Vaso-occlusive crisis in sickle cell disease: current paradigm on pain management

Development, implementation, and acceptability of a bedside mindfulness intervention for adults with sickle cell disease

Acute and chronic pain are the most frequent complications of sickle cell disease (SCD), often severely reducing quality of life and requiring management with long-term pharmacological interventions. A biopsychosocial approach conceptualizing pain in SCD as the result of complex biological, psychological, and social factors could facilitate targeted behavioral interventions. Mindfulness is one procedure for management of pain in individuals with chronic pain/illness. The goal of the current project was to design and implement a bedside mindfulness intervention to help patients with SCD enhance self-efficacy of pain management and reduce distress. As part of a quality improvement project in SCD clinics in a large health system, we developed a bedside mindfulness intervention to be provided during infusion sessions for patients presenting for acute vaso-occlusive episodes (VOE). The approach to development and implementation involved engagement of professionals working directly with patients. Concept planning meetings with these professionals along with qualitative patient and provider feedback informed feasibility, design, and intervention application. During a quantitative phase, patients completed validated surveys items on acceptability. Interview data (N = 11) supported patient interest in mindfulness skills and highlighted a need for tailored, person-centered interventions and non-pharmacological treatment strategies. On quantitative items, participants (N = 14) liked the intervention and agreed mindfulness skills would help manage disease-related distress. Following the interventions, participants reported increased mindfulness (p = .005). While preliminary, these results provide support for the continued development of evidence-based, mindfulness-oriented services to help individuals with SCD manage pain and other psychological difficulties.

Inpatient Management of Pain Episodes in Children with Sickle Cell Disease: A Review

Sickle cell disease (SCD) is the most common hemoglobinopathy in the world. Sickle cell vaso-occlusive episodes (VOEs) are very painful acute events and the most common complication as well as reason for hospitalization. SCD pain is best evaluated holistically with a pain functional assessment to aid in focusing pain management on reducing pain in addition to improving function. Patients with SCD have long endured structural racism and negative implicit bias surrounding the management of pain. Thus, it is important to approach the management of inpatient pain systematically with the use of multi-modal medications and nonpharmacologic treatments. Furthermore, equitable pain management care can be better achieved with standardized pain plans for an entire system and individualized pain plans for patients who fall outside the scope of the standardized pain plans. In this article, we discuss the best practices to manage SCD VOEs during an inpatient hospitalization.

Opioid Control for Patients With Sickle Cell Anemia in Emergency Departments in the Western Region of Saudi Arabia

Introduction Sickle cell anemia (SCA) affects the Saudi Arabian population significantly, with 4.2% carriers and 0.26% affected. Vaso-occlusive crises cause severe pain due to blood vessel blockage by sickled cells, leading to frequent emergency visits, where treatment includes the use of nonsteroidal anti-inflammatory drugs (NSAIDs), oxygen, and opioids. This study examines opioid use in managing SCA crises in Saudi emergency departments. Method A retrospective cross-sectional study in western Saudi Arabia surveyed board-certified emergency physicians (consultants, fellows, specialists) via the Sickle Cell Disease Implementation Consortium (SCDIC). Non-board-certified physicians and general practitioners were excluded. Data were gathered through structured surveys and supplemented by interviews. Results The study included 53 emergency physicians, mostly specialists (60.4%), with one to three years' experience, primarily from King Abdul Aziz University Hospital (28.3%) and King Abdullah Medical Complex (22.6%). While more than half of the participants felt adequately trained for SCA management, 20.8% faced challenges referring patients to case management programs. Major barriers included department overcrowding and the opioid epidemic. Conclusion The study reveals challenges in managing SCA in Saudi emergency departments, particularly with opioid use. Despite physician training, gaps in administrative support, medication access, and follow-up care persist. Institutional policies and opioid epidemic concerns restrict Schedule-II opioid prescriptions. Implementing a comprehensive opioid administration tracking system and standardizing protocols are crucial for enhancing patient outcomes. Future efforts should focus on improving resources and inter-institutional collaboration.

Patient Evaluation of Patient-Controlled Analgesia for Pain Crises in Sickle Cell Disease

BACKGROUND

Vaso-occlusive crisis causing severe pain can be seen in patients with sickle cell anemia and potent opioids should be used in this process. Although sickle cell disease (SCD) patients use patient-controlled analgesia (PCA), we encountered no study evaluating this method from the participants' perspective.

AIM

This descriptive study aimed to evaluate the use and effectiveness of PCA administered using the Mersin Algology Protocol (MAP) during painful episodes of SCD based on participants reports.

METHODS

After obtaining approval from the local ethics committee, 109 SCD participants using PCA as per the MAP between 2018 and 2020 were recruited for the study. The participants answered a 28-item questionnaire regarding their annual number of pain crises, sites of pain, knowledge about PCA, the number of times they used PCA, and the positive and negative aspects of the PCA method.

RESULTS

The mean age of the participants was 28.80 ± 11.5 years. Ninety-nine (90.8%) of the participants considered PCA superior to other pain management methods they had used previously. The 53 participants (48.6%) who waited for their pain to worsen before administering the demand dose expressed fear of taking high doses of medication. As the number of times a participant used PCA increased, NRS scores for pain at the time of demand dosing decreased from 7-10 to 4-6 (p = .013). Eighty-five (78%) of the participants reported having no problems related to the device or drug while using PCA.

