Quantifications of CD4+ T-Lymphocytes levels in adult sickle cell patients: Examining immunological vulnerability and Vaso-Occlusive crises in a low-resource setting, northwestern Nigeria.

HIV and sickle cell disease (SCD) are significant causes of morbidity and mortality in sub-Saharan Africa. Given their separate roles in immune dysregulation, our objective was to characterise the impact that SCD has on the presentation and progression of paediatric HIV. The study was a retrospective cohort study (study period 2004-2018). Cases of HIV+and SCD-afflicted patients (HIV+/SCD+) were obtained via electronic chart review from a paediatric HIV clinic in Kampala, Uganda and matched 1:3 with HIV+controls without SCD (HIV+/SCD-). Thirty-five HIV+/SCD+subjects and 95 HIV+/SCD- controls were analysed (39% female (51/130), age 3.6years (SD3.9)). At baseline, WHO clinical stage (64% total cohort Stage III/IV) and nutritional status (9.4% severe acute malnutrition) were similar for both groups, whereas HIV+/SCD+had higher though non-significant baseline CD4 count (1036 (SD713) vs 849 (SD638) cells/microlitre, P=0.20, two-tailed t-test). There were 19 deaths, 6 (17%) HIV+/SCD+and 13 (14%) HIV+/SCD-, with unadjusted/adjusted models showing no significant difference. Nutritional progression and clinical stage progression showed no significant differences between groups. Kaplan-Meier analysis showed a slower rate of treatment failures in the HIV+/SCD+cohort (P=0.11, log-rank survival test). Trajectory analysis showed that in the time period analysed, the HIV+/SCD+cohort showed a more rapid rise and higher total CD4 count (P=0.012, regression analysis). The study suggests that SCD does not adversely affect the progression of HIV in patients on ART. Further, HIV+/SCD+achieved higher CD4 counts and fewer HIV treatment failures, suggesting physiological effects due to SCD might mitigate HIV progression.

Review question/objective The research question is: what are the modifiable and non-modifiable factors that influence the utilization of hospital services by adult sickle cell disease patients? The objective of this systematic review is to determine what modifiable and non-modifiable factors influence utilization of hospital services by adult sickle cell disease patients. Background Sickle cell disease (SCD) is the most common genetic disorder of hemoglobin. The illness is caused by a single point substitution of amino acid valine for glutamic acid at the sixth position of beta-chain hemoglibin.1 As a result of this mutation, red blood cells exposed to low oxygen conditions polymerize, develop a sickle shape and become inflexible.1 This process causes hemolysis (rupture of the red blood cells), hyperviscosity (excessive thickening of the blood) and micro-vascular hypoperfusion (decreased distribution of blood to the tissues). Sickle cell disease affects every major organ system and shortens the life expectancy of affected individuals by approximately 30 years.1 Several SCD genotypes exist. The most prevalent genotype, homozygous HgbSS disease, is associated with the most severe clinical manifestations. Between 70,000 and 100,000 individuals in the United States have HgbSS disease.2 Most of those affected are of African ancestry, with a minority being of Hispanic, Middle Eastern, or Asian Indian descent.1 An additional 3.5 million people in the United States are heterozygote carriers of the gene for Hemoglobin S.1 The hallmark of the disease is an acute painful vaso-occlusive crisis. The mechanism by which polymerization of hemoglobin leads to perception of pain in the central nervous system is not well understood.3 Current research suggests highly complex interactions between red blood cells, inflammatory mediators, and the central nervous system.3 Sickle cell disease pain is often unpredictable, poorly controlled and tends to become chronic.4 A current standard of care includes administration of opioids for pain control along with other supportive measures, often in emergency departments (EDs) or inpatient units.1 Vaso-occlusive crises are responsible for the majority of hospital services utilization by SCD patients.5–8 Despite the burden of both chronic and acute pain imposed by SCD, most affected individuals manage the disease at home, and only a minority of crises results in acute care visits.3,9,10 More than two inpatient admissions per year are unusual, and most have no hospital or emergency department (ED) visits in a given year.11 However, people with SCD are overrepresented among high utilizers of EDs and inpatient beds, even when compared to other serious conditions that affect hemoglobin.6,11,12 The evidence suggests that a small proportion of SCD