Fall In Hemoglobin Level Research Articles

Clinical predictors of arterial extravasation, rebleeding and mortality following angiographic interventions in gastrointestinal bleeding.

The aim of this study was to identify clinical and imaging predictors of arterial extravasation, post embolization rebleeding and 30-day mortality in gastrointestinal (GI) bleeding. This retrospective study included 114 patients who underwent angiography for upper or lower GI bleeding. Multivariate logistic regression was used to identify clinical and imaging predictors. Angiography demonstrated arterial extravasation in 22 patients (19%) and embolization was performed in 48 (42%) patients including prophylactic embolization in 26 (56%). Fall in hemoglobin level from baseline was an independent predictor of arterial extravasation with 65% increased odds for every unit drop (OR 1.65, 95%CI 1.13-2.40, p=0.01). Age <60 years was a negative predictor of rebleed within 30-days (OR 0.94, 95%CI 0.89-1.00, p=0.04). Patients with a history of malignancy were more likely to rebleed (OR 4.4, 95%CI 1.06-18.36, p=0.04). Hemodynamic instability prior to angiography (OR 13.22, 95%CI 1.65-106.07, p=0.02), history of malignancy (OR 1.36, 95%CI 1.49-10.49, p=0.01), number of units of platelets transfused (OR 1.42, 95%CI 1.02-1.97, p=0.04) and rebleed after angiography (OR 46.8, 95%CI 4.80-456.14, p<0.01) were predictors of 30-day mortality. Prophylactic embolization was not a predictor of rebleed or 30-day mortality. This paper identified important clinical predictors of arterial extravasation, rebleed and 30-day mortality in GI bleedings, which will assist in patient selection and help to improve the overall angiographic management of GI bleeding.

Frequency of Anemia and Obstetric Outcome in Young Primigravida

Pregnancy and childbirth is an event celebrated worldwide. During pregnancy physiological changes and increasing demand causes fall in hemoglobin level leading to anemia and adverse pregnancy outcome especially in young girls. Anemia is a major public health problem. Around 58.27 million women worldwide are anemic during pregnancy 95% of whom live in countries that are developing. To know the frequency of anemia, and obstetric outcome in terms of preterm delivery, low birth weight and rate of caesarean section in young Primigravida. It was a cross sectional study, conducted in the department of Gynae &amp; Obstetric unit 5 King Edward Medical University Lahore during a period of one year from May2013 April 2014. All primigravida young 15-24years with anemia enrolled for the study. Anemia is defined as hemoglobin&lt; 10.5g/dl (WHO Criteria), Iron deficiency Anemia is defined as serum ferritin level less than 12 micro gram per ml and on Red Blood Cell indices, i.e. decrease in MCV, MCH and MCHC, and Microcytic Hypochromic cells in Peripheral Smear. Megaloblastic anemia was labeled when Macrocytic Hypochromic cells seen. Obstetric outcome in terms of Preterm delivery defined as delivery at &lt;37 weeks of gestation (36 +6 weeks) and birth weight &lt;2500g mand a need for operative delivery. Patients fulfilling the selection criteria as per operational definition were included in the study after taking informed consent using non probability consecutive sampling technique. Data was collected on a pre-designed questionnaire. A total of 3855 deliveries during study period in which 1318 were primigravida. Mean age in study group was 15 to 24 years. We observed mild anemia in 46% of woman, moderate anemia in 41% and severe anemia in 13% in young primigravida. Preterm delivery was noted in 25% of the females and low birth weight babies were noted by 33% in teenage and young primigravida. Statistically significant relationship was found between maternal age, education and socio economic status. Anemia in pregnancy nowadays is still a common problem in adolescent and young primigravida and associated with adverse pregnancy outcome. Prompt measure should be taken by the stake holders at local and national level to prevent and treat this problem in order to reduce morbidity and mortality associated with it.

