Ischemic Stroke in Children and Young Adults with Sickle Cell Disease (SCD) in the Post-STOP Era

Abstract Background: The Stroke Prevention Trial in Sickle Cell Anemia (STOP) and Optimizing Primary Stroke Prevention in Sickle Cell Anemia (STOP 2) established routine transcranial Doppler ultrasound (TCD) screening with indefinite chronic red cell transfusions (CRCT) for children with abnormal TCD as standard of care. To identify children at high-risk of stroke, annual TCD screening is recommended from ages 2 to 16 years, with more frequent monitoring if the result is not normal. A reduction in stroke incidence in children with SCD has been reported in several clinical series and analyses utilizing large hospital databases when comparing rates before and after the publication of the STOP study in 1998. We sought to determine the rate of first ischemic stroke in a multicenter cohort of children who had previously participated in the STOP and/or STOP 2 trials and to determine whether these strokes were screening or treatment failures. Subjects and Methods: Between 1995 and 2005, STOP and STOP 2 (STOP/2) were conducted at 26 sites in the US and Canada. These studies included 3,835 children, ages 2 to 16 y with SCD type SS or S-beta-0-thalassemia. Participation in STOP/2 ranged from a single screening TCD to randomization. STOP 2 also had an observational arm for children on CRCT for abnormal TCD whose TCD had not reverted to normal. The Post-STOP study was designed to follow-up the outcomes of children who participated in one or both trials. 19 of the 26 original study sites participated in Post-STOP, contributing a total of 3,539 (92%) of the STOP/2 subjects. After exit from STOP/2, these children received TCD screening and treatment according to local practices. Data abstractors visited each clinical site and obtained retrospective data from STOP/2 study exit to 2012-2014 (depending on site) including follow-up TCD and brain imaging results, clinical information, and laboratory results. Two vascular neurologists, blinded to STOP/2 status and prior TCD and neuroimaging results, reviewed source records to confirm all ischemic strokes, defined as a symptomatic cerebral infarction; discordant opinions were resolved through discussion. For the first Post-STOP ischemic stroke, prior TCD result and treatment history subsequently were analyzed. Results: Of the 3,539 subjects, follow-up data were available for 2,850 (81%). Twelve children who had a stroke during STOP or STOP2 were excluded from these analyses resulting in data on 2,838 subjects. The mean age at the start of Post-STOP was 10.5 y and mean duration of follow-up after exiting STOP/2 was 9.1 y. A total of 69 first ischemic strokes occurred in the Post-STOP observation period (incidence 0.27 per 100 pt years). The mean age at time of stroke was 14.4±6.2 (median 13.8, range 3.5-28.9) y. Twenty-five of the 69 patients (36%) had documented abnormal TCD (STOP/2 or Post-STOP) prior to the stroke; 15 (60%) were receiving CRCT and 9 (36%) were not (treatment data not available for 1 subject). Among the 44 subjects without documented abnormal TCD, 29 (66%) had not had TCD re-screen in the Post-STOP period prior to the event; 7 of these 29 (24%) were 16 y or older at the start of Post-STOP, which is beyond the recommended screening age. Four of the 44 (9%) patients had inadequate TCD in Post-STOP (1 to 10.7 y prior to event). Six (14%) had normal TCD more than a year before the event (1.2 - 4 y); all but one of these children were younger than 16 y at the time of that TCD. Only 5 (11%) had a documented normal TCD less than 1 year prior to the event. Conclusions: In the Post-STOP era, the rate of first ischemic stroke was substantially lower than that reported in the Cooperative Study of Sickle Cell Disease, prior to implementation of TCD screening. Many (39%) of the Post-STOP ischemic strokes were associated with a failure to re-screen according to current guidelines, while only 11% occurred in children who had had recent low-risk TCD. Among those known to be at high risk prior to stroke, treatment refusal or inadequate treatment may have contributed. While TCD screening and treatment are effective at reducing ischemic stroke in clinical practice, significant gaps in screening and treatment, even at sites experienced in the STOP protocol, remain to be addressed. Closing these gaps should provide yet further reduction of ischemic stroke in SCD. Disclosures No relevant conflicts of interest to declare

Transcranial doppler re-screening of subjects who participated in STOP and STOP II.

