Fungemia by Candida pelliculosa (Pichia anomala) in a Neonatal Intensive Care Unit: A Possible Clonal Origin

Neonatal candidemia can occur, however, infections caused by Candida pelliculosa are rare. Here, we describe an outbreak of candidemia caused by C. pelliculosa among babies hospitalized in a neonatal intensive care unit.     

Efficacy assessment of Candida oleophila (strain O) and Pichia anomala (strain K) against major postharvest diseases of citrus fruits in Morocco

Two yeasts, Candida oleophila (strain O) and Pichia anomala (strain K), were previously selected for their antagonistic activity against postharvest diseases on apples and pears. The objective of the study was to determine the efficacy of both antagonistic yeast's against wound postharvest pathogens of citrus fruits. The efficacy of both strains (applied at 10(5), 10(6) and 10(8) CFU/ml) was assessed against Penicillium digitatum and P. italicum inoculated after one hour (at a concentration of 10(5), 10(6) and 10(7) spores/ml) on citrus varieties 'clementine' and 'valencia-late'. Fruits were incubated for one week at 24 degrees C before measurement of lesion diameter. The protective levels were positively correlated with high concentration of antagonist and low concentration of pathogen. Highest protective levels (from 73 to 100%) were detected with the application of strain O or strain K at 10(8) CFU/ml whatever the pathogen (applied at 10(5) spores/ml) and the citrus variety. The antagonistic activity of both strains was also dependent on the incubation period before pathogen Inoculation. The protective level increased with time between application of the antagonist and inoculation of fungal spores. Whatever the yeast strain (10(8) CFU/ml). the protective level exceed 70% when wounded oranges were inoculated with P. digitatum or P. italicum (both at 10(6) spores/ml) 12 hours after yeast treatment. These protective levels reached 100% when the incubation period separating the antagonist application and the pathogenic inoculation was 24 hours. On the other hand, high protective levels (< 80%) were also observed against the sour rot decay on citrus variety 'clementine' caused by Geotrichum candidum inoculated at concentration of 10(6) spores/ml when strain O or strain K were applied at 10(8) CFU/ml 24 hours before pathogen. All these results support the potential practical application of both strains against major postharvest pathogens on citrus.     

Routine Paediatric Sickle Cell Disease (SCD) Outpatient Care in a Rural Kenyan Hospital: Utilization and Costs

Background

More than 70% of children with sickle cell disease (SCD) are born in sub-Saharan Africa where the prevalence at birth of this disease reaches 2% or higher in some selected areas. There is a dearth of knowledge on comprehensive care received by children with SCD in sub-Saharan Africa and its associated cost. Such knowledge is important for setting prevention and treatment priorities at national and international levels. This study focuses on routine care for children with SCD in an outpatient clinic of the Kilifi District Hospital, located in a rural area on the coast of Kenya.

Objective

To estimate the per-patient costs for routine SCD outpatient care at a rural Kenyan hospital.

Methods

We collected routine administrative and primary cost data from the SCD outpatient clinic and supporting departments at Kilifi District Hospital, Kenya. Costs were estimated by evaluating inputs - equipment, medication, supplies, building use, utility, and personnel - to reflect the cost of offering this service within an existing healthcare facility. Annual economic costs were similarly calculated based on input costs, prorated lifetime of equipment and appropriate discount rate. Sensitivity analyses evaluated these costs under different pay scales and different discount rate.

Results

We estimated that the annual economic cost per patient attending the SCD clinic was USD 138 in 2010 with a range of USD 94 to USD 229.

Conclusion

This study supplies the first published estimate of the cost of routine outpatient care for children born with SCD in sub-Saharan Africa. Our study provides policy makers with an indication of the potential future costs of maintaining specialist outpatient clinics for children living with SCD in similar contexts.     

