The psychosocial impact of leg ulcers in patients with sickle cell disease: I don't want them to know my little secret

Sickle cell leg ulcer successfully managed by hyperbaric oxygen: a case report

Sickle cell leg ulcers (SCLUs) are usually chronic, painful, and devastating complications of sickle cell disease. Skin vaso-occlusion with compromised blood flow, chronic inflammation, and endothelial dysfunction is thought to be the underlying mechanism. It is usually slow to heal, and it may become chronic and superinfected. The management of SCLUs is usually challenging and requires a multidisciplinary team. Multiple systemic and local therapies have been tried in SCLU treatment. However, the outcome is variable: currently, there are no official recommendations for the best effective treatment. Herein, we report a 34-year-old male patient with non-transfusion-dependent sickle cell disease who was suffering from a chronic left ankle ulcer and was successfully managed with hyperbaric oxygen therapy, resulting in a complete resolution of this devastating complication.

Prevalence of people with sickle cell disease and leg ulcers in Brazil: Socioeconomic and clinical overview

Objective

To identify the prevalence of people with leg ulcers resulting from sickle cell disease, as well as to describe the clinical, social, economic, and demographic conditions of these people.

Method

Descriptive study, carried out at the Minas Gerais Hematology and Hemotherapy Center Foundation. The study population consisted of individuals over the age of 18 with a diagnosis of sickle cell disease in the State of Minas Gerais, Brazil. Data collection was performed from August 2019 to April 2020 through interviews. For the prevalence calculation, a census was taken of 5,379 people over the age of 18 with sickle cell disease, 77 of whom had active leg ulcers. Descriptive data analysis was performed using SPSS software (version 20.0, Chicago, IL, USA).

Results

The prevalence of people with leg ulcers in Minas Gerais, Brazil was 1.4%. Of the 72 respondents, the average age was 39 years (range 18–64 years), 41.7% were single, 48.6% said they were black, 84.7% lived in their own house, 38.9% were retired, 61.1% had an income of one minimum wage. The median years of education was 10.5, 50% cited the church as a place for leisure activities, 79.2% denied smoking. Regarding pain, the median score was 3, the median baseline hemoglobin was 7.7 g/dL, and 91.7% had the HbSS genotype. The median age of the first ulcer was 18 years, 77.8% of active ulcers were recurrent, and 59.7% had only one active ulcer. The median time of existence of the ulcer was 3 years. The ulcer prevented 80.6% of people from doing some activity. Prejudice was experienced by 48.6% of the participants.

Conclusion

The estimated prevalence of leg ulcers was lower than what it reported in the literature, however, the recurrence and the duration of ulcers were high. These findings bring reflection about the assistance to people with leg ulcer.

Association of Sickle Cell Pain & Symptoms on Health-Related Quality of Life Among Pediatric Patients

CONTEXT

Sickle cell disease (SCD) may cause significant complications leading to increased disease burden and poor psychosocial functioning. Yet, little is known about specific disease-related variables associated with decreased health-related quality of life (HRQOL) of this population.

OBJECTIVES

This study aims to discover whether pain and disease-related symptoms are associated with the HRQOL of pediatric patients diagnosed with SCD.

METHODS

A total of 150 patient (ages 8-17 years) and parent dyads were enrolled in this cross-sectional quantitative research study. Measures of HRQOL were gathered using the Pediatric Quality of Life (PedsQL) 3.0 SCD module, while the frequency of pain and SCD-related symptoms was reported by parent-proxy. Linear regression was deployed to analyze whether pain and SCD-related symptoms separately predict HRQOL scores in youth with SCD.

RESULTS

Study results revealed that the frequency of pain (P < 0.001) and SCD-related symptoms (P < 0.001) predicted lower HRQOL scores in children and adolescents with SCD. Moreover, age (P < 0.05) emerged as a significant predictor of HRQOL in this sample.

CONCLUSION

Pain and disease-related symptoms separately predicted lower HRQOL scores in the study sample, which shows that other SCD-related symptoms aside from pain has the potential to negatively impact youth with SCD. Implications for these findings extend the knowledge of clinicians in the healthcare setting to recognize the detriment of other SCD-related symptoms that may be overlooked, as pain is often the focus.

