Proportion of the population with one or more decayed surfaces in primary teeth ds. Measures designed to reduce the risk of introduction, establishment, and spread of animal diseases, infections, or infestations to, from, and within an animal population. Chapter Nursing Homes Definitions. In addition, one in three individuals who have survived a heart attack experience major depression National Institutes of Health, He grew up in a large Midwestern family. Retrieved 1 October
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For more information, visit our website www. The conference will benefit pediatricians, family practice physicians, advanced practice providers NP's, PA's , nurses, fellows, and residents. Other healthcare professionals involved in the care of pediatric patients with sickle cell disease mayfind the information useful and are welcome to attend. The purpose of this symposium is to update pediatricians and family practitioners on the most current research and clinical guidelines related to pediatric sickle cell disease, particularly in the school-aged child, and to discuss key considerations when caring for these patients.
For more information, contact ashley. This year the event will be held in Atlanta, Georgia, a city near and dear to the sickle cell community! SCiF is a two-day, intensive, educational update on sickle cell disease. This two-day intensive educational conferences includes both clinical and scientific lectures, aimed at clinicians, academics, and other healthcare professionals involved in sickle cell disease around the world.
Sickle Cell News for June — To join or leave the listserv visit http: If approved, Endari would be the first FDA-approved treatment for pediatric patients with sickle cell disease, and the first new treatment for adult patients in almost 2 decades. The FDA documented that while the difference was statistically different, the efficacy data was complicated by differences in discontinuation rates observed during the course of the study. While that was a concern, the FDA documented that their own exploration of the data favored L-glutamine over placebo in reducing the rates of crises.
New York Times - Patient Voices: Sickle Cell Anemia https: Here, six men and women speak about the impact sickle cell anemia has had on their lives and families. Mixing Music and Medicine: Grammy-nominated songwriter and music producer, Nana Kwabena has helped create hits for many notable artists including John Legend, Rick Ross and fellow Wondaland label mates Janelle Monae and Jidenna.
However, his musical genius and path to the entertainment industry began in one of the most unlikely places—a hospital. The year-old was diagnosed with sickle cell disease at a young age and says that he spent so much of his childhood in and out of medical facilities; it often felt like he was raised in the hospital.
As a teenager, complications from the disease often meant that Kwabena was in the hospital for up to two months at a time. He taught himself how to use the music production program Fruity Loops and started to create his own songs.
After that experience Kwabena says he knew he wanted to pursue music and at the same time shed light on sickle cell disease. Biol Blood Marrow Transplant. Results of a Phase I Trial. A calcineurin inhibitor and mycophenolate mofetil were used for graft-versus-host-disease GVHD prophylaxis. With median follow up of 2. Thus, this RIC regimen was able to achieve donor engraftment in the majority.
Future efforts will focus on further reducing acute GVHD and viral infection rates. Sickle cell trait SCT is usually benign. However, there are some conditions that may lead to SCT-related problems and put athletes with the trait at particular risk. Athletic trainers and team physicians play key roles in the policy implementation and we examined their perceptions and practices.
We used an interview guide with open-ended questions covering knowledge of SCT, historical screening and education practices, current implementation, and policy benefits and challenges. Participants were knowledgeable about SCT and thought the policy was beneficial in providing SCT health information to and for student-athletes. Schools varied in provision of genetic counseling, offering the waiver, SCT tests administered, and other aspects. Athletic staff found the policy valuable, but felt it needs clarity and standardization.
Sensitivity of alternative measures of functioning and wellbeing for adults with sickle cell disease: Demand is growing for valid and reliable measures to systematically document these effects, particularly in adults. Statistical analyses, including analysis of variance and multiple linear regression, were conducted to determine the sensitivity of measures to SCD severity. SCD severity was assessed via a checklist of associated treatments and conditions.
The clinical implications of these results require further investigation. Increased complications of chronic erythrocytapheresis compared with manual exchange transfusions in children and adolescents with sickle cell disease. Children and adolescents with sickle cell disease SCD are at high risk of strokes and are frequently treated with red blood cell RBC transfusions.
The goal is to suppress hemoglobin Hb S while minimizing transfusion-induced iron overload. Chronic transfusion practices vary among institutions. This single-institution, retrospective cohort study compares Hb S control and therapy complication rates between MET and aRBCX in a cohort of children and adolescents with SCD and stroke during a 5-year period from through Duration and mode of transfusion therapy, achievement of Hb S suppression goal, iron burden by ferritin levels, and catheter complications were evaluated.
Thirty-seven children were included in analysis. There was no significant difference between modalities in achieving Hb S suppression or ferritin goals, but those receiving aRBCX had a greater likelihood of discontinuing chelation therapy. Transfusion therapy modalities should be compared in prospective studies for stroke prevention in children with SCD.
Neuropsychological deficits, including difficulties with attention, are well described in children with sickle cell disease SCD. This prospective, cross-sectional study included patients age, 4 to 18 y with SCD and completion of a neuropsychological evaluation between December and March ADHD medication usage rate was obtained by medical record review. Patients with sickle cell disease SCD are at risk of fatal sepsis with encapsulated bacteria, such as Streptococcus pneumoniae, because of the inherent autosplenectomy that occurs in SCD.
This risk is thwarted with oral penicillin prophylaxis during the first 5 years of life, and with stringent vaccination against S. But compared with the general African American pediatric population, the rate of invasive pneumococcal disease IPD in patients with SCD still remains high, resulting in hospitalization and fatality. Descriptive analysis of presence of risk factors for IPD, type of SCD, pneumococcal vaccination and prophylaxis status, clinical presentation, microbiological data, and the outcome of IPD was performed.
Three of the 8 isolates underwent serotype analysis 15 C in 2 and 15A in 1 , none covered with the current vaccination program. One patient had fatal outcome 15A. Breakthrough cases of IPD may involve nonvaccine isolates, and seem to occur after 5 years of age when oral penicillin prophylaxis has been terminated.
A feasibility randomized controlled trial. Sickle cell disease SCD is a childhood and adult disease that primarily affects African Americans, characterized by life threatening sequelae mitigated by medications.
One-way and two-way short message service SMS medication reminders have differing efficacy in chronic diseases. Participants were randomly allocated to standard care or reminders. Participants were enrolled 28 to 60 days with a common termination date. Among the 47 study participants enrolled, Medication adherence scores improved significantly in the intervention group 3. Childhood-ACT scores improved in the intervention group Adult-ACT scores within the intervention arm were unchanged ACT scores did not improve significantly.
This study demonstrated the feasibility for two-way SMS medication reminders to improve medication adherence in a high-risk population where daily medication adherence is critical to health outcomes and quality of life. Sickle cell disease SCD is a complex illness with many social-behavioral co-morbidities.
