Reduction In Hemoglobin Research Articles

Prognostic implication of hemoglobin reduction with and without clinical bleeding after percutaneous coronary intervention in patients with acute coronary syndromes.

Bleeding events are associated with higher mortality rates in patients with cardiovascular diseases, including patients presenting with acute coronary syndrome (ACS) undergoing coronary revascularization. We aimed to determine whether a reduction in hemoglobin (Hgb) from pre- to postpercutaneous coronary intervention (PCI), with or without evidence of clinical bleeding, is a correlate of in-hospital mortality for patients presenting with ACS who underwent primary PCI. We divided 33816 consecutive patients with ACS who underwent PCI into threecategories: (1) target group (defined as Hgb reduction without overt bleeding [n = 112]); (2) Hgb reduction with overt bleeding (n = 48); and (3) control group (defined as no Hgb reduction and no overt bleeding [n = 3156]). Hgb reduction was defined as a drop of >3 g/dLin Hgb value from preprocedure and postprocedure during the index hospitalization. The primary outcome was in-hospital mortality. We used logistic regression to examine the relationship between Hgb reduction with and without bleeding and in-hospital mortality. In crude analysis, the Hgb reduction with overt bleed group had a higher in-hospital mortality rate (16.7%) than the target (9.8%) and control groups (0.6%). Adjusted logistic regression estimates a 0.393 (95% confidence interval [CI]: 0.137, 1.869) odds ratio for in-hospital death of the target group over the Hgb reduction with bleed group, and a 54.517 (95% CI: 2.07, >1000) odds ratio of the target group over the control group. In patients presenting with ACS undergoing PCI, Hgb reduction with and without overt bleeding were both independently associated with in-hospital mortality.

Rker-050, a Modified Activin Receptor Type Iia Ligand Trap, Promoted Erythropoiesis in a Murine Model of Myelofibrosis

Myelofibrosis (MF) is one of several myeloproliferative neoplasms most often associated with anemia due to ineffective hematopoiesis, inflammation, aberrant bone metabolism and progressive fibrosis in the bone marrow (BM). As a compensatory mechanism, extramedullary hematopoiesis is initiated in the spleen, resulting in splenomegaly. Megakaryocyte hyperplasia/dysplasia are thought to be one of the main drivers of MF disease progression. Evidence also suggests that dysregulated TGF-β superfamily activity contributes to ineffective hematopoiesis. KER-050 and its research form, RKER-050, are investigational modified activin receptor type IIA ligand traps designed to inhibit specific TGF-β superfamily ligands, including activin A, activin B, growth and differentiation factor (GDF) 8 and GDF11, to promote erythropoiesis and thrombopoiesis. Additionally, the KER-050 target ligands promoted fibrosis and bone resorption in preclinical studies. Therefore, by inhibiting these ligands, KER-050 could potentially rebalance the bone marrow microenvironment, including reducing fibrosis, allowing restoration of hematopoiesis and alleviating extramedullary hematopoiesis and associated splenomegaly. To investigate the potential of RKER-050 to reverse ineffective hematopoiesis in MF, a hypomorphic Gata1 MF mouse model (Gata1Low; MF mice) was utilized which presents similar characteristics to human MF, including ineffective hematopoiesis, cytopenias, extramedullary hematopoiesis, defective bone deposition and BM fibrosis. this study, we also observed aberrant bone growth in the cortex of the hind limb long bones which inappropriately extended into the bone marrow, resulting in limited BM compartment space and demonstrating a severe disease state in these mice. Anemia status of MF mice was confirmed at the start of the treatment. MF mice showed a 16% reduction in hemoglobin (Hgb) compared to WT control mice. After 12 weeks of treatment, MF+VEH mice continued to exhibit a significant or trending decrease in red blood cells (RBCs; -19%), Hgb (-20%), and hematocrit (Hct; -10%) compared to WT mice. In contrast, MF+050 mice had a significant recovery of RBCs (+31%), Hgb (+24%) and Hct (+20%), compared to MF+VEH mice, demonstrating that RKER-050 reversed anemia in this advanced disease MF model. To assess the mechanism of action of RKER-050, we evaluated erythroid precursor populations in the BM. While MF+VEH mice showed a significant reduction in erythroid progenitors compared to WT mice, These data support increased BM erythropoiesis with RKER-050 treatment. In addition, we evaluated the effect of RKER-050 on thrombopoiesis. MF+VEH mice were severely thrombocytopenic and had significantly increased megakaryocyte progenitors (MkP; +591%) compared to WT mice. Although RKER-050 significantly reduced MkP (-33%; MF+050), suggesting RKER-050 may positively influence the megakaryocyte lineage, this did not translate to improvements in thrombocytopenia, and platelet counts remained similar to MF+VEH. Additional data will be presented that investigates the potential of RKER-050 treatment in (6-month vs 10-month-old mice, where disease is less severe) to further evaluate the potential to impact cytopenias, extramedullary hematopoiesis and BM fibrosis. Overall, in the context of severe disease, our results suggest RKER-050 can promote erythropoiesis and reverse anemia in the BM in by rebalancing hematopoiesis in the BM niche. Reestablishing BM hematopoiesis could obviate the need for compensatory extramedullary hematopoiesis in the spleen, the major driver of splenomegaly in MF patients. In conclusion, KER-050 represents a potentially promising approach for patients with MF and other hematological diseases where ineffective hematopoiesis occurs.

