An investigation of vascular anomalies centers' transition of care practices

This study aims to examine transition of care (TOC) practices of multidisciplinary vascular anomalies centers (VACs). Thirty-seven of 71 VAC leaders to whom the survey was sent completed the questionnaire. TOC and transfer practices varied with only 16% of VACs having TOC programs. The most frequently cited barriers to developing a TOC program were lack of resources and difficulty finding expert adult providers.

Acute chest syndrome, airway inflammation and lung function in sickle cell disease

BACKGROUND

Acute chest syndrome (ACS) is an acute complication in SCD but its effects on lung function are not well understood. Inflammation is a key component of SCD pathophysiology but with an unclear association with lung function. We hypothesized that children with ACS had worse lung function than children without ACS and aimed to investigate the association of lung function deficits with inflammatory cytokines.

METHODS

Patients enrolled in a previous 2-year randomized clinical trial who had consented to future data use, were enrolled for the present exploratory study. Patients were categorized into ACS and non-ACS groups. Demographic and clinical information were collected. Serum samples were used for quantification of serum cytokines and leukotriene B4 levels and pulmonary function tests (PFTs) were assessed.

RESULTS

Children with ACS had lower total lung capacity (TLC) at baseline and at 2 years, with a significant decline in forced expiratory volume in 1 sec (FEV1) and mid-maximal expiratory flow rate (FEF25-75%) in the 2 year period (p = 0.015 and p = 0.039 respectively). For children with ACS, serum cytokines IL-5, and IL-13 were higher at baseline and at 2 years compared to children with no ACS. IP-10 and IL-6 were negatively correlated with PFT markers. In multivariable regression using generalized estimating equation approach for factors predicting lung function, age was significantly associated FEV1 (p = 0.047) and ratio of FEV1 and forced vital capacity (FVC)- FEV1/FVC ratio (p = 0.006); males had lower FEV1/FVC (p = 0.035) and higher TLC (p = 0.031). Asthma status was associated with FEV1 (p = 0.017) and FVC (p = 0.022); history of ACS was significantly associated with TLC (p = 0.027).

CONCLUSION

Pulmonary function abnormalities were more common and inflammatory markers were elevated in patients with ACS, compared with those without ACS. These findings suggest airway inflammation is present in children with SCD and ACS, which could be contributing to impaired pulmonary function.

Food insecurity, housing instability, and dietary quality among children with sickle cell disease: Assessment from a single urban center

BACKGROUND

Food insecurity and housing instability, both social determinants of health (SDoH), disproportionately affect economically unstable, under-resourced US communities in which children with sickle cell disease (SCD) live. Association between these SDoH markers and dietary quality among children with SCD is unknown.

PROCEDURES

We assessed a cross-sectional sample of dyadic parent-child patients and young adult patients up to age 21 from one pediatric SCD center. Food insecurity, housing instability, and dietary quality were measured using validated US instruments and a food frequency questionnaire. Better dietary quality was defined using US dietary guidelines. Multivariate regression assessed for associations among dietary quality and food insecurity with or without (±) housing instability and housing instability alone.

RESULTS

Of 100 enrolled participants, 53% were Black and 43% Hispanic; mean age 10.6 ± 5.6 years. Overall, 70% reported less than or equal to one economic instability: 40% housing instability alone and 30% both food insecurity and housing instability. Eighty percent received more than or equal to one federal food assistance benefit. Compared to no economic instability, food insecurity ± housing instability was significantly associated with higher intake of higher dairy and pizza, while housing instability alone was significantly associated with higher dairy intake. Food insecurity ± housing instability was significantly associated with lower intake of whole grains compared to housing instability alone.

CONCLUSIONS

Our sample reported high frequencies of both food insecurity and housing instability; having more than or equal to one SDoH was associated with elements of poorer diet quality. Screening families of children with SCD for food insecurity and housing instability may identify those with potential nutrition-related social needs.

Validation of a Questionnaire to Identify Respiratory Tract Infections in Children With Sickle Cell Disease

BACKGROUND

No validated questionnaires have been published that are specific for identifying respiratory infections in children with sickle cell disease (SCD).

METHODS

A questionnaire was developed that included 6 respiratory symptoms (difficulty breathing, wheezing, fever, cough, runny or stuffy nose, and sore throat) to identify respiratory events for a clinical trial. The questionnaire results were compared with identification of viral respiratory pathogens from nasal samples by reverse transcriptase polymerase chain reaction.

RESULTS

Eighty questionnaire responses (40 with symptom/s and 40 without) paired with isolation of viral respiratory pathogen from nasal samples were obtained from 53 children with SCD, ages 4 to 18 years over 2 separate periods in different seasons. The questionnaire yielded a sensitivity of 82%, specificity of 72% with an overall accuracy of 76%. The kappa value was 0.53, indicating moderate agreement, and the Fleiss' kappa test statistic was 4.77 with P<0.001, indicating that agreement between the 2 methods was not by chance.

CONCLUSION

These results provide evidence for validity of this 6-symptom respiratory questionnaire in identification of respiratory viral infections for use in SCD-related research.

Vitamin D supplementation to prevent acute respiratory infections: a systematic review and meta-analysis of aggregate data from randomised controlled trials

BACKGROUND

A 2017 meta-analysis of data from 25 randomised controlled trials (RCTs) of vitamin D supplementation for the prevention of acute respiratory infections (ARIs) revealed a protective effect of this intervention. We aimed to examine the link between vitamin D supplementation and prevention of ARIs in an updated meta-analysis.

METHODS

For this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and the ClinicalTrials.gov registry for studies listed from database inception to May 1, 2020. Double-blind RCTs of vitamin D₃, vitamin D₂, or 25-hydroxyvitamin D (25[OH]D) supplementation for any duration, with a placebo or low-dose vitamin D control, were eligible if they had been approved by a research ethics committee, and if ARI incidence was collected prospectively and prespecified as an efficacy outcome. Studies reporting results of long-term follow-up of primary RCTs were excluded. Aggregated study-level data, stratified by baseline 25(OH)D concentration and age, were obtained from study authors. Using the proportion of participants in each trial who had one or more ARIs, we did a random-effects meta-analysis to obtain pooled odds ratios (ORs) and 95% CIs to estimate the effect of vitamin D supplementation on the risk of having one or more ARIs (primary outcome) compared with placebo. Subgroup analyses were done to estimate whether the effects of vitamin D supplementation on the risk of ARI varied according to baseline 25(OH)D concentration (<25 nmol/L vs 25·0-49·9 nmol/L vs 50·0-74·9 nmol/L vs >75·0 nmol/L), vitamin D dose (daily equivalent of <400 international units [IU] vs 400-1000 IU vs 1001-2000 IU vs >2000 IU), dosing frequency (daily vs weekly vs once per month to once every 3 months), trial duration (≤12 months vs >12 months), age at enrolment (<1·00 years vs 1·00-15·99 years vs 16·00-64·99 years vs ≥65·00 years), and presence versus absence of airway disease (ie, asthma only, COPD only, or unrestricted). Risk of bias was assessed with the Cochrane Collaboration Risk of Bias Tool. The study was registered with PROSPERO, CRD42020190633.

