Position paper on advancing sickle cell disease management in France by bridging the clinical practices and guidelines through expert insights

In France, sickle cell disease (SCD) is the most common rare disease and represents the most prevalent genetic disorder, with 19,800 to 32,400 patients diagnosed in 2016 and 1:714 newborns affected in 2019. SCD is caused by a single mutation in the β-globin gene, resulting in the production of abnormal hemoglobin (called HbS), chronic hemolytic anemia, and impaired red blood cell rheology. SCD patients face several severe acute and chronic complications, including stroke, acute chest syndrome (ACS), painful vaso-occlusive crisis (VOC), organ failure, and a high risk of infections. As patients' care pathway remains unclear in France, a roundtable advisory board meeting was organized in the country to provide insights into the management of SCD in alignment with clinical guidelines. The meeting brought together a panel of esteemed key opinion leaders (KOLs) in SCD management, encompassing both clinical practice and research. During the meeting, the KOLs discussed clinical practices and their alignment with French guidelines, identifying areas of concordance and discrepancy. They also addressed disparities in SCD clinical practices across regions and medical centers. The KOLs discussed the prophylactic and therapeutic options currently available for SCD patients in France, with a focus on transfusion therapies, especially automated red blood cell exchange (aRBCX). The results of this advisory board meeting provide a valuable platform for gathering expert perspectives on SCD management, clinical practices, guideline alignment, and the potential for contributions to guideline updates.

Differential Effect of Targeted Temperature Management Between 32 °C and 36 °C Following Cardiac Arrest According to Initial Severity of Illness: Insights From Two International Data Sets

BACKGROUND

Recent guidelines have emphasized actively avoiding fever to improve outcomes in patients who are comatose following resuscitation from cardiac arrest (ie, out-of-hospital cardiac arrest). However, whether targeted temperature management between 32 °C and 36 °C (TTM32-36) can improve neurologic outcome in some patients remains debated.

RESEARCH QUESTION

Is there an association between the use of TTM32-36 and outcome according to severity assessed at ICU admission using a previously derived risk score?

STUDY DESIGN AND METHODS

Data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (France) between May 2011 and December 2017 and in the Resuscitation Outcomes Consortium Continuous Chest Compressions (ROC-CCC) trial (United States and Canada) between June 2011 and May 2015 were used for this study. Severity at ICU admission was assessed through a modified version of the Cardiac Arrest Hospital Prognosis (mCAHP) score, divided into tertiles of severity. The study explored associations between TTM32-36 and favorable neurologic status at hospital discharge by using multiple logistic regression as well as in tertiles of severity for each data set.

RESULTS

A total of 2,723 patients were analyzed in the SDEC data set and 4,202 patients in the ROC-CCC data set. A favorable neurologic status at hospital discharge occurred in 728 (27%) patients in the French data set and in 1,239 (29%) patients in the North American data set. Among the French data set, TTM32-36 was independently associated with better neurologic outcome in the tertile of patients with low (adjusted OR, 1.63; 95% CI, 1.15-2.30; P = .006) and high (adjusted OR, 1.94; 95% CI, 1.06-3.54; P = .030) severity according to mCAHP at ICU admission. Similar results were observed in the North American data set (adjusted ORs of 1.36 [95% CI, 1.05-1.75; P = .020] and 2.42 [95% CI, 1.38-4.24; P = .002], respectively). No association was observed between TTM32-36 and outcome in the moderate groups of the two data sets.

INTERPRETATION

TTM32-36 was significantly associated with a better outcome in patients with low and high severity at ICU admission assessed according to the mCAHP score. Further studies are needed to evaluate individualized temperature control following out-of-hospital cardiac arrest.

301 BENEFITS OF ENVIRONMENTAL MUSIC THERAPY IN AN ACUTE HOSPITAL

Background

Environmental Music Therapy (EMT) uses live music played by a music therapist to enhance the surrounding environment and is increasingly used in clinical settings. Studies show that EMT may reduce anxiety, enhance wellbeing, promote better communication between patients and staff, and reduce patient perception of waiting times in hospital. We aimed to explore the benefit of EMT for older adults in a geriatric outpatient setting and on rehabilitation wards.

Methods

Harp music was played by a music therapist in the vicinity of ambulatory clinics and on rehabilitation wards for 4 hours per week (over a 2-day period) for 20 weeks. Music exposure on any given day was to an estimated 50 outpatients, as well as 50 people passing the vicinity or to about 30 patients on the rehabilitation ward. Music was selected and played in a dynamic process, responding to verbal and non-verbal reactions of patients, family, and staff. Voluntary responses were recorded and collated.

