ALBERT

Description: Abstract 2648 Introduction: Pain is a common acute and chronic complication of sickle cell disease (SCD) in pediatric patients. However there are very few pain assessment tools that can assess patients for the multidimensional components of pain. The Adolescent Pediatric Pain Tool (APPT) is a validated, self-administered paper and pencil pain assessment tool validated in children and adolescents. The McGill Pain questionnaire (MPQ) is a pain assessment tool validated in adolescents and adults. PAINReportIt (PR) is a self-administered, computerized version of the MPQ. The APPT and PR can each be administered in a single outpatient clinic visit. The Composite Pain Index (CPI), a multidimensional representation of pain, can be calculated with both the APPT and PR. It is calculated by summing the individual standardized-scores for each of the four pain dimensions: (1) number of sites, (2) intensity, (3) total pain rating index, and (4) the pain pattern score. The use of these tools can present pain as the all-important 5th vital sign and may assist providers in the treatment of the multiple components of pain in pediatric SCD. The aim of this study was to compare the use of two pain assessment tools, the APPT and PR in pediatric SCD patients with respect to the composite pain index and the multiple dimensions of pain. Patients/Methods: Patients with the following genotypes were eligible for this study: Hb SS, Hb SC, Hb Sb0-thalassemia, and Hb Sb+-thalassemia. Patients who were 14 years and older were eligible to complete both tools on a single, outpatient visit to a comprehensive SCD clinic. The number of pain sites, intensity and the CPI were analyzed with descriptive, correlation, and independent t-test statistics. Results: 57 patients completed both pain tools. The mean age was 17.5 +/− 2.6 years (mean +/− SD). There were 29 females (51%) and 28 males (49%). 84% of the patients had Hb SS; 14% had Hb SC and 2% had Hb Sb0-thalassemia. Pain was described in every body segment, with the most frequent sites including the: back, legs, chest, and abdomen. Pain intensity was moderate for the average subject (mean pain intensity score out of 10 was 3.7 +/− 2.6 for PR and 4.3 +/− 3.2 with the APPT, r=.46, p

Description: Abstract 4613 Aim PAINReportIt® is a computer based, self-reporting pain assessment tool that was designed to serve as a communication tool between patients and medical care providers. Originally developed and validated for the reporting of cancer pain, the application of this tool to sickle cell pain is novel. One aspect of this computer program incorporates a body outline in which patients can indicate specific pain locations by drawing on the anterior and posterior facing body images. However, because of the systemic nature of SCD, affected individuals may experience a wider range in the number of painful sites and their distribution than individual cancer patients. Therefore, the established algorithms within the computer program, which convert a graphic pain representation into a numerical description of the number of painful sites and their anatomic distribution, must be able to account for this variability. The purpose of this study was to ensure the reliability and accuracy of the computer generated data by comparing it to human generated data regarding painful sites, and to account for all factors that may impinge on the accuracy of computer generated data. Methods Individual PAINReportIt® body outlines completed by 49 adolescent SCD patients ranging from 14 to 27 years in age (mean=18 +/- 2.6) were analyzed by two researchers based on a specific set of guidelines. The researchers were blinded to the computer generated data as they coded the data following guidelines that defined 1) the method for counting the number of pain sites in each drawing, 2) an ordering hierarchy for assigning a site number to each site, and 3) whether or not a particular body segment was included in each site. The 9 body segments included the head, chest, right and left arms, abdomen, right and left legs, upper back and lower back. A third researcher and consensus discussion resolved coding discrepancies between researchers. Descriptive and t test statistics were used to compare the data results of the researcher and results generated by the computer. Results There was strong accuracy in the interpretation of site number and locations between the researcher's data and the computer-generated data. For example, patients reported a mean value of 3.9 (+/- 3.3) and 3.8 (+/- 3.5) painful sites according to the computer program and researcher, respectively. Also, there was strong accuracy in patients' reports of site assignments for 8 of the 9 body segments. For example, the fraction of painful sites that included the head was found to be 0.2 +/- 0.4 and 0.3 +/- 0.5 by the computer and researcher, respectively. However, a significant difference between the computer and the researcher was found for inclusion of the lower back segment – 0.1 +/- 0.2 and 0.5 +/- 0.5 of painful sites, respectively (P 〈 10-3). Conclusion Findings suggest that the algorithms used to interpret patient drawings in the PAINReportIt® computer program generally accounts for the intentions of the patients. The minor discrepancies may reflect ambiguities in the guidelines used by the researcher in identifying involvement of this particular body segment, or an idiosyncrasy in the computer algorithm itself. Analysis of painful site data by multiple independent observers will likely resolve this discrepancy. Findings also indicate that there is still room for adjustment so that differences between the algorithms of the computer program and the specific guidelines used by the researcher can be reconciled to accurately reflect the patient's pain location report. Disclosures: No relevant conflicts of interest to declare.

