Decline In Hemoglobin Concentration Research Articles

Evaluation of the International Society on Thrombosis and Haemostasis definition of major bleeding in Arizona rattlesnake bites

Introduction In 2023, a group of experts proposed that a definition of major bleeding in pharmaceutically anticoagulated patients be used in all snakebite trials. This includes bleeding that results in death, is life-threatening, causes chronic sequelae, or consumes major healthcare resources, including bleeding into a major area or hemoglobin concentration decrease ≥20 g/L. We hypothesized that a decline in hemoglobin concentration ≥20 g/L is common but rarely clinically significant in our population of Arizona rattlesnake bite patients. Methods Poison center records of rattlesnake bites in humans from 2018 through 2022 were retrospectively reviewed and assessed for major bleeding by the above criteria. Results Four hundred and eighty-one patients met the inclusion criteria, of whom 265 (55.1%) had a hemoglobin concentration decrease ≥20 g/L. No patients died, and there was no evidence of bleeding into a critical organ. Three patients (1.1%) received blood transfusions. A decrease in hemoglobin concentration ≥20 g/L was 100% sensitive for identifying the major bleeding-associated outcomes; however, specificity was only 45.2%. Measures of healthcare utilization and chronic sequelae were somewhat higher in patients with a decrease in hemoglobin concentration ≥20 g/L. Discussion Laboratory manifestations of hemotoxicity were common in this population, but hemorrhage was rare. While over half of patients met the major bleeding criterion of a decline in hemoglobin concentration ≥20 g/L, only 1.1% had bleeding that was potentially life-threatening as measured by receipt of a red blood cell transfusion. None died or had bleeding into a critical area. While nonspecific for major bleeding, a drop in hemoglobin concentration correlated with worse envenomation severity: these patients received more vials of antivenom, had a higher medical bill, a longer hospital stay, and were less likely to report full recovery at 90 days. Conclusions A decrease in hemoglobin concentration ≥20 g/L should not be used as evidence of major bleeding for Arizona rattlesnake envenomation studies, but it may have a role as an indirect marker of envenomation severity.

The Effect of Blood Loss on the Hemodynamics of Pediatric Patients Undergoing Simultaneous Bilateral Cochlear Implantation.

Our objectives were to find the mean blood loss volume and the mean hemoglobin decrease in patients undergoing simultaneous bilateral cochlear implant surgery, to determine whether they had clinical effects, and to calculate a minimum weight for pediatric patients that is independent of any age criteria. A retrospective chart review of the pre- and post-operative hemoglobin concentrations and mean blood loss volumes were calculated for children between 12-24 months of age who underwent cochlear implant surgery. A postoperative decline in hemoglobin concentration was found in 67 cases (92%), with a mean difference between the pre- and post-operative values measuring 1.9 g/dL. Preoperative hemoglobin concentrations decreased from 13.4 g/dL to 11.5 g/dL. Mean blood loss volume was 82.3±12 cc. Although simultaneous bilateral cochlear implant surgery is reimbursed by the state for those who are greater than one year of age and who meet the appropriate audiological criteria, our findings suggest that these patients should weigh ≥10 kg to prevent hemodynamic instability due to blood loss during surgery.

THE INFLUENCE OF OCCUPATIONAL FACTORS ON INDICES OF RED BLOOD OF DONORS OF THE INDUSTRIAL CITY

The problem of blood transfusion is closely associated with a reduction in the number of donors - people donating blood voluntarily, which is especially important for the modern industrial city. There was executed the study of the movement of the donation at the enterprises with harmful working conditions in the city of Tyumen. These enterprises with a large number of workers have the stable gain in persons willing to donate blood, but in parallel, there is increasing the number of persons receiving the allotment. In the work there was investigated an influence of occupational factors on indices (hemoglobin concentration, number of red blood cells, ESR, hematocrit, color index ) of the red blood of donors, with taking into account their gender and age. Results of the survey of 4 267 blood donors in 2011-2014 show an increase in the number of medical counterindications for donations, due to changes in red blood indices in persons, working at enterprises with harmful working conditions. In all examined men and women whose work is associated with harmful occupational factors, there was revealed a significant decline in hemoglobin concentration and erythrocyte count. Objective hematologic observations along with subjective assessments of donors of their own health have shown the development of anemic syndrome - one of the main syndromes of lead professional pathology. It is necessary to continue the search for factors contributing to the increase in the share of the withdrawal of donors due to low hemoglobin concentration. It is recommended the supplement of industry reporting with stratified rates of the withdrawal of donors before donation and the development of an algorithm for the rehabilitation of exempted donors. Among the most promising measures for the maintenance and development of the donation at enterprises with harmful working conditions, specific plans for improving health including specific means and conditions for the recovery of the blood system should be developed.

