Maintenance of a High Influenza Vaccination Rate and Improvement in Health Outcomes in a Pediatric Sickle Cell Disease Clinic

BACKGROUND

Children with sickle cell disease (SCD) are at high-risk of complications from influenza and should receive an influenza vaccination seasonally. Despite this recommendation, vaccination rates remain suboptimal. Boston Medical Center (BMC) previously achieved high influenza vaccination rates among its pediatric patients with SCD. The purpose of this study was to determine whether this high vaccination rate has been maintained and whether it has influenced outcome measures.

PATIENTS AND METHODS

A retrospective chart review was conducted in the hematology clinic at an urban, academic medical center. Fisher's exact test and the independent samples t test were used to determine if there were any significant differences in characteristics between patients with influenza and patients without influenza, as well as between vaccinated and unvaccinated patients. Influenza vaccination rate, influenza-related hospitalization rate, and influenza-positive rate were collected and compared with reported rates.

RESULTS

Data from 124 pediatric patients with SCD were examined. The influenza vaccination rate for pediatric patients with SCD at BMC (90.32%) was higher than previous studies that were not conducted at BMC, while BMC's influenza-related hospitalization rate (0) and influenza-positive rate (4.84%) were lower than other studies. Subjects who contracted influenza were younger than those who did not (4.67 vs. 10.03 y, P=0.005).

CONCLUSIONS

BMC has maintained a high influenza vaccination rate among pediatric patients with SCD. BMC's vaccination strategy has been successful at improving outcome measures including rates of influenza and influenza hospitalizations without requiring additional staff. Such efforts should be replicated at other centers.

Two Sides of a Coin: Case Report of Unilateral Synangiosis and Contralateral Stroke Highlighting Consequences of Disease Progression and Efficacy of Revascularization in Sickle Cell Disease Associated Moyamoya Syndrome

Moyamoya syndrome increases the risk of stroke in sickle cell disease, but revascularization surgery can modify this risk. Collaborative management between hematology and neurosurgery offers effective strategies to reduce stroke risk in these patients. We describe a challenging case where a patient with sickle cell disease undergoing standard of care management as prescribed by the Stroke Prevention Trial in Sickle Cell Anemia (STOP) and revascularization with pial synangiosis subsequently developed rapidly progressive disease in other cerebral vessels and suffered ischemic hemispheric stroke. This case demonstrates the success of management in accordance with American Heart Association (AHA) and American Stroke Association (ASA) guidelines, but also demonstrates critical areas where we lack understanding of disease progression.

Engaging Caregivers and Providers of Children With Sickle Cell Anemia in Shared Decision Making for Hydroxyurea: Protocol for a Multicenter Randomized Controlled Trial

BACKGROUND

Sickle cell anemia (SCA) is a genetic blood disorder that puts children at a risk of serious medical complications, early morbidity and mortality, and high health care utilization. Until recently, hydroxyurea was the only disease-modifying treatment for this life-threatening disease and has remained the only option for children younger than 5 years. Evidence-based guidelines recommend using a shared decision-making (SDM) approach for offering hydroxyurea to children with SCA (HbSS or HbS/β0 thalassemia) aged as early as 9 months. However, the uptake remains suboptimal, likely because caregivers lack information about hydroxyurea and have concerns about its safety and potential long-term side effects. Moreover, clinicians do not routinely receive training or tools, especially those that provide medical evidence and consider caregivers' preferences and values, to facilitate a shared discussion with caregivers.

OBJECTIVE

The aim of this study is to understand how best to help parents of young children with sickle cell disease and their clinicians have a shared discussion about hydroxyurea (one that considers medical evidence and parent values and preferences).

METHODS

We designed our study to compare the effectiveness of two methods for disseminating hydroxyurea guidelines to facilitate SDM: a clinician pocket guide (ie, usual care) and a clinician hydroxyurea SDM toolkit (H-SDM toolkit). Our primary outcomes are caregiver reports of decisional uncertainty and knowledge of hydroxyurea. The study also assesses the number of children (aged 0-5 years) who were offered and prescribed hydroxyurea and the resultant health outcomes.

RESULTS

The Ethics Committee of the Cincinnati Children's Hospital Medical Center approved this study in November 2017. As of February 2021, we have enrolled 120 caregiver participants.

CONCLUSIONS

The long-term objective of this study is to improve the quality of care for children with SCA. Using multicomponent dissemination methods developed in partnership with key stakeholders and designed to address barriers to high-quality care, caregivers of patients with SCA can make informed and shared decisions about their health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03442114; https://clinicaltrials.gov/ct2/show/NCT03442114.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/27650.