A Description of the Hemolytic Component in Sickle Leg Ulcer: The Role of Circulating miR-199a-5p, miR-144, and miR-126

Sickle leg ulcers (SLU) are malleoli lesions with exuberant hemolytic pathophysiology. The microRNAs are potential genetic biomarkers for several pathologies. Thereby, we aimed to assess the expression of circulating miR-199a-5p, miR-144, and miR-126 in association with hemolytic biomarkers in SLU. This cross-sectional study included 69 patients with sickle cell disease, 52 patients without SLU (SLU-) and 17 patients with active SLU or previous history (SLU+). The results demonstrated elevated expression of circulating miR-199a-5p and miR-144 in SLU+ patients while miR-126 expression was reduced. Circulating miR-199a-5p and miR-144 were associated with hemolytic biomarkers such as LDH, indirect bilirubin, AST, GGT, iron, ferritin, RBC, hemoglobin, and NOm, in addition to association with impaired clinical profile of SLU. Furthermore, in silico analyses indicated interactions of miR-199a-5p with HIF1A, Ets-1, and TGFB2 genes, which are associated with vasculopathy and reduced NO. In contrast, miR-126 was associated with an attenuating clinical profile of SLU, in addition to not characterizing hemolysis. In summary, this study demonstrates, for the first time, that hemolytic mechanism in SLU can be characterized by circulating miR-199a-5p and miR-144. The circulating miR-126 may play a protective role in SLU. Thus, these microRNAs can support to establish prognosis and therapeutic strategy in SLU.

Severe Pain Profiles and Associated Sociodemographic and Clinical Characteristics in Individuals With Sickle Cell Disease

OBJECTIVE

The aim of this study was to identify classes of individuals with sickle cell disease (SCD) who share distinct severe pain profiles and evaluate differences in demographic, clinical, and psychosocial characteristics between classes.

METHODS

This exploratory, cross-sectional study used data collected for the SCD Implementation Consortium Research Registry at Duke University. Using Adult Sickle Cell Quality of Life-Measurement System pain-item data from 291 adults with SCD, latent class analysis was used to determine classes of individuals sharing distinct severe pain profiles. Bivariate analyses and logistic regression models were used to assess the relationships between pain profile classes and demographic, clinical, and psychosocial characteristics.

RESULTS

Three classes sharing distinct severe pain profiles were identified: Low Frequency and Impact class (n=73), Moderate Frequency and Impact class (n=94), and High Frequency and Impact class (n=124). When compared with the Low Frequency and Impact class and controlling for age and sex, individuals in the Moderate Frequency and Impact class were more likely to: be female (P=0.031) and unemployed (P=0.013); report worse sleep (P=0.005) and social functioning (P=0.005); have less emotional distress (P=0.004); describe pain as "sore" (P=0.002); and have previous SCD-related lung complications (P=0.016). When compared with the Low Frequency and Impact class, individuals in the High Frequency and Impact class: had worse social functioning (P<0.001) and previous SCD-related lung complications (P=0.006); described pain as "sore" (P<0.001); and were taking pain medication daily for SCD (P=0.001).

DISCUSSION

Severe pain experiences in SCD are complex; however, there are subgroups of people who report similar experiences of severe pain.

Insights into the skin microbiome of sickle cell disease leg ulcers

Leg ulcers are estimated to occur in 1%-10% of North American patients with sickle cell disease (SCD). Their pathophysiology remains poorly defined, but as with other chronic wounds, it is hypothesised that the microbial milieu, or microbiome, contributes to their healing and clinical outcomes. This study utilises 16S ribosomal RNA (rRNA) gene sequencing to describe, for the first time, the microbiome of the SCD leg ulcer and its association with clinical factors. In a cross-sectional analysis of 42 ulcers, we recovered microbial profiles similar to other chronic wounds in the predominance of anaerobic bacteria and opportunistic pathogens including Staphylococcus, Corynebacterium, and Finegoldia. Ulcers separated into two clusters: one defined by predominance of Staphylococcus and smaller surface area, and the other displaying a greater diversity of taxa and larger surface area. We also find that the relative abundance of Porphyromonas is negatively associated with haemoglobin levels, a key clinical severity indicator for SCD, and that Finegoldia relative abundance is negatively associated with CD19+ B cell count. Finally, ratios of Corynebacterium:Lactobacillus and Staphylococcus:Lactobacillus are elevated in the intact skin of individuals with a history of SCD leg ulcers, while the ratio of Lactobacillus:Bacillus is elevated in that of individuals without a history of ulcers. Investigations of the skin microbiome in relation to SCD ulcer pathophysiology can inform clinical guidelines for this poorly understood chronic wound, as well as enhance broader understanding about the role of the skin microbiome in delayed wound healing.

