Intranasal fentanyl and discharge from the emergency department among children with sickle cell disease and vaso-occlusive pain: A multicenter pediatric emergency medicine perspective

Children with sickle cell disease (SCD) commonly experience vaso-occlusive pain episodes (VOE) due to sickling of erythrocytes, which often requires care in the emergency department. Our objective was to assess the use and impact of intranasal fentanyl for the treatment of children with SCD-VOE on discharge from the emergency department in a multicenter study. We conducted a cross-sectional study at 20 academic pediatric emergency departments in the United States and Canada. We used logistic regression to test bivariable and multivariable associations between the outcome of discharge from the emergency department and candidate variables theoretically associated with discharge. The study included 400 patients; 215 (54%) were female. The median age was 14.6 (interquartile range 9.8, 17.6) years. Nineteen percent (n = 75) received intranasal fentanyl in the emergency department. Children who received intranasal fentanyl had nearly nine-fold greater adjusted odds of discharge from the emergency department compared to those who did not (adjusted odds ratio 8.99, 95% CI 2.81-30.56, p < .001). The rapid onset of action and ease of delivery without intravenous access offered by intranasal fentanyl make it a feasible initial parenteral analgesic in the treatment of children with SCD presenting with VOE in the acute-care setting. Further study is needed to determine potential causality of the association between intranasal fentanyl and discharge from the emergency department observed in this multicenter study.

Normal saline bolus use in pediatric emergency departments is associated with poorer pain control in children with sickle cell anemia and vaso-occlusive pain

Vaso-occlusive pain events (VOE) are the leading cause of emergency department (ED) visits in sickle cell anemia (SCA). This study assessed the variability in use of intravenous fluids (IVFs), and the association of normal saline bolus (NSB), on pain and other clinical outcomes in children with SCA, presenting to pediatric emergency departments (PED) with VOE. Four-hundred charts of children age 3-21 years with SCA/VOE receiving parenteral opioids at 20 high-volume PEDs were evaluated in a retrospective study. Data on type and amount of IVFs used were collected. Patients were divided into two groups: those who received NSB and those who did not. The association of NSB use on change in pain scores and admission rates was evaluated. Among 400 children studied, 261 (65%) received a NSB. Mean age was 13.8 ± 4.9 years; 46% were male; 92% had hemoglobin-SS. The IVFs (bolus and/or maintenance) were used in 84% of patients. Eight different types of IVFs were utilized and IVF volume administered varied widely. Mean triage pain scores were similar between groups, but improvement in pain scores from presentation-to-ED-disposition was smaller in the NSB group (2.2 vs 3.0, P = .03), while admission rates were higher (71% vs 59%, P = .01). Use of NSB remained associated with poorer final pain scores and worse change in pain scores in our multivariable model. In conclusion, wide variations in practice utilizing IVFs are common. NSB is given to >50% of children with SCA/VOE, but is associated with poorer pain control; a controlled prospective trial is needed to determine causality.

Characterization of pica prevalence among patients with sickle cell disease

OBJECTIVE

To determine the prevalence of pica and its characteristics among children with sickle cell disease.

DESIGN

Retrospective, observational study.

SETTING

An urban, ambulatory care, interdisciplinary center.

PATIENTS

The medical records of all 480 patients who visited the center from March 1, 1998, to June 30, 1999, were reviewed. Patients were excluded for history of stroke, long-term transfusions, pregnancy, acute illness, or age younger than 3 years.

MAIN OUTCOME MEASURES

Sex, age, weight, height, Tanner stage, complete blood cell count, sickle cell genotype, pica history, and levels of iron, zinc, lead, and fetal hemoglobin (Hb).

RESULTS

Of 395 study patients, 134 (33.9%) reported pica. Ingested items included paper, foam, and powders. There was a significantly higher prevalence of pica among patients homozygous for Hb S (Hb SS, sickle cell anemia) compared with the combined group of double heterozygous patients with Hb SC, Hb SD, and Hb Sbeta thallasemia (Sbeta(+)or Sbeta(0)) (35.6% vs 25.5%; P =.03). Within genotype, mean Hb levels were significantly lower and reticulocyte counts were significantly higher in the patients with pica. Overall, the mean age of patients with pica was significantly lower; however, the prevalence was 23.3% (27/116) among those aged 10.0 to 14.9 years and 14.8% (8/54) among those aged 15.0 to 19.0 years. Within age groups, patients with pica weighed significantly less.

CONCLUSIONS

Pica appeared to have an unusually high prevalence in patients with sickle cell disease and a correlation with lower Hb levels. It is unclear whether pica is a specific marker of disease severity, because our review did not show a relationship to increased number and duration of hospitalizations. The association between pica and low body weight suggests a nutritional effect on its prevalence.