FINDINGS

We identified 1528 articles, of which 46 RCTs (75 541 participants) were eligible. Data for the primary outcome were obtained for 48 488 (98·1%) of 49 419 participants (aged 0-95 years) in 43 studies. A significantly lower proportion of participants in the vitamin D supplementation group had one or more ARIs (14 332 [61·3%] of 23 364 participants) than in the placebo group (14 217 [62·3%] of 22 802 participants), with an OR of 0·92 (95% CI 0·86-0·99; 37 studies; I²=35·6%, p_{heterogeneity}=0·018). No significant effect of vitamin D supplementation on the risk of having one or more ARIs was observed for any of the subgroups defined by baseline 25(OH)D concentration. However, protective effects of supplementation were observed in trials in which vitamin D was given in a daily dosing regimen (OR 0·78 [95% CI 0·65-0·94]; 19 studies; I²=53·5%, p_{heterogeneity}=0·003), at daily dose equivalents of 400-1000 IU (0·70 [0·55-0·89]; ten studies; I²=31·2%, p_{heterogeneity}=0·16), for a duration of 12 months or less (0·82 [0·72-0·93]; 29 studies; I²=38·1%, p_{heterogeneity}=0·021), and to participants aged 1·00-15·99 years at enrolment (0·71 [0·57-0·90]; 15 studies; I²=46·0%, p_{heterogeneity}=0·027). No significant interaction between allocation to the vitamin D supplementation group versus the placebo group and dose, dose frequency, study duration, or age was observed. In addition, no significant difference in the proportion of participants who had at least one serious adverse event in the vitamin supplementation group compared with the placebo group was observed (0·97 [0·86-1·07]; 36 studies; I²=0·0%, p_{heterogeneity}=0·99). Risk of bias within individual studies was assessed as being low for all but three trials.

INTERPRETATION

Despite evidence of significant heterogeneity across trials, vitamin D supplementation was safe and overall reduced the risk of ARI compared with placebo, although the risk reduction was small. Protection was associated with administration of daily doses of 400-1000 IU for up to 12 months, and age at enrolment of 1·00-15·99 years. The relevance of these findings to COVID-19 is not known and requires further investigation.

FUNDING

None.

Vitamin D supplementation to prevent acute respiratory infections: systematic review and meta-analysis of aggregate data from randomised controlled trials

BACKGROUND

A 2017 meta-analysis of data from 25 randomised controlled trials of vitamin D supplementation for the prevention of acute respiratory infections revealed a protective effect of the intervention. Since then, 20 new RCTs have been completed.

METHODS

Systematic review and meta-analysis of data from randomised controlled trials (RCTs) of vitamin D for ARI prevention using a random effects model. Pre-specified sub-group analyses were done to determine whether effects of vitamin D on risk of ARI varied according to baseline 25-hydroxyvitamin D (25[OH]D) concentration or dosing regimen. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and the ClinicalTrials.gov registry from inception to 1st May 2020. Double-blind RCTs of supplementation with vitamin D or calcidiol, of any duration, were eligible if they were approved by a Research Ethics Committee and if ARI incidence was collected prospectively and pre-specified as an efficacy outcome. Aggregate data, stratified by baseline 25(OH)D concentration, were obtained from study authors. The study was registered with PROSPERO (no. CRD42020190633).

FINDINGS

We identified 45 eligible RCTs (total 73,384 participants). Data were obtained for 46,331 (98.0%) of 47,262 participants in 42 studies, aged 0 to 95 years. For the primary comparison of vitamin D supplementation vs. placebo, the intervention reduced risk of ARI overall (Odds Ratio [OR] 0.91, 95% CI 0.84 to 0.99; P for heterogeneity 0.01). No statistically significant effect of vitamin D was seen for any of the sub-groups defined by baseline 25(OH)D concentration. However, protective effects were seen for trials in which vitamin D was given using a daily dosing regimen (OR 0.75, 95% CI 0.61 to 0.93); at daily dose equivalents of 400-1000 IU (OR 0.70, 95% CI 0.55 to 0.89); and for a duration of ≤12 months (OR 0.82, 95% CI 0.72 to 0.93). No significant interaction was seen between allocation to vitamin D vs. placebo and dose frequency, dose size, or study duration. Vitamin D did not influence the proportion of participants experiencing at least one serious adverse event (OR 0.97, 95% CI 0.86 to 1.09). Risk of bias within individual studies was assessed as being low for all but three trials. A funnel plot showed left-sided asymmetry (P=0.008, Egger's test).

INTERPRETATION

Vitamin D supplementation was safe and reduced risk of ARI, despite evidence of significant heterogeneity across trials. Protection was associated with administration of daily doses of 400-1000 IU vitamin D for up to 12 months. The relevance of these findings to COVID-19 is not known and requires investigation.

FUNDING

None.

Rural Clients' Continuity Into Follow-Up Substance Use Disorder Treatment: Impacts of Travel Time, Incentives, and Alerts

PURPOSE

Treatment after discharge from detoxification or residential treatment is associated with improved outcomes. We examined the influence of travel time on continuity into follow-up treatment and whether financial incentives and weekly alerts have a modifying effect.

METHODS

For a research intervention during October 2013 to December 2015, detoxification and residential substance use disorder treatment programs in Washington State were randomized into 4 groups: potential financial incentives for meeting performance goals, weekly alerts to providers, both interventions, and control. Travel time was used as both a main effect and interacted with other variables to explore its modifying impact on continuity of care in conjunction with incentives or alerts. Continuity was defined as follow-up care occurring within 14 days of discharge from detoxification or residential treatment programs. Travel time was estimated as driving time from clients' home ZIP Code to treatment agency ZIP Code.

FINDINGS

Travel times to the original treatment agency were in some cases significant with longer travel times predicting lower likelihood of continuity. For detoxification clients, those with longer travel times (over 91 minutes from their residence) are more likely to have timely continuity. Conversely, residential clients with travel times of more than 1 hour are less likely to have timely continuity. Interventions such as alerts or incentives for performance had some mitigating effects on these results. Travel times to the closest agency for potential further treatment were not significant.

CONCLUSIONS

Among rural clients discharged from detoxification and residential treatment, travel time can be an important factor in predicting timely continuity.

Effects of dietary Antrodia cinnamomea fermented product supplementation on antioxidation, anti-inflammation, and lipid metabolism in broiler chickens

Objective

This study was investigated the effects of dietary supplementation of Antrodia cinnamomea fermented product on modulation of antioxidation, anti-inflammation, and lipid metabolism in broilers.

Methods

Functional compounds and in vitro antioxidant capacity were detected in wheat bran (WB) solid-state fermented by Antrodia cinnamomea for 16 days (FAC). In animal experiment, 400 d-old broiler chickens were allotted into 5 groups fed control diet, and control diet replaced with 5% WB, 10% WB, 5% FAC, and 10% FAC respectively. Growth performance, intestinal microflora, serum antioxidant enzymes and fatty acid profiles in pectoral superficial muscle were measured.