patients account for most health care utilization.6,11,13 Epstein et al. found that 20% of all SCD patients accounted for 54% of total ED visits and 52% of hospital bed days in this population.13 The high utilization of hospital services by a small percentage of adult SCD patients is a legitimate source of concern because of the following reasons. First, the high number of health care visits leads to questions about the appropriateness of these visits and contribute to negative provider attitudes toward SCD patients in general.4,11,14–18 In the context of chronically crowded EDs and overbooked inpatient units, frequent utilizers of these services are commonly considered as time-consuming illegitimate users of health care resources.4 It is a common perception among providers that these visits can be potentially prevented, and similar and even more appropriate medical care can be delivered at outpatient facilities. Also, SCD patients who are high hospital users for pain management are often viewed in a negative light as “drug-seeking” individuals.4,19–22 As a result, frequent hospitalizations and ED visits lead to tremendous frustration among medical and nursing staff, create mistrust between SCD patients and providers and contribute to negative provider attitudes.11 The evidence suggests that negative provider attitudes toward SCD patients serve as a general barrier to the provision of adequate pain management and are associated with poor adherence to evidence-based guidelines.15,23,24 Second, frequent utilization of hospital services generate a high health care cost.5,6,25–27 A lifetime cost of care per patient with SCD averages $460,151.25 Notably, the majority of the cost (80.5%) is associated with hospitalizations.25 In a recent study analyzing ED charges for SCD, Lanzkron and colleagues found that the overall charges for ED visits for SCD were three times higher when compared to those for asthma, congestive heart failure and human immunodeficiency virus (HIV). The difference was due to a greater frequency of SCD-related visits rather than higher mean charges per hospitalization.26 Also, several studies reported a skewed distribution of hospital utilization by adult SCD patients, such that only 10% to 20% of all SCD patients account for over 50% of the costs of care for this disease.3,8,14 Finally, frequent hospitalizations are risk factors for early mortality in SCD patients.28,29 Houston-Yu et al. analyzed mortality data in patients with SCD who had more than 50 hospitalization days/year or more than six admissions/year.20 During a 24-month follow-up, 15% of these patients died. The mean age of death was 33.5 years. The subset of patients that was included in this study had severe chronic or recurrent pain and other serious complications of SCD. Patients who died had a higher mean number of hospitalization days, suggesting that frequent and prolonged admissions are associated with early mortality in SCD patients. Utilization of hospital services by adult SCD patients is correlated with high health care costs and adverse clinical outcomes. In this context, understanding the factors that influence utilization of hospital services by adult SCD patients is a first step in improving their medical care while reducing health care expenditures. Several studies have addressed the effect of non-modifiable (age, gender, ethnicity) and modifiable factors (insurance status, disease-related complications and comorbidities, availability of outpatient care) on the pattern of hospitalizations and acute ED visits in this population.4,13,14,30,31 Several variables have been found to be associated with higher hospital utilization: more severe disease and disease-related complications, worse pain, higher white blood cell counts, lower hemoglobin levels, asthma, being publically insured, being 18 to 30 years old, and an inability to obtain follow-up appointments with hematology.4,11,13,14,30,32 The evidence from a number of studies has shown that a substantial minority of SCD patients are high hospital utilizers. However, high utilizers with SCD are more severely ill, as measured by laboratory variables, have more pain, more distress, and a lower quality of life.3,4 Despite the growing interest in the factors associated with the use of hospital services among SCD patients, to date no comprehensive appraisal of the evidence has been attempted. A systematic review of the available studies will add to the body of knowledge and will inform hospital administrators, policy makers and clinicians caring for this patient population of the factors that influence hospital utilization by individuals affected by SCD in order to develop tailored interventions to address