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Hood AM, Strong H, Nwankwo C, Johnson Y, Peugh J, Mara CA, Shook LM, Brinkman WB, Real FJ, Klein MD, Hackworth R, Badawy SM, Thompson AA, Raphael JL, Yates AM, Smith-Whitley K, King AA, Calhoun C, Creary SE, Piccone CM, Hildenbrand AK, Reader SK, Neumayr L, Meier ER, Sobota AE, Rana S, Britto M, Saving KL, Treadwell M, Quinn CT, Ware RE, Crosby LE. Engaging Caregivers and Providers of Children With Sickle Cell Anemia in Shared Decision Making for Hydroxyurea: Protocol for a Multicenter Randomized Controlled Trial. JMIR Res Protoc 2021; 10:e27650. [PMID: 34018965 PMCID: PMC8178738 DOI: 10.2196/27650] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 02/17/2021] [Accepted: 02/22/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Sickle cell anemia (SCA) is a genetic blood disorder that puts children at a risk of serious medical complications, early morbidity and mortality, and high health care utilization. Until recently, hydroxyurea was the only disease-modifying treatment for this life-threatening disease and has remained the only option for children younger than 5 years. Evidence-based guidelines recommend using a shared decision-making (SDM) approach for offering hydroxyurea to children with SCA (HbSS or HbS/β0 thalassemia) aged as early as 9 months. However, the uptake remains suboptimal, likely because caregivers lack information about hydroxyurea and have concerns about its safety and potential long-term side effects. Moreover, clinicians do not routinely receive training or tools, especially those that provide medical evidence and consider caregivers' preferences and values, to facilitate a shared discussion with caregivers. OBJECTIVE The aim of this study is to understand how best to help parents of young children with sickle cell disease and their clinicians have a shared discussion about hydroxyurea (one that considers medical evidence and parent values and preferences). METHODS We designed our study to compare the effectiveness of two methods for disseminating hydroxyurea guidelines to facilitate SDM: a clinician pocket guide (ie, usual care) and a clinician hydroxyurea SDM toolkit (H-SDM toolkit). Our primary outcomes are caregiver reports of decisional uncertainty and knowledge of hydroxyurea. The study also assesses the number of children (aged 0-5 years) who were offered and prescribed hydroxyurea and the resultant health outcomes. RESULTS The Ethics Committee of the Cincinnati Children's Hospital Medical Center approved this study in November 2017. As of February 2021, we have enrolled 120 caregiver participants. CONCLUSIONS The long-term objective of this study is to improve the quality of care for children with SCA. Using multicomponent dissemination methods developed in partnership with key stakeholders and designed to address barriers to high-quality care, caregivers of patients with SCA can make informed and shared decisions about their health. TRIAL REGISTRATION ClinicalTrials.gov NCT03442114; https://clinicaltrials.gov/ct2/show/NCT03442114. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/27650.
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Affiliation(s)
- Anna M Hood
- Developmental Neurosciences, Institute of Child Health, University College London, London, United Kingdom
| | - Heather Strong
- Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Cara Nwankwo
- Department of Psychology, Oklahoma State University, Stillwater, OK, United States
| | - Yolanda Johnson
- Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - James Peugh
- Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Constance A Mara
- Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Lisa M Shook
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - William B Brinkman
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Francis J Real
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Melissa D Klein
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Rogelle Hackworth
- Cincinnati Children's Hospital Medical Center Partner, Cincinnati, OH, United States
| | - Sherif M Badawy
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
- Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Alexis A Thompson
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
- Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Jean L Raphael
- Center for Child Health Policy and Advocacy, Baylor College of Medicine, Houston, TX, United States
| | - Amber M Yates
- Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
| | - Kim Smith-Whitley
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Perelman School of Medicine, Philadelphia, PA, United States
| | - Allison A King
- Program in Occupational Therapy and Pediatrics, Division of Hematology and Oncology, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, MO, United States
- Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Cecelia Calhoun
- Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Susan E Creary
- Center for Innovation in Pediatric Practice, Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, United States
| | - Connie M Piccone
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, United States
| | - Aimee K Hildenbrand
- Center for Healthcare Delivery Science, Nemours Children's Health System, Wilmington, DE, United States
- Division of Behavioral Health, Nemours/ Alfred I duPont Hospital for Children, Wilmington, DE, United States
| | - Steven K Reader
- Center for Healthcare Delivery Science, Nemours Children's Health System, Wilmington, DE, United States
- Division of Behavioral Health, Nemours/ Alfred I duPont Hospital for Children, Wilmington, DE, United States
| | - Lynne Neumayr
- Department of Hematology/Oncology, Children's Hospital Oakland, Oakland, CA, United States
- AbbVie, North Chicago, IL, United States
- University of California San Francisco, San Francisco, CA, United States
| | - Emily R Meier
- Pediatrics, Pediatric Hematology/Oncology, Indiana Hemophilia and Thrombosis Center, Indianapolis, IN, United States
| | - Amy E Sobota
- Pediatric Hematology and Oncology, Boston Medical Center, Boston, MA, United States
| | - Sohail Rana
- Pediatrics and Child Health, College of Medicine, Howard University, Washington, DC, United States
| | - Maria Britto
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Kay L Saving
- Department of Pediatrics, University of Illinois College of Medicine, Peoria, IL, United States
| | - Marsha Treadwell
- Department of Hematology/Oncology, University of California San Francisco Benioff Children's Hospital, Oakland, CA, United States
| | - Charles T Quinn
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Russell E Ware
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Lori E Crosby
- Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
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Klopstock T, Tricta F, Neumayr L, Karin I, Zorzi G, Fradette C, Kmieć T, Büchner B, Steele HE, Horvath R, Chinnery PF, Basu A, Küpper C, Neuhofer C, Kálmán B, Dušek P, Yapici Z, Wilson I, Zhao F, Zibordi F, Nardocci N, Aguilar C, Hayflick SJ, Spino M, Blamire AM, Hogarth P, Vichinsky E. Safety and efficacy of deferiprone for pantothenate kinase-associated neurodegeneration: a randomised, double-blind, controlled trial and an open-label extension study. Lancet Neurol 2019; 18:631-642. [PMID: 31202468 DOI: 10.1016/s1474-4422(19)30142-5] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [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: 12/13/2018] [Revised: 03/24/2019] [Accepted: 03/27/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Pantothenate kinase-associated neurodegeneration (PKAN) is a rare genetic disorder characterised by progressive generalised dystonia and brain iron accumulation. We assessed whether the iron chelator deferiprone can reduce brain iron and slow disease progression. METHODS We did an 18-month, randomised, double-blind, placebo-controlled trial (TIRCON2012V1), followed by a pre-planned 18-month, open-label extension study, in patients with PKAN in four hospitals in Germany, Italy, England, and the USA. Patients aged 4 years or older with a genetically confirmed diagnosis of PKAN, a total score of at least 3 points on the Barry-Albright Dystonia (BAD) scale, and no evidence of iron deficiency, neutropenia, or abnormal hepatic or renal function, were randomly allocated (2:1) to receive an oral solution of either deferiprone (30 mg/kg per day divided into two equal doses) or placebo for 18 months. Randomisation was done with a centralised computer random number generator and with stratification based on age group at onset of symptoms. Patients were allocated to groups by a randomisation team not masked for study intervention that was independent of the study. Patients, caregivers, and investigators were masked to treatment allocation. Co-primary endpoints were the change from baseline to month 18 in the total score on the BAD scale (which measures severity of dystonia in eight body regions) and the score at month 18 on the Patient Global Impression of Improvement (PGI-I) scale, which is a patient-reported interpretation of symptom improvement. Efficacy analyses were done on all patients who received at least one dose of the study drug and who provided a baseline and at least one post-baseline efficacy