CONCLUSION

We found that PCA was used more correctly by participants with more experience using the device. Participants who delay demand dosing do so because of anxiety about developing dependence and to avoid high doses.

Applying Comfort Theory to Improve Outcomes for People in Sickle Cell Crisis

When people with sickle cell disease in vaso-occlusive crisis need hospitalization, they often experience fragmented and disparate treatment. Racial, gender, and socioeconomic treatment bias by providers, including nurses, is complicated by the current reactionary United States (US) controlled substance policies. To provide high-quality and respectful care, nurses can use Kolcaba's Comfort Theory as the framework for a holistic plan to assess, deliver individualized interventions, and evaluate outcomes for people experiencing vaso-occlusive crisis. Once in the electronic medical record, it can guide care during future hospitalizations. By refocusing on the nursing value of providing comfort care to individuals in distress, nurses can change treatment outcomes for clients.

Hospitalization Events Among Adolescents and Adults With Sickle Cell Disease in a Tertiary Care Center in Central India

BACKGROUND

Sickle cell disease (SCD) is an inherited red blood cell disorder, wherein mutation causes the substitution of glutamic acid to valine at the sixth position of the β-globin chain. These include sickle cell anemia (homozygous sickle mutation), sickle-beta thalassemia, and hemoglobin SCD. The clinical manifestations of SCD are protean. Individuals with SCD suffer from both acute and chronic complications, which include recurring episodes of pain commonly called vaso-occlusive crisis (VOC) - acute chest syndrome (ACS); aseptic necrosis of the bone; micro-infarction of the spleen, brain, and kidney; infections; stroke; and organ damage affecting every part of the body. SCD necessitates frequent hospitalizations because of severe complications, which pose a significant burden on caregivers and economic strain on healthcare systems. The pattern of hospital admission with SCD varies in different parts of the world.

OBJECTIVE

This study aimed to determine the causes of hospitalization among adolescent and adult patients with SCD and to determine factors associated with their hospital stay.

METHODS

The study was a hospital-based prospective observational study comprising adolescent and adult patients diagnosed with SCD, aged 15-45 years, who were hospitalized in the Department of General Medicine at All India Institute of Medical Sciences in Raipur from August 2021 to August 2022.

RESULT

According to our study, the primary reason for hospitalization was a painful crisis, accounting for 63% of cases, followed by infection (17%), ACS (11%), and acute hemolytic crisis (9%). Notably, we did not observe any significant differences between genders and causes of admission (p > 0.05). Joint pain (p = 0.005), back pain (p = 0.001), and chest pain (p = 0.001) were more frequently reported by adults over the age of 19. In addition, our analysis of the duration of hospital stays and various factors revealed that patients admitted for infections had a significantly longer mean hospital stay duration (p = 0.040).

CONCLUSION

Acute painful crises were the primary cause of hospital admission among individuals with SCD; many patients also encountered infections and ACS. Furthermore, patients who experienced infections and VOC had a lengthier duration of hospital stay. Therefore, it is essential to provide them with comprehensive instructions on various preventive measures against infections and the factors that trigger painful crises.

Regional anesthesia and sickle cell crisis in pediatric patients: An educational-focused review

INTRODUCTION

Sickle cell disease (SCD) is the most common inherited hemoglobinopathy, affecting approximately 100 000 patients in United States and millions worldwide. Although the mainstay of pain management for VOC remains systemic opioids, given the potential for adverse effects including respiratory depression and hypoxemia, there remains interest in the use of regional anesthetic techniques (neuraxial or peripheral nerve blockade).

METHODS

A systematic search of pubMed, Scopus, and Google Scholar was conducted using the terms sickle cell disease, sickle cell crisis, pain crisis, vaso-occlusive crisis, regional anesthesia, peripheral nerve blockade, and neuraxial anesthesia.

RESULTS

We identified 7 publications, all of which were retrospective case series or single case reports, outlining the use of neuraxial anesthesia in a total of 26 patients with SCD. Additionally, we identified 4 publications, including one retrospective case series and 3 single case reports, entailing the use of peripheral blockade in patients with VOC and SCD.

DISCUSSION

The available literature, albeit all retrospective or anecdotal, suggests the potential utility of regional anesthesia to treat pain in patients with SCD. Additional benefits have included avoidance of the potential deleterious physiologic effects of systemic opioids and in one case series, an improvement in respiratory function as judged by pulse oximetry. The anecdotal and retrospective nature of the available reports with an absence of prospective trials limits the evidence based medicine available from which to develop to guidlines for the optimal local anesthetic agent to use, its concentration, the rate of infusion, and the choice of adjunctive agents.

Rates of Opioid Misuse Amongst Patients Receiving Pain Management for Sickle Cell Disease in An Urban Setting

Background and Objective: Sickle Cell Disease (SCD) is known to cause acute severe pain episodes known as vaso-occlusive crisis (VOC) mainly treated with opioid analgesics. Since the opioid epidemic there is an interest in determining the opioid misuse potential in these patients. Therefore, the primary objective of this study is to determine the rates of opioid misuse among patients with SCD by assessing the rate of unexpected drug screening results in a sickle cell disease clinic. Methods: This was a retrospective chart review study conducted at the outpatient sickle cell disease clinic. The primary independent variables were the prescribed opioid medications while the primary dependent variable was the collected opioid metabolite. Descriptive statistics, linear regression and multivariate logistic regression analysis were conducted using SPSS version 24. Results: A total of 100 participants were recruited from July 1, 2018, to June 30, 2020 with 71 included in the analysis. The total mean of morphine milligram equivalents (MME) for all participants was 71.1±104.9 with 71% of participants having a daily calculated MME of <90MME. The odds of misusing an opioid were 6.72 times higher (P<.02) if a participant used marijuana compared to a participant who didn't. In addition, the odds of misusing an opioid were 2.47 times higher (P<.04) if the patient was prescribed an opioid daily dose greater than 90 MME as opposed to a daily dose less than 90 MME. Conclusion: Participants who consumed greater than 90 MME's per day and utilized marijuana were more likely to misuse opioids.