Inducible Knockout of Codanin-1: An Adult Mouse Model of Congenital Dyserythropoietic Anemia Type-I

Congenital dyserythropoietic anemias (CDAs) are a heterogenous group of congenital blood diseases, characterized by ineffective erythropoiesis, hemolysis, and the presence of bi- or multi-nucleated erythroblasts in the bone marrow (BM). Several CDA types exist, originally classified by bone marrow pathology and now more accurately by their causative mutations, when known. Mutations in codanin-1 ( Cdan1) are the major contributor (≈80%) to CDA type-I (CDA-I). Patients with CDA-I frequently require transfusions in utero to survive and present with varying degrees of hemolytic anemia with relative reticulocytopenia suggesting ineffective erythropoiesis, binucleated erythroblasts, and, under transmission electron microscopy (TEM), a “swiss cheese” appearance in the nuclear heterochromatin of erythroblasts. Treatment for patients with CDA-I includes blood transfusions and iron chelation, or IFN-α, which allows most treated patients to achieve transfusion independence. However, the molecular mechanisms of dyserythropoiesis in CDA-I as well as those of the therapeutic effect of IFN-α are unknown. To study the pathogenesis of the disease and the mechanisms of IFN-α action in vivo, we generated an adult mouse model of CDA-I. Previous efforts to produce a CDA-I mouse model were achieved via a constitutional, EpoR Cre+/--driven erythroid-specific deletion of Cdan1; however, this mouse suffered embryonic lethality by E12.5 [Noy-Lotan et al, Frontiers in Physiology, 2021]. We developed a transgenic mouse model in which the most common CDAN1 missense mutation (p.R1042W in humans corresponding to mouse p.R1047W) was introduced using CRISPR-Cas9 editing, and the mice were bred to homozygosity. These mice survived to term but exhibited no significant anemia, altered erythropoiesis, or the characteristic “swiss cheese” appearance in the heterochromatin of the erythroblasts under TEM. They demonstrated no differences from control mice in recovery after induction of stress erythropoiesis by phlebotomy (in agreement to the findings reported in parallel by Noy-Lotan et al, 2021), suggesting that this model is inadequate for studying the CDA-I phenotype. Therefore, we proceeded to generate an inducible Cdan1 knockout mouse model to test the hypothesis that deletion of Cdan1 in the erythroid lineage,mediated by Gata1 creERT2 [Yu et al. Blood. 2021], will recapitulate the CDA-I phenotype in adult mice. This maneuver avoids embryonal lethality during the extreme stress erythropoiesis phase of fetal development. We bred mice with the wildtype (WT) or floxed Cdan1 gene ( Cdan1WT/WT and Cdan1Fl/Fl, respectively) with mice carrying Gata1 creERT2. Cdan1WT/WT; Gata1creERT2+/- mice served as WT controls and Cdan1Fl/Fl; Gata1creERT2+/- mice served as the experimental mice with erythroid-specific Cdan1 deficiency after 10 injections of tamoxifen every other day to activate Cre expression. We evaluated the phenotype of these mice using complete blood counts (CBCs), light microscopy, TEM, and flow cytometry of erythroid progenitors and precursors. The Cdan1-deficient mice became anemic with reduction in RBC count, hemoglobin ( Fig. 1), and hematocrit. Light microscopy of the BM and spleen revealed erythroblasts joined by a thin-interchromatin bridge and binucleated erythroblasts in the Cdan1-deficientcompared to WT mice (z-test of proportions, P < 0.001), appearing at a frequency of ≈13% of all erythroblasts (see Fig. 2). TEM revealed a “swiss cheese” appearance in the heterochromatin of erythroblasts, the pathognomonic finding of CDA-I. Flow cytometry of the BM and spleen revealed decreased late-stage erythroblasts, demonstrating ineffective erythropoiesis. To determine a possible stage in which IFN-α may be directly acting on erythropoiesis, we examined the expression of IFNαR1 in erythroblasts. In all mice, basophilic, polychromatic, and orthochromatic erythroblasts had relatively low expression of IFNαR1. Interestingly, proerythroblasts had relatively high expression of IFNαR1 but only in the spleen. These data provide a starting point for localizing the effect of IFNα in the CDA-I phenotype. In conclusion, erythroid-specific deletion of Cdan1 via Gata1 creERT2 in adult mice recapitulates the CDA-I phenotype and provides a viable mouse model to investigate the disease mechanism and the therapeutic effect of IFN-α on CDA-I.

Bone Marrow Sinusoidal Endothelial Cells Are a Site of Fgf23 Upregulation in Murine ß-Thalassemia

Fibroblast growth factor-23 (FGF23) is a bone-derived hormonal regulator of mineral metabolism with emerging functions in the bone marrow. FGF23 has been reported to negatively regulate erythropoiesis [PMID:24509850] and promote hematopoietic progenitor mobilization from the bone marrow [PMID:33512467]. Elevated FGF23 levels in the circulation have been described in iron-deficient subjects and also in subjects with the iron-loading anemia β-thalassemia. Recently, we reported bone marrow sinusoidal endothelial cells (BM-SEC) as a novel site of Fgf23 upregulation in mice with chronic iron-deficiency anemia and acute, phlebotomy-induced anemia [PMID:37417950]. We and others have detected Fgf23 mRNA elevation in total bone marrow of Hbb th3/+ mice, a model of non-transfusion dependent β-thalassemia that exhibits systemic iron loading. In the present study, we sought to clarify sites of Fgf23 promoter activity in Hbb th3/+ bone marrow using a reporter allele in which the enhanced green fluorescent protein (eGFP) coding sequence is knocked into the endogenous Fgf23 locus ( Fgf23 eGFP). We generated Hbb +/+ and Hbb th3/+ female littermates that carried either one ( Fgf23 +/eGFP) or zero ( Fgf23 +/+) copies of the Fgf23 reporter allele, which were raised on a standard rodent diet (200 mg/kg iron, 1.0% calcium, 0.7% phosphorus). Fgf23 eGFP/eGFP homozygotes were not generated due to known early growth retardation and mortality in Fgf23 null mice. After blood and tissue collection at 8 weeks of age, phenotypes of the 4 Hbb-Fgf23 genotype combinations were compared by two-way ANOVA. Compared to mice with intact Hbb and Fgf23 alleles ( Hbb +/+ Fgf23 +/+), Hbb th3/+ Fgf23 +/+ mice showed markedly elevated plasma levels of “total” FGF23 (sum of intact, active hormone and C-terminal cleaved fragments). Plasma total FGF23 levels in Hbb th3/+ Fgf23 +/+ and Hbb th3/+ Fgf23 +/eGFP mice were similar, indicating utility of the latter genotype for interrogating sites of increased Fgf23 expression in murine b-thalassemia. We therefore used anti-GFP immunohistochemistry in formalin-fixed bone marrow sections to assess Fgf23 eGFP reporter allele expression in the context of tissue architecture. Hbb th3/+ Fgf23 +/eGFP mice showed GFP expression in BM-SEC throughout the bone marrow, which was more intense than in non-anemic Hbb +/+ Fgf23 +/eGFP mice; controls lacking the Fgf23 eGFP allele confirmed anti-GFP antibody specificity. Hbb th3/+ mice also showed Fgf23 eGFP reporter expression in the thymic vasculature but not vasculature of the liver, spleen, or kidney. In contrast to their marked elevation in plasma total FGF23, Hbb th3/+ Fgf23 +/+ mice showed plasma levels of the intact, biologically-active FGF23 hormone that overlapped with levels in Hbb +/+ Fgf23 +/+ controls. Interestingly, compared with Hbb th3/+ Fgf23 +/+ mice, Hbb th3/+ Fgf23 +/eGFP mice showed 45% lower plasma intact FGF23, suggesting an effect of Fgf23 gene dosage. Given prior reported effects of FGF23 on hematopoiesis, we assessed if Fgf23 gene dosage modulated the severity of ineffective erythropoiesis in Hbb th3/+ mice. Compared to Hbb +/+ Fgf23 +/+ controls, Hbb th3/+ Fgf23 +/+ mice showed reductions in RBC, hemoglobin, and mean corpuscular hemoglobin, as well as increases in RDW and in spleen weight (reflecting extramedullary hematopoiesis). However, the severity of these parameters was not modified by heterozygous Fgf23 disruption ( Hbb th3/+ Fgf23 +/eGFP).While FGF23 has been reported to induce left ventricular hypertrophy [PMID:21985788], Hbb th3/+ Fgf23 +/+ and Hbb th3/+ Fgf23 +/eGFP mice showed similarly increased heart-to-body weight ratios compared to Hbb +/+ Fgf23 +/+ controls. In non-thalassemic mice, heterozygous Fgf23 disruption ( Hbb +/+ Fgf23 +/eGFP) caused a trend ( P=0.10) towards lower plasma intact FGF23 while not impacting hematological parameters or spleen weight. In summary, by showing that Fgf23 gene dosage modulates plasma intact FGF23 levels in Hbb th3/+ mice without altering severity of anemia or splenomegaly, our data suggest that moderate reductions in circulating levels of the intact FGF23 hormone do not alter the severity of ineffective erythropoiesis in Hbb th3/+mice at 8 weeks of age. Our finding that β-thalassemic mice exhibit Fgf23 upregulation in BM-SEC lays the groundwork for future investigation of the functional effects of locally-produced FGF23 in the thalassemic hematopoietic stem cell niche.

