Comprehensive, Integrative Management of Pain for Patients with Sickle-Cell Disease

Self-management for sickle cell disease among patients and parents: A qualitative study

OBJECTIVE

This study aimed to explore self-management practices among patients and parents of children with sickle cell disease (SCD).

METHODS

The qualitative descriptive design was employed. The study involved 19 participants comprising adult SCD patients ≥16 years, and nine parents of SCD children ≤ 15 years. Purposive sampling was conducted to select participants from a teaching hospital and SCD association. Data was collected using one-on-one interviews, transcribed verbatim, and analysed using qualitative content analysis.

RESULTS

Self-management was reported through four categories including preventive health, self-monitoring, self-diagnosis, and self-treatment. Hydration, nutrition, activity limitation, avoidance of cold temperatures, and supportive medications were the most common preventive health actions. Regarding self-monitoring and self-diagnosis, the parents emphasized objective indicators such as changes in urine and eye colour compared to the adults who utilize subjective indicators such as feeling unwell and easy fatigue. Pharmacological and non-pharmacological measures were reported by both groups for treating painful episodes, fever, leg ulcers, priapism, and unspecified symptoms.

DISCUSSION

The participants in this study practice several self-management actions with some differences in application between adults and children. Tailored self-management services may be helpful for adults and children when developing services for SCD patients.

Hybrid effectiveness-implementation trial of guided relaxation and acupuncture for chronic sickle cell disease pain (GRACE): A protocol

Background

People with sickle cell disease frequently use complementary and integrative therapies to cope with their pain, yet few studies have evaluated their effectiveness. The 3-arm, 3-site pragmatic Hybrid Effectiveness-implementation Trial of Guided Relaxation and Acupuncture for Chronic Sickle Cell Disease Pain (GRACE) has 3 priorities: (1) evaluate guided relaxation and acupuncture to improve pain control; (2) determine the most appropriate and effective treatment sequence for any given patient based on their unique characteristics; and (3) describe the processes and structures required to implement guided relaxation and acupuncture within health care systems.

Methods

Participants (N = 366) are being recruited and randomized 1:1:1 to one of 2 intervention groups or usual care. The acupuncture intervention group receives 10 sessions over approximately 5 weeks. The guided relaxation intervention group receives access to video sessions ranging from 2 to 20 min each viewed daily over 5 weeks. The usual care group receives the standard of clinical care for sickle cell disease. Participants are re-randomized at 6 weeks depending on their pain impact score. Assessments occur at 6 weeks, 12 weeks, and 24 weeks. The primary outcome is the change in pain impact score and secondary measures include opioid use, anxiety, depression, sleep, pain catastrophizing, substance use, global impression of change, constipation, and hospitalizations. The GRACE study uses the Consolidated Framework for Implementation Research to plan, execute, and evaluate the associated implementation processes.

Conclusion

The results from GRACE will represent a critical step toward improving management of pain affecting patients with sickle cell disease.ClinicalTrials.gov Identifier: NCT04906447.

Non-pharmacological pain interventions for sickle cell crisis in pediatrics: A scoping review

PROBLEM

Sickle cell crises (SCC) are recurrent, severe pain episodes experienced by people living with sickle cell disease (SCD). Non-pharmacological interventions have been recommended for SCC pain management however, little is known about the impact of these interventions on SCC pain. This scoping review aims to systematically identify evidence on the use and effectiveness of non-pharmacological interventions for pain management during SCC in the pediatric population.

ELIGIBILITY CRITERIA

Studies were eligible if they are published in English and focusing on the use of any non-pharmacological interventions on pain during SCC in pediatric patients. Nine databases were searched including Medline, CINAHL and PsychInfo. Also, the reference lists of relevant studies were searched.

SAMPLE

The database searching yielded 1517 studies. After the title and abstract screening, 1348 studies were excluded, and 169 full texts were retrieved and screened. One study was identified through handsearching. Finally, 27 articles were included in this scoping review.

RESULTS

Across all studies, 27 different non-pharmacological interventions were identified. There were inconsistent results regarding the effectiveness of virtual reality, guided imagery, and cognitive-behavioral interventions in experimental studies. The most common interventions used at home were prayer, massage, and distraction. The main interventions used in hospitals were prayer and fluid intake, but this was explored by a few studies.

CONCLUSION

Pediatric SCD patients use numerous non-pharmacological interventions to manage pain during SCC. However, the impact of many interventions on SCC pain has not been empirically investigated.

