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Coleman KD, McKinley K, Ellison AM, Alpern ER, Hariharan S, Topoz I, Wurtz M, Nielsen B, Cook LJ, Morris CR, Brandow AM, Campbell AD, Liem RI, Nuss R, Quinn CT, Thompson AA, Villella A, King AA, Baumann A, Frankenberger W, Brousseau DC. Return visit rates after an emergency department discharge for children with sickle cell pain episodes. Pediatr Blood Cancer 2023; 70:e30553. [PMID: 37458568 DOI: 10.1002/pbc.30553] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/20/2023] [Accepted: 06/28/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND High return visit rates after hospitalization for people with sickle cell disease (SCD) have been previously established. Due to a lack of multicenter emergency department (ED) return visit rate data, the return visit rate following ED discharge for pediatric SCD pain treatment is currently unknown. PROCEDURE A seven-site retrospective cohort study of discharged ED visits for pain by children with SCD was conducted using the Pediatric Emergency Care Applied Research Network Registry. Visits between January 2017 and November 2021 were identified using previously validated criteria. The primary outcome was the 14-day return visit rate, with 3- and 7-day rates also calculated. Modified Poisson regression was used to analyze associations for age, sex, initial hospitalization rate, and a visit during the COVID-19 pandemic with return visit rates. RESULTS Of 2548 eligible ED visits, approximately 52% were patients less than 12 years old, 50% were female, and over 95% were non-Hispanic Black. The overall 14-day return visit rate was 29.1% (95% confidence interval [CI]: 27.4%-30.9%; site range 22.7%-31.7%); the 7- and 3-day return visit rates were 23.0% (95% CI: 21.3%-24.6%) and 16.7% (95% CI: 15.3%-18.2%), respectively. Younger children had slightly lower 14-day return visit rates (27.3% vs. 31.1%); there were no associations for site hospitalization rate, sex, and a visit occurring during the pandemic with 14-day returns. CONCLUSION Nearly 30% of ED discharged visits after SCD pain treatment had a return visit within 14 days. Increased efforts are needed to identify causes for high ED return visit rates and ensure optimal ED and post-ED care.
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Affiliation(s)
- Keli D Coleman
- Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin and the Children's Research Institute of Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Kenneth McKinley
- Children's National Medical Center, Washington, District of Columbia, USA
| | - Angela M Ellison
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth R Alpern
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Selena Hariharan
- University of Cincinnati College of Medicine, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Irina Topoz
- Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Morgan Wurtz
- Nationwide Children's Hospital, Columbus, Ohio, USA
| | | | | | - Claudia R Morris
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Amanda M Brandow
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplantation, Medical College of Wisconsin and Children's Research Institute of Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Andrew D Campbell
- Center for Cancer and Blood Disorders, Children's National Hospital, Washington, District of Columbia, USA
| | - Robert I Liem
- Division of Hematology, Oncology & Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Rachelle Nuss
- Center for Cancer and Blood Disorders, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Charles T Quinn
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alexis A Thompson
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Allison A King
- Pediatric Hematology/Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ana Baumann
- Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - David C Brousseau
- Nemours Children's Health and Sidney Kimmel Medical College at Thomas Jefferson University, Wilmington, Delaware, USA
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Lisk C, Cendali F, Setua S, Thangaraju K, Pak DI, Swindle D, Dzieciatkowska M, Gamboni F, Hassell K, Nuss R, George G, Davizon-Castillo P, Buehler PW, D'Alessandro A, Irwin DC. Metabolic and Proteomic Divergence Is Present in Circulating Monocytes and Tissue-Resident Macrophages from Berkeley Sickle Cell Anemia and β-Thalassemia Mice. J Proteome Res 2023; 22:2925-2935. [PMID: 37606205 DOI: 10.1021/acs.jproteome.3c00224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
Sickle cell disease and β-thalassemia represent hemoglobinopathies arising from dysfunctional or underproduced β-globin chains, respectively. In both diseases, red blood cell injury and anemia are the impetus for end organ injury. Because persistent erythrophagocytosis is a hallmark of these genetic maladies, it is critical to understand how macrophage phenotype polarizations in tissue compartments can inform on disease progression. Murine models of sickle cell disease and β-thalassemia allow for a basic understanding of the mechanisms and provide for translation to human disease. A multi-omics approach to understanding the macrophage metabolism and protein changes in two murine models of β-globinopathy was performed on peripheral blood mononuclear cells as well as spleen and liver macrophages isolated from Berkley sickle cell disease (Berk-ss) and heterozygous B1/B2 globin gene deletion (Hbbth3/+) mice. The results from these experiments revealed that the metabolome and proteome of macrophages are polarized to a distinct phenotype in Berk-ss and Hbbth3/+ compared with each other and their common-background mice (C57BL6/J). Further, spleen and liver macrophages revealed distinct disease-specific phenotypes, suggesting that macrophages become differentially polarized and reprogrammed within tissue compartments. We conclude that tissue recruitment, polarization, and metabolic and proteomic reprogramming of macrophages in Berk-ss and Hbbth3/+ mice may be relevant to disease progression in other tissue.
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Affiliation(s)
- Christina Lisk
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado 80045, United States
| | - Francesca Cendali
- Department of Biochemistry & Molecular Genetics, Graduate School, University of Colorado, Anschutz, Medical Campus, Aurora, Colorado 80045, United States
| | - Saini Setua
- The Center for Blood Oxygen Transport, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland 21201, United States
| | - Kiruphararan Thangaraju
- The Center for Blood Oxygen Transport, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland 21201, United States
| | - David I Pak
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado 80045, United States
| | - Delaney Swindle
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado 80045, United States
| | - Monika Dzieciatkowska
- Department of Biochemistry & Molecular Genetics, Graduate School, University of Colorado, Anschutz, Medical Campus, Aurora, Colorado 80045, United States
| | - Fabia Gamboni
- Department of Biochemistry & Molecular Genetics, Graduate School, University of Colorado, Anschutz, Medical Campus, Aurora, Colorado 80045, United States
| | - Kathryn Hassell
- Division of Hematology Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, Colorado 80045, United States
| | - Rachelle Nuss
- Division of Hematology Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, Colorado 80045, United States
| | - Gemlyn George
- Division of Hematology Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, Colorado 80045, United States
| | - Pavel Davizon-Castillo
- Department of Pediatrics, Hemophilia and Thrombosis Center, University of Colorado, Anschutz, Medical Campus, Aurora, Colorado 80045, United States
| | - Paul W Buehler
- The Center for Blood Oxygen Transport, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland 21201, United States
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland 21201, United States
| | - Angelo D'Alessandro
- Department of Biochemistry & Molecular Genetics, Graduate School, University of Colorado, Anschutz, Medical Campus, Aurora, Colorado 80045, United States
| | - David C Irwin
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado 80045, United States
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Lisk C, Cendali F, Pak DI, Swindle D, Hassell K, Nuss R, George G, Davizon-Castillo P, Buehler PW, D’Alessandro A, Irwin DC. Moderate hypoxia induces metabolic divergence in circulating monocytes and tissue resident macrophages from Berkeley sickle cell anemia mice. Front Med (Lausanne) 2023; 10:1149005. [PMID: 37502360 PMCID: PMC10370499 DOI: 10.3389/fmed.2023.1149005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/09/2023] [Indexed: 07/29/2023] Open
Abstract
Introduction Human and murine sickle cell disease (SCD) associated pulmonary hypertension (PH) is defined by hemolysis, nitric oxide depletion, inflammation, and thrombosis. Further, hemoglobin (Hb), heme, and iron accumulation are consistently observed in pulmonary adventitial macrophages at autopsy and in hypoxia driven rodent models of SCD, which show distribution of ferric and ferrous Hb as well as HO-1 and ferritin heavy chain. The anatomic localization of these macrophages is consistent with areas of significant vascular remodeling. However, their contributions toward progressive disease may include unique, but also common mechanisms, that overlap with idiopathic and other forms of pulmonary hypertension. These processes likely extend to the vasculature of other organs that are consistently impaired in advanced SCD. Methods To date, limited information is available on the metabolism of macrophages or monocytes isolated from lung, spleen, and peripheral blood in humans or murine models of SCD. Results Here we hypothesize that metabolism of macrophages and monocytes isolated from this triad of tissue differs between Berkley SCD mice exposed for ten weeks to moderate hypobaric hypoxia (simulated 8,000 ft, 15.4% O2) or normoxia (Denver altitude, 5000 ft) with normoxia exposed wild type mice evaluated as controls. Discussion This study represents an initial set of data that describes the metabolism in monocytes and macrophages isolated from moderately hypoxic SCD mice peripheral lung, spleen, and blood mononuclear cells.
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Affiliation(s)
- Christina Lisk
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver–Anschutz Medical Campus, Aurora, CO, United States
| | - Francesca Cendali
- Department of Biochemistry and Molecular Genetics, Graduate School, University of Colorado, Anschutz, Medical Campus, Aurora, CO, United States
| | - David I. Pak
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver–Anschutz Medical Campus, Aurora, CO, United States
| | - Delaney Swindle
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver–Anschutz Medical Campus, Aurora, CO, United States
| | - Kathryn Hassell
- Division of Hematology Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, United States
| | - Rachelle Nuss
- Division of Hematology Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, United States
| | - Gemlyn George
- Division of Hematology Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, United States
| | - Pavel Davizon-Castillo
- Department of Pediatrics, Hemophilia and Thrombosis Center, University of Colorado Anschutz, Medical Campus, Aurora, CO, United States
| | - Paul W. Buehler
- The Center for Blood Oxygen Transport, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Angelo D’Alessandro
- Department of Biochemistry and Molecular Genetics, Graduate School, University of Colorado, Anschutz, Medical Campus, Aurora, CO, United States
| | - David C. Irwin
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver–Anschutz Medical Campus, Aurora, CO, United States
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Fraley CE, Neiman JS, Feddersen CR, James C, Jones TG, Mikkelsen M, Nuss R, Schlenz AM, Winters AC, Green AL, Compas BE. Identifying patterns of neurocognitive dysfunction through direct comparison of children with leukemia, central nervous system tumors, and sickle cell disease. Pediatr Blood Cancer 2023; 70:e30299. [PMID: 37036272 PMCID: PMC10546486 DOI: 10.1002/pbc.30299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/06/2023] [Accepted: 02/23/2023] [Indexed: 04/11/2023]
Abstract
PURPOSE To quantify and compare the magnitude and type of neurocognitive dysfunction in at-risk children with central nervous system (CNS) tumors, acute lymphoblastic leukemia (ALL), and sickle cell disease (SCD) using a common instrument and metric to directly compare these groups with each other. METHODS Fifty-three participants between the ages of 7 and 12 years (n = 27 ALL, n = 11 CNS tumor, n = 15 SCD) were enrolled and assessed using the NIH Toolbox Cognition Battery (NIHTCB). Participants with ALL or CNS tumor were 0-18 months posttherapy, while participants with SCD possessed the SS or Sβ0 genotype, took hydroxyurea, and had no known history of stroke. RESULTS Independent sample t-tests showed that participants with ALL and CNS tumor experienced greatest deficits in processing speed (ALL d = -0.96; CNS tumor d = -1.2) and inhibitory control and attention (ALL d = -0.53; CNS tumor d = -0.97) when compared with NIHTCB normative data. Participants with SCD experienced deficits in cognitive flexibility only (d = -0.53). Episodic memory was relatively spared in all groups (d = -0.03 to -0.32). There were no significant differences in function when groups were compared directly with each other by analysis of variance. CONCLUSIONS Use of a common metric to quantify the magnitude and type of neurocognitive dysfunction across at-risk groups of participants by disease shows that participants perform below age-expected norms in multiple domains and experience dysfunction differently than one another. This approach highlights patterns of dysfunction that can inform disease- and domain-specific interventions.