The Physical Foundation of Vasoocclusion in Sickle Cell Disease

The pathology of sickle cell disease arises from the occlusion of small blood vessels because of polymerization of the sickle hemoglobin within the red cells. We present measurements using a microfluidic method we have developed to determine the pressure required to eject individual red cells from a capillary-sized channel after the cell has sickled. We find that the maximum pressure is only ∼100 Pa, much smaller than typically found in the microcirculation. This explains why experiments using animal models have not observed occlusion beginning in capillaries. The magnitude of the pressure and its dependence on intracellular concentration are both well described as consequences of sickle hemoglobin polymerization acting as a Brownian ratchet. Given the recently determined stiffness of sickle hemoglobin gels, the observed obstruction seen in sickle cell disease as mediated by adherent cells can now be rationalized, and surprisingly suggests a window of maximum vulnerability during circulation of sickle cells.Human capillaries are narrower than the erythrocytes they convey. In sickle cell disease, red cells can become rigid in those capillaries, because the hemoglobin inside the red cell will aggregate into stiff polymers. This happens once the molecules deliver their oxygen, and led to the long-held view that capillary occlusion was central to the pathophysiology of the disease (1,2). This was challenged when microscopic study of animal model tissues perfused with sickle blood revealed blockages that began further downstream, in the somewhat larger venules (3–5), at the site of adherent red or white cells which diminished the vessel lumen without fully obstructing the flow. Yet no rationale has been presented for the failure of the prior assumption of capillary blockage. Microfluidic methods (6) are ideally suited to discover why cells don’t get stuck in the capillaries, yet occlude subsequent vessels, and we have constructed a system to address this question. Our measurements show that the pressure differences across capillaries in vivo can easily dislodge a cell sickled within a capillary, giving an experimental answer to the question of why sickled cells don’t stick in capillaries. It turns out that the pressure a cell can withstand is quantitatively explained by the Brownian ratchet behavior of sickle hemoglobin polymerization.We constructed single-cell channels in transparent polydimethylsiloxane, with a cross section (1.5 μm × 4 μm) that is smaller than the resting diameter of red cells (Fig. 1). These channels are much narrower than those that have been employed in other recent studies of the sickling process (7,8), and they resemble human capillaries in permitting only one cell at a time to pass through them. We used a laser photolysis method to create ligand free (deoxygenated) cells, and this requires that the hemoglobin bind CO, which can then be readily removed by strong illumination, in contrast to bound O₂ which is released with far lower efficiency than CO. The microfluidic chips were enclosed in a gas-tight chamber flushed with CO to avoid introduction of oxygen and keep the cells fully ligated before photolysis. The profiles of the channels were confirmed by microscopic observation. To confirm that liquid did not pass around the cells when they were trapped in the channels, fluorescent beads were introduced into some cell solutions. The beads did not pass the cells, nor did they approach the cell when it was occluded, verifying that no significant flow occurred around the cell when it was stuck.Open in a separate windowFigure 1An erythrocyte enters a channel (moving left to right) and is positioned in the center, where it will be photolyzed. The channel cross section is 1.5 μm × 4 μm, smaller than a resting red cell diameter.Optical measurements were carried out on a microspectrophotometer constructed on an optical table. The system employed ×32 LWD objectives (Leitz, Wetzlar, Germany), which were autofocused during collection of absorption spectra to minimize aberrations. Spectra were obtained using a series 300 camera (Photometrics, Tucson, AZ); video imaging was done with a high-speed camera (Photron, San Diego, CA). Photolysis was provided by a 2020 Argon Ion laser (Spectra Physics, Houston, TX). Sickle cells were obtained from patients at the Marian Anderson Sickle Cell Center at St. Christopher''s Hospital for Children, Philadelphia, PA by phlebotomy into EDTA-containing tubes. The blood was centrifuged at 5°C at 1200g for 4 min, and then the pellet was washed 4× with 15 volumes of buffer (120 mM NaCl, 2 mM KCl, 10 mM dibasic Na Phosphate, 7 mM monobasic Na Phosphate, 3.4 mM Na Bicarbonate, and 6 mM Dextrose) by repeated suspension and centrifugation at 30g for 4 min. This minimizes fibrinogen and platelets in the final suspension, to insure that these studies are controlled by the mechanical properties of the cells themselves.Our experiment began by parking a cell in the center of a channel (Fig. 1). The cell, its hemoglobin, and the microchannel environment all were saturated with CO. Because the thickness of the channel is known, we were able to determine the hemoglobin concentration inside the cell from its absorption spectrum (Fig. 2 A). Steady-state laser illumination then removed the CO, allowing the hemoglobin to polymerize, in which condition it remained while the laser was kept on. Removal of CO was confirmed by observing the spectral difference between COHb and deoxyHb. Photolysis of COHb generates negligible heating (9–11). During illumination, hydrostatic pressure was applied until the cell broke