Effect of Angiotensin Converting Enzyme Inhibitors and Angiotensin Receptor Blockers on Kidney Function in Patients with Sickle Cell Disease

Elevated systemic blood pressure and chronic kidney disease are commonly observed in people with sickle cell disease (SCD) and are independent predictors for increased morbidity and early mortality. Based on limited studies with small samples sizes and short durations of follow up, angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) are used to treat SCD patients with elevated urine albumin concentration expressed as albumin-to-creatinine ratio. We conducted a retrospective study to evaluate the effects of ACE-inhibitors and ARBs on urine albumin concentration and systemic blood pressure and to record potential toxicities of these agents in SCD patients receiving their care at the University of Illinois at Chicago. Comparisons of variables from pre-therapy to therapy of 1 year ± 6 months duration were conducted using the paired t-test or repeated measures ANOVA.Between 11/1/2001 and 11/1/2015, 64 patients were prescribed an ACE-inhibitor (n=43) or ARB (n=21) by their treating physician. The median age at the time of prescription was 37 years old (interquartile range 29-49 years), 40% were female, and the majority had hemoglobin SS disease (Hb SS: n=54, Hb SC n=9, Hb Sβ+-thalassemia, n=1).The urine albumin concentration was available both pre-treatment and after 1 year of treatment with ACE-inhibitor or ARB therapy in 29 patients. Trends for decreases in urine albumin concentration (baseline 166±37 mg/g creatinine vs. 1-year 104±28 mg/g creatinine; one-sided P=0.04) (Figure 1A) and systolic blood pressure (baseline 126±2 mmHg vs. 1-year 121±2 mmHg; one-sided P=0.03) (Figure 1B) were observed. The starting dose of the ACE-inhibitor or ARB was a significant predictor of the decrease in urine albumin (P=0.02) and this association persisted after adjusting for hemoglobin SS genotype (P=0.03) or age (P=0.02). Trends for associations between the starting dose and a 50% decline in urine albumin (P=0.09) were also observed. No significant urine albumin changes based on ACE-inhibitor versus ARB therapy or the concomitant use of hydroxyurea or other anti-hypertensive medications were observed.Assessment for toxicity in all 64 patients during the observation period revealed the following. Two patients developed hyperkalemia and 1 developed worsening kidney disease requiring the ACE-inhibitor or ARB therapy to be discontinued. In those that continued therapy, other potential toxicities included trends for a reduction in mean (±SEM) estimated glomerular filtration rate (baseline 126±8 mL/min/1.73m2 vs. 1-year 115±9 mL/min/1.73m2; P=0.1), a decline in hemoglobin concentration (9.1±0.2 g/dL vs. 8.8±0.2 g/dL; P=0.08), and an increase in serum potassium concentration (4.3±0.05 mEq/L vs. 4.4±0.07mEq/L, P=0.04).In conclusion, ACE-inhibitors or ARBs were associated with trends for reduction in urine albumin and systolic blood pressure at 1 year of follow up and the initiating dose may influence the urine albumin response. Toxicities that need to be closely monitored include hyperkalemia and worsening kidney function. Our findings highlight the need for a prospective, randomized study to evaluate the starting dose, efficacy and safety of ACE-inhibitor and ARB therapy in SCD. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Mortality, Hospitalization, and Quality of Life among Patients with Hepatitis C Infection on Hemodialysis.

Hepatitis C virus (HCV) infection is widely prevalent among patients on hemodialysis (HD), but very rarely treated. The aim of our study is to evaluate the burdens of HCV suffered by patients on HD. The Dialysis Outcomes and Practice Patterns Study is an international, prospective, cohort study of patients on HD. We reviewed the HCV status of 76,689 adults enrolled between 1996 and 2015. We compared HCV-positive (HCV+) with HCV-negative (HCV-) patients for risk of mortality, hospitalization, decline in hemoglobin concentration <8.5 g/dl, and red blood cell transfusion. We also compared health-related quality of life scores using the Kidney Disease Quality of Life instrument and the Center for Epidemiologic Studies Short Depression Scale. We adjusted for age, sex, race, years on dialysis, 14 comorbid conditions (including hepatitis B infection), and serum albumin, phosphorus, and creatinine concentrations. A total of 7.5% of patients were HCV+ at enrollment. Serum concentrations of alanine aminotransferase and aspartate aminotransferase were not markedly elevated in HCV+ patients on HD; the mean concentrations were only 22.6 and 21.8 U/L, respectively. Median follow-up was 1.4 years. Case-mix adjusted hazard ratios (95% confidence intervals) for HCV+ versus HCV- patients were 1.12 (1.05 to 1.20) for all-cause mortality, 5.90 (3.67 to 9.50) for hepatic-related mortality, 1.09 (1.04 to 1.13) for all-cause hospitalization, and 4.40 (3.14 to 6.15) for hepatic-related hospitalization. Quality of life measures indicated significantly worse scores for physical function, pain, vitality, mental health, depression, pruritus, and anorexia among HCV+ patients. The adjusted hazard ratio for transfusion was 1.36 (95% CI, 1.20 to 1.55) and incidence of hemoglobin concentration <8.5 g/dl was 1.12 (95% CI, 1.03 to 1.21). Only 1.5% of HCV+ patients received antiviral medication. HCV infection among patients on HD is associated with higher risk of death, hospitalization, and anemic complications, and worse quality of life scores. Internationally, HCV infection is almost never treated in patients on HD. Our data provide a rationale for more frequent treatment of HCV in this population.