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Affiliation(s)
- Claire E Fraley
- Center for Cancer and Blood Disorders, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jamie S Neiman
- Center for Cancer and Blood Disorders, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Charlotte R Feddersen
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Claire James
- Department of Biology, Carleton College, Northfield, Minnesota, USA
| | - Taylor G Jones
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Margit Mikkelsen
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Rachelle Nuss
- Center for Cancer and Blood Disorders, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Alyssa M Schlenz
- Developmental Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Amanda C Winters
- Center for Cancer and Blood Disorders, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Adam L Green
- Center for Cancer and Blood Disorders, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Bruce E Compas
- Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee, USA
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5
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Thangaraju K, Setua S, Lisk C, Swindle D, Stephenson D, Dzieciatkowska M, Lamb DR, Moitra P, Pak D, Hassell K, George G, Nuss R, Davizon-Castillo P, Stenmark KR, D’Alessandro A, Irwin DC, Buehler PW. Extracellular Vesicle Size Reveals Cargo Specific to Coagulation and Inflammation in Pediatric and Adult Sickle Cell Disease. Clin Appl Thromb Hemost 2023; 29:10760296231186144. [PMID: 37469147 PMCID: PMC10363884 DOI: 10.1177/10760296231186144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/02/2023] [Accepted: 06/18/2023] [Indexed: 07/21/2023] Open
Abstract
Aberrant coagulation in sickle cell disease (SCD) is linked to extracellular vesicle (EV) exposure. However, there is no consensus on the contributions of small EVs (SEVs) and large EVs (LEVs) toward underlying coagulopathy or on their molecular cargo. The present observational study compared the thrombin potential of SEVs and LEVs isolated from the plasma of stable pediatric and adult SCD patients. Further, EV lipid and protein contents were analyzed to define markers consistent with activation of thrombin and markers of underlying coagulopathy. Results suggested that LEVs-but not SEVs-from pediatrics and adults similarly enhanced phosphatidylserine (PS)-dependent thrombin generation, and cell membrane procoagulant PS (18:0;20:4 and 18:0;18:1) were the most abundant lipids found in LEVs. Further, LEVs showed activated coagulation in protein pathway analyses, while SEVs demonstrated high levels of cholesterol esters and a protein pathway analysis that identified complement factors and inflammation. We suggest that thrombin potential of EVs from both stable pediatric and adult SCD patients is similarly dependent on size and show lipid and protein contents that identify underlying markers of coagulation and inflammation.
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Affiliation(s)
- Kiruphagaran Thangaraju
- Department of Pediatrics, Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Saini Setua
- Department of Pediatrics, Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christina Lisk
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO, USA
| | - Delaney Swindle
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel Stephenson
- Department of Biochemistry & Molecular Genetics, Graduate School, University of Colorado, Anschutz, Medical Campus, Aurora, CO, USA
| | - Monika Dzieciatkowska
- Department of Biochemistry & Molecular Genetics, Graduate School, University of Colorado, Anschutz, Medical Campus, Aurora, CO, USA
| | - Derek R. Lamb
- Department of Pediatrics, Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Parikshit Moitra
- Department of Pediatrics, Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David Pak
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO, USA
| | - Kathryn Hassell
- Division of Hematology Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - Gemlyn George
- Division of Hematology Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - Rachelle Nuss
- Division of Hematology Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
- Department of Pediatrics, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Pavel Davizon-Castillo
- Department of Pediatrics, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Kurt R. Stenmark
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO, USA
- Department of Pediatrics, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Angelo D’Alessandro
- Department of Biochemistry & Molecular Genetics, Graduate School, University of Colorado, Anschutz, Medical Campus, Aurora, CO, USA
| | - David C. Irwin
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO, USA
| | - Paul W. Buehler
- Department of Pediatrics, Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
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7
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Underdown MJ, Nuss R. Thrombocytopenia in a teen with sickle cell disease following COVID-19 vaccination. Pediatr Blood Cancer 2021; 68:e29271. [PMID: 34331506 PMCID: PMC8441926 DOI: 10.1002/pbc.29271] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 07/15/2021] [Accepted: 07/18/2021] [Indexed: 12/21/2022]
Affiliation(s)
- M. Jane Underdown
- Center for Cancer and Blood DisordersDepartment of PediatricsChildren's Hospital of Colorado and University of ColoradoAuroraColoradoUSA
| | - Rachelle Nuss
- Center for Cancer and Blood DisordersDepartment of PediatricsChildren's Hospital of Colorado and University of ColoradoAuroraColoradoUSA
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Buehler PW, Swindle D, Pak DI, Fini MA, Hassell K, Nuss R, Wilkerson RB, D’Alessandro A, Irwin DC. Murine models of sickle cell disease and beta-thalassemia demonstrate pulmonary hypertension with distinctive features. Pulm Circ 2021; 11:20458940211055996. [PMID: 34777785 PMCID: PMC8579334 DOI: 10.1177/20458940211055996] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/21/2021] [Indexed: 01/26/2023] Open
Abstract
Sickle cell anemia and β-thalassemia intermedia are very different genetically determined hemoglobinopathies predisposing to pulmonary hypertension. The etiologies responsible for the associated development of pulmonary hypertension in both diseases are multi-factorial with extensive mechanistic contributors described. Both sickle cell anemia and β-thalassemia intermedia present with intra and extravascular hemolysis. And because sickle cell anemia and β-thalassemia intermedia share features of extravascular hemolysis, macrophage iron excess and anemia we sought to characterize the common features of the pulmonary hypertension phenotype, cardiac mechanics, and function as well as lung and right ventricular metabolism. Within the concept of iron, we have defined a unique pulmonary vascular iron accumulation in lungs of sickle cell anemia pulmonary hypertension patients at autopsy. This observation is unlike findings in idiopathic or other forms of pulmonary arterial hypertension. In this study, we hypothesized that a common pathophysiology would characterize the pulmonary hypertension phenotype in sickle cell anemia and β-thalassemia intermedia murine models. However, unlike sickle cell anemia, β-thalassemia is also a disease of dyserythropoiesis, with increased iron absorption and cellular iron extrusion. This process is mediated by high erythroferrone and low hepcidin levels as well as dysregulated iron transport due transferrin saturation, so there may be differences as well. Herein we describe common and divergent features of pulmonary hypertension in aged Berk-ss (sickle cell anemia) and Hbbth/3+ (intermediate β-thalassemia) mice and suggest translational utility as proof-of-concept models to study pulmonary hypertension therapeutics specific to genetic anemias.
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Affiliation(s)
- Paul W. Buehler
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
- The Center for Blood Oxygen Transport, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
- Paul W. Buehler, Department of Pathology University of Maryland School of Medicine, HSF III, 8th Floor, Room 8180, Baltimore, MD 21201, USA. David C. Irwin, Department of Cardiology, University of Colorado Anschutz, Medical Campus Research Building 2, B133, Room 8121 Aurora, Colorado 80045, USA.
| | - Delaney Swindle
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver – Anschutz Medical Campus, Aurora, CO, USA
| | - David I. Pak
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver – Anschutz Medical Campus, Aurora, CO, USA
| | - Mehdi A. Fini
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver – Anschutz Medical Campus, Aurora, CO, USA
| | - Kathryn Hassell
- Division of Hematology Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - Rachelle Nuss
- Division of Hematology Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - Rebecca B. Wilkerson
- Division of Hematology Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - Angelo D’Alessandro
- Division of Hematology Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - David C. Irwin
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver – Anschutz Medical Campus, Aurora, CO, USA
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9
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Buehler PW, Swindle D, Pak DI, Ferguson SK, Majka SM, Karoor V, Moldovan R, Sintas C, Black J, Gentinetta T, Buzzi RM, Vallelian F, Wassmer A, Edler M, Bain J, Schu D, Hassell K, Nuss R, Schaer DJ, Irwin DC. Hemopexin dosing improves cardiopulmonary dysfunction in murine sickle cell disease. Free Radic Biol Med 2021; 175:95-107. [PMID: 34478834 PMCID: PMC9231663 DOI: 10.1016/j.freeradbiomed.2021.08.238] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/26/2021] [Accepted: 08/29/2021] [Indexed: 01/13/2023]
Abstract
Hemopexin (Hpx) is a crucial defense protein against heme liberated from degraded hemoglobin during hemolysis. High heme stress creates an imbalance in Hpx bioavailability, favoring heme accumulation and downstream pathophysiological responses leading to cardiopulmonary disease progression in sickle cell disease (SCD) patients. Here, we evaluated a model of murine SCD, which was designed to accelerate red blood cell sickling, pulmonary hypertension, right ventricular dysfunction, and exercise intolerance by exposure of the mice to moderate hypobaric hypoxia. The sequence of pathophysiology in this model tracks with circulatory heme accumulation, lipid oxidation, extensive remodeling of the pulmonary vasculature, and fibrosis. We hypothesized that Hpx replacement for an extended period would improve exercise tolerance measured by critical speed as a clinically meaningful therapeutic endpoint. Further, we sought to define the effects of Hpx on upstream cardiopulmonary function, histopathology, and tissue oxidation. Our data shows that tri-weekly administrations of Hpx for three months dose-dependently reduced heme exposure and pulmonary hypertension while improving cardiac pressure-volume relationships and exercise tolerance. Furthermore, Hpx administration dose-dependently attenuated pulmonary fibrosis and oxidative modifications in the lung and myocardium of the right ventricle. Observations in our SCD murine model are consistent with pulmonary vascular and right ventricular pathology at autopsy in SCD patients having suffered from severe pulmonary hypertension, right ventricular dysfunction, and sudden cardiac death. This study provides a translational evaluation supported by a rigorous outcome analysis demonstrating therapeutic proof-of-concept for Hpx replacement in SCD.