Description: Abstract 2576 Poster Board II-553 Pain remains the most frustrating and debilitating symptom of sickle cell disease (SCD). Yet, because pain is a perception of a sensation, objective assessment of pain remains elusive. In order to achieve adequate pain control, it is imperative that the patient be able to effectively communicate with the physician regarding the extent, severity and quality of the pain, as well as the response of the pain to the therapeutic intervention. Moreover, SCD pain may have two components, nociceptive (due to organ/tissue injury) and neuropathic (due to somatosensory system lesion or disease), with differing pathophysiologies, and differing responses to pain medications. PAINReportIt® is a multi-dimensional computerized, self-assessment pain reporting tool based on the McGill Pain Questionnaire (MPQ). The MPQ has been validated for adolescents and adults. However, the PAINReportIt®, which was developed originally for the evaluation of cancer pain, has not previously been used in adolescents, nor in the study of adolescents' SCD pain. The purpose of this study was to examine the frequency with which pain experienced in various body areas by adolescents and young adults had characteristics consistent with nociceptive and neuropathic pain. Methods. Inclusion criteria included an SCD diagnosis (SS, SC or S-beta thal) and age at least 14 years. Patients attending two pediatric/adolescent comprehensive sickle cell clinics were invited to participate. Consenting subjects were first instructed and then allowed to complete the PAINReportIt® tool, in which they marked their painful sites on a graphic body outline, selected pain quality descriptors from word lists provided by the computer, and for each site they matched each site to the pain quality descriptors that represented the site. The descriptors included sensory descriptors that are known to be characteristic of either neuropathic pain or nociceptive pain. Results. PAINReportIt® tools were completed by 49 SCD subjects, whose ages ranged from 14 to 27 years (mean, 18 +/− 2.6 years). For analysis, the body was divided into nine segments, and the computer analyzed the marked painful body outline sites and identified the body segments involved. Descriptive statistics were used to determine the frequency for which each body segment included a painful site, and the frequencies for which that site was characterized as having neuropathic or nociceptive pain qualities, or both. These results are summarized in the Table below. As the Table shows, virtually all body segments were frequently involved with pain, the upper back and legs being the most frequently reported, and the lower back the least (Column 1). For body segments reported as painful, few were reported as having only nociceptive (Column 2) or neuropathic (Column 3) pain qualities. The majority of painful sites were described by subjects as having mixed pain qualities (Column 4). As Column 5 shows, from 76% to 100% of all painful sites were characterized as having a neuropathic pain component. When the number of descriptors associated with each site was reviewed (data not shown), the right leg was matched to the largest number of neuropathic descriptors (Aching, Burning, Cold, Drilling, Flickering, Numb, Penetrating, Radiating, Shooting, Spreading, Tight, Tingling). The upper back was matched to the largest number of nociceptive descriptors (Beating, Cramping, Crushing, Gnawing, Hurting, Piercing, Pounding, Pressing, Pulsing, Sharp, Sore, Splitting, Squeezing, Tender, Throbbing). Conclusions. When utilizing a computer-based self-reporting pain tool, SCD patients overwhelmingly describe a neuropathic component to their pain as well as a nociceptive component. The high frequency of neuropathic pain has been underappreciated, and this may contribute to the difficulty in managing sickle cell pain, since this pain component is not well controlled by opioid analgesics. Disclosures: No relevant conflicts of interest to declare.