Results

Pretreatment with hot water extracted fermented product significantly reduced chicken peripheral blood mononuclear cells death induced by lipopolysaccharide and 2,2′-Azobis(2-amidinopropane) dihydrochloride. Birds received 5% and 10% FAC had higher weight gain than WB groups. Cecal coliform and lactic acid bacteria were diminished and increased respectively while diet replaced with FAC. For FAC supplemented groups, superoxide dismutase (SOD) activity increased at 35 days only, with catalase elevated at 21 and 35 day. Regarding serum lipid parameters, 10% FAC replacement significantly reduced triglyceride and low-density lipoprotein level in chickens. For fatty acid composition in pectoral superficial muscle of 35-d-old chickens, 5% and 10% FAC inclusion had birds with significantly lower saturated fatty acids as compared with 10% WB group. Birds on the 5% FAC diet had a higher degree of unsaturation, followed by 10% FAC, control, 5% WB, and 10% WB.

Conclusion

In conclusion, desirable intestinal microflora in chickens obtaining FAC may be attributed to the functional metabolites detected in final fermented product. Moreover, antioxidant effects observed in FAC were plausibly exerted in terms of improved antioxidant enzymes activities, increased unsaturated degree of fatty acids in chicken muscle and better weight gain in FAC inclusion groups, indicating that FAC possesses promising favorable mechanisms worthy to be developed.

Effects of dietary Antrodia cinnamomea fermented product supplementation on metabolism pathways of antioxidant, inflammatory, and lipid metabolism pathways-a potential crosstalk

Objective

This study was conducted to fathom the underlying mechanisms of nutrition intervention and redox sensitive transcription factors regulated by Antrodia cinnamomea fermented product (FAC) dietary supplementation in broiler chickens.

Methods

Four hundreds d-old broilers (41±0.5 g/bird) assigned to 5 groups were examined after consuming control diet, or control diet replaced with 5% wheat bran (WB), 10% WB, 5% FAC, and 10% FAC. Liver mRNA expression of antioxidant, inflammatory and lipid metabolism pathways were analyzed. Prostaglandin E2 (PGE₂) concentration in each group were tested in the chicken peripheral blood mononuclear cells (cPBMCs) of 35-d old broilers to represent the stress level of the chickens. Furthermore, these cells were stimulated with 2,2′-Azobis(2-amidinopropane) dihydrochloride (AAPH) and lipopolysaccharide (LPS) to evaluate the cell stress tolerance by measuring cell viability and oxidative species.

Results

Heme oxygenase-1, glutathione S-transferase, glutamate-cysteine ligase, catalytic subunit, and superoxide dismutase, and nuclear factor (erythroid-derived 2)-like 2 (Nrf2) that regulates the above antioxidant genes were all up-regulated significantly in FAC groups. Reactive oxygen species modulator protein 1 and NADPH oxygenase 1 were both rather down-regulated in 10% FAC group as comparison with two WB groups. Despite expressing higher level than control group, birds receiving diet containing FAC had significantly lower expression level in nuclear factor-kappa B (NF-κB) and other genes (inducible nitric oxide synthase, tumor necrosis factor-α, interleukin-1β, nucleotide-binding domain, leucine-rich-containing family, pyrin domain-containing-3, and cyclooxygenase 2) involving in inflammatory pathways. Additionally, except for 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase that showed relatively higher in both groups, the WB, lipoprotein lipase, Acetyl-CoA carboxylase, fatty acid synthase, fatty acid binding protein, fatty acid desaturase 2 and peroxisome proliferator-activated receptor alpha genes were expressed at higher levels in 10% FAC group. In support of above results, promoted Nrf2 and inhibited NF-κB nuclear translocation in chicken liver were found in FAC containing groups. H₂O₂ and NO levels induced by LPS and AAPH in cPBMCs were compromised in FAC containing diet. In 35-d-old birds, PGE₂ production in cPBMCs was also suppressed by the FAC diet.

Conclusion

FAC may promote Nrf2 antioxidant pathway and positively regulate lipid metabolism, both are potential inhibitor of NF-κB inflammatory pathway.

Potential crosstalk of oxidative stress and immune response in poultry through phytochemicals - A review

Phytochemicals which exist in various plants and fungi are non-nutritive compounds that exert numerous beneficial bioactive actions for animals. In recent years following the restriction of antibiotics, phytochemicals have been regarded as a primal selection when dealing with the challenges during the producing process in the poultry industry. The selected fast-growing broiler breed was more fragile when confronting the stressors in their growing environments. The disruption of oxidative balance that impairs the production performance in birds may somehow be linked to the immune system since oxidative stress and inflammatory damage are multi-stage processes. This review firstly discusses the individual influence of oxidative stress and inflammation on the poultry industry. Next, studies related to the application of phytochemicals or botanical compounds with the significance of their antioxidant and immunomodulatory abilities are reviewed. Furthermore, we bring up nuclear factor (erythroid-derived 2)-like 2 (Nrf2) and nuclear factor kappa B (NF-κB) for they are respectively the key transcription factors involved in oxidative stress and inflammation for elucidating the underlying signal transduction pathways. Finally, by the discussion about several reports using phytochemicals to regulate these transcription factors leading to the improvement of oxidative status, heme oxygenase-1 gene is found crucial for Nrf2-mediated NF-κB inhibition.

Response to Long-term Vitamin D Therapy for Bone Disease in Children With Sickle Cell Disease

Patients with sickle cell disease (SCD) are at risk for bone fragility from multiple factors including vitamin D deficiency. To date, no studies have evaluated the efficacy and safety of long-term vitamin D therapy for bone disease in children with SCD. We report a cohort of 4 children with SCD found to have severe vitamin D deficiency, secondary hyperparathyroidism, and abnormal bone mineral density treated with monthly high-dose oral cholecalciferol over 2 years. All patients exhibited a positive response to therapy without hypervitaminosis D or hypercalcemia. Further studies are needed to standardize guidelines for optimal vitamin D dosing and prevention of toxicity.

Effects of mulberry leaves on production performance and the potential modulation of antioxidative status in laying hens

This study evaluated the antioxidant ability of Taisung No. 3 mulberry leaf extract (MLE) as well as the potential of mulberry leaf (ML)-based dietary supplementation for modulating the antioxidative status of laying hens. The results showed that the MLE had a total phenolic compound content of 7.4 ± 0.15 mg of gallic acid equivalent/g dry weight (DW) and a total flavonoid content of 4.4 ± 0.19 mg of quercetin equivalent/g DW. The 2, 2-diphenyl-1-picrylhydrazyl free-radical-scavenging ability was 45.9% when 0.1 mg/mL MLE was added. The lipid oxidation inhibition ability was 43.9% when 50 mg/mL MLE was added. We subjected 96 laying hens (Hendrix Genetics) to 4 treatments, namely diets supplemented with dry ML at 0 (control), 0.5, 1, or 2% for 12 weeks. Each treatment involved 8 replicates with 3 hens each. The results indicated that the 0.5% ML-supplemented group exhibited significantly higher mRNA levels of antioxidant-regulated genes, such as Nrf2, HO-1, and GST, and significantly lower ROMO1 gene expression levels at wk 12. The serum malondialdehyde level was lower and the catalase activity and superoxide dismutase activity were higher in all the ML-supplemented groups than in the control group. The egg mass and feed conversion rate significantly improved in the ML-supplemented groups compared with the control group, and, overall, 1% ML supplementation had the most favorable effects at one to 12 weeks. The egg yolk weight, shell weight, shell strength, shell thickness, yolk color, and Haugh unit were increased among all ML-supplemented groups at one to 12 weeks. On the basis of these observations, we conclude that 0.5% ML can be used as a new feed additive to potentially modulate the antioxidative status of laying hens and improve their production performance and egg quality.