Longitudinal Characterization of Hemodynamic Changes with Multimodal Optical Techniques in Patients with Sickle Cell Disease Treated with Mitapivat

The physiological impacts of sickle cell disease (SCD) are widespread and severe if left untreated. Sickled RBCs initiate vaso-occlusion (VOC) and have altered biomechanical properties that negatively affect blood rheology and microvascular hemodynamics in patients with SCD. Therapeutics can target different mechanistic pathways including reduction of hemoglobin S (HbS) polymerization, oxidative stress, or inflammation. There is an unmet need for non-invasive, point-of-care technologies that characterize the microvascular hemodynamics in SCD which could potentially broaden understanding of the underlying pathophysiology and supplement a clinician's ability to monitor therapeutic changes. Current clinical approaches can be time- and resource- intensive which limit their accessibility. Near-infrared spectroscopy (NIRS) is a non-invasive, optical technique that quantifies microvascular hemodynamics including hemoglobin (Hb) concentration, tissue oxygen saturation (StO 2), and blood flow (Cerussi et al, 2005). We evaluate the sensitivity of NIRS technologies to hemodynamic changes in patients with SCD undergoing treatment with mitapivat, an investigational oral allosteric activator of pyruvate kinase (PK), and compare the optical changes to changes in standard hematology markers with regard to the initial response and consistency of the response over time. Fifteen patientswith HbSSwere enrolled in a study (ClinicalTrials.gov, NCT04610866) evaluating the long-term safety and tolerability of mitapivat in patients with SCD. We performed an optical hemodynamic assessment for each patient for a total of eight study visits over the span of a year including at baseline prior to drug initiation. NIRS probes were affixed to the forearm and forehead to collect hemodynamic information characteristic of brain and skeletal muscle while performing a brachial cuff occlusion challenge. We quantified concentration of oxy- and deoxy- Hb as well as StO 2 during the resting baseline prior to the occlusion. Additionally, we analyzed the post-occlusion reactive hyperemic response to assess vascular reactivity. Analysis was focused on quantifying the degree of change due to mitapivat treatment as well as the consistency of the response over the course of a year. Optical metrics were first compared against changes in Hb (Quang et, 2022) and then evaluated for consistency throughout the rest of the study period. Nine out of 15 patients were assessed as baseline NIRS data were not available for six patients.We calculated optical hemodynamic metrics for all 72 measurement visits; two visits were excluded due to poor NIRS data quality. Figure 1A shows a typical measurement setup with NIRS probes acquiring simultaneous measurements from the forehead and forearm. Figure 1B compares the mean Hb level, mean forehead StO 2, and mean forearm StO 2 across the first year of treatment. Over the first six months, we observed an increase in forehead StO 2 from 56% to 60% and forearm StO 2 from 59% to 63%; blood Hb levels exhibited a similar increase going from 8.5 g/dL to 9.8 g/dL; this increase was sustained over the second six months for all three parameters. Average forehead StO 2 remained +3.6% above baseline while forearm StO 2 remained +1.7% above baseline at the end of a year. NIRS can non-invasively provide objective measures of tissue composition, metabolism and vascular reactivity and can be performed in a simple manner with a series of simple perturbations.In this limited dataset, we have demonstrated that NIRS appears to reflect changes in Hb related to mitapivat both in response to an acute change and over an extended period. Furthermore, we observed that on average, the NIRS responses were consistently elevated throughout the course of the year, mirroring what was observed in the blood Hb levels. Hemodynamic changes appear to be more easily observed in the brain rather than the skeletal muscle. Our data suggest that NIRS could be an adjunct for non-invasive hemodynamic monitoring in patients with SCD undergoing treatment.

Lipedema Reduction Surgery Improves Pain, Mobility, Physical Function, and Quality of Life: Case Series Report.

