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Morrone K, Andreca M, Silver EJ, Xiang A, Strumph K, Manwani D, Rinke ML, Kurian J, Orentlicher R, Liszewski MC. Associating a standardized reporting tool for chest radiographs with clinical complications in pediatric acute chest syndrome. Pediatr Pulmonol 2023; 58:3139-3146. [PMID: 37671823 DOI: 10.1002/ppul.26634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/07/2023] [Accepted: 07/29/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Acute chest syndrome (ACS) is an important cause of morbidity in sickle cell disease (SCD). A standardized tool for reporting chest radiographs in pediatric SCD patients did not previously exist. OBJECTIVE To analyze the interobserver agreement among pediatric radiologists' interpretations for pediatric ACS chest radiographs utilizing a standardized reporting tool. We also explored the association of radiographic findings with ACS complications. METHODS This was a retrospective cohort study of pediatric ACS admissions from a single institution in 2019. ICD-10 codes identified 127 ACS admissions. Two radiologists independently interpreted the chest radiographs utilizing a standardized reporting tool, a third radiologist adjudicated discrepancies, and κ analysis assessed interobserver agreement. Clinical outcomes were correlated with chest radiograph findings utilizing Pearsons' χ2 , t tests, and Mann-Whitney U tests. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS Interobserver agreement was moderate to near-perfect across variables, with κ analysis showing near-perfect agreement for opacity reported in the right upper lobe (0.84), substantial agreement for right lower lobe (0.63), and vertebral bony changes (0.72), with moderate agreement for all other reported variables. On the initial chest radiograph, an opacity located in the left lower lobe (LLL) correlated with pediatric intensive care unit transfer (p = .03). Pleural effusion on the initial chest radiograph had a 3.98 OR (95% CI: 1.35-11.74) of requiring blood products and a 10.67 OR (95% CI: 3.62-31.39) for noninvasive ventilation. CONCLUSION The standardized reporting tool showed moderate to near-perfect agreement between radiologists. LLL opacity, and pleural effusion were associated with increased risk of ACS complications.
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Affiliation(s)
- Kerry Morrone
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Mihai Andreca
- Department of Radiology, Yale New Haven Health, New Haven, Connecticut, USA
| | - Ellen J Silver
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Angell Xiang
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Kaitlin Strumph
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Deepa Manwani
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Michael L Rinke
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jessica Kurian
- Department of Radiology, Westchester Medical Center, Valhalla, New York, USA
| | - Rona Orentlicher
- Department of Radiology, Mount Sinai Hospital, New York, New York, USA
| | - Mark C Liszewski
- Department of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
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Elsayh KI, Saad K, Hetta HF, Youssef MAM, Embaby MM, Mohamed IL, Abdel-Aziz SM, Zahran ZAM, Elhoufey A, Ghandour AMA, Zahran AM. Impact of hydroxyurea on lymphocyte subsets in children with sickle cell anemia. Pediatr Res 2023; 93:918-923. [PMID: 34897281 DOI: 10.1038/s41390-021-01892-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/27/2021] [Accepted: 11/13/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hydroxyurea (HU) has beneficial effects in the management of sickle cell anemia (SCA), but there is a paucity of data on the effect of HU on immune cells in SCA. Herein we aimed to evaluate the effect of HU on immune profiles of Egyptian children with SCA. METHODS This was a controlled prospective cohort study conducted in 30 children with SCA and 30 healthy age-matched controls. Flow cytometry was used to evaluate lymphocyte profiles, including CD8+ T, CD19+ B, CD3+, CD4+, natural killer (NK), NK T, T helper 1 (Th1), Th2, T cytotoxic (Tc1), and Tc2 cells, prior to and after 1 year of treatment with HU. RESULTS HU treatment led to significant increases in hemoglobin (Hb), red blood cell, and hematocrit counts and a significant decrease in the percentage of sickle Hb, with subsequent improvement in SCA complications. Compared with baseline values, CD3+, CD4+, Th1, and CD8+ T cells were significantly increased, while NK, Th2, and Tc2 cells were significantly decreased, with a resulting increase in the Th1/Th2 and Tc1/Tc2 ratios. CONCLUSIONS HU has the beneficial effect of restoring the abnormally elevated immune parameters in children with SCA. IMPACT Hydroxyurea treatment restores the abnormal immune parameters in children with sickle cell anemia. HU treatment led to significantly increased CD3+, CD4+, Th1, and CD8+ T cells, while NK, Th2, and Tc2 cells were significantly decreased, with a resulting increase in the Th1/Th2 and Tc1/Tc2 ratios. Our study showed the impact of HU therapy on immune parameters in children with SCA.
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Affiliation(s)
- Khalid I Elsayh
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Khaled Saad
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt.
| | - Helal F Hetta
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mervat A M Youssef
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mostafa M Embaby
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ismail L Mohamed
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Safwat M Abdel-Aziz
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
| | | | - Amira Elhoufey
- Department of Community Health Nursing, Faculty of Nursing, Assiut University, Assiut, Egypt
- Department of Community Health Nursing, Alddrab University College, Jazan University, Jazan, Saudi Arabia
| | - Aliaa M A Ghandour
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Asmaa M Zahran
- Department of Clinical Pathology, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
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Desai AA, Machado RF, Cohen RT. The Cardiopulmonary Complications of Sickle Cell Disease. Hematol Oncol Clin North Am 2022; 36:1217-1237. [PMID: 36400540 PMCID: PMC10323820 DOI: 10.1016/j.hoc.2022.07.014] [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] [Indexed: 11/17/2022]
Abstract
Sickle cell disease (SCD) is a genetic hemoglobinopathy associated with extensive morbidity and early mortality. While there have been recent improvements in available disease-modifying therapies for SCD, cardiopulmonary complications remain a major risk factor for death in this population. We provide an overview of current knowledge regarding several of the major acute and chronic cardiopulmonary complications in SCD, including: acute chest syndrome, airway disease, lung function abnormalities, nocturnal hypoxemia and sleep disordered breathing, pulmonary vascular disease, and sickle cell cardiomyopathy.
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Affiliation(s)
- Ankit A Desai
- Department of Medicine, Indiana School of Medicine, Indianapolis, IN, USA; Indiana University, 950 W. Walnut Street R2 Building, Room 466, Indianapolis, IN 46202, USA
| | - Roberto F Machado
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Room C400, Walther Hall, R3 980 W. Walnut Street, Indianapolis, IN 46202, USA
| | - Robyn T Cohen
- Department of Pediatrics, Boston Medical Center/Boston University School of Medicine, 801 Albany Street 4th Floor, Boston, MA 02118, USA.
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Ferreira de Matos C, Comont T, Castex MP, Lafaurie M, Walter O, Moulis G, Dion J, Cougoul P. Risk of vaso-occlusive episodes in patients with sickle cell disease exposed to systemic corticosteroids: a comprehensive review. Expert Rev Hematol 2022; 15:1045-1054. [PMID: 36412212 DOI: 10.1080/17474086.2022.2149488] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Sickle cell disease (SCD) is the most frequent inherited disorder in the world. It is caused by a single amino acid mutation on the beta-globin chain, which lead to red blood cell deformation, haemolysis, and chronic inflammation. Clinical consequences are vaso-occlusives crisis, acute chest syndrome, thrombosis, infection, and chronic endothelial injury. AREAS COVERED Corticosteroids are an old therapeutic class, that are inexpensive and widely available, which can be administered in different forms. Their adverse effects are numerous and well-known. This class could appear to be useful in SCD treatment due to its anti-inflammatory effect. Moreover, corticosteroids remain an essential therapeutic class for many indications, besides SCD. Although specific adverse effects of corticosteroids have been suspected in SCD patients for decades, recent papers has reported strong evidence of specific and severe adverse effects in this population. Based on a literature review, we will discuss pathophysiological considerations, consequences, and practical use of corticosteroids in SCD. EXPERT OPINION High corticosteroid doses, for any indication , induce vaso-occlusive crises, acute chest syndrome, and re-hospitalization in patients with SCD. There is no evidence of any benefits of corticosteroid use in the SCD acute events. Prevention by hydroxyurea and/or red blood cell transfusion or exchange should be discussed when corticosteroid use is indispensable.
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Affiliation(s)
| | - Thibault Comont
- Internal Medicine Department, Toulouse University Hospital, Toulouse, France
| | - Marie-Pierre Castex
- Pediatric Oncology Immunology Hematology Unit, Children's University Hospital - Toulouse University Hospital, Toulouse, France
| | - Margaux Lafaurie
- CIC 1436, Team Pharmacologie en Population, Cohortes, Biobanques (PEPSS), Toulouse, France.,Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France
| | - Ondine Walter
- Internal Medicine Department, Toulouse University Hospital, Toulouse, France.,CIC 1436, Team Pharmacologie en Population, Cohortes, Biobanques (PEPSS), Toulouse, France
| | - Guillaume Moulis
- Internal Medicine Department, Toulouse University Hospital, Toulouse, France.,CIC 1436, Team Pharmacologie en Population, Cohortes, Biobanques (PEPSS), Toulouse, France
| | - Jérémie Dion
- Internal Medicine Department, Toulouse University Hospital, Toulouse, France
| | - Pierre Cougoul
- Internal Medicine Department, Toulouse University Hospital, Toulouse, France
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The Role of Systems Biology in Deciphering Asthma Heterogeneity. LIFE (BASEL, SWITZERLAND) 2022; 12:life12101562. [PMID: 36294997 PMCID: PMC9605413 DOI: 10.3390/life12101562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/28/2022] [Accepted: 10/04/2022] [Indexed: 11/17/2022]
Abstract
Asthma is one of the most common and lifelong and chronic inflammatory diseases characterized by inflammation, bronchial hyperresponsiveness, and airway obstruction episodes. It is a heterogeneous disease of varying and overlapping phenotypes with many confounding factors playing a role in disease susceptibility and management. Such multifactorial disorders will benefit from using systems biology as a strategy to elucidate molecular insights from complex, quantitative, massive clinical, and biological data that will help to understand the underlying disease mechanism, early detection, and treatment planning. Systems biology is an approach that uses the comprehensive understanding of living systems through bioinformatics, mathematical, and computational techniques to model diverse high-throughput molecular, cellular, and the physiologic profiling of healthy and diseased populations to define biological processes. The use of systems biology has helped understand and enrich our knowledge of asthma heterogeneity and molecular basis; however, such methods have their limitations. The translational benefits of these studies are few, and it is recommended to reanalyze the different studies and omics in conjugation with one another which may help understand the reasons for this variation and help overcome the limitations of understanding the heterogeneity in asthma pathology. In this review, we aim to show the different factors that play a role in asthma heterogeneity and how systems biology may aid in understanding and deciphering the molecular basis of asthma.
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Kotwal N, Pillai DK, Darbari DS, Sun K, Koumbourlis AC. Spirometric Changes After Initiation of Hydroxyurea in Children With Sickle Cell Anemia. J Pediatr Hematol Oncol 2022; 44:e923-e925. [PMID: 34966092 DOI: 10.1097/mph.0000000000002371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 10/25/2021] [Indexed: 11/25/2022]
Abstract
Individuals with sickle cell disease (SCD) develop a decline in lung function over time. Hydroxyurea (HU) is the most common disease-modifying therapy used in SCD. We hypothesized that children with SCD treated with HU will have a slower decline in pulmonary function. We performed a retrospective chart review of children with HbSS and HbS-beta zero thalassemia referred to pulmonology for respiratory symptoms. We compared the spirometry results at 2 time points between children on HU (HU group) and not on HU (control group). For the HU group, these endpoints were evaluated before and after being on HU. The mean time interval between 2 spirometry studies was not significantly different between the groups (2.6±1.5 y for HU group vs. 3.0±1.8 y for the control group; P =0.33). The mean age of patients in the HU group was 9.8±3.8 years (55% male) and 10.7±4.9 years (50% male) in the control group. The spirometry data was compared within and between the groups using t test. There was a significant increase in forced vital capacity in HU group during follow-up, while children in the control group showed a decline (7.2±17.1 vs. -3.4±18.2; P <0.01). Our study suggests that HU therapy may help preserve lung function over time in children with SCD.