Impact of Agency Receipt of Incentives and Reminders on Engagement and Continuity of Care for Clients With Co-Occurring Disorders

OBJECTIVE

This study examined whether having co-occurring substance use and mental disorders influenced treatment engagement or continuity of care and whether offering financial incentives, client-specific electronic reminders, or a combination to treatment agencies improved treatment engagement and continuity of care among clients with co-occurring disorders.

METHODS

The study used a randomized cluster design to assign agencies (N=196) providing publicly funded substance use disorder treatment in Washington State to a research arm: incentives only, reminders only, incentives and reminders, and a control condition. Data were analyzed for 76,044 outpatient, 32,797 residential, and 39,006 detoxification admissions from Washington's treatment data system. Multilevel logistic regressions were conducted, with clients nested within agencies, to examine the effect of the interventions on treatment engagement and continuity of care.

RESULTS

Compared with clients with a substance use disorder only, clients with co-occurring disorders were less likely to engage in outpatient treatment or have continuity of care after discharge from residential treatment, but they were more likely to have continuity of care after discharge from detoxification. The interventions did not influence treatment engagement or continuity of care, except the reminders had a positive impact on continuity of care after residential treatment among clients with co-occurring disorders.

CONCLUSIONS

In general, the interventions did not result in improved treatment engagement or continuity of care. The limited number of significant results supporting the influence of incentives and alerts on treatment engagement and continuity of care add to the mixed findings reported by previous research. Multiple interventions may be needed for performance improvement.

Influencing quality of outpatient SUD care: Implementation of alerts and incentives in Washington State

Financial incentives for quality improvement and feedback on specific clients are two approaches to improving the quality of treatment for individuals with substance use disorders. We examined the impacts of these interventions in Washington State by randomizing outpatient substance use treatment agencies into intervention and control groups. From October 2013 through December 2015, agencies could earn financial incentives for meeting performance goals incorporating both achievement relative to a benchmark and improvement from agencies' own baselines. Weekly feedback was e-mailed to agencies in the alert or alert plus incentives arms. Difference-in difference regressions controlling for client and agency characteristics showed that none of the interventions significantly affected client engagement after outpatient admissions, overall or for sub-groups based on race/ethnicity, age, rural residence, or agency baseline performance. Treatment agencies offered insights related to several themes: delivery system context (e.g., agency time and resources needed during transition to a managed behavioral healthcare system), implementation (e.g., data lag), agency issues (e.g., staff turnover), and client factors (e.g., motivation). Interventions took place during a time of Medicaid expansion and planning for statewide integration of mental health and substance use disorder treatment into a managed care model, which may have resulted in agencies not responding to the interventions. Moreover, incentives and alerts at the agency-level may not be effective when factors are at play beyond the agency's control.

Optical Coherence Tomography Angiography and Ultra-widefield Fluorescein Angiography for Early Detection of Adolescent Sickle Retinopathy

PURPOSE

Based on standard screening techniques, sickle retinopathy reportedly occurs in 10% of adolescents with sickle cell disease (SCD). We performed a prospective, observational clinical study to determine if ultra-widefield fluorescein angiography (UWFA), spectral-domain optical coherence tomography (SD-OCT), and optical coherence tomography angiography (OCT-A) detect more-frequent retinopathy in adolescents with SCD.

DESIGN

Cross-sectional study.

METHODS

Setting: Institutional.

SUBJECTS

Sixteen adolescents with SCD, aged 10-19 years (mean age 14.9 years), and 5 age-equivalent controls (mean age 17.4 years).

OBSERVATION PROCEDURES

Examinations including acuity, standard slit-lamp biomicroscopy, UWFA, SD-OCT, and OCT-A were performed.

MAIN OUTCOME MEASURES

Sickle retinopathy defined by biomicroscopic changes, Goldberg stages I-V, Penman scale, flow void on OCT-A, or macular thinning on SD-OCT.

RESULTS

While 22 of 32 SCD eyes (68.8%) had retinopathy on biomicroscopy, by UWFA 4 of 24 (16.7%) SCD eyes had peripheral arterial occlusion (Goldberg I), and 20 of 24 eyes (83.3%) had peripheral arteriovenous anastomoses (Goldberg II) in addition. No patients had Goldberg stages III-V. By SD-OCT and OCT-A, thinning of the macula and flow voids in both the superficial and deep retinal capillary plexus were found in 6 of 30 (20%) eyes.

CONCLUSIONS

All 24 eyes with adequate UWFA studies demonstrated sickle retinopathy. SD-OCT and OCT-A, which have not been previously reported in the adolescent population, detected abnormal macular thinning and flow abnormalities undetected by biomicroscopy. These findings suggest that pediatric sickle retinopathy may be more prevalent than previously suspected. If these findings are confirmed with larger cross-sectional and prospective analyses, these approaches may enhance early screening for sickle retinopathy.

Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for Pharmacogenetics-Guided Warfarin Dosing: 2017 Update

This document is an update to the 2011 Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline for CYP2C9 and VKORC1 genotypes and warfarin dosing. Evidence from the published literature is presented for CYP2C9, VKORC1, CYP4F2, and rs12777823 genotype-guided warfarin dosing to achieve a target international normalized ratio of 2-3 when clinical genotype results are available. In addition, this updated guideline incorporates recommendations for adult and pediatric patients that are specific to continental ancestry.

Antioxidant capacity of phytochemicals and their potential effects on oxidative status in animals - A review

Oxidative stress suppresses animal health, performance, and production, subsequently impacting economic feasibility; hence, maintaining and improving oxidative status especially through natural nutrition strategy are essential for normal physiological process in animals. Phytochemicals are naturally occurring antioxidants that could be considered as one of the most promising materials used in animal diets in various forms. In this review, their antioxidant effects on animals are discussed as reflected by improved apparent performance, productivity, and the internal physiological changes. Moreover, the antioxidant actions toward animals further describe a molecular basis to elucidate their underlying mechanisms targeting signal transduction pathways, especially through the antioxidant response element/nuclear factor (erythroid-derived 2)-like 2 transcription system.

Diagnosis of a rare fetal haemoglobinopathy in the age of next-generation sequencing

Neonatal cyanosis resulting from a fetal methaemoglobin variant is rare. Most such variants are only described in a few published case reports. We present the case of a newborn with unexplained persistent cyanosis, ultimately determined to have a γ-chain mutation causing Hb FM-Fort Ripley. This neonatal haemoglobinopathy can be challenging to diagnose, as significant oxygen desaturation may result from barely detectable levels of the mutant haemoglobin and co-oximetry studies may show a falsely normal methaemoglobin level. Our analysis of the infant's haemoglobin included high-performance liquid chromatography, cellulose acetate electrophoresis and citrate agar electrophoresis, which showed trace amounts of a suspected variant. Ultimately, the diagnosis was made through a novel application of next-generation sequencing (NGS). NGS-based diagnostic approaches are becoming increasingly available to clinicians, and our case provides a framework and evidence for the utilisation of such testing paradigms in the diagnosis of a rare cause of neonatal cyanosis.