Lipedema is a chronic inflammatory subcutaneous adipose-rich connective tissue disease affecting millions of women worldwide. Disproportionate fat accumulation on the extremities characterized by heaviness, tenderness, and swelling can affect function, mobility, and quality of life. Treatments include conservative measures and lipedema reduction surgery (LRS). Here, we report lipedema comorbidities and surgical techniques, outcomes measures, and complications after LRS. This is a single outpatient clinic retrospective chart review case series of comorbidities and complications in 189 women with lipedema. Bioelectrical impedance analyses, knee kinematics, gait, physical examinations, Patient-Reported Outcomes Measurement Information System, and RAND Short Form-36 questionnaires collected before and after LRS were analyzed for 66 of the 189 women. Hemoglobin levels were measured by transdermal hemoglobin monitor (Masimo noninvasive hemoglobin monitoring; Irvine, Calif.). Common comorbidities in 189 women were hypermobile joints (50.5%), spider/varicose veins (48.6/24.5%), arthritis (29.1%), and hypothyroidism (25.9%). The most common complication in 5.5% of these women after LRS was lightheadedness with a 2-g reduction or more in hemoglobin. After conservative measures and LRS in 66 women, significant improvements (P ≤ 0.0009) were found for: (1) knee flexion (10 degrees); (2) gait; (3) Patient-Reported Outcomes Measurement Information System T-score (16%); (4) mobility questions: gait velocity, rising from a chair, stair ascent; (5) RAND Short Form-36 scores: physical functioning, energy/fatigue, emotional well-being, social function, general health; (6) and Bioelectrical impedance analyses total and segmental body fat mass. LRS provided significant improvements to women with lipedema using direct physical measurements and validated outcome measures, comparable to those seen after total knee replacement.

Haematological parameters of nematode infected goat treated three medicinal plants

This study investigates haematological parameters in goat treated with three medicinal plants (Vernonia amygdalina, Ocimum grattisimum and Talinum triangulare). Twenty goats were infected with L3 larval stage of nematode parasite and the experiment lasted for 22 days. Standard procedures were employed to investigate the extraction of medicinal plants, animal infection and treatment and blood parameters of the treated goat with medicinal plants. The goat treated with Vernonia amygdalina and Ocimum grattissimum showed high reduction in Packed Cell Volume (PCV), Red Blood Cell (RBC) and Haemoglobin (HB). This showed that the goat treated with these medicinal plants were anaemic. The goat treated with Talinum triangulare showed little reduction in PCV, RBC and HB. This signified that Talinum triangulare can be used to improve vitality of goat. Other parameters like White Blood Cell (WBC), Mean Cell Volume (MCV), Mean Cell Haemoglobin (MCH) and Mean Cell Heamoglobin Concentration (MCHC) had no significant difference from control. Erythrocyte Sedimentation Rate (ESR) had significant difference from control. Hence the research can be used for increasing the economy status of the goat.

Modern Treatment of Pulmonary Embolism (USCDT vs MT): Results From a Real-World, Big Data Analysis (REAL-PE)

BackgroundAdvanced therapies are increasingly utilized to treat pulmonary embolism (PE). A unique data platform allows access to electronic health record data for comparison of the safety of PE therapies. MethodsAll data from Truveta (Truveta, Inc) were analyzed (16 systems, 83,612,413 patients, 535,567 with PE). All patients treated with ultrasound-assisted catheter-directed thrombolysis (USCDT) (Boston Scientific) or mechanical thrombectomy (MT) (Inari Medical) for PE were identified. The primary analysis was based on index procedures performed from January 2009 to May 2023, and contemporary analysis on those performed from January 2018 to May 2023. Bleeding was assessed via direct laboratory analysis and transfusion administration documentation. International Society for Thrombosis and Hemostasis (ISTH) and Bleeding Academic Research Consortium (BARC) 3b definitions were recreated. Multiple logistic regression analysis of major bleeding was performed. In-hospital death and median length of stay were measured. ResultsFor the primary analysis, 2259 patients (N = 1577 USCDT, N = 682 MT) and for the contemporary analysis 1798 patients (N = 1137 USCDT, N = 661 MT) met the criteria. Incidence of hemoglobin reduction (>2 and >5 g/dL) and transfusions received were significantly higher among MT-treated patients in both analyses, as was ISTH and BARC 3b major bleeding (primary: ISTH MT 17.3% vs USCDT 12.4% P = .002; BARC 3b MT 15.4% vs USCDT 11.8% P = .019) (contemporary: ISTH MT 17.2% vs USCDT 11.0% P = .0002; BARC 3b MT 15.4% vs USCDT 10.6% P = .002). Regression analysis demonstrated that MT is associated with major bleeding. Median length of stay, all-cause 30-day readmission and in-hospital mortality were similar between groups. Intracranial hemorrhage was more common with MT. ConclusionsMajor bleeding derived from direct laboratory and transfusion data occurred more frequently with MT vs USCDT. Intracranial hemorrhage was more common among MT-treated patients. In the absence of randomized data, these results provide guidance regarding the bleeding risk and safety of strategies for advanced PE therapy.

Association of Periprocedural Haemoglobin Reduction and Myocardial Injury in Patients with Unstable Angina Undergoing Percutaneous Coronary Intervention

Background: Patients undergoing percutaneous coronary intervention are at risk of different complications such as periprocedural bleeding and acute hemoglobin reduction that can lead to myocardial injury. Blood loss through the catheter during the procedure and through puncture site haematoma causes periprocedural acute haemoglobin drop. Objectives: To find out the association between acute haemoglobin reduction and myocardial injury after PCI in patients with unstable angina. Methods: This prospective observational study was conducted at the National Institute of Cardiovascular Diseases (NICVD) for one year of time. A total of 130 patients were enrolled based on inclusion and exclusion criteria during the study period. Haemoglobin and troponin-I were measured before and after PCI within 24 to 48 hours of the procedure. On the basis of post-procedural acute haemoglobin level, the study population was categorized into two groups: Group I patients with normal haemoglobin levels and Group II patients with significant acute haemoglobin reduction (≥ 1 gm/dl). Results: A total of 24 patients developed a periprocedural myocardial injury, among them 17 (70.8%) were in the reduced haemoglobin group and 7 (29.2%) in the normal haemoglobin group. Elevation of troponin I after PCI was higher in group II than in group I patients with a statistically significant difference. Multivariate logistic regression analysis showed that haemoglobin reduction was an independent predictor of PMI (OR 1.94; 95% CI, 1.241-8.684; p = 0.01). Conclusion: Periprocedural haemoglobin reduction in patients with unstable angina was associated with myocardial injury after percutaneous coronary intervention (PCI).