The aim of this project was to describe unmet social-behavioral health needs for adults with SCD who presented to the emergency department for treatment of vaso-occlusive episodes VOEs. A descriptive study using 1: We conducted interviews over 14 months. Four major themes emerged: Many patients with SCD who are treated in the emergency department have social or behavioral health risk factors. Emergency departments have an opportunity to screen and refer patients for follow-up.
Future research should investigate referral outcomes and their effect on ED and hospital use. Interventions for preventing silent cerebral infarcts in people with sickle cell disease. Sickle cell disease SCD is one of the commonest severe monogenic disorders in the world, due to the inheritance of two abnormal hemoglobin beta globin genes. SCD can cause severe pain, significant end-organ damage, pulmonary complications, and premature death.
Silent cerebral infarcts are the commonest neurological complication in children and probably adults with SCD. Silent cerebral infarcts also affect academic performance, increase cognitive deficits and may lower intelligence quotient. To assess the effectiveness of interventions to reduce or prevent silent cerebral infarcts in people with SCD. Randomised controlled trials comparing interventions to prevent silent cerebral infarcts in people with SCD.
There were no restrictions by outcomes examined, language or publication status. We included five trials children or adolescents published between and Four of the five trials were terminated early. One trial focused on preventing silent cerebral infarcts or stroke; three trials were for primary stroke prevention and one trial dealt with secondary stroke prevention. Three trials compared the use of regular long-term red blood cell transfusions to standard care. Two of these trials included children with no previous long-term transfusions: The third trial included children and adolescents on long-term transfusion.
Two trials compared the drug hydroxyurea and phlebotomy to long-term transfusions and iron chelation therapy: The quality of the evidence was moderate to very low across different outcomes according to GRADE methodology. This was due to trials being at high risk of bias because they were unblinded; indirectness available evidence was only for children with HbSS ; and imprecise outcome estimates.
Long-term red blood cell transfusions versus standard care Children with no previous long-term transfusions and higher risk of stroke abnormal TCD velocities or previous history of silent cerebral infarcts Long-term red blood cell transfusions may reduce the incidence of silent cerebral infarcts in children with abnormal TCD velocities, risk ratio RR 0.
No deaths were reported in either trial. Long-term red blood cell transfusions may reduce the incidence of: Long-term red blood cell transfusions may improve quality of life in children with previous silent cerebral infarcts difference estimate Transfusions continued versus transfusions halted: We are very uncertain whether continuing red blood cell transfusions has any effect on all-cause mortality, Peto odds ratio OR 8.
The trial did not report: Hydroxyurea and phlebotomy versus transfusions and chelation Primary prevention, children participants; one trial We are very uncertain whether switching to hydroxyurea and phlebotomy has any effect on: Secondary prevention, children and adolescents with a history of stroke participants; one trial We are very uncertain whether switching to hydroxyurea and phlebotomy has any effect on: Neither trial reported on quality of life or cognitive function.
Long-term red blood cell transfusions may reduce the incidence of silent cerebral infarcts in children with abnormal TCD velocities, but may have little or no effect on children with normal TCD velocities. In children who are at higher risk of stroke and have not had previous long-term transfusions, long-term red blood cell transfusions probably reduce the risk of stroke, and other SCD-related complications acute chest syndrome and painful crises.
In children and adolescents at high risk of stroke whose TCD velocities have normalised, continuing red blood cell transfusions may reduce the risk of silent cerebral infarcts. No treatment duration threshold has been established for stopping transfusions. Switching to hydroxyurea with phlebotomy may increase the risk of silent cerebral infarcts and SCD-related serious adverse events in secondary stroke prevention.
All other evidence in this review is of very low-quality. Potential therapeutic action of nitrite in sickle cell disease. Sickle cell disease is caused by a mutant form of hemoglobin that polymerizes under hypoxic conditions, increasing rigidity, fragility, calcium influx-mediated dehydration, and adhesivity of red blood cells.
Increased red cell fragility results in hemolysis, which reduces nitric oxide NO bioavailability, and induces platelet activation and inflammation leading to adhesion of circulating blood cells. Nitric Oxide inhibits adhesion and platelet activation. Nitrite has emerged as an attractive therapeutic agent that targets delivery of NO activity to areas of hypoxia through bioactivation by deoxygenated red blood cell hemoglobin.
In this study, we demonstrate anti-platelet activity of nitrite at doses achievable through dietary interventions with comparison to similar doses with other NO donating agents. Unlike other NO donating agents, nitrite activity is shown to be potentiated in the presence of red blood cells in hypoxic conditions. We also show that nitrite reduces calcium associated loss of phospholipid asymmetry that is associated with increased red cell adhesion, and that red cell deformability is also improved.
We show that nitrite inhibits red cell adhesion in a microfluidic flow-channel assay after endothelial cell activation. In further investigations, we show that leukocyte and platelet adhesion is blunted in nitrite-fed wild type mice compared to control after either lipopolysaccharide- or hemolysis-induced inflammation. Moreover, we demonstrate that nitrite treatment results in a reduction in adhesion of circulating blood cells and reduced red blood cell hemolysis in humanized transgenic sickle cell mice subjected to local hypoxia.
These data suggest that nitrite is an effective anti-platelet and anti-adhesion agent that is activated by red blood cells, with enhanced potency under physiological hypoxia and in venous blood that may be useful therapeutically. For more information- go to: Pediatric Sickle Cell Mini Symposium: Contact Rusinel Amarante rusinel. Sickle Cell News for March —April There was a lack of awareness of sickle cell and lots of stigma around the condition particularly in the high risk African and Caribbean communities most at risk of inheriting sickle cell so it was important to educate about sickle cell, testing and associated myths.
These resources now published include a good practice guide for people who commission, fund, deliver and evaluate outreach programmes, an overview of the work delivered and the research underpinning it. The resources capture the learning from years of outreach work.
They include a detailed guide that explains the learning, video clips from public events and interviews with service users and people who delivered the outreach. Resources can be accessed from: Stem cell transplant resource page: Local mom starts new career to help sons fight sickle cell disease http: Years ago, Tiffany was a school teacher.
But after she became a mom, her 9 to 5 changed. The boys are now 12 and 8, trying to live normal lives with a tough disease. Tiffany also has a new career: There are so many side effects—one of them being stroke—even for kids.
But another major part of the job at Virginia Blood Services is done in labs. Researchers are always looking for rare blood that will go only to patients who desperately need it. Beth Johnson, of Virginia Blood Services, says they handle rare blood in a special way. Aside from working at Virginia Blood Services, Tiffany Dews is also continuing her work outside of the labs, within local communities.
Her mission is to get more African Americans to donate blood that could help sickle cell patients—like her two sons. NFL player Santonio Holmes knows the pain of sickle cell disease. He sees it in his year-old son, T.
Holmes wants to change that. Sickle cell in the Medical Literature. Epub Feb 9. Sickle cell disease and venous thromboembolism in pregnancy and the puerperium. Noubouossie D 1 , Key NS 2. Recent data strongly suggest an increased risk of venous thromboembolism in subjects with sickle cell disease and to a lesser extent, sickle cell trait.