assessment. Safety analyses were done for all patients who received at least one dose of the study drug. Patients who completed the randomised trial were eligible to enrol in a single-arm, open-label extension study of another 18 months, in which all participants received deferiprone with the same regimen as the main study. The trial was registered on ClinicalTrials.gov, number NCT01741532, and EudraCT, number 2012-000845-11. FINDINGS Following a screening of 100 prospective patients, 88 were randomly assigned to the deferiprone group (n=58) or placebo group (n=30) between Dec 13, 2012, and April 21, 2015. Of these, 76 patients completed the study (49 in the deferiprone group and 27 in the placebo group). After 18 months, the BAD score worsened by a mean of 2·48 points (SE 0·63) in patients in the deferiprone group versus 3·99 points (0·82) for patients in the control group (difference -1·51 points, 95% CI -3·19 to 0·16, p=0·076). No subjective change was detected as assessed by the PGI-I scale: mean scores at month 18 were 4·6 points (SE 0·3) for patients in the deferiprone group versus 4·7 points (0·4) for those in the placebo group (p=0·728). In the extension study, patients continuing deferiprone retained a similar rate of disease progression as assessed by the BAD scale (1·9 points [0·5] in the first 18 months vs 1·4 points [0·4] in the second 18 months, p=0·268), whereas progression in patients switching from placebo to deferiprone seemed to slow (4·4 points [1·1] vs 1·4 points [0·9], p=0·021). Patients did not detect a change in their condition after the additional 18 months of treatment as assessed by the PGI-I scale, with mean scores of 4·1 points [0·2] in the deferiprone-deferiprone group and of 4·7 points [0·3] in the placebo-deferiprone group. Deferiprone was well tolerated and adverse events were similar between the treatment groups, except for anaemia, which was seen in 12 (21%) of 58 patients in the deferiprone group, but was not seen in any patients in the placebo group. No patient discontinued therapy because of anaemia, and three discontinued because of moderate neutropenia. There was one death in each group of the extension study and both were secondary to aspiration. Neither of these events was considered related to deferiprone use. INTERPRETATION Deferiprone was well tolerated, achieved target engagement (lowering of iron in the basal ganglia), and seemed to somewhat slow disease progression at 18 months, although not significantly, as assessed by the BAD scale. These findings were corroborated by the results of an additional 18 months of treatment in the extension study. The subjective PGI-I scale was largely unchanged during both study periods, indicating that might not be an adequate tool for assessment of disease progression in patients with PKAN. Our trial provides the first indication of a decrease in disease progression in patients with neurodegeneration with brain iron accumulation. The extensive information collected and long follow-up of patients in the trial will improve the definition of appropriate endpoints, increase the understanding of the natural history, and thus help to shape the design of future trials in this ultra-orphan disease. FUNDING European Commission, US Food and Drug Administration, and ApoPharma Inc.
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Affiliation(s)
- Thomas Klopstock
- Department of Neurology, Friedrich-Baur-Institute, Ludwig-Maximilians-University of Munich, Munich, Germany; German Center for Neurodegenerative Diseases, Munich, Germany; Munich Cluster for Systems Neurology, Munich, Germany.
| | | | - Lynne Neumayr
- Department of Hematology Oncology, UCSF Benioff Children's Hospital and Research Center Oakland, Oakland, CA, USA
| | - Ivan Karin
- Department of Neurology, Friedrich-Baur-Institute, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Giovanna Zorzi
- Department of Pediatric Neuroscience, Neurological Institute Carlo Besta, Milan, Italy
| | | | - Tomasz Kmieć
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
| | - Boriana Büchner
- Department of Neurology, Friedrich-Baur-Institute, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Hannah E Steele
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Rita Horvath
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK; Department of Clinical Neurosciences, Cambridge University, Cambridge, UK
| | - Patrick F Chinnery
- Department of Clinical Neurosciences, Cambridge University, Cambridge, UK
| | - Anna Basu
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Clemens Küpper
- Department of Neurology, Friedrich-Baur-Institute, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Christiane Neuhofer
- Department of Neurology, Friedrich-Baur-Institute, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Bernadette Kálmán
- Institute of Laboratory Medicine, Szentagothai Research Center, University of Pécs, Pécs, Hungary
| | - Petr Dušek
- Charles University, Prague, Czech Republic
| | - Zuhal Yapici
- Department of Child Neurology, Istanbul Faculty of Medicine, Turkey
| | - Ian Wilson
- Institute of Cellular Medicine and Newcastle Magnetic Resonance Centre, Newcastle University, Newcastle upon Tyne, UK
| | | | - Federica Zibordi
- Department of Pediatric Neuroscience, Neurological Institute Carlo Besta, Milan, Italy
| | - Nardo Nardocci
- Department of Pediatric Neuroscience, Neurological Institute Carlo Besta, Milan, Italy
| | - Christine Aguilar
- Pediatric Rehabilitation Department, UCSF Benioff Children's Hospital and Research Center Oakland, Oakland, CA, USA
| | - Susan J Hayflick
- Department of Molecular & Medical Genetics, Oregon Health and Science University, Portland, OR, USA
| | | | - Andrew M Blamire
- Institute of Cellular Medicine and Newcastle Magnetic Resonance Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Penelope Hogarth
- Department of Molecular & Medical Genetics, Oregon Health and Science University, Portland, OR, USA
| | - Elliott Vichinsky
- Department of Hematology Oncology, UCSF Benioff Children's Hospital and Research Center Oakland, Oakland, CA, USA
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3
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Abstract
Screening and early detection of organ injury, as well as expanded use of red cell transfusion and hydroxyurea in children have changed best practices for clinical care in sickle cell disease. The current standard of care for children with sickle cell disease is discussed through a review of screening recommendations, disease monitoring, and approach to treatment. Novel pharmacologic agents under investigation in clinical trials are also reviewed.
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Affiliation(s)
- Carolyn Hoppe
- Department of Pediatrics, Division of Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, 747 52nd Street, Oakland, CA 94609, USA.
| | - Lynne Neumayr
- Department of Pediatrics, Division of Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, 747 52nd Street, Oakland, CA 94609, USA
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4
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Neumayr L, Vichinsky E. Stroke recurrence in adult sickle cell patients: it is time for action! Transfusion 2018; 56:1001-4. [PMID: 27167352 DOI: 10.1111/trf.13614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 03/15/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Lynne Neumayr
- UCSF Benioff Children's Hospital Oakland, Oakland, CA
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Winstead M, Sun PP, Martin K, Earl J, Neumayr L, Hoppe C, Vichinsky E. Encephaloduroarteriosynangiosis (EDAS) in young patients with cerebrovascular complications of sickle cell disease: Single-institution experience. Pediatr Hematol Oncol 2017; 34:100-106. [PMID: 28532265 DOI: 10.1080/08880018.2017.1313917] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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] [Indexed: 10/19/2022]
Abstract
Moyamoya syndrome occurs in sickle cell disease (SCD) as a secondary complication of large-artery stenosis. Moyamoya increases the risk of stroke, but its optimal management in SCD is not established. Encephaloduroarteriosynangiosis (EDAS) is a neurosurgical revascularization procedure for moyamoya whose use has been reported in SCD patients. We report the outcomes of 11 patients with SCD systematically evaluated for EDAS by a multidisciplinary team and compare the rate of stroke in patients who received EDAS to those who did not. Moyamoya syndrome was diagnosed by flow abnormalities on magnetic resonance angiography at median age of 8.2 years. Four patients deferred surgery. Seven patients underwent EDAS at median age of 19 years. There were no intraoperative complications, perioperative strokes, or deaths. Transient postoperative complications occurred in six cases (86%). On follow-up, three patients (43%) had no evidence of flow in their EDAS grafts, and one later developed a hemorrhagic stroke. Five EDAS patients (71%) had radiographically stable vasculopathy. Compared to the four patients who deferred surgery, the incidence of stroke in EDAS group was no different. The optimal use of EDAS in patients with SCD-associated moyamoya syndrome requires further investigation by a prospective, controlled clinical trial.