Randomized controlled trial of rectal misoprostal and intramuscular oxytocin in the prevention of PPH

Background: PPH accounts for merely 23% of maternal mortality in developing countries. Misoprostol is a uterotonic agent and is a PGE analogue commonly used in management of PPH. Oxytocin is another uterotonic agent which is now been introduced as intramuscularly effective agent to prevent PPH.This study aims to compare rectal misoprostol with intramuscular oxytocin in reducing blood loss in third stage of labor to prevent PPH. Objective of present study is to compare the clinical effect of rectal misoprostol with intramuscular oxytocin in prevention of PPH.Methods: A randomized study was conducted over duration of 3 months, at Department of OBG, BRIMS, Bidar, Karnataka, India. Patients with singleton pregnancy with the history of one previous LSCS and opting for elective LSCS were included in the study. Patients with risk pregnancy, such as pre eclampsia, cardiac disease and asthma or grand multipara were excluded from the study. Immediately after spinal anesthesia rectal misoprostol was given while oxytocin was administered after delivery of the baby. Incidence of PPH and amount of blood loss was observed and compared.Results: The difference in both the groups with regard to mean amount of blood loss, mean duration of the third stage of labor, and mean amount of fall in hemoglobin level was not statistically significant as P value was &gt;0.05. The incidence of PPH and the need for additional oxytocic are slightly more in the misoprostol group. The incidence of shivering and pyrexia was more in the misoprostol group, but not so disturbing so as to lead to disuse of this drug.Conclusions: Oral misoprostol, though not a replacement of parenterally administered oxytocin, can be used safely in all deliveries for the prevention of postpartum hemorrhage.

Comparative study of cemented hemiarthroplasty with or without close suction drain

A drain is device used to prevent collection of fluids in a cavity or closed space, but retropulsive infection can contaminated this clean surgical wound from the drain. The study was conducted between 1stApril 2013 and 31stMarch 2014, in 62 patients who underwent cemented Hemiarthroplasty of hip for fracture neck femur. 12 patients having pre-existing medical/cardiac co morbidities were excluded from the study. The randomization of patients was made by placing even and odd values in a computer-generated table of randomized numbers. We observe Post-operative 3rd day fall in Hematocrit value, Hemoglobin level and infection rate. Analysis of our study showed no significant difference with respect to fall in hemoglobin levels, MCHC levels and infection rate between the patients who had drains after the operation and the ones without drains.-Using drain in cemented Hemiarthroplasty surgeries for neck femur fracture is not showing any statistically significant advantage over not using it, although there is potential risk of retrograde migration of infection.

Analysis of the Hemoglobin Level Drop in Patients with Hip Fracture After Admission.

The studies that evaluated blood loss during hip surgery found a relatively small loss that does not explain the large hemoglobin drop postoperatively. The aim of this study was to determine the fall in hemoglobin level after admission and rehydration in patients with hip fractures and to identify the patients that need blood transfusion. This retrospective study included data on 374 patients with hip fracture with surgery delayed by more than 24 hours and complete blood count repeated prior to surgery after fluid resuscitation for a minimum of 24 hours. The hemoglobin level (g/L) was analyzed after admission and after rehydration. The results were compared by Student's t-test. The mean hemoglobin drop was 6.1 g/L, 12.05 g/L and 16.52 g/L for capsular, pertrochanteric and subtrochanteric fractures, respectively. This hemoglobin drop was statistically significant in all frac-ture types. The significant drop of preoperative hemoglobin should be taken in consideration when planning transfusion for hip fracture patients. Collection of blood sample after rehydration preopera-tively would enable prompt diagnosis and treatment of anemia in these patients, along with proper transfusion planning and cross-matching.

The Effectiveness and Safety of Direct Oral Anticoagulants (DOACs) Vs. Traditional Anticoagulants in Patients with Cirrhosis

