Initial Hemoglobin Concentration Research Articles

Factors that determine cell-free hemoglobin concentration in blood prime during cardiac surgery with cardiopulmonary bypass: a prospective observational study

INTRODUCTION: Plasma cell-free hemoglobin (Hbf) has a negative effect on the results of cardiac surgery. OBJECTIVE: Analysis of the dynamics of the Hbf during cardiosurgical operations with CPB. Identification of the main factors for increasing the Hbf. MATERIALS AND METHODS: A prospective, single-center, cohort study included 50 patients who underwent cardiac surgery with CPB. Hbf was monitored before surgery, during CPB (10 minutes after the start, then every 30 minutes) and every 6 hours for two days. RESULTS: An increase in Hbf levels was found in 90 % of surgical procedure. In 8 % of cases, hemolysis was mild (0.1 < Hbf ≤ 0.4 g/l), in 48 % — moderate (0.4 < Hbf < 1 g/l), severe (Hbf ≥ 1 g/l) was after 34 % of operations. After weaning from CPB Hbf rapidly decreases and after 12 hours drop to the preoperative level. Aortic cross-clamping is a risk factor with an odds ratio of 1.038 (p = 0.036). A positive correlation was established between the Hbf level and the duration of CPB (r = 0.76; p < 0.001). In ROC-analysis, a good predictive ability for development of severe hemolysis was demonstrated by the time of CPB: AUC 0.74 (p = 0.014) with a threshold value of 76 minutes. During CABG, severe hemolysis developed significantly less frequently than during valve corrections — 12.5 % versus 44.1 %, p = 0.026. Hbf content was significantly lower with an initial hemoglobin concentration < 140 g/l than in patients with an initial hemoglobin level ≥ 140 g/l — 0.7 (0.5; 0.95) g/l versus 0.9 (0.7; 1.28) g/l, p = 0.036. CONCLUSIONS: Hemolysis is typical for the cardiac surgeries with CPB. The time of aoral clamping and CPB, the type of surgcry, the hemoglobin content before surgcry have an impact on the severity of hemolysis.

Safety of Intravenous Iron in CKD Stage 3-5 Patients Not on Dialysis: A Retrospective Cohort Study.

Iron deficiency is common in chronic kidney disease (CKD) patients not on dialysis (ND). Restoring depleted iron stores through intravenous (IV) route is faster and associated with less side effects. There is conflicting data regarding intravenous iron use and its impact on clinical outcomes in this population. This study aims at evaluating any negative clinical impact associated with IV iron use in CKD patients at stages (3-5) before dialysis. Retrospective chart review. Chart analysis of ND CKD 3-5 (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2) patients who received IV iron between January 2013 and January 2018 in 3 major hospitals in Kuwait. Outcomes analyzed were rates of all-cause hospitalizations, infection-related hospitalizations, mortality rates, and eGFR decline over 12 months after IV iron infusion in this population divided into 3 groups according to CKD stage. A total of 738 patients were included in our analysis. Mean initial hemoglobin concentration was 111.5 ± 15.0 g/L in group 1 (CKD 3: eGFR 30-59 mL/min/1.73 m2), 103.6 ± 17.7 g/L in group 2 (CKD 4: eGFR 15-29 mL/min/1.73 m2), and 99.4 ± 14.5 g/L in group 3 (CKD 5: eGFR < 15 mL/min/1.73 m2 but not on dialysis). All-cause hospitalization and infection-related hospitalization were more common among group 3 subjects (adjusted odds ratio =2.12 [95% confidence interval, CI: 1.32-3.41] and 2.02 [95% CI: 1.15-3.55]), respectively. No deaths occurred during 12 months of follow-up. Lack of control group, retrospective study. Intravenous iron use in CKD 3-5 ND is generally safe. Higher hospitalization rates in patients with eGFR <30 mL/min are possibly associated with lower baseline hemoglobin, lower baseline eGFR, and higher comorbidity burden, and not related to iron infusion.

A True Positive and a False Negative? The Dilemma of Negative Colonoscopy After a Positive Fecal Occult Blood Test.

