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Alcolumbre Tobelem FL, de Andrade GALR, Paschoal JKSF, de Oliveira Cardoso MDS, Sarmento Trindade SM, Paschoal EHA, Paschoal-Jr FM, Bor-Seng-Shu E. Cerebral Vasculopathy in Children With Sickle Cell Disease in an Amazonian Population. J Child Neurol 2022; 37:8830738221100088. [PMID: 35611504 DOI: 10.1177/08830738221100088] [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] [Indexed: 11/17/2022]
Abstract
Introduction: Sickle cell disease is the most prevalent hereditary disease in the country. The aim of this study was to use transcranial Doppler as a screening method for identifying cerebral vasculopathy in children with sickle cell disease. Methods: An epidemiologic, descriptive, and cross-sectional study was conducted. Patients aged 2-16 years with sickle cell disease and followed at a neurology referral service between January 2014 and March 2020 underwent transcranial Doppler and complementary examinations to screen for cerebral vasculopathy. Results: Screening and confirmatory examinations diagnosed 14 of 164 patients (8.5%) with cerebral vasculopathy. Regarding stroke risk, as measured by cerebral blood flow velocity, 2 of 14 patients (14.2%) were classified as conditional risk (170-199 cm/s) and 12 of 14 (85.7%) as high risk of stroke. Conclusion: Complementary examinations should be performed in all patients with changes on transcranial Doppler to confirm cerebral vasculopathy. Further studies, particularly genetic, are needed to better understand the relationship between sickle cell disease and cerebral vasculopathy.
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Affiliation(s)
| | | | - Joelma Karin Sagica Fernandes Paschoal
- Amazônia Neurovascular Research Group, Federal University of Pará, Belém, Brazil
- Department of Neurology, Federal University of Pará Medical School, Belém, Brazil
| | - Maria do Socorro de Oliveira Cardoso
- Department of Hematology, Federal University of Pará Medical School, Belém, Brazil
- Foundation Center of Hematology and Hemotherapy of Pará (HEMOPA), Belém, Brazil
| | | | - Eric Homero Albuquerque Paschoal
- Amazônia Neurovascular Research Group, Federal University of Pará, Belém, Brazil
- Department of Neurosurgery, Federal University of Pará, Belém, Brazil
| | - Fernando M Paschoal-Jr
- Amazônia Neurovascular Research Group, Federal University of Pará, Belém, Brazil
- Department of Neurology, Federal University of Pará Medical School, Belém, Brazil
| | - Edson Bor-Seng-Shu
- Laboratory for Neurosonology and Cerebral Hemodynamics, Division of Neurological Surgery, Hospital das Clinicas, São Paulo University Medical School, São Paulo, Brazil
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2
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Kirkham FJ, Lagunju IA. Epidemiology of Stroke in Sickle Cell Disease. J Clin Med 2021; 10:4232. [PMID: 34575342 PMCID: PMC8469588 DOI: 10.3390/jcm10184232] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 12/18/2022] Open
Abstract
Sickle cell disease is the most common cause of stroke in childhood, both ischaemic and haemorrhagic, and it also affects adults with the condition. Without any screening or preventative treatment, the incidence appears to fall within the range 0.5 to 0.9 per 100 patient years of observation. Newborn screening with Penicillin prophylaxis and vaccination leading to reduced bacterial infection may have reduced the incidence, alongside increasing hydroxyurea prescription. Transcranial Doppler screening and prophylactic chronic transfusion for at least an initial year has reduced the incidence of stroke by up to 10-fold in children with time averaged mean of the maximum velocity >200 cm/s. Hydroxyurea also appears to reduce the incidence of first stroke to a similar extent in the same group but the optimal dose remains controversial. The prevention of haemorrhagic stroke at all ages and ischaemic stroke in adults has not yet received the same degree of attention. Although there are fewer studies, silent cerebral infarction on magnetic resonance imaging (MRI), and other neurological conditions, including headache, epilepsy and cognitive dysfunction, are also more prevalent in sickle cell disease compared with age matched controls. Clinical, neuropsychological and quantitative MRI screening may prove useful for understanding epidemiology and aetiology.
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Affiliation(s)
- Fenella Jane Kirkham
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, Faculty of Population Health Sciences, 30 Guilford Street, London WC1N 1EH, UK
- Child Health, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton and University Hospital Southampton, Southampton SO16 6YD, UK
- Paediatric Neurosciences, King’s College Hospital, London SE5 9RS, UK
| | - Ikeoluwa A. Lagunju
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan PMB 3017, Nigeria;
- Department of Paediatrics, University College Hospital, Ibadan PMB 5116, Nigeria
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3
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Jacob M, Saunders DE, Sangeda RZ, Ahmed M, Tutuba H, Kussaga F, Musa B, Mmbando B, Slee AE, Kawadler JM, Makani J, Kirkham FJ. Cerebral Infarcts and Vasculopathy in Tanzanian Children With Sickle Cell Anemia. Pediatr Neurol 2020; 107:64-70. [PMID: 32111561 DOI: 10.1016/j.pediatrneurol.2019.12.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 12/09/2019] [Accepted: 12/14/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cerebral infarcts and vasculopathy in neurologically asymptomatic children with sickle cell anemia (SCA) have received little attention in African settings. This study aimed to establish the prevalence of silent cerebral infarcts (SCI) and vasculopathy and determine associations with exposure to chronic hemolysis, anemia, and hypoxia. METHODS We prospectively studied 224 children with SCA with transcranial Doppler (TCD), and magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA). Regressions were undertaken with contemporaneous hemoglobin, reticulocyte count, mean prior hemoglobin, oxygen content, reticulocyte count, and indirect bilirubin. RESULTS Prevalence of SCI was 27% (61 of 224); cerebral blood flow velocity was abnormal (>200 cm/s) in three and conditional (>170<200 cm/s) in one. Vasculopathy grades 2 (stenosis) and 3 (occlusion) occurred in 16 (7%) and two (1%), respectively; none had grade 4 (moyamoya). SCI was associated with vasculopathy on MRA (odds ratio 2.68; 95% confidence intervals [95% CI] 1.32 to 5.46; P = 0.007) and mean prior indirect bilirubin (odds ratio 1.02, 95% CI 1.00 to 1.03, P = 0.024; n = 83) but not age, sex, non-normal TCD, or contemporaneous hemoglobin. Vasculopathy was associated with mean prior values for hemoglobin (odds ratio 0.33, 95% CI 0.16 to 0.69, P = 0.003; n = 87), oxygen content (odds ratio 0.43, 95% CI 0.25 to 0.74, P = 0.003), reticulocytes (odds ratio 1.20, 95% CI 1.01-1.42, P = 0.041; n = 77), and indirect bilirubin (odds ratio 1.02, 95% CI 1.01 to 1.04, P = 0.009). CONCLUSIONS SCI and vasculopathy on MRA are common in neurologically asymptomatic children with SCA living in Africa, even when TCD is normal. Children with vasculopathy on MRA are at increased risk of SCI. Longitudinal exposure to anemia, hypoxia, and hemolysis appear to be risk factors for vasculopathy.
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Affiliation(s)
- Mboka Jacob
- Department of Radiology & Imaging, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania.
| | - Dawn E Saunders
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Raphael Z Sangeda
- Department of Pharmaceutical Microbiology, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Magda Ahmed
- Department of Radiology & Imaging, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Hilda Tutuba
- Department of Heamatology and Blood Transfusion, Muhimbili Sickle Cell Program, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Frank Kussaga
- Department of Radiology & Imaging, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Balowa Musa
- Department of Radiology & Imaging, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Bruno Mmbando
- Department of Heamatology and Blood Transfusion, Muhimbili Sickle Cell Program, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania; Department of Heamatology and Blood Transfusion, Muhimbili Sickle Cell Program, Muhimbili University of Health and Allied Sciences & National Institute for Medical Research, Tanga Center, Tanga, Tanzania
| | - April E Slee
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jamie M Kawadler
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Julie Makani
- Department of Heamatology and Blood Transfusion, Muhimbili Sickle Cell Program, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania; Muhimbili Sickle Cell Program & Department of Hematology and Blood Transfusion, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Fenella J Kirkham
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
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4
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Václavů L, Petr J, Petersen ET, Mutsaerts HJ, Majoie CB, Wood JC, VanBavel E, Nederveen AJ, Biemond BJ. Cerebral oxygen metabolism in adults with sickle cell disease. Am J Hematol 2020; 95:401-412. [PMID: 31919876 PMCID: PMC7155077 DOI: 10.1002/ajh.25727] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/02/2020] [Accepted: 01/03/2020] [Indexed: 02/01/2023]
Abstract
In sickle cell disease (SCD), oxygen delivery is impaired due to anemia, especially during times of increased metabolic demand, and cerebral blood flow (CBF) must increase to meet changing physiologic needs. But hyperemia limits cerebrovascular reserve (CVR) and ischemic risk prevails despite elevated CBF. The cerebral metabolic rate of oxygen (CMRO2 ) directly reflects oxygen supply and consumption and may therefore be more insightful than flow-based CVR measures for ischemic risk in SCD. We hypothesized that adults with SCD have impaired CMRO2 at rest and that a vasodilatory challenge with acetazolamide would improve CMRO2 . CMRO2 was calculated from CBF and oxygen extraction fraction (OEF), measured with arterial spin labeling and T2 -prepared tissue relaxation with inversion recovery (T2 -TRIR) MRI. We studied 36 adults with SCD without a clinical history of overt stroke, and nine healthy controls. As expected, CBF was higher in patients with SCD versus controls (mean ± SD: 74 ± 16 versus 46 ± 5 mL/100 g/min, P < .001), resulting in similar oxygen delivery (SCD: 377 ± 67 versus controls: 368 ± 42 μmol O2 /100g/min, P = .69). OEF was lower in patients versus controls (27 ± 4 versus 35 ± 4%, P < .001), resulting in lower CMRO2 in patients versus controls (102 ± 24 versus 127 ± 20 μmol O2 /100g/min, P = .002). After acetazolamide, CMRO2 declined further in patients (P < .01) and did not decline significantly in controls (P = .78), indicating that forcing higher CBF worsened oxygen utilization in SCD patients. This lower CMRO2 could reflect variation between healthy and unhealthy vascular beds in terms of dilatory capacity and resistance whereby dysfunctional vessels become more oxygen-deprived, hence increasing the risk of localized ischemia.