A Qualitative Study Inquiry among Patients with Diabetic Foot Ulcers: What have They Felt?

BACKGROUND: Diabetic foot ulcers (DFU) caused physical and psychosocial problems and the risk of amputations and death. AIM: The aim of the study was to overview the feelings of diabetes mellitus patients with DFU. METHODS: A phenomenological qualitative study design was undertaken from January to April 2020. A total of 25 patients with DFU were determined through the purposive sampling technique. The study was conducted among the patients undertaking home-based wound care in Bojonegoro, Indonesia. The proposed discussion guidelines were used to collect the data through in-depth interviews. Colaizzi’s technique was used to analyze the data and it was managed by NVIVO. RESULTS: We emerged two themes: Psychological and physiological response of patients with DFU and coping mechanisms in caring DFU. Among the patients with DFU, we determined their psychological responses and coping mechanisms as reported in this study. CONCLUSIONS: Patients with DFU are expected to be able to control themselves psychologically. Health workers such as doctors and nurses can provide interventions by considering the psychological condition of patients with DFU. A good psychological condition can ensure that their blood sugar is regulated properly.

Social support networks of adults with sickle cell disease

Sickle cell disease (SCD) can cause both physical and psychological complications, such as severe pain and depression. These effects often necessitate social and caregiving support. Few studies have assessed support networks within the adult SCD population. Here, we describe the support networks of adults with SCD and identify who in these networks (1) provides emotional support, (2) is dependable during crisis situations, including social and financial adversities, and (3) provides assistance in health crises. Forty-nine adults with SCD completed surveys and social network assessments through interview. Generalized mixed-effects linear regression models were fitted to investigate the composition of support provision within these personal networks. Our findings indicate that parents and 'other important people' (e.g., friends, spouses) play key roles in the support provided to those with SCD. Siblings with SCD appeared to be more emotionally supportive than unaffected siblings. With much research centered around the pediatric and adolescent SCD populations, focus needs to extend to adults and the individuals involved in their care and disease management. Understanding the flow of support within these networks can help genetic counselors and healthcare providers to better identify both social ties that serve as support resources and less supportive relationships for individuals living with SCD and other chronic genetic conditions that might be targeted for intervention.

PROFILE OF WOMEN WITH LEG ULCERS DUE TO SICKLE CELL DISEASE

Objective: to characterize the profile of women with leg ulcers resulting from sickle cell disease treated at a public health institution in Brazil. Method: historical cohort study conducted in the outpatient sector with a sample of women with sickle cell disease and leg ulcer, followed from 1998 to 2014. The data were extracted from the medical record and included sociodemographic, clinical and ulcer-related variables, and underwent descriptive statistical analysis. Results: of the 17 women, 64.7% were cured, 58.8% were aged between 30 and 39 years, 64.7% declared themselves brown, 70.6% were without partners, 41.2% had incomplete elementary education, 52, 9% had an income of 2 to 3 minimum wages, 70.6% were eutrophic and 82.4% used vitamin supplements. Women had a total of 29 ulcers, 52.9% had a single ulcer, 41.4% were located in the malleolar region, 55.17% were between 2 and 36 months, all classified as stage 3. The treatment was with coverings and Unna’s boot. Conclusion: the women received care from specialist nurses and most were cured with up to eight months of follow-up, which required a nursing consultation, including clinical evaluation, topical treatment and application of compression therapy.