Many colonoscopies following a positive fecal immunochemical test (FIT) will not identify a probable cause for fecal blood, and missed neoplasia is a concern. The study determined whether the absence of neoplasia at a FIT positive diagnostic colonoscopy was due to a missed lesion and whether the initial FIT hemoglobin (f-Hb) concentration could predict missed lesions. This was a retrospective audit of patients who had undergone diagnostic colonoscopy after FIT screening (2 sample ≥ 20µg Hb/g feces). Probable bleeding lesions including cancer, advanced adenoma, colitis, and angiodysplasia were considered a "positive colonoscopy outcome." For those with a negative outcome, findings at the subsequent colonoscopy were assessed. There were 1087 good quality colonoscopies within 12months of a positive FIT. In total, 171 (15.7%) patients had a positive outcome at the diagnostic colonoscopy. Subsequent colonoscopies of negative outcome cases (n = 418, median of 3.1y later) were reviewed; of these, there were 57 (13.6%) cases with a positive outcome. This included CRC in 0.5% (n = 2) and advanced adenoma in 11.7% (n = 49). High f-Hb and having both FIT samples ≥ 20µg/g feces were associated with a positive outcome at the original diagnostic colonoscopy (p < 0.05). However, f-Hb was not predictive for a positive outcome at the subsequent colonoscopy by either maximum f-Hb (p = 0.768), total f-Hb (p = 0.459), or both FIT samples ≥ 20µg/g (p = 0.091). A small proportion of "false" positive FIT results had cancer or advanced adenoma found at the subsequent colonoscopy. A missed lesion could not be predicted by the initial FIT f-Hb.

The epidemiology of overtransfusion of red cells in trauma resuscitation patients in the context of a mature massive transfusion protocol

PurposePacked red blood cell (PRBC) transfusion remains an integral part of trauma resuscitation and an independent predictor of unfavourable outcomes. It is often administered urgently based on clinical judgement. These facts put trauma patients at high risk of potentially dangerous overtransfusion. We hypothesised that trauma patients are frequently overtransfused and overtransfusion is associated with worse outcomes.MethodsTrauma patients who received PRBCs within 24 h of admission were identified from the trauma registry during the period January 1 2011–December 31 2018. Overtransfusion was defined as haemoglobin concentration of greater than or equal to 110 g/L at 24 h post ED arrival (± 12 h). Demographics, injury severity, injury pattern, shock severity, blood gas values and outcomes were compared between overtransfused and non-overtransfused patients.ResultsFrom the 211 patients (mean age 45 years, 71% male, ISS 27, mortality 12%) who met inclusion criteria 27% (56/211) were overtransfused. Patients with a higher pre-hospital systolic blood pressure (112 vs 99 mmHg p < 0.01) and a higher initial haemoglobin concentration (132 vs 124 p = 0.02) were more likely to be overtransfused. Overtransfused patients received smaller volumes of packed red blood cells (5 vs 7 units p = 0.049), fresh frozen plasma (4 vs 6 units p < 0.01) and cryoprecipitate (6 vs 9 units p = 0.01) than non-overtransfused patients.ConclusionMore than a quarter of patients in our cohort were potentially given more blood products than required without obvious clinical consequences. There were no clinically relevant associations with overtransfusion.

Barriers to and Facilitators of Iron Therapy in Children with Iron Deficiency Anemia

To characterize barriers to and facilitators of successful iron therapy in young children with iron deficiency anemia (IDA) from an in-depth parental perspective. Prospective, mixed methods study of children age 9months to 4years with a diagnosis of nutritional IDA by clinical history and laboratory criteria and their parents. Clinical data were obtained from the electronic health record. Semistructured interviews focused on knowledge of IDA, clinical effects, experience with iron therapies, and motivation were conducted with the parent who identified as the child's primary caregiver. Twenty patient-parent dyads completed the study; 80% (n=16) identified as Hispanic/Latino (white). Patients' median age was 23months (50% male); median initial hemoglobin concentration was 8.2g/dL and duration of oral iron therapy was 3months. Parents' median age was 29years (85% female); 8 interviews (40%) were conducted in Spanish. Barriers included difficulty in administering oral iron owing to side effects and poor taste. Facilitators included provision of specific instructions; support from healthcare providers and additional caregivers at home; motivation to benefit child's health, which was strengthened by strong emotional reactions (ie, stress, anxiety) to therapy and follow-up; and an appreciation of child's improvement with successful completion of therapy. Our findings support the need for interventions designed to promote oral iron adherence in children with IDA. Rather than focusing on knowledge content related to IDA, interventions should aim to increase parental motivation by emphasizing the health benefits of adhering to iron therapy and avoiding more invasive interventions.

