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Cohen CT, Powers JM. Nutritional Strategies for Managing Iron Deficiency in Adolescents: Approaches to a Challenging but Common Problem. Adv Nutr 2024:100215. [PMID: 38556251 DOI: 10.1016/j.advnut.2024.100215] [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: 01/26/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/02/2024] Open
Abstract
Iron deficiency (ID) is a common and challenging problem in adolescence. In order to prevent, recognize, and treat ID in this age range, it is critical to understand the recommended daily intake of iron in relation to an adolescent's activity, dietary habits, and basal iron losses. Adolescents following vegetarian or vegan diets exclusively rely on plant-based, nonheme iron, which has decreased bioavailability compared with heme iron and requires increased total iron intake. Individuals with disordered eating habits, excessive menstrual blood loss, and certain chronic health conditions (including inflammatory bowel disease and heart failure) are at high risk of ID and the development of symptomatic iron deficiency anemia (IDA). Adolescent athletes and those with sleep and movement disorders may also be more sensitive to changes in iron status. Iron deficiency is typically treated with oral iron supplementation. To maximize iron absorption, oral iron should be administered no more than once daily, ideally in the morning, while avoiding foods and drinks that inhibit iron absorption. Oral iron therapy should be provided for ≥3 mo in the setting of ID to reach a ferritin of 20 ng/mL before discontinuation. Intravenous iron is being increasingly used in this population and has demonstrated efficacy and safety in adolescents. It should be considered in those with persistent ID despite a course of oral iron, severe and/or symptomatic IDA, and chronic inflammatory conditions characterized by decreased gastrointestinal iron absorption.
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Affiliation(s)
- Clay T Cohen
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Cancer and Hematology Center, Texas Children's Hospital, Houston, TX, United States
| | - Jacquelyn M Powers
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Cancer and Hematology Center, Texas Children's Hospital, Houston, TX, United States.
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Equitz E, Powers JM, Kirk S. Etiologies and Outcomes of Normocytic Anemia in Children. J Pediatr 2024:114041. [PMID: 38554748 DOI: 10.1016/j.jpeds.2024.114041] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/25/2024] [Accepted: 03/26/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE To characterize the evaluation and outcomes of children referred to pediatric hematology for normocytic anemia. STUDY DESIGN Retrospective cohort study of children aged 0 to 21 years referred to a tertiary pediatric hematology clinic for normocytic anemia from 2019 through 2021. Normocytic anemia was defined as a low hemoglobin and normal mean corpuscular volume, per the referring laboratory reference range. RESULTS Two-hundred seventy-one patients (48% female, median age 5.4 years) were included. The most common hematologic diagnoses included iron deficiency (n=90, 33%), statistical anemia (n=64, 24%), transient marrow suppression (n=36, 13%), and transient erythroblastopenia of childhood (TEC, n=19, 7%). There were 17 (6%) patients in whom anemia was thought to be secondary to a non-hematologic disorder and therefore were referred to another pediatric specialty. Sixteen patients (6%) had anemia which spontaneously resolved without an underlying etiology being identified. Aside from iron deficient patients, 35 (13%) had diagnoses requiring ongoing hematology care including TEC, hemolytic anemia, Diamond Blackfan Anemia, and abnormal beta globin traits. Two-hundred-fifty-one patients (93%) were discharged from hematology care after a median of 25 days (range 0-2124 days). CONCLUSION Pediatric patients with normocytic anemia have diverse underlying etiologies with iron deficiency being most common. These data support initial management within the primary care setting including assessment of a serum ferritin, iron panel, and reticulocyte count, with only a subset of patients requiring ongoing subspecialty care.
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Affiliation(s)
- Emily Equitz
- Universisty of Colorado, Division of Hospital Medicine, Aurora, CO, USA
| | - Jacquelyn M Powers
- Baylor College of Medicine, Department of Pediatrics, Division of Hematology/Oncology, Houston, TX, USA; Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - Susan Kirk
- Baylor College of Medicine, Department of Pediatrics, Division of Hematology/Oncology, Houston, TX, USA; Texas Children's Cancer and Hematology Center, Houston, Texas, USA.
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Cohen CT, Tarango C, Powers JM. Emicizumab use in infancy: A survey of United States Pediatric Hemophilia Treatment Center Medical Directors. Haemophilia 2024. [PMID: 38421188 DOI: 10.1111/hae.14959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 01/30/2024] [Accepted: 01/30/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Clay T Cohen
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - Cristina Tarango
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jacquelyn M Powers
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, Texas, USA
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Cohen CT, Powers JM. Intravenous iron therapy in pediatrics: who should get it and when is the right time? Hematology Am Soc Hematol Educ Program 2023; 2023:630-635. [PMID: 38066925 PMCID: PMC10727076 DOI: 10.1182/hematology.2023000496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Iron-deficiency anemia occurs most commonly in young children due to a low-iron diet and adolescent girls due to menstrual blood loss. However, children with gastrointestinal conditions such as intestinal failure, inflammatory bowel disease, celiac disease, and/or other chronic conditions, including chronic kidney disease and heart failure, also commonly have iron deficiency. Many patients with classic iron-deficiency anemia will improve with oral iron therapy. However, in children who have an incomplete response to oral iron, intravenous iron therapy is increasingly being used. Benefits of intravenous iron therapy include a rapid repletion of iron stores in addition to resolution of anemia, less gastrointestinal side effects, and relief for patients and families struggling with long-term iron supplementation. Indications for first-line therapy with intravenous iron in children with chronic conditions have also increased. Four intravenous iron formulations have approved indications in pediatrics, and many are increasingly used off-label in children as well. Here we discuss the indications and appropriate timing of intravenous iron therapy in children with a wide range of underlying etiologies.
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Affiliation(s)
- Clay T Cohen
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Cancer and Hematology Center, Houston, TX
| | - Jacquelyn M Powers
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Cancer and Hematology Center, Houston, TX
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Cohen CT, Zobeck M, Powers JM. Initial von Willebrand factor antigen values in adolescent females predict future values. Haemophilia 2023; 29:1547-1555. [PMID: 37718627 PMCID: PMC10693906 DOI: 10.1111/hae.14865] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 08/28/2023] [Accepted: 09/07/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION Diagnosing von Willebrand Disease (VWD) in adolescent females is challenging as menstruation and physiologic stress elevate von Willebrand factor (VWF) laboratory values. AIM To develop a VWF prediction model for adolescent females based on initial VWF results. METHODS We identified female patients aged 9 to 21 years with any VWF laboratory test over a 5-year period (2017-2021) at any Texas Children's Hospital facility. Patient demographics, VWF testing, haemoglobin concentration, serum ferritin and site of clinical testing were collected (initial and subsequent laboratory evaluations). A Bayesian linear regression model was developed. Prediction intervals were analysed to identify thresholds for patients in whom repeat testing was unlikely to identify low VWF levels (< 50%), consistent with VWD. RESULTS A total of 6125 adolescent females underwent VWF testing; 1204 (19.7%) had repeat testing. Based on the prediction model, initial VWF antigen values of 80%, 90% and ≥100% carried a 92.6%, 96.6% and ≥98.0% probability of having repeat normal repeat VWF values, respectively. Subjects assessed in outpatient adolescent medicine or gynaecology clinics were more likely to have low VWF values compared to those assessed in the acute care setting (p < .001). Median presenting haemoglobin and serum ferritin were 12.4 g/dL and 13 ng/mL, respectively and were similar in those with normal versus low VWF antigen values. CONCLUSION Repeat testing in adolescent females whose initial VWF antigen values are ≥90% is unlikely to identify additional patients with VWD. Iron deficiency screening should be performed in all adolescent females.
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Affiliation(s)
- Clay T. Cohen
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Cancer and Hematology Center, Houston, Texas, USA
| | - Mark Zobeck
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Cancer and Hematology Center, Houston, Texas, USA
| | - Jacquelyn M. Powers
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Cancer and Hematology Center, Houston, Texas, USA
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Powers JM, Auerbach M. When taking iron, a glass of orange juice a day keeps anemia away. Am J Hematol 2023; 98:1354-1355. [PMID: 37403430 DOI: 10.1002/ajh.27017] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 06/21/2023] [Indexed: 07/06/2023]
Affiliation(s)
- Jacquelyn M Powers
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - Michael Auerbach
- School of Medicine, Georgetown University, Washington, District of Columbia, USA
- Private Practice, Baltimore, Maryland, USA
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Cohen CT, Zobeck M, Han H, Spinner JA, Powers JM, Lee-Kim Y, Sartain SE. Bleeding outcomes and management of supratherapeutic episodes secondary to warfarin in children: A single center 10-year experience. Thromb Res 2023; 228:148-150. [PMID: 37329724 PMCID: PMC10699501 DOI: 10.1016/j.thromres.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/06/2023] [Accepted: 06/12/2023] [Indexed: 06/19/2023]
Affiliation(s)
- Clay T Cohen
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, TX, USA.