Description: Background The mutations in KMT2D gene are well known to be associated with Kabuki syndrome. Up to date, 1,027 different germline KMT2D variants have been reported in ClinVar (https://www.ncbi.nlm.nih.gov/clinvar/?term=KMT2D%5Bgene%5D), and among them, 365 variants (35.5%) are classified as uncertain significance and 53 (5.2%) are assigned to conflicting interpretations. This means about 40% of KMTD2 variants still need further evaluation to figure out whether they are 'pathogenic' or 'likely pathogenic'. Currently, the problem with the respect to the interpretation of variants is that they are prone to be reported as variants of unknown significance (VUS) without further study if the KMT2D variants have not been clinically described and reported previously. And in the clinical field, the KMT2D variants interpreted as VUS most likely do not get paid attention by the clinicians and can be easily ignored without further testing. Recently, Hadjadj et al.1 brought up the criteria 'probably pathogenic' variants which include the minor allele frequency less than 0.01 in the general population, and in Silico algorithms predicts the pathogenicity of missense variants. The authors found these 'probably pathogenic' variants were not significantly different from 'pathogenic' mutations in Evans syndrome in terms of clinical manifestations. Hypothesis and objective We hypothesized that there could be 'probably pathogenic' KMT2D variants which have been reported as VUS in patients with hematologic cytopenias and primary immune deficiency and we sought to find these 'probably pathogenic' variants for further evaluation to figure out their pathogenicity. Methods We analyzed the next generation sequencing data performed on patients with hematologic cytopenias and primary immune deficiency at the Ann and Robert H. Lurie Children's Hospital from March 2017 to May 2019. This primary immune deficiency (PID) panel analyzes 290 genes and the clinical manifestations of the patients were compared with the previous reports published regarding the KMT2D pathogenic mutations. We reviewed not only the online PubMed resource, but the websites well known for gene analysis were also used as references (https://www.ncbi.nlm.nih.gov/clinvar/, http://exac.broadinstitute.org/, http://genetics.bwh.harvard.edu/pph2/, http://provean.jcvi.org/index.php, https://sift.bii.a-star.edu.sg/, etc). Results Among 52 patients who had a PID panel ordered, 10 patients (19.2%) were found to have KMT2D variants. Among them, 4 variants (7.6%) were polymorphisms (c.7705G〉A, p.Gly2569Ser; c.11849A〉G, p.Gln3950Arg; c.1408C〉T, p.Pro470Ser; c.2506C〉A, p.Ile238Val) and 6 (11.5%) 'probably pathogenic' KMT2D variants were newly identified. Novel heterozygous KMT2D variants, previously reported as VUS: c.15341A〉C, p.His5114Pro; c.10640G〉A, p.Arg3547; c.6902C〉T, p.Pro2301Leu; c.7328G〉T, p.Arg2443Leu; c.15694A〉G, p.I5232V; c.7001G〉A, p.R2334Q were identified in patients who presented with various clinical manifestations known to be associated with KMT2D mutations which are neutropenia, anemia, thrombocytopenia, cardiac anomaly, urogenital anomaly, primary immune deficiency, variable degrees of mental retardation and distinctive facial features that include arched eyebrows, long eyelashes, elongated eyelids with lower lids that turn out, prominent ears, a flat tip of the nose, and a downward slant to the mouth. Further parental testing revealed one of them was a novel de novo mutation which was reclassified as 'likely pathogenic', 4 variants were inherited from mother or father and parental testing was not done for 1 patient. Conclusion We concluded that the mutational gene analysis should be correlated with patients' clinical manifestations. The second look analysis of the 'probably pathogenic' variants reported as VUS to figure out the clinical meaning would be important in terms of diagnosis and treatment of patients in the future. Further evaluation regarding family history and gene analysis would be necessary as well as further downstream pathway studies to confirm the pathogenicity of the 'probably pathogenic' KMT2D variants. References 1. Jérôme Hadjadj, Nathalie Aladjidi, Helder Fernandes, et al. Pediatric Evans syndrome is associated with a high frequency of potentially damaging variants in immune genes, Blood 2019 134:9-21. Disclosures Thompson: Baxalta: Research Funding; Novartis: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; bluebird bio, Inc.: Consultancy, Research Funding.