PERFIL DE MULHERES COM ÚLCERAS DA PERNA DECORRENTES DE DOENÇA FALCIFORME

Objetivo:caracterizar o perfil de mulheres com úlceras da perna decorrentes da doença falciforme atendidas em uma instituição pública de saúde do Brasil. Método: estudo de coorte histórica realizado no setor ambulatorial com amostra de mulheres com doença falciforme e úlcera da perna, acompanhadas de 1998 a 2014. Os dados foram extraídos do prontuário e contemplaram variáveis sociodemográficas, clínicas e relacionadas à úlcera, e passaram por análise estatística descritiva. Resultados: das 17 mulheres, 64,7% obtiveram cura, 58,8% tinham idade entre 30 e 39 anos, 64,7% se autodeclaram pardas, 70,6% estavam sem parceiros, 41,2% possuíam ensino fundamental incompleto, 52,9% tinham renda de 2 a 3 salários mínimos, 70,6% eram eutróficas e 82,4% faziam uso de suplementos vitamínicos. As mulheres apresentaram o total de 29 úlceras, 52,9% tinham úlcera única, 41,4% localizadas na região maleolar, 55,17% com existência entre 2 e 36 meses, todas classificadas em estágio 3. O tratamento foi com coberturas e bota de Unna. Conclusão: as mulheres receberam cuidados de enfermeiros especialistas e a maioria obteve a cura com até oito meses de acompanhamento que demandou a consulta de enfermagem, contemplando a avaliação clínica, o tratamento tópico e aplicação da terapia de compressão.

Topical Sevoflurane: A Novel Treatment for Chronic Pain Caused by Venous Stasis Ulcers

In the US, an estimated 1 - 2% of chronic venous insufficiency (CVI) patients (of 6 - 7 million nationwide) develop at least one venous stasis ulcer (VSU) during their illness. Of these, approximately 40% develop subsequent ulcers, making VSU prognostically poor. Current management of VSU is costly, with poor prognosis, high recurrence rate, inadequate pain management, and significantly reduced quality of life (QoL). Topical volatile anesthetic agents, such as sevoflurane, offer improved pain relief and symptom control in patients suffering from chronic VSU. The immediate impact of topical sevoflurane in reducing pain associated with ulcer bed debridement has several implications in improving the quality of life in patients with CVI induced ulcers and in the prognosis and healing of the ulcers. This review summarizes a topical formulation of a volatile anesthetic and its implications for the management of VSUs.

Interventions for treating leg ulcers in people with sickle cell disease

BACKGROUND

The frequency of skin ulceration makes an important contributor to the morbidity burden in people with sickle cell disease. Many treatment options are available to the healthcare professional, although it is uncertain which treatments have been assessed for effectiveness in people with sickle cell disease. This is an update of a previously published Cochrane Review.

OBJECTIVES

To assess the clinical effectiveness and harms of interventions for treating leg ulcers in people with sickle cell disease.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register. We searched LILACS (1982 to January 2020), ISI Web of Knowledge (1985 to January 2020), and the Clinical Trials Search Portal of the World Health Organization (January 2020). We checked the reference lists of all the trials identified. We also contacted those groups or individuals who may have completed relevant randomised trials in this area. Date of the last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register: 13 January 2020; date of the last search of the Cochrane Wounds Group Trials Register: 17 February 2017.

SELECTION CRITERIA

Randomised controlled trials of interventions for treating leg ulcers in people with sickle cell disease compared to placebo or an alternative treatment.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion. All three authors independently assessed the risk of bias of the included studies and extracted data. We used GRADE to assess the quality of the evidence.

MAIN RESULTS

Six studies met the inclusion criteria (198 participants with 250 ulcers). Each trial investigated a different intervention and within this review we have grouped these as systemic pharmaceutical interventions (L-cartinine, arginine butyrate, isoxsuprine) and topical pharmaceutical interventions (Solcoseryl® cream, arginine-glycine-aspartic acid (RGD) peptide dressing and topical antibiotics). No trials on non-pharmaceutical interventions were included in the review. All trials had an overall unclear or high risk of bias, and drug companies sponsored four of them. We were unable to pool findings due to the heterogeneity in outcome definitions, and inconsistency between the units of randomisation and analysis. Three interventions reported on the change in ulcer size (arginine butyrate, RGD peptide, L-cartinine). Of these, only arginine butyrate showed a reduction of ulcer size compared with a control group, mean reduction -5.10 cm² (95% CI -9.65 to -0.55), but we are uncertain whether this reduces ulcer size compared to standard care alone as the certainty of the evidence has been assessed as very low. Three trials reported on complete leg ulcer closure (isoxsuprine, arginine butyrate, RGD peptide matrix; very low quality of evidence). None reported a clinical benefit. No trial reported on: the time to complete ulcer healing; ulcer-free survival following treatment for sickle cell leg ulcers; quality of life measures; incidence of amputation or harms.