| | - Mark Zobeck
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, TX, USA
| | - HyoJeong Han
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, TX, USA
| | - Joseph A Spinner
- Division of Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Jacquelyn M Powers
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, TX, USA
| | - YoungNa Lee-Kim
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, TX, USA
| | - Sarah E Sartain
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, TX, USA
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Munro MG, Mast AE, Powers JM, Kouides PA, O'Brien SH, Richards T, Lavin M, Levy BS. The relationship between heavy menstrual bleeding, iron deficiency, and iron deficiency anemia. Am J Obstet Gynecol 2023; 229:1-9. [PMID: 36706856 DOI: 10.1016/j.ajog.2023.01.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 01/09/2023] [Accepted: 01/14/2023] [Indexed: 01/26/2023]
Abstract
For reproductive-aged women, the symptom of heavy menstrual bleeding is highly prevalent and a major contributor to iron deficiency and its most severe manifestation, iron deficiency anemia. It is recognized that these 2 clinical entities are not only highly prevalent, but their interrelationship is poorly appreciated and frequently normalized by society, healthcare providers, and affected girls and women themselves. Both heavy menstrual bleeding and iron deficiency, with or without anemia, adversely impact quality of life-heavy menstrual bleeding during the episodes of bleeding and iron deficiency on a daily basis. These combined issues adversely affect the lives of reproductive-aged girls and women of all ages, from menarche to menopause, and their often-insidious nature frequently leads to normalization. The effects on cognitive function and the related work and school absenteeism and presenteeism can undermine the efforts and function of women in all walks of life, be they students, educators, employers, or employees. There is also an increasing body of evidence that suggests that iron deficiency, even in early pregnancy, may adversely impact fetal neurodevelopment with enduring effects on a spectrum of cognitive and psychological disorders, critically important evidence that begs the normalization of iron stores in reproductive-aged women. The authors seek to raise individual, societal, and professional awareness of this underappreciated situation in a fashion that leads to meaningful and evidence-based changes in clinical guidance and healthcare policy directed at preventing, screening, diagnosing, and appropriately managing both disorders. This manuscript provides evidence supporting the need for action and describes the elements necessary to address this pervasive set of conditions that not only affect reproductive-aged girls and women but also the lives of children everywhere.
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Affiliation(s)
- Malcolm G Munro
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA.
| | - Alan E Mast
- Versiti Blood Research Institute, Milwaukee, WI
| | - Jacquelyn M Powers
- Department of Pediatrics, Baylor College of Medicine, Houston TX; Cancer and Hematology Center, Texas Children's Hospital, Houston, TX
| | - Peter A Kouides
- Mary M. Gooley Hemophilia Center, Rochester, NY; University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Sarah H O'Brien
- Center for Health Equity and Outcomes Research and the Hemostasis and Thrombosis Center, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH; Division of Pediatric Hematology, Oncology & Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, OH
| | - Toby Richards
- Division of Surgery, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
| | - Michelle Lavin
- National Coagulation Centre, St James' Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Barbara S Levy
- Department of Obstetrics and Gynecology, University of California, San Diego, San Diego, CA; Department of Obstetrics and Gynecology, The George Washington University, Washington, DC
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Cohen CT, Agrusa JE, Hui SKR, Teruya J, Powers JM. A preventable death: Fatal stroke due to severe iron deficiency anemia. Pediatr Blood Cancer 2023; 70:e30014. [PMID: 36152002 DOI: 10.1002/pbc.30014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 08/31/2022] [Accepted: 08/30/2022] [Indexed: 02/06/2023]
Affiliation(s)
- Clay T Cohen
- Division of Hematology/Oncology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Jennifer E Agrusa
- Division of Hematology/Oncology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Shiu-Ki Rocky Hui
- Division of Transfusion Medicine & Coagulation, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA.,Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
| | - Jun Teruya
- Division of Transfusion Medicine & Coagulation, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA.,Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
| | - Jacquelyn M Powers
- Division of Hematology/Oncology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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McEvoy MT, Stuckert AJ, Castellanos MI, Gilbert MM, Pfeiffer T, Prudowsky Z, Rios X, Airewele G, Okcu MF, Powers JM. Management of nutritional iron deficiency anemia for young children in the emergency department. Pediatr Blood Cancer 2023; 70:e30181. [PMID: 36579803 DOI: 10.1002/pbc.30181] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/01/2022] [Accepted: 12/06/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Guidelines for young children with nutritional iron deficiency anemia (IDA) presenting to the emergency department (ED) are lacking, leading to variability in care. We aimed to standardize management of these patients through the development and implementation of an evidence-based algorithm using quality improvement methodology. PROCEDURE Baseline data of the target population (n = 42; 60% male; median age 22.5 months, median hemoglobin 5.3 g/dl) identified variability across four key measures of clinical management: laboratory evaluation, therapy choice, therapy administration, and patient disposition. Literature review and consensus from pediatric hematology providers informed a draft algorithm that was refined in an iterative multidisciplinary process. From September 2020 to June 2021, we aimed to increase IDA management per the algorithm by ≥20% relative to baseline for the four key outcome measures using sequential Plan-Do-Study-Act (PDSA) cycles. Process measures focusing on provider communication/documentation and balancing measures involving efficiency and therapy-related adverse events were assessed concurrently. RESULTS Thirty-five patients were evaluated among four PDSA cycles and shared similar characteristics as the baseline population. Improvements of ≥20% above baseline adherence levels or 100% adherence were achieved for all outcome measure across four PDSA cycles. Adherence to recommended laboratory evaluation improved from 43 (baseline) to 71%, therapy choice from 78 to 100%, therapy administration from 50 to 83%, and disposition from 85 to 100%. ED length of stay remained stable. CONCLUSIONS Implementation of a standardized algorithm for young children with nutritional IDA in the ED increased adherence to evidence-based patient care.
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Affiliation(s)
- Matthew T McEvoy
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Austin J Stuckert
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Maria I Castellanos
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA.,UCSF Benioff Children's Hospitals, Department of Pediatrics, San Francisco/Oakland, California, USA
| | - Megan M Gilbert
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Thomas Pfeiffer
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA.,St. Louis Children's Hospital, Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Zachary Prudowsky
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Xavier Rios
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Gladstone Airewele
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - M Fatih Okcu
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Jacquelyn M Powers
- Texas Children's Hospital, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
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Gunn E, Powers JM, Rahman AF, Bemrich-Stolz C, Mennemeyer S, Lebensburger JD, Wilson HP. Diagnosis and management of isolated neutropenia: A survey of pediatric hematologist oncologists. Pediatr Blood Cancer 2023; 70:e29946. [PMID: 36495229 DOI: 10.1002/pbc.29946] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/05/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Isolated neutropenia is a common referral to pediatric hematology oncology (PHO) physicians. There are no established consensus guidelines in the diagnosis and management of patients with isolated, asymptomatic, and incidentally discovered neutropenia. METHODS A survey was distributed to PHO physicians on the American Society of Pediatric Hematology Oncology member discussion page to determine the common diagnostic and management decisions regarding patients with isolated neutropenia and to explore beliefs regarding the term "benign ethnic neutropenia." RESULTS One hundred twenty-six PHO attending physicians completed the survey. The most common tests reportedly ordered for this patient population included complete blood cell count (CBC) (98%), peripheral smear (75%), antineutrophil antibody testing (29%), and immunoglobulins (24%). Providers were more likely to order an antineutrophil antibody in toddlers (p = .0085), and antinuclear antibody (ANA) panels in adolescents (p < .001). Half of providers do not request additional CBCs prior to their initial consultation, and most suggest referring patients with mild neutropenia after confirming a declining absolute neutrophil count (ANC) (51%). The three most important factors influencing ongoing follow-up included: history of recurrent/severe infections (98%), family history of blood disorders (98%), and more severe/progressively worsening neutropenia (97%). Seventy percent of respondents have diagnosed patients with "benign ethnic neutropenia," and 75% support replacement of the term to "typical neutrophil count with Fy(a-/b-) status," if confirmed with red cell phenotyping. CONCLUSION We identified practice patterns of PHO physicians for the diagnosis and management of patients referred for asymptomatic and isolated neutropenia. These data provide the framework to conduct cost-effectiveness studies.
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Affiliation(s)
- Elizabeth Gunn
- Division of Pediatric Hematology Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jacquelyn M Powers
- Division of Pediatric Hematology Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Birmingham, Alabama, USA
| | - Akm Fazlur Rahman
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Christina Bemrich-Stolz
- Division of Pediatric Hematology Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Stephen Mennemeyer
- School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey D Lebensburger
- Division of Pediatric Hematology Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Hope P Wilson
- Division of Pediatric Hematology Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Long JM, Powers JM, Katona BW. Evaluation of Classic, Attenuated, and Oligopolyposis of the Colon. Gastrointest Endosc Clin N Am 2022; 32:95-112. [PMID: 34798989 PMCID: PMC8607742 DOI: 10.1016/j.giec.2021.08.003] [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] [Indexed: 02/04/2023]
Abstract
The goal of this review is to provide an overview of evaluating patients with adenomatous polyposis of the colon, including elements such as generating a differential diagnosis, referral considerations for genetic testing, genetic testing options, and expected outcomes from genetic testing in these individuals. In more recent years, adenomatous colonic polyposis has evolved beyond the more robustly characterized familial adenomatous polyposis (FAP) and MUTYH-associated polyposis (MAP) now encompassing more newly described genes and associated syndromes. Technological innovation, from whole-exome sequencing to multigene panel testing, has dramatically increased the amount of genotypic and phenotypic data amassed in adenomatous polyposis cohorts, which has contributed greatly to informing diagnosis and clinical management of affected individuals and their families.
