Quality of life in adults with sickle cell disease: an integrative review of the literature

Unmet Need: Mechanistic and Translational Studies of Sickle Cell Disease Pain as a Whole-Person Health Challenge

Sickle cell disease (SCD) is a lifelong monogenic, autosomal-recessive blood disease that predominantly affects individuals of African descent and those who self-identify as Black or Hispanic. Common SCD pathophysiological processes include adhesion, hemolysis, hypoxia, ischemia, oxidative stress, and vaso-occlusion, which often lead to substantial comorbidities and complications. Pain is one of the most common and significant clinical complications for individuals with SCD. Despite advancements in understanding the pathophysiology of SCD, the ways in which SCD pathophysiological processes contribute to nociception and pain signaling, processing, and perception remain largely unclear. Pain management for individuals with SCD is complex and presents unique challenges that must be considered depending on the presenting pain type (eg, acute pain episode vs chronic pain). Racism, stigma (including stigma associated with opioid use), and limited resources present additional challenges. Limited research has been conducted on major clinical features of SCD pain such as its ischemic, inflammatory, and neuropathic components; on its transition from acute to chronic form and across the lifespan; and on factors influencing SCD pain perception. Research on and management of SCD pain requires a whole-person approach, bringing together investigators from multiple disciplines such as hematologists, organ biologists, pain experts, physiologists, neuroscientists, psychologists, geneticists, microbiologists, immunologists, behavioral scientists, and clinicians. Multidisciplinary cross-training, with different platforms for information dissemination and communication, could help promote basic, mechanistic, and translational research to inform the optimization of current treatment strategies and the development of novel therapies for SCD pain. PERSPECTIVE: This review presents the research challenges and negative impact of SCD pain, a grossly understudied condition in a highly underserved population. It also highlights the barriers and opportunities in SCD pain research and could help clinicians better understand current treatment strategies from the whole-person perspective.

Mental health, pain and likelihood of opioid misuse among adults with sickle cell disease

Depressive symptoms are prevalent in individuals living with sickle cell disease (SCD) and may exacerbate pain. This study examines whether higher depressive symptoms are associated with pain outcomes, pain catastrophizing, interference and potential opioid misuse in a large cohort of adults with SCD. The study utilized baseline data from the 'CaRISMA' trial, which involved 357 SCD adults with chronic pain. Baseline assessments included pain intensity, daily mood, the Patient Health Questionnaire (PHQ), the Generalized Anxiety Disorders scale, PROMIS Pain Interference, Pain Catastrophizing Scale, the Adult Sickle Cell Quality of Life Measurement Information System and the Current Opioid Misuse Measure. Participants were categorized into 'high' or 'low' depression groups based on PHQ scores. Higher depressive symptoms were significantly associated with increased daily pain intensity, negative daily mood, higher pain interference and catastrophizing, poorer quality of life and a higher likelihood of opioid misuse (all p < 0.01). SCD patients with more severe depressive symptoms experienced poorer pain outcomes, lower quality of life and increased risk of opioid misuse. Longitudinal data from this trial will determine whether addressing depressive symptoms may potentially reduce pain frequency and severity in SCD.

Cerebral hemodynamic changes after haploidentical hematopoietic stem cell transplant in adults with sickle cell disease

