Clinical Biomarkers of Acute Vaso-Occlusive Sickle Cell Crisis

It is known that an inherited blood condition called sickle cell disease (SCD) is a result of one gene. A number of blood and urine biomarkers have been determined in association with lab and clinical history for SCD patients. SCD has numerous interacting pathways associated with it, which have been identified by biomarkers. These mechanisms consist of some examples, such as endothelial vasodilation response, hypercoagulability, hemolysis, inflammation, oxidative stress, vascular dysfunction, and reperfusion injury among others. To effectively manage SCD, a comprehensive panel of validated blood and urine biomarkers must be established. Despite its monogenic inheritance, the complex nature of the SCD phenotype has impeded progress in its treatment. However, significant strides have been made in clinical biotechnology, paving the way for potential breakthroughs. In SCD, a panel of verified blood and urine biomarkers must be established, however. Despite monogenic inheritance, the great complexity of the SCD phenotype has hindered progress in its management. With few exceptions, clinical biomarkers of illness severity have been found through epidemiological investigations; nevertheless, systematic integration of these biomarkers into clinical treatment algorithms has not occurred. Furthermore, sickle cell crisis, the primary acute consequence of SCD, has been difficult to diagnose with the biomarkers now in use. Inadequate care and a lack of appropriate outcome measures for clinical research are the consequences of these diagnostic constraints. A new chapter in SCD customized treatment has begun with recent advancements in molecular and imaging diagnostics. Strategies in precision medicine are especially relevant now that molecular therapies are within reach. The significance of biochemical indicators linked to clinical manifestation and sub-phenotype identification in SCD is reviewed in this research.

Intravenous Hydration and Associated Outcomes in Patients With Sickle Cell Disease Admitted With Vaso-Occlusive Crises: A Systematic Review

Acute painful vaso-occlusive crisis (VOC) is the common presentation of sickle cell disease (SCD) leading to emergency room visits, admissions, morbidity, mortality, and negative impacts on quality of life. Among various treatment approaches commonly employed to manage the condition, intravenous (IV) hydration is also frequently used in emergency and inpatient settings. Although helpful to overcome dehydration, IV hydration often leads to adverse outcomes like fluid overload, pulmonary edema, increased length of stay, transfer to intensive care unit, new oxygen requirement, etc. Small-scale retrospective studies are conducted to study the outcomes of IV hydration but have failed to conclusively demonstrate its benefits as well as choice of IV fluids, rate of IV fluid replacement, etc. We conduct this review as an attempt to summarize the available evidence on the role and utility of IV hydration in sickle cell crises along with reported adverse outcomes.

A case report and review of literature on the role of automated red cell exchange in managing sickle cell crisis in India

Red cell exchanges (RCE) help in the treatment of complications of sickle cell anemia (SCA) by reducing the viscosity of blood and improving the oxygen-carrying capacity. We present a case of sickle cell crisis (SCC) managed with automated RCE and also reviewed the literature to assess the utilization and clinical efficiency of this therapy in India. A 19-year-old gentleman diagnosed with SCA presented with acute chest syndrome. Hemoglobin (Hb) was 8.8 g%, hematocrit (HCT) was 24%, and HbS was 90%. As there was worsening of symptoms with conventional management, the patient underwent two procedures of automated RCE. The clinical condition of the patient was improved, HbS was reduced to 16% and HCT was remained at 21% postprocedure. Articles on automated RCE in SCA conducted in India were reviewed and four articles were analyzed based on the search strategy. All the included articles concluded automated RCE as an effective procedure for complications of SCA. Common indication in India was SCA patients undergoing surgery as a prophylactic measure. Automated RCEs are promising as an acute treatment for indicated sickle cell complications. This therapy is underutilized in the Indian scenario, especially in patients with SCC.