Red Cell Aplasia in Chronic Kidney Disease Patient Treated with Erythropoietin : A Case Report

Kidneys are the major source of erythropoietin production, anemia of chronic kidney disease is mainly caused by erythropoietin deficiency. Chronic kidney disease patients are treated with erythropoiesis stimulating agents (epoietin Alfa, epoietin beta), which is considered the gold standard for treatment of anemia in chronic kidney disease patients. One of rare and serious complication in patients treated by erythropoiesis stimulating agents is pure red cell aplasia, which is characterized by rapid decline in hemoglobin concentration of 5-10g/l per week, with normal count of white blood cells and platelets, and absolute reticulocyte count less than 10,000/ml. Pure red cell aplasia is treated by stopping erythropoiesis stimulating agents, cytotoxic drugs and peginesatide.

Decline in serum hemoglobin in the 7 days after cardiac catheterization.

Bleeding is an established complication following cardiac catheterization and lower preoperative hemoglobin concentration is a potentially modifiable risk factor for adverse outcomes after cardiac surgery. However, typical changes in serum hemoglobin concentration after cardiac catheterization are poorly defined. The authors sought to identify the pattern of change in serum hemoglobin concentration within 7 days after cardiovascular catheterization, factors associated with this change and any association with adverse outcomes. Retrospective observational study over a 1-year period. U.S. academic medical institution. Participants were 284 adult patients with baseline hemoglobin concentration≥12 g/dL undergoing nonemergent cardiac surgery after cardiovascular catheterization via the femoral arterial route. None. Lowest daily hemoglobin concentration was recorded where available for up to 7 days after catheterization and before surgery. Generalized estimating equations identified the pattern of change in serum hemoglobin while regression models identified factors associated with hemoglobin decline. Following cardiovascular catheterization average serum hemoglobin declined over time, reaching a nadir 1.4 g/dL (95% CI 1.0-1.8) below baseline 6 days after catheterization. A higher baseline hemoglobin concentration and lower body mass index were associated with greater maximal decline in hemoglobin concentration after catheterization. Acute preoperative hemoglobin decline was not associated with acute kidney injury (AKI) or a composite adverse outcome that may reflect organ ischemia. In a cohort of patients before cardiac surgery serum hemoglobin declines during the week after cardiac catheterization, with maximal average decline observed 5 to 7 days after catheterization.

Investigation of the role of interleukin-6 and hepcidin antimicrobial peptide in the development of anemia with age

Anemia is common in older adults and associated with adverse health outcomes in epidemiological studies. A thorough understanding of the complex pathophysiological mechanisms driving anemia in the elderly is lacking; but inflammation, iron restriction, and impaired erythroid maturation are thought to influence the phenotype. We hypothesized that interleukin-6 contributes to this anemia, given its pro-inflammatory activities, its ability to induce hepcidin antimicrobial peptide, and its negative impact on several tissues in older adults. We tested this hypothesis by comparing changes in indices of inflammation, iron metabolism and erythropoiesis in aged C57BL/6 mice to aged mice with targeted deletions of interleukin-6 or hepcidin antimicrobial peptide. Circulating neutrophil and monocyte numbers and inflammatory cytokines increased with age. Decline in hemoglobin concentration and red blood cell number indicated that C57BL/6, interleukin-6 knockout mice, and hepcidin antimicrobial peptide knockout mice all demonstrated impaired erythropoiesis by 24 months. However, the interleukin-6 knock out genotype and the hepcidin antimicrobial peptide knock out genotype resulted in improved erythropoiesis in aged mice. Increased erythropoietic activity in the spleen suggested that the erythroid compartment was stressed in aged C57BL/6 mice compared to aged interleukin-6 knockout mice. Our data suggest C57BL/6 mice are an appropriate mammalian model for the study of anemia with age. Furthermore, although interleukin-6 and hepcidin antimicrobial peptide are not required, they can participate in the development of anemia in aging mice, and could be targeted, pre-clinically, with existing interventions to determine the feasibility of such agents for the treatment of anemia in older adults.