Imaging of sickle cell disease

Sickle cell disease is an important health care issue in the United States and in certain areas in Africa, the Middle East and India. Although a great deal of progress has been made in understanding the disease at the molecular and pathophysiologic level, specific treatment which is safe and accessible for most patients is still elusive. Going into the next millennium, the management of this disease is still largely dependent on early diagnosis and the treatment of complications with supportive care. Thus, diagnosis and evaluation of the complications of the disease are crucial in directing clinical care at the bedside. Modern imaging modalities have greatly improved, and their application in the patient with the sickling disorders has enhanced the decision - making process. The purpose of this article is to review the clinical aspects of common complications of the disease and to discuss imaging approaches which are useful in their evaluation.

Biodegradation of methyl violet by Pseudomonas mendocina MCM B-402

Pseudomonas mendocina MCM B-402 was found to utilize a triphenylmethane dye, methyl violet as the sole source of carbon when incorporated in synthetic medium. Almost complete decolorization of methyl violet by P. mendocina was observed within 48 h of incubation at ambient temperature (28 +/- 2 degrees C) under aerated culture conditions, when the bacteria were inoculated into Davis Mingioli's synthetic medium at a concentration of 100 mg/l medium. Methyl violet was mineralized to CO2 through three unknown intermediate metabolites and phenol. The decolorization of the dye involved demethylation.

Low frequency of meperidine-associated seizures in sickle cell disease

Pain control measures in sickle cell diseases are not uniform. Most clinicians use parenteral morphine or meperidine for severe pain. Reports of seizures associated with meperidine have led to a growing reliance on intravenous morphine, usually with patient-controlled devices. Acceptance of morphine has been poor among patients, and many prefer meperidine. The aim of this retrospective study was to determine the incidence of meperidine-associated seizures in a large, mostly pediatric population with sickling disorders. The results suggest that the incidence of seizures with meperidine is extremely small (0.4% of patients; 0.06% of admissions). The risk of seizures should not dissuade clinicians from using this drug.

Prevalence of microalbuminuria in children with sickle cell disease

Renal involvement is common in homozygous sickle cell disease (HbSS), including glomerular hypertension and hypertrophy similar to that seen in rodent models of ablative nephrectomy and stage I diabetic nephropathy (DN). The proteinuria in the rodent models is attenuated by angiotensin converting enzyme inhibition (ACEI). Microalbuminuria (MA) is a sensitive marker for renal involvement in DN prior to the development of proteinuria, and is also attenuated with ACEI. Elevated urinary microalbumin/creatinine ratios (U Alb/Cr) >20 mg/g Cr are reported in 39%-43% of adults with HbSS, and studies are ongoing in this age group to assess the effect of attenuated proteinuria by ACEI on long-term renal function. The purpose of this study was to prospectively investigate the prevalence of MA in children with HbSS and determine factors which affect its expression. U Alb/Cr values were measured on spot urine samples in 102 children (aged 2-18 years, mean 9.47+/-4.62, M:F=53:49) by rate nephelometry. Children with prior known proteinuria, hypertension, or fever/pain episode in the last 15 days were excluded. MA was present in 26.5% of all children with HbSS. However, in children between the ages of 10 and 18 years, the prevalence was 46% (similar to the prevalence in adults). There was a strong correlation between patient age and prevalence of MA (P<0.0001) by both univariate and multivariate analysis. However, pain frequency, hospitalization, transfusion program, ferritin levels, and Cr clearance (C(Cr)) did not correlate with prevalence, although C(Cr) (as estimated by Schwartz formula) was elevated in all. We conclude that the prevalence of MA in the 2nd decade of life is similar to that in adults.

Priapism associated with sickle cell hemoglobinopathy in children: long-term effects on potency

PURPOSE

Children with sickle cell priapism have traditionally been treated conservatively with surgery done as a last resort. Only sparse subjective data are available on the long-term assessment of potency in these patients.

MATERIALS AND METHODS

We retrospectively reviewed the charts of all pediatric patients with sickle cell priapism who presented to Children's Hospital of Michigan between 1972 and 1992, and subsequently assessed erectile capabilities subjectively by questionnaire and objectively by RigiScan.

RESULTS

Of the 15 patients interviewed 5 had undergone shunt procedures. The return of potency tended to vary inversely with patient age at onset and duration of priapism.

CONCLUSIONS

Shunts performed within 48 hours, especially in postpubertal children, seemed more likely to preserve potency.