these factors. Inclusion criteria Types of participants The review will consider studies that include adult SCD patients of both sexes who have utilized hospital services. The review will include adult SCD patients who have visited EDs, been admitted to the hospital from the EDs or been admitted directly to the hospital from the community. This review will include adult SCD patients who have utilized hospital services for acute or emergent care. The review will exclude participants who have utilized hospital services for elective treatments in order to determine factors that may be exclusive to the use of hospital services for acute care. Types of intervention(s)/phenomena of interest This review will consider studies that explore factors that influence utilization of hospital services (such as the frequency of ED visits and inpatient admissions among adult SCD patients, and the risk of high utilization of hospital services). The factors will include non-modifiable (age, sex, ethnicity, SCD genotype) and modifiable factors, such as socioeconomic (education, income, insurance status, availability of outpatient care), psychological (anxiety, depression, perceived optimism, perceived discrimination) and disease-related factors (Hgb level, presence of complications, presence of comorbidities, severity of pain, opioid dependence). Types of outcomes The primary outcome of interest is the utilization of hospital services which may be measured as: the frequency of ED visits and inpatient admissions among adult SCD patients, and the risk of high utilization of hospital services. Studies that do not report on the outcome of interest, as a primary or secondary outcome, will be excluded. Types of studies The review will consider epidemiological study designs including before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies. Search strategy The search strategy will aim to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will be then undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Only studies published in the English language will be considered for inclusion for this review. A search range based on the year of publication will not be set to allow greater sensitivity. The databases to be searched include: MEDLINE, CINAHL, ScienceDirect, PsycINFO, ProQuest, Academic Search Premier and HNS Research Register. The search for gray literature will include: ProQuest Dissertation and Theses Database, the directory of gray literature via the New York Academy of Medicine website and Google Scholar/MedNar. Initial keywords to be used will be: Sickle cell disease OR Sickle cell anemia AND Adult AND Emergency department OR Emergency room OR Emergency ward AND Hospital OR Hospital services OR Hospitalization OR Inpatient AND Utilization OR Use OR Admission OR Visit. Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers (IB and YTJ) for methodological validity prior to inclusion in the review using standardized critical appraisal instrument from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). The decision as whether to include or exclude a study can be made based on the meeting five out of nine criteria of JBI-MAStARI critical appraisal instrument. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer (ME). Reviewers will try to contact authors of primary studies for missing information or to clarify unclear data. Data extraction Data will be extracted from papers included in the review using standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the modifiable and non-modifiable factors of interest, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odd ratio (for categorical data), weighted mean differences and correlation coefficients (for continuous data) and their 95% confidence intervals will be calculated for analysis. For studies that report only the results of regression analyses, we will aim to extract the unadjusted effect sizes for the predictors of interest to facilitate greater comparability of the effect size data across studies. Where effect sizes are expressed as odd ratios or weighted mean differences, JBI-MAStARI will be used for statistical pooling. Where effect sizes are expressed as correlation coefficients, Comprehensive Meta-Analysis software will be utilized. Heterogeneity will be assessed statistically using the standard Chi-square and also be explored using subgroup analysis based on the different study designs included in this review. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Conflicts of interest The authors declare that there are no conflicts of interests. Acknowledgements This systematic review is undertaken in partial fulfillment of the requirements of the Doctor of Nursing Practice degree (IB).