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Affiliation(s)
- Michael Winstead
- a Department of Hematology-Oncology , Children's Hospital and Research Center Oakland , Oakland , California , USA.,b Blood and Marrow Transplantation and Cellular Therapies Division , Children's Hospital of Pittsburgh of UPMC , Pittsburgh , Pennsylvania , USA
| | - Peter P Sun
- c Department of Neurosurgery , Children's Hospital and Research Center Oakland , Oakland , California , USA
| | - Kenneth Martin
- d Department of Radiology , Children's Hospital and Research Center Oakland , Oakland , California , USA
| | - Janice Earl
- a Department of Hematology-Oncology , Children's Hospital and Research Center Oakland , Oakland , California , USA
| | - Lynne Neumayr
- a Department of Hematology-Oncology , Children's Hospital and Research Center Oakland , Oakland , California , USA
| | - Carolyn Hoppe
- a Department of Hematology-Oncology , Children's Hospital and Research Center Oakland , Oakland , California , USA
| | - Elliott Vichinsky
- a Department of Hematology-Oncology , Children's Hospital and Research Center Oakland , Oakland , California , USA
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Dowling MM, Quinn CT, Ramaciotti C, Kanter J, Osunkwo I, Inusa B, Iyer R, Kwiatkowski JL, Johnson C, Rhodes M, Owen W, Strouse JJ, Panepinto JA, Neumayr L, Sarnaik S, Plumb PA, Dlamini N, Kirkham F, Hynan LS. Increased prevalence of potential right-to-left shunting in children with sickle cell anaemia and stroke. Br J Haematol 2016; 176:300-308. [PMID: 27766637 DOI: 10.1111/bjh.14391] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 08/03/2016] [Indexed: 01/28/2023]
Abstract
'Paradoxical' embolization via intracardiac or intrapulmonary right-to-left shunts (RLS) is an established cause of stroke. Hypercoagulable states and increased right heart pressure, which both occur in sickle cell anaemia (SCA), predispose to paradoxical embolization. We hypothesized that children with SCA and overt stroke (SCA + stroke) have an increased prevalence of potential RLS. We performed contrasted transthoracic echocardiograms on 147 children (aged 2-19 years) with SCA + stroke) mean age 12·7 ± 4·8 years, 54·4% male) and a control group without SCA or stroke (n = 123; mean age 12·1 ± 4·9 years, 53·3% male). RLS was defined as any potential RLS detected by any method, including intrapulmonary shunting. Echocardiograms were masked and adjudicated centrally. The prevalence of potential RLS was significantly higher in the SCA+stroke group than controls (45·6% vs. 23·6%, P < 0·001). The odds ratio for potential RLS in the SCA + stroke group was 2·7 (95% confidence interval: 1·6-4·6) vs controls. In post hoc analyses, the SCA + stroke group had a higher prevalence of intrapulmonary (23·8% vs. 5·7%, P < 0·001) but not intracardiac shunting (21·8% vs. 18·7%, P = 0·533). SCA patients with potential RLS were more likely to report headache at stroke onset than those without. Intrapulmonary and intracardiac shunting may be an overlooked, independent and potentially modifiable risk factor for stroke in SCA.
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Affiliation(s)
- Michael M Dowling
- Departments of Pediatrics and Neurology & Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Charles T Quinn
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Claudio Ramaciotti
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Julie Kanter
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Ifeyinwa Osunkwo
- The Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA
| | - Baba Inusa
- Haematology, Evelina Children's Hospital, Guy's and St. Thomas NHS Trust, London, UK
| | - Rathi Iyer
- University of Mississippi Medical Center, Jackson, MS, USA
| | - Janet L Kwiatkowski
- Division of Hematology, Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Melissa Rhodes
- Pediatric Hematology/Oncology, University of Mississippi Medical Center, Jackson, MS, USA
| | - William Owen
- Children's Cancer and Blood Disorders Center, Children's Hospital of the King's Daughters, Norfolk, VA, USA
| | - John J Strouse
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Julie A Panepinto
- Department of Pediatrics, Hematology/Oncology, Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Lynne Neumayr
- Department of Hematology Oncology, UCSF Benioff Children's Hospital, Oakland, CA, USA
| | - Sharada Sarnaik
- Department of Pediatrics, Division of Hematology & Oncology, Wayne State University, Detroit, MI, USA
| | - Patricia A Plumb
- Department of Neurology & Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Nomazulu Dlamini
- Department of Paediatric Neurology, Evelina Children's Hospital, London, UK
| | - Fenella Kirkham
- Developmental Neurosciences, UCL Institute of Child Health, London, UK
| | - Linda S Hynan
- Departments of Clinical Science (Biostatistics) and Psychiatry, UT Southwestern Medical Center, Dallas, TX, USA
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Kelly S, Quirolo K, Marsh A, Neumayr L, Garcia A, Custer B. Erythrocytapheresis for chronic transfusion therapy in sickle cell disease: survey of current practices and review of the literature. Transfusion 2016; 56:2877-2888. [DOI: 10.1111/trf.13800] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 05/04/2016] [Accepted: 06/13/2016] [Indexed: 12/26/2022]
Affiliation(s)
- Shannon Kelly
- Blood Systems Research Institute; San Francisco California
- University of California San Francisco Benioff Children's Hospital Oakland; Oakland California
| | - Keith Quirolo
- University of California San Francisco Benioff Children's Hospital Oakland; Oakland California
| | - Anne Marsh
- University of California San Francisco Benioff Children's Hospital Oakland; Oakland California
| | - Lynne Neumayr
- University of California San Francisco Benioff Children's Hospital Oakland; Oakland California
| | - Alicia Garcia
- University of California San Francisco Benioff Children's Hospital Oakland; Oakland California
| | - Brian Custer
- Blood Systems Research Institute; San Francisco California
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Paulukonis S, Vichinsky E, Neumayr L, Treadwell M, Coates T, Feuchtbaum L, Hulihan M. 278 Emergency Department Utilization by Californians With Sickle Cell Disease, 2005-2014. Ann Emerg Med 2016. [DOI: 10.1016/j.annemergmed.2016.08.293] [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: 10/20/2022]
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Dowling MM, Ramaciotti C, Kanter J, Osunkwo I, Inusa B, Iyer R, Kwiatkowski J, Johnson C, Rhodes MM, Owen W, Strouse JJ, Quinn C, Panepinto JA, Neumayr L, Sarnaik S, Hynan LS, Plumb P, Kirkham F. Abstract T P369: Increased Prevalence of Potential Right-to-Left Shunting in Children with Sickle Cell Anemia and Stroke. Stroke 2015. [DOI: 10.1161/str.46.suppl_1.tp369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Children with sickle cell anemia (SCA; HbSS and HgbSβ
0
thalassemia) suffer stroke at a rate 220x higher than other children, but are typically less extensively investigated for modifiable risk factors. In patients without SCA, “paradoxical embolization” via intracardiac or intrapulmonary "right-to-left" shunting is a recognized stroke risk factor. Hypercoagulable states and increased right heart pressures predispose to paradoxical embolization and both occur in SCA. We hypothesized that children with SCA and overt stroke have an increased prevalence of potential right-to-left shunting compared to controls.