Blood transfusions and immunophenotypic alterations of lymphocyte subsets in sickle cell anemia. The Transfusion Safety Study Group

Transfusions purportedly induce dysfunction of cell-mediated immunity in sickle cell anemia (SCA). We studied hematologic and lymphocytic indices in 173 human immunodeficiency virus (HIV)-negative subjects with SCA and 131 black controls. Children aged 1 to 7 years with SCA had leukocyte counts and percentages of granulocytes, monocytes, natural killer cells, and T-cell markers (CD2+CD11b+, CD4+CD26+, CD4+CD29+) that were significantly higher than those for control children. Percent total lymphocytes was decreased for this age group, but the total number of lymphocytes and T and B cell counts were similar to controls. Platelets were not increased. Adolescents (aged 8 to 17 years) and adults (aged > or = 18 years) with SCA had increased total leukocytes and monocytes and lymphocytes counts that remained level instead of decreasing, as did comparably aged controls. Lymphocyte subsets typically increased in count, but their percentage remained similar to children. The exception was CD56+ cell counts, which were increased in adolescents and adults. No lymphocytic subset change suggested impaired cellular immunity, and none could be related to transfusion. Prophylactically transfused patients had higher granulocyte counts, but these may arise from the complications of SCA itself.

Bepridil as an antisickling agent: membrane internalization and cell rigidity

The calcium channel antagonist, bepridil, beta-(2-methylpropoxy)methyl-N-phenyl-N-(phenylmethyl)-1-pyrrol idineethanamine monochloride monohydrate, inhibits the sickling of deoxygenated sickle (SS) erythrocytes, as determined by light microscopy. The anti-sickling effect was seen only in dilute suspensions of red cells. In concentrated erythrocyte suspensions, sickling was not inhibited and measurements of hematocrit and cell density were unchanged by bepridil. The determination of cell volume in dilute suspensions was complicated by bepridil's tendency to aggregate, but rapid measurements by electronic sizing also indicated no increase in cell volume, up to a bepridil concentration of 200 microM. Ektacytometry of dilute sickle cell suspensions suggested an explanation for the anti-sickling action of bepridil. Osmotic scan ektacytometry disclosed that bepridil initially increased the surface area of the red cell, as shown by a shift in the low osmolality minimum. This change was complete in 10 sec, the shortest time that could be measured. Subsequently, at concentrations that were observed to inhibit the sickling of deoxygenated sickle cells (100 microM or greater), red cells underwent a loss in surface area that was complete in 1 min. There was a concomitant loss of cell deformability. Light and scanning electron microscopy has previously shown that bepridil is a stomatocytic agent. Using transmission electron microscopy, we verified that the loss of surface area was a consequence of endocytosis, presumably as the end stage of the stomatocytic transformation induced by bepridil. Bepridil did not inhibit intracellular hemoglobin S polymerization even at 200 microM, as shown by oxygen scan ektacytometry. Bepridil thus appears to inhibit the sickling of deoxygenated SS cells by inducing endocytosis and lowering cell deformability. This mechanism may explain the anti-sickling effect of other basic amphiphiles, such as chlorpromazine.

Evaluation of Acacia nilotica (L.) del. and Casuarina equisetifolia forst. for tolerance and growth on microbially treated dyestuff wastewater

Two tree species, Acacia nilotica (L.) Del. and Casuarina equisetifolia Forst., were tested for their tolerance and growth on dyestuff wastewater containing phenol, aniline, and methyl violet. The wastewater was treated microbially by using a culture of Pseudomonas alcaligenes in a fixed-film bioreactor. The plants were watered with untreated and treated wastewater and tap water (control) at the rate of 2 litre per plant per week. A. nilotica exhibited 100% survival with both untreated and treated wastewater, and growth (increase in height) was comparable to that of control plants. However, growth of C. equisetifolia was adversely affected. It exhibited 100% survival with treated wastewater but only 87% survival with untreated waste-water and the percentage increase in height was less with both treated and untreated wastewater. There was no effect on soil except for an increase in chloride content.

An activated sludge process to reduce the pollution load of a dye-industry waste

A laboratory-scale activated sludge process was developed to reduce the pollution load of a dye-industry waste, containing aniline, phenol, methyl violet and rhodamine B as its major components. The waste exerted an organic load of 5576 mg litre(-1) as the chemical oxygen demand (COD), of 896 mg litre(-1) as total organic carbon (TOC), and had a 31.5 mg litre(-1) phenol content. A microbial sludge, capable of growing on the waste, was developed from cattle dung, adapted to the waste and used as a bioinoculum for the process. This resulted in reductions of 60% in COD, 37% in TOC, and 92% in phenol content, and a decrease in optical density of the colour of the waste from an initial 0.915 to 0.360 at 580 nm. Microorganisms isolated from sludge were identified as Pseudomonas alcaligenes and P. mendocina.

