Little has been published about long-acting opioid (LAO) versus short-acting opioid (SAO) use for pain in sickle cell disease (SCD), which is often chronic. We report on home LAO versus SAO use among a cohort of SCD adults (n=219) who completed daily pain diaries for up to 6 months and had at least one home pain day. We measured daily use of any opioids, LAO, SAO, other analgesics, adjuvants, and pain intensity (0-9 Likert scale), as well as pain frequency (0-100% of days), hydroxyurea (HU) use and avascular necrosis (AVN). Eighty-five patients (38.8%) used LAO ± SAO, and 103 (47.0%) used SAO only. Twenty-one (9.6%) patients used only other analgesics, and 10 (4.6%) used none. Morphine and oxycodone were the most commonly used LAO and SAO, respectively. Compared to SAO only users, LAO users had higher pain intensity (4.8 ±1.5 vs 4.1 ±1.4, p<0.0001) and frequency (81.9 ±25.4% vs 51.9 ±35.3%, p<0.0001). Controlled for pain, HU use was more likely among opioid users than non-users (OR=14.17, CI 1.81-109.69), and among LAO users than SAO users (OR=2.16, CI 1.06-4.38). Controlled for pain, LAO users were more likely to have AVN (p=0.0271). Patients age 25-45 were more likely to be LAO users (p=0.03), but not after controlling for pain. Opioid users with AVN and older users used opioids more frequently (p<.05), but not after controlling for pain. We conclude LAO were used by nearly 40% of SCD adults, and SAO only by >40%. Pain and disease severity variables often correlate with opioid use and LAO use in SCD.

Little is published about the relationship of daily opioid use in sickle cell disease (SCD) to pain and psychosocial health. We report among cohort of SCD adults (n=219) who completed daily pain diaries for up to 6 months and had at least one home pain day, the relationship between daily home opioid use, controlled for daily pain intensity (Likert scale 0-9), and psychosocial variables. We measured use of long- or short-acting opioids, other analgesics, or adjuvants, the proportion of home days, home pain days, and home crisis days with opioid use, and these two outcomes according to patient characteristics. Patients used opioids on 12,311 (78%) of 15,778 home pain days. Compared to non-users, opioid users reported higher daily pain intensity (3.04 ± 2.10 vs 0.39 ± 0.66, p<0.0001), and pain frequency (65.5% vs 15.3%, p<0.0001). Significant relationships were found between any opioid use and: somatic symptom burden, SCD stress, negative coping, and physical and mental quality of life (QOL), but not depression/anxiety or alcoholism. The relationship with SCD stress and physical QOL remained when controlled for mean pain. Similar associations were found between frequency of opioid use among users and somatic symptom burden, active coping, positive coping, and physical QOL. We conclude that opioids were used on the majority of home days for these adults with SCD, and use was associated with psychosocial variables, even when controlled for pain. Cognitive-behavioral therapy in SCD could target these variables. Little is published about the relationship of daily opioid use in sickle cell disease (SCD) to pain and psychosocial health. We report among cohort of SCD adults (n=219) who completed daily pain diaries for up to 6 months and had at least one home pain day, the relationship between daily home opioid use, controlled for daily pain intensity (Likert scale 0-9), and psychosocial variables. We measured use of long- or short-acting opioids, other analgesics, or adjuvants, the proportion of home days, home pain days, and home crisis days with opioid use, and these two outcomes according to patient characteristics. Patients used opioids on 12,311 (78%) of 15,778 home pain days. Compared to non-users, opioid users reported higher daily pain intensity (3.04 ± 2.10 vs 0.39 ± 0.66, p<0.0001), and pain frequency (65.5% vs 15.3%, p<0.0001). Significant relationships were found between any opioid use and: somatic symptom burden, SCD stress, negative coping, and physical and mental quality of life (QOL), but not depression/anxiety or alcoholism. The relationship with SCD stress and physical QOL remained when controlled for mean pain. Similar associations were found between frequency of opioid use among users and somatic symptom burden, active coping, positive coping, and physical QOL. We conclude that opioids were used on the majority of home days for these adults with SCD, and use was associated with psychosocial variables, even when controlled for pain. Cognitive-behavioral therapy in SCD could target these variables.