In children with Sickle Cell Disease, the combination of risk stratification with Transcranial Doppler Ultrasound (TCD) and selective chronic red cell transfusion (CRCT-the STOP Protocol) is one of the most effective stroke prevention strategies in medicine. How fully it is being implemented is unclear. Nineteen of 26 sites that conducted the two pivotal clinical trials (STOP and STOP II) participated in Post STOP, a comprehensive medical records review assessing protocol implementation in the 10-15 years since the trials ended. Professional abstractors identified medical records in the Post STOP era in 2851 (74%) of the 3,840 children who took part in STOP and/or STOP II, and documented TCD rescreening, maintenance of CRCT in those at risk, and stroke. Among 1,896 children eligible for TCD rescreening (target group), evidence of any rescreening was found in 1,090 (57%). There was wide site variation in TCD rescreening ranging from 18% to 91% of eligible children. Both younger age and having a conditional TCD during STOP/II were associated with a higher likelihood of having a TCD in Post STOP. Sixty eight new abnormal, high risk cases were identified. Despite clear evidence of benefit the STOP protocol is not fully implemented even at experienced sites. Site variation suggests that system improvements might remove barriers to implementation and result in even greater reduction of ischemic stroke in children with SCD. Am. J. Hematol. 91:1191-1194, 2016. © 2016 Wiley Periodicals, Inc

The Biogeography of Oregon White Oak (\u3ci\u3eQuercus garryana\u3c/i\u3e) in Central Oregon

The study proceeded as follows: The distribution of Quercus garryana was mapped through field reconnaissance. Annual rings from fifteen trees were counted in order to establish age versus trunk diameter ratios. This greatly simplified the dating of trees. Transects were then run through individual groves to determine population age structures. These age structures, along with Q. garryana\u27s distribution patterns, were graphically compared with historic temperature, precipitation, and growing season data. The effect of livestock grazing on oak reproduction was examined. Potential vagility of the species was evaluated by estimating the potential for acorn dispersion by airfall, streams, vertebrates, and the human (aboriginal) population. Finally, pollen evidence was scrutinized in conjunction with acorn dispersal rates in order to determine the longer term history of Q. garryana in this portion of its range

Indian Diaspora Gastronomy: On the Changing Use of Herbs and Spices Among Southern California's Indian Immigrant Women

Southern California has witnessed a burgeoning Indian immigrant population in recent decades. And among the cultural features that most distinguishes Indians is their cuisine. Their use of herbs and spices in food and medicine, in particular, is tightly bound to language, religion, gender, and overall cultural identity. Identifying how Indian immigrants' culinary choices adapt to southern California's varied and often fast-food based gastronomy, particularly impacts on the inter-generational transmission of traditional culinary knowledge, is important in terms of understanding the role of cultural retention and assimilation, as well as culturally-defined notions of food in physical and psychological well-being. We explored these questions by means of interviews with 31 Indian immigrant women in southern California. Participants were selected by means of snowball sampling. Our working hypothesis was that problems with sourcing and cultural assimilation pressures would have eroded the use of traditional herbs and spices. A total of 66 herbs and spices (and associated seasonings) were reported. Of these, the highest frequency of use was recorded for turmeric (100% of respondents) followed by cilantro, cinnamon, clove, cumin, curry leaves, and ginger (all 97%). The highest Species Medicinal Use Values were recorded, in descending order, for turmeric, ginger, fenugreek seeds, clove, cinnamon, curry leaves, and Tulsi. Contrary to expectations, there was no significant association between years resident in the United States and decreasing use of herbs and spices. Indeed, in some cases the confluence of northern and southern Indian immigrant women with a new identity simply as "Indian" resulted in an increase in the knowledge and use of herbs and spices. Spices are nearly all locally sourced, and where specific herbs are not readily accessible, they are cultivated in homegardens or brought directly from India. Many Indian immigrants are relatively prosperous and able to travel frequently to and from India, thus maintaining close cultural ties with their homeland. Indian immigrant women are fully aware of the health benefits associated with the use of traditional herbs and spices, and all participants reported that Indian food is a healthier choice than American cuisine. Knowledge is passed via vertical transmission, primarily through mothers and grandmothers to daughters. Overall, there is little concern among female Indian immigrants to southern California that knowledge and use of their traditional herbs and spices are in a state of decline.610081https://doi.org/10.3389/fsufs.2021.61008

Fish sauce to french fries: changing foodways of the Vietnamese diaspora in Orange County, California