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Affiliation(s)
- Lena Václavů
- Radiology & Nuclear Medicine, Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
- C.J. Gorter Center for High Field MRI, Department of Radiology Leiden University Medical Center, Leiden University Leiden The Netherlands
| | - Jan Petr
- Helmholtz‐Zentrum Dresden‐Rossendorf Institute of Radiopharmaceutical Cancer Research Dresden Germany
| | - Esben Thade Petersen
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research Copenhagen University Hospital Hvidovre Hvidovre Denmark
- Center for Magnetic Resonance, Department of Health Technology Technical University of Denmark Kongens Lyngby Denmark
| | - Henri J.M.M. Mutsaerts
- Radiology & Nuclear Medicine, Amsterdam UMC Vrije Universiteit Amsterdam The Netherlands
| | - Charles B.L. Majoie
- Radiology & Nuclear Medicine, Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - John C. Wood
- Cardiology & Radiology Children's Hospital of Los Angeles Los Angeles California
| | - Ed VanBavel
- Biomedical Engineering & Physics, Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Aart J. Nederveen
- Radiology & Nuclear Medicine, Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Bart J. Biemond
- Hematology, Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
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5
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Brennan LC, Kirkham FJ, Gavlak JC. Sleep-disordered breathing and comorbidities: role of the upper airway and craniofacial skeleton. Nat Sci Sleep 2020; 12:907-936. [PMID: 33204196 PMCID: PMC7667585 DOI: 10.2147/nss.s146608] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 04/11/2019] [Indexed: 01/09/2023] Open
Abstract
Obstructive sleep-disordered breathing (SDB), which includes primary snoring through to obstructive sleep apnea syndrome (OSAS), may cause compromise of respiratory gas exchange during sleep, related to transient upper airway narrowing disrupting ventilation, and causing oxyhemoglobin desaturation and poor sleep quality. SDB is common in chronic disorders and has significant implications for health. With prevalence rates globally increasing, this condition is causing a substantial burden on health care costs. Certain populations, including people with sickle cell disease (SCD), exhibit a greater prevalence of OSAS. A review of the literature provides the available normal polysomnography and oximetry data for reference and documents the structural upper airway differences between those with and without OSAS, as well as between ethnicities and disease states. There may be differences in craniofacial development due to atypical growth trajectories or extramedullary hematopoiesis in anemias such as SCD. Studies involving MRI of the upper airway illustrated that OSAS populations tend to have a greater amount of lymphoid tissue, smaller airways, and smaller lower facial skeletons from measurements of the mandible and linear mental spine to clivus. Understanding the potential relationship between these anatomical landmarks and OSAS could help to stratify treatments, guiding choice towards those which most effectively resolve the obstruction. OSAS is relatively common in SCD populations, with hypoxia as a key manifestation, and sequelae including increased risk of stroke. Combatting any structural defects with appropriate interventions could reduce hypoxic exposure and consequently reduce the risk of comorbidities in those with SDB, warranting early treatment interventions.
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Affiliation(s)
- Lucy Charlotte Brennan
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Fenella Jane Kirkham
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, UK.,Department of Child Health, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Clinical and Experimental Sciences, University of Southampton, Southampton, UK
| | - Johanna Cristine Gavlak
- Department of Child Health, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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6
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Merlet AN, Chatel B, Hourdé C, Ravelojaona M, Bendahan D, Féasson L, Messonnier LA. How Sickle Cell Disease Impairs Skeletal Muscle Function: Implications in Daily Life. Med Sci Sports Exerc 2019; 51:4-11. [PMID: 30095751 DOI: 10.1249/mss.0000000000001757] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Sickle cell disease (SCD) is the most frequent life-threatening genetic hemoglobinopathy in the world and occurs due to the synthesis of abnormal hemoglobin S (HbS). hemoglobin S-containing red blood cells (RBC) are fragile, leading to hemolysis and anemia, and adhere to the endothelium, leading to hemorheological and hemodynamical disturbances. In its deoxygenated form, HbS may polymerize, leading to sickling of red blood cells and potentially to vasoocclusive crises. Recent findings observed that SCD patients demonstrate significant skeletal muscle remodeling and display reduced muscle functional capacities, contributing to exercise intolerance and poor quality of life. Although acute high-intensity exercise is not recommended for SCD patients because it may increase the risk of sickling, regular moderate-intensity physical activity could have beneficial effects on skeletal muscle and more generally on the well-being of SCD patients. This article reviews the literature regarding the impact of the disease on muscular tissue characteristics and function, as well as the corresponding implications for SCD patients' quality of life.
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Affiliation(s)
- Angèle N Merlet
- Inter-university Laboratory of Human Movement Sciences, University of Lyon, UJM Saint-Etienne, Saint-Etienne, FRANCE
| | - Benjamin Chatel
- Inter-university Laboratory of Human Movement Sciences, University of Savoie Mont Blanc, Chambéry, FRANCE.,Aix-Marseille University, Marseille, FRANCE
| | - Christophe Hourdé
- Inter-university Laboratory of Human Movement Sciences, University of Savoie Mont Blanc, Chambéry, FRANCE
| | - Marion Ravelojaona
- Inter-university Laboratory of Human Movement Sciences, University of Lyon, UJM Saint-Etienne, Saint-Etienne, FRANCE.,Myology Unit, Department of Clinical and Exercise Physiology, University Hospital of Saint-Etienne, Saint-Etienne, FRANCE
| | | | - Léonard Féasson
- Inter-university Laboratory of Human Movement Sciences, University of Lyon, UJM Saint-Etienne, Saint-Etienne, FRANCE.,Inter-university Laboratory of Human Movement Sciences, University of Savoie Mont Blanc, Chambéry, FRANCE.,Aix-Marseille University, Marseille, FRANCE.,Myology Unit, Department of Clinical and Exercise Physiology, University Hospital of Saint-Etienne, Saint-Etienne, FRANCE
| | - Laurent A Messonnier
- Inter-university Laboratory of Human Movement Sciences, University of Savoie Mont Blanc, Chambéry, FRANCE
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7
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Hirtz D, Kirkham FJ. Sickle Cell Disease and Stroke. Pediatr Neurol 2019; 95:34-41. [PMID: 30948147 DOI: 10.1016/j.pediatrneurol.2019.02.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 01/04/2023]
Abstract
Cerebral infarction is a common complication of sickle cell disease and may manifest as overt stroke or cognitive impairment associated with "silent" cerebral infarction on magnetic resonance imaging. Vasculopathy may be diagnosed on transcranial Doppler or magnetic resonance angiography. The risk factors in sickle cell disease for cognitive impairment, overt ischemic stroke, silent cerebral infarction, overt hemorrhagic stroke, and vasculopathy defined by transcranial Doppler or magnetic resonance angiography overlap, with severe acute and chronic anemia, acute chest crisis, reticulocytosis, and low oxygen saturation reported with the majority. However, there are differences reported in different cohorts, which may reflect age, geographic location, or neuroimaging techniques, for example, magnetic resonance imaging field strength. Regular blood transfusion reduces, but does not abolish, the risk of neurological complications in children with sickle cell disease and either previous overt stroke or silent cerebral infarction or abnormal transcranial Doppler. There are relatively few data on the use of hydroxyurea or other management strategies. Early assessment of the risk of neurocognitive complications is likely to become increasingly important in the management of sickle cell disease.
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Affiliation(s)
- Deborah Hirtz
- University of Vermont School of Medicine, Burlington, Vermont
| | - Fenella J Kirkham
- Developmental Neurosciences Section and Biomedical Research Unit, Clinical and Experimental Sciences, University of Southampton, UCL Great Ormond Street Institute of Child Health, London, UK.
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8
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Guilliams KP, Fields ME, Dowling MM. Advances in Understanding Ischemic Stroke Physiology and the Impact of Vasculopathy in Children With Sickle Cell Disease. Stroke 2019; 50:266-273. [PMID: 30661504 PMCID: PMC6385587 DOI: 10.1161/strokeaha.118.020482] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 11/28/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Kristin P Guilliams
- From the Department of Neurology (K.P.G.), Washington University School of Medicine, St Louis, MO
- Department of Pediatrics (K.P.G., M.E.F.), Washington University School of Medicine, St Louis, MO
| | - Melanie E Fields
- Department of Pediatrics (K.P.G., M.E.F.), Washington University School of Medicine, St Louis, MO
| | - Michael M Dowling
- Department of Pediatrics and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (M.M.D.)
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9
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Coates TD. You don't always get what you want: Does hypoxia cause sickle cell crisis? Am J Hematol 2018; 93:475-477. [PMID: 29377212 DOI: 10.1002/ajh.25048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 01/22/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Thomas D. Coates
- Section Head of Hematology, Childrens Center for Cancer, Blood Disease and Bone Marrow Transplantation, Childrens Hospital Los Angeles
- Professor of Pediatrics and Pathology; University of Southern California Keck School of Medicine; Los Angeles California
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10
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Farrell AN, Goudy SL, Yee ME, Leu RM, Landry AM. Adenotonsillectomy in children with sickle cell disease and obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 2018; 111:158-161. [PMID: 29958601 PMCID: PMC6408690 DOI: 10.1016/j.ijporl.2018.05.034] [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] [Received: 04/07/2018] [Revised: 05/26/2018] [Accepted: 05/28/2018] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is prevalent and may be more severe in children with Sickle Cell Disease (SCD) compared to the general pediatric population. OBJECTIVES The objective of this study was to describe the therapeutic effects and complications of tonsillectomy and adenoidectomy (T&A) for treatment of OSA in children with SCD. METHODS A comprehensive database of pediatric SCD patients was reviewed to identify all patients who underwent T&A between 2010 and 2016. An IRB-approved, retrospective review of laboratory values, perioperative course, pre- and post-T&A hospital utilization, and polysomnography was conducted. RESULTS There were 132 SCD children (108 HbSS) who underwent T&A. Mean age was 7.6 ± 4.6 years. The mean baseline hemoglobin of these patients was 9.3 ± 1.4 g/dL; 72.7% of patients had pre-operative transfusion, such that the mean Hb at time of T&A was 11.4 ± 1.0 g/dL. The average admission length surrounding T&A was 3.5 ± 1.2 days. Complications were documented in 11.4% of operative cases. Polysomnography was available in 104 pre-T&A and 45 post-T&A. The Apnea-Hypopnea Index decreased on post-T&A polysomnogram (7.6 ± 8.7 vs. 1.3 ± 1.9, p = 0.0001). The O2 nadir improved on post-T&A polysomnogram (81.2 ± 10.8 vs. 89.3 ± 7, p = 0.0003). Emergency room visits (mean events per year) decreased post-operatively (2.6 ± 2.8 vs. 1.8 ± 2.2, p = 0.0002). CONCLUSIONS T&A can be a safe and effective option to treat OSA in pediatric patients with SCD and was significantly associated with reduced AHI and fewer ER visits post-operatively.