Management of Acute Sickle Cell Disease Pain

Pain is a common complication of sickle cell disease. Sickle cell pain can often be effectively managed by pediatricians in outpatient and hospital settings. Acute pain management should be initiated quickly. Patients need to be evaluated for sickle cell complications and other causes of pain. Nonsteroidal anti-inflammatory drugs and opioids are the mainstay of pain treatment, but additional therapies include hydration, local pain control, muscle relaxants, and nonpharmacologic approaches. Healthy lifestyle habits and good behavioral and mental health are important for preventing and coping with sickle cell disease pain. Disease-modifying therapies, such as hydroxyurea, can help prevent sickle hemoglobin polymerization and acute pain episodes. Because sickle cell disease largely affects people who are racialized minorities in the United States, health-care providers need to be aware of how their own personal biases may affect care of these patients.

Adolescents and Young Adults With Sickle Cell Disease: Nociplastic Pain and Pain Catastrophizing as Predictors of Pain Interference and Opioid Consumption

OBJECTIVES

Some patients with sickle cell disease (SCD) have features of nociplastic pain. While research suggests that many patients with nociplastic pain consume more opioids due to opioid nonresponsiveness, little is known about the impact of nociplastic pain and pain catastrophizing on opioid consumption and pain interference among adolescents and young adults (AYA) with SCD. The purpose of this study was to (1) characterize nociplastic pain and pain catastrophizing among AYA with SCD, and (2) determine whether these characterizations are associated with subsequent opioid consumption and pain interference 1 month after characterization.

METHODS

Participants completed surveys characterizing nociplastic pain and catastrophizing at a routine clinic visit (baseline). Thereafter, participants received weekly text messages that included pain interference and opioid consumption surveys. Multipredictor 2-part models were used to evaluate the predictive relationships between baseline characterizations and subsequent pain interference, and opioid consumption.

RESULTS

Forty-eight AYA aged 14 to 35 completed baseline measures. Twenty-five percent of participants had scores suggestive of nociplastic pain. Greater nociplastic pain features significantly increased the odds of consuming opioids (odds ratio=1.2) and having greater interference from pain (odds ratio=1.46). Regression analyses found that greater baseline nociplastic pain characteristics were significantly associated with opioid consumption (β=0.13) and pain interference (β=0.061); whereas higher pain catastrophizing scores predicted less opioid consumption (β=-0.03) and less pain interference (β=-0.0007).

DISCUSSION

In this sample of AYA with SCD, features of nociplastic pain predicted higher subsequent opioid consumption and pain interference. Being aware of nociplastic pain features in patients with SCD may better guide individualized pain management.

Massage therapy for children, adolescents, and young adults: Clinical delivery and effectiveness in hematology and oncology

BACKGROUND

Children, adolescents, and young adults with hematologic and/or oncologic conditions experience multiple, significant symptoms (e.g., pain, stress, and anxiety), which may be addressed by nonpharmacologic approaches such as massage therapy (MT). The purpose of this study was to describe the clinical delivery of MT provided by a certified pediatric massage therapist and assess effectiveness in two patient groups: those with sickle cell disease (SCD) or hematologic and/or oncologic conditions excluding SCD (HemOnc).

METHODS

Investigators conducted a retrospective review of MT sessions provided to patients 0-39 years with hematologic and/or oncologic conditions at a large pediatric academic medical center.

RESULTS

Between October 2019 and December 2021, 3015 MT sessions were provided to 243 patients (171 HemOnc; 72 SCD) and documented in the electronic health record. Patients (mean age: 12.21 ± 7.19 years) were generally White (49.4%) or Black/African American (43.2%), non-Hispanic (94.2%), and 52.3% female. Patients in the SCD group (vs. patients in the HemOnc group) reported significantly higher (p < .05) pretreatment pain (6.95 vs. 4.46), stress (6.47 vs. 4.58), and anxiety (6.67 vs. 4.59). All patients reported clinically and statistically significant (p < .001) mean reductions in pain (-2.25 ± 1.87), stress (-2.50 ± 1.73), and anxiety (-2.52 ± 1.69), with patients in the HemOnc group reporting greater mean pain change (-2.54 vs. -1.87) than patients in the SCD group.

CONCLUSIONS

This study supports the clinical effectiveness of MT for addressing acute pain, stress, and anxiety among youth with hematologic and/or oncologic conditions. Future research is needed to identify optimal MT utilization.