Abstract 3 Impact of Trainee Experience on the Decision to Perform Endoscopy on Weekends

Guidelines recommend endoscopy with 24 hours of admission for patients who present with suspected upper gastrointestinal bleeding (GIB). Endoscopy units often operate only during weekdays, however, resulting in logistical barriers to performing endoscopy on weekends. Weekend endoscopy is therefore typically reserved for a subset of higher acuity patients. We sought to determine if trainee experience influences the decision to proceed with upper endoscopy on weekends. In this single-center retrospective cohort study, we reviewed all inpatients who underwent upper endoscopy for suspected GIB within 72 hours of emergency department (ED) triage. Adults who presented between November 2011 and August 2015 were eligible for inclusion. Patient demographics, triage vitals, labs, and transfusion requirements were obtained from the electronic health record. Indications for endoscopy, findings, and need for endoscopic hemostatic therapy were noted. Weekend procedures were defined as endoscopies performed between Friday 6pm and Monday 7am. Initial evaluation of all gastroenterology consults was performed by first-year (PGY 4) fellows, who start their training on July 1. As such, we used progress in the academic year as a surrogate for trainee experience, dividing it in 4 quarters (Jul—Sep, Oct—Dec, Jan—Apr and May—Jun). 690 patients underwent upper endoscopy for an indication of hematemesis, melena, or hematochezia (Table 1). Patients who underwent endoscopy on weekends were more likely to be tachycardic and hypotensive than those who underwent weekday endoscopy. The mean initial hemoglobin concentration was lower and transfusion requirements were higher on weekends. Endoscopic hemostatic therapy was performed more frequently on weekends than weekdays (29.5% vs 18.3%, P = .002). The proportion of all endoscopies performed on the weekend decreased monotonically through the course of the academic year, from 17% in the first 3 months (Jul—Sep) to 10% in final 3 months (Apr—Jun). In the final logistic model, after adjusting for day of patient triage, and patient severity factors including tachycardia, transfusion requirements, and need for endoscopic hemostasis, period in the academic year was independently associated with increased odds of weekend endoscopy (aOR 2.42 for Jul—Sep vs Apr—Jun, 95% CI 1.10—5.35, P = .028, Table 2). Progress through the academic year is associated with decreased likelihood of performing endoscopy on the weekend. The effect of academic progress in determining whether weekend endoscopy is performed is comparable to the effect of patient tachycardia. Greater trainee experience may result in greater comfort with resuscitating and waiting for a weekday procedure. Further study on the impact of trainee behavior on patient outcomes in endoscopy is warranted.Table 1Characteristics of 690 Patients Who Presented to the ED With GIB and Underwent Upper Endoscopy Within 72 Hours of AdmissionMon—Fri EndoscopyWeekend EndoscopyP valuencol %ncol %N59298Males36862.26664.3.688Age, mean (SD)62.8(17.3)65.515.0.137Tachycardia, HR > 10021836.85556.1<.001Hypotension, MAP < 65447.41414.3.024Initial hemoglobin, mean (SD) g/dL9.52.88.42.6.002Units PRBC in first 24h 023639.91313.3 1—218631.43535.7 2—49115.42121.4 ≥57913.32929.6<.001ICU admission16327.58283.7<.001Endoscopic hemostatic therapy None48381.66970.4 Injection/Clip/Thermal/Combo8113.62323.4 Banding284.766.1.002Trainee academic quarternrow %nrow %Q1: Jul–Sep13283.02717.0Q2: Oct–Dec14184.42615.5Q3: Jan–Mar15785.32714.7Q4: Apr–Jun16290.01810.0.066 Open table in a new tab Table 2Logistic Regression for Independent Predictors of Weekend EndoscopyaOR95% CIP valueWeekend ED triage40.518.0—91.4<.001Tachycardia (HR > 100)1.731.03—2.90.037PRBC in first 24h/per unit1.111.05—1.18<.001Endoscopic hemostatic therapy1.271.10—1.50.003Trainee academic quarter Q1: Jul–Sep2.421.10—5.35.028 Q2: Oct–Dec1.490.69—3.21.305 Q3: Jan–Mar1.430.67—3.06.353 Q4: Apr–Jun1 (ref) Open table in a new tab

An Investigation into the Side Effects of Entonox on Primiparas in Painless Labor