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Affiliation(s)
- Nidhi Kotwal
- Department of Pediatrics, Division of Pulmonology and Allergy
- Division of Pulmonary and Sleep Medicine
| | | | - Deepika S Darbari
- Division of Hematology, Children's National Hospital, Washington, DC
| | - Kai Sun
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
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Brandow AM, Liem RI. Advances in the diagnosis and treatment of sickle cell disease. J Hematol Oncol 2022; 15:20. [PMID: 35241123 PMCID: PMC8895633 DOI: 10.1186/s13045-022-01237-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/15/2022] [Indexed: 12/12/2022] Open
Abstract
Sickle cell disease (SCD), which affects approximately 100,000 individuals in the USA and more than 3 million worldwide, is caused by mutations in the βb globin gene that result in sickle hemoglobin production. Sickle hemoglobin polymerization leads to red blood cell sickling, chronic hemolysis and vaso-occlusion. Acute and chronic pain as well as end-organ damage occur throughout the lifespan of individuals living with SCD resulting in significant disease morbidity and a median life expectancy of 43 years in the USA. In this review, we discuss advances in the diagnosis and management of four major complications: acute and chronic pain, cardiopulmonary disease, central nervous system disease and kidney disease. We also discuss advances in disease-modifying and curative therapeutic options for SCD. The recent availability of L-glutamine, crizanlizumab and voxelotor provides an alternative or supplement to hydroxyurea, which remains the mainstay for disease-modifying therapy. Five-year event-free and overall survival rates remain high for individuals with SCD undergoing allogeneic hematopoietic stem cell transplant using matched sibling donors. However, newer approaches to graft-versus-host (GVHD) prophylaxis and the incorporation of post-transplant cyclophosphamide have improved engraftment rates, reduced GVHD and have allowed for alternative donors for individuals without an HLA-matched sibling. Despite progress in the field, additional longitudinal studies, clinical trials as well as dissemination and implementation studies are needed to optimize outcomes in SCD.
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Affiliation(s)
- A. M. Brandow
- grid.30760.320000 0001 2111 8460Department of Pediatrics, Section of Pediatric Hematology/Oncology/Bone Marrow Transplantation, Medical College of Wisconsin, Milwaukee, WI USA
| | - R. I. Liem
- grid.413808.60000 0004 0388 2248Division of Hematology, Oncology and Stem Cell Transplantation, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL USA
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Klings ES, Steinberg MH. Acute chest syndrome of sickle cell disease: genetics, risk factors, prognosis and management. Expert Rev Hematol 2022; 15:117-125. [PMID: 35143368 DOI: 10.1080/17474086.2022.2041410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IntroductionSickle cell disease, one of the world's most prevalent Mendelian disorders, is a chronic hemolytic anemia punctuated by acute vasoocclusive events. Both hemolysis and vasoocclusion lead to irreversible organ damage and failure. Among the many sub-phenotypes of sickle cell disease is the acute chest syndrome (ACS) characterized by combinations of chest pain, cough, dyspnea, fever, abnormal lung exam, leukocytosis, hypoxia, and new radiographic opacities. ACS is a major cause of morbidity and mortality.Area coveredWe briefly review the diagnosis, epidemiology, etiology, and current treatments for ACS and focus on understanding and estimating the risks for developing this complication, how prognosis and outcomes might be improved and the genetic elements that might impact the risk of ACS.Expert opinionThe clinical heterogeneity of ACS has hindered our understanding of risk stratification. Lacking controlled clinical trials most treatment is based on expert opinion. Fetal hemoglobin levels and coexistent α thalassemia affect the incidence of ACS; other genetic associations are tenuous. Transfusions, whose use not innocuous, should be targeted to the severity and likelihood of ACS progression. Stable, non-hypoxic patients with favorable hematologic and radiographic findings usually do not need transfusion; severe progressive ACS is best managed with exchange transfusion.
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Affiliation(s)
- Elizabeth S Klings
- Sections of Pulmonary, Allergy, Sleep and Critical Care Medicine, Boston University School of Medicine, Boston, USA
| | - Martin H Steinberg
- Hematology and Medical Oncology, Center of Excellence for Sickle Cell Disease, Boston University School of Medicine and Boston Medical Center, Boston, USA
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Lung Clearance Index May Detect Early Peripheral Lung Disease in Sickle Cell Anemia. Ann Am Thorac Soc 2022; 19:1507-1515. [PMID: 35104199 DOI: 10.1513/annalsats.202102-168oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Chronic lung injury is common in sickle cell anemia (SCA) and worsens outcomes. Sensitive lung function tests might predict reversible disease that might benefit from therapeutic interventions. OBJECTIVE To evaluate whether Lung Clearance Index (LCI), Sacin & Scond, measuring global, intracinar & conductive ventilation inhomogeneity respectively, are more frequently abnormal than lung volumes in young people with SCA. METHODS Nitrogen multiple breath washout, spirometry and body plethysmography were cross-sectionally evaluated at steady state in subjects with SCA (hemoglobin SS) and healthy controls aged 8-21 years from London, UK. RESULTS 35 patients (51% boys; mean±SD 16.4±3.5 years) and 31 controls (48% boys; 16.2±3.2 years) were tested. There were significant differences between the study and control group in mean LCI (mean difference 0.42 units, 95%CI 0.22 to 0.63, p = 0.0001), Sacin (mean difference 0.014 units, 95%CI 0.001 to 0.026, p = 0.04), FEV1 (mean difference -0.79 z-scores, 95%CI -1.28 to -0.30, p = 0.002), FVC (mean difference -0.80 z-scores, 95%CI -1.28 to -0.31) and TLC (mean difference -0.79 z-scores, 95%CI -1.25 to -0.29), but not in Scond and FEV1/FVC ratio. While 29% (10/35) of patients had LCI >95th percentile of controls, 23% (8/35) had abnormal FEV1 (<5th of the reference population). CONCLUSION Lung clearance index detected slightly more abnormalities than lung volumes in young people with SCA. Significant differences with controls in LCI and Sacin but not in Scond and FEV1/FVC ratio suggest that the lung function changes were most likely due to patchy peripheral lung disease.
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Taksande A, Jameel PZ, Pujari D, Taksande B, Meshram R. Variation in pulmonary function tests among children with sickle cell anemia: a systematic review and meta-analysis. Pan Afr Med J 2021; 39:140. [PMID: 34527156 PMCID: PMC8418170 DOI: 10.11604/pamj.2021.39.140.28755] [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: 03/07/2021] [Accepted: 05/06/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction the spectrum of pulmonary complications in sickle cell anemia (SCA) comprises mainly of acute chest syndrome (ACS), pulmonary hypertension (PH) and airway hyper-responsiveness (AHR). This study was conducted to examine the abnormalities in pulmonary function tests (PFTs) seen in children with SCA. Methods electronic databases (Cochrane library, PubMed, EMBASE, Scopus, Web of Science) were used as data sources. Two authors independently reviewed studies. All case-control studies with PFT performed in patients with SCA and normal controls were reviewed. Pulmonary functions were assessed with the help of spirometry, lung volume and gas diffusion findings. Results nine studies with 788 SCA children and 1101 controls were analyzed. For all studies, the pooled mean difference for forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, peak expiratory flow rate (PEFR), total lung capacity (TLC) and carbon mono-oxide diffusing capacity (DLCO) were -12.67, (95% CI: -15.41,-9.94), -11.69, (95% CI: -14.24, -9.14), -1.90, (95% CI: -4.32, 0.52), -3.36 (95% CI: -6.69, -0.02), -7.35, (95% CI: -14.97, -0.27) and -4.68, (95% CI -20.64, -11.29) respectively. FEV1 and FVC and were the only parameters found to be significantly decreased. Conclusion sickle cell anemia was associated with lower FEV1 and FVC, thus, supporting the role of routine monitoring for the progression of lung function decline in children with SCA with ACS. We recommend routine screening and lung function monitoring for early recognition of pulmonary function decline.
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Affiliation(s)
- Amar Taksande
- Department of Paediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Sawangi Meghe, Wardha, Maharashtra State, India
| | - Patel Zeeshan Jameel
- Department of Paediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Sawangi Meghe, Wardha, Maharashtra State, India
| | - Divya Pujari
- Department of Paediatrics, Bai Jerbai Wadia Hospital for Children, Parel, Mumbai, Maharashtra, India
| | - Bharati Taksande
- Department of Medicine, Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sewagram, Wardha, Maharashtra State, India
| | - Revat Meshram
- Department of Paediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Sawangi Meghe, Wardha, Maharashtra State, India
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Gray DM, Owusu SK, van der Zalm MM. Chronic lung disease in children: disease focused use of lung function. CURRENT OPINION IN PHYSIOLOGY 2021. [DOI: 10.1016/j.cophys.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Sange I, Cherukuri PB, Parchuri V, Srinivas N, Ramanan SP, Sange AH, Modi S, Khot FA. Sickle Cell Disease and the Respiratory System: A Tangential Perspective to the Hematopulmonological Dilemma. Cureus 2021; 13:e15562. [PMID: 34277185 PMCID: PMC8271619 DOI: 10.7759/cureus.15562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/10/2021] [Indexed: 11/05/2022] Open
Abstract
Sickle cell disease (SCD) is a genetically inherited hematological condition that predominantly affects the African-American subset of the population. It leads to the precipitation of multi-systematic manifestations throughout the course of the life of the patient leading to an increased rate of inpatient admissions and decreased quality of life. This article has reviewed some of the most common pulmonary complications of SCD with a brief overview of the clinical features and their management and has also highlighted the fatality of the complications placing a strong focus on screening, monitoring, and the treatment of the disease. The article has also discussed the management of SCD from a pulmonological perspective rather than hematological alone.
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Affiliation(s)
- Ibrahim Sange
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Research, K. J. Somaiya Medical College, Mumbai, IND
| | | | | | - Natasha Srinivas
- Research, B.G.S. Global Institute of Medical Sciences, Bangalore, IND
| | - Sruthi Priyavadhana Ramanan
- Neurology, California Institute of Behavioral Neurosciences & Psychology, California, USA.,Medicine/Surgery, Saveetha Medical College, Chennai, IND
| | | | - Srimy Modi
- Research, K. J. Somaiya Medical College, Mumbai, IND
| | - Farhat A Khot
- Research, Maharashtra Institute of Medical Education and Research (MIMER) Medical College, Pune, IND
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13
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Machogu EM, Khurana M, Kaericher J, Clem CC, Slaven JE, Hatch JE, Davis SD, Peterson-Carmichael S. Lung clearance index in children with sickle cell disease. Pediatr Pulmonol 2021; 56:1165-1172. [PMID: 33241925 DOI: 10.1002/ppul.25186] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/08/2020] [Accepted: 11/03/2020] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The lung clearance index (LCI) derived from the multiple breath washout test (MBW), is both feasible and sensitive to early lung disease detection in young children with cystic fibrosis and asthma. The utility of LCI has not been studied in children with sickle cell disease (SCD). We hypothesized that children with SCD, with or without asthma or airway hyperreactivity (AHR), would have an elevated LCI compared to healthy controls. METHODS Children with SCD from a single center between the ages of 6 and 18 years were studied at baseline health and completed MBW, spirometry, plethysmography and blood was drawn for serum markers. Results were compared to healthy controls of similar race, age, and gender. RESULTS Healthy controls (n = 35) had a significantly higher daytime oxygen saturation level, weight and body mass index but not height compared to participants with SCD (n = 34). Total lung capacity (TLC) z-scores were significantly higher in the healthy controls compared to those with SCD (0.87 [1.13] vs. 0.02 [1.27]; p = .005) while differences in forced expiratory volume in 1 s z-scores approached significance (0.26 [0.97] vs. -0.22 [1.09]; p = .055). There was no significant difference in LCI between the healthy controls compared to participants with SCD (7.29 [0.72] vs. 7.40 [0.69]; p = .514). CONCLUSION LCI did not differentiate SCD from healthy controls in children between the ages of 6 and 18 years at baseline health. TLC may be an important pulmonary function measure to follow longitudinally in the pediatric SCD population.
