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Wise TJ, Ott ME, Joseph MS, Welsby IJ, Darrow CC, McMahon TJ. Modulation of the allosteric and vasoregulatory arms of erythrocytic oxygen transport. Front Physiol 2024; 15:1394650. [PMID: 38915775 PMCID: PMC11194670 DOI: 10.3389/fphys.2024.1394650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 04/24/2024] [Indexed: 06/26/2024] Open
Abstract
Efficient distribution of oxygen (O2) to the tissues in mammals depends on the evolved ability of red blood cell (RBC) hemoglobin (Hb) to sense not only O2 levels, but metabolic cues such as pH, PCO2, and organic phosphates, and then dispense or take up oxygen accordingly. O2 delivery is the product of not only oxygen release from RBCs, but also blood flow, which itself is also governed by vasoactive molecular mediators exported by RBCs. These vascular signals, including ATP and S-nitrosothiols (SNOs) are produced and exported as a function of the oxygen and metabolic milieu, and then fine-tune peripheral metabolism through context-sensitive vasoregulation. Emerging and repurposed RBC-oriented therapeutics can modulate either or both of these allosteric and vasoregulatory activities, with a single molecule or other intervention influencing both arms of O2 transport in some cases. For example, organic phosphate repletion of stored RBCs boosts the negative allosteric effector 2,3 biphosphoglycerate (BPG) as well as the anti-adhesive molecule ATP. In sickle cell disease, aromatic aldehydes such as voxelotor can disfavor sickling by increasing O2 affinity, and in newer generations, these molecules have been coupled to vasoactive nitric oxide (NO)-releasing adducts. Activation of RBC pyruvate kinase also promotes a left shift in oxygen binding by consuming and lowering BPG, while increasing the ATP available for cell health and export on demand. Further translational and clinical investigation of these novel allosteric and/or vasoregulatory approaches to modulating O2 transport are expected to yield new insights and improve the ability to correct or compensate for anemia and other O2 delivery deficits.
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Affiliation(s)
- Thomas J. Wise
- Duke University School of Medicine, Durham, NC, United States
| | - Maura E. Ott
- Duke University School of Medicine, Durham, NC, United States
| | - Mahalah S. Joseph
- Duke University School of Medicine, Durham, NC, United States
- Florida International University School of Medicine, Miami, FL, United States
| | - Ian J. Welsby
- Duke University School of Medicine, Durham, NC, United States
| | - Cole C. Darrow
- Duke University School of Medicine, Durham, NC, United States
| | - Tim J. McMahon
- Duke University School of Medicine, Durham, NC, United States
- Durham VA Health Care System, Durham, NC, United States
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Yadav A, Munir F, Chan KH, Quraishi MZ, Harris TS, Brown DL, Menon N, Nguyen TT, Srivaths L. Oxygen saturation thresholds in managing sickle cell disease at US children's hospitals. Pediatr Blood Cancer 2024; 71:e30879. [PMID: 38279845 DOI: 10.1002/pbc.30879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 12/20/2023] [Accepted: 01/05/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Adequate oxygen saturation (SpO2 ) is crucial for managing sickle cell disease (SCD). Children with SCD are at increased risk for occult hypoxemia; therefore, understanding SpO2 threshold practices would help identify barriers to oxygen optimization in a population sensitive to oxyhemoglobin imbalances. We investigated SpO2 cutoff levels used in clinical algorithms for management of acute SCD events at children's hospitals across the United States, and determined their consistency with recommended national guidelines (SpO2 > 95%). METHODS Clinical pathways and algorithms used for the management of vaso-occlusive crisis (VOC) and acute chest syndrome (ACS) in SCD were obtained and reviewed from large children's hospitals in the United States. RESULTS Responses were obtained from 94% (140/149) of eligible children's hospitals. Of these, 63 (45%) had available clinical algorithms to manage VOC and ACS. SpO2 cutoff was provided in 71.4% (45/63) of clinical algorithms. Substantial variation in SpO2 cutoff levels was noted, ranging from ≥90% to more than 95%. Only seven hospitals (5% of total hospitals and 15.6% of hospitals with clinical algorithms available) specified oxygen cutoffs that were consistent with national guidelines. Hospitals geographically located in the South (46.8%; n = 29/62) and Midwest (54.8%; n = 17/31) were more likely to have VOC and ACS clinical algorithms, compared to the Northeast (26.5%; n = 9/34) and West (36.4%; n = 8/22). CONCLUSION There is inconsistency in the use of clinical algorithms and oxygen thresholds for VOC and ACS across US children's hospitals. Children with SCD could be at risk for insufficient oxygen therapy during adverse acute events.
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Affiliation(s)
- Aravind Yadav
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Faryal Munir
- Department of Pediatrics, Pediatric Hematology Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kok Hoe Chan
- Division of Hematology/Oncology, Department of Internal Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston), Houston, Texas, USA
| | - Mariam Z Quraishi
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Tomika S Harris
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Deborah L Brown
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Neethu Menon
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Trinh T Nguyen
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Lakshmi Srivaths
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann Hospital, Houston, Texas, USA
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Dcosta JV, Ochoa D, Sanaur S. Recent Progress in Flexible and Wearable All Organic Photoplethysmography Sensors for SpO 2 Monitoring. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2023; 10:e2302752. [PMID: 37740697 PMCID: PMC10625116 DOI: 10.1002/advs.202302752] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 07/09/2023] [Indexed: 09/25/2023]
Abstract
Flexible and wearable biosensors are the next-generation healthcare devices that can efficiently monitor human health conditions in day-to-day life. Moreover, the rapid growth and technological advancements in wearable optoelectronics have promoted the development of flexible organic photoplethysmography (PPG) biosensor systems that can be implanted directly onto the human body without any additional interface for efficient bio-signal monitoring. As an example, the pulse oximeter utilizes PPG signals to monitor the oxygen saturation (SpO2 ) in the blood volume using two distinct wavelengths with organic light emitting diode (OLED) as light source and an organic photodiode (OPD) as light sensor. Utilizing the flexible and soft properties of organic semiconductors, pulse oximeter can be both flexible and conformal when fabricated on thin polymeric substrates. It can also provide highly efficient human-machine interface systems that can allow for long-time biological integration and flawless measurement of signal data. In this work, a clear and systematic overview of the latest progress and updates in flexible and wearable all-organic pulse oximetry sensors for SpO2 monitoring, including design and geometry, processing techniques and materials, encapsulation and various factors affecting the device performance, and limitations are provided. Finally, some of the research challenges and future opportunities in the field are mentioned.
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Affiliation(s)
- Jostin Vinroy Dcosta
- Mines Saint‐ÉtienneCentre Microélectronique de ProvenceDepartment of Flexible Electronics880, Avenue de MimetGardanne13541France
| | - Daniel Ochoa
- Mines Saint‐ÉtienneCentre Microélectronique de ProvenceDepartment of Flexible Electronics880, Avenue de MimetGardanne13541France
| | - Sébastien Sanaur
- Mines Saint‐ÉtienneCentre Microélectronique de ProvenceDepartment of Flexible Electronics880, Avenue de MimetGardanne13541France
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Lucas F, Connell NT, Tolan NV. Correctly Establishing and Interpreting Oxygenation Status in Sickle Cell Disease. J Appl Lab Med 2023; 8:583-597. [PMID: 36592159 DOI: 10.1093/jalm/jfac096] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/06/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND As hypoxemia and hypoxia are central elements of disease pathophysiology and disease-related morbidity and mortality in individuals affected by sickle cell disease (SCD), clinical management aims to optimize oxygenation. CONTENT Hypoxemia is primarily screened for with pulse oximetry. However, in SCD pulse oximetry can inaccurately reflect arterial saturation, posing the risk of undetected (occult) hypoxemia. Solely relying on pulse oximetry might therefore lead to misdiagnosis or mismanagement, with devastating effects on tissue oxygenation. The interpretation of oxygenation status is multifaceted, and "oxygen saturation" is often used as an umbrella term to refer to distinctly different measured quantities-estimated oxygen saturation (O2Sat), hemoglobin oxygen saturation (SO2) by either pulse oximetry or co-oximetry, and fractional oxyhemoglobin (FO2Hb). While in many clinical situations this ambiguous use is of little consequence, O2Sat, SO2, and FO2Hb cannot be used interchangeably in the setting of SCD, as dyshemoglobins, anemia, cardiopulmonary comorbidities, concomitant medications, and frequent transfusions need to be accounted for. This article describes the parameters that determine blood and tissue oxygen concentration, discusses laboratory method performance characteristics and the correct interpretation of currently available clinical laboratory testing, and reviews the literature on noninvasive vs invasive oxygenation measurements in SCD. SUMMARY By correctly establishing and interpreting oxygenation parameters, clinical and laboratory teams can ensure high-quality, equitable healthcare, counteracting systemic exacerbations of health disparities frequently experienced by individuals with SCD.
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Affiliation(s)
- Fabienne Lucas
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nathan T Connell
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicole V Tolan
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Wang Y, Guilliams KP, Fields ME, Fellah S, Binkley MM, Reis M, Vo KD, Chen Y, Ying C, Blinder M, King AA, Hulbert ML, An H, Lee JM, Ford AL. Silent Infarcts, White Matter Integrity, and Oxygen Metabolic Stress in Young Adults With and Without Sickle Cell Trait. Stroke 2022; 53:2887-2895. [PMID: 35545940 PMCID: PMC9398918 DOI: 10.1161/strokeaha.121.036567] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Individuals with sickle cell anemia have heightened risk of stroke and cognitive dysfunction. Given its high prevalence globally, whether sickle cell trait (SCT) is a risk factor for neurological injury has been of interest; however, data have been limited. We hypothesized that young, healthy adults with SCT would show normal cerebrovascular structure and hemodynamic function. METHODS As a case-control study, young adults with (N=25, cases) and without SCT (N=24, controls) underwent brain magnetic resonance imaging to quantify brain volume, microstructural integrity (fractional anisotropy), silent cerebral infarcts (SCI), intracranial stenosis, and aneurysms. Pseudocontinuous arterial spin labeling and asymmetric spin echo sequences measured cerebral blood flow and oxygen extraction fraction, respectively, from which cerebral metabolic oxygen demand was calculated. Imaging metrics were compared between SCT cases and controls. SCI volume was correlated with baseline characteristics. RESULTS Compared with controls, adults with SCT demonstrated similar normalized brain volumes (SCT 0.80 versus control 0.81, P=0.41), white matter fractional anisotropy (SCT 0.41 versus control 0.43, P=0.37), cerebral blood flow (SCT 62.04 versus control, 61.16 mL/min/100 g, P=0.67), oxygen extraction fraction (SCT 0.27 versus control 0.27, P=0.31), and cerebral metabolic oxygen demand (SCT 2.71 versus control 2.70 mL/min/100 g, P=0.96). One per cohort had an intracranial aneurysm. None had intracranial stenosis. The SCT cases and controls showed similar prevalence and volume of SCIs; however, in the subset of participants with SCIs, the SCT cases had greater SCI volume versus controls (0.29 versus 0.07 mL, P=0.008). Of baseline characteristics, creatinine was mildly elevated in the SCT cohort (0.9 versus 0.8 mg/dL, P=0.053) and correlated with SCI volume (ρ=0.49, P=0.032). In the SCT cohort, SCI distribution was similar to that of young adults with sickle cell anemia. CONCLUSIONS Adults with SCT showed normal cerebrovascular structure and hemodynamic function. These findings suggest that healthy individuals with SCT are unlikely to be at increased risk for early or accelerated ischemic brain injury.
