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Stroke Recurrence in Nigerian Children With Sickle Cell Disease: Evidence for a Secondary Stroke Prevention Trial.
Abdullahi SU, DeBaun MR, Jordan LC, Rodeghier M, Galadanci NA
(2019) Pediatr Neurol 95: 73-78
MeSH Terms: Adolescent, Anemia, Sickle Cell, Antisickling Agents, Child, Child, Preschool, Female, Follow-Up Studies, Humans, Hydroxyurea, Infant, Male, Nigeria, Prospective Studies, Recurrence, Secondary Prevention, Stroke
Show Abstract · Added March 24, 2020
BACKGROUND - To improve the quality of care for children with sickle cell anemia in Kano, Nigeria, we initiated a standard care protocol in 2014 to manage children with strokes at Aminu Kano Teaching Hospital.
METHODS - The standard care protocol requires that children with acute strokes be treated with hydroxyurea at a fixed dose of 20 mg/kg/day within two months of the stroke.
RESULTS - Twenty-nine children with sickle cell anemia and initial stroke were identified based on clinical World Health Organization criteria from 2014 to 2017. Follow-up was a median of 1.04 years (interquartile range 0.43 to 1.83 years) to either July 2017 or a second stroke, corresponding to an initial stroke incidence rate of 0.88 per 100 patient-years. Eight children had a recurrent stroke, six of whom were prescribed hydroxyurea 20 mg/kg/day by two months after initial stroke. Two children died. Six of the recurrent strokes occurred within six months of the initial stroke, two before hydroxyurea prescription. The stroke recurrence rate was 17.4 events per 100 patient-years. Adherence was approximately 60%, partly because families had to pay for hydroxyurea. Stroke incidence is probably underestimated because despite formal training for stroke detection during the quality improvement period, no participant had assessment using a standardized pediatric stroke scale and neuroimaging was not available.
CONCLUSIONS - In children with sickle cell anemia, a high rate of initial and recurrent strokes exists in a low-resource setting. Ongoing needs include training to detect strokes with an objective stroke assessment and government-supported free access to hydroxyurea for stroke prevention.
Copyright © 2019 Elsevier Inc. All rights reserved.
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16 MeSH Terms
Controlled trial of transfusions for silent cerebral infarcts in sickle cell anemia.
DeBaun MR, Gordon M, McKinstry RC, Noetzel MJ, White DA, Sarnaik SA, Meier ER, Howard TH, Majumdar S, Inusa BP, Telfer PT, Kirby-Allen M, McCavit TL, Kamdem A, Airewele G, Woods GM, Berman B, Panepinto JA, Fuh BR, Kwiatkowski JL, King AA, Fixler JM, Rhodes MM, Thompson AA, Heiny ME, Redding-Lallinger RC, Kirkham FJ, Dixon N, Gonzalez CE, Kalinyak KA, Quinn CT, Strouse JJ, Miller JP, Lehmann H, Kraut MA, Ball WS, Hirtz D, Casella JF
(2014) N Engl J Med 371: 699-710
MeSH Terms: Adolescent, Anemia, Sickle Cell, Blood Transfusion, Cerebral Infarction, Child, Child, Preschool, Female, Ferritins, Hemoglobin, Sickle, Humans, Intelligence, Intention to Treat Analysis, Male, Secondary Prevention, Single-Blind Method, Transfusion Reaction
Show Abstract · Added October 7, 2014
BACKGROUND - Silent cerebral infarcts are the most common neurologic injury in children with sickle cell anemia and are associated with the recurrence of an infarct (stroke or silent cerebral infarct). We tested the hypothesis that the incidence of the recurrence of an infarct would be lower among children who underwent regular blood-transfusion therapy than among those who received standard care.
METHODS - In this randomized, single-blind clinical trial, we randomly assigned children with sickle cell anemia to receive regular blood transfusions (transfusion group) or standard care (observation group). Participants were between 5 and 15 years of age, with no history of stroke and with one or more silent cerebral infarcts on magnetic resonance imaging and a neurologic examination showing no abnormalities corresponding to these lesions. The primary end point was the recurrence of an infarct, defined as a stroke or a new or enlarged silent cerebral infarct.
RESULTS - A total of 196 children (mean age, 10 years) were randomly assigned to the observation or transfusion group and were followed for a median of 3 years. In the transfusion group, 6 of 99 children (6%) had an end-point event (1 had a stroke, and 5 had new or enlarged silent cerebral infarcts). In the observation group, 14 of 97 children (14%) had an end-point event (7 had strokes, and 7 had new or enlarged silent cerebral infarcts). The incidence of the primary end point in the transfusion and observation groups was 2.0 and 4.8 events, respectively, per 100 years at risk, corresponding to an incidence rate ratio of 0.41 (95% confidence interval, 0.12 to 0.99; P=0.04).