ABSTRACT

Preliminary evidence from a series of 4 adults with sickle cell disease (SCD) suggests that hematopoietic stem cell transplant (HSCT) improves cerebral hemodynamics. HSCT largely normalizes cerebral hemodynamics in children with SCD. We tested the hypothesis in adults with SCD that cerebral blood flow (CBF), oxygen extraction fraction (OEF), and cerebral metabolic rate of oxygen (CMRO2) measured using magnetic resonance imaging, normalized to healthy values, comparing measurements from ∼1 month before to 12 to 24 months after HSCT (n = 11; age, 33.3 ± 8.9 years; 389 ± 150 days after HSCT) with age-, race- and sex-matched values from healthy adults without sickle trait (n = 28; age, 30.2 ± 5.6 years). Before transplant, 7 patients had neurological indications for transplant (eg, overt stroke) and 4 had nonneurological reasons for haploidentical bone marrow transplant (haplo-BMT). All received haplo-BMT from first-degree relatives (parent, sibling, or child donor) with reduced-intensity preparation and maintained engraftment. Before transplant, CBF was elevated (CBF, 69.11 ± 24.7 mL/100 g/min) compared with that of controls (P = .004). Mean CBF declined significantly after haplo-BMT (posttransplant CBF, 48.2 ± 13.9 mL/100 g/min; P = .003). OEF was not different from that of controls at baseline and did not change significantly after haplo-BMT (pretransplant, 43.1 ± 6.7%; posttransplant, 39.6 ± 7.0%; P = .34). After transplant, CBF and OEF were not significantly different from controls (CBF, 48.2 ± 13.4 mL/100 g/min; P = .78; and OEF, 39.6 ± 7.0%; P > .99). CMRO2 did not change significantly after haplo-BMT (pretransplant, 3.18 ± 0.87 mL O2/100 g/min; posttransplant, 2.95 ± 0.83; P = .56). Major complications of haplo-BMT included 1 infection-related death and 1 severe chronic graft-versus-host disease. Haplo-BMT in adults with SCD reduces CBF to that of control values and maintains OEF and CMRO2 on average at levels observed in healthy adult controls. The trial was registered at www.clinicaltrials.gov as #NCT01850108.

Protocol for a comparative cross-sectional study on characterisation of auditory impairment in sickle cell disease and sickle cell trait and its impact on health-related quality of life in Nigeria

INTRODUCTION

Sickle cell disease (SCD) and sickle cell traits (SCT) are genetically inherited red blood cell disorders common among people of African descent. Nigeria has a high prevalence of SCD, with a prevalence of 2.28%-3% and SCT, 25%-30%. Poorly managed SCD and SCT can lead to sensorineural hearing loss and health-related quality of life (HRQoL) issues. This research aims to assess these possible complications of SCD and SCT in Nigeria.

METHODS AND ANALYSIS

The study will use a comparative cross-sectional design at study power 80% to investigate the association between SCD/SCT, hearing impairment and HRQoL. Participants will be divided into two groups: a cohort and a control group. Hearing levels will be assessed through audiometric assessments and categorised by type and severity of hearing impairments using WHO classifications. HRQoL will also be assessed using WHO Disability Assessment Schedule 2.0. Statistical analyses will be performed using the SAS V.9.4, with parametric or non-parametric analysis depending on the distribution. Relationship between key variables will be determined via correlational tests, χ2, Fisher's exact test and multivariable logistic regression analyses.

ETHICS AND DISSEMINATION

The proposal has been fully reviewed and registered by the University of Cape Town's Faculty of Health Sciences Human Research Ethics Committee (HREC REF 228/2022) and the University of Abuja Teaching Hospital Human Research Ethics Committee (HREC/PR/2020/08/007). Information dissemination will be through conferences, peer-review publication and personal communications. The Strengthening the Reporting of Observational Studies in Epidemiology statement will be followed in writing the manuscript.

Vaso-occlusive crisis pain intensity, frequency, and duration: which best correlates with health-related quality of life in adolescents and adults with sickle cell disease?

ABSTRACT

In a cross-sectional analysis of baseline data from a randomized clinical trial, we studied 198 adolescents and adults aged 15+ with sickle cell disease. Interest was in assessing the relative strengths of the relationship of vaso-occlusive crisis (VOC) pain domains of intensity, frequency, and duration, with health-related quality of life (HRQOL). Variation in psychosocial, physical function, and pain expression domains of HRQOL was partially explained by frequency, intensity, and duration of VOC pain, separately and together, over and above differences in age, sex, genotype, and organ system damage. However, no single domain measure accounted for more than an additional partial R2 of 12.5% alone. Vaso-occlusive crisis pain frequency explained the most variation, when simultaneously considering VOC intensity and duration, except for stiffness , where duration was most predictive. Yet VOC pain intensity, and even VOC duration, also contributed to variability in HRQOL. We recommend that for most purposes, because all 3 VOC pain domains contribute to variability in HRQOL, all 3 domains should be assessed and interventions should be targeted to improve all 3 domains to maximize HRQOL outcomes (Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT02197845 ).