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Affiliation(s)
- Paul W Buehler
- University of Maryland, Department of Pathology and the Center for Blood Oxygen Transport, Department of Pediatrics, School of Medicine, Baltimore, MD, USA.
| | - Delaney Swindle
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - David I Pak
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Scott K Ferguson
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Department of Kinesiology and Exercise Sciences, College of Natural and Health Sciences, University of Hawaii at Hilo, Hilo, HI, USA
| | - Susan M Majka
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Hospital, Denver, CO, USA
| | - Vijaya Karoor
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Radu Moldovan
- Advanced Light Microscopy Core, CU Anschutz Medical Campus, Aurora,, CO, USA
| | - Chantal Sintas
- Department of Pathology and Laboratory Medicine at Children's Hospital Colorado, USA
| | - Jennifer Black
- Department of Pathology, Pediatrics, University of Colorado School of Medicine, USA
| | | | - Raphael M Buzzi
- Division of Internal Medicine, University and University Hospital of Zurich, Zurich, Switzerland
| | - Florence Vallelian
- Division of Internal Medicine, University and University Hospital of Zurich, Zurich, Switzerland
| | | | - Monika Edler
- CSL Behring AG, Research and Development, Bern, Switzerland
| | - Joseph Bain
- CSL Behring AG, Innovations GmbH, Marburg, Germany
| | - Daniel Schu
- CSL Behring AG, Innovations GmbH, Marburg, Germany
| | - Kathryn Hassell
- Division of Hematology Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora,, CO, USA
| | - Rachelle Nuss
- Division of Hematology Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora,, CO, USA
| | - Dominik J Schaer
- Division of Internal Medicine, University and University Hospital of Zurich, Zurich, Switzerland
| | - David C Irwin
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA.
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Karoor V, Swindle D, Pak DI, Strassheim D, Fini MA, Dempsey E, Stenmark KR, Hassell K, Nuss R, Buehler PW, Irwin DC. Evidence supporting a role for circulating macrophages in the regression of vascular remodeling following sub-chronic exposure to hemoglobin plus hypoxia. Pulm Circ 2021; 11:20458940211056806. [PMID: 34777787 PMCID: PMC8573496 DOI: 10.1177/20458940211056806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/12/2021] [Indexed: 11/15/2022] Open
Abstract
Macrophages are a heterogeneous population with both pro- and anti-inflammatory functions play an essential role in maintaining tissue homeostasis, promoting inflammation under pathological conditions, and tissue repair after injury. In pulmonary hypertension, the M1 phenotype is more pro-inflammatory compared to the M2 phenotype, which is involved in tissue repair. The role of macrophages in the initiation and progression of pulmonary hypertension is well studied. However, their role in the regression of established pulmonary hypertension is not well known. Rats chronically exposed to hemoglobin (Hb) plus hypoxia (HX) share similarities to humans with pulmonary hypertension associated with hemolytic disease, including the presence of a unique macrophage phenotype surrounding distal vessels that are associated with vascular remodeling. These lung macrophages are characterized by high iron content, HO-1, ET-1, and IL-6, and are recruited from the circulation. Depletion of macrophages in this model prevents the development of pulmonary hypertension and vascular remodeling. In this study, we specifically investigate the regression of pulmonary hypertension over a four-week duration after rats were removed from Hb + HX exposure with and without gadolinium chloride administration. Withdrawal of Hb + HX reversed systolic pressures and right ventricular function after Hb + Hx exposure in four weeks. Our data show that depleting circulating monocytes/macrophages during reversal prevents complete recovery of right ventricular systolic pressure and vascular remodeling in this rat model of pulmonary hypertension at four weeks post exposure. The data presented offer a novel insight into the role of macrophages in the processes of pulmonary hypertension regression in a rodent model of Hb + Hx-driven disease.
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Affiliation(s)
- Vijaya Karoor
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
- Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Delaney Swindle
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - David I Pak
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Derek Strassheim
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Mehdi A Fini
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Edward Dempsey
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
- Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Kurt R Stenmark
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Kathryn Hassell
- Division of Hematology Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - Rachelle Nuss
- Division of Hematology Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - Paul W. Buehler
- Department of Pathology, University of Maryland, Baltimore, MD, USA
- The Center for Blood Oxygen Transport, Department of Pediatrics, School of Medicine, Baltimore, MD, USA
| | - David C. Irwin
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
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11
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Casella JF, Barton BA, Kanter J, Black LV, Majumdar S, Inati A, Wali Y, Drachtman RA, Abboud MR, Kilinc Y, Fuh BR, Al-Khabori MK, Takemoto CM, Salman E, Sarnaik SA, Shah N, Morris CR, Keates-Baleeiro J, Raj A, Alvarez OA, Hsu LL, Thompson AA, Sisler IY, Pace BS, Noronha SA, Lasky JL, de Julian EC, Godder K, Thornburg CD, Kamberos NL, Nuss R, Marsh AM, Owen WC, Schaefer A, Tebbi CK, Chantrain CF, Cohen DE, Karakas Z, Piccone CM, George A, Fixler JM, Singleton TC, Moulton T, Quinn CT, de Castro Lobo CL, Almomen AM, Goyal-Khemka M, Maes P, Emanuele M, Gorney RT, Padgett CS, Parsley E, Kronsberg SS, Kato GJ, Gladwin MT. Effect of Poloxamer 188 vs Placebo on Painful Vaso-Occlusive Episodes in Children and Adults With Sickle Cell Disease: A Randomized Clinical Trial. JAMA 2021; 325:1513-1523. [PMID: 33877274 PMCID: PMC8058640 DOI: 10.1001/jama.2021.3414] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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: 12/13/2022]
Abstract
IMPORTANCE Although effective agents are available to prevent painful vaso-occlusive episodes of sickle cell disease (SCD), there are no disease-modifying therapies for ongoing painful vaso-occlusive episodes; treatment remains supportive. A previous phase 3 trial of poloxamer 188 reported shortened duration of painful vaso-occlusive episodes in SCD, particularly in children and participants treated with hydroxyurea. OBJECTIVE To reassess the efficacy of poloxamer 188 for vaso-occlusive episodes. DESIGN, SETTING, AND PARTICIPANTS Phase 3, randomized, double-blind, placebo-controlled, multicenter, international trial conducted from May 2013 to February 2016 that included 66 hospitals in 12 countries and 60 cities; 388 individuals with SCD (hemoglobin SS, SC, S-β0 thalassemia, or S-β+ thalassemia disease) aged 4 to 65 years with acute moderate to severe pain typical of painful vaso-occlusive episodes requiring hospitalization were included. INTERVENTIONS A 1-hour 100-mg/kg loading dose of poloxamer 188 intravenously followed by a 12-hour to 48-hour 30-mg/kg/h continuous infusion (n = 194) or placebo (n = 194). MAIN OUTCOMES AND MEASURES Time in hours from randomization to the last dose of parenteral opioids among all participants and among those younger than 16 years as a separate subgroup. RESULTS Of 437 participants assessed for eligibility, 388 were randomized (mean age, 15.2 years; 176 [45.4%] female), the primary outcome was available for 384 (99.0%), 15-day follow-up contacts were available for 357 (92.0%), and 30-day follow-up contacts were available for 368 (94.8%). There was no significant difference between the groups for the mean time to last dose of parenteral opioids (81.8 h for the poloxamer 188 group vs 77.8 h for the placebo group; difference, 4.0 h [95% CI, -7.8 to 15.7]; geometric mean ratio, 1.2 [95% CI, 1.0-1.5]; P = .09). Based on a significant interaction of age and treatment (P = .01), there was a treatment difference in time from randomization to last administration of parenteral opioids for participants younger than 16 years (88.7 h in the poloxamer 188 group vs 71.9 h in the placebo group; difference, 16.8 h [95% CI, 1.7-32.0]; geometric mean ratio, 1.4 [95% CI, 1.1-1.8]; P = .008). Adverse events that were more common in the poloxamer 188 group than the placebo group included hyperbilirubinemia (12.7% vs 5.2%); those more common in the placebo group included hypoxia (12.0% vs 5.3%). CONCLUSIONS AND RELEVANCE Among children and adults with SCD, poloxamer 188 did not significantly shorten time to last dose of parenteral opioids during vaso-occlusive episodes. These findings do not support the use of poloxamer 188 for vaso-occlusive episodes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01737814.
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Affiliation(s)
- James F. Casella
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Julie Kanter
- Medical University of South Carolina, Charleston
- University of Alabama at Birmingham, Birmingham
| | - L. Vandy Black
- Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana
- University of Florida College of Medicine, Gainesville
| | - Suvankar Majumdar
- University of Mississippi Medical Center, Jackson
- Children’s National Hospital, Washington, DC
| | - Adlette Inati
- Lebanese American University, Byblos and Beirut, Lebanon
- Nini Hospital, Tripoli, Lebanon
| | | | | | | | - Yurdanur Kilinc
- Çukurova University Medical Faculty Balcali Hospital, University of Çukurova, Adana, Turkey
| | - Beng R. Fuh
- East Carolina University, Greenville, North Carolina
| | | | - Clifford M. Takemoto
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Emad Salman
- Golisano Children’s Hospital of Southwest Florida, Ft Myers
| | - Sharada A. Sarnaik
- Wayne State University School of Medicine, Detroit, Michigan
- Children’s Hospital of Michigan, Detroit
| | - Nirmish Shah
- Duke University School of Medicine, Durham, North Carolina
| | - Claudia R. Morris
- Emory University School of Medicine, Atlanta, Georgia
- Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - Ashok Raj
- University of Louisville/Norton Children’s Hospital, Louisville, Kentucky
| | | | | | - Alexis A. Thompson
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Evanston, Illinois
| | - India Y. Sisler
- Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond
| | | | - Suzie A. Noronha
- University of Rochester School of Medicine and Dentistry, Golisano Children’s Hospital at University of Rochester Medical Center, Rochester, New York
| | - Joseph L. Lasky
- Harbor-UCLA Medical Center, Torrance, California
- Cure 4 The Kids Foundation, Las Vegas, Nevada
| | - Elena Cela de Julian
- Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Courtney Dawn Thornburg
- Rady Children’s Hospital - San Diego, San Diego, California
- UC San Diego School of Medicine, La Jolla, California
| | - Natalie L. Kamberos
- University of Iowa Children’s Hospital, Iowa City
- Loyola University Medical Center, Maywood, Illinois
| | - Rachelle Nuss
- Children’s Hospital Colorado, University of Colorado, Aurora
| | - Anne M. Marsh
- UCSF Benioff Children’s Hospital Oakland (UBCHO), Oakland, California
- University of Wisconsin–Madison, Madison
| | - William C. Owen
- Children’s Hospital of the King’s Daughters, Norfolk, Virginia
| | - Anne Schaefer
- Joe DiMaggio Children’s Hospital, Hollywood, Florida
| | | | | | - Debra E. Cohen
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Studer Family Children’s Hospital Ascension Sacred Heart, University of Florida, Pensacola
| | - Zeynep Karakas
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Connie M. Piccone
- Rainbow Babies and Children’s Hospital, Cleveland, Ohio
- Carle Foundation Hospital, Urbana, Illinois
| | - Alex George
- Baylor College of Medicine, Houston, Texas
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jason M. Fixler
- The Herman and Walter Samuelson Children’s Hospital at Sinai, Baltimore, Maryland
| | - Tammuella C. Singleton
- Tulane University, New Orleans, Louisiana
- Mississippi Center for Advanced Medicine, Slidell, Louisiana
| | - Thomas Moulton
- Bronx-Lebanon Hospital, Bronx, New York City, New York
- Bayer Pharmaceuticals, Whippany, New Jersey
| | | | | | - Abdulkareem M. Almomen
- Blood and Cancer Center, King Khalid University Hospital (KKUH), King Saud University Medical City, Riyadh, Saudi Arabia
| | - Meenakshi Goyal-Khemka
- Phoenix Children’s Hospital, Phoenix, Arizona
- Rutgers Cancer Institute of New Jersey, New Brunswick
| | - Philip Maes
- University Hospital of Antwerp (UZA), Edegem, Belgium
| | - Marty Emanuele
- Visgenx, San Diego, California
- Mast Therapeutics Inc, San Diego, California
| | | | - Claire S. Padgett
- Mast Therapeutics Inc, San Diego, California
- Sanifit Therapeutics, San Diego, California
| | - Ed Parsley
- Mast Therapeutics Inc, San Diego, California
- Biotechnology, San Diego, California
| | | | - Gregory J. Kato
- CSL Behring, King of Prussia, Pennsylvania
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mark T. Gladwin
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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12
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Affiliation(s)
- Michele Loi
- Center for Cancer and Blood DisordersDepartment of PediatricsChildren's Hospital Colorado and University of ColoradoAuroraColorado,Division of Pediatric Critical Care, Department of PediatricsChildren's Hospital Colorado and University of ColoradoAuroraColorado
| | - Brian Branchford
- Center for Cancer and Blood DisordersDepartment of PediatricsChildren's Hospital Colorado and University of ColoradoAuroraColorado
| | - John Kim
- Heart Institute, Division of Cardiology, Department of PediatricsChildren's Hospital Colorado and University of ColoradoAuroraColorado
| | - Chelsea Self
- Center for Cancer and Blood DisordersDepartment of PediatricsChildren's Hospital Colorado and University of ColoradoAuroraColorado
| | - Rachelle Nuss
- Center for Cancer and Blood DisordersDepartment of PediatricsChildren's Hospital Colorado and University of ColoradoAuroraColorado
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13
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McKinney C, Caruso-Brown A, Montgomery K, Gillespie A, Coughlin R, Law D, Brouwer A, Tytler L, Hilden J, Nuss R. A Quality Initiative to Decrease Time to Antibiotics in Children with Sickle Cell Disease and Fever. Pediatr Qual Saf 2020; 5:e245. [PMID: 32190792 PMCID: PMC7056294 DOI: 10.1097/pq9.0000000000000245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 11/18/2019] [Indexed: 11/25/2022] Open
Abstract
Children with sickle cell disease (SCD) are at increased risk for sepsis secondary to functional asplenia. Timely administration of antibiotics, within 60 minutes of triage, is a national indicator of quality SCD care in the United States. However, there are no reports demonstrating the feasibility of doing so in the outpatient hematology-oncology clinic setting. Local Problem At baseline, in our pediatric hematology-oncology outpatient center, just 10% of children with SCD and fever received timely antibiotics. Methods We implemented a process improvement initiative for children with SCD and fever with the aim of ≥90% receiving timely antibiotics. We enacted interventions focused on general clinic processes from check-in to antibiotics and population-specific interventions, including an intravenous access protocol, notification/communication among staff members, and design of an electronic order set. Results The percentage of children receiving timely antibiotics improved from 10% to 77% with successful maintenance following the interventions. Residual delays are due to nonexpeditious order placement and difficult intravenous access. Conclusion Improving the timely administration of antibiotics in the outpatient hematology-oncology clinic setting for children with SCD and fever is possible. Achieving at least 90% timely antibiotics for children with SCD and fever in the outpatient clinic setting will require ongoing efforts at expeditious order placement and intravenous access.