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Affiliation(s)
- Annie N. Farrell
- Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA, 30307, USA,Corresponding author. (A.N. Farrell)
| | - Steven L. Goudy
- Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA, 30307, USA,Department of Otolaryngology, Children’s Hospital of Atlanta, Division of Pediatric Otolaryngology, 2015 Uppergate Drive, Atlanta, GA, 30322, USA
| | - Marianne E. Yee
- Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA, 30307, USA,Department of Pediatrics, Children’s Hospital of Atlanta, Division of Hematology/Oncology, 2015 Uppergate Drive, Atlanta, GA, 30322, USA,Children’s Hospital of Atlanta, Aflac Cancer and Blood Disorders Center, 1405 Clifton Road, Atlanta, GA, 30329, USA
| | - Roberta M. Leu
- Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA, 30307, USA,Department of Pediatrics, Children’s Hospital of Atlanta, Division of Pulmonary, Allergy/Immunology, Cystic Fibrosis, and Sleep, 1605 Chantilly Drive NE, Atlanta, GA, 30324, USA
| | - April M. Landry
- Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA, 30307, USA,Department of Otolaryngology, Children’s Hospital of Atlanta, Division of Pediatric Otolaryngology, 2015 Uppergate Drive, Atlanta, GA, 30322, USA
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11
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Kawadler JM, Hales PW, Barker S, Cox TCS, Kirkham FJ, Clark CA. Cerebral perfusion characteristics show differences in younger versus older children with sickle cell anaemia: Results from a multiple-inflow-time arterial spin labelling study. NMR IN BIOMEDICINE 2018; 31:e3915. [PMID: 29601112 DOI: 10.1002/nbm.3915] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 02/07/2018] [Accepted: 02/11/2018] [Indexed: 06/08/2023]
Abstract
Sickle cell anaemia (SCA) is associated with chronic anaemia and oxygen desaturation, which elevate cerebral blood flow (CBF) and increase the risk of neurocognitive complications. Arterial spin labelling (ASL) provides a methodology for measuring CBF non-invasively; however, ASL techniques using only a single inflow time are not sufficient to fully characterize abnormal haemodynamic behaviour in SCA. This study investigated haemodynamic parameters from a multi-inflow-time ASL acquisition in younger (8-12 years) and older (13-18 years) children with SCA with and without silent cerebral infarction (SCI+/-) (n = 20 and 19 respectively, 6 and 4 SCI+ respectively) and healthy controls (n = 9 and 7 respectively). Compared with controls, CBF was elevated globally in both groups of patients. In the younger SCA patients, blood oxygen content was negatively correlated with CBF in the middle and posterior cerebral artery territories and significantly positively correlated with bolus arrival time (BAT) in the anterior and middle cerebral artery territories. In older children, SCA patients had significantly shorter BAT than healthy controls and there was a significant negative correlation between CBF and oxygen content only in the territory of the posterior cerebral artery, with a trend for a correlation in the anterior cerebral artery but no relationship for the middle cerebral artery territory. In the younger group, SCI+ patients had significantly higher CBF in the posterior cerebral artery territory (SCI+ mean = 92.78 ml/100 g/min; SCI- mean = 72.71 ml/100 g/min; F = 4.28, p = 0.04), but this no longer reached significance when two children with abnormal transcranial Doppler and one with haemoglobin SC disease were excluded, and there were no significant differences between patients with and without SCI in the older children. With age, there appears to be increasing disparity between patients and controls in terms of the relationship between CBF and oxygen content in the anterior circulation, potentially predicting the risk of acute and chronic compromise of brain tissue.
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Affiliation(s)
- Jamie M Kawadler
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Patrick W Hales
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Simon Barker
- Wessex Neurological Centre and Child Health, University Hospital Southampton, Southampton, UK
| | - Timothy C S Cox
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - Fenella J Kirkham
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
- Wessex Neurological Centre and Child Health, University Hospital Southampton, Southampton, UK
- Clinical and Experimental Sciences, University of Southampton, Southampton, UK
| | - Chris A Clark
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
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12
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Belisário AR, Silva CM, Velloso-Rodrigues C, Viana MB. Genetic, laboratory and clinical risk factors in the development of overt ischemic stroke in children with sickle cell disease. Hematol Transfus Cell Ther 2018; 40:166-181. [PMID: 30057991 PMCID: PMC6003005 DOI: 10.1016/j.bjhh.2017.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 08/30/2017] [Indexed: 12/22/2022] Open
Abstract
Cerebrovascular disease, particularly stroke, is one of the most severe clinical complications associated with sickle cell disease and is a significant cause of morbidity in both children and adults. Over the past two decades, considerable advances have been made in the understanding of its natural history and enabled early identification and treatment of children at the highest risk. Transcranial Doppler screening and regular blood transfusions have markedly reduced the risk of stroke in children. However, transcranial Doppler has a limited positive predictive value and the pathophysiology of cerebrovascular disease is not completely understood. In this review, we will focus on the current state of knowledge about risk factors associated with ischemic stroke in patients with sickle cell disease. A search of PubMed was performed to identify studies. Full texts of the included articles were reviewed and data were summarized in a table. The coinheritance of alpha-thalassemia plays a protective role against ischemic stroke. The influence of other genetic risk factors is controversial, still preliminary, and requires confirmatory studies. Recent advances have established the reticulocyte count as the most important laboratory risk factor. Clinical features associated with acute hypoxemia as well as silent infarcts seem to influence the development of strokes in children. However, transcranial Doppler remains the only available clinical prognostic tool to have been validated. If our understanding of the many risk factors associated with stroke advances further, it may be possible to develop useful tools to detect patients at the highest risk early, improving the selection of children requiring intensification therapy.
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Affiliation(s)
- André Rolim Belisário
- Centro de Tecidos Biológicos de Minas Gerais, Fundação Hemominas, Lagoa Santa, MG, Brazil
- Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
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Rankine-Mullings AE, Morrison-Levy N, Soares D, Aldred K, King L, Ali S, Knight-Madden JM, Wisdom-Phipps M, Adams RJ, Ware RE, Reid M. Transcranial Doppler velocity among Jamaican children with sickle cell anaemia: determining the significance of haematological values and nutrition. Br J Haematol 2018; 181:242-251. [PMID: 29504121 DOI: 10.1111/bjh.15162] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 01/03/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Angela E. Rankine-Mullings
- Sickle Cell Unit; Caribbean Institute for Health Research; University of the West Indies; Kingston Jamaica
| | - Nadine Morrison-Levy
- Sickle Cell Unit; Caribbean Institute for Health Research; University of the West Indies; Kingston Jamaica
| | - Deanne Soares
- Tropical Metabolism Research Unit; Caribbean Institute for Health Research Institute; University of the West Indies; Kingston Jamaica
| | - Karen Aldred
- Sickle Cell Unit; Caribbean Institute for Health Research; University of the West Indies; Kingston Jamaica
| | - Lesley King
- Sickle Cell Unit; Caribbean Institute for Health Research; University of the West Indies; Kingston Jamaica
| | - Susanna Ali
- Sickle Cell Unit; Caribbean Institute for Health Research; University of the West Indies; Kingston Jamaica
| | - Jennifer M. Knight-Madden
- Sickle Cell Unit; Caribbean Institute for Health Research; University of the West Indies; Kingston Jamaica
| | - Margaret Wisdom-Phipps
- Sickle Cell Unit; Caribbean Institute for Health Research; University of the West Indies; Kingston Jamaica
| | - Robert J. Adams
- Neurology; College of Medicine; Medical University of South Carolina; Charleston SC USA
| | - Russell E. Ware
- Cincinnati Children's Hospital Medical Centre; Cincinnati OH USA
| | - Marvin Reid
- Tropical Metabolism Research Unit; Caribbean Institute for Health Research Institute; University of the West Indies; Kingston Jamaica
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14
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Neumayr L, Vichinsky E. Stroke recurrence in adult sickle cell patients: it is time for action! Transfusion 2018; 56:1001-4. [PMID: 27167352 DOI: 10.1111/trf.13614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 03/15/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Lynne Neumayr
- UCSF Benioff Children's Hospital Oakland, Oakland, CA
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15
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Dlamini N, Saunders DE, Bynevelt M, Trompeter S, Cox TC, Bucks RS, Kirkham FJ. Nocturnal oxyhemoglobin desaturation and arteriopathy in a pediatric sickle cell disease cohort. Neurology 2017; 89:2406-2412. [PMID: 29117957 PMCID: PMC5729796 DOI: 10.1212/wnl.0000000000004728] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 09/05/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The purpose of this study of sickle cell disease (SCD) was to determine whether arteriopathy, measurable as intracranial vessel signal loss on magnetic resonance angiography (MRA), was associated with low nocturnal hemoglobin oxygen saturation (SpO2) or hemolytic rate, measurable as reticulocytosis or unconjugated hyperbilirubinemia. METHODS Ninety-five East London children with SCD without prior stroke had overnight pulse oximetry, of whom 47 (26 boys, 39 hemoglobin SS; mean age 9.1 ± 3.1 years) also had MRA, transcranial Doppler (TCD), steady-state hemoglobin, and reticulocytes within 34 months. Two radiologists blinded to the other data graded arteriopathy on MRA as 0 (none) or as increasing severity grades 1, 2, or 3. RESULTS Grades 2 or 3 arteriopathy (n = 24; 2 with abnormal TCD) predicted stroke/TIA compared with grades 0 and 1 (log-rank χ2 [1, n = 47] = 8.1, p = 0.004). Mean overnight SpO2 correlated negatively with reticulocyte percentage (r = -0.387; p = 0.007). Despite no significant differences across the degrees of arteriopathy in genotype, mean overnight SpO2 was higher (p < 0.01) in those with grade 0 (97.0% ± 1.6%) than those with grades 2 (93.9 ± 3.7%) or 3 (93.5% ± 3.0%) arteriopathy. Unconjugated bilirubin was not associated but reticulocyte percentage was lower (p < 0.001) in those with grade 0 than those with grades 2 and 3 arteriopathy. In multivariable logistic regression, lower mean overnight SpO2 (odds ratio 0.50, 95% confidence interval 0.26-0.96; p < 0.01) predicted arteriopathy independent of reticulocyte percentage (odds ratio 1.47, 95% confidence interval 1.15-1.87; p = 0.003). CONCLUSION Low nocturnal SpO2 and reticulocytosis are associated with intracranial arteriopathy in children with SCD. Preventative strategies might reduce stroke risk.