Labor pain causes a great fear of vaginal delivery as well as increase of cesarean among women. Therefore, using harmless and efficacious pain relief methods is of great significance. Accordingly, the present study aimed at investigating the side effects of nitrous oxide on mother and fetus. This is a randomized controlled trial study carried out on 178 primipara candidates for natural. During the active labor phase, women were assigned to two groups; intervention group(89 women inhaling Entonox) and control group(89 women inhaling oxygen). The required data including age, gestational age, evidence of abruption, mode of delivery, meconium staining, fetal Apgar score, side effects of drug consumption, the amount of postpartum bleeding, initial hemoglobin concentration and its concentration 6 hours after delivery were recorded. Then the data were analyzed using SPSS software v.16, Chi-square formulas. There was no significant difference between the two groups in terms of the evidence of abruption, accelerated labor, meconium staining by the fetus, mean Apgar scores at 1 and 5 min and the final mode of delivery(P>0.05). Side effects such as dizziness and dry mouth were reported in the group inhaling Entonox. In two modes of vaginal delivery and cesarean section, the mean reduction in hemoglobin concentration 6 hours postpartum in the group inhaling Entonox was less than that in the control group(P<0.05). Compared to the use of oxygen, the use of Entonox gas for painless labor did not cause adverse effects on the mother and fetus; however, only minor side effects including drowsiness and dry mouth were observed. Furthermore, it was observed that Entonox causes less reduction in hemoglobin concentration of mother which may pertain to its positive effects on labor progress and its duration.

Iron Deficiency Anemia in Adolescents Who Present with Heavy Menstrual Bleeding

Study ObjectiveTo assess the clinical severity and initial treatment of iron deficiency anemia (IDA) in female adolescents with heavy menstrual bleeding (HMB) in our center. DesignRetrospective cohort study of electronic medical records via search of administrative records using International Classification of Diseases Ninth Revision codes for IDA or unspecified anemia and disorders of menstruation. SettingChildren's Medical Center in Dallas, Texas. ParticipantsOne hundred seven patients with HMB and concomitant IDA (median age, 14.4 years) who presented to the outpatient, emergency department, and/or inpatient settings. ResultsThe median initial hemoglobin concentration for all patients (n = 107) was 7.4 g/dL, and most (74%, n = 79) presented to the emergency department or via inpatient transfer. Symptomatic IDA was treated with blood transfusion in 46 (43%, n = 46). Ferrous sulfate was the most commonly prescribed oral iron therapy. Seven patients received intravenous iron therapy either initially or after oral iron treatment failure. Combined oral contraceptives were commonly prescribed for abnormal uterine bleeding, yet 10% of patients (n = 11) received no hormonal therapy during their initial management. Evaluation for underlying bleeding disorders was inconsistent. ConclusionSevere anemia because of IDA and HMB resulting in urgent medical care, including hospitalization and blood transfusion, is a common but underemphasized problem in adolescent girls. In addition to prevention and early diagnosis, meaningful efforts to improve initial management of adolescents with severe HMB and IDA are necessary.

Protocolo diagnóstico diferencial del síndrome anémico

IntroductionAnemia is a decrease in the amount of red blood cells reducing the capacity of the blood to transport oxygen to tissues, leading to tissue hypoxia. The symptoms and signs of tissue hypoxia constitute the anemia syndrome. Initial clinical assessmentBlood hemoglobin concentration below WHO referral values is considered positive anemia diagnosis. However, its clinical relevance depends on patient's clinical context. Diagnostic sequenceIn order to achieve an initial differential diagnosis of anemia according with morphological criteria (microcytic, normocytic or macrocytic) and pathogenic characteristics (regenerative or central), a detailed clinical history and thorough physical examination along with complete blood count and additional laboratory studies (blood smear, reticulocyte count, Coombs test and ferric pattern) are necessary.

Efficient polymeric material for separation of human hemoglobin

In this study, negatively charged acrylic acid was used as a functional ligand to synthesise net-poly(2-hydroxyethyl methacrylate-co-acrylic acid) microparticles for the removal of hemoglobin having a positively charged Fe2+ ion in the core, as an alternative to conventional techniques to achieve a cost effective high-capacity purification. The characterization of microparticles was performed via Fourier transform infrared spectroscopy, scanning electron microscopy, transmission electron microscopy, atomic force microscopy, the Brunauer – Emmett – Teller surface area analysis, and swelling test methods. Optimum adsorption conditions such as pH, initial hemoglobin concentration, temperature, and interaction time were studied batch wise. The highest adsorption capacity of microparticles was observed at pH 7.4 as 1276.4 mg hemoglobin/g polymer. The reusability of microparticles was also promising with ∼5% decrease in the adsorption capacity at the end of the five adsorption-desorption cycles.