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Affiliation(s)
- Christopher McKinney
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colo.,Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colo
| | - Amy Caruso-Brown
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colo.,Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colo
| | - Kathleen Montgomery
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colo
| | - Anne Gillespie
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colo
| | - Rebecca Coughlin
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colo
| | - Dawn Law
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colo
| | - Anna Brouwer
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colo
| | - Lauren Tytler
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colo
| | - Joanne Hilden
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colo.,Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colo
| | - Rachelle Nuss
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colo.,Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colo.,Colorado Sickle Cell Treatment and Research Center, University of Colorado, Aurora, Colo
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14
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Redinus K, Baek JH, Yalamanoglu A, Shin HKH, Moldova R, Harral JW, Swindle D, Pak D, Ferguson SK, Nuss R, Hassell K, Nozik-Grayck E, Palmer AF, Fini MA, Karoor V, Stenmark KR, Buehler PW, Irwin DC. An Hb-mediated circulating macrophage contributing to pulmonary vascular remodeling in sickle cell disease. JCI Insight 2019; 4:127860. [PMID: 31391342 DOI: 10.1172/jci.insight.127860] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 06/19/2019] [Indexed: 12/13/2022] Open
Abstract
Circulating macrophages recruited to the lung contribute to pulmonary vascular remodeling in various forms of pulmonary hypertension (PH). In this study we investigated a macrophage phenotype characterized by intracellular iron accumulation and expression of antioxidant (HO-1), vasoactive (ET-1), and proinflammatory (IL-6) mediators observed in the lung tissue of deceased sickle cell disease (SCD) patients with diagnosed PH. To this end, we evaluated an established rat model of group 5 PH that is simultaneously exposed to free hemoglobin (Hb) and hypobaric hypoxia (HX). Here, we tested the hypothesis that pulmonary vascular remodeling observed in human SCD with concomitant PH could be replicated and mechanistically driven in our rat model by a similar macrophage phenotype with iron accumulation and expression of a similar mixture of antioxidant (HO-1), vasoactive (ET-1), and inflammatory (IL-6) proteins. Our data suggest phenotypic similarities between pulmonary perivascular macrophages in our rat model and human SCD with PH, indicating a potentially novel maladaptive immune response to concomitant bouts of Hb and HX exposure. Moreover, by knocking out circulating macrophages with gadolinium trichloride (GdCl3), the response to combined Hb and hypobaric HX was significantly attenuated in rats, suggesting a critical role for macrophages in the exacerbation of SCD PH.
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Affiliation(s)
- Katherine Redinus
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
| | - Jin Hyen Baek
- Division of Blood Components and Devices, Office of Blood Research and Review, The Center for Biologics Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Ayla Yalamanoglu
- Division of Blood Components and Devices, Office of Blood Research and Review, The Center for Biologics Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Hye Kyung H Shin
- Division of Blood Components and Devices, Office of Blood Research and Review, The Center for Biologics Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | | | - Julie W Harral
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
| | - Delaney Swindle
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
| | - David Pak
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
| | - Scott K Ferguson
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
| | - Rachelle Nuss
- Division of Hematology and Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
| | - Kathryn Hassell
- Division of Hematology and Colorado Sickle Cell Treatment and Research Center, School of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
| | - Eva Nozik-Grayck
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
| | - Andre F Palmer
- William G. Lowrie Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Mehdi A Fini
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
| | - Vijaya Karoor
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
| | - Kurt R Stenmark
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
| | - Paul W Buehler
- Division of Blood Components and Devices, Office of Blood Research and Review, The Center for Biologics Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - David C Irwin
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
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15
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Ferguson SK, Redinius K, Yalamanoglu A, Harral JW, Hyen Baek J, Pak D, Loomis Z, Hassell D, Eigenberger P, Nozik-Grayck E, Nuss R, Hassell K, Stenmark KR, Buehler PW, Irwin DC. Effects of living at moderate altitude on pulmonary vascular function and exercise capacity in mice with sickle cell anaemia. J Physiol 2018; 597:1073-1085. [PMID: 29931797 DOI: 10.1113/jp275810] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 06/11/2018] [Indexed: 01/07/2023] Open
Abstract
KEY POINTS Sickle cell disease (SCD) results in cardiopulmonary dysfunction, which may be exacerbated by prolonged exposure to environmental hypoxia. It is currently unknown whether exposure to mild and moderate altitude exacerbates SCD associated cardiopulmonary and systemic complications. Three months of exposure to mild (1609 m) and moderate (2438 m) altitude increased rates of haemolysis and right ventricular systolic pressures in mice with SCD compared to healthy wild-type cohorts and SCD mice at sea level. The haemodynamic changes in SCD mice that had lived at mild and moderate altitude were accompanied by changes in the balance between pulmonary vascular endothelial nitric oxide synthase and endothelin receptor expression and impaired exercise tolerance. These data demonstrate that chronic altitude exposure exacerbates the complications associated with SCD and provides pertinent information for the clinical counselling of SCD patients. ABSTRACT Exposure to high altitude worsens symptoms and crises in patients with sickle cell disease (SCD). However, it remains unclear whether prolonged exposure to low barometric pressures exacerbates SCD aetiologies or impairs quality of life. We tested the hypothesis that, relative to wild-type (WT) mice, Berkley sickle cell mice (BERK-SS) residing at sea level, mild (1609 m) and moderate (2438 m) altitude would have a higher rate of haemolysis, impaired cardiac function and reduced exercise tolerance, and that the level of altitude would worsen these decrements. Following 3 months of altitude exposure, right ventricular systolic pressure was measured (solid-state transducer). In addition, the adaptive balance between pulmonary vascular endothelial nitric oxide synthase and endothelin was assessed in lung tissue to determine differences in pulmonary vascular adaptation and the speed/duration relationship (critical speed) was used to evaluate treadmill exercise tolerance. At all altitudes, BERK-SS mice had a significantly lower percentage haemocrit and higher total bilirubin and free haemoglobin concentration (P < 0.05 for all). right ventricular systolic pressures in BERK-SS were higher than WT at moderate altitude and also compared to BERK-SS at sea level (P < 0.05, for both). Critical speed was significantly lower in BERK-SS at mild and moderate altitude (P < 0.05). BERK-SS demonstrated exacerbated SCD complications and reduced exercise capacity associated with an increase in altitude. These results suggest that exposure to mild and moderate altitude enhances the progression of SCD in BERK-SS mice compared to healthy WT cohorts and BERK-SS mice at sea level and provides crucial information for the clinical counselling of SCD patients.
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Affiliation(s)
- Scott K Ferguson
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - Katherine Redinius
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - Ayla Yalamanoglu
- Division of Blood Components and Devices, Office of Blood Research and Review, The Center for Biologics Evaluation and Research, United States Food and Drug Administration, Bethesda, MD, USA
| | - Julie W Harral
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - Jin Hyen Baek
- Division of Blood Components and Devices, Office of Blood Research and Review, The Center for Biologics Evaluation and Research, United States Food and Drug Administration, Bethesda, MD, USA
| | - David Pak
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - Zoe Loomis
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - Daniel Hassell
- Division of Hematology and Colorado Sickle Cell Treatment and Research Center, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - Paul Eigenberger
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - Eva Nozik-Grayck
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - Rachelle Nuss
- Division of Hematology and Colorado Sickle Cell Treatment and Research Center, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - Kathryn Hassell
- Division of Hematology and Colorado Sickle Cell Treatment and Research Center, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - Kurt R Stenmark
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
| | - Paul W Buehler
- Division of Blood Components and Devices, Office of Blood Research and Review, The Center for Biologics Evaluation and Research, United States Food and Drug Administration, Bethesda, MD, USA
| | - David C Irwin
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, Anschutz Medical Campus, University of Colorado-Denver School of Medicine, Aurora, CO, USA
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Nuss R, Haver T, Jacobson L, Thompson A, Manco-Johnson M, Lefkowitz J. Factor IX Denver, ASN 346→ASP Mutation Resulting in a Dysfunctional Protein with Defective Factor VIIIa Interaction. Thromb Haemost 2017. [DOI: 10.1055/s-0037-1616144] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
SummaryHemophilia B is a sex-linked recessive bleeding disorder characterized by the presence of either a decreased amount of normal factor IX (FIX) or the presence of a dysfunctional FIX. We have identified a unique mutation in a family with mild hemophilia B. DNA analysis of family members revealed a single base transition in the 8th exon of the FIX gene predicting an amino acid change of Asn 346→Asp in the catalytic domain. The FIX variant, named FIX Denver, was purified from proband plasma. Kinetic studies of factor X (FX) interactions with normal FIXa or FIXa Denver and phospholipid (PL) showed little difference in kcat, but a significant difference when factor VIIIa (FVIIIa) was included in the reaction. Using kinetic assays to infer the Kd of FIXa for FVIIIa, normal FIXa had a Kd of 0.095 nM while that of FIXa Denver was 9.85 nM. The major defect caused by this point mutation is a marked decrease in the affinity of FIXa Denver for factor VIIIa.