Description: Abstract 1535 Poster Board I-558 Introduction Pain in sickle cell disease (SCD) is a common acute and chronic complication across the life span, but a single multidimensional pain assessment tool is not available that can be used in children, adolescents and adults. The Adolescent Pediatric Pain Tool (APPT) is a self-administered, paper and pencil tool that has been validated in children and adolescents with SCD; the McGill Pain Questionnaire (MPQ) is valid for adolescents and adults. To begin to create a multidimensional pain assessment tool that is valid across the life span, we compared the APPT to the PAINReportIt®, a self-administered computerized version of the MPQ in adolescent outpatients with SCD. The use of a computer/web based system would allow for ease of storage and retrieval of data. The utilization of a computerized pain assessment tool may provide clues to treatment of the multidimensional pain experience of pediatric patients with SCD. Patients and Methods Patients with sickle cell disease (Hb SS, Hb SC, Hb Sβ0 and Hb Sβ+ thalassemia) aged 14 years of age and older were eligible for this study. A convenience sample of patients attending comprehensive sickle cell clinics were recruited for enrollment. In random order, on the same day, patients completed the PAINReportIt® and the APPT in an outpatient clinic. The number of pain sites, pain intensity, qualitative pain descriptors (sensory, affective, and evaluative), pain pattern, as well as nociceptive and neuropathic descriptors were analyzed with descriptive, correlation, and independent t-test statistics. Results A total of 49 patients completed both pain assessment tools. 26 were female (53%) and 23 were male (47%). 41 (84%) patients had Hb SS, 7 (14.3%) had Hb SC, and 1 patient (2%) had Hb SB0 thalassemia. 46 (94%) of the patients described themselves as African American, 2 (4%) as Hispanic, and one (2%) as other. The mean number of pain sites with PAINReportIt® was 3.65 +/- 3.4; the mean number of pain sites with the APPT was 4.71 +/- 4.87 (r= 0.76, p= 0.01). Pain sites where more than 25% of the patients had pain included the chest, abdomen and forearm. More than 35% of the patients had pain in the thighs, knees and lower legs, and 59% of the patients reported pain in the lower back. The pain intensity with PAINReportIt® was 3.76 +/- 2.53 (on a 10-point scale) and with the APPT was 4.63 +/- 3.12 (on a 10-point scale) (r= 0.29, p= 0.05). In terms of qualitative pain descriptors between the tools, sensory (r= 0.69, p= 0.01), affective (r= 0.69, p= 0.01), and evaluative (r= 0.48, p= 0.001) terms each had a statistically significant correlation. There also was a statistically significant correlation between tools with the patient's pain pattern (r= 0.35, p= 0.01). There was a statistically significant difference by gender with the number of pain sites (females: 4.88 +/- 4.07, males: 2.26 +/-1.60, p= 0.005), and with the following qualitative pain descriptors: neuropathic (females: 4.31 +/- 3.08, males: 2.04 +/- 1.89, p= 0.03), nociceptive (females: 6.58 +/- 3.97, males: 3.91 +/- 2.71, p= 0.008), sensory (females: 17.54 +/- 8.29, males: 12.69 +/- 7.11, p= 0.03) and affective (females: 4.65 +/- 4.08, males: 2.27 +/- 2.70, p= 0.02). There was a statistically significant correlation with both tools regardless of which tool was completed first for the number of pain sites and with the use of sensory and affective qualitative descriptive terms (data not shown). Conclusion There were significant, moderate to strong correlations between the PAINReportIt® and the APPT with regard to pain location, intensity, quality and pattern, validating the use of PAINReportIt® in adolescent patients with SCD. This is the first study utilizing this important tool in pediatric patients with SCD. The minor differences in scores between the two tools may reflect differences in instructions. This computerized pain assessment tool may become an important diagnostic tool to assist pediatric practitioners in the management of the multidimensional components of pain in SCD. Disclosures No relevant conflicts of interest to declare.