free.Open in a separate windowFigure 2(A) Absorption of the cell (points), fit to a standard spectrum (9). (B) Pressure to dislodge a cell sickled in the microchannel, as a function of intracellular concentration. Note that typical intracellular concentrations are ∼32 g/dL. (Line) Brownian-ratchet theory described in the text. The coefficient of friction (0.036) is within the observed range, and is the only parameter varied.The magnitude of the dislodging pressure, measured by simple height difference between input and output cell reservoirs, is shown in Fig. 2 B. The pressure needed to dislodge the cell increased with increasing intracellular Hb concentration, implying that an increased mass of polymerized hemoglobin is more difficult to dislodge. A clear concentration threshold for capture is apparent. While there is a well-known solubility below which polymers cannot form (18.5 g/dL for the 22°C of this experiment (12)), the threshold here is significantly higher.Central to explaining these observations is a Brownian ratchet mechanism (13) which derives from the metastable nature of this polymerization process. Unless disrupted, as by centrifugation, polymerization in sickle hemoglobin terminates before the thermodynamic limit of monomer solubility is reached (14,15). This arises from the fact that polymers only grow at their ends, which are easily occluded in the dense mass of polymers that form. This end obstruction leaves the system in a metastable state and fluctuations accordingly provide polymers with space into which they can incrementally grow. This Brownian ratchet has been shown to lead to dramatic fiber buckling when individual fibers are isolated in sickle cells (16). The force can be simply expressed as f = (kT/δ) ln S(c), where k is Boltzmann’s constant, T the absolute temperature, δ the net spatial elongation from addition of a single monomer, and S is the supersaturation of the solution when the metastable limit is reached, at monomer concentration c. In this calculation, c is taken as the terminal concentration, computed from our empirical finding (15) that in this metastable system the amount of polymerized hemoglobin Δ is Δ(∞) = 2/3 (c_o-c_s), rather than the expected thermodynamic limit c_o-c_s, where c_o is the initial concentration and c_s is the solubility.For determining the net force, the total number of fibers must be known, and can be calculated based on the double nucleation mechanism (17) which has been quantitatively successful in describing polymerization. The concentration of polymers [p(t)] initially grows exponentially, described by[p(t)]=(AB2J)exp(Bt),where A and B are parameters related to nucleation, and J is the polymer elongation rate, as described in Ferrone et al. (17). Because A and B are both extremely concentration-dependent (9), they will drop dramatically once monomers begin to add to polymers in any significant numbers, and thereby diminish the remaining monomer pool. Thanks to the extreme concentration dependence of the reaction, this rapidly shuts off further polymerization. This happens at approximately the 10th time (the time when the reaction has reached 1/10 of its maximum). Thus, the [p(t_1/10)] ≈ [p(∞)]. Moreover, at one-tenth of the reaction,Δ(t1/10)=12Aexp(Bt1/10)=Δ(∞)10,and thus[p(∞)]=(BJ)(Δ(∞)10)=(BJ)((co−cs)15).For computing the number of fibers, the volume of the cell was taken as 90 μm³. This calculation shows, as expected, that the number of polymers in the cell is highly concentration-dependent, and very few fibers are produced at concentrations just above solubility, but the number grows sharply as concentration rises. This is the main contribution to the threshold in holding force shown by the data.With the force per fiber, and the total number of fibers, the net force against the wall is known. With a coefficient of friction, this reveals the force that a trapped cell can withstand. If the force is divided by the cross-sectional area across which the force is applied, we get a prediction of the dislodging pressure, which can be compared to the data. For a quantitative comparison with the results, two further corrections, of order unity, were applied. Because only normal force will contribute to friction, the calculated force was determined by integrating cos θ. This integration is not over all angles (π) because of the possibility that large incidence angles of the fibers against the wall will lead to fiber runaway (18). Therefore, the integration described is taken to the runaway threshold, here ∼1 rad. Finally, it is necessary to assign a coefficient of friction. Known values span the range of 0.03–0.06 (19). We therefore selected a value within the range, 0.036, as the best match for the data. The predicted pressures match the measurements well, as the line in Fig. 2 B shows.Because the flow resistance is comparable for red cells traversing glass channels and endothelial-lined capillaries (20), we conclude that in vivo the pressures a sickled cell inside a capillary can withstand are no more than hundreds of Pa. This is significantly smaller than typical arteriovenous pressure differentials that have been measured, which range from 0.7 kPa (in hamster skin (21)) to 7.9 kPa (in rat mesentery (22)).Our measurements coupled with recent determination of the stiffness of sickle hemoglobin gels (23) provide the missing physical basis for the processes of vasoocclusion seen in ex vivo tissue and animal models of sickle cell disease, arguing that these observations indeed represent fundamental behavior of sickle cell disease. We now understand this behavior in terms of three possible outcomes, all intimately connected with kinetics:

• 1.Certain escape: A cell that does not polymerize until after passing the obstruction can reach the lungs where it reoxygenates and resets its polymerization clock.
• 2.Possible escape: A cell that polymerizes within the capillary will assume an elongated sausage shape. The forces that it can exert against the wall cannot hold it there, and it will emerge into the postcapillary venule. There it has some chance of passing a subsequent obstruction, though it might also obstruct flow were it to rotate before reaching the adherent cell, so as to present its long dimension to the reduced space it must traverse.
• 3.Certain occlusion: A cell that does not polymerize in the capillary reassumes a larger diameter as soon as it escapes. If the cell then polymerizes before it encounters a cell attached to the venule wall, this rigidified cell will not be able to squeeze past the adherent cell, because that kind of deformation takes MPa (23). This would precipitate the type of blockage that is observed. This suggests that there is a window of greatest vulnerability, toward which therapies might be addressed.

     

Urinary Bladder Dysfunction in Transgenic Sickle Cell Disease Mice

Background

Urological complications associated with sickle cell disease (SCD), include nocturia, enuresis, urinary infections and urinary incontinence. However, scientific evidence to ascertain the underlying cause of the lower urinary tract symptoms in SCD is lacking.

Objective

Thus, the aim of this study was to evaluate urinary function, in vivo and ex vivo, in the Berkeley SCD murine model (SS).

Methods

Urine output was measured in metabolic cage for both wild type and SS mice (25-30 g). Bladder strips and urethra rings were dissected free and mounted in organ baths. In isolated detrusor smooth muscle (DSM), relaxant response to mirabegron and isoproterenol (1nM-10μM) and contractile response to (carbachol (CCh; 1 nM-100μM), KCl (1 mM-300mM), CaCl₂ (1μM-100mM), α,β-methylene ATP (1, 3 and 10 μM) and electrical field stimulation (EFS; 1-32 Hz) were measured. Phenylephrine (Phe; 10nM-100μM) was used to evaluate the contraction mechanism in the urethra rings. Cystometry and histomorphometry were also performed in the urinary bladder.

Results

SS mice present a reduced urine output and incapacity to produce typical bladder contractions and bladder emptying (ex vivo), compared to control animals. In DSM, relaxation in response to a selective β3-adrenergic agonist (mirabegron) and to a non-selective β-adrenergic (isoproterenol) agonist were lower in SS mice. Additionally, carbachol, α, β-methylene ATP, KCl, extracellular Ca²⁺ and electrical-field stimulation promoted smaller bladder contractions in SS group. Urethra contraction induced by phenylephrine was markedly reduced in SS mice. Histological analyses of SS mice bladder revealed severe structural abnormalities, such as reductions in detrusor thickness and bladder volume, and cell infiltration.

Conclusions

Taken together, our data demonstrate, for the first time, that SS mice display features of urinary bladder dysfunction, leading to impairment in urinary continence, which may have an important role in the pathogenesis of the enuresis and infections observed the SCD patients.     