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Jacobson L, Hathaway WE, Manco-Johnson M, Nuss R. Evidence for Antiphospholipid Antibodies in Hemophilic Children with Factor VIII Inhibitors. Thromb Haemost 2017. [DOI: 10.1055/s-0037-1614875] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Loomis Z, Eigenberger P, Redinius K, Lisk C, Karoor V, Nozik-Grayck E, Ferguson SK, Hassell K, Nuss R, Stenmark KR, Buehler PW, Irwin DC. Correction: Hemoglobin induced cell trauma indirectly influences endothelial TLR9 activity resulting in pulmonary vascular smooth muscle cell activation. PLoS One 2017; 12:e0173652. [PMID: 28264019 PMCID: PMC5338835 DOI: 10.1371/journal.pone.0173652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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19
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Loomis Z, Eigenberger P, Redinius K, Lisk C, Karoor V, Nozik-Grayck E, Ferguson SK, Hassell K, Nuss R, Stenmark K, Buehler P, Irwin DC. Hemoglobin induced cell trauma indirectly influences endothelial TLR9 activity resulting in pulmonary vascular smooth muscle cell activation. PLoS One 2017; 12:e0171219. [PMID: 28152051 PMCID: PMC5289566 DOI: 10.1371/journal.pone.0171219] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 01/17/2017] [Indexed: 12/23/2022] Open
Abstract
It is now well established that both inherited and acquired forms of hemolytic disease can promote pulmonary vascular disease consequent of free hemoglobin (Hb) induced NO scavenging, elevations in reactive oxygen species and lipid peroxidation. It has recently been reported that oxidative stress can activate NFkB through a toll-like receptor 9 (TLR9) mediated pathway; further, TLR9 can be activated by either nuclear or mitochondrial DNA liberated by stress induced cellular trauma. We hypothesis that Hb induced lipid peroxidation and subsequent endothelial cell trauma is linked to TLR9 activation, resulting in IL-6 mediated pulmonary smooth muscle cell proliferation. We examined the effects of Hb on rat pulmonary artery endothelial and smooth muscle cells (rPAEC and rPASMC, respectively), and then utilized TLR9 and IL6 inhibitors, as well as the Hb and heme binding proteins (haptoglobin (Hp) and hemopexin (Hpx), respectively) to further elucidate the aforementioned mediators. Further, we explored the effects of Hb in vivo utilizing endothelial cell (EC) specific myeloid differentiation primary response gene-88 (MyD88) and TLR9 null mice. Our data show that oxidized Hb induces lipid peroxidation, cellular toxicity (5.5 ± 1.7 fold; p≤0.04), increased TLR9 activation (60%; p = 0.01), and up regulated IL6 expression (1.75±0.3 fold; p = 0.04) in rPAEC. Rat PASMC exhibited a more proliferative state (13 ± 1%; p = 0.01) when co-cultured with Hb activated rPAEC. These effects were attenuated with the sequestration of Hb or heme by Hp and Hpx as well as with TLR9 an IL-6 inhibition. Moreover, in both EC-MyD88 and TLR9 null mice Hb-infusion resulted in less lung IL-6 expression compared to WT cohorts. These results demonstrate that Hb-induced lipid peroxidation can initiate a modest TLR9 mediated inflammatory response, subsequently generating an activated SMC phenotype.
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Affiliation(s)
- Zoe Loomis
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Paul Eigenberger
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Katherine Redinius
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Christina Lisk
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Vijaya Karoor
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Eva Nozik-Grayck
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Scott K. Ferguson
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Kathryn Hassell
- Division of Hematology and Colorado Sickle Cell Treatment and Research Center, University of Colorado-Denver School of Medicine, Aurora, Colorado, United States of America
| | - Rachelle Nuss
- Division of Hematology and Colorado Sickle Cell Treatment and Research Center, University of Colorado-Denver School of Medicine, Aurora, Colorado, United States of America
| | - Kurt Stenmark
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Paul Buehler
- Division of Hematology, The Center for Biologics Evaluation and Research, United States Food and Drug Administration, Bethesda, Maryland, United States of America
| | - David C. Irwin
- Cardiovascular and Pulmonary Research Laboratory, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States of America
- * E-mail:
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Huszti HC, Parsons JT, Cotton D, Mendoza J, Harlow L, Rich L, Parish KL, Nuss R, Riske B. Determinants of Safer Sexual Behavior in a Long-term HIV-seropositive Population. J Health Psychol 2016; 3:507-22. [DOI: 10.1177/135910539800300405] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Determinants of safer sexual behaviors among HIV-infected adult men with hemophilia were examined. A model was proposed that personal adjustment, communication skills, self-efficacy, and perceived advantages of condom use would influence safer sex practices. The model was tested with 181 men with hemophilia and HIV infection from 27 hemophilia treatment centers across the United States. The hypothesized model was tested using LISREL and explained 35 percent of the variance in safer sexual behaviors. Personal adjustment was significantly associated with general communication skills. General communication was linked with communication about safer sex which, in turn, influenced self-efficacy and perceived advantages of condom use. Communication about safer sex, efficacy and perceived advantages of condom use were all directly related to safer sexual behaviors.
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Affiliation(s)
- Heather C. Huszti
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - David Cotton
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Lisa Harlow
- University of Rhode Island, Kingston, RI, USA
| | - Louise Rich
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Rachelle Nuss
- University of Colorado Health Sciences Center, Denver, CO, USA
| | - Brenda Riske
- University of Colorado Health Sciences Center, Denver, CO, USA
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Abstract
The medical records of 25 individuals with sickle cell trait and altitude-associated splenic infarct, reported to two Colorado physicians, were reviewed. Electrospray mass spectroscopy was performed on blood samples from a cohort of 10 of the individuals to rapidly confirm beta hemoglobin phenotype. Only males were identified with a 1.4:1 ratio of non-African Americans to African Americans, and 44% of African Americans and 85% of non-African Americans were unaware they had sickle cell trait. Left upper quadrant pain and an elevated bilirubin were nearly uniformly present. Either abdominal CT or ultrasound was confirmatory. Conservative treatment at a lower altitude generally resulted in a favorable outcome.
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22
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Irwin DC, Baek JH, Hassell K, Nuss R, Eigenberger P, Lisk C, Loomis Z, Maltzahn J, Stenmark KR, Nozik-Grayck E, Buehler PW. Hemoglobin-induced lung vascular oxidation, inflammation, and remodeling contribute to the progression of hypoxic pulmonary hypertension and is attenuated in rats with repeated-dose haptoglobin administration. Free Radic Biol Med 2015; 82:50-62. [PMID: 25656991 PMCID: PMC4387123 DOI: 10.1016/j.freeradbiomed.2015.01.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 12/11/2014] [Accepted: 01/20/2015] [Indexed: 12/28/2022]
Abstract
Haptoglobin (Hp) is an approved treatment in Japan for trauma, burns, and massive transfusion-related hemolysis. Additional case reports suggest uses in other acute hemolytic events that lead to acute kidney injury. However, Hp's protective effects on the pulmonary vasculature have not been evaluated within the context of mitigating the consequences of chronic hemoglobin (Hb) exposure in the progression of pulmonary hypertension (PH) secondary to hemolytic diseases. This study was performed to assess the utility of chronic Hp therapy in a preclinical model of Hb and hypoxia-mediated PH. Rats were simultaneously exposed to chronic Hb infusion (35 mg per day) and hypobaric hypoxia for 5 weeks in the presence or absence of Hp treatment (90 mg/kg twice a week). Hp inhibited the Hb plus hypoxia-mediated nonheme iron accumulation in lung and heart tissue, pulmonary vascular inflammation and resistance, and right-ventricular hypertrophy, which suggests a positive impact on impeding the progression of PH. In addition, Hp therapy was associated with a reduction in critical mediators of PH, including lung adventitial macrophage population and endothelial ICAM-1 expression. By preventing Hb-mediated pathology, Hp infusions: (1) demonstrate a critical role for Hb in vascular remodeling associated with hypoxia and (2) suggest a novel therapy for chronic hemolysis-associated PH.
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Affiliation(s)
- David C. Irwin
- Cardiovascular Pulmonary Research Group, Division of Cardiology, School of Medicine, University of Colorado Denver | Anschutz Medical Campus, Aurora, Colorado
- Corresponding Author: David C. Irwin, Ph.D., Assistant Professor, 12700 East 19th Avenue, Research Building 2, Room 8121, Aurora, CO 80045, Phone: 303 724-3684, Fax: 303 724-3693,
| | - Jin Hyen Baek
- Laboratory of Biochemistry and Vascular Biology, Office of Blood Research and Review, Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Bethesda, Maryland
| | - Kathryn Hassell
- Colorado Sickle Cell Treatment and Research Center, University of Colorado Denver | Anschutz Medical Campus, Aurora, Colorado
| | - Rachelle Nuss
- Colorado Sickle Cell Treatment and Research Center, University of Colorado Denver | Anschutz Medical Campus, Aurora, Colorado
| | - Paul Eigenberger
- Cardiovascular Pulmonary Research Group, Division of Cardiology, School of Medicine, University of Colorado Denver | Anschutz Medical Campus, Aurora, Colorado
| | - Christina Lisk
- Cardiovascular Pulmonary Research Group, Division of Cardiology, School of Medicine, University of Colorado Denver | Anschutz Medical Campus, Aurora, Colorado
| | - Zoe Loomis
- Colorado Sickle Cell Treatment and Research Center, University of Colorado Denver | Anschutz Medical Campus, Aurora, Colorado
| | - Joanne Maltzahn
- Cardiovascular Pulmonary Research Group, Division of Cardiology, School of Medicine, University of Colorado Denver | Anschutz Medical Campus, Aurora, Colorado
| | - Kurt R Stenmark
- Cardiovascular Pulmonary Research Group, Pediatrics, School of Medicine, University of Colorado Denver | Anschutz Medical Campus, Aurora Colorado
| | - Eva Nozik-Grayck
- Cardiovascular Pulmonary Research Group, Pediatrics, School of Medicine, University of Colorado Denver | Anschutz Medical Campus, Aurora Colorado
| | - Paul W. Buehler
- Cardiovascular Pulmonary Research Group, Division of Cardiology, School of Medicine, University of Colorado Denver | Anschutz Medical Campus, Aurora, Colorado
- Laboratory of Biochemistry and Vascular Biology, Office of Blood Research and Review, Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Bethesda, Maryland
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McKinney CM, Siringo F, Olson JL, Capocelli KE, Ambruso DR, Nuss R. Red cell exchange transfusion halts progressive proliferative sickle cell retinopathy in a teenaged patient with hemoglobin SC disease. Pediatr Blood Cancer 2015; 62:721-3. [PMID: 25631233 DOI: 10.1002/pbc.25397] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [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: 10/13/2014] [Accepted: 11/19/2014] [Indexed: 11/09/2022]
Abstract
A male with sickle SC disease presented at age 8 years with proliferative sickle cell retinopathy (PSCR) and bilateral vitreous hemorrhage which spontaneously resolved, then recurred at 13 years of age. Despite conventional therapy with repeated pan-retinal photocoagulation and pars plana vitrectomy, he developed progressive PSCR and recurrent vitreous hemorrhage over the next 30 months. We describe the successful use of chronic red cell exchange transfusion (RCE) to preserve his vision and stabilize the retinopathy.