Results

There were 36 recorded responses and all reflected positively on EMT. Patients cited that the music created a welcoming space and stimulated interaction and conversation. Several patients waiting for their clinic appointment noted that it distracted from fearful expectation and was a source of comfort. Some commented that they felt more relaxed and that it reduced stress. On rehabilitation wards, patients found familiar music to be calming with nurses citing that it stimulated social interaction between patients, family and staff. Responses to EMT gave insights that resulted in patient referrals for music therapy.

Conclusion

Environmental music played by a music therapist was found to modify patient hospital experiences. In particular, it appeared to reduce self-perceived stress and stimulate positive social interaction and conversation. This supports the use of EMT to advance the integration of the arts for wellbeing in an acute hospital.

Update on RFA Increasing Use of Cardiac and Pulmonary Rehabilitation in Traditional and Community Settings NIH-Funded Trials: ADDRESSING CLINICAL TRIAL CHALLENGES PRESENTED BY THE COVID-19 PANDEMIC

We previously described the design of six NIH-funded clinical trials designed to increase uptake and reduce disparities in the use of cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) based on age, gender, race/ethnicity, and socioeconomic status. The onset of the COVID-19 global pandemic necessitated signifi cant revisions to the trials to ensure the safety of participants and research staff. This article described necessary modifi cations for assessments, interventions, and data collection to support a no-contact approach centered on the use of virtual/remote techniques that maintain both safety and the original intent and integrity of the trials. The general shift from site-based to home-based interventions and hybrid models of CR and PR will be increasingly important in a post-COVID world.

Health Disparities Scientific Research in the Division of Geriatrics and Clinical Gerontology

The Division of Geriatrics and Clinical Gerontology (DGCG) supports clinical and translational research on health and disease in the aged, and research on aging over the human lifespan, including its relationships to health outcomes. Key areas include development of new interventions for age-related conditions and pathologies, prevention and treatment of multiple chronic conditions, geriatric palliative care, factors influencing the progression of chronic diseases over the life span, and predictive markers of aging that may inform potential interventions for extension of health span. Population diversity and health disparities are critical aspects of science that cut across DGCG research areas. This presentation will highlight several examples of DGCG-supported studies related to health disparities and discuss potential future research directions. One potential upcoming research area of interest involves leveraging large data sets to examine disparities in risks and benefits of long-term osteoporosis drug therapy and drug holidays according to racial and ethnic groupings

Tolérance du vaccin anti-COVID19 chez les patients drépanocytaires adultes

Introduction

Les patients drépanocytaires adultes sont considérés depuis le début de l’épidémie comme plus fragiles face à la COVID-19. L’analyse de la littérature et des travaux Français montrent que les patients de génotype SC et les plus de 40 ans sont les plus à risque de développer des formes sévères. De plus, des crises vaso-occlusives (CVO) peuvent être provoquées par l’infection, ce qui conduit à des hospitalisations plus fréquentes dans cette population. La vaccination prioritaire a donc été recommandée. Cependant, la tolérance du vaccin n’a pas été étudiée dans cette population, notamment le risque de crise induite par l’inflammation ou la fièvre post-vaccinale. Nous avons souhaité étudier les complications liées au vaccins anti-COVID19 dans une cohorte consécutive de patients drépanocytaires adultes.

Patients et méthodes

Étude observationnelle rétrospective réalisée sur une cohorte de patients d’un centre de référence Français. Tous les patients de notre cohorte, vaccinés jusqu’au 31 juillet 2021, ont été rappelés systématiquement dans les 2 mois suivant leur injection pour connaître les effets secondaires des vaccins. En plus des effets secondaires attendus, était notifié s’ils avaient eu des CVO à domicile ou des hospitalisations dans les 21 jours suivant le vaccin. La prévalence de CVO hospitalisées a été comparée à celle survenue dans les 3 semaines chez tous les patients drépanocytaires non vaccinés, venus dans la même période en consultation ou hospitalisation de jour (HDJ) dans notre centre.