Hydroxycarbamide versus chronic transfusion for maintenance of transcranial doppler flow velocities in children with sickle cell anaemia-TCD With Transfusions Changing to Hydroxyurea (TWiTCH): a multicentre, open-label, phase 3, non-inferiority trial

BACKGROUND

For children with sickle cell anaemia and high transcranial doppler (TCD) flow velocities, regular blood transfusions can effectively prevent primary stroke, but must be continued indefinitely. The efficacy of hydroxycarbamide (hydroxyurea) in this setting is unknown; we performed the TWiTCH trial to compare hydroxyurea with standard transfusions.

METHODS

TWiTCH was a multicentre, phase 3, randomised, open-label, non-inferiority trial done at 26 paediatric hospitals and health centres in the USA and Canada. We enrolled children with sickle cell anaemia who were aged 4-16 years and had abnormal TCD flow velocities (≥ 200 cm/s) but no severe vasculopathy. After screening, eligible participants were randomly assigned 1:1 to continue standard transfusions (standard group) or hydroxycarbamide (alternative group). Randomisation was done at a central site, stratified by site with a block size of four, and an adaptive randomisation scheme was used to balance the covariates of baseline age and TCD velocity. The study was open-label, but TCD examinations were read centrally by observers masked to treatment assignment and previous TCD results. Participants assigned to standard treatment continued to receive monthly transfusions to maintain 30% sickle haemoglobin or lower, while those assigned to the alternative treatment started oral hydroxycarbamide at 20 mg/kg per day, which was escalated to each participant's maximum tolerated dose. The treatment period lasted 24 months from randomisation. The primary study endpoint was the 24 month TCD velocity calculated from a general linear mixed model, with the non-inferiority margin set at 15 cm/s. The primary analysis was done in the intention-to-treat population and safety was assessed in all patients who received at least one dose of assigned treatment. This study is registered with ClinicalTrials.gov, number NCT01425307.

FINDINGS

Between Sept 20, 2011, and April 17, 2013, 159 patients consented and enrolled in TWiTCH. 121 participants passed screening and were then randomly assigned to treatment (61 to transfusions and 60 to hydroxycarbamide). At the first scheduled interim analysis, non-inferiority was shown and the sponsor terminated the study. Final model-based TCD velocities were 143 cm/s (95% CI 140-146) in children who received standard transfusions and 138 cm/s (135-142) in those who received hydroxycarbamide, with a difference of 4·54 (0·10-8·98). Non-inferiority (p=8·82 × 10(-16)) and post-hoc superiority (p=0·023) were met. Of 29 new neurological events adjudicated centrally by masked reviewers, no strokes were identified, but three transient ischaemic attacks occurred in each group. Magnetic resonance brain imaging and angiography (MRI and MRA) at exit showed no new cerebral infarcts in either treatment group, but worsened vasculopathy in one participant who received standard transfusions. 23 severe adverse events in nine (15%) patients were reported for hydroxycarbamide and ten serious adverse events in six (10%) patients were reported for standard transfusions. The most common serious adverse event in both groups was vaso-occlusive pain (11 events in five [8%] patients with hydroxycarbamide and three events in one [2%] patient for transfusions).

INTERPRETATION

For high-risk children with sickle cell anaemia and abnormal TCD velocities who have received at least 1 year of transfusions, and have no MRA-defined severe vasculopathy, hydroxycarbamide treatment can substitute for chronic transfusions to maintain TCD velocities and help to prevent primary stroke.

FUNDING

National Heart, Lung, and Blood Institute, National Institutes of Health.

Effects of hydroxyurea treatment for patients with hemoglobin SC disease

Although hemoglobin SC (HbSC) disease is usually considered less severe than sickle cell anemia (SCA), which includes HbSS and HbS/β(0) -thalassemia genotypes, many patients with HbSC experience severe disease complications, including vaso-occlusive pain, acute chest syndrome, avascular necrosis, retinopathy, and poor quality of life. Fully 20 years after the clinical and laboratory efficacy of hydroxyurea was proven in adult SCA patients, the safety and utility of hydroxyurea treatment for HbSC patients remain unclear. Recent NHLBI evidence-based guidelines highlight this as a critical knowledge gap, noting HbSC accounts for ∼30% of sickle cell patients within the United States. To date, only 5 publications have reported short-term, incomplete, or conflicting laboratory and clinical outcomes of hydroxyurea treatment in a total of 71 adults and children with HbSC. We now report on a cohort of 133 adult and pediatric HbSC patients who received hydroxyurea, typically for recurrent vaso-occlusive pain. Hydroxyurea treatment was associated with a stable hemoglobin concentration; increased fetal hemoglobin (HbF) and mean corpuscular volume (MCV); and reduced white blood cell count (WBC), absolute neutrophil count (ANC), and absolute reticulocyte count (ARC). Reversible cytopenias occurred in 22% of patients, primarily neutropenia and thrombocytopenia. Painful events were reduced with hydroxyurea, more in patients >15 years old. These multicenter data support the safety and potentially salutary effects of hydroxyurea treatment for HbSC disease; however, a multicenter, placebo-controlled, Phase 3 clinical trial is needed to determine if hydroxyurea therapy has efficacy for patients with HbSC disease.

Effects of co-fermented Pleurotus eryngii stalk residues and soybean hulls by Aureobasidium pullulans on performance and intestinal morphology in broiler chickens

Soybean hulls are a by-product of soybean processing for oil and meal production; Pleurotus eryngii stalk residues (PESR) are by-products of the edible portion of the fruiting body enriched in bioactive metabolites. This study evaluated the effects of co-fermented PESR and soybean hulls with Aureobasidium pullulans on performance and intestinal morphology in broiler chickens. The in vitro experimental results showed that xylananse and mannanase activity of solid-state fermented soybean hulls (100% SBH) and soybean hulls partially replaced with PESR (75:25, SHP) reached peak at day 12; solid-state fermentation (SSF) enhanced the total phenolic content and trolox equivalency in both products as well. Additionally, FSHP had higher xylotriose and mannobiose levels than fermented FSBH did. A total of 400 broilers (Ross 308) were assigned randomly into four groups receiving the basal diet (control) or the basal diet supplemented with 0.5% fermented SBH (0.5% FSBH), 0.5% fermented SBHP (0.5% FSHP) and 1.0% fermented SBHP (1.0% FSHP) until 35 d of age, respectively. Results demonstrated that 0.5% FSHP addition increased body weight gain as compared with corresponding normal diet fed control in birds during entire experimental period. Compared with the control group, 0.5% FSHP group significantly increased the ratio of lactic acid bacteria to Clostridium perfringens in ceca as well as ileum villus height and jejunum villus height/crypt depth ratio of 35 d old birds. In conclusion, 0.5% FSHP supplementation in the diet could obtain not only improved body weight gain, but optimal intestinal morphology by exerting its bioactive metabolite properties when fed to broilers.