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Affiliation(s)
- Christopher M McKinney
- Department of Pediatrics, Center for Cancer and Blood Disorders, Children's Hospital Colorado, University of Colorado Denver, Aurora, Colorado
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Lisk C, Kominsky D, Ehrentraut S, Bonaventura J, Nuss R, Hassell K, Nozik-Grayck E, Irwin DC. Hemoglobin-induced endothelial cell permeability is controlled, in part, via a myeloid differentiation primary response gene-88-dependent signaling mechanism. Am J Respir Cell Mol Biol 2014; 49:619-26. [PMID: 23713977 DOI: 10.1165/rcmb.2012-0440oc] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The release of hemoglobin (Hb) with hemolysis causes vascular dysfunction. New evidence implicates Hb-induced NF-κB and hypoxia inducible factor (HIF) activation, which may be under the control of a Toll-like receptor (TLR)-signaling pathway. Nearly all TLR-signaling pathways activate the myeloid differentiation primary response gene-88 (MyD88) that regulates NF-κB. We hypothesized that the differing transition states of Hb influence endothelial cell permeability via NF-κB activation and HIF regulation through a MyD88-dependent pathway. In cultured human dermal microvascular endothelial cells (HMECs-1), we examined the effects of Hb in the ferrous (HbFe(2+)), ferric (HbFe(3+)), and ferryl (HbFe(4+)) transition states on NF-κB and HIF activity, HIF-1α and HIF-2α mRNA up-regulation, and monolayer permeability, in the presence or absence of TLR4, MyD88, NF-κB, or HIF inhibition, as well as superoxide dismutase (SOD) and catalase. Our data showed that cell-free Hb, in each transition state, induced NF-κB and HIF activity, up-regulated HIF-1α and HIF-2α mRNA, and increased HMEC-1 permeability. The blockade of either MyD88 or NF-κB, but not TLR4, attenuated Hb-induced HIF activity, the up-regulation HIF-1 and HIF-2α mRNA, and HMEC-1 permeability. The inhibition of HIF activity exerted less of an effect on Hb-induced monolayer permeability. Moreover, SOD and catalase attenuated NF-κB, HIF activity, and monolayer permeability. Our results demonstrate that Hb-induced NF-κB and HIF are regulated by two mechanisms, either MyD88 activation or Hb transition state-induced ROS formation, that influence HMEC-1 permeability.
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Affiliation(s)
- Christina Lisk
- 1 Cardiovascular Pulmonary Research Group, Division of Cardiology, Department of Medicine
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25
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Ball JB, Khan SY, McLaughlin NJD, Kelher MR, Nuss R, Cole L, Liang X, Silliman CC. A two-event in vitro model of acute chest syndrome: the role of secretory phospholipase A2 and neutrophils. Pediatr Blood Cancer 2012; 58:399-405. [PMID: 21793188 DOI: 10.1002/pbc.23265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Accepted: 06/09/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND Acute chest syndrome (ACS) in sickle cell disease is associated with elevation of secretory phospholipase A(2) (sPLA(2) ). We hypothesize that sPLA(2) cleaves membrane lipids from sickled red blood cells (RBCs) causing PMN-mediated endothelial cell injury (ECI) as the second event in a two-event model. METHODS Whole blood was collected from children when in steady state or daily during admissions for vaso-occlusive pain (VOC) or ACS. The plasma and RBCs were separated, sPLA(2) levels were measured, and the RBCs were incubated with sPLA(2) . Plasma and lipids, extracted from the plasma or the supernatant of sPLA(2) -treated RBCs, were assayed for PMN priming activity and used as the second event in a model of PMN-mediated ECI. Phosphatidylserine (PS) surface expression on RBCs was quantified by flow cytometry. RESULTS Increased sPLA(2) -IIa levels were associated with ACS. SPLA(2) -liberated lipids from VOC and the plasma, plasma lipids and sPLA(2) -liberated lipids from ACS primed PMNs and caused PMN-mediated ECI (P < 0.01). RBCs from VOC had increased in PS surface expression versus steady state. CONCLUSIONS ACS plasma and lipids and sPLA(2) -released lipids from RBCs during VOC or ACS induce PMN-mediated ECI. VOC elicited increases in PS surface expression providing a membrane substrate for sPLA(2) lysis of sickle RBCs.
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Affiliation(s)
- J Bradley Ball
- The Research Department, Bonfils Blood Center, 717 Yosemite Street, Denver, CO 80230, USA
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26
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Micel L, Nuss R, Fenton L, Lovell M, Silliman CC. Non-palpable splenic enlargement as the etiology of abdominal pain in an adolescent with hemoglobin SC disease. Pediatr Blood Cancer 2011; 57:352-3. [PMID: 21584930 DOI: 10.1002/pbc.23076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Accepted: 01/14/2011] [Indexed: 11/08/2022]
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Gladwin MT, Kato GJ, Weiner D, Onyekwere OC, Dampier C, Hsu L, Hagar RW, Howard T, Nuss R, Okam MM, Tremonti CK, Berman B, Villella A, Krishnamurti L, Lanzkron S, Castro O, Gordeuk VR, Coles WA, Peters-Lawrence M, Nichols J, Hall MK, Hildesheim M, Blackwelder WC, Baldassarre J, Casella JF. Nitric oxide for inhalation in the acute treatment of sickle cell pain crisis: a randomized controlled trial. JAMA 2011; 305:893-902. [PMID: 21364138 PMCID: PMC3403835 DOI: 10.1001/jama.2011.235] [Citation(s) in RCA: 158] [Impact Index Per Article: 12.2] [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] [Indexed: 01/10/2023]
Abstract
CONTEXT Inhaled nitric oxide has shown evidence of efficacy in mouse models of sickle cell disease (SCD), case series of patients with acute chest syndrome, and 2 small placebo-controlled trials for treatment of vaso-occlusive pain crisis (VOC). OBJECTIVE To determine whether inhaled nitric oxide gas reduces the duration of painful crisis in patients with SCD who present to the emergency department or hospital for care. DESIGN, SETTING, AND PARTICIPANTS Prospective, multicenter, double-blind, randomized, placebo-controlled clinical trial for up to 72 hours of inhaled nitric oxide gas vs inhaled nitrogen placebo in 150 participants presenting with VOC of SCD at 11 centers between October 5, 2004, and December 22, 2008. Intervention Inhaled nitric oxide gas vs inhaled nitrogen placebo. MAIN OUTCOME MEASURES The primary end point was the time to resolution of painful crisis, defined by (1) freedom from parenteral opioid use for 5 hours; (2) pain relief as assessed by visual analog pain scale scores of 6 cm or lower (on 0-10 scale); (3) ability to walk; and (4) patient's and family's decision, with physician consensus, that the remaining pain could be managed at home. RESULTS There was no significant change in the primary end point between the nitric oxide and placebo groups, with a median time to resolution of crisis of 73.0 hours (95% confidence interval [CI], 46.0-91.0) and 65.5 hours (95% CI, 48.1-84.0), respectively (P = .87). There were no significant differences in secondary outcome measures, including length of hospitalization, visual analog pain scale scores, cumulative opioid usage, and rate of acute chest syndrome. Inhaled nitric oxide was well tolerated, with no increase in serious adverse events. Increases in venous methemoglobin concentration confirmed adherence and randomization but did not exceed 5% in any study participant. Significant increases in plasma nitrate occurred in the treatment group, but there were no observed increases in plasma or whole blood nitrite. CONCLUSION Among patients with SCD hospitalized with VOC, the use of inhaled nitric oxide compared with placebo did not improve time to crisis resolution. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00094887.
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Affiliation(s)
- Mark T Gladwin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Vascular Medicine Institute, University of Pittsburgh, 3459 Fifth Ave, 628 NW, Pittsburgh, PA 15213.
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LaSalle-Williams M, Nuss R, Le T, Cole L, Hassell K, Murphy JR, Ambruso DR. Extended red blood cell antigen matching for transfusions in sickle cell disease: a review of a 14-year experience from a single center (CME). Transfusion 2011; 51:1732-9. [DOI: 10.1111/j.1537-2995.2010.03045.x] [Citation(s) in RCA: 162] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Macedo S, Nuss R, Lubanco G, Lovatti R, Pereira S, Lima G, Siqueira C, Siqueira S, Lima D, Torres R. Magnesium use on prophylaxis of vasospasm morbidity and the mortality rate in subarachnoid hemorrhage. Crit Care 2009. [PMCID: PMC4083990 DOI: 10.1186/cc7268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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31
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Villavicencio K, Ivy D, Cole L, Nuss R. Symptomatic pulmonary hypertension in a child with sickle cell disease. J Pediatr 2008; 152:879-81. [PMID: 18492535 PMCID: PMC3128440 DOI: 10.1016/j.jpeds.2008.01.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [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] [Received: 06/01/2007] [Revised: 11/30/2007] [Accepted: 01/30/2008] [Indexed: 11/18/2022]
Abstract
Pulmonary hypertension is a survival-limiting complication in adults with homozygous sickle cell disease (SS), but little is known about the development, course, or best treatment of pulmonary hypertension in children with SS. We report the clinical course and treatment of a child with SS-associated, hemolysis-driven pulmonary hypertension.
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Affiliation(s)
- Karrie Villavicencio
- Department of Cardiology, University of Colorado at Denver Health Sciences Center, Denver, CO, USA
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Abstract
A 6-year-old female with homozygous sickle cell disease had a central venous access device (CVAD) placed to facilitate chronic erythrocytapheresis. Erythrocytapheresis was ineffective due to the rare pinch-off syndrome causing communication between the dual lumen tubing. Awareness of and monitoring for the pinch-off syndrome is indicated in people with sickle cell disease and a CVAD for chronic erythrocytapheresis.
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Affiliation(s)
- Rachelle Nuss
- Department of Pediatric Hematology, The Children's Hospital and the University of Colorado at Denver Health Sciences Center, Denver, Colorado, USA.