Graft versus host disease (GVHD) is a major cause of morbidity and mortality after allogeneic hematopoietic cell transplant (HCT). Extracorporeal photopheresis (ECP) has been used successfully in the treatment of steroid refractory GVHD. Our center first used ECP for GVHD in 1999. Our protocol for treatment of cutaneous GVHD is ECP two days per week every other week for three months then reevaluate. If GVHD is improving, the frequency of treatment would be reduced to two days per month. For visceral GVHD, ECP treatment would be given three days per week every other week for three months and then reassess and taper as above. We currently use vortex ports (AngioDynamics, Latham, NY) for long term access in our HCT patients and we hypothesize that it is possible to perform ECP using vortex ports in patients with steroid refractory GVHD and that the use of the port instead of external catheters or venopuncture will improve quality of life for these patients. Patients who received at least one ECP treatment for treatment of steroid refractory GVHD at our center between 1/1/07 and 9/30/10 were included (n = 47). During that time our center performed 1632 ECP procedures for treatment of GVHD including 552 procedures after vortex port placement in 19 patients. Fifteen patients completed 100% of their ECP procedures with the vortex port after it was placed. These patients had a total of 400 procedures with a range of 6-51 procedures and a mean of 26.7 per patient. Four patients had some of their procedures done with the port but required another access method for 19 procedures. These patients had a total of 133 procedures with a range of 27-36 and a mean 33.25 per patient. Of the patients that did not use the vortex port 100% of the time, one had an uncomplicated line infection, one preferred IV access to port use, one had anatomic issues with port placement, and one had access to the port impaired by scleroderma. Overall, 97% (533/552) of ECP procedures performed in patients with a vortex port were completed using the port. Therefore, we conclude that the use of the vortex port for ECP patients with steroid refractory GVHD is feasible. Future studies are needed to evaluate infection rate, bleeding risk, and quality of life in these patients compared with those receiving ECP with external catheters or venopuncture particularly in patients with sclerodermatous cutaneous GVHD.

Study Objective: To establish the utility of selective tubal infusion of a saline-air mixture for sonographic identification of tubal patency (selective sonohysterosalpingography (SSHS)), including uterine cavity demonstration using the FemVue Catheter. Design: Multicenter prospective observation of twenty-three female volunteers (45 tubes) undergoing SSHS by FemVue in a single procedure. Setting: Seven sites in outpatient offices of various practice types (university and private obstetrics and gynecology practices, and infertility centers). Patients: Seventeen women (74%) with infertility and six women with unknown fertility. Intervention: Transcervical placement of the FemVue™ Catheter (Femasys Inc.) and infusion of sterile saline for sonohysterography followed by sequential advancement to each cornua under ultrasound guidance. The FemJect™ Saline-Air Device (Femasys Inc.) was then attached to the FemVue Catheter and a continuous sterile saline-air train was delivered to each tube during sonographic observation with video recording. Measurements and Main Results: The FemVue Catheter was used for a standard sonohysterogram, then advanced to each cornua in turn. The balloon was observed to be correctly positioned at the cornuas in all twenty-three patients allowing for the saline-air contrast to enter one tube at a time. Sonographic criteria for tubal patency were met by 89% (40/45) of the tubes, namely, sonographic observation of bubbles entering the fallopian tube combined with either sustained tube flow without production of a hydrosalpinx or exit of bubbles into the peritoneal cavity. Conclusion: The FemVue Catheter and FemJect Saline-Air Device allows sonographic determination of selective tubal patency in the outpatient office. This method allows complete sonographic assessment of the pelvic organs as well as specific demonstration of all the reproductive lumens in one office visit. This eliminates the need for an HSG referral, the use of synthetic chemical contrast agents, and exposure to radiation.