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Affiliation(s)
- Yan Wang
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Kristin P Guilliams
- Division of Pediatric Neurology, Washington University School of Medicine, St. Louis, MO
| | - Melanie E Fields
- Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St. Louis, MO
| | - Slim Fellah
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Michael M Binkley
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Martin Reis
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Katie D. Vo
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Yasheng Chen
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Chunwei Ying
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Morey Blinder
- Program in Occupational Therapy and Pediatrics, Division of Hematology and Oncology, Washington University School of Medicine and St. Louis Children’s Hospital, St. Louis, MO
| | - Allison A. King
- Department of Medicine, Division of hematology/oncology, Washington University School of Medicine, St. Louis, MO
| | - Monica L. Hulbert
- Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St. Louis, MO
| | - Hongyu An
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Jin-Moo Lee
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Andria L. Ford
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
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Stotesbury H, Hales PW, Hood AM, Koelbel M, Kawadler JM, Saunders DE, Sahota S, Rees DC, Wilkey O, Layton M, Pelidis M, Inusa BPD, Howard J, Chakravorty S, Clark CA, Kirkham FJ. Individual Watershed Areas in Sickle Cell Anemia: An Arterial Spin Labeling Study. Front Physiol 2022; 13:865391. [PMID: 35592036 PMCID: PMC9110791 DOI: 10.3389/fphys.2022.865391] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/22/2022] [Indexed: 12/25/2022] Open
Abstract
Previous studies have pointed to a role for regional cerebral hemodynamic stress in neurological complications in patients with sickle cell anemia (SCA), with watershed regions identified as particularly at risk of ischemic tissue injury. Using single- and multi-inflow time (TI) arterial spin labeling sequences (ASL) in 94 patients with SCA and 42 controls, the present study sought to investigate cerebral blood flow (CBF) and bolus arrival times (BAT) across gray matter, white matter with early arrival times, and in individual watershed areas (iWSAs). In iWSAs, associations between hemodynamic parameters, lesion burden, white matter integrity, and general cognitive performance were also explored. In patients, increases in CBF and reductions in BAT were observed in association with reduced arterial oxygen content across gray matter and white matter with early arrival times using both sequences (all p < 0.001, d = -1.55--2.21). Across iWSAs, there was a discrepancy between sequences, with estimates based on the single-TI sequence indicating higher CBF in association with reduced arterial oxygen content in SCA patients, and estimates based on the multi-TI sequence indicating no significant between-group differences or associations with arterial oxygen content. Lesion burden was similar between white matter with early arrival times and iWSAs in both patients and controls, and using both sequences, only trend-level associations between iWSA CBF and iWSA lesion burden were observed in patients. Further, using the multi-TI sequence in patients, increased iWSA CBF was associated with reduced iWSA microstructural tissue integrity and slower processing speed. Taken together, the results highlight the need for researchers to consider BAT when estimating CBF using single-TI sequences. Moreover, the findings demonstrate the feasibility of multi-TI ASL for objective delineation of iWSAs and for detection of regional hemodynamic stress that is associated with reduced microstructural tissue integrity and slower processing speed. This technique may hold promise for future studies and treatment trials.
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Affiliation(s)
- Hanne Stotesbury
- Imaging and Biophysics Section, Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, United Kingdom
| | - Patrick W. Hales
- Imaging and Biophysics Section, Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, United Kingdom
| | - Anna M. Hood
- Division of Psychology and Mental Health, Manchester Centre for Health Psychology, University of Manchester, Manchester, United Kingdom
| | - Melanie Koelbel
- Imaging and Biophysics Section, Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, United Kingdom
| | - Jamie M. Kawadler
- Imaging and Biophysics Section, Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, United Kingdom
| | - Dawn E. Saunders
- Radiology, Great Ormond Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Sati Sahota
- Imaging and Biophysics Section, Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, United Kingdom
| | - David C. Rees
- Paediatric Haematology, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Olu Wilkey
- Paediatric Haematology and Oncology, North Middlesex University Hospital NHS Foundation Trust, London, United Kingdom
| | - Mark Layton
- Haematology, Imperial College Healthcare NHS Foundation Trust, London, United Kingdom
| | - Maria Pelidis
- Department of Haematology and Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Baba P. D. Inusa
- Department of Haematology and Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Jo Howard
- Department of Haematology and Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Subarna Chakravorty
- Paediatric Haematology, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Chris A. Clark
- Imaging and Biophysics Section, Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, United Kingdom
| | - Fenella J. Kirkham
- Clinical Neurosciences Section, Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, United Kingdom
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Keller SB, Bumpus JM, Gatenby JC, Yang E, Kassim AA, Dampier C, Gore JC, Buck AKW. Characterizing Intracranial Hemodynamics in Sickle Cell Anemia: Impact of Patient-Specific Viscosity. Cardiovasc Eng Technol 2022; 13:104-119. [PMID: 34286479 PMCID: PMC9030946 DOI: 10.1007/s13239-021-00559-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 06/18/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE Pediatric and adult patients with sickle cell anemia (SCA) are at increased risk of stroke and cerebrovascular accident. In the general adult population, there is a relationship between arterial hemodynamics and pathology; however, this relationship in SCA patients remains to be elucidated. The aim of this work was to characterize circle of Willis hemodynamics in patients with SCA and quantify the impact of viscosity choice on pathophysiologically-relevant hemodynamics measures. METHODS Based on measured vascular geometries, time-varying flow rates, and blood parameters, detailed patient-specific simulations of the circle of Willis were conducted for SCA patients (n = 6). Simulations quantified the impact of patient-specific and standard blood viscosities on wall shear stress (WSS). RESULTS These results demonstrated that use of a standard blood viscosity introduces large errors into the estimation of pathophysiologically-relevant hemodynamic parameters. Standard viscosity models overpredicted peak WSS by 55% and 49% for steady and pulsatile flow, respectively. Moreover, these results demonstrated non-uniform, spatial patterns of positive and negative WSS errors related to viscosity, and standard viscosity simulations overpredicted the time-averaged WSS by 32% (standard deviation = 7.1%). Finally, differences in shear rate demonstrated that the viscosity choice alters the simulated near-wall flow field, impacting hemodynamics measures. CONCLUSIONS This work presents simulations of circle of Willis arterial flow in SCA patients and demonstrates the importance and feasibility of using a patient-specific viscosity in these simulations. Accurately characterizing cerebrovascular hemodynamics in SCA populations has potential for elucidating the pathophysiology of large-vessel occlusion, aneurysms, and tissue damage in these patients.
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Affiliation(s)
- Sara B. Keller
- Department of Bioengineering, University of Washington; Seattle, WA, USA
| | - Jacob M. Bumpus
- Department of Biomedical Engineering, Vanderbilt University; Nashville, TN, USA; currently at Northgate Technologies, Inc.; Elgin, IL, USA
| | | | - Elizabeth Yang
- Center for Cancer and Blood Disorders, Pediatric Specialists of Virginia; Fairfax, VA, USA
| | - Adetola A. Kassim
- Department of Medicine, Vanderbilt University Medical Center; Nashville, TN, USA
| | - Carlton Dampier
- Department of Pediatrics, Emory University and Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta; Atlanta, GA, USA
| | - John C. Gore
- Vanderbilt University Institute of Imaging Science, Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center; Nashville, TN, USA,Department of Biomedical Engineering, Vanderbilt University; Nashville, TN, USA,Department of Physics and Astronomy, Vanderbilt University; Nashville, TN, USA
| | - Amanda K. W. Buck
- Vanderbilt University Institute of Imaging Science, Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center; Nashville, TN, USA,Department of Biomedical Engineering, Vanderbilt University; Nashville, TN, USA,Corresponding author: Amanda Kathleen Wake Buck, , Vanderbilt University Medical Center, 1161 21st Avenue South, Medical Center North, AA-1105, Nashville, TN 37232-2310
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Johnson S, Gordeuk VR, Machado R, Gibbs JSR, Hildesheim M, Little JA, Kato GJ, Gladwin MT, Nouraie M. Exercise-induced changes of vital signs in adults with sickle cell disease. Am J Hematol 2021; 96:1630-1638. [PMID: 34626431 DOI: 10.1002/ajh.26369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/27/2021] [Accepted: 10/04/2021] [Indexed: 11/10/2022]
Abstract
The six-minute walk test (6MWT) has been used in patients with sickle cell disease (SCD), in conjunction with tricuspid regurgitant velocity (TRV) and plasma N-terminal pro-brain natriuretic peptide (NT-pro BNP), to assess risk of having pulmonary hypertension. Exercise-induced vital sign changes (VSCs) are predictors of clinical outcomes in other diseases. In this study, we assess the predictors and prognostic value of 6MWT VSC in adult SCD patients. Data from a multinational study of SCD patients (Treatment of Pulmonary Hypertension with Sildenafil: walk-PHaSST) were used to calculate the 6MWT VSC. Predictors of VSC were identified by a multivariable analysis, and a survival analysis was conducted by the Cox proportional hazard method. An increase in heart rate was observed in 90% of the 630 SCD adults, 77% of patients had an increase in systolic blood pressure (SBP), and 50% of patients had a decrease in oxygen saturation. TRV (odds ratio [OR] = 1.82, p = .020), absolute reticulocyte count (OR = 1.03, p < .001), and hemoglobin (OR = 0.99, p = .035) predicted oxygen desaturation ≥ 3% during the 6MWT. In the adjusted analysis, SBP increase during the 6MWT was associated with improved survival (hazards ratio = 0.3, 95% confidence interval: 0.1-0.8). Increases in heart rate and blood pressure, as well as oxygen desaturation, are common in adults with SCD during the 6MWT. VSC is associated with markers of anemia and TRV and can be used for risk stratification. Any increase in SBP during the 6MWT was associated with improved survival and may be indicative of a patient's ability to increase stroke volume.
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Affiliation(s)
- Solomon Johnson
- Department of Medicine University of Pittsburgh Pittsburgh Pennsylvania USA
| | - Victor R. Gordeuk
- Department of Medicine University of Illinois at Chicago Chicago Illinois USA
| | - Roberto Machado
- Department of Medicine Indiana University Bloomington Indiana USA
| | | | - Mariana Hildesheim
- Department of Medicine University of Pittsburgh Pittsburgh Pennsylvania USA
| | - Jane A. Little
- Department of Medicine University of North Carolina Chapel Hill North Carolina USA
| | - Gregory J. Kato
- Department of Medicine University of Pittsburgh Pittsburgh Pennsylvania USA
| | - Mark T. Gladwin
- Department of Medicine University of Pittsburgh Pittsburgh Pennsylvania USA
| | - Mehdi Nouraie
- Department of Medicine University of Pittsburgh Pittsburgh Pennsylvania USA
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Arigliani M, Gupta A. Management of chronic respiratory complications in children and adolescents with sickle cell disease. Eur Respir Rev 2020; 29:29/157/200054. [PMID: 32817114 DOI: 10.1183/16000617.0054-2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/14/2020] [Indexed: 12/25/2022] Open
Abstract
Sickle cell disease (SCD) is a life-threatening hereditary blood disorder that affects millions of people worldwide, especially in sub-Saharan Africa. This condition has a multi-organ involvement and highly vascularised organs, such as the lungs, are particularly affected. Chronic respiratory complications of SCD involve pulmonary vascular, parenchymal and airways alterations. A progressive decline of lung function often begins in childhood. Asthma, sleep-disordered breathing and chronic hypoxaemia are common and associated with increased morbidity. Pulmonary hypertension is a serious complication, more common in adults than in children. Although there is a growing attention towards respiratory care of patients with SCD, evidence regarding the prognostic meaning and optimal management of pulmonary issues in children with this condition is limited.This narrative review presents state-of-the-art evidence regarding the epidemiology, pathophysiology and therapeutic options for chronic respiratory complications commonly seen in paediatric patients with SCD. Furthermore, it highlights the gaps in the current knowledge and indicates future directions for studies that aim to improve our understanding of chronic respiratory complications in children with SCD.
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Affiliation(s)
- Michele Arigliani
- Dept of Medicine, University Hospital of Udine, Udine, Italy.,Paediatric Respiratory Medicine and Lung Transplantation, Great Ormond Street Hospital for Children, and UCL Institute of Child Health, London, UK
| | - Atul Gupta
- Dept of Paediatric Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK .,Institute for Women's and Children's Health, King's College London, London, UK
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Chen L, Gong J, Matta E, Morrone K, Manwani D, Rastogi D, De A. Pulmonary disease burden in Hispanic and non-Hispanic children with sickle cell disease. Pediatr Pulmonol 2020; 55:2064-2073. [PMID: 32484996 DOI: 10.1002/ppul.24883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 05/29/2020] [Indexed: 12/19/2022]
Abstract
RATIONALE Pulmonary complications are the leading cause of morbidity and mortality in sickle cell disease (SCD) patients. Research in SCD has predominantly been conducted on African-Americans, and the disease burden of SCD in other races and ethnicities, including Hispanic patients, is not well characterized. OBJECTIVE To compare pulmonary disease burden between Hispanic and non-Hispanic ethnic groups among children with SCD. METHODS In a retrospective chart review on 566 SCD patients followed at the Children's Hospital at Montefiore, NY, we compared the pulmonary disease burden and disease management in Hispanic patients to their non-Hispanic counterparts. We also compared the contribution of demographic and clinical variables to acute chest syndrome (ACS), vaso-occlusive crisis (VOC), and hospitalizations for SCD related complications between the two ethnic groups. RESULTS Hispanic patients had a greater proportion of ACS, and had lower forced expiratory volume (FEV1), forced vital capacity, and vital capacity, compared to non-Hispanics. Hispanic patients were more likely to be evaluated in pulmonary clinic and to be on inhaled corticosteroids, short-acting β agonizts, and leukotriene receptor antagonists. In addition, Hispanic children were more likely to be on hydroxyurea, and receive exchange transfusions. However, the association of asthma with the proportion of ACS did not differ between Hispanics and non-Hispanics. CONCLUSION Hispanic children with SCD had differences in their pulmonary function profile and received more pulmonary evaluations than non-Hispanic children.