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

PROBLEM

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

ELIGIBILITY CRITERIA

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

SAMPLE

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS

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

Predicting Pain in People With Sickle Cell Disease in the Day Hospital Using the Commercial Wearable Apple Watch: Feasibility Study

BACKGROUND

Sickle cell disease (SCD) is a genetic red blood cell disorder associated with severe complications including chronic anemia, stroke, and vaso-occlusive crises (VOCs). VOCs are unpredictable, difficult to treat, and the leading cause of hospitalization. Recent efforts have focused on the use of mobile health technology to develop algorithms to predict pain in people with sickle cell disease. Combining the data collection abilities of a consumer wearable, such as the Apple Watch, and machine learning techniques may help us better understand the pain experience and find trends to predict pain from VOCs.

OBJECTIVE

The aim of this study is to (1) determine the feasibility of using the Apple Watch to predict the pain scores in people with sickle cell disease admitted to the Duke University SCD Day Hospital, referred to as the Day Hospital, and (2) build and evaluate machine learning algorithms to predict the pain scores of VOCs with the Apple Watch.

METHODS

Following approval of the institutional review board, patients with sickle cell disease, older than 18 years, and admitted to Day Hospital for a VOC between July 2021 and September 2021 were approached to participate in the study. Participants were provided with an Apple Watch Series 3, which is to be worn for the duration of their visit. Data collected from the Apple Watch included heart rate, heart rate variability (calculated), and calories. Pain scores and vital signs were collected from the electronic medical record. Data were analyzed using 3 different machine learning models: multinomial logistic regression, gradient boosting, and random forest, and 2 null models, to assess the accuracy of pain scores. The evaluation metrics considered were accuracy (F₁-score), area under the receiving operating characteristic curve, and root-mean-square error (RMSE).

RESULTS

We enrolled 20 patients with sickle cell disease, all of whom identified as Black or African American and consisted of 12 (60%) females and 8 (40%) males. There were 14 individuals diagnosed with hemoglobin type SS (70%). The median age of the population was 35.5 (IQR 30-41) years. The median time each individual spent wearing the Apple Watch was 2 hours and 17 minutes and a total of 15,683 data points were collected across the population. All models outperformed the null models, and the best-performing model was the random forest model, which was able to predict the pain scores with an accuracy of 84.5%, and a RMSE of 0.84.

CONCLUSIONS

The strong performance of the model in all metrics validates feasibility and the ability to use data collected from a noninvasive device, the Apple Watch, to predict the pain scores during VOCs. It is a novel and feasible approach and presents a low-cost method that could benefit clinicians and individuals with sickle cell disease in the treatment of VOCs.

Population Pharmacokinetics and Pharmacodynamics of Crizanlizumab in Healthy Subjects and Patients with Sickle Cell Disease

BACKGROUND AND OBJECTIVES

Crizanlizumab is a humanized monoclonal antibody against P-selectin for the prevention of vaso-occlusive crises in sickle cell disease (SCD). The objective of this study was to investigate crizanlizumab population pharmacokinetics (PK) and pharmacodynamics (PD), as well as influential covariates.

METHODS

A population PK model for crizanlizumab was developed from healthy volunteer and SCD patient data, using a two-compartment intravenous infusion model utilizing a target-mediated drug disposition (TMDD) approach. The relationship between crizanlizumab concentration and ex vivo P-selectin inhibition was fitted to a non-linear sigmoidal Emax model. Covariate selection was performed in a stepwise manner.

RESULTS

Crizanlizumab exhibits nonlinear pharmacokinetics in the wide dose range of 0.2-8 mg/kg body weight. The population pharmacokinetic base model incorporated body weight as covariate in the form of allometric scaling wherein the exponents were fixed to 0.8. SCD patients had higher baseline soluble P-selectin concentration, resulting in a higher estimated initial target concentration. The typical individual in the model is a 70 kg SCD patient with normal renal function and a baseline albumin of 43 g/L; CL was 0.012 L/h while V_ss was 5.2 L. For the population PD model, none of the identified additional factors beyond PD assay and covariates, such as body weight at baseline nor patient type differences, led to relevant differences in P-selectin % inhibition.

CONCLUSIONS

Renal and hepatic impairments, concomitant hydroxyurea usage, and presence of anti-drug antibody are not expected to impact the exposure of crizanlizumab. The model allows for extrapolating the PK of crizanlizumab to pediatric population and evaluation of alternative regimens and route of administration. TRIAL REGISTRATION NUMBER [DATE OF REGISTRATION]: SUSTAIN (CSEG101A2201 Phase 2), ClinicalTrials.gov identifier: NCT01895361 [10 July 2013]; CSEG101A2202 (Phase 2), ClinicalTrials.gov identifier: NCT03264989 [29 August 2017].

Pupil Size and Reactivity in Pediatric Patients With Sickle Cell Disease

Pupil size and reactivity have been studied to objectively measure pain utilizing pupillometry measurements. Given the challenges associated with treating vaso-occlusive pain in pediatric patients with sickle cell disease, better assessment tools are needed. The objective of this study is to establish normative values for pupil size and reactivity in pediatric patients with sickle cell disease with the hope that pupillometry can be used as a tool to objectively measure pain and response to treatment with analgesic medications. Readings were performed using a NeurOptics PLR-2000 pupillometer. Forty-four males and 38 females, all black, were studied. Their median age was 11 years (range: 2 to 21). When comparing our participants with white participants in a previously published pediatric study, there was a significant difference in maximum constriction velocity ( t =3.45, P =0.009), maximum pupil size ( t =-5.57 mm, P <0.0001), and minimum pupil size ( t =-3.24, P =0.002). There was no significant difference in pupil size and reactivity between patients with sickle cell disease and black patients without the disease when compared with the previously published study. Therefore, further investigation of pupillometry within the black population during vaso-occlusive crisis and in the "well state" is warranted in pediatric patients with sickle cell disease.