Mechanical properties of sickle cell membranes

The mechanical properties of sickle erythrocyte membranes were evaluated in the ektacytometer. When ghosts from the total red blood cell population were examined, the rigidity of the resealed ghosts and their rate of fragmentation by shear stress (t1/2) were normal. However, fractionation on Stractan density gradients revealed that sickle cells were heterogenous in their membrane mechanical properties. The ghosts from dense cell fractions exhibited both increased rigidity and decreased stability. Presumably, these altered mechanical properties are a reflection of the well-documented biochemical damage found in irreversibly sickle cell membranes. Nevertheless, neither of the alterations in mechanical properties are likely to be significant elements in the hemolysis of sickle cell anemia. Earlier studies of abnormal erythrocytes suggest that increases in membrane rigidity per se do not increase hemolysis, and they are, therefore, unlikely to do so in this case. The stability of membranes from the dense cell fractions was reduced to about two thirds of the control value. Comparison with the results of studies of red blood cell membranes with genetically defective or deficient spectrin suggests that a reduction in t 1/2 of 50% is not associated with significant increases in the rate of hemolysis. Although altered ghost stability and flexibility can be demonstrated in dense sickle cells, these changes in membrane mechanical properties are not likely to be significant factors in the hemolytic process.

Studies on Pneumococcus vaccine alone or mixed with DTP and on Pneumococcus type 6B and Haemophilus influenzae type b capsular polysaccharide-tetanus toxoid conjugates in two- to five-year-old children with sickle cell anemia

Pneumococcus vaccine, injected alone or mixed with diphtheria-tetanus toxoid-pertussis, did not elicit significant concentrations of pneumococcus type 6 antibodies in 2- to 5-year-old sickle cell anemia patients (n = 22). Reinjection 5 months later failed to elicit a booster response to pneumococcus type 6. We then injected conjugates of pneumococcus type 6B and of Haemophilus influenzae type b (Hib), each bound to tetanus toxoid (TT), alternatively at monthly intervals into sickle cell anemia patients of the same age group (n = 25); most received 3 injections of each vaccine. Pneumococcus vaccine was administered to 19 patients and Hib to 1 at approximately 1 year of age. Blood samples were taken before each and approximately 6 months after the last injection. Infrequent and minimal local reactions and only 6 episodes of fever (3%) occurred after injection of the conjugates. Pneumococcus type 6B-TT elicited a rise in the geometric mean concentration of pneumococcus type 6 antibodies (Ab) from 104 ng of antibody nitrogen (AbN)/ml in preimmunization sera to 385 ng of AbN/ml after the first injection (P less than 0.01). There were further increases after the 2 subsequent injections; 6 months after the third injection, the mean concentration was 940 ng of AbN/ml and 15 of 16 (94%) had greater than 300 ng of AbN/ml. Hib-TT elicited a 160-fold increase of Hib antibodies to a geometric mean concentration of 39.0 micrograms of Ab/ml after the first injection. These levels rose approximately 2-fold following 2 additional injections to 71.7 micrograms/ml and declined to 10.7 micrograms/ml at the 6-month sampling.(ABSTRACT TRUNCATED AT 250 WORDS)

The incidence of development of irregular red cell antibodies in patients with sickle cell anemia

Two hundred and forty-five patients with SS hemoglobinopathy were screened for alloimmunization; they had all been transfused previously. Their median age was 10 years. Nineteen patients (7.75%) were found to be sensitized to various red cell antigens. The median number of transfusions received by sensitized patients was 23 compared to three in the unsensitized group, indicating an increased risk with more transfusion exposures. Thirteen sensitized patients were re-exposed to transfusion and four (30%) developed new alloantibodies. Once immunized, the risk of developing more alloantibodies on re-exposure did not increase with increasing number of exposures. The most frequently observed alloantibody was anti-K, accounting for 38 percent of all instances. Anti-Lea and -Leb were next in frequency (24%); Rh antibodies were seen in 14 percent of cases. Children with sickle cell anemia who were multiply transfused had a low frequency of alloimmunization. Responders had an increased rate of further sensitization which did not increase with number of subsequent exposures. Phenotypically matched blood is probably not warranted in most patients receiving transfusions for sickle cell anemia.