AUTHORS' CONCLUSIONS

Given the very low quality of the evidence identified in this updated Cochrane Review we are uncertain whether any of the assessed pharmaceutical interventions reduce ulcer size or result in leg ulcer closure in treated participants compared to controls. However, this intervention was assessed as having a high risk of bias due to inadequacies in the single trial report. Other included studies were also assessed as having an unclear or high risk of bias. The harm profile of the all interventions remains inconclusive.

Leg ulcers in sickle cell disease patients

Leg ulcers are the most common cutaneous complication of sickle cell disease. These lesions occur mainly in homozygous forms, are slow to heal and often relapse, causing negative physical, emotional, and economic impacts. In this paper, we discuss the clinical presentation, diagnosis, and pathophysiology of sickle cell leg ulcers and their implications for treatment.

Meanings of living with a chronic wound: a meta-synthesis study

Objective: explore qualitative research on the meanings of living with a chronic wound. Method: it is a qualitative meta-synthesis. 13 articles were included, totaling a sample of 248 individuals who self-reported living with a chronic wound. The Critical Appraisal Skills Program instrument was used to evaluate the eligible articles, and to report the qualitative synthesis, the recommendations of Enhancing transparency in reporting the synthesis of qualitative research were followed. The analysis and extraction of information and construction of the synthesis were carried out by two independent reviewers, with the assistance of a third expert reviewer. Results: living with a chronic wound involves initial concerns and the appearance of symptoms, especially marked pain. They report that the increase in pain led to low functional capacity, as well as weakened social relationships and financial conditions. The experiences illustrate the challenges of emotional burden and the implications of illness, which contributed to social isolation. Religiosity and spirituality were the main coping strategies. Conclusion: living with a chronic wound means a condition of pain, limits physical and functional capacity, causes negative feelings and emotions that result in people’s isolation.

Significados de viver com ferida crônica: estudo de metassíntese

Objetivo: explorar pesquisas qualitativas sobre os significados de viver com ferida crônica. Método: trata-se de uma metassíntese qualitativa. Foram incluídos 13 artigos, totalizando uma amostra de 248 indivíduos que autorreportaram viver com ferida crônica. Utilizou-se o instrumento do Critical Appraisal Skills Programme para avaliação dos artigos elegíveis, e para relatar a síntese qualitativa, seguiram-se as recomendações do Enhancing transparency in reporting the synthesis of qualitative research. A análise e extração das informações e construção da síntese foram feitas por dois revisores independentes, sob o auxílio de um terceiro revisor especialista. Resultados: viver com ferida crônica envolve preocupações iniciais e aparecimento dos sintomas, especialmente dor marcante. Relatam que o aumento da dor levou à baixa capacidade funcional, bem como relações sociais e condição financeira fragilizadas. As experiências ilustram os desafios da carga emocional e das implicações do adoecimento, que contribuíram para o isolamento social. A religiosidade e espiritualidade foram as principais estratégias de enfrentamento. Conclusão: viver com ferida crônica significa uma condição de dor, limita a capacidade física e funcional, provoca sentimentos e emoções negativas que resultam no isolamento das pessoas.

Communicating and understanding pain: Limitations of pain scales for patients with sickle cell disorder and other painful conditions

Pain communication in healthcare is challenging. We examine use of pain scales to communicate pain severity via a case study of people with sickle cell disorder (SCD). We show how pain communication involves complex social interactions between patients, healthcare professionals and significant others – none of which are included in pain ratings. Failure to account for relational aspects of pain may cause problems for any patient. For SCD, mutual distrust shapes pain communication, further complicating clinical assessments. Moreover, SCD pain is particularly severe, making ratings hard to interpret compared with ratings from non-SCD patients, potentially exacerbating problems in managing pain relief.