Introduction: The coagulopathy associated with cirrhosis is complex and places patients at risk for both bleeding and thrombosis. Direct oral anticoagulants (DOACs) have been shown to have superior efficacy and safety compared to vitamin K antagonists; however their efficacy and safety in cirrhotic patients is not clear. The aim of this study is to retrospectively compare the effectiveness and bleeding complications of DOACs as compared to traditional anticoagulants in cirrhotic patients.Methods: This study was a retrospective review of patients treated at a single academic center between 2012-2015 who were prescribed a DOAC (apixaban or rivaroxaban), or a traditional anticoagulant (warfarin or low molecular weight heparin), with an ICD-9 code for the diagnosis of cirrhosis. The primary outcomes of interest are recurrent thrombosis or stroke (efficacy failure), or bleeding events (safety failure). Major bleeds were characterized as fatal bleeding, symptomatic bleeding in critical organ area, or bleeding causing a fall in hemoglobin level >2 or leading to transfusion of 2+ units of packed red blood cells.Results: During the study period, 27 cirrhotic patients were prescribed a DOAC and 18 were prescribed a traditional anticoagulant (either LMWH or warfarin). Both groups had similar total bleeding events (8 DOAC vs. 10 traditional anticoagulation, p = 0.12). There were significantly less major bleeding episodes in the DOAC group, (1 (4%) vs. 5 (28%), p = 0.03) and less intracranial bleeding (3 (17% ) vs. 0 (0%) p=0.06). Recurrent thrombosis or stroke occurred in 1 (4%) patient in the DOAC group and 1 (6%) patient in the traditional group (p = 1.0).Conclusions: Anticoagulation with DOACs in cirrhotic patients may be as safe as traditional anticoagulants with respect to bleeding events. Patients with cirrhosis at our center prescribed DOACs had less major bleeding events, while maintaining efficacy at preventing stroke or recurrent thrombosis. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Nitric Oxide-Dependent Endothelial Dysfunction and Reduced Arginine Bioavailability in Plasmodium vivax Malaria but No Greater Increase in Intravascular Hemolysis in Severe Disease.

Pathogenesis of severe Plasmodium vivax malaria is poorly understood. Endothelial dysfunction and reduced nitric oxide (NO) bioavailability characterize severe falciparum malaria, but have not been assessed in severe vivax malaria. In patients with severe vivax malaria (n = 9), patients with nonsevere vivax malaria (n = 58), and healthy controls (n = 79), we measured NO-dependent endothelial function by using reactive hyperemia-peripheral arterial tonometry (RH-PAT) and assessed associations with arginine, asymmetric dimethylarginine (ADMA), and hemolysis. The L-arginine level and the L-arginine to ADMA ratio (a measure of L-arginine bioavailability) were reduced in patients with severe vivax malaria and those with nonsevere vivax malaria, compared with healthy controls (median L-arginine level, 65, 66, and 98 µmol/mL, respectively [P = .0001]; median L-arginine to ADMA ratio, 115, 125, and 187, respectively [P = .0001]). Endothelial function was impaired in proportion to disease severity (median RH-PAT index, 1.49, 1.73, and 1.97 in patients with severe vivax malaria, those with nonsevere vivax malaria, and healthy controls, respectively; P = .018) and was associated with the L-arginine to ADMA ratio. While the posttreatment fall in hemoglobin level was greater in severe vivax malaria as compared to nonsevere vivax malaria (2.5 vs 1 g/dL; P = .0001), markers of intravascular hemolysis were not higher in severe disease. Endothelial function is impaired in nonsevere and severe vivax malaria, is associated with reduced L-arginine bioavailability, and may contribute to microvascular pathogenesis. Severe disease appears to be more associated with extravascular hemolysis than with intravascular hemolysis.

Hematological spectrum in patients with alcoholic liver cirrhosis: a model of end-stage liver disease score based approach