Résultats

Sur une cohorte active d’environ 300 patients, seuls 100 patients drépanocytaires (68 % homozygotes, 22 % de génotype SC ; 55 % de femmes) étaient vaccinés au 31/07/2021. 95 % ont reçu un schéma vaccinal complet. 93 patients ont reçu le vaccin Pfizer, 3 le Moderna, 4 l’Astra Zeneca. L’âge médian des sujets vaccinés était de 30 ans (extrêmes 18-67). L’incidence des hospitalisations dans les 3 semaines était de 12 % après la première dose : 9 CVO simples, une CVO avec syndrome thoracique aigu, une thrombose veineuse profonde dans le bras injecté, une CVO avec séquestration splénique et rupture de rate entraînant un décès. Parmi ces 12 patients, quatre avaient été vaccinés dans les 30 jours suivant une CVO hospitalisée (incluant le patient décédé, vacciné à la fin d’une hospitalisation pour CVO). Dans la même période, l’incidence des hospitalisations sur notre cohorte de patients vus en consultation ou HDJ était de 9 % à 3 semaines (27/285) (P = 0,58, comparaison non significative par rapport aux vaccinés).

Des CVO gérées à domicile ont été rapportées par 4 patients ayant reçu leur première dose. Les autres complications les plus fréquentes survenant dans les 48 heures suivant la première injection vaccinale étaient les suivantes : douleur musculaire au point d’injection (31 %), asthénie (23 %), courbatures (13 %), céphalées (13 %), fièvre (12 %), [MOU1] [A2] frissons (3 %), nausées (2 %), douleurs oculaires (1 %), orgelet (1 %), règles très douloureuses (1 %), diarrhées (1 %), malaise (1 %), vertiges rotatoires (1 %). Parmi les patients avec fièvre, seuls 2/12 ont été hospitalisés pour CVO.

Enfin, seuls deux des 78 patients ayant eu la deuxième injection (2,5 %) ont été hospitalisés dans les 3 semaines (2 CVO). [MOU1]Peut être pas pour l’abstract mais il faudrait regarder si la majortité de ces 12 patients avec fièvre ne sont pas ceux qui ont été hospitalisés. si c’est la cas on pourra rajouter une phrase en ce sens [A2]3 de ces patients ont fait une CVO et seulement 2 ont été hospitalisés.

Conclusion

La tolérance du vaccin anti-COVID19 est très acceptable chez le patient drépanocytaire adulte, avec des effets secondaires minimes, proches de ceux de la population générale. Nos résultats rassurent sur le risque potentiel de CVO nécessitant une hospitalisation induite par l’injection vaccinale, même si la prudence imposerait de se placer à distance d’une crise pour la réalisation du vaccin. Ces résultats devraient diminuer l’appréhension d’une population à risque de la COVID-19 mais réticente à la vaccination, comme le montre le taux insuffisant de patients vaccinés dans notre cohorte, pourtant régulièrement incités à se faire vacciner depuis mars 2021.

Detecting national human enteric disease outbreaks linked to animal contact in the United States of America

Enteric pathogens, such as non-typhoidal Salmonella, Campylobacter and Escherichia coli, can reside in the intestinal tract of many animals, including livestock, companion animals, small mammals and reptiles. Often, these animals can appear healthy; nonetheless, humans can become infected after direct or indirect contact, resulting in a substantial illness burden. An estimated 14% of the 3.2 million illnesses that occur in the United States of America (USA) each year from such enteric pathogens are attributable to animal contact. Surveillance for enteric pathogens in the USA includes the compilation and interpretation of both laboratory and epidemiologic data. However, the authors feel that a collaborative, multisectoral and transdisciplinary - or One Health - approach is needed for data collection and analysis, at every level. In addition, they suggest that the future of enteric illness surveillance lies in the development of improved technologies for pathogen detection and characterisation, such as genomic sequencing and metagenomics. In particular, using whole-genome sequencing to compare genetic sequences of enteric pathogens from humans, food, animals and the environment, can help to predict antimicrobial resistance among these pathogens, determine their genetic relatedness and identify outbreaks linked to a common source. In this paper, the authors describe three recent, multi-state human enteric illness outbreaks linked to animal contact in the USA and discuss how integrated disease surveillance was essential to outbreak detection and response. Additional datasharing between public health and animal health laboratories and epidemiologists at the local, national, regional and international level may help to improve surveillance for emerging animal and human health threats and lead to new opportunities for prevention.