Association between virological response and decline in hemoglobin concentration during pegylated interferon and ribavirin therapy in HCV genotype 1: another story

We read with great interest the article in Hepatology by Sievert et al.,1 which retrospectively evaluated the CHARIOT study of 871 treatment-naive patients who were infected with hepatitis C virus (HCV) genotype 1 (HCV-1) to determine whether hemoglobin decline is associated with sustained virological response (SVR) achieved through pegylated interferon (PegIFN) and ribavirin treatment. With 16% of patients developing anemia (serum hemoglobin <100 g/L) and 76% of patients developing a hemoglobin decline of >30 g/L from baseline, SVR rate was higher in anemic patients compared to those without anemia (61% versus 50%, respectively; P = 0.02). The authors concluded that the development of anemia or experience of a decline in hemoglobin of >30 g/L predicts better SVR in HCV-1 patients who receive PegIFN/ribavirin treatment which has also been reported in the post hoc analysis of the IDEAL study by Sulkowski et al. (74%).2 We examined the 100 Taiwanese HCV-1 patients who received 48-week PegIFN/ribavirin treatment in our randomized trial that enrolled a total of 200 patients.3 The means (±standard deviations) for baseline, lowest, and decline of hemoglobin levels were 146 ± 14 g/L, 103 ± 17 g/L, and 42 ± 14 g/L, respectively. We found 45% of patients developed anemia (serum hemoglobin <100 g/L) and 78% developed hemoglobin decline of >30 g/L from baseline. With 79 patients (79%) achieving SVR, the SVR rate was similar between patients with and without anemia (77.8% versus 80%, P = 0.786). Also, the SVR rate in patients with hemoglobin decline >30 g/L was similar compared to patients without hemoglobin decline >30 g/L (78.2% versus 81.8%, P = 1.000). The means (±standard deviations) for baseline, lowest, and decline of hemoglobin level were similar between patients with and without SVR (146 ± 13 g/L versus 143 ± 15 g/L, P = 0.286; 104 ± 17 versus 102 ± 19 g/L, P = 0.670; 43 ± 14 versus41 ± 14 g/L, P = 0.600). The treatment-related anemia seems to play a minimal role in predicting SVR in Taiwanese patients infected with HCV-1. We showed the percentage of hemoglobin decline >30 g/L (78%) in Taiwanese patients who received PegIFN/ribavirin treatment without erythropoietin was similar to reports by Sievert et al. (76%) and Sulkowski et al. (74%). Nevertheless, we reported a higher percentage (45%) of anemia (serum hemoglobin <100 g/L) in Taiwanese patients than that reported by Sievert et al. (16%)1 and Sulkowski et al. (29%).2 In addition to the lack of erythropoietin use in our study, another major reason for the higher rate of ribavirin-related anemia may be due to the significantly lower body weight (67.5 kg) of our patients than those of Sievert et al. (77.9 kg) and Sulkowski et al. (83.4 kg), leading to relatively higher initial ribavirin exposure (up to 15 mg/kg body weight/day).2 The high ribavirin exposure—just as the water that bears the boat is the same that swallows it up—may induce more anemia during treatment but leads to a higher SVR rate. In addition, the recent novel finding showed Asian patients have the highest frequency of the advantageous genotype in the gene region encoding interleukin-28B (IL-28B, also called IFNλ3), which is a very strong predictor of treatment response.4 We have recently conducted a large-scale study5 to test 552 Taiwanese HCV-1 patients; of these, 469 (85.0%) have favorable rs8099917, located ∼8 kilobases upstream of the IL-28B TT genotype, which enhances the treatment outcome in HCV-1 infection6, 7 and is associated with the rapid virological response in HCV genotype 2 infection in Taiwanese patients.8 Taken together, it is not difficult to understand why Taiwanese HCV-1 patients have a high SVR rate with PegIFN/ribavirin therapy. We consider that such a good response in Taiwanese HCV-1 patients might also possibly contribute to minimizing the role of anemia on predicting the treatment outcome shown by Sievert et al.1 and Sulkowski et al.,2 and further studies are needed. Chia-Yen Dai M.D., Ph.D.* , Chung-Feng Huang M.D., M.S.* ¶, Jee-Fu Huang M.D.* § **, Wan-Long Chuang M.D., Ph.D.* §, Ming-Lung Yu M.D., Ph.D.* § ¶, * Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, Hepatobiliary Division, Department of Occupational Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, § Faculty of Internal Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ¶ Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan, ** Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan.