Background: Patients with alcoholic liver cirrhosis have anaemia, leucocytosis as well as leukopenia and thrombocytopenia in various proportions, which are, to a greater extent, determine mortality and morbidity among them. There is a growing need of a scale to determine the stages at which these hematological parameters could be corrected so as to decrease their adverse impacts on the patients’ lives. The model of end-stage liver disease (MELD) score is built to predict survival in cirrhotic patients undergoing transplantation and to assign priority for liver transplantation. To simplify the task of early identification and management of patients with deranged blood indices, we studied the relationship between various hematological parameters and MELD score. Methods: This was a prospective observational study in which spectrum of various hematological indices and complications of alcoholic liver disease were observed in 88 patients with stigmata of chronic liver failure on clinical examination substantiated by histopathological evidence and imaging. Hematological parameters including anaemia, leukocyte count and platelet count were assessed in the subjects and were categorized under the different groups of MELD score. The relationship of these variables with MELD score was studied and statistical analysis was done. Results: We observed a progressive fall in hemoglobin levels with the increase in MELD score. All the patients in group 1 had normal leukocyte count. Leukocytosis predominated in MELD group 2 and 3 patients. In group 4, leukopenia was more prevalent. All the patients in group 5 had leukopenia. Group 1 and 2 patients did not have thrombocytopenia. Thrombocytopenia started occurring in MELD group 3 patients, while involving all the patients of group 4 and 5. Conclusions: The statistically significant association between the variables and the groups shows that MELD score grouping system could be an important tool in the assessment of these patients. This association strongly depicts that the clinicians could effectively apply the classification in predicting the hematological complications in these patients and take precautions early in preventing the further progression of the disease thus decreasing the mortality in these patients.

The study of clinical, biochemical and hematological profile in malaria patients

Background: Malaria is a major health problem in India. Malaria is the most important parasitic infection which causes major health challenges. Malaria pathogenesis is based on extensive changes in hematological and biochemical parameters. The objective of this study was to study the clinical features, hematological and biochemical parameters in malaria patients and correlate them. Methods: The present study was done in the department of medicine, M.G.M.M.C & M.Y.H. Indore (M.P.). In this study various signs and symptoms and frequency of changes in hematological and biochemical parameters caused by Plasmodium species were determined. Mean, standard deviation, minimum, maximum values of laboratory alterations were noted and associations were calculated. Results: 104 patients who had peripheral smear positive for malaria parasite were included in this study. Out of these 104 patients 53 (50.96%) patients of P. falciparum , 48 (46.15%) patients of P. vivax and 3 (2.88%) patients of mixed infection. In the present study most common system involved was haematological (69%) followed by hepatic (42.3%), renal (29.04%), neurological (28.84%), cardiovascular (16.34%) and pulmonary (2.88%). Conclusions: Malaria though potentially treatable, still kills many patients every year in India. The most common presentation of malaria is fever, so in endemic region malaria may be considered as a leading differential diagnosis in all patients presenting as acute febrile illness, especially patients who also have organomegaly, fall in hemoglobin level, thrombocytopenia and altered liver function tests. Therefore, it is vital to know and perform hematological and biochemical investigations to detect early complications and to treat them effectively.

Postoperative biological and clinical outcomes following uncomplicated pancreaticoduodenectomy.

Backgrounds/AimsThe aim of this study was to describe clinical and biological changes in a group of patients who underwent pancreaticoduodenectomy (PD) without any complication during the postoperative period. These changes reflect the "natural history" of PD, and a deviation should be considered as a warning sign.MethodsBetween January 2000 and December 2009, 131 patients underwent PD. We prospectively collected and retrospectively analyzed demographic data, pathological variables, associated pathological conditions, and preoperative, intraoperative, and postoperative variables. Postoperative variables were validated using an external prospective database of 158 patients.ResultsThe mean postoperative length of hospital stay was 20.3±4 days. The mean number of days until removal of nasogastric tube was 6.3±1.6 days. The maximal fall in hemoglobin level occurred on day 3 and began to increase after postoperative day (POD) 5, in patients with or without transfusions. The white blood cell count increased on POD 1 and persisted until POD 7. There was a marked rise in aminotransferase levels at POD 3. The peak was significantly higher in patients with hepatic pedicle occlusion (866±236 IU/L versus 146±48 IU/L; p<0.001). For both γ-glutamyl transpeptidase and alkaline phosphatase, there was a fall on POD1, which persisted until POD 5, followed with a stabilization. Bilirubin decreased progressively from POD 1 onwards.ConclusionsThis study facilitates a standardized biological and clinical pathway of follow-up. Patients who do not follow this recovery indicator could be at risk of complications and additional exams should be made to prevent consequences of such complications.

Supracostal percutaneous nephrolithotomy: A prospective comparative study.

