The sickle cell crisis: a dilemma in pain relief

Comparative antisickling and antioxidant activities of Pseudobombax ellipticum cultivars in relation to their metabolite profiling using LC/MS

Pseudobombax ellipticum is native to South America and is cultivated worldwide mostly for its medicinal benefits. The plant is used traditionally in respiratory disorders such as dry cough, in the treatment of fever and stomach pain, and as an antimicrobial and analgesic. The antisickling and antioxidant effects of the flowers of P. ellipticum (Kunth) Dugand (red) and P. ellipticum cultivar alba (white) were compared using an in vitro assay in 2% sodium metabisulfite sickling induction model, DPPH, and metal chelation assays. Both red and white flowers exhibited antioxidant and antisickling activities. In DPPH assay, lower IC₅₀ (34.89 ± 0.98 and 53.28 ± 1.14 μg mL^-1) in red and white flowers respectively were detected relative to Trolox as a positive control (56.82 ± 0.87 μg mL^-1). Comparable metal chelation activity (81.4 and 77.8 μM EDTA equivalent/mg) was detected in red and white flowers of both cultivars respectively. The average readings of the "reversal of sickling test "revealed a decrease in sickling percent from 49% to 15% in red flowers and to 18% in white flowers. Also, polymerization inhibition rate was increased from 0.34 to 1 and to 0.92 in red and white flowers respectively. Total phenolics, flavonoids and anthocyanins were quantified in red and white flowers as (163.9, 43.13 mg gallic acid equivalent/g extract), (71.92, 34.5 mg rutin equivalent/g extract) and (127.0, 85.9 mg pelargonidine-3-mono glucoside equivalent/kg extract), respectively. Liquid chromatography mass spectrometry (LC-MS) analysis was further employed for detection and identification of anthocyanins in flower extracts. Eight new anthocyanins were identified for the first time in genus Pseudobombax. These results reveal the potential role for both red and white flower extracts as possible antisickling agents in sickle cell anemia management.

Evaluation of Guideline-Recommended Pain Management in Acute Sickle Cell Crisis and Its Effect on Patient Outcomes

This was a retrospective, multi-site observational cohort of 233 encounters of patients with Sickle Cell Disease (SCD) who received analgesia for acute pain crisis related to SCD from January 1, 2019 to December 31, 2019. Patient encounters were categorized based on whether they received analgesia within guideline directed 60 minutes of emergency department (ED) arrival. The primary outcome was time to a pain score reduction of ≥30% on the numerical rating scale. Assessments were also conducted for potential disparities leading to suboptimal care. Time to pain score reduction of ≥30% was significantly less in those receiving analgesia within 60 minutes of arrival compared to delayed analgesia [3.5 hours (2.5-10) vs 8.0 hours (4.5-22.5), p < 0.001]. Patients receiving timely analgesia also saw a faster time to ED disposition and achieved pain reduction goals more frequently at hospital discharge. We found that patients with a history of substance use disorder documented in their chart were less likely to receive timely analgesia. Our study indicated that when patients with SCD received analgesia in accordance with guideline recommendations, pain goals were achieved faster with an improvement in outcomes. Providing optimal care can be difficult, but education and standardized policies may help mitigate this gap.

Emergency Department Health Care Utilization and Opioid Administration Among Pediatric Patients With Sickle Cell Vasoocclusive Pain Crisis and Coexisting Mental Health Illness

OBJECTIVES

To determine whether patients with sickle cell disease (SCD) who present to the emergency department (ED) with vasoocclusive pain crises (VOC), and have coexisting mental health (MH) diagnoses, are more likely to have increased health care utilization and more frequent opioid administration compared with those without coexisting MH conditions.

METHODS

This is a retrospective study of patients aged 5 to 18 years with SCD who presented to a tertiary care ED with a primary complaint of VOC between January 1, 2013, and December 31, 2017. We excluded patients with sickle cell trait and without a pain management plan in the electronic medical record. Outcomes included ED length of stay (LOS), admission rate, and opioid administration in the ED. Morphine equivalents were used to standardize opioid dosing. Mann-Whitney U and χ2 tests were used for univariate analysis. Multivariable logistic was performed for categorical and continuous outcomes, respectively, after adjusting for confounding factors.

RESULTS

We identified 978 encounters. We excluded 196 without a pain management plan and one with inaccurate ED LOS, resulting in 781 encounters (148 patients) for analysis. Coexisting MH diagnoses were present in 75.0% of encounters, with anxiety (83.0%) and depressive disorders (55.9%) being most common. Compared with SCD patients without coexisting MH diagnoses, those with coexisting MH diagnoses had significantly longer ED LOS (252 ± 139 minutes vs 232 ± 145 minutes, P = 0.03), longer median hospital LOS (1.4 ± 3.2 days vs 0.3 ± 2.4 days, P < 0.001) in univariate analyses, but these differences were no longer significant in adjusted regression models. Patients with coexisting MH diagnoses had higher frequency of opioid administration in the ED (85.6% vs 71.4%, P < 0.0001) and higher odds of receiving opioids (adjusted odds ratio, 2.07; 95% confidence interval, 1.28-3.33).

