1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia...
Transcript of 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia...
![Page 1: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/1.jpg)
Sickle Cell Anemia –An OverviewVictoria Price
Blood Matters HalifaxBlood Matters, Halifax28 November 2014
![Page 2: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/2.jpg)
Conflict of InterestsConflict of Interests
• NoneNone
![Page 3: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/3.jpg)
ObjectivesObjectives
• Epidemiology• PathophysiologyPathophysiology• Diagnosis• Complications of SCD• Complications of SCD• Current therapies• Future therapies• Future therapies
![Page 4: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/4.jpg)
HistoryHistory
• 1910 - described by Herrick (Chicago)
• First patient - Dr Walter Clement N l (1884 1916 G d )Noel (1884-1916, Grenada)
• 1920s - named sickle cell disease• 1949 – Linus Pauling refers to “the
first molecular disease” 1949, Science
1956 V I d ib• 1956 – Vernon Ingram describes qualitative defect Hb S: β6
G→V
1956 Nature1956, Nature
![Page 5: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/5.jpg)
Geographic DistributionGeographic Distribution
www.ox.ac.uk
![Page 6: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/6.jpg)
InheritanceInheritance
![Page 7: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/7.jpg)
EpidemiologyEpidemiology
African Americans:African Americans:• Hb S Carriers 1/12• HbSS: 1/425HbSS: 1/425• Hb SC: 1/1000• HbSβ+thal: 1/3000• HbSβ+thal: 1/3000Prevalence in Nova Scotia?
![Page 8: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/8.jpg)
Pathophysiologyy gy
Lancet 2010;376:2018
![Page 9: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/9.jpg)
Diagnosis
![Page 10: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/10.jpg)
Screening – NewbornsScreening Newborns
• Universal screening: Ontario, BC, NS 2014
• Rationale: early therapy prevents M&M
• HPLC• Identifies carriersde t es ca e s• False negative: transfusion,
prematurity (<30 wks)p y ( )
![Page 11: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/11.jpg)
Screening - In ERScreening In ER
Kit test • Sickle solubility test– Kit test– Red cells are
hemolysed
• Sickle solubility test
y– Reducing buffer is
added and HbS precipitatesprecipitates
– Requires >20% HbS– Positive in carriersPositive in carriers
![Page 12: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/12.jpg)
ConfirmationConfirmation
• Peripheral smear review
• HPLC• ElectrophoresisElectrophoresis• IEF• Capillarys• Capillarys
![Page 13: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/13.jpg)
ComplicationsComplications
• Hemolysis
• Vaso-occlusionVaso occlusion
![Page 14: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/14.jpg)
HemolysisHemolysis
• Anemia• CholelithiasisCholelithiasis• Retarded growth• Delayed sexual maturation• Delayed sexual maturation• Pulmonary hypertension
![Page 15: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/15.jpg)
Vaso-occlusionVaso occlusion
• Recurrent painful crises• Recurrent painful crises• Functional asplenia• Stroke• Splenic sequestration• Acute chest syndrome• Avascular necrosis of femoral and
humeral heads• Chronic organ damageChronic organ damage• Priapism• Leg ulcersg
![Page 16: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/16.jpg)
FeverFever
41/2 ld i l• 41/2 yr old girl• HPI: cough 5 days
fever vomitingfever, vomiting, abdominal pain
• PMH: HbSS• PMH: HbSSSplenectomyPneumovax PenVPneumovax, PenV
• ED: 22h00• Died that morning of pneumococcalDied that morning of pneumococcal
sepsis.
![Page 17: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/17.jpg)
FeverFever
• Functional asplenia 3-5 years• Encapsulated organismsp g
• Prevention of infections– Immunizations– Penicillin prophylaxis
• Give antibiotics within 30 i t f t timinutes of presentation.
