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Kelleher SC, Kirkham FJ, Hood AM. Executive Function and Processing Speed in Children Living with Sickle Cell Anemia. Children (Basel) 2023; 10:1585. [PMID: 37892248 PMCID: PMC10605810 DOI: 10.3390/children10101585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/22/2023] [Accepted: 09/15/2023] [Indexed: 10/29/2023]
Abstract
Executive function and processing speed difficulties are observed in children living with sickle cell anemia (SCA). The influence of processing speed on executive function is not well understood. We recruited 59 children living with SCA and 24 matched controls aged 8-18 years between 2010 and 2016 from clinics in the UK. Children completed tests in processing speed and cognitive flexibility, subdomains of executive function. MRI scans were conducted within one year of testing; oxygen saturation was obtained on the day of testing. Hemoglobin levels were obtained from medical records. Caregivers completed the executive function questionnaire. Hierarchical linear regressions found that hemoglobin, oxygen saturation, age, infarct status, and processing speed were not independent predictors for any model. However, for all cognitive flexibility tests, there was a significant interaction between infarct status and processing speed; children without silent cerebral infarction (SCI) with faster processing speed had better cognitive flexibility. Our findings indicate that, when interpreting executive function difficulties, it is important to account for the relationship between SCI status and processing speed. More research is needed to elucidate the mechanisms, but clinically, including executive function testing as part of clinic visits by embedding psychologists within the healthcare team would appear to be a critical step.
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Affiliation(s)
- Stephanie C. Kelleher
- Developmental Neurosciences Unit and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
| | - Fenella J. Kirkham
- Developmental Neurosciences Unit and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Clinical and Experimental Sciences, University of Southampton, Southampton SO17 1BJ, UK
| | - Anna M. Hood
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, University of Manchester, Manchester M13 9PL, UK
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2
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Jain D, Kirkham FJ. Laboratory Associations With Transcranial Doppler Categories in Sickle Cell Disease. Indian Pediatr 2023; 60:622-623. [PMID: 37565437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Affiliation(s)
- Dipty Jain
- Arihant Superspecialty Hospital, Nagpur, Maharashtra, India.
| | - Fenella J Kirkham
- Developmental Neurosciences Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
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3
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Hamdule S, Kirkham FJ. Brain Volumes and Cognition in Patients with Sickle Cell Anaemia: A Systematic Review and Meta-Analysis. Children (Basel) 2023; 10:1360. [PMID: 37628359 PMCID: PMC10453222 DOI: 10.3390/children10081360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/28/2023] [Accepted: 08/04/2023] [Indexed: 08/27/2023]
Abstract
Cognitive decline is a major problem in paediatric and adult patients with sickle cell anaemia (SCA) and affects the quality of life. Multiple studies investigating the association between quantitative and qualitative neuroimaging findings and cognition have had mixed results. Hence, the aetiology of cognitive decline in this population is not clearly understood. Several studies have established cerebral atrophy in SCA children as well as adults, but the relationship between cognition and brain volumes remains unclear. The purpose of this systematic review was therefore to evaluate the literature on regional brain volumes and their association with cognitive outcomes. We also meta-analysed studies which compared regional brain volumes between patients and controls. Studies report that patients with SCA tend to have lower grey matter volumes, including total subcortical volumes in childhood as compared to controls, which stabilise in young adulthood and may be subjected to decline with age in older adulthood. White matter volumes remain stable in children but are subjected to reduced volumes in young adulthood. Age and haemoglobin are better predictors of cognitive outcomes as compared to regional brain volumes.
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Affiliation(s)
- Shifa Hamdule
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK;
| | - Fenella J. Kirkham
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK;
- Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK
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4
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Koelbel M, Hamdule S, Kirkham FJ, Stotesbury H, Hood AM, Dimitriou D. Mind the gap: trajectory of cognitive development in young individuals with sickle cell disease: a cross-sectional study. Front Neurol 2023; 14:1087054. [PMID: 37560456 PMCID: PMC10408298 DOI: 10.3389/fneur.2023.1087054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 06/26/2023] [Indexed: 08/11/2023] Open
Abstract
STUDY OBJECTIVES Compared to typically developing children and young adults (CYA-TD), those living with Sickle Cell Disease (CYA-SCD) experience more cognitive difficulties, particularly with executive function. Few studies have examined the relative importance of silent cerebral infarction (SCI), haemoglobin and arterial oxygen content on age-related cognitive changes using cross-sectional or longitudinal (developmental trajectory) data. This study presents cohort data from a single timepoint to inform studies with multiple timepoints. METHODS We compared cross-sectional raw and scaled scores as age-related changes in cognition (trajectories) in CYA-SCD and age-and ethnicity-matched CYA-TD. We also compared cross-sectional age-related changes in cognition (trajectories) in CYA-SCD with and without SCI to CYA-TD. General cognitive abilities were assessed using Wechsler Intelligence Scales, including the Verbal Comprehension Index (VCI) and Perceptual Reasoning Index (PRI) underpinning IQ. Executive function was evaluated using the Delis-Kaplan Executive Function System (D-KEFS) Tower subtest and the Behaviour Rating Inventory of Executive Function (BRIEF) questionnaire. SCI were identified from contemporaneous 3 T MRI; participants with overt stroke were excluded. Recent haemoglobin was available and oxygen saturation (SpO2) was measured on the day of the MRI. RESULTS Data were available for 120 CYA-SCD [62 male; age = 16.78 ± 4.79 years; 42 (35%) with SCI] and 53 CYA-TD (23 male; age = 17.36 ± 5.16). Compared with CYA-TD, CYA-SCD experienced a delayed onset in VCI and slower rate of development for BRIEF Global Executive Composite, Metacognition Index (MI), and Behaviour Regulation Index. The rate of executive function development for the BRIEF MI differed significantly between CYA-TD and CYA-SCD, with those with SCI showing a 26% delay compared with CYA-TD. For CYA-SCD with SCI, arterial oxygen content explained 22% of the variance in VCI and 37% in PRI, while haemoglobin explained 29% of the variance in PRI. CONCLUSION Age-related cognitive trajectories of CYA-SCD may not be impaired but may progress more slowly. Longitudinal studies are required, using tests unaffected by practice. In addition to initiation of medical treatment, including measures to improve arterial oxygen content, early cognitive intervention, educational support, and delivery of extracurricular activities could support cognitive development for CYA-SCD.Graphical Abstract.
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Affiliation(s)
- Melanie Koelbel
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
- Sleep Education and Research Laboratory, UCL Institute of Education, London, United Kingdom
| | - Shifa Hamdule
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Fenella J. Kirkham
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
- Clinical and Experimental Sciences, University of Southampton, Southampton, United Kingdom
| | - Hanne Stotesbury
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Anna Marie Hood
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
- Division of Psychology and Mental Health, Manchester Centre for Health Psychology, University of Manchester, Manchester, United Kingdom
| | - Dagmara Dimitriou
- Sleep Education and Research Laboratory, UCL Institute of Education, London, United Kingdom
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Walker EJ, Kirkham FJ, Stotesbury H, Dimitriou D, Hood AM. Tele-neuropsychological Assessment of Children and Young People: A Systematic Review. J Pediatr Neuropsychol 2023; 9:1-14. [PMID: 37359106 PMCID: PMC10231293 DOI: 10.1007/s40817-023-00144-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 06/28/2023]
Abstract
The coronavirus pandemic identified a clinical need for pediatric tele-neuropsychology (TeleNP) assessment. However, due to limited research, clinicians have had little information to develop, adapt, or select reliable pediatric assessments for TeleNP. This preliminary systematic review aimed to examine the feasibility of pediatric TeleNP assessment alongside (1) patient/family acceptability, (2) reliability, and (3) the quality of the literature. Between May 2021 and November 2022, manual searches of PubMed, PsycINFO, and Google Scholar were conducted using terms related to "pediatric" and "tele-neuropsychology." After extracting relevant papers with samples aged 0-22 years, predefined exclusion criteria were applied. Quality assessment was completed using the AXIS appraisal tool (91% rater-agreement). Twenty-one studies were included in the review, with reported qualitative and quantitative data on the feasibility, reliability, and acceptability extracted. Across included studies, TeleNP was completed via telephone/video conference with participants either at home, in a local setting accompanied by an assistant, or in a different room but in the same building as the assessor. Pediatric TeleNP was generally reported to be feasible (e.g., minimal behavioral differences) and acceptable (e.g., positive feedback). Nineteen studies conducted some statistical analyses to assess reliability. Most observed no significant difference between in-person and TeleNP for most cognitive domains (i.e., IQ), with a minority finding variable reliability for some tests (e.g., attention, speech, visuo-spatial). Limited reporting of sex-assigned birth, racialized identity, and ethnicity reduced the quality and generalizability of the literature. To aid clinical interpretations, studies should assess underexamined cognitive domains (e.g., processing speed) with larger, more inclusive samples. Supplementary Information The online version contains supplementary material available at 10.1007/s40817-023-00144-6.
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Affiliation(s)
- Elise J. Walker
- Developmental Neurosciences Unit and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, England
| | - Fenella J. Kirkham
- Developmental Neurosciences Unit and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, England
- Clinical and Experimental Sciences, University of Southampton, Southampton, England
| | - Hanne Stotesbury
- Developmental Neurosciences Unit and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, England
| | - Dagmara Dimitriou
- Sleep Education and Research Laboratory, Department of Psychology and Human Development, UCL Institute of Education, London, England
| | - Anna M. Hood
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, University of Manchester, Coupland 1 Building, Manchester, M15 6FH Manchester, England
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6
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Abdi SS, De Haan M, Kirkham FJ. Neuroimaging and Cognitive Function in Sickle Cell Disease: A Systematic Review. Children 2023; 10:children10030532. [PMID: 36980090 PMCID: PMC10047189 DOI: 10.3390/children10030532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/07/2023] [Accepted: 02/13/2023] [Indexed: 03/12/2023]
Abstract
Sickle cell disease (SCD) is the most common inherited single-gene disease. Complications include chronic anaemia, reduced oxygen-carrying capability, and cerebral vasculopathy, resulting in silent cerebral infarction, stroke, and cognitive dysfunction with impairments in measures of executive function, attention, reasoning, language, memory, and IQ. This systematic review aims to investigate the association between neuroimaging findings and cognition in children with SCD. Searches of PubMed and Embase were conducted in March 2022. Studies were included if participants were <18 years, if original data were published in English between 1960 and 2022, if any genotype of SCD was included, and if the relationship between cognition and neuroimaging was examined. Exclusion criteria included case studies, editorials, and reviews. Quality was assessed using the Critical Appraisal Skills Programme Case Control Checklist. A total of 303 articles were retrieved; 33 met the eligibility criteria. The presence of overt or silent strokes, elevated blood flow velocities, abnormal functional connectivity, and decreased fMRI activation were associated with neuropsychological deficits in children with SCD when compared to controls. There is a critical need to address the disease manifestations of SCD early, as damage appears to begin at a young age. Most studies were cross-sectional, restricting the interpretation of the directionality of relationships. Future research employing longitudinal neuroimaging and neuropsychological assessments could improve our understanding of the cumulative consequences of SCD on the developing brain.
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Affiliation(s)
- Suad S. Abdi
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
| | - Michelle De Haan
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
| | - Fenella J. Kirkham
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK
- Child Health, University Hospital Southampton, Southampton SO16 6YD, UK
- Correspondence:
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7
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Juttukonda MR, Vaclavu L, Kirkham FJ, Fields ME, Bush AM. Editorial: Cerebral oxygen supply and demand in sickle cell disease: Evidence of local ischemia despite global hyperemia. Front Physiol 2022; 13:1079889. [PMID: 36479342 PMCID: PMC9720841 DOI: 10.3389/fphys.2022.1079889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/04/2022] [Indexed: 12/01/2023] Open
Affiliation(s)
- Meher R. Juttukonda
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, United States
- Department of Radiology, Harvard Medical School, Boston, MA, United States
| | - Lena Vaclavu
- C.J. Gorter MRI Center, Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Fenella J. Kirkham
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Melanie E. Fields
- Division of Pediatric Hematology/Oncology, Washington University in St. Louis, Saint Louis, MO, United States
| | - Adam M. Bush
- Department of Biomedical Engineering, Cockrell School of Engineering, University of Texas at Austin, Austin, TX, United States
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8
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Jacob M, Kawadler JM, Murdoch R, Ahmed M, Tutuba H, Masamu U, Shmueli K, Saunders DE, Clark CA, Kim J, Hamdule S, Makani J, Stotesbury H, Kirkham FJ. Brain volume in Tanzanian children with sickle cell anaemia: A neuroimaging study. Br J Haematol 2022; 201:114-124. [PMID: 36329651 DOI: 10.1111/bjh.18503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/10/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
Brain injury is a common complication of sickle cell anaemia (SCA). White matter (WM) and cortical and subcortical grey matter (GM), structures may have reduced volume in patients with SCA. This study focuses on whether silent cerebral infarction (SCI), vasculopathy or anaemia affects WM and regional GM volumes in children living in Africa. Children with SCA (n = 144; aged 5-20 years; 74 male) and sibling controls (n = 53; aged 5-17 years; 29 male) underwent magnetic resonance imaging. Effects of SCI (n = 37), vasculopathy (n = 15), and haemoglobin were assessed. Compared with controls, after adjusting for age, sex and intracranial volume, patients with SCA had smaller volumes for WM and cortical, subcortical and total GM, as well as bilateral cerebellar cortex, globus pallidus, amygdala and right thalamus. Left globus pallidus volume was further reduced in patients with vasculopathy. Putamen and hippocampus volumes were larger in patients with SCA without SCI or vasculopathy than in controls. Significant positive effects of haemoglobin on regional GM volumes were confined to the controls. Patients with SCA generally have reduced GM volumes compared with controls, although some subcortical regions may be spared. SCI and vasculopathy may affect the trajectory of change in subcortical GM and WM volume. Brain volume in non-SCA children may be vulnerable to contemporaneous anaemia.
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Affiliation(s)
- Mboka Jacob
- Department of Radiology and Imaging Muhimbili University of Health and Allied Sciences Dar Es Salaam Tanzania
| | - Jamie M. Kawadler
- Developmental Neurosciences Section UCL Great Ormond Street Institute of Child Health London UK
| | - Russell Murdoch
- Department of Medical Physics and Biomedical Engineering UCL London UK
| | - Magda Ahmed
- Department of Radiology Muhimbili Orthopaedic Institute Dar Es Salaam Tanzania
| | - Hilda Tutuba
- Muhimbili Sickle cell Program Muhimbili University of Health and Allied Sciences Dar Es Salaam Tanzania
| | - Upendo Masamu
- Muhimbili Sickle cell Program Muhimbili University of Health and Allied Sciences Dar Es Salaam Tanzania
| | - Karin Shmueli
- Department of Medical Physics and Biomedical Engineering UCL London UK
| | - Dawn E. Saunders
- Developmental Neurosciences Section UCL Great Ormond Street Institute of Child Health London UK
| | - Chris A. Clark
- Developmental Neurosciences Section UCL Great Ormond Street Institute of Child Health London UK
- Biomedical Research Centre Great Ormond Street hospital for Children London UK
| | - Jinna Kim
- Department of Radiology Yonsei University Seoul South Korea
| | - Shifa Hamdule
- Developmental Neurosciences Section UCL Great Ormond Street Institute of Child Health London UK
| | - Julie Makani
- Department of Haematology and Blood Transfusion Muhimbili University of Health and Allied Sciences Dar Es Salaam Tanzania
| | - Hanne Stotesbury
- Developmental Neurosciences Section UCL Great Ormond Street Institute of Child Health London UK
| | - Fenella J. Kirkham
- Developmental Neurosciences Section UCL Great Ormond Street Institute of Child Health London UK
- Biomedical Research Centre Great Ormond Street hospital for Children London UK
- Clinical Experimental Sciences University of Southampton Southampton UK
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9
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Murdoch R, Stotesbury H, Kawadler JM, Saunders DE, Kirkham FJ, Shmueli K. Quantitative susceptibility mapping (QSM) and R2 * of silent cerebral infarcts in sickle cell anemia. Front Neurol 2022; 13:1000889. [PMID: 36341122 PMCID: PMC9632444 DOI: 10.3389/fneur.2022.1000889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/27/2022] [Indexed: 11/16/2022] Open
Abstract
Silent cerebral infarction (SCI) is the most commonly reported radiological abnormality in patients with sickle cell anemia (SCA) and is associated with future clinical stroke risk. To date, there have been few histological and quantitative MRI studies of SCI and multiple radiological definitions exist. As a result, the tissue characteristics and composition of SCI remain elusive. The objective of this work was therefore to investigate the composition of segmented SCI lesions using quantitative MRI for R2 * and quantitative magnetic susceptibility mapping (QSM). 211 SCI lesions were segmented from 32 participants with SCA and 6 controls. SCI were segmented according to two definitions (FLAIR+/-T1w-based threshold) using a semi-automated pipeline. Magnetic susceptibility (χ) and R2 * maps were calculated from a multi-echo gradient echo sequence and mean SCI values were compared to an equivalent region of interest in normal appearing white matter (NAWM). SCI χ and R2 * were investigated as a function of SCI definition, patient demographics, anatomical location, and cognition. Compared to NAWM, SCI were significantly less diamagnetic (χ = -0.0067 ppm vs. -0.0153 ppm, p < 0.001) and had significantly lower R2 * (16.7 s-1 vs. 19.2 s-1, p < 0.001). SCI definition had a significant effect on the mean SCI χ and R2 * , with lesions becoming significantly less diamagnetic and having significantly lower R2 * after the application of a more stringent T1w-based threshold. SCI-NAWM R2 * decrease was significantly greater in patients with SCA compared with controls (-2.84 s-1 vs. -0.64 s-1, p < 0.0001). No significant association was observed between mean SCI-NAWM χ or R2* differences and subject age, lesion anatomical location, or cognition. The increased χ and decreased R2 * in SCI relative to NAWM observed in both patients and controls is indicative of lower myelin or increased water content within the segmented lesions. The significant SCI-NAWM R2 * differences observed between SCI in patients with SCA and controls suggests there may be differences in tissue composition relative to NAWM in SCI in the two populations. Quantitative MRI techniques such as QSM and R2 * mapping can be used to enhance our understanding of the pathophysiology and composition of SCI in patients with SCA as well as controls.