Illness Intrusiveness in Adults with Sickle Cell Disease: The Role of Fatigue

Chronic illness experiences often interfere with daily functioning (a concept known as illness intrusiveness) and health-related quality of life (HRQoL). However, less is known about the role of specific symptoms in predicting illness intrusiveness in sickle cell disease (SCD). This exploratory study examined associations between common SCD-related symptoms (i.e., pain, fatigue, depression, and anxiety), illness intrusiveness, and HRQoL among adults with SCD (n = 60). Illness intrusiveness significantly correlated with fatigue severity (r = .39, p = .002), depression severity (r = .45, p < .001), anxiety severity (r = .41, p = .001), physical HRQoL (r = - .53, p < .001), and mental HRQoL (r = - .44, p < .001). Multiple regression revealed a significant overall model, (R2 = .28, F(4, 55) = 5.21, p = .001), with fatigue, but not pain, depression, or anxiety, significantly predicting illness intrusiveness (β = .29, p = .036). Results suggest that fatigue may be a primary factor contributing to illness intrusiveness-a determinant of HRQoL-in individuals with SCD. Given the limited sample size, larger confirmatory studies are warranted.

Dental arch form in a sample of Iraqi adults with sickle cell anemia using 3D scanning technique: A cross-sectional study

OBJECTIVE

Sickle cell anemia (SCA) is a hematological condition that involves the synthesis of sickle-shaped, hemoglobin with a short lifespan. This study employed three-dimensional (3D) scanning to pinpoint the most common arch form in a sample of Iraqi adults with SCA.

MATERIALS AND METHODS

A cross-sectional study included maxillary and mandibular casts of 50 patients (25 male and 25 female) with SCA and 50 participants in a control group (25 male and 25 female). The facio-axial (FA) point was digitized on each tooth's labial or buccal surface using SolidWorks® 2020 software. The dimensions of the arch were calculated using two proportional measures and four linear measurements. The dental arch form was determined using 3M templates, and the arches were categorized as square, ovoid, or tapered to establish the most-common arch form. Chi-square was used to compare arch form distribution, and an independent t-test was used to calculate the difference between the control group and the SCA group.

RESULTS

The tapered arch was the predominant form in SCA males and females for the maxilla and the mandible. The molar vertical distance (upper and lower) was significantly higher in males in the SCA group than in males in the control group. There was no significant difference between females in the SCA group and females in the control group.

CONCLUSION

Most patients with SCA had tapered arches. Sagittal jaw dimensions in males with SCA were more affected by marrow hyperplasia. There was little if any to no effect on females with SCA.

Social inequalities in the temporal trend of mortality from sickle cell disease in Brazil, 1996-2019

Contrary to international trends, the mortality rate of sickle cell disease increased in Brazil after the implementation of the neonatal screening program, probably due to improving access to diagnosis. This study aimed to assess differences in the temporal trend of the mortality rate and median age at death from sickle cell disease in Brazil, considering implemented measures to expand diagnosis, and improve health care access in-country and in the international scenario. Time series were extracted from the Brazilian Mortality Information System from 1996 to 2019. Changes in the mortality rate and median age at death were verified via segmented regression models, which were stratified by sex, region of residence, and age. Most deaths occurred in non-white people, young adults, and the Southeast and Northeast population. Sickle cell disease mortality rate increased until 2010 (13.31%; 95%CI: 6.37; 20.70), particularly in individuals aged 30 years or more (12.78%; 95%CI: 2.98; 23.53) and in the Northeast (12.27%; 95%CI: 8.92; 15.72). Most deaths occurred in the second decade of life (3.01 deaths/million), with a 59% increase in the median age of death in Brazil, from 27.6 to 30.3 years, more pronounced in females and the North Region. The observed gain in the survival of sickle cell disease in Brazil is still much lower than in developed countries and presents regional disparities, probably due to the lack of access to health care and recent treatments, such as hydroxyurea, still restricted to hematological referral centers in Brazilian capitals.