![Page 18: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/18.jpg)
PainPain
• 5 years male5 years, male• Abdominal and right hip pain • PMH: episodic abdo pain,PMH: episodic abdo pain,
constipation• Sickle screen positive• Uncle HbSC• Diagnosis: HbSC, recurrent
i f l ipainful crises• MRI: bone infarcts
![Page 19: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/19.jpg)
Acute Pain Episodes
InfectionF
HbS polymerizationTissue hypoxiaFever
DehydrationC ld
Hypoxemia
ColdHeat
Hypoxemiaacidosis Veno-occlusion
![Page 20: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/20.jpg)
Management in ERManagement in ER
• EmergentMild-moderate pain:• acetaminophen + ibuprofen• 30-60 min, no relief give
morphinemorphine
Severe pain:Severe pain:• Morphine infusion• HospitalizationHospitalization
![Page 21: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/21.jpg)
TreatmentTreatment
![Page 22: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/22.jpg)
Hydroxyurea
Ware R E Blood 2010;115:5300-5311
©2010 by American Society of Hematology
![Page 23: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/23.jpg)
HydroxyureaHydroxyurea
Green, Pediatric Research (2014) 75, 196–204
![Page 24: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/24.jpg)
TransfusionTransfusion
Sept 2014, JAMA
![Page 25: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/25.jpg)
TransfusionTransfusion
Goals:Goals: 1. Increase oxygen-carrying
capacity p y2. Replace rigid sickle RBCs with
deformable RBCs, to restore ,blood flow
![Page 26: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/26.jpg)
Transfusion- IndicationsTransfusion Indications
• Episodic vs chronic• Always consider :Always consider :
– Benefits vs risks of transfusionAlternatives– Alternatives
– Clinical status of the patientBaseline Hb– Baseline Hb
• Some indications per experience/clinical judgementexperience/clinical judgement
![Page 27: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/27.jpg)
Transfusion MethodsTransfusion Methods
Simple Manual exchange ErythrocytapheresispTransfusion
gTransfusion
y y p
Easy to perform venous access (1)
Time-consuming Manual
ExpensiveSpecialized equipmentvenous access (1) Manual
Trained personnelSpecialized equipment Trained personnel Venous accesses (2)↑Exposure RBC units↑Exposure RBC units
Iron Overload +++ Iron Overload + No iron overload
www.sicklecellsociety.org/carebook.pdf
![Page 28: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/28.jpg)
TransfusionAcute Complications
• Acute chest syndrome• Acute chest syndrome• Splenic sequestration• Stroke• Hepatic sequestration• Hepatic sequestration• Intrahepatic cholestasis• Multi-organ failure• Aplastic crises• Aplastic crises
Sept 2014, JAMA
![Page 29: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/29.jpg)
Transfusion-SurgeryTransfusion Surgery
• Transfuse to Hb 100g/L prior to GA (simple)prior to GA (simple)
• NEJM 1995, Lancet 2013
E h i l f• Exchange vs simple for HbSS with Hb > 85g/Lg HbSβthal and HbSC
Sept 2014,JAMA
![Page 30: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/30.jpg)
Chronic TransfusionsChronic Transfusions
• Child TCD > 200mm/secSTOP I, NEJM 1998
• Previous overt stroke SWITCH, Blood 2012
• Previous silent strokeSIT, NEJM August 2014
Sept 2014, JAMA
![Page 31: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/31.jpg)
Risks of TransfusionsRisks of Transfusions
ACUTE• Acute hemolytic
transfusion reaction
DELAYED• Bloodborne pathogens• Delayed hemolytic
• Bacterial contamination• Allergic reaction• Hypotension
Delayed hemolytic transfusion reaction (DHTR)
• HyperhemolysisHypotension• TRALI
yp y• Alloimmunization• Iron overlaod• PTPPTP• TA-GvHD
![Page 32: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/32.jpg)
Alloimmunization in SCD
• Historical data (1980-1990):( 980 990)– Alloimmunization rate varied from 7.5% to 36% in SCD
patients compared to 5% in -thalassemia patients.Rate of alloimmunization increases exponentially with– Rate of alloimmunization increases exponentially with increasing number of transfusions
– Alloimmunization usually occurs with less than 15 transfusions– Specificity of alloantibodies (% of patients sensitized):
Anti-E Anti-C Anti-K Anti-Fya Anti-Jkb Anti-S
42.3% 30.2% 28.1% 18.3% 10.7% 9.2%
Rosse WF et al. Blood. 1990:76:1431-1437
![Page 33: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/33.jpg)
Alloimmunization: Rh variants
• ↑Frequency Rh variants in African descent.