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Affiliation(s)
- Laura Chen
- Division of Pediatric Respiratory and Sleep Medicine, Children's Hospital at Montefiore, Bronx, New York
| | - Jacqueline Gong
- College of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Esther Matta
- Division of Pediatric Respiratory and Sleep Medicine, Children's Hospital at Montefiore, Bronx, New York
| | - Kerry Morrone
- Division of Hematology and Oncology, Children's Hospital at Montefiore, Bronx, New York
| | - Deepa Manwani
- Division of Hematology and Oncology, Children's Hospital at Montefiore, Bronx, New York
| | - Deepa Rastogi
- Division of Pulmonary and Sleep Medicine, Children's National Health System, Washington, DC
| | - Aliva De
- Division of Pediatric Pulmonology, Columbia University Medical Center, Vagelos College of Physicians and Surgeons, New York, New York
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11
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van Geyzel L, Arigliani M, Inusa B, Singh B, Kozlowska W, Chakravorty S, Bossley CJ, Ruiz G, Rees D, Gupta A. Higher oxygen saturation with hydroxyurea in paediatric sickle cell disease. Arch Dis Child 2020; 105:575-579. [PMID: 31871045 DOI: 10.1136/archdischild-2019-317862] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/11/2019] [Accepted: 12/05/2019] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Sickle cell disease (SCD) is one of the most common inherited diseases worldwide. It is associated with lifelong morbidity and reduced life expectancy. Hydroxyurea (HU) has been shown to reduce the frequency and severity of vaso-occlusive episodes in SCD. Hypoxaemia and intermittent nocturnal oxygen desaturations occur frequently in children with SCD and contribute to the associated morbidity, including risk of cerebrovascular disease. OBJECTIVE To evaluate the effect of HU on oxygen saturation (SpO2) overnight and on daytime SpO2 spot checks in children with SCD. METHODS A retrospective review of children with SCD and respiratory problems who attended two UK tertiary sickle respiratory clinics and were treated with HU. Longitudinal data were collected from 2 years prior and up to 3 years after the commencement of HU. RESULTS Forty-three children, 23 males (53%) with a median age of 9 (range 1.8-18) years were included. In the 21 children who had comparable sleep studies before and after starting HU, mean SpO2 was higher (95.2% from 93.5%, p=0.01) and nadir SpO2 was higher (87.2% from 84.3%, p=0.009) when taking HU. In 32 of the children, spot daytime oxygen saturations were also higher (96.3% from 93.5%, p=0.001). CONCLUSION Children with SCD had higher oxygen saturation overnight and on daytime spot checks after starting HU. These data suggest HU may be helpful for treating persistent hypoxaemia in children with SCD pending more evidence from a randomised clinical trial.
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Affiliation(s)
- Lisa van Geyzel
- Department of Paediatric Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Michele Arigliani
- Department of Medicine, Division of Pediatrics, University Hospital of Udine, Udine, Italy
| | - Baba Inusa
- Department of Paediatric Haematology, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Bethany Singh
- Department of Paediatric Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Wanda Kozlowska
- Department of Paediatric Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK.,Department of Paediatric Respiratory Medicine, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Subarna Chakravorty
- Department of Paediatric Haematology, King's College Hospital NHS Foundation Trust, London, UK
| | - Cara J Bossley
- Department of Paediatric Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Gary Ruiz
- Department of Paediatric Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - David Rees
- Department of Paediatric Haematology, King's College Hospital NHS Foundation Trust, London, UK
| | - Atul Gupta
- Department of Paediatric Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
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12
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Noronha SA. Cardiac causes of hypoxia in sickle cell disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2019.101192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Arigliani M, Zheng S, Ruiz G, Chakravorty S, Bossley CJ, Rees D, Gupta A. Comparison of pulse oximetry and earlobe blood gas with CO-oximetry in children with sickle cell disease: a retrospective review. BMJ Paediatr Open 2020; 4:e000690. [PMID: 32577536 PMCID: PMC7299039 DOI: 10.1136/bmjpo-2020-000690] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES To investigate the agreement between pulse oximetry (SpO2) and oxygen saturation (SaO2) measured by CO-oximetry on arterialised earlobe blood gas (EBG) in children and adolescents with sickle cell disease (SCD). DESIGN AND SETTING We retrospectively reviewed 39 simultaneous and paired SaO2 EBG and SpO2 measurements from 33 ambulatory patients with SCD (32 subjects with Haemoglobin SS and one with Haemoglobin Sß+, 52% male, mean±SD age 11.0±3.6, age range 5-18). Measurements were performed between 2012 and 2015 when participants were asymptomatic. Hypoxaemia was defined as SaO2 ≤93%. A Bland-Altman analysis was performed to assess the accuracy of SpO2 as compared with EBG SaO2. RESULTS The mean±SD SpO2 and SaO2 values in the same patients were, respectively, 93.6%±3.7% and 94.3%±2.9%. The bias SpO2-SaO2 was -0.7% (95% limits of agreement from -5.4% to 4.1%) and precision was 2.5%. In 9/39 (23%) cases, the difference in SpO2-SaO2 was greater than the expected error range ±2%, with SaO2 more often underestimated by SpO2 (6/9), especially at SpO2values ≤93%. Thirteen participants (33%) were hypoxaemic. The sensitivity of SpO2 for hypoxaemia was 100%, specificity 85% and positive predictive value 76%. CONCLUSIONS Pulse oximetry was inaccurate in almost a quarter of measurements in ambulatory paediatric patients with SCD, especially at SpO2values ≤93%. In these cases, oxygen saturation can be confirmed through EBG CO-oximetry, which is easier to perform and less painful than traditional arterial blood sampling.
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Affiliation(s)
- Michele Arigliani
- Paediatric Respiratory Medicine and Lung Transplantation, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Sean Zheng
- Department of Paediatric Respiratory Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Gary Ruiz
- Department of Paediatric Respiratory Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Subarna Chakravorty
- Department of Paediatric Haematology, King's College Hospital NHS Foundation Trust, London, UK
| | - Cara J Bossley
- Department of Paediatric Respiratory Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - David Rees
- Department of Paediatric Haematology, King's College Hospital NHS Foundation Trust, London, UK
- King's College London, London, United Kingdom
| | - Atul Gupta
- Department of Paediatric Respiratory Medicine, King’s College Hospital NHS Foundation Trust, London, UK
- King's College London, London, United Kingdom
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14
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Ruhl AP, Sadreameli SC, Allen JL, Bennett DP, Campbell AD, Coates TD, Diallo DA, Field JJ, Fiorino EK, Gladwin MT, Glassberg JA, Gordeuk VR, Graham LM, Greenough A, Howard J, Kato GJ, Knight-Madden J, Kopp BT, Koumbourlis AC, Lanzkron SM, Liem RI, Machado RF, Mehari A, Morris CR, Ogunlesi FO, Rosen CL, Smith-Whitley K, Tauber D, Terry N, Thein SL, Vichinsky E, Weir NA, Cohen RT. Identifying Clinical and Research Priorities in Sickle Cell Lung Disease. An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2019; 16:e17-e32. [PMID: 31469310 PMCID: PMC6812163 DOI: 10.1513/annalsats.201906-433st] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background: Pulmonary complications of sickle cell disease (SCD) are diverse and encompass acute and chronic disease. The understanding of the natural history of pulmonary complications of SCD is limited, no specific therapies exist, and these complications are a primary cause of morbidity and mortality.Methods: We gathered a multidisciplinary group of pediatric and adult hematologists, pulmonologists, and emergency medicine physicians with expertise in SCD-related lung disease along with an SCD patient advocate for an American Thoracic Society-sponsored workshop to review the literature and identify key unanswered clinical and research questions. Participants were divided into four subcommittees on the basis of expertise: 1) acute chest syndrome, 2) lower airways disease and pulmonary function, 3) sleep-disordered breathing and hypoxia, and 4) pulmonary vascular complications of SCD. Before the workshop, a comprehensive literature review of each subtopic was conducted. Clinically important questions were developed after literature review and were finalized by group discussion and consensus.Results: Current knowledge is based on small, predominantly observational studies, few multicenter longitudinal studies, and even fewer high-quality interventional trials specifically targeting the pulmonary complications of SCD. Each subcommittee identified the three or four most important unanswered questions in their topic area for researchers to direct the next steps of clinical investigation.Conclusions: Important and clinically relevant questions regarding sickle cell lung disease remain unanswered. High-quality, multicenter, longitudinal studies and randomized clinical trials designed and implemented by teams of multidisciplinary clinician-investigators are needed to improve the care of individuals with SCD.
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15
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Stotesbury H, Kawadler JM, Hales PW, Saunders DE, Clark CA, Kirkham FJ. Vascular Instability and Neurological Morbidity in Sickle Cell Disease: An Integrative Framework. Front Neurol 2019; 10:871. [PMID: 31474929 PMCID: PMC6705232 DOI: 10.3389/fneur.2019.00871] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/26/2019] [Indexed: 12/20/2022] Open
Abstract
It is well-established that patients with sickle cell disease (SCD) are at substantial risk of neurological complications, including overt and silent stroke, microstructural injury, and cognitive difficulties. Yet the underlying mechanisms remain poorly understood, partly because findings have largely been considered in isolation. Here, we review mechanistic pathways for which there is accumulating evidence and propose an integrative systems-biology framework for understanding neurological risk. Drawing upon work from other vascular beds in SCD, as well as the wider stroke literature, we propose that macro-circulatory hyper-perfusion, regions of relative micro-circulatory hypo-perfusion, and an exhaustion of cerebral reserve mechanisms, together lead to a state of cerebral vascular instability. We suggest that in this state, tissue oxygen supply is fragile and easily perturbed by changes in clinical condition, with the potential for stroke and/or microstructural injury if metabolic demand exceeds tissue oxygenation. This framework brings together recent developments in the field, highlights outstanding questions, and offers a first step toward a linking pathophysiological explanation of neurological risk that may help inform future screening and treatment strategies.
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Affiliation(s)
- Hanne Stotesbury
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom
| | - Jamie M Kawadler
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom
| | - Patrick W Hales
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom
| | - Dawn E Saunders
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom.,Department of Radiology, Great Ormond Hospital, London, United Kingdom
| | - Christopher A Clark
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom
| | - Fenella J Kirkham
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom.,Clinical and Experimental Sciences, University of Southampton, Southampton, United Kingdom.,Department of Child Health, University Hospital Southampton, Southampton, United Kingdom.,Department of Paediatric Neurology, Kings College Hospital NHS Foundation Trust, London, United Kingdom
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16
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Hypobaric birth room may prevent intraventricular hemorrhage in extremely low birth weights infants. Med Hypotheses 2018; 119:11-13. [PMID: 30122480 DOI: 10.1016/j.mehy.2018.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 07/02/2018] [Accepted: 07/14/2018] [Indexed: 02/06/2023]
Abstract
In the early postnatal period, intraventricular hemorrhage may develop in infants with extremely low birth weights due to hemodynamic instability. One of the most significant factors in intraventricular hemorrhage development is fluctuations in the cerebral blood flow due to left-to-right shunting as a result of patent ductus arteriosus, and such cases most frequently develop intraventricular hemorrhage within the first 72 h. The frequency of intraventricular hemorrhage may be reduced through the prevention of fluctuations in the cerebral blood flow in this time frame. Based on our hypothesis, we recommend that extremely low birth weight infants should be delivered and monitored in hypobaric rooms for the first three days after birth, as this may reduce left-to-right shunting as a result of patent ductus arteriosus by preventing the rapid drops seen in pulmonary pressure after birth. A more stable hemodynamic status may be achieved by increasing the cerebral blood flow during an acute term in a hypobaric environment. Gradual transition to the normobaric status at the end of the third day may prevent the long-term negative effects of hypobaric conditions.
