"SCULP" study: The benefits of skin graft pellets on the pain of sickle cell leg ulcers (SCLU)

BACKGROUND

Leg ulcers associated with major sickle cell disease (SCLU) are a chronic, painful complication, often treated by autologous skin graft. The analgesic effect of skin grafting in SCLU is poorly studied. The aim of this study was to evaluate the effect of skin grafting on the pain and healing of SCLU.

METHODS

Patients hospitalized for SCLU skin grafting were included in a retrospective and prospective observational cohort, between 2019 and 2023: 53 autologous pinch grafts were performed on a total of 35 SCLUs in 25 sickle cell patients. The primary endpoint was the evaluation of the analgesic effect of the skin graft, measured by visual analog scale (VAS) and weekly cumulative analgesic consumption between day (D)0, D7 and D30. Wound healing was assessed by variation in wound areas between D0 and D30.

RESULTS

Twenty-five patients with a median age range of 45.5years old were included, 68% were men, SS genotype was present in 96% of the cases. At D7, a significant decrease in VAS and consumption of analgesics of all classes was observed. At D30, only a significant decrease in VAS and consumption of mild opioids was present, as well as a significant reduction in wound surface area compared with D0.

CONCLUSION

Pinch grafts have a significant early analgesic effect in the management of patients with SCLU, and significantly notice reduction of wound surface area within one month.

Preventive treatment of unruptured intracranial aneurysms in adult patients with sickle cell anemia: A cohort study

BACKGROUND AND PURPOSE

Intracranial aneurysms are frequent in patients with sickle cell anemia, while subarachnoid hemorrhage is a major cause of death and disability in young adult patients. Several characteristics, such as younger age and smaller size at rupture, may incline therapeutic decision towards exclusion treatments. Clinical guidelines on treatment of unruptured intracranial aneurysms in this population are still missing. We aimed to assess the safety and efficacy of the treatment of unruptured intracranial aneurysm in patients with sickle cell anemia, using an adapted hematological preparation regimen.

PATIENTS AND METHODS

Adult patients with sickle cell anemia and treated unruptured aneurysms by endovascular therapy or neurosurgery were included in this retrospective cohort study. Treatment decision was reached after multi-disciplinary assessment. A pre-operative blood transfusion protocol was undertaken targeting a HbS below 30%. Demographic data, hematological preparation parameters and clinical and radiological outcomes were documented.

RESULTS AND CONCLUSIONS

Twenty-five procedures were performed in 18 patients encompassing 19 aneurysms treated by embolization and 6 by surgery. Median age at treatment was 34 years-old and median aneurysm dome size was 4.4 mm. Immediate aneurysm exclusion rate was 85.7% after endovascular therapy and 100% after neurosurgery. Median follow-up was 6 months, with all patients being asymptomatic at last follow-up. Two transitory ischemic neurological deficits, as well as four cases of iodine-induced encephalopathy were identified after embolization. No complication occurred after surgery. Endovascular therapy by coiling and neurosurgical treatment of unruptured intracranial aneurysms appears to be safe in patients with sickle cell anemia and should be considered given the specific hemorrhagic risk observed in this population. A rigorous hematological preparation, associated with a dedicated peri‑operative protocol and an adequate therapeutic strategy are essential prerequisites.

Echocardiographic phenotypes of patients with sickle cell disease. An unsupervised analysis based on etendard cohort

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): PHRC

Backgroung

Echocardiography is the cornerstone in the diagnosis of cardiopulmonary involvement in sickle cell disease (SCD). However, given the unique pathophysiology of SCD associating high cardiac output, and various degrees of peripheral vasculopathy, differentiate the pathological from the physiological using echocardiography can be particularly challenging.

Purpose

This study sought to link cardiac phenotypes in homozygous SCD patients with clinical profiles and outcomes using cluster analysis.

Methods

We analyzed data of 379 patients with a sufficient echographic dataset included in the French Etendard Cohort, a prospective cohort initially designed to assess the prevalence of pulmonary hypertension. A cluster analysis was performed on echocardiographic variables, and the association between clusters and clinical profiles and outcomes was assessed.

Results

Three clusters were identified. Cluster 1 (N = 122) patients had the lowest cardiac output, only mild left cavities remodeling, diastolic dysfunction, and high tricuspid regurgitation velocity (TRV). They were predominantly female, as old as cluster 2, and displayed the most severe functional limitation. Cluster 2 (N = 103) patients had the highest cardiac output, left ventricular mass and a severely dilated left atrium. Diastolic function and TRV were similar to cluster 1. These patients had a higher blood pressure and a severe hemolytic anemia. Cluster 3 (N = 154) patients had mild left cavities remodeling, the best diastolic function and the lowest TRV. They were younger patients with the highest hemoglobin and lowest hemolytic markers. Right heart catheterization was performed in 94 patients. Cluster 1 gathered the majority of precapillary PH while cluster 2 gathered postcapillary PH and no PH was found in cluster 3. After a follow-up of 9.9 years (IQR: 9.3 to 10.5 years) death occurred in 38 patients (10%). Clusters 2 had the worst prognosis with 18% mortality rate vs. 12% in cluster 2 and 5% in cluster 1 (P log-rank = 0,02). Results are summarized in the central illustration.