Introduction:A widely prevalent fear of thoracic complications with the supracostal approach has led to its underutilization in percutaneous nephrolithotomy (PCNL). We frequently use the supracostal approach and compared the efficacy and thoracic complications of infracostal, supra 12th, and supra 11th punctures.Materials and Methods:This was a prospective study of patients who underwent PCNL between January 2005 and December 2012. The patients were divided into three groups based on the access: infracostal, supra 12th (between the 11th and 12th ribs) and supra 11th (between the 10th and 11th ribs). Clearance rates, fall in hemoglobin levels, transfusion rates, perioperative analgesic requirements, hospital stay and thoracic complications were compared.Results:Seven hundred patients were included for analysis. There were 179 (25.5%) patients in the supra 11th group, 187 (26.7%) patients in the supra 12th group and 334 (47.8%) patients in the infracostal group. The overall clearance rate was 78% with no difference in the three groups. The postoperative analgesic requirements were significantly higher in the supracostal groups and showed a graded increase from infracostal to supra 12th to supra 11th. During the study period, only 2 patients required angioembolization (0.3%) and none required open exploration. The number of patients requiring intercostal chest drain insertion was extremely low, at 1.6% and 2.2% in the supra 12th and supra 11th groups, respectively.Conclusions:Our results confirm the feasibility of the supracostal approach including punctures above the 11th rib, albeit at the cost of an increase in thoracic complications. Staying in the line of the calyx has helped us to minimize the most dreaded complication of bleeding requiring angioembolization.

Clinical experience with respect to safety &amp; efficacy of polyclonel anti D immunoglobulin for intravenous use (KamRho D IV) for management of thrombocytopenia of varied origin.

Background Severe thrombocytopenia is one of the major manifestations of many critical emergencies apart from idiopathic thrombocytopenic purpura ITP Lymphoproliferative disorders and Myelodysplastic syndrome MDS. Objective Present study was carried out to study efficacy and safety of polyclonal Anti-D i.v immunoglobulin in thrombocytopenia of varied origin other than ITP MDS and Lymphoproliferative disorders. Method This was a prospective clinical trial 3 carried out on 28 adults with thrombocytopenia of varied origin with platelet count less than 35000 mm . They were given polyclonal Anti D immunoglobulin by iv route. The dose was 75 microgkg body weight as a bolus after enrolling the patients. The rise in platelets was observed daily for three consecutive days and then at day 7. Hb levels were observed on day 1 2 and 7. Results efficacy -Out of 26 patients included 57 responded to kamRho D IV within 24 hrs with a significant rise in platelet counts. After 48 hrs the percentage of respondents increased to 88.5 and after 72 hrs there were no non-respondents left in the study population. 96 of patients has platelet count above 100000 after day 7. Safety Of 26 patients 23 showed a fall in haemoglobin level. The mean decrease in Hb was 1.39 gmdl. There were no side effects. Conclusion Intravenous Anti-D is safe effective and well tolerated treatment in secondary thrombocytopenia of varied origin. IV Anti-D can be safe alternative for secondary thrombocytopenia where immediate platelet transfusion is not available.nbsp

Carbetocin vs. Syntometrine in Prevention of Postpartum Hemorrhage: a Double Blind Randomized Control Trial

BackgroundPostpartum hemorrhage is a significant cause of maternal mortality and morbidity, worldwide.ObjectivesThe aim of this study was to compare the efficacy between carbetocin and syntometrine in prevention of postpartum hemorrhage.Materials and MethodsThis study was a double blind randomized clinical trial that carried out on 200 pregnant women referred to Shabiehkhani maternity center of Kashan, during 2011. The first group received intramuscular syntometrine and the second group received intramuscular carbetocin after placental delivery. All of the participants were followed for 24 hours and blood pressure, pulse rate, uterine tone, hemoglobin concentration at first and 24 hours after delivery, and the need for additional uterotonic drugs and drug side effects were evaluated. Finally all data were analyzed using t-test, chi square tests and logistic regression.ResultsThe mean fall in hemoglobin level in the carbetocin group was significantly lower than the syntometrine group (P < 0.001). Also there were significant differences between the two groups, regarding additional uterotonic drug requirements (P = 0.002). Moreover systolic blood pressure and uterine tone immediately and 30 minutes after drug administration were significantly different (P < 0.001). Incidence rate of tachycardia in the carbetocin group was 13%, in contrast to 5% in the syntometrine group (P = 0.04).ConclusionsThis study revealed that carbetocin is more effective than syntometrine in prevention of postpartum hemorrhages. Thus it can be used as a good alternative of syntometrine for low-risk women.