Exogenous interleukin-2 can rescue in-vitro T cell activation and proliferation in patients with a novel capping protein regulator and myosin 1 linker 2 mutation

Capping protein regulator and myosin 1 linker 2 (CARMIL2) deficiency is characterized by impaired T cell activation, which is attributed to defective CD28-mediated co-signaling. Herein, we aimed to analyze the effect of exogenous interleukin (IL)-2 on in-vitro T cell activation and proliferation in a family with CARMIL2 deficiency. This study included four children (one male and three females; aged 2·5-10 years at presentation). The patients presented with inflammatory bowel disease and recurrent viral infections. Genetic analysis revealed a novel homozygous 25-base pairs deletion in CARMIL2. Immunoblotting demonstrated the absence of CARMIL2 protein in all four patients and confirmed the diagnosis of CARMIL2 deficiency. T cells were activated in-vitro with the addition of IL-2 in different concentrations. CD25 and interferon (IFN)-γ levels were measured after 48 h and 5 days of activation. CD25 surface expression on activated CD8+ and CD4+ T cells was significantly diminished in all patients compared to healthy controls. Additionally, CD8+ T cells from all patients demonstrated significantly reduced IFN-γ production. When cells derived from CARMIL2-deficient patients were treated with IL-2, CD25 and IFN-γ production increased in a dose-dependent manner. T cell proliferation, as measured by Cell Trace Violet, was impaired in one patient and it was also rescued with IL-2. In conclusion, we found that IL-2 rescued T cell activation and proliferation in CARMIL2-deficient patients. Thus, IL-2 should be further studied as a potential therapeutic modality for these patients.

Molecular Transducers of Physical Activity Consortium (MoTrPAC) Progress and Study Protocol Design

Objectives

Physical activity is beneficial to human health and wellbeing across the lifespan. The numerous benefits of regular physical activity (PA) have long been recognized. Despite this, most exercise studies are associational and the molecular mechanisms that are the bases for the beneficial effects remain obscure as are the mechanisms of multiorgan communications and benefits. MoTrPAC is a large NIH discovery project (19 grants; 37 Principal Investigators; 23 institutions) whose goals are to assemble a comprehensive map of the molecular changes that occur in response to exercise and provide insights into how they are altered by age, sex, body composition and fitness level and develop a user-friendly database to facilitate investigator-initiated studies and catalyze the field of PA research and explore hypotheses exploring novel mechanisms by which PA improves or preserves health.

Methods

This project will explore and document changes in molecules mobilized in blood, muscle and fat in humans as well as 15 additional tissues for rats in response to different aerobic and resistance exercise regimes. The human studies are a multicenter clinical trial cohort of people of both sexes from 10–80 years of age and recruitment has begun. Preclinical animal Studies (PASS) have been conducted in 6 and 18-month old F344 rats and tissues harvested from control inactive rats and rats at seven time-points following a single 30 minute acute bout of treadmill running. A separate group of rats were subjected to an intensive (70% VO2max) and progressive run training program of 5 day/week for 1,2, 4, or 8 weeks with 18 tissues collected. Multiple state of art and omics platforms including genomic, transcriptomic, epigenomic, proteomic and metabolomics are being employed to define and discover the molecules mobilized in response to exercise.

Results

This presentation will highlight the study protocol design and data from the initial public data release (November 15th, 2019). Data will be available to the extramural community to collaborate with the MoTrPAC investigators to explore innovative mechanisms to expand the impact of the initial studies.

Conclusions

The product from this consortium will begin to characterize the molecular mechanisms of molecules identified in the ‘molecular map’ that underlie the beneficial effects of PA.

Funding Sources

National Institutes of Health.

NIA HEALTH DISPARITIES RESEARCH NETWORK: APPROACHES AND FINDINGS FROM GERIATRICS AND CLINICAL GERONTOLOGY

Health disparities are differences in the incidence, prevalence and burden of diseases, mortality rates and causes of death that exist among population groups. Health disparities are associated with a broad, complex, and interrelated array of factors that influence health, accelerate aging and reduce life expectancy. NIA’s health disparities research goals are to understand environmental and sociocultural factors and related behavioral and biological mechanisms that diminish health and reduce life expectancy for vulnerable populations, explore the biological mechanisms through which disparities influence age-related change, and identify where disparities emerge in diagnosis, prognosis or treatment in geriatric conditions. Presentations will focus on whether structural-level discrimination may be a key factor in potentiating well known race-related health disparities especially those with an accelerated onset and may be associated with MRI-indicators of subclinical brain pathology; identifying biomarkers for early detection of cognitive and functional decline in high risk subpopulations and how ethnicity influences cerebral spinal fluid and imaging biomarkers link to early identification of cognitive and functional impairment ; effects of medication management and deprescribing among African American and Hispanic older adults with Alzheimer’s disease and related dementias and multiple chronic conditions; examine the use of multi-level factors and technology to overcome the barriers to urban-rural health disparities in managing many chronic diseases such as hepatitis C virus infection and delivery of appropriate medical services; and understanding the racial and ethnic differences in the link between environmental exposures and auto-immune comorbid asthma.

