Social and Psychological Factors Associated With Health Care Transition for Young Adults Living With Sickle Cell Disease.

Introduction: Due to advances in disease management, mortality rates in children with sickle cell disease (SCD) have decreased. However, mortality rates for young adults (YA) increased, and understanding of social and psychological factors is critical. The aim of this study was to explore factors associated with health care transition experiences for YA with SCD. Method: This was a qualitative descriptive study. A 45-minute semistructured interview was conducted with 13 YA (M = 21.5 years, SD = 1.73). Results: Results suggest that social and psychological factors and self-management experiences influence health care transition. Eight themes emerged: "need for accessible support"; "early assistance with goal setting"; "incongruence among expectations, experiences, and preparation"; "spiritual distress"; "stigma"; "need for collaboration"; "appreciation for caring providers"; and "feeling isolated." Discussion: Consideration of cultural contexts will guide nurses in supporting health care transition. Designing culturally relevant interventions that address unique needs for YA living with SCD is warranted.

Opioid management strategy decreases admissions in high-utilizing adults with sickle cell disease.

BACKGROUND: A subset of adults with sickle cell disease (SCD) heavily utilizes the emergency department (ED) and hospital. The objective of our study was to determine the efficacy of a multidisciplinary strategy to address unmet needs in highly utilizing adults with SCD. METHODS: In a prospective study, adults with SCD with ≥10 admissions per year were assessed by a multidisciplinary team for gaps in medical, social, and psychological care. Thereafter, the team decided upon the subject's predominant domain that drove admissions and instituted an interventional plan. All plans included an opioid management strategy. Preintervention and postintervention admission rate, as well as opioid use, was compared. RESULTS: Twelve subjects were enrolled. Median rate of ED and hospital admissions preintervention was 25 per year. The predominant domains identified were social needs (n = 6), psychological disorder (n = 1), and substance use disorder (n = 5). Multifaceted interventional plans were developed to address a wide range of gaps in care, but an opioid management strategy was the only intervention successfully completed. Even so, when the preintervention versus postintervention admission rate was compared, regardless of the domain, there was a 40 percent decline in hospital admissions (p = 0.03). Consistent with the successful implementation of an opioid management plan, the decrease in admissions was accompanied by a 37 percent decrease in intravenous opioid use (p = 0.02) and 10 percent decrease in oral opioid use (p = 0.04). CONCLUSION: An opioid management strategy, as part of a larger effort to improve care for high-utilizing adults with SCD, decreased rate of admissions and opioid use.

Maternal opioid dose is associated with neonatal abstinence syndrome in children born to women with sickle cell disease.

The objective of this study was to test the hypothesis that higher daily opioid dose is associated with the presence and severity of neonatal abstinence syndrome (NAS) in pregnant women with sickle cell disease (SCD). This was a retrospective study of pregnant women with SCD who required opioids. NAS was evaluated using the Finnegan scoring system and classified as none, mild, and severe. Severe NAS was defined as a Finnegan score ≥ 8 on 3 consecutive tests. Thirty-four pregnancies were examined in 30 women with SCD. Higher daily morphine dose was associated with a higher percentage of days in the hospital during pregnancy (P < 0.001). Hospital days contributed disproportionately to daily morphine dose as larger amounts of opioids were administered in the hospital compared to home (P = 0.002). Median maternal oral morphine dose was 416 mg for infants with severe NAS compared with 139 mg for those with mild NAS (P = 0.04). For infants with no NAS, median maternal morphine was 4 mg, significantly less than those with mild NAS (P < 0.001). Infants born to women who used on average >200 mg/day of oral morphine equivalent in the last month of pregnancy had a 13-fold increased risk of severe NAS compared with those who used <200 mg/day. These data demonstrate that higher median daily opioid dose is associated with progressively more severe NAS in pregnant women with SCD. Strategies to decrease pain and avoid hospitalizations are needed to reduce opioid use and NAS.

Modifications to the fathead minnow (Pimephales promelas) chronic test method to remove mortality due to pathogenic organisms.

Whole effluent toxicity testing is used to evaluate the discharge of materials that may be harmful to indigenous aquatic life. Unlike most environmental analyses, receiving water (the water body into which the effluent is discharged) often is used as dilution water in whole effluent toxicity tests to simulate the aquatic environment into which the effluent is introduced. In approximately 26% of whole effluent toxicity tests conducted by Wisconsin (USA) certified labs between 1988 and 1998, a pathogenic effect caused failure of the receiving water controls during the fathead minnow chronic test (i.e., > 20% mortality). We performed microbiological work to isolate pathogenic organisms from receiving waters, the fish, and their food. We found pathogenic organisms such as Flexibacter columnaris, Aeromonas hydrophila, and Flavobacter spp. to be ubiquitous and were not able to remove them from the test (e.g., through decontamination of the fish food and carefully following sterility procedures). To eliminate the pathogenic effect, we evaluated manipulations of the sample and the test method including filtering receiving water, irradiating receiving water, using older fish (48 h), using clean test beakers each day of the test, and using smaller test beakers (30 ml) with two fish per beaker. In samples demonstrating the pathogenic effect, most of these manipulations significantly reduced mortality. The use of smaller tests cups was significantly better at reducing the effect than all of the other sample and method manipulations. These results indicate that a simple method modification to the fathead minnow chronic test will improve test reliability when diluting effluents with receiving waters.