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Affiliation(s)
- Nomazulu Dlamini
- From Developmental Neurosciences (N.D., F.J.K.), UCL Great Ormond Street Institute of Child Health, London, UK; Hospital for Sick Children (N.D.), Toronto, Canada; Department of Radiology (D.E.S., M.B., T.C.C.), Great Ormond Street Hospital for Children NHS Trust, London, UK; University of Western Australia (M.B., R.S.B.), Perth; and Department of Haematology (S.T.), University College London Hospital, UK
| | - Dawn E Saunders
- From Developmental Neurosciences (N.D., F.J.K.), UCL Great Ormond Street Institute of Child Health, London, UK; Hospital for Sick Children (N.D.), Toronto, Canada; Department of Radiology (D.E.S., M.B., T.C.C.), Great Ormond Street Hospital for Children NHS Trust, London, UK; University of Western Australia (M.B., R.S.B.), Perth; and Department of Haematology (S.T.), University College London Hospital, UK
| | - Michael Bynevelt
- From Developmental Neurosciences (N.D., F.J.K.), UCL Great Ormond Street Institute of Child Health, London, UK; Hospital for Sick Children (N.D.), Toronto, Canada; Department of Radiology (D.E.S., M.B., T.C.C.), Great Ormond Street Hospital for Children NHS Trust, London, UK; University of Western Australia (M.B., R.S.B.), Perth; and Department of Haematology (S.T.), University College London Hospital, UK
| | - Sara Trompeter
- From Developmental Neurosciences (N.D., F.J.K.), UCL Great Ormond Street Institute of Child Health, London, UK; Hospital for Sick Children (N.D.), Toronto, Canada; Department of Radiology (D.E.S., M.B., T.C.C.), Great Ormond Street Hospital for Children NHS Trust, London, UK; University of Western Australia (M.B., R.S.B.), Perth; and Department of Haematology (S.T.), University College London Hospital, UK
| | - Timothy C Cox
- From Developmental Neurosciences (N.D., F.J.K.), UCL Great Ormond Street Institute of Child Health, London, UK; Hospital for Sick Children (N.D.), Toronto, Canada; Department of Radiology (D.E.S., M.B., T.C.C.), Great Ormond Street Hospital for Children NHS Trust, London, UK; University of Western Australia (M.B., R.S.B.), Perth; and Department of Haematology (S.T.), University College London Hospital, UK
| | - Romola S Bucks
- From Developmental Neurosciences (N.D., F.J.K.), UCL Great Ormond Street Institute of Child Health, London, UK; Hospital for Sick Children (N.D.), Toronto, Canada; Department of Radiology (D.E.S., M.B., T.C.C.), Great Ormond Street Hospital for Children NHS Trust, London, UK; University of Western Australia (M.B., R.S.B.), Perth; and Department of Haematology (S.T.), University College London Hospital, UK
| | - Fenella J Kirkham
- From Developmental Neurosciences (N.D., F.J.K.), UCL Great Ormond Street Institute of Child Health, London, UK; Hospital for Sick Children (N.D.), Toronto, Canada; Department of Radiology (D.E.S., M.B., T.C.C.), Great Ormond Street Hospital for Children NHS Trust, London, UK; University of Western Australia (M.B., R.S.B.), Perth; and Department of Haematology (S.T.), University College London Hospital, UK.
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16
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Croal PL, Leung J, Kosinski P, Shroff M, Odame I, Kassner A. Assessment of cerebral blood flow with magnetic resonance imaging in children with sickle cell disease: A quantitative comparison with transcranial Doppler ultrasonography. Brain Behav 2017; 7:e00811. [PMID: 29201539 PMCID: PMC5698856 DOI: 10.1002/brb3.811] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 08/01/2017] [Accepted: 08/05/2017] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Transcranial Doppler ultrasonography (TCD) is a clinical tool for stratifying ischemic stroke risk by identifying abnormal elevations in blood flow velocity (BFV) in the middle cerebral artery (MCA). However, TCD is not effective at screening for subtle neurologic injury such as silent cerebral infarcts. To better understand this disparity, we compared TCD measures of BFV with tissue-level cerebral blood flow (CBF) using arterial spin-labeling MRI in children with and without sickle cell disease, and correlated these measurements against clinical hematologic measures of disease severity. METHODS TCD and MRI assessment were performed in 13 pediatric sickle cell disease patients and eight age-matched controls. Using MRI measures of MCA diameter and territory weight, TCD measures of BFV in the MCA [cm/s] were converted into units of CBF [ml min-1100 g-1] for comparison. RESULTS There was no significant association between TCD measures of BFV in the MCA and corresponding MRI measures of CBF in patients (r = .28, p = .39) or controls (r = .10, p = .81). After conversion from BFV into units of CBF, a strong association was observed between TCD and MRI measures (r = .67, p = .017 in patients, r = .86, p = .006 in controls). While BFV in the MCA showed a lack of correlation with arterial oxygen content, an inverse association was observed for CBF measurements. CONCLUSIONS This study demonstrates that BFV in the MCA cannot be used as a surrogate marker for tissue-level CBF in children with sickle cell disease. Therefore, TCD alone may not be sufficient for understanding and predicting subtle pathophysiology in this population, highlighting the potential clinical value of tissue-level CBF.
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Affiliation(s)
- Paula L Croal
- Physiology & Experimental Medicine The Hospital for Sick Children Toronto ON Canada
| | - Jackie Leung
- Physiology & Experimental Medicine The Hospital for Sick Children Toronto ON Canada
| | | | - Manohar Shroff
- Department of Diagnostic Imaging The Hospital for Sick Children Toronto ON Canada
| | - Isaac Odame
- Division of Haematology/Oncology The Hospital for Sick Children Toronto ON Canada
| | - Andrea Kassner
- Physiology & Experimental Medicine The Hospital for Sick Children Toronto ON Canada.,Institute of Medical Science University of Toronto Toronto ON Canada
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17
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Coloigner J, Phlypo R, Coates TD, Lepore N, Wood JC. Graph Lasso-Based Test for Evaluating Functional Brain Connectivity in Sickle Cell Disease. Brain Connect 2017; 7:443-453. [PMID: 28747064 PMCID: PMC5647492 DOI: 10.1089/brain.2016.0474] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Sickle cell disease (SCD) is a vascular disorder that is often associated with recurrent ischemia-reperfusion injury, anemia, vasculopathy, and strokes. These cerebral injuries are associated with neurological dysfunction, limiting the full developing potential of the patient. However, recent large studies of SCD have demonstrated that cognitive impairment occurs even in the absence of brain abnormalities on conventional magnetic resonance imaging (MRI). These observations support an emerging consensus that brain injury in SCD is diffuse and that conventional neuroimaging often underestimates the extent of injury. In this article, we postulated that alterations in the cerebral connectivity may constitute a sensitive biomarker of SCD severity. Using functional MRI, a connectivity study analyzing the SCD patients individually was performed. First, a robust learning scheme based on graphical lasso model and Fréchet mean was used for estimating a consistent descriptor of healthy brain connectivity. Then, we tested a statistical method that provides an individual index of similarity between this healthy connectivity model and each SCD patient's connectivity matrix. Our results demonstrated that the reference connectivity model was not appropriate to model connectivity for only 4 out of 27 patients. After controlling for the gender, two separate predictors of this individual similarity index were the anemia (p = 0.02) and white matter hyperintensities (WMH) (silent stroke) (p = 0.03), so that patients with low hemoglobin level or with WMH have the least similarity to the reference connectivity model. Further studies are required to determine whether the resting-state connectivity changes reflect pathological changes or compensatory responses to chronic anemia.
