donors and reduced NO bioavailability that is associated with vasoconstriction, decreased blood flow, platelet activation, increased endothelin-1 expression, and end-organ injury. Emerging epidemiological data now suggest that chronic intravascular hemolysis is associated with certain clinical complications: pulmonary hypertension, cutaneous leg ulcerations, priapism, and possibly stroke. New therapeutic strategies to limit intravascular hemolysis and ROS generation and increase NO bioavailability are discussed.
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Affiliation(s)
- Katherine C Wood
- Vascular Medicine Branch, National Heart Lung Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
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Arterial access for sickle stroke predictors. Blood 2008. [DOI: 10.1182/blood-2008-01-133348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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32
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Inherited and acquired risk factors for arterial ischemic stroke in childhood. J Thromb Thrombolysis 2008; 27:239-48. [DOI: 10.1007/s11239-008-0202-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2007] [Accepted: 01/28/2008] [Indexed: 10/22/2022]
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Abstract
PURPOSE OF REVIEW Pediatric arterial ischemic stroke is relatively rare but carries a considerable impact and high risk of recurrence--especially in patients with sickle cell disease and various forms of vasculopathy. We will discuss risk factors, vascular physiology, and primary/secondary/rehabilitative therapies. Goals for future investigation and treatment are suggested. RECENT FINDINGS Risk factors include chronic disease, vasculopathy, acute illness, cardiac disease, head and neck trauma, infection, and prothrombic disorders. Research has begun to implicate genetic risk factors--initially in sickle cell disease and more recently in prothrombotic disorders, moyamoya, and nitric oxide regulation. The vascular physiology of pediatric arterial ischemic stroke, especially sickle cell disease stroke, is currently undergoing study in animal models and in humans. No primary prevention therapy for pediatric arterial ischemic stroke is known. Various primary and secondary prevention therapies are used, however, in at-risk sickle cell disease patients. Aspirin, coumadin, and heparin are often initiated as secondary prevention therapies for non-sickle cell disease-associated arterial ischemic stroke, but no studies have assessed efficacy. SUMMARY Pediatric arterial ischemic stroke is under-recognized and under-studied. Investigation into the hemodynamic aspects of arterial ischemic stroke, although best studied thus far in sickle cell disease, has been neglected. It is likely that enhanced study of hemodynamics and autoregulation will elucidate both new prevention opportunities and novel treatments.
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Affiliation(s)
- Carly Seidman
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
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