Identification of Fusarium from a Patient with Fungemia after Multiple Organ Injury

Fusarium is a filamentous fungus widely distributed in nature, which is an important opportunistic pathogen and could cause fusariosis both in plants and animals. In human, Fusarium could cause local and disseminated infections both in immunocompetent and immunocompromised patients. We describe here a case of a male patient suffered from multiple organ injury, whose blood fungal culture was positive. The isolate was confirmed as “Fusarium solani” according to the morphology of the fungus and the results of phenotypic and molecular identification.     

Placenta Growth Factor (PlGF), a Novel Inducer of Plasminogen Activator Inhibitor-1 (PAI-1) in Sickle Cell Disease (SCD)

Sickle cell disease (SCD) is characterized by a prothrombotic state. Plasminogen activator inhibitor-1 (PAI-1) is known to modulate fibrinolysis, lung injury/fibrosis, and angiogenesis. However, its role in SCD is less understood, and the molecular mechanisms underlying increased PAI-1 are unknown. Herein, we show a novel link between PAI-1 and sickle erythropoiesis. Plasma PAI-1 levels were high in SCD patients at steady state and in two humanized sickle mouse models, with increased PAI-1 immunolabeling in sickle mouse lung, bronchial epithelial cells, alveolar macrophages, and pulmonary microvascular endothelial cells. Placenta growth factor (PlGF), released at high levels by sickle erythroblasts, induced PAI-1 expression in primary human pulmonary microvascular endothelial cells and monocytes through activation of c-Jun N-terminal kinase (JNK), NADPH oxidase, and hypoxia-inducible factor-1α (HIF-1α). Analysis of the human PAI-1 promoter revealed this induction was mediated by hypoxia-response element (HRE)-1, HRE-2, and distal activator protein (AP-1) sites. We also identify the involvement of c-Jun, c-Jun/c-Fos, and JunD, but not JunB, in binding with AP-1 sites of the PAI-1 promoter upon PlGF induction. Consistent with these findings, levels of PAI-1 were low in PlGF knock-out mice and sickle-PlGF knock-out mice; overexpression of PlGF in normal mice increased circulating PAI-1. In conclusion, we identify a novel mechanism of PAI-1 elevation in SCD.     

Characterization of two different toxins of Wickerhamomyces anomalus (Pichia anomala) VKM Y-159

Wickerhamomyces anomalus VKM Y-159 strain produces two types of toxin designated as WAKT a and WAKT b, encoded by chromosomal genes. The WAKT a toxin is heat-labile, pronase sensitive acting in pH range 3-4 affecting on several yeasts including pathogenic Candida species while the WAKT b toxin is protease- and thermo-resistant, acting in pH range 3-7 on two species, Candida alai and Candida norvegica. The rapid decrease of the number of viable cells after toxin treatment demonstrates that both toxins have cytocidic effect.     

Severe Nocturnal and Postexercise Hypoxia in Children and Adolescents with Sickle Cell Disease

Hypoxia is a common feature in children with sickle cell disease (SCD) that is inconsistently associated with painful crises and acute chest syndrome. To assess the prevalence and risk factors of hypoxia, we recorded daytime, nocturnal, and postexercise pulse oximetry (SpO₂) values in 39 SCD patients with a median age of 10.8 years. Median daytime SpO₂ was 97% (range, 89%–100%), and 36% of patients had daytime hypoxia defined as SpO₂<96%. Median nocturnal SpO₂ was 94.7% (range, 87.7%–99.5%), 50% of patients had nocturnal hypoxia defined as SpO₂≤93%, and 11(37%) patients spent more than 10% of their total sleep time with SpO₂<90%. Median postexercise SpO₂ was 94% (range, 72%–100%) and 44.7% of patients had postexercise hypoxia defined as an SpO₂ decrease ≥3% after a 6-minute walk test. Among patients with normal daytime SpO₂, 35% had nocturnal and 42% postexercise hypoxia. Compared to 9 patients without daytime, nocturnal, or postexercise hypoxia, 25 patients with hypoxia under at least one of these three conditions had greater anemia severity (P = 0.01), lower HbF levels (P = 0.04), and higher aspartate aminotransferase levels (P = 0.03). Males predominated among patients with postexercise hypoxia (P = 0.004). Hypoxia correlated neither with painful crises nor with acute chest syndrome. Of 32 evaluable patients, 6 (18.8%) had a tricuspid regurgitation velocity ≥2.6 m/s, and this feature was associated with anemia (P = 0.044). Median percentage of the predicted distance covered during a 6-minute walk test was 86% [46–120]; the distance was negatively associated with LDH (P = 0.044) and with a past history of acute chest syndrome (P = 0.009). In conclusion, severe episodes of nocturnal and postexercise hypoxia are common in children with SCD, even those with normal daytime SpO₂.     