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Affiliation(s)
- Julie Coloigner
- CIBORG, Division of Radiology, Children's Hospital Los Angeles, Los Angeles, California
| | - Ronald Phlypo
- University of Grenoble Alpes, CNRS, Grenoble INP, GIPSA-Lab, Grenoble, France
| | - Thomas D. Coates
- Division of Hematology, Children's Hospital Los Angeles, Los Angeles, California
| | - Natasha Lepore
- CIBORG, Division of Radiology, Children's Hospital Los Angeles, Los Angeles, California
| | - John C. Wood
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, California
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18
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Nkya S, Mgaya J, Urio F, Makubi A, Thein SL, Menzel S, Cox SE, Newton CR, Kirkham FJ, Mmbando BP, Makani J. Fetal Hemoglobin is Associated with Peripheral Oxygen Saturation in Sickle Cell Disease in Tanzania. EBioMedicine 2017; 23:146-149. [PMID: 28844412 PMCID: PMC5605324 DOI: 10.1016/j.ebiom.2017.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 07/31/2017] [Accepted: 08/05/2017] [Indexed: 11/10/2022] Open
Abstract
Fetal hemoglobin (HbF) and peripheral hemoglobin oxygen saturation (SpO2) both predict clinical severity in sickle cell disease (SCD), while reticulocytosis is associated with vasculopathy, but there are few data on mechanisms. HbF, SpO2 and routine clinical and laboratory measures were available in a Tanzanian cohort of 1175 SCD individuals aged ≥ 5 years and the association with SpO2 (as response variable transformed to a Poisson distribution) was assessed by negative binomial model with age and sex as covariates. Increase in HbF was associated with increased SpO2 (rate ratio, RR = 1.19; 95% confidence intervals [CI] 1.04, 1.37 per natural log unit of HbF; p = 0.0004). In univariable analysis, SpO2 was inversely associated with age, reticulocyte count, and log (total bilirubin) and directly with pulse, SBP, hemoglobin, and log(HbF). In multivariable regression log(HbF) (RR 1.191; 95%CI 1.04, 1.37; p = 0.013), pulse (RR 1.01; 95%CI 1.00, 1.01; p = 0.026), SBP (RR 1.008; 95%CI 1.00, 1.02; p = 0.014), and hemoglobin (1.120; 95%CI 1.05, 1.19; p = 0.001) were positively and independently associated with SpO2 while reticulocyte count (RR 0.985; 95%CI 0.97, 0.99; p = 0.019) was independently inversely associated with SpO2. In SCD, improving SpO2, in part through cardiovascular compensation and associated with reduced reticulocytosis, may be a mechanism by which HbF reduces disease severity. Fetal hemoglobin may moderate sickle cell disease through increased oxygen saturation. Low oxygen saturation is associated with reticulocytosis which might moderate cerebral vasculopathy and stroke risk. Higher pulse rate and systolic blood pressure in those with higher SpO2 suggests cardiovascular compensation for low SpO2.
Fetal hemoglobin (HbF) is normally synthesized during intrauterine life and it starts to decline before birth being replaced by adult hemoglobin (HbA). However some individuals continue to synthesize HbF to adulthood and are relatively protected from severe sickle cell disease. The mechanism of HbF protection in SCD has not been entirely established. This study reports a positive association between HbF and oxygen saturation (SpO2). Higher SpO2 is associated with decreased reticulocytes but increased pulse rate and systolic blood pressure, suggesting SpO2 is maintained in part through cardiovascular compensation. Increasing HbF may reduce disease severity partly through increasing SpO2.
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Affiliation(s)
- Siana Nkya
- Sickle Cell Programme, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania; Dar-es-Salaam University College of Education, Dar-es-Salaam, Tanzania.
| | - Josephine Mgaya
- Sickle Cell Programme, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Florence Urio
- Sickle Cell Programme, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Abel Makubi
- Sickle Cell Programme, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Swee Lay Thein
- King's College London, Molecular Haematology, Division of Cancer Studies, UK; Sickle Cell Branch, National Heart, Lung and Blood Institute, The National Institutes of Health, USA
| | - Stephan Menzel
- King's College London, Molecular Haematology, Division of Cancer Studies, UK
| | - Sharon E Cox
- Sickle Cell Programme, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania; Graduate School of Tropical Medicine & Global Health, Nagasaki University, Nagasaki, Japan; Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Charles R Newton
- Sickle Cell Programme, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania; Nuffield Department of Medicine, University of Oxford, UK
| | - Fenella J Kirkham
- UCL Great Oromnd Street Institute of Child Health, London, UK; Clinical and Experimental Sciences, University of Southampton, UK; Southampton Children's Hospital, UK
| | - Bruno P Mmbando
- Sickle Cell Programme, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania; National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Julie Makani
- Sickle Cell Programme, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania; Nuffield Department of Medicine, University of Oxford, UK
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19
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Brewin J, Kaya B, Chakravorty S. How I manage sickle cell patients with high transcranial doppler results. Br J Haematol 2017; 179:377-388. [DOI: 10.1111/bjh.14850] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- John Brewin
- Department of Haematology; King's College London; London UK
| | - Banu Kaya
- Department of Haematology; Royal London Hospital; London UK
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20
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Meier ER, Fasano RM, Levett PR. A systematic review of the literature for severity predictors in children with sickle cell anemia. Blood Cells Mol Dis 2017; 65:86-94. [DOI: 10.1016/j.bcmd.2017.01.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 01/27/2017] [Accepted: 01/28/2017] [Indexed: 12/19/2022]
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21
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Di Liberto G, Kiger L, Marden MC, Boyer L, Poitrine FC, Conti M, Rakotoson MG, Habibi A, Khorgami S, Vingert B, Maitre B, Galacteros F, Pirenne F, Bartolucci P. Dense red blood cell and oxygen desaturation in sickle-cell disease. Am J Hematol 2016; 91:1008-13. [PMID: 27380930 DOI: 10.1002/ajh.24467] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 07/01/2016] [Indexed: 02/02/2023]
Abstract
Production of abnormal hemoglobin (HbS) in sickle-cell disease (SCD) results in its polymerization in deoxygenated conditions and in sickled-RBC formation. Dense RBCs (DRBCs), defined as density >1.11 and characterized by increased rigidity are absent in normal AA subjects, but present at percentages that vary of a patient to another remaining stable throughout adulthood for each patient. Polymerized HbS has reduced affinity for oxygen, demonstrated by the rightward shift of the oxygen-dissociation curve, leading to disturbances in oxygen transport. Ninety-two SCD patients' total RBCs were separated into LightDRBC (LRBC) (d < 1.11 g/mL) and DRBC fractions. Venous blood partial oxygen pressure and RBC-fraction-deoxygenation and -reoxygenation Hb-oxygen-equilibrium curves were determined. All patients took a 6-minute walking test (6MWT); 10 had results before and after >6 months on hydroxyurea. 6MWT time with SpO2 < 88% (TSpO2 < 88) assessed the physiological impact of exertion. Elevated mean corpuscular hemoglobin (Hb) concentrations, decreased %HbF, and 2,3-bisphosphoglycerates in DRBCs modulated Hb-oxygen affinity. Deoxygenation and reoxygenation Hb-oxygen equilibrium curves differed between normal Hb AA and SS RBCs and between LRBCs and DRBCs, with rightward shifts confirming HbS-polymerization's role in affinity loss. In bivariate analyses, 50% Hb saturation correlated positively with %DRBCs (P < 0.0001, r(2) = 0.34) and negatively with %HbF (P < 0.0001, r(2) = 0.25). The higher the %DRBCs, the longer the TSpO2 88 (P = 0.04). Hydroxyurea was associated with significantly shorter TSpO2 < 88 (P = 0.01). We report that the %DRBCs directly affects SCD patients' SpO2 during exertion; hydroxyurea improves oxygen affinity and lowers the %DRBCs. Am. J. Hematol. 91:1008-1013, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Gaetana Di Liberto
- INSERM-U955, Equipe 2: Transfusion Et Maladies Du Globule Rouge, Laboratoire D'Excellence, GRex, Institut Mondor; Créteil France
- Etablissement Français Du Sang, Île-de-France Mondor; Créteil France
| | - Laurent Kiger
- INSERM-U955, Equipe 2: Transfusion Et Maladies Du Globule Rouge, Laboratoire D'Excellence, GRex, Institut Mondor; Créteil France
| | - Michael C. Marden
- INSERM-U955, Equipe 2: Transfusion Et Maladies Du Globule Rouge, Laboratoire D'Excellence, GRex, Institut Mondor; Créteil France
| | - Laurent Boyer
- INSERM, Unité U955, Equipe 4: Physiopathologie De La Bronchopneumopathie Chronique Obstructive Et Autres Conséquences Respiratoires De L'inhalation De Particules De L'environnement; Créteil France
| | - Florence Canoui Poitrine
- Pôle Recherche Clinique - Santé Publique, Hôpital Henri-Mondor, and Laboratoire D'Investigation Clinique: Epidémiologie Clinique - Evaluation Médico-Economique, LIC EA 4393, Université Paris-Est Créteil; Créteil 94010 France
| | - Marc Conti
- Service De Biochimie, Hôpital Henri-Mondor, AP-HP, Université Paris-Est; Créteil 94010 France
| | - Marie Georgine Rakotoson
- INSERM-U955, Equipe 2: Transfusion Et Maladies Du Globule Rouge, Laboratoire D'Excellence, GRex, Institut Mondor; Créteil France
| | - Anoosha Habibi
- Centre De Référence Des Syndromes Drépanocytaires Majeurs, Hôpital Henri-Mondor, Assistance Publique-Hôpitaux De Paris (AP-HP), Université Paris-Est Créteil; Créteil France
| | - Sanam Khorgami
- Etablissement Français Du Sang, Île-de-France Mondor; Créteil France
| | - Benoit Vingert
- Etablissement Français Du Sang, Île-de-France Mondor; Créteil France
| | - Bernard Maitre
- Service De Réanimation Médicale, Hôpital Henri-Mondor, AP-HP, Université Paris-Est; Créteil France
| | - Frederic Galacteros
- INSERM-U955, Equipe 2: Transfusion Et Maladies Du Globule Rouge, Laboratoire D'Excellence, GRex, Institut Mondor; Créteil France
- Centre De Référence Des Syndromes Drépanocytaires Majeurs, Hôpital Henri-Mondor, Assistance Publique-Hôpitaux De Paris (AP-HP), Université Paris-Est Créteil; Créteil France
| | - France Pirenne
- INSERM-U955, Equipe 2: Transfusion Et Maladies Du Globule Rouge, Laboratoire D'Excellence, GRex, Institut Mondor; Créteil France
- Etablissement Français Du Sang, Île-de-France Mondor; Créteil France
| | - Pablo Bartolucci
- INSERM-U955, Equipe 2: Transfusion Et Maladies Du Globule Rouge, Laboratoire D'Excellence, GRex, Institut Mondor; Créteil France
- Centre De Référence Des Syndromes Drépanocytaires Majeurs, Hôpital Henri-Mondor, Assistance Publique-Hôpitaux De Paris (AP-HP), Université Paris-Est Créteil; Créteil France
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22
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Belisário AR, Sales RR, Toledo NE, Muniz MBDSR, Velloso-Rodrigues C, Silva CM, Viana MB. Reticulocyte count is the most important predictor of acute cerebral ischemia and high-risk transcranial Doppler in a newborn cohort of 395 children with sickle cell anemia. Ann Hematol 2016; 95:1869-80. [PMID: 27520094 DOI: 10.1007/s00277-016-2789-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 08/05/2016] [Indexed: 10/21/2022]
Abstract
Stroke is a severe clinical manifestation of sickle cell anemia (SCA). Despite the prognostic relevance of transcranial Doppler (TCD), more accurate tools to assess stroke risk in children with SCA are required. Here, we describe the effect of clinical, laboratory, and molecular features on the risk of stroke and high-risk TCD in children from the newborn cohort of Minas Gerais, Brazil. Outcomes studied were acute cerebral ischemia and high-risk TCD. Clinical and hematological data were retrieved from children's records. Genetic markers, which were known for their association with stroke risk, were genotyped by polymerase chain reaction/restriction fragment length polymorphism and sequencing. The cumulative incidence of acute cerebral ischemia by the age of 8 years was 7.4 % and that of high-risk TCD by the age of 11.5 years was 14.2 %. The final multivariate model for acute cerebral ischemia risk included high white blood cell count and reticulocyte count, acute chest syndrome rate, and the single nucleotide polymorphisms (SNPs) TEK rs489347 and TNF-α rs1800629. The model for high-risk TCD included high reticulocyte count and the SNPs TEK rs489347 and TGFBR3 rs284875. Children with risk factors should be considered for intensive risk monitoring and for intervention therapy.