Background: Sickle cell anaemia (SCA) patients are prone to require long-term frequent blood transfusion because of chronic haemolysis and overlapping hyper-haemolysis. Hence, they become vulnerable to iron overload and its complications. On the other hand, iron deficiency has been documented among un-transfused SCA cases. Thus, there is a need to effectively and efficiently determine iron status of SCA patients. Objective: We investigated whether adult SCA patients in steady state (SSt) or those with vaso-occlusive crisis (VOC) have significantly different iron status viz-a-viz Serum Iron (SI), Serum Ferritin (SF), Total Iron Binding Capacity (TIBC), Transferrin (TRF), percentage TFS and haematological parameters when compared with age and sexmatched controls. Materials and Methods: Ninety subjects, comprising 30 SCA patients in SSt, 30 SCA patients with VOC and 30 HbAA, ethnicity, age and sex-matched controls (NC), were consecutively recruited. Serum samples were analysed for SF, TRF and TIBC using

Incidence of Maternal and Perinatal Morbidity in Sickle Cell Disease and Sickle Cell Trait Patients during Pregnancy

anemia. Blood 2010;115:5300–5311. 10. Thornburg CD, Calatroni A, Telen M, Kemper AR. Adherence to hydroxyurea therapy in children with sickle cell anemia. J Pediatr 2010;156:415–419. 11. Sichle Cell Disease Guidelines-Hydroxyurea Chapter. http://rover.nhlbi.nih. gov/guidelines/scd/about.htm. Accessed November 21, 2011. 12. de Montalembert M, Brousse V, Elie C, et al. Long-term hydroxyurea treatment in children with sickle cell disease: Tolerance and clinical outcomes. Haematologica 2006;91:125–128. 13. Zimmerman SA, Schultz WH, Davis JS, et al. Sustained long-term hematologic efficacy of hydroxyurea at maximum tolerated dose in children with sickle cell disease. Blood 2004;103:2039–2045. 14. Burgess SW SP, Morawska A, Devadason SG. Assessing adherence and factors associated with adherence in young children with asthma. Respirology 2008;13:559–563. 15. Jentzsch NS, Camargos PA, Colosimo EA, Bousquet J. Monitoring adherence to beclomethasone in asthmatic children and adolescents through four different methods. Allergy 2009;64:1458–1462. 16. Thornburg CD, Calatroni A, Telen M, Kemper AR. Adherence to hydroxyurea therapy in children with sickle cell anemia. J Pediatr 2010;156:415– 419. 17. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353: 487–497. 18. Franklin VL, Waller A, Pagliari C, Greene SA. A randomized controlled trial of Sweet Talk, a text-messaging system to support young people with diabetes. Diabet Med 2006;23:1332–1338. 19. Lee SJ, Joffe S, Kim HT, et al. Physicians’ attitudes about quality-of-life issues in hematopoietic stem cell transplantation. Blood 2004;104:2194– 2200. 20. Wong EC, Perez-Albuerne E, Moscow JA, Luban NL. Transfusion management strategies: A survey of practicing pediatric hematology/oncology specialists. Pediatr Blood Cancer 2005;44:119–127. 21. Streiff MB, Smith B, Spivak JL. The diagnosis and management of polycythemia vera in the era since the Polycythemia Vera Study Group: A survey of American Society of Hematology members’ practice patterns. Blood 2002;99: 1144–1149.

The Oxygenscan Provides Clinically Relevant Biomarkers for Treatment Efficacy That Are Associated with Frequency of Vaso-Occlusive Crisis in Sickle Cell Disease

Micronutrient deficiency is recognized in sickle cell anaemia (SCA) but it is not known for certain whether changes in zinc, copper and copper-to-zinc ratio are associated with Sickle cell disease severity scores. To compare serum levels of copper, zinc and copper-to-zinc ratio in SCA subjects with control group and correlate the variables with objective disease severity scores. Serum copper and zinc were determined in 100 SCA patients and 50 controls using kits supplied by Centronic, Germany. Unpaired Students't-test was used to compare the variables between SCA patients in steady clinical state, vaso-occlusive crisis and controls, while Spearman correlation coefficient was used to associate the parameters with disease severity scores. Serum copper level was higher (P=0.008) in SCA patients than controls, while serum zinc level was lower (P<0.001) in SCA patients than controls. The copper/zinc ratio was higher (P<0.001) in SCA patients than controls. Significantly higher (P<0.001) copper and lower (P<0.001) zinc levels were observed in patients in vaso-occlusive crisis than in steady clinical state. Zinc correlated inversely (r=-0.2743; P=0.006) while copper-to-zinc ratio correlated positively with disease severity scores. Copper-to-zinc ratio may be an indicator of disease severity in SCA patients.