Development of quality indicators for transition from pediatric to adult care in sickle cell disease: A modified Delphi survey of adult providers

BACKGROUND

Transition from pediatric to adult care is a vulnerable time for young adults with sickle cell disease (SCD); however, improvements in transition are limited by a lack of quality indicators. The purpose of this study was to establish quality indicators for transition in SCD and to determine the optimal timing between the final pediatric visit and the first adult provider visit.

PROCEDURE

We conducted a modified Delphi survey to reach a consensus on which quality indicators are most important for a successful transition. Our expert panel consisted of members of the Sickle Cell Adult Provider Network. In the first round, the participants ranked a list of quality indicators by importance. In the second round, the participants chose their "top 5" quality indicators in terms of importance and also ranked them on feasibility.

RESULTS

The response rates for the two rounds were 68 and 96%, respectively. Nine quality indicators were chosen as "top 5" by a majority of respondents, including communication between pediatric and adult providers, timing of first adult visit, patient self-efficacy, quality of life, and trust with their adult provider. Based on the comments from round 1, respondents were also asked for the optimal timing between leaving pediatric care and entering adult care. Most recommended a first adult visit within 2 months of the final pediatric visit.

CONCLUSIONS

By using these quality indicators chosen by the majority of respondents, we can better develop and evaluate transition programs for young adults with SCD and improve health outcomes for these vulnerable patients.

Young Adult Perspectives on a Successful Transition from Pediatric to Adult Care in Sickle Cell Disease

Objective

This qualitative study sought to learn from young adults with sickle cell disease (SCD) about their experience leaving pediatric care and perspective on what makes a successful transition.

Methods

Fifteen young adults with SCD who had left pediatric care within the previous five years participated in focus groups led by a trained moderator. Transcripts were analyzed using grounded theory.

Results

Four main themes emerged from the analysis: facilitators of transition (meeting the adult provider prior to transfer, knowing what to expect, gradually taking over disease self-management and starting the process early), barriers to transition (negative perceived attitude of adult staff, lack of SCD specific knowledge by both patients and staff, and competing priorities interfering with transition preparation), what young adults wished for in a transition program (opportunities to meet more staff prior to transfer, more information about the differences between pediatric and adult care, learning from a peer who has been through the process, more SCD teaching, and flexibility in transition preparation) and how they define a successful transition (gradually assuming responsibility for self-management of their SCD).

Conclusion

Our findings present unique opportunities to learn from young adults with SCD about ways to improve current transition programs.

Improvement in influenza vaccination rates in a pediatric sickle cell disease clinic

BACKGROUND

Children with sickle cell disease (SCD) are at increased risk of complications from influenza. However, despite widespread recommendations that these patients receive an annual influenza immunization, reported vaccination rates remain very low at under 50%.

PROCEDURE

Our aim was to increase the influenza vaccination rate among our pediatric patients with SCD aged 6 months to 21 years over two influenza seasons, 2012-2013 and 2013-2014, to 80%, consistent with the Health People 2020 goal. We used multiple quality improvement methods, based on the literature and our previous experience in other aspects of SCD care, including parent and provider education, enhancement of our EHR, use of a SCD patient registry and reminder and recall done by a patient navigator.

RESULTS

We vaccinated 80% of our pediatric patients with SCD for influenza during the 2012-2013 season and 90% of patients in 2013-2014. Our early season vaccination rates were nearly double that of those for the general population.

CONCLUSIONS

Use of quality improvement methods can increase rates of influenza vaccination for this high-risk population, suggesting that less health care utilization and lower cost might result.

Reduction in the anti-adherence activity of Tamm-Horsfall protein with increasing concentration of calcium

Tamm-Horsfall glycoprotein (THP), at concentrations occurring in normal urine, was demonstrated to show anti-adherence activity for type-1 fimbriated Escherichia coli. Urine also showed anti-adherence activity, and urine from which the THP was precipitated showed a significant drop in activity. The addition of calcium to the incubation medium with THP, at concentrations normally found in the urine, had no effect on the anti-adherence activity of THP. However, concentrations of calcium higher than those normally occurring in the urine significantly decreased the anti-adherence activity of THP. It is suggested that individuals with above normal concentrations of calcium in the urine may be at increased risk for urinary tract infections since the protective effect of THP is compromised.