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Affiliation(s)
- Russell Murdoch
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Hanne Stotesbury
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jamie M. Kawadler
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Dawn E. Saunders
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Fenella J. Kirkham
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
- University Hospital Southampton NHS Foundation Trust, and Clinical and Experimental Sciences, University of Southampton, Southampton, United Kingdom
| | - Karin Shmueli
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
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10
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Murdoch R, Stotesbury H, Hales PW, Kawadler JM, Kölbel M, Clark CA, Kirkham FJ, Shmueli K. A Comparison of MRI Quantitative Susceptibility Mapping and TRUST-Based Measures of Brain Venous Oxygen Saturation in Sickle Cell Anaemia. Front Physiol 2022; 13:913443. [PMID: 36105280 PMCID: PMC9465016 DOI: 10.3389/fphys.2022.913443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
In recent years, interest has grown in the potential for magnetic resonance imaging (MRI) measures of venous oxygen saturation (Yv) to improve neurological risk prediction. T2-relaxation-under-spin-tagging (TRUST) is an MRI technique which has revealed changes in Yv in patients with sickle cell anemia (SCA). However, prior studies comparing Yv in patients with SCA relative to healthy controls have reported opposing results depending on whether the calibration model, developed to convert blood T2 to Yv, is based on healthy human hemoglobin (HbA), bovine hemoglobin (HbBV) or sickle hemoglobin (HbS). MRI Quantitative Susceptibility Mapping (QSM) is an alternative technique that may hold promise for estimating Yv in SCA as blood magnetic susceptibility is linearly dependent upon Yv, and no significant difference has been found between the magnetic susceptibility of HbA and HbS. Therefore, the aim of this study was to compare estimates of Yv using QSM and TRUST with five published calibration models in healthy controls and patients with SCA. 17 patients with SCA and 13 healthy controls underwent MRI. Susceptibility maps were calculated from a multi-parametric mapping acquisition and Yv was calculated from the mean susceptibility in a region of interest in the superior sagittal sinus. TRUST estimates of T2, within a similar but much smaller region, were converted to Yv using five different calibration models. Correlation and Bland-Altman analyses were performed to compare estimates of Yv between TRUST and QSM methods. For each method, t-tests were also used to explore group-wise differences between patients with SCA and healthy controls. In healthy controls, significant correlations were observed between QSM and TRUST measures of Yv, while in SCA, there were no such correlations. The magnitude and direction of group-wise differences in Yv varied with method. The TRUST-HbBV and QSM methods suggested decreased Yv in SCA relative to healthy controls, while the TRUST-HbS (p < 0.01) and TRUST-HbA models suggested increased Yv in SCA as in previous studies. Further validation of all MRI measures of Yv, relative to ground truth measures such as O15 PET and jugular vein catheterization, is required in SCA before QSM or TRUST methods can be considered for neurological risk prediction.
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Affiliation(s)
- Russell Murdoch
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Hanne Stotesbury
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Patrick W. Hales
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jamie M. Kawadler
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Melanie Kölbel
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Christopher A. Clark
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Fenella J. Kirkham
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
- Clinical and Experimental Sciences, University of Southampton, Southampton, United Kingdom
| | - Karin Shmueli
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
- *Correspondence: Karin Shmueli,
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11
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Ampomah MA, Drake JA, Anum A, Amponsah B, Dei-Adomakoh Y, Anie K, Mate-Kole CC, Jonassaint CR, Kirkham FJ. A case-control and seven-year longitudinal neurocognitive study of adults with sickle cell disease in Ghana. Br J Haematol 2022; 199:411-426. [PMID: 36017640 DOI: 10.1111/bjh.18386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/13/2022] [Accepted: 07/17/2022] [Indexed: 11/28/2022]
Abstract
Ageing in sickle cell disease (SCD) is associated with a myriad of end-organ complications, including cerebrovascular damage and cognitive impairment (CI). Although CI is very common in SCD, little is known about cognitive functioning and how it changes with age. This study examines cognitive patterns of 63 adults with SCD and 60 non-SCD, age- and education-matched controls in Ghana. Of those adults with SCD, 34 completed the neuropsychological battery at baseline and again seven years later. In cross-sectional data, adults with SCD performed worse than controls in all cognitive test domains (p < 0.01 for all). The seven-year follow-up data showed that the group exhibited a significant decline in visuospatial abilities (ranging from Cohen's d = 1.40 to 2.38), and to a lesser extent, in processing speed and executive functioning. Exploratory analyses showed a significant time-by-education interaction, indicating that education may be protective from decline in cognitive performance. These findings have implications for clinical practice. Early neuropsychological surveillance coupled with early assessment and remedial programmes will provide avenues for enhancing the quality of life of adults living with SCD in Ghana.
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Affiliation(s)
- Mary A Ampomah
- Family and Community Health, School of Public Health, University of Health and Allied Sciences, Ho, Ghana
| | - Jermon A Drake
- Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adote Anum
- Department of Psychology, School of Social Sciences, University of Ghana, Legon, Ghana
| | - Benjamin Amponsah
- Department of Psychology, School of Social Sciences, University of Ghana, Legon, Ghana
| | - Yvonne Dei-Adomakoh
- Department of Haematology, School of Medicine and Dentistry, University of Ghana Medical School, Ghana Institute of Clinical Genetics, Accra, Ghana
| | - Kofi Anie
- School of Public Health, Imperial College London, London, UK.,London North West University Healthcare NHS Trust, London, UK
| | - Christopher C Mate-Kole
- Department of Psychology, School of Social Sciences, University of Ghana, Legon, Ghana.,Centre for Ageing Studies, College of Humanities, University of Ghana, Legon, Ghana
| | | | - Fenella J Kirkham
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK.,Clinical and Experimental Sciences, University of Southampton, Southampton, UK
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12
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Stotesbury H, Kawadler JM, Clayden JD, Saunders DE, Hood AM, Koelbel M, Sahota S, Rees DC, Wilkey O, Layton M, Pelidis M, Inusa BPD, Howard J, Chakravorty S, Clark CA, Kirkham FJ. Quantification of Silent Cerebral Infarction on High-Resolution FLAIR and Cognition in Sickle Cell Anemia. Front Neurol 2022; 13:867329. [PMID: 35847220 PMCID: PMC9277177 DOI: 10.3389/fneur.2022.867329] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/27/2022] [Indexed: 01/18/2023] Open
Abstract
Research in sickle cell anemia (SCA) has used, with limited race-matched control data, binary categorization of patients according to the presence or absence of silent cerebral infarction (SCI). SCI have primarily been identified using low-resolution MRI, with radiological definitions varying in lesion length and the requirement for abnormality on both fluid attenuated inversion recovery (FLAIR) and T1-weighted images. We aimed to assess the effect of published SCI definitions on global, regional, and lobar lesion metrics and their value in predicting cognition. One hundred and six patients with SCA and 48 controls aged 8-30 years underwent 3T MRI with a high-resolution FLAIR sequence and Wechsler cognitive assessment. Prevalence, number, and volume of lesions were calculated using a semi-automated pipeline for SCI defined as: (1) Liberal: any length (L-SCI); (2) Traditional: >3 mm in greatest dimension (T-SCI); (3) Restrictive; >3 mm in greatest dimension with a corresponding T1-weighted hypo-intensity (R-SCI). Globally, as hypothesized, there were large effects of SCI definition on lesion metrics in patients and controls, with prevalence varying from 24-42% in patients, and 4-23% in controls. However, contrary to hypotheses, there was no effect of any global metric on cognition. Regionally, there was a consistent distribution of SCI in frontal and parietal deep and juxta-cortical regions across definitions and metrics in patients, but no consistent distribution in controls. Effects of regional SCI metrics on cognitive performance were of small magnitude; some were paradoxical. These findings expose the challenges associated with the widespread use of SCI presence as a biomarker of white-matter injury and cognitive dysfunction in cross-sectional high-resolution MRI studies in patients with SCA. The findings indicate that with high-resolution MRI: (1) radiological definitions have a large effect on resulting lesion groups, numbers, and volumes; (2) there is a non-negligible prevalence of lesions in young healthy controls; and (3) at the group-level, there is no cross-sectional association between global lesion metrics and general cognitive impairment irrespective of lesion definition and metric. With high-resolution multi-modal MRI, the dichotomy of presence or absence of SCI does not appear to be a sensitive biomarker for the detection of functionally significant pathology; the search for appropriate endpoints for clinical treatment trials should continue.
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Affiliation(s)
- Hanne Stotesbury
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jamie M Kawadler
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jonathan D Clayden
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Dawn E Saunders
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Anna M Hood
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.,Division of Psychology and Mental Health, Manchester Centre for Health Psychology, University of Manchester, Manchester, United Kingdom
| | - Melanie Koelbel
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Sati Sahota
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | | | - Olu Wilkey
- North Middlesex University Hospital NHS Foundation Trust, London, United Kingdom
| | - Mark Layton
- Haematology, Imperial College Healthcare NHS Foundation Trust, London, United Kingdom
| | - Maria Pelidis
- Department of Haematology and Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Baba P D Inusa
- Department of Haematology and Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jo Howard
- Department of Haematology and Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - Chris A Clark
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Fenella J Kirkham
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.,Clinical and Experimental Sciences, University of Southampton, Southampton, United Kingdom
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13
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Hood AM, Crosby LE, Stotesbury H, Kölbel M, Kirkham FJ. Considerations for Selecting Cognitive Endpoints and Psychological Patient-Reported Outcomes for Clinical Trials in Pediatric Patients With Sickle Cell Disease. Front Neurol 2022; 13:835823. [PMID: 35800079 PMCID: PMC9253275 DOI: 10.3389/fneur.2022.835823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 05/20/2022] [Indexed: 12/04/2022] Open
Abstract
Pediatric patients with sickle cell disease (SCD) experience a range of medical complications that result in significant morbidity and mortality. Recent advances in prophylactic and curative treatment approaches have highlighted the need for sensitive and clinically-meaningful trial endpoints. The detrimental effects of cognitive and psychological difficulties on social and economic mobility are well described. Although numerous reviews have assessed cognitive outcomes in other rare genetic disorders, SCD has not received the same focus. This review describes the cognitive (i.e., executive function and processing speed) and psychological domains (i.e., depression and anxiety) that are consistently associated with SCD pathology and, therefore, may be of particular interest as clinical trial endpoints. We then discuss corresponding well-validated and reliable cognitive tests and patient-reported outcomes (PROs) that may be appropriate for clinical trials given their robust psychometric properties, ease of administration, and previous use in the SCD population. Further, we provide a discussion of potential pitfalls and considerations to guide endpoint selection. In line with the move toward patient-centered medicine, we identify specific tests (e.g., NIH Toolbox Cognition Module, Wechsler Cancellation Test) and psychological PROs (e.g., PROMIS depression and anxiety scales) that are sensitive to SCD morbidity and have the potential to capture changes that are clinically meaningful in the context of patients' day to day lives. In particularly vulnerable cognitive domains, such as executive function, we highlight the advantages of composite over single-test scores within the context of trials. We also identify general (i.e., practice effects, disease heterogeneity) and SCD-specific considerations (i.e., genotype, treatment course, and disease course, including degree of neurologic, pain, and sleep morbidity) for trial measures. Executive function composites hold particular promise as trial endpoints that are clinically meaningful, amenable to change, relatively easy to collect, and can be incorporated into the routine care of patients with SCD in various settings and countries.
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Affiliation(s)
- Anna M. Hood
- Division of Psychology and Mental Health, Manchester Centre for Health Psychology, University of Manchester, Manchester, United Kingdom
| | - Lori E. Crosby
- Division of Behavioral Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Hanne Stotesbury
- Developmental Neurosciences Unit and Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Melanie Kölbel
- Developmental Neurosciences Unit and Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Fenella J. Kirkham
- Developmental Neurosciences Unit and Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
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14
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Stotesbury H, Hales PW, Koelbel M, Hood AM, Kawadler JM, Saunders DE, Sahota S, Rees DC, Wilkey O, Layton M, Pelidis M, Inusa BPD, Howard J, Chakravorty S, Clark CA, Kirkham FJ. Venous cerebral blood flow quantification and cognition in patients with sickle cell anemia. J Cereb Blood Flow Metab 2022; 42:1061-1077. [PMID: 34986673 PMCID: PMC9121533 DOI: 10.1177/0271678x211072391] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/29/2021] [Accepted: 12/09/2021] [Indexed: 12/28/2022]
Abstract
Prior studies have described high venous signal qualitatively using arterial spin labelling (ASL) in patients with sickle cell anemia (SCA), consistent with arteriovenous shunting. We aimed to quantify the effect and explored cross-sectional associations with arterial oxygen content (CaO2), disease-modifying treatments, silent cerebral infarction (SCI), and cognitive performance. 94 patients with SCA and 42 controls underwent cognitive assessment and MRI with single- and multi- inflow time (TI) ASL sequences. Cerebral blood flow (CBF) and bolus arrival time (BAT) were examined across gray and white matter and high-signal regions of the sagittal sinus. Across gray and white matter, increases in CBF and reductions in BAT were observed in association with reduced CaO2 in patients, irrespective of sequence. Across high-signal sagittal sinus regions, CBF was also increased in association with reduced CaO2 using both sequences. However, BAT was increased rather than reduced in patients across these regions, with no association with CaO2. Using the multiTI sequence in patients, increases in CBF across white matter and high-signal sagittal sinus regions were associated with poorer cognitive performance. These novel findings highlight the utility of multiTI ASL in illuminating, and identifying objectively quantifiable and functionally significant markers of, regional hemodynamic stress in patients with SCA.
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Affiliation(s)
- Hanne Stotesbury
- Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, UK
| | - Patrick W Hales
- Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, UK
| | - Melanie Koelbel
- Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, UK
| | - Anna M Hood
- Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, UK
| | - Jamie M Kawadler
- Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, UK
| | - Dawn E Saunders
- Division of Psychology and Mental Health, Manchester Centre for Health Psychology, University of Manchester, Manchester, UK
| | - Sati Sahota
- Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, UK
| | - David C Rees
- Radiology, Great Ormond Hospital for Children NHS Trust, London, UK
| | | | - Mark Layton
- North Middlesex University Hospital NHS Foundation Trust, London, UK
| | - Maria Pelidis
- Haematology, Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Baba PD Inusa
- Haematology, Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Jo Howard
- Haematology, Imperial College Healthcare NHS Foundation Trust, London, UK
| | | | - Chris A Clark
- Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, UK
| | - Fenella J Kirkham
- Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, UK
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15
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Thompson JY, Menzies JC, Manning JC, McAnuff J, Brush EC, Ryde F, Rapley T, Pathan N, Brett S, Moore DJ, Geary M, Colville GA, Morris KP, Parslow RC, Feltbower RG, Lockley S, Kirkham FJ, Forsyth RJ, Scholefield BR. Early mobilisation and rehabilitation in the PICU: a UK survey. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2021-001300. [PMID: 36053640 PMCID: PMC9185558 DOI: 10.1136/bmjpo-2021-001300] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 02/25/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To understand the context and professional perspectives of delivering early rehabilitation and mobilisation (ERM) within UK paediatric intensive care units (PICUs). DESIGN A web-based survey administered from May 2019 to August 2019. SETTING UK PICUs. PARTICIPANTS A total of 124 staff from 26 PICUs participated, including 22 (18%) doctors, 34 (27%) nurses, 28 (23%) physiotherapists, 19 (15%) occupational therapists and 21 (17%) were other professionals. RESULTS Key components of participants' definitions of ERM included tailored, multidisciplinary rehabilitation packages focused on promoting recovery. Multidisciplinary involvement in initiating ERM was commonly reported. Over half of respondents favoured delivering ERM after achieving physiological stability (n=69, 56%). All age groups were considered for ERM by relevant health professionals. However, responses differed concerning the timing of initiation. Interventions considered for ERM were more likely to be delivered to patients when PICU length of stay exceeded 28 days and among patients with acquired brain injury or severe developmental delay. The most commonly identified barriers were physiological instability (81%), limited staffing (79%), sedation requirement (73%), insufficient resources and equipment (69%), lack of recognition of patient readiness (67%), patient suitability (63%), inadequate training (61%) and inadequate funding (60%). Respondents ranked reduction in PICU length of stay (74%) and improvement in psychological outcomes (73%) as the most important benefits of ERM. CONCLUSION ERM is gaining familiarity and endorsement in UK PICUs, but significant barriers to implementation due to limited resources and variation in content and delivery of ERM persist. A standardised protocol that sets out defined ERM interventions, along with implementation support to tackle modifiable barriers, is required to ensure the delivery of high-quality ERM.