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Affiliation(s)
- André Rolim Belisário
- Centro de Tecidos Biológicos de Minas Gerais, Fundação Hemominas, Rua das Goiabeiras, 779, Lagoa Santa, Minas Gerais, 33400-000, Brazil. .,Faculdade de Medicina/NUPAD, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.
| | | | | | | | - Cibele Velloso-Rodrigues
- Departamento Básico-Área de Saúde, Universidade Federal de Juiz de Fora (UFJF), Governador Valadares, Minas Gerais, Brazil
| | - Célia Maria Silva
- Serviço de Pesquisa, Fundação Hemominas, Belo Horizonte, Minas Gerais, Brazil
| | - Marcos Borato Viana
- Faculdade de Medicina/NUPAD, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
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Zhang X, Li C, Li Q. Magnetic resonance imaging in pediatric sickle cell anemia. Exp Ther Med 2016; 12:555-558. [PMID: 27446243 PMCID: PMC4950809 DOI: 10.3892/etm.2016.3417] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 06/02/2016] [Indexed: 12/24/2022] Open
Abstract
Sickle cell disease is the result of altered genetic make up due to hereditary encounter and its form as homozygous sickle cell anemia is the most common and severe. The disease is characterized by chronic anemia, recurrent pain crises and vascular occlusion. Neurologically, there is a high incidence of stroke in childhood, as well as cognitive dysfunction. Newborn screening programmes and preventative treatments have allowed a much longer lifespan. However, recently, neurological research has shifted to characterizing more subtle aspects of brain development and functioning that may be critically important to the individual's quality of life. The present review article examines the neurological and neurocognitive complications of sickle cell disease, and discusses the importance of magnetic resonance imaging scans in the management of the disease.
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Affiliation(s)
- Xinxian Zhang
- Department of Radiology, Xuzhou Children's Hospital, Xuzhou, Jiangsu 221002, P.R. China
| | - Chenglong Li
- Department of Radiology, Xuzhou Children's Hospital, Xuzhou, Jiangsu 221002, P.R. China
| | - Qiancheng Li
- Department of Radiology, Xuzhou Children's Hospital, Xuzhou, Jiangsu 221002, P.R. China
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Sommet J, Alberti C, Couque N, Verlhac S, Haouari Z, Mohamed D, François M, Missud F, Holvoet L, Elmaleh M, Ithier G, Denjean A, Elion J, Baruchel A, Benkerrou M. Clinical and haematological risk factors for cerebral macrovasculopathy in a sickle cell disease newborn cohort: a prospective study. Br J Haematol 2016; 172:966-77. [DOI: 10.1111/bjh.13916] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 11/13/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Julie Sommet
- U 1123; ECEVE; Hôpital Robert-Debré; INSERM; Paris France
- UMR-S 1123; ECEVE; Sorbonne Paris Cité; Univ Paris Diderot; Paris France
- Hôpital Robert-Debré; Unité d'Epidémiologie Clinique; AP-HP; Paris France
| | - Corinne Alberti
- U 1123; ECEVE; Hôpital Robert-Debré; INSERM; Paris France
- UMR-S 1123; ECEVE; Sorbonne Paris Cité; Univ Paris Diderot; Paris France
- Hôpital Robert-Debré; Unité d'Epidémiologie Clinique; AP-HP; Paris France
| | - Nathalie Couque
- Hôpital Robert-Debré; UF de Génétique Moléculaire; AP-HP; Paris France
| | - Suzanne Verlhac
- Hôpital Robert-Debré; Service de Radiologie; AP-HP; Paris France
| | - Zinedine Haouari
- Hôpital Robert-Debré; Service d'Hématologie; AP-HP; Paris France
- Hôpital Robert-Debré; Centre de Référence de la Drépanocytose; AP-HP; Paris France
| | - Damir Mohamed
- Hôpital Robert-Debré; Unité d'Epidémiologie Clinique; AP-HP; Paris France
| | | | - Florence Missud
- Hôpital Robert-Debré; Service d'Hématologie; AP-HP; Paris France
- Hôpital Robert-Debré; Centre de Référence de la Drépanocytose; AP-HP; Paris France
| | - Laurent Holvoet
- Hôpital Robert-Debré; Service d'Hématologie; AP-HP; Paris France
- Hôpital Robert-Debré; Centre de Référence de la Drépanocytose; AP-HP; Paris France
| | - Monique Elmaleh
- Hôpital Robert-Debré; Service de Radiologie; AP-HP; Paris France
| | - Ghislaine Ithier
- Hôpital Robert-Debré; Service d'Hématologie; AP-HP; Paris France
- Hôpital Robert-Debré; Centre de Référence de la Drépanocytose; AP-HP; Paris France
| | - André Denjean
- Hôpital Robert-Debré; Service de Physiologie; AP-HP; Paris France
- UMR 1141; Sorbonne Paris Cité; Univ Paris Diderot; Paris France
| | - Jacques Elion
- Hôpital Robert-Debré; UF de Génétique Moléculaire; AP-HP; Paris France
- UMR-S 1134; Laboratoire d'Excellence GR-Ex; INSERM; Paris France
| | - André Baruchel
- Hôpital Robert-Debré; Service d'Hématologie; AP-HP; Paris France
- Institut Universitaire d'Hématologie EA3518; Hôpital Saint Louis; Univ Paris Diderot; Sorbonne Paris Cité; Paris France
| | - Malika Benkerrou
- U 1123; ECEVE; Hôpital Robert-Debré; INSERM; Paris France
- UMR-S 1123; ECEVE; Sorbonne Paris Cité; Univ Paris Diderot; Paris France
- Hôpital Robert-Debré; Service d'Hématologie; AP-HP; Paris France
- Hôpital Robert-Debré; Centre de Référence de la Drépanocytose; AP-HP; Paris France
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Evidence for a Profound Remodeling of Skeletal Muscle and Its Microvasculature in Sickle Cell Anemia. THE AMERICAN JOURNAL OF PATHOLOGY 2015; 185:1448-56. [DOI: 10.1016/j.ajpath.2015.01.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 01/09/2015] [Accepted: 01/23/2015] [Indexed: 11/20/2022]
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Hankins JS, Verevkina NI, Smeltzer MP, Wu S, Aygun B, Clarke DF. Assessment of Sleep-Related Disorders in Children With Sickle Cell Disease. Hemoglobin 2014; 38:244-51. [DOI: 10.3109/03630269.2014.919941] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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28
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Dowling MM, Noetzel MJ, Rodeghier MJ, Quinn CT, Hirtz DG, Ichord RN, Kwiatkowski JL, Roach ES, Kirkham FJ, Casella JF, DeBaun MR. Headache and migraine in children with sickle cell disease are associated with lower hemoglobin and higher pain event rates but not silent cerebral infarction. J Pediatr 2014; 164:1175-1180.e1. [PMID: 24529619 PMCID: PMC4078657 DOI: 10.1016/j.jpeds.2014.01.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 10/31/2013] [Accepted: 01/02/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To identify risk factors for headache and migraine in children with sickle cell disease and test the hypothesis that either or both are independently associated with silent cerebral infarcts. STUDY DESIGN In this cross-sectional study, we evaluated the health history, laboratory values, and brain magnetic resonance imaging findings of participants with sickle cell disease (hemoglobinSS or hemoglobinSβ°-thalassemia) with no history of overt stroke or seizures. Participants characterized headache severity and quality. Migraine was defined by International Headache Society criteria modified for increased sensitivity in children. Neuroradiology and neurology committees adjudicated the presence of silent cerebral infarction by review of magnetic resonance imaging and standardized examination by pediatric neurologists. RESULTS The cohort included 872 children (51.1% males), ranging in age from 5 to 15 years (mean age, 9.1 years). Of these children, 317 (36.4%) reported recurrent headaches, and 132 (15.1%) reported migraines. In multivariable logistic regression analyses, both were associated with lower steady-state hemoglobin (P = .01 for headaches; P < .01 for migraines) and higher pain rate (P < .01 for headaches; P < .01 for migraines), defined as the number of admissions requiring opioids in the previous 3 years. The presence of silent cerebral infarction was not associated with recurrent headaches or migraines. Only 1.9% (6 of 317) of children with recurrent headaches received medication for headache prophylaxis. CONCLUSION Recurrent headaches and migraines are common and undertreated in children with sickle cell disease. Low hemoglobin levels and high pain rates are associated with recurrent headaches and migraines; whereas, silent cerebral infarction is not.