However, most studies have been retrospective, case-control or cross-sectional based on data obtained from administrative databases. More data from adequately powered prospective studies that include matched controls are needed to definitely establish the link between venous thromboembolism during pregnancy and sickle hemoglobin disorders.
Similarly, there remains a need for properly designed randomized control trials to establish the safety of various hormonal contraceptive methods in women with sickle cell disorders. Red blood cell transfusions are associated with HLA class I but not H-Y alloantibodies in children with sickle cell disease. Blood transfusions can induce alloantibodies to antigens on red blood cells RBCs , white blood cells and platelets, with these alloantibodies affecting transfusion and transplantation.
While transfusion-related alloimmunization against RBC antigens and human leucocyte antigens HLA have been studied, transfusion-related alloimmunization to minor histocompatibility antigens mHA , such as H-Y antigens, has not been clinically characterized.
These results are consistent with immunological responder and non-responder phenotypes, wherein a subset of patients with SCD may be at higher risk for transfusion-related alloimmunization.
Adv Skin Wound Care. Case studies evaluating transdermal continuous oxygen for the treatment of chronic sickle cell ulcers. Refractory leg ulcerations are common in homozygous sickle cell anemia. In this case series, patients were treated with transdermal continuous oxygen therapy TCOT , based on the hypothesis that oxygen deprivation caused by arteriovenous shunting may be remedied by providing oxygen directly to the wound bed.
The authors believe this is the first attempt to treat sickle cell ulcers with TCOT. The patients had recurring nonhealing wounds for 30, 21, 20, 20, and 15 years, respectively. All 5 patients healed or showed substantial improvement in the treatment periods of 3 to 36 weeks. The authors conclude that TCOT may be a novel, effective, and inexpensive modality in treating patients with sickle cell disease ulcers.
Improvement was typically noticeable within 2 weeks. Further clinical trials may be considered to evaluate the efficacy of TCOT in sickle cell ulcers.
Depression and quality of life in children with sickle cell disease: The majority of available studies have shown that children with sickle cell disease SCD have a higher risk of depressive symptoms than those without.
The present study aimed to: A total of children were included in the study, 60 group I with SCD and 60 matched, healthy control children group II. A higher level of parent support was a significantly associated with decreased depressive symptoms, demonstrated by lower CDI scores. Better quality of life was shown by the associated higher total PedsQL 4.
The present study demonstrates that higher levels of parent support were significantly associated with decreased depressive symptoms and better quality of life in children with SCD. Interventions focused on increasing parent support may be an important part of treatment for depression in children with SCD. Pak J Med Sci. The purpose of this study was to determine the impact of mean platelet volume MPV on the frequency and severity of vaso-occlusive and cerebrovascular events in patients with sickle cell anemia SCA.
The cases diagnosed with SCA were evaluated retrospectively with respect to the occurrence of painful crisis for the previous year. The incidence, severity and type of the vaso-occlusive crises of the patients with SCA between March and March were recorded. The last MPV values in patients who were free of erythrocyte transfusion for the last three months and who had no current vaso-occlusive crises were evaluated.
All the patients were grouped according to the frequency of the crises for the previous year preceding the data collection. In accordance with the results obtained during the evaluation of the cases diagnosed with sickle-cell anemia, MPV value was found to be significantly higher in patients with cerebrovascular events.
One of the contributing factors for this clinical heterogeneity may be related to the MPV values in patients with sickle cell anemia. The higher MPV values may be an early predictor of future cerebrovascular events in patients with sickle cell anemia and may require close follow-up and additional measures. West Indian Med J. To determine the clinical factors associated with the length of hospitalization and mortality in patients with sickle cell disease SCD. Data were extracted from hospital charts and comprised demographic and clinical information, investigations, interventions, duration of stay, pathological data and outcomes.
Overall mean age was The mean length of hospitalization was The main admission diagnoses were painful crisis, acute chest syndrome, severe anaemia, sepsis, hepatic sequestration, congestive cardiac failure and renal failure.
The mean value for the following laboratory investigations were: There were 40 deaths with four autopsies done. There were repeat SCD admissions. Sickle cell disease still carries a high morbidity and mortality in patients admitted to hospital. Recurrent admissions are a concern, as they impact on patient's morbidity and quality of life. Estimated pulmonary artery systolic pressure and sickle cell disease: Many studies report estimated pulmonary artery systolic pressure ePASP in patients with sickle cell disease SCD screened by echocardiography.
To better understand the prevalence and outcomes of elevated ePASP in clinically stable SCD patients, we conducted a random-effects meta-analysis. A total of 45 studies, representing 15 countries and including individuals, met our inclusion criteria. Few studies reported 6-min walk tests or mortality outcomes, and estimates were highly heterogeneous. Reduced fitness and abnormal cardiopulmonary responses to maximal exercise testing in children and young adults with sickle cell anemia.
Physiologic contributors to reduced exercise capacity in individuals with sickle cell anemia SCA are not well understood. The objective of this study was to characterize the cardiopulmonary response to maximal cardiopulmonary exercise testing CPET and determine factors associated with reduced exercise capacity among children and young adults with SCA.
A cross-sectional cohort of 60 children and young adults mean In the largest study to date using maximal CPET in SCA, we demonstrate that children and young adults with SCA have reduced exercise capacity attributable to factors independent of anemia. Complex derangements in gas exchange and oxygen uptake during maximal exercise are common in this population.
Physiological Reports published by Wiley Periodicals, Inc. Cochrane Database Syst Rev. Phytomedicines medicines derived from plants for sickle cell disease. Oniyangi O 1 , Cohall DH. Sickle cell disease, a common recessively inherited haemoglobin disorder, affects people from sub-Saharan Africa, the Middle East, Mediterranean basin, Indian subcontinent, Caribbean and South America.
It is associated with complications and a reduced life expectancy. Phytomedicines medicine derived from plants in their original state encompass many of the plant remedies from traditional healers which the populations most affected would encounter. There has been little systematic appraisal of their benefits. This is an update of a Cochrane Review first published in and updated in To assess the benefits and risks of phytomedicines in people with sickle cell disease of all types, of any age, in any setting.
Dates of most recent searches: Randomized or quasi-randomized trials with participants of all ages with sickle cell disease, in all settings, comparing the administration of phytomedicines, by any mode to placebo or conventional treatment, including blood transfusion and hydroxyurea. Both authors independently assessed trial quality and extracted data.
It did not affect the risk of severe complications or the level of anaemia. No serious adverse effects were reported. This needs to be further validated in future trials. More trials are required on the safety and efficacy of phytomedicines used in managing sickle cell disease. Cognitive behavioral therapy in patients with sickle cell disease. Sickle cell disease SCD is an inherited autosomal recessive disorder. SCD is a lifelong disorder with no known cure.