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17
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Heilbronner C, Merckx A, Brousse V, Allali S, Hubert P, de Montalembert M, Lesage F. Early Noninvasive Ventilation and Nonroutine Transfusion for Acute Chest Syndrome in Sickle Cell Disease in Children: A Descriptive Study. Pediatr Crit Care Med 2018; 19:e235-e241. [PMID: 29356722 DOI: 10.1097/pcc.0000000000001468] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To describe the need for transfusion and short- and long-term evolutions of pediatric sickle cell disease patients with acute chest syndrome for whom early continuous noninvasive ventilation represented first-line treatment. DESIGN Single-center retrospective chart study in PICU. SETTING A tertiary and quaternary referral PICU. PATIENTS All sickle cell disease patients 5-20 years old admitted with confirmed acute chest syndrome and not transfused in the previous month were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic data, laboratory and radiologic findings, transfusions, invasive ventilation, oxygen and noninvasive ventilation settings, duration of opioid treatment, length of hospital stay, and severe sickle cell disease complications in the ensuing 2 years were extracted from medical charts. Sixty-six acute chest syndrome in 48 patients were included. Continuous early noninvasive ventilation was well tolerated in 65 episodes, with positive expiratory pressure 4 cm H2O and pressure support 10 cm H2O (median) administered continuously, then discontinued during 7 days (median). No patient necessitated invasive ventilation or died. Twenty-three acute chest syndrome (35%) received transfusions; none received blood exchange. Transfused patients had more frequent upper lobe radiologic involvement, more severe anemia, higher reticulocyte counts, and higher C-reactive protein than nontransfused patients. Their evolution was more severe in terms of length of opioid requirement, length of noninvasive ventilation treatment, overall time on noninvasive ventilation, and length of stay. At 2-year follow-up after the acute chest syndrome episode, no difference was observed between the two groups. CONCLUSIONS Early noninvasive ventilation combined with nonroutine transfusion is well tolerated in acute chest syndrome in children and may spare transfusion in some patients. Early recognition of patients still requiring transfusion is essential and warrants further studies.
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Affiliation(s)
- Claire Heilbronner
- Pediatric Intensive Care Unit, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Audrey Merckx
- Pediatric Intensive Care Unit, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Valentine Brousse
- Department of Pediatric, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Slimane Allali
- Department of Pediatric, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Philippe Hubert
- Pediatric Intensive Care Unit, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | | | - Fabrice Lesage
- Pediatric Intensive Care Unit, AP-HP, Hôpital Necker Enfants Malades, Paris, France
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18
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Fields ME, Guilliams KP, Ragan DK, Binkley MM, Eldeniz C, Chen Y, Hulbert ML, McKinstry RC, Shimony JS, Vo KD, Doctor A, An H, Ford AL, Lee JM. Regional oxygen extraction predicts border zone vulnerability to stroke in sickle cell disease. Neurology 2018; 90:e1134-e1142. [PMID: 29500287 PMCID: PMC5880632 DOI: 10.1212/wnl.0000000000005194] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 12/05/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine mechanisms underlying regional vulnerability to infarction in sickle cell disease (SCD) by measuring voxel-wise cerebral blood flow (CBF), oxygen extraction fraction (OEF), and cerebral metabolic rate of oxygen utilization (CMRO2) in children with SCD. METHODS Participants underwent brain MRIs to measure voxel-based CBF, OEF, and CMRO2. An infarct heat map was created from an independent pediatric SCD cohort with silent infarcts and compared to prospectively obtained OEF maps. RESULTS Fifty-six participants, 36 children with SCD and 20 controls, completed the study evaluation. Whole-brain CBF (99.2 vs 66.3 mL/100 g/min, p < 0.001), OEF (42.7% vs 28.8%, p < 0.001), and CMRO2 (3.7 vs 2.5 mL/100 g/min, p < 0.001) were higher in the SCD cohort compared to controls. A region of peak OEF was identified in the deep white matter in the SCD cohort, delineated by a ratio map of average SCD to control OEF voxels. CMRO2 in this region, which encompassed the CBF nadir, was low relative to all white matter (p < 0.001). Furthermore, this peak OEF region colocalized with regions of greatest infarct density derived from an independent SCD cohort. CONCLUSIONS Elevated OEF in the deep white matter identifies a signature of metabolically stressed brain tissue at increased stroke risk in pediatric patients with SCD. We propose that border zone physiology, exacerbated by chronic anemic hypoxia, explains the high risk in this region.
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Affiliation(s)
- Melanie E Fields
- From the Division of Pediatric Hematology/Oncology (M.E.F., M.L.H.), Division of Pediatric Neurology (K.P.G.), Division of Pediatric Critical Care Medicine (K.P.G., A.D.), Department of Neurology (D.K.R., Y.C., A.L.F., J.-M.L.), and Mallinckrodt Institute of Radiology (C.E., R.C.M., J.S.S., K.D.V., H.A., J.-M.L.), Washington University School of Medicine; and Department of Biomedical Engineering (M.B.M., J.-M.L.), Washington University, St. Louis, MO
| | - Kristin P Guilliams
- From the Division of Pediatric Hematology/Oncology (M.E.F., M.L.H.), Division of Pediatric Neurology (K.P.G.), Division of Pediatric Critical Care Medicine (K.P.G., A.D.), Department of Neurology (D.K.R., Y.C., A.L.F., J.-M.L.), and Mallinckrodt Institute of Radiology (C.E., R.C.M., J.S.S., K.D.V., H.A., J.-M.L.), Washington University School of Medicine; and Department of Biomedical Engineering (M.B.M., J.-M.L.), Washington University, St. Louis, MO
| | - Dustin K Ragan
- From the Division of Pediatric Hematology/Oncology (M.E.F., M.L.H.), Division of Pediatric Neurology (K.P.G.), Division of Pediatric Critical Care Medicine (K.P.G., A.D.), Department of Neurology (D.K.R., Y.C., A.L.F., J.-M.L.), and Mallinckrodt Institute of Radiology (C.E., R.C.M., J.S.S., K.D.V., H.A., J.-M.L.), Washington University School of Medicine; and Department of Biomedical Engineering (M.B.M., J.-M.L.), Washington University, St. Louis, MO
| | - Michael M Binkley
- From the Division of Pediatric Hematology/Oncology (M.E.F., M.L.H.), Division of Pediatric Neurology (K.P.G.), Division of Pediatric Critical Care Medicine (K.P.G., A.D.), Department of Neurology (D.K.R., Y.C., A.L.F., J.-M.L.), and Mallinckrodt Institute of Radiology (C.E., R.C.M., J.S.S., K.D.V., H.A., J.-M.L.), Washington University School of Medicine; and Department of Biomedical Engineering (M.B.M., J.-M.L.), Washington University, St. Louis, MO
| | - Cihat Eldeniz
- From the Division of Pediatric Hematology/Oncology (M.E.F., M.L.H.), Division of Pediatric Neurology (K.P.G.), Division of Pediatric Critical Care Medicine (K.P.G., A.D.), Department of Neurology (D.K.R., Y.C., A.L.F., J.-M.L.), and Mallinckrodt Institute of Radiology (C.E., R.C.M., J.S.S., K.D.V., H.A., J.-M.L.), Washington University School of Medicine; and Department of Biomedical Engineering (M.B.M., J.-M.L.), Washington University, St. Louis, MO
| | - Yasheng Chen
- From the Division of Pediatric Hematology/Oncology (M.E.F., M.L.H.), Division of Pediatric Neurology (K.P.G.), Division of Pediatric Critical Care Medicine (K.P.G., A.D.), Department of Neurology (D.K.R., Y.C., A.L.F., J.-M.L.), and Mallinckrodt Institute of Radiology (C.E., R.C.M., J.S.S., K.D.V., H.A., J.-M.L.), Washington University School of Medicine; and Department of Biomedical Engineering (M.B.M., J.-M.L.), Washington University, St. Louis, MO
| | - Monica L Hulbert
- From the Division of Pediatric Hematology/Oncology (M.E.F., M.L.H.), Division of Pediatric Neurology (K.P.G.), Division of Pediatric Critical Care Medicine (K.P.G., A.D.), Department of Neurology (D.K.R., Y.C., A.L.F., J.-M.L.), and Mallinckrodt Institute of Radiology (C.E., R.C.M., J.S.S., K.D.V., H.A., J.-M.L.), Washington University School of Medicine; and Department of Biomedical Engineering (M.B.M., J.-M.L.), Washington University, St. Louis, MO
| | - Robert C McKinstry
- From the Division of Pediatric Hematology/Oncology (M.E.F., M.L.H.), Division of Pediatric Neurology (K.P.G.), Division of Pediatric Critical Care Medicine (K.P.G., A.D.), Department of Neurology (D.K.R., Y.C., A.L.F., J.-M.L.), and Mallinckrodt Institute of Radiology (C.E., R.C.M., J.S.S., K.D.V., H.A., J.-M.L.), Washington University School of Medicine; and Department of Biomedical Engineering (M.B.M., J.-M.L.), Washington University, St. Louis, MO
| | - Joshua S Shimony
- From the Division of Pediatric Hematology/Oncology (M.E.F., M.L.H.), Division of Pediatric Neurology (K.P.G.), Division of Pediatric Critical Care Medicine (K.P.G., A.D.), Department of Neurology (D.K.R., Y.C., A.L.F., J.-M.L.), and Mallinckrodt Institute of Radiology (C.E., R.C.M., J.S.S., K.D.V., H.A., J.-M.L.), Washington University School of Medicine; and Department of Biomedical Engineering (M.B.M., J.-M.L.), Washington University, St. Louis, MO
| | - Katie D Vo
- From the Division of Pediatric Hematology/Oncology (M.E.F., M.L.H.), Division of Pediatric Neurology (K.P.G.), Division of Pediatric Critical Care Medicine (K.P.G., A.D.), Department of Neurology (D.K.R., Y.C., A.L.F., J.-M.L.), and Mallinckrodt Institute of Radiology (C.E., R.C.M., J.S.S., K.D.V., H.A., J.-M.L.), Washington University School of Medicine; and Department of Biomedical Engineering (M.B.M., J.-M.L.), Washington University, St. Louis, MO
| | - Allan Doctor
- From the Division of Pediatric Hematology/Oncology (M.E.F., M.L.H.), Division of Pediatric Neurology (K.P.G.), Division of Pediatric Critical Care Medicine (K.P.G., A.D.), Department of Neurology (D.K.R., Y.C., A.L.F., J.-M.L.), and Mallinckrodt Institute of Radiology (C.E., R.C.M., J.S.S., K.D.V., H.A., J.-M.L.), Washington University School of Medicine; and Department of Biomedical Engineering (M.B.M., J.-M.L.), Washington University, St. Louis, MO
| | - Hongyu An
- From the Division of Pediatric Hematology/Oncology (M.E.F., M.L.H.), Division of Pediatric Neurology (K.P.G.), Division of Pediatric Critical Care Medicine (K.P.G., A.D.), Department of Neurology (D.K.R., Y.C., A.L.F., J.-M.L.), and Mallinckrodt Institute of Radiology (C.E., R.C.M., J.S.S., K.D.V., H.A., J.-M.L.), Washington University School of Medicine; and Department of Biomedical Engineering (M.B.M., J.-M.L.), Washington University, St. Louis, MO
| | - Andria L Ford
- From the Division of Pediatric Hematology/Oncology (M.E.F., M.L.H.), Division of Pediatric Neurology (K.P.G.), Division of Pediatric Critical Care Medicine (K.P.G., A.D.), Department of Neurology (D.K.R., Y.C., A.L.F., J.-M.L.), and Mallinckrodt Institute of Radiology (C.E., R.C.M., J.S.S., K.D.V., H.A., J.-M.L.), Washington University School of Medicine; and Department of Biomedical Engineering (M.B.M., J.-M.L.), Washington University, St. Louis, MO
| | - Jin-Moo Lee
- From the Division of Pediatric Hematology/Oncology (M.E.F., M.L.H.), Division of Pediatric Neurology (K.P.G.), Division of Pediatric Critical Care Medicine (K.P.G., A.D.), Department of Neurology (D.K.R., Y.C., A.L.F., J.-M.L.), and Mallinckrodt Institute of Radiology (C.E., R.C.M., J.S.S., K.D.V., H.A., J.-M.L.), Washington University School of Medicine; and Department of Biomedical Engineering (M.B.M., J.-M.L.), Washington University, St. Louis, MO.