The pathogenesis of sickle vaso-occlusive crisis (VOC) in sickle cell disease (SCD) patients involves the accumulation of rigid sickle cells and the stimulation of an ongoing inflammatory response, as well as the stress of infections. The immune response, via cytokine imbalances and deregulated T-cell subsets, also has been proposed to contribute to the development of VOC. In this study, a panel of high-sensitivity cytokine kits was used to investigate cytokines in the sera of SCD patients in VOC. The results were compared primarily with those for stable SCD patients and secondarily with those for normal healthy people who served as controls. The cytokines studied included interleukin-2 (IL-2), IL-4, and IL-10. Lymphocyte subsets of patients with VOC were also studied and were compared with those of both control groups (20 stable patients without crisis [SCD group] and 20 normal healthy controls [NHC]). The VOC group was notable for remarkably elevated levels of IL-4, among the three cytokines tested, compared with those for the SCD and NHC groups. Patients with VOC also differed from stable SCD patients and NHC by having notably lower IL-10 levels, as well as the lowest ratio of CD4(+) to CD8(+) T cells (0.7). The patterns of the proinflammatory cytokine IL-2 did not differ between VOC and stable SCD patients, but NHC had significantly lower IL-2 levels than both the VOC and SCD groups. Our results demonstrate coexisting levels, both high and low, of TH1- and TH2-type cytokines, as well as diminished levels of T-cell subsets in VOC. These results are discussed in an effort to better understand the importance of the immune system profile in the pathogenesis of sickle cell VOC. Since the possibility that a cytokine imbalance is implicated in the pathogenesis of sickle cell crisis has been raised, our results should prompt further investigation of the host immune response in terms of TH1 and TH2 balance in sickle cell crisis.

Patients with sickle cell disease (SCD) suffer recurrent painful vaso-occlusive crisis (VOC), poor quality of life and a shortened lifespan. Although hydroxyurea and blood transfusion remain the mainstay of SCD therapy, the only cure currently available is allogeneic stem cell transplant (allo-SCT). However, many barriers prevent allo-SCT from being widely offered to adult SCD patients. The SCD patients most in need of allo-SCT transplant are also those at highest risk for transplant-related complications and mortality.1 Other therapeutic approaches are, therefore, much needed. Neutrophils have been implicated in regulating the disease course of VOC. The SCD patients with WBC > 15 × 109/L are more likely to develop stroke,2 acute chest syndrome,3 and premature death.4 Neutrophils in SCD also exhibit higher levels of activation molecules, for example, CD645 and CD11b/CD18,6 and their sera have elevated soluble CD62L.5, 7 Circulating aged neutrophils (CANs), a subset of neutrophils with high surface expression of CXCR4 and low CD62L, are also significantly elevated.7, 8 Both activated and aged neutrophils may be immobilized on endothelium, and form the nidus for sickled erythrocytes to adhere to, eliciting VOC. Several recent observations from our laboratory and others have supported frequent microbial and pathophysiologic changes in the intestines of SCD patients. These include enterocyte injury,7 altered microbial composition,9 increased permeability7 and bacterial overgrowth.10 We have previously proposed that increased translocation of intestinal bacteria/bacterial products into the systemic circulation is responsible for the increased number of activated neutrophils in SCD.11 Others have found intestinal microbiota to regulate CANs in SCD mice.8 Modulating intestinal microbial composition may, therefore, be a therapeutic option in SCD to reduce VOC, by decreasing both activated and aged neutrophils. We recently reported that rifaximin treatment reduced CANs in SCD patients treated in a clinical study (Clinicaltrials.gov: NCT03719729) funded by Bausch Health Companies, Inc.12 Rifaximin also shifted the intestinal microbiome in these patients towards increased abundance of Bacteroides.12 In this current paper, we report the clinical outcome on the same cohort of SCD patients accrued to the study, to determine whether the changes in the intestinal microbiome and reduction in the CANs were translated into clinical benefits of reduction in VOC. This study was approved by the Institutional Review Board of New York Medical College. The SCD patients were eligible for the study if they were 18 years or over, had a diagnosis of SCD (HbSS, HbSC, HbSβ-thalassemia), and had at least two