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33
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Doria AS, Lundin B, Kilcoyne RF, Babyn PS, Miller S, Nuss R, Rivard G, Stephens D, Pettersson H. Reliability of progressive and additive MRI scoring systems for evaluation of haemophilic arthropathy in children: Expert MRI Working Group of the International Prophylaxis Study Group. Haemophilia 2005; 11:245-53. [PMID: 15876270 DOI: 10.1111/j.1365-2516.2005.01097.x] [Citation(s) in RCA: 44] [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] [Indexed: 11/28/2022]
Abstract
Effective treatment of haemophilic arthropathy requires a detailed evaluation of joint integrity. Methodological assessment of magnetic resonance imaging (MRI) scores are needed to assure reproducibility of measurements when comparing results of clinical trials conducted in different centres. We compared the reliability of two MRI scoring systems for assessment of haemophilic arthropathy: one progressive system that displays the most severe change and one additive system that depicts osteochondral and soft tissue-related changes. A total of 47 1.5 T MRI examinations of knees (n = 21) and ankles (n = 26) of 42 haemophilic boys, age range, 22 months to 18 years, performed at different centres (Toronto, n = 20, Europe, n = 12 and Denver, n = 15) were independently reviewed by four radiologists at two occasions. Twenty-two examinations were from children <9 years and 25 from children >/=9. Sagittal and coronal gradient-echo (MPGR, 3D FLASH with fat saturation, GRASS) images were obtained. The MRI examinations of the ankle and knee studies presented with osteochondral abnormalities in 38.5% and 23.8% of the cases respectively. The two scoring systems demonstrated an excellent inter-reader [progressive, 0.88; additive (A, e, s and h components), 0.86] and intra-reader [progressive, 0.92; additive (A, e, s and h components), 0.93] reliability using intraclass correlation coefficients (ICCs). Although ICCs were slightly higher for knees when compared with ankles, and for older children when compared with younger children, all values fell within excellent inter- and intra-reader reliability categories. The two MRI scoring systems demonstrated a comparable reliability. This result constitutes the basis for further development of a combined MRI scoring system for assessment of haemophilic arthropathy, which incorporates progressive and additive components.
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Affiliation(s)
- A S Doria
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada.
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34
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Lundin B, Babyn P, Doria AS, Kilcoyne R, Ljung R, Miller S, Nuss R, Rivard GE, Pettersson H. Compatible scales for progressive and additive MRI assessments of haemophilic arthropathy. Haemophilia 2005; 11:109-15. [PMID: 15810912 DOI: 10.1111/j.1365-2516.2005.01049.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The international MRI expert subgroup of the International Prophylaxis Study Group (IPSG) has developed a consensus for magnetic resonance imaging (MRI) scales for assessment of haemophilic arthropathy. A MRI scoring scheme including a 10 step progressive scale and a 20 step additive scale with identical definitions of mutual steps is presented. Using the progressive scale, effusion/haemarthrosis can correspond to progressive scores of 1, 2, or 3, and synovial hypertrophy and/or haemosiderin deposition to 4, 5, or 6. The progressive score can be 7 or 8 if there are subchondral cysts and/or surface erosions, and it is 9 or 10 if there is loss of cartilage. Using the additive scale, synovial hypertrophy contributes 1-3 points to the additive score and haemosiderin deposition contributes 1 point. For osteochondral changes, 16 statements are evaluated as to whether they are true or false, and each true statement contributes 1 point to the additive score. The use of these two compatible scales for progressive and additive MRI assessments can facilitate international comparison of data and enhance the accumulation of experience on MRI scoring of haemophilic arthropathy.
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Affiliation(s)
- B Lundin
- Department of Radiology, University Hospital of Lund, Lund, Sweden.
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Manco-Johnson MJ, Pettersson H, Petrini P, Babyn PS, Bergstrom BM, Bradley CS, Doria AS, Feldman BM, Funk S, Hilliard P, Kilcoyne R, Lundin B, Nuss R, Rivard G, Schoenmakers MAGC, Van den Berg M, Wiedel J, Zourikian N, Blanchette VS. Physical therapy and imaging outcome measures in a haemophilia population treated with factor prophylaxis: current status and future directions. Haemophilia 2004; 10 Suppl 4:88-93. [PMID: 15479378 DOI: 10.1111/j.1365-2516.2004.00978.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Routine infusions of factor VIII to prevent bleeding, known as prophylaxis, and other intensive therapies are being more broadly applied to patients with haemophilia. These therapies differ widely in replacement product usage, cost, frequency of venous access and parental effort. In order to address residual issues relating to recommendations, implementation, and evaluations of prophylaxis therapy in persons with haemophila, a multinational working group was formed and called the International Prophylaxis Study Group (IPSG). The group was comprised of haemophilia treaters actively involved in studies of prophylaxis from North America and Europe. Two expert committees, the Physical Therapy (PT) Working Group and the Magnetic Resonance Imaging (MRI) Working Group were organized to critically assess existing tools for assessment of joint outcome. These two committees independently concluded that the WFH Physical Examination Scale (WFH PE Scale) and the WFH X-ray Scale (WFH XR Scale) were inadequately sensitive to detect early changes in joints. New scales were developed based on suggested modifications of the existing scales and called the Haemophilia Joint Health Score (HJHS) and the International MRI Scales. The new scales were piloted. Concordance was measured by the intra-class correlation coefficient of variation. Reliability of the HJHS was excellent with an inter-observer co-efficient of 0.83 and a test-retest value of 0.89. The MRI study was conducted using both Denver and European scoring approaches; inter-reader reliability using the two approaches was 0.88 and 0.87; test-retest reliability was 0.92 and 0.93. These new PT and MRI scales promise to improve outcome assessment in children on early preventive treatment regimens.
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Affiliation(s)
- M J Manco-Johnson
- Department of Pediatrics, Mountain States Regional Hemophilia and Thrombosis Centre, University of Colorado Health Sciences Centre, Denver, Colorado 800445-0507, USA.
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Lefkowitz JB, Weller A, Nuss R, Santiago-Borrero PJ, Brown DL, Ortiz IR. A common mutation, Arg457-->Gln, links prothrombin deficiencies in the Puerto Rican population. J Thromb Haemost 2003; 1:2381-8. [PMID: 14629473 DOI: 10.1046/j.1538-7836.2003.00420.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [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] [Indexed: 11/20/2022]
Abstract
Five unrelated families with Puerto Rican ancestry were identified as having at least one member with bleeding due to a prothrombin deficiency. Genetic prothrombin deficiencies are extremely rare, but at the University of Puerto Rico Hemophilia Center, prothrombin deficiency is the third most common congenital coagulation factor deficiency. Because Puerto Rico is relatively isolated, there was a reasonable expectation of a founder effect. Prothrombin genes from probands and their parents were directly sequenced from PCR amplified exons using forward and reverse primers. Four novel prothrombin mutations were identified. The first, a G-->A substitution at DNA position 10150 predicting an Arg457-->Gln (R457Q) replacement, is common to all five families. In two of the families, the proband children are homozygous for R457Q. In the other three families, the probands are compound heterozygotes for R457Q and one of the other three mutations, which include another point mutation (gamma16Q), a deletion and a splice junction mutation. The two point mutations have been designated Puerto Rico I and Puerto Rico II. The crystal structure of alpha-thrombin predicts that the R457Q mutation removes a salt bridge that links the A- and B-chains of thrombin. The primary effect of this defect appears to be destabilization of the circulating prothrombin, creating a moderate hypoprothrombinemia. However, prothrombin antigen/activity ratios indicate a dysprothrombinemia as well, most likely due to the inability of R457Q prothrombin to activate fully to thrombin.
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Affiliation(s)
- J B Lefkowitz
- Department of Pathology, University of Colorado School of Medicine, Denver, Colorado 80262, USA.
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Leissinger C, Nuss R, Wulff K, Giambartolomei S, Raith C, Urbancik W, Spotts G. Pilot introduction study of a needleless transfer device (BAXJECT) for reconstitution of Factor VIII concentrates for infusion. J Thromb Haemost 2003. [DOI: 10.1111/j.1538-7836.2003.tb03528.x] [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: 11/29/2022]
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Abstract
Medical imaging of haemophilic joints is important for detecting abnormalities, grading their severity and selecting the appropriate therapy. The plain-film scoring systems for staging joint disease that were developed prior to the availability of magnetic resonance imaging (MRI) are inadequate for planning modern prevention and treatment. MRI is capable of delineating all of the soft tissue findings long before they are evident on plain radiographs. In this paper, an MRI scoring system is presented along with examples of joint effusion, haemarthrosis, synovial hypertrophy, haemosiderin deposition, erosions, cysts and cartilage loss. MRI is a powerful tool in the diagnosis, staging and treatment of patients with haemophilic joint disease.
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Affiliation(s)
- R F Kilcoyne
- Department of Radiology, University of Colorado Health Sciences Center, Denver 80262, USA.
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Abstract
Hemophilia leads to recurrent bleeding episodes in joints resulting in a severe destructive arthropathy in many cases. Staging of hemophilic joint disease is important for identifying the site of bleeding and planning appropriate therapy. However, classification systems based on plain X-ray findings have been insensitive at detecting the earlier, possibly reversible, changes of synovial hyperplasia. They may also underestimate the severity of cartilage damage. Magnetic resonance imaging (MRI) has been shown to more accurately assess a hemophilic joint. Tentative hemophilic arthropathy scales based on MRI findings are being developed. Hopefully, use of these scales will result in more consistent assessment of hemophilic joints and facilitate development of more targeted treatment and thus prevent or delay the later, destructive changes in the articular cartilage and bone.
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Affiliation(s)
- Ray F Kilcoyne
- Department of Radiology, University of Colorado Health Sciences Center, Denver, Colorado, USA.
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Brown SA, Aledort LM, Astermark J, Berntorp E, van den Berg M, Blanchette V, Donfield S, Gringeri A, Hilgartner M, Kulkarni R, Leissinger C, Negrier C, Nuss R, Petterson H, Petrini P, Poulios N, Schramm W. Unresolved issues in prophylaxis. Haemophilia 2002; 8:817-21. [PMID: 12410654 DOI: 10.1046/j.1365-2516.2002.00685.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- S A Brown
- Katharine Dormandy Haemophilia Centre & Haemostasis Unit, Royal Free Hospital, London, UK.
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Abstract
BACKGROUND This study was performed to prospectively evaluate the safety, efficacy, and cost of injecting P-colloid into joints of children with hemophilia and synovitis to decrease the rate of joint bleeding. PATIENTS AND METHODS Eligibility included a diagnosis of hemophilia, history of more than six hemorrhages into a joint within a 6-month period, and evidence of synovitis by objective imaging. With written, informed consent, 0.25 to 1.0 mCi of P-colloid was injected into the problem joints. Safety was monitored by external beta-scanning and physical assessment. Efficacy was determined by analysis of the change in joint hemorrhage frequency from 6 months before and up to 96 months after the injection using a signed-rank test. Physical assessment and pain assessment were analyzed similarly using values obtained within 1 week before and 6 months after the radiosynoviorthesis. Cost was modeled using charges from the authors' institution in relation to existing alternative therapies. RESULTS One hundred injections were given into 91 joints in 59 children. Seven children had high-titer neutralizing antibodies to factor VIII or IX. Nine children were infected with HIV. Joints injected included 44 ankles, 19 knees, 27 elbows, and 1 shoulder. Nine joints required reinjection. All children showed a significant decrease in bleeding rate (P < 0.0001) and pain (P = 0.03), with improved physical function (P = 0.02). In one child acute lymphocytic leukemia developed, but it was judged unrelated to the two P injections that he had received 3 and 10 months before the leukemia diagnosis. There were no cases of bleeding, infection, or inflammation caused by the injection. Cost was substantially less than medical and surgical alternatives. CONCLUSIONS Radiosynoviorthesis is effective in limiting the frequency of joint hemorrhage, decreasing pain and improving function in children with hemophilia. However, long-term safety studies are needed.