Factors Affecting Breathing Capacity and Early Tracheal Extubation After Liver Transplantation: Analysis of 506 Cases

BackgroundEarly extubation is a standard procedure after liver transplantation (LT). MethodsThe preoperative and perioperative data of 506 adult patients undergoing LT from July 2000 to March 2015 were analyzed. The goal of this study was to determine preoperative and perioperative independent predictors of early tracheal extubation. ResultsOf the 506 study patients, 73.7% were extubated early after LT. Patients in this group exhibited better preoperative and perioperative outcomes. However, according to multivariate logistic regression analysis, only 3 parameters were independent predictors of early extubation: initial hemoglobin concentration (odds ratio [OR], 1.187 [95% confidence interval (CI), 1.033–1.364]), application of epidural anesthesia (OR, 2.762 [95% CI, 1.025–7.445), and units of perioperative packed red blood cells and fresh frozen plasma transfused (OR, 0.919 [95% CI, 0.888–0.952]). ConclusionsEarly extubation of patients undergoing LT is a safe and widely used procedure. However, the decision regarding this procedure should be made after thorough analysis of the patient's current status, the course of operation, and the patient's preoperative parameters. Based on our findings, we believe that the decision regarding early extubation can be aided by taking into account the patient's initial hemoglobin concentration, the number of packed red blood cells and fresh frozen plasma transfused during surgery, and pain control by application of a thoracic epidural catheter.

The Negative Impact of Anemia in Outcome from Traumatic Brain Injury

Whether anemia complicating traumatic brain injury (TBI) has an impact on patient outcomes is controversial; therefore, recommendations for blood transfusions for such patients are inconsistent. We hypothesized that patient outcome after TBI would be worse in patients with lower hemoglobin levels. We retrospectively reviewed records of patients with TBI and head Abbreviated Injury Scale >3 with abnormal head computed tomography findings and neurologic injury. The relationships between initial hemoglobin and lowest hemoglobin during hospitalization at threshold values of ≤7, ≤8, ≤9, and ≤10 g/dL were investigated relative to Glasgow Outcome Score at last follow-up not exceeding 1 year. Of 939 patients meeting inclusion criteria, initial and lowest hemoglobin concentrations were significant predictors of poor outcome (P < 0.0001). For each 1 g/dL higher hemoglobin value, the likelihood of a good outcome increased by 33%. More severe levels of initial anemia were associated with lower Glasgow Coma Scale, greater head Abbreviated Injury Scale, and greater Injury Severity Score (P < 0.0001). Female patients had worse outcome than male patients only for initial hemoglobin between 7 and 8 g/dL (P < 0.05). Blood transfusion was associated with poorer outcome at hemoglobin levels ≤9 and ≤10 g/dL (P < 0.05), but not at lower hemoglobin thresholds. Patient outcome after TBI is worse in patients with lower hemoglobin. Initial hemoglobin and lowest hemoglobin after admission are independently associated with poor outcome. Our data support consideration of blood transfusion when hemoglobin is ≤8 g/dl.

Predictive factors and practice trends in red blood cell transfusions for very-low-birth-weight infants.

BackgroundRed blood cell (RBC) transfusions in very low birthweight (VLBW) infants, while common, carry risk. Our objective was to determine clinical predictors of and trends in RBC transfusions among VLBW infants.MethodsRBC transfusion practice and its clinical predictors in 1,750 VLBW (≤1500 g) infants were analyzed in a single-center cohort across sequential epochs: 2000–2004 (Epoch 1), 2005– 2009 (Epoch 2), and 2010–2013 (Epoch 3).ResultsOverall, 1,168 (67 %) infants received ≥1 transfusions. The adjusted likelihood of ≥1 transfusions decreased for each 1-g/dL increment in initial hemoglobin concentration following birth, for females, and for each 100-g increment in birthweight. The adjusted likelihood of ≥1 transfusions increased with infants receiving mechanical ventilation, with increasing length of hospital stay, with necrotizing enterocolitis and with non-lethal congenital anomalies requiring surgery. The adjusted mean (SEM) number of transfusions per patient was decreased in Epoch 3, compared with Epoch 1 and Epoch 2. For an initial hemoglobin of ≥16.5 g/dL, the predicted probability of being transfused was ≤50%.ConclusionAdjusted RBC transfusions declined and female sex conferred an unexplained protection over the study period. Modest increases in initial hemoglobin by placentofetal transfusion at delivery may reduce the need for RBC transfusion.