CONCLUSIONS - Regular blood-transfusion therapy significantly reduced the incidence of the recurrence of cerebral infarct in children with sickle cell anemia. (Funded by the National Institute of Neurological Disorders and Stroke and others; Silent Cerebral Infarct Multi-Center Clinical Trial ClinicalTrials.gov number, NCT00072761, and Current Controlled Trials number, ISRCTN52713285.).
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16 MeSH Terms
Improving outcomes by changing hemodialysis practice patterns.
Fissell R, Hakim RM
(2013) Curr Opin Nephrol Hypertens 22: 675-80
MeSH Terms: Anemia, Anticoagulants, Hemodialysis Solutions, Humans, Hypertension, Hypertrophy, Left Ventricular, Nutritional Status, Renal Dialysis, Secondary Prevention, Time Factors, Treatment Outcome, Vascular Access Devices
Show Abstract · Added May 20, 2014
PURPOSE OF REVIEW - This review examines recent advances in understanding of how clinical outcomes for hemodialysis patients may be improved by achieving longer or more frequent treatment times, lower ultrafiltration rates (UFRs), improving nutritional status, and individualizing dialysate composition. This review also discusses the controversy related to timing of dialysis initiation.
RECENT FINDINGS - Many observational studies and several randomized controlled trials indicate longer dialysis treatment times, particularly nocturnal dialysis, and/or more frequent dialysis improve morbidity and mortality. Recent evidence also suggests that lower UFR and more consistent achievement of 'dry weight' may help minimize the damage from myocardial stunning and chronic volume overload that occurs in the majority of patients who receive conventional hemodialysis during the day with a standard schedule of 3-5 h, 3 times a week. Other aspects of the dialysis procedure such as appropriate estimated glomerular filtration rate for dialysis initiation and individualizing dialysate composition may also minimize cardiovascular risk. Finally, several studies have highlighted the benefits of oral nutritional supplementation (ONS) during dialysis.
SUMMARY - Greater treatment times per week with slower UFR, consistent attainment of 'dry weight', individualized dialysate prescriptions, and administration of ONS to malnourished patients are likely to reduce hospitalizations and improve survival in this high-risk population of end-stage renal disease patients.
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12 MeSH Terms
Clinical practice guideline: Tympanostomy tubes in children.
Rosenfeld RM, Schwartz SR, Pynnonen MA, Tunkel DE, Hussey HM, Fichera JS, Grimes AM, Hackell JM, Harrison MF, Haskell H, Haynes DS, Kim TW, Lafreniere DC, LeBlanc K, Mackey WL, Netterville JL, Pipan ME, Raol NP, Schellhase KG
(2013) Otolaryngol Head Neck Surg 149: S1-35
MeSH Terms: Age Factors, Anti-Bacterial Agents, Child, Child, Preschool, Equipment Design, Hearing Loss, Humans, Infant, Middle Ear Ventilation, Otitis Media, Patient Selection, Risk Assessment, Secondary Prevention, Treatment Outcome
Show Abstract · Added March 7, 2014
OBJECTIVE - Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy. Despite the frequency of tympanostomy tube insertion, there are currently no clinical practice guidelines in the United States that address specific indications for surgery. This guideline is intended for any clinician involved in managing children, aged 6 months to 12 years, with tympanostomy tubes or being considered for tympanostomy tubes in any care setting, as an intervention for otitis media of any type.