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Affiliation(s)
- Jessica M. Long
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacquelyn M. Powers
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Bryson W. Katona
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Stroman PW, Powers JM, Ioachim G, Warren HJM, McNeil K. Investigation of the neural basis of expectation-based analgesia in the human brainstem and spinal cord by means of functional magnetic resonance imaging. Neurobiol Pain 2021; 10:100068. [PMID: 34381928 PMCID: PMC8333346 DOI: 10.1016/j.ynpai.2021.100068] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/12/2021] [Accepted: 07/12/2021] [Indexed: 12/12/2022]
Abstract
Expectation of lower pain results in lower perceived pain in healthy humans. This expectation analgesia is mediated by descending regulation of the spinal cord. Connectivity analyses showed effects of expecting lower pain prior to stimulation. Expectation analgesia involves regions linked to arousal and autonomic regulation.
Purpose The expected intensity of pain resulting from a noxious stimulus has been observed to have a strong influence on the pain that is perceived. The neural basis of pain reduction, as a result of expecting lower pain, was investigated using functional magnetic resonance imaging (fMRI) in the brainstem and spinal cord. Methods Functional MRI studies were carried out in a region spanning the brainstem and cervical spinal cord in healthy participants. Participants were familiarized with a noxious heat stimulus and study procedures in advance, and were informed during each trial that either a heat calibrated to produce moderate pain (Base state), or a temperature 1 °C lower (Low state), would be applied to their hand. However, the Base temperature was applied in every trial. Results Pain ratings were significantly reduced as a result of expecting lower temperatures. FMRI results demonstrate blood oxygenation-level dependent (BOLD) signal variations in response to participants being informed of the stimulus to expect, in advance of stimulation, and in response to stimulation. Significant coordination of BOLD signals was also detected across specific brainstem and spinal cord regions, with connectivity strengths that varied significantly with the study condition, and with individual pain ratings. The results identify regions that are known to be involved with arousal and autonomic regulation. Conclusions Expectation-based analgesia is mediated by descending regulation of spinal cord nociceptive responses. This regulation appears to be related to arousal and autonomic regulation, consistent with the cognitive/affective dimension of pain.
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Affiliation(s)
- P W Stroman
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario K7L 3N6, Canada.,Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario K7L 3N6, Canada.,Department of Physics, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - J M Powers
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - G Ioachim
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - H J M Warren
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - K McNeil
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario K7L 3N6, Canada.,Royal Military College of Canada, Kingston, Ontario K7L 3N6, Canada
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Heeney MM, Berhe S, Campagna DR, Oved JH, Kurre P, Shaw PJ, Teo J, Shanap MA, Hassab HM, Glader BE, Shah S, Yoshimi A, Ameri A, Antin JH, Boudreaux J, Briones M, Dickerson KE, Fernandez CV, Farah R, Hasle H, Keel SB, Olson TS, Powers JM, Rose MJ, Shimamura A, Bottomley SS, Fleming MD. SLC25A38 congenital sideroblastic anemia: Phenotypes and genotypes of 31 individuals from 24 families, including 11 novel mutations, and a review of the literature. Hum Mutat 2021; 42:1367-1383. [PMID: 34298585 DOI: 10.1002/humu.24267] [Citation(s) in RCA: 4] [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] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 06/10/2021] [Accepted: 07/21/2021] [Indexed: 01/19/2023]
Abstract
The congenital sideroblastic anemias (CSAs) are a heterogeneous group of inherited disorders of erythropoiesis characterized by pathologic deposits of iron in the mitochondria of developing erythroblasts. Mutations in the mitochondrial glycine carrier SLC25A38 cause the most common recessive form of CSA. Nonetheless, the disease is still rare, there being fewer than 70 reported families. Here we describe the clinical phenotype and genotypes of 31 individuals from 24 families, including 11 novel mutations. We also review the spectrum of reported mutations and genotypes associated with the disease, describe the unique localization of missense mutations in transmembrane domains and account for the presence of several alleles in different populations.
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Affiliation(s)
- Matthew M Heeney
- Division of Hematology, Dana-Farber Boston Children's Cancer and Blood Disorders Center and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Simon Berhe
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Dean R Campagna
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph H Oved
- Cellular Therapy and Transplant Section, Division of Oncology and Comprehensive Bone Marrow Failure Center, Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Philadelphia, USA
| | - Peter Kurre
- Pediatric Comprehensive Bone Marrow Failure Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Peter J Shaw
- BMT Services, Children's Hospital at Westmead; Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Juliana Teo
- Department of Haematology, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | | | - Hoda M Hassab
- Department of Paediatrics, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Bertil E Glader
- Division of Hematology-Oncology, Lucille Packard Children's Hospital, Stanford, California, USA
| | - Sanjay Shah
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Ayami Yoshimi
- Department of Paediatrics and Adolescent Medicine, Division of Paediatric Haematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Afshin Ameri
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Joseph H Antin
- Hematopoietic Stem Cell Transplantation Program, Dana-Farber Cancer Institute, and Harvard Medical School, Boston, Massachusetts, USA
| | - Jeanne Boudreaux
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia, USA
| | - Michael Briones
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia, USA
| | - Kathryn E Dickerson
- Department of Pediatrics, University of Texas Southwestern, Dallas, Texas, USA
| | - Conrad V Fernandez
- Division of Hematology-Oncology, IWH Center, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Roula Farah
- Department of Pediatrics, Lebanese American University Medical Center, Beirut, Lebanon
| | - Henrik Hasle
- Department of Pediatrics, Aarhus University Hospital, Aarhus University, Aarhus, Denmark
| | - Sioban B Keel
- Division of Hematology, University of Washington and Seattle Cancer Care Alliance, Seattle, Washington, USA
| | - Timothy S Olson
- Cellular Therapy and Transplant Section, Division of Oncology and Comprehensive Bone Marrow Failure Center, Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jacquelyn M Powers
- Texas Children's Hospital and Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Melissa J Rose
- Division of Hematology & Oncology, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Akiko Shimamura
- Division of Hematology, Dana-Farber Boston Children's Cancer and Blood Disorders Center and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Sylvia S Bottomley
- Hematology-Oncology Section, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Mark D Fleming
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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15
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Detlefs S, Powers JM. Anemia in pregnant women with HIV: Insights and implications about iron for all pregnant women and infants. Am J Clin Nutr 2021; 113:1390-1391. [PMID: 33829224 DOI: 10.1093/ajcn/nqab056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Sarah Detlefs
- Department of Obstetrics and Gynecology, Maternal Fetal Medicine, Baylor College of Medicine, Houston TX, USA
| | - Jacquelyn M Powers
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine and Texas Children's Cancer and Hematology Center, Houston, TX, USA
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Kirk SE, Scheurer ME, Bernhardt MB, Mahoney DH, Powers JM. Phosphorus levels in children treated with intravenous ferric carboxymaltose. Am J Hematol 2021; 96:E215-E218. [PMID: 33735470 DOI: 10.1002/ajh.26165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/10/2021] [Accepted: 03/15/2021] [Indexed: 01/20/2023]
Affiliation(s)
- Susan E. Kirk
- Department of Pediatrics, Baylor College of Medicine Texas Children's Cancer and Hematology Centers Houston Texas
| | - Michael E. Scheurer
- Department of Pediatrics, Baylor College of Medicine Texas Children's Cancer and Hematology Centers Houston Texas
| | - Melanie Brooke Bernhardt
- Department of Pediatrics, Baylor College of Medicine Texas Children's Cancer and Hematology Centers Houston Texas
| | - Donald H. Mahoney
- Department of Pediatrics, Baylor College of Medicine Texas Children's Cancer and Hematology Centers Houston Texas
| | - Jacquelyn M. Powers
- Department of Pediatrics, Baylor College of Medicine Texas Children's Cancer and Hematology Centers Houston Texas
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17
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Kirk SE, Powers JM. Isolated neutropenia appears unlikely to require intervention. J Pediatr 2021; 232:307-310. [PMID: 33896459 DOI: 10.1016/j.jpeds.2021.02.056] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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18
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Boone S, Powers JM. Response to Letter to the Editor "Therapeutic Alternative to Transfusion in Nonpregnant Women With Iron Deficiency Anemia Caused by Uterine Blood Loss". J Emerg Med 2021; 60:566-567. [PMID: 33902883 DOI: 10.1016/j.jemermed.2020.10.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/25/2020] [Indexed: 10/21/2022]
Affiliation(s)
- Stephen Boone
- Departments of Emergency Medicine and Internal Medicine, Baylor College of Medicine, Houston, Texas
| | - Jacquelyn M Powers
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas
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19
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Highberger M, Mendoza A, John T, Nguyen T, Powers JM. Best Practice Algorithm Development for Identification and Management of Transfusion-Related Iron Overload in Post-Hematopoietic Stem Cell Transplant Patients. Transplant Cell Ther 2021. [DOI: 10.1016/s2666-6367(21)00136-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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20
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Affiliation(s)
- Jacquelyn M Powers
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Michael Auerbach
- School of Medicine, Georgetown University, Washington, DC, USA.,Private Practice, Baltimore, MD, USA
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21
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Jacobson-Kelly AE, Stanek JR, Powers JM, Dotson JL, O'Brien SH. Trends in Anemia, Iron, Therapy, and Transfusion in Hospitalized Pediatric Patients with Inflammatory Bowel Disease. J Pediatr 2020; 222:141-145.e1. [PMID: 32444225 DOI: 10.1016/j.jpeds.2020.02.071] [Citation(s) in RCA: 5] [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: 12/12/2019] [Revised: 01/27/2020] [Accepted: 02/26/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate trends in diagnosis and management of iron deficiency anemia using a large national children's hospital database in pediatric patients admitted with inflammatory bowel disease (IBD). STUDY DESIGN In this retrospective multicenter cohort study, we used the Pediatric Health Information System de-identified administrative database. Patients age <21 years with ≥2 admissions with International Classification of Disease, Ninth Revision and Tenth Revision codes for Crohn's disease or ulcerative colitis from 2012 to 2018 were included. We extracted data regarding diagnoses of anemia and/or iron deficiency, and receipt of oral iron, intravenous (IV) iron, and/or blood transfusion. Data were analyzed descriptively. RESULTS We identified 8007 unique patients meeting study criteria for a total of 28 260 admissions. The median age at admission was 15.4 years. A diagnosis of anemia was documented in 29.8% of admissions and iron studies were performed in 12.6%. IV iron was given in 6.3% of admissions and blood transfusions in 7.4%. The prevalence of the diagnosis of anemia among IBD admissions increased from 24.6% in 2012 to 32.4% in 2018 (P < .0001). There was a steady increase in the proportion of IBD admissions that used IV iron, from 3.5% in 2012 to 10.4% in 2018 (P < .0001), and the proportion of admissions with red cell transfusions decreased over time from 9.4% to 4.4% (P < .0001). CONCLUSIONS Iron deficiency anemia is prevalent among pediatric patients with IBD admitted to US children's hospitals. From 2012 to 2018, there was an increase in the use of inpatient IV iron for the treatment of iron deficiency anemia and a decrease in transfusions.