SCD causes anemia, frequent painful episodes, and reduced life expectancy. The most disturbing clinical problem associated with SCD is severe pain episodes, the most common reason for hospitalization. Pharmacological interventions have been the mainstream for treatment; however, psychological interventions such as cognitive behavioral therapy CBT may complement current medical treatment, leading to better coping and overall improved quality of life.
In a quasi-experimental one-group pretest-posttest study, 9 African American individuals with SCD completed 3 weekly educational sessions learning CBT methods. Participants demonstrated increased frequency of use of CBT methods post-intervention, including diverting attention, coping self-statements, and behavioral activities, leading to better pain control.
However, quality of life and role limitation did not show significant improvement. CBT may be beneficial to those suffering from SCD when combined with conventional treatment options; however, there are still barriers to incorporating psychological interventions into practice.
CBT shows promise for individuals with chronic conditions such as SCD, but more investigation into its efficacy is needed with larger sample sizes over longer periods of time. This analysis examined the influence of quantifiable parameters of daily sleep continuity, primarily sleep duration and sleep fragmentation, on daily pain in adults with Sickle Cell Disease SCD. Seventy-five adults with SCD completed baseline psychosocial measures and daily morning sleep and evening pain diaries over a three-month period.
Mixed-effect modeling was used to examine daily between- and within-subjects effects of sleep continuity parameters on pain, as well as the synergistic effect of sleep fragmentation and sleep duration on pain. Results revealed nights of shorter sleep duration and time in bed, increased fragmentation, and less efficient sleep relative to one's own mean were followed by days of greater pain severity.
Further, the analgesic benefit of longer sleep duration was attenuated when sleep fragmentation was elevated. These results suggest that both the separate and combined effects of sleep duration and fragmentation should be considered in evaluating pain in adults with SCD. Subjective parameters of sleep continuity e. Additionally, sleep duration should not be considered in isolation and its association with pain may be qualified by sleep fragmentation.
Research and practice should include assessments of both when addressing pain severity. The aim of this study was to identify the factors associated with delays in treatment of sickle pain crisis in the pediatric emergency department with the goal of discerning whether earlier pain management is correlated with better clinical outcome.
This retrospective study examined data collected from clinical records of patients, aged 21 years or younger, who was treated for sickle cell pain crisis between January and June Demographic and clinical characteristics were extracted from electronic records, as well as time of registration, triage, initial pain assessment, analgesic administration, and pain reassessment.
A total of sickle cell pain crises visits by 67 unique patients were identified. Opiates were the most common initial pain medication prescribed and administered.
The mean time to initial analgesic administration and pain reassessment was 89 and 60 minutes, respectively. Patients with orders for imaging studies experienced significant delays in time to initial analgesic medication and pain reassessment. In addition, higher triage pain score correlated with shorter time to first dose of pain medication.
However, age, sex, and final disposition did not affect time to administration of analgesic medications. Earlier pain management resulted in shorter ED length of stay for all patients regardless of disposition. However, earlier pain management did not affect the total length of hospitalization for patients admitted to the inpatient services.
Pediatric patients with sickle cell pain crises experienced significant delays to initial analgesic medication. The lifespan of patients with sickle-cell disease SCD continues to increase, and most affected individuals in high-resource countries now live into adulthood. This necessitates a successful transition from pediatric to adult health care. Care for transitioning patients with SCD often falls to primary care providers who may not be fully aware of the many challenges and issues faced by patients and the current management strategies for SCD.
In this review, we aim to close the knowledge gap between primary care providers and specialists who treat transitioning patients with SCD. We describe the challenges and issues encountered by these patients, and we propose a biopsychosocial multidisciplinary approach to the management of the identified issues. Examples of this approach, such as transition-focused integrated care models and quality improvement collaboratives, with the potential to improve health outcomes in adulthood are also described.
Patients with sickle cell disease frequently experience severe pain events that lead to unplanned healthcare utilization. Mobile health tools mHealth may help prevent these events by providing remote monitoring and self-management support.
This article describes the feasibility of the Sickle cell disease Mobile Application to Record symptoms via Technology SMART , an mHealth app developed to help sickle cell disease patients monitor and manage their day-to-day symptoms. Patients continued using SMART to record clinical symptoms, pain intensity, location and perceived severity, and treatment strategies for at least 28 days.
Patient median age was 29 years range ; Patients who were over age 35 or used an iPad for the study had the highest compliance rates. This study showed that SMART is a useable and feasible method for monitoring daily pain symptoms among adolescents and adults with sickle cell disease-related pain. How I treat acute strokes and long-term management in sickle cell disease. Neurological complications are a major cause of morbidity and mortality in sickle cell disease.
Limited evidence is available to guide acute and chronic management of individuals with sickle cell disease and strokes. Current management strategies are based primarily on single arm clinical trials and observational studies, coupled with principles of neurology and hematology. Standard therapy for secondary prevention of strokes and silent cerebral infarcts includes regular blood transfusion therapy and in selected cases, hematopoietic stem cell transplantation. A critical component of the medical care following an infarct is cognitive and physical rehabilitation.
We will discuss our strategy of acute and long-term management of strokes in sickle cell disease. Guideline on the management of acute chest syndrome in sickle cell disease. How I treat priapism. Priapism is a disorder of persistent penile erection unrelated to sexual interest or desire. This pathologic condition, specifically the ischemic variant, is often associated with devastating complications, notably erectile dysfunction.
Because priapism demonstrates high prevalence in patients with hematological disorders, most commonly sickle cell disease SCD , there is significant concern for its sequelae in this affected population. Thus, timely diagnosis and management are critical for the prevention or at least reduction of cavernosal tissue ischemia and potential damage consequent to each episode.
Current guidelines and management strategies focus primarily on reactive treatments. However, an increasing understanding of the molecular pathophysiology of SCD-associated priapism has led to the identification of new potential therapeutic targets. Future agents are being developed and explored for use in the prevention of priapism.
Allogeneic donor availability for hematopoietic stem cell transplantation in children with sickle cell disease. Hematopoietic stem cell transplant is curative of sickle cell disease SCD but limited by donor availability.
Sickle Cell Conferences and Events. Monday 15 — Tuesday 16 June The 9th Sickle Cell in Focus returns to London in This year, in addition to updating on the emerging and current clinical and management issues related to sickle cell disease, there will be a focus on new drug developments, clinical trials and new genetics. Sickle Cell in Focus has become a internationally renowned educational update for sickle cell disease. It attracts a wide audience of clinicians, academics and other healthcare professionals involved in the disease from around the world.
Online booking will be open soon. September 23 - 26, Hilton - Baltimore, MD. While innovations in drug development improve patient health, care management plans in hospitals and academic health institutes are evolving simultaneously to allow for better patient care at reduced costs. SCD, a commonly inherited blood disorder resulting from abnormal hemoglobin, is associated with lifelong disabilities and can reduce life expectancy. As you may have heard from Dr. Swee Lay Thein, M.