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Affiliation(s)
- Evans M Machogu
- Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Monica Khurana
- Section of Pediatric Hematology and Oncology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jennifer Kaericher
- Section of Pediatric Hematology and Oncology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Charles C Clem
- Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Joseph E Hatch
- Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Stephanie D Davis
- Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Pediatrics, University of North Carolina (UNC) at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Stacey Peterson-Carmichael
- Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Division of Pediatric Pulmonology, Department of Pediatrics, Brenner Children's Hospital Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
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14
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Gbotosho OT, Kapetanaki MG, Kato GJ. The Worst Things in Life are Free: The Role of Free Heme in Sickle Cell Disease. Front Immunol 2021; 11:561917. [PMID: 33584641 PMCID: PMC7873693 DOI: 10.3389/fimmu.2020.561917] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 12/04/2020] [Indexed: 12/15/2022] Open
Abstract
Hemolysis is a pathological feature of several diseases of diverse etiology such as hereditary anemias, malaria, and sepsis. A major complication of hemolysis involves the release of large quantities of hemoglobin into the blood circulation and the subsequent generation of harmful metabolites like labile heme. Protective mechanisms like haptoglobin-hemoglobin and hemopexin-heme binding, and heme oxygenase-1 enzymatic degradation of heme limit the toxicity of the hemolysis-related molecules. The capacity of these protective systems is exceeded in hemolytic diseases, resulting in high residual levels of hemolysis products in the circulation, which pose a great oxidative and proinflammatory risk. Sickle cell disease (SCD) features a prominent hemolytic anemia which impacts the phenotypic variability and disease severity. Not only is circulating heme a potent oxidative molecule, but it can act as an erythrocytic danger-associated molecular pattern (eDAMP) molecule which contributes to a proinflammatory state, promoting sickle complications such as vaso-occlusion and acute lung injury. Exposure to extracellular heme in SCD can also augment the expression of placental growth factor (PlGF) and interleukin-6 (IL-6), with important consequences to enthothelin-1 (ET-1) secretion and pulmonary hypertension, and potentially the development of renal and cardiac dysfunction. This review focuses on heme-induced mechanisms that are implicated in disease pathways, mainly in SCD. A special emphasis is given to heme-induced PlGF and IL-6 related mechanisms and their role in SCD disease progression.
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Affiliation(s)
- Oluwabukola T. Gbotosho
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Maria G. Kapetanaki
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Gregory J. Kato
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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15
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Liem R, Baynard T, Hsu L, Garofano R, Green N, Hankins J, Ness K, Rodeghier M, Radom-Aizik S. The Sickle Cell Pro-Inflammatory Response to Interval Testing Study (SPRINTS) in children and young adults with sickle cell anemia - Study design and methodological strategies. Contemp Clin Trials Commun 2020; 20:100668. [PMID: 33089004 PMCID: PMC7566951 DOI: 10.1016/j.conctc.2020.100668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/07/2020] [Accepted: 10/03/2020] [Indexed: 01/26/2023] Open
Abstract
The impact of sickle cell anemia (SCA) and its complications on physical functioning and cardiopulmonary/aerobic fitness in affected individuals is significant. Although limited data support the safety of maximal cardiopulmonary exercise testing (CPET) for children and adults with SCA, the safety of submaximal moderate and high intensity, and longer duration, exercise in this population is not clear. The Sickle Cell Pro-Inflammatory Response to Interval Testing Study (SPRINTS) is a multicenter, randomized, prospective trial. SPRINTS leverages unique collaborations between investigators in pediatric hematology and exercise science to evaluate the impact of exercise intensity on the acute phase inflammatory response to exercise and changes in airway dynamics in children and young adults with SCA. Here we describe the study design and methodological strategies employed in SPRINTS, including an exercise challenge that mimics real-life patterns of childhood physical activity, characterized by multiple moderate and high intensity brief bouts of exercise interspersed with rest periods. Primary outcomes comprise pre- and post-exercise biomarkers of inflammation and endothelial dysfunction and spirometry. Secondary outcomes include assessment of physical activity and functioning, genomic studies and near-infrared spectroscopy measurements to assess tissue oxygenation status during exercise. SPRINTS aims to enroll 70 subjects with SCA and 70 matched, healthy controls. We anticipate that data from SPRINTS will address gaps in our understanding of exercise responses and safety in SCA and support the future development of evidence-based, exercise prescription guidelines in this population.
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Affiliation(s)
- R.I. Liem
- Division of Hematology, Oncology & Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 30, Chicago, IL, 60611, USA
- Corresponding author.
| | - T. Baynard
- Integrative Physiology Laboratory, University of Illinois at Chicago, 1640 West Roosevelt Road, Chicago, IL, 60608, USA
| | - L.L. Hsu
- Division of Pediatric Hematology/Oncology, University of Illinois at Chicago, 840 South Wood Street, MC 856, Chicago, IL, 60612, USA
| | - R. Garofano
- Division of Pediatric Cardiology, Columbia University Medical Center, 3959 Broadway, New York, NY, 10032, USA
| | - N.S. Green
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Columbia University Medical Center, 3959 Broadway, New York, NY, 10032, USA
| | - J.S. Hankins
- Department of Hematology, St. Jude Children's Research Hospital, 262 Danny Thomas Place, MS 800, Memphis, TN, 38105, USA
| | - K.K. Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, 262 Danny Thomas Place, MS 735, Memphis, TN, 38105, USA
| | - M. Rodeghier
- Rodeghier Consulting, Inc, 6244 North Nordica Avenue, Chicago, IL, 60631, USA
| | - S. Radom-Aizik
- Pediatric Exercise and Genomics Research Center, University of California Irvine, 101 Academy, Irvine, CA, 92617, USA
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16
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End points for sickle cell disease clinical trials: renal and cardiopulmonary, cure, and low-resource settings. Blood Adv 2020; 3:4002-4020. [PMID: 31809537 DOI: 10.1182/bloodadvances.2019000883] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 10/07/2019] [Indexed: 01/19/2023] Open
Abstract
To address the global burden of sickle cell disease and the need for novel therapies, the American Society of Hematology partnered with the US Food and Drug Administration to engage the work of 7 panels of clinicians, investigators, and patients to develop consensus recommendations for clinical trial end points. The panels conducted their work through literature reviews, assessment of available evidence, and expert judgment focusing on end points related to patient-reported outcome, pain (non-patient-reported outcomes), the brain, end-organ considerations, biomarkers, measurement of cure, and low-resource settings. This article presents the findings and recommendations of the end-organ considerations, measurement of cure, and low-resource settings panels as well as relevant findings and recommendations from the biomarkers panel.
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17
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Angel A, Wandalsen GF, Solé D, Lanza FC, Cobra CL, Johnston C, Braga JAP. Asthma, allergic sensitization and lung function in sickle cell disease. Allergol Immunopathol (Madr) 2020; 48:450-457. [PMID: 32249096 DOI: 10.1016/j.aller.2019.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/30/2019] [Accepted: 12/17/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pulmonary disease is a frequent acute and chronic manifestation in sickle cell disease (SCD), presenting high morbidity and mortality. OBJECTIVES To identify the prevalence and association of asthma, allergic sensitization and altered pulmonary function in patients with SCD (SS and Sβo). METHODS A single-center, cross-sectional study was conducted, in which 70 patients with SCD and 44 controls, aged six to 18 years, responded to the questionnaire of the International Study of Asthma and Allergies in Childhood (ISAAC), complemented with an anamnesis regarding the associated clinical outcomes. All patients underwent immediate hypersensitivity skin tests with aeroallergens and a pulmonary function evaluation (spirometry). Regarding the statistical analysis, parametric and non-parametric methods were used, depending on the variables studied. Tests were considered significant when p<0.05. RESULTS There was no significant difference between the patients and controls regarding the prevalence of asthma and allergic sensitization (p>0.05). The number of occurrences of acute chest syndrome per patient per year was significantly higher for asthmatic patients than for non-asthmatic patients (p=0.04). Obstructive pulmonary function occurred in 30.9% of the patients and in 5.4% of the controls, and restrictive pulmonary function occurred in 5.5% of the patients and 5.4% of the controls. Asthma and wheezing in the last 12months had significant associations with obstructive pulmonary function (p=0.014 and p=0.027, respectively). CONCLUSIONS The occurrence of asthma, allergic sensitization and alteration in lung function in patients with SCD reinforces the importance of routine monitoring of these diagnoses, which allows for early treatment and prevention of the evolution of pulmonary disease in adulthood.
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18
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Arigliani M, Gupta A. Management of chronic respiratory complications in children and adolescents with sickle cell disease. Eur Respir Rev 2020; 29:29/157/200054. [PMID: 32817114 DOI: 10.1183/16000617.0054-2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/14/2020] [Indexed: 12/25/2022] Open
Abstract
Sickle cell disease (SCD) is a life-threatening hereditary blood disorder that affects millions of people worldwide, especially in sub-Saharan Africa. This condition has a multi-organ involvement and highly vascularised organs, such as the lungs, are particularly affected. Chronic respiratory complications of SCD involve pulmonary vascular, parenchymal and airways alterations. A progressive decline of lung function often begins in childhood. Asthma, sleep-disordered breathing and chronic hypoxaemia are common and associated with increased morbidity. Pulmonary hypertension is a serious complication, more common in adults than in children. Although there is a growing attention towards respiratory care of patients with SCD, evidence regarding the prognostic meaning and optimal management of pulmonary issues in children with this condition is limited.This narrative review presents state-of-the-art evidence regarding the epidemiology, pathophysiology and therapeutic options for chronic respiratory complications commonly seen in paediatric patients with SCD. Furthermore, it highlights the gaps in the current knowledge and indicates future directions for studies that aim to improve our understanding of chronic respiratory complications in children with SCD.
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Affiliation(s)
- Michele Arigliani
- Dept of Medicine, University Hospital of Udine, Udine, Italy.,Paediatric Respiratory Medicine and Lung Transplantation, Great Ormond Street Hospital for Children, and UCL Institute of Child Health, London, UK
| | - Atul Gupta
- Dept of Paediatric Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK .,Institute for Women's and Children's Health, King's College London, London, UK
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19
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Chen L, Gong J, Matta E, Morrone K, Manwani D, Rastogi D, De A. Pulmonary disease burden in Hispanic and non-Hispanic children with sickle cell disease. Pediatr Pulmonol 2020; 55:2064-2073. [PMID: 32484996 DOI: 10.1002/ppul.24883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 05/29/2020] [Indexed: 12/19/2022]
Abstract
RATIONALE Pulmonary complications are the leading cause of morbidity and mortality in sickle cell disease (SCD) patients. Research in SCD has predominantly been conducted on African-Americans, and the disease burden of SCD in other races and ethnicities, including Hispanic patients, is not well characterized. OBJECTIVE To compare pulmonary disease burden between Hispanic and non-Hispanic ethnic groups among children with SCD. METHODS In a retrospective chart review on 566 SCD patients followed at the Children's Hospital at Montefiore, NY, we compared the pulmonary disease burden and disease management in Hispanic patients to their non-Hispanic counterparts. We also compared the contribution of demographic and clinical variables to acute chest syndrome (ACS), vaso-occlusive crisis (VOC), and hospitalizations for SCD related complications between the two ethnic groups. RESULTS Hispanic patients had a greater proportion of ACS, and had lower forced expiratory volume (FEV1), forced vital capacity, and vital capacity, compared to non-Hispanics. Hispanic patients were more likely to be evaluated in pulmonary clinic and to be on inhaled corticosteroids, short-acting β agonizts, and leukotriene receptor antagonists. In addition, Hispanic children were more likely to be on hydroxyurea, and receive exchange transfusions. However, the association of asthma with the proportion of ACS did not differ between Hispanics and non-Hispanics. CONCLUSION Hispanic children with SCD had differences in their pulmonary function profile and received more pulmonary evaluations than non-Hispanic children.