We performed contrasted transthoracic echocardiograms (conventional 2D, color Doppler, and 4 contrast injections with agitated saline, including 2 during Valsalva) on children (ages 2-19y) with SCA and history of overt stroke, and a control group of children with neither SCA nor stroke, at 14 institutions in the US and UK. Potential right-to-left shunting was defined as any potential shunt detected by any method, including “late bubbles” (contrast appearing in the left heart >5 cardiac cycles following injection). Echocardiograms were reviewed locally and centrally, with adjudication of conflicts.
We enrolled 153 children with SCA and stroke and 129 controls. There were no significant differences in age or gender between the groups. The prevalence of potential right-to-left shunting was significantly higher in the SCA and stroke group (43.1% vs. 20.0% in controls (p<0.001). There was no significant difference in intracardiac shunting (22.9% vs. 16.2%, p=0.157) but there was a higher proportion with intrapulmonary shunting (“late bubbles” only) in the SCA and stroke group (27.5% vs. 5.5% in controls, p<0.001).
Our findings suggest that intracardiac and intrapulmonary shunting could be an independent, potentially modifiable risk factor for stroke or stroke recurrence in children with SCA. Additional therapeutic interventions in patients at risk of stroke or stroke recurrence via paradoxical embolization, including antiplatelet agents or shunt closure, should be evaluated in children with SCA.
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Affiliation(s)
| | | | | | | | - Baba Inusa
- Guys and St Thomas, London, United Kingdom
| | | | | | | | | | - William Owen
- Childrens Hosp of the Kings Daughters, Norfolk, VA
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Paulukonis ST, Harris WT, Coates TD, Neumayr L, Treadwell M, Vichinsky E, Feuchtbaum LB. Population based surveillance in sickle cell disease: methods, findings and implications from the California registry and surveillance system in hemoglobinopathies project (RuSH). Pediatr Blood Cancer 2014; 61:2271-6. [PMID: 25176145 DOI: 10.1002/pbc.25208] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [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: 03/20/2014] [Accepted: 07/10/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND There are no population-based surveillance systems to determine prevalence, impact or outcomes in sickle cell disease (SCD). Estimates of the SCD population in California range broadly from 4,500 to 7,000, and little is known about their health status, health care utilization or health outcomes. A surveillance strategy was implemented using diverse data sources to develop a multi-dimensional, state-based surveillance system for SCD that includes adults and children and describes utilization, treatment and outcomes. PROCEDURE Data from California newborn screening, inpatient and emergency room records, Medi-Cal/Medicaid claims and two SCD special care centers were collected for 2004-2008. A multi-step, iterative linkage process was used to link and de-duplicate these data sources, and case definitions were used to categorize cases. RESULTS After linking and de-duplicating, there were 1,975 confirmed cases of SCD, 3,159 probable cases as well as 8,024 possible cases. Among individual data sources, newborn screening and data from clinics contributed the greatest number of unique cases to the total. Select analyses of utilization and treatments for the population are described. CONCLUSIONS Using linked existing data sources, an estimate of the statewide count of the SCD population is possible. The approach can be used to create an in-depth health status profile of the affected population by aggregating utilization, treatment, and outcomes data including mortality and morbidity information. This effort sets the stage for development of an on-going, state-based surveillance system.
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11
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Vichinsky E, Neumayr L, Trimble S, Giardina PJ, Cohen AR, Coates T, Boudreaux J, Neufeld EJ, Kenney K, Grant A, Thompson AA. Transfusion complications in thalassemia patients: a report from the Centers for Disease Control and Prevention (CME). Transfusion 2013; 54:972-81; quiz 971. [PMID: 23889533 DOI: 10.1111/trf.12348] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 05/06/2013] [Accepted: 06/01/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND Transfusions are the primary therapy for thalassemia but have significant cumulative risks. In 2004, the Centers for Disease Control and Prevention (CDC) established a national blood safety monitoring program for thalassemia. This report summarizes the population and their previous nonimmune and immune transfusion complications. STUDY DESIGN AND METHODS The CDC Thalassemia Blood Safety Network is a consortium of centers longitudinally following patients. Enrollment occurred from 2004 through 2012. Demographics, transfusion history, infectious exposures, and transfusion and nontransfusion complications were summarized. Logistic regression analyses of factors associated with allo- and autoimmunization were employed. RESULTS The race/ethnicity of these 407 thalassemia patients was predominantly Asian or Caucasian. The mean ± SD age was 22.3 ± 13.2 years and patients had received a mean ± SD total number of 149 ± 103.4 units of red blood cells (RBCs). Multiorgan dysfunction was common despite chelation. Twenty-four percent of transfused patients had previous exposure to possible transfusion-associated pathogens including one case of babesia. As 27% were immigrants, the infection source cannot be unequivocally linked to transfusion. Transfusion reactions occurred in 48%, including allergic, febrile, and hemolytic; 19% were alloimmunized. Common antigens were E, Kell, and C. Years of transfusion was the strongest predictor of alloimmunization. Autoantibodies occurred in 6.5% and were associated with alloimmunization (p < 0.0001). Local institutional policies, not patient characteristics, were major determinants of blood preparation and transfusion practices. CONCLUSION Hemosiderosis, transfusion reactions, and infections continue to be major problems in thalassemia. New pathogens were noted. National guidelines for RBC phenotyping and preparation are needed to decrease transfusion-related morbidity.