Conclusions

Cluster analysis of echocardiographic variables identified 3 phenotypes among SCD patients, each associated with different clinical features and outcome. These findings underlines the necessity to rethink echocardiographic evaluation of SCD patients, with an integrative approach based on simultaneous evaluation of TRV along with left cavities remodeling and diastolic parameters.

Abstract Figure.

Echocardiographic evaluation of patients with sickle cell disease. A study based on Etendar Cohort

Background

Echocardiography is the main non-invasive screening tool for pulmonary hypertension (PH) in Sickle Cell Disease (SCD), but relies mostly on the tricuspid regurgitation velocity (TRV) assessment, without distinction between pre and postcapillary patterns.

Purpose

Using Etendard Cohort data, the aim of this study was to refine echocardiographic assessment of PH in SCD patients.

Methods

The French Etendard Study is a prospective cohort initially designed to assess the prevalence of PH among 398 SCD participants. We analyzed echocardiography data of the 96 Etendard patients who underwent Right Heart Catheterization (RCH), because of a TRV≥2.5m/s, and compared them to invasive haemodynamic measurements. Based on RHC results, patients were classified as follows: Absence of pulmonary hypertension if mean pulmonary arterial pressure (mPAP) was <25mmHg. Precapillary PH if mPAP≥25mmHg and pulmonary-capillary wedge pressure (PCWP) ≤15mmHg. Postcapillary PH if mPAP≥25mmHg and PCWP >15mmHg.

Results

PH was found in 24/96 patients with 11 precapillary and 13 postcapillary. In addition to TRV, multivariate analysis identified indexed left atrial volume (LAVind) and lateral E' wave velocity (E'lat) as independent echocardiographic predictors of PH (OR=1.06 and 0.6 respectively, p<0.01). LAVind and E'lat showed good correlation with mPAP (R=0.51 and R=0.40 respectively and p<10–3 for both) and had good accuracy to predict PH with an optimal cut-off of 48ml/m2 for LAVind (AUC=0.78, Se=81% and Sp=75%) and 12cm/s for E'lat (AUC=0.8, Se=72% and Sp=79). Using the association of a TRV≥3m/s or a TRV [2.5; 2.9] m/s with LAVind>48ml/m2 and E'lat<12cm/s, we could predict PH with a PPV of 68% and NPV of 90%.

Moreover, comparing echocardiography data of pre and post-capillary PH patients, we observed that Pulmonary acceleration time (PAcT) was different in the two groups (104±22ms vs. 160±21ms, p<0.001) with an excellent accuracy for the differentiation of both phenotypes (AUC=0.95, optimal cut-off=115ms, Se=100% and Sp=78%). PAcT correlated with pulmonary vascular resistance (PVR) assessed by RHC (R=0.34, p=0.001) but not with mPAP (R=0.1, p=0.2) and a PAcT>115ms ruled out pre-capillary PH with a NPV of 97%.

Conclusion

Echocardiography can accurately estimates the probability of PH in SCD patients with an integrated approach using TRV, LAVind and E'lat. In addition, among patients with suspected PH, measuring PAcT as a PVR surrogate allows a good differentiation between pre and post-capillary phenotypes. We propose a new echocardiographic algorithm for the diagnosis of PH in SCD that could be a true assistance in referring patients for RHC.

TTE Algorithm for PH in SCD

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Funded by the French Ministry of Health and Assistance Publique–Hôpitaux de Paris

New insights into the natural history of hepatitis E virus infection through a longitudinal study of multitransfused immunocompetent patients in France

Little is known about the natural history of Hepatitis E virus (HEV) infection in immunocompetent individuals. The prevalence, the course of infection and the occurrence of transmission by transfusion were investigated in multitransfused immunocompetent patients/blood donor pairs included in a longitudinal sample repository collection and followed up between 1988 and 2010. Ninety-eight subjects aged 6-89 years and suffering from acquired haemoglobinopathies were tested for HEV markers (IgM, IgG and RNA) in serial samples collected every 2 or 3 years. Eighteen patients (18.4%) were positive for HEV-IgG at baseline with a prevalence increasing from 12.5% below 26 years to 32% above 56 years. Nine patients remained IgG positive along the study and nine lost their antibodies after a mean follow-up of 7.4 years (1-22 years). One seropositive patient showed an increase of IgG level and RNA-HEV reappearance 1 year after inclusion, suggesting a reinfection and one seroconversion, probably acquired through blood transfusion was observed. This first longitudinal study including immunocompetent individuals confirms that HEV infection is common in Western Europe and that transfusion transmission occurs probably less frequently than expected. In addition, seroreversion and reinfection seem to be common. This suggests that the anti-HEV may not persist overtime naturally. However, repeat exposure to the virus related to the high prevalence of HEV infection may result in a sustainable specific IgG response.

