Patients with sickle cell disease do not have continual painful crises but events tend to follow well-defined conditions. In addition to skin cooling (winter, rain, swimming, cold showers, washing cars or clothes), other precipitating events include physical exertion, dehydration, emotional stress, nd infections. The physiological paths whereby these events cause bone marrow necrosis are usually unclear, although skin cooling has been shown to invoke shunting of blood away from the skin. It is presumed that deep shunts accommodating the diverted blood flow may offer less resistance than the bone marrow and so also compromise bone marrow blood flow.
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