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Affiliation(s)
- Laura Chen
- Division of Pediatric Respiratory and Sleep Medicine, Children's Hospital at Montefiore, Bronx, New York
| | - Jacqueline Gong
- College of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Esther Matta
- Division of Pediatric Respiratory and Sleep Medicine, Children's Hospital at Montefiore, Bronx, New York
| | - Kerry Morrone
- Division of Hematology and Oncology, Children's Hospital at Montefiore, Bronx, New York
| | - Deepa Manwani
- Division of Hematology and Oncology, Children's Hospital at Montefiore, Bronx, New York
| | - Deepa Rastogi
- Division of Pulmonary and Sleep Medicine, Children's National Health System, Washington, DC
| | - Aliva De
- Division of Pediatric Pulmonology, Columbia University Medical Center, Vagelos College of Physicians and Surgeons, New York, New York
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20
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Samarasinghe AE, Rosch JW. Convergence of Inflammatory Pathways in Allergic Asthma and Sickle Cell Disease. Front Immunol 2020; 10:3058. [PMID: 32038616 PMCID: PMC6992560 DOI: 10.3389/fimmu.2019.03058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 12/16/2019] [Indexed: 01/19/2023] Open
Abstract
The underlying pathologies of sickle cell disease and asthma share many characteristics in terms of respiratory inflammation. The principal mechanisms of pulmonary inflammation are largely distinct, but activation of common pathways downstream of the initial inflammatory triggers may lead to exacerbation of both disease states. The altered inflammatory landscape of these respiratory pathologies can differentially impact respiratory pathogen susceptibility in patients with sickle cell disease and asthma. How these two distinct diseases behave in a comorbid setting can further exacerbate pulmonary complications associated with both disease states and impact susceptibility to respiratory infection. This review will provide a concise overview of how asthma distinctly affects individuals with sickle cell disease and how pulmonary physiology and inflammation are impacted during comorbidity.
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Affiliation(s)
- Amali E Samarasinghe
- Division of Pulmonology, Allergy-Immunology, and Sleep, Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States.,Department of Microbiology Immunology and Biochemistry, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States.,Children's Foundation Research Institute, Memphis, TN, United States
| | - Jason W Rosch
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, United States
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21
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De A, Agrawal S, Morrone K, Zhang J, Bjorklund NL, Manwani D, Rastogi D. Airway Inflammation and Lung Function in Sickle Cell Disease. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2019; 32:92-102. [PMID: 31559108 DOI: 10.1089/ped.2019.1014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 06/29/2019] [Indexed: 12/20/2022]
Abstract
Rationale: Asthma is a common comorbid condition in sickle cell disease (SCD). However, obstructive lung disease is prevalent in SCD, independent of a diagnosis of asthma. It is speculated that the heightened state of inflammation in SCD, involving pathways distinct from allergic asthma, may underlie the SCD-specific obstructive disease. Objective: The objective of the study was to compare airway and systemic inflammatory markers between SCD patients with pulmonary manifestations and patients with allergic asthma, and correlate the discriminating inflammatory markers with clinical measures of pulmonary disease. Materials and Methods: In a pilot translational study conducted at the Children's Hospital at Montefiore, 15 patients with SCD, and history of asthma, airway obstruction, or airway hyper-reactivity, and 15 control patients with allergic asthma 6-21 years of age were recruited. Inflammatory markers, including peripheral blood T helper cell subsets, serum and exhaled breath condensate (EBC) cytokines and chemokines of the Th-1/Th-17, Th-2, and monocytic pathways, and serum cysteinyl leukotrienes B4 (LTB4), were quantified, compared between the study groups, and correlated with atopic sensitization, pulmonary function tests, and markers of hemolysis. Results: White blood cells (P < 0.05) and monocytes (P < 0.001) were elevated in the SCD group, while atopic characteristics were higher in the control asthma group. Tumor necrosis factor-alpha (P < 0.01), interferon gamma inducible protein (IP)-10 (P < 0.05), and interleukin-4 (P < 0.01) in serum and monocyte chemotactic protein (MCP)-1 in EBC were higher in the SCD group (P ≤ 0.05). Forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1) in patients with SCD inversely correlated with serum IP-10 and LTB4 levels. Conclusions: Compared with atopic asthmatic patients, inflammatory markers involving Th-1, Th-2, and monocytic pathways were higher in the SCD group, among which Th-1 measures correlated with pulmonary function deficits.
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Affiliation(s)
- Aliva De
- Division of Pediatric Pulmonology, Columbia University Medical Center, Vagelos College of Physicians and Surgeons, New York, New York
| | - Sabhyata Agrawal
- Division of Respiratory and Sleep Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Kerry Morrone
- Division of Hematology/Oncology, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Jinghang Zhang
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
| | - Nicole L Bjorklund
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Deepa Manwani
- Division of Hematology/Oncology, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Deepa Rastogi
- Division of Respiratory and Sleep Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
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22
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Ruhl AP, Sadreameli SC, Allen JL, Bennett DP, Campbell AD, Coates TD, Diallo DA, Field JJ, Fiorino EK, Gladwin MT, Glassberg JA, Gordeuk VR, Graham LM, Greenough A, Howard J, Kato GJ, Knight-Madden J, Kopp BT, Koumbourlis AC, Lanzkron SM, Liem RI, Machado RF, Mehari A, Morris CR, Ogunlesi FO, Rosen CL, Smith-Whitley K, Tauber D, Terry N, Thein SL, Vichinsky E, Weir NA, Cohen RT. Identifying Clinical and Research Priorities in Sickle Cell Lung Disease. An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2019; 16:e17-e32. [PMID: 31469310 PMCID: PMC6812163 DOI: 10.1513/annalsats.201906-433st] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background: Pulmonary complications of sickle cell disease (SCD) are diverse and encompass acute and chronic disease. The understanding of the natural history of pulmonary complications of SCD is limited, no specific therapies exist, and these complications are a primary cause of morbidity and mortality.Methods: We gathered a multidisciplinary group of pediatric and adult hematologists, pulmonologists, and emergency medicine physicians with expertise in SCD-related lung disease along with an SCD patient advocate for an American Thoracic Society-sponsored workshop to review the literature and identify key unanswered clinical and research questions. Participants were divided into four subcommittees on the basis of expertise: 1) acute chest syndrome, 2) lower airways disease and pulmonary function, 3) sleep-disordered breathing and hypoxia, and 4) pulmonary vascular complications of SCD. Before the workshop, a comprehensive literature review of each subtopic was conducted. Clinically important questions were developed after literature review and were finalized by group discussion and consensus.Results: Current knowledge is based on small, predominantly observational studies, few multicenter longitudinal studies, and even fewer high-quality interventional trials specifically targeting the pulmonary complications of SCD. Each subcommittee identified the three or four most important unanswered questions in their topic area for researchers to direct the next steps of clinical investigation.Conclusions: Important and clinically relevant questions regarding sickle cell lung disease remain unanswered. High-quality, multicenter, longitudinal studies and randomized clinical trials designed and implemented by teams of multidisciplinary clinician-investigators are needed to improve the care of individuals with SCD.
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Abstract
PURPOSE OF REVIEW Asthma is common in children with sickle cell disease (SCD) and appears to be associated with increased morbidity. Providers caring for children with SCD have struggled with the question of whether asthma exists as a true comorbidity or whether certain aspects of the chronic inflammatory disease gives children with SCD an asthma-like phenotype. RECENT FINDINGS Clinical signs and symptoms seen in children with asthma in the general population, such as wheezing, airway hyperresponsiveness, atopy, elevated leukotrienes, and abnormal lung function are seen in children with SCD both with and without a diagnosis of asthma. SUMMARY Current evidence highlights that the presence of lung disease in children with SCD has significant implications irrespective of the underlying cause, including asthma. Further research should focus on well tolerated and effective interventions to prevent disease-related complications for children with pulmonary complications of SCD.
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Kopel LS, Klings ES, Monuteaux MC, Gaffin JM, Heeney MM, Phipatanakul W. Bronchodilator Use for Acute Chest Syndrome Among Large Pediatric Hospitals in North America. Clin Pediatr (Phila) 2018; 57:1630-1637. [PMID: 30173539 PMCID: PMC6505689 DOI: 10.1177/0009922818796661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The utility of bronchodilators to treat acute chest syndrome (ACS) in patients with sickle cell disease is unknown. Our objectives were to examine the variability in bronchodilator use for ACS among pediatric hospitals contributing to a large database and to examine the relationship between bronchodilator use and length of stay (LOS) and mortality. Between 2005 and 2011, bronchodilators were used during 6812/11 328 hospitalizations (60.1%) and use varied from 0.0% to 97.0% (median = 46.0%, interquartile range = 37.0% to 74.0%). Median LOS was 4 days, and interquartile range was 2 to 6 days. Bronchodilator use was associated with a 13.2% increase in LOS (95% confidence interval = 9.2% to 17.3%, P < .001). However, in the subgroup with asthma, bronchodilator use was associated with a 17.9% decrease in LOS (95% confidence interval = 1.7% to 31.4%, P = .03). There is wide variability in bronchodilator use for ACS, and it has variable association with LOS, depending on comorbid asthma. Prospective trials are needed to evaluate bronchodilators for ACS.
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Affiliation(s)
| | | | | | | | | | - Wanda Phipatanakul
- Boston Children’s Hospital, Boston, MA, USA,Brigham and Women’s Hospital, Boston, MA, USA
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25
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Lunt A, Sturrock SS, Greenough A. Asthma and the outcome of sickle cell disease. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1547964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Alan Lunt
- Department of Child Health, King’s College Hospital NHS Foundation Trust, London, UK
| | - Sarah S. Sturrock
- Department of Child Health, King’s College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Department of Child Health, King’s College Hospital NHS Foundation Trust, London, UK
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26
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How I treat hypoxia in adults with hemoglobinopathies and hemolytic disorders. Blood 2018; 132:1770-1780. [PMID: 30206115 DOI: 10.1182/blood-2018-03-818195] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 06/13/2018] [Indexed: 01/19/2023] Open
Abstract
Hemoglobinopathies are caused by genetic mutations that result in abnormal hemoglobin molecules, resulting in hemolytic anemia. Chronic complications involving the lung parenchyma, vasculature, and cardiac function in hemoglobinopathies result in impaired gas exchange, resulting in tissue hypoxia. Hypoxia is defined as the deficiency in the amount of oxygen reaching the tissues of the body and is prevalent in patients with hemoglobinopathies, and its cause is often multifactorial. Chronic hypoxia in hemoglobinopathies is often a sign of disease severity and is associated with increased morbidity and mortality. Therefore, a thorough understanding of the pathophysiology of hypoxia in these disease processes is important in order to appropriately treat the underlying cause and prevent complications. In this article, we discuss management of hypoxia based on three different cases: sickle cell disease, β-thalassemia, and hereditary spherocytosis. These cases are used to review the current understanding of the disease pathophysiology, demonstrate the importance of a thorough clinical history and physical examination, explore diagnostic pathways, and review the current management.