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Affiliation(s)
- Amanda E Jacobson-Kelly
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University, Columbus, OH
| | - Joseph R Stanek
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University, Columbus, OH
| | - Jacquelyn M Powers
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine; Texas Children's Hospital, Houston, TX
| | - Jennifer L Dotson
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital/The Ohio State University; Center for Innovation in Pediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University, Columbus, OH; Center for Innovation in Pediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH.
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22
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Powers JM, Nagel M, Raphael JL, Mahoney DH, Buchanan GR, Thompson DI. Barriers to and Facilitators of Iron Therapy in Children with Iron Deficiency Anemia. J Pediatr 2020; 219:202-208. [PMID: 32014276 PMCID: PMC7098469 DOI: 10.1016/j.jpeds.2019.12.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 09/04/2019] [Revised: 11/12/2019] [Accepted: 12/18/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To characterize barriers to and facilitators of successful iron therapy in young children with iron deficiency anemia (IDA) from an in-depth parental perspective. STUDY DESIGN Prospective, mixed methods study of children age 9 months to 4 years with a diagnosis of nutritional IDA by clinical history and laboratory criteria and their parents. Clinical data were obtained from the electronic health record. Semistructured interviews focused on knowledge of IDA, clinical effects, experience with iron therapies, and motivation were conducted with the parent who identified as the child's primary caregiver. RESULTS Twenty patient-parent dyads completed the study; 80% (n = 16) identified as Hispanic/Latino (white). Patients' median age was 23 months (50% male); median initial hemoglobin concentration was 8.2 g/dL and duration of oral iron therapy was 3 months. Parents' median age was 29 years (85% female); 8 interviews (40%) were conducted in Spanish. Barriers included difficulty in administering oral iron owing to side effects and poor taste. Facilitators included provision of specific instructions; support from healthcare providers and additional caregivers at home; motivation to benefit child's health, which was strengthened by strong emotional reactions (ie, stress, anxiety) to therapy and follow-up; and an appreciation of child's improvement with successful completion of therapy. CONCLUSIONS Our findings support the need for interventions designed to promote oral iron adherence in children with IDA. Rather than focusing on knowledge content related to IDA, interventions should aim to increase parental motivation by emphasizing the health benefits of adhering to iron therapy and avoiding more invasive interventions.
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Affiliation(s)
- Jacquelyn M. Powers
- Department of Pediatrics, Baylor College of Medicine, Houston, TX;,Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX;,Texas Children’s Hospital, Houston, TX
| | | | - Jean L. Raphael
- Department of Pediatrics, Baylor College of Medicine, Houston, TX;,Texas Children’s Hospital, Houston, TX
| | - Donald H. Mahoney
- Department of Pediatrics, Baylor College of Medicine, Houston, TX;,Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX;,Texas Children’s Hospital, Houston, TX
| | - George R. Buchanan
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Deborah I. Thompson
- Department of Pediatrics, Baylor College of Medicine, Houston, TX;,United States Department of Agriculture, Agricultural Research Center, Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX
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23
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Kirk SE, Grimes AB, Shelke S, Despotovic JM, Powers JM. The cost of a "benign" condition: Healthcare utilization and infectious outcomes in young children with primary autoimmune neutropenia. Pediatr Blood Cancer 2020; 67:e28146. [PMID: 31886613 DOI: 10.1002/pbc.28146] [Citation(s) in RCA: 6] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 12/05/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Autoimmune neutropenia (AIN) is a common cause of chronic neutropenia in childhood. Despite an expected benign clinical course, many patients undergo extensive evaluation. Data on healthcare utilization and rates of bloodstream infections in young patients with AIN are limited. METHODS All patients with a diagnosis code of leukopenia, neutropenia, or AIN followed within the outpatient hematology clinic of a single institution from 2014 to 2016 were identified. Patients aged ≤5 years with absolute neutrophil count (ANC) ≤500/µL persisting for ≥3 months, a clinical diagnosis of AIN, and documented resolution of neutropenia were included. Data on clinical management, including infectious outcomes and emergency center (EC) encounters, were collected. RESULTS Forty-three patients with AIN (18 male [42%], median age at diagnosis 12 months) met eligibility criteria. Children were followed by hematology for a median duration of 18 (range, 2-85) months. Diagnostic evaluations were variable. Thirty patients (70%) had ≥ 1 EC encounters for evaluation of isolated fever with a total of 113 EC encounters for the overall cohort. Patients with ANC < 500/µL and isolated fever were admitted for observation, which resulted in 24 hospitalizations in 16 patients. Of 138 blood cultures drawn, two were positive, both later determined to be contaminants. CONCLUSION At a large tertiary care center, no bloodstream infections were identified in a cohort of 43 children with AIN presenting to the EC for assessment of fever. A less-intensive, more cost-effective management paradigm, which continues to prioritize patient safety, among young children with AIN is needed.
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Affiliation(s)
- Susan E Kirk
- Baylor College of Medicine, Department of Pediatrics, Section of Hematology/Oncology, Houston, Texas.,Texas Children's Cancer and Hematology Centers, Houston, Texas
| | - Amanda Bell Grimes
- Baylor College of Medicine, Department of Pediatrics, Section of Hematology/Oncology, Houston, Texas.,Texas Children's Cancer and Hematology Centers, Houston, Texas
| | | | - Jenny M Despotovic
- Baylor College of Medicine, Department of Pediatrics, Section of Hematology/Oncology, Houston, Texas.,Texas Children's Cancer and Hematology Centers, Houston, Texas
| | - Jacquelyn M Powers
- Baylor College of Medicine, Department of Pediatrics, Section of Hematology/Oncology, Houston, Texas.,Texas Children's Cancer and Hematology Centers, Houston, Texas
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24
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Powers JM. A step toward an expanded iron toolkit: Hepcidin values in healthy Dutch children. Pediatr Blood Cancer 2020; 67:e28122. [PMID: 31850660 DOI: 10.1002/pbc.28122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 01/08/2023]
Affiliation(s)
- Jacquelyn M Powers
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas.,Texas Children's Cancer and Hematology Centers, Houston, Texas
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25
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Powers JM, Ebrahimzadeh JE, Katona BW. Genetic testing for hereditary gastrointestinal cancer syndromes: Interpreting results in today's practice. Curr Treat Options Gastroenterol 2019; 17:636-649. [PMID: 31761969 PMCID: PMC6926154 DOI: 10.1007/s11938-019-00253-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Advances in genomics have led to the discovery of multiple predisposition genes linked to increased risk for gastrointestinal (GI) cancer. The goal of this review is to assist physicians and allied health care professionals in understanding the current paradigm shift in clinical genetic testing for hereditary GI cancer predisposition syndromes; with a focus on multigene panel testing (MGPT) and test results interpretation. Additionally, this review introduces direct-to-consumer and at-home genetic testing. Both delivery models are increasing in popularity and clinicians will be expected to address results from patients who utilize these approaches. RECENT FINDINGS Technological advancement and reduced costs have transformed the genetic testing approach from single syndrome genetic testing to broad-based MGPT. MGPT has the benefit of aiding in efficient genetic diagnosis; however, clinicians should be knowledgeable of possible results including variants of uncertain significance, secondary findings, and pathogenic variants within high- and low-to-moderate risk genes, as well as genes for which risks are ill-defined. The landscape of clinical cancer genetics continues to evolve rapidly. Timely updates are critical to ensure the medical community is familiar with current considerations and ongoing challenges regarding genetic testing for hereditary GI cancer susceptibility.