Introduction: Bronchiolitis obliterans (BO) is a serious, often fatal complication of allogeneic stem cell transplantation (SCT). Most patients do not respond to conventional immunosuppressive therapy. We retrospectively reviewed records of patients with BO treated with extracorporeal photopheresis (ECP), given its efficacy in managing chronic corticosteroid refractory cutaneous, oral, and hepatic graft versus host disease (GVHD). Patients and Methods: Forty two patients were treated at our center for chronic GVHD with ECP from 2003–2007. Thirteen patients (31%) met diagnostic criteria for BO defined as the presence of pulmonary symptoms, hypoxemia and one of the following 1) decrease in FEV1 by >20% or 2) air-trapping, small airway thickening or bronchiectasis on lung CT without evidence of an infection. ECP was performed on 2 consecutive days every 2 weeks for the first 4 months and less frequently thereafter. Results: Nine of thirteen patients met criteria due to decrease in FEV1 and lung changes on CT; 4 due to radiographic findings alone. ECP was initiated at a median of 954 days (range, 173–2122 days) after allogeneic SCT (11 matched related donors, 2 unrelated donors). All but one patient had failed prior corticosteroid-based immunosuppressive therapy. With a median follow-up of 782 days from diagnosis of BO, 11/13 (85%) of the patients are alive. Seven of thirteen (54%) patients had a 50% decrease in steroid dosage without deterioration of pulmonary function; 3/13 (23%) patients had improvement of radiographic abnormalities; 4/7 (57%) patients with oxygen requirements prior to initiation of ECP were completely titrated off oxygen. No patients had a decline in pulmonary function tests despite steroid withdrawal. Only 3 patients experienced grade III or higher adverse events related to the indwelling catheter (3 infectious, 1 bleeding and 2 thromboses). Two of thirteen patients died, one due to progression of BO and 1 from pneumonia. Our observed survival rate of 85% in patients with BO is in contrast to the 44–73% survival rate noted in prior studies using treatment with conventional immunosuppressive therapy. Conclusion: In this retrospective study, we demonstrate the feasibility of using ECP to manage BO occurring after allogeneic SCT. ECP should be considered as early second-line therapy in patients developing BO following SCT; however, further study is warranted to confirm these results.

OBJECTIVES:Hemolysis is a significant complication of extracorporeal membrane oxygenation (ECMO), with a reported incidence of 12.2%. The aims of this study were (1) to investigate hemolysis caused by saline-washed versus unwashed RBCs, (2) to determine in vitro the effects of saline washing on erythrocyte hemolytic markers and (3) to investigate hemolysis by centrifugal versus roller pumps.STUDY DESIGN:(1) To evaluate the effect of pre-transfusion saline-washing versus non-washing, the peak plasma-free hemoglobin (FHb) and total bilirubin in the first 3 days versus the next 4 days of ECMO were compared (2) Pre- and postsaline-washed RBCs were analyzed for K+ hemoglobin, mean corpuscular volume, FHb and hemolysis at baseline and after 4 h of storage at 4 degrees C. (3) Over 10 000 neonatal ECMO cases were retrospectively reviewed to study the effect of pump type on hemolysis.RESULTS:(1) The washed blood group had significantly more hemolysis within the first 3 days of ECMO. (2) Immediately after saline washing, the K+ and Hb concentrations were significantly decreased compared with unwashed blood, and these differences were maintained after 4 h. The osmotic fragility of washed RBCs after 4 h of storage at 4 degrees C was significantly higher than at baseline. (3) Hemolysis was reported more often in the centrifugal than in the roller pump group.CONCLUSIONS:(1) Using unwashed RBCs decreased hemolysis within the first 3 days of ECMO. (2) Saline washing, while decreasing the concentration of K+ in the plasma, significantly increases RBC membrane osmotic fragility. (3) Hemolysis is linked to the use of centrifugal pumps.