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Affiliation(s)
- Elliott Vichinsky
- Children's Hospital Oakland, Oakland, California; Centers for Disease Control and Prevention, Atlanta, Georgia; Weill Medical College of Cornell University, New York, New York; Children's Hospital Philadelphia, Philadelphia, Pennsylvania; Children's Hospital Los Angeles, Los Angeles, California; Children's Healthcare of Atlanta at Scottish Rite, Atlanta, Georgia; Boston Children's Hospital, Boston, Massachusetts; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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12
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Morris CR, Kuypers FA, Lavrisha L, Ansari M, Sweeters N, Stewart M, Gildengorin G, Neumayr L, Vichinsky EP. A randomized, placebo-controlled trial of arginine therapy for the treatment of children with sickle cell disease hospitalized with vaso-occlusive pain episodes. Haematologica 2013; 98:1375-82. [PMID: 23645695 DOI: 10.3324/haematol.2013.086637] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Painful episodes of vaso-occlusion are the leading cause of hospitalizations and emergency department visits in sickle cell disease, and are associated with increased mortality. Low nitric oxide bioavailability contributes to vasculopathy in sickle cell disease. Since arginine is the obligate substrate for nitric oxide production, and an acute deficiency is associated with pain, we hypothesized that arginine may be a beneficial treatment for pain related to sickle cell disease. Thirty-eight children with sickle cell disease hospitalized for 56 episodes of pain were randomized into this double-blinded placebo-controlled trial. Patients received L-arginine (100 mg/kg tid) or placebo for 5 days or until discharge. A significant reduction in total parenteral opioid use by 54% (1.9 ± 2.0 mg/kg versus 4.1 ± 4.1 mg/kg, P=0.02) and lower pain scores at discharge (1.9 ± 2.4 versus 3.9 ± 2.9, P=0.01) were observed in the treatment arm compared to the placebo one. There was no significant difference in hospital length of stay (4.1 ± 01.8 versus 4.8 ± 2.5 days, P=0.34), although a trend favored the arginine arm, and total opioid use was strongly correlated with the duration of the admission (r=0.86, P<0.0001). No drug-related adverse events were observed. Arginine therapy represents a novel intervention for painful vaso-occlusive episodes. A reduction of narcotic use by >50% is remarkable. Arginine is a safe and inexpensive intervention with narcotic-sparing effects that may be a beneficial adjunct to standard therapy for sickle cell-related pain in children. A large multi-center trial is warranted in order to confirm these observations.
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Affiliation(s)
- Claudia R Morris
- Department of Pediatrics, Division of Emergency Medicine, Emory-Children's Center for Developmental Lung Biology, Emory University School of Medicine, Atlanta, GA, USA.
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13
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Lal A, Porter J, Sweeters N, Ng V, Evans P, Neumayr L, Kurio G, Harmatz P, Vichinsky E. Combined chelation therapy with deferasirox and deferoxamine in thalassemia. Blood Cells Mol Dis 2012; 50:99-104. [PMID: 23151373 DOI: 10.1016/j.bcmd.2012.10.006] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 10/14/2012] [Accepted: 10/16/2012] [Indexed: 01/19/2023]
Abstract
Iron overload is the primary cause of mortality and morbidity in thalassemia major despite advances in chelation therapy. We performed a pilot clinical trial to evaluate the safety and efficacy of combined therapy with deferasirox (DFX, 20-30 mg/kg daily) and deferoxamine (DFO, 35-50mg/kg on 3-7 days/week) in 22 patients with persistent iron overload or organ damage. In the 18 subjects completing 12 months of therapy, median liver iron concentration decreased by 31% from 17.4 mg/g (range 3.9-38.2mg/g) to 12.0mg/g (range 0.96-26.7 mg/g, p<0.001). Median ferritin decreased by 24% from 2465 ng/mL (range 1110-10,700 ng/mL) to 1875 ng/mL (range 421-5800 ng/mL, p=0.002). All 6 subjects with elevated myocardial iron showed improvement in MRI T2* (p=0.031). The mean±S.E. plasma non-transferrin-bound iron (NTBI) declined from 3.10±0.25μM to 2.15±0.29μM (p=0.028). The administration of DFX during infusion of DFO further lowered NTBI (-0.28±0.08 μM, p=0.004) and labile plasma iron (LPI, -0.03±0.01 μM, p=0.006). The simultaneous administration of DFO and DFX rapidly reduced systemic and myocardial iron, and provided an excellent control of the toxic labile plasma iron species without an increase in toxicity.
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Affiliation(s)
- Ashutosh Lal
- Hematology/Oncology, Children's Hospital & Research Center, Oakland, CA 94609, USA.
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14
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Kutlar A, Ataga K, Reid M, Vichinsky EP, Neumayr L, Blair-Britt L, Labotka R, Glass J, Keefer JR, Wargin WA, Berenson R, Perrine SP. A phase 1/2 trial of HQK-1001, an oral fetal globin inducer, in sickle cell disease. Am J Hematol 2012; 87:1017-21. [PMID: 22887019 DOI: 10.1002/ajh.23306] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [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: 05/22/2012] [Revised: 06/21/2012] [Accepted: 06/25/2012] [Indexed: 12/18/2022]
Abstract
Therapeutics which reduce the pathology in sickle cell syndromes are needed, particularly noncytotoxic therapeutics. Fetal hemoglobin (HbF, α(2) γ(2) ) is established as a major regulator of disease severity; increased HbF levels correlate with milder clinical courses and improved survival. Accordingly, sodium dimethylbutyrate (HQK-1001), an orally-bioavailable, promoter-targeted fetal globin gene-inducing agent, was evaluated in a randomized, blinded, dose-ranging Phase I/II trial in 24 adult patients with HbSS or S/β thalassemia, to determine safety and tolerability of three escalating dose levels. The study therapeutic was administered once daily for two 6-week cycles, with a two-week interim dose holiday. Twenty-one patients completed the study. Five patients received study drug at 10 or 20 mg/kg doses, seven patients received study drug at 30 mg/kg/dose, and 4 patients received placebo. HQK-1001 was well-tolerated with no unexpected drug-related adverse events; a dose-limiting toxicity was not identified. Plasma drug levels were sustained above targeted levels for 24 hr. Increases in HbF above baseline were observed particularly with 30 mg/kg/day doses; in five of seven treated patients, a mean absolute increase in HbF of 0.2 g/dl and a mean increase in total hemoglobin (Hgb) of 0.83 g/dl above baseline were observed, whereas no increases occurred in placebo-treated controls. These findings of favorable PK profiles, tolerability, early rises in HbF, and total Hgb indicate that trials of longer duration appear warranted to more definitively evaluate the therapeutic potential of HQK-1001 in sickle cell disease.
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Affiliation(s)
- Abdullah Kutlar
- Department of Medicine, Sickle Cell Center, Medical College of Georgia, Augusta, GA, USA
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15
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Kanathezhath B, Mizokami M, Stanislaus S, Hounshell C, Neumayr L, Guo H, Hearst JE, Walters MC, Kuypers FA. Improved engraftment with minimal graft-versus-host disease after major histocompatibility complex-mismatched cord blood transplantation with photochemically treated donor lymphocytes. Exp Biol Med (Maywood) 2011; 236:492-504. [PMID: 21454375 DOI: 10.1258/ebm.2011.010216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
There is a significant risk of severe graft-versus-host disease (GVHD) and graft failure after unrelated umbilical cord blood transplantation (CBT) if donor-recipient pairs are mismatched at major histocompatibility complex (MHC) loci. To mitigate these risks after MHC-mismatched CBT, we infused psoralen-treated, photochemically inactivated, mature donor T-lymphocytes with MHC (H2-haplotype) mismatched murine donor fetal near-term peripheral blood (FNPB) cells after sublethal irradiation. We analyzed the rates of donor engraftment, GVHD and long-term survival in H2 haplotype disparate (C57BL/6 [H-2(b)/Thy1.1] → AKR [H-2(k)/Thy1.2]) recipient mice. We observed inconsistent donor engraftment after transplantation with cord blood alone, but superior engraftment and long-term survival after FNPB transplantation supplemented with psoralen-treated donor T-lymphocytes. Additionally, there was fatal GVHD after FNPB co-infusion with untreated donor T-lymphocytes, but minimal GVHD after FNPB supplemented with psoralen-treated donor T-lymphocytes transplantation. Donor MHC(high)/c-Kit(+)/lineage(-)/CD34(-) stem cells were noted in the recipient bone marrow compartment following co-infusion of photochemically inactivated T-cells with FNPB. Despite the non-myeloablative preparation before FNPB infusion, complete hematological recovery was delayed until 50-60 d after transplantation. We observed that co-transplantation of psoralen-treated donor T-lymphocytes with FNPB facilitated durable engraftment of donor hematopoietic stem cells in the marrow and splenic compartments with complete but delayed recovery of all hematopoietic lineages. This CBT model establishes the possibility of ensuring donor engraftment across a MHC barrier without severe GVHD.