IMPLICATIONS

Further research is necessary to establish the effectiveness of non-pharmacological interventions on SCC pain.

Complementary and alternative medicine for children with sickle cell disease: A systematic review

BACKGROUND

Complementary and alternative medicine (CAM) is a popular alternative to opioid and other analgesics in sickle cell disease (SCD). We review the effectiveness, prevalence, and factors associated with CAM use in the pediatric SCD population.

METHODS

The review protocol was created based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search was conducted in MEDLINE, Embase, Cochrane Library, PubMed, and Web of Science.

RESULTS

Twenty-four studies were examined. The prevalence of CAM use in pediatric patients with SCD ranged from 36 to 84.5%. Common inpatient CAM interventions were yoga, virtual reality, and acupuncture, which decreased pain scale scores. Outpatient CAMs were consisted of cognitive behavioral therapy, massage therapy, and guided-imagery, which increased pain tolerability and decreased pain scale scores.

CONCLUSIONS

CAM modalities can decrease pain scale scores. However, the impact of specific CAM modalities on emergency department visits, hospitalizations, and school absences were inconclusive.

Sickle Cell Disease and Pain: Is it all Vaso-occlusive Crises?

OBJECTIVES

Acute pain is the main complication of sickle cell disease. Chronic pain (CP) and neuropathic pain (NP) may also be experienced, but have not been formally described in Jamaican patients. A cross-sectional study was conducted to determine their prevalence and characteristics, and to determine the common pain locations and modalities of management.

MATERIALS AND METHODS

All well individuals with sickle cell disease patients 14 years and older, not pregnant and without a history of clinical stroke were consecutively recruited. Anthropometric measurements, hematology studies, an analgesia checklist, and the Adult Sickle Cell Quality of Life Measurement Information System questionnaire were completed. The painDETECT questionnaire was completed to describe NP and pain patterns-from which CP was defined.

RESULTS

There were 257 patients in total, with 55.6% being females; the mean age of the patients was 31.7±12 years, and 75% had the SS genotype. Almost all patients (92.6%) had had an acute pain crisis in their lifetime and 72.4% in the last year. The mean severity at last attack was 6.8±3.1 on a scale of 0 to 10. The prevalences of CP and NP were 21.5% and 17.9%, respectively. Female sex, the presence of current leg ulcers, and the use of a strong opioid in the last 4 weeks produced higher odds of NP, whereas older age, milder genotypes, and daily analgesic use had the highest odds of CP. Opioids were used by 40.1% of the patients in the previous 4 weeks, whereas nonpharmacological treatments such as physiotherapy was less used, but reported to be very effective.

DISCUSSION

CP and NP should be assessed during routine care of sickle cell pain so that targeted therapies can be applied.

The Use of Music by Adolescents and Young Adults With Sickle Cell Disease

Pain is common and often severe in people with sickle cell disease (SCD), occurring as acute intermittent pain episodes called vaso-occlusive episodes (VOEs), as well as chronic pain conditions including bone infarctions, avascular necrosis of joints, and neuropathic pain. Analgesics such as opioids, nonsteroidal anti-inflammatory medications (NSAIDS), and anticonvulsants for neuropathic pain, although often necessary to manage these types of pain, are associated with side effects. Nonpharmacologic interventions such as to listening to music and music therapy may reduce pain. The objectives of this study were to determine whether the use of music by adolescents and young adults with SCD was helpful, and if so, the types of music that helped, and how music helped them. A convenience sample of nine English-speaking inpatients ages 13 to 21 years, with SCD and at least two prior hospitalizations for VOE, took part in interviews with music therapists. Participants were asked open-ended questions about both pain and music. Participants identified that music was helpful for pain relief as well as for mood regulation, focusing attention during cognitive tasks such as homework, distraction, relaxation, and feeling understood or connected with others. Despite this, while hospitalized, participants reported that they did not tend to use music to help with pain. These findings support the use of both music medicine and music therapy as interventions for pain and distress in adolescents and young adults with SCD.