Chemotherapy-induced myelosuppression in ovarian cancer patients with germline BRCA1/2 mutations: A case control study.

5571 Background: Ovarian cancer patients with germline BRCA1 or BRCA2 (gBRCA1/2) mutations frequently respond to multiple lines of chemotherapy. Having noticed significant myelosuppression during chemotherapy in gBRCA1/2 patients we wished to determine whether this was a chance finding or related to a heterozygous gene dosage effect in the bone marrow. Methods: gBRCA1/2 ovarian cancer patients from Edinburgh, Glasgow and Dundee were identified and matched for chemotherapy regimen, dose and age to controls from the Edinburgh Ovarian Cancer Database. Case notes and transfusion service records were analysed for chemotherapy details, haematology results, G-CSF use, red cell and platelet transfusions during first line chemotherapy. Results: Of 91 gBRCA1/2 patients, 35 patients were excluded who had previously received cytotoxic chemotherapy (mostly for breast cancer) or unusual chemotherapy regimens unable to be matched to controls. 56 were matched to controls. Baseline haematological indices were similar. There was a significant difference in the fall in haemoglobin levels from baseline to cycle 4 in gBRCA1/2 patients compared to controls (12.23% v 5.14%, p = 0.0005) and gBRCA1/2 patients had longer delays during their chemotherapy (mean 7.73 v 4.51 days, p = 0.0375) and more dose reductions for haemotoxicity (14 v 4 p = 0.0011). gBRCA1/2 were more likely to have a red cell transfusion (19 v 11, p = 0.099), and received more red cells (69 v 31 units, p = 0.0318). G-CSF was required in 3 BRCA patients versus 0 controls. Differences in platelet and white cell counts at cycle 4 were not significant. Conclusions: Patients with ovarian cancer and germline BRCA1/2 mutations were more likely to have significant falls in haemoglobin levels and require red cell transfusions and to experience delays during chemotherapy. This susceptibility to anaemia may be a hemizygous BRCA1/2 gene dosage effect manifest in the bone marrow and may have implications for the optimisation of cytotoxic and PARP inhibitor therapy in this patient group.

Practical Management of Boceprevir and Immunosuppressive Therapy in Liver Transplant Recipients with Hepatitis C Virus Recurrence

Hepatitis C virus (HCV) recurrence is the most important complication in HCV liver transplant patients. Boceprevir with pegylated interferon and ribavirin (PegIFN/RBV) enabled improvement in sustained virological response rates of patients with genotype 1 HCV. Boceprevir interacts with immunosuppressive therapy (IT) by inhibiting the cytochrome P450 3A enzyme. Our aim was to study interactions and assess the safety of boceprevir in the context of HCV recurrence. Boceprevir (800 mg three times a day) initiated after a 4-week lead-in phase was associated with cyclosporine (three patients), tacrolimus (two patients), and everolimus (one patient) in five liver transplant patients with genotype 1 HCV infection who experienced HCV recurrence. The mean follow-up period after HCV therapy was 14.8 ± 3.1 weeks. Estimated oral clearances of IT decreased on average by 50%, requiring reduced dosing regimens. Anemia occurred in all patients, with a mean fall in hemoglobin levels between baseline and week 12 of 3.12 ± 2.27 g/dl. All patients required administration of β-erythropoietin (n = 5), three needed ribavirin dose reduction, and one needed a blood transfusion. A virological response was observed in all patients (mean HCV viral load [HVL] decrease at week 12, 6.64 ± 0.35 log(10) IU/ml). These preliminary results in liver transplant patients with HCV recurrence demonstrate the feasibility and safety of coadministration of boceprevir and IT.