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Affiliation(s)
- Bindu Kanathezhath
- Department of Pediatric Hematology/Oncology, Children's Hospital & Research Center Oakland, CA 94609, USA.
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16
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Wang W, Brugnara C, Snyder C, Wynn L, Rogers Z, Kalinyak K, Brown C, Qureshi A, Bigelow C, Neumayr L, Smith-Whitley K, Chui DHK, Delahunty M, Woolson R, Steinberg M, Telen M, Kesler K. The effects of hydroxycarbamide and magnesium on haemoglobin SC disease: results of the multi-centre CHAMPS trial. Br J Haematol 2011; 152:771-6. [PMID: 21275961 DOI: 10.1111/j.1365-2141.2010.08523.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
In a phase-II multi-centre double-blinded trial, we evaluated haematological effects of oral hydroxycarbamide (HC) and magnesium (Mg) in patients with HbSC, aged 5-53 years old. Subjects were randomized to HC + placebo, Mg + placebo, HC + Mg, or placebo + placebo. The primary endpoint was the proportion of hyperdense red blood cells after 8 weeks. Thirty-six subjects were evaluable, but the study was terminated early because of slow enrollment. In the combined HC groups, mean cell volume and HbF were increased, but differences were not seen in hyperdense red cells or vaso-occlusive events. Mg had no effects. Further investigation of hydroxycarbamide as monotherapy in HbSC disease is warranted.
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Affiliation(s)
- Winfred Wang
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
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17
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Neumayr L, Pringle S, Giles S, Quirolo KC, Paulukonis S, Vichinsky EP, Treadwell MJ. Chart Card: feasibility of a tool for improving emergency department care in sickle cell disease. J Natl Med Assoc 2011; 102:1017-23. [PMID: 21141289 DOI: 10.1016/s0027-9684(15)30728-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with sickle cell disease (SCD) are concerned with emergency department care, including time to treatment and staff attitudes and knowledge. Providers are concerned about rapid access to patient information and SCD treatment protocols. A software application that stores and retrieves encrypted personal medical information on a plastic credit card-sized Chart Card was designed. OBJECTIVE To determine the applicability and feasibility of the Chart Card on patient satisfaction with emergency department care and provider accessibility to patient information and care protocols. METHODS One-half of 44 adults (aged -18 years) and 50 children with SCD were randomized to either the Chart Card or usual care. Patient satisfaction was surveyed pre and post implementation of the Chart Card program, and emergency department staff was surveyed about familiarity with SCD treatment protocols. CONCLUSION Patient satisfaction with emergency department care and efficacy in health care increased post Chart Card implementation. Providers valued immediate access to patient information and SCD treatment guidelines. The technology has potential for application in the treatment of other illnesses in other settings.
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Affiliation(s)
- Lynne Neumayr
- Children's Hospital and Research Center Oakland, 747 52nd St, Oakland, CA 94609, USA
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18
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Kanathezhath B, Neumayr L, Guo H, Walters M, Kuypers F. Augmentation Of Hematopoietic Engraftment Without Graft Versus Host Disease By “Add-Back” Of Photochemically Treated T Lymphocytes In Mismatched Cord Blood Transplantation. Biol Blood Marrow Transplant 2010. [DOI: 10.1016/j.bbmt.2009.12.029] [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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19
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Fung EB, Harmatz PR, Milet M, Coates TD, Thompson AA, Ranalli M, Mignaca R, Scher C, Giardina P, Robertson S, Neumayr L, Vichinsky EP. Fracture prevalence and relationship to endocrinopathy in iron overloaded patients with sickle cell disease and thalassemia. Bone 2008; 43:162-168. [PMID: 18430624 PMCID: PMC2500183 DOI: 10.1016/j.bone.2008.03.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [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: 12/08/2007] [Revised: 03/01/2008] [Accepted: 03/04/2008] [Indexed: 01/19/2023]
Abstract
Transfusional iron overload leads to gonadal failure and low bone mass in patients with thalassemia (Thal). However, gonadal failure is rarely reported in transfused patients with sickle cell disease (SCD) and the literature regarding fracture prevalence in SCD is limited. The objective of this study was to assess self-reported fracture prevalence and its relationship to endocrinopathy in transfused Thal or SCD subjects and compare to non-transfused subjects with SCD (NonTxSCD). Eligibility was based on age> or =12 years and liver iron concentration> or =10 mg/g dry wt or serum ferritin> or =2000 ng/mL (Thal or TxSCD) or for NonTxSCD, ferritin<500 ng/mL. Data were collected by patient interview and chart review at 31 clinical centers in the U.S., Canada and the U.K. 152 subjects with Thal (52% Male; 25.6+/-0.7 years), 203 subjects with TxSCD (44% Male, 24.7+/-0.9 years: Mean+/-SE), and 65 NonTxSCD (50% Male, 22.2+/-1.3 years) were enrolled. Overall, male subjects with Thal were more likely to have sustained a fracture in their lifetime (51%) compared to TxSCD (28%) or NonTxSCD (32%) (p=0.005). There was no difference in fracture prevalence among women (Thal: 26%, TxSCD 17%, NonTxSCD: 16%). Fracture was most frequently reported in the upper extremities (53.3% of all fractures) while spine and pelvic fractures were relatively common for such a young cohort: 10.6%. Though overall fracture prevalence was not distinctly different from published healthy cohorts, fewer fractures occurred during the adolescent years. In multivariate analysis, the significant predictors of fracture prevalence were Thal diagnosis (Odds Ratio: 2.3; 1.2-4.6; 95%CI), male gender (OR: 2.6; 1.5-4.5), hypothyroidism (OR: 3.3; 1.1-9.8) and age (OR: 1.1; 1.03-1.08). These data suggest that despite similar iron burden, transfused patients with Thal are at greater risk for fracture than subjects with SCD. Male subjects with Thal and hypothyroidism are at particular risk for fracture, in contrast, transfused subjects with SCD had no greater risk of fracture compared to non-transfused SCD. Though ethnic differences in fracture risk cannot be ignored, endocrinopathy is rare in TxSCD which may also provide some protection from fracture.