Transcranial doppler as screening method for sickling crises in children with sickle cell anemia: a latin America cohort study

Background

Sickle cell anemia (SCA) is the leading cause of childhood stroke. We aimed to evaluate whether altered cerebral flow velocities, as measured by transcranial Doppler (TCD), are associated with vaso-occlusive complications in addition to stroke in pediatric SCA patients.

Methods

We evaluated 37 children aged between 2 and 16 years with SCA who underwent screening for TCD between January 2012 and October 2018. Genotypic profiles and demographic data were collected, TCD examinations were performed during follow-up, and the presence of sickling crises was compared. Survival analyses were performed using simple frailty models, in which each predictor variable was analyzed separately in relation to the occurrence of a sickling crisis.

Results

The variables related to sickle cell crises in the univariate analysis were peak systolic velocity (PSV) in the middle cerebral artery (MCA), hazard ratio (HR) 1.01 (1.00—1.02) p = 0.04; end-diastolic velocity (EDV) in the MCA, HR 1.02 (1.01—1.04) p = 0.01; time average mean maximum velocity (TAMMV) in the basilar artery (BA), HR 1.02 (1.00—1.04) p = 0.04; hemoglobin, HR 0.49 (0.38—0.65) p < 0.001; hematocrit, HR 0.78 (0.71—0.85) p < 0.001; leukocyte counts, HR 1.1 (1.05—1.15) p < 0.001; platelets counts, HR 0.997 (0.994—0.999) p = 0.02; and reticulocyte numbers, HR 1.14 (1.06—1.23) p < 0.001.

Conclusions

Our results indicate PSV and EDV in the MCA and TAMMV in the BA as markers of risk for the occurrence of sickling crises in SCA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03429-5.

A Standardized Emergency Department Order Set Decreases Admission Rates and In-Patient Length of Stay for Adults Patients with Sickle Cell Disease

INTRODUCTION

Pain associated with sickle cell disease (SCD) causes severe complications and frequent presentation to the emergency department (ED). Patients with SCD frequently report inadequate pain treatment in the ED, resulting in hospital admission. A retrospective analysis was conducted to assess a quality improvement project to standardize ED care for patients presenting with pain associated with SCD.

METHODS

A 3-year prospective quality improvement initiative was performed. Our multidisciplinary team of providers implemented an ED order set in 2019 to improve care and provide adequate analgesia management. Our primary outcome was the overall hospital admission rate for patients after the intervention. Secondary outcome measures included ED disposition, rate of return to the ED within 72 hours, ED pain scores at admission and discharge, ED treatment time, in-patient length of stay, non-opioid medication use, and opioid medication use.

RESULTS

There was an overall 67% reduction in the hospital admission rate after implementation of the order set (P = 0.005) and a significant decrease in the percentage admission rate month over month (P = 0.047). Time to the first non-opioid analgesic decreased by 71 minutes (P > 0.001), and there was no change in time to the first opioid medication. The rate of return to the ED within 72 hours remained unchanged (7.0% vs 7.1%) (P = 0.93), and the ED elopement rate remained unchanged (1.3% vs 1.85%) (P = 0.93). After the implementation, there were significant increases in the prescribing of orally administered acetaminophen (7%), celecoxib (1.2%), and tizanidine (12.5%) and intravenous ketamine (30.5%) and ketorolac (27%). ED pain scores at discharge were unchanged for both hospital-admitted (7.12 vs 7.08) (P = 0.93) and non-admitted (5.51 vs 6.11) (P = 0.27) patients. The resulting potential cost reduction was determined to be $193,440 during the 12-month observation period, with the mean cost per visit decreasing by $792.

CONCLUSIONS

Use of a standardized and multimodal ED order set reduced hospital admission rates and the timeliness of analgesia without negatively impacting patients' pain.

Targeting Genetic Modifiers of HBG Gene Expression in Sickle Cell Disease: The miRNA Option

Sickle cell disease (SCD) is one of the most common inherited hemoglobinopathy disorders that affects millions of people worldwide. Reactivation of HBG (HBG1, HBG2) gene expression and induction of fetal hemoglobin (HbF) is an important therapeutic strategy for ameliorating the clinical symptoms and severity of SCD. Hydroxyurea is the only US FDA-approved drug with proven efficacy to induce HbF in SCD patients, yet serious complications have been associated with its use. Over the last three decades, numerous additional pharmacological agents that reactivate HBG transcription in vitro have been investigated, but few have proceeded to FDA approval, with the exception of arginine butyrate and decitabine; however, neither drug met the requirements for routine clinical use due to difficulties with oral delivery and inability to achieve therapeutic levels. Thus, novel approaches that produce sufficient efficacy, specificity, and sustainable HbF induction with low adverse effects are desirable. More recently, microRNAs (miRNAs) have gained attention for their diagnostic and therapeutic potential to treat various diseases ranging from cancer to Alzheimer’s disease via targeting oncogenes and their gene products. Thus, it is plausible that miRNAs that target HBG regulatory genes may be useful for inducing HbF as a treatment for SCD. Our laboratory and others have documented the association of miRNAs with HBG activation or suppression via silencing transcriptional repressors and activators, respectively, of HBG expression. Herein, we review progress made in understanding molecular mechanisms of miRNA-mediated HBG regulation and discuss the extent to which molecular targets of HBG might be suitable prospects for development of SCD clinical therapy. Lastly, we discuss challenges with the application of miRNA delivery in vivo and provide potential strategies for overcoming barriers in the future.