A Comprehensive Review of Pregnancy in Sickle Cell Disease

Sickle cell hemoglobinopathies encompass a range of qualitative and quantitative hemoglobin disorders that are inherited genetically. This group of disorders includes sickle cell beta thalassemia, sickle cell trait, and sickle cell disease (SCD). Globally, SCD is the most common disorder. Even epidemiological data suggests the majority of diseases, as well as traits, are concentrated in Sub-Saharan Africa, North-East Africa, the Middle East, and India. The physiological changes in pregnancy predispose to an increased risk of catastrophic events like a vaso-occlusive crisis, thromboembolic events, and their related sequelae, leading eventually to villous infarction, necrosis, and fibrosis leading to compromising uteroplacental circulation. Conversely, the mother may exhibit exacerbated symptoms of gestational hypertension, placental abruption, preterm labor, and venous thromboembolism. Although this disease is manageable, it has the potential to adversely impact maternal and child health on a national level. The chances of severe complications in the pregnant state affecting both mother and fetus attract due attention of health services towards redefining and researching this disease and its management frequently. The literature review on the following situation advocates the general treatment to be observed under the headings of preconceptual care, strengthened antenatal care, strict intranatal care, and compliant post-natal care. Preconceptually, genetic screening of couples, with education on the adverse effects of the disease, comes as the first line of management. Newer facilities like preimplantation genetic diagnosis and celocentesis may even allow for early diagnosis as well as help patients who do not wish to terminate the pregnancy by selective transfer of unaffected embryos. This may be combined with an extensive evaluation of the psychosocial aspect and socioeconomic status of couples who administer vaccines as prophylaxis for preventable diseases. Strengthening antenatal care is associated with routine blood investigations for every registered antenatal patient with adequate awareness about the conditions that precipitate the crisis. All patients should be prophylactically treated with appropriate doses of aspirin, iron, folic acid, and multivitamins. Radiological examinations by ultrasonography may be used to monitor placenta previa, abruption, or preterm labor. Later in pregnancy, it should be recommended to perform biophysical profiling and assessment of umbilical artery flow. Intranatal care deals with strict-term institutional delivery of all sickle cell-diseased mothers with a preference for vaginal delivery. Post-natal care requires a precise assessment of blood loss during labor to initiate transfusion therapy as soon as needed. Exclusive breastfeeding, with the importance of early initiation of it, must be emphasized. Screening of neonates as quickly as possible must be done for hemoglobinopathies. Through this review, authors are trying to make aware of the complications that can be faced during pregnancy in SCD patients, its prevention, and its treatment according to various new guidelines and research available.

Newly diagnosed PRES in a sickle cell diseased patient: a case report

Sickle cell disease has many clinical impacts, one such rare finding is systemic hypertension although the literature to support it is debatable. Hypertension along with other key components of sickle cell pathology is one of the reversible causes of posterior reversible encephalopathy syndrome (PRES). Although its triggering factors and pathophysiology is not well documented, hypertension is one of the easily reversible causes of PRES. A well-controlled blood pressure is an aim for reversibility and future recurrence of PRES. However, the addition of other medications like anticonvulsants (levetiracetam and lacosamide) to prevent seizures as a consequence of PRES still remains debatable. Considering the case reported below, the addition of Hydroxyurea to the treatment can be another cause of the recurrence of PRES and needs to be weighed for its risks and benefits.

Emerging Therapies for the Management of Pain and Vaso-Occlusive Crises in Patients With Sickle Cell Disease: A Systematic Review of Randomized Controlled Trials

Sickle cell disease (SCD) is an inherited disorder that impairs red blood cells (RBCs) and disrupts the delivery of oxygen to tissues. There is currently no cure. Symptoms can appear as early as six months of age and include anemia, acute episodes of pain, swelling, infections, delayed growth, and vision problems. A growing number of therapies are being investigated for reducing these episodes of pain, also known as vaso-occlusive crises (VOCs). The research literature evidence, however, currently includes far more approaches that have not shown superiority versus placebo than ones that have been proven effective. The purpose of this systematic review is to evaluate the body of randomized controlled trials (RCTs) to determine the quality of support for and against the use of a variety of current and emerging therapies for treading SCD VOCs. Several important new papers have emerged since previous systematic reviews with similar objectives were published. This review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and focused on PubMed exclusively. Only RCTs were sought, and no other filters, except for a five-year historical timeline cut-off, were used. Of the 46 publications that were returned in response to the query, 18 were ultimately accepted as meeting the pre-established inclusion criteria. The Cochrane risk-of-bias tool was utilized as a quality assessment measure, and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework was used to assess the certainty of the evidence. Among the included publications, five out of 18 featured positive results with superiority and statistical significance versus placebo for either reduction in pain score or number/duration of VOCs. The approaches featured therapies ranging from de novo molecules to currently available drugs approved for other indications to naturally occurring metabolites such as amino acids and vitamins. A single therapy, arginine, was supported for both clinical endpoints: pain score reduction and shortened VOC duration. Currently, two therapies are approved by the United States Food and Drug Administration (FDA) and are commercially available (crizanlizumab, ADAKVEO and L-glutamine, Endari). All other therapies are investigational only in nature. Several studies included measurement of biomarker endpoints as well as clinical outcomes. Generally, beneficial outcomes related to improving biomarker levels did not also translate into statistically significant reduction of pain scores or number/duration of VOCs. While measuring biomarkers may contribute to the understanding of pathophysiology, it does not appear to directly offer predictive value toward treatment success clinically. It can be concluded that there exists a specific opportunity to design, fund, and execute investigations that both compare emerging and existing therapies versus one another and compare combinational therapies versus placebo.