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Affiliation(s)
| | - Julie C Menzies
- Department of Paediatric Intensive Care, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Joseph C Manning
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Children and Young People Health Research, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Jennifer McAnuff
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Emily Clare Brush
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Francesca Ryde
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Tim Rapley
- Northumbria University, Newcastle upon Tyne, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Stephen Brett
- Department of Surgery and Cancer, Imperial College of Science, Technology and Medicine, London, UK
| | - David J Moore
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, England
| | - Michelle Geary
- Department of Child Health, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Gillian A Colville
- Paediatric Psychology Service, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Kevin P Morris
- Birmingham Women's & Children's NHS Foundation Trust, Birmingham, UK
| | | | | | | | | | - Rob J Forsyth
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
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16
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Stotesbury H, Hales PW, Hood AM, Koelbel M, Kawadler JM, Saunders DE, Sahota S, Rees DC, Wilkey O, Layton M, Pelidis M, Inusa BPD, Howard J, Chakravorty S, Clark CA, Kirkham FJ. Individual Watershed Areas in Sickle Cell Anemia: An Arterial Spin Labeling Study. Front Physiol 2022; 13:865391. [PMID: 35592036 PMCID: PMC9110791 DOI: 10.3389/fphys.2022.865391] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/22/2022] [Indexed: 12/25/2022] Open
Abstract
Previous studies have pointed to a role for regional cerebral hemodynamic stress in neurological complications in patients with sickle cell anemia (SCA), with watershed regions identified as particularly at risk of ischemic tissue injury. Using single- and multi-inflow time (TI) arterial spin labeling sequences (ASL) in 94 patients with SCA and 42 controls, the present study sought to investigate cerebral blood flow (CBF) and bolus arrival times (BAT) across gray matter, white matter with early arrival times, and in individual watershed areas (iWSAs). In iWSAs, associations between hemodynamic parameters, lesion burden, white matter integrity, and general cognitive performance were also explored. In patients, increases in CBF and reductions in BAT were observed in association with reduced arterial oxygen content across gray matter and white matter with early arrival times using both sequences (all p < 0.001, d = -1.55--2.21). Across iWSAs, there was a discrepancy between sequences, with estimates based on the single-TI sequence indicating higher CBF in association with reduced arterial oxygen content in SCA patients, and estimates based on the multi-TI sequence indicating no significant between-group differences or associations with arterial oxygen content. Lesion burden was similar between white matter with early arrival times and iWSAs in both patients and controls, and using both sequences, only trend-level associations between iWSA CBF and iWSA lesion burden were observed in patients. Further, using the multi-TI sequence in patients, increased iWSA CBF was associated with reduced iWSA microstructural tissue integrity and slower processing speed. Taken together, the results highlight the need for researchers to consider BAT when estimating CBF using single-TI sequences. Moreover, the findings demonstrate the feasibility of multi-TI ASL for objective delineation of iWSAs and for detection of regional hemodynamic stress that is associated with reduced microstructural tissue integrity and slower processing speed. This technique may hold promise for future studies and treatment trials.
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Affiliation(s)
- Hanne Stotesbury
- Imaging and Biophysics Section, Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, United Kingdom
| | - Patrick W. Hales
- Imaging and Biophysics Section, Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, United Kingdom
| | - Anna M. Hood
- Division of Psychology and Mental Health, Manchester Centre for Health Psychology, University of Manchester, Manchester, United Kingdom
| | - Melanie Koelbel
- Imaging and Biophysics Section, Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, United Kingdom
| | - Jamie M. Kawadler
- Imaging and Biophysics Section, Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, United Kingdom
| | - Dawn E. Saunders
- Radiology, Great Ormond Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Sati Sahota
- Imaging and Biophysics Section, Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, United Kingdom
| | - David C. Rees
- Paediatric Haematology, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Olu Wilkey
- Paediatric Haematology and Oncology, North Middlesex University Hospital NHS Foundation Trust, London, United Kingdom
| | - Mark Layton
- Haematology, Imperial College Healthcare NHS Foundation Trust, London, United Kingdom
| | - Maria Pelidis
- Department of Haematology and Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Baba P. D. Inusa
- Department of Haematology and Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Jo Howard
- Department of Haematology and Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Subarna Chakravorty
- Paediatric Haematology, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Chris A. Clark
- Imaging and Biophysics Section, Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, United Kingdom
| | - Fenella J. Kirkham
- Clinical Neurosciences Section, Developmental Neurosciences, UCL Great Ormond St. Institute of Child Health, London, United Kingdom
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17
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Choi EJ, Westmacott R, Kirkham FJ, Robertson A, Muthusami P, Shroff M, Moharir M, Williams T, Dirks P, MacGregor D, Slim M, Pulcine E, Bhathal I, Kaseka ML, Kassner A, Logan W, deVeber G, Dlamini N. Fronto-Parietal and White Matter Haemodynamics Predict Cognitive Outcome in Children with Moyamoya Independent of Stroke. Transl Stroke Res 2022; 13:757-773. [PMID: 35338434 DOI: 10.1007/s12975-022-01003-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 03/03/2022] [Accepted: 03/04/2022] [Indexed: 10/18/2022]
Abstract
Moyamoya disease is a major arteriopathy characterised by progressive steno-occlusion of the arteries of the circle of Willis. Studies in adults with moyamoya suggest an association between abnormal fronto-parietal and white matter regional haemodynamics and cognitive impairments, even in the absence of focal infarction. However, these associations have not been investigated in children with moyamoya. We examined the relationship between regional haemodynamics and ratings of intellectual ability and executive function, using hypercapnic challenge blood oxygen level-dependent magnetic resonance imaging of cerebrovascular reactivity in a consecutive cohort of children with confirmed moyamoya. Thirty children were included in the final analysis (mean age: 12.55 ± 3.03 years, 17 females, 15 idiopathic moyamoya and 15 syndromic moyamoya). Frontal haemodynamics were abnormal in all regardless of stroke history and comorbidity, but occipital lobe haemodynamics were also abnormal in children with syndromic moyamoya. Executive function deficits were noted in both idiopathic and syndromic moyamoya, whereas intellectual ability was impaired in syndromic moyamoya, even in the absence of stroke. Analysis of the relative effect of regional abnormal haemodynamics on cognitive outcomes demonstrated that executive dysfunction was predominantly explained by right parietal and white matter haemodynamics independent of stroke and comorbidity, while posterior circulation haemodynamics predicted intellectual ability. These results suggest that parietal and posterior haemodynamics play a compensatory role in overcoming frontal vulnerability and cognitive impairment.
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Affiliation(s)
- Eun Jung Choi
- Neurosciences and Mental Health Program, Stroke Imaging Laboratory for Children, The Hospital for Sick Children, Toronto, ON, Canada
| | - Robyn Westmacott
- Department of Neuropsychology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Fenella J Kirkham
- Developmental Neurosciences and Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Amanda Robertson
- Neurosciences and Mental Health Program, Stroke Imaging Laboratory for Children, The Hospital for Sick Children, Toronto, ON, Canada.,Stroke Program, Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada.,Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, ON, Canada
| | - Prakash Muthusami
- Diagnostic Imaging, The Hospital for Sick Children, ON, Toronto, Canada.,Medical Imaging, University of Toronto, ON, Toronto, Canada
| | - Manohar Shroff
- Diagnostic Imaging, The Hospital for Sick Children, ON, Toronto, Canada.,Medical Imaging, University of Toronto, ON, Toronto, Canada
| | - Mahendranath Moharir
- Stroke Program, Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Tricia Williams
- Department of Neuropsychology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Peter Dirks
- Department of Neurosurgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Daune MacGregor
- Stroke Program, Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mahmoud Slim
- Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, ON, Canada
| | - Elizabeth Pulcine
- Stroke Program, Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ishvinder Bhathal
- Stroke Program, Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Matsanga Leyila Kaseka
- Stroke Program, Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Andrea Kassner
- Medical Imaging, University of Toronto, ON, Toronto, Canada.,Department of Translational Medicine, The Hospital for Sick Children, Peter Gilgan Centre for Research & Learning, ON, Toronto, Canada
| | - William Logan
- Stroke Program, Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Gabrielle deVeber
- Stroke Program, Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada.,Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, ON, Canada
| | - Nomazulu Dlamini
- Neurosciences and Mental Health Program, Stroke Imaging Laboratory for Children, The Hospital for Sick Children, Toronto, ON, Canada. .,Stroke Program, Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada. .,Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, ON, Canada.
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18
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Abdullahi SU, Jibir BW, Bello-Manga H, Gambo S, Inuwa H, Tijjani AG, Idris N, Galadanci A, Hikima MS, Galadanci N, Borodo A, Tabari AM, Haliru L, Suleiman A, Ibrahim J, Greene BC, Ghafuri DL, Rodeghier M, Slaughter JC, Kirkham FJ, Neville K, Kassim A, Trevathan E, Jordan LC, Aliyu MH, DeBaun MR. Hydroxyurea for primary stroke prevention in children with sickle cell anaemia in Nigeria (SPRING): a double-blind, multicentre, randomised, phase 3 trial. Lancet Haematol 2022; 9:e26-e37. [PMID: 34971579 PMCID: PMC10072240 DOI: 10.1016/s2352-3026(21)00368-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/15/2021] [Accepted: 11/16/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND In high-income countries, standard care for primary stroke prevention in children with sickle cell anaemia and abnormal transcranial Doppler velocities results in a 92% relative risk reduction of strokes but mandates initial monthly blood transfusion. In Africa, where regular blood transfusion is not feasible for most children, we tested the hypothesis that initial moderate-dose compared with low-dose hydroxyurea decreases the incidence of strokes for children with abnormal transcranial Doppler velocities. METHODS SPRING is a double-blind, parallel-group, randomised, controlled, phase 3 trial of children aged 5-12 years with sickle cell anaemia with abnormal transcranial Doppler velocities conducted at three teaching hospitals in Nigeria. For randomisation, we used a permuted block allocation scheme with block sizes of four, stratified by sex and site. Allocation was concealed from all but the pharmacists and statisticians. Participants were assigned in a 1:1 ratio to low-dose (10 mg/kg per day) or moderate-dose (20 mg/kg per day) oral hydroxyurea taken once daily with monthly clinical evaluation and laboratory monitoring. The primary outcome was initial stroke or transient ischaemic attack, centrally adjudicated. The secondary outcome was all-cause hospitalisation. We used the intention-to-treat population for data analysis. The trial was stopped early for futility after a planned minimum follow-up of 3·0 years to follow-up for participants. This trial was registered with ClinicalTrials.gov, number NCT02560935. FINDINGS Between Aug 2, 2016, and June 14, 2018, 220 participants (median age 7·2 years [IQR 5·5-8·9]; 114 [52%] female) were randomly allocated and followed for a median of 2·4 years (IQR 2·0-2·8). All participants were Nigerian and were from the following ethnic groups: 179 (82%) people were Hausa, 25 (11%) were Fulani, and 16 (7%) identified as another ethnicity. In the low-dose hydroxyurea group, three (3%) of 109 participants had strokes, with an incidence rate of 1·19 per 100 person-years and in the moderate-dose hydroxyurea group five (5%) of 111 had strokes with an incidence rate of 1·92 per 100 person-years (incidence rate ratio 0·62 [95% CI 0·10-3·20], p=0·77). The incidence rate ratio of hospitalisation for any reason was 1·71 (95% CI 1·15-2·57, p=0·0071), with higher incidence rates per 100 person-years in the low-dose group versus the moderate-dose group (27·43 vs 16·08). No participant had hydroxyurea treatment stopped for myelosuppression. INTERPRETATION Compared with low-dose hydroxyurea therapy, participants treated with moderate-dose hydroxyurea had no difference in the stroke incidence rate. However, secondary analyses suggest that the moderate-dose group could lower incidence rates for all-cause hospitalisations. These findings provide an evidence-based guideline for the use of low-dose hydroxyurea therapy for children with sickle cell anaemia at risk of stroke. FUNDING National Institute of Neurological Disorders and Stroke.
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Affiliation(s)
- Shehu U Abdullahi
- Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Binta W Jibir
- Department of Pediatrics, Hasiya Bayero Pediatric Hospital, Kano, Nigeria
| | - Halima Bello-Manga
- Department of Haematology and Blood Transfusion, Kaduna State University/Barau Dikko Teaching Hospital, Kaduna, Nigeria
| | - Safiya Gambo
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Hauwa Inuwa
- Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Aliyu G Tijjani
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Nura Idris
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Aisha Galadanci
- Department of Haematology and Blood Transfusion, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Mustapha S Hikima
- Department of Radiology, Muhammad Abdullahi Wase Teaching Hospital, Kano, Nigeria
| | - Najibah Galadanci
- Department of Epidemiology, School of Public health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Awwal Borodo
- Department of Medicine, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Abdulkadir M Tabari
- Department of Radiology, Kaduna State University, Barau Dikko Teaching Hospital, Kaduna, Nigeria
| | - Lawal Haliru
- Department of Pediatrics, Kaduna State University, Barau Dikko Teaching Hospital, Kaduna, Nigeria
| | - Aisha Suleiman
- Department of Pediatrics, Kaduna State University, Barau Dikko Teaching Hospital, Kaduna, Nigeria
| | - Jamila Ibrahim
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Brittany C Greene
- Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Djamila L Ghafuri
- Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - James C Slaughter
- Department of Biostatistics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fenella J Kirkham
- Developmental Neurosciences, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Kathleen Neville
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Adetola Kassim
- Department of Hematology and Oncology, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edwin Trevathan
- Vanderbilt Institute for Global Health, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pediatrics, Neurology, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lori C Jordan
- Department of Pediatrics, Neurology, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Muktar H Aliyu
- Vanderbilt Institute for Global Health, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael R DeBaun
- Vanderbilt Institute for Global Health, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA.
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19
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Hood AM, Stotesbury H, Kölbel M, DeHaan M, Downes M, Kawadler JM, Sahota S, Dimitriou D, Inusa B, Wilkey O, Pelidis M, Trompeter S, Leigh A, Younis J, Drasar E, Chakravorty S, Rees DC, Height S, Lawson S, Gavlak J, Gupta A, Ridout D, Clark CA, Kirkham FJ. Study of montelukast in children with sickle cell disease (SMILES): a study protocol for a randomised controlled trial. Trials 2021; 22:690. [PMID: 34629091 PMCID: PMC8502503 DOI: 10.1186/s13063-021-05626-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 09/14/2021] [Indexed: 01/20/2023] Open
Abstract
Background Young children with sickle cell anaemia (SCA) often have slowed processing speed associated with reduced brain white matter integrity, low oxygen saturation, and sleep-disordered breathing (SDB), related in part to enlarged adenoids and tonsils. Common treatments for SDB include adenotonsillectomy and nocturnal continuous positive airway pressure (CPAP), but adenotonsillectomy is an invasive surgical procedure, and CPAP is rarely well-tolerated. Further, there is no current consensus on the ability of these treatments to improve cognitive function. Several double-blind, randomised controlled trials (RCTs) have demonstrated the efficacy of montelukast, a safe, well-tolerated anti-inflammatory agent, as a treatment for airway obstruction and reducing adenoid size for children who do not have SCA. However, we do not yet know whether montelukast reduces adenoid size and improves cognition function in young children with SCA. Methods The Study of Montelukast In Children with Sickle Cell Disease (SMILES) is a 12-week multicentre, double-blind, RCT. SMILES aims to recruit 200 paediatric patients with SCA and SDB aged 3–7.99 years to assess the extent to which montelukast can improve cognitive function (i.e. processing speed) and sleep and reduce adenoidal size and white matter damage compared to placebo. Patients will be randomised to either montelukast or placebo for 12 weeks. The primary objective of the SMILES trial is to assess the effect of montelukast on processing speed in young children with SCA. At baseline and post-treatment, we will administer a cognitive evaluation; caregivers will complete questionnaires (e.g. sleep, pain) and measures of demographics. Laboratory values will be obtained from medical records collected as part of standard care. If a family agrees, patients will undergo brain MRIs for adenoid size and other structural and haemodynamic quantitative measures at baseline and post-treatment, and we will obtain overnight oximetry. Discussion Findings from this study will increase our understanding of whether montelukast is an effective treatment for young children with SCA. Using cognitive testing and MRI, the SMILES trial hopes to gain critical knowledge to help develop targeted interventions to improve the outcomes of young children with SCA. Trial registration ClinicalTrials.govNCT04351698. Registered on April 17, 2020. European Clinical Trials Database (EudraCT No. 2017-004539-36). Registered on May 19, 2020
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Affiliation(s)
- Anna M Hood
- Developmental Neurosciences Unit and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.
| | - Hanne Stotesbury
- Developmental Neurosciences Unit and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Melanie Kölbel
- Developmental Neurosciences Unit and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Michelle DeHaan
- Developmental Neurosciences Unit and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Michelle Downes
- School of Psychology, University College Dublin, Dublin, Ireland
| | - Jamie M Kawadler
- Developmental Neurosciences Unit and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Satwinder Sahota
- Developmental Neurosciences Unit and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Dagmara Dimitriou
- Department of Psychology and Human Development, UCL Institute of Education, London, UK
| | - Baba Inusa
- Children's Sickle Cell and Thalassaemia Centre, Evelina London Children's Hospital, Guy's and St Thomas' NHS Trust, London, UK
| | - Olu Wilkey
- North Middlesex Hospital National Health Service Trust, London, UK
| | - Maria Pelidis
- Department of Paediatric Haematology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Trust, London, UK
| | - Sara Trompeter
- University College London Hospitals NHS Foundation Trust, London, UK.,NHS Blood and Transplant, London, UK
| | - Andrea Leigh
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Emma Drasar
- Whittington Health NHS Trust, London, UK.,Department of Clinical Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - David C Rees
- Department of Haematological Medicine, King's College Hospital NHS Trust, London, UK
| | - Sue Height
- Paediatric Haematology, King's College Hospital NHS Trust, London, UK
| | - Sarah Lawson
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Johanna Gavlak
- Department of Child Health, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Atul Gupta
- Department of Paediatric Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Deborah Ridout
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Christopher A Clark
- Developmental Neurosciences Unit and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Fenella J Kirkham
- Developmental Neurosciences Unit and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.,Department of Clinical Haematology, University College London Hospitals NHS Foundation Trust, London, UK.,Department of Child Health, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Clinical and Experimental Sciences, University of Southampton, Southampton, UK
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20
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Hood AM, Stotesbury H, Murphy J, Kölbel M, Slee A, Springall C, Paradis M, Corral-Frías NS, Reyes-Aguilar A, Cuellar Barboza AB, Noser AE, Gomes S, Mitchell M, Watkins SM, Butsch Kovacic M, Kirkham FJ, Crosby LE. Attitudes About COVID-19 and Health (ATTACH): Online Survey and Mixed Methods Study. JMIR Ment Health 2021; 8:e29963. [PMID: 34357877 PMCID: PMC8500353 DOI: 10.2196/29963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/12/2021] [Accepted: 07/28/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Behavioral mitigation strategies to slow the spread of COVID-19 have resulted in sweeping lifestyle changes, with short- and long-term psychological, well-being, and quality of life implications. The Attitudes About COVID-19 and Health (ATTACH) study focuses on understanding attitudes and beliefs while considering the impact on mental and physical health and the influence of broader demographic and geographic factors on attitudes, beliefs, and mental health burden. OBJECTIVE In this assessment of our first wave of data collection, we provide baseline cohort description of the ATTACH study participants in the United Kingdom, the United States, and Mexico. Additionally, we assess responses to daily poll questions related to COVID-19 and conduct a cross-sectional analysis of baseline assessments collected in the UK between June 26 and October 31, 2020. METHODS The ATTACH study uses smartphone app technology and online survey data collection. Participants completed poll questions related to COVID-19 2 times daily and a monthly survey assessing mental health, social isolation, physical health, and quality of life. Poll question responses were graphed using 95% Clopper-Pearson (exact) tests with 95% CIs. Pearson correlations, hierarchical linear regression analyses, and generalized linear models assessed relationships, predictors of self-reported outcomes, and group differences, respectively. RESULTS By October 31, 2020, 1405, 80, and 90 participants had consented to participate in the UK, United States, and Mexico, respectively. Descriptive data for the UK daily poll questions indicated that participants generally followed social distancing measures, but worry and negative impacts on families increased as the pandemic progressed. Although participants generally reported feeling that the reasons for current measures had been made clear, there was low trust that the government was doing everything in its power to meet public needs. In the UK, 1282 participants also completed a monthly survey (94.99% [1326/1396] White, 72.22% [1014/1404] female, and 20.12% [277/1377] key or essential workers); 18.88% (242/1282) of UK participants reported a preexisting mental health disorder, 31.36% (402/1282) reported a preexisting chronic medical illness, and 35.11% (493/1404) were aged over 65; 57.72% (740/1282) of participants reported being more sedentary since the pandemic began, and 41.89% (537/1282) reported reduced access to medical care. Those with poorer mental health outcomes lived in more deprived neighborhoods, in larger households (Ps<.05), had more preexisting mental health disorders and medical conditions, and were younger than 65 years (all Ps<.001). CONCLUSIONS Communities who have been exposed to additional harm during the COVID-19 pandemic were experiencing worse mental outcomes. Factors including having a medical condition, or living in a deprived neighborhood or larger household were associated with heightened risk. Future longitudinal studies should investigate the link between COVID-19 exposure, mental health, and sociodemographic and residential characteristics.