Somatic Cell and Sperm Cell Cytogenetics in a Patient with t(14; 21)

Approximately 15%-20% of clinically recognizable pregnancies end in spontaneous abortion. About half of the spontaneous abortions in the early stage of the pregnancy are due to chromosomal abnormalities. Using GTG chromosome banding and dual-color fluorescence in situ hybridization (FISH) techniques, we determined the cytogenetic aberration in the husband of a couple with spontaneous recurrent abortions. Karyotype analysis showed 46, XX in the wife and 45, XY, −14, −21, +t(14; 21) in the husband. We studied the mechanism of formation of the abnormal chromosome with Robertsonian translocation between chromosomes 14 and 21 by FISH and flow cytometric sorting in the sperm cells. The result showed that 71% of the gametes were balanced and the remaining 29% were not. As a result, the couple was given genetic counseling.     

t(14;21)平衡易位携带者体细胞和生殖细胞的细胞遗传学研究

15%-20%的妊娠因为自发流产而中止,其中约50%是因为染色体异常所致.夫妇中的一方为平衡的染色体异常携带者时,即可能产生不平衡的配子和胚胎,临床症状可以有不同程度的变化：如不育、反复流产、甚至产出染色体综合症的患儿.以临床接诊的一对具有反复自然流产史夫妇为研究对象,常规进行精液、激素水平检测.取患者外周血淋巴细胞用RPMI 1640培养基进行短期培养,经低渗、固定处理制备染色体标本片,对染色体数目和结构进行核型分析.选用特异的21qter和14qter DNA标记作为探针,对患者外周血淋巴细胞中期染色体进行FISH分析.运用FISH技术对患者精子细胞进行研究,配合流式细胞分析技术对精细胞DNA组份进行检测,分析配子中遗传物质的组成及各种类型配子的比例.结果发现女方核型正常为46,XX,男方核型为罗伯逊易位的携带者45,XY-14,-21,＋t（14;21）.患者外周血体细胞的分裂相染色体FISH显示一个细胞中分别存在1个红色的21qter和1个绿色的14qter杂交信号,另外有1个红色和1个绿色信号共同存在于一条由易位形成的亚中着丝粒染色体上.在患者精液样本的精细胞FISH研究中,可以观察到5种不同类型的杂交信号,异常的配子的种类与理论推断相同,但各型所占的比例有其特点,结合精液中精细胞流式细胞术的分析表明,平衡的单倍体配子占71%,不平衡的配子占29%.通过国内外文献资料统计,对罗伯逊易位染色体的常见和罕见类型进行综述,为其生育的临床治疗方案提供建议.     

In vitro susceptibilities of Candida spp. to Panomycocin, a novel exo-beta-1,3-glucanase isolated from Pichia anomala NCYC 434

Panomycocin, the killer toxin of Pichia anomala NCYC 434 (K5), is a 49 kDa monomeric glycoprotein with exo-beta-1,3-glucanase activity (patent pending). In this study we evaluated the in vitro activity of panomycocin against a panel of 109 human isolates of seven different pathogenic Candida spp. using microdilution and time-kill methods. Panomycocin was most active against C. tropicalis, C. pseudotropicalis and C. glabrata with MIC(90) values of 1 microg/ml. It displayed significant activity against C. albicans and C. parapsilosis with MIC(90) values of 4 and 2 microg/ml, respectively. For C. krusei, the MIC(90) value was 8 microg/ml. Panomycocin was fungicidal against all the tested Candida spp. The MFC values were only one or 2 dilutions higher than the MICs with the exception of C. krusei isolates with MFCs greater than or equal to 4xMIC. Results of this study indicated that panomycocin could be considered as a natural antifungal agent against Candida infections and has significant potential for further investigation.     