Increased risk of urinary tract infection associated with the use of calcium supplements

Since ions are known to influence the interaction between cells, we undertook an examination of the effect of various ions on bacterial adherence to uroepithelial cells. While most of the ions examined had no effect or decreased bacterial adherence, calcium ions significantly increased bacterial adherence. It was demonstrated, in vitro that as the concentration of calcium was increased to levels higher than normally found in the urine, there was a significant increase in bacterial adherence. It was also found that if the diet was supplemented with calcium there was an increase in the excretion of calcium in the urine and a corresponding increase in bacterial adherence when bacteria and uroepithelial cells were incubated in this urine. It is suggested that an excretion of excess calcium in the urine may lead to an increased bacterial adherence in vivo and an increased potential for urinary tract infections.

Inhibition of bacterial adherence by cranberry juice: potential use for the treatment of urinary tract infections

Cranberry juice has been widely used for the treatment and prevention of urinary tract infections and is reputed to give symptomatic relief from these infections. Attempts to account for the potential benefit derived from the juice have focused on urine acidification and bacteriostasis. In this investigation it is demonstrated that cranberry juice is a potent inhibitor of bacterial adherence. A total of 77 clinical isolates of Escherichia coli were tested. Cranberry juice inhibited adherence by 75 per cent or more in over 60 per cent of the clinical isolates. Cranberry cocktail was also given to mice in the place of their normal water supply for a period of 14 days. Urine collected from these mice inhibited adherence of E. coli to uroepithelial cells by approximately 80 per cent. Antiadherence activity could also be detected in human urine. Fifteen of 22 subjects showed significant antiadherence activity in the urine 1 to 3 hours after drinking 15 ounces of cranberry cocktail. It is concluded that the reported benefits derived from the use of cranberry juice may be related to its ability to inhibit bacterial adherence.

A Method for Eliminating the Contribution of Agrobacterium tumefaciens to Studies of Nucleic Acid Biosynthesis in Crown Gall Tumors

A procedure is described that permits the use of radiotracer methods for examining crown gall tumors in the presence of the initiating agent Agrobacterium tumefaciens. On the basis of sensitivity testing using the disc diffusion technique and the minimum inhibitory concentration procedure and incorporation of radioactive phosphorus into nucleic acids, it was determined that A. tumefaciens was most sensitive to tetracycline, oxytetracycline, and methacycline. It was further demonstrated that nucleic acid synthesis in tumor tissue from four representative plants including tomato (Lycopersicum esculentum L.), Bryophyllum daigremontiana (Hamet and Perrier), pinto beans (Phaseolus vulgaris L.), and carrot (Daucus carota L.) was unaffected by a concentration of tetracycline (50 mug/ml) which completely inhibited nucleic acid synthesis in the bacterium. On this basis a procedure is described which first eliminates surface contamination and then uses tetracycline to nullify the contribution of A. tumefaciens in radioactive studies using tumors initiated by this bacterium.

Ribonucleic Acid Synthesis Associated with a Developmental Change in the Gametophyte of Pteridium aquilinum

When bacteria are subjected to step-down conditions, there is an enhanced production of a messenger-type of RNA for a short time after the shift. A cultural shift, which appears to be similar to step-down, is described for gametophytes of Pteridium aquilinum. When the cultures are grown in white light, a population of rapidly dividing cells is produced, whereas in red light cell elongation predominates. If the cultures growing in white light are shifted to red light, a transition occurs which involves a rapid decrease in growth and nucleic acid synthesis. In particular, there is a marked decline in RNA synthesis for a short time following the shift and prior to the initiation of the new mode of growth. It appears that this observed change in RNA synthesis is related to the initiation of the new mode of growth.

A detailed evaluation of the possible contribution of bacteria to radioactive precursor incorporation into nucleic acids of plant tissues

An investigation of the possible contribution of bacteria to the labeling patterns of soybean seedling nucleic acid was made. The results using sucrose gradient, MAK column, and acrylamide gel electrophoretic fractionation together with base composition analyses of nucleic acid preparations show that contaminating bacteria do not contribute to the incorporation of (32)P-orthophosphate into the RNA of excised hypocotyl or soybean root tip. Sterile, non-sterile, and CM-treated soybean hypocotyl synthesize D-RNA to the same extent. The contaminating bacteria do not synthesize an AMP-rich RNA. The G-C rich (32)P-DNA component of the soybean tissues used in these studied results, at least primarily, from the incorporation by contaminating bacteria. CM can be used successfully to eliminate the contribution of bacteria to the labeling of nucleic acids by etiolated plant tissues. Bacterial counts, although valuable, are not sufficient to determine if contaminating bacteria will significantly contribute to nucleic acid labeling in plants.