Do chronic pain and comorbidities affect brain function in sickle cell patients? A systematic review of neuroimaging and treatment approaches

Sickle cell disease (SCD) is a medical condition in which chronic pain is common and negatively impacts psychosocial function and quality of life. Although the brain mechanisms underlying chronic pain are well studied in other painful conditions, the brain mechanisms underlying chronic pain and the associated psychosocial comorbidities are not well established in SCD. A growing literature demonstrates the effect of treatment of chronic pain, including pharmacological and nonpharmacological treatments, on brain function. The present systematic review aimed to (1) determine the effects of chronic pain and psychosocial comorbidities on brain function of patients with SCD; (2) summarize pharmacological and nonpharmacological approaches to treat these symptoms; and (3) identify areas for further investigation of potential beneficial effects of treatments on brain function. Titles were screened using predefined criteria, including SCD, and abstracts and full texts were reviewed by 2 independent reviewers. A total of 1167 SCD articles were identified, and 86 full articles were included covering 3 sections: chronic pain (4 studies), psychosocial comorbidities (11 studies), and pharmacological and nonpharmacological treatments (71 studies). Neuroimaging evidence demonstrates aberrant neural processing related to chronic pain and psychosocial comorbidities in SCD beyond ischemic stroke and cerebral hemorrhage. Although neuroimaging studies show an important role for psychological factors, pain management is nearly exclusively based on opioids. Behavior therapy seems useful to improve psychological symptoms as well as chronic pain and quality of life. Further investigation is required with larger cohorts, matched controls, and examination of treatment-related neural mechanisms.

Incorporating integrative medicine and patient preferences into a pilot interdisciplinary sickle cell wellness clinic

OBJECTIVE

Sickle Cell Disease (SCD) is an inherited blood disorder that includes acute pain episodes and chronic pain that can dramatically impact quality of life and goal-achievement. Our staff had limited success in connecting families with the Pain, Palliative Care and Integrative Medicine Clinic (PPCIM) to receive specialized skills for pain management. We created a partnership between Hematology and PPCIM to provide SCD patients/families with needed resources.

DESIGN/SETTING

In 2016, key stakeholders collaborated to create a Sickle Cell Wellness Clinic (SCWC) clinic to provide families access to integrative medicine and wellness strategies. Design/structure, based on family focus group data and staff expertise, included a half-day, 7-discipline clinic housed in the PPCIM space. Patients with SCD, ages 8-20, learned strategies in an effort to improve health care utilization and increase overall quality of life.

MAIN OUTCOME MEASURES/RESULTS

Feedback from two successful pilot clinics in 2017 was incorporated into the formal roll-out of SCWC in 2018. SCWCs continued monthly for one year, serving a total of 20 families post-pilot. SCD patients increased follow-up appointment engagement in the PPCIM clinic following SCWC and reported high levels of satisfaction with their healthcare experience.

CONCLUSIONS

It is feasible to run a multidisciplinary clinic focused on pain management, coping skills, and healthy living with SCD. Providers benefited from the opportunity to collaborate with other disciplines. Patient and family feedback was positive, highlighted benefits of being introduced to new modalities, and reported advantages of meeting other patients/families in a new setting.

New and emerging treatments for vaso-occlusive pain in sickle cell disease

Introduction: Acute pain from episodic vaso-occlusion (VOC) spans the lifespan of almost everyone with sickle cell disease (SCD), while additional chronic pain develops in susceptible individuals in early adolescences. Frequent acute pain with chronic pain causes significant physical and psychological morbidity, and frequent health-care utilization. Available pharmacologic therapies reduce acute pain frequency but few evidence-based therapies are available for chronic pain. Areas covered: An extensive PubMed literature search was performed with appropriate search criteria. The pathophysiology of acute pain from VOC in SCD is very complex with many events subsequent to sickle polymer formation. Sensitization of pain pathways and alterations of brain networks contributes to the experience of chronic pain. Numerous therapies targeting putative VOC mechanisms are in clinical trials, and show considerable promise. Alternative analgesic treatments for acute and chronic pain have been examined in small patient cohorts, but formal clinical trials are lacking. Expert opinion: Childhood is likely a critical window for prevention of acute and later chronic pain. New multimodal analgesic therapies are needed, particularly for chronic pain, and should be examined in clinical trials. Given the multifactorial nature of both pain and VOC, simultaneously targeting multiple mechanisms may be the optimal approach for effective preventive therapies.