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Abstract
Hemophilia is a rare disorder affecting 1 in 5,000 males. Because hemophilia-associated hemorrhage may occur at anytime, affected males frequently seek care in the ED. We studied the epidemiology of ED visits by males with hemophilia. The medical records of all identified Coloradan males with hemophilia who sought care in Colorado EDs in 1998 were reviewed. Fifty-one males with hemophilia had a total of 125 ED visits; hemorrhage accounted for 64.8% of visits (95% CI=55.6, 73.1). On 13.0% (95% CI=6.4, 22.6) of visits for hemorrhage, treatment was warranted, but not given. On 12.3% (95% CI=5.5, 22.8) of visits when treatment was given, there were errors in product choice or dose. Documentation of factor concentrate brand and lot number was present for just 13.9% (95% CI=6.5, 24.7) and 24.6% (95% CI=14.8, 36.9) of visits, respectively. There is substantial room for improvement in the prescribing practices and documentation related to hemophilia care in the ED. Available resources should be utilized by ED physicians.
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Affiliation(s)
- Rachelle Nuss
- Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado Health Sciences Center and the Colorado Department of Public Health and Environment, Denver, CO, USA.
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Lefkowitz JB, Nuss R, Haver T, Jacobson L, Thompson AR, Manco-Johnson M. Factor IX Denver, ASN 346-->ASP mutation resulting in a dysfunctional protein with defective factor VIIIa interaction. Thromb Haemost 2001; 86:862-70. [PMID: 11583320] [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: 02/21/2023]
Abstract
Hemophilia B is a sex-linked recessive bleeding disorder characterized by the presence of either a decreased amount of normal factor IX (FIX) or the presence of a dysfunctional FIX. We have identified a unique mutation in a family with mild hemophilia B. DNA analysis of family members revealed a single base transition in the 8th exon of the FIX gene predicting an amino acid change of Asn 346-->Asp in the catalytic domain. The FIX variant, named FIX Denver, was purified from proband plasma. Kinetic studies of factor X (FX) interactions with normal FIXa or FIXa Denver and phospholipid (PL) showed little difference in kcat but a significant difference when factor VIIIa (FVIIIa) was included in the reaction. Using kinetic assays to infer the Kd of FIXa for FVIIIa, normal FIXa had a Kd of 0.095 nM while that of FIXa Denver was 9.85 nM. The major defect caused by this point mutation is a marked decrease in the affinity of FIXa Denver for factor VIIIa.
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Affiliation(s)
- J B Lefkowitz
- Department of Pathology, University of Colorado School of Medicine, Denver 80262, USA.
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Abstract
This cross-sectional study was conducted to determine the incidence of autoantibodies to phospholipids and coagulation proteins in children with acute varicella zoster virus (VZV) infection. Study groups included children with VZV alone or complicated by purpura fulminans and/or thromboembolism. VZV naïve children and children who had VZV >1 y before sample collection formed a control group. Blood was assayed for the following: free protein S (PS), protein C, antithrombin, and prothrombin; antibody binding to these proteins; lupus anticoagulant; anticardiolipin antibody; antiphospholipid antibodies; and prothrombin fragment 1+2. Data regarding coinfections was collected. Forty-three VZV-infected children showed an increased frequency of lupus anticoagulant, anticardiolipin antibody, antiphospholipid antibodies, and autoantibodies to PS, protein C, prothrombin, and antithrombin in comparison to 52 children without acute VZV (p < 0.0001). Seventeen children with VZV and purpura fulminans and/or thromboembolism showed a statistically significant decrease in free PS, significantly increased PS IgG antibody, and significantly increased prothrombin fragment 1+2 (p < 0.0001) compared with the group without acute VZV and the group with uncomplicated VZV. Twenty-six children with uncomplicated VZV showed increased PS IgG antibody (p < 0.001) compared with the children without acute VZV. For all groups combined, elevated PS IgG antibody showed negative correlation with free PS (p < 0.0001) and positive correlation with prothrombin fragment 1+2 (p = 0.0002). Autoantibodies were transient. Transient antiphospholipid and coagulation protein autoantibodies were common with VZV infection, but were not predictive of thrombotic complications.
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Affiliation(s)
- C Josephson
- Departments of Pediatrics, University of Colorado Health Sciences Center, Denver, Colorado 80262, USA
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45
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Abstract
Recent studies suggest that rates of intracranial hemorrhage (ICH) increased concomitant with the HIV epidemic among the hemophilia population, but no studies have directly examined factors associated with ICH. To determine ICH rates and identify factors associated with ICH, we performed a nested case-control study of a cohort composed of all hemophilic males identified by a surveillance system. Data were obtained from medical records of care received during 1993-1997. Patients with ICH listed in hospital records or on death certificates during the 5-year period were compared to the remainder of the cohort to examine associations between ICH and patients' demographic and clinical factors including the presence of HIV infection. Among the 3,269 males in the cohort, 88 (2.7%) had an ICH during follow-up, an average incidence rate of 0.0054 case/year. Hemorrhage sites were intracerebral for 37.5%, subdural for 34.1%, unspecified for 19.3%, subarachnoid for 12.5%, and epidural for 8% of cases. For 22% of cases, the ICH was trauma-related, and, overall, 16 patients (18.2%) died. Several factors were independently associated with ICH (odds ratio, P value): severe disease (2.0, 0.05); age 51+ years compared to 6-10 year olds (3.7, 0.02); presence of an inhibitor (3.5, <0.001); and HIV infection among whites only (4.0, <0.001). ICH rates in our cohort were 2-fold higher compared to rates from previous reports. Much of the increase was attributed to HIV infection, which raised ICH risk primarily in whites and was frequently associated with spontaneous ICH among older individuals. Published 2001 Wiley-Liss, Inc.
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Affiliation(s)
- R Nuss
- Mountain States Regional Hemophilia and Thrombosis Center, Denver, Colorado, USA
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46
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Manco-Johnson MJ, Nuss R. Thrombophilia in the infant and child. Adv Pediatr 2001; 48:363-84. [PMID: 11480763] [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: 02/20/2023]
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Abstract
With the heightened interest in protocols to prevent or treat complications of haemophilia related to recurrent haemarthroses, there is a need for sensitive joint-evaluation tools. The World Federation of Haemophilia (WFH) Physical Joint Examination instrument, which was developed for persons with haemophilia worldwide, is not sensitive enough to detect early structural or functional abnormalities. Therefore, we have expanded the WFH instrument to detect more subtle abnormalities of joint structure and function, and in addition, developed a new scale specifically tailored to the dynamic growth and gait development of children. We compared the original and three new instruments in 43 children with haemophilia. The three new scales all showed better correlation with the WFH pain instrument than did the original WFH physical examination instrument (P < 0.01 for each of the new instruments vs. P > 0.05 for the WFH instrument). In addition, results of the new child physical examination instrument best conformed to a normal distribution (P=0.35) and this instrument had better overall statistical performance. This instrument should be studied further in prospective, longitudinal clinical trials of young children.
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Affiliation(s)
- M J Manco-Johnson
- Department of Paediatrics, Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado Health Sciences Center, Aurora, CO 80045-0507, USA.
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48
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Nuss R, Kilcoyne RF, Rivard GE, Murphy J. Late clinical, plain X-ray and magnetic resonance imaging findings in haemophilic joints treated with radiosynoviorthesis. Haemophilia 2000; 6:658-63. [PMID: 11122392 DOI: 10.1046/j.1365-2516.2000.00433.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The clinical, plain X-ray and magnetic resonance imaging (MRI) findings were studied in 13 haemophilic joints previously treated with radiosynoviorthesis. (32)P had been injected into the joints at a median of 16 years earlier in an attempt to halt recurrent haemorrhage. Prior to (32)P injection, the majority of joints demonstrated bone damage evident on plain X-ray, secondary to recurrent haemorrhage. At the follow-up evaluation we found plain X-rays were adequate to identify cysts, erosions and cartilage loss in these very damaged joints. MRI was superior to clinical examination and plain X-ray in identifying synovial hyperplasia and effusions.
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Affiliation(s)
- R Nuss
- Mountain States Regional Hemophilia and Thrombosis Centre, University of Colorado Health Sciences Centre, Denver, Colorado, USA.
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Abstract
Skin necrosis and priapism are unusual complications of warfarin therapy. We report a teenager with warfarin-associated skin necrosis and priapism who was subsequently found to be a compound heterozygote for protein C deficiency and a heterozygote for the factor V Leiden mutation.
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Affiliation(s)
- J Zimbelman
- Department of Pediatrics, University of Colorado Health Sciences Center, Aurora, Colorado 80045-0507, USA
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Soucie JM, Nuss R, Evatt B, Abdelhak A, Cowan L, Hill H, Kolakoski M, Wilber N. Mortality among males with hemophilia: relations with source of medical care. The Hemophilia Surveillance System Project Investigators. Blood 2000; 96:437-42. [PMID: 10887103] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
Although persons with hemophilia are known to be at increased risk of death, no studies have examined the source of medical care and other personal characteristics for associations with mortality. To determine death rates and to identify causes of death and predictors of mortality, we studied a cohort comprised of all hemophilic males identified by a six-state surveillance system. Data were obtained by medical record review of contacts with physicians, hemophilia treatment centers (HTCs), and other sources of care during 1993-1995 and from death certificates. Factors examined included age, race, state of residence, health insurance type, medical care source, hemophilia type/severity, presence of inhibitor, liver disease, HIV infection, and AIDS. A total of 2950 subjects were followed for an average of 2.6 years. Their median age was 22 years; 73% were white, 79% had hemophilia A, 42% had severe disease, and 67% had visited an HTC. During 7575 person years (PYs) of observation, 236 persons died-an age-adjusted mortality rate of 40.4 deaths/1000 PYs; 65% of deaths were HIV related. In addition to age, factors independently associated with increased risk of death (relative risk, P value) were the following: AIDS (33.5, <.001); HIV infection (4.7, <.001); liver disease (2.4, <.001); and Medicare/Medicaid insurance (1.4,. 01). Those persons who had received care in an HTC had a significantly decreased risk of death (0.6,.002). Although HIV infection and the presence of severe liver disease remain strong predictors of mortality, survival is significantly greater among hemophilics who receive medical care in HTCs. (Blood. 2000;96:437-442)
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Affiliation(s)
- J M Soucie
- Hematologic Diseases Branch, Division of AIDS, STD, and TB Laboratory Research, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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