Foodways constitute salient symbols of cultural identity and sense of place. This is particularly true in the case of immigrants as they struggle to strike a balance between cultural retention and assimilation. In this study, we investigate changing foods and foodways among Vietnamese Americans residing in and around southern Orange County, California’s, Little Saigon, the primary cultural hub of ethnic Vietnamese outside of Vietnam. Vietnamese refugees and immigrants began entering the United States in considerable numbers after the fall of Saigon in 1975. Since arriving, they have experienced myriad socio-cultural changes as they adjust to life in the United States. We employ qualitative and quantitative methods, including questionnaires, participant observation, and formal and informal interviews, to explore food preparation and consumption habits among different waves and ages of immigrants. Results reveal that degree of change in Vietnamese foodways is time and space contingent. Significant changes are associated with generational differences of immigrants as well as distance of residence from Little Saigon. Although age of immigrants was not associated with degree of foodway retention, qualitative data suggest a rescue effect of traditional foodways as Vietnamese Americans associate with peers during their college years.The California Geographer 52: 35-550575-570

Mollusks of Candomblé: symbolic and ritualistic importance

Human societies utilize mollusks for myriad material and spiritual ends. An example of their use in a religious context is found in Brazil's African-derived belief systems. Candomblé, an Afro-Brazilian religion introduced during the 18th-19th centuries by enslaved Yoruba, includes various magical and liturgical uses of mollusks. This work inventoried the species utilized by adherents and to analyzed their symbolic and magical context. Data were obtained from Candomblé temples in two cities in the northeast of Brazil-Caruaru, in the state of Pernambuco, and Campina Grande, in the state of Paraíba. Questionnaires administered to eleven adepts revealed that at least nineteen mollusk species are being used. Shells from Monetaria moneta, M. annulus and Erosaria caputserpentis were cited by all of the interviewees. Three uses stood out: divination (jogo de búzios); utilization as ritual objects; and employment as sacrificial offerings (Igbin or Boi-de-Oxalá). The jogo de búzios (shell toss), employed in West Africa, Brazil and Cuba, is of fundamental importance to the cult, representing the means by which the faithful enter in contact with the divinities (Orixás) and consult people's futures (Odu). The utilization of mollusks in Candomblé is strongly influenced by ancient Yoruba myths (Itãs) which, having survived enslavement and generations of captive labor, continue to guide the lives of Brazil's African Diaspora

The genetic legacy of fragmentation and overexploitation in the threatened medicinal African pepper-bark tree Warburgia salutaris

The pepper-bark tree (Warburgia salutaris) is one of the most highly valued medicinal plant species worldwide. Native to southern Africa, this species has been extensively harvested for the bark, which is widely used in traditional health practices. Illegal harvesting coupled with habitat degradation has contributed to fragmentation of populations and a severe decline in its distribution. Even though the species is included in the IUCN Red List as Endangered, genetic data that would help conservation efforts and future re-introductions are absent. We therefore developed new molecular markers to understand patterns of genetic diversity, structure, and gene flow of W. salutaris in one of its most important areas of occurrence (Mozambique). In this study, we have shown that, despite fragmentation and overexploitation, this species maintains a relatively high level of genetic diversity supporting the existence of random mating. Two genetic groups were found corresponding to the northern and southern locations. Our study suggests that, if local extinctions occurred in Mozambique, the pepper-bark tree persisted in sufficient numbers to retain a large proportion of genetic diversity. Management plans should concentrate on maintaining this high level of genetic variability through both in and ex-situ conservation actionsinfo:eu-repo/semantics/publishedVersio

The Challenge of Examining Social Determinants of Health in People Living With Tourette Syndrome

Background: To examine the association between race, ethnicity, and parental educational attainment on tic-related outcomes among Tourette Syndrome (TS) participants in the Tourette Association of America International Consortium for Genetics (TAAICG) database. Methods: 723 participants in the TAAICG dataset aged ≤21 years were included. The relationships between tic-related outcomes and race and ethnicity were examined using linear and logistic regressions. Parametric and nonparametric tests were performed to examine the association between parental educational attainment and tic-related outcomes. Results: Race and ethnicity were collapsed as non-Hispanic white (N=566, 88.0%) versus Other (N=77, 12.0%). Tic symptom onset was earlier by 1.1 years (P &lt; 0.0001) and TS diagnosis age was earlier by 0.9 years (P = 0.0045) in the Other group (versus non-Hispanic white). Sex and parental education as covariates did not contribute to the differences observed in TS diagnosis age. There were no significant group differences observed across the tic-related outcomes in parental education variable. Conclusions: Our study was limited by the low number of nonwhite or Hispanic individuals in the cohort. Racial and ethnic minoritized groups experienced an earlier age of TS diagnosis than non-Hispanic white individuals. Tic severity did not differ between the two groups, and parental educational attainment did not affect tic-related outcomes. There remain significant disparities and gaps in knowledge regarding TS and associated comorbid conditions. Our study suggests the need for more proactive steps to engage individuals with tic disorders from all racial and ethnic minoritized groups to participate in research studies.</p