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27
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Vance Utset L, Ivy Z, Willen SM, Rodeghier M, Watt A, Schilling L, Jenkins CL, Pepper S, Speller-Brown B, Darbari DS, Majumdar S, Adisa O, DeBaun MR. Inhaled corticosteroid use to prevent severe vaso-occlusive episode recurrence in children between 1 and 4 years of age with sickle cell disease: a multicenter feasibility trial. Am J Hematol 2018; 93:E101-E103. [PMID: 29322539 DOI: 10.1002/ajh.25033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 01/05/2018] [Indexed: 01/09/2023]
Affiliation(s)
- Leah Vance Utset
- Vanderbilt University School of Medicine; Vanderbilt University Medical Center; Nashville Tennessee
| | - Zalaya Ivy
- School of Medicine; , Meharry Medical College; Nashville Tennessee
| | - Shaina M. Willen
- Division of Hematology/Oncology, Department of Pediatrics; Vanderbilt University Medical Center; Nashville Tennessee
| | | | - Amanda Watt
- Aflac Cancer and Blood Disorder Center, Children's Healthcare of Atlanta; Atlanta Georgia
| | - Leann Schilling
- Aflac Cancer and Blood Disorder Center, Children's Healthcare of Atlanta; Atlanta Georgia
| | - Chantel L. Jenkins
- Department of Pediatrics; Children's National Health System; Washington District of Columbia
| | - Stefanie Pepper
- Department of Pediatrics; University of Mississippi Medical Center; Jackson Mississippi
| | - Barbara Speller-Brown
- Department of Pediatrics; Children's National Health System; Washington District of Columbia
| | - Deepika S. Darbari
- Department of Pediatrics; Children's National Health System; Washington District of Columbia
| | - Suvankar Majumdar
- Department of Pediatrics; University of Mississippi Medical Center; Jackson Mississippi
| | - Olufolake Adisa
- Aflac Cancer and Blood Disorder Center, Children's Healthcare of Atlanta; Atlanta Georgia
| | - Michael R. DeBaun
- Division of Hematology/Oncology, Department of Pediatrics; Vanderbilt University Medical Center; Nashville Tennessee
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28
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De A, Manwani D, Rastogi D. Airway inflammation in sickle cell disease-A translational perspective. Pediatr Pulmonol 2018; 53:400-411. [PMID: 29314737 DOI: 10.1002/ppul.23932] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 11/29/2017] [Indexed: 12/14/2022]
Abstract
Asthma and sickle cell disease (SCD) are common chronic conditions in children of African ancestry that are characterized by cough, wheeze, and obstructive patterns on pulmonary function. Pulmonary function testing in children with SCD has estimated a prevalence of obstructive lung disease ranging from 13% to 57%, and airway hyper-responsiveness of up to 77%, independent of a diagnosis of asthma. Asthma co-existing with SCD is associated with increased risk of acute chest syndrome (ACS), respiratory symptoms, pain episodes, and death. However, there are inherent differences in the pathophysiology of SCD and asthma. While classic allergic asthma in the general population is associated with a T-helper 2 cell (Th-2 cells) pattern of cell inflammation, increased IgE levels and often positive allergy testing, inflammation in SCD is associated with different inflammatory pathways, involving neutrophilic and monocytic pathways, which have been explored to a limited extent in mouse models and with a dearth of human studies. The current review summarizes the existent literature on sickle cell related airway inflammation and its cross roads with allergic asthma-related inflammation, and discusses the importance of further elucidating and understanding these common and divergent inflammatory pathways in human studies to facilitate development of targeted therapy for children with SCD and pulmonary morbidity.
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Affiliation(s)
- Aliva De
- Division of Respiratory and Sleep Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Deepa Manwani
- Division of Hematology/Oncology, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Deepa Rastogi
- Division of Respiratory and Sleep Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
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Leonard A, Godiwala N, Herrera N, McCarter R, Sharron M, Meier ER. Early initiation of inhaled corticosteroids does not decrease acute chest syndrome morbidity in pediatric patients with sickle cell disease. Blood Cells Mol Dis 2018; 71:55-62. [PMID: 29550053 DOI: 10.1016/j.bcmd.2018.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 03/05/2018] [Accepted: 03/06/2018] [Indexed: 10/17/2022]
Abstract
Acute chest syndrome (ACS) is a leading cause of mortality in patients with sickle cell disease (SCD). Systemic corticosteroids decrease ACS severity, but the risk of readmission for vaso-occlusive crises (VOC) has limited their use. The efficacy of inhaled corticosteroids (ICS) as a safer alternative is currently unknown. An observational, historic cohort study compared patients with SCD with ACS who received ICS at admission (ICS) to those who did not (non-ICS). Outcome measures included rates of transfusion, oxygen requirement, BiPAP initiation, PICU transfer, intubation, readmission, hospital cost, and length of stay. One hundred twenty patients with SCD (55 non-ICS, 65 ICS) were included. A significantly higher proportion of the non-ICS group had bilateral infiltrates, but fewer had asthma. More children in the ICS group had BiPAP initiated, however transfer to the PICU, intubation, transfusion rates, oxygen requirement, hospital cost, length of stay, and readmission rates did not differ between groups. Regression analysis did not reveal any differences in outcomes, nor were outcomes changed when patients were separated based on the presence or absence of asthma. In this observational cohort study, ICS did not demonstrate a significant reduction in ACS morbidity, though ICS use should be studied in a prospective manner.
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Affiliation(s)
- Alexis Leonard
- Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, D.C. 20010, United States
| | - Nihal Godiwala
- Division of Critical Care Medicine, Children's National Medical Center, Washington, D.C. 20010, United States
| | - Nicole Herrera
- Division of Biostatistics and Study Methodology, Children's National Medical Center, Washington, D.C. 20010, United States
| | - Robert McCarter
- Division of Biostatistics and Study Methodology, Children's National Medical Center, Washington, D.C. 20010, United States; Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, D.C. 20037, United States
| | - Matthew Sharron
- Division of Critical Care Medicine, Children's National Medical Center, Washington, D.C. 20010, United States; Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, D.C. 20037, United States
| | - Emily Riehm Meier
- Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, D.C. 20010, United States; Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, D.C. 20037, United States.
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Willen SM, Cohen R, Rodeghier M, Kirkham F, Redline SS, Rosen C, Kirkby J, DeBaun MR. Age is a predictor of a small decrease in lung function in children with sickle cell anemia. Am J Hematol 2018; 93:408-415. [PMID: 29226507 DOI: 10.1002/ajh.25003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 12/05/2017] [Accepted: 12/07/2017] [Indexed: 12/20/2022]
Abstract
The longitudinal pattern of lung function in children with sickle cell anemia (SCA) has shown a decrease in FEV1 % predicted, a risk factor for death in adults with SCA, but predictors for this decline are poorly characterized. In a prospective longitudinal multi-center cohort of children with SCA, we tested the hypotheses that: (1) FEV1 % predicted declines over time; and (2) SCA-specific characteristics and therapy predict this decline. At three clinical centers, children with SCA (HbSS or HbSβ0 thalassemia), unselected for respiratory disease, were enrolled in the Sleep and Asthma Cohort (SAC) study. Study-certified pulmonary function technicians performed spirometry and lung volumes. Each assessment was reviewed centrally. Predicted values were determined for TLC, FEV1 , FVC, and FEV1 /FVC ratio. A total of 197 participants, mean age 11.0 years at first testing (range 4-19.3 years), had a minimum of three spirometry measurements, over an average of 4.4 years (range 1.1-6.5 years) from baseline to endpoint. In a multivariable model, FEV1 % predicted declines by 0.3% for every additional year of age (95% CI -0.56 to -0.05, P = .020). Sex, asthma history, hemoglobin, reticulocyte count, white blood cell count, incidence rate of severe acute pain and acute chest syndrome episodes, and hydroxyurea therapy were not associated with a decline in FEV1 % predicted. In a large, rigorously evaluated, prospective cohort of an unselected group of children with SCA, FEV1 % predicted declines minimally over an average of 4 years, and none of the examined disease features predict the decline.
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Affiliation(s)
- Shaina M. Willen
- Department of Pediatrics, Division of Hematology/Oncology; Vanderbilt-Meharry Center for Excellence in Sickle Cell Disease, Vanderbilt University Medical Center; Nashville Tennessee
| | - Robyn Cohen
- Department of Pediatrics, Division of Pediatric Pulmonary and Allergy; Boston University School of Medicine; Boston Massachusetts
| | | | - Fenella Kirkham
- Developmental Neurosciences Unit; UCL Great Ormond Street, Institute of Child Health; London United Kingdom
| | - Susan S. Redline
- Department of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital; Boston Massachusetts
| | - Carol Rosen
- Department of Pediatrics, Division of Pediatric Pulmonary, Allergy/Immunology and Sleep; University Hospitals-Cleveland Medical Center, Rainbow Babies and Children's Hospitals; Cleveland Ohio
| | - Jane Kirkby
- Respiratory, Critical Care and Anaesthesia; UCL Great Ormond Street, Institute of Child Health, University College London; London United Kingdom
| | - Michael R. DeBaun
- Department of Pediatrics, Division of Hematology/Oncology; Vanderbilt-Meharry Center for Excellence in Sickle Cell Disease, Vanderbilt University Medical Center; Nashville Tennessee
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31
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Cohen RT, Klings ES. Commentary: Heterogeneity of respiratory disease in children and young adults with sickle cell disease. Thorax 2018; 73:503. [PMID: 29353255 DOI: 10.1136/thoraxjnl-2017-211370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Robyn T Cohen
- Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Elizabeth S Klings
- Department of Medicine, The Pulmonary Center, Boston University Medical Campus, Boston, Massachusetts, USA
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Willen SM, Rodeghier M, Strunk RC, Rosen CL, Kirkham FJ, Field JJ, DeBaun MR, Cohen RT. Airway Hyperresponsiveness Does Not Predict Morbidity in Children with Sickle Cell Anemia. Am J Respir Crit Care Med 2017; 195:1533-1534. [PMID: 28569575 DOI: 10.1164/rccm.201610-1970le] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Shaina M Willen
- 1 Vanderbilt University School of Medicine Nashville, Tennessee.,2 Monroe Carell Jr. Children's Hospital at Vanderbilt Nashville, Tennessee
| | | | - Robert C Strunk
- 4 Washington University School of Medicine St Louis, Missouri
| | - Carol L Rosen
- 5 University Hospitals-Cleveland Medical Center Cleveland, Ohio
| | | | | | - Michael R DeBaun
- 1 Vanderbilt University School of Medicine Nashville, Tennessee.,2 Monroe Carell Jr. Children's Hospital at Vanderbilt Nashville, Tennessee
| | - Robyn T Cohen
- 8 Boston University School of Medicine Boston, Massachusetts
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Sadreameli SC, Alade RO, Mogayzel PJ, McGrath-Morrow S, Strouse JJ. Asthma Screening in Pediatric Sickle Cell Disease: A Clinic-Based Program Using Questionnaires and Spirometry. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2017; 30:232-238. [PMID: 29279789 DOI: 10.1089/ped.2017.0776] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 10/23/2017] [Indexed: 01/31/2023]
Abstract
A clinician diagnosis of asthma is associated with increased morbidity and mortality in people with sickle cell disease (SCD). We hypothesized that a screening program would help identify children with asthma needing referral to pulmonary clinic. We conducted a single-center project to screen patients with SCD for asthma using a previously validated questionnaire (Breathmobile) and for pulmonary function abnormalities with portable spirometry. Participants with a positive questionnaire and/or abnormal spirometry were referred to pediatric pulmonary clinic. We evaluated clinical associations with abnormal spirometry and questionnaire responses. Of the 157 participants, 58 (37%) had a positive asthma screening questionnaire. Interpretable spirometry was available for 105 (83% of those eligible) and of these, 35 (34%) had abnormal results. The asthma questionnaire was 87.5% sensitive [95% confidence interval (CI) 74.8-95.3] and 85.3% specific (95% CI 77.3-91.4) to detect a clinician diagnosis of asthma. Participants with positive questionnaires were older (mean age 12.2 vs. 9.9 years, P = 0.012). Spirometry identified 16 additional participants who had normal asthma questionnaires. Seventy-four participants (47%) were referred to pediatric pulmonary clinic and 25 (34%) of these participants scheduled clinic appointments; however, only 13 (52%) were evaluated in pulmonary clinic. Clinic-based asthma screening and spirometry frequently identified individuals with asthma and pulmonary function abnormalities. Only 22% of those referred were eventually seen in pulmonary clinic. The impact of improved screening and treatment on the pulmonary morbidity in SCD needs to be defined and is an area for future investigation. In addition, case management or multidisciplinary clinics may enhance future screening programs.