painful crises needing inpatient or outpatient intravenous opioid analgesia (IOA), during the preceding 12 months. Patients may continue on the hydroxyurea or L-glutamine if they were already taking the medication long-term. Patients were only added to the study if their last episode of painful crisis was more than 4 weeks before starting rifaximin. Each patient received 550 mg of rifaximin twice a day for 6 months. The dose of rifaximin chosen was similar to that for preventing hepatic encephalopathy in patients with liver cirrhosis. Each patient was also given a self-reporting diary to record daily ingestion of the medication and associated side effects. All patients were followed up every 4 weeks, or earlier if they developed VOC. Each patient completed the FANLTC (Functional Analysis of Non-life-Threatening Conditions) questionnaire before, and 3 and 6 months after being started on rifaximin. The FANLTC questionnaire consists of four subjective blocks of questions covering physical, emotional, social/family, and functional well-being. Each question scores as follow: 0 = not at all; 1 = a little bit; 2 = somewhat; 3 = quite a bit; 4 = very much. Efficacy analyses were performed on data obtained from all the patients who completed 6 months of rifaximin. Changes in the number of VOC and days needing IOA during the study period, were compared to those expected for a six-month period, calculated from the average of the previous 12 months. Thirteen adult patients with SCD consented to the study. Their clinical characteristics are shown in Table S1. There were eight males and five females. Ten patients had HbSS, two HbSβ0thal, and one HbSC. Their median age was 29 years (range 24-56). The median number of VOC in the previous 12 months was 4.5 (range 2-13), and the number of days needing IOA was 25.5 days (range 8-198). In 12 of the 13 patients, the VOC was in the form of musculo-skeletal pain typical in distribution for the VOC that normally affected individual patients, and in one patient the VOC was predominantly in the form of recurrent priapism. Five of the patients were already taking hydroxyurea, and none were taking L-glutamine or on a transfusion program. Six patients were taking oral opioid at home for chronic pain. The study ran between November 2018 and early August 2019, covering the winter months when most of the patients reported having most frequent VOC. In all 12 evaluable patients, rifaximin was started during the winter months. Twelve of the 13 patients accrued to the study were evaluable for response. One patient (HbSC) did not return to be started on the rifaximin after consenting for the study. The remaining 12 patients completed 6 months of rifaximin. The mean self-reported medication compliance of the intended doses was 86% (range 50-100). The median number of VOC during the study period decreased from the expected 2.25 (range 1-6.5) per 6 months to one per 6 months (range 0-4) (P = .003) (Figure 1A). The one patient whose VOC was predominantly in the form of priapism did not respond. His self-reported medication compliance was 100%. The median decrease in days needing IOA over the six-month study-period was nine (range 1-55), and the median percent reduction was 82% (range 20%-100%) (P = .008) (Figure 1B). Total number of days needing IOA was reduced from the expected 254 in 6 months to 98 during the study period. Laboratory analyses did not show any significant change in hemoglobin, white cell counts, serum lactate dehydrogenase, bilirubin, or haptoglobin due to rifaximin therapy. There was no significant change in the FANLTC scores in all four well-being blocks of questions when the patients were analyzed as a group. Subset analysis, however, found that functional well-being significantly improved at 6 months, for those who reported below average scores before rifaximin (mean score 11.4+/−1.7 to 14.6+/−2.19) (P = .02). The average score to the question "I am able to enjoy life" increased from 1.4+/−0.5 to 2.1+/−0.69 (P = .046). There was also improvement among those with below average scores for physical well-being. The average score to the question "I have pain" decreased from 3.56+/−0.72 to 2.3+/−1.6 (P = .022) at month three, and from 3.56+/−0.72 to 2.22+/−1.4 (P = .016) at month six. The average score to the question "I feel ill" also improved, decreased from 2.5+/−0.58 to 0.75+/−0.5 (P = .035) at months three and six. Rifaximin was well tolerated. Mild nausea was common in the first 1-2 weeks of rifaximin therapy and occurred in eight of the 12 patients. Other adverse events included self-limiting diarrhea (n = 1) (negative for pathogens by culture, Clostridium difficile