Introduction of angiotensin-converting enzyme inhibitors induces a fall in hemoglobin levels in elderly patients hospitalized with heart failure: a cohort study

Although the use of angiotensin-converting enzyme-inhibitors (ACE-I) is a cornerstone of treatment for heart failure (HF), these agents have been associated with decreasing hemoglobin levels in several settings. The aim of this study was to assess whether ACE-I are associated with decreasing hemoglobin in older subjects, and whether this effect is enhanced among patients with HF. The association between starting use of ACE-I and variations in hemoglobin levels was investigated in 10,354 hospitalized elderly, 1217 of whom had a verified diagnosis of HF, enrolled in a multicenter pharmacoepidemiology survey. According to Cox regression analysis, the relative risk of a decrease in hemoglobin levels >0.5 g/dL associated with starting treatment with ACE-I was 1.12 (95% CI 0.98-1.26, p=0.081) among participants without HF, and 1.98 (95% CI 1.54-2.53, p<0.0001) among patients with HF, after adjusting for potential confounders. Analysis of the interaction term in Cox regression confirmed that the association between use of ACE-I and hemoglobin decrease varied according to diagnosis of HF (p=0.003) and older age (p=0.029). Starting treatment with ACE-I is independently associated with increased risk of hemoglobin decrease among older hospitalized patients with HF. Hemoglobin levels should be monitored in older subjects who start ACE-I.

Three-hour interval drain clamping reduces postoperative bleeding in total knee arthroplasty: a prospective randomized controlled trial

Total knee arthroplasty (TKA) is a common procedure that has a risk of significant blood loss and blood transfusion, and carries a substantial risk for immunologic reactions and disease transmission. Drain clamping is a popular method that is applied to reduce blood loss after TKA. However, the clamping protocol remains controversial. Therefore, we established a new protocol, 3-h interval clamping, and compared the bleeding control efficacy of this protocol following TKA with the non-clamping technique. Between March and July 2008, we enrolled 100 patients (100 knees) who underwent uncomplicated TKA using a minimally invasive surgical technique. The patients were randomly assigned into two groups based on the draining protocol: non-clamping (group A) and 3-h interval clamping (group B). For group A, a vacuum drain was connected to a container and was run continuously during the first postoperative day, whereas the vacuum was stopped twice (for ~3h each time) for group B. Demographic characteristics and clinical data were collected, including the levels of hemoglobin and hematocrit, the total blood loss volume, the number of patients who required a blood transfusion, and any complications that developed. The perioperative data were compared between the two groups. The drainage blood volume in the interval-clamping group (group B) was significantly lower than that in the non-clamping group (group A) during the first 48h following the procedure (p<0.001 and p=0.005 for first and second postoperative days, respectively). The mean fall in hemoglobin levels at 12h in the interval-clamping group (2.8±0.9g/dL) was also lower than in the non-clamping group (3.2±0.8g/dL). In the 3-h interval clamping protocol, the number of patients requiring a transfusion was 2.2 times less than the number in the non-clamping protocol, but was not significantly different (odds ratio=2.20, p=0.24), and the significant predictor of blood transfusion was the preoperative hemoglobin level (odds ratio=7.73, p<0.001). No wound infection or clinical venous thromboembolisms were detected in our study. The 3-h interval clamping is a newly developed protocol for reducing blood loss after TKA. The protocol lessens the decrease in postoperative hemoglobin levels. This protocol can be applied easily without increasing clinical thromboembolic events and wound complications.

Increased mean corpuscular volume of red blood cells predicts response to metronomic capecitabine and cyclophosphamide in combination with bevacizumab