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Affiliation(s)
- Sara C Sadreameli
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rachel O Alade
- Division of Pediatric Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peter J Mogayzel
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sharon McGrath-Morrow
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John J Strouse
- Division of Pediatric Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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34
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Jain S, Bakshi N, Krishnamurti L. Acute Chest Syndrome in Children with Sickle Cell Disease. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2017; 30:191-201. [PMID: 29279787 PMCID: PMC5733742 DOI: 10.1089/ped.2017.0814] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 10/11/2017] [Indexed: 02/02/2023]
Abstract
Acute chest syndrome (ACS) is a frequent cause of acute lung disease in children with sickle cell disease (SCD). Patients may present with ACS or may develop this complication during the course of a hospitalization for acute vaso-occlusive crises (VOC). ACS is associated with prolonged hospitalization, increased risk of respiratory failure, and the potential for developing chronic lung disease. ACS in SCD is defined as the presence of fever and/or new respiratory symptoms accompanied by the presence of a new pulmonary infiltrate on chest X-ray. The spectrum of clinical manifestations can range from mild respiratory illness to acute respiratory distress syndrome. The presence of severe hypoxemia is a useful predictor of severity and outcome. The etiology of ACS is often multifactorial. One of the proposed mechanisms involves increased adhesion of sickle red cells to pulmonary microvasculature in the presence of hypoxia. Other commonly associated etiologies include infection, pulmonary fat embolism, and infarction. Infection is a common cause in children, whereas adults usually present with pain crises. Several risk factors have been identified in children to be associated with increased incidence of ACS. These include younger age, severe SCD genotypes (SS or Sβ0 thalassemia), lower fetal hemoglobin concentrations, higher steady-state hemoglobin levels, higher steady-state white blood cell counts, history of asthma, and tobacco smoke exposure. Opiate overdose and resulting hypoventilation can also trigger ACS. Prompt diagnosis and management with intravenous fluids, analgesics, aggressive incentive spirometry, supplemental oxygen or respiratory support, antibiotics, and transfusion therapy, are key to the prevention of clinical deterioration. Bronchodilators should be considered if there is history of asthma or in the presence of acute bronchospasm. Treatment with hydroxyurea should be considered for prevention of recurrent episodes. This review evaluates the etiology, pathophysiology, risk factors, clinical presentation of ACS, and preventive and treatment strategies for effective management of ACS.
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Affiliation(s)
- Shilpa Jain
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Women and Children's Hospital of Buffalo, Hemophilia Center of Western New York, Buffalo, New York
| | - Nitya Bakshi
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Lakshmanan Krishnamurti
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
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Lunt A, Mortimer L, Rees D, Height S, Thein SL, Greenough A. Heterogeneity of respiratory disease in children and young adults with sickle cell disease. Thorax 2017; 73:575-577. [PMID: 29187592 DOI: 10.1136/thoraxjnl-2017-210206] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 11/13/2017] [Accepted: 11/20/2017] [Indexed: 11/04/2022]
Abstract
To detect and characterise different phenotypes of respiratory disease in children and young adults with sickle cell disease (SCD), 11 lung function and haematological biomarkers were analysed using k-means cluster analysis in a cohort of 114 subjects with SCD aged between 5 and 27 years. Three clusters were detected: cluster 1 had elevated pulmonary capillary blood volume, mixed obstructive/restrictive lung disease, hypoxia and moderately severe anaemia; cluster 2 were older patients with restrictive lung disease; and cluster 3 were younger patients with obstructive lung disease, elevated serum lactate dehydrogenase and bronchodilator reversibility. These results may inform more personalised management strategies to improve outcomes.
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Affiliation(s)
- Alan Lunt
- Division of Asthma, Allergy and Lung Biology, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
| | - Lucy Mortimer
- Division of Asthma, Allergy and Lung Biology, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
| | - David Rees
- Department of Paediatric Haematology, King's College Hospital NHS Foundation Trust, London, UK
| | - Sue Height
- Department of Paediatric Haematology, King's College Hospital NHS Foundation Trust, London, UK
| | - Swee Lay Thein
- Department of Paediatric Haematology, King's College Hospital NHS Foundation Trust, London, UK.,Molecular Haematology, Division of Cancer Studies, King's College London, London, UK
| | - Anne Greenough
- Division of Asthma, Allergy and Lung Biology, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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36
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Shilo NR, Morris CR. Pathways to pulmonary hypertension in sickle cell disease: the search for prevention and early intervention. Expert Rev Hematol 2017; 10:875-890. [PMID: 28817980 DOI: 10.1080/17474086.2017.1364989] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Pulmonary hypertension (PH) develops in a significant number of patients with sickle cell disease (SCD), resulting in increased morbidity and mortality. This review focuses on PH pathophysiology, risk stratification, and new recommendations for screening and treatment for patients with SCD. Areas covered: An extensive PubMed literature search was performed. While the pathophysiology of PH in SCD is yet to be fully deciphered, it is known that the etiology is multifactorial; hemolysis, hypercoagulability, hypoxemia, ischemic-reperfusion injury, oxidative stress, and genetic susceptibility all contribute in varying degrees to endothelial dysfunction. Hemolysis, in particular, seems to play a key role by inciting an imbalance in the regulatory axis of nitric oxide and arginine metabolism. Systematic risk stratification starting in childhood based on clinical features and biomarkers that enable early detection is necessary. Multi-faceted, targeted interventions, before irreversible vasculopathy develops, will allow for improved patient outcomes and life expectancy. Expert commentary: Despite progress in our understanding of PH in SCD, clinically proven therapies remain elusive and additional controlled clinical trials are needed. Prevention of disease starts in childhood, a critical window for intervention. Given the complex and multifactorial nature of SCD, patients will ultimately benefit from combination therapies that simultaneously targets multiple mechanisms.
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Affiliation(s)
- Natalie R Shilo
- a Department of Pediatrics, Division of Pulmonary Medicine , University of Connecticut Heath Center , Farmington , CT , USA
| | - Claudia R Morris
- b Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory-Children's Center for Cystic Fibrosis and Airways Disease Research , Emory University School of Medicine , Atlanta , GA , USA
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37
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Placenta growth factor mediated gene regulation in sickle cell disease. Blood Rev 2017; 32:61-70. [PMID: 28823762 DOI: 10.1016/j.blre.2017.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/08/2017] [Accepted: 08/15/2017] [Indexed: 01/07/2023]
Abstract
Sickle cell anemia (SCA) is an autosomal recessive disorder caused by mutation in the β-globin gene. Pulmonary hypertension (PH), a complication of SCA, results in severe morbidity and mortality. PH is a multifactorial disease: systemic vasculopathy, pulmonary vasoconstriction, and endothelial dysfunction and remodeling. Placenta growth factor (PlGF), an angiogenic growth factor, elaborated from erythroid cells, has been shown to contribute to inflammation, pulmonary vasoconstriction and airway hyper-responsiveness (AH) in mouse models of sickle cell disease. In this review, we summarize the cell-signaling mechanism(s) by which PlGF regulates the expression of genes involved in inflammation, PH and AH in cell culture and corroborate these findings in mouse models of SCA and in individuals with SCA. The role of microRNAs (miRNAs) in the post-transcriptional regulation of these genes is presented and how these miRNAs located in their host genes are transcriptionally regulated. An understanding of the transcriptional regulation of these miRNAs provides a new therapeutic approach to ameliorate the clinical manifestations of SCA.
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Secondhand Smoke Is an Important Modifiable Risk Factor in Sickle Cell Disease: A Review of the Current Literature and Areas for Future Research. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13111131. [PMID: 27845754 PMCID: PMC5129341 DOI: 10.3390/ijerph13111131] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 11/04/2016] [Accepted: 11/07/2016] [Indexed: 02/02/2023]
Abstract
Sickle cell disease (SCD) is an autosomal recessive hemoglobinopathy that causes significant morbidity and mortality related to chronic hemolytic anemia, vaso-occlusion, and resultant end-organ damage. Tobacco smoke exposure (TSE) through secondhand smoke exposure in people with SCD of all ages and through primary smoking in adolescents and adults is associated with significantly increased morbidity, with increased rates of emergency department visits and hospitalizations for painful vaso-occlusive crises and acute chest syndrome (ACS). Secondhand smoke is also associated with pulmonary function abnormalities in children with SCD who are already at risk for pulmonary function abnormalities on the basis of SCD. TSE is emerging as one of the few modifiable risk factors of SCD. This review discusses the current state of the evidence with respect to TSE and SCD morbidity, discusses potential mechanisms, and highlights current gaps in the evidence and future research directions.