Over the course of her career she has made major contributions to our understanding of sickle cell phenotypes as well as pioneered new treatment strategies in clinical trials. He received his M. Also joining this newly created Branch will be Drs.
Stopping kids' silent strokes http: About , Americans have sickle cell disease -- a genetic condition where the body's red blood cells are deformed, clogging up arteries, and causing pain, disability or major stroke, even in kids. Patients who suffer strokes often have regular blood transfusions to prevent a repeat attack. Researchers now say those transfusions can be crucial for many more young sickle cell patients, even those who are showing no outward signs of brain injury.
Alexis Haynes, 12, has come a long way. At age 6, a sudden stroke put her in a coma for a full month. Every six weeks, Alexis spends hours getting her blood transfused. New red blood cells replace her sickle-shaped ones. While Alexis' stroke was apparent, experts say one in three children with sickle cell suffer silent strokes.
These kids have a higher risk of memory problems. Many have trouble at school. They're also at much higher risk for having a major stroke. Noetzel studied children age 5 and older, who had brain scans that showed evidence of silent strokes.
For three years, 99 received monthly transfusions, the rest did not. Researchers found the transfusions reduced the risk of strokes of any kind by 58 percent. Identifying kids at risk before any damage is done. Risks from transfusions include infections, reactions to donated blood and buildup of iron in the bloodstream.
Researchers are planning longer-term studies to see whether transfusions, in combination with other sickle cell treatment options -- like stem cell transplantation -- can help prevent kids from losing cognitive function.
Sickle cell patient, 51, advocates screening for intending couples before marriage - See more at: If a person is born with it, steps should be taken to reduce complications resulting from. But it can be prevented as well if intending couples should go for genotype screening and counseling in order to know their genotypes before getting married to avoid having a child with sickle cell disease.
This would go a long way in curbing the prevalence of sickle cell anaemia in our society. Olajide who revealed that he was diagnosed with sickle cell anaemia in , at the age of two disclosed that Africa Sickle Cell News and World Report will make every edition of sickle cell news available online for free starting from January to strengthen sickle cell awareness in Africa and throughout the world and help reduce its spread.
During my school days I started conducting research on sickle cell, read different books to know more about the disease and that is what helped me to live up to this stage of life. People who are at high risk of having a child with sickle cell anemia planning to have children should consider genetic counseling.
A counselor can explain the risk of likelihood of having a child who has the disease. He or she also can help explain the choices that are available. Sickle erythrocytes and platelets augment lung leukotriene synthesis with downregulation of anti-inflammatory proteins: Abstract Initiation, progression, and resolution of vaso-occlusive pain episodes in sickle cell disease SCD have been recognized as reperfusion injury, which provokes an inflammatory response in the pulmonary circulation.
Some 5-lipoxygenase 5-lox metabolites are potent vasoconstrictors in the pulmonary circulation. We studied stimulation of production of the inflammatory eicosanoids leukotrienes LTs and prostaglandin E2 PGE2 by isolated rat lungs perfused with sickle HbSS erythrocytes.
Lung weight gain and blood gas data were not different among the groups. Inclusion of autologous platelets platelet-rich plasma elevated LTC4 production to The data suggest that HbSS erythrocytes and activated platelets in patient's pulmonary microcirculation will enhance the synthesis and release of the proinflammatory mediators LTC4 and PGE2, both of which may contribute to onset of the acute chest syndrome in SCD. Sleep and Asthma Cohort. Abstract Previous studies have shown that the highest incidence of acute chest syndrome ACS in sickle cell disease SCD occurs in children less than 4 years old, and a history of ACS at this age is a risk factor for future ACS episodes.
However, the interval associated with the highest risk of subsequent ACS or severe pain is not known. A total of Abstract Intravenous immunoglobulin IVIG decreases neutrophil adhesion to endothelium and red blood cell-neutrophil interactions in sickle cell mice undergoing vaso-occlusion. There were no significant increases in neutrophil and leukocyte counts, suggesting that IVIG may more selectively inhibit Mac-1 function as opposed to neutrophil adhesion.
This study provides the first in-human validation of pre-clinical murine studies that IVIG can decrease Mac-1 function. Abstract Limited data exists regarding health care utilization HCU in patients receiving allogeneic hematopoietic cell transplantation alloHCT for sickle cell disease. Abstract Serial phlebotomy was performed on sixty children with sickle cell anaemia, stroke and transfusional iron overload randomized to hydroxycarbamide in the Stroke With Transfusions Changing to Hydroxyurea trial.
There were phlebotomy procedures with only 33 adverse events, all of which were grade 2. Abstract We developed a microfluidics-based model to quantify cell-level processes modulating the pathophysiology of sickle cell disease SCD. This in vitro model enabled quantitative investigations of the kinetics of cell sickling, unsickling, and cell rheology.
We created short-term and long-term hypoxic conditions to simulate normal and retarded transit scenarios in microvasculature. From these measurements, we identified two severe cases of SCD that were also independently validated as severe from a genotype-based disease severity classification. These results point to the potential of this method as a diagnostic indicator of disease severity. In addition, we investigated the role of cell density in the kinetics of cell sickling.
We observed an effect of HU therapy mainly in relatively dense cell populations, and that the sickled fraction increased with cell density. These results lend support to the possibility that the microfluidic platform developed here offers a unique and quantitative approach to assess the kinetic, rheological, and hematological factors involved in vasoocclusive events associated with SCD and to develop alternative diagnostic tools for disease severity to supplement other methods.
Such insights may also lead to a better understanding of the pathogenic basis and mechanism of drug response in SCD. Abstract Hemoglobin SC disease is a very prevalent hemoglobinopathy, however very little is known specifically about this condition. There appears to be an increased risk of thromboembolic events in hemoglobin SC disease, but studies evaluating the hemostatic alterations are lacking.
We describe a cross-sectional observational study evaluating coagulation activation markers in adult hemoglobin SC patients, in comparison with sickle cell anemia patients and healthy controls.
A total of 56 hemoglobin SC and 39 sickle cell anemia patients were included in the study, all in steady state, and 27 healthy controls. None of the patients were in use of hydroxyurea. Endothelial activation soluble thrombomodulin and soluble vascular cell adhesion molecule-1 , and inflammation tumor necrosis factor-alpha markers were both significantly elevated in hemoglobin SC patients when compared to controls, being as high as the levels seen in sickle cell anemia.
Overall, in hemoglobin SC patients, higher hemolytic activity and inflammation were associated with a more intense activation of coagulation, and hemostatic activation was associated with two very prevalent chronic complications seen in hemoglobin SC disease: In summary, our results demonstrate that hemoglobin SC patients present a hypercoagulable state, although this manifestation was not as intense as that seen in sickle cell anemia. J Pediatr Hematol Oncol.