Low dose ketamine versus morphine for acute severe vaso occlusive pain in children: a randomized controlled trial

BACKGROUND AND AIMS

Acute pain episodes associated with sickle cell disease (SCD) are very difficult to manage effectively. Opioid tolerance and side effects have been major roadblocks in our ability to provide these patients with adequate pain relief. Ketamine is cheap, widely safe, readily available drug, with analgesic effects at sub-anesthetic doses and has been used in wide range of surgeries, pediatric burns dressing change and cancer related pain however, literature concerning its use in sickle cell crises is still limited in our setting. This study aimed to establish if 1 mg/kg of intravenous ketamine is non inferior to intravenous morphine 0.1 mg/kg in severe SCD-associated pain.

METHODS

We performed an institutional review board-approved randomized, prospective, double-blinded, active-control, non-inferiority trial at the national referral sickle cell center. Children between 7 and 18 years of age with severe painful sickle cell crisis, defined by numerical rating scale score of greater or equal to 7 were enrolled. Patients were consented and randomized to receive, either IV ketamine (LDK) 1 mg/kg or IV morphine (MOR) 0.1 mg/kg as an infusion over 10 min. The primary endpoint is maximal change in Numerical Rating Scale (NRS) pain score. Secondary outcomes were, incidence of adverse effects, optimal time to and duration of action of ketamine and incidence of treatment failures by treatment group. A clinically meaningful difference in validated pain scores was defined as 1.3 units. Assuming both treatments are on average equal, a sample size of 240 patients (120 per group) provided 95% power to demonstrate that IV LDK is non-inferior to IV morphine with a 0.05 level of significance and a 10% non-inferiority margin. All analyses were based on a modified intention to treat. This trial was registered with clinicaltrials.gov NCT02434939.

RESULTS

Two hundred and forty patients were enrolled (LDK120, MOR120). Demographic variables and baseline NRS scores (8.9 vs. 9.2) were similar. LDK was comparable to MOR in the maximum change in NRS scores, 66.4% vs. 61.3% (MD 5.5; 95% CI -2.2 to -13.2). Time to achieve maximum reduction in NRS pain scores was at 19.8 min for LDK and 34.1 min for MOR. The average duration of action for LDK was 60 min. MOR had more patients still at maximum effect at 120 min (45.8% vs. 37.5%; RR 1.2; 95% CI 0.9-1.7). LDK patients were 11.3 times more likely to develop side effects, though were transient, anticipated and non-life threatening (37.5% vs. 3.3%). MOR had significantly more treatment failures 40% vs. 28.3% (RR 0.7; 95% CI 0.5-1.03, p=0.07) Vital signs and sedation scores were similar in both groups.

CONCLUSIONS

Intravenous LDK at 1 mg/kg provides comparable analgesic effectiveness as IV MOR in the acute treatment of severe painful sickle cell crisis in children in the day care sickle cell center. However, it is associated with a high incidence of several transient, non-life threatening mild side effects.

IMPLICATIONS

Intravenous ketamine at 1 mg/kg can be a reliable alternative to morphine in the management of severe painful sickle cell crisis especially in a resource limited area where morphine is not readily available.

Self-management recommendations for sickle cell disease: A Ghanaian health professionals' perspective

OBJECTIVE

To describe self-management recommendations for sickle cell disease (SCD) care among health professionals who manage SCD in Ghana.

METHOD

Nine health care professionals (nurses, doctors, and physician assistants) who work in SCD were interviewed. The semistructured interviews were recorded, transcribed, and analysed using the qualitative content analysis method. Self-management recommendations were conceptualised as preventive health, self-monitoring, self-diagnosis, self-treatment, and self-evaluation.

RESULTS

Preventive health recommendations were the commonest, where the professionals described similar topics including avoidance of cold temperature, frequent oral hydration, and healthy nutrition. Self-monitoring recommendations included regular checks for pallor, urine colour, and splenic enlargement. Self-diagnosis recommendations were captured as warning signs and included pain, fever, unusual feelings, and enlarged spleen. Pain and fever management were the focus of most self-treatment advice, and there were some self-treatment recommendations for dactylitis, anaemia, and priapism. There was considerable variation in the strategies recommended for the management of individual SCD-related problems.

CONCLUSION

Ghanaian health professionals involved in SCD care provide limited and inconsistent self-management recommendations. There is a need for the development of SCD standards and guidelines that support effective self-management. Health professionals working in SCD require continuing education in self-management.

Characterization of opioid use in sickle cell disease

PURPOSE

Opioid analgesics are commonly used to treat vaso-occlusive pain episodes in sickle cell disease (SCD), but comprehensive evidence characterizing opioid use in this patient population is limited. Our objective was to characterize opioid use patterns among SCD patients using a large nationwide database.