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Shilo NR, Alawadi A, Allard-Coutu A, Robitaille N, Pastore Y, Bérubé D, Jacob SV, Abish S, Dauletbaev N, Lands LC. Airway hyperreactivity is frequent in non-asthmatic children with sickle cell disease. Pediatr Pulmonol 2016; 51:950-7. [PMID: 26716600 DOI: 10.1002/ppul.23374] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 11/02/2015] [Accepted: 12/15/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND Asthma is associated with poorer outcomes in sickle cell disease (SCD). Whether AHR can exist in SCD as a distinct entity, separate and independent of asthma, is unknown. AIMS Our goal was to elucidate the prevalence of AHR, as measured by a methacholine challenge test (MCT), in children with SCD who did not have concomitant asthma or any recent history of acute chest syndrome (ACS). To determine if AHR was associated with asthma-like symptoms, we compared the results of the MCT to a validated asthma questionnaire. We also examined if a correlation between AHR and inflammatory markers exists. METHODS AHR was identified with a positive MCT defined as a provocation concentration (PC20 ) < 4 mg/ml. The children and/or their parents completed the ISAAC (International Study of Asthma and Allergies in Children) questionnaire. We obtained blood, urine, and exhaled breath condensate samples. We measured cysteinyl leukotriene levels in urine and exhaled breath condensate via enzyme immunoassay. RESULTS Twenty-nine of forty children (72.5%) had a positive MCT. Nine (31.0%) also reported asthma-like symptoms on questionnaire. Inflammatory markers did not correlate with AHR. Among MCT positive subjects, those on hydroxyurea had significantly less severe AHR as quantified by PC20 (P = 0.014). CONCLUSIONS In children with SCD, there is a high prevalence of AHR that is not associated with asthma-like symptoms. AHR may be a distinct entity in children with SCD, existing in the absence of concomitant asthma. Hydroxyurea therapy might lessen the severity of AHR in affected individuals. Pediatr Pulmonol. 2016; 51:950-957. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Natalie R Shilo
- Division of Respiratory Medicine, Department of Pediatrics, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Aceel Alawadi
- Division of Respiratory Medicine, Department of Pediatrics, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Alexandra Allard-Coutu
- Division of Respiratory Medicine, Department of Pediatrics, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Nancy Robitaille
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - Yves Pastore
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - Denis Bérubé
- Division of Pulmonology, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - Sheila V Jacob
- Division of Pulmonology, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - Sharon Abish
- Division of Hematology-Oncology, Department of Pediatrics, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Nurlan Dauletbaev
- Division of Respiratory Medicine, Department of Pediatrics, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.,Research Institute, McGill University Health Centre, Montreal, QC, Canada
| | - Larry C Lands
- Division of Respiratory Medicine, Department of Pediatrics, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.,Research Institute, McGill University Health Centre, Montreal, QC, Canada
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40
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Cohen RT, Rodeghier M, Kirkham FJ, Rosen CL, Kirkby J, DeBaun MR, Strunk RC. Exhaled nitric oxide: Not associated with asthma, symptoms, or spirometry in children with sickle cell anemia. J Allergy Clin Immunol 2016; 138:1338-1343.e4. [PMID: 27521278 DOI: 10.1016/j.jaci.2016.06.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/25/2016] [Accepted: 06/13/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND The significance of fractional exhaled nitric oxide (Feno) levels in children with sickle cell anemia (SCA) is unclear, but increased levels can be associated with features of asthma and thus increased morbidity. OBJECTIVES We sought to determine factors associated with Feno and whether Feno levels are associated with increased rates of acute chest syndrome (ACS) and pain. METHODS All participants had SCA, were part of the prospective observational Sleep and Asthma Cohort study, and had the following assessments: Feno levels, spirometry, blood samples analyzed for hemoglobin, white blood cell counts, eosinophil counts and total serum IgE levels, questionnaires about child medical and family history, and review of medical records. RESULTS The analytic sample included 131 children with SCA (median age, 11.2 years; age range, 6-18 years) followed for a mean of 16.2 years, including a mean of 5.1 years after baseline Feno data measurements. In multivariable analyses higher Feno levels were associated with ln(IgE) levels (P < .001) and the highest quartile of peripheral eosinophil counts (P = .03) but not wheezing symptoms, baseline spirometric indices, or response to bronchodilator. Multivariable analyses identified that the incident rate of ACS was associated with ln(Feno) levels (P = .03), as well as male sex (P = .025), wheezing causing shortness of breath (P = .002), and ACS at less than 4 years of age (P < .001). Feno levels were not associated with future pain episodes. CONCLUSIONS Steady-state Feno levels were not associated with an asthma diagnosis, wheezing symptoms, lung function measures, or prior sickle cell morbidity but were associated with markers of atopy and increased risk of future ACS events.
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Affiliation(s)
- Robyn T Cohen
- Department of Pediatrics, Boston University School of Medicine, Boston, Mass.
| | | | - Fenella J Kirkham
- Neurosciences Unit, University College London, Institute of Child Health, London, United Kingdom
| | - Carol L Rosen
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jane Kirkby
- Portex Respiratory Unit, University College London, Institute of Child Health, London, United Kingdom
| | - Michael R DeBaun
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Robert C Strunk
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, Mo
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41
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Cohen RT, Strunk RC, Rodeghier M, Rosen CL, Kirkham FJ, Kirkby J, DeBaun MR. Pattern of Lung Function Is Not Associated with Prior or Future Morbidity in Children with Sickle Cell Anemia. Ann Am Thorac Soc 2016; 13:1314-23. [PMID: 27300316 PMCID: PMC5021073 DOI: 10.1513/annalsats.201510-706oc] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 04/15/2016] [Indexed: 01/22/2023] Open
Abstract
RATIONALE Patient factors associated with development of abnormal lung function in children with sickle cell anemia (SCA) have not been fully characterized. OBJECTIVES To characterize lung function abnormalities among children with SCA and to determine whether these steady-state lung function results were associated with morbidity before or after testing among children with SCA. METHODS This study was part of the prospective National Institutes of Health-funded Sleep and Asthma Cohort Study. Children with HbSS or Hb Sβ(o) (SCA) were enrolled without regard for sickle cell-related comorbidities or diagnosis of asthma. Lung function was measured by spirometry and plethysmography on the same day, when free of acute disease. Standardized asthma symptom questionnaires and review of the medical records were also performed. MEASUREMENTS AND MAIN RESULTS A total of 149 children aged 6 to 19 years completed lung function testing, of whom 139 participants had retrospective morbidity data from birth to the test date, and 136 participants were followed prospectively for a median of 4.3 years from the test date. At baseline, percentages with normal, obstructive, restrictive, nonspecific, and mixed lung function patterns were 70, 16, 7, 6, and 1, respectively. Neither retrospective rates of pain nor acute chest syndrome was associated with lung function patterns. Furthermore, baseline lung function pattern was not predictive of future pain or acute chest syndrome episodes. CONCLUSIONS The majority of children with SCA have lung function that is within the normal range. Abnormal lung function patterns were not associated with prior vasoocclusive pain or acute chest syndrome episodes, and baseline lung function patterns did not predict future vasoocclusive pain or chest syndrome episodes.
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Affiliation(s)
- Robyn T. Cohen
- Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
| | - Robert C. Strunk
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | | | - Carol L. Rosen
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - Jane Kirkby
- Respiratory, Critical Care, and Anaesthesia Section of IIIP, University College London, Institute of Child Health, London, United Kingdom; and
| | - Michael R. DeBaun
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
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42
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Mehari A, Klings ES. Chronic Pulmonary Complications of Sickle Cell Disease. Chest 2016; 149:1313-24. [PMID: 26836905 DOI: 10.1016/j.chest.2015.11.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 10/19/2015] [Accepted: 11/14/2015] [Indexed: 01/31/2023] Open
Abstract
Sickle cell disease (SCD), the most common genetic hemolytic anemia worldwide, affects 250,000 births annually. In the United States, SCD affects approximately 100,000 individuals, most of African descent. Hemoglobin S (HbS) results from a glutamate-to-valine mutation of the sixth codon of the β-hemoglobin allele; the homozygous genotype (HbSS) is associated with the most prevalent and severe form of the disease. Other SCD genotypes include HbSC, composed of one HbS allele and one HbC (glutamate-to-lysine mutation) allele; and HbS-β-thalassemia(0) or HbS-β-thalassemia(+), composed of one HbS allele and one β-thalassemia allele with absent or reduced β-chain production, respectively. Despite advances in care, median survival remains in the fifth decade, due in large part to chronic complications of the disease. Chronic pulmonary complications in SCD are major contributors to this early mortality. Although our understanding of these conditions has improved much over the past 10 to 15 years, there remains no specific treatment for pulmonary complications of SCD. It is unclear whether conventional treatment regimens directed at non-SCD populations have equivalent efficacy in patients with SCD. This represents a critical research need. In this review, the authors review the state-of-the-art understanding of the following pulmonary complications of SCD: (1) pulmonary hypertension; (2) venous thromboembolic disease; (3) sleep-disordered breathing; (4) asthma and recurrent wheezing; and (5) pulmonary function abnormalities. This review highlights the advances as well as the knowledge gaps in this field to update clinicians and other health care providers and to garner research interest from the medical community.
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Affiliation(s)
- Alem Mehari
- Department of Pulmonary Diseases, Howard University College of Medicine, Washington, DC
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43
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Novelli EM, Gladwin MT. Crises in Sickle Cell Disease. Chest 2015; 149:1082-93. [PMID: 26836899 DOI: 10.1016/j.chest.2015.12.016] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 12/04/2015] [Accepted: 12/11/2015] [Indexed: 12/16/2022] Open
Abstract
In spite of significant strides in the treatment of sickle cell disease (SCD), SCD crises are still responsible for high morbidity and early mortality. While most patients initially seek care in the acute setting for a seemingly uncomplicated pain episode (pain crisis or vaso-occlusive crisis), this initial event is the primary risk factor for potentially life-threatening complications. The pathophysiological basis of these illnesses is end-organ ischemia and infarction combined with the downstream effects of hemolysis that results from red blood cell sickling. These pathological changes can occur acutely and lead to a dramatic clinical presentation, but are frequently superimposed over a milieu of chronic vasculopathy, immune dysregulation, and decreased functional reserve. In the lungs, acute chest syndrome is a particularly ominous lung injury syndrome with a complex pathogenesis and potentially devastating sequelae, but all organ systems can be affected. It is, therefore, critical to understand the SCD patients' susceptibility to acute complications and their risk factors so that they can be recognized promptly and managed effectively. Blood transfusions remain the mainstay of therapy for all severe acute crises. Recommendations and indications for the safest and most efficient implementation of transfusion strategies in the critical care setting are therefore presented and discussed, together with their pitfalls and potential future therapeutic alternatives. In particular, the importance of extended phenotypic red blood cell matching cannot be overemphasized, due to the high prevalence of severe complications from red cell alloimmunization in SCD.
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Affiliation(s)
- Enrico M Novelli
- Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA; Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA; Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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44
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Eiymo Mwa Mpollo MS, Brandt EB, Shanmukhappa SK, Arumugam PI, Tiwari S, Loberg A, Pillis D, Rizvi T, Lindsey M, Jonck B, Carmeliet P, Kalra VK, Le Cras TD, Ratner N, Wills-Karp M, Hershey GKK, Malik P. Placenta growth factor augments airway hyperresponsiveness via leukotrienes and IL-13. J Clin Invest 2015; 126:571-84. [PMID: 26690703 DOI: 10.1172/jci77250] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 11/12/2015] [Indexed: 12/25/2022] Open
Abstract
Airway hyperresponsiveness (AHR) affects 55%-77% of children with sickle cell disease (SCD) and occurs even in the absence of asthma. While asthma increases SCD morbidity and mortality, the mechanisms underlying the high AHR prevalence in a hemoglobinopathy remain unknown. We hypothesized that placenta growth factor (PlGF), an erythroblast-secreted factor that is elevated in SCD, mediates AHR. In allergen-exposed mice, loss of Plgf dampened AHR, reduced inflammation and eosinophilia, and decreased expression of the Th2 cytokine IL-13 and the leukotriene-synthesizing enzymes 5-lipoxygenase and leukotriene-C4-synthase. Plgf-/- mice treated with leukotrienes phenocopied the WT response to allergen exposure; conversely, anti-PlGF Ab administration in WT animals blunted the AHR. Notably, Th2-mediated STAT6 activation further increased PlGF expression from lung epithelium, eosinophils, and macrophages, creating a PlGF/leukotriene/Th2-response positive feedback loop. Similarly, we found that the Th2 response in asthma patients is associated with increased expression of PlGF and its downstream genes in respiratory epithelial cells. In an SCD mouse model, we observed increased AHR and higher leukotriene levels that were abrogated by anti-PlGF Ab or the 5-lipoxygenase inhibitor zileuton. Overall, our findings indicate that PlGF exacerbates AHR and uniquely links the leukotriene and Th2 pathways in asthma. These data also suggest that zileuton and anti-PlGF Ab could be promising therapies to reduce pulmonary morbidity in SCD.