Eg:Hybrid RHD CE D allele → altered C: 25%Eg:Hybrid RHD-CE-D allele → altered C: 25% • Alloimmunization occurs despite
conventional antigen-matching.g g• Many of the antibodies present as
autoantibodies, but they can cause serious hemolytic reactionsserious hemolytic reactions.
• Samples should be sent to a reference lab.
![Page 34: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/34.jpg)
Prevention of AlloimmunizationPrevention of Alloimmunization1. Transfuse when clinically indicated2 Perform phenotypic matching for C E and Kell antigens2. Perform phenotypic matching for C, E and Kell antigens
for non-alloimmunized SCD patients.– Vichinksy et al. Transfusion 2001
↓ ll i i ti t f 3% t 0 5%/ it• ↓ alloimmunization rate from 3% to 0.5%/unit• ↓ in hemolytic transfusion reactions by 90%
– Reproduced in other studiesSIT t i l ll i i ti t 0 278%/ it• SIT trial: allo-immunisation rate 0.278%/unit
– Castro et al. Transfusion 2002• Limited phenotyping (C, c, E, e, K) would prevent 53,3% of
ll ll tib di d t 70 8% f t d dall alloantibodies compared to 70.8% for a more extended phenotyping (C, c, E, e, K, S, Fya and Jkb ).
• However, finding compatible blood would be problematic (13 6% vs 0 6% of random white blood donors)(13.6% vs 0,6% of random white blood donors)
![Page 35: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/35.jpg)
Prevention of Alloimmunization
3 Communication between transfusion services in order to know the3. Communication between transfusion services in order to know the patient’s transfusion history
4. Recruit and supply RBCs from African-American donors – Blue Tag Program, ARC, Philadelphia
5. Genotype SCD patients and blood donors.
![Page 36: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/36.jpg)
HSCTHSCT
• Only curative intervention• HLA matched unaffected sibHLA matched unaffected sib
(18%)• Unrelated donor: experimentalUnrelated donor: experimental• Graft loss and GVHD• Reduced intensity conditioning• Reduced intensity conditioning
(NIH, ACH) JAMA, July 2014
![Page 37: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/37.jpg)
Future ConsiderationsFuture Considerations
• Excessive cellular adhesion• Ischaemic reperfusion injuryIschaemic reperfusion injury• Hb modifiers that ↑O2 affinity• New generation HbF inducers• New generation HbF inducers• Inflammation-vasculopathy• Gene therapy• Gene therapy
Hematology/Oncology Clinics of NA, April 2014
![Page 38: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/38.jpg)
Take Home PointsTake Home Points
• SCD rare in MaritimesSCD rare in Maritimes• Increasing due to immigrant population• Early diagnosis to prevent complicationsEarly diagnosis to prevent complications• Emergent management of complications to
prevent morbidity and mortalityprevent morbidity and mortality• Requires a multidisciplinary team approach
![Page 39: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/39.jpg)
ResourcesResources
apphon rohppa com• www.apphon-rohppa.com• http://www.nhlbi.nih.gov/health/prof
/blood/sickle/sc mngt pdf/blood/sickle/sc_mngt.pdf• http://www.sickleandthal.org.uk
htt // i kl lldi /• http://www.sicklecelldisease.org/
![Page 40: 1. Sickle Cell Anemia An Overview - Capital Health Nova Scotia · 2020-07-18 · Sickle Cell Anemia – An Overview Victoria Price Blood Matters HalifaxBlood Matters, Halifax 28 November](https://reader033.fdocuments.us/reader033/viewer/2022050312/5f7428e09711fa12740f0cf8/html5/thumbnails/40.jpg)
Questions??Questions??