METHODS

A large, US medical claims database was utilized to identify a cohort of 3882 SCD patients, and characteristics of opioid use were analyzed. Clinical variables including age, gender, medication use, health care utilization, and medical history were evaluated for correlations with opioid use.

RESULTS

Forty percent of patients took opioid medications during a 12-month span, and the prevalence of any opioid use was highest for 20 to 29-year-old patients (58%). The median daily opioid dose was 1.85 mg (interquartile range: 0.62-10.68 mg) oral morphine equivalents (OME). While most opioid users took between 0 and 5 mg OME daily, 3% of pediatric patients and 23% of adult patients used more than 30-mg OME daily. High-dose opioid use was associated with older age, hydroxyurea therapy, nonsteroidal anti-inflammatory drug (NSAID) use, and frequent inpatient hospitalizations. In multivariable-adjusted analyses, patients with vaso-occlusive complications such as pain crisis (OR = 3.8, 95% CI 2.7-5.3) and avascular necrosis (AVN) (OR = 3.7, 95% CI 2.7-5.1) were associated with high-dose opioid use.

CONCLUSIONS

Our study showed that only 40% SCD patients were on opioid analgesics during a 12-month span. However, a non-trivial number of patients used a much higher dose of opioids despite a relatively low average daily opioid dose among SCD patients, particularly with vaso-occlusive complications.

Patterns of opioid use in sickle cell disease

Pain, the hallmark complication of sickle cell disease (SCD), is largely managed with opioid analgesics in the United States, but comprehensive data regarding the long-term use of opioids in this patient population is lacking. The pain medication prescription records from a cohort of 203 SCD patients were analyzed. Twenty-five percent were not prescribed opioid medications while 47% took only short-acting opioids, 1% took only long-acting opioids, and 27% took a combination of short-acting and long-acting opioids. The median (interquartile range) daily opioid dose was 6.1 mg (1.7-26.3 mg) of oral morphine equivalents, which is lower than the published opioid use among patients with other pain syndromes. The dose of opioids correlated with the number of admissions due to vaso-occlusive crisis (VOC) (r = 0.53, P < 0.001). When the patients were grouped into quartiles based on daily dose opioid use, a logistic regression model showed that history of avascular necrosis (AVN) (OR: 2.87, 95% CI: 1.37-6.02, P = 0.005), 25-OHD levels (OR: 0.59, 95% CI: 0.38-0.93, P = 0.024) and total bilirubin concentration (OR: 0.64, 95% CI: 0.42-0.99, P = 0.043) were independently associated with opioid use quartiles. In conclusion, doses and types of opioid medications used by adult SCD patients vary widely. Our findings implicate AVN and lower vitamin D levels as factors associated with higher opioid use. They also suggest an association of higher bilirubin levels, possibly suggesting higher hemolytic rate, with lower opioid use. Am. J. Hematol. 91:1102-1106, 2016. © 2016 Wiley Periodicals, Inc.

The Role of Spirituality and Religiosity in Persons Living With Sickle Cell Disease

Purpose: Sickle cell disease (SCD) is a serious debilitating chronic illness, affecting approximately 90,000 Americans and millions globally. Spirituality and religiosity (S/R) may ease the burden faced by persons living with SCD. The purpose of this study was to examine the role of S/R in adolescents and adults living with SCD in the research literature. Method: The electronic databases Cumulative Index to Nursing and Allied Health Literature, Health Source Nursing/Academic, ProQuest Health Module, PsycINFO, Medline, PubMed, and the American Theological Library Association were searched from January 1995 to December 2014. Findings: Of the 89 studies retrieved, 11 articles between 2001 and 2013 met the inclusion criteria and were reviewed. Four themes emerged. The themes included (a) S/R as sources of coping, (b) S/R enhance pain management, (c) S/R influence health care utilization, and (d) S/R improve quality of life. Discussion: Use of S/R may be significant in coping with SCD, managing pain, affecting hospitalizations, and affecting quality of life. This review can direct researchers exploring S/R in adolescents and adults living with SCD.

Sickle Cell Disease: A Review of Nonpharmacological Approaches for Pain

CONTEXT

Sickle cell disease (SCD) is a life-threatening condition that affects more than seven million people worldwide. The most common complication experienced by persons living with SCD is pain. Evidence supports the use of nonpharmacologic therapies in managing psychological and social complications of pain in persons with SCD, but there is little consensus if these approaches can also be applied for the treatment of pain in SCD.

