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To the Editor: I have 4 concerns about the study by Dr Steinberg and colleagues.¹ First, the authors did not analyze the differences in outcomes between patients with low vs high initial levels of hemoglobin F (HbF) that rose with hydroxyurea treatment. Such an analysis would best assess the authors' hypothesis that the hydroxyurea-induced rise in HbF confers hydroxyurea's beneficial effect on morbidity.

Second, the authors reported that undetermined, and yet-to-be-classified deaths were among the most common causes of mortality. Depending on the actual causes of death in these patients, the relative importance of the other causes of death among patients receiving hydroxyurea may have been quite different than those the authors reported. A similar problem is that the authors did not obtain toxicology screens, especially for cocaine, a drug that is not uncommon among patients with SCA, and which may be associated with all of the causes of death . . . [Full Text of this Article]

Ward Hagar, MD
Adult Sickle Cell Program
Children's Hospital and Research Center at Oakland
Oakland, Calif

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