Abstract Given the availability of various pain severity scales, greater understanding of the agreement between pain scales is warranted. The agreement between the 2 measures improved at increasing levels of pain severity. Blinder MA 1, Russel S 2. Over time, a number of risks have emerged, and among these are rare but catastrophic episodes of sudden death in athletes and other individuals associated with physical activities which is often described as exercise collapse associated with sickle trait ECAST.
Despite an epidemiologic link between SCT and sudden death as well as numerous case reports in both medical literature and lay press, no clear understanding of the key pathophysiologic events has been identified. Strategies for identification of individuals at risk and prevention of ECAST have been both elusive and controversial. Stakeholders have advocated for different approaches to this issue particularly with regard to screening for hemoglobin S. Furthermore, the recommendations and guidelines that are in place for the early recognition of ECAST and the prevention and treatment of the illness are not well defined and remain fragmented.
Among the cases identified, those in collegiate football players in the United States are often highlighted. This manuscript examines these case studies and the current recommendations to identify areas of consensus and controversy regarding recommendations for prevention, recognition and treatment of ECAST.
Extended red blood cell RBC antigen matching is recommended to limit alloimmunization in patients with sickle cell disease SCD. DNA-based testing to predict blood group phenotypes has enhanced availability of antigen-negative donor units and improved typing of transfused patients, but replacement of routine serologic typing for non-ABO antigens with molecular typing for patients has not been reported.
This study compared the historical RBC antigen phenotypes obtained by hemagglutination methods with genotype predictions in patients with SCD. Seventy-one typing discrepancies were identified among antigen comparisons 1. New specimens for repeat serologic testing were obtained for 66 discrepancies and retyping agreed with the genotype in 64 cases.
Fifteen false-negative serologic results were associated with alleles encoding weak antigens or single-dose Fyb expression. Vaso-occlusive pain, the hallmark of sickle cell disease SCD , is a major contributor to morbidity, poor health-related quality of life and healthcare utilization associated with this disease.
There is wide variation in the burden, frequency and severity of pain experienced by patients with SCD. As compared to healthcare utilization for pain, a daily pain diary captures the breadth of the pain experience and is a superior measure of pain burden and its impact on patients. Electronic pain diaries based on real time data capture methods overcome methodological barriers and limitations of paper pain diaries but their psychometric properties have not been formally established in patients with SCD.
To develop and establish the content validity of a web-based multi-dimensional pain diary for adolescents and young adults with SCD and conduct an end-user review to refine the prototype. Following identification of items, a conceptual model was developed. Interviews with adolescents and young adults with SCD were conducted. Subsequently, end-user review with use of the electronic pain diary prototype was conducted.
Two iterative cycles of in-depth cognitive interviews in adolescents and young adults with SCD informed the design and guided the addition, removal and modification of items in the multi-dimensional pain diary. Potential end-users provided positive feedback on the design and prototype of the electronic diary.
A multi-dimensional web-based electronic pain diary for adolescents and young adults with SCD has been developed and content validity and initial end-user reviews have been completed.
Advances in sickle cell therapies in the hydroxyurea era. Abstract In the hydroxyurea era, insights into mechanisms downstream of erythrocyte sickling have led to new therapeutic approaches for patients with sickle cell disease SCD. Therapies have been developed that target vascular adhesion, inflammation and hemolysis, including innovative biologics directed against P-selectin and invariant natural killer T cells.
Advances in hematopoietic stem cell transplant and gene therapy may also provide more opportunities for cures in the near future. Several clinical studies are underway to determine the safety and efficacy of these new treatments. Novel approaches to treat SCD are desperately needed, since current therapies are limited and rates of morbidity and mortality remain high. In the United States the most-striking increase in cancer mortality is seen in persons between the ages of 55 and A decline in cancer mortality in persons older than 75 simply reflects the lower number of persons in that population.
Age-adjusted death rates deaths per , population for specific types of tumours have changed significantly over the years. In , for the first time since data began being compiled, cancer deaths in the United States decreased almost 3 percent , and the declines continued through the first decade of the 21st century.
Worldwide, however, death rates from cancer were on the rise. In the United States and certain other developed countries, decreases in death rates from cancer can be attributed to successes of therapy or prevention. For example, a reduction in the number of deaths due to lung cancer has been attributed to warnings that have altered cigarette-smoking habits. Therapy has greatly lessened mortality from Hodgkin disease and testicular cancer , and it also has improved the chances of surviving breast cancer.
Preventive measures have played a major role in the decrease of cancer mortality as well. For example, colonoscopy, which is used to detect early asymptomatic cancers or premalignant growths polyps in the colon, has contributed to declines in death rates from colon cancer.
Routine Pap smear , an examination used to screen for carcinoma of the uterine cervix , has resulted in a downward trend in mortality observed for that disease. The identification of certain types of HPV as the causal agents of cervical cancer has improved cervical-cancer-screening programs by enabling samples obtained from asymptomatic women to be tested for the presence of harmful viral types that could later give rise to cancer.
The effectiveness of preventative measures for cervical cancer is thought to have been greatly increased by the availability of HPV vaccines such as Gardasil , which was approved for the immunization of young girls and boys prior to their becoming sexually active.
Striking differences in incidence and age-adjusted death rates of specific forms of cancer are seen in various parts of the world. For example, deaths caused by malignant melanoma , a cancer of the pigmented cells in the skin, are six times more frequent in New Zealand than in Iceland, a variation attributed to differences in sun exposure.
Most observed geographic differences probably result from environmental or cultural influences rather than from differences in the genetic makeup of separate populations. That view is illustrated by examining the differing incidences of stomach cancer that occur in Japanese immigrants to the United States, in Japanese-Americans born to immigrant parents, and in long-term resident populations of both countries.
Gastric cancer mortality rates are much higher in Japan than they are in California probably because of dietary and lifestyle differences. Rates for first-generation Japanese immigrants, on the other hand, are intermediate between those of native Japanese and native Californians, and mortality rates among descendants of Japanese immigrants approach those of the general Californian population with each passing generation.
Such observable trends clearly suggest that environmental and cultural factors play an important role in the causation of cancer. Exposure to high levels of carcinogens substances or forms of energy that are known to cause cancer—for instance, asbestos or ionizing radiation can occur in the workplace.
Occupational exposure can result in small epidemics of unusual cancers, such as an increase in angiosarcoma of the liver documented in among American workers who cleaned vinyl chloride polymerization vessels.
Likewise, dramatic increases of certain types of cancer, such as leukemia and thyroid cancer, have been detected in populations exposed to high doses of radiation associated with the malfunction of nuclear reactors.
The transition of cells through the different stages from normal to cancerous can be thought of as an evolutionary process, in which there occurs a succession of genetic changes that undergo selection and determine the ultimate genotype genetic constitution of a tumour and its metastases. Many benign tumours are encased in a well-formed capsule.
Malignant tumours, on the other hand, lack a true capsule and, even when limited to a specific location, invariably can be seen to have infiltrated surrounding tissues. The ability to invade adjacent tissues is a major characteristic that distinguishes malignant tumours from benign tumours.