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Affiliation(s)
- Jacquelyn M Powers
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jessica E Ebrahimzadeh
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Bryson W Katona
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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26
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Boone S, Powers JM, Goodgame B, Peacock WF. Identification and Management of Iron Deficiency Anemia in the Emergency Department. J Emerg Med 2019; 57:637-645. [DOI: 10.1016/j.jemermed.2019.08.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 08/25/2019] [Accepted: 08/28/2019] [Indexed: 12/30/2022]
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Abstract
Iron deficiency anemia is the leading cause of anemia worldwide and affects many young children and adolescent girls in the United States. Its signs and symptoms are subtle despite significant clinical effects. Iron deficiency anemia is diagnosed clinically by the presence of risk factors and microcytic anemia. Improvement following a trial of oral iron therapy is confirmative. An array of iron laboratory tests is available with variable indications. Clinical trial and iron absorption data support a shift to lower-dose oral iron therapy. Intravenous iron should be considered in children who fail oral iron or who have more complex disorders.
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Affiliation(s)
- Jacquelyn M Powers
- Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine, Texas Children's Cancer and Hematology Centers, 6701 Fannin Street, Suite 1580, Houston, TX 77030, USA.
| | - George R Buchanan
- Pediatric Hematology-Oncology, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, H3.104A, Dallas, TX 75390-9063, USA
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28
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Powers JM, O'Brien SH. How I approach iron deficiency with and without anemia. Pediatr Blood Cancer 2019; 66:e27544. [PMID: 30393941 DOI: 10.1002/pbc.27544] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 10/18/2018] [Accepted: 10/19/2018] [Indexed: 12/13/2022]
Abstract
Iron deficiency anemia remains a common referral to the pediatric hematology-oncology subspecialist. Improved understanding of iron homeostasis, including the effects of the regulatory hormone hepcidin, recent adult and pediatric clinical trial data, as well as the availability of safer formulations of intravenous iron, have resulted in additional considerations when making treatment recommendations in such patients. Young children and adolescent females remain the most commonly affected groups, but children with complex medical or chronic inflammatory conditions including comorbid gastrointestinal disorders also require special consideration.
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Affiliation(s)
- Jacquelyn M Powers
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas.,Texas Children's Hospital, Houston, Texas
| | - Sarah H O'Brien
- Division of Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University, Columbus, Ohio
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29
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Powers JM, Stanek JR, Srivaths L, Haamid FW, O'Brien SH. Hematologic Considerations and Management of Adolescent Girls with Heavy Menstrual Bleeding and Anemia in US Children's Hospitals. J Pediatr Adolesc Gynecol 2018; 31:446-450. [PMID: 29940313 DOI: 10.1016/j.jpag.2018.06.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [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: 02/16/2018] [Revised: 06/11/2018] [Accepted: 06/14/2018] [Indexed: 01/27/2023]
Abstract
STUDY OBJECTIVE To assess the frequency, severity, and inpatient management of girls admitted with heavy menstrual bleeding and iron deficiency anemia at US children's hospitals, with a focus on hematologic considerations. DESIGN Retrospective multicenter cohort study from October 2012 through September 2015. SETTING Children's hospitals submitting data to the Pediatric Health Information System. PARTICIPANTS Female patients, age 8-18 years, admitted with heavy menstrual bleeding and anemia as either a primary or secondary diagnosis. Patients with cancer, immune thrombocytopenic purpura, aplastic anemia, and pregnancy were excluded. INTERVENTIONS AND MAIN OUTCOME MEASURES Hemostatic evaluation; provision of iron therapy. RESULTS We identified 1183 admissions (1134 unique patients). Patients' median (interquartile range) age was 14 (11-17) years. Forty-one percent were Caucasian (n = 480), 31% African American (n = 371), and 26% Hispanic ethnicity (n = 310). Intensive care use occurred in 5% of admissions (n = 56). Hemostatic assessment was inconsistent; 15% (n = 182) had no such evaluation. Two-thirds (n = 797; 67%) involved transfusions, 37% (n = 433) received no inpatient iron therapy, and 17% (n = 197) received no hormonal or antifibrinolytic therapy. Hemostatic evaluation was associated with intensive care use: odds ratio (OR), 4.80 (95% confidence interval [CI], 1.16-19.86; P = .03); emergency department visit: OR, 2.60 (95% CI, 1.86-3.65; P < .01); private insurance: OR, 1.62 (95% CI, 1.12-2.35; P = .01); and younger age: OR, 0.84 (95% CI, 0.77-0.92; P < .01). CONCLUSION Hundreds of girls with heavy menstrual bleeding and anemia are hospitalized at US children's hospitals each year with variable inpatient hematologic evaluation and management. Future guidelines should emphasize early identification of at-risk patients and promote effective implementation strategies to reduce the burden of this preventable complication.
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Affiliation(s)
- Jacquelyn M Powers
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston, Texas.
| | - Joseph R Stanek
- Division of Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio
| | - Lakshmi Srivaths
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston, Texas
| | - Fareeda W Haamid
- Division of Adolescent Medicine, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Sarah H O'Brien
- Division of Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State University, Columbus, Ohio
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30
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Affiliation(s)
- Jacquelyn M Powers
- Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas
| | - George R Buchanan
- Division of Hematology/Oncology, University of Texas Southwestern Medical Center, Dallas
| | - Timothy L McCavit
- Division of Hematology/Oncology, Cook Children's Medical Center, Fort Worth, Texas
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31
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Powers JM, Buchanan GR. Potential for Improved Screening, Diagnosis, and Treatment for Iron Deficiency and Iron Deficiency Anemia in Young Children. J Pediatr 2017; 188:8-10. [PMID: 28549635 DOI: 10.1016/j.jpeds.2017.04.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 04/28/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Jacquelyn M Powers
- Section of Hematology/Oncology Department of Pediatrics Baylor College of Medicine Houston, Texas
| | - George R Buchanan
- Division of Hematology/Oncology Department of Pediatrics The University of Texas Southwestern Medical Center Dallas, Texas.
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Powers JM, Buchanan GR, Adix L, Zhang S, Gao A, McCavit TL. Effect of Low-Dose Ferrous Sulfate vs Iron Polysaccharide Complex on Hemoglobin Concentration in Young Children With Nutritional Iron-Deficiency Anemia: A Randomized Clinical Trial. JAMA 2017; 317:2297-2304. [PMID: 28609534 PMCID: PMC5815003 DOI: 10.1001/jama.2017.6846] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Iron-deficiency anemia (IDA) affects millions of persons worldwide, and is associated with impaired neurodevelopment in infants and children. Ferrous sulfate is the most commonly prescribed oral iron despite iron polysaccharide complex possibly being better tolerated. OBJECTIVE To compare the effect of ferrous sulfate with iron polysaccharide complex on hemoglobin concentration in infants and children with nutritional IDA. DESIGN, SETTING, AND PARTICIPANTS Double-blind, superiority randomized clinical trial of infants and children aged 9 to 48 months with nutritional IDA (assessed by history and laboratory criteria) that was conducted in an outpatient hematology clinic at a US tertiary care hospital from September 2013 through November 2015; 12-week follow-up ended in January 2016. INTERVENTIONS Three mg/kg of elemental iron once daily as either ferrous sulfate drops or iron polysaccharide complex drops for 12 weeks. MAIN OUTCOMES AND MEASURES Primary outcome was change in hemoglobin over 12 weeks. Secondary outcomes included complete resolution of IDA (defined as hemoglobin concentration >11 g/dL, mean corpuscular volume >70 fL, reticulocyte hemoglobin equivalent >25 pg, serum ferritin level >15 ng/mL, and total iron-binding capacity <425 μg/dL at the 12-week visit), changes in serum ferritin level and total iron-binding capacity, adverse effects. RESULTS Of 80 randomized infants and children (median age, 22 months; 55% male; 61% Hispanic white; 40 per group), 59 completed the trial (28 [70%] in ferrous sulfate group; 31 [78%] in iron polysaccharide complex group). From baseline to 12 weeks, mean hemoglobin increased from 7.9 to 11.9 g/dL (ferrous sulfate group) vs 7.7 to 11.1 g/dL (iron complex group), a greater difference of 1.0 g/dL (95% CI, 0.4 to 1.6 g/dL; P < .001) with ferrous sulfate (based on a linear mixed model). Proportion with a complete resolution of IDA was higher in the ferrous sulfate group (29% vs 6%; P = .04). Median serum ferritin level increased from 3.0 to 15.6 ng/mL (ferrous sulfate) vs 2.0 to 7.5 ng/mL (iron complex) over 12 weeks, a greater difference of 10.2 ng/mL (95% CI, 6.2 to 14.1 ng/mL; P < .001) with ferrous sulfate. Mean total iron-binding capacity decreased from 501 to 389 μg/dL (ferrous sulfate) vs 506 to 417 μg/dL (iron complex) (a greater difference of -50 μg/dL [95% CI, -86 to -14 μg/dL] with ferrous sulfate; P < .001). There were more reports of diarrhea in the iron complex group than in the ferrous sulfate group (58% vs 35%, respectively; P = .04). CONCLUSIONS AND RELEVANCE Among infants and children aged 9 to 48 months with nutritional iron-deficiency anemia, ferrous sulfate compared with iron polysaccharide complex resulted in a greater increase in hemoglobin concentration at 12 weeks. Once daily, low-dose ferrous sulfate should be considered for children with nutritional iron-deficiency anemia. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01904864.