Virological response is associated with decline in hemoglobin concentration during pegylated interferon and ribavirin therapy in hepatitis C virus genotype 1

Anemia may increase the likelihood of achieving a sustained virological response (SVR) during pegylated interferon and ribavirin treatment of hepatitis C virus (HCV) infection. To determine whether hemoglobin decline is associated with SVR, we retrospectively evaluated the CHARIOT study of 871 treatment-naïve HCV genotype 1 patients. Anemia (serum hemoglobin <100 g/L) occurred in 137 (16%) patients, of whom only 14 (10%) received erythropoietin. Hemoglobin decline >30g/L from baseline occurred in 76% of patients overall, including 526 patients who did not become anemic. Virological responses were higher in anemic patients compared with those who did not develop anemia (end of treatment, 80% versus 65%, P = 0.003; SVR, 61% versus 50%, P = 0.02); these differences remained significant when patients receiving erythropoietin were excluded from analysis. SVR was also higher in patients with hemoglobin decline >30 g/L compared with patients without a similar decline. In multiple logistic regression analyses with treatment group and baseline characteristics, the odds ratio for SVR was 1.97 (95% confidence interval, 1.08-3.62) for anemia and 2.17 (95% confidence interval, 1.31-3.62) for hemoglobin decline >30 g/L. Patients who first developed a hemoglobin decline >30 g/L during weeks 5-12 and 13-48 were more likely to achieve SVR than those who first developed such changes in weeks 0-4 or who never experienced them. Patients with HCV genotype 1 infection who develop anemia or experience a hemoglobin decline >30 g/L during weeks 5-48 of therapy achieve higher virological responses to pegylated interferon and ribavirin therapy that are unrelated to erythropoietin use.

Obturator Artery Injury after Hip Fracture Surgery

We present the case of a 55-year-old woman who sustained a left femoral neck fracture which was managed by insertion of a dynamic hip screw. Six hours after surgery, distension appeared in the left lower quadrant of her abdomen associated with a decline in haemoglobin concentration and clinical signs of ongoing bleeding. Computed tomography showed a left retroperitoneal mass without concomitant extravasation of contrast material. Exploratory laparotomy revealed a damaged left obturator artery with a large haematoma in its vicinity. After arterial ligation and retroperitoneal space decompression her postoperative course was uneventful. Reviewing intraoperative C arm images a 0.8 cm protrusion of the threaded guide wire was identified as the cause of obturator artery damage.

Highlights of This Issue

The incidence rates of HCC among male Asian Americans and Pacific Islanders (API) is almost twelve times the incidence rates for non-Hispanic White men. To explore this disparity, Kwong and colleagues analyzed data from Californians of Asian ancestry with HCC. They report that cause-specific mortality was significantly higher among Laotian/Hmong and Cambodian patients. Both of these groups also had higher proportions of their populations at low socioeconomic status and Laotian/Hmong patients presented at later stages of disease. Therefore, Kwong and colleagues adjusted for time period of diagnosis, age at diagnosis, gender, geographic region, stage at diagnosis, type of surgery, and socio-economic status and found that HCC survival disparities remained for Laotian/Hmong and Cambodian patients. This study highlights the need for community-based interventions that target Laotian/Hmong and Cambodians for programs that can detect and manage HCC.Among US whites, melanoma incidence rates are higher among persons with college educations or high household incomes compared with those in the lowest categories of education or income. In addition, residing at lower latitude is often correlated with increased exposure to ultraviolet radiation (UVR). Because high SES populations often co-locate in areas of high UVR, Clarke and colleagues assessed the joint influences of SES and UVR on melanoma occurrence. They report that UVR exposure was significantly and positively associated with melanoma incidence among persons living in the top 40% (by SES) of California neighborhoods. Melanoma prevention and early detection efforts should target these high SES populations in areas of high UVR exposure.There is continued debate regarding the risks and benefits of mammography for women in their forties. Disadvantages of screening include false-positive results, or the recall of women for further investigations that do not result in a diagnosis of breast cancer. Reported false-positive rates vary widely in women aged 40 to 64. In this study, Cuckle and colleagues analyzed attendance and screening outcome data for the intervention arm of the UK Age trial. The study found that false-positive rates for women aged 40 to 48 were significantly lower than many reported rates for US women under 50. In addition, Cuckle and colleagues report that false-positive results did not discourage further screening; 89% of women experiencing false-positive screens continued with routine screening. These important findings refute the increased false-positive rates reported for women under 50.Exercise intervention could help counteract the decline in hemoglobin concentration [Hb] often observed in breast cancer patients undergoing chemotherapy. To explore this, Dolan and colleagues monitored [Hb] and aerobic fitness in breast cancer patients receiving supervised exercise training to determine if exercise influenced [Hb] in these patients. The authors report that [Hb] declined over the course of chemotherapy, regardless of exercise. There were also moderate correlations between the change in aerobic fitness and [Hb]. This study indicates that regular exercise does not protect against the decline in [Hb] associated with chemotherapy in breast cancer patients.