by PCR, and gastrointestinal multiplex PCR) which occurred during the first month of therapy, and polydipsia (n = 2). The results of this study, therefore, suggest that rifaximin may potentially benefit patients, as measured by a decrease in the number of VOCs and days needing IOA, in patients with SCD. These clinical benefits were translated into improvement in the QOL, as measured by FANLTC, for those who experienced below average quality of life prior to the study. Reducing the intestinal microbial load using antibiotics has been found beneficial in SCD mice. Mice with SCD acquired by transplantation when treated with an oral combination of ampicillin, neomycin, vancomycin and metronidazole exhibited lower number of CANs, and were protected against tumor necrosis factor-α-induced fatal VOC.8 The identical cocktail of oral antibiotics, when given to the Townes SCD mice reduced intestinal microbial load and SCD-related osteopenia.10 Although the beneficial effects of the combination antibiotics on SCD are likely related to reduction in the intestinal microbial density, because two of the four antibiotics are absorbed into the systemic circulation, any systemic effects of the antibiotics in modifying SCD complications cannot be totally ruled out. Furthermore, while the findings in these two studies were interesting, the approach is clearly not directly translational. It is highly impractical to administer the combination of the four antibiotics long-term to SCD patients. In our study, more than 90% of those consented remained in the study for 6 months. This high retention rate is likely due to two factors. Besides telephone calls to the patients, until the patients answered the call, on the morning of their follow-up appointments, text messages were also sent to the patients. The clinical benefits, in terms of less frequent painful VOC and improved QOL, experienced by the patients may also contribute to the high patient retention rate. We have chosen to test rifaximin in this study for three reasons. First, rifaximin has an established safety profile for long-term use in patients with liver cirrhosis to prevent hepatic encephalopathy.13 Second, the risks for the development of antibiotic-associated Clostridium difficile infection induced by long-term use of antibiotics is likely low, since rifaximin also has activities against Clostridium difficile. Third, being a minimally absorbed antibiotic, rifaximin provided the opportunity to dissect the effect of reducing intestinal microbial load in SCD, from any systemic effect an antibiotic might also have on the disease process. The results of our study using rifaximin, therefore, support the local effects of an antibiotics in the intestine in modifying the course in SCD. The mechanisms responsible for the beneficial effects of rifaximin in reducing VOC remains to be determined. It is likely that rifaximin works via decreasing the intestinal microbial load, and hence reducing translocation of intestinal bacteria/bacterial products into the systemic circulation to activate and age neutrophils, as reported by us previously that CANs in these individuals dropped significantly while taking the rifaximin during the study period.12 Since rifaximin has an anti-inflammatory property,14 the role contributed by a reduction in the inflammatory process associated with enterocyte injury7 and bacteria/bacterial products translocated across the intestinal barrier as a result of improvement in the integrity of the intestinal barrier cannot be totally ruled out. In summary, this is the first human study showing the potential efficacy of microbial modulation on VOC in patients with SCD. Intestinal microbial modulation with rifaximin is also safe and well-tolerated. The major limitations in our work is the small sample size and the single-center single-arm nature of the study. Furthermore, any placebo effects of the intervention on the QOL of the patients cannot be totally ruled out. The intense follow up of the patients may also be responsible in part for the observed clinical improvement. A multicenter placebo-controlled randomized trial is, therefore, warranted to confirm our findings. We would like to thank the following for their critiques and advice during the preparation of the manuscript: Dr. Peter Gillette at State University of New York Downstate Medical School and King's County Medical Center, Dr. Howard Franklin at Salix Pharmaceuticals, and Dr. Robert Israel at Bausch Health Companies, Inc. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Benefit of Inpatient Pain Plan Utilization on Hospital Length of Stay in Adolescents and Young Adults with Sickle Cell Disease