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Affiliation(s)
- Jacquelyn M. Powers
- Division of Hematology and Oncology, Baylor College of Medicine, Houston, Texas
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Texas Children’s Hospital, Houston
| | - George R. Buchanan
- Division of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
- Children’s Health, Dallas, Texas
| | | | - Song Zhang
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
| | - Ang Gao
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
| | - Timothy L. McCavit
- Division of Hematology and Oncology, Cook Children’s Medical Center, Ft Worth, Texas
- Department of Pediatrics, Cook Children’s Medical Center, Ft Worth, Texas
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Cooke AG, McCavit TL, Buchanan GR, Powers JM. Iron Deficiency Anemia in Adolescents Who Present with Heavy Menstrual Bleeding. J Pediatr Adolesc Gynecol 2017; 30:247-250. [PMID: 27789349 DOI: 10.1016/j.jpag.2016.10.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 10/09/2016] [Accepted: 10/17/2016] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE To assess the clinical severity and initial treatment of iron deficiency anemia (IDA) in female adolescents with heavy menstrual bleeding (HMB) in our center. DESIGN Retrospective cohort study of electronic medical records via search of administrative records using International Classification of Diseases Ninth Revision codes for IDA or unspecified anemia and disorders of menstruation. SETTING Children's Medical Center in Dallas, Texas. PARTICIPANTS One hundred seven patients with HMB and concomitant IDA (median age, 14.4 years) who presented to the outpatient, emergency department, and/or inpatient settings. RESULTS The median initial hemoglobin concentration for all patients (n = 107) was 7.4 g/dL, and most (74%, n = 79) presented to the emergency department or via inpatient transfer. Symptomatic IDA was treated with blood transfusion in 46 (43%, n = 46). Ferrous sulfate was the most commonly prescribed oral iron therapy. Seven patients received intravenous iron therapy either initially or after oral iron treatment failure. Combined oral contraceptives were commonly prescribed for abnormal uterine bleeding, yet 10% of patients (n = 11) received no hormonal therapy during their initial management. Evaluation for underlying bleeding disorders was inconsistent. CONCLUSION Severe anemia because of IDA and HMB resulting in urgent medical care, including hospitalization and blood transfusion, is a common but underemphasized problem in adolescent girls. In addition to prevention and early diagnosis, meaningful efforts to improve initial management of adolescents with severe HMB and IDA are necessary.
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Affiliation(s)
- Amanda G Cooke
- Department of Pediatrics, Johns Hopkins All Children's Hospital, St Petersburg, Florida
| | - Timothy L McCavit
- Division of Hematology-Oncology, Department of Pediatrics, Cook Children's Hospital, Fort Worth, Texas
| | - George R Buchanan
- Division of Hematology-Oncology, Department of Pediatrics, UT Southwestern Medical Center and Children's Medical Center, Dallas, Texas
| | - Jacquelyn M Powers
- Division of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas.
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Powers JM, Shamoun M, McCavit TL, Adix L, Buchanan GR. Intravenous Ferric Carboxymaltose in Children with Iron Deficiency Anemia Who Respond Poorly to Oral Iron. J Pediatr 2017; 180:212-216. [PMID: 27776750 DOI: 10.1016/j.jpeds.2016.09.053] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 07/28/2016] [Accepted: 09/19/2016] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To assess the benefits and risks of intravenous (IV) ferric carboxymaltose (FCM) in children with iron deficiency anemia (IDA). STUDY DESIGN In a retrospective cohort study of patients seen at our center, we identified all FCM infusions in children with IDA over a 12-month period through a query of pharmacy records. Clinical data, including hematologic response and adverse effects, were extracted from the electronic medical record. RESULTS A total of 116 IV FCM infusions were administered to 72 patients with IDA refractory to oral iron treatment (median age, 13.7 years; range, 9 months to 18 years). Median preinfusion and postinfusion hemoglobin values were 9.1 g/dL and 12.3 g/dL, respectively (at 4-12 weeks after the initial infusion; n = 53). Sixty-five patients (84%) experienced no adverse effects. Minor transient complications were encountered during or immediately after 7 infusions. CONCLUSION FCM administered as a short IV infusion without a test dose proved to be safe and highly effective in a small yet diverse population of infants, children, and adolescents with IDA refractory to oral iron therapy.
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Affiliation(s)
- Jacquelyn M Powers
- Division of Hematology/Oncology, Baylor College of Medicine, Houston, TX; Department of Pediatrics, Baylor College of Medicine, Houston, TX; Texas Children's Hospital, Houston, TX.
| | - Mark Shamoun
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX; Children's Health, Dallas, TX
| | - Timothy L McCavit
- Division of Hematology/Oncology, Cook Children's Hospital, Fort Worth, TX; Department of Pediatrics, Cook Children's Hospital, Fort Worth, TX
| | | | - George R Buchanan
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX; Children's Health, Dallas, TX; Division of Hematology/Oncology, The University of Texas Southwestern Medical Center, Dallas, TX
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Powers JM, Daniel CL, McCavit TL, Buchanan GR. Deficiencies in the Management of Iron Deficiency Anemia During Childhood. Pediatr Blood Cancer 2016; 63:743-5. [PMID: 26728130 PMCID: PMC4755821 DOI: 10.1002/pbc.25861] [Citation(s) in RCA: 20] [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: 08/24/2015] [Accepted: 11/10/2015] [Indexed: 11/06/2022]
Abstract
Limited high-quality evidence supports the management of iron deficiency anemia (IDA). To assess our institutional performance in this area, we retrospectively reviewed IDA treatment practices in 195 consecutive children referred to our center from 2006 to mid-2010. The majority of children were ≤4 years old (64%) and had nutritional IDA (74%). In 11- to 18-year-old patients (31%), the primary etiology was menorrhagia (42%). Many were referred directly to the emergency department and/or prescribed iron doses outside the recommended range. Poor medication adherence and being lost-to-follow-up were common. Substantial improvements are required in the management of IDA.
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Affiliation(s)
- Jacquelyn M. Powers
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX,Children’s Health, Dallas, TX
| | - Catherine L. Daniel
- Department of Internal Medicine, The University of Pennsylvania, Philadelphia, PA
| | - Timothy L. McCavit
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX,Children’s Health, Dallas, TX
| | - George R. Buchanan
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX,Children’s Health, Dallas, TX
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Powers JM, McCavit TL, Buchanan GR. Management of iron deficiency anemia: a survey of pediatric hematology/oncology specialists. Pediatr Blood Cancer 2015; 62:842-6. [PMID: 25663613 PMCID: PMC4376588 DOI: 10.1002/pbc.25433] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [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: 11/13/2014] [Accepted: 12/23/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Iron deficiency anemia (IDA) is the most common hematologic condition in children and adolescents in the United States (US). No prior reports have described the management of IDA by a large cohort of pediatric hematology/oncology specialists. PROCEDURE A 20-question electronic survey that solicited responses to two hypothetical cases of IDA was sent to active members of the American Society of Pediatric Hematology/Oncology (ASPHO) in the US. RESULTS Of 1,217 recipients, 398 (32.7%) reported regularly treating IDA and completed the survey. In a toddler with nutritional IDA, 15% (N = 61) of respondents reported ordering no diagnostic test beyond a complete blood count. Otherwise, wide variability in laboratory testing was reported. For treatment, most respondents would prescribe ferrous sulfate (N = 335, 84%) dosed at 6 mg/kg/day (N = 248, 62%) divided twice daily (N = 272, 68%). The recommended duration of iron treatment after resolution of anemia and normalized serum ferritin varied widely from 0 to 3 months. For an adolescent with heavy menstrual bleeding and IDA, most respondents recommended ferrous sulfate (N = 327, 83%), with dosing based on the number of tablets daily. For IDA refractory to oral treatment, intravenous iron therapy was recommended most frequently, 48% (N = 188) using iron sucrose, 17% (N = 68) ferric gluconate, and 15% (N = 60) low molecular weight iron dextran. CONCLUSION The approach to diagnosis and treatment of IDA in childhood was widely variable among responding ASPHO members. Given the lack of an evidence base to guide clinical decision making, further research investigating IDA management is needed.