A tumour mass is composed not only of abnormal tumour cells but also of normal host cells, which nourish the tumour, and immune cells, which attempt to react to the tumour. In some instances, tumour cells and cells in the tumour stroma cooperate or compete with one another, resulting in complex tumour behaviour. The rate of tumour growth is determined by comparing the excess of cell production with cell loss.
For a transformed tumour cell to produce a tumour of about one billion cells a mass that weighs about 1 gram [0. A tumour nodule can grow to only a certain diameter 1 to 2 millimetres [0. For tumour expansion to occur, new capillaries tiny blood vessels must form within the tumour—a process called vascularization, or angiogenesis. At some point, after months or even years as a harmless cluster of cells, tumours may suddenly begin to generate blood vessels. This occurs because they develop the ability to synthesize growth factors that specifically stimulate the formation of vessels.
Once they have begun to grow, tumours are able to sustain their own growth in a semi-independent fashion. This results from growth factors produced by the tumour cells themselves a self-stimulatory process called autocriny and by the stromal cells a process called paracriny. Cancer cells can be distinguished from normal cells, and even from benign tumour cells, by microscopic examination.
Differences in appearance include inconsistencies in size and shape and misshapen internal structures such as the nucleus , where genetic material is found. Genetic instability of the cell often gives rise to abnormal cells with giant nuclei that contain enormous amounts of DNA deoxyribonucleic acid. When those highly abnormal cells divide by mitosis , the number of chromosomes formed is abnormally elevated, and the mitotic figures the structures that help to coordinate the division of the chromosomes are often distorted.
Cancer cells also tend to be less-well-differentiated than normal cells, a characteristic that is called anaplasia.
When a malignant tumour no longer resembles the tissue of origin, it is said to be undifferentiated, or anaplastic. Most tumours take many years to grow and form to the point where they produce clinical manifestations. Laryngeal cancer , for instance, appears only after several years of constant exposure to alcohol and tobacco smoke—a behaviour shared by many common tumours caused by environmental conditions.
Careful studies of individuals with polyps of the colon benign tumours of the inner lining of the large intestine show that it takes three to five years for a new polyp to form and the same amount of time for the polyp to transform or progress into a carcinoma. Thus, when malignant tumours finally present with clinical manifestations, they are well into the last phase of their life. In some instances it is known that certain abnormal cellular changes precede cancer. Those alterations are collectively referred to as precancerous lesions.
A number of terms, such as hyperplasia , dysplasia , and neoplasia , are used to describe precancerous lesions. For example, endometrial hyperplasia increased cell growth in the endometrium, or inner lining of the uterus often precedes, and may even set the stage for, cancer of the endometrium.
Some clinical conditions are also known to be associated with an increased risk of carcinoma. Indeed, long-standing ulcerative colitis and leukoplakia of the oral cavity carry such an increase in risk that they are known as preneoplastic conditions for adenocarcinoma of the colon and squamous cell carcinoma of the mouth.
Throughout the extended period of time that it takes for cells to acquire the abnormal changes that lead to cancer, they transmit encoded information to their daughter cells. Ultimately, it is the accumulation of that information that is responsible for giving rise to the gene products that in turn cause the abnormal behaviour displayed by cancer cells.
In other words, the natural history of a tumour is similar to the natural history of an organism—both obey the tenets of evolutionary theory. Before tumours metastasize, or spread to other tissues of the body, they pass through a long period as noninvasive lesions. During that stage the earliest stage in which cancer is recognized as such the tumour remains in the anatomic site where it arose and does not invade beyond those confines.
An example of such a lesion might be a carcinoma that has arisen from an epithelial cell lining the uterine cervix; as long as this carcinoma is confined to the mucosal lining and has not penetrated the basement membrane, which separates the lining from other tissue layers, it is known as a noninvasive tumour or an in situ tumour.
A tumour at that stage lacks its own network of blood vessel s to supply nutrients and oxygen, and it has not sent cells into the circulatory system to give rise to new tumours. It also is usually asymptomatic—an unfortunate circumstance, because in situ tumours are curable. In the next stage of tumour progression, a solid tumour invades nearby tissues by breaching the basement membrane.
The basement membrane, or basal lamina, is a sheet of proteins and other substances to which epithelial cells adhere and that forms a barrier between tissues. Once tumours are able to break through this membrane, cancerous cells not only invade surrounding tissue substances but also enter the bloodstream—often via a lymphatic vessel, which discharges its contents into the blood. Tumour cells that have invaded a lymphatic vessel often become trapped in lymph nodes , whereas cells that gain access to blood vessels are disseminated to various parts of the body such as the bones , the lungs , and the brain.
At such distant sites cancer cells form secondary tumours, or metastases. That ability to metastasize is what makes cancer such a lethal disease. The primary tumour the original tumour growing at the site of origin usually can be controlled by available therapies, but it is the disseminated disease that eventually proves fatal to the host.
In order to disseminate throughout the body, the cells of a solid tumour must be able to accomplish the following tasks. They must detach from neighbouring cells, break through supporting membranes, burrow through other tissues until they reach a lymphatic or blood vessel, and then migrate through the lining of that vessel.
Next, individual cells or clumps of cells must enter the circulatory system for transport throughout the body. If they survive the journey through lymphatic vessels, veins , and arteries , they will eventually lodge in a capillary of another organ, where they may begin to multiply and form a secondary tumour. Laboratory researchers have intensively studied this process in the hope that insight into the mechanisms of metastasis will provide ways to devise effective therapies.
Each step has been individualized and studied, and mechanisms have been elucidated at the cellular and even the molecular level. Several of those mechanisms are described in this section. The formation of capillaries, or angiogenesis, is an important step that a tumour undergoes in its transition from a small harmless mass of cells to a life-threatening malignant tumour. When they first arise in healthy tissue, tumour cells are not able to stimulate capillary development.
At some point in their development, however, they call on proteins that stimulate angiogenesis, and they also develop the ability themselves to synthesize proteins with that capacity. One of those proteins is known as vascular endothelial growth factor VEGF. VEGF induces endothelial cells the building blocks of capillaries to penetrate a tumour nodule and begin the process of capillary development. As the endothelial cells divide, they in turn secrete growth factors that stimulate the growth or motility of tumour cells.
Thus, endothelial cells and tumour cells mutually stimulate each other. Cancer cells also produce another type of protein that inhibits the growth of blood vessels. It seems, therefore, that a balance between angiogenesis inhibitors and angiogenesis stimulators determines whether the tumour begins capillary development.
Evidence suggests that angiogenesis begins when cells decrease their production of the inhibiting proteins. Angiogenesis inhibitors are seen as promising therapeutic agents. The process of invasion begins when one cancer cell detaches itself from the mass of tumour cells. Normally, cells are cohesive and stick to one another by a series of specialized molecules. An important early step in cancer invasion appears to be the loss of this property, known as cellular adhesion. In many epithelial tumours it has been shown that cell-adhesion molecules such as E-cadherin , which helps to keep cells in place, are in short supply.