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Affiliation(s)
- Anna M Hood
- Developmental Neurosciences Unit and Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Hanne Stotesbury
- Developmental Neurosciences Unit and Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jennifer Murphy
- Department of Psychology, Royal Holloway University of London, London, United Kingdom
| | - Melanie Kölbel
- Developmental Neurosciences Unit and Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - April Slee
- Axio Research LLC, Seattle, WA, United States
| | | | | | | | - Azalea Reyes-Aguilar
- Department of Psychobiology, Facultad de Psicología, Universidad Nacional Autónoma de México, Ciudad de México, Mexico
- Department of Neuroscience, Facultad de Psicología, Universidad Nacional Autónoma de México, Ciudad de México, Mexico
| | | | - Amy E Noser
- Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Stacey Gomes
- Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- College of Criminal Justice, Education and Human Services, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Monica Mitchell
- Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Sharon M Watkins
- Cincinnati-Hamilton County Community Action Agency, Cincinnati, OH, United States
| | - Melinda Butsch Kovacic
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Fenella J Kirkham
- Developmental Neurosciences Unit and Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Lori E Crosby
- Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
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21
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Hood AM, Kölbel M, Stotesbury H, Kawadler J, Slee A, Inusa B, Pelidis M, Howard J, Chakravorty S, Height S, Awogbade M, Kirkham FJ, Liossi C. Biopsychosocial Predictors of Quality of Life in Paediatric Patients With Sickle Cell Disease. Front Psychol 2021; 12:681137. [PMID: 34594262 PMCID: PMC8476744 DOI: 10.3389/fpsyg.2021.681137] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 08/18/2021] [Indexed: 11/13/2022] Open
Abstract
Sickle cell disease (SCD) refers to a group of inherited blood disorders with considerable morbidity that causes severe pain, reduces life expectancy, and requires significant self-management. Acute painful episodes are the hallmark of SCD, but persistent daily pain is also highly prevalent in this population. Characterising the impact and experience of SCD-related morbidity (i.e., sleep disruption, frequent emergency department visits, cognitive dysfunction) on health-related quality of life (HRQOL) requires multiple assessment methods to best capture the underlying mechanisms. To gain a greater understanding of the effect of common symptom categories on HRQOL and to determine potential pain coping targets, the present study investigated whether demographic, socioeconomic, sleepiness, pain burden, frequency of emergency department (ED) visits, and cognition predicted HRQOL in a paediatric sample of patients with SCD. Our study was a secondary analysis of baseline assessment data of children with SCD aged 8-15 years (n = 30) in the Prevention of Morbidity in Sickle Cell Anaemia Phase 2b (POMSb2) randomised controlled clinical trial of auto-adjusting continuous positive airways pressure. Patients completed cognitive testing (IQ, Processing Speed Index, Delis-Kaplan Executive Function Scale (DKEFS) Tower, Conner's Continuous Performance Test), sleepiness (Epworth Sleepiness Scale), and HRQOL (PedsQL Sickle Cell Module) at baseline. Patients reported pain burden (Sickle Cell Pain Burden Inventory-Youth) each month over 8 visits. Caregivers provided demographic information and reported their child's executive function (Behavioural Rating Inventory of Executive Function) at baseline. Data from our analysis demonstrated that demographic factors (i.e., age, gender, level of neighbourhood deprivation) and treatment variables (i.e., hydroxyurea use) did not independently predict HRQOL, and laboratory values (i.e., haemoglobin, haematocrit, mean oxygen saturation) were not significantly correlated with HRQOL (ps > 0.05). However, sleepiness, pain burden, ED visits, and executive dysfunction independently predicted HRQOL (R 2 = 0.66) with large effects (η2 = 0.16 to 0.32). These findings identify specific, measurable symptom categories that may serve as targets to improve HRQOL that are responsive to change. This knowledge will be useful for multimodal interventions for paediatric patients with SCD that include sleep management, pain coping strategies, and executive function training.
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Affiliation(s)
- Anna M Hood
- Developmental Neurosciences Unit and Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Melanie Kölbel
- Developmental Neurosciences Unit and Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Hanne Stotesbury
- Developmental Neurosciences Unit and Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jamie Kawadler
- Developmental Neurosciences Unit and Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - April Slee
- Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Baba Inusa
- Department of Paediatric Haematology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Maria Pelidis
- Department of Paediatric Haematology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Jo Howard
- Department of Haematological Medicine, King's College London, London, United Kingdom.,Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Subarna Chakravorty
- Paediatric Haematology, King's College Hospital NHS Trust, London, United Kingdom
| | - Sue Height
- Paediatric Haematology, King's College Hospital NHS Trust, London, United Kingdom
| | - Moji Awogbade
- Department of Haematological Medicine, King's College Hospital NHS Trust, London, United Kingdom
| | - Fenella J Kirkham
- Developmental Neurosciences Unit and Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom.,Department of Clinical Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom.,Department of Child Health, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.,Clinical and Experimental Sciences, University of Southampton, Southampton, United Kingdom
| | - Christina Liossi
- Department of Psychology, University of Southampton, Southampton, United Kingdom.,Paediatric Psychology, Great Ormond Hospital for Children NHS Foundation Trust, London, United Kingdom
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22
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Kölbel M, Kirkham FJ, Dimitriou D. Developmental Profile of Sleep and Its Potential Impact on Daytime Functioning from Childhood to Adulthood in Sickle Cell Anaemia. Brain Sci 2020; 10:brainsci10120981. [PMID: 33327459 PMCID: PMC7764980 DOI: 10.3390/brainsci10120981] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 01/12/2023] Open
Abstract
Young individuals with sickle cell anaemia (SCA) experience sleep disturbances and often experience daytime tiredness, which in turn may impact on their daytime functioning and academic attainment, but there are few longitudinal data. METHODS Data on sleep habits and behaviour were taken on the same day as an in-hospital polysomnography. This study assesses the developmental sleep profiles of children and young adults aged 4-23 years old with SCA. We examined retrospective polysomnography (PSG) and questionnaire data. RESULTS A total of 256 children with a median age of 10.67 years (130 male) were recruited and 179 returned for PSG 1.80-6.72 years later. Later bedtimes and a decrease in total sleep time (TST) were observed. Sleep disturbances, e.g., parasomnias and night waking, were highest in preschool children and young adults at their first visit. Participants with lower sleep quality, more movement during the night and increased night waking experienced daytime sleepiness, potentially an indicator of lower daytime functioning. Factors influencing sleep quantity included age, hydroxyurea prescription, mean overnight oxygen saturation, sleep onset latency, periodic limb movement, socioeconomic status and night waking. CONCLUSION Sleep serves an important role for daytime functioning in SCA; hence, quantitative (i.e., PSG for clinical symptoms, e.g., sleep-disordered breathing, nocturnal limb movement) and qualitative (i.e., questionnaires for habitual sleep behaviour) assessments of sleep should be mutually considered to guide interventions.
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Affiliation(s)
- Melanie Kölbel
- Department of Developmental Neurosciences Unit, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK;
| | - Fenella J. Kirkham
- Department of Developmental Neurosciences Unit, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK;
- Clinical and Experimental Sciences, University of Southampton, Southampton SO17 1BJ, UK
- Child Health, University Hospital Southampton, Southampton SO16 6YD, UK
- Paediatric Neurosciences, King’s College Hospital, London SE5 9RS, UK
- Correspondence: ; Tel.: +44-2079052981
| | - Dagmara Dimitriou
- Sleep Education and Research Laboratory, UCL Institute of Education, 25 Woburn Square, London WC1H 0AA, UK;
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23
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Sankar R, Kirkham FJ, Holmes GL, Pina-Garza JE, Wheless J, Gama H, Moreira J, Cantu D, Tosiello R, Blum D, Grinnell T. Long-term safety and tolerability of adjunctive eslicarbazepine acetate in children with focal seizures. Epilepsy Behav 2020; 112:107458. [PMID: 33181890 DOI: 10.1016/j.yebeh.2020.107458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/26/2020] [Accepted: 08/31/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate long-term safety and tolerability outcomes in two open-label extension (OLE) studies of adjunctive eslicarbazepine acetate (ESL) in children with focal seizures. METHODS Safety data from patients aged 4-17 years in OLEs of Studies 2093-208 and -305 were pooled and analyzed. Studies 208 and 305 were randomized, double-blind, placebo-controlled studies of adjunctive treatment with ESL in children with focal seizures refractory to treatment with 1-2 antiseizure drugs; patients could continue into uncontrolled OLEs (up to 5 years total duration). The OLEs evaluated the safety and tolerability of ESL (10-30 mg/kg/day; maximum 1200 mg/day). RESULTS The 1-year OLE and post-1-year OLE safety populations comprised 337 and 177 ESL-treated patients, respectively. The overall incidence of treatment-emergent adverse events (TEAEs) with ESL was 64.1% during the 1-year OLE and 52.5% during the post-1-year OLE. Nasopharyngitis, partial seizures, vomiting, pyrexia, headache, somnolence, and respiratory tract infection were the most frequently reported TEAEs during the 1-year OLE. The overall incidence of serious adverse events (AEs) was 8.9% during the 1-year OLE and 10.2% during the post-1-year OLE. Partial seizures (1.2%) and pneumonia (1.2%) were the most frequently reported serious AEs during the 1-year OLE. The overall incidence of TEAEs leading to discontinuation was 4.2% during the 1-year OLE and 0.6% during the post-1-year OLE. Partial seizures (1.5%) was the most frequently reported TEAE leading to discontinuation during the 1-year OLE. CONCLUSIONS Overall, long-term treatment with ESL was generally well tolerated in pediatric patients aged 4-17 years with focal seizures. TEAEs were comparable to those observed in adults with no new events of concern.
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Affiliation(s)
- Raman Sankar
- David Geffen School of Medicine, UCLA Mattel Children's Hospital, Los Angeles, CA, USA.
| | - Fenella J Kirkham
- University Hospital Southampton, Southampton, UK; UCL Great Ormond Street Institute of Child Health, London, UK.
| | - Gregory L Holmes
- College of Medicine, University of Vermont, Burlington, VT, USA.
| | | | - James Wheless
- UTHSC Pediatric Neurology, Le Bonheur Children's Hospital, Memphis, TN, USA.
| | - Helena Gama
- BIAL - Portela & Cª, S.A., Coronado (S. Romão e S. Mamede), Portugal.
| | - Joana Moreira
- BIAL - Portela & Cª, S.A., Coronado (S. Romão e S. Mamede), Portugal.
| | - David Cantu
- Sunovion Pharmaceuticals Inc., Fort Lee, NJ, USA.
| | | | - David Blum
- Sunovion Pharmaceuticals Inc., Marlborough, MA, USA.
| | - Todd Grinnell
- Sunovion Pharmaceuticals Inc., Marlborough, MA, USA.
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24
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Downes M, de Haan M, O'Leary T, Telfer PT, Kirkham FJ. Temperament in preschool children with sickle cell anaemia. Arch Dis Child 2020; 105:900-902. [PMID: 30578248 DOI: 10.1136/archdischild-2018-315054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 12/04/2018] [Accepted: 12/05/2018] [Indexed: 11/04/2022]
Abstract
AIMS Few studies have investigated the potential impact of sickle cell anaemia (SCA) on temperament. The aim of the current study was to investigate temperament in preschool children with SCA and to establish the reliability of the Children's Behaviour Questionnaire (CBQ) in this population. METHODS The CBQ, a parent-report measure of temperament, was completed by parents of 21 preschool children with SCA and a control group of parents of typically developing children, matched for age, ethnicity and socioeconomic status. RESULTS A significant difference between groups was identified for the dimension of negative affectivity only, with specific differences observed in the discomfort subdomain. Patients with a greater number of hospital admissions in the previous year were reported to have higher levels of discomfort. CONCLUSIONS Preschool children with SCA are reported to have higher rates of negative affectivity, particularly discomfort. Future research is required to investigate the potential influence of dysregulated negative emotions and discomfort on disease management and quality of life throughout childhood.
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Affiliation(s)
- Michelle Downes
- School of Psychology, University College Dublin, Dublin, Ireland.,Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Michelle de Haan
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Tess O'Leary
- School of Psychology, University College Dublin, Dublin, Ireland
| | - Paul T Telfer
- Department of Haematology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Fenella J Kirkham
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
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Galadanci NA, Abdullahi SU, Ali Abubakar S, Wudil Jibir B, Aminu H, Tijjani A, Abba MS, Tabari MA, Galadanci A, Borodo AM, Belonwu R, Salihu AS, Rodeghier M, Ghafuri DL, Covert C Greene BV, Neville K, Kassim AA, Kirkham FJ, Jordan LC, Aliyu MH, DeBaun MR. Moderate fixed-dose hydroxyurea for primary prevention of strokes in Nigerian children with sickle cell disease: Final results of the SPIN trial. Am J Hematol 2020; 95:E247-E250. [PMID: 32510680 DOI: 10.1002/ajh.25900] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 05/31/2020] [Indexed: 01/04/2023]
Affiliation(s)
- Najibah A. Galadanci
- Department of Epidemiology, School of Public Health University of Alabama at Birmingham Birmingham Alabama
| | - Shehu U. Abdullahi
- Department of Pediatrics Bayero University/Aminu Kano Teaching Hospital Kano Nigeria
| | - Shehi Ali Abubakar
- Department of Radiology Bayero University/Aminu Kano Teaching Hospital Kano Nigeria
| | - Binta Wudil Jibir
- Department of Pediatrics Hasiya Bayero Childrenʼs Hospital Kano Nigeria
| | - Hauwa Aminu
- Murtala Mohammed Specialist Hospital Kano Nigeria
| | | | - Muhammad S. Abba
- Department of Pharmacy Aminu Kano Teaching Hospital Kano Nigeria
| | - Musa A. Tabari
- Department of Radiology Barau‐Dikko Teaching Hospital Kaduna Nigeria
| | - Aisha Galadanci
- Department of Hematology Bayero University/Aminu Kano Teaching Hospital Kano Nigeria
| | - Awwal Musa Borodo
- Department of Medicine Murtala Muhammad Specialist Hospital Kano Nigeria
| | - Raymond Belonwu
- Department of Pediatrics Bayero University/Aminu Kano Teaching Hospital Kano Nigeria
| | - Auwal S. Salihu
- Department of Psychiatry Bayero University/Aminu Kano Teaching Hospital Kano Nigeria
| | | | - Djamila L. Ghafuri
- Division of Hematology and Oncology, Department of Pediatrics Vanderbilt‐Meharry of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center Nashville Tennessee
| | - Brittany V. Covert C Greene
- Division of Hematology and Oncology, Department of Pediatrics Vanderbilt‐Meharry of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center Nashville Tennessee
| | - Kathleen Neville
- Department of Pediatrics, Divisions of Pediatric Hematology‐Oncology and Clinical Pharmacology and Toxicology University of Arkansas for Medical Sciences Little Rock Arkansas
| | - Adetola A. Kassim
- Division of Hematology and Oncology Department of Medicine Vanderbilt University School of Medicine Nashville Tennessee
| | - Fenella J. Kirkham
- Department of Pediatrics University College of London, Great Ormond Street Institute of Child Health London UK
| | - Lori C. Jordan
- Division of Pediatric Neurology, Department of Pediatrics Vanderbilt University Medical Center Nashville Tennessee
| | | | - Michael R. DeBaun
- Division of Hematology and Oncology, Department of Pediatrics Vanderbilt‐Meharry of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center Nashville Tennessee
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Abstract
L-Glutamine is a conditionally essential amino acid required for synthesis of the pyridines for nucleotides, including nicotinamide adenine dinucleotide (NAD) and glutathione, as well as glutamate, and becomes essential during oxidative stress exposure. The NADH:[NAD⁺ + NADH] (redox) ratio in sickle red blood cells (RBCs) is lower than in normal RBCs, consistent with oxidative stress, therefore glutamine availability is important in sickle cell disease (SCD). RBC glutamine levels vary between SCD studies but the ratio glutamine:glutamate was inversely related to tricuspid regurgitant jet velocity in one. Oral L-glutamine was associated with an increase in NADH and reduction in RBC endothelium adhesion in small studies of SCD patients. In a sickle mouse model, glutamine levels were directly related to cerebral blood flow. Phase II and III randomized, double-blind, controlled trials of L-glutamine 0.6 g/kg/day compared with placebo in children and adults with SCD and = 2 episodes of pain in the previous year provide evidence that L-glutamine is safe and associated with a reduction in painful episodes and in hospitalizations. However, L-glutamine was only tolerated in two-thirds of patients, anemia and hemolysis did not improve and there are few data on mortality and organ complications. Future studies should investigate the effect of other amino acids and total protein intake.
