Cerebral revascularization surgery reduces cerebrovascular events in children with sickle cell disease and moyamoya syndrome: Results of the stroke in sickle cell revascularization surgery retrospective study

BACKGROUND

Recent studies suggest that cerebral revascularization surgery may be a safe and effective therapy to reduce stroke risk in patients with sickle cell disease and moyamoya syndrome (SCD-MMS).

METHODS

We performed a multicenter, retrospective study of children with SCD-MMS treated with conservative management alone (conservative group)-chronic blood transfusion and/or hydroxyurea-versus conservative management plus surgical revascularization (surgery group). We monitored cerebrovascular event (CVE) rates-a composite of strokes and transient ischemic attacks. Multivariable logistic regression was used to compare CVE occurrence and multivariable Poisson regression was used to compare incidence rates between groups. Covariates in multivariable models included age at treatment start, age at moyamoya diagnosis, antiplatelet use, CVE history, and the risk period length.

RESULTS

We identified 141 patients with SCD-MMS, 78 (55.3%) in the surgery group and 63 (44.7%) in the conservative group. Compared with the conservative group, preoperatively the surgery group had a younger age at moyamoya diagnosis, worse baseline modified Rankin scale scores, and increased prevalence of CVEs. Despite more severe pretreatment disease, the surgery group had reduced odds of new CVEs after surgery (odds ratio = 0.27, 95% confidence interval [CI] = 0.08-0.94, p = .040). Furthermore, comparing surgery group patients during presurgical versus postsurgical periods, CVEs odds were significantly reduced after surgery (odds ratio = 0.22, 95% CI = 0.08-0.58, p = .002).

CONCLUSIONS

When added to conservative management, cerebral revascularization surgery appears to reduce the risk of CVEs in patients with SCD-MMS. A prospective study will be needed to validate these findings.

Establishing cost-effective allocation of proton therapy for patients with mediastinal Hodgkin lymphoma

PURPOSE

For curative treatment of Hodgkin lymphoma, radiotherapy benefit must be weighed against toxicity. Although more costly, proton radiotherapy reduces dose to healthy tissue, potentially improving the therapeutic ratio compared to photons. We sought to determine the cost-effectiveness of proton versus photon therapy for mediastinal Hodgkin lymphoma (MHL) based on reduced heart disease.

METHODS

Our model approach was two-fold: (1) Utilize patient-level dosimetric information for a cost-effectiveness analysis using a Markov cohort model. (2) Utilize population-based data to develop guidelines for policy-makers to determine thresholds of proton therapy favorability for a given photon dose. The HD14 trial informed relapse risk; coronary heart disease risk was informed by the Framingham risk calculator modified by the mean heart dose (MHD) from radiation. Sensitivity analyses assessed model robustness and identified the most influential model assumptions. A 30-year-old adult with MHL was the base case using 30.6-Gy proton therapy versus photon intensity-modulated radiotherapy.

RESULTS

Proton therapy was not cost-effective in the base case for male ($129K/QALY) or female patients ($196/QALY). A 5-Gy MHD decrease was associated with proton therapy incremental cost-effectiveness ratio<$100K/QALY in 40% of scenarios. The hazard ratio associating MHD and heart disease was the most influential clinical parameter.

CONCLUSION

Proton therapy may be cost-effective a select minority of patients with MHLbased on age, sex, and MHD reduction. We present guidance for clinicians utilizing MHD to aid decision-making for radiotherapy modality.

The relation between health-related quality of life, treatment adherence and disease severity in a paediatric sickle cell disease sample

BACKGROUND

The purpose of this study was to provide a comprehensive examination of the potential factors associated with health-related quality of life (HRQOL) in a paediatric sickle cell disease sample.

METHODS

Caregivers of 78 paediatric sickle cell disease patients completed surveys, which included measures of HRQOL, treatment adherence and barriers to treatment adherence. Medical chart reviews were also conducted to assess disease severity.

RESULTS

Barriers to treatment adherence and pain crisis frequency were found to be the most robust factors associated with HRQOL.

CONCLUSIONS

This study provides insight into the factors related to paediatric sickle cell disease and informs both clinicians and researchers interested in understanding and improving HRQOL in this population. In particular, the reduction of pain crises frequency and barriers to adherence may be particularly effective strategies to improve HRQOL.

Pneumocystis carinii pneumonia complicating Hodgkin's disease: a case report

A case of Hodgkin's disease who developed Pneumocystis carinii pneumonia (PCP) is described. The diagnosis of P. carinii was confirmed on post-mortem lung biopsy. The rarity of its occurrence in our country is emphasised as is the need for high degree of suspicion and early institution of treatment.