PURPOSE - The primary purpose of this clinical practice guideline is to provide clinicians with evidence-based recommendations on patient selection and surgical indications for and management of tympanostomy tubes in children. The development group broadly discussed indications for tube placement, perioperative management, care of children with indwelling tubes, and outcomes of tympanostomy tube surgery. Given the lack of current published guidance on surgical indications, the group focused on situations in which tube insertion would be optional, recommended, or not recommended. Additional emphasis was placed on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes. ACTION STATEMENTS: The development group made a strong recommendation that clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea. The panel made recommendations that (1) clinicians should not perform tympanostomy tube insertion in children with a single episode of otitis media with effusion (OME) of less than 3 months' duration; (2) clinicians should obtain an age-appropriate hearing test if OME persists for 3 months or longer (chronic OME) or prior to surgery when a child becomes a candidate for tympanostomy tube insertion; (3) clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer (chronic OME) and documented hearing difficulties; (4) clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who did not receive tympanostomy tubes until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected; (5) clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media (AOM) who do not have middle ear effusion in either ear at the time of assessment for tube candidacy; (6) clinicians should offer bilateral tympanostomy tube insertion to children with recurrent AOM who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy; (7) clinicians should determine if a child with recurrent AOM or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors; (8) in the perioperative period, clinicians should educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications; (9) clinicians should not encourage routine, prophylactic water precautions (use of earplugs, headbands; avoidance of swimming or water sports) for children with tympanostomy tubes. The development group provided the following options: (1) clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for 3 months or longer (chronic OME) and symptoms that are likely attributable to OME including, but not limited to, vestibular problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life and (2) clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is unlikely to resolve quickly as reflected by a type B (flat) tympanogram or persistence of effusion for 3 months or longer (chronic OME).
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14 MeSH Terms
Genetic variation in donor CTLA-4 regulatory region is a strong predictor of outcome after allogeneic hematopoietic cell transplantation for hematologic malignancies.
Jagasia M, Clark WB, Brown-Gentry KD, Crawford DC, Fan KH, Chen H, Kassim A, Greer JP, Engelhardt BG, Savani BN
(2012) Biol Blood Marrow Transplant 18: 1069-75
MeSH Terms: Adolescent, Adult, Aged, CTLA-4 Antigen, Female, Graft vs Tumor Effect, Hematologic Neoplasms, Hematopoietic Stem Cell Transplantation, Humans, Male, Middle Aged, Polymorphism, Single Nucleotide, Risk Factors, Secondary Prevention, Survival Analysis, T-Lymphocytes, Cytotoxic, Tissue Donors, Transplantation, Homologous, Treatment Outcome
Show Abstract · Added December 10, 2013
Relapse remains a major cause of death after allogeneic hematopoietic cell transplantation (allo-HCT). Graft-versus-tumor effect is primarily mediated by donor T cells. Cytotoxic T lymphocyte antigen-4 (CTLA-4) is a critical inhibitor of T cell proliferation. Single nucleotide polymorphisms (SNPs) in CTLA-4 may affect immune responses. We hypothesized that CTLA-4 SNPs will be associated with disease control after allo-HCT. One hundred sixty-four adult patients with the availability of pretransplantation recipient and donor DNA samples were included in this analysis. Ten tagSNPs of the CTLA-4 gene were identified. Donor CTLA-4 SNP rs4553808 was associated with decreased relapse-free survival (RFS) (P = .019) and overall survival (OS) (P = .033). In multivariable analysis of an additive genetic model, genotype of CTLA-4 SNP rs4553808 was an independent risk factor for inferior RFS (hazard ratio [HR] = 1.73, 95% confidence interval [CI] 1.10-2.71, P = .017) and OS (HR = 1.84, 95% CI 1.13-3.0, P = .015). CTLA-4 SNPs can be used to identify high-risk patient subsets that may benefit from preemptive immunomodulation to decrease relapse rates and improve survival.
Copyright © 2012 American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.
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19 MeSH Terms
What is the evidence for using hydroxyurea for secondary stroke prevention?
Lebensburger JD, DeBaun MR, Thompson AA
(2011) Hematology Am Soc Hematol Educ Program 2011: 440-2
MeSH Terms: Blood Transfusion, Child, Humans, Hydroxyurea, Male, Secondary Prevention, Stroke
Show Abstract · Added November 27, 2013
A 10-year-old male patient with hemoglobin SS suffered a stroke at 7 years of age and was initially transfused at the time of presentation to lower the hemoglobin S concentration to < 30%. You are asked by the family if their child can be treated with oral hydroxyurea rather than monthly transfusions for the secondary prevention of strokes.
1 Communities
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7 MeSH Terms
Choosing a treatment for patients at the time a fracture is presented.
Tanner SB
(2011) Curr Osteoporos Rep 9: 156-9
MeSH Terms: Antibodies, Monoclonal, Antibodies, Monoclonal, Humanized, Denosumab, Diphosphonates, Fractures, Spontaneous, Humans, Osteoporosis, RANK Ligand, Secondary Prevention, Teriparatide
Show Abstract · Added January 20, 2015
The occurrence of a fragility fracture is an opportunity to recognize osteoporosis and begin treatment to reduce the risk of another fracture. However, selecting the treatment may have an impact on the incident fracture and this requires careful consideration of the patient and the treatment choices. There is no consensus regarding the management of osteoporosis at the time of an incident fracture. This review will consider the treatment options after a fragility fracture.