Feasibility and Acceptability of Online Recruitment and an Online Brief Mindfulness Intervention Among Patients With Sickle Cell Disease

Background Pain among young adult patients with sickle cell disease (PWSCD) is a highly significant public health problem associated with reduced quality of life. Due to issues uniquely affecting PWSCD, including distrust of research, challenging life situations, debilitating pain, stigma, and logistical challenges (e.g., child or elder care and transportation), SCD researchers often find it challenging to meet sample size and enrollment targets. To our knowledge, all known SCD studies have solely recruited participants in person (e.g., clinics and local organizations) and utilized lengthy interventions with suboptimal recruitment and retention results. Newer recruitment methods, such as online recruitment, need to be explored for research among PWSCD. In this pilot project, we sought to address these challenges by investigating: 1) a novel method of using online outreach to recruit/enroll young PWSCD and 2) a novel, brief online mindfulness intervention adapted from Mindfulness-Oriented Recovery Enhancement (MORE): Mini-MORE designed to treat pain among PWSCD.  Methods Participants (N = 32) were recruited online (e.g., paid advertisements on Facebook and NextDoor; free advertisements on Facebook groups and Reddit) and screened by phone from October 25 to November 8, 2022. Participants watched an online Mini-MORE video. Immediately before and after watching the video, participants rated their pain intensity and unpleasantness on an 11-point numeric rating scale (NRS). Afterward, participants were emailed an individualized link to additional audio recordings for ongoing practice. Immediately before and after accessing the additional recordings, participants rated their pain intensity, anxiety, and depression on an 11-point NRS. T-tests were used to examine the impact of Mini MORE on outcomes at two-time points. Results A total of 84 participants completed the self-screening. The majority of self-screeners resulted from free posts in Facebook groups (77%), Reddit (1%), and Craigslist (6%). Thirty-two (32) eligible participants agreed to join a Zoom meeting to watch the video. The entire Mini-MORE video was viewed by 31 of 32 participants (97%). Pain intensity decreased by 1.7 points (p<0.001, Cohen's d=2.19), and pain unpleasantness decreased by 2.1 points (p<0.001, Cohen's d=2.20). Listening to the supplemental recordings was associated with significant, immediate decreases in pain intensity by 1.3 points (p=0.015, Cohen's d=2.05), anxiety by 1.8 points (p=0.022, Cohen's d=3.10), and depression by 1.74 points (p=0.019, Cohen's d=2.94). Conclusions Results suggest that online methods are feasible in recruiting and enrolling young PWSCD, and the online Mini-MORE intervention is acceptable among PWSCD. Future research is needed to assess whether Mini-MORE is associated with decreased pain symptomology in young PWSCD.

Compound Heterogeneous Sickle Cell-B+ Thalassemia Incidentally Discovered Through Cytological Examination of a Fine-Needle Aspiration Specimen from an Aneurysmal Bone Cyst in a Young Child: A Case Report

Sickle cell beta-thalassemia (S/β) is a rare inherited variant of sickling disorders, usually occurring due to the inheritance of two abnormal genes, namely, the sickle cell gene, and the beta-thalassemia gene. There are two types of sickle cell β-thalassemia: (S/β+) and (S/β0), based on a decrease or complete absence of beta-globin synthesis, respectively. Skeletal complications, such as osteonecrosis, osteomyelitis, and septic arthritis, are well-known sequelae in sickle cell patients due to vaso-occlusive events. Nevertheless, the occurrence of aneurysmal bone cysts in patients with sickle cell hemoglobinopathy is an exceptional phenomenon. Herein, we report a case of a young boy who presented with nonspecific clinical symptoms over a few years. The patient was referred to our institution as a case of short stature with recurrent joint pain. A clinical workup was done and an aneurysmal bone cyst (ABC) of the left humerus was discovered radiologically with incidental detection of sickle cells through cytological evaluation of the cyst fluid. Further clinical investigation, including molecular and additional laboratory tests, confirmed the diagnosis of compound heterogeneous sickle cell-B+ thalassemia. Unfortunately, neither was the underlying pathology detected nor was the precise clinical diagnosis attained at the outside primary healthcare facility.