Coagulation Activation in Children with Sickle Cell Disease Is Associated with Cerebral Small Vessel Vasculopathy

Background

Thrombotic complications in Sickle Cell Disease (SCD) arise since infancy, but the role of the coagulation system in children has been poorly explored. To determine its role in the development of clinical complications in childhood we measured coagulation and endothelial parameters in children with SCD at steady state.

Methods

Markers of thrombin generation, fibrin dissolution and endothelial activation were evaluated in 38 children with SS-Sβ°, 6 with SC disease and 50 age and blood group matched controls. Coagulation variables were correlated with markers of hemolysis and inflammation, with the presence of cerebral and lung vasculopathy and with the frequency of clinical complications.

Results

SS-Sβ° patients presented higher levels of factor VIII, von Willebrand factor antigen (VWF:Ag) and collagen binding activity, tissue plasminogen activator antigen (t-PA:Ag), D-dimer, p-selectin, prothrombin fragment1+2 (F1+2) and lower ADAMTS-13:activity/VWF:Ag (p<0.05) compared to controls and SC patients. In SS-Sβ° patients coagulation variables correlated positively with markers of inflammation, hemolysis, and negatively with HbF (p<0.05). Patients with cerebral silent infarcts showed significant decrease in t-PA:Ag and ADAMTS-13 Antigen and a tendency toward higher D-dimer, F1+2, TAT compared to patients without them. D-dimer was associated with a six fold increased risk of cerebral silent infarcts. No correlation was found between coagulation activation and large vessel vasculopathy or other clinical events except for decreased t-PA:Ag in patients with tricuspid Rigurgitant Velocity >2.5m/sec.

Conclusions

SS-Sβ° disease is associated with extensive activation of the coagulation system at steady state since young age. ADAMTS-13 and t-PA:Ag are involved in the development of cerebral silent infarcts.     

Elevated Pulse Pressure is Associated with Hemolysis,Proteinuria and Chronic Kidney Disease in Sickle Cell Disease

A seeming paradox of sickle cell disease is that patients do not suffer from a high prevalence of systemic hypertension in spite of endothelial dysfunction, chronic inflammation and vasculopathy. However, some patients do develop systolic hypertension and increased pulse pressure, an increasingly recognized major cardiovascular risk factor in other populations. Hence, we hypothesized that pulse pressure, unlike other blood pressure parameters, is independently associated with markers of hemolytic anemia and cardiovascular risk in sickle cell disease. We analyzed the correlates of pulse pressure in patients (n  =  661) enrolled in a multicenter international sickle cell trial. Markers of hemolysis were analyzed as independent variables and as a previously validated hemolytic index that includes multiple variables. We found that pulse pressure, not systolic, diastolic or mean arterial pressure, independently correlated with high reticulocyte count (beta  =  2.37, p  =  0.02) and high hemolytic index (beta  =  1.53, p = 0.002) in patients with homozygous sickle cell disease in two multiple linear regression models which include the markers of hemolysis as independent variables or the hemolytic index, respectively. Pulse pressure was also independently associated with elevated serum creatinine (beta  =  3.21, p  =  0.02), and with proteinuria (beta  =  2.52, p  =  0.04). These results from the largest sickle cell disease cohort to date since the Cooperative Study of Sickle Cell Disease show that pulse pressure is independently associated with hemolysis, proteinuria and chronic kidney disease. We propose that high pulse pressure may be a risk factor for clinical complications of vascular dysfunction in sickle cell disease. Longitudinal and mechanistic studies should be conducted to confirm these hypotheses.     

Candidate Sequence Variants and Fetal Hemoglobin in Children with Sickle Cell Disease Treated with Hydroxyurea

Background

Fetal hemoglobin level is a heritable complex trait that strongly correlates swith the clinical severity of sickle cell disease. Only few genetic loci have been identified as robustly associated with fetal hemoglobin in patients with sickle cell disease, primarily adults. The sole approved pharmacologic therapy for this disease is hydroxyurea, with effects largely attributable to induction of fetal hemoglobin.