Differences in the prevalence of mental health disorders among Black American adults with sickle cell disease compared to those with non-heritable medical conditions or no medical conditions

Our aim was to determine differences in the prevalence of mental health disorders between Black Americans living with sickle cell disease (SCD) and Black Americans with other, non-heritable medical conditions, or no medical conditions. We examined the prevalence of mental health disorders among a non-institutionalized, community sample of Black adults in the US from the National Survey of American Life. We compared the odds of mental health disorders between Black American adults with SCD and those with other medical conditions, or no medical condition. Among the SCD group, 38·8% reported at least one mental health disorder: 17·6% endorsed a mood disorder, 24·7% an anxiety disorder, 2·4% an eating disorder, and 11·8% a childhood disorder. Compared to those with other medical conditions, Black Americans with SCD had greater poverty, more children in the household, and were less likely to be married/cohabitating (all P < 0·05). Yet, Black Americans with SCD were not at greater odds of having a mental health disorder compared to those with other medical conditions. When compared to the group with no conditions, however, individuals with SCD had 2·57 greater odds of mood disorder (95% confidence interval: 1·43-4·65; P = 0·002). The effect remained when controlling for socioeconomic status, marital status, and perceived physical health. In this study, almost 40% of Black American adults with SCD presented with a mental health disorder. Prevalence of mental health disorders was similar among those with non-heritable medical conditions, but those without a medical condition had a lower prevalence than in SCD. Among Black Americans, there appear to be unmeasured factors, common across medical conditions, that are linked to mental health disorders.

Impact of neuropathic pain on quality of life in adults with sickle cell disease: observational study

INTRODUCTION

Knowledge on the characteristics of neuropathic pain in people with sickle cell disease (SCD) may help to provide more effective treatment procedures.

OBJECTIVE

To describe the characteristics of neuropathic pain in patients with sickle cell disease and identify the impact on their quality of life.

METHOD

A cross-sectional study (CAAE 57274516.8.0000.5544) was conducted at a reference center in Salvador, Bahia, Brazil. The instruments used were the Brief Pain Inventory (BPI), the Douleur Neuropatique Questionnaire (DN-4), the Anxiety and Depression Hospital scale (ADH) and the abbreviated version of the World Health Organization of Quality of Life questionnaire (WHOQOL-brief). The Mann-Whitney test was used to evaluate the association between the scores (5% alpha).

RESULTS

A total of 100 adults with SCD participated in the study, 69.7% of whom had neuropathic pain. Anxiety was present in 99% of the sample and depression, in 100%. Patients with neuropathic pain had worse scores in all domains of quality of life (p < 0.05), but no association was found with pain intensity.

CONCLUSION

Neuropathic pain was more frequent than nociceptive pain in adults with SCD and generated worse scores in all domains of quality of life. Anxiety and depression were present in patients with both types of pain.

Descriptive analysis of sickle cell patients living in France: The PHEDRE cross-sectional study

Background

Sickle cell disease (SCD) induces chronic haemolytic anaemia and intermittent vaso-occlusion that results in tissue ischaemia causing acute, severe pain episodes that can lead to frequent hospitalizations. These consequences can have repercussions on family, social, school and/or professional life. Here, we present some of the results of the PHEDRE study (Pharmacodépendance Et DREpanocytose—drug dependence and sickle-cell disease), which is the largest study of patients with SCD in France. This paper intends to describe characteristics of the French SCD population. We also aimed to assess the impact of the disease on the lives of patients using objective and subjective variables.

Methods

The PHEDRE study was a national multicentric observational study. Adults, adolescents and children with a confirmed SCD diagnosis were included in the study by their referring doctor. Then, they were interviewed by phone about their socioeconomic status, about the impact of the disease on their lives and about their analgesic and psychoactive drug use.

Results

The study population consisted of 872 patients (28% were minors). Seventy-two percent of adults were active, and all minors were in school. Many patients presented criteria of severe SCD. Seventy-five percent were homozygous SS, 15% were double heterozygotes SC and 8% were heterozygotes Sβthal, 87% received specific treatment, 58% were hospitalized at least once for vaso-occlusive crisis in the past 12 months, and the number of analgesic drugs taken averaged 3.8. Seventy-five percent of patients reported academic or professional consequences related to their SCD, and 52% reported social consequences.