Description: Patients with sickle cell disease have decreased nitric oxide bioavailability, and studies from several groups have confirmed a blunted response to various NO donors in humans and mice with sickle cell disease. Recently published studies show that nitrite induces vasodilation in humans, apparently mediated by conversion of nitrite to NO. This study is designed to determine the potential therapeutic effect of intra-arterial nitrite infusion to restore nitric oxide dependent blood flow in the forearms of patients with sickle cell disease. Venous occlusion strain gauge plethysmography is used to measure the change of forearm blood flow in patients with sickle cell disease, before and after sequential brachial artery infusions of increasing doses of sodium nitrite. In addition, NO responsiveness before and after nitrite infusion is measured by test doses of the NO donor sodium nitroprusside (SNP). Six patients have completed the study and enrollment is continuing. These data indicate that nitrite promotes regional blood flow in patients with sickle cell disease, albeit with a blunted response compared to our healthy control subjects, in whom we previously have found increased blood flow up to 187% with comparable dosing. The significant but blunted response is consistent with the state of nitric oxide resistance to NO donors that has been seen by several groups in patients and mice with SCD. Additionally, we find in these patients that nitrite partially restores SNP responsiveness, with baseline maximal SNP responses more than doubling on average following nitrite infusion, although this finding is preliminary. No adverse effects of nitrite were seen in these six patients. Our early results support a role for nitrite as an NO donor effective in restoring NO-dependent blood flow in patients with sickle cell disease. Additional translational studies are warranted to evaluate the therapeutic effects of systemic nitrite dosing. Table 1. Forearm Blood Flow Response to Nitrite Infusion Nitrite Dose (micromole/min) Sickle Cell Disease Historical Controls P〈 .0001 (ANOVA) 0.4 5 +/−7.2% N=6 22 +/−3.2% N=10 4 15 +/− 11% N=6 Not infused 40 49 +/− 8.9% N=6 187 +/− 16%N=18 Table 2. Nitrite Effect on Nitroprusside Responsiveness SNP Dose (micrograms/min) Pre-Nitrite Post-Nitrite P= .02 (RM-ANOVA) N=6 0.8 +21 +/− 5.6% +33 +/− 8.3% 1.6 +15 +/− 5.9% +62 +/− 15.1% 3.2 +29 +/− 6.3% +67 +/− 11.5%

Description: Abstract 4618 Aim The Adolescent Pediatric Pain Tool (APPT) explores the patient's self-report of pain, and has been studied and validated as a pain assessment tool in pediatric patients as young as 8 years of age. This tool consists of three components: a pictorial body outline (pain location), a Word Graphic pain Rating Scale (WGRS; pain intensity), and a qualitative descriptive word list (pain quality and pain pattern). Although straightforward for the patient to complete, the interpretation of the APPT by the medical professional is subject to individual reader bias. This bias is particularly crucial when the APPT is used as a research tool in studies of SCD pain, where data must be transcribed into a form suitable for analysis across patients. The purpose of this study was to determine accuracy of APPT pain analysis and ensure meaningful data collection in a research setting. Methods APPTs submitted by 102 adolescent and young adult (mean age 14.2 years, range 8 to 27; 48 female, 54 male) SCD patients (75 SS, 24 SC, 3 S-beta thal) were independently analyzed and entered into Excel spreadsheets by two trained raters. For the analysis, the anterior and posterior body outlines were divided into a total of 43 body ‘segments’. Each mark drawn on the body outline was considered a painful ‘site’. Each rater recorded: 1) the number of painful sites; 2) the body segments involved in each painful site; 3) a numeric scale (ranging from 0.0 to 10.0) estimate of the WGRS; and 4, the word descriptors selected by the patient. The % disagreement between raters was calculated for each of 3 APPT components: location, intensity, and quality. Results Of the 102 APPTS submitted, 96 were found by the raters to be sufficiently complete for analysis. Regarding pain location - Over the span of 43 potentially involved body segments, the two raters disagreed in only 1.01% of instances. These disagreements appeared to arise primarily from ambiguity in interpreting the patient's drawing (e.g., circle not closed, or line circles area twice). Regarding pain intensity – For 83% of patients, the measurement of pain intensity differed by +/- 0.2 or less. Intensity errors arose primarily from irregularities in marking of the pain scale by the patient (62.5% of patients did not follow instructions in marking the scale, i.e., making a circle or an “X” instead of a vertical line), as well as differences in the interpretation of the mark by the raters (15.6% disagreement between raters on whether or not the scale was marked per instructions). Regarding pain quality and pattern – disagreement between raters in word selections occurred in 16.7% of APPTs. Of these, the two readers differed by 1 word, 2 words or 3 words in 53.8%, 23.1%, and 23.1% of instances, respectively. Quality discrepancies frequently arose from ambiguities in patient word recording (such as incompletely circling words, or placing a mark next to the word instead of circling), and rater interpretation of that recording (such as what markings to consider as purposeful selection of a word), but may potentially arise from data transcription errors. Conclusion In adaptation of the APPT as a research tool, multiple sources of error need to be addressed and minimized. These include ambiguities introduced by the patient (which may be improved by careful instruction or practiced use of the tool by the patient), the algorithms used by raters to interpret results (which may need detailed instructions for dealing with ambiguous results), and data transcription errors (which may be identified and corrected by double data entry). Disclosures: No relevant conflicts of interest to declare.