CONCLUSIONS

Patients with SCD and coexisting MH diagnoses presenting with VOC have greater odds of receiving opioids compared with patients with SCD without coexisting MH diagnoses. Our results indicate a need for more MH resources in this vulnerable population and may help guide future management strategies.

Perinatal and Neonatal Implications of Sickle Cell Disease

Sickle cell disease is the genetic disorder most commonly detected with state-mandated newborn screening. Women with sickle cell disease struggle with psychosocial, emotional, and physical challenges throughout their lives. Pregnancy for women with sickle cell disease brings greater risk for maternal and fetal morbidity and mortality and increased likelihood of hospitalization for complications, including sickle cell pain crisis. Chronic maternal opioid use for pain can place newborns at risk for neonatal abstinence syndrome. Care of a pregnant woman with sickle cell disease requires a collaborative, multidisciplinary team addressing the medical, social, and emotional needs of the woman and her family.

Potential of Three Ethnomedicinal Plants as Antisickling Agents

Sickle cell disease (SCD) is a genetic blood disorder that affects the shape and transportation of red blood cells (RBCs) in blood vessels, leading to various clinical complications. Many drugs that are available for treating the disease are insufficiently effective, toxic, or too expensive. Therefore, there is a pressing need for safe, effective, and inexpensive therapeutic agents from indigenous plants used in ethnomedicines. The potential of aqueous extracts of Cajanus cajan leaf and seed, Zanthoxylum zanthoxyloides leaf, and Carica papaya leaf in sickle cell disease management was investigated in vitro using freshly prepared 2% sodium metabisulfite for sickling induction. The results indicated that the percentage of sickled cells, which was initially 91.6% in the control, was reduced to 29.3%, 41.7%, 32.8%, 38.2%, 47.6%, in the presence of hydroxyurea, C. cajan seed, C. cajan leaf, Z. zanthoxyloides leaf, and C. papaya leaf extracts, respectively, where the rate of polymerization inhibition was 6.5, 5.9, 8.0, 6.6, and 6.0 (×10^-2) accordingly. It was also found that the RBC resistance to hemolysis was increased in the presence of the tested agents as indicated by the reduction of the percentage of hemolyzed cells from 100% to 0%. The phytochemical screening results indicated the presence of important phytochemicals including tannins, saponins, alkaloids, flavonoids, and glycosides in all the plant extracts. Finally, gas chromatography-mass spectrometry analysis showed the presence of important secondary metabolites in the plants. These results suggest that the plant extracts have some potential to be used as alternative antisickling therapy to hydroxyurea in SCD management.

Improving Emergency Providers' Attitudes Toward Sickle Cell Patients in Pain

BACKGROUND

Provider biases and negative attitudes are recognized barriers to optimal pain management in sickle cell disease, particularly in the emergency department (ED).

MEASURES

This prospective cohort measures preintervention and postintervention providers' attitudes toward patients with sickle pain crises using a validated survey instrument.

INTERVENTION

ED providers viewed an eight-minute online video that illustrated challenges in sickle cell pain management, perspectives of patients and providers, as well as misconceptions and stereotypes of which to be wary.

OUTCOMES

Ninety-six ED providers were enrolled. Negative attitude scoring decreased, with a mean difference -11.5 from baseline, and positive attitudes improved, with a mean difference +10. Endorsement of red-flag behaviors similarly decreased (mean difference -12.8). Results were statistically significant and sustained on repeat testing three months after intervention.

CONCLUSIONS/LESSONS LEARNED

Brief video-based educational interventions can improve emergency providers' attitudes toward patients with sickle pain crises, potentially curtailing pain crises early, improving health outcomes and patient satisfaction scores.

Pain assessment during a vaso-occlusive crisis in the pediatric and adolescent patient: rethinking practice

Pain assessment of the child and adolescent with sickle cell disease is complex and challenging. We present a paradigm of pain assessment during a vaso-occlusive crisis in children and adolescents based on the Pain Assessment as a Social Transaction model. Using this model, the assessment of pain severity in sickle cell disease is uniquely highlighted as comprising at least 4 key factors: the limitations of current pain assessment tools, the existence of acute pain of various origins and the emergence and coexistence of chronic pain, the prevalence of cognitive deficits, and the sociocultural dynamics in America. Improved tools for pain assessment and targeted practitioner education are warranted.