OBJECTIVES

To describe and synthesize the use of nonpharmacological therapies for reducing pain of any type and origin in persons with SCD.

METHODS

A literature search was conducted using PsycINFO, PsycARTICLES, PubMed, CINAHL, and Embase. Databases were searched using the following terms: sickle cell, pain, and nonpharmacological therapies. Interventions were graded for methodological quality and categorized as 1) peer-support group therapies, 2) educational/psychological therapies, and 3) skill-based therapies.

RESULTS

Twenty-eight nonpharmacological interventions for persons with SCD were examined. Of these studies, a wide variety of nonpharmacological interventions were tested. Twelve studies yielded significant improvements in pain, three studies reported no positive effect or differences between experimental and control conditions on pain or a pain-related outcome, and one study reported a negative or detrimental intervention effect.

CONCLUSION

Approximately half of the studies reviewed demonstrated success in alleviating pain, suggesting that patients are able to use nonpharmacological interventions to reduce pain with some degree of success. Questions still remain regarding the efficacy and generalizability of these interventions for persons with SCD.

Spirituality and Religiosity in Adolescents Living With Sickle Cell Disease

This study purports to address paucity in the literature regarding how adolescents with sickle cell disease (SCD) describe and experience spirituality and religiosity (S/R). This was a qualitative descriptive study. Two semi-structured interviews were conducted with nine adolescents (Mage = 16.2 years). Data were analyzed using a template analysis style and a concurrent analysis process of data reduction. Three major themes encompassed the participants' descriptions of the relationships between S/R, health and illness in their lives including S/R as sources for coping, influence of S/R beliefs on health and illness, and sharing S/R with Health Care Providers (HCPs). S/R as coping mechanisms included six threads: interconnecting with God, interconnecting with others, interconnecting with creative arts, scriptural metanarratives, transcendent experiences, and acceptance and finding meaning. Expectations of health providers included two threads: Religiosity is private/personal and sharing spiritual and religious beliefs is risky. S/R are particularly salient for adolescents with SCD.

Provider Perspective on Integrative Medicine for Pediatric Sickle Cell Disease-related Pain

OBJECTIVE

Integrative medicine (IM) approaches are sometimes used to manage sickle cell disease (SCD)-related pain. The purpose of this research is to (1) understand provider perspective towards the use of IM for pain in children with SCD at a large urban children's hospital and (2) provide recommendations on how to better promote IM for children and adolescents with SCD.

METHODS

After approval from the institutional review board, a qualitative case study approach was used with criterion-type purposeful sampling to select providers from the division of hematology to adequately inform the study. Semistructured interviews were completed using audiotape to facilitate transcription. NVivo 10 analytic software (QSR International Pty Ltd, Doncaster, Victoria, Australia) was used to organize data into themes to answer the study questions.

RESULTS

Ten provider interviews were completed. Attitudes were generally positive, and most providers felt that IM is generally helpful. All providers reported that they do not optimally use integrative therapies for children with SCD. The barriers uncovered focused on lack of process for integration of IM, specifically that IM resources seem transient and based on short-term funding. Provider attitude towards CAM is generally positive, but provider comfort level is highly variable. No providers are completely comfortable with their knowledge base about IM, and increased knowledge is desired.

CONCLUSIONS

Creation of protocols and processes to incorporate IM into management plans for patients with SCD could help to promote its use. Education of providers about utility and efficacy of IM for SCD-related pain and about existing resources would aid in promotion of IM for children with SCD.

How French paediatric emergency departments manage painful vaso-occlusive episodes in sickle cell disease patients

AIM

The most common manifestation of sickle cell disease (SCD) is painful vaso-occlusive episodes (PVOE), and inappropriate treatment leads to unnecessary suffering and potentially fatal complications. This study describes how French paediatric emergency departments (EDs) manage PVOE and their knowledge, and implementation of the French National Authority for Health recommendations on the management of sickle cell patients.

METHODS

A questionnaire on managing PVOE was sent to all the 111 French paediatric EDs.

RESULTS

We received responses from 81 (72.9%) of the EDs. Of those who responded to each individual question, 85% said that they had read the national recommendations, 71.6% said they used nalbuphine for moderate PVOE, and 85% used intravenous morphine for severe PVOE. The majority (91.7%) of EDs thought that intravenous morphine provided relief for severe PVOE, but only 30.9% thought that intravenous nalbuphine did. A 50:50 nitrous oxide/oxygen mix was used by 71.3% of departments to relieve procedural pain and by 48% to enhance analgesia when morphine was insufficient for severe pain.