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Affiliation(s)
- Jacquelyn M. Powers
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Timothy L. McCavit
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX,Children’s Medical Center, Dallas, TX
| | - George R. Buchanan
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX,Children’s Medical Center, Dallas, TX
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van der Voorn JP, Pouwels PJW, Powers JM, Kamphorst W, Martin JJ, Troost D, Spreeuwenberg MD, Barkhof F, van der Knaap MS. Correlating quantitative MR imaging with histopathology in X-linked adrenoleukodystrophy. AJNR Am J Neuroradiol 2011; 32:481-9. [PMID: 21273354 DOI: 10.3174/ajnr.a2327] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Quantitative MR imaging techniques may improve the pathologic specificity of MR imaging regarding white matter abnormalities. Our purposes were to determine whether ADC, FA, MTR, and MRS metabolites correlate with the degree of white matter damage in patients with X-ALD; whether differences in ADC, FA, and MTR observed in vivo are retained in fresh and formalin-fixed postmortem brain tissue; and whether the differences predict histopathology. MATERIALS AND METHODS MRS metabolites, MTR, ADC, and FA, were determined in 7 patients with X-ALD in 3 white matter areas (NAWM, active demyelination, and complete demyelination) and were compared with values obtained in 14 controls. MTR, ADC, and FA were assessed in postmortem brains from 15 patients with X-ALD and 5 controls. Values were correlated with the degree of astrogliosis and density of myelin, axons, and cells. Equations to estimate histopathology from MR imaging parameters were calculated by linear regression analysis. RESULTS MRS showed increased mIns, Lac, and Cho and decreased tNAA in living patients with X-ALD; the values depended on the degree of demyelination. MTR, ADC, and FA values were different in postmortem than in vivo white matter, but differences related to degrees of white matter damage were retained. ADC was high and FA and MTR were low in abnormal white matter. Correlations between histopathologic findings and MR imaging parameters were strong. A combination of ADC and FA predicted pathologic parameters best. CONCLUSIONS Changes in quantitative MR imaging parameters, present in living patients and related to the severity of white matter pathology, are retained in postmortem brain tissue. MR imaging parameters predict white matter histopathologic parameters.
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Affiliation(s)
- J P van der Voorn
- Department of Child Neurology, VU University Medical Center, Amsterdam, the Netherlands.
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Gourlay ML, Powers JM, Lui LY, Ensrud KE. Clinical performance of osteoporosis risk assessment tools in women aged 67 years and older. Osteoporos Int 2008; 19:1175-83. [PMID: 18219434 PMCID: PMC2562917 DOI: 10.1007/s00198-007-0555-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Accepted: 11/20/2007] [Indexed: 10/22/2022]
Abstract
UNLABELLED Clinical performance of osteoporosis risk assessment tools was studied in women aged 67 years and older. Weight was as accurate as two of the tools to detect low bone density. Discriminatory ability was slightly better for the OST risk tool, which is based only on age and weight. INTRODUCTION Screening performance of osteoporosis risk assessment tools has not been tested in a large, population-based US cohort. METHODS We conducted a diagnostic accuracy analysis of the Osteoporosis Self-assessment Tool (OST), Osteoporosis Risk Assessment Instrument (ORAI), Simple Calculated Osteoporosis Risk Estimation (SCORE), and individual risk factors (age, weight or prior fracture) to identify low central (hip and lumbar spine) bone mineral density (BMD) in 7779 US women aged 67 years and older participating in the Study of Osteoporotic Fractures. RESULTS The OST had the greatest area under the receiver operating characteristic curve (AUC 0.76, 95% CI 0.74, 0.77). Weight had an AUC of 0.73 (95% CI 0.72, 0.75), which was >or=AUC values for the ORAI, SCORE, age or prior fracture. Using cut points from the development papers, the risk tools had sensitivities >or=85% and specificities CONCLUSIONS Weight identified low central BMD as accurately as the ORAI and SCORE. The risk tools would be unlikely to show an advantage over simple weight cut points in an osteoporosis screening protocol for elderly women.
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Affiliation(s)
- M L Gourlay
- Department of Family Medicine, University of North Carolina, Chapel Hill, NC 27599-7595, USA.
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39
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Abstract
The study objective was to explore a new method for quantifying the color adjustment potential originating from physical translucency on a set of 7 resin composites, and then for testing the hypothesis that color adjustment potential is dependent on the composites and shades studied. Two-composite specimens (an outer base shade with an inner hole filled with inner test shades) and single-composite specimens of all shades were made. A 1-mm circular area, with its center in the middle of the specimen (P0mm), was measured by means of spectroradiometry. A newly developed equation for quantification of the color adjustment potential was tested. Color adjustment potential at P0mm ranged from -0.19 (negative color adjustment/contrast) to 0.61. Within the limitations of this study, a newly developed concept and equation have proved the existence of the physical component of color adjustment of translucent dental materials. Color adjustment potential was dependent on composite and shade.
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Affiliation(s)
- R D Paravina
- Deparment of Restoration, University of Texas Dental Branch at Houston, Houston, TX 77030-3402, USA.
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Abstract
Neurological dysfunction is a prominent feature of most peroxisomal disorders. Enormous progress in defining their gene defects has been achieved. The genes and gene products, peroxins (PEX), in five of the complementation groups have been defined. These studies confirm that Zellweger syndrome (ZS), neonatal adrenoleukodystrophy (NALD), and infantile Refsum disease (IRD) are a disease continuum. The gene defect in adreno-leukodystrophy (ALD) / adrenomyeloneuropathy (AMN) involves an integral peroxisomal membrane protein. Neuropathologic lesions are of three major classes: (i) abnormalities in neuronal migration or differentiation, (ii) defects in the formation or maintenance of central white matter, and (iii) postdevelopmental neuronal degenerations. The central white matter lesions are those of: (i) inflammatory demyelination, (ii) non-inflammatory dysmyelination, and (iii) non-specific reductions in myelin volume or staining with or without reactive astrocytosis. The neuronal degenerations are of two major types: (i) the axonopathy of AMN involving ascending and descending tracts of the spinal cord, and (ii) cerebellar atrophy in rhizomelic chondrodysplasia punctata and probably IRD. We postulate that the abnormal fatty acids in peroxisomal disorders, particularly very long chain fatty acids and phytanic acid, are incorporated into cell membranes and perturb their microenvironments resulting in dysfunction, atrophy and death of vulnerable cells. The advent of mouse models for ZS and ALD is anticipated to provide even greater pathogenetic insights into the peroxisomal disorders.
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Affiliation(s)
- J M Powers
- Department of Pathology (Neuropathology and Postmortem Medicine), University of Rochester Medical Center, NY 14642, USA.
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Affiliation(s)
- P Brown
- Laboratory of CNS Studies, National Institute of Neurological Disorders and Stroke, National Institute of Health, Bethesda, MD 20892, USA
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Abstract
This study investigated the efficacy of one experimental and three conventional techniques for denture repair. Forty maxillary dentures were constructed in dental stone casts duplicated from an edentulous copper-aluminium maxillary master cast. Two groups of 20 dentures each were prepared with Lucitone 199 (water-bath, 8 h/74 degrees C) or Acron MC (microwave, 3 min/500 W) denture base materials processed in gypsum moulds. The 40 dentures were all separated sagittally in the middle. After that, five dentures of each denture base material were repaired with one of the four following techniques: L (Lucitone 199, water-bath, 8 h/74 degrees C, gypsum mould), A (Acron MC, microwave, 3 min/500 W, gypsum mould), AR (Acron MC/R, autopolymerized, 60 psi/45 degrees C/15 min) and the experimental technique AS (Acron MC, 1 min/500 W + 1 min/0 W + 1 min/500 W, hard silicone mould). The parameters denture accuracy (DA), horizontal (HC) and vertical changes (VC) of the occlusal plane measured the efficacy of the repair techniques. The DA was determined by weighing a film of silicone impression material set in contact to the tissue surface of the denture seated on the metallic master die. For HC, cross-arch measurements were made among reference marks drilled on the teeth 11, 21, 16 and 26. The VC was obtained by calculating the relative differences in height between similar teeth of each semi-arch (pairs 13-23, 14-24, 15-25 e 16-26). For DA, HC and VC, the percentage differences between the percentage means obtained before and after repair were calculated and grouped for comparisons. Analysis of variance (SuperANOVA) and means compared by Tukey-Kramer intervals (0.05) revealed that AR repair had the best percentage difference value for DA [0.5% (P < 0.05)], while the others were not statistically different [L = 27.2%, A = 28.9%, AS = 21.2% (P > 0.05)]. For HC, there was a statistical difference (P < 0.05) between AR and the other techniques for the tooth pairs, 16-26, 11-26 and 21-16; repairs with AR and AS differed for the 11-21 pair, while those with A and AS techniques differed for the 16-26 pair (P < 0.05). The VC differences were not detected between repair methods (P > 0.05). Denture accuracy was not affected by the interaction of base material-repair technique; repair with AR technique gave the best adaptation; the interaction of base material-repair technique did not affect HC; HC was affected by the repair technique.
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Affiliation(s)
- R N Rached
- Department of Dental Materials, School of Dentistry, Pontifical Catholic University of Paraná (PUCPR), Curitiba, Brazil.