Conclusions

The impact of SCD on patients’ lives can be significant, nevertheless their social integration seems to be maintained. We highlighted respect of recommendations regarding analgesic treatments and only a few patients used tobacco, alcohol or cannabis.

Trial registration

Clinical Trials, NCT02580565; https://clinicaltrials.gov/ Registered 16 October 2015.

Characterization of HIV risks in a Brazilian sickle cell disease population

BACKGROUND

A low prevalence of HIV in sickle cell disease (SCD) patients has been reported in the literature though mechanisms for this are not understood.

METHODS

HIV risk behaviors were compared between SCD cases and non-SCD controls using a self-administered audio computer-assisted self-interview. SCD cases were recruited from a multi-center SCD cohort established in Brazil; controls were recruited from SCD social contacts. Categorical variables were analyzed using Chi-Square or Fisher exact test. Continuous variables were compared using the Mann-Whitney U test.

RESULTS

There were 152 SCD cases and 154 age/location matched controls enrolled at three participating Brazilian centers during 2016-17. No significant differences in number of sexual partners (lifetime or previous 12 months), male-to-male sex partners or intravenous drug use were observed. Cases received more transfusions, surgeries, and acupuncture treatment.

CONCLUSIONS

Besides the risk of transfusion-transmitted HIV, which is now exceedingly rare, SCD and non-SCD participants demonstrated similar HIV risk behaviors. Causes other than risk behaviors such as factors inherent to SCD pathophysiology may explain the reported low prevalence of HIV in SCD.

Cross-cultural adaptation of the Pain Medication Questionnaire for use in Brazil

BACKGROUND

The Pain Medication Questionnaire (PMQ) assesses the risk of opioid abuse in people with non-oncological chronic pain.

METHODS

This is a methodological study conducted at a hemotherapy centre in Recife, Pernambuco state, Brazil. A Cross-cultural adaptation was carried out by a committee of nine specialists, and we applied the PMQ to a pre-final sample of 40 individuals with sickle cell anemia, in addition to a sociodemographic and clinical questionnaire.

RESULTS

The mean agreement indexes for PMQ equivalences were the following: semantic (0.996), idiomatic (0.970), experiential (0.991), conceptual (0.953), language clarity (0.991), practical relevance (0.906), and theoretical relevance (0.945). Assessment of the PMQ showed that 50% of participants obtained a score equivalent to medium risk of opioid abuse. Cronbach's alpha coefficient for the adapted PMQ instrument was 0.705, ranging from 0.641 to 0.736 among its items.

CONCLUSION

The cross-cultural adaptation of the Pain Medication Questionnaire was satisfactory and easy to apply in the Brazilian population. It is clinically relevant, contributing professional practice and enlightening patients with sickle cell anemia on their behavioral dynamics with respect to opioid consumption. It will also contribute to teaching and research, because it is a useful tool for investigating the risk of abusive behavior in people with chronic pain.

Does sickle cell disease have a psychosomatic component? A particular focus on anxiety and depression

Sickle cell disease, an early-age genetic condition, encompasses a range of blood disorders with severe complications. This disease is characterized by the synthesis of abnormal hemoglobin molecules, which tend to polymerize due to their low solubility upon deoxygenation in the peripheral capillary beds, resulting in sickle-like red blood cells. Sickled cells lose their normal functioning and hemodynamic properties, leading to chronic fatigue as well as to episodes of painful crises. Over the last two decades, a growing body of clinical evidence has pointed out that these somatic complaints can give rise to neuropsychiatric disorders, among which anxiety and depression are the most common, that worsen the health-related quality of life in patients. At first glance, this somatic influence may be unsurprising, as both anxiety and depressive signs are prevalent in almost all chronic diseases. However, in the case of a genetic condition such as sickle cell disease whose somatic disturbances are predetermined, the fact that mood disorders can increase fatigue and pain through a psychosomatic component has attracted increasing attention. In this review, we address the hypothesis of a psychosomatic component in patients with sickle cell disease by underlining the most relevant clinical studies that have highlighted the existence of a bidirectional link between physical and psychological sequelae, which are reported to be relieved not only by pharmacological cotreatments but also by the concomitant application of cognitive behavioral therapy.