Liver iron concentration measurements by MRI in chronically transfused children with sickle cell anemia: baseline results from the TWiTCH trial

Noninvasive, quantitative, and accurate assessment of liver iron concentration (LIC) by MRI is useful for patients receiving transfusions, but R2 and R2* MRI techniques have not been systematically compared in sickle cell anemia (SCA). We report baseline LIC results from the TWiTCH trial, which compares hydroxyurea with blood transfusion treatment for primary stroke prophylaxis assessed by transcranial Doppler sonography in pediatric SCA patients. Liver R2 was collected and processed using a FDA-approved commercial process (FerriScan®), while liver R2* quality control and processing were performed by a Core Laboratory blinded to clinical site and patient data. Baseline LIC studies using both MRI techniques were available for 120 participants. LICR2* and LICR2 results were highly correlated (r(2)  = 0.93). A proportional bias of LIC(R2*)/LIC(R2), decreasing with average LIC, was observed. Systematic differences between LICR2* and LICR2 were also observed by MRI manufacturer. Importantly, LICR2* and LICR2 estimates had broad 95% limits of agreement with respect to each other. We recommend LICR2 and LICR2* not be used interchangeably in SCA patients to follow individual patient trends in iron burden.

Vitamin D deficiency and acute vaso-occlusive complications in children with sickle cell disease

BACKGROUND

Vitamin D is increasingly recognized for its roles in non-skeletal disorders. Patients with sickle cell disease (SCD) have a high prevalence of vitamin D deficiency but data are limited with respect to possible associations between low vitamin D and acute vaso-occlusive complications. We examined whether vitamin D deficiency is associated with acute pain and acute chest syndrome (ACS) in children with SCD.

PROCEDURE

A cross-sectional study was conducted in 95 children with SCD who had serum 25-hydroxyvitamin D (25-OHD) measured during comprehensive care examinations. History of acute pain and ACS within two years of obtaining 25-OHD was collected. Associations between 25-OHD levels and acute vaso-occlusive events were analyzed by logistic regression. Odds ratios and 95% confidence intervals were calculated for the risk of pain and ACS associated with vitamin D deficiency (25-OHD <20 ng/ml).

RESULTS

Subjects were 3-20 years old (median 10.6); 48 males, 47 females; 46 African, 49 Hispanic; 72 SS, 20 SC, 1 S/β(0) Thalassemia, and 2 S/β(+) Thalassemia. Median 25-OHD was 16 ng/ml. Fifty-six (59%) were vitamin D-deficient. Thirty-one (33%) and 29 (31%) had at least one episode of pain and ACS, respectively. Serum 25-OHD was significantly associated with pain (P = 0.0121) but not with ACS (P = 0.628). Of those with pain, 73% (23/31) were vitamin D-deficient while 26% (8/31) had 25-OHD ≥20 ng/ml (P = 0.04, OR = 2.7, 95%CI = 1.05-6.94).

CONCLUSIONS

Our findings emphasize the high prevalence of vitamin D deficiency and its potential association with acute pain in SCD. Correcting low vitamin D may offer a simple, low-cost intervention to help reduce acute vaso-occlusive complications.

Performance measures and racial/ethnic disparities in the treatment of substance use disorders

OBJECTIVE

A limited literature on racial/ethnic disparities in the treatment of substance use disorders suggests that quality of treatment may differ based on client's race/ethnicity. This study examined whether (a) disparities exist in the probability of treatment engagement, a performance measure for substance use disorders, and (b) treatment engagement is associated with similar reductions in likelihood of arrest for Whites, Blacks, Latinos, and American Indians.

METHOD

Adult clients who began an outpatient treatment episode in 2008 in public sector specialty treatment facilities in Connecticut, New York, Oklahoma, and Washington made up the sample (N = 108,654). Administrative treatment data were linked to criminal justice data. The criminal justice outcome was defined as an arrest within a year after beginning treatment. Engagement is defined as receiving a treatment service within 14 days of beginning a new outpatient treatment episode and at least two additional services within the next 30 days. Two-step Heckman probit models and hierarchical time-to-event models were used in the analyses.

RESULTS

Black clients in New York and American Indian clients in Washington had significantly lower likelihood of engagement than White clients. As moderators of engagement, race/ethnicity had inconsistent effects across states on the hazard of arrest.

CONCLUSIONS

Racial/ethnic minority groups may benefit from additional treatment support to reduce criminal justice involvement. States should examine whether disparities exist within their treatment system and incorporate disparities reduction in their quality improvement initiatives.

A performance measure for continuity of care after detoxification: relationship with outcomes

Administrative data from five states were used to examine whether continuity of specialty substance abuse treatment after detoxification predicts outcomes. We examined the influence of a 14-day continuity of care process measure on readmissions. Across multiple states, there was support that clients who received treatment for substance use disorders within 14-days after discharge from detoxification were less likely to be readmitted to detoxification. This was particularly true for reducing readmissions to another detoxification that was not followed with treatment and when continuity of care was in residential treatment. Continuity of care in outpatient treatment was related to a reduction in readmissions in some states, but not as often as when continuity of care occurred in residential treatment. A performance measure for continuity of care after detoxification is a useful tool to help providers monitor quality of care delivered and to alert them when improvement is needed.

Engagement in outpatient substance abuse treatment and employment outcomes

This study, a collaboration between an academic research center and Washington State's health, employment, and correction departments, investigates the extent to which treatment engagement, a widely adopted performance measure, is associated with employment, an important outcome for individuals receiving treatment for substance use disorders. Two-stage Heckman probit regressions were conducted using 2008 administrative data for 7,570 adults receiving publicly funded treatment. The first stage predicted employment in the year following the first treatment visit, and three separate second-stage models predicted the number of quarters employed, wages, and hours worked. Engagement as a main effect was not significant for any of the employment outcomes. However, for clients with prior criminal justice involvement, engagement was associated with both employment and higher wages following treatment. Clients with criminal justice involvement face greater challenge regarding employment, so the identification of any actionable step which increases the likelihood of employment or wages is an important result.

Regulatory B-cell compartment in transfused alloimmunized and non-alloimmunized patients with sickle cell disease

Transfusion therapy is a life-sustaining treatment for patients with sickle cell disease (SCD), but can cause serious complications including alloimmunization. We previously reported diminished regulatory T cells (Tregs) and skewed Th2 responses in alloimmunized SCD patients. We hypothesized that the B cell regulatory (Breg) compartment, which controls Treg and Th differentiation, may also be compromised in allosensitized SCD patients. Phenotypically, we did not find differences in the frequency or numbers of CD24(hi) CD38(hi) and CD24(hi) CD27(+) B cell subsets, both previously identified as human Bregs, between alloimmunized and non-alloimmunized SCD patients on regular transfusions. However, at the functional level, CD19+ B cells from alloimmunized SCD patients expressed lower levels of IL-10 following stimulation as compared with non-alloimmunized patients (P < 0.05), and had reduced ability in inhibiting autologous CD14+ monocyte TNF-α expression (P < 0.05). These findings suggest that Bregs from alloimmunized and non-alloimmunized SCD patients differ in their ability to produce IL-10 and dampen monocyte activation, all consistent with an altered immunoregulatory state in alloimmunized SCD patients.