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Affiliation(s)
- S E Cox
- London School of Hygiene and Tropical Medicine, London, UK
| | - E Hart
- Medical School, University College London, London, UK
| | - F J Kirkham
- Developmental Neurosciences, UCL Institute of Child Health, London, UK; University of Southampton and University Hospital Southampton, Southampton, UK.
| | - H Stotesbury
- Developmental Neurosciences, UCL Institute of Child Health, London, UK
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Dlamini N, Pohl K, Eley B, Van Toorn R, Kilborn T, Padayachee S, Pontigon AM, Kirkham FJ, Wilmshurst J. Stroke transcranial Doppler in children with human immunodeficiency virus. Dev Med Child Neurol 2020; 62:735-741. [PMID: 31916251 DOI: 10.1111/dmcn.14439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2019] [Indexed: 11/28/2022]
Abstract
AIMS To describe stroke syndromes and transcranial Doppler (TCD) findings in children with human immunodeficiency virus (HIV) and examine the associations between TCD and clinical and laboratory data. METHOD We enrolled 42 children (24 males, 18 females) with HIV (median age=7y 6mo; 2y 7mo-15y 6mo), with and without stroke who underwent a TCD examination of the anterior and posterior circulations to derive time-averaged maximum mean velocity (TAMMV) measurements for comparison with previous studies. Clinical and laboratory variables were extracted from the medical records. RESULTS Of the 42 children with HIV, five had right-sided hemiparesis, three had chronic lung disease, two occurred post-varicella infection, one after herpetic oral ulceration, and one had a poorly functioning left ventricle. Neuroimaging showed middle cerebral artery (MCA) TAMMV greater than 200cm/s, moyamoya-like arteriopathy, left basal ganglia infarction with ipsilateral stenosis, hygroma consistent with venous thrombosis, and a hyperdense left MCA. Eight neurologically asymptomatic children had atypical TCD. The CD4 cell count was non-significantly lower in 6 out of 30 children with atypical TCD (median=21.5; interquartile range=16.1-26.5) compared with the remainder (median=29; interquartile range=21.3-35.0; p=0.09). INTERPRETATION A variety of stroke syndromes occur in children with HIV. TCD suggests atypical intracranial vessels and/or haemodynamics in some children with HIV infection, consistent with vasculopathy, possibly related directly to immunodeficiency and/or infection. WHAT THIS PAPER ADDS A range of stroke syndromes are found in children with human immunodeficiency virus (HIV). Transcranial Doppler (TCD) velocities in HIV are commonly outside the range for typically developing children. TCD and neuroimaging data in children with HIV suggest intracranial vasculopathy as one mechanism for stroke. CD4 cell count is non-significantly lower in children with HIV and atypical TCD.
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Affiliation(s)
- Nomazulu Dlamini
- Evelina Children's Hospital, London, UK.,The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Brian Eley
- Red Cross War Memorial Hospital, University of Cape Town, Cape Town, South Africa
| | | | - Tracy Kilborn
- Red Cross War Memorial Hospital, University of Cape Town, Cape Town, South Africa
| | | | | | - Fenella J Kirkham
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, UK.,Clinical and Experimental Sciences, University of Southampton, Southampton, UK.,Child Health, University Hospital Southampton, Southampton, UK.,Paediatric Neurosciences, King's College Hospital, London, UK
| | - Jo Wilmshurst
- Red Cross War Memorial Hospital, University of Cape Town, Cape Town, South Africa
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28
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Jacob M, Saunders DE, Sangeda RZ, Ahmed M, Tutuba H, Kussaga F, Musa B, Mmbando B, Slee AE, Kawadler JM, Makani J, Kirkham FJ. Cerebral Infarcts and Vasculopathy in Tanzanian Children With Sickle Cell Anemia. Pediatr Neurol 2020; 107:64-70. [PMID: 32111561 DOI: 10.1016/j.pediatrneurol.2019.12.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 12/09/2019] [Accepted: 12/14/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cerebral infarcts and vasculopathy in neurologically asymptomatic children with sickle cell anemia (SCA) have received little attention in African settings. This study aimed to establish the prevalence of silent cerebral infarcts (SCI) and vasculopathy and determine associations with exposure to chronic hemolysis, anemia, and hypoxia. METHODS We prospectively studied 224 children with SCA with transcranial Doppler (TCD), and magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA). Regressions were undertaken with contemporaneous hemoglobin, reticulocyte count, mean prior hemoglobin, oxygen content, reticulocyte count, and indirect bilirubin. RESULTS Prevalence of SCI was 27% (61 of 224); cerebral blood flow velocity was abnormal (>200 cm/s) in three and conditional (>170<200 cm/s) in one. Vasculopathy grades 2 (stenosis) and 3 (occlusion) occurred in 16 (7%) and two (1%), respectively; none had grade 4 (moyamoya). SCI was associated with vasculopathy on MRA (odds ratio 2.68; 95% confidence intervals [95% CI] 1.32 to 5.46; P = 0.007) and mean prior indirect bilirubin (odds ratio 1.02, 95% CI 1.00 to 1.03, P = 0.024; n = 83) but not age, sex, non-normal TCD, or contemporaneous hemoglobin. Vasculopathy was associated with mean prior values for hemoglobin (odds ratio 0.33, 95% CI 0.16 to 0.69, P = 0.003; n = 87), oxygen content (odds ratio 0.43, 95% CI 0.25 to 0.74, P = 0.003), reticulocytes (odds ratio 1.20, 95% CI 1.01-1.42, P = 0.041; n = 77), and indirect bilirubin (odds ratio 1.02, 95% CI 1.01 to 1.04, P = 0.009). CONCLUSIONS SCI and vasculopathy on MRA are common in neurologically asymptomatic children with SCA living in Africa, even when TCD is normal. Children with vasculopathy on MRA are at increased risk of SCI. Longitudinal exposure to anemia, hypoxia, and hemolysis appear to be risk factors for vasculopathy.
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Affiliation(s)
- Mboka Jacob
- Department of Radiology & Imaging, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania.
| | - Dawn E Saunders
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Raphael Z Sangeda
- Department of Pharmaceutical Microbiology, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Magda Ahmed
- Department of Radiology & Imaging, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Hilda Tutuba
- Department of Heamatology and Blood Transfusion, Muhimbili Sickle Cell Program, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Frank Kussaga
- Department of Radiology & Imaging, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Balowa Musa
- Department of Radiology & Imaging, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Bruno Mmbando
- Department of Heamatology and Blood Transfusion, Muhimbili Sickle Cell Program, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania; Department of Heamatology and Blood Transfusion, Muhimbili Sickle Cell Program, Muhimbili University of Health and Allied Sciences & National Institute for Medical Research, Tanga Center, Tanga, Tanzania
| | - April E Slee
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jamie M Kawadler
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Julie Makani
- Department of Heamatology and Blood Transfusion, Muhimbili Sickle Cell Program, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania; Muhimbili Sickle Cell Program & Department of Hematology and Blood Transfusion, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Fenella J Kirkham
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
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29
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Jacob M, Stotesbury H, Kawadler JM, Lapadaire W, Saunders DE, Sangeda RZ, Chamba C, Kazema R, Makani J, Kirkham FJ, Clark CA. White Matter Integrity in Tanzanian Children With Sickle Cell Anemia: A Diffusion Tensor Imaging Study. Stroke 2020; 51:1166-1173. [PMID: 32138633 DOI: 10.1161/strokeaha.119.027097] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background and Purpose- Widespread reductions in white matter integrity are associated with cognitive dysfunction in sickle cell anemia. Silent cerebral infarction (SCI), vasculopathy (VSC), and low hemoglobin concentration (Hb) are implicated; we aimed to determine independent contributions to microstructural white matter injury and whether white matter integrity differs across arterial territories. Methods- Sixty two children with sickle cell anemia aged 6 to 19 years were prospectively studied at Muhimbili National Hospital, Tanzania. SCI± and VSC± were identified on magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA) scans by 2 neuroradiologists. Tract-based spatial statistics tested for voxel-wise differences in diffusion tensor imaging metrics (ie, fractional anisotropy, mean diffusivity, radial diffusivity, and axial diffusivity) between SCI± and VSC± groups, with correlations between diffusion tensor imaging metrics and Hb. In tract-based spatial statistics analyses, potentially mediating factors (ie, age, sex, as well as Hb, SCI, and/or vasculopathy) were covariates. Differences in mean diffusion tensor imaging metrics across regions of interest in arterial territories were explored. Results- Compared with SCI- patients (n=45), SCI+ patients (n=17) exhibited increased radial diffusivity in multiple regions; negative relationships were observed between mean diffusivity, axial diffusivity, and Hb (P<0.005). Compared with VSC- patients (n=49), mild (n=6) or moderate (n=7) VSC+ patients exhibited reduced fractional anisotropy in widespread regions (P<0.05) including the anterior longitudinal fasciculi, corpus callosum, internal capsule, corona radiata, and corticospinal tracts. Overall, the posterior cerebral arterial territory had higher mean mean diffusivity and mean radial diffusivity than the anterior and middle cerebral arterial territories, although no patient had vasculopathy in this area. There was an interaction between territory and vasculopathy. Conclusions- SCI, vasculopathy, and Hb are independent risk factors, and thus treatment targets, for diffuse white matter injury in patients with sickle cell anemia. Exacerbation of hemodynamic stress may play a role.
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Affiliation(s)
- Mboka Jacob
- From the Department of Radiology and Imaging, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania (M.J., R.K.).,Muhimbili Sickle Cell Program (M.J., R.Z.S., J.M.), Muhimbili University of Health and Allied Sciences
| | - Hanne Stotesbury
- Developmental Neurosciences Section (H.S., J.M.K., W.L., D.E.S., F.J.K., C.A.C.), UCL Great Ormond Street Hospital for Children, London, United Kingdom
| | - Jamie M Kawadler
- Developmental Neurosciences Section (H.S., J.M.K., W.L., D.E.S., F.J.K., C.A.C.), UCL Great Ormond Street Hospital for Children, London, United Kingdom
| | - Winok Lapadaire
- Developmental Neurosciences Section (H.S., J.M.K., W.L., D.E.S., F.J.K., C.A.C.), UCL Great Ormond Street Hospital for Children, London, United Kingdom
| | - Dawn E Saunders
- Developmental Neurosciences Section (H.S., J.M.K., W.L., D.E.S., F.J.K., C.A.C.), UCL Great Ormond Street Hospital for Children, London, United Kingdom
| | - Raphael Z Sangeda
- Muhimbili Sickle Cell Program (M.J., R.Z.S., J.M.), Muhimbili University of Health and Allied Sciences.,Department of Pharmaceutical Microbiology (R.Z.S.), Muhimbili University of Health and Allied Sciences
| | - Clara Chamba
- Department of Haematology and Blood Transfusion (C.C., J.M.), Muhimbili University of Health and Allied Sciences
| | - Ramadhan Kazema
- From the Department of Radiology and Imaging, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania (M.J., R.K.)
| | - Julie Makani
- Muhimbili Sickle Cell Program (M.J., R.Z.S., J.M.), Muhimbili University of Health and Allied Sciences.,Department of Haematology and Blood Transfusion (C.C., J.M.), Muhimbili University of Health and Allied Sciences
| | - Fenella J Kirkham
- Developmental Neurosciences Section (H.S., J.M.K., W.L., D.E.S., F.J.K., C.A.C.), UCL Great Ormond Street Hospital for Children, London, United Kingdom.,Biomedical Research Unit (F.J.K., C.A.C.), UCL Great Ormond Street Hospital for Children, London, United Kingdom.,Clinical Experimental Sciences, University of Southampton, University Hospital Southampton NHS Foundation Trust, United Kingdom (F.J.K.).,King's College Hospital, London, United Kingdom (F.J.K.)
| | - Chris A Clark
- Developmental Neurosciences Section (H.S., J.M.K., W.L., D.E.S., F.J.K., C.A.C.), UCL Great Ormond Street Hospital for Children, London, United Kingdom.,Biomedical Research Unit (F.J.K., C.A.C.), UCL Great Ormond Street Hospital for Children, London, United Kingdom
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30
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Guilliams KP, Kirkham FJ, Holzhauer S, Pavlakis S, Philbrook B, Amlie-Lefond C, Noetzel MJ, Dlamini N, Sharma M, Carpenter JL, Fox CK, Torres M, Ichord RN, Jordan LC, Dowling MM. Arteriopathy Influences Pediatric Ischemic Stroke Presentation, but Sickle Cell Disease Influences Stroke Management. Stroke 2020; 50:1089-1094. [PMID: 31009343 DOI: 10.1161/strokeaha.118.022800] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Sickle cell disease (SCD) and arteriopathy are pediatric stroke risk factors that are not mutually exclusive. The relative contributions of sickled red blood cells and arteriopathy to stroke risk are unknown, resulting in unclear guidelines for primary and secondary stroke prevention when both risk factors are present. We hypothesized that despite similarities in clinical presentation and radiographic appearance of arteriopathies, stroke evaluation and management differ in children with SCD compared with those without SCD. Methods- We compared presentation and management of children with and without SCD enrolled in the IPSS (International Pediatric Stroke Study) with acute arterial ischemic stroke, according to SCD and arteriopathy status. Regression modeling determined relative contribution of SCD and arteriopathy in variables with significant frequency differences. Results- Among 930 childhood arterial ischemic strokes, there were 98 children with SCD, 67 of whom had arteriopathy, and 466 without SCD, 392 of whom had arteriopathy. Arteriopathy, regardless of SCD status, increased likelihood of hemiparesis (odds ratio [OR], 1.94; 95% CI, 1.46-2.56) and speech abnormalities (OR, 1.67; 95% CI, 1.29-2.19). Arteriopathy also increased likelihood of headache but only among those without SCD (OR, 1.89; 95% CI, 1.40-2.55). Echocardiograms were less frequently obtained in children with SCD (OR, 0.58; 95% CI, 0.37-0.93), but the frequency of identified cardiac abnormalities was similar in both groups ( P=0.57). Children with SCD were less likely to receive antithrombotic therapy, even in the presence of arteriopathy (OR, 0.14; 95% CI, 0.08-0.22). Arteriopathy was associated with a significantly higher likelihood of antithrombotic therapy in children without SCD (OR, 5.36; 95% CI, 3.55-8.09). Conclusions- Arteriopathy, and not SCD status, was most influential of stroke presentation. However, SCD status influenced stroke management because children with SCD were less likely to have echocardiograms or receive antithrombotic therapy. Further work is needed to determine whether management differences are warranted.
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Affiliation(s)
- Kristin P Guilliams
- From the Departments of Neurology and Pediatrics, Washington University School of Medicine, St Louis, MO (K.P.G., M.J.N.)
| | - Fenella J Kirkham
- Developmental Neurosciences and Biomedical Research Unit, UCL Great Ormond Street Institute of Child Health, London and Clinical and Experimental Sciences, University of Southampton, United Kingdom (F.J.K.)
| | - Susanne Holzhauer
- Department of Pediatric Hematology and Oncology Charité University Medicine, Berlin, Germany (S.H.)
| | - Steven Pavlakis
- Department of Pediatrics and Neurology, The Brooklyn Hospital Center, Icahn School of Medicine at Mount Sinai, Brooklyn, NY (S.P.)
| | - Bryan Philbrook
- Department of Pediatrics, Pediatric Neurology, Emory University, Children's Healthcare of Atlanta, GA (B.P.)
| | - Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital, University of Washington, Seattle (C.A.-L.)
| | - Michael J Noetzel
- From the Departments of Neurology and Pediatrics, Washington University School of Medicine, St Louis, MO (K.P.G., M.J.N.)
| | - Nomazulu Dlamini
- Department of Neurology, The Hospital for Sick Children, Toronto, Canada (N.D.)
| | - Mukta Sharma
- Department of Pediatric Hematology Oncology, Children's Mercy Hospital, University of Missouri Kansas City School of Medicine (M.S.)
| | - Jessica L Carpenter
- Department of Pediatrics, Neurology, and Neuroscience, George Washington University, Children's National Medical Center, Washington DC (J.L.C.)
| | - Christine K Fox
- Departments of Neurology and Pediatrics, University of California San Francisco (C.K.F.)
| | - Marcela Torres
- Department of Pediatric Hematology Oncology, Cook Children's Medical Center, Fort Worth, TX (M.T.)
| | - Rebecca N Ichord
- Departments of Neurology and Pediatrics, Perlman School of Medicine at the University of Pennsylvania, Philadelphia (R.N.I.)
| | - Lori C Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN (L.C.J.)
| | - Michael M Dowling
- Departments of Pediatrics, Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center at Dallas and Children's Health Dallas (M.M.D.)