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Abstract
This study determined the influence of optical properties of constituent layers on the colour of double-layer aesthetic filling materials. Multiple regression equations for the Commission Internationale de I'Eclairage (CIE) L*, a* and b* of layered materials were calculated from the optical values of the covering and underlying layers. Specimens (10 mm diameter, 1 mm thickness) of two light-cured resin composites and one compomer of seven to 11 shades were used. CIE L*, a* and b* values of each specimen were measured with a colour spectrophotometer backed by a standard white background. The scattering coefficient (S), absorption coefficient (K), contrast ratio (C) and translucency parameter (T) were calculated. Double-layered specimens were formed in optical contact by joining two different shades from the same material, or resin composite as covering with a compomer underlying layer. Each of the L*, a* and b* of layered material was used as a dependent variable, and 14 optical values of underlying and covering layers were used as independent variables in forward regression analysis (P = 0.01). CIE L* after layering had a positive correlation with S of covering layer (correlation coefficient; beta = 0.79-0.91, P < 0.01) and a correlation with L* of underlying layer (beta = 0.14-0.16). CIE a* after layering had a correlation with a* of covering layer (beta = 0.83-0.94) and a correlation with a* of underlying layer (beta = 0.30-0.56). CIE b* after layering had a correlation with b* of covering layer (beta = 0.77-0.90) and a correlation with T of covering layer (beta = 0.40-0.59). The layered colour of these materials can be predicted by the derived regression equations within the limitations of this study. CIE L*, a* and b* values of double-layer material are mainly influenced by S, CIE a* and b* of covering layer, respectively.
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Affiliation(s)
- Y-K Lee
- Department of Dental Biomaterials Science, College of Dentistry, Seoul National University, Seoul, Korea.
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Abstract
Genetic background, pesticide exposure, age, gender, diet and lifestyle are implicated risk factors in Parkinson's disease. We demonstrate dopamine neuron loss and other features of Parkinsonism based on the interaction of several of these human risk factors in transgenic mice expressing human alpha-synuclein. Mice expressing different forms of human alpha-synuclein had progressive declines in locomotor activity and abnormal responses to apomorphine that were modified by transgenic status. Stereological counts of tyrosine hydroxylase-positive neurons significantly declined with age only in the transgenic lines, consistent with a constant or decreasing risk, with the line expressing a double-mutant form of human alpha-synuclein more severely affected than the line expressing wild-type human alpha-synuclein. Treatment with Mn2+-ethylenebisdithiocarbamate and paraquat resulted in significantly greater effects in the double-mutant line than the other lines. Inclusions were not identified in the transgenic lines. Overexpression of human alpha-synuclein had adverse effects on substantia nigra pars compacta dopaminergic neurons that were modified by risk factors interacting in humans, including human alpha-synuclein mutations, ageing, and exposure to pesticides.
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Affiliation(s)
- M J Thiruchelvam
- Department of Environmental Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA
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Powers JM, Byrne NP, Ito M, Takao M, Yankopoulou D, Spillantini MG, Ghetti B. A novel leukoencephalopathy associated with tau deposits primarily in white matter glia. Acta Neuropathol 2003; 106:181-7. [PMID: 12783250 DOI: 10.1007/s00401-003-0719-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [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: 01/10/2003] [Revised: 04/04/2003] [Accepted: 04/04/2003] [Indexed: 11/28/2022]
Abstract
A 79-year-old woman had a 10-year history of dementia, initially presenting as non-fluent aphasia. Magnetic resonance imaging showed frontal atrophy (left greater than right) and hyperintense foci within white matter. Neuropathologically, there was severe frontal atrophy due to cortical neuronal loss with spongy change and to an even greater loss of white matter that contained prominent eosinophilic deposits. The deposits were immunoreactive for phosphorylated tau, non-reactive for Abeta and alpha-synuclein and equivocally or weakly reactive for ubiquitin. They stained with the Gallyas, Bielschowsky, and Bodian techniques. Ultrastructural examination revealed the deposits to be composed of straight filaments with a diameter of approximately 10 nm, primarily in white matter glia. Moderate loss of neurons in substantia nigra and numerous argyrophilic threads in gray and particularly white matter were noted. The precise relationship between this disorder and other frontotemporal degenerations/tauopathies, as well as the pathogenetic basis of the leukoencephalopathy, remains to be determined.
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Affiliation(s)
- J M Powers
- Department of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, Box 626, 601 Elmwood Avenue, Rochester, NY 14642, USA.
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Brantley WA, Svec TA, Iijima M, Powers JM, Grentzer TH. Differential scanning calorimetric studies of nickel-titanium rotary endodontic instruments after simulated clinical use. J Endod 2002; 28:774-8. [PMID: 12470023 DOI: 10.1097/00004770-200211000-00007] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Differential scanning calorimetric (DSC) analyses have been performed between -130 degrees and 100 degrees C on single-segment specimens obtained from ProFile and Lightspeed nickel-titanium rotary endodontic instruments in the as-received condition and after one, three, and six periods of simulated clinical use in extracted teeth. The DSC analyses showed that both brands of instruments were always in the superelastic condition, although the enthalpy values for the transformation from martensitic NiTi to austenitic NiTi were much smaller for the Lightspeed instruments. Simulated clinical use had no evident effect upon this transformation for both brands, which is attributed to insufficient mechanical deformation of the instruments. There were substantial differences in the enthalpy change associated with the transformation from martensitic NiTi to austenitic NiTi for test segments from different positions along the shafts of the instruments and for as-received instruments from two different batches that were analyzed in this study and a previous study. These differences are attributed to variations in work hardening along the shaft during instrument fabrication and to processing differences during production of the two batches of each instrument brand.
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Affiliation(s)
- W A Brantley
- Section of Restorative Dentistry, Prosthodontics and Endodontics, College of Dentistry, The Ohio State University, Columbus, USA
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Abstract
The objectives of this paper were to evaluate the effects of colour measuring modes [specular component excluded (SCE) versus specular component included (SCI)] and the standard light source (C, A or D65) on the colour of shade guides. After the labial part of shade tabs of two shade guides (Vita and Chromascop) was polished flat up to no. 2400 silicone carbide paper, the colour was measured according to the International Commission on Illumination (CIE)L*a*b* colour scale on a spectrophotometer. In both shade guides, all the average CIE L* values of each shade series, and most of CIE b* values were different depending on the measuring mode (P < 0.01). However, there was no difference in CIE a* values depending on the measuring mode. Colour difference (deltaE*) between the values measured with SCE mode and with SCI mode was 3.21-6.50 in Vita shade guide, 3.22-5.47 in Chromascop shade guide. DeltaE* caused by the difference in light source was very small in Vita shade guide regardless of the measuring mode. In the Vita shade guide, the shade series (A-D) was negatively correlated with CIE L* and CIE a* values measured with SCE mode. In the Chromascop shade guide, the shade series (100-500) was negatively correlated with CIE L* value measured with SCI mode.
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Affiliation(s)
- Y-K Lee
- Department of Dental Biomaterials, College of Dentistry and Intellectual Biointerface Engineering Center, Seoul National University, Seoul, Korea.
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48
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Penney DP, Powers JM, Frank M, Willis C, Churukian C. Analysis and testing of biological stains--the Biological Stain Commission Procedures. Biotech Histochem 2002; 77:237-75. [PMID: 12564600 DOI: 10.1080/bih.77.5-6.237.275] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- D P Penney
- Biological Stain Commission, Department of Pathology, University of Rochester School of Medicine, Rochester, New York 14642, USA.
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49
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Byrne NP, Henry JC, Herrmann DN, Abdelhalim AN, Shrier DA, Francis CW, Powers JM. Neuropathologic findings in a Guillain-Barré patient with strokes after IVIg therapy. Neurology 2002; 59:458-61. [PMID: 12177388 DOI: 10.1212/wnl.59.3.458] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Strokes have been rarely associated with immunoglobulin G (IVIg) therapy. A 70-year-old woman with stable polycythemia vera developed Guillain-Barré syndrome and received IVIg, 8 days following which she became comatose due to bilaterally symmetric cerebral infarcts. Autopsy showed intravascular aggregates of fibrin-IgG but also platelets and a necrotizing microangiopathy in the infarcts.
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Affiliation(s)
- N P Byrne
- Department of Pathology and Laboratory Medicine (Neuropathology), School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA
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50
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Abstract
Differential scanning calorimetric (DSC) analyses were performed between -130 degrees and 100 degrees C on specimens prepared from nickel-titanium (NiTi) rotary endodontic instruments: ProFile (n = 5), Lightspeed (n = 4), and Quantec (n = 3). The ProFile and Lightspeed instruments were in the as-received condition, whereas the Quantec instruments were randomly selected from a dental clinic and had unknown history. The DSC plots showed that the ProFile and Lightspeed instruments analyzed had the superelastic NiTi property, with an austenite-finish (Af) temperature of approximately 25 degrees C. Differences in DSC plots for the ProFile instruments and the starting wire blanks (n = 2) were attributed to the manufacturing process. The phase transformation behavior when the specimens were heated and cooled between -130 degrees and 100 degrees C, the temperature ranges for the phase transformations, and the resulting enthalpy changes were similar to those previously reported for nickel-titanium orthodontic wires having superelastic characteristics or shape memory behavior in the oral environment. The experiments demonstrated that DSC is a powerful tool for materials characterization of these rotary instruments, providing direct information not readily available from other analytical techniques about the NiTi phases present, which are fundamentally responsible for their clinical behavior.
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Affiliation(s)
- W A Brantley
- Section of Restorative Dentistry, Prosthodontics and Endodontics, College of Dentistry, The Ohio State University, Columbus, USA
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