Probing Beyond the Pain Scale: A Rare Case of Cutibacterium Acnes Septic Arthritis

Patients with sickle cell disease frequently present to the hospital for pain control secondary to vaso-occlusive crises (VOCs). Diagnostic challenges exist for healthcare providers in distinguishing joint pain secondary to a VOC from an intraarticular infection at initial presentation due to the lack of established clinical markers exclusive to one or the other. We present a 35-year-old female with sickle cell disease and avascular necrosis of bilateral hips and the right shoulder with several previous admissions for VOC pain control complaining of a "different" kind of pain in her shoulder. Treated initially for pain control, our patient was found to be suffering from culture-positive septic arthritis of the shoulder with Cutibacterium acnes, a rare source of de novo intraarticular infection. This case highlights the importance of incorporating patients' subjective descriptions of illness into differential diagnosis considerations, notably for those caring for patients with sickle cell disease. This case also establishes C. acnes as a rare organism responsible for de novo septic arthritis in the setting of sickle cell disease.

Individuals with Sickle Cell Disease Using SBAR as a Communication Tool: A Pilot Study

BACKGROUND

Sickle cell disease (SCD) is a hemoglobinopathy that causes debilitating pain. Patients often report dissatisfaction during care seeking for pain or a sickle cell crisis (SCC). The Theory of Self-Care Management for SCD conceptualizes assertive communication as a self-care management resource that improves healthcare outcomes.

OBJECTIVES

This pilot study aimed to determine whether adults with SCD could learn to use the Situation, Background, Assessment, Recommendation (SBAR) communication method using a web-based trainer, and it aimed to determine their perceptions of the training.

METHODS

The participants included n = 18 adults with SCD. Inter-rater reliability (IRR) among three reviewers was used to evaluate the participants' ability to respond as expected to prompts using SBAR communication within the web-based platform. Content analysis was used to describe the participants' perspectives of the acceptability of using the SBAR patient-HCP communication simulation.

RESULTS

The SBAR IRR ranged from 64 to 94%, with 72% to 94% of the responses being evaluated as the using of the SBAR component as expected. The predominant themes identified were (1) Patient-Provider Communication and Interaction; (2) Patients want to be Heard and Believed; (3) Accuracy of the ED Experience and Incorporating the Uniqueness of each Patient; and (4) the Overall Usefulness of the Video Trainer emerging.

CONCLUSIONS

This pilot study supported the usefulness and acceptability of a web-based intervention in training adults with SCD to use SBAR to enhance patient-HCP communication. Enhancing communication may mitigate the barriers that individuals with SCD encounter during care seeking and improve the outcomes. Additional studies with larger samples need to be conducted.

Myocardial Performance Index Among Patients of Sickle Cell Disorder in Rural Teaching Hospital: A Case-Control Study

OBJECTIVE

To evaluate the myocardial performance index (MPI) in sickle cell disease (SCD) patients, and to compare MPI in healthy individuals.

METHODS

In this case-controlled study, patients of SCD and age- and sex-matched controls were included. MPI was determined using echocardiographic Doppler-derived parameters. MPI according to disease type, sickle cell crisis, and in the presence of co-morbidities was compared.  Results: Between October 2018 and September 2020, we enrolled 100 SCD patients and 100 age and sex-matched controls. The MPI was significantly higher in SCD than in the control group (0.411±0.028 vs. 0.387±0.015, respectively; p<0.0001). There was no difference in MPI according to disease type as SS or AS (p=0.903). In patients with sickle cell crisis, mean MPI was significantly higher than those without sickle cell crisis (0.443±0.003 vs. 0.403±0.025, respectively; p<0.0001). In patients with comorbidities, mean MPI was significantly higher than those without any comorbidity (0.432±0.021 vs. 0.404±0.026, respectively; p<0.0001).

CONCLUSION

MPI can be a non-invasive tool for assessing subclinical cardiac dysfunction and should be considered for evaluating patients with SCD.