Opioid Use in Patients With Sickle Cell Disease During a Vaso-Occlusive Crisis: A Systematic Review

Sickle cell disease (SCD) affects the red blood cells, which become sickle-shaped, leading to their adhesion to vascular walls, impeding blood flow and causing the unpredictable, abrupt onset of intense pain episodes in the form of vaso-occlusive crises (VOC) as well as affecting multiple organ systems. The primary aim of this review is to assess the effectiveness of opioid analgesic intervention for pain management in sickle cell disease during an acute painful crisis. A literature search was done electronically on PubMed Central (PMC), PubMed, and Google Scholar databases. The reports included in the study were from 2010 to 2021, and the bibliographies of retrieved studies are included in the references. This systematic review was undertaken as per the Preferred Reporting Items for Systematic Review and Meta-Analysis. This study included reports discussing opioid analgesics in SCD patients during VOC in different settings. After extensive research, there were no clear current opioid treatment patterns described, and our conclusion suggested conducting more evidence-based research to improve the quality of VOC management and outcome.

Reasons for Hospitalization of Sickle Cell Disease Patients in the Eastern Province of Saudi Arabia: A Single-Center Study

Background: Sickle cell disease (SCD) is among the prevalent chronic diseases in the Eastern Province of Saudi Arabia. To our knowledge, there is no published research that reports the reasons for hospitalization in the Eastern Province of the country. Therefore, this study aimed to fill this gap.

Design and methods: This is a retrospective cohort study that was conducted in the period from January 2018 to December 2019. Patients with sickle cell disease who were admitted and treated in the hospital were included in this study. Patients’ sociodemographic data and reasons for hospitalization were collected and analyzed using the statistical package for social sciences, version 21 (SPSS, Chicago, IL, USA).

Results: There were 103 SCD patients, and the age range was from 18 to 62 years old. The majority of the patients were males (56.3%) and were in the younger age group (≤30 years old; 60.2%). The results showed that the most frequent cause of admission was a vaso-occlusive crisis (VOC) (n=94, 91.3%), followed by acute chest syndrome (ACS) (n=32, 31.1%), and then by hemolytic crisis (27 of the cases; 26.2%). However, we found that a higher number of hip avascular necrosis (AVN) cases were statistically significant in relation to the higher number of hospital admissions (p<0.05), whereas other reasons were not found to have a statistically significant association.

Conclusion: The most frequent cause of admission was VOC episodes, followed by ACS, and then by hemolytic crises. Also, a higher number of hip AVN episodes were statistically significant with the higher number of hospital admissions.

Identifying elevated risk for future pain crises in sickle-cell disease using photoplethysmogram patterns measured during sleep: A machine learning approach

Transient increases in peripheral vasoconstriction frequently occur in obstructive sleep apnea and periodic leg movement disorder, both of which are common in sickle cell disease (SCD). These events reduce microvascular blood flow and increase the likelihood of triggering painful vaso-occlusive crises (VOC) that are the hallmark of SCD. We recently reported a significant association between the magnitude of vasoconstriction, inferred from the finger photoplethysmogram (PPG) during sleep, and the frequency of future VOC in 212 children with SCD. In this study, we present an improved predictive model of VOC frequency by employing a two-level stacking machine learning (ML) model that incorporates detailed features extracted from the PPG signals in the same database. The first level contains seven different base ML algorithms predicting each subject's pain category based on the input PPG characteristics and other clinical information, while the second level is a meta model which uses the inputs to the first-level model along with the outputs of the base models to produce the final prediction. Model performance in predicting future VOC was significantly higher than in predicting VOC prior to each sleep study (F1-score of 0.43 vs. 0.35, p-value <0.0001), consistent with our hypothesis of a causal relationship between vasoconstriction and future pain incidence, rather than past pain leading to greater propensity for vasoconstriction. The model also performed much better than our previous conventional statistical model (F1 = 0.33), as well as all other algorithms that used only the base-models for predicting VOC without the second tier meta model. The modest F1 score of the present predictive model was due in part to the relatively small database with substantial imbalance (176:36) between low-pain and high-pain subjects, as well as other factors not captured by the sleep data alone. This report represents the first attempt ever to use non-invasive finger PPG measurements during sleep and a ML-based approach to predict increased propensity for VOC crises in SCD. The promising results suggest the future possibility of embedding an improved version of this model in a low-cost wearable system to assist clinicians in managing long-term therapy for SCD patients.

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.

Does Intravenous Acetaminophen Reduce Opioid Requirement in Pediatric Emergency Department Patients With Acute Sickle Cell Crises?

OBJECTIVE

We evaluated the ability of intravenous (IV) acetaminophen to reduce the amount of opioid medication administered in pediatric patients with sickle cell disease (SCD) having vasoocclusive crisis (VOC) in an emergency department (ED) setting.