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Affiliation(s)
| | - Michael J Noetzel
- St. Louis Children’s Hospital and Washington University School of Medicine
| | | | - Charles T Quinn
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Deborah G Hirtz
- National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD
| | - Rebecca N Ichord
- Children’s Hospital of Philadelphia and the University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Janet L Kwiatkowski
- Children’s Hospital of Philadelphia and the University of Pennsylvania School of Medicine, Philadelphia, PA
| | - E Steven Roach
- Division of Child Neurology, Ohio State College of Medicine
| | | | - James F Casella
- Department of Pediatrics, Division of Pediatric Hematology, the Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael R DeBaun
- Department of Pediatrics Vanderbilt-Meharry-Matthew Walker Center of Excellence in Sickle Cell Disease, Vanderbilt University School of Medicine, Nashville, TN.
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King AA, Strouse JJ, Rodeghier MJ, Compas BE, Casella JF, McKinstry RC, Noetzel MJ, Quinn CT, Ichord R, Dowling MM, Miller JP, DeBaun MR. Parent education and biologic factors influence on cognition in sickle cell anemia. Am J Hematol 2014; 89:162-7. [PMID: 24123128 DOI: 10.1002/ajh.23604] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 09/30/2013] [Indexed: 11/08/2022]
Abstract
Children with sickle cell anemia have a high prevalence of silent cerebral infarcts (SCIs) that are associated with decreased full-scale intelligence quotient (FSIQ). While the educational attainment of parents is a known strong predictor of the cognitive development of children in general, the role of parental education in sickle cell anemia along with other factors that adversely affect cognitive function (anemia, cerebral infarcts) is not known. We tested the hypothesis that both the presence of SCI and parental education would impact FSIQ in children with sickle cell anemia. A multicenter, cross-sectional study was conducted in 19 US sites of the Silent Infarct Transfusion Trial among children with sickle cell anemia, age 5-15 years. All were screened for SCIs. Participants with and without SCI were administered the Wechsler Abbreviated Scale of Intelligence. A total of 150 participants (107 with and 43 without SCIs) were included in the analysis. In a multivariable linear regression model for FSIQ, the absence of college education for the head of household was associated with a decrease of 6.2 points (P = 0.005); presence of SCI with a 5.2 point decrease (P = 0.017); each $1000 of family income per capita with a 0.33 point increase (P = 0.023); each increase of 1 year in age with a 0.96 point decrease (P = 0.023); and each 1% (absolute) decrease in hemoglobin oxygen saturation with 0.75 point decrease (P = 0.030). In conclusion, FSIQ in children with sickle cell anemia is best accounted for by a multivariate model that includes both biologic and socioenvironmental factors.
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Affiliation(s)
- Allison A. King
- Program in Occupational Therapy and Department of Pediatrics Hematology/Oncology; Washington University School of Medicine; St. Louis Missouri
| | - John J. Strouse
- Department of Pediatrics and Medicine; Division of Hematology; Johns Hopkins University School of Medicine; Baltimore Maryland
| | | | - Bruce E. Compas
- Department of Psychology and Human Development; Vanderbilt University; Nashville Tennessee
| | - James F. Casella
- Department of Pediatrics; Division of Hematology; the Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Robert C. McKinstry
- Departments of Radiology and Pediatrics; Washington University School of Medicine; St. Louis Missouri
| | - Michael J. Noetzel
- Departments of Neurology and Pediatrics; Washington University School of Medicine; St Louis Missouri
| | - Charles T. Quinn
- Department of Pediatrics; Division of Hematology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Rebecca Ichord
- Department of Neurology; Children's Hospital of Philadelphia; Philadelphia Pennsylvania
| | - Michael M. Dowling
- Department of Pediatrics; Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center at Dallas, Children's Medical Center Dallas; Dallas Texas
| | - J. Philip Miller
- Division of Biostatistics and Department of Internal Medicine; Washington University School of Medicine; St. Louis Missouri
| | - Michael R. DeBaun
- Department of Pediatrics; Division of Hematology/Oncology; Vanderbilt University; Nashville Tennessee
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Finch P, Stocks RM, Smeltzer MP, Kimble A, Schoumacher R, Hankins JS. Effects of adenotonsillectomy on polysomnographic parameters in children with sickle cell disease. Pediatr Blood Cancer 2013; 60:E26-8. [PMID: 23382091 DOI: 10.1002/pbc.24479] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 12/27/2012] [Indexed: 11/09/2022]
Abstract
Obstructive sleep apnea (OSA) in the pediatric sickle cell disease (SCD) population can promote nightly hemoglobin oxygen desaturation, which increases the risk of central nervous system insult and may impair cognitive function. Adenotonsillectomy can ameliorate OSA symptoms, but its effect in children with SCD has not been fully investigated. We reviewed the effects of adenotonsillectomy in thirteen children with SCD by comparison of pre and post-adenotonsillectomy polysomnography (PSG) parameters. Significant reduction in hemoglobin oxygen desaturation, decreased apnea-hypopnea index, and increased rapid eye movement sleep occurred after adenotonsillectomy. Adenotonsillectomy promotes improvement in sleep quality in children with SCD and PSG-confirmed OSA.
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Affiliation(s)
- Paul Finch
- Department of Pediatrics Otolaryngology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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31
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Hematological and Genetic Predictors of Daytime Hemoglobin Saturation in Tanzanian Children with and without Sickle Cell Anemia. ISRN HEMATOLOGY 2013; 2013:472909. [PMID: 23691341 PMCID: PMC3649307 DOI: 10.1155/2013/472909] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 03/07/2013] [Indexed: 12/27/2022]
Abstract
Low hemoglobin oxygen saturation (SpO2) is common in Sickle Cell Anemia (SCA) and associated with complications including stroke, although determinants remain unknown. We investigated potential hematological, genetic, and nutritional predictors of daytime SpO2 in Tanzanian children with SCA and compared them with non-SCA controls. Steady-state resting pulse oximetry, full blood count, transferrin saturation, and clinical chemistry were measured. Median daytime SpO2 was 97% (IQ range 94–99%) in SCA (N = 458), lower (P < 0.0001) than non-SCA (median 99%, IQ range 98–100%; N = 394). Within SCA, associations with SpO2 were observed for hematological variables, transferrin saturation, body-mass-index z-score, hemoglobin F (HbF%), genotypes, and hemolytic markers; mean cell hemoglobin (MCH) explained most variability (P < 0.001, Adj r2 = 0.09). In non-SCA only age correlated with SpO2. α-thalassemia 3.7 deletion highly correlated with decreased MCH (Pearson correlation coefficient −0.60, P < 0.0001). In multivariable models, lower SpO2 correlated with higher MCH (β-coefficient −0.32, P < 0.001) or with decreased copies of α-thalassemia 3.7 deletion (β-coefficient 1.1, P < 0.001), and independently in both models with lower HbF% (β-coefficient 0.15, P < 0.001) and Glucose-6-Phosphate Dehydrogenase genotype (β-coefficient −1.12, P = 0.012). This study provides evidence to support the hypothesis that effects on red cell rheology are important in determining SpO2 in children with SCA. Potential mechanisms and implications are discussed.
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32
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Kato GJ. Anemia, age, desaturation, and impaired neurocognition in sickle cell anemia. Pediatr Blood Cancer 2012; 59:773-4. [PMID: 22949104 PMCID: PMC3442134 DOI: 10.1002/pbc.24276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 07/10/2012] [Indexed: 11/08/2022]
Affiliation(s)
- Gregory J Kato
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
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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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L'Esperance VS, Cox SE, Simpson D, Gill C, Makani J, Soka D, Mgaya J, Kirkham FJ, Clough GF. Peripheral vascular response to inspiratory breath hold in paediatric homozygous sickle cell disease. Exp Physiol 2012; 98:49-56. [PMID: 22660812 PMCID: PMC4463767 DOI: 10.1113/expphysiol.2011.064055] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
New Findings • What is the central question of this study? Autonomic nervous dysfunction is implicated in complications of sickle cell anaemia (SCA). In healthy adults, a deep inspiratory breath hold (IBH) elicits rapid transient SNS- mediated vasoconstriction detectable using Laser Doppler Flux (LDF) assessment of the finger-tip cutaneous micovasculature. • What is the main finding and its importance? We demonstrate significantly increased resting peripheral blood flow and sympathetic activity in African children with SCA compared to sibling controls and increased sympathetic stimulation in response to vasoprovocation with DIG. This study is the first to observe an inverse association between resting peripheral blood flow and haemoglobin oxygen saturation (SpO2). These phenomena may be an adaptive response to the hypoxic exposure in SCA. There is increasing evidence that autonomic dysfunction in adults with homozygous sickle cell (haemoglobin SS) disease is associated with enhanced autonomic nervous system-mediated control of microvascular perfusion. However, it is unclear whether such differences are detectable in children with SS disease. We studied 65 children with SS disease [38 boys; median age 7.2 (interquartile range 5.1–10.6) years] and 20 control children without symptoms of SS disease [8 boys; 8.7 (5.5–10.8) years] and recorded mean arterial blood pressure (ABP) and daytime haemoglobin oxygen saturation (). Cutaneous blood flux at rest (RBF) and during the sympathetically activated vasoconstrictor response to inspiratory breath hold (IBH) were measured in the finger pulp of the non-dominant hand using laser Doppler fluximetry. Local factors mediating flow motion were assessed by power spectral density analysis of the oscillatory components of the laser Doppler signal. The RBF measured across the two study groups was negatively associated with age (r=−0.25, P < 0.0001), ABP (r=−0.27, P= 0.02) and daytime (r=−0.30, P= 0.005). Children with SS disease had a higher RBF (P= 0.005) and enhanced vasoconstrictor response to IBH (P= 0.002) compared with control children. In children with SS disease, higher RBF was associated with an increase in the sympathetic interval (r=−0.28, P= 0.022). The SS disease status, daytime and age explained 22% of the variance in vasoconstrictor response to IBH (P < 0.0001). Our findings suggest that blood flow and blood flow responses in the skin of young African children with SS disease differ from those of healthy control children, with increased resting peripheral blood flow and increased sympathetic stimulation from a young age in SS disease. They further suggest that the laser Doppler flowmetry technique with inspiratory breath hold manoeuvre appears to be robust for use in young children with SS disease, to explore interactions between , ABP and autonomic function with clinical complications, e.g. skin ulceration.