α+‐Thalassemia Protects against Anemia Associated with Asymptomatic Malaria: Evidence from Community‐Based Surveys in Tanzania and Kenya

In hospital-based studies, alpha(+)-thalassemia has been found to protect against severe, life-threatening falciparum malaria. alpha(+)-Thalassemia does not seem to prevent infection or high parasite densities but rather limits progression to severe disease--in particular, severe malarial anemia. We assessed to what extent alpha(+)-thalassemia influences the association between mild, asymptomatic Plasmodium falciparum infection and hemoglobin concentration. The study was based on 2 community-based surveys conducted among afebrile children (0.5-8 years old; n=801) in Kenya and Tanzania. Among children without inflammation (whole-blood C-reactive protein concentration <or=10 mg/L), P. falciparum infection was associated with only small reductions in hemoglobin concentration, and effects were similar across alpha-globin genotypes. By contrast, the reduction in hemoglobin concentration associated with P. falciparum infection accompanied by inflammation was larger and strongly depended on genotype (normal, -21.8 g/L; heterozygous, -16.7 g/L; and homozygous, -4.6 g/L). Relative to children with a normal genotype, this difference in effect was 5.1 g/L (95% confidence interval [CI], -1.0 to 11.1 g/L) for heterozygotes and 17.2 g/L (95% CI, 8.3 to 26.2 g/L) for homozygotes (estimates are adjusted for study site, age, height-for-age z score, and iron deficiency). alpha(+)-Thalassemia limits the decline in hemoglobin concentration that is associated with afebrile infections, particularly those that are accompanied by inflammation.

Tolerance of Acute Anemia: The Anesthesiology Perspective

SUMMARY Anesthesiologists have to face anemia in a variety of surgical interventions and have had the challenge of assuring positive patient outcomes. As such, treatment of acute anemia has traditionally resulted in increased exposure to allogeneic blood transfusions. Enhancing our knowledge of the hemoglobin molecule, its functions and reserve, allows the anesthesiologist to utilize compensatory mechanisms to achieve a positive outcome, with the reduction or elimination of patient's exposure to allogeneic blood transfusions. Since the inception of anesthesiology as a medical specialty, one of the most important issues for anesthesiologists has been oxygen delivery and consumption. Anemia has been a long-time challenge for the anesthesiologist. Anemia is defined as a decline of hemoglobin concentration or hematocrit. During acute normovolemic anemia, compensatory mechanisms are elicited at both the macrocirculatory (systemic) and microcirculatory level. Acute normovolemic hemodilution (ANH) is the intentional dilution of blood (a state of anemia) caused by controlled withdrawal of surgical patient's blood for reinfusion within 8 hours during and following surgical blood loss. This technique provides fresh whole blood for transfusion and avoids the pitfalls of predonated blood. ANH is an iatrogenic condition where dilutional anemia is used to the advantage of a patient for blood conservation, i.e. as an alternative for allogeneic blood transfusion. The effects of ANH-induced anemia on various organ systems and functions are discussed in addition to the effect of anesthesia and anesthetic depth.

Insulin-like Growth Factor-Binding Protein 3 and Hemoglobin Concentration in Older Persons Living in the Community

A decreased hemoglobin concentration is a common clinical condition in elderly subjects, and in at least 20% of the cases it is not possible to directly attribute the anemia to specific factors. The aim of the present study was to evaluate the relationship of different levels of insulin-like growth factor-binding protein 3 (IGFBP-3) with the blood concentration of hemoglobin in persons aged 80 years and older. Data are from a baseline evaluation of the Aging and Longevity in the Sirente Geographic Area (ilSIRENTE) study (n=253). Analysis of covariance was used to examine the effect of different IGFBP-3 levels on hemoglobin concentration. After adjustment for potential confounding variables, which included age, sex, number of diseases, renal failure, cancer, gastric ulcer, albumin, and iron concentrations, individuals in the group with higher IGFBP-3 concentrations showed a significantly higher mean hemoglobin concentration than participants in the group with lower IGFBP-3 concentrations (13.4 +/- 1.4 g/dL versus 12.9 +/- 1.9 g/dL, respectively; P=.03). In conclusion, the present study has shown that a higher IGFBP-3 level is associated with a higher hemoglobin concentration among older people living in the community. This finding suggests that the growth hormone/IGF axis may play an important role in hematopoiesis, and it may be implicated in the age-related decline in hemoglobin concentration.