Development and preliminary validation of a patient-reported outcome measure for swallowing after total laryngectomy (SOAL questionnaire)

OBJECTIVES

To develop and validate a laryngectomee-specific questionnaire to investigate swallowing function. This paper describes the generation of questionnaire items, pretesting with laryngectomees and a preliminary validation.

DESIGN

This study employed 2 phases: questionnaire development and questionnaire validation. Items were developed from patient (n = 10) and clinician (n = 6) focus groups. Content checking, acceptability and face validity were determined through pretesting with 10 laryngectomees and via consensus feedback from 35 speech and language therapists. During preliminary validation, the 17-item final questionnaire was administered to 3 different groups. Discrimination amongst groups was established by comparing questionnaire responses of a laryngectomee group (n = 19) with known dysphagic (n = 19) and non-dysphagic groups (n = 20). Questionnaire responses from the reference dysphagic group were compared with an instrumental assessment of swallowing, the modified barium swallow (MBS).

SETTING

Large urban teaching hospital.

PARTICIPANTS

Speech and language therapists, laryngectomees, non-dysphagic volunteers, post-radiotherapy dysphagic patients.

MAIN OUTCOME MEASURE

Preliminary validation of SOAL questionnaire.

RESULTS

Normal, laryngectomee and dysphagic groups had significantly different SOAL scores, as did laryngectomees with different degrees of swallowing impairment (Kruskall Wallis, P << 0.001). The subjective SOAL score had a strong positive correlation with the reference measure of ratings on the MBS (r = 0.5; P = 0.03).

CONCLUSIONS

The swallowing outcome after laryngectomy (SOAL) questionnaire is a simple, self-administered tool to assess swallowing function post-total laryngectomy. Further specific testing with a laryngectomy cohort is necessary for full validation. Its potential value lies in screening for dysphagia in clinics or during long-term follow-up of laryngectomees.

Experimental and theoretical investigations on photoabsorption and photoionization of trimethylphosphate in the vacuum-ultraviolet energy range

In this work, we report a joint experimental-theoretical investigation on interaction of vacuum-ultraviolet radiation with trimethylphosphate (TMP) molecule (C(3)H(9)O(4)P) in gas phase. This species together with tetrahydrofuran (THF) are model compounds of deoxyribose nucleic acids (DNA)/ribose nucleic acids (RNA) backbone. Absolute photoabsorption cross sections (σ(a)) and ionization yields (η) are measured using the double-ion-chamber technique in the 11.0-21.45 eV energy range. Photoionization (σ(i)) and neutral-decay (σ(n)) cross sections in absolute scale are also derived. Moreover, theoretical photoabsorption cross sections are calculated using the time-dependent density functional theory from the excitation threshold up to 16 eV. Good agreement between the present calculated and experimental photoabsorption cross sections in the 11.0-14.5 eV range is encouraging. Also, the present measured data of σ(a) and σ(i) for TMP are about 1.3 and 1.5 times of those of THF, respectively. Thus, the experimental evidences that the majority of strand breaks being located at sugar rings in the irradiated DNA/RNA backbone moiety may be induced by a possible migration of the hole, initially created at phosphate group, to the linked sugar groups. Finally, absolute partial photoionization cross sections are derived from the experimental time-of-flight mass spectra.

The Washington circle engagement performance measures' association with adolescent treatment outcomes

BACKGROUND

For adolescents, substance use disorder (SUD) treatment outcomes (e.g., abstinence, problematic behaviors) often cannot be measured soon enough to influence treatment trajectory. Although process measures (e.g., treatment engagement) can play an important role, it is essential to demonstrate their association with outcomes. This study explored the extent to which engagement in outpatient treatment was associated with outcomes and whether demographic/clinical characteristics moderated these relationships.

METHODS

This is a prospective study of adolescents (N=1491) who received outpatient treatment for SUDs at one of 28 treatment sites taking part in a national evidence-based practice implementation initiative. Information from the Global Appraisal of Individual Needs interviews at intake and six-month follow-up, as well as encounter data, were used. Adjusted hierarchical logistic models were used to estimate effects of engagement on six-month outcomes.

RESULTS

Sixty-one percent of adolescents engaged in outpatient treatment. Adolescents engaging in treatment had significantly lower likelihoods of reporting any substance use (OR 0.60, 95% CI 0.41, 0.87), alcohol use (OR 0.63, 95% CI 0.45, 0.87), heavy alcohol use (OR 0.53, 95% CI 0.33, 0.86), and marijuana use (OR 0.64, 95% CI 0.45, 0.93). This association of engagement with abstinence outcomes was not limited to any particular group. Treatment engagement, however, was not associated with adolescents' self-report of illegal activity or trouble controlling behavior at follow-up.

CONCLUSION

At the individual level, the Washington Circle engagement measure was a predictor of some positive outcomes for adolescents in outpatient treatment. Efforts to better engage adolescents in treatment could improve quality of care.

Racial and ethnic differences in substance abuse treatment initiation and engagement

This study examined variations by race and ethnicity in initiation and engagement, two performance measures of treatment for substance use disorders that focus on the timely receipt of services during the early stage of substance abuse treatment. Administrative data from the Oklahoma Department of Mental Health and Substance Abuse Services were linked with facility-level information from the National Survey of Substance Abuse Treatment Services. We found that Black clients were least likely to initiate treatment, but no race or ethnic differences in treatment engagement were found when compared by race or ethnicity. Most client and facility characteristics' association with initiation or engagement did not differ across racial or ethnic groups. Increased attention is needed to understand what may contribute to the differences and how to address them. This study also offers an approach that state agencies may implement for monitoring treatment quality and examining racial and ethnic disparities in substance abuse treatment services.

Adolescent treatment initiation and engagement in an evidence-based practice initiative

This study examined client and program factors predicting initiation and engagement for 2,191 adolescents at 28 outpatient substance abuse treatment sites implementing evidence-based treatments. Using Washington Circle criteria for treatment initiation and engagement, 76% of the sample initiated, with 59% engaging in treatment. Analyses used a 2-stage Heckman probit regression, accounting for within-site clustering, to identify factors predictive of initiation and engagement. Adolescents treated in a pay-for-performance (P4P) group were more likely to initiate, whereas adolescents in the race/ethnicity category labeled other (Native American, Asian, Pacific Islander, Native Alaskan, Native Hawaiian, mixed race/ethnicity), or who reported high truancy, were less likely to initiate. Race/ethnicity groups other than Latinos were equally likely to engage. Among White adolescents, each additional day from first treatment to next treatment reduced likelihood of engagement. Although relatively high initiation and engagement rates were achieved, the results suggest that attention to program and client factors may further improve compliance with these performance indicators.

Effects of chronic transfusions on abdominal sonographic abnormalities in children with sickle cell anemia

OBJECTIVE

To assess the effects of chronic erythrocyte transfusions on prevalence of sonographic incidence of organ damage in children with sickle cell anemia (SCA).