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31
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Kirkham FJ, Vigevano F, Raspall-Chaure M, Wilken B, Lee D, Le Reun C, Werner-Kiechle T, Lagae L. Health-related quality of life and the burden of prolonged seizures in noninstitutionalized children with epilepsy. Epilepsy Behav 2020; 102:106340. [PMID: 31733569 DOI: 10.1016/j.yebeh.2019.04.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 04/09/2019] [Accepted: 04/13/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study aimed to provide information on the burden of illness and health-related quality of life (HRQoL) in children with epilepsy who experience prolonged acute convulsive seizures (PACS) in the community setting, and to investigate factors that may predict poor HRQoL in this population. METHODS Noninstitutionalized children (aged 3-16 years) who had experienced at least one PACS within the past year and had currently prescribed PACS rescue medication were enrolled in a cross-sectional study in Germany, Italy, Spain, and the United Kingdom (Practices in Emergency and Rescue medication For Epilepsy managed with Community-administered Therapy 3 [PERFECT-3]). Clinicians, parents/guardians, and patients completed web-based questionnaires regarding clinical characteristics, PACS frequency, and day-to-day impairment. Patients' HRQoL was rated by clinicians, parents/guardians, and patients themselves using the 5-dimension EuroQol questionnaire (EQ-5D) and summarized as a utility score. Potential predictors of poor HRQoL were tested in individual univariate generalized linear models and a global multivariable model. RESULTS Enrolled children (N = 286) had experienced 1-400 PACS (median: 4) in the past year. Clinicians reported that 216/281 patients (76.9%) had learning disabilities of varying severity. Mean EQ-5D utility scores rated by clinicians (n = 279), parents (n = 277), and patients (n = 85) were 0.52 (standard deviation: 0.41), 0.51 (0.39), and 0.74 (0.29), respectively. Increasing PACS frequency, increasing severity of learning disability, and specialist school attendance were significantly associated with decreasing EQ-5D utility score. In the multivariable model, having learning disabilities was the best predictor of poor HRQoL. SIGNIFICANCE Health-related quality of life was very poor in many children with epilepsy whose PACS were managed with rescue medication in the community, with learning disability being the most powerful predictor of patients' HRQoL. Mean EQ-5D utility scores were lower (worse) than published values for many other chronic disorders, indicating that optimal treatment should involve helping children and their families to manage learning disabilities and day-to-day impairments, in addition to preventing seizures.
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Affiliation(s)
- Fenella J Kirkham
- Department of Child Health, University Hospital Southampton NHS Trust, Southampton, United Kingdom; Developmental Neurosciences Unit and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Clinical and Experimental Sciences, University of Southampton, Southampton, United Kingdom.
| | - Federico Vigevano
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
| | - Miquel Raspall-Chaure
- Department of Pediatric Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Bernd Wilken
- Department of Pediatric Neurology, Klinikum Kassel, Kassel, Germany
| | - Dawn Lee
- BresMed Health Solutions, Sheffield, United Kingdom
| | | | - Tamara Werner-Kiechle
- Global Medical Affairs, Shire (a member of the Takeda group of companies), Zug, Switzerland
| | - Lieven Lagae
- Department of Pediatric Neurology, University Hospitals, Katholieke Universiteit Leuven, Leuven, Belgium
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Farrell AT, Panepinto J, Carroll CP, Darbari DS, Desai AA, King AA, Adams RJ, Barber TD, Brandow AM, DeBaun MR, Donahue MJ, Gupta K, Hankins JS, Kameka M, Kirkham FJ, Luksenburg H, Miller S, Oneal PA, Rees DC, Setse R, Sheehan VA, Strouse J, Stucky CL, Werner EM, Wood JC, Zempsky WT. End points for sickle cell disease clinical trials: patient-reported outcomes, pain, and the brain. Blood Adv 2019; 3:3982-4001. [PMID: 31809538 PMCID: PMC6963237 DOI: 10.1182/bloodadvances.2019000882] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 09/26/2019] [Indexed: 12/12/2022] Open
Abstract
To address the global burden of sickle cell disease (SCD) and the need for novel therapies, the American Society of Hematology partnered with the US Food and Drug Administration to engage the work of 7 panels of clinicians, investigators, and patients to develop consensus recommendations for clinical trial end points. The panels conducted their work through literature reviews, assessment of available evidence, and expert judgment focusing on end points related to: patient-reported outcomes (PROs), pain (non-PROs), the brain, end-organ considerations, biomarkers, measurement of cure, and low-resource settings. This article presents the findings and recommendations of the PROs, pain, and brain panels, as well as relevant findings and recommendations from the biomarkers panel. The panels identify end points, where there were supporting data, to use in clinical trials of SCD. In addition, the panels discuss where further research is needed to support the development and validation of additional clinical trial end points.
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Affiliation(s)
| | - Julie Panepinto
- Pediatric Hematology, Medical College of Wisconsin/Children's Wisconsin, Milwaukee, WI
| | - C Patrick Carroll
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Ankit A Desai
- Krannert Institute of Cardiology, Indiana University, Bloomington, IN
| | - Allison A King
- Division of Hematology and Oncology in Pediatrics and Medicine, Washington University School of Medicine, St. Louis, MO
| | - Robert J Adams
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | | | - Amanda M Brandow
- Pediatric Hematology, Medical College of Wisconsin/Children's Wisconsin, Milwaukee, WI
| | - Michael R DeBaun
- Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN
| | - Manus J Donahue
- Department of Radiology and Radiological Sciences
- Department of Neurology, and
- Department of Psychiatry, School of Medicine, Vanderbilt University, Nashville, TN
| | - Kalpna Gupta
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN
| | - Jane S Hankins
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN
| | - Michelle Kameka
- Nicole Wertheim College of Nursing and Health Sciences, Florida International University, Miami, FL
| | - Fenella J Kirkham
- Developmental Neurosciences Unit and
- Biomedical Research Unit, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Harvey Luksenburg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | | | | | - David C Rees
- Department of Haematological Medicine, King's College Hospital, London, United Kingdom
- School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom
| | | | - Vivien A Sheehan
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - John Strouse
- Division of Hematology, Department of Medicine, and
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Cheryl L Stucky
- Department of Cell Biology, Neurobiology, and Anatomy, Medical College of Wisconsin, Milwaukee, WI
| | - Ellen M Werner
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - John C Wood
- Children's Hospital Los Angeles, Los Angeles, CA; and
| | - William T Zempsky
- Department of Pediatrics, Connecticut Children's/School of Medicine, University of Connecticut, Hartford, CT
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33
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Downes M, de Haan M, Telfer PT, Kirkham FJ. The Role of Family Functioning in the Development of Executive Functions in Preschool Children with Sickle Cell Anemia. Dev Neuropsychol 2019; 44:452-467. [PMID: 31450996 DOI: 10.1080/87565641.2019.1660779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Executive functions are compromised in children with sickle cell anemia. There is limited research on the development of executive functions in preschool children with sickle cell anemia and the factors that contribute to executive dysfunction. We looked at the relation between biomedical and environmental factors, including family functioning and socioeconomic status, and executive functions in 22 preschool children with sickle cell anemia. We found that family functioning was the strongest predictor of executive outcomes in young children with sickle cell anemia with no evidence for an influence of disease severity at this early stage.
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Affiliation(s)
- Michelle Downes
- School of Psychology, University College Dublin , Dublin , Ireland
| | - Michelle de Haan
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health , London , UK
| | - Paul T Telfer
- Department of Hematology, Barts Health NHS Trust , London , UK
| | - Fenella J Kirkham
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health , London , UK
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34
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Stotesbury H, Kawadler JM, Hales PW, Saunders DE, Clark CA, Kirkham FJ. Vascular Instability and Neurological Morbidity in Sickle Cell Disease: An Integrative Framework. Front Neurol 2019; 10:871. [PMID: 31474929 PMCID: PMC6705232 DOI: 10.3389/fneur.2019.00871] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/26/2019] [Indexed: 12/20/2022] Open
Abstract
It is well-established that patients with sickle cell disease (SCD) are at substantial risk of neurological complications, including overt and silent stroke, microstructural injury, and cognitive difficulties. Yet the underlying mechanisms remain poorly understood, partly because findings have largely been considered in isolation. Here, we review mechanistic pathways for which there is accumulating evidence and propose an integrative systems-biology framework for understanding neurological risk. Drawing upon work from other vascular beds in SCD, as well as the wider stroke literature, we propose that macro-circulatory hyper-perfusion, regions of relative micro-circulatory hypo-perfusion, and an exhaustion of cerebral reserve mechanisms, together lead to a state of cerebral vascular instability. We suggest that in this state, tissue oxygen supply is fragile and easily perturbed by changes in clinical condition, with the potential for stroke and/or microstructural injury if metabolic demand exceeds tissue oxygenation. This framework brings together recent developments in the field, highlights outstanding questions, and offers a first step toward a linking pathophysiological explanation of neurological risk that may help inform future screening and treatment strategies.
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Affiliation(s)
- Hanne Stotesbury
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom
| | - Jamie M Kawadler
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom
| | - Patrick W Hales
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom
| | - Dawn E Saunders
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom.,Department of Radiology, Great Ormond Hospital, London, United Kingdom
| | - Christopher A Clark
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom
| | - Fenella J Kirkham
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom.,Clinical and Experimental Sciences, University of Southampton, Southampton, United Kingdom.,Department of Child Health, University Hospital Southampton, Southampton, United Kingdom.,Department of Paediatric Neurology, Kings College Hospital NHS Foundation Trust, London, United Kingdom
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35
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Prussien KV, Salihu A, Abdullahi SU, Galadanci NA, Bulama K, Belonwu RO, Kirkham FJ, Yarboi J, Bemis H, DeBaun MR, Compas BE. Associations of transcranial doppler velocity, age, and gender with cognitive function in children with sickle cell anemia in Nigeria. Child Neuropsychol 2019; 25:705-720. [PMID: 30269648 PMCID: PMC6545195 DOI: 10.1080/09297049.2018.1526272] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 09/12/2018] [Indexed: 12/16/2022]
Abstract
Children with sickle cell anemia (SCA) have elevated cerebral blood velocity relative to healthy peers. The primary aim of this study was to evaluate the association between cerebral blood velocity, measured by transcranial Doppler (TCD) ultrasound, age, and gender with cognitive function in children with SCA in Nigeria. Eighty-three children (Mage = 9.10, SD = 1.90 years; 55% female) with SCA in Nigeria completed cognitive assessments and a TCD ultrasound. The association between TCD velocity and measures of perceptual reasoning (Raven's Progressive Matrices), working memory (WISC-IV Digit Span), and executive planning (Tower of London, TOL) were assessed. Results showed that elevated TCD velocity significantly predicted lower scores on TOL Time Violations and Total Problem-Solving Time when controlling for BMI, hemoglobin level, and parent education, suggesting that TCD velocity is related to the efficiency of executive function. Further, age was negatively related to children's performance on the Ravens Matrices and TOL Total Correct, and boys showed greater deficits on the TOL Total Correct relative to girls. Moderation analyses for gender showed that there was a conditional negative association between TCD velocity and Digit Span for boys, but not for girls. Findings suggest that children with SCA in Nigeria with elevated TCD velocity are at risk for deficits in efficiency of executive planning, and boys with elevated TCD velocity are particularly at increased risk for deficits in auditory working memory. Implications of this study are important for interventions to reduce cerebral blood velocity and the use of TCD in this population.
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Affiliation(s)
- Kemar V. Prussien
- Department of Psychology & Human Development, Vanderbilt University, Nashville, TN, USA
| | - Auwal Salihu
- Department of Psychiatry, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Shehu U. Abdullahi
- Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Najibah A. Galadanci
- Department of Hematology and Blood Transfusion, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Khadija Bulama
- Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Raymond O. Belonwu
- Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Fenella J. Kirkham
- Developmental Neurosciences Unit, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Janet Yarboi
- Department of Psychology & Human Development, Vanderbilt University, Nashville, TN, USA
| | - Heather Bemis
- Department of Psychology & Human Development, Vanderbilt University, Nashville, TN, USA
| | - Michael R. DeBaun
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bruce E. Compas
- Department of Psychology & Human Development, Vanderbilt University, Nashville, TN, USA
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36
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Howard J, Lee SA, Inusa B, Cheng MYE, Bavenjit C, Reading IC, Wakeford SA, Gavlak JC, Murphy PB, Hart N, Gupta A, Sahota S, Jacob E, Chorozoglou M, Ossai C, Gwam M, Kirkham FJ, Wade AM, Liossi C. Prevention of Morbidity in Sickle Cell Disease (POMS2a)-overnight auto-adjusting continuous positive airway pressure compared with nocturnal oxygen therapy: a randomised crossover pilot study examining patient preference and safety in adults and children. Trials 2019; 20:442. [PMID: 31319882 PMCID: PMC6637584 DOI: 10.1186/s13063-019-3461-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 05/20/2019] [Indexed: 11/10/2022] Open
Abstract
DESIGN This randomised crossover trial compared nocturnal auto-adjusting continuous positive airway pressure (APAP) and nocturnal oxygen therapy (NOT) in adults and children with sickle cell anaemia, with patient acceptability as the primary outcome. Secondary outcomes included pulmonary physiology (adults), safety, and daily pain during interventions and washout documented using tablet technology. METHODS Inclusion criteria were age > 8 years and the ability to use an iPad to collect daily pain data. Trial participation was 4 weeks; week 1 involved baseline data collection and week 3 was a washout between interventions, which were administered for 7 days each during weeks 2 and 4 in a randomised order. Qualitative interviews were transcribed verbatim and analysed for content using a funnelling technique, starting generally and then gaining more detailed information on the experience of both interventions. Safety data included routine haematology and median pain days between each period. Missing pain day values were replaced using multiple imputation. RESULTS Ten adults (three female, median age 30.2 years, range 18-51.5 years) and eleven children (five female, median age 12 years, range 8.7-16.9 years) enrolled. Nine adults and seven children completed interviews. Qualitative data revealed that the APAP machine was smaller, easier to handle, and less noisy. Of 16 participants, 10 preferred APAP (62.5%, 95% confidence interval (CI) 38.6-81.5%). Haemoglobin decreased from baseline on APAP and NOT (mean difference -3.2 g/L (95% CI -6.0 to -0.2 g/L) and -2.5 g/L (95% CI -4.6 to 0.3 g/L), respectively), but there was no significant difference between interventions (NOT versus APAP, 1.1 (-1.2 to 3.6)). Pulmonary function changed little. Compared with baseline, there were significant decreases in the median number of pain days (1.58 for APAP and 1.71 for NOT) but no significant difference comparing washout with baseline. After adjustment for carry-over and period effects, there was a non-significant median difference of 0.143 (95% CI -0.116 to 0.401) days additional pain with APAP compared with NOT. CONCLUSION In view of the point estimate of patient preference for APAP, and no difference in haematology or pulmonary function or evidence that pain was worse during or in washout after APAP, it was decided to proceed with a Phase II trial of 6 months APAP versus standard care with further safety monitoring for bone marrow suppression and pain. TRIAL REGISTRATION ISRCTN46078697 . Registered on 18 July 2014.
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Affiliation(s)
- Jo Howard
- Department of Haematology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Sophie A Lee
- Centre for Applied Statistics Courses, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Baba Inusa
- Evelina Children's Hospital, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | | | | | - Isabel C Reading
- Research Design Service, University Hospital Southampton, Southampton, UK
| | - Sally Ann Wakeford
- Department of Child Health, University Hospital Southampton, Southampton, UK
| | - Johanna C Gavlak
- Department of Child Health, University Hospital Southampton, Southampton, UK.,Developmental Neurosciences Section and NIHR Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Patrick B Murphy
- King's College London, London, UK.,Lane Fox Respiratory Unit, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Nicholas Hart
- King's College London, London, UK.,Lane Fox Respiratory Unit, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | | | - Sati Sahota
- Developmental Neurosciences Section and NIHR Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Eufemia Jacob
- School of Nursing, University of California Los Angeles, Los Angeles, CA, USA
| | - Maria Chorozoglou
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Carol Ossai
- Sickle Cell and Young Stroke Survivors Charity, London, UK
| | - Maureen Gwam
- Sickle Cell and Young Stroke Survivors Charity, London, UK
| | - Fenella J Kirkham
- Department of Child Health, University Hospital Southampton, Southampton, UK. .,Developmental Neurosciences Section and NIHR Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK. .,Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
| | - Angela M Wade
- Evelina Children's Hospital, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Christina Liossi
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Department of Psychology, University of Southampton, Southampton, UK.,Department of Psychology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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37
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Kija EN, Saunders DE, Munubhi E, Darekar A, Barker S, Cox TCS, Mango M, Soka D, Komba J, Nkya DA, Cox SE, Kirkham FJ, Newton CRJC. Transcranial Doppler and Magnetic Resonance in Tanzanian Children With Sickle Cell Disease. Stroke 2019; 50:1719-1726. [PMID: 31195937 PMCID: PMC6594727 DOI: 10.1161/strokeaha.118.018920] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— We determined prevalences of neurological complications, vascular abnormality, and infarction in Tanzanian children with sickle cell disease. Methods— Children with sickle cell disease were consecutively enrolled for transcranial Doppler; those with slightly elevated (>150 cm/s), low (<50 cm/s) or absent cerebral blood flow velocity (CBFv) were invited for brain magnetic resonance imaging and magnetic resonance angiography. Results— Of 200 children (median age 9; range 6–13 years; 105 [2.5%] boys), 21 (11%) and 15 (8%) had previous seizures and unilateral weakness, respectively. Twenty-eight (14%) had elevated and 39 (20%) had low/absent CBFv, all associated with lower hemoglobin level, but not higher indirect bilirubin level. On multivariable analysis, CBFv>150 cm/s was associated with frequent painful crises and low hemoglobin level. Absent/low CBFv was associated with low hemoglobin level and history of unilateral weakness. In 49 out of 67 children with low/absent/elevated transcranial Doppler undergoing magnetic resonance imaging, 43% had infarction, whereas 24 out of 48 (50%) magnetic resonance angiographies were abnormal. One had hemorrhagic infarction; none had microbleeds. Posterior circulation infarcts occurred in 14%. Of 11 children with previous seizure undergoing magnetic resonance imaging, 10 (91%) had infarction (5 silent) compared with 11 out of 38 (29%) of the remainder (P=0.003). Of 7 children with clinical stroke, 2 had recurrent stroke and 3 died; 4 out of 5 had absent CBFv. Of 193 without stroke, 1 died and 1 had a stroke; both had absent CBFv. Conclusions— In one-third of Tanzanian children with sickle cell disease, CBFv is outside the normal range, associated with frequent painful crises and low hemoglobin level, but not hemolysis. Half have abnormal magnetic resonance angiography. African children with sickle cell disease should be evaluated with transcranial Doppler; those with low/absent/elevated CBFv should undergo magnetic resonance imaging/magnetic resonance angiography.