BackgroundThere is an urgent need for the identification of commonly assessable predictive factors in the treatment of patients with metastatic breast cancer. MethodsDuring the course of a treatment including low dose metronomic oral cyclophosphamide and capecitabine plus i.v. bevacizumab (plus erlotinib in one third of the patients) for metastatic breast cancer, we observed that a relevant number of patients developed repeatedly elevated levels of mean corpuscular volume (MCV) of red blood cells without a significant fall in hemoglobin levels. We conducted a retrospective analysis on these 69 patients to evaluate if the increase in MCV could be associated to tumor response. ResultsDuring the course of treatment 42 out of 69 patients (61%) developed macrocytosis. Using Cox proportional hazards modeling that incorporated macrocytosis (MCV≥100 fl) as a time-dependent covariate, macrocytosis resulted in a halved risk of disease progression (HR 0.45; 95% CI, 0.22–0.92, p-value 0.028). In a landmark analysis limited to patients with no sign of progression after 24 weeks of treatment, median time to progression was 72 weeks (48 weeks after landmark) in patients who had developed macrocytosis, and 43 weeks (19 weeks after landmark) in patients who had not (p = 0.023). ConclusionMacrocytosis inversely related to risk of disease progression in patients treated with metronomic capecitabine plus cyclophosphamide and bevacizumab for metastatic breast cancer. This finding may be explained through thymidylate synthase inhibition by capecitabine. Whether bevacizumab has a role in determining macrocytosis, similarly to what happens with sunitinib, has to be further investigated. If other studies will confirm our findings, macrocytosis might be used as an early marker of response during metronomic treatment with capecitabine and cyclophosphamide with or without bevacizumab.

Hemolysis and methemoglobinemia due to hepatitis E virus infection in patient with G6PD deficiency

Dear Editor, A 54-year-old Chinese male hepatitis B virus (HBV) carrier presented with jaundice, cyanosis, and confusion. Despite oxygen supplement, pulse oximetry showed persistent desaturation and investigations showed raised methemoglobin (16.8%, normal 6,000 IU), bilirubin (763 IU), and lactate dehydrogenase (5,211 IU) and he was referred for liver failure. This was followed 2 days later by a rapid fall in hemoglobin levels (from 14.1 g/dl to 5.8 g/dl) with reactive leukocytosis. A peripheral blood film showed abundant hemighost cells (arrows, Fig. 1). Glucose-6-phosphate dehydrogenase (G6PD) deficiency was confirmed (0.83 IU/g Hb, normal 6.3–10.3). Interestingly, his HBV–DNA was negative and antibodies to hepatitis A and C viruses (HAV-IgM, HCV-Ab) were undetectable. However, hepatitis E virus (HEV) IgM was positive, indicating recent infection. His relatives volunteered recent consumption of undercooked porcine liver, a major source of HEV infection in Hong Kong [1]. He was treated as HEV-related hepatitis complicate by methemoglobin and hemolysis, with hemodialysis and transfusion but died of cerebral hemorrhage. Fig. 1 Peripheral blood film showing abundant hemighost cells (blister cells, arrows) classical for oxidative hemolysis in glucose 6-phosphate dehydrogenase deficient patients Massive hemolysis complicating G6PD deficiency during HAV liver failure is well recognized in the Far East [2]. HEV, another non-enveloped oral-fecal transmitted RNA virus, produces a similar syndrome in the Indian subcontinent [3]. In G6PD deficiency, oxidative drugs can cause hemolysis or methemoglobinemia, rarely both at the same time [4]. This is the first report of concurrent hemolysis and methemoglobinemia related to viral hepatitis. The pathogenetic link between viral hepatitis and oxidative hemolysis is unclear, and hemolysis can occur in non-G6PD deficient patients [2]. Hence, in some cases, antibody or complement-mediated mechanisms are involved [5, 6]. In our patient, however, the methemoglobulinemia strongly suggest oxidative stress to the G6PD-deficient erythrocytes. In the liver, the G6PD-deficient hepatocytes may also be more prone to viral cytopathic effect, causing fulminant hepatitis and cholestasis [7]. Both factors may combine to lead to a high fatality rate in these cases [2, 3]. Hence, in Far East countries, where G6PD deficiency and raw food consumption are both common, such a clinical picture should be recognized. Proper preventive measures (e.g., vaccination and better hygiene) would also be prudent for health officials and susceptible individuals [5].

Continuous fall in hemoglobin level is a poor prognostic factor in patients with nasopharyngeal carcinoma treated with radiotherapy

Continuous fall in hemoglobin level is a poor prognostic factor in patients with nasopharyngeal carcinoma treated with radiotherapy