Effects of hypoglycaemic agents on reducing surrogate metabolic parameters for the prevention of cardiovascular events and death in patients with type 2 diabetes: A systematic review and meta-analysis.

To investigate the impact of glucose-lowering therapy-induced glycated haemoglobin (HbA1c) reduction on the risk of major clinical events according to body weight change and, as a secondary objective, to evaluate the impact of concomitant reductions in HbA1c and body weight on major clinical events. We searched the MEDLINE and EMBASE databases up to June 30, 2022, for large-scale studies on glucose-lowering therapies in which more than 1000 patient-years of follow-up in each randomized group were completed. The primary outcome was all-cause mortality. The study was registered in PROSPERO (CRD42022355479). Thirty-four trials involving 227 220 patients with type 2 diabetes were meta-analysed using a random-effects model. Each 1% reduction in HbA1c was associated with a different risk of mortality depending on the ability of glucose-lowering therapies to induce body weight loss or gain. When glucose-lowering therapies were associated with weight gain, the risk of mortality increased by 8% (hazard ratio [HR] 1.08, 95% confidence interval [CI] 1.00-1.16) for each 1% reduction in HbA1c. When glucose-lowering therapies were associated with weight loss, the risk of mortality was reduced by 22% (HR 0.78, 95% CI 0.72-0.85) for each 1% reduction in HbA1c. In addition, concomitant reductions in HbA1c and body weight were associated with a significantly lower risk of mortality and vascular events. In patients with type 2 diabetes, concomitant reductions in HbA1c and body weight might be more effective in preventing the risk of vascular events and mortality.

Pulmonary haemorrhage as a frequent cause of death among patients with severe complicated Leptospirosis in Southern Sri Lanka.

Leptospirosis is a tropical disease associated with life threatening complications. Identifying clinical and investigation-based parameters that predict mortality and morbidity is vital to provide optimal supportive care. We conducted an observational study in an endemic setting, in the southern Sri Lanka. Consecutive patients having complicated leptospirosis were recruited over 18 months. Clinical, investigational and treatment data were collected and the predictors of mortality were analysed. Out of 88 patients having complicated leptospirosis, 89% were male. Mean age was 47yrs (±16.0). Among the total major complications 94.3% had acute kidney injury, 38.6% pulmonary haemorrhages, 12.5% fulminant hepatic failure, 60.2% hemodynamic instability and 33% myocarditis. An acute significant reduction of haemoglobin (Hb) was observed in 79.4% of patients with pulmonary haemorrhage. The mean of the highest haemoglobin reduction in patients with pulmonary haemorrhage was 3.1g/dL. The presence of pulmonary haemorrhage (PH) and hemodynamic instability within first 48 hours of admission significantly predicted mortality (p<0.05) in severe leptospirosis. Additionally, within first 48 hours of admission, elevated SGOT (AST), presence of atrial fibrillation, presence of significant haemoglobin reduction, higher number of inotropes used, prolonged shock, invasive ventilation and admission to ICU significantly predicted mortality. Out of major complications during the first week after admission, pulmonary haemorrhage and fulminant hepatic failure (FHF) combination had significant adjusted odds of mortality (OR = 6.5 and 4.8, p<0.05). Six patients with severe respiratory failure due to PH underwent ECMO and four survived. The overall mortality in complicated leptospirosis was 17%. In PH and FHF, the mortality rate was higher reaching 35.4% and 54.5%, respectively. Within first 48 hours of admission, major complications such as pulmonary haemorrhage and haemodynamic instability and other parameters such as atrial fibrillation, acute haemoglobin reduction, elevated SGOT level could be used as early parameters predictive of mortality in severe leptospirosis. PH and FHF during the first week of admission in leptospirosis are associated with high morbidity and mortality requiring prolonged ICU care and hospitalisation. Above parameters could be used as parameters indicating severity for triaging and intensifying treatment. Using ECMO is a plausible treatment option in patients with severe pulmonary haemorrhage.

Indirect comparison of efficacy and safety of chiglitazar and thiazolidinedione in patients with type 2 diabetes: A meta-analysis.

Chiglitazar is an emerging pan-agonist of all peroxisome proliferator activated receptors (PPAR)-α, δ and γ, and has therapeutic potential for type 2 diabetes (T2D). However, to date, no clinical studies or meta-analyses have compared the efficacy and safety of chiglitazar and traditional PPAR-γ agonist thiazolidinediones (TZDs). A meta-analysis concerning this topic is therefore required. To compare the efficacy and safety of chiglitazar and TZD in patients with T2D. PubMed, Medline, Embase, the Cochrane Central Register of Controlled Trials, Reference Citation Analysis and Clinicaltrial.gov websites were searched from August 1994 to March 2022. Randomized controlled trials (RCTs) of chiglitazar or TZD vs placebo in patients with T2D were included. Indirect comparisons and sensitivity analyses were implemented to evaluate multiple efficacy and safety endpoints of interest. We included 93 RCTs that compared TZD with placebo and one that compared chiglitazar with placebo. For efficacy endpoints, the augmented dose of chig-litazar resulted in greater reductions in hemoglobin (Hb)A1c [weighted mean difference (WMD) = -0.15%, 95% confidence interval (CI): -0.27 to -0.04%], triglycerides (WMD = -0.17 mmol/L, 95%CI: -0.24 to -0.11 mmol/L) and alanine aminotransferase (WMD = -5.25 U/L, 95%CI: -8.50 to -1.99 U/L), and a greater increase in homeostasis model assessment-β (HOMA-β) (WMD = 17.75, 95%CI: 10.73-24.77) when compared with TZD treatment. For safety endpoints, the risks of hypoglycemia, edema, bone fractures, upper respiratory tract infection, urinary tract infection, and weight gain were all comparable between the augmented dose of chiglitazar and TZD. In patients with baseline HbA1c ≥ 8.5%, body mass index ≥ 30 kg/m2 or diabetes duration < 10 years, the HbA1c reduction and HOMA-β increase were more conspicuous for the augmented dose of chiglitazar compared with TZD. Augmented dose of chiglitazar, a pan-activator of PPARs, may serve as an antidiabetic agent with preferable glycemic and lipid control, better β-cell function preserving capacity, and does not increase the risk of safety concerns when compared with TZD.