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Affiliation(s)
- Edward N Kija
- From the Muhimbili Wellcome Programme, Dar es Salaam, Tanzania (E.N.K., E.M., D.S., J.K., D.A.N., S.E.C., C.R.J.C.N.).,Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (E.N.K., M.M., D.S., C.R.J.C.N.)
| | - Dawn E Saunders
- Developmental Neurosciences and Biomedical Research Unit, UCL Great Ormond Street Institute of Child Health, United Kingdom (D.E.S., T.C.S.C., F.J.K.)
| | - Emmanuel Munubhi
- From the Muhimbili Wellcome Programme, Dar es Salaam, Tanzania (E.N.K., E.M., D.S., J.K., D.A.N., S.E.C., C.R.J.C.N.)
| | - Angela Darekar
- University Hospital Southampton, United Kingdom (A.D., S.B., F.J.K.)
| | - Simon Barker
- University Hospital Southampton, United Kingdom (A.D., S.B., F.J.K.)
| | - Timothy C S Cox
- Developmental Neurosciences and Biomedical Research Unit, UCL Great Ormond Street Institute of Child Health, United Kingdom (D.E.S., T.C.S.C., F.J.K.)
| | - Mechris Mango
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (E.N.K., M.M., D.S., C.R.J.C.N.)
| | - Deogratias Soka
- From the Muhimbili Wellcome Programme, Dar es Salaam, Tanzania (E.N.K., E.M., D.S., J.K., D.A.N., S.E.C., C.R.J.C.N.).,Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (E.N.K., M.M., D.S., C.R.J.C.N.)
| | - Joyce Komba
- From the Muhimbili Wellcome Programme, Dar es Salaam, Tanzania (E.N.K., E.M., D.S., J.K., D.A.N., S.E.C., C.R.J.C.N.)
| | - Deogratias A Nkya
- From the Muhimbili Wellcome Programme, Dar es Salaam, Tanzania (E.N.K., E.M., D.S., J.K., D.A.N., S.E.C., C.R.J.C.N.)
| | - Sharon E Cox
- From the Muhimbili Wellcome Programme, Dar es Salaam, Tanzania (E.N.K., E.M., D.S., J.K., D.A.N., S.E.C., C.R.J.C.N.).,London School of Hygiene and Tropical Medicine, United Kingdom (S.E.C.).,Nagasaki University School of Tropical Medicine and Global Health, Japan (S.E.C.)
| | - Fenella J Kirkham
- Developmental Neurosciences and Biomedical Research Unit, UCL Great Ormond Street Institute of Child Health, United Kingdom (D.E.S., T.C.S.C., F.J.K.).,Clinical and Experimental Sciences, University of Southampton, United Kingdom (F.J.K.).,University Hospital Southampton, United Kingdom (A.D., S.B., F.J.K.)
| | - Charles R J C Newton
- From the Muhimbili Wellcome Programme, Dar es Salaam, Tanzania (E.N.K., E.M., D.S., J.K., D.A.N., S.E.C., C.R.J.C.N.).,Department of Psychiatry, University of Oxford, United Kingdom (C.R.J.C.N.)
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Abstract
Cerebral infarction is a common complication of sickle cell disease and may manifest as overt stroke or cognitive impairment associated with "silent" cerebral infarction on magnetic resonance imaging. Vasculopathy may be diagnosed on transcranial Doppler or magnetic resonance angiography. The risk factors in sickle cell disease for cognitive impairment, overt ischemic stroke, silent cerebral infarction, overt hemorrhagic stroke, and vasculopathy defined by transcranial Doppler or magnetic resonance angiography overlap, with severe acute and chronic anemia, acute chest crisis, reticulocytosis, and low oxygen saturation reported with the majority. However, there are differences reported in different cohorts, which may reflect age, geographic location, or neuroimaging techniques, for example, magnetic resonance imaging field strength. Regular blood transfusion reduces, but does not abolish, the risk of neurological complications in children with sickle cell disease and either previous overt stroke or silent cerebral infarction or abnormal transcranial Doppler. There are relatively few data on the use of hydroxyurea or other management strategies. Early assessment of the risk of neurocognitive complications is likely to become increasingly important in the management of sickle cell disease.
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Affiliation(s)
- Deborah Hirtz
- University of Vermont School of Medicine, Burlington, Vermont
| | - Fenella J Kirkham
- Developmental Neurosciences Section and Biomedical Research Unit, Clinical and Experimental Sciences, University of Southampton, UCL Great Ormond Street Institute of Child Health, London, UK.
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39
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Kawadler JM, Slee A, Stotesbury H, Koelbel M, Balfour P, Saunders DE, Rees D, Howard J, Inusa B, Pelidis M, Kesse-Adu R, Chakravorty S, Awogbade M, Clark CA, Kirkham FJ, Liossi C. Index of Pain Experience in Sickle Cell Anaemia (IPESCA): development from daily pain diaries and initial findings from use with children and adults with sickle cell anaemia. Br J Haematol 2019; 186:360-363. [PMID: 30836440 DOI: 10.1111/bjh.15841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Jamie M Kawadler
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - April Slee
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Hanne Stotesbury
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Melanie Koelbel
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Philippa Balfour
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Dawn E Saunders
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - David Rees
- Department of Paediatric Haematology, King's College Hospital NHS Foundation Trust, King's College London, London, UK
| | - Jo Howard
- Department of Haematology, Guy's and St. Thomas NHS Foundation Trust, King's College London, London, UK
| | - Baba Inusa
- Department of Paediatrics, Evelina Children's Hospital, Guy's and St. Thomas' National Health Service (NHS) Foundation Trust, London, UK
| | - Maria Pelidis
- Department of Paediatrics, Evelina Children's Hospital, Guy's and St. Thomas' National Health Service (NHS) Foundation Trust, London, UK
| | - Rachel Kesse-Adu
- Department of Paediatrics, Evelina Children's Hospital, Guy's and St. Thomas' National Health Service (NHS) Foundation Trust, London, UK
| | - Subarna Chakravorty
- Department of Paediatric Haematology, King's College Hospital NHS Foundation Trust, King's College London, London, UK
| | - Moji Awogbade
- Department of Paediatric Haematology, King's College Hospital NHS Foundation Trust, King's College London, London, UK
| | - Chris A Clark
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Fenella J Kirkham
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK.,Clinical and Experimental Sciences, University of Southampton, Southampton, UK
| | - Christina Liossi
- School of Psychology, University of Southampton, Southampton, UK.,Psychological Services Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
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40
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Affiliation(s)
- Fenella J Kirkham
- Developmental Neurosciences section, UCL Great Ormond Street Institute of Child Health, London, UK.,Clinical and Experimental Sciences, University of Southampton, Southampton, UK
| | - Annette Keylock
- Infection, Inflammation and Rheumatology section, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Dawn E Saunders
- Developmental Neurosciences section, UCL Great Ormond Street Institute of Child Health, London, UK
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41
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Jacob M, Saunders DE, Kawadler JM, Mussa B, Murdoch R, Lapidaire W, Tluway F, Kazema RR, Nkya S, Ahmed M, Kija E, Fundikira L, Kussaga F, Darekar A, Tutuba H, Shmueli K, Clark CA, Makani J, Kirkham FJ. Neuroimaging in patients with sickle cell anemia: capacity building in Africa. Blood Adv 2018; 2:26-29. [PMID: 30504194 PMCID: PMC6438286 DOI: 10.1182/bloodadvances.2018gs112714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Mboka Jacob
- Department of Radiology and Imaging, Muhimbili University of Health and Allied Sciences
- Developmental Neurosciences, Section and Biomedical Research Centre, University College London, Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Dawn E Saunders
- Developmental Neurosciences, Section and Biomedical Research Centre, University College London, Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jamie M Kawadler
- Developmental Neurosciences, Section and Biomedical Research Centre, University College London, Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Balowa Mussa
- Department of Radiology and Imaging, Muhimbili University of Health and Allied Sciences
| | - Russell Murdoch
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Winok Lapidaire
- Developmental Neurosciences, Section and Biomedical Research Centre, University College London, Great Ormond Street Institute of Child Health, London, United Kingdom
| | | | - Ramadhan R Kazema
- Department of Radiology and Imaging, Muhimbili University of Health and Allied Sciences
| | | | - Magda Ahmed
- Department of Radiology and Imaging, Muhimbili University of Health and Allied Sciences
| | | | - Lulu Fundikira
- Department of Radiology and Imaging, Muhimbili University of Health and Allied Sciences
| | | | - Angela Darekar
- University Hospital Southampton, Southampton, United Kingdom; and
| | | | - Karin Shmueli
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Christopher A Clark
- Developmental Neurosciences, Section and Biomedical Research Centre, University College London, Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Julie Makani
- Department of Hematology and Blood Transfusion, Muhimbili University of Health and Allied Sciences
| | - Fenella J Kirkham
- Developmental Neurosciences, Section and Biomedical Research Centre, University College London, Great Ormond Street Institute of Child Health, London, United Kingdom
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42
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Makani J, Tluway F, Makubi A, Soka D, Nkya S, Sangeda R, Mgaya J, Rwezaula S, Kirkham FJ, Kindole C, Osati E, Meda E, Snow RW, Newton CR, Roberts D, Aboud M, Thein SL, Cox SE, Luzzatto L, Mmbando BP. A ten year review of the sickle cell program in Muhimbili National Hospital, Tanzania. BMC Hematol 2018; 18:33. [PMID: 30459954 PMCID: PMC6236876 DOI: 10.1186/s12878-018-0125-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 10/16/2018] [Indexed: 11/10/2022]
Abstract
Background Africa has the highest burden of Sickle cell disease (SCD) but there are few large, systematic studies providing reliable descriptions of the disease spectrum. Tanzania, with 11,000 SCD births annually, established the Muhimbili Sickle Cell program aiming to improve understanding of SCD in Africa. We report the profile of SCD seen in the first 10 years at Muhimbili National Hospital (MNH). Methods Individuals seen at MNH known or suspected to have SCD were enrolled at clinic and laboratory testing for SCD, haematological and biochemical analyses done. Ethnicity was self-reported. Clinical and laboratory features of SCD were documented. Comparison was made with non-SCD population as well as within 3 different age groups (< 5, 5–17 and ≥ 18 years) within the SCD population. Results From 2004 to 2013, 6397 individuals, 3751 (58.6%) SCD patients, were enrolled, the majority (47.4%) in age group 5–17 years. There was variation in the geographical distribution of SCD. Individuals with SCD compared to non-SCD, had significantly lower blood pressure and peripheral oxygen saturation (SpO2). SCD patients had higher prevalence of severe anemia, jaundice and desaturation (SpO2 < 95%) as well as higher levels of reticulocytes, white blood cells, platelets and fetal hemoglobin. The main causes of hospitalization for SCD within a 12-month period preceding enrolment were pain (adults), and fever and severe anemia (children). When clinical and laboratory features were compared in SCD within 3 age groups, there was a progressive decrease in the prevalence of splenic enlargement and an increase in prevalence of jaundice. Furthermore, there were significant differences with monotonic trends across age groups in SpO2, hematological and biochemical parameters. Conclusion This report confirms that the wide spectrum of clinical expression of SCD observed elsewhere is also present in Tanzania, with non-uniform geographical distribution across the country. Age-specific analysis is consistent with different disease-patterns across the lifespan.
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Affiliation(s)
- Julie Makani
- 1Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania.,2University of Oxford, Oxford, UK.,3Muhimbili National Hospital, Dar-es-Salaam, Tanzania
| | - Furahini Tluway
- 1Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Abel Makubi
- 1Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Deogratius Soka
- 1Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Siana Nkya
- 1Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania.,4Dar-es-Salaam University College of Education, Dar-es-Salaam, Tanzania
| | - Raphael Sangeda
- 1Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Josephine Mgaya
- 1Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Stella Rwezaula
- 1Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania.,3Muhimbili National Hospital, Dar-es-Salaam, Tanzania
| | | | - Christina Kindole
- 1Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania.,3Muhimbili National Hospital, Dar-es-Salaam, Tanzania
| | - Elisha Osati
- 1Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania.,3Muhimbili National Hospital, Dar-es-Salaam, Tanzania
| | - Elineema Meda
- 3Muhimbili National Hospital, Dar-es-Salaam, Tanzania
| | - Robert W Snow
- 2University of Oxford, Oxford, UK.,6Centre for Geographic Medicine Research, Kenya Medical Research Institute, Kilifi, Kenya
| | - Charles R Newton
- 2University of Oxford, Oxford, UK.,6Centre for Geographic Medicine Research, Kenya Medical Research Institute, Kilifi, Kenya
| | | | - Muhsin Aboud
- 1Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | | | - Sharon E Cox
- 8London School of Hygiene & Tropical Medicine, London, UK
| | - Lucio Luzzatto
- 1Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Bruno P Mmbando
- 1Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania.,National Institute for Medical Research Tanga Centre, Tanga, Tanzania
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Kirkham FJ, Zafeiriou D, Howe D, Czarpran P, Harris A, Gunny R, Vollmer B. Fetal stroke and cerebrovascular disease: Advances in understanding from lenticulostriate and venous imaging, alloimmune thrombocytopaenia and monochorionic twins. Eur J Paediatr Neurol 2018; 22:989-1005. [PMID: 30467085 DOI: 10.1016/j.ejpn.2018.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 12/17/2022]
Abstract
Fetal stroke is an important cause of cerebral palsy but is difficult to diagnose unless imaging is undertaken in pregnancies at risk because of known maternal or fetal disorders. Fetal ultrasound or magnetic resonance imaging may show haemorrhage or ischaemic lesions including multicystic encephalomalacia and focal porencephaly. Serial imaging has shown the development of malformations including schizencephaly and polymicrogyra after ischaemic and haemorrhagic stroke. Recognised causes of haemorrhagic fetal stroke include alloimmune and autoimmune thrombocytopaenia, maternal and fetal clotting disorders and trauma but these are relatively rare. It is likely that a significant proportion of periventricular and intraventricular haemorrhages are of venous origin. Recent evidence highlights the importance of arterial endothelial dysfunction, rather than thrombocytopaenia, in the intraparenchymal haemorrhage of alloimmune thrombocytopaenia. In the context of placental anastomoses, monochorionic diamniotic twins are at risk of twin twin transfusion syndrome (TTTS), or partial forms including Twin Oligohydramnios Polyhydramnios Sequence (TOPS), differences in estimated weight (selective Intrauterine growth Retardation; sIUGR), or in fetal haemoglobin (Twin Anaemia Polycythaemia Sequence; TAPS). There is a very wide range of ischaemic and haemorrhagic injury in a focal as well as a global distribution. Acute twin twin transfusion may account for intraventricular haemorrhage in recipients and periventricular leukomalacia in donors but there are additional risk factors for focal embolism and cerebrovascular disease. The recipient has circulatory overload, with effects on systemic and pulmonary circulations which probably lead to systemic and pulmonary hypertension and even right ventricular outflow tract obstruction as well as the polycythaemia which is a risk factor for thrombosis and vasculopathy. The donor is hypovolaemic and has a reticulocytosis in response to the anaemia while maternal hypertension and diabetes may influence stroke risk. Understanding of the mechanisms, including the role of vasculopathy, in well studied conditions such as alloimmune thrombocytopaenia and monochorionic diamniotic twinning may lead to reduction of the burden of antenatally sustained cerebral palsy.
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Affiliation(s)
- Fenella J Kirkham
- Developmental Neurosciences Section and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom.
| | - Dimitrios Zafeiriou
- 1st Department of Pediatrics, "Hippokratio' General Hospital, Aristotle University, Thessaloniki, Greece
| | - David Howe
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom
| | - Philippa Czarpran
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom
| | - Ashley Harris
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom
| | - Roxanna Gunny
- Developmental Neurosciences Section and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Department of Radiology, St George's hospital, London, United Kingdom
| | - Brigitte Vollmer
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom
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Downes M, Kirkham FJ, Berg C, Telfer P, de Haan M. Executive performance on the preschool executive task assessment in children with sickle cell anemia and matched controls. Child Neuropsychol 2018; 25:278-285. [PMID: 29954249 DOI: 10.1080/09297049.2018.1491962] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Executive deficits are commonly reported in children with sickle cell anemia. Earlier identification of executive deficits would give more scope for intervention, but this cognitive domain has not been routinely investigated due to a lack of age-appropriate tasks normed for preschool children. In particular, information relating to patient performance on an executive task that reflects an everyday activity in the classroom could provide important insight and practical recommendations for the classroom teacher at this key developmental juncture as they enter the academic domain. The performance of 22 children with sickle cell anemia was compared to 24 matched control children on the Preschool Executive Task Assessment. Findings reveal that children with sickle cell anemia are performing poorer than their matched peers on this multi-step assessment. In particular, children with sickle cell anemia required more structured support to shift focus after a completed step, as reflected by poorer scores in the quantitative Sequencing and Completion domains. They also required more support to stay on task, as seen by poorer ratings in the qualitative Distractibility domain. Abbreviations:PETA: Preschool Executive Task Assessment; SCA: Sickle Cell Anemia; EF: Executive Functioning.