Therapeutic Efficacy of a Single Dose of Anti-D Immunoglobulin 50µg/kg in Childhood Acute Immune Thrombocytopenic Purpura

Methods: We serially evaluated the platelet count in 21 acute ITP patients that were treated with anti-D immunoglobulin (50μg/kg) to determine how many patients achieved platelet counts over the levels of 20×10 3 /mm 3 , 50×10 3 /mm 3 and 100×10 3 /mm 3 after the infusion of anti-D immunoglobulin. In addition, constitutional symptoms were monitored and changes in the hemoglobin levels were serially evaluated. Results: By three days after treatment, 90.5% of the patients had achieved a platelet count over 20× 10 3 /mm 3 . At seven days after treatment, 66.7% of patients achieved a platelet count of 50×10 3 /mm 3 . In addition, at seven days after treatment 61.9% of patients achieved a platelet count of 100×10 3 /mm 3 . Constitutional adverse symptoms were observed 61.9% of patients, and the symptoms diminished spon- taneously without any severe sequelaes. The decline of hemoglobin concentration after treatment recovered to the initial level after two weeks. Conclusion: A single dose of anti-D immunoglobulin (50 μg/kg)was effective in Korean children with acute ITP to raise the platelet count rapidly. The adverse effects of anti-D immunoglobulin, including hemolytic anemia, were not severe to prevent the use of the anti-D. (Korean J Hematol 2007;42:258-263.)

Hematuria and Hemoglobinuria in Pediatric Patients Diagnosed with Newly Diagnosed Immune Thrombocytopenic Purpura.

With the recent popularity of anti-D immune globulin for the treatment of immune thrombocytopenic purpura (ITP) has come an uncommon observation of hemoglobinuria and presumed intravascular hemolysis (IVH) during or after treatment. Rarely, IVH has led or contributed to severe acute renal failure, disseminated intravascular coagulation and death. The mechanism of IVH is unknown but may involve a particular predisposition of the patient to aggravated or exaggerated hemolysis. Analysis of two reports by Gaines (Blood 2000; 95:2525–9; Blood 2005; 106:1415–21), and others suggest that a considerable proportion of patients with IVH have had comorbid conditions, including myelodysplasia, hematologic malignancy, suspected autoimmune disease or acute infections associated with hemolysis. From a recent prospective randomized trial in children with newly diagnosed ITP (Tarantino, et al J Pediatr 2006; 148:489–94), we studied the impact of preexisting hematuria or presumed hemoglobinuria on treatment outcome and adverse events related to hemolysis. In the clinical trial, children with newly diagnosed ITP were randomized to receive either anti-D immune globulin (either 50 μg/kg [anti-D50] or 75μg/kg [anti-D75], once) or IVIg (0.8g/kg once). The mean decline in hemoglobin concentration on day 7 following treatment was 1.6 g/dL, 2.0 g/dL and 0.2 g/dL, respectively. No patients were observed to have frank hematuria or hemoglobinuria following anti-D or IVIg treatment. However, the maximum decline in hemoglobin concentration (measured on day 7 after treatment) was 5.5 g/dL, 5.2 g/dL and 2.6 g/dL in the anti-D 50, anti-D75 and IVIg groups, respectively. Pretreatment analysis of urine revealed that 24 of 91 (9 male, 15 female) patients had a positive dipstick for at least trace blood. The age of patients with a heme-positive and heme-negative urine dipstick was not significantly different. Seventy-seven (85%) had a microscopic analysis performed. Of those that were dipstick positive for blood, 56% (13/24) were positive for the presence of red blood cells (RBCs), defined as greater than three RBC/high power field (HPF), 44% had 3 or less red blood cells present. One patient had moderate blood and 2+ bacteria on the dipstick, 15–19 RBC per high power field. The decline in hemoglobin concentration 7 days after treatment was not significantly influenced by pretreatment hematuria or hemoglobinuria. The mean decline in hemoglobin was 1.49 g/dL in patients with a heme-positive urine dipstick (including one patient with a 5.5g/dL decline in hemoglobin), 1.26 g/dL in patients with heme-negative urine and 1.2 g/dL in patients with hematuria (>3 RBCs/HPF). The decline in hemoglobin at 7 days did not differ significantly between the anti-D treated groups among patients with heme-positive urine before treatment. Patients were less likely to have a positive platelet response (platelet count >20 × 109/L) at 24 hours and at 7 days (>50 × 109/L) if RBCs were present in the pretreatment urine, p = 0.05 and 0.03, respectively. Similarly, patients were less likely to have a positive platelet response at 24 hours and at 7 days if the pretreatment urine dipstick was heme-positive, p = 0.03 and 0.03, respectively. Pretreatment hematuria or presumed hemoglobinuria was not a predictor of hemoglobin decline following anti-D or IVIg treatment in children with newly diagnosed ITP but was associated with a poorer platelet response to treatment.