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Affiliation(s)
- Veline S L'Esperance
- Vascular Research Group, Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
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35
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Jordan LC, Casella JF, DeBaun MR. Prospects for primary stroke prevention in children with sickle cell anaemia. Br J Haematol 2012; 157:14-25. [PMID: 22224940 DOI: 10.1111/j.1365-2141.2011.09005.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This review will focus on the strengths and limitations associated with the current standard of care for primary prevention of ischaemic strokes in children with sickle cell anaemia (SCA) - transcranial Doppler ultrasound (TCD) screening followed by regular blood transfusion therapy when TCD measurement is above a threshold defined by a randomized clinical trial (RCT). The theoretical basis for potential alternative strategies for primary prevention of neurological injury in SCA is also discussed. These strategies will include, but will not be limited to: immunizations to prevent bacterial infections, particularly in low income countries; management of elevated blood pressure; and targeted strategies to increase baseline haemoglobin levels with therapies such as hyroxycarbamide or potentially definitive haematopoietic stem cell transplant.
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Affiliation(s)
- Lori C Jordan
- Department of Neurology, Division of Pediatric Neurology, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
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36
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Sangkatumvong S, Khoo MCK, Kato R, Detterich JA, Bush A, Keens TG, Meiselman HJ, Wood JC, Coates TD. Peripheral vasoconstriction and abnormal parasympathetic response to sighs and transient hypoxia in sickle cell disease. Am J Respir Crit Care Med 2011; 184:474-81. [PMID: 21616995 DOI: 10.1164/rccm.201103-0537oc] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
RATIONALE Sickle cell disease is an inherited blood disorder characterized by vasoocclusive crises. Although hypoxia and pulmonary disease are known risk factors for these crises, the mechanisms that initiate vasoocclusive events are not well known. OBJECTIVES To study the relationship between transient hypoxia, respiration, and microvascular blood flow in patients with sickle cell. METHODS We established a protocol that mimics nighttime hypoxic episodes and measured microvascular blood flow to determine if transient hypoxia causes a decrease in microvascular blood flow. Significant desaturations were induced safely by five breaths of 100% nitrogen. MEASUREMENTS AND MAIN RESULTS Desaturation did not induce change in microvascular perfusion; however, it induced substantial transient parasympathetic activity withdrawal in patients with sickle cell disease, but not controls subjects. Marked periodic drops in peripheral microvascular perfusion, unrelated to hypoxia, were triggered by sighs in 11 of 11 patients with sickle cell and 8 of 11 control subjects. Although the sigh frequency was the same in both groups, the probability of a sigh inducing a perfusion drop was 78% in patients with sickle cell and 17% in control subjects (P < 0.001). Evidence for sigh-induced sympathetic nervous system dominance was seen in patients with sickle cell (P < 0.05), but was not significant in control subjects. CONCLUSIONS These data demonstrate significant disruption of autonomic nervous system balance, with marked parasympathetic withdrawal in response to transient hypoxia. They draw attention to an enhanced autonomic nervous system–mediated sigh–vasoconstrictor response in patients with sickle cell that could increase red cell retention in the microvasculature, promoting vasoocclusion.
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Affiliation(s)
- Suvimol Sangkatumvong
- Biomedical Engineering Department, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Daly B, Kral MC, Tarazi RA. The Role of Neuropsychological Evaluation in Pediatric Sickle Cell Disease. Clin Neuropsychol 2011; 25:903-25. [DOI: 10.1080/13854046.2011.560190] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Silva CM, Giovani P, Viana MB. High reticulocyte count is an independent risk factor for cerebrovascular disease in children with sickle cell anemia. Pediatr Blood Cancer 2011; 56:116-21. [PMID: 20949593 DOI: 10.1002/pbc.22680] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2009] [Accepted: 05/06/2010] [Indexed: 11/08/2022]
Abstract
BACKGROUND Transcranial Doppler ultrasonography (TCD) is an important way of detecting risk of ischemic stroke in children with sickle cell anemia. PROCEDURE A random sample of 262 FS-hemoglobin children from a newborn screening inception cohort in Brazil (1998-2005) was followed up to May 2009. Pulsed TCD followed STOP protocol. Children with mean blood flow velocity < 170 cm/sec in cerebral arteries were classified as low risk; between 170 and 184, low conditional risk; between 185 and 199, high conditional risk; and ≥ 200, high risk. RESULTS Median age, 6.2 years (2-11.2 years); 147 female; 13 children (5%) had ischemic stroke prior to TCD; 186/249 (74.7%) were classified as low risk; 19 (7.6%) as low conditional; 7 (2.8%) as high conditional; and 8 (3.2%) as high risk; inadequate tests, 11.6%. The probability of ischemic stroke at 10 years was 8.3% (SEM 2.3%); of stroke or high-risk TCD 15.6% (3.5%). Children with stroke or altered TCD (conditional and high risk) were compared to children with normal examinations. They were younger (P = 0.03), with lower hemoglobin (P = 0.003), higher leukocytosis (P = 0.015), and higher reticulocytosis (P < 0.001). Episodes per year of acute chest syndrome were also higher in that group, but not significantly (P = 0.09). Reticulocytosis remained the only significant variable upon multivariate analysis (P = 0.004). Basilar and middle cerebral artery velocities were significantly correlated (R = 0.55; P < 0.001). CONCLUSIONS Probability of stroke was similar to international reports; of belonging to high-risk group, lower. High-reticulocyte count was the most important factor associated with cerebrovascular disease. Basilar artery velocity > 130 cm/sec seems to be an indirect sign of an underlying cerebrovascular disease.
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Vichinsky EP, Neumayr LD, Gold JI, Weiner MW, Rule RR, Truran D, Kasten J, Eggleston B, Kesler K, McMahon L, Orringer EP, Harrington T, Kalinyak K, De Castro LM, Kutlar A, Rutherford CJ, Johnson C, Bessman JD, Jordan LB, Armstrong FD. Neuropsychological dysfunction and neuroimaging abnormalities in neurologically intact adults with sickle cell anemia. JAMA 2010; 303:1823-31. [PMID: 20460621 PMCID: PMC2892214 DOI: 10.1001/jama.2010.562] [Citation(s) in RCA: 214] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Sickle cell anemia (SCA) is a chronic illness causing progressive deterioration in quality of life. Brain dysfunction may be the most important and least studied problem affecting individuals with this disease. OBJECTIVE To measure neurocognitive dysfunction in neurologically asymptomatic adults with SCA vs healthy control individuals. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study comparing neuropsychological function and neuroimaging findings in neurologically asymptomatic adults with SCA and controls from 12 SCA centers, conducted between December 2004 and May 2008. Participants were patients with SCA (hemoglobin [Hb] SS and hemoglobin level < or = 10 mg/dL) aged 19 to 55 years and of African descent (n = 149) or community controls (Hb AA and normal hemoglobin level) (n = 47). Participants were stratified on age, sex, and education. MAIN OUTCOME MEASURES The primary outcome measure was nonverbal function assessed by the Wechsler Adult Intelligence Scale, third edition (WAIS-III) Performance IQ Index. Secondary exploratory outcomes included performance on neurocognitive tests of executive function, memory, attention, and language and magnetic resonance imaging measurement of total intracranial and hippocampal volume, cortical gray and white matter, and lacunae. RESULTS The mean WAIS-III Performance IQ score of patients with SCA was significantly lower than that of controls (adjusted mean, 86.69 for patients with SCA vs 95.19 for controls [mean difference, -5.50; 95% confidence interval {CI}, -9.55 to -1.44]; P = .008), with 33% performing more than 1 SD (<85) below the population mean. Among secondary measures, differences were observed in adjusted mean values for global cognitive function (full-scale IQ) (90.47 for patients with SCA vs 95.66 for controls [mean difference, -5.19; 95% CI, -9.24 to -1.13]; P = .01), working memory (90.75 vs 95.25 [mean difference, -4.50; 95% CI, -8.55 to -0.45]; P = .03), processing speed (86.50 vs 97.95 [mean difference, -11.46; 95% CI, -15.51 to -7.40]; P < .001), and measures of executive function. Anemia was associated with poorer neurocognitive function in older patients. No differences in total gray matter or hippocampal volume were observed. Lacunae were more frequent in patients with SCA but not independently related to neurocognitive function. CONCLUSION Compared with healthy controls, adults with SCA had poorer cognitive performance, which was associated with anemia and age.
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Affiliation(s)
- Elliott P Vichinsky
- Department of Hematology/Oncology, Children's Hospital & Research Center Oakland, 747 52nd St, Oakland, CA 94609, USA.
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Abstract
PURPOSE OF REVIEW Stroke and cerebrovascular disorders in childhood are a cause for significant morbidity in childhood. There is growing emphasis on understanding the mechanisms of stroke so as to inform developments in investigation and management. RECENT FINDINGS Advances have been made in the classification of pediatric stroke, aided by clinical and radiological recognition of patterns of injury and differential outcomes dependent on timing of stroke occurrence. Risk factors are multifactorial, with evidence of geographical and national variation. Causality, however, remains difficult to prove. Recent studies highlight a significant association between stroke recurrence and outcome and the presence of steno-occlusive arterial disease, Moyamoya disease and progressive arteriopathy. Focal arteriopathy of childhood is a new term proposed to refine the nomenclature of childhood arteriopathy. The association between infection and childhood stroke is increasingly recognized, with associations with sinovenous thrombosis and childhood arteriopathy. The recommendation to screen for arteriopathy in genetic conditions such as sickle cell disease is now extended to include children with neurofibromatosis type 1. Perfusion and magnetic resonance wall imaging have helped in the determination of the cause of stroke with impact on management in adults. Two new treatment guidelines have been published (American Heart Association and Chest), but barriers remain to the use of thrombolysis in childhood stroke. SUMMARY Continued developments in understanding and practice in childhood stroke are encouraging. However, the absence of clinical trials and evidence-based guidelines is limiting. The conduct of such trials is a goal towards which the International Pediatric Stroke Study is moving.
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Affiliation(s)
- Nomazulu Dlamini
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
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