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Affiliation(s)
- Michelle Downes
- a School of Psychology , University College Dublin , Dublin , Ireland.,b Developmental Neurosciences , UCL Great Ormond Street Institute of Child Health , London , UK
| | - Fenella J Kirkham
- b Developmental Neurosciences , UCL Great Ormond Street Institute of Child Health , London , UK
| | - Christine Berg
- c School of Medicine , Washington University in St. Louis , MO , USA
| | - Paul Telfer
- d Barts Health NHS Trust , Royal London Hospital , London , UK
| | - Michelle de Haan
- b Developmental Neurosciences , UCL Great Ormond Street Institute of Child Health , London , UK
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45
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Jordan LC, Roberts Williams DO, Rodeghier MJ, Covert Greene BV, Ponisio MR, Casella JF, McKinstry RC, Noetzel MJ, Kirkham FJ, Meier ER, Fuh B, McNaull M, Sarnaik S, Majumdar S, McCavit TL, DeBaun MR. Children with sickle cell anemia with normal transcranial Doppler ultrasounds and without silent infarcts have a low incidence of new strokes. Am J Hematol 2018. [PMID: 29520844 DOI: 10.1002/ajh.25085] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In a prospective cohort study, we tested the hypothesis that children with sickle cell anemia (SCA) with normal transcranial Doppler ultrasound (TCD) velocities and without silent cerebral infarcts (SCIs) would have a lower incidence rate of new neurological events (strokes, seizures or transient ischemic attacks) compared to children with normal TCD measurements and SCIs, not receiving regular blood transfusions. Nonrandomized participants from the silent cerebral infarct transfusion (SIT) Trial who had screening magnetic resonance imaging (MRI) of the brain and normal TCD measurements were included. Follow-up ended at the time of first neurological event (stroke, seizure or transient ischemic attack), start of regular blood transfusion, or loss to follow-up, whichever came first. The primary endpoint was a new neurological event. Of 421 participants included, 68 had suspected SCIs. Mean follow-up was 3.6 years. Incidence rates of new neurological events in nontransfused participants with normal TCD values with SCIs and without SCIs were 1.71 and 0.47 neurological events per 100 patient-years, respectively, P = .065. The absence of SCI(s) at baseline was associated with a decreased risk of a new neurological event (hazard ratio 0.231, 95% CI 0.062-0.858; P = .029). Local pediatric neurologists examined 67 of 68 participants with suspected SCIs and identified 2 with overt strokes classified as SCIs by local hematologists; subsequently one had a seizure and the other an ischemic stroke. Children with SCA, without SCIs, and normal TCD measurements have a significantly lower rate of new neurological events when compared to those with SCIs and normal TCD measurements. Pediatric neurology assessment may assist risk stratification.
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Affiliation(s)
- Lori C. Jordan
- Department of Pediatrics, Division of Pediatric NeurologyVanderbilt University Medical CenterNashville Tennessee
| | - Dionna O. Roberts Williams
- Department of Pediatrics, Division of Hematology/OncologyVanderbilt‐Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical CenterNashville Tennessee
| | | | - Brittany V. Covert Greene
- Department of Pediatrics, Division of Hematology/OncologyVanderbilt‐Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical CenterNashville Tennessee
| | - Maria R. Ponisio
- Department of RadiologyWashington University School of MedicineSt. Louis Missouri
| | - James F. Casella
- Department of Pediatrics, Division of Hematologythe Johns Hopkins University School of MedicineBaltimore Maryland
| | - Robert C. McKinstry
- Departments of Radiology and PediatricsWashington University School of MedicineSt. Louis Missouri
| | - Michael J. Noetzel
- Departments of Neurology and PediatricsWashington University School of MedicineSt Louis Missouri
| | - Fenella J. Kirkham
- Developmental NeurosciencesUniversity College London Great Ormond Street Institute of Child HealthLondon United Kingdom
| | - Emily R. Meier
- Indiana Hemophilia & Thrombosis CenterIndianapolis Indiana
| | - Beng Fuh
- Department of PediatricsHematology/Oncology, Brody School of Medicine at East Carolina UniversityGreenville North Carolina
| | - Melissa McNaull
- Department of PediatricsHematology/Oncology, University of Mississippi Medical CenterJackson Mississippi
| | - Sharada Sarnaik
- Department of Pediatrics, Division of Hematology/OncologyWayne State UniversityDetroit Michigan
| | - Suvankar Majumdar
- Center for Cancer and Blood Disorders, Children's National Medical CenterWashington DC
| | - Timothy L. McCavit
- Department of Pediatrics, Division of Hematology/OncologyCook Children's HospitalFort Worth Texas
| | - Michael R. DeBaun
- Department of Pediatrics, Division of Hematology/OncologyVanderbilt‐Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical CenterNashville Tennessee
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Kawadler JM, Hales PW, Barker S, Cox TCS, Kirkham FJ, Clark CA. Cerebral perfusion characteristics show differences in younger versus older children with sickle cell anaemia: Results from a multiple-inflow-time arterial spin labelling study. NMR Biomed 2018; 31:e3915. [PMID: 29601112 DOI: 10.1002/nbm.3915] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 02/07/2018] [Accepted: 02/11/2018] [Indexed: 06/08/2023]
Abstract
Sickle cell anaemia (SCA) is associated with chronic anaemia and oxygen desaturation, which elevate cerebral blood flow (CBF) and increase the risk of neurocognitive complications. Arterial spin labelling (ASL) provides a methodology for measuring CBF non-invasively; however, ASL techniques using only a single inflow time are not sufficient to fully characterize abnormal haemodynamic behaviour in SCA. This study investigated haemodynamic parameters from a multi-inflow-time ASL acquisition in younger (8-12 years) and older (13-18 years) children with SCA with and without silent cerebral infarction (SCI+/-) (n = 20 and 19 respectively, 6 and 4 SCI+ respectively) and healthy controls (n = 9 and 7 respectively). Compared with controls, CBF was elevated globally in both groups of patients. In the younger SCA patients, blood oxygen content was negatively correlated with CBF in the middle and posterior cerebral artery territories and significantly positively correlated with bolus arrival time (BAT) in the anterior and middle cerebral artery territories. In older children, SCA patients had significantly shorter BAT than healthy controls and there was a significant negative correlation between CBF and oxygen content only in the territory of the posterior cerebral artery, with a trend for a correlation in the anterior cerebral artery but no relationship for the middle cerebral artery territory. In the younger group, SCI+ patients had significantly higher CBF in the posterior cerebral artery territory (SCI+ mean = 92.78 ml/100 g/min; SCI- mean = 72.71 ml/100 g/min; F = 4.28, p = 0.04), but this no longer reached significance when two children with abnormal transcranial Doppler and one with haemoglobin SC disease were excluded, and there were no significant differences between patients with and without SCI in the older children. With age, there appears to be increasing disparity between patients and controls in terms of the relationship between CBF and oxygen content in the anterior circulation, potentially predicting the risk of acute and chronic compromise of brain tissue.
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Affiliation(s)
- Jamie M Kawadler
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Patrick W Hales
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Simon Barker
- Wessex Neurological Centre and Child Health, University Hospital Southampton, Southampton, UK
| | - Timothy C S Cox
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - Fenella J Kirkham
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
- Wessex Neurological Centre and Child Health, University Hospital Southampton, Southampton, UK
- Clinical and Experimental Sciences, University of Southampton, Southampton, UK
| | - Chris A Clark
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
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Stotesbury H, Kirkham FJ, Kölbel M, Balfour P, Clayden JD, Sahota S, Sakaria S, Saunders DE, Howard J, Kesse-Adu R, Inusa B, Pelidis M, Chakravorty S, Rees DC, Awogbade M, Wilkey O, Layton M, Clark CA, Kawadler JM. White matter integrity and processing speed in sickle cell anemia. Neurology 2018; 90:e2042-e2050. [PMID: 29752305 PMCID: PMC5993179 DOI: 10.1212/wnl.0000000000005644] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/14/2018] [Indexed: 11/15/2022] Open
Abstract
Objective The purpose of this retrospective cross-sectional study was to investigate whether changes in white matter integrity are related to slower processing speed in sickle cell anemia. Methods Thirty-seven patients with silent cerebral infarction, 46 patients with normal MRI, and 32 sibling controls (age range 8–37 years) underwent cognitive assessment using the Wechsler scales and 3-tesla MRI. Tract-based spatial statistics analyses of diffusion tensor imaging (DTI) and neurite orientation dispersion and density imaging (NODDI) parameters were performed. Results Processing speed index (PSI) was lower in patients than controls by 9.34 points (95% confidence interval: 4.635–14.855, p = 0.0003). Full Scale IQ was lower by 4.14 scaled points (95% confidence interval: −1.066 to 9.551, p = 0.1), but this difference was abolished when PSI was included as a covariate (p = 0.18). There were no differences in cognition between patients with and without silent cerebral infarction, and both groups had lower PSI than controls (both p < 0.001). In patients, arterial oxygen content, socioeconomic status, age, and male sex were identified as predictors of PSI, and correlations were found between PSI and DTI scalars (fractional anisotropy r = 0.614, p < 0.00001; r = −0.457, p < 0.00001; mean diffusivity r = −0.341, p = 0.0016; radial diffusivity r = −0.457, p < 0.00001) and NODDI parameters (intracellular volume fraction r = 0.364, p = 0.0007) in widespread regions. Conclusion Our results extend previous reports of impairment that is independent of presence of infarction and may worsen with age. We identify processing speed as a vulnerable domain, with deficits potentially mediating difficulties across other domains, and provide evidence that reduced processing speed is related to the integrity of normal-appearing white matter using microstructure parameters from DTI and NODDI.
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Affiliation(s)
- Hanne Stotesbury
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Fenella J Kirkham
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK.
| | - Melanie Kölbel
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Philippa Balfour
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Jonathan D Clayden
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Sati Sahota
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Simrat Sakaria
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Dawn E Saunders
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Jo Howard
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Rachel Kesse-Adu
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Baba Inusa
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Maria Pelidis
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Subarna Chakravorty
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK
| | - David C Rees
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Moji Awogbade
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Olu Wilkey
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Mark Layton
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Christopher A Clark
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Jamie M Kawadler
- From Developmental Neurosciences (H.S., F.J.K., M.K., P.B., J.D.C., S. Sahota, S. Sakaria, C.A.C., J.M.K.), UCL Great Ormond Street Institute of Child Health, London; University Hospital Southampton NHS Foundation Trust (F.J.K.); Clinical and Experimental Sciences (F.J.K.), University of Southampton; Department of Radiology (D.E.S.), Great Ormond Street Hospital NHS Foundation Trust, London; Department of Haematology and Evelina Children's Hospital (J.H., R.K.-A., B.I., M.P.), Guy's and St Thomas' NHS Foundation Trust, London; King's College Hospital NHS Foundation Trust (S.C., D.C.R., M.A.), London; North Middlesex University Hospital NHS Foundation Trust (O.W.), London; and Department of Haematology (M.L.), Imperial College Healthcare NHS Foundation Trust, London, UK
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Cox SE, Ellins EA, Marealle AI, Newton CR, Soka D, Sasi P, Luca Di Tanna G, Johnson W, Makani J, Prentice AM, Halcox JP, Kirkham FJ. Ready-to-use food supplement, with or without arginine and citrulline, with daily chloroquine in Tanzanian children with sickle-cell disease: a double-blind, random order crossover trial. Lancet Haematol 2018; 5:e147-e160. [PMID: 29548623 PMCID: PMC5871644 DOI: 10.1016/s2352-3026(18)30020-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 01/15/2018] [Accepted: 01/15/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Sickle-cell disease increases the risk of malnutrition. Low arginine and nitric oxide bioavailability are implicated in morbidity related to sickle-cell disease. Simple interventions are required, especially in low-income settings. We aimed to test the hypotheses that: (1) supplementary arginine, citrulline, and daily chloroquine increase bioavailable arginine and flow-mediated dilatation (FMD; maximal diameter change; FMDmax%), a measure of nitric oxide-dependent endothelial function; and (2) protein energy supplementation in the form of ready-to-use supplementary food (RUSF) improves the height-for-age and body-mass index-for-age Z-scores in children with sickle-cell disease. METHODS We performed a double-blind, random order crossover trial with two 4-month intervention periods (each followed by 4-month washout periods) in Muhimbili National Hospital in Dar-es-Salaam, Tanzania. We enrolled 119 children from the Muhimbili Sickle Cohort who were aged 8-12 years, naive to hydroxyurea, and had documented HbSS phenotype. Two formulations of RUSF (providing 500 kcal/day) were tested: basic (RUSF-b), with which children also received weekly chloroquine (150 mg or 225 mg chloroquine base, dependent on bodyweight); and vascular (RUSF-v), which was fortified with arginine and citrulline (designed to achieve mean intakes of 0·2 g/kg per day of arginine and 0·1 g/kg per day of citrulline), and with which children received daily chloroquine (maximum 3 mg chloroquine base/kg per day). Children were randomly allocated to receive either RUSF-b first or RUSF-v first and, after a washout period, were then given the other treatment. The primary outcomes in comparing the two RUSF formulations were mean plasma arginine, arginine to ornithine ratio, and arginine to asymmetric dimethylarginine ratio, and mean FMDmax%. The primary outcomes of the combined effect of both RUSF interventions were mean height-for-age Z-score and body-mass index-for-age Z-score. Analyses were done on the eligible intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT01718054; and with ISRCTN74331412. FINDINGS Between Aug 9, 2012, and Feb 26, 2014, 145 children were randomised (71 children to RUSF-v first and 74 children to RUSF-b first) and 119 children were treated, of whom 114 children yielded complete data for all reported endpoints. The ratio of arginine to ornithine (mean of individual differences -8·67%, 95% CI -19·55 to 2·20; p=0·12) and the mean FMDmax% (1·00, -0·47 to 2·47; p=0·18) did not significantly differ between the RUSF-b and RUSF-v treatments. However, the arginine to asymmetric dimethylarginine ratio was significantly increased by RUSF-v compared with RUSF-b (56·26%, 31·13 to 81·38; p<0·0001). In planned analyses that used mixed effects models to estimate the effect of each intervention compared with the participants at baseline or during washout periods, the arginine to asymmetric dimethylarginine ratio increased following both RUSF-v treatment (86%; p<0·0001) and RUSF-b treatment (40%; p<0·0001). However, FMDmax% was higher after treatment with RUSF-v (0·92; p<0·0001) but not RUSF-b (0·39; p=0·22). Following either intervention (RUSF-b and RUSF-v, pooled) body-mass index-for-age Z-score (0·091; p=0·001) and height-for-age Z-score (0·013; p=0·081) increased compared with baseline and washout timepoints. In 83 participants in the treated population, there were 71 adverse events during the intervention, of which 21 (30%) were serious, and 81 adverse events during the washout periods, of which 26 (32%) were serious (p=0·31), including one patient who died in the second washout period. INTERPRETATION RUSF providing 500 kcal/day results in small weight gains in children with sickle-cell disease. However, even without arginine and citrulline fortification, RUSF seems to ameliorate arginine dysregulation and might improve endothelial function. Long-term studies are required to assess whether these physiological effects translate to improved clinical outcomes and better growth and development in patients with sickle-cell disease. FUNDING Wellcome Trust.
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Affiliation(s)
- Sharon E Cox
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK; School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan; Muhimbili Wellcome Programme, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Elizabeth A Ellins
- Institute of Life Sciences, Swansea University Medical School, Swansea University, Swansea, UK
| | - Alphonce I Marealle
- Muhimbili Wellcome Programme, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Charles R Newton
- Muhimbili Wellcome Programme, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Deogratias Soka
- Muhimbili Wellcome Programme, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Department of Haematology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Philip Sasi
- Department of Clinical Pharmacology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Gian Luca Di Tanna
- Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK; Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - William Johnson
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, Leicestershire, UK
| | - Julie Makani
- Muhimbili Wellcome Programme, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Department of Haematology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Andrew M Prentice
- Medical Research Council Unit The Gambia, London School of Hygiene & Tropical Medicine, London, UK
| | - Julian P Halcox
- Institute of Life Sciences, Swansea University Medical School, Swansea University, Swansea, UK
| | - Fenella J Kirkham
- Developmental Neurosciences Programme, UCL Great Ormond Street Institute of Child Health, London, UK; Clinical and Experimental Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK; University Child Health, University Hospital Southampton, Southampton, UK
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Affiliation(s)
- Hanne Stotesbury
- From Developmental Neuroscience (H.S., F.J.K.) and Developmental Imaging and Biophysics (H.S., P.W.H.), UCL Great Ormond Street Institute of Child Health, London, UK
| | - Patrick W Hales
- From Developmental Neuroscience (H.S., F.J.K.) and Developmental Imaging and Biophysics (H.S., P.W.H.), UCL Great Ormond Street Institute of Child Health, London, UK
| | - Fenella J Kirkham
- From Developmental Neuroscience (H.S., F.J.K.) and Developmental Imaging and Biophysics (H.S., P.W.H.), UCL Great Ormond Street Institute of Child Health, London, UK.
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50
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Galadanci NA, Umar Abdullahi S, Vance LD, Musa Tabari A, Ali S, Belonwu R, Salihu A, Amal Galadanci A, Wudil Jibir B, Bello-Manga H, Neville K, Kirkham FJ, Shyr Y, Phillips S, Covert BV, Kassim AA, Jordan LC, Aliyu MH, DeBaun MR. Feasibility trial for primary stroke prevention in children with sickle cell anemia in Nigeria (SPIN trial). Am J Hematol 2018; 93:E83. [PMID: 29411418 DOI: 10.1002/ajh.25012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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