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Guilliams KP, Fields ME, Ragan DK, Eldeniz C, Binkley MM, Chen Y, Comiskey LS, Doctor A, Hulbert ML, Shimony JS, Vo KD, McKinstry RC, An H, Lee JM, Ford AL. Red cell exchange transfusions lower cerebral blood flow and oxygen extraction fraction in pediatric sickle cell anemia. Blood 2018; 131:1012-1021. [PMID: 29255068 PMCID: PMC5833262 DOI: 10.1182/blood-2017-06-789842] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 12/04/2017] [Indexed: 01/13/2023] Open
Abstract
Blood transfusions are the mainstay of stroke prevention in pediatric sickle cell anemia (SCA), but the physiology conferring this benefit is unclear. Cerebral blood flow (CBF) and oxygen extraction fraction (OEF) are elevated in SCA, likely compensating for reduced arterial oxygen content (CaO2). We hypothesized that exchange transfusions would decrease CBF and OEF by increasing CaO2, thereby relieving cerebral oxygen metabolic stress. Twenty-one children with SCA receiving chronic transfusion therapy (CTT) underwent magnetic resonance imaging before and after exchange transfusions. Arterial spin labeling and asymmetric spin echo sequences measured CBF and OEF, respectively, which were compared pre- and posttransfusion. Volumes of tissue with OEF above successive thresholds (36%, 38%, and 40%), as a metric of regional metabolic stress, were compared pre- and posttransfusion. Transfusions increased hemoglobin (Hb; from 9.1 to 10.3 g/dL; P < .001) and decreased Hb S (from 39.7% to 24.3%; P < .001). Transfusions reduced CBF (from 88 to 82.4 mL/100 g per minute; P = .004) and OEF (from 34.4% to 31.2%; P < .001). At all thresholds, transfusions reduced the volume of peak OEF found in the deep white matter, a location at high infarct risk in SCA (P < .001). Reduction of elevated CBF and OEF, both globally and regionally, suggests that CTT mitigates infarct risk in pediatric SCA by relieving cerebral metabolic stress at patient- and tissue-specific levels.
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Affiliation(s)
| | | | | | - Cihat Eldeniz
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO; and
| | - Michael M Binkley
- Department of Mechanical Engineering and Material Science, Washington University in St. Louis, St. Louis, MO
| | | | | | | | | | - Joshua S Shimony
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO; and
| | - Katie D Vo
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO; and
| | - Robert C McKinstry
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO; and
| | - Hongyu An
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO; and
| | - Jin-Moo Lee
- Department of Neurology
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO; and
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Standard measures for sickle cell disease research: the PhenX Toolkit sickle cell disease collections. Blood Adv 2017; 1:2703-2711. [PMID: 29296922 DOI: 10.1182/bloodadvances.2017010702] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 11/03/2017] [Indexed: 01/19/2023] Open
Abstract
Standard measures and common data elements for sickle cell disease (SCD) will improve the data quality and comparability necessary for cross-study analyses and the development of guidelines that support effective treatments and interventions. In 2014, the National Institutes of Health, National Heart, Lung, and Blood Institute (NHLBI) funded an Administrative Supplement to the PhenX Toolkit (consensus measures for Phenotypes and eXposures; https://www.phenxtoolkit.org/) to identify common measures to promote data comparability across SCD research. An 11-member Sickle Cell Disease Research and Scientific Panel provided guidance to the project, establishing a core collection of SCD-related measures and defining the scope of 2 specialty collections: (1) cardiovascular, pulmonary, and renal complications, and (2) neurology, quality-of-life, and health services. For each specialty collection, a working group of SCD experts selected high-priority measures using a consensus process that included scientific community input. The SCD measures were released into the Toolkit in August 2015. The 25 measures included in the core collection are recommended for use by all NHLBI-funded investigators performing human-subject SCD research. The 10 neurology, quality-of-life, and health services measures and 14 cardiovascular, pulmonary, and renal measures are recommended for use within these specialized research areas. For SCD and other researchers, PhenX measures will promote collaborations with clinicians and patients, facilitate cross-study analysis, accelerate translational research, and lead to greater understanding of SCD phenotypes and epigenetics. For clinicians, using PhenX measures will help elucidate the etiology, progression, and treatment of SCD, leading to improved patient care and quality of life.
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Shilo NR, Morris CR. Pathways to pulmonary hypertension in sickle cell disease: the search for prevention and early intervention. Expert Rev Hematol 2017; 10:875-890. [PMID: 28817980 DOI: 10.1080/17474086.2017.1364989] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Pulmonary hypertension (PH) develops in a significant number of patients with sickle cell disease (SCD), resulting in increased morbidity and mortality. This review focuses on PH pathophysiology, risk stratification, and new recommendations for screening and treatment for patients with SCD. Areas covered: An extensive PubMed literature search was performed. While the pathophysiology of PH in SCD is yet to be fully deciphered, it is known that the etiology is multifactorial; hemolysis, hypercoagulability, hypoxemia, ischemic-reperfusion injury, oxidative stress, and genetic susceptibility all contribute in varying degrees to endothelial dysfunction. Hemolysis, in particular, seems to play a key role by inciting an imbalance in the regulatory axis of nitric oxide and arginine metabolism. Systematic risk stratification starting in childhood based on clinical features and biomarkers that enable early detection is necessary. Multi-faceted, targeted interventions, before irreversible vasculopathy develops, will allow for improved patient outcomes and life expectancy. Expert commentary: Despite progress in our understanding of PH in SCD, clinically proven therapies remain elusive and additional controlled clinical trials are needed. Prevention of disease starts in childhood, a critical window for intervention. Given the complex and multifactorial nature of SCD, patients will ultimately benefit from combination therapies that simultaneously targets multiple mechanisms.
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Affiliation(s)
- Natalie R Shilo
- a Department of Pediatrics, Division of Pulmonary Medicine , University of Connecticut Heath Center , Farmington , CT , USA
| | - Claudia R Morris
- b Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory-Children's Center for Cystic Fibrosis and Airways Disease Research , Emory University School of Medicine , Atlanta , GA , USA
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Grady AJ, Hankins JS, Haberman B, Schoumacher R, Stocks RM. Hydroxyurea treatment effect on children with sickle cell disease and obstructive sleep apnea. Sleep Breath 2017; 21:697-701. [PMID: 28078488 DOI: 10.1007/s11325-017-1458-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 01/05/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND While hydroxyurea is the mainstay of treatment for many of the comorbidities associated with sickle cell disease, its effect on obstructive sleep apnea has not been fully investigated. The purpose of this project is to help characterize the effects of hydroxyurea on obstructive sleep apnea in children with sickle cell disease and determine its therapeutic role in the condition. METHODS Chart review was conducted on two pediatric patients with sickle cell disease who experienced resolution of obstructive sleep apnea following hydroxyurea administration. RESULTS After undergoing approximately 11 months of hydroxyurea therapy, sleep apnea symptoms improved and obstructive sleep apnea resolution was confirmed by repeat polysomnography in both cases. This resolution was largely secondary to a reduction in the obstructive component of the apnea hypopnea index, highlighting a previously unreported association. CONCLUSIONS As adenotonsillectomy is associated with significant risks in patients with sickle cell disease, it appears reasonable to consider a period of observation for improvement of obstructive sleep apnea following hydroxyurea administration rather than directly proceeding with surgery.
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Affiliation(s)
- Anthony J Grady
- Department of Otolaryngology, Head and Neck Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Suite 420, Memphis, TN, 38163, USA.
| | - Jane S Hankins
- Department of Hematology, St. Jude Children's Research Hospital, 262 Danny Thomas place, Memphis, TN, 38105, USA
| | - Brent Haberman
- Department of Pediatric Pulmonology, University of Tennessee Health Science Center, 50 N. Dunlap, 534R W Patient Tower, LBCMC, Memphis, TN, 38103, USA
| | - Robert Schoumacher
- Department of Pediatric Pulmonology, University of Tennessee Health Science Center, 50 N. Dunlap, 534R W Patient Tower, LBCMC, Memphis, TN, 38103, USA
| | - Rose Mary Stocks
- Department of Otolaryngology, Head and Neck Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Suite 420, Memphis, TN, 38163, USA
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23
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Khan SA, Damanhouri G, Ali A, Khan SA, Khan A, Bakillah A, Marouf S, Al Harbi G, Halawani SH, Makki A. Precipitating factors and targeted therapies in combating the perils of sickle cell disease--- A special nutritional consideration. Nutr Metab (Lond) 2016; 13:50. [PMID: 27508000 PMCID: PMC4977632 DOI: 10.1186/s12986-016-0109-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 07/22/2016] [Indexed: 01/19/2023] Open
Abstract
Nutritional research in sickle cell disease has been the focus in recent times owing to not only specific nutritional deficiencies, but also the improvements associated with less painful episodes. Though hydroxyurea remains the drug of choice, certain adverse health effects on long term supplementation makes room for researches of different compounds. Macro and micro nutrient deficiencies, along with vitamins, play an important role in not only meeting the calorific needs, but also reducing clinical complications and growth abnormalities. Symptoms of hyper protein metabolism, increased cell turnover, increased cardiac output, and appetite suppression due to enhanced cytokine production, might give us leads for better understanding of the mechanisms involved. Different nutritional approaches comprising of traditional herbal therapies, antioxidants, flavonoids, vitamins, minerals etc., reducing oxidative stress and blood aggregation, have been tried out to increase the health potential. Nutritional therapies may also serve complementary to the newer therapies using ozone, hematopoietic stem cell transplantation, antifungal medications, erythropoietin etc. Herein we try to present a holistic picture of the different patho-physiological mechanisms, and nutritional strategies adopted.
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Affiliation(s)
- Shahida A Khan
- King Fahd Medical Research Center, King Abdulaziz University, P.O. Box 80216, Jeddah, 21589 Kingdom of Saudi Arabia
| | - Ghazi Damanhouri
- King Fahd Medical Research Center, King Abdulaziz University, P.O. Box 80216, Jeddah, 21589 Kingdom of Saudi Arabia
| | - Ashraf Ali
- King Fahd Medical Research Center, King Abdulaziz University, P.O. Box 80216, Jeddah, 21589 Kingdom of Saudi Arabia
| | - Sarah A Khan
- National Brain Research Center, Manesar, Gurgaon, 122051 India
| | - Aziz Khan
- King Fahd Medical Research Center, King Abdulaziz University, P.O. Box 80216, Jeddah, 21589 Kingdom of Saudi Arabia
| | - Ahmed Bakillah
- Department of Medicine, SUNY Downstate Medical Center, 450 Clarkson Ave., Brooklyn, New York 11203 United State of America (USA)
| | - Samy Marouf
- Department of Hematology, King Fahd Hospital of the Armed forces, Jeddah, Kingdom of Saudi Arabia ; Department of Medical Laboratory, King Fahd Hospital of the Armed forces, Jeddah, Kingdom of Saudi Arabia
| | - Ghazi Al Harbi
- Department of Hematology, Soliman Fakeeh Hospital Jeddah, Jeddah, Kingdom of Saudi Arabia
| | - Saeed H Halawani
- Department of Hematology, Umm Al Qura University, Faculty of Medicine, Makkah, Kingdom of Saudi Arabia
| | - Ahmad Makki
- King Fahd Medical Research Center, King Abdulaziz University, P.O. Box 80216, Jeddah, 21589 Kingdom of Saudi Arabia
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24
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Lu X, Wood DK, Higgins JM. Deoxygenation Reduces Sickle Cell Blood Flow at Arterial Oxygen Tension. Biophys J 2016; 110:2751-2758. [PMID: 27332133 PMCID: PMC4919586 DOI: 10.1016/j.bpj.2016.04.050] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 03/29/2016] [Accepted: 04/13/2016] [Indexed: 10/21/2022] Open
Abstract
The majority of morbidity and mortality in sickle cell disease is caused by vaso-occlusion: circulatory obstruction leading to tissue ischemia and infarction. The consequences of vaso-occlusion are seen clinically throughout the vascular tree, from the relatively high-oxygen and high-velocity cerebral arteries to the relatively low-oxygen and low-velocity postcapillary venules. Prevailing models of vaso-occlusion propose mechanisms that are relevant only to regions of low oxygen and low velocity, leaving a wide gap in our understanding of the most important pathologic process in sickle cell disease. Progress toward understanding vaso-occlusion is further challenged by the complexity of the multiple processes thought to be involved, including, but not limited to 1) deoxygenation-dependent hemoglobin polymerization leading to impaired rheology, 2) endothelial and leukocyte activation, and 3) altered cellular adhesion. Here, we chose to focus exclusively on deoxygenation-dependent rheologic processes in an effort to quantify their contribution independent of the other processes that are likely involved in vivo. We take advantage of an experimental system that, to our knowledge, uniquely enables the study of pressure-driven blood flow in physiologic-sized tubes at physiologic hematocrit under controlled oxygenation conditions, while excluding the effects of endothelium, leukocyte activation, adhesion, inflammation, and coagulation. We find that deoxygenation-dependent rheologic processes are sufficient to increase apparent viscosity significantly, slowing blood flow velocity at arterial oxygen tension even without additional contributions from inflammation, adhesion, and endothelial and leukocyte activation. We quantify the changes in apparent viscosity and define a set of functional regimes of sickle cell blood flow personalized for each patient that may be important in further dissecting mechanisms of in vivo vaso-occlusion as well as in assessing risk of patient complications, response to transfusion, and the optimization of experimental therapies in development.