STUDY DESIGN

Children (N=148; mean age, 13.0 years) with SCA, receiving chronic transfusions (average, 7 years), underwent abdominal sonography at 25 institutions. After central imaging review, spleen, liver, and kidney measurements were compared with published normal values. Potential relations between ultrasound, clinical, and laboratory data were explored via analysis of variance, Student t test, and Cochran-Mantel-Haenzel tests of non-zero correlation.

RESULTS

Average spleen length was similar to normal children, but over one-third had spleen volumes >300 mL, 15 had previous splenectomy for splenomegaly, and 24 had abnormal splenic echotexture. Two-thirds had hepatobiliary disease; 37 had prior cholecystectomy, 46 had gallstones, and 16 had gallbladder sludge. Gallbladder disease correlated with older age (P=.002), longer liver length (P<.001), longer duration of transfusions (P=.034), and higher total bilirubin (P<.001). Liver (P<.001) and renal lengths (P≤.005) were larger than published norms.

CONCLUSIONS

In children with SCA, long-term transfusion therapy may not prevent development or progression of abdominal organ dysfunction.

Immune regulation in chronically transfused allo-antibody responder and nonresponder patients with sickle cell disease and β-thalassemia major

Red blood cell alloimmunization is a major complication of transfusion therapy. Host immune markers that can predict antibody responders remain poorly described. As regulatory T cells (Tregs) play a role in alloimmunization in mouse models, we analyzed the Treg compartment of a cohort of chronically transfused patients with sickle cell disease (SCD, n = 22) and β-thalassemia major (n = 8) with and without alloantibodies. We found reduced Treg activity in alloantibody responders compared with nonresponders as seen in mice. Higher circulating anti-inflammatory IL-10 levels and lower IFN-γ levels were detected in non-alloimmunized SCD patients. Stimulated sorted CD4+ cells from half of the alloimmunized patients had increased frequency of IL-4 expression compared with nonresponders, indicating a skewed T helper (Th) 2 humoral immune response in a subgroup of antibody responders. All patients had increased Th17 responses, suggesting an underlying inflammatory state. Although small, our study indicates an altered immunoregulatory state in alloantibody responders which may help future identification of potential molecular risk factors for alloimmunization.

Lessons from five states: public sector use of the Washington Circle performance measures

Five states (Connecticut, Massachusetts, New York, North Carolina, and Oklahoma) have incorporated the Washington Circle (WC) substance abuse performance measures in various ways into their quality improvement strategies. In this article, we focus on what other states and local providers might learn from these states' experiences as they consider using WC performance measures. Using a case study approach, we report that the use of WC measures differs across these five states, although there are important common themes required for adoption and sustainability of performance measures, which include leadership, evaluation of specification and use of measures over time, state-specific adaptation of the WC measure specifications, collaboration with consultants and partners, inclusion of WC measures in the context of other initiatives, reporting to providers and the public, and data and resource requirements. As additional states adopt some of the WC measures, or adopt other performance measurement approaches, these states' experiences could help them to develop implementations based on their particular needs.

Role of adsorption effects on absolute electron-molecule cross-section calibration using the relative flow technique

In this work, we report an experimental investigation on relative flow-rate determination for vapors. The mechanism of adsorption-desorption of vapors on surfaces is considered. In contrast to previous investigations, our study shows that the adsorption of vapors on surfaces may significantly affect the flow-rate determination and consequently the measured cross sections. Particularly, for water, it can result in an overestimation of 35% in the cross sections.

Doppler-defined pulmonary hypertension and the risk of death in children with sickle cell disease followed for a mean of three years

Pulmonary hypertension (PH) is associated with increased mortality in adults with sickle cell disease (SCD), but its prognostic significance in children is unknown. Eighty-eight children with SCD were followed after echocardiographic screening for PH. After a mean follow-up of 3 years, all 18 subjects with PH were alive. In our children, as in adults with SCD, PH was associated with increased haemolysis. In contrast, our subjects with PH did not have overt systemic disease observed in adults. PH may be a manifestation of progressive organ damage from chronic haemolysis and systemic vasculopathy that ultimately leads to early death in adulthood.

The Washington Circle continuity of care performance measure: predictive validity with adolescents discharged from residential treatment

This study examined the predictive validity of the Washington Circle (WC) continuity of care after long-term residential treatment performance measure, as well as the impact of assertive continuing care interventions on achieving continuity of care. This measure is a process measure that focuses on timely delivery of a minimal floor of services that are necessary to provide sufficient quality of treatment but should not be construed to be the optimal continuity of care after residential treatment for any specific adolescent. Participants included 342 adolescents who were admitted to long-term residential treatment and randomly assigned to either standard continuing care or an assertive continuing care condition. Overall, results provide initial support for the WC continuity of care after residential treatment performance measure as a useful predictor of 3-month recovery status. In addition, assignment to an assertive continuing care condition was found to significantly increase the likelihood of achieving continuity of care.

Probing molecular frame photoionization via laser generated high-order harmonics from aligned molecules

Present experiments cannot measure molecular frame photoelectron angular distributions (MFPAD) for ionization from the outermost valence orbitals of molecules. We show that the details of MFPAD can be retrieved with high-order harmonics generated by infrared lasers from aligned molecules. Using accurately calculated photoionization transition dipole moments for fixed-in-space molecules, we show that the dependence of the magnitude and phase of the high-order harmonics on the alignment angle of the molecules observed in recent experiments can be quantitatively reproduced. This result provides the needed theoretical basis for ultrafast dynamic chemical imaging using infrared laser pulses.

Adapting Washington Circle performance measures for public sector substance abuse treatment systems

The Washington Circle, a group focused on developing and disseminating performance measures for substance abuse services, developed three such measures for private health plans. In this article, we explore whether these measures are appropriate for meeting measurement goals in the public sector and feasible to calculate in the public sector using data collected for administrative purposes by state and local substance abuse and/or mental health agencies. Working collaboratively, 12 states specified revised measures and 6 states pilot tested them. Two measures were retained from the original specifications: initiation of treatment and treatment engagement. Additional measures were focused on continuity of care after assessment, detoxification, residential or inpatient care. These data demonstrate that state agencies can calculate performance measures from routinely available information and that there is wide variability in these indicators. Ongoing research is needed to examine the reasons for these results, which might include lack of patient interest or commitment, need for quality improvement efforts, or financial issues.

Chronic transfusion practice for children with sickle cell anaemia and stroke

Chronic transfusions to maintain haemoglobin S (HbS) < or =30% are the mainstay of treatment for children with sickle cell anaemia (SCA) and previous stroke. This HbS target is often hard to maintain, however, and values achieved in current practice are unknown. In preparation for the Phase III Stroke With Transfusions Changing to Hydroxyurea (SWiTCH) trial, we collected data on 295 children with SCA and stroke who received transfusions at 23 institutions. The overall average pre-transfusion %HbS was 35 +/- 11% (institutional range 22-51%). Receiving scheduled transfusions on time was the most predictive variable for maintaining HbS at the < or =30% goal.