Background/Objectives: Sickle cell anemia (SCA) is a major public health problem and renal insufficiency is common in adult sickle cell disease (SCD) patients, but the presence of high levels of fetal hemoglobin (HbF) may be protective against organ damage. This study correlates the levels of HbF with proteinuria and indices of iron status in adult SCD patients in a steady clinical state. Materials and Methods: HbF, serum iron, transferrin, total iron binding capacity (TIBC), percentage transferrin saturation, urine protein, and full blood count were determined in adult SCD patients. Serum iron, unsaturated iron binding capacity were determined by spectrophotometric method. TIBC and percentage transferrin saturation were calculated from iron concentration and unsaturated iron binding capacity using the appropriate formula. Serum transferrin was calculated using the formula of the Miami Valley Burn Unit. Results: Out of the 97 subjects, 24 (25%) had mean HbF level of 8.48 ΁ 0.54% and none of them had proteinuria, while 28 (29%) who had mean HbF level of 3.00 ΁ 0.11% had proteinuria. The mean age of those who had proteinuria was higher (P < 0.001) than those without proteinuria. The mean HbF level of those with proteinuria was significantly lower (P < 0.001) than those without proteinuria. Significantly higher levels of serum iron and percentage transferrin saturation (P < 0.001) and significantly lower levels (P < 0.001) of TIBC and transferrin levels were observed in those without proteinuria compared to those with proteinuria. HbF negatively correlated (r = −0.315; P < 0.01) with proteinuria in adult SCD patients. HbF also correlated with indices of iron status in SCD patients with and without proteinuria. Conclusion: HbF correlated with proteinuria and indices of iron status in adult SCD patients in steady clinical state.

This is a case-controlled study designed to evaluate iron status of adult sickle cell anaemia patients and to compare findings with vaso-occlusive crises in sickle cell anaemia. One hundred and one (101) subjects aged 18-46 years participated in this study and these participants were divided into thirty five (35) sickle cell anaemia subjects in stable state (SS), thirty five (35) sickle cell anaemia subjects with history of vaso-occlusive crises (VOC) in the last preceding three months and thirty one (31) apparently healthy subjects (Hb AA) as control subjects (C) were recruited into the study using simple random sampling. Approximately 4 ml of venous blood samples was collected from each subject into a plain tube, allowed to clot and serum sample separated from it was analysed for serum iron, ferritin, total iron binding capacity (TIBC) and percentage transferrin saturation. The haemoglobin electrophoresis was determined using the alkaline cellulose acetate electrophoresis method Serum iron was analysed using atomic absorption spectrophotometer (AAS). Serum ferritin was determined using Ferritin Enzyme Immunoassay (Genway). TIBC was done using Ferene method and percentage transferrin saturation (%TFS) was derived from serum iron and TIBC. The mean values of serum iron and ferritin were significantly lower (P=0.00, P=0.00) respectively in SCA subjects compared with control. However, there was no significance difference in the mean values of TIBC and %TFS between SCA subject and control (P=0.56, P=0.14) respectively. There was significant difference in the mean values of serum iron and ferritin between SCA in stable state and control subjects (P=0.00, P=0.00) respectively. Also, there was significant difference in the mean values of serum iron and ferritin between SCA subjects with vaso-occlusive crises and control subjects (P=0.00, P=0.00) respectively. However, the comparison of the mean values of TIBC and %TFS between SCA in stable state and control subjects did not show any significance difference (P=0.56, P=0.33) respectively. Also, the mean values of TIBC and %TFS between SCA with vaso-occlusive crises and control subjects did not show any significant difference (P=0.88, P=0.37) respectively. The mean values of serum iron, ferritin, TIBC and %TFS between SS and VOC did not show any significant difference (P=1.00, P=0.99, P=0.79, P=0.97) respectively. The outcome of this work show reduced serum iron and ferritin levels in SCA subjects. Periodic assessment of iron status is therefore suggested in the monitoring and management of sickle cell anaemia.

No abstract available.

Enhanced Pain Sensitivity in Adult Sickle Cell Disease Patients: Potential Mediating Factors

Real-World Outcomes in Adult Sickle Cell Disease Patients Treated with Crizanlizumab, Voxelotor or Both