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Affiliation(s)
- Xinran Lu
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, Minnesota
| | - David K Wood
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, Minnesota.
| | - John M Higgins
- Center for Systems Biology and Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts; Department of Systems Biology, Harvard Medical School, Boston, Massachusetts.
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25
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Abstract
Hypoxemia is common in SCD and likely exacerbates SCD vasculopathy. Pulse oximeter correlation with arterial oxygen tension in patients with SCD may at times be poor and arterial blood gas confirmation is required in hypoxic patients. Supplemental oxygen should be administered for the correction of hypoxemia, which if untreated creates a risk of multi-organ failure. Transfusion and hydroxyurea can improve oxygen delivery to tissues and organs. The role of supplemental oxygen therapy in preventing or reversing SCD vasculopathy is controversial. Nitric oxide therapy for VOC pain has not fulfilled promise to date. On the other hand, lung distension (CPAP, incentive spirometry, PEP therapy) are promising treatments requiring further study.
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Affiliation(s)
- Jason B Caboot
- Division of Pediatric Pulmonology, Department of Pediatrics, Madigan Army Medical Center, Joint Base Lewis-McChord, WA.
| | - Julian L Allen
- Division of Pulmonary Medicine, Department of Pediatrics, University of Pennsylvania School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
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26
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Waltz X, Romana M, Lalanne-Mistrih ML, Machado RF, Lamarre Y, Tarer V, Hardy-Dessources MD, Tressières B, Divialle-Doumdo L, Petras M, Maillard F, Etienne-Julan M, Connes P. Hematologic and hemorheological determinants of resting and exercise-induced hemoglobin oxygen desaturation in children with sickle cell disease. Haematologica 2013; 98:1039-44. [PMID: 23539539 DOI: 10.3324/haematol.2013.083576] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The aim of the study was to determine the factors associated with resting and exercise-induced hemoglobin oxygen desaturation. The well-established six-minute walk test was conducted in 107 sickle cell children (50 with sickle hemoglobin C disease and 57 with sickle cell anemia) at steady state. Hemoglobin oxygen saturation was measured before and immediately after the six-minute walk test. Blood samples were obtained on the same day to measure hematologic and hemorheological parameters. Exercise-induced hemoglobin oxygen desaturation was defined as a drop in hemoglobin oxygen saturation of 3% or more at the end of the six-minute walk test compared to resting levels. No children with sickle hemoglobin C disease, but approximately 50% of children with sickle cell anemia showed mild or moderate oxygen desaturation at rest, which was independently associated with the percentage of reticulocytes. Exercise-induced hemoglobin oxygen desaturation was observed in 18% of children with sickle hemoglobin C disease and 34% of children with sickle cell anemia, and was independently associated with the six-minute walk test, acute chest syndrome rate and the strength of red blood cell aggregates in children with sickle cell anemia. No association was found in children with sickle hemoglobin C disease between exercise-induced hemoglobin oxygen desaturation and the measured parameters. Hemoglobin oxygen desaturation at rest was common in children with sickle cell anemia but not in children with sickle hemoglobin C disease, and was mainly associated with greater hemolysis. Physiological strain during exercise and red blood cell aggregation properties may predict the occurrence of exercise-induced hemoglobin oxygen desaturation in children with sickle cell anemia.
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Affiliation(s)
- Xavier Waltz
- UMR Inserm 665, Pointe-à-Pitre, Guadeloupe, Université des Antilles et de la Guyane, Pointe-à-Pitre, France
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27
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Connes P, Verlhac S, Bernaudin F. Advances in understanding the pathogenesis of cerebrovascular vasculopathy in sickle cell anaemia. Br J Haematol 2013; 161:484-98. [DOI: 10.1111/bjh.12300] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Philippe Connes
- UMR Inserm 665; Academic Hospital of Pointe à Pitre; Pointe à Pitre Guadeloupe
- Laboratory ACTES EA3596; Department of Physiology; University of Antilles-Guyane; Pointe à Pitre Guadeloupe
- Laboratory of Excellence GR-Ex “The red cell: from genesis to death”; PRES Sorbonne Paris Cité; Paris France
| | - Suzanne Verlhac
- Medical Imaging; Centre Hospitalier Intercommunal; Creteil France
| | - Françoise Bernaudin
- Department of Paediatrics; Referral Centre for Sickle Cell Disease; Centre Hospitalier Intercommunal; Creteil France
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28
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Bomhard EM, Gelbke HP. Hypoxaemia affects male reproduction: a case study of how to differentiate between primary and secondary hypoxic testicular toxicity due to chemical exposure. Arch Toxicol 2013; 87:1201-18. [PMID: 23430139 DOI: 10.1007/s00204-013-1024-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 02/06/2013] [Indexed: 02/02/2023]
Abstract
Classification for fertility is based on two conditions, namely on evidence of an adverse effect on sexual function and fertility and that the effect is not secondary to other toxic effects. To decide on an adverse effect is a relatively simple day-to-day decision in toxicology but whether this effect is secondary often leads to serious controversy. As the seminiferous epithelium operates on the verge of hypoxia, oxygen deficit can lead to secondary impairment of testicular function. This is well known from healthy mountaineers exposing themselves to high altitude. They have reduced blood oxygen content that goes in parallel with impairment of testicular function and this effect remains for some time in spite of a compensatory polycythaemia. Similar findings are described for experimental animals exposed to hypobaric oxygen/high altitude. In addition, testicular function is affected in severe diseases in humans associated with systemic oxygen deficit like chronic obstructive pulmonary disease, sickle cell disease or beta-thalassaemia as well as in transgenic animals simulating haemolytic anaemia or sickle cell disease. The problem of insufficient oxygen supply as the underlying cause for testicular impairment has received relatively little attention in toxicology, mainly because blood oxygen content is generally not measured in these animal experiments. The difficulties associated with the decision whether testicular toxicity is primary or secondary to hypoxia are exemplified by the results of inhalation studies with nickel subsulphide and gallium arsenide (GaAs). Both of these particulate substances lead to severe lung toxicity that might impair oxygen uptake, but testicular toxicity is only observed with GaAs. This may first be explained by different effects on the blood: nickel subsulphide inhalation leads to a compensatory erythropoiesis that may mitigate pulmonary lack of oxygen uptake. In contrast, GaAs exposure is associated with microcytic haemolytic anaemia thereby aggravating any possible oxygen undersupply. Furthermore, the predominant pulmonary effect caused by GaAs (but not by nickel subsulphide) is alveolar proteinosis. Pulmonary alveolar proteinosis is also known as a severe disease in humans associated with hypoxaemia. Therefore, we conclude that the testicular effects observed after GaAs are secondary to hypoxaemia caused by the combination of pulmonary proteinosis and haemolytic anaemia. This publication tries to raise awareness to the severe consequences of hypoxaemia on testicular function that may already be caused by reduced oxygen pressure at high altitude without any chemical exposure.
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29
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Strauss T, Sin S, Marcus CL, Mason TBA, McDonough JM, Allen JL, Caboot JB, Bowdre CY, Jawad AF, Smith-Whitley K, Ohene-Frempong K, Pack AI, Arens R. Upper airway lymphoid tissue size in children with sickle cell disease. Chest 2012; 142:94-100. [PMID: 22241762 DOI: 10.1378/chest.11-2013] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The prevalence of obstructive sleep apnea syndrome (OSAS) is higher in children with sickle cell disease (SCD) as compared with the general pediatric population. It has been speculated that overgrowth of the adenoid and tonsils is an important contributor. METHODS The current study used MRI to evaluate such an association. We studied 36 subjects with SCD (aged 6.9 ± 4.3 years) and 36 control subjects (aged 6.6 ± 3.4 years). RESULTS Compared with control subjects, children with SCD had a significantly smaller upper airway (2.8 ± 1.2 cm(3) vs 3.7 ± 1.6 cm(3), P < .01), and significantly larger adenoid (8.4 ± 4.1 cm(3) vs 6.0 ± 2.2 cm(3), P < .01), tonsils (7.0 ± 4.3 cm(3) vs 5.1 ± 1.9 cm(3), P < .01), retropharyngeal nodes (3.0 ± 1.9 cm(3) vs 2.2 ± 0.9 cm(3), P < .05), and deep cervical nodes (15.7 ± 5.7 cm(3) vs 12.7 ± 4.0 cm(3), P < .05). Polysomnography showed that 19.4% (seven of 36) of children with SCD had OSAS compared with 0% (zero of 20) of control subjects (P < .05) and that in children with SCD the apnea-hypopnea index correlated positively with upper airway lymphoid tissues size (r = 0.57, P < 001). In addition, children with SCD had lower arterial oxygen saturation nadir (84.3% ± 12.3% vs 91.2% ± 4.2%, P < .05), increased peak end-tidal CO(2) (53.4 ± 8.5 mm Hg vs 42.3 ± 5.3 mm Hg, P < .001), and increased arousals (13.7 ± 4.7 events/h vs 10.8 ± 3.8 events/h, P < .05). CONCLUSIONS Children with SCD have reduced upper airway size due to overgrowth of the surrounding lymphoid tissues, which may explain their predisposition to OSAS.
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Affiliation(s)
- Temima Strauss
- Division of Respiratory and Sleep Medicine, The Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY
| | - Sanghun Sin
- Division of Respiratory and Sleep Medicine, The Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY
| | - Carole L Marcus
- Sleep Center, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Thornton B A Mason
- Sleep Center, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Joseph M McDonough
- Division of Pulmonary Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Julian L Allen
- Division of Pulmonary Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Jason B Caboot
- Division of Pulmonary Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Cheryl Y Bowdre
- Division of Hematology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Abbas F Jawad
- Division of Pediatrics, The Children's Hospital of Philadelphia, and the Center for Sleep, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Kim Smith-Whitley
- Division of Hematology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Kwaku Ohene-Frempong
- Division of Hematology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Allan I Pack
- Circadian Neurobiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Raanan Arens
- Division of Respiratory and Sleep Medicine, The Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY.
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30
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Quinn CT, Dowling MM. Cerebral tissue hemoglobin saturation in children with sickle cell disease. Pediatr Blood Cancer 2012; 59:881-7. [PMID: 22678814 PMCID: PMC3534844 DOI: 10.1002/pbc.24227] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 05/16/2012] [Indexed: 11/09/2022]
Abstract
BACKGROUND Desaturation of hemoglobin (Hb) in cerebral tissue, a physiologic marker of brain vulnerable to ischemic injury, can be detected non-invasively by transcranial oximetry. Absolute cerebral oximetry has not been studied in sickle cell disease (SCD), a group at very high risk of cerebral infarction in whom prevention of brain injury is key. PROCEDURE We measured absolute Hb saturation in cerebral tissue (S(CT)O(2)) in children with SCD using near-infrared spectrophotometry and investigated the contributions of peripheral Hb saturation (S(P)O(2)), hematologic measures, cerebral arterial blood flow velocity, and cerebral arterial stenosis to S(CT)O(2). We also assessed the effects of transfusion. RESULTS We studied 149 children with SCD (112 HbSS/Sβ(0); 37 HbSC/Sβ(+)). S(CT)O(2) was abnormally low in 75% of HbSS/Sβ(0) and 35% of HbSC/Sβ(+) patients. S(CT)O(2) (mean ± SD) was 53.2 ± 14.2 in HbSS/Sβ(0) and 66.1 ± 9.2% in SC/Sβ(+) patients. S(CT)O(2) correlated with age, sex, Hb concentration, reticulocytes, Hb F, and S(P)O(2), but not transcranial Doppler arterial blood flow velocities as continuous measures. In multivariable models, S(P)O(2), Hb concentration, and age were significant independent determinants of S(CT)O(2). Cerebral vasculopathy was associated with ipsilateral cerebral desaturation. Transfusion increased S(CT)O(2) and minimized the inter-hemispheric differences in S(CT)O(2) due to vasculopathy. CONCLUSIONS Cerebral desaturation, a physiologic marker of at-risk brain, is common in SCD, more severe in HbSS/Sβ(0) patients, and associated with peripheral desaturation, more severe anemia, and increasing age. Cerebral oximetry has the potential to improve the identification of children with SCD at highest risk of neurologic injury and possibly serve as a physiologic guide for neuroprotective therapy.