Surgical outcomes of laparoscopic proximal gastrectomy for upper-third gastric cancer: esophagogastrostomy, gastric tube reconstruction, and double-tract reconstruction

BackgroundThere is no consensus on the optimal reconstruction technique after proximal gastrectomy. The purpose of this study was to retrospectively compare the surgical outcomes among esophagogastrostomy (EG) anastomosis, gastric tube (GT) reconstruction and double-tract (DT) reconstruction in patients who underwent laparoscopic proximal gastrectomy (LPG) to clarify the superior reconstruction method.MethodsThis study enrolled 164 patients who underwent LPG at the Northern Jiangsu People's Hospital in Jiangsu between January 2017 to January 2022 (EG: 51 patients; GT: 77 patients; DT: 36 patients). We compared the clinical and pathological characteristics, surgical features, postoperative complications, nutritional status, and quality of life (QOL) among the above three groups.ResultsMean operative time was longer with the DT group than the remaining two groups (p = 0.001). With regard to postoperative complications, considerable differences in the postoperative reflux symptoms (p = 0.042) and reflux esophagitis (p = 0.040) among the three groups were found. For the nutritional status, total protein, hemoglobin and albumin reduction rates in the GT group were significantly higher than the other two groups at 12 months postoperatively. In the PGSAS-45, three assessment items were better in the DT group significantly compared with the esophageal reflux subscale (p = 0.047, Cohen’s d = 0.44), dissatisfaction at the meal (p = 0.009, Cohen’s d = 0.58), and dissatisfaction for daily life subscale (p = 0.012, Cohen’s d = 0.56).ConclusionsDT after LPG is a valuable reconstruction technique with satisfactory surgical outcomes, especially regarding reduced reflux symptoms, improving the postoperative nutritional status and QOL.

Impact of secondary infections on dengue presentation: A cross-sectional study in a tertiary care hospital in Uttar Pradesh, India

BackgroundRecently, a wide range variety of manifestations, including a self‑limiting to severe illness, has been increasingly reported in dengue. Few studies attract attention to severe dengue, mainly observed in secondary infection. With this background, this study aims to provide a comprehensive overview to differentiate primary from secondary dengue using serology (IgG) and the possible association of severity of illness in secondary dengue. MethodsPresent retrospective cross-sectional study was conducted at a North Indian tertiary care center from September 2021 to January 2022. Clinical data of confirmed dengue patients from the medicine department were collected and assigned as primary and secondary dengue. ResultsOf the 220 dengue patients, 22 (10 %) had secondary dengue infection. Hemorrhagic manifestations were reported in 58/220 (26.4 %) cases while 7/22 (31.8 %) in secondary dengue. Prevalent hemorrhagic manifestations in secondary dengue include purpura (27.3 %), vaginal bleeding (4.5 %), melaena (9.1 %), and epistaxis (4.5 %). In addition, 42 (19.1 %) patients had pancytopenia, and 8 (36.6 %) cases were of secondary dengue. Hepatic dysfunction was noted in 164 (74.5 %) cases. Notably, all secondary dengue cases (22;100 %) had hepatic dysfunction and severe in 9 (40.9 %) cases. In addition, in secondary dengue patients, evidence of plasma leakages such as hypoproteinemia 7 (31.8 %) and ascites (35 %) were statistically more frequent. Overall, two deaths (0.9 %) were reported, and were one in each group. ConclusionsMany parameters, including hemorrhagic manifestation (melaena), hematological characteristic (pancytopenia), evidence of plasma leakage (hypoproteinemia and ascites), gastrointestinal (GB wall thickening and hepatic dysfunction) and reduction in mean hemoglobin and platelet count were found to be statistically significant in secondary dengue infection. Additionally, early classification of secondary dengue may help to anticipate its severity and allow for early strategic intervention/management to lower morbidity and mortality.

Effect of Penicillin on Hematological and Plasma Biochemical Parameters in Female Wistar Rats

An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention of such infections. This study was designed to investigate effect of penicillin on blood parameters in female rats. Ten female Wistar rats (130 – 150 g) were grouped into control and penicillin (17.14 mg/kg) – treated groups for blood assay. The penicillin was administered orally for 50 days. Haematological assay was carried out using haemocytometer, while biochemical assay was carried out using spectrophotometry. Mean +/- SEM and student’s t-test at p&lt;0.05 were determined. Penicillin (17.14 mg/kg) significantly decreased haemoglobin and lymphocyte values, but induced significant increase in eosinophil value relative to their controls. It also significantly decreased total protein and ALP values relative to their controls. Conclusively, it can be suggested that penicillin had harmful effects on blood parameters in female Wistar rats via induction of significant reductions in hemoglobin, lymphocyte and total protein values. However, it also had advantageous effects on blood parameters in female Wistar rats via induction of significant increase in eosinophil value as well as significant decrease in ALP activity.

Carbetocin versus Oxytocin with or without Tranexamic Acid for Prophylactic Prevention of Postpartum Hemorrhage after a Vaginal Delivery: A Randomized Clinical Trial