[French guidelines for the management of adult sickle cell disease: 2015 update]

Sickle cell disease is a systemic genetic disorder, causing many functional and tissular modifications. As the prevalence of patients with sickle cell disease increases gradually in France, every physician can be potentially involved in the care of these patients. Complications of sickle cell disease can be acute and chronic. Pain is the main symptom and should be treated quickly and aggressively. In order to reduce the fatality rate associated with acute chest syndrome, it must be detected and treated early. Chronic complications are one of the main concerns in adults and should be identified as early as possible in order to prevent end organ damage. Many organs can be involved, including bones, kidneys, eyes, lungs, etc. The indications for a specific treatment (blood transfusion or hydroxyurea) should be regularly discussed. Coordinated health care should be carefully organized to allow a regular follow-up near the living place and access to specialized departments. We present in this article the French guidelines for the sickle cell disease management in adulthood.

[Issues and difficulties in the relationship between patients and caregivers in painful sickle cell vaso-occlusive crisis]

Sickle cell patients in acute pain situation experiment cognitive, behavioral and emotional changes that can accentuate their pain and disrupt communication with caregivers. On the other hand, caregivers have to face pain assessment difficulties and their own psychological reactions to their patient's pain. The gap between the patient's experience and caregiver's evaluation can lead to conflict and non-adherence treatment, and have a direct impact on the sickle cell disease prognosis. There is nothing inevitable about these phenomena, whose knowledge allows the action and opens up prospects for improving the management of sickle cell disease pain. This article is a narrative review updating the interactions between acute pain and some configurations, such as the inability to discern emotions, catastrophizing, post-traumatic stress or feeling ostracized. The overestimation of patient's addiction by caregivers also influences the pain itself. Open communication, as well as some treatments, medicated or not, a consistent institutional organization and a multidisciplinary approach altogether have an analgesic role by acting on pain cognitive and emotional components.

[Guidelines for management of adult sickle cell disease]

Sickle cell disease is a systemic disease that can potentially involve all organs. As the prevalence of patients with sickle cell disease increases gradually in France, every physician can be potentially involved in the care of these patients. Complications of sickle cell disease can be acute or chronic. Pain is the main symptom and should be treated quickly and aggressively. Acute chest syndrome is the leading cause of acute death and must be prevented, detected, and treated without delay. Chronic complications are one of the main concerns in adults and should be identified as early as possible in order to prevent sequels. Many organs can be involved, including the bones, kidneys, eyes, lungs... The indications for a specific treatment (blood transfusion or hydroxyurea) should be discussed. Health care should be carefully organized to allow both a regular follow-up near the living place and access to specialized departments. We present in this article the French guidelines for the sickle cell disease management in adulthood.

Unusual sites of Salmonella osteoarthritis in patients with sickle cell disease: two cases

Salmonella osteoarticular infections involve mainly long bones such as the femur, tibia, and humerus in patients with sickle cell disease (SCD). We report here two unusual cases of Salmonella osteoarthritis affecting sacroiliac and sternoclavicular joints in two patients with SCD, one patient also being followed for rheumatoid arthritis. Because of misleading presentation, diagnosis of septic osteoarthritis in patients with SCD requires a high index of suspicion and an early treatment.

Acute myocardial ischemia after high-dose therapy with BEAM regimen

We describe a case of acute myocardial ischemia following carmustine treatment during the BEAM regimen. Despite this, full completion of the autologous peripheral stem-cell transplant was possible.

Neurological complications of varicella-zoster virus infection in adults with human immunodeficiency virus infection

This multicentre retrospective study describes the clinical features and prognostic significance of Varicella-zoster virus (VZV)-associated neurological complications. The study was performed in patients with human immunodeficiency virus (HIV) infection, hospitalized for VZV neurological complications, confirmed in every case by positive VZV polymerase chain reaction (PCR) in cerebrospinal fluid (CSF). Between 1990 and 1995, 34 HIV-infected patients were included in the study. At diagnosis, 59% had AIDS, with a median CD4 count of 11 x 10(9)/l. A past history of zoster was noted in 35% of cases. A concomitant herpes zoster rash and/or acute retinal necrosis were noted in 71% and 12% of patients, respectively. The predominant neurological manifestations were encephalitis (13), myelitis (8), radiculitis (7) and meningitis (6). The mean CSF white blood cell count was 126/mm3 and the mean CSF protein concentration was 2.3 g/l. Interferon-alpha level was increased in 36% of patients. VZV was isolated from CSF cultures in 2/6 cases. Magnetic resonance imaging was abnormal, demonstrating encephalitis lesions. After intravenous antiviral therapy, complete recovery was obtained in 18 cases (53%), serious sequelae were observed in 10 cases (29%) and 6 patients died (18%). Severe symptoms and a low CD4 cell count appeared to be associated with death or sequelae. In conclusion, VZV should be considered as a possible cause of encephalitis, myelitis, radiculitis or meningitis in HIV-infected patients, especially in patients with a history of or concomitant herpes zoster or acute retinal necrosis. VZV-PCR in the CSF may allow rapid diagnosis and early specific antiviral treatment.