METHODS

This was a prospective, randomized, double-blind placebo-controlled trial at an academic urban pediatric ED. Participants included patients with SCD, aged 4 to 16 years, with VOC pain. All patients received a 0.1 mg/kg dose of IV morphine, 0.5 mg/kg ketorolac, or both. Patients were randomized to receive either 15 mg/kg IV acetaminophen or placebo. Patients were reassessed every 30 minutes to see whether additional opioid doses were indicated to a maximum of three doses. The total morphine given, pain scores, rates of admissions, 72-hour return visits, and adverse events were assessed for each group.

RESULTS

Of 71 subjects randomized, 35 patients in the acetaminophen group and 36 patients in the control group were analyzed. Baseline characteristics and initial pain scores were similar in both groups. The mean total amount of morphine given was 8.6 mg (95% confidence interval [CI] = 6.5 to 10.8) in the acetaminophen group and 8.0 mg (95% CI = 5.9 to 10.2) in the placebo group. The mean total cumulative morphine dosing was 0.2 mg/kg (95% CI = 0.1 to 0.2 mg/kg) in the acetaminophen group and 0.2 mg/kg (95% CI = 0.1 to 0.2 mg/kg) in the control group. The mean pain score at time of disposition was 5.5 (95% CI = 4.3 to 6.6) in the acetaminophen group and 5.2 (95% CI = 4.2 to 6.3) in the placebo group. There were no clinical or statistically significant differences between the rates of admission, 72-hour return visits, or adverse events.

CONCLUSION

In this study, patients who received IV acetaminophen did not receive less morphine than patients in the placebo group. Disposition pain scores for the two groups were also equivalent. We conclude that IV acetaminophen, when used in addition to morphine for pediatric sickle cell VOC pain, does not provide an opioid-sparing effect. Further searches for adjunctive nonaddictive pain medicines are indicated.

Targeting Neutrophil Adhesive Events to Address Vaso-Occlusive Crisis in Sickle Cell Patients

Neutrophils are essential to protect the host against invading pathogens but can promote disease progression in sickle cell disease (SCD) by becoming adherent to inflamed microvascular networks in peripheral tissue throughout the body. During the inflammatory response, leukocytes extravasate from the bloodstream using selectin adhesion molecules and migrate to sites of tissue insult through activation of integrins that are essential for combating pathogens. However, during vaso-occlusion associated with SCD, neutrophils are activated during tethering and rolling on selectins upregulated on activated endothelium that line blood vessels. Recently, we reported that recognition of sLex on L-selectin by E-selectin during neutrophil rolling initiates shear force resistant catch-bonds that facilitate tethering to endothelium and activation of integrin bond clusters that anchor cells to the vessel wall. Evidence indicates that blocking this important signaling cascade prevents the congestion and ischemia in microvasculature that occurs from neutrophil capture of sickled red blood cells, which are normally deformable ellipses that flow easily through small blood vessels. Two recently completed clinical trials of therapies targeting selectins and their effect on neutrophil activation in small blood vessels reveal the importance of mechanoregulation that in health is an immune adaption facilitating rapid and proportional leukocyte adhesion, while sustaining tissue perfusion. We provide a timely perspective on the mechanism underlying vaso-occlusive crisis (VOC) with a focus on new drugs that target selectin mediated integrin adhesive bond formation.

Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit

Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.

Early Detection of Acute Chest Syndrome Through Electronic Recording and Analysis of Auscultatory Percussion

Acute chest syndrome (ACS) is the leading cause of death among people with sickle cell disease. ACS is clinically defined and diagnosed by the presence of a new pulmonary infiltrate on chest imaging with accompanying fever and respiratory symptoms like hypoxia, tachypnea, and shortness of breath. However, the characteristic chest x-ray (CXR) findings necessary for a clinical diagnosis of ACS can be difficult to detect, as is determining which patient needs a CXR. This makes early detection difficult; but it is critical in order to limit ACS severity and subsequent fatalities. This research project looks to apply percussion and auscultation techniques that can provide an immediate diagnosis of acute pulmonary conditions by using an automated standard percussive input and electronic auscultation for computational analysis of the measured signal. Measurements on sickle cell patients having ACS, vaso-occlusive crisis (VOC), and regular clinic visits (healthy) were recorded and analyzed. Average intensity of sound transmission through the chest and lungs was determined in the ACS and healthy subject groups, revealing an average of 10–14 dB decrease in sound intensity in the ACS group compared to the healthy group. A random under-sampling boosted tree classification model identified with 94% accuracy the positive ACS and healthy observations. The analysis also revealed unique measurable changes in a small number of cases clinically classified as complicated VOC, which later developed into ACS. This suggests the developed approach may also have early predictive capability, identifying patients at risk for developing ACS prior to current clinical practice.

Weight Loss as an Effective Strategy to Decrease Opioid Use and Frequency of Vaso-Occlusive Crises in Patients with Sickle Cell Disease