CONCLUSIONS

Most French EDs follow the national recommendations for PVOE. Nalbuphine was the most commonly used opioid for moderate PVOE and morphine for severe PVOE. A nitrous oxide/oxygen mixture was widely used for PVOE.

A biopsychosocial-spiritual model of chronic pain in adults with sickle cell disease

Chronic pain in adults with sickle cell disease (SCD) is a complex multidimensional experience that includes biologic, psychologic, sociologic, and spiritual factors. To date, three models of pain associated with SCD (i.e., biomedical model, biopsychosocial model for SCD pain, and Health Beliefs Model) have been published. The biopsychosocial multidimensional approach to chronic pain developed by Turk and Gatchel is a widely used model of chronic pain. However, this model has not been applied to chronic pain associated with SCD. In addition, a spiritual/religious dimension is not included in this model. Because spirituality/religion is central to persons affected by SCD, that dimension needs to be added to any model of chronic pain in adults with SCD. In fact, data from one study suggest that spirituality/religiosity is associated with decreased pain intensity in adults with chronic pain from SCD. A biopsychosocial-spiritual model is proposed for adults with chronic pain from SCD, because it embraces the whole person. This model includes the biologic, psychologic, sociologic, and spiritual factors relevant to adults with SCD based on past and current research. The purpose of this paper is to describe an adaptation of Turk and Gatchel's model of chronic pain for adults with SCD and to summarize research findings that support each component of the revised model (i.e., biologic, psychologic, sociologic, spiritual). The paper concludes with a discussion of implications for the use of this model in research.

Beyond the definitions of the phenotypic complications of sickle cell disease: an update on management

The sickle hemoglobin is an abnormal hemoglobin due to point mutation (GAG → GTG) in exon 1 of the β globin gene resulting in the substitution of glutamic acid by valine at position 6 of the β globin polypeptide chain. Although the molecular lesion is a single-point mutation, the sickle gene is pleiotropic in nature causing multiple phenotypic expressions that constitute the various complications of sickle cell disease in general and sickle cell anemia in particular. The disease itself is chronic in nature but many of its complications are acute such as the recurrent acute painful crises (its hallmark), acute chest syndrome, and priapism. These complications vary considerably among patients, in the same patient with time, among countries and with age and sex. To date, there is no well-established consensus among providers on the management of the complications of sickle cell disease due in part to lack of evidence and in part to differences in the experience of providers. It is the aim of this paper to review available current approaches to manage the major complications of sickle cell disease. We hope that this will establish another preliminary forum among providers that may eventually lead the way to better outcomes.

Faith healing in paediatrics: what do we know about its relevance to clinical practice?

There is widespread use of complementary or alternative medicine among adults and children. Families may use faith healing alongside conventional medicine or as an alternative. In their clinical practice, professionals should be aware of this and need to consider asking patients and their families about complementary or alternative medicine use, including faith healing.

Religious coping and the use of prayer in children with sickle cell disease

BACKGROUND

While adolescents and adults with sickle cell disease (SCD) have reported using religion to cope with SCD, there is no data examining religious coping in young children with SCD. The purpose of this qualitative study was to: (1) describe the types of religious coping used by children with SCD; (2) describe the content and frequency of prayer used in relation to SCD; and (3) examine how children viewed God/Higher Power in relation to their SCD.

PROCEDURE

Children with SCD participated in a semi-structured interview and an art drawing exercise focused on the use of general coping and religious coping. Interviews were coded, organized, and analyzed using a template organizational style of interpretation and NVivo 8.0 qualitative software.

RESULTS

Of the 19 participants, the average age was 8.05 years (SD ±1.81); 11 were female (58%); all (100%) were African-American and 9 (47%) were Protestant. Children used religion to gain control, make meaning, and find comfort. Most children reported praying to get well, to keep from getting sick, and to get out of the hospital. Children described a functional God who made them take their medicine or took them to the hospital and an emotional God who made them happy and comforted them when they were sad or scared.

CONCLUSIONS

These children with SCD reported using religion to help cope with the illness. Providers should be aware of the importance of religion to many of these children and integrate religion, as appropriate, into discussions about coping with SCD.