Zinc finger nucleases for targeted mutagenesis and repair of the sickle-cell disease mutation: An in-silico study

Background

Sickle cell disease (or simply, SCD) is an inherited hemoglobinopathy which is mostly prevalent among persons of African descent. SCD results from a monogenic (Hemoglobin, beta) point-mutation (substitution of the base Adenine with Thymine at position six) that leads to replacement of the amino acid glutamic acid (E) with valine (V). Management of SCD within resource-poor settings is largely syndromic, since the option of cure offered by bone-marrow transplantation (BMT) is risky and unaffordable by most affected individuals. Despite previous reports of repair and inhibition of the sickle beta-globin gene and messenger ribonucleic acids (mRNAs), respectively in erythrocyte precursor cells via gene-targeting using an oligomer-restriction enzyme construct and either ribozyme- or RNA-DNA chimeric oligonucleotides (or simply third strand binding), gene-therapy to treat SCD still remains largely preclinical. In the wake of the advances in target- gene- mutagenesis and repair wrought by zinc finger nuclease (ZFN) technology, it was hypothesized that SCD may be cured by the same. The goal of this study thus, was constructing a database of zinc finger arrays (ZFAs) and engineering ZFNs, that respectively bind and cleave within or around specific sequences in the sickle hemoglobin, beta (−β^S) gene.

Methods and results

First, using the complete 1606 genomic DNA base pair (bp) sequences of the normal hemoglobin-beta (β^A) chain gene, and the ZiFiT-CoDA-ZFA software preset at default, 57 three-finger arrays (ZFAs) that specifically bind 9 base-pair sequences within the normal hemoglobin-beta chain, were computationally assembled. Second, by serial linkage of these ZFAs to the Flavobacterium okeanokoites endonuclease Fok I― four ZFNs with unique specificity to >24 bp target-sequences at the genomic contextual positions 82, 1333, 1334, and 1413 of the β^A chain-gene were constructed in-silico. Third, localizing the point-mutation of SCD at genomic contextual position −69-70-71- bp (a position corresponding to the 6^th codon) of the β^A chain-gene, inspired the final design of five more ZFNs specific to >24 bp target-sequences within the 8,954 bp that are genomically adjacent to the 5′ end of the β^A chain-gene.

Conclusions

This set of 57 ZFAs and 9 ZFNs offers us gene-therapeutic precursors for the targeted mutagenesis and repair of the SCD mutation or genotype.

Genomics and pain research in sickle cell disease: an explanation of heterogeneity?

Sickle cell disease (SCD) is a chronic illness, and the major complication, pain, results in complex multidimensional problems that affect an individual's ability to maintain adequate quality of life in multiple areas. Chronic SCD pain is inadequately treated, because it is not well understood, and the degree of chronic pain, clinical presentation, and sequela complications can vary from patient to patient, even among individuals with the same SCD genotype. The reason for this variation is unknown, but the underlying cause might be genetic. Researchers have not explored the contribution of a genomic variable to the occurrence of heterogeneous chronic SCD pain. Previous research on the guanosine triphosphate cyclohydrolase (GCH1) gene suggests that in some cases, phenotypic heterogeneity in human sensitivity to pain correlates with underlying genotypic variations in the GCH1 gene. These findings imply that genotypic variations might also explain why some SCD patients experience more chronic pain than others.

A "neurosurgical crisis" of sickle cell disease

The occurrence of spontaneous acute epidural hematomas is rare in patients with sickle cell disease. The authors report the case of a patient with sickle cell anemia who presented with a sickle cell crisis that was complicated by the development of multiple acute epidural and subgaleal hematomas requiring surgical evacuation. Possible underlying mechanisms are discussed. Although rare, clinicians should be aware of this phenomenon as part of a spectrum of neurological complications in these patients.

Can Heterogeneity of Chronic Sickle-Cell Disease Pain Be Explained by Genomics? A Literature Review

This literature review explores the potential of genomics to explain, or at least contribute to the discussion about, heterogeneity in chronic pain in sickle-cell disease (SCD). Background: Adults with SCD, a single-gene disorder, are living longer than in years past, yet report being burdened by chronic pain. With only a few studies on chronic pain in this population, the epidemiology is unclear. However, research in the area of pain genetics continues to advance since the conclusion of the Human Genome Project. Two pain susceptibility genes, catechol-O-methyltransferase (COMT) and cytochrome P450, have, to date, been discovered that can increase individual susceptibility to the development of chronic pain. Method: A search was conducted in PubMed, CINAHL, and EBSCO using the terms ``sickle cell,'' ``chronic pain,'' ``polymorphism,'' ``genetics,'' ``pain genetics,'' ``human,'' ``adult,'' ``association studies,'' and ``pain susceptibility genes'' to search for articles published between 1970 and 2008. Findings: Chronic pain generally is more prevalent and severe than previously reported, and individuals with SCD report daily pain. The genomic era has made it possible for scientists to identify pain susceptibility genes that contribute to variability in the interindividual experience of chronic pain. Conclusion: Nurses are well positioned to generate and translate genomic research, thus improving care delivery. Such research may lead to the identification of polymorphisms associated with pain sensitivity in individuals with SCD.