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10 MeSH Terms
Extramedullary relapses after allogeneic stem cell transplantation for acute myeloid leukemia and myelodysplastic syndrome.
Clark WB, Strickland SA, Barrett AJ, Savani BN
(2010) Haematologica 95: 860-3
MeSH Terms: Animals, Humans, Leukemia, Myeloid, Acute, Myelodysplastic Syndromes, Postoperative Complications, Secondary Prevention, Stem Cell Transplantation, Transplantation, Homologous
Added March 28, 2014
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8 MeSH Terms
Preventing glycaemic relapse in recently controlled type 2 diabetes patients: a randomised controlled trial.
Huizinga MM, Gebretsadik T, Garcia Ulen C, Shintani AK, Michon SR, Shackleford LO, Wolff KL, Brown AW, Rothman RL, Elasy TA
(2010) Diabetologia 53: 832-9
MeSH Terms: Adolescent, Adult, Aged, Community Health Services, Diabetes Mellitus, Type 2, Female, Humans, Hyperglycemia, Hypoglycemic Agents, Male, Middle Aged, Patient Education as Topic, Patient Selection, Secondary Prevention, Treatment Outcome
Show Abstract · Added February 23, 2015
AIMS/HYPOTHESIS - After achieving glycaemic control, many type 2 diabetic patients relapse to clinically significant levels of hyperglycaemia. We sought to determine the optimal frequency of telephone contact by nurse practitioners that was necessary to prevent glycaemic relapse.
METHODS - This parallel, randomised controlled trial ran from June 2002 to February 2006 at an academic medical centre, studying 164 type 2 diabetic patients who had recently achieved glycaemic control. Participants were randomly assigned by sequential, concealed, computer-generated allocation to a 2 year maintenance strategy consisting of: (1) routine follow-up (n = 54); (2) routine follow-up and quarterly telephone contact (n = 55); or (3) routine follow-up and monthly telephone contact (n = 55). Blinding was not possible. The primary outcome was cumulative incidence of glycaemic relapse, defined as an increase in HbA(1c) of > or =1%; all participants were analysed. Cumulative incidence and prevalent proportions were compared. Weight change and hypoglycaemia were also assessed.
RESULTS - All participants randomised were included in the analyses. The study was completed by 90% of participants and intervention fidelity was high. At 24 months, the cumulative incidence of relapse was 41%. At 12 months, prevalent proportions of relapse were 20%, 14% and 15% for control, quarterly contact and monthly contact, respectively. At 24 months, they were 25%, 21% and 29%, respectively. There was no statistically significant difference in cumulative incidence or prevalent proportions of relapse among the study arms. Adverse events did not differ between study arms.
CONCLUSIONS/INTERPRETATION - This first randomised controlled trial to test an intervention to prevent glycaemic relapse found that regularly scheduled telephone contact by a nurse practitioner was no more effective than routine follow-up care in preventing glycaemic relapse.
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15 MeSH Terms
Hepatocellular carcinoma in viral hepatitis: improving standard therapy.
Masuzaki R, Yoshida H, Tateishi R, Shiina S, Omata M
(2008) Best Pract Res Clin Gastroenterol 22: 1137-51
MeSH Terms: Antineoplastic Agents, Biomarkers, Tumor, Carcinoma, Hepatocellular, Catheter Ablation, Chemoembolization, Therapeutic, Comorbidity, Drug Delivery Systems, Hepatectomy, Hepatitis B, Hepatitis C, Humans, Liver Neoplasms, Liver Transplantation, Primary Prevention, Prognosis, Randomized Controlled Trials as Topic, Secondary Prevention
Show Abstract · Added May 2, 2014
Hepatocellular carcinoma (HCC) is a common malignancy worldwide, and its incidence is increasing in the United States and elsewhere. The prognosis of HCC patients depends not only on tumour stage but also on the background liver function reservoir. Current options for the treatment of HCC are surgical resection, liver transplantation, transcatheter arterial embolization, chemotherapy, and percutaneous ablation therapy. The choice of optimal treatment for individual patients, especially those at an earlier cancer stage, is sometimes controversial. Short-term prognosis of HCC patients has been much improved recently due to advances in early diagnosis and treatment, although long-term prognosis is as yet far from satisfactory as indicated by the overall survival at 10 years after apparently curative treatment of only 22-35%. Prevention of HCC recurrence, or tertiary prevention, is one of the most challenging tasks in current hepatology.
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17 MeSH Terms