Objective: Our study’s primary objective was to examine the effects of four different prophylactic protocols on the prevention of postpartum hemorrhage following vaginal birth, including carbetocin only, oxytocin only, and a combination of carbetocin or oxytocin with tranexamic acid. Design: A multicentric randomized controlled trial. Participants/Materials, Setting, and Methods: This multicentric center prospective randomized controlled trial was conducted at the Department of Obstetrics and Gynecology of Bezmialem University and Van Health Teaching and Research Hospital from August 2022 to January 2023. The collected data included age, gravidity, parity, gestational age at birth, duration of delivery stages, prepartum hemoglobin and hematocrit concentrations, changes in hemoglobin and hematocrit concentrations, intrapartum blood loss, estimated blood loss after 2 h of vaginal delivery, Apgar scores at 1 and 5 min, birth weight, and neonatal intensive care unit (NICU) admission. Intrapartum blood loss was objectively measured in milliliters using a postpartum drape with a calibrated bag. The amount of bleeding was measured by subtracting the empty weight of the pads placed under the patient in the patient’s bed within 2 h after delivery. Group I: carbetocin 100 μg/mL (n = 75), group II: oxytocin 5 IU/mL (n = 75), group III: carbetocin and tranexamic acid 50 mg/mL (n = 75), group IV: oxytocin and tranexamic acid (n = 75). Results: The hemoglobin concentration decrease significantly differed between groups (1.03 ± 1.04, 1.3 ± 0.85, 1.4 ± 0.85, 1.41 ± 0.87, respectively; p < 0.001). Group 4 has the highest decrease in hemoglobin and hematocrit concentrations. When we investigated the subgroup differences, the decrease in hemoglobin concentration was significantly higher in group 2 than group 1 (1.30 ± 0.85 vs. 1.03 ± 1.04; p = 0.023), in group 2 than group 3 (1.3 ± 0.85 vs. 1.04 ± 0.9; p = 0.013), and in group 4 than group 3 (1.41 ± 0.87 vs. 1.04 ± 0.9; p < 0.001). The decrease in hematocrit level was significantly different between groups (3.07 ± 3.23, 3.55 ± 2.44, 2.13 ± 3.09, 4.25 ± 2.52; p < 0.001, respectively). No significant differences were observed in terms of mean blood loss between the four groups (277.19 ± 208.10, 294.13 ± 198.64, 274.33 ± 199.57, and 283.97 ± 178.11; p = 0.445, respectively). Furthermore, there was no significant difference between the groups in the rate of need for blood transfusion (1.3%, 5.4%, 4%, and 4%, respectively; p = 0.6). Limitations: The most important limitation of the study is a relatively small number of participants. Conclusion: In conclusion, our findings suggest that carbetocin may be more successful than oxytocin and oxytocin plus tranexamic acid regimens in terms of postpartum hemoglobin reduction, and there is no difference in terms of the need for blood transfusion when it is used for postpartum hemorrhage prophylaxis after vaginal delivery.

Impact of calcium channel blockers and angiotensin receptor blockers on hematological parameters in type 2 diabetic patients.

Antihypertensive medications have been associated with a reduction in hemoglobin (Hb) levels, leading to clinically significant anemia. We aimed to provide valuable insights into the impact of angiotensin receptor blockers (ARBs) and calcium channel blockers (CCBs) on hematological parameters by measuring the levels of erythropoietin (EPO), ferritin, and complete blood count (CBC) in individuals with type 2 diabetes mellitus (T2DM), particularly considering the duration of the antihypertensives use. In addition to comparing their effects on blood pressure, glycemic status, and renal function, a retrospective cohort study was conducted at the consultation unit of Alsalam Teaching Hospital, Mosul, Nineveh Province, between October 2022 and February 2023. A total of 160 participants were enrolled after being fully examined by the consultants to detect their eligibility for inclusion in the study and to rule out any abnormality. They consisted of 40 healthy controls, 30 T2DM patients (T2DM group), 30 T2DM patients with newly diagnosed hypertension (HT) (T2DM+HT group), 30 type 2 diabetic-hypertensives on ARBs (T2DM+HT+ARBs group), and 30 type 2 diabetic-hypertensives on CCBs (T2DM+HT+CCBs group). Five milliliters of blood was drawn from a vein and divided into two parts. Two milliliters was transferred into an anticoagulant tube for the measurement of HbA1c and complete blood picture. Serum was obtained from the remaining blood and used for assessment of ferritin, EPO, FSG, creatinine, urea, and uric acid. Significantly reduced FSG and HbA1c levels were observed in T2DM+HT+CCBs and T2DM+HT+ARBs groups vs T2DM+HT group (p < 0.05). The T2DM+HT+CCBs group had statistically higher urea levels than the T2DM group (p < 0.05). Both CCBs and ARBs use resulted in reduced creatinine clearance (CrCl). T2DM+HT+CCBs group exhibited slightly higher uric acid levels compared to controls (p < 0.05). Prolonged use of CCBs and ARBs led to disturbances in hematological parameters, with CCBs users showing the lowest levels of hemoglobin (Hb), RBCs, and hematocrit (Hct) among the groups. ARBs users displayed the lowest values of EPO and ferritin compared to other patient groups, along with reduced levels of Hb, RBCs, and Hct, albeit slightly higher than CCBs users. Our study highlights the importance of a balanced approach in prescribing ARBs and CCBs to patients with T2DM, given their potential to induce blood abnormalities, particularly with prolonged usage.

Primaquine dose and the risk of haemolysis in patients with uncomplicated Plasmodium vivax malaria: a systematic review and individual patient data meta-analysis