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Affiliation(s)
- Ellen B Fung
- Department of Hematology at the Children's Hospital & Research Center, Oakland, CA, USA.
| | - Paul R Harmatz
- Department of Gastroenterology at the Children's Hospital & Research Center, Oakland, CA, USA
| | - Meredith Milet
- Pediatric Clinical Research Center at the Children's Hospital and Research Center at Oakland, CA, USA
| | - Thomas D Coates
- Departments of Hematology at the Children Hospital Los Angeles, CA, USA
| | | | - Mark Ranalli
- Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Charles Scher
- Tulane University Medical Center, New Orleans, LA, USA
| | | | - Shanda Robertson
- Department of Hematology at the Children's Hospital & Research Center, Oakland, CA, USA
| | - Lynne Neumayr
- Department of Hematology at the Children's Hospital & Research Center, Oakland, CA, USA
| | - Elliott P Vichinsky
- Department of Hematology at the Children's Hospital & Research Center, Oakland, CA, USA
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Abstract
Bone and joint disorders are the most common cause of chronic pain in patients who have sickle cell disease. The femoral head is the most common area of bone destruction in sickle cell patients, although other disease-related problems include avascular necrosis of the humeral head, changes in the thoracic and lumbar spine, infection with encapsulated organisms (Salmonella and Staphylococcus aureus are the most common), bone marrow disturbances, and dental effects. Complications can occur at any location: epiphyseal, metaphyseal, or diaphyseal. The location and the extensiveness of the problems determine the pain and structural damage. The hip joint is particularly vulnerable in sickle cell disease. This article highlights aspects of sickle cell disease that affect healthy bone and joint function and discusses treatment options.
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21
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Neumayr L, Lennette E, Kelly D, Earles A, Embury S, Groncy P, Grossi M, Grover R, McMahon L, Swerdlow P, Waldron P, Vichinsky E. Mycoplasma disease and acute chest syndrome in sickle cell disease. Pediatrics 2003; 112:87-95. [PMID: 12837872 DOI: 10.1542/peds.112.1.87] [Citation(s) in RCA: 47] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Acute chest syndrome (ACS) is the leading cause of hospitalization, morbidity, and mortality in patients with sickle cell disease. Radiographic and clinical findings in ACS resemble pneumonia; however, etiologies other than infectious pathogens have been implicated, including pulmonary fat embolism (PFE) and infarction of segments of the pulmonary vasculature. The National Acute Chest Syndrome Study Group was designed to identify the etiologic agents and clinical outcomes associated with this syndrome. METHODS Data were analyzed from the prospective study of 671 episodes of ACS in 538 patients with sickle cell anemia. ACS was defined as a new pulmonary infiltrate involving at least 1 complete segment of the lung, excluding atelectasis. In addition, the patients had to have chest pain, fever >38.5C, tachypnea, wheezing, or cough. Samples of blood and deep sputum were analyzed for evidence of bacteria, viruses, and PFE. Mycoplasma pneumoniae infection was determined by analysis of paired serologies. Detailed information on patient characteristics, presenting signs and symptoms, treatment, and clinical outcome were collected. RESULTS Fifty-one (9%) of 598 episodes of ACS had serologic evidence of M pneumoniae infection. Twelve percent of the 112 episodes of ACS occurring in patients younger than 5 years were associated with M pneumoniae infection. At the time of diagnosis, 98% of all patients with M pneumoniae infection had fever, 78% had a cough, and 51% were tachypneic. More than 50% developed multilobar infiltrates and effusions, 82% were transfused, and 6% required assisted ventilation. The average hospital stay was 10 days. Evidence of PFE with M pneumoniae infection was seen in 5 (20%) of 25 patients with adequate deep respiratory samples for the PFE assay. M pneumoniae and Chlamydia pneumoniae was found in 16% of patients with diagnostic studies for C pneumoniae. Mycoplasma hominis was cultured in 10 (2%) of 555 episodes of ACS and occurred more frequently in older patients, but the presenting symptoms and clinical course was similar to those with M pneumoniae. CONCLUSIONS M pneumoniae is commonly associated with the ACS in patients with sickle cell anemia and occurs in very young children. M hominis should be considered in the differential diagnosis of ACS. Aggressive treatment with broad-spectrum antibiotics, including 1 from the macrolide class, is recommended for all patients as well as bronchodilator therapy, early transfusion, and respiratory support when clinically indicated.
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Affiliation(s)
- Lynne Neumayr
- Hematology/Oncology Department, Children's Hospital Oakland, Oakland, California 94609, USA.
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22
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Dean D, Neumayr L, Kelly DM, Ballas SK, Kleman K, Robertson S, Iyer RV, Ware RE, Koshy M, Rackoff WR, Pegelow CH, Waldron P, Benjamin L, Vichinsky E. Chlamydia pneumoniae and acute chest syndrome in patients with sickle cell disease. J Pediatr Hematol Oncol 2003; 25:46-55. [PMID: 12544773 DOI: 10.1097/00043426-200301000-00010] [Citation(s) in RCA: 37] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED PURPOSE Few studies address the association of Chlamydia pneumoniae infection with pulmonary disease and outcome in patients with underlying pathology such as sickle cell disease (SCD). SCD patients are susceptible to the pulmonary disorder known as acute chest syndrome (ACS), where the etiology remains ill defined. The purpose of this study was to analyze the clinical course and outcome of C. pneumoniae-associated ACS among SCD patients as part of the National Acute Chest Syndrome Study. PATIENTS AND METHODS This was a longitudinal study of SCD patients presenting with ACS to multiple U.S. medical centers. Two hundred ninety-six SCD patients who developed ACS were tested by PCR for C. pneumoniae and by standard techniques for other respiratory pathogens. These infections were evaluated for association with ACS, clinical course, and complications. RESULTS Forty-one (14%) patients with first episodes of ACS were PCR positive for C. pneumoniae. Compared with other infections, C. pneumoniae-infected patients were older, were more likely to present with chest pain, and had higher hemoglobin levels at diagnosis. Both groups had similar rates of respiratory failure and prolonged hospitalization. Of the 89 patients with single-pathogen infections, 27 (30%) were due to C. pneumoniae, 21% to Mycoplasma pneumoniae, 10% to RSV, 4% to Staphylococcus aureus, and 3% to Streptococcus pneumoniae. CONCLUSIONS C. pneumoniae was the most prevalent pathogen in this study of ACS and was responsible for significant morbidity. Additional research is required to develop effective treatment guidelines for ACS.
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Affiliation(s)
- Deborah Dean
- Children's Hospital Oakland Research Institute, 5700 Martin Luther King Jr. Way, Oakland, CA 94609, USA.
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Harmatz P, Butensky E, Quirolo K, Williams R, Ferrell L, Moyer T, Golden D, Neumayr L, Vichinsky E. Severity of iron overload in patients with sickle cell disease receiving chronic red blood cell transfusion therapy. Blood 2000; 96:76-9. [PMID: 10891433] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
Chronic transfusion therapy is being used more frequently to prevent and treat the complications of sickle cell disease. Previous studies have shown that the iron overload that results from such therapy in other patient populations is associated with significant morbidity and mortality. In this study we examined the extent of iron overload as well as the presence of liver injury and the predictive value of ferritin in estimating iron overload in children with sickle cell disease who receive chronic red blood cell transfusions. A poor correlation was observed between serum ferritin and the quantitative iron on liver biopsy (mean 13.68 +/- 6.64 mg/g dry weight; R = 0.350, P =.142). Quantitative iron was highly correlated with the months of transfusion (R = 0.795, P <.001), but serum ferritin at biopsy did not correlate with months of transfusion (R = 0.308, P =.200). Sixteen patients had abnormal biopsies showing mild to moderate changes on evaluation of inflammation or fibrosis. Liver iron was correlated with fibrosis score (R = 0.50, P =.042). No complications were associated with the liver biopsy. Our data suggest that, in patients with sickle cell disease, ferritin is a poor marker for accurately assessing iron overload and should not be used to direct long-term chelation therapy. Despite high levels of liver iron, the associated liver injury was not severe.