Background: Vaso-occlusive crises (VOCs) are a hallmark of sickle cell disease (SCD) during which patients experience localized pain. The current mainstay of treatment for SCD-related pain syndrome is nonsteroidal anti-inflammatory agents (NSAIDs) and opioid analgesics. Opioids, however, carry a high risk of depression, addiction, and life-threatening hypoventilation. In this study we report weight loss through a multidisciplinary program and bariatric surgery as an effective nonopioid modality to decrease the use of opioids and frequency of VOCs in a patient with SCD. Case Description: A 35-year-old woman with SCD and morbid obesity (body mass index [BMI] of 42 kg/m²) required high doses of opioids for pain control [870 morphine milligram equivalents (MME) per day], and experienced monthly hospitalizations for VOCs that precluded her from working or having meaningful interpersonal relationships. Palliative care identified that the patient had no admissions for VOCs when her BMI was <25 kg/m². Given this observation, it was recommended to the patient that she lose weight. The patient enrolled in a multidisciplinary wellness program and underwent laparoscopic sleeve gastrectomy. She subsequently lost 30 kg (BMI of 29 kg/m²), decreased her basal opioid requirement by 58% (365 MME per day), and experienced no further hospitalizations for VOCs after the intervention, thereby improving her quality of life. Conclusions: The pervasive use and overreliance on opioid analgesics in the treatment of VOCs increase morbidity and mortality among patients with SCD. This case study offers compelling evidence for weight loss through a multidisciplinary program as an adjunctive therapy to decrease the use of opioids and frequency of hospitalizations for VOCs.

Neuropathic Pain and Sickle Cell Disease: a Review of Pharmacologic Management

PURPOSE OF REVIEW

Sickle cell disease (SCD) remains among the most common and severe monogenic disorders present in the world today. Although sickle cell pain has been traditionally characterized as nociceptive, a significant portion of sickle cell patients has reported neuropathic pain symptoms. Our review article will discuss clinical aspects of SCD-related neuropathic pain, epidemiology of neuropathic pain among individuals with SCD, pain mechanisms, and current and future potential pharmacological interventions.

RECENT FINDINGS

Neuropathic pain in SCD is a complicated condition that often has a lifelong and significant negative impact on life; therefore, improved pain management is considered a significant and unmet need. Neuropathic pain mechanisms are heterogeneous, and the difficulty in determining their individual contribution to specific pain types may contribute to poor treatment outcomes in this population. Our review article outlines several pharmacological modalities which may be employed to treat neuropathic pain in SCD patients.

Efficacy of Sucrose in Reducing Pain during Immunization among 10- to 18-Month-Old Infants and Young Children: A Randomized Controlled Trial

PURPOSE

Sucrose is recommended to reduce pain associated with vaccination in neonates. However, research results concerning its effectiveness in infants and young children are inconclusive. This study aims to determine the efficacy of sucrose administration in reducing pain during immunization in 10- to 18-month-old infants and young children as assessed by behavioral pain parameters, crying time, and saliva substance (P) concentration.

DESIGN AND METHODS

This was a double-blind, randomized controlled trial and included healthy infants and young children undergoing their 10- to 18-month immunization. Behavioral pain outcome was measured during, and shortly after the last injection. The infant's pain was also measured by a salivary test using substance (P), and videotaping of crying time.

RESULTS

The study results indicate that, compared with a placebo group, the sucrose group had significantly less pain post-immunization (F (1,129) = 1.72, p = 0.001). Moreover, substance (P) was lower in the intervention group post-immunization, and it could be considered a good predictor of pain reduction associated with immunization.

CONCLUSIONS

Sucrose administration during immunization injection helps in reducing pain, which is one of the most critical factors affecting compliance with the immunization schedule. Substance (P) measurement can be used as a predictor of immunization pain level in 10- to 18-month-old infants and young children.

PRACTICE IMPLICATIONS

Sucrose is an effective method to reduce needle pain during immunization; therefore, healthcare providers should administer sucrose as a pain relief intervention in the immunization clinical setting.

Updated mechanisms underlying sickle cell disease-associated pain

Sickle cell disease (SCD) is one of the most common severe genetic diseases around the world. A majority of SCD patients experience intense pain, leading to hospitalization, and poor quality of life. Opioids form the bedrock of pain management, but their long-term use is associated with severe side effects including hyperalgesia, tolerance and addiction. Recently, excellent research has shown some new potential mechanisms that underlie SCD-associated pain. This review focused on how transient receptor potential vanilloid 1, endothelin-1/endothelin type A receptor, and cannabinoid receptors contributed to the pathophysiology of SCD-associated pain. Understanding these mechanisms may open a new avenue in managing SCD-associated pain and improving quality of life for SCD patients.

Profile of crizanlizumab and its potential in the prevention of pain crises in sickle cell disease: evidence to date

Sickle cell disease (SCD) is one of the most common inherited blood disorders globally. It is a grouping of autosomal recessive genetic disorders identified by a genetic mutation that replaces glutamic acid with valine at the sixth amino acid on the hemoglobin β-globin chain. Millions of people around the world live with a severe genotype of SCD that is often associated with occlusion of the microvasculature resulting in episodes of severe pain and multiple organ system dysfunction. These episodes, commonly categorized as vaso-occlusive crises (VOC), are a distinctive clinical presentation of SCD which represents the majority of SCD morbidity and associated hospitalizations. Though the complete process by which these crises occur is complex and not fully outlined, evidence reveals this process to be multifactorial and heterocellular. For nearly two decades, hydroxyurea was the only FDA-approved therapy for SCD. Evidence to date shows that hydroxyurea treatment significantly reduces the rate of VOC, hospitalizations, and mortality. Despite these benefits, adherence remains problematic due to a variety of adverse effects and interpatient variability connected with hydroxyurea therapy. Crizanlizumab, an adhesion inhibitor of sickled red blood cells, was recently granted breakthrough therapy designation. Results of a phase 2 study have reported a successful reduction in annual rates of vaso-occlusive crisis with a favorable safety profile. This paper reviews the available literature concerning crizanlizumab use in patients with SCD.