Acute Chest Syndrome, Avascular Necrosis of Femur, and Pulmonary Embolism All at Once: An Unexpected Encounter in the First-Ever Admission of a Sickle Cell Patient

Acute chest syndrome (ACS) is defined as the radiological appearance of pulmonary infiltrates with fever or respiratory symptoms like chest pain, breathlessness, and cough in a patient with sickle cell disease (SCD). It is also a very common cause of mortality in sickle cell patients, if not identified in early stages and treated aggressively. Radiological image is similar to bacterial pneumonia, so sickle cell disease with a radiological picture similar to pneumonia and associated respiratory symptoms is known as acute chest syndrome. Pneumonia and infarction have been implicated in pathogenesis. The reason for the appearance of acute chest syndrome in patients with SCD is not established but some triggers like sepsis, presence of vaso-occlusive crises have been noted. When there is a block in the blood supply to the bone, patients with sickle cell disease may also develop avascular necrosis of the neck of the femur causing narrowing of joint and collapse of the bone. Patients with sickle cell disease have a baseline hypercoagulable state thereby predisposing the patient to develop deep vein thrombosis and pulmonary embolism. Here, we present a case of a 25-year-old SCD patient with a fairly stable course of the disease. He had no history of prior admissions and he had his first-ever episode of sickle cell crisis lading in with acute chest syndrome, avascular necrosis of femur, and pulmonary embolism all at once. After an extensive review of the literature, we found this to be the first case report in the world where all these three complications of sickle cell disease developed simultaneously in a patient.

Utilization of Patient-Controlled Analgesia Reduces Length of Stay of Sickle Cell Crisis Hospitalizations

Background

Sickle cell crisis hospitalizations are emotionally and financially burdensome to patients and healthcare systems, and processes to decrease the frequency or length of stay of these crises should be examined.

Methods

This is a multicenter retrospective hospital record review of sickle cell crisis hospitalizations as defined by ICD-10 codes (D57.1-4), from January 2016 through December 2019, examining inpatient medication administration records and length of stay among admitted adults aged 18-65 years. Patient controlled analgesia orders using morphine, hydromorphone, fentanyl and/or merperidine at any point of an admission (n=188) were compared to admissions without any patient-controlled analgesia orders (n=2,159). The primary end point was hospital length of stay in days. A secondary analysis examining patients with or without greater than four admissions was also conducted.

Results

The 1,675 patients who met criteria comprised 2,347 sickle cell hospitalizations during the four years examined. Of those admissions, 188 had at least one patient-controlled analgesic documented in their chart and had an average length of stay of 4.54 days (SD 3.34). The 2,159 admissions without any patient-controlled analgesia had an average length of stay of 5.74 days (SD 4.64). The difference of 1.2 days between the groups was statistically significant (p≤0.0001) using a Wilcoxon signed-rank test.

Conclusion

Among patients with sickle cell crises who required inpatient hospitalizations, the use of patient-controlled analgesia demonstrated a statistically significant reduction of 1.2 days in their total length of stay. These findings support potentially changing hospital protocols to increase patient-controlled analgesia utilization.

A Comparison of Two Regimens for Managing Sickle Cell Pain and Reducing Readmissions

This was a multicenter retrospective analysis comparing intravenous push (IVP) analgesia versus patient-controlled analgesia (PCA) in patients admitted for sickle cell pain crisis. The primary objective was to compare the analgesic management, measured in total daily morphine milligram equivalents (MME). Secondary objectives included length of hospitalization, 30-day hospital readmissions and pain scores. Of the 98 patients identified between August 2017 and August 2018, 68 patients were included in this study. There were 51% (n = 35) in the IVP group and 49% (n = 33) in the PCA group. The majority of patients were on 90 or more daily MME prior to admission. The average total daily MME was significantly higher in patients on PCA compared to IVP on the first three days of hospitalization (289 vs 146, p < 0.01). Length of hospitalization was not different between patients on IVP and PCA (7.14 vs. 6.39 days, p = 0.53). There was no difference in 30-day readmissions, average pain scores on days 1-3 of hospitalization and adverse side effects between the groups. This study showed patients on IVP had significantly lower total daily MME requirements compared to PCA within the first three calendar days of admission.