Whole-exome sequencing indicates FLG2 variant associated with leg ulcers in Brazilian sickle cell anemia patients

Although sickle cell anemia results from homozygosity for a single mutation at position 7 of the β-globin chain, the clinical aspects of this condition are very heterogeneous. Complications include leg ulcers, which have a negative impact on patients’ quality of life and are related to the severity of the disease. Nevertheless, the complex pathogenesis of this complication has yet to be elucidated. To identify novel genes associated with leg ulcers in sickle cell anemia, we performed whole-exome sequencing of extreme phenotypes in a sample of Brazilian sickle cell anemia patients and validated our findings in another sample. Our discovery cohort consisted of 40 unrelated sickle cell anemia patients selected based on extreme phenotypes: 20 patients without leg ulcers, aged from 40 to 61 years, and 20 with chronic leg ulcers. DNA was extracted from peripheral blood leukocytes and used for whole-exome sequencing. After the bioinformatics analysis, eight variants were selected for validation by Sanger sequencing and TaqMan® genotyping in 293 sickle cell anemia patients (153 without leg ulcers) from two different locations in Brazil. After the validation, Fisher’s exact test revealed a statistically significant difference in a stop codon variant (rs12568784 G/T) in the FLG2 gene between the GT and GG genotypes ( P = 0.035). We highlight the importance of rs12568784 in leg ulcer development as this variant of the FLG2 gene results in impairment of the skin barrier, predisposing the individual to inflammation and infection. Additionally, we suggest that the remaining seven variants and the genes in which they occur could be strong candidates for leg ulcers in sickle cell anemia.

Impact statement

To our knowledge, the present study is the first to use whole-exome sequencing based on extreme phenotypes to identify new candidate genes associated with leg ulcers in sickle cell anemia patients. There are few studies about this complication; the pathogenesis remains complex and has yet to be fully elucidated. We identified interesting associations in genes never related with this complication to our knowledge, especially the variant in the FLG2 gene. The knowledge of variants related with leg ulcer in sickle cell anemia may lead to a better comprehension of the disease’s etiology, allowing prevention and early treatment options in risk genotypes while improving quality of life for these patients.

Sickle cell disease: Hemostatic and inflammatory changes, and their interrelation

Sickle cell disease, the most common genetic blood disorder in the world, has high clinical variability, negatively impacts quality of life and contributes to early mortality. Sickled erythrocytes cause blood flow obstruction, hemolysis, and several hemostatic changes that promote coagulation. These events, in turn, induce chronic inflammation, characterized by elevated plasma levels of pro-inflammatory markers, which aggravates the already unfavorable state of the circulatory system. Empirical evidence indicates that the hemostatic and inflammatory systems continuously interact with each other and thereby further propagate the hypercoagulability and inflammatory conditions. In this review article, we discuss the pathophysiological aspects of sickle cell disease and the hemostatic and inflammatory changes that underlie its pathogenesis.

Iron Chelation with Transdermal Deferoxamine Accelerates Healing of Murine Sickle Cell Ulcers

Objective: Sickle cell ulcers (SCUs) are a devastating comorbidity affecting patients with sickle cell disease (SCD). SCUs form over the medial or lateral malleoli of the lower extremity, are slow to heal, and prone to recidivism. Some SCUs may never heal, leading to chronic pain and foot deformities. There is no specific and effective therapy for SCUs. Systemic deferoxamine (DFO) has been demonstrated to prevent some of the sequelae of SCD by chelating iron. In this study, we tested the ability of DFO delivered via a transdermal delivery system (DFO-TDDS) to accelerate healing in a murine model of SCU. Approach: Excisional wounds were created in a transgenic murine model of SCD expressing >99% human sickle hemoglobin, and healing rates were compared with wounds in wild-type mice. Next, excisional wounds in SCD mice were treated with DFO-TDDS, DFO injection, or left untreated. Wound closure rates, histology, and iron in the healed wounds were analyzed. Results: Wounds in SCD mice healed significantly slower than wild-type mice (***p < 0.001). DFO-TDDS-treated wounds demonstrated significantly accelerated time to closure, reduced size, and improved wound remodeling compared with untreated wounds (***p < 0.001) and DFO injection treatment (*p < 0.05). DFO released from the TDDS into wounds resulted in chelation of excessive dermal-free iron. Innovation: DFO-TDDS is a novel therapeutic that is effective in healing wounds in sickle cell mice. Conclusion: DFO-TDDS significantly accelerates healing of murine SCUs by chelation of excessive free iron and is currently manufactured in an FDA-compliant facility to be translated for treating human SCUs.