Effect of presurgical local infiltration of levobupivacaine in the surgical field on postsurgical wound pain in laparoscopic gynecological surgery

To maintain a high standard of patient care, it is essential to provide adequate pain management in patients who undergo laparoscopic surgery. We randomly enrolled 74 women who underwent laparoscopic surgery for gynecological benign diseases. Patients in the levobupivacaine group (n=37) were injected with 7 ml of 5 mg/ml levobupivacaine at all incisional areas patients in the control group (n=37) were injected with an equal volume of physiologic saline solution. In the postoperative period the following variables were assessed for each group: decline of hemoglobin concentration, consumption of analgesics, time of ambulation, length of postoperative ileus, length of postoperative hospital stay, and VAS scores at 6, 12, and 24 h after surgery. Mean pain intensity at 6 and 12 h after surgery was significantly lower in the levobupivacaine group than in the control group (p<0.01). Analgesic requirement was significantly lower (p<0.01) in the levobupivacaine group (0.3 phial+/-0.2) than in the control group (2.1 phial+/-1.0). The mean time of ambulation was significantly lower (p<0.05) in the levobupivacaine group (16+/-4) than in the control group (22+/-6). No significant difference was observed between the two groups in mean pain intensity 24 h after surgery, decline of hemoglobin concentration, length of postoperative ileus, or length of postoperative hospital stay. Our results suggest that presurgical infiltration of levobupivacaine in addition to general anesthesia and standard analgesic therapy significantly decreases the intensity of postsurgical pain, especially for the first 12 h after surgery, and reduces analgesic consumption after surgery.

Apparent hemolysis following intravenous antithymocyte globulin treatment in a patient with marrow failure and a paroxysmal nocturnal hemoglobinuria clone

Antithymocyte globulin (ATG) is a commonly used medication in the treatment of aplastic anemia. Although serum sickness has been described with the use of ATG, few cases of acute intravascular hemolysis have been reported. We report a case of apparent ATG-related hemolysis in a patient with aplastic anemia and a paroxysmal nocturnal hemoglobinuria (PNH) clone. A 62-year-old, group A, RhoD+ man with aplastic anemia and an 11.6 percent glycosylphosphatidylinositol (GPI)-anchored protein-negative population of red cells (RBCs), representing approximately 190 mL of his RBC volume, and 90 percent GPI-negative neutrophils were scheduled to receive equine ATG at 40 mg per kg per day for 4 days. After the first infusion, he developed a 1.6 g per dL decline in hemoglobin concentration and an increase in serum lactate dehydrogenase (normal, 113-226 U/L) from 284 to 1127 U per L. The hemolytic process was complicated by acute renal failure characterized by an increase in serum creatinine from 0.9 to 4.2 mg per dL and the appearance of dark-colored urine. Pre- and post-ATG direct antiglobulin tests were negative. The temporal association of intravenous ATG to lysis of complement-sensitive RBCs suggests a causal relationship. Although intravascular hemolysis after ATG administration appears to be uncommon, the clinical consequences may be severe, and determining the pathophysiology may yield clues to the mechanism of intravascular hemolysis.

Optimal anemia management reduces cardiovascular morbidity, mortality, and costs in chronic kidney disease

Anemia is a frequent complication of chronic kidney disease, occurring in over 90% of patients undergoing renal replacement therapy. The pathogenesis of the anemia of chronic kidney disease is multifactorial, but the predominant and most consistent cause is the failure of adequate production of endogenous erythropoietin (EPO) by the kidneys. Anemia is seen early in the course of chronic kidney disease, the decline in hemoglobin concentration starting at levels of creatinine clearance of around 70 mL/min among men and 50 mL/min among women1. The fundamental impact of anemia on organ function is reduced oxygen delivery to tissues. Fatigue and effort intolerance are the cardinal symptoms, but other consequences such as impaired cognitive function and concentration, sleep disorders, altered hemostasis, depressed immune function, and impaired cardiac function are not uncommon.