Acute Liver Failure in Sickle Cell Disease: A Perfect Storm

Sickle cell hepatopathy is a well-described but uncommonly seen complication of sickle cell disease and is usually caused by multiple overlapping processes. A more acute liver complication is hepatic sequestration which is important to recognize in order to initiate life-saving treatment. A 33-year-old woman with sickle cell disease complicated by painful crises, splenic infarction and significant alcohol abuse presented with gastrointestinal distress, pain crisis, acute-on-chronic anemia, and hyperbilirubinemia in the setting of greater than baseline alcohol consumption. She was found to have hepatomegaly, encephalopathy, severe jaundice, and severe hyperbilirubinemia. She was treated with red cell exchange and supportive care which resulted in an improvement in her symptoms as well as hyperbilirubinemia. She was discharged with plans for monthly red cell exchange, iron chelation therapy, and close monitoring of liver disease was planned upon discharge. This case illustrates that chronic liver disease can occur in sickle cell disease (Hgb SS) especially in the setting of acquired iron overload. More acutely, sequestration is a serious and life-threatening complication of sickle cell disease that can culminate in acute liver failure. Primary treatment for hepatic sequestration is red cell exchange along with management of contributing comorbidities, and symptomatic management of encephalopathy. In end-stage liver disease, transplantation may be considered in the context of the patient’s clinical status.

Acute Liver Failure From Sickle Cell Hepatopathy Treated With Exchange Transfusion

Sickle cell disease (SCD) is a qualitative hemoglobinopathy that can cause widespread sickling and vaso-occlusive events in all organ systems. Sickle cell hepatopathy is an umbrella term for various acute and chronic pathologies of the liver as a result of sickling in SCD patients. We present below the case of a 49-year-old woman who had an acute liver failure in the setting of a hepatic crisis with recovery after exchange transfusion. Hepatic involvement in SCD may be life-threatening. Understanding the etiology and severity of hepatic involvement by sickling is necessary for appropriate treatment.

Role of Emergency Automated Red Cell Exchange in Sickle Cell Crisis: A Case Report

For many years main stay of treatment for sickle cell anaemia was transfusion therapy. But repeated transfusions put the patient at risk of iron overload. Automated red cell exchange is an evolving and newer technique which rapidly removes the sickle cells and has benefit in decreasing sickle cell load and related complications. Red cell exchange is a therapeutic procedure in which the patient’s whole blood is processed centrifugally in cell separator. Patient’s red cells are separated from other blood components and removed and replaced with donor red cells and colloids. We report our first experience of automated red cell exchange in 24-year-old female diagnosed case of sickle cell anaemia presented to us with acute chest syndrome with septic shock. Red cell exchange was planned to tide over the acute sickle cell crisis and provide symptomatic improvement. We also highlight that compound heterozygous thalassaemia could be associated with sickle cell disease which could make the diagnosis difficult. New generation automated Apheresis equipment’s provides better monitoring of the procedure that can be useful in severely ill patients also.

Transient Second-Degree Atrioventricular Block: A Rare Finding in Sickle Cell Crisis

Sickle cell disease (SCD) affects approximately 100,000 Americans, and it occurs in one out of every 365 African American births. Cardiac complications are a common feature of SCD and are an essential cause of the morbidity and mortality associated with SCD. However, there is insufficient literature on SCD and atrioventricular (AV) blocks. We present a case of a young African American male with transient second-degree Mobitz type 1 block during an acute episode of sickle cell crisis. 

Brodie's Abscess Masquerading as Vaso-occlusive Crisis in a Sickle-cell Disease Patient

Brodie’s abscess is a rare form of subacute osteomyelitis, most commonly found in children between the ages of two to fifteen years. It has slight preponderance for males. It is characterised by centrally placed, well-circumscribed abscess within the medulla or metaphysis of long bone, most commonly tibia, surrounded by a sclerotic wall. It is sometimes considered a transitional phase for the development of chronic osteomyelitis due to infection persisting between two to six months without showing any systemic symptoms specific to osteomyelitis. It is assumed that it is clinically quiescent due to its intraosseous location. It rarely presents with overt symptoms, which occurs if either the abscess enlarges to create pressure against the periosteum, or if the purulent material extrudes from the confines from its sclerotic walls. Due to subliminal clinical features and indolent clinical course, radiologic investigations are the diagnostic modality of choice. Diagnosis requires a high degree of suspicion, especially in the scenario of sepsis with an unknown source of infection. We describe a case of Brodie's abscess in a sickle-cell disease patient which presented as episodes of vaso-occlusive crisis repeatedly before it was diagnosed along with a review of the literature. 