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Affiliation(s)
- Charles T. Quinn
- Hematology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Michael M. Dowling
- Pediatrics and Neurology, U.T. Southwestern Medical Center at Dallas, Dallas, TX, USA
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31
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Caboot JB, Jawad AF, McDonough JM, Bowdre CY, Arens R, Marcus CL, Mason TBA, Smith-Whitley K, Ohene-Frempong K, Allen JL. Non-invasive measurements of carboxyhemoglobin and methemoglobin in children with sickle cell disease. Pediatr Pulmonol 2012; 47:808-15. [PMID: 22328189 PMCID: PMC3368100 DOI: 10.1002/ppul.22504] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 12/17/2011] [Accepted: 12/18/2011] [Indexed: 11/10/2022]
Abstract
Assessment of oxyhemoglobin saturation in patients with sickle cell disease (SCD) is vital for prompt recognition of hypoxemia. The accuracy of pulse oximeter measurements of blood oxygenation in SCD patients is variable, partially due to carboxyhemoglobin (COHb) and methemoglobin (MetHb), which decrease the oxygen content of blood. This study evaluated the accuracy and reliability of a non-invasive pulse co-oximeter in measuring COHb and MetHb percentages (SpCO and SpMet) in children with SCD. We hypothesized that measurements of COHb and MetHb by non-invasive pulse co-oximetry agree within acceptable clinical accuracy with those made by invasive whole blood co-oximetry. Fifty children with SCD-SS underwent pulse co-oximetry and blood co-oximetry while breathing room air. Non-invasive COHb and MetHb readings were compared to the corresponding blood measurements. The pulse co-oximeter bias was 0.1% for COHb and -0.22% for MetHb. The precision of the measured SpCO was ± 2.1% within a COHb range of 0.4-6.1%, and the precision of the measured SpMet was ± 0.33% within a MetHb range of 0.1-1.1%. Non-invasive pulse co-oximetry was useful in measuring COHb and MetHb levels in children with SCD. Although the non-invasive technique slightly overestimated the invasive COHb measurements and slightly underestimated the invasive MetHb measurements, there was close agreement between the two methods.
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Affiliation(s)
- Jason B Caboot
- Division of Pulmonary Medicine, Department of Pediatrics, University of Pennsylvania School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
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Huang J, Pinto SJ, Allen JL, Arens R, Bowdre CY, Jawad AF, Mason TBA, Ohene-Frempong K, Smith-Whitley K, Marcus CL. Upper airway genioglossal activity in children with sickle cell disease. Sleep 2011; 34:773-8. [PMID: 21629365 DOI: 10.5665/sleep.1046] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES The prevalence of obstructive sleep apnea syndrome (OSAS) in sickle cell disease (SCD) has been reported to be higher than that in the general pediatric population. However, not all subjects with SCD develop OSAS. We hypothesized that SCD patients with OSAS have a blunted neuromuscular response to subatmospheric pressure loads during sleep, making them more likely to develop upper airway collapse. DESIGN Subjects with SCD with and without OSAS underwent pressure-flow measurements during sleep using intraoral surface electrodes to measure genioglossal EMG (EMGgg). Two techniques were applied to decrease the nasal pressure (P(N)) to subatmospheric levels, resulting in an activated and relatively hypotonic upper airway. The area under the curve of the inspiratory EMGgg moving time average was analyzed. EMGgg activity was expressed as a percentage of baseline. Changes in EMGgg in response to decrements in nasal pressure were expressed as the slope of the EMGgg vs. nasal pressure (slope of EMGgg-P(N)). SETTING Sleep laboratory. PARTICIPANTS 4 children with SCD and OSAS and 18 children with SCD but without OSAS. RESULTS THE MAJOR FINDINGS OF THIS STUDY WERE: (1) using the activated but not the hypotonic technique, the slope of EMGgg-P(N) was more negative in SCD controls than SCD OSAS; (2) the slope of EMGgg-P(N) was significantly lower using the activated technique compared to the hypotonic technique in SCD controls only; (3) similarly, the critical closing pressure, Pcrit, was more negative using the activated technique than the hypotonic technique in SCD controls but not in SCD OSAS. CONCLUSION This preliminary study has shown that children with SCD but without OSAS have more prominent upper airway reflexes than children with SCD and OSAS.
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Affiliation(s)
- Jingtao Huang
- Sleep Center, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
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Crabtree EA, Mariscalco MM, Hesselgrave J, Iniguez SF, Hilliard TJ, Katkin JP, McCarthy K, Velasquez MP, Airewele G, Hockenberry MJ. Improving care for children with sickle cell disease/acute chest syndrome. Pediatrics 2011; 127:e480-8. [PMID: 21242225 DOI: 10.1542/peds.2010-3099] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Acute chest syndrome (ACS) is a leading cause of hospitalization and death of children with sickle cell disease (SCD). An evidence-based ACS/SCD guideline was established to standardize care throughout the institution in February 2008. However, by the summer of 2009 use of the guideline was inconsistent, and did not seem to have an impact on length of stay. As a result, an implementation program was developed. OBJECTIVE This quality-improvement project evaluated the influence of the development and implementation of a clinical practice guideline for children with SCD with ACS or at risk for ACS on clinical outcomes. METHODS Clinical outcomes of 139 patients with SCD were evaluated before and after the development of the implementation program. Outcomes included average length of stay, number of exchange transfusions, average cost per SCD admission, and documentation of the clinical respiratory score and pulmonary interventions. RESULTS Average length of stay decreased from 5.8 days before implementation of the guideline to 4.1 days after implementation (P = .033). No patients required an exchange transfusion. Average cost per SCD admission decreased from $30 359 before guideline implementation to $22 368. Documentation of the clinical respiratory score increased from 31.0% before implementation to 75.5%, which is an improvement of 44.5% (P < .001). Documentation of incentive spirometry and positive expiratory pressure increased from 23.3% before implementation to 50.4%, which is an improvement of 27.1% (P < .001). CONCLUSIONS Implementation of a guideline for children with SCD with ACS or at risk for ACS improved outcomes for patients with SCD.
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Affiliation(s)
- Elizabeth A Crabtree
- Evidence Based Outcomes Center, Texas Children’s Hospital, Houston, Texas 77030, USA.
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Quinn CT, Variste J, Dowling MM. Haemoglobin oxygen saturation is a determinant of cerebral artery blood flow velocity in children with sickle cell anaemia. Br J Haematol 2009; 145:500-5. [PMID: 19344400 DOI: 10.1111/j.1365-2141.2009.07652.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Steady-state haemoglobin (Hb) desaturation is a common finding in sickle cell anaemia (Hb SS) that could predispose to stroke by limiting oxygen delivery to the brain. To determine its association with the risk of overt stroke, we examined the relationship between daytime Hb saturation measured by pulse oximetry (SpO(2)) and cerebral artery blood flow velocity measured by transcranial Doppler ultrasonography (TCD), an established risk factor for overt stroke in Hb SS. We studied 181 children using multivariate models to control for known determinants of TCD velocity, including age, haematocrit, and a measure of stenosis. We found that SpO(2) correlated significantly and inversely with TCD velocity in both the right and left middle cerebral arteries. Hb desaturation was associated with increased cerebral artery blood flow velocities and increased odds of abnormal TCD velocities, hence increased risk of stroke. About 5% of the variation in TCD velocity could be ascribed to Hb saturation while controlling for other determinants of TCD velocity. In conclusion, Hb saturation is a determinant of TCD velocity and a risk factor for stroke in children with Hb SS.
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Affiliation(s)
- Charles T Quinn
- Hematology-Oncology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX 75390-9063, USA.
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Abstract
OBJECTIVE To characterize polysomnographic (PSG) findings of children with sickle cell disease (SCD) suspected of having sleep disordered breathing (SDB). METHODS Families of 100 consecutively referred children with SCD completed the Children's Sleep Habit Questionnaire during a routine visit to identify concerns regarding sleep habits and sleep behavior. Of these, 48 children were identified as displaying behaviors suspicious of SDB. Nineteen agreed to an overnight PSG. The results from the PSGs of the SCD with obstructive sleep apnea syndrome (OSAS) group (SCD-OSAS; group 1) were compared with the results of 10 age, sex, and ethnicity-matched patients identified as OSAS with no medical comorbidities (uncomplicated OSAS; group 2). RESULTS SDB was identified in 79% of the SCD group. As compared with the uncomplicated OSAS group, the SCD with OSAS group displayed nocturnal desaturation with lower nadir values, of longer duration, with a 4-fold increased risk for oxygen desaturation below 85%, higher percentage of total sleep time with end-tidal carbon dioxide (ET CO2) values >50 mm Hg, with a 3.7-fold increased risk for spending more than 25% of total sleep time with ET CO2 more than 50 mm Hg and higher peak ET CO2 with a 7-fold increase for peak ET CO2 above 53 mm Hg. CONCLUSIONS Children with SCD suspicious of SDB may have not only a higher incidence of OSAS, but also more severe nocturnal desaturation and hypercapnia as compared with children with uncomplicated OSAS.
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Souza LCNAD, Viegas CADA. Quality of sleep and pulmonary function in clinically stable adolescents with sickle cell anemia. J Bras Pneumol 2008; 33:275-81. [PMID: 17906788 DOI: 10.1590/s1806-37132007000300008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2006] [Accepted: 08/22/2006] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To evaluate quality of sleep and pulmonary function in clinically stable adolescents with sickle cell anemia (SCA). METHODS A cross-sectional descriptive study involving 50 patients with SCA submitted to nocturnal polysomnography and spirometry at the Brasília University Hospital. Anthropometric, polysomnographic and pulmonary function data were analyzed. Patients were divided into two groups according to oxygen saturation by pulse oximetry (SpO2) during rapid eye movement (REM) sleep: SpO2 < 93%; and SpO2 > 93%. Descriptive statistics, Student's t-test, chi-square test and Pearson's correlation coefficient were used. RESULTS Mean age was 13.9 +/- 2.5 years. Total sleep time and REM sleep percentage were lower, whereas REM sleep latency, the number of awakenings, movement during sleep, changes in sleep stage, sleep-disordered breathing index and obstructive apnea index were higher. Two patients (4%) did not present REM. There were statistically significant differences between the groups in most of the polysomnographic variables. The SpO2 in REM sleep presented a strong positive correlation with waking SpO2 and with SpO2 in non-REM sleep, whereas it presented a strong negative correlation with the percentage of total sleep time during which SPO2 was < 90%. Mean spirometric values were within normal ranges. Residual volume and the residual volume/total lung capacity/functional residual capacity ratio were elevated. CONCLUSION Sleep impairment in clinically stable patients with SCA is probably due to hemoglobin desaturation and not to individual alterations in pulmonary function.
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Krishnan S, Siegel J, Pullen G, Hevelow M, Dampier C, Stuart M. Increased von Willebrand factor antigen and high molecular weight multimers in sickle cell disease associated with nocturnal hypoxemia. Thromb Res 2008; 122:455-8. [PMID: 18230405 DOI: 10.1016/j.thromres.2007.12.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2007] [Revised: 11/28/2007] [Accepted: 12/06/2007] [Indexed: 12/27/2022]
Abstract
We evaluated vWF profiles in children and adolescents with SCD and sleep hypoxemia. Mean vWF:Ag levels were significantly elevated in the SCD-hypoxemia group when compared with SCD-normoxia and control groups (p=0.007); and correlated inversely with pulse oximetry (r=-0.54, p=0.01). Densitographic analyses of vWF multimer distribution also showed an inverse correlation between %HMW-multimers and oxygen saturation (r=-0.62, p=0.03). The previously reported association between nocturnal desaturation and SCD vascular complications, including stroke, may be influenced by hypoxemic modulation of vWF as noted in this study.