Methodology/Principal Findings

In a multi-site observational analysis of children with sickle cell disease, candidate single nucleotide polymorphisms associated with baseline fetal hemoglobin levels in adult sickle cell disease were examined in children at baseline and induced by hydroxyurea therapy. For baseline levels, single marker analysis demonstrated significant association with BCL11A and the beta and epsilon globin loci (HBB and HBE, respectively), with an additive attributable variance from these loci of 23%. Among a subset of children on hydroxyurea, baseline fetal hemoglobin levels explained 33% of the variance in induced levels. The variant in HBE accounted for an additional 13% of the variance in induced levels, while variants in the HBB and BCL11A loci did not contribute beyond baseline levels.

Conclusions/Significance

These findings clarify the overlap between baseline and hydroxyurea-induced fetal hemoglobin levels in pediatric disease. Studies assessing influences of specific sequence variants in these and other genetic loci in larger populations and in unusual hydroxyurea responders are needed to further understand the maintenance and therapeutic induction of fetal hemoglobin in pediatric sickle cell disease.     

An Experimental-Computational Approach to Quantify Blood Rheology in Sickle Cell Disease

In sickle cell disease, aberrant blood flow due to oxygen-dependent changes in red cell biomechanics is a key driver of pathology. Most studies to date have focused on the potential role of altered red cell deformability and blood rheology in precipitating vaso-occlusive crises. Numerous studies, however, have shown that sickle blood flow is affected even at high oxygen tensions, suggesting a potentially systemic role for altered blood flow in driving pathologies, including endothelial dysfunction, ischemia, and stroke. In this study, we applied a combined experimental-computation approach that leveraged an experimental platform that quantifies sickle blood velocity fields under a range of oxygen tensions and shear rates. We computationally fitted a continuum model to our experimental data to generate physics-based parameters that capture patient-specific rheological alterations. Our results suggest that sickle blood flow is altered systemically, from the arterial to the venous circulation. We also demonstrated the application of this approach as a tool to design patient-specific transfusion regimens. Finally, we demonstrated that patient-specific rheological parameters can be combined with patient-derived vascular models to identify patients who are at higher risk for cerebrovascular complications such as aneurysm and stroke. Overall, this study highlights that sickle blood flow is altered systemically, which can drive numerous pathologies, and this study demonstrates the potential utility of an experimentally parameterized continuum model as a predictive tool for patient-specific care.     

Phase 1 Study of a Sulforaphane-Containing Broccoli Sprout Homogenate for Sickle Cell Disease

Sickle cell disease (SCD) is the most common inherited hemoglobinopathy worldwide. Our previous results indicate that the reduced oxidative stress capacity of sickle erythrocytes may be caused by decreased expression of NRF2 (Nuclear factor (erythroid-derived 2)-like 2), an oxidative stress regulator. We found that activation of NRF2 with sulforaphane (SFN) in erythroid progenitors significantly increased the expression of NRF2 targets HMOX1, NQO1, and HBG1 (subunit of fetal hemoglobin) in a dose-dependent manner. Therefore, we hypothesized that NRF2 activation with SFN may offer therapeutic benefits for SCD patients by restoring oxidative capacity and increasing fetal hemoglobin concentration. To test this hypothesis, we performed a Phase 1, open-label, dose-escalation study of SFN, contained in a broccoli sprout homogenate (BSH) that naturally contains SFN, in adults with SCD. The primary and secondary study endpoints were safety and physiological response to NRF2 activation, respectively. We found that BSH was well tolerated, and the few adverse events that occurred during the trial were not likely related to BSH consumption. We observed an increase in the mean relative whole blood mRNA levels for the NRF2 target HMOX1 (p = 0.02) on the last day of BSH treatment, compared to pre-treatment. We also observed a trend toward increased mean relative mRNA levels of the NRF2 target HBG1 (p = 0.10) from baseline to end of treatment, but without significant changes in HbF protein. We conclude that BSH, in the provided doses, is safe in stable SCD patients and may induce changes in gene expression levels. We therefore propose investigation of more potent NRF2 inducers, which may elicit more robust physiological changes and offer clinical benefits to SCD patients.Trial Registration: ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01715480","term_id":"NCT01715480"}}NCT01715480