Cardiovascular changes in children with sickle cell crisis

BACKGROUND

Sickle cell anaemia is characterised by frequent, sometimes serious events referred to as "crisis". Cardiopulmonary consequences such as pulmonary hypertension and myocardial ischaemia may accompany a serious crisis.

OBJECTIVE

To determine the cardiovascular changes that occur during a severe sickle cell crisis.

METHODS

A cross-sectional comparative study of sickle cell anaemia in children (5-17 years) admitted during a severe crisis (cases) and those in steady state (controls) was conducted over a 2-year period. Effects of the crisis on the cardiopulmonary system were assessed. The diagnosis of myocardial ischaemia was made using electrocardiography and serological cardiac biomarkers, while cardiac dysfunction and the presence of pulmonary hypertension were determined using echocardiography. The presence of systemic hypertension and tachycardia was also evaluated.

RESULTS

A total of 176 patients were recruited, 92 in steady state (male:female ratio, 1.2:1) and 84 in severe crisis (male:female ratio, 1.3:1). The mean age was 10.4 ± 3.2 years for steady state and 10.5 ± 3.4 years for those in crisis. The mean heart rate in crisis was higher than in steady state (p < 0.0001). The blood pressures (systolic, p < 0.0001, diastolic, p < 0.0001, mean, p < 0.0001) as well as myocardial ischaemia scores (p < 0.0001) were higher in patients with crisis than in those in steady state. Similarly, conduction abnormalities, pulmonary hypertension, and ventricular dysfunction were more prevalent in the crisis than in the steady state.

CONCLUSION

The present data suggest that sickle cell crisis results in a derangement of clinical, electrocardiographical, and echocardiographical parameters in children with sickle cell anaemia. Further research on these cardiovascular events may improve the overall care of these patients.

Serum 25-Hydroxyvitamin D and Diet Mediates Vaso-Occlusive Related Hospitalizations in Sickle-Cell Disease Patients

Sickle cell disease (SCD) is a genetic disorder resulting from the presence of mutated hemoglobin S (HbS). Homozygous carriers will present with early manifestations of painful vaso-occlusive crises. SCD patients have been reported to be severely deficient in vitamin D (<20 ng/mL). Four years (2010–2014) of individual de-identified Sickle Cell Clinic of Southern Louisiana (SCCSL-SCD) patient records were analyzed for vitamin D status and the level of crisis-related ER/hospital utilization. To determine the dietary, and behavioral mediators of SCD-crisis in our study population, a cohort of 102 SCCSL-SCD patients were administered a survey that evaluated sun exposure, dietary behaviors, and pain frequency and severity. Patients with circulating levels of 25(OH)D₃ less than 14.1 ng/mL reported having more crisis-related hospital visits per year (10) than patients with 25(OH)D₃ serum levels >34 ng/mL. The result of the dietary survey detailed a relationship between patients who reported to have “Almost Never” consumed fish or milk in their diets and more frequent hospital stays and ER visits than those who reported consuming these products on a daily basis. Those who consumed these foods in their diet several times a month also had fewer ER visits when compared to the “Almost Never” category.

Glucocorticoid receptor single nucleotide polymorphisms are associated with acute crisis pain in sickle cell disease

AIM

Pain in sickle cell disease patients is heterogeneous and genetic polymorphisms may predispose an individual to varied vulnerability to painful events. We studied the association of SNPs in the glucocorticoid receptor gene (NR3C1) with pain in sickle cell disease.

METHOD

Acute pain was scored as the number of utilizations due to crisis pain in a 12-month period. Chronic pain was calculated as the Composite Pain Index score.

RESULTS & CONCLUSION

rs33389 T allele (IRR = 1.53, p = 0.014 additive; IRR = 1.64, p = 0.011 recessive), rs2963155 G allele (IRR = 1.80, p < 0.001 additive; IRR = 2.25, p = 0.021 dominant; IRR = 2.07, p < 0.001 recessive) and rs9324918 C allele (IRR = 1.43, p = 0.021 additive) were associated with higher utilization rates, indicating the potential contribution of NR3C1 polymorphisms to acute pain heterogeneity in sickle cell disease.