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45
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Cohen RT, Klings ES, Strunk RC. Sickle cell disease: wheeze or asthma? Asthma Res Pract 2015; 1:14. [PMID: 27965767 PMCID: PMC5142438 DOI: 10.1186/s40733-015-0014-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 11/26/2015] [Indexed: 01/31/2023] Open
Abstract
Sickle cell disease (SCD) is the most common life-limiting genetic disease among African Americans, affecting more than 100,000 people in the United States. Respiratory disorders in patients with sickle cell disease have been associated with increased morbidity and mortality. Associations between asthma and pain, acute chest syndrome (ACS), and even death have long been reported. More recently wheezing, even in the absence of an asthma diagnosis, has gained attention as a possible marker of SCD severity. Several challenges exist with regards to making the diagnosis of asthma in patients with SCD, including the high prevalence of wheezing, evidence of airway obstruction on pulmonary function testing, and/or airway hyperresponsiveness among patients with SCD. These features often occur in isolation, in the absence of other clinical criteria necessary for an asthma diagnosis. In this review we will summarize: 1) Our current understanding of the epidemiology of asthma, wheezing, airway obstruction, and airway responsiveness among patients with SCD; 2) The evidence supporting associations with SCD morbidity; 3) Our understanding of the pathophysiology of airway inflammation in SCD; 4) Current approaches to diagnosis and management of asthma in SCD; and 5) Future directions.
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Affiliation(s)
- Robyn T Cohen
- Division of Pediatric Pulmonary and Allergy, Department of Pediatrics, Boston University School of Medicine, 850 Harrison Avenue, Boston, MA 02118 USA
| | - Elizabeth S Klings
- Pulmonary Center, Department of Medicine, Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118 USA
| | - Robert C Strunk
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO USA
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Andemariam B, Adami AJ, Singh A, McNamara JT, Secor ER, Guernsey LA, Thrall RS. The sickle cell mouse lung: proinflammatory and primed for allergic inflammation. Transl Res 2015; 166:254-68. [PMID: 25843670 PMCID: PMC4537824 DOI: 10.1016/j.trsl.2015.03.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 02/09/2015] [Accepted: 03/10/2015] [Indexed: 01/22/2023]
Abstract
Comorbid asthma in sickle cell disease (SCD) confers higher rates of vaso-occlusive pain and mortality, yet the physiological link between these two distinct diseases remains puzzling. We used a mouse model of SCD to study pulmonary immunology and physiology before and after the induction of allergic airway disease (AAD). SCD mice were sensitized with ovalbumin (OVA) and aluminum hydroxide by the intraperitoneal route followed by daily, nose-only OVA-aerosol challenge to induce AAD. The lungs of naive SCD mice showed signs of inflammatory and immune processes: (1) histologic and cytochemical evidence of airway inflammation compared with naive wild-type mice; (2) bronchoalveolar lavage (BAL) fluid contained increased total lymphocytes, %CD8+ T cells, granulocyte-colony stimulating factor, interleukin 5 (IL-5), IL-7, and chemokine (C-X-C motif) ligand (CXCL)1; and (3) lung tissue and hilar lymph node (HLN) had increased CD4+, CD8+, and regulatory T (Treg) cells. Furthermore, SCD mice at AAD demonstrated significant changes compared with the naive state: (1) BAL fluid with increased %CD4+ T cells and Treg cells, lower %CD8+ T cells, and decreased interferon gamma, CXCL10, chemokine (C-C motif) ligand 2, and IL-17; (2) serum with increased OVA-specific immunoglobulin E, IL-6, and IL-13, and decreased IL-1α and CXCL10; (3) no increase in Treg cells in the lung tissue or HLN; and (4) hyporesponsiveness to methacholine challenge. In conclusion, SCD mice have an altered immunologic pulmonary milieu and physiological responsiveness. These findings suggest that the clinical phenotype of AAD in SCD mice differs from that of wild-type mice and that individuals with SCD may also have a unique, divergent phenotype perhaps amenable to a different therapeutic approach.
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Affiliation(s)
- Biree Andemariam
- Division of Hematology-Oncology, Lea Center for Hematologic Disorders, Adult Sickle Cell Center, University of Connecticut Health Center, Farmington, Conn.
| | - Alexander J Adami
- Department of Immunology, University of Connecticut Health Center, Farmington, Conn
| | - Anurag Singh
- Department of Immunology, University of Connecticut Health Center, Farmington, Conn
| | - Jeffrey T McNamara
- Department of Immunology, University of Connecticut Health Center, Farmington, Conn
| | - Eric R Secor
- Department of Immunology, University of Connecticut Health Center, Farmington, Conn
| | - Linda A Guernsey
- Department of Immunology, University of Connecticut Health Center, Farmington, Conn
| | - Roger S Thrall
- Department of Immunology, University of Connecticut Health Center, Farmington, Conn
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47
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Yadav A, Corrales-Medina FF, Stark JM, Hashmi SS, Carroll MP, Smith KG, Meulmester KM, Brown DL, Jon C, Mosquera RA. Application of an Asthma Screening Questionnaire in Children with Sickle Cell Disease. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2015; 28:177-182. [PMID: 26421214 DOI: 10.1089/ped.2015.0515] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Objective: Asthma in sickle cell disease (SCD) patients is associated with elevated morbidity and mortality. Early detection and initiation of treatment may therefore lead to improved outcome. Utility of an asthma screening questionnaire to identify obstructive airway disease and physician diagnosed asthma in children with SCD at an outpatient setting as an effective, easy-to-administer screening tool has not previously been evaluated in this population. Methods: A previously validated asthma screening questionnaire and spirometry were prospectively administered to 41 SCD children at a routine clinic visit. Results: Prevalence of obstructive airway was 51.2% (n = 21) and physician diagnosis of asthma 33.3% (n = 13). Sensitivity (40%) and specificity (75%) of the questionnaire was poor in detecting obstructive airway disease, but sensitivity (77%), specificity (100%), positive predictive value (100%), and negative predictive value (90%) were high in detecting physician diagnosis of asthma. Conclusion: An asthma screening questionnaire could be a useful tool in identifying at-risk SCD children who may benefit from further management.
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Affiliation(s)
- Aravind Yadav
- Department of Pediatrics, University of Texas Health Science Center , Houston Medical School, Houston, Texas
| | - Fernando F Corrales-Medina
- Department of Pediatrics, University of Texas Health Science Center , Houston Medical School, Houston, Texas. ; Division of Pediatrics Hematology-Oncology, Department of Pediatrics, University of Miami-Miller School of Medicine , Miami, FL
| | - James M Stark
- Department of Pediatrics, University of Texas Health Science Center , Houston Medical School, Houston, Texas
| | - S Shahrukh Hashmi
- Department of Pediatrics, University of Texas Health Science Center , Houston Medical School, Houston, Texas
| | - Mary P Carroll
- Department of Pediatrics, University of Texas Health Science Center , Houston Medical School, Houston, Texas
| | - Keely G Smith
- Department of Pediatrics, University of Texas Health Science Center , Houston Medical School, Houston, Texas
| | - Kristen M Meulmester
- Department of Pediatrics, University of Texas Health Science Center , Houston Medical School, Houston, Texas
| | - Deborah L Brown
- Department of Pediatrics, University of Texas Health Science Center , Houston Medical School, Houston, Texas
| | - Cindy Jon
- Department of Pediatrics, University of Texas Health Science Center , Houston Medical School, Houston, Texas
| | - Ricardo A Mosquera
- Department of Pediatrics, University of Texas Health Science Center , Houston Medical School, Houston, Texas
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48
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Diep RT, Busani S, Simon J, Punzalan A, Skloot GS, Glassberg JA. Cough and wheeze events are temporally associated with increased pain in individuals with sickle cell disease without asthma. Br J Haematol 2015; 170:732-4. [PMID: 25753135 DOI: 10.1111/bjh.13325] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Robert T Diep
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Jena Simon
- Department of Nursing, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alexa Punzalan
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gwen S Skloot
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeffrey A Glassberg
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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49
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Abstract
In children with sickle cell disease (SCD), wheezing may occur in the absence of asthma. However, the prevalence of wheezing in children with SCD when compared with children without SCD (controls) in the same setting is unknown. Using a case-control study design, we tested the hypothesis that children with SCD would have a higher rate of wheezing than those without SCD. We enrolled 163 children with SCD (cases) and 96 children without SCD (controls) from a community hospital in Nigeria. Parent reports of respiratory symptoms were identified based on responses to questions taken from the American Thoracic Society Division of Lung Diseases' Questionnaire. The median age was 8.5 years for children with SCD and 7.7 years for controls. Cases were more likely than controls to report wheezing both with colds (17.3% vs. 2.1%, P<0.01) and without colds (4.9% vs. 0%, P=0.03). Cases had 9.8 times greater odds of wheezing (95% confidence interval, 2.3-42.2). In the multivariable model, the only variable associated with wheezing was SCD status (odds ratio=18.7, 95% confidence interval, 2.5-142; P=0.005). Children with SCD experience a significantly higher rate of wheezing when compared with children of similar age without SCD.
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50
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DeBaun MR, Rodeghier M, Cohen R, Kirkham FJ, Rosen CL, Roberts I, Cooper B, Stocks J, Wilkey O, Inusa B, Warner JO, Strunk RC. Factors predicting future ACS episodes in children with sickle cell anemia. Am J Hematol 2014; 89:E212-7. [PMID: 25088663 DOI: 10.1002/ajh.23819] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 07/31/2014] [Indexed: 01/07/2023]
Abstract
While a doctor-diagnosis of asthma is associated with an increased risk of pain and acute chest syndrome (ACS) in children with sickle cell anemia (SCA), little is known about the relationship between specific asthma characteristics and clinical factors and future morbidity in children with SCA. We evaluated the relationship between (i) asthma risk factors at the time of a clinical visit (respiratory symptoms, maternal history of asthma, allergy skin tests, spirometry results) and (ii) the known risk factor of ACS early in life, on prospective pain and ACS episodes in a cohort of 159 children with SCA followed from birth to a median of 14.7 years. An ACS episode prior to 4 years of age, (incidence rate ratio [IRR] = 2.84; P < 0.001], female gender (IRR = 1.80; P = 0.009), and wheezing causing shortness of breath (IRR = 1.68; P = 0.042) were associated with future ACS rates. We subsequently added spirometry results (obstruction defined as FEV1 /FVC less than the lower limits of normal; and bronchodilator response, FEV1 ≥ 12%) and prick skin test responses to the model. Only ≥ 2 positive skin tests had a significant effect (IRR 1.87; P = 0.01). Thus, early in life ACS events, wheezing causing shortness of breath, and ≥ 2 positive skin tests predict future ACS events.
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Affiliation(s)
- Michael R. DeBaun
- Department of Pediatrics; Vanderbilt University School of Medicine; Nashville Tennessee
| | | | - Robyn Cohen
- Department of Pediatrics; Boston Medical Center/Boston University School of Medicine; Boston Massachusetts
| | - Fenella J. Kirkham
- Department of Paediatrics; Imperial College and the Biomedical Centre of Imperial College Healthcare NHS Trust; London United Kingdom
| | - Carol L. Rosen
- Department of Pediatrics; Case Western Reserve University School of Medicine, Rainbow Babies and Children's Hospitals, University Hospitals Case Medical Center; Cleveland Ohio
| | - Irene Roberts
- Department of Paediatrics; Imperial College and the Biomedical Centre of Imperial College Healthcare NHS Trust; London United Kingdom
| | - Ben Cooper
- Brown School of Social Work, Washington University; St. Louis Missouri
| | - Janet Stocks
- University College London Institute of Child Health; London United Kingdom
| | - Olu Wilkey
- Department of Paediatrics; North Middlesex Hospital NHS Trust; London United Kingdom
| | - Baba Inusa
- Department of Paediatrics; Evelina Children's Hospital, Guy's and St. Thomas' National Health Service Foundation Trust; London United Kingdom
| | - John O. Warner
- Department of Paediatrics; Imperial College and the Biomedical Centre of Imperial College Healthcare NHS Trust; London United Kingdom
| | - Robert C. Strunk
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics; Washington University School of Medicine; St. Louis Missouri
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