Asthma in sickle cell disease: implications for treatment

Objective. To review issues related to asthma in sickle cell disease and management strategies. Data Source. A systematic review of pertinent original research publications, reviews, and editorials was undertaken using MEDLlNE, the Cochrane Library databases, and CINAHL from 1947 to November 2010. Search terms were [asthma] and [sickle cell disease]. Additional publications considered relevant to the sickle cell disease population of patients were identified; search terms included [sickle cell disease] combined with [acetaminophen], [pain medications], [vitamin D], [beta agonists], [exhaled nitric oxide], and [corticosteroids]. Results. The reported prevalence of asthma in children with sickle cell disease varies from 2% to approximately 50%. Having asthma increases the risk for developing acute chest syndrome , death, or painful episodes compared to having sickle cell disease without asthma. Asthma and sickle cell may be linked by impaired nitric oxide regulation, excessive production of leukotrienes, insufficient levels of Vitamin D, and exposure to acetaminophen in early life. Treatment of sickle cell patients includes using commonly prescribed asthma medications; specific considerations are suggested to ensure safety in the sickle cell population. Conclusion. Prospective controlled trials of drug treatment for asthma in patients who have both sickle cell disease and asthma are urgently needed.

Analyzing traditional medical practitioners’ information-seeking behaviour using Taylor’s information-use environment model

This survey-based study examined the information-seeking behaviour of traditional medical practitioners using Taylor’s information use model. Respondents comprised all 160 traditional medical practitioners that treat sickle cell anaemia. Data were collected using an interviewer-administered, structured questionnaire. Frequency and percentage distributions were employed for data analysis using the Statistical Package for the Social Sciences (SPSS) software. Analysis revealed that traditional medical practice in the study area was male dominated and the majority of the traditional medical practitioners seek information primarily from informal sources, particularly from colleagues within the same professional association. Knowledge of traditional medical practice was revealed to be orally preserved. The low level of education of the traditional medical practitioners denied them access to knowledge that could improve and make their services in the treatment/management of sickle cell anaemia more relevant to the health needs of Nigerian society. Traditional medical practitioners have some good advice for the holistic care of sickle cell anaemia but their information and communication system is very dependent on ‘what works, in some situations’ moving upwards to the experts, and the associations, who then pass this on to other practitioners who may have specific queries. If the associations could actively collect information about the practices of their members, and subject them to some open debate, then good practice might drive out less effective practices faster — and the associations would be in a better situation and have a basis to ‘accredit’ and help train junior traditional medical practitioners. There is therefore a need to bring the traditional medical practitioners into the mainstream by providing them with proper training, facilities and back-up for referral.

Pain syndromes in sickle cell disease: an update

OBJECTIVE

Pain has a critical role in the management of sickle cell disease (SCD). Patients may suffer from several pain syndromes, which may be or not may be associated with other clinical complications, such as anemia, organ failures, and infections.

DESIGN

Data for review were identified by using PubMed to search MEDLINE, limiting the search to abstract/articles in English, Italian, French, and Dutch. The key words pain, sickle cell disease, anemia, hemoglobin, hemoglobinopathy, analgesics, opioids, morphine, acetaminophen, paracetamol, nonsteroidal anti-inflammatory drugs, hematology, and quality of life were variously combined in the title, abstract, and key word search list. The abstract database of most hematological congresses and the bibliographies of most relevant articles were also considered.

RESULTS

There are two major types of SCD pain: acute and chronic. Sometimes, mixed and neuropathic pain can be also observed. Acute pain is mostly related to vaso-occlusion. Chronic pain may be due to some SCD complications, such as leg ulcers and avascular necrosis.

CONCLUSIONS

Pain management in the SCD setting needs multidisciplinary approaches, given the several syndromes and the pathogenic mechanisms that are likely involved. Pain management is not standardized and often difficult, so that many patients with SCD are still poorly treated. Further efforts to develop care plans and treatment protocols as well as management guidelines are required.

Understanding the paradox of patient pain and patient satisfaction

Pain, in all probability, is the most common symptom experienced by individuals who interact with health care providers. It is understood as a complex and highly individual experience. This complexity is reflected in the paradoxical relationship between patient satisfaction and patient reported pain scores. Using a holistic, caring approach, nurses can optimize the effect of analgesia and facilitate comfort for the person living in pain. Caring for the patient in pain begins with heartfelt compassion and intention to help the person who is suffering. The author describes how the complex relationship and interchange between the patient and the holistic nurse explains the paradox.