Therapeutic Red Cell Exchange Transfusion as an Adjuvant Therapy for Management of Sickle Cell Crisis in Adults

Sickle cell crisis is an acute clinical condition, caused due to capillary occlusion by the deformed red blood cells, leading to vaso-occlusive status. Vaso-occlusion is an emergency condition requiring intensive care admission and carries a high mortality. Sickle cell crisis is usually managed with hydration, analgesics, and supportive care. Therapeutic red cell exchange transfusion is advised as an adjuvant, for the management of sickle cell crisis, and it is mainly practiced in the pediatric population. We report an adult case of sickle cell crisis managed with therapeutic red cell exchange transfusion in Intensive Care Unit and successful outcome in patient management.

Differentiation Between Sickle Cell Anemia and S/β⁰ Thalassemia

CLINICAL HISTORY PATIENT

37-year-old man of half African and half Italian ethnicity.

CHIEF COMPLAINT

Sickle cell crisis (SCC).

HISTORY OF PRESENT ILLNESS

The patient had severe pain in his lower back that radiated to both thighs. He had been admitted twice in the previous 2 weeks at another hospital due to SCC. Each time, he had been discharged with a prescription for oxycodone. His condition did not respond to the pain medicine; his pain remained uncontrollable.

MEDICAL HISTORY

The patient has had multiple sickle cell crises since childhood and is a former smoker. He denied alcohol consumption or illegal drug use.

PHYSICAL EXAMINATION FINDINGS

The patient had normal vital signs. No splenomegaly was present.

FAMILY HISTORY

Both parents carry sickle cell thalassemia.

PRINCIPAL LABORATORY FINDINGS

Table 1, Table 2, and Image 1.

Dental infections increase the likelihood of hospital admissions among adult patients with sickle cell disease

THE OBJECTIVE

To determine if dental infections increase the likelihood of hospital admission among adult patients with sickle cell disease (SCD).

BASIC RESEARCH DESIGN

Cross-sectional analysis of data from the Nationwide Emergency Department Sample (NEDS) pooled for the years 2006 through 2008. Prevalence ratios (PR) for the effects of interest were estimated using Poisson regression with robust estimates of the variance.

PARTICIPANTS

Adults, aged 18 and over, diagnosed with SCD using ICD-9-CM codes excluding participants discharged with a code for sickle cell trait.

MAIN OUTCOME MEASURE

Emergency department (ED) visit disposition, dichotomised to represent whether or not the ED visit ended in admission versus being treated and released.

RESULTS

Among patients having a sickle cell crisis, those with dental infections were 72% more likely to be admitted compared to those not having dental infections (PR = 1.72, 95% CI 1.58-1.87). No association was observed among adult SCD patients not having a sickle crisis event. Based on preliminary data from this analysis, prevention of dental infection among patients with SCD could result in an estimated cost saving of $2.5 million dollars per year.

CONCLUSIONS

Having a dental infection complicated by a sickle cell crisis significantly increases the likelihood of hospital admission among adult SCD patients presenting to the ED.

Anesthetic management of a patient with sickle cell disease for common bile duct exploration

Patients with sickle cell disease (SCD) may present to the anesthetist in different clinical settings like perioperative care, management of acute painful crisis and intensive therapy for acute respiratory failure. We describe the successful management of a 34-year-old female patient with SCD, posted for cholecystectomy with common bile duct exploration under general and epidural anesthesia. The importance of preoperative stabilization and careful anesthetic strategy is emphasized.

A review of the literature on the multiple dimensions of chronic pain in adults with sickle cell disease

Sickle cell disease (SCD) is a major health care and societal problem that affects millions of people worldwide. In Nigeria, 45,000 to 90,000 babies are born each year with SCD. In the United States, SCD is the most common genetic disorder, affecting more than 80,000 people, the majority of whom are African American. Sickle cell pain is the hallmark feature of SCD. Most of the research on pain from SCD has focused on children with acute pain associated with sickle cell crisis. Consequently, very little is known about the occurrence and characteristics of chronic pain, especially in adults with SCD. Individuals with SCD who experience chronic pain are often underserved, and their pain is undertreated. This undertreatment may result in millions of dollars per year spent on emergency room visits, hospitalizations, and lost work productivity. The primary purpose of this literature review was to summarize the findings from studies that evaluated the characteristics of chronic pain in adults with SCD. Each of the studies included in this review was evaluated to determine if it provided data on the following multidimensional characteristics of chronic pain: occurrence, number of pain episodes, duration, pattern, quality, location, intensity, aggravating factors, relieving factors, and impact of pain on function. A secondary purpose was to identify gaps in knowledge and directions for future research on the multiple dimensions of chronic pain in adults with SCD.