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Affiliation(s)
- P Harmatz
- Departments of Gastroenterology, Hematology/Oncology, and Pathology, Children's Hospital Oakland, Oakland, CA 94609, USA.
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Waldron P, Pegelow C, Neumayr L, Haberkern C, Earles A, Wesman R, Vichinsky E. Tonsillectomy, adenoidectomy, and myringotomy in sickle cell disease: perioperative morbidity. Preoperative Transfusion in Sickle Cell Disease Study Group. J Pediatr Hematol Oncol 1999; 21:129-35. [PMID: 10206459 DOI: 10.1097/00043426-199903000-00009] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [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: 11/25/2022]
Abstract
PURPOSE To compare the rates of perioperative morbidity of patients with sickle cell anemia who were randomly assigned to 2 preoperative transfusion regimens and to identify predisposing factors for perioperative complications. PATIENTS AND METHODS Investigators at 36 centers enrolled 118 patients who were scheduled to have elective surgery and agreed to randomization between 2 preoperative transfusion regimens. Forty-seven subjects were enrolled but not randomized, including 20 who were not transfused before surgery. Perioperative management was based on a prescribed care plan. RESULTS Tonsillectomy and/or adenoidectomy (TA) were performed on 136 persons, and 29 had myringotomy as their primary procedure. There were no differences in the frequency of complications between the randomized groups. The serious, non-transfusion complication rates for randomized patients were 32% (34 of 107) for TA and 36% (4 of 11) for myringotomy. A history of pulmonary disease was a predictor of postoperative sickle cell-related events for patients undergoing TA surgery. CONCLUSIONS The more intensive transfusion regimen did not result in fewer perioperative complications. The high frequency of complications emphasizes the need for anticipatory management of persons undergoing TA. A history of pulmonary disease identifies patients at increased risk for sickle cell-related events after TA surgery. Patients undergoing myringotomy have a low frequency of sickle cell-related events but a significant frequency of other serious perioperative complications.
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Affiliation(s)
- P Waldron
- Department of Pediatrics, University of Virginia, Charlottesville, USA
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25
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Neumayr L, Koshy M, Haberkern C, Earles AN, Bellevue R, Hassell K, Miller S, Black D, Vichinsky E. Surgery in patients with hemoglobin SC disease. Preoperative Transfusion in Sickle Cell Disease Study Group. Am J Hematol 1998; 57:101-8. [PMID: 9462540 DOI: 10.1002/(sici)1096-8652(199802)57:2<101::aid-ajh2>3.0.co;2-#] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
While surgery is commonly required for complications related to hemoglobin SC (HbSC) disease, little is known about the perioperative complications or the indications for preoperative transfusion in this group. We describe the patient characteristics, preoperative transfusion regimens, and outcome in 92 patients with HbSC and sickle-variants undergoing elective surgery. Thirty-eight percent of the patients were transfused preoperatively. Patients transfused were more likely to have been hospitalized in the year prior to the surgery and scheduled for abdominal procedures. Abdominal and ear, nose and throat procedures were the most common surgeries in our study. The overall complication rate was 18% and sickle cell-related complications occurred in 9% of patients. In patients undergoing intra-abdominal procedures, the incidence of sickle cell-related complications was significantly higher in those patients not transfused prior to their surgery (35 vs. 0%). There were two deaths. We recommend selective use of preoperative transfusion in patients with HbSC disease undergoing surgery. Transfusion appears to be beneficial in abdominal cases but is not necessary with minor procedures such as myringtomy.
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Affiliation(s)
- L Neumayr
- Department of Hematology/Oncology, Children's Hospital Oakland, California 94609, USA
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26
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Vichinsky EP, Haberkern CM, Neumayr L, Earles AN, Black D, Koshy M, Pegelow C, Abboud M, Ohene-Frempong K, Iyer RV. A comparison of conservative and aggressive transfusion regimens in the perioperative management of sickle cell disease. The Preoperative Transfusion in Sickle Cell Disease Study Group. N Engl J Med 1995; 333:206-13. [PMID: 7791837 DOI: 10.1056/nejm199507273330402] [Citation(s) in RCA: 387] [Impact Index Per Article: 13.3] [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: 01/27/2023]
Abstract
BACKGROUND Preoperative transfusions are frequently given to prevent perioperative morbidity in patients with sickle cell anemia. There is no consensus, however, on the best regimen of transfusions for this purpose. METHODS We conducted a multicenter study to compare the rates of perioperative complications among patients randomly assigned to receive either an aggressive transfusion regimen designed to decrease the hemoglobin S level to less than 30 percent (group 1) or a conservative regimen designed to increase the hemoglobin level to 10 g per deciliter (group 2). RESULTS Patients undergoing a total of 604 operations were randomly assigned to group 1 or group 2. The severity of the disease, compliance with the protocol, and the types of operations were similar in the two groups. The preoperative hemoglobin level was 11 g per deciliter in group 1 and 10.6 g per deciliter in group 2. The preoperative value for hemoglobin S was 31 percent in group 1 and 59 percent in group 2. The most frequent operations were cholecystectomies (232), head and neck surgery (156), and orthopedic surgery (72). With the exception of transfusion-related complications, which occurred in 14 percent of the operations in group 1 and in 7 percent of those in group 2, the frequency of serious complications was similar in the two groups (31 percent in group 1 and 35 percent in group 2). The acute chest syndrome developed in 10 percent of both groups and resulted in two deaths in group 1. A history of pulmonary disease and a higher risk associated with surgery were significant predictors of the acute chest syndrome. CONCLUSIONS A conservative transfusion regimen was as effective as an aggressive regimen in preventing perioperative complications in patients with sickle cell anemia, and the conservative approach resulted in only half as many transfusion-associated complications.
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Affiliation(s)
- E P Vichinsky
- Department of Hematology/Oncology, Children's Hospital Oakland, CA 94609, USA
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Abstract
Growth, enterotoxin A (SEA) and thermonuclease (TNase) production of S. aureus (Strains CP 7 and FRI 722) was determined in media produced from the following heat or irradiation sterilized legumes: peas, black beans, mung beans, adzuki beans and soybeans. Media containing the five legumes alone or in combination with Brain Heart Infusion Broth (BHI) were tested. With the exception of heat-sterilized black beans and adzuki beans, S. aureus growth was excellent in all media with cell counts after 48 h (25 degrees C) exceeding 10(8) cfu/ml. In black beans and adzuki beans cell counts were 1-2 log-cycles lower. Enterotoxin A was produced in amounts of 33 to 72 ng/ml in BHI after 48 h. Almost no toxin was produced in the four different beans following heat or irradiation treatment; in peas the toxin concentration reached 14 to 15 ng/ml. In the medium prepared from irradiated soybeans and BHI the final toxin concentration was about the same as in BHI alone. In all the other media consisting of a combination of legumes with BHI toxin concentrations were three to four times higher than in BHI alone. Production of thermonuclease showed variation and did not always correlate with enterotoxin production.
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Affiliation(s)
- L Neumayr
- Department of Agricultural and Food Microbiology, University of Bonn, F.R.G
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Neumayr L, Heyderhoff G, Krämer J. Differences in the resistance between vegetative cells and ascospores of selected yeast-strains against disinfectants on the basis of biguanides, peracetic acid and quaternary ammonium compounds. Yeast 1989; 5 Spec No:S17-22. [PMID: 2750305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- L Neumayr
- Department of Agricultural and Food-Microbiology, University of Bonn, Germany
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