Another type of adhesion that keeps cells in place is their attachment to the extracellular matrix , the network of substances secreted by cells and found between them that helps to provide structure in tissues. Normally, if a cell is unable to attach to the extracellular matrix, it dies through induction of the cell suicide program known as apoptosis.
Cancer cells, however, develop a means to avoid death in that situation. In order to gain access to a blood or lymphatic channel, cancer cells must move through the extracellular matrix and penetrate the basement membrane of the vessel.
To do that, they must be able to forge a path through tissues, a task they perform with the aid of enzymes that digest the extracellular matrix. The cell either synthesizes those proteins or stimulates cells in the matrix to do so.
The breakdown of the extracellular matrix not only creates a path of least resistance through which cancer cells can migrate but also gives rise to many biologically active molecules—some that promote angiogenesis and others that attract additional cells to the site. Once in the bloodstream, tumour cells are disseminated to regions throughout the body. Eventually those cells lodge in capillaries of other organs and exit into those organs, where they grow and establish new metastases.
Not all the cancer cells within a malignant tumour are able to spread. Although all the cells in a tumour derive from a single cell, successive divisions give rise to a heterogeneous group of cancer cells, only some of which develop the genetic alterations that allow the cell to seed other tissues.
Of those cells that are able to break away from the parent tumour and enter the circulation, probably less than 1 in 10, actually ends up creating a new tumour at a distant site. Although the location and nature of the primary tumour determine the patterns of dissemination, many tumours spread preferentially to certain sites. This situation can be explained in part by the architecture of the circulatory system and the natural routes of blood flow.
For example, because the lungs are usually the first organ through which the blood flows after leaving most organs, they are the most-common site of metastasis. But circulation alone does not explain all cases of preferential spread. Clinical evidence suggests that a homing mechanism is responsible for some unlikely metastatic deposits. For example, prostate and breast cancers often disseminate first to the bone, and lung cancer often seeds new tumours in the adrenal glands.
That may occur because of an affinity that exists between receptor proteins on the surface of cancer cells and molecules that are abundant in the extracellular matrix of specific tissues.
In some instances, the circulating cells may even home back to the primary source, thus contributing to the growth of the primary tumour by reseeding. Because metastasis is such a biologically complex phenomenon, it is unlikely that a single genetic defect brings it about. It seems more reasonable to predict that a number of aberrant genes contribute to the process. Attempts to discover what genes are involved are ongoing and, it is hoped, will lead to new therapeutic approaches that halt tumour spread.
The signs and symptoms of benign or malignant tumours result for the most part from the local effects of either the primary tumour or its metastases. In some cases the primary tumour and the secondary metastases do not progress at the same pace, and in such an instance the primary tumour may manifest itself while the metastases do not cause symptoms and, as a result, go undetected for years. In addition to local effects, malignant neoplasms produce systemic effects such as body wasting cachexia and a variety of clinical manifestations known as paraneoplastic syndromes.
Both local and systemic effects are described in this section. Metastatic tumours those that result from the spread of the primary tumour can produce the same consequences. A tumour affects normal bodily functions by compressing, invading, and destroying normal tissues and also by producing substances that circulate in the bloodstream. The location of the tumour will determine how fast it manifests itself. Tumours arising in the deep soft tissues of the retroperitoneal space the area next to the kidney can grow very large before they produce discomfort.
On the other hand, a relatively small tumour in the lungs can produce partial obstruction of secondary airways and cause pneumonia , which can draw attention to the tumour at an early stage. The expansive growth of benign neoplasms or the more destructive growth of malignant tumours may erode natural surfaces and lead to the development of ulcers and bleeding and create conditions that favour infection. Tumours of the colon are indicated when small quantities of blood are found in the stools through an occult blood test.
Metastases growing in the adrenal gland , for instance, eventually can destroy the gland and produce adrenal insufficiency a condition called Addison disease. Sometimes the clinical manifestations of a tumour result from a malfunction in the tumour cell itself.
This is commonly seen in tumours of endocrine glands, whose cells produce excessive amounts of hormones. For example, benign tumours of the parathyroid gland called parathyroid adenomas oversecrete parathormone, which causes calcium levels in the blood to rise. Symptoms such as muscle weakness, fatigue , anorexia , nausea , and constipation are caused by the excess calcium levels. In the life of a tumour, acute accidents can produce dramatic symptoms. For example, ovarian cysts can rupture and produce immediate and severe abdominal discomfort.
Tumours growing freely in a cavity can become twisted and cut off the blood supply to the tumour. That interruption of blood flow can cause tissue death infarction , which may result in internal bleeding and cause intense pain for the individual. About 10 percent of persons with cancer have signs and symptoms that are not directly related to the location of a tumour or its metastases.
Effects that appear at a distance from the tumour are called paraneoplastic syndromes. Such symptoms may be the first manifestation of a small tumour and thus may allow early detection and treatment of the disease.
It is important that those symptoms not be confused with symptoms caused by advanced metastatic disease, as misdiagnosis can lead to inappropriate therapy.
Among the most-dramatic paraneoplastic syndromes are those mediated by abnormal hormone production. For example, small-cell carcinomas of the lung can produce excessive amounts of adrenocortical-stimulating hormone. The hormone is circulated in the bloodstream and acts at a distance from the tumour, stimulating the adrenal glands to oversecrete corticosteroids that in turn produces Cushing syndrome —characterized by such symptoms as muscle weakness, hypertension , and high levels of glucose in the blood.
Body wasting is a common systemic effect of malignant tumours, particularly at advanced stages of growth. It may appear with loss of appetite anorexia and weight loss. It is likely that a chemical mediator called tumour necrosis factor-alpha is one of the multiple molecules that bring about wasting effects.
This factor is produced by immune cells called macrophages and sometimes is secreted by tumour cells. Another common paraneoplastic manifestation is an increase in the clotting ability of the blood hypercoagulability. A number of abnormalities can result from the hypercoagulable state, including migratory thrombophlebitis , a recurrent inflammation and thrombosis of the veins. Many paraneoplastic syndromes that affect nervous and muscle functions are thought to be caused by autoimmune reactions that damage healthy tissue.
Such a reaction occurs when the immune system produces antibodies that react to an antigen e. If this tumour antigen closely resembles an antigen normally found on the surface of neurons or muscle cells, the antibodies can cross-react with these healthy cells, causing tissue damage. The autoimmune reaction described above is a negative effect of the immune response to cancer cells, but it does indicate that the body can mount a protective response to cancer.
Because foreign substances are usually dangerous to the body, the immune system is programmed to destroy them. This constant monitoring of the body for small tumours is known as immune surveillance. The immune system inhibits the formation of tumours in several ways.