Sickle-cell nephropathy: MR imaging

To study the nephropathy associated with sickle-cell disease (SCD), spin-echo magnetic resonance (MR) imaging of the kidneys was performed in 19 SCD patients, six with beta-thalassemia major (BTM), and ten healthy individuals as controls. Eleven SCD patients had decreased relative cortical signal, most evident on T2-weighted images. No correlation with serum ferritin, urine-concentrating ability, serum blood urea nitrogen, or creatinine levels was established. Iron deposition in the renal cortices of sickle-cell nephropathy patients may, at least in part, be responsible for the relatively diminished cortical signal intensity. No BTM patients, all of whom were clinically and biochemically in iron overload from frequent transfusions, demonstrated diminished renal cortical signal intensity. This suggests that renal changes in SCD seen on MR images are not due simply to systemic iron overload per se but perhaps reflect abnormalities of iron metabolism in the renal cortex peculiar to SCD nephropathy.

Diminished helper/suppressor lymphocyte ratios and natural killer activity in recipients of repeated blood transfusions

Immunologic abnormalities qualitatively similar to those seen in acquired immunodeficiency syndrome (AIDS), including a low helper/suppressor lymphocyte ratio and low natural killer (NK) activity, have been observed in many hemophiliacs receiving clotting factor concentrates. To determine whether these changes also occur after repeated blood transfusion, we measured helper/suppressor (T4/T8) ratios and NK activity in four groups of test subjects: (A) 30 subjects with sickle cell anemia (SCA) receiving monthly transfusions, (B) 30 nontransfused sickle cell anemia subjects, (C) 87 individuals with hemophilia or severe von Willebrand's disease, and (D) 30 normal controls. Like the hemophiliacs, transfused SCA subjects had low T4/T8 ratios and low NK activity compared to controls. Nontransfused SCA subjects had normal values. These findings suggest that a modest decrease in T4/T8 ratio and NK activity may be part of the normal immune response to repeated transfusion.

Preoperative exchange transfusion in sickle cell anemia

Preoperative transfusion therapy is largely responsible for the recently improved morbidity and mortality in patients with sickle cell anemia undergoing surgery. The transfusion techniques recommended are several. Fifty patients have undergone 67 operations over the past 15 yr. The complications encountered in patients receiving simple transfusion or partial exchange transfusion do not differ. There remains theoretic advantage in the use of preoperative partial exchange transfusion with quantitation of hemoglobin S.

Incidence of cholelithiasis in sickle cell anemia using the ultrasonic gray-scale technique

Gray-scale ultrasound examination of the gallbladder was successfully performed in 226 patients with sickle cell hemoglobinopathy from 2 to 18 years of age. Sixty-three (27%) demonstrated the presence of gallstones; 14 additional patients had "sludge." The incidence of gallstones increased significantly with age, from 12% in the 2- to 4-year age group to 42% in the 15- to 18-year-old group. The proportion of females with gallstones increased significantly in adolescence. Patients with gallstones had higher mean bilirubin levels, but their mean hemoglobin values and reticulocyte counts were not significantly different from those in patients without gallstones. Ultrasound examination of the gallbladder is a simple, noninvasive technique for evaluating the biliary system. The incidence of gallstones in patients below the age of 10 is higher than expected and raises management questions that must be resolved.

Periodic transfusions for sickle cell anemia and CNS infarction

Recurrences of CNS infarction often lead to progressive neurologic disability in sickle cell anemia. To prevent such reccurrence, a periodic blood transfusion program was begun in 1969. Currently, 27 patients are on this regimen. Before inclusion in the program, 12 patients had had one to nine CNS recurrences each. Since the program was started, two patients have had transient CNS ischemia. There were no other recurrences and none of the patients have shown progression of neurologic abnormalities. In addition, there was a striking decrease in bacterial infection and pain. We conclude that periodic transfusions are effective in preventing recurrent CNS infarction in sickle cell anemia. The benefits must be weighed against the potentially serious problem of iron overload, as evidenced by moderately elevated serum ferritin values.

IMFRA (intermittent intrathecal methotrexate and fractional radiation) plus chemotherapy in childhood leukemia

A protocol for the prophylaxis of CNS leukemia was devised involving intermittent low-dosage radiation of the craniospinal axis combined with single intrathecal injections of MTX. The retionale for this protocol was the timing of first CNS relapses in patients not receiving prophylaxis which suggests that leukemic colonization of the CNS is not restricted to the initial stage of the disease and that periodic measures might be advantageous. The low dosage of radiation was chosen because it is well tolerated and has been found temporaily effective in overt CNS relapse. The two series of patients were comparable as to various parameters. Results after three years of observation were comparable to those obtained by other with a single initial course of high-dose radiation, with an expected 50% uninterrupted complete 5-year remission. On the basis of 30 months follow up in 26 patients, the therapy is well tolerated. An increase in morbidity due to infections in remission was not associated with a higher mortality.