NIH PATHWAYS TO PREVENTION WORKSHOP: RESEARCH GAPS FOR LONG-TERM DRUG THERAPIES FOR FRACTURE PREVENTION

The NIH Pathways to Prevention Workshop was held on October 30-31, 2018 to present scientific evidence, as well as physician and patient perspectives to better understand the benefits and harms of drug therapies for osteoporosis fracture prevention. Osteoporotic fractures lead to substantial morbidity, mortality, and economic costs. The underlying medical condition, is a skeletal disorder characterized by compromised bone strength predisposing to increased fracture risk. Several medications approved by the U.S. Food and Drug Administration to prevent osteoporotic fractures have been effective when taken by people who are at high risk of fracture. These include bisphosphonates , denosumab, teriparatide, estrogens, and selective estrogen-receptor modulators. However, rare but serious adverse events, such as atypical femoral fractures and osteonecrosis of the jaw associated with bisphosphonates have raised questions regarding the safety of their use. There is limited evidence on the benefits and harms of long-term osteoporosis drug therapy, including the timing and duration of drug discontinuation or drug holidays. It is not clearly known which patients will benefit or may be harmed from continued drug intervention, who should and should not be put on drug holiday, how to identify such patients and properly treat them, and how to predict their outcomes. Key scientific areas covered by the workshop included: the benefits and risks of osteoporotic drugs with short-term and long-term use and factors that influence outcomes; the impact of drug discontinuation and drug holidays on outcomes; and patient and clinician factors that impact the use of and adherence to osteoporotic drugs.

Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study

Aims

Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes.

Methods and results

We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8–2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5–1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5–10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5–5.9; P = 0.002).

Conclusions

In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.

Longitudinal assessment of health-related quality of life in osteoporosis: data from the population-based Canadian Multicentre Osteoporosis Study

Little is known about the association between health-related quality of life (HRQOL) and osteoporosis in the absence of fracture, and how HRQOL may change over time. This study provides evidence of substantially reduced HRQOL in women and men with self-reported and/or BMD-confirmed osteoporosis, even in the absence of fragility fracture.

INTRODUCTION

Fragility fractures have a detrimental effect on the health-related quality of life (HRQOL) of those with osteoporosis. Less is known about the association between HRQOL and osteoporosis in the absence of fracture.

METHODS

Canadian Multicentre Osteoporosis Study participants completed the SF-36, a detailed health questionnaire and measures of bone mineral density (BMD) at baseline and follow-up. We report the results of participants ≥ 50 years with 10-year follow-up. Self-reported osteoporosis at baseline and BMD-based osteoporosis at follow-up were ascertained. Multivariable linear regression models were developed for baseline SF-36 domains, component summaries, and change over time, adjusting for relevant baseline information.

RESULTS

Baseline data were available for 5266 women and 2112 men. Women in the osteoporosis group had substantially lower SF-36 baseline scores, particularly in the physically oriented domains, than those without osteoporosis. A similar but attenuated pattern was evident for the men. After 10-year follow-up (2797 women and 1023 men), most domain scores dropped for women and men regardless of osteoporosis status, with the exception of mentally-oriented ones. In general, a fragility fracture was associated with lower SF-36 scores and larger declines over time.

CONCLUSIONS

This study provides evidence of substantially reduced HRQOL in women and men with self-reported and/or BMD-confirmed osteoporosis, even in the absence of fragility fracture. HRQOL should be thoroughly investigated even prior to fracture, to develop appropriate interventions for all stages of the disease.

First isolation of Ascotricha chartarum from bronchoalveolar lavage of two patients with pulmonary infections

Ascotricha chartarum is a rare human pathogen. We describe the isolation and characterization of A. chartarum from bronchoalveolar lavage samples of two patients with underlying pulmonary infections. The identity of both isolates was established by typical phenotypic characteristics and by sequencing of the internal transcribed spacer region and D1/D2 domains of recombinant DNA and β-tubulin gene fragment. The demonstration of branched, septate hyphae in direct microscopic examination of both the specimens and isolation of the fungus in pure cultures suggest its aetiologic role in the disease process. Because of phenotypic similarities of A. chartarum with Chaetomium spp. and other Chaetomium-like fungi, the application of molecular methods is needed for its accurate identification. Although in the absence of histopathologic evidence the aetiologic role of A. chartarum could not be established unequivocally, nonetheless, in view of the rarity of its isolation from clinical specimens and demonstration of hyphal elements in bronchoalveolar lavage sample, this report assumes considerable significance. It serves to create awareness about environmental fungi that previously have missed attention but may play a role in respiratory infections.