Primaquine radical cure is used to treat dormant liver-stage parasites and prevent relapsing Plasmodium vivax malaria but is limited by concerns of haemolysis. We undertook a systematic review and individual patient data meta-analysis to investigate the haematological safety of different primaquine regimens for P vivax radical cure. For this systematic review and individual patient data meta-analysis, we searched MEDLINE, Web of Science, Embase, and Cochrane Central for prospective clinical studies of uncomplicated P vivax from endemic countries published between Jan 1, 2000, and June 8, 2023. We included studies if they had active follow-up of at least 28 days, if they included a treatment group with daily primaquine given over multiple days where primaquine was commenced within 3 days of schizontocidal treatment and was given alone or coadministered with chloroquine or one of four artemisinin-based combination therapies (ie, artemether-lumefantrine, artesunate-mefloquine, artesunate-amodiaquine, or dihydroartemisinin-piperaquine), and if they recorded haemoglobin or haematocrit concentrations on day 0. We excluded studies if they were on prevention, prophylaxis, or patients with severe malaria, or if data were extracted retrospectively from medical records outside of a planned trial. For the meta-analysis, we contacted the investigators of eligible trials to request individual patient data and we then pooled data that were made available by Aug 23, 2021. The main outcome was haemoglobin reduction of more than 25% to a concentration of less than 7 g/dL by day 14. Haemoglobin concentration changes between day 0 and days 2-3 and between day 0 and days 5-7 were assessed by mixed-effects linear regression for patients with glucose-6-phosphate dehydrogenase (G6PD) activity of (1) 30% or higher and (2) between 30% and less than 70%. The study was registered with PROSPERO, CRD42019154470 and CRD42022303680. Of 226 identified studies, 18 studies with patient-level data from 5462 patients from 15 countries were included in the analysis. A haemoglobin reduction of more than 25% to a concentration of less than 7 g/dL occurred in one (0·1%) of 1208 patients treated without primaquine, none of 893 patients treated with a low daily dose of primaquine (<0·375 mg/kg per day), five (0·3%) of 1464 patients treated with an intermediate daily dose (0·375 mg/kg per day to <0·75 mg/kg per day), and six (0·5%) of 1269 patients treated with a high daily dose (≥0·75 mg/kg per day). The covariate-adjusted mean estimated haemoglobin changes at days 2-3 were -0·6 g/dL (95% CI -0·7 to -0·5), -0·7 g/dL (-0·8 to -0·5), -0·6 g/dL (-0·7 to -0·4), and -0·5 g/dL (-0·7 to -0·4), respectively. In 51 patients with G6PD activity between 30% and less than 70%, the adjusted mean haemoglobin concentration on days 2-3 decreased as G6PD activity decreased; two patients in this group who were treated with a high daily dose of primaquine had a reduction of more than 25% to a concentration of less than 7 g/dL. 17 of 18 included studies had a low or unclear risk of bias. Treatment of patients with G6PD activity of 30% or higher with 0·25-0·5 mg/kg per day primaquine regimens and patients with G6PD activity of 70% or higher with 0·25-1 mg/kg per day regimens were associated with similar risks of haemolysis to those in patients treated without primaquine, supporting the safe use of primaquine radical cure at these doses. Australian National Health and Medical Research Council, Bill & Melinda Gates Foundation, and Medicines for Malaria Venture.

Glycaemic Control and Weight Reduction: A Narrative Review of New Therapies for Type 2 Diabetes.

Early and intensive treatment of type 2 diabetes (T2D) has been associated with lower risk of diabetes-related complications. Control of overweight and obesity, which are strongly associated with T2D and many of its complications, is also key in the management of the disease. New therapies allow for individualised glycaemic control targets with greater safety. Thus, in patients with a higher cardiovascular and renal risk profile, current guidelines encourage early treatment with metformin together with glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose co-transporter-2 inhibitors with proven cardiovascular benefit. GLP-1 RAs combine highly efficacious glucose-lowering activity with a reduced risk of hypoglycaemia. Recently, tirzepatide, a first-in-class drug that activates both glucose-dependent insulinotropic polypeptide and GLP-1 receptors, has demonstrated very high efficacy in glycated haemoglobin (HbA1c) and weight reduction in clinical trials. Tirzepatide has the potential to help people with T2D reach recommended glycaemic and weight targets (HbA1c < 7% and > 5% weight reduction) and to allow some patients to reach HbA1c measurements close to normal physiological levels and substantial weight reduction. In 2022, tirzepatide was approved by the US Food and Drug Administration and the European Medicines Agency for treatment of people with T2D and is currently in development for chronic weight management.

Clinical characteristics and their influences on the survival of leptomeningeal metastasis derived from lung adenocarcinoma harboring epithelial growth factor receptor mutation

Objective: To analyze the clinical characteristics of leptomeningeal metastasis (LM) patients from epithelial growth factor receptor (EGFR)-mutated lung adenocarcinoma, and their impacts on the survival of the patients. Methods: From July 2018 to July 2022, the clinicopathological data of 81 patients diagnosed as EGFR-mutated lung adenocarcinoma LM by cytopathology who admitted to the Department of Oncology of Xiangya Hospital of Central South University were retrospectively analyzed, including 33 males and 48 females. The age ranged from 31 to 76 years, with a median age of 54 years. All the 81 patients were followed up, with a median follow-up of 21.0 months (95%CI: 12.5 to 29.5 months). The Kaplan Meier method was used to draw survival curve. Cox proportional hazards regression model was used to analyze the impact of the factors on the survival of patients. Results: Among the 81 patients, the interval between the initial diagnosis of lung cancer and the pathological diagnosis of LM in cerebrospinal fluid (CSF) was 0-108 months, with a median interval of 14 months. Fifty-two patients (64.2%) used the third-generation epithelial growth factor receptor tyrosine kinase inhibitor (EGFR-TKIs), while 17 patients (21.0%) used EGFR-TKIs in combination with other drugs, and 12 patients (14.8%) were treated with best supportive care (BSC). Sixty patients (74.1%) had a Kanofsky performance status (KPS) score of less than 60 points, and 71 patients (87.7%) had brain parenchymal metastasis and/or spinal metastasis. Twenty-two patients (27.2%) used pemetrexed through intrathecal CSF, and 17 patients (21.0%) used pemetrexed through the Ommaya sac to the CSF of the ventricle. The incidence of adverse event related to the administration of pemetrexed through CSF was 64.1% (25/39), mainly manifested as myelosuppression, including 22 patients of leukocyte reduction, 25 patients of hemoglobin reduction, and 14 patients of platelet reduction. The median post-leptomeningeal metastasis overall survival (pLM-OS) in 81 patients was 11.0 (95%CI: 7.7-14.3) months. KPS score≥60 points (HR=0.407, 95%CI: 0.170-0.973, P=0.043), CSF cytology negative after treatment (vs persistent positive, HR=0.351, 95%CI: 0.155-0.792, P=0.012), intraventricular administration of pemetrexed (vs non intraventricular administration of pemetrexed, HR=0.319, 95%CI: 0.137-0.745, P=0.008) and the treatment with third-generation EGFR-TKIs after LM (vs EGFR-TKIs in combination with other drugs, HR=0.486, 95%CI: 0.237-0.998, P=0.049) were a factor affecting pLM-OS of patients. Conclusions: Brain parenchyma, or/and spine are the most sites where the LM patients concurrently metastasize. KPS score≥60 points and CSF cytology negative after treatment, intraventricular administration of pemetrexed and the treatment with third-generation EGFR-TKIs are indictors affecting pLM-OS of the patients.