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Affiliation(s)
- Suba Krishnan
- Department of Pediatrics, Division of Hematology, Cardeza Foundation for Hematologic Research, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
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Quinn CT, Sargent JW. Daytime steady-state haemoglobin desaturation is a risk factor for overt stroke in children with sickle cell anaemia. Br J Haematol 2007; 140:336-9. [PMID: 18042265 DOI: 10.1111/j.1365-2141.2007.06927.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Haemoglobin (Hb) desaturation could increase the risk of stroke in sickle cell anaemia (SS) by perturbing endothelial function and limiting oxygen delivery to the brain. We performed a nested case-control study of the Dallas Newborn Cohort to determine whether daytime steady-state Hb desaturation was associated with overt stroke in children with SS. Cases had SS and overt ischaemic strokes. Controls had comparable genotypes but no overt stroke. Cases had lower prestroke steady-state pulse oximetry values (SpO(2)) than controls, and cases' SpO(2) fell even lower as the time to impending stroke decreased. The odds ratio for stroke was 1.32 for each 1% decrease in SpO(2). In conclusion, steady-state Hb desaturation is a risk factor for overt ischaemic stroke in children with SS. Decline in SpO(2) over time further increases this risk. Hb desaturation is easily measured, potentially modifiable, and could be used to identify children with SS at increased risk of stroke.
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Affiliation(s)
- Charles T Quinn
- Center for Cancer and Blood Disorders, Children's Medical Center Dallas, Dallas, TX, USA.
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Lopez BL, Cogen JF, Kerkula L, Corbin T, Flenders P. Pulse oximetry in the adult ED patient with sickle cell. Am J Emerg Med 2005; 23:429-32. [PMID: 16032605 DOI: 10.1016/j.ajem.2004.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We performed a retrospective chart review of adult patients with sickle cell presenting with vasoocclusive crisis to determine the association between pulse oximetry and emergency department (ED) disposition. Subjects were divided into a NORMAL (pulse oximetry > or = 95%) and a LOW (pulse oximetry <95%) group. Two hundred ten consecutive charts showed no significant difference between NORMAL (n = 163) and LOW (n = 47) groups regarding admission or discharge from the ED ( P > .05). A higher percentage in the LOW group received chest radiographs (40.9% vs 29%, P < .05), suggesting that pulse oximetry may have influenced ordering of this test. No significant differences in historical and physical exam characteristics were found. The pulse oximetry level does not appear to be associated with a particular ED disposition in adult sickle cell anemia.
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Affiliation(s)
- Bernard L Lopez
- Department of Emergency Medicine, Jefferson Medical College, Philadelphia, PA 19107, USA.
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40
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41
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Setty BNY, Stuart MJ, Dampier C, Brodecki D, Allen JL. Hypoxaemia in sickle cell disease: biomarker modulation and relevance to pathophysiology. Lancet 2003; 362:1450-5. [PMID: 14602439 DOI: 10.1016/s0140-6736(03)14689-2] [Citation(s) in RCA: 141] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Nocturnal oxyhaemoglobin desaturation might have a role in CNS complications related to sickle cell disease, and rates of painful crises. We attempted to examine the biological relations, and describe the haematological risk factors for oxyhaemoglobin desaturation. METHODS The study population included children with sickle cell disease and controls. Cellular activation was assessed by measurement of soluble vascular cell adhesion molecule 1, P-selectin, L-selectin, and leukotriene B4. Erythrocyte-endothelial adhesion and routine haematological variables were assessed. Oxygen saturation (SaO2) was measured by pulse oximetry while children were awake and asleep. Children with a mean sleeping SaO2 of < or =93% were identified as hypoxaemic. Children were divided into four groups: controls (ten children), HbSC (nine, all normoxic), HbSS normoxic (13), and HbSS hypoxaemic (15). FINDINGS Among haematological variables, sleeping SaO2 correlated only with packed-cell volume (r=0.7; p<0.0001). Inverse relations were noted between sleeping SaO2 and adhesion (-0.45; p<0.01), and markers of white-cell (-0.51; p<0.01), platelet (-0.61; p<0.001), and endothelial activation (-0.46; p<0.01). In the HbSS group who had sleeping hypoxaemia, waking SaO2 measurements showed continuing hypoxaemia, with similar correlation between SaO2 and cell activation markers. INTERPRETATION Our adhesion-related findings suggest a potential mechanism for the increased occurrence of clinical vaso-occlusive crises in individuals with sickle cell disease who have oxyhaemoglobin desaturation. Release of cellular mediators in hypoxaemia, and the relation between anaemia and oxyhaemoglobin desaturation, suggest that risk factors for stroke, including anaemia, might have a role in CNS-vasculopathy through hypoxia-mediated pathways. Further more, hypoxaemia in the older child also occurs during the day; such mild untreated hypoxia could lead to an increased risk of vaso-occlusive episodes.
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Affiliation(s)
- B N Yamaja Setty
- Department of Pediatrics and the Marian Anderson Sickle Cell Center Core Laboratory, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA
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Abstract
Pulmonary complications account for significant morbidity and mortality in patients with sickle cell disease. Clinical lung involvement manifests in two major forms: the acute chest syndrome and sickle cell chronic lung disease. Acute chest syndrome is characterised by fever, chest pain, and appearance of a new infiltrate on chest radiograph. Sickle cell chronic lung disease, on the other hand, manifests as radiographic interstitial abnormalities, impaired pulmonary function, and, in its most severe form, by the evidence of pulmonary hypertension. Progress has been made in understanding the pathophysiology and management of these complications. In this review the current knowledge of the mechanism, diagnosis, and treatment of pulmonary complications of sickle cell disease are discussed.
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Affiliation(s)
- A K Siddiqui
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, USA
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Morris CR, Morris SM, Hagar W, Van Warmerdam J, Claster S, Kepka-Lenhart D, Machado L, Kuypers FA, Vichinsky EP. Arginine therapy: a new treatment for pulmonary hypertension in sickle cell disease? Am J Respir Crit Care Med 2003; 168:63-9. [PMID: 12626350 DOI: 10.1164/rccm.200208-967oc] [Citation(s) in RCA: 237] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pulmonary hypertension is a life-threatening complication of sickle cell disease. L-Arginine is the nitrogen donor for synthesis of nitric oxide, a potent vasodilator that is deficient during times of sickle cell crisis. This deficiency may play a role in pulmonary hypertension. The enzyme arginase hydrolyzes arginine to ornithine and urea, and thus, it may compete with nitric oxide synthase, leading to decreased nitric oxide production. Nitric oxide therapy by inhalation has improved pulmonary hypertension associated with acute chest syndrome in sickle cell disease, and several studies demonstrate therapeutic benefits of arginine therapy for primary and secondary pulmonary hypertension. We sought to determine the effects of arginine therapy on pulmonary hypertension in patients with sickle cell disease. Arginase activity was also determined. Oral arginine produced a 15.2% mean reduction in estimated pulmonary artery systolic pressure (63.9 +/- 13 to 54.2 +/- 12 mm Hg, p = 0.002) after 5 days of therapy in 10 patients. Arginase activity was elevated almost twofold (p = 0.07) in patients with pulmonary hypertension and may limit arginine bioavailability. With limited treatment options and a high mortality rate for patients with sickle cell disease who develop pulmonary hypertension, arginine is a promising new therapy that warrants further investigation.
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Affiliation(s)
- Claudia R Morris
- Department of Emergency Medicine, Children's Hospital Oakland, 747 52nd Street, Oakland, CA 94609, USA.
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Nifong TP, Domen RE. Oxygen saturation and hemoglobin A content in patients with sickle cell disease undergoing erythrocytapheresis. THERAPEUTIC APHERESIS : OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY FOR APHERESIS AND THE JAPANESE SOCIETY FOR APHERESIS 2002; 6:390-3. [PMID: 12423535 DOI: 10.1046/j.1526-0968.2002.00425.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Severe hypoxia occurs in patients with acute chest syndrome, and erythrocytapheresis has been shown to improve oxygenation. Patients with sickle cell anemia also have decreased baseline oxygen saturation values, but the effect of erythrocytapheresis on steady-state oxygenation has not been well studied. We investigated the changes in oxygen saturation versus hematocrit, fraction of hemoglobin A, and transfusion volume during 71 prophylactic erythrocytapheresis procedures performed in 5 stable patients with sickle cell anemia. Each patient had a history of either acute chest syndrome or stroke, but no serious events occurred while enrolled in the chronic exchange program. The oxygen saturation improved from 1% to 6% during erythrocytapheresis in each of our patients (p < 0.001) regardless of preprocedure saturation level or total hematocrit. We have shown that decreased baseline oxygen saturation in sickle cell disease is related to abnormal hemoglobin S levels, and oxygen saturation can be improved with erythrocytapheresis, independent of any change in the total hematocrit.
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Affiliation(s)
- Thomas P Nifong
- Department of Pathology, Penn State Milton S Hershey Medical Center, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA.
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Hrinczenko BW, Alayash AI, Wink DA, Gladwin MT, Rodgers GP, Schechter AN. Effect of nitric oxide and nitric oxide donors on red blood cell oxygen transport. Br J Haematol 2000; 110:412-9. [PMID: 10971400 DOI: 10.1046/j.1365-2141.2000.02203.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
A mechanism has been proposed in which nitric oxide (NO) may bind to cysteine beta93 and be transported by haemoglobin from the lungs to the tissues and modify vascular tone. In addition, it has been reported that treatment of sickle cell anaemia blood with 80 p.p.m. NO gas in air shifts the oxygen affinity, as measured by P50 to the left. We exposed normal and sickle cell anaemia blood to 80 p.p.m. NO in air for 1 h in vitro and found no change in P50 of either normal or sickle cell blood. In addition, we exposed normal and sickle cell blood in buffer to aqueous NO (NO gas dissolved in buffer) at varying concentrations and found that the induced left shift in P50 correlates strongly and linearly with methaemoglobin formation. We also treated normal and sickle cell blood with other nitric oxide donors, such as sodium 2-(N, N-diethylamino)-diazenolate-2-oxide (DEANO), S-nitrosocysteine (CysNO) and sodium trioxodinitrate (OXINO, or Angeli's salt). In all cases, we found a dose-dependent increase in methaemoglobin that was strongly correlated with the dose-dependent P50 reduction. Our data do not support the report that low NO concentrations can selectively increase the oxygen affinity of sickle cell blood without affecting methaemoglobin levels significantly. NO, however, may have benefit in sickle cell disease by other mechanisms.
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Affiliation(s)
- B W Hrinczenko
- Laboratory of Chemical Biology, NIDDK, National Institutes of Health, Bethesda, MD 20892-1822, USA
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Needleman JP, Franco ME, Varlotta L, Reber-Brodecki D, Bauer N, Dampier C, Allen JL. Mechanisms of nocturnal oxyhemoglobin desaturation in children and adolescents with sickle cell disease. Pediatr Pulmonol 1999; 28:418-22. [PMID: 10587416 DOI: 10.1002/(sici)1099-0496(199912)28:6<418::aid-ppul6>3.0.co;2-d] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Oxyhemoglobin desaturation in patients with sickle cell disease has been proposed as a possible mechanism in the initiaton of vasco-occlusive pain crises. Nocturnal oxyhemoglobin desaturation (NOD) has been described with a prevalence of up to 40% in children and adolescents with sickle cell disease. The objective of this study was to evaluate the mechanisms of nocturnal oxyhemoglobin desaturation in sickle cell disease and determine the role of obstructive sleep apnea. We performed 16-channel polysomnograms and pulmonary function testing in 20 patients with sickle cell disease (ages 7-21 years) who had documented desaturation on home oximetry studies. The median saturation awake was 94% (quartile range, 88-95). Median saturation during REM sleep was 93.5% (88-95) and during non-REM sleep 93.5% (87.5-95). The median respiratory disturbance index was low (1.35 quartile range, 0.25-2.85). Twelve patients had no obstructive apnea recorded, while 3 patients had a total of 9 or 10 episodes during the entire study. The median snoring time was 5. 65% of total sleep time (quartile range, 1.35-22.65). There was no correlation between number of obstructive apneas and mean sleeping saturation (r = 0.012, p = 0.95). There was no correlation between pulmonary function data and prevalence of NOD. There was a strong, positive correlation between sleeping and awake saturation (r = 0.96, p < 0.001). We conclude that while nocturnal oxyhemoglobin desaturation may be common in children and adolescents with sickle cell disease, upper airway obstruction does not appear to play an important role in its genesis.
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Affiliation(s)
- J P Needleman
- Department of Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
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