Significance of Initial Maternal Hemoglobin Concentration during Pregnancy in Birth Weight and Preterm Delivery in Sri Lanka

Objective: The study was conducted to investigate the influence of initial hemoglobin (Hb) concentration of Sri Lankan pregnant mothers on baby’s birth weight and preterm delivery. Methods: For this retrospective study, 3867 primigravid pregnant women in Sri Lanka were followed till they deliver the baby. Sampling method was cluster sampling where all the pregnant mothers giving singleton birth in the selected 15 health division were followed for three years. Mothers’ initial Hb concentration, weight gain during the pregnancy and neonatal outcomes were assessed. Results: Severe iron deficiency anemia at the initial stage of pregnancy had 3.9 - 14.4 folder higher relative risk of low birth weight (LBW) and 3.0 - 8.1 folder higher relative risk of preterm delivery at 95% confidence interval. The minimum incidence of preterm delivery and maximum weight gain of mothers occurs in association with an initial Hb concentration of 105 - 125 g/L. Conclusion: The excess level of initial iron content at pregnancy does not contribute for any adverse effect on pregnancy outcome as like in the later part of pregnancy and therefore supplement of iron during the initial pregnancy for mothers can be carried out regardless of whether the mother is anemic.

Simulation of repetitive diagnostic blood loss and onset of iatrogenic anemia in critical care patients with a mathematical model

Anemia is prevalent among critical care patients and is attributed to pathologic and iatrogenic processes and bleeding. The extent that diagnostic blood loss contributes to anemia among adult critical care patients is controversial and multi-factorial. The aim of this study is to describe an erythrokinetic model that integrates rates of phlebotomy, erythropoiesis and red cell senescence with patient characteristics to predict the onset of iatrogenic anemia in an objective manner. Using sex-specific parameters, the model predicts that adults with (average body weight and average blood volume), initial hemoglobin concentration at mid-reference interval, active erythropoiesis and losing 53mL of blood per day by phlebotomy would require 40–70 days to reach 70g/L of hemoglobin. To mimic critical care patients with low initial hemoglobin and suppressed erythropoiesis, the influence of daily blood loss and total blood volume was predicted. Simultaneous lack of erythropoiesis, initial hemoglobin concentrations at the lower limit of the reference interval (110g/L), low body weight and increased phlebotomy accelerated onset of ∼70g/L hemoglobin transfusion threshold to 9–14 days. This computer simulation depicts the extent that adult critical care patients with anemia risk factors could benefit from conservative test ordering practices and subsequent reduced diagnostic phlebotomy.

Initial Mean Corpuscular Hemoglobin Concentration Is Stroke Subtype Dependent and Correlates with Stroke Severity and Outcome (P01.020)

Initial Mean Corpuscular Hemoglobin Concentration Is Stroke Subtype Dependent and Correlates with Stroke Severity and Outcome (P01.020)

Adult Polycystic Kidney Disease: Who Needs Hospital Follow‐Up?

Clinical data from 120 adult patients with genetically undifferentiated polycystic kidney disease who had been followed up for more than 3 months (range 3-172) were reviewed in order to try to identify clinical indicators that might predict deterioration in renal function. They were split into two groups dependent on whether annualized fall in estimated glomerular filtration rate (ΔeGFR mL/min/1.73 m(2) /year) was statistically significant or not. Only 26 patients (22%) had a statistically significantly decreasing ΔeGFR with a median decrease of -2.6 mL/min/1.73 m(2) /year (range -6.2 to -0.7). There was no difference in initial age, gender, or racial distributions between the groups or in initial eGFR. Follow-up was longer (median 86, range 23-172 months vs. 46, range 3-161 months; P = 0.002) and initial blood pressure values tended to be lower (with mean systolic values of 128 vs. 148 mm Hg; P = 0.02) in the group with statistically significant fall in ΔeGFR, but this trend failed to achieve an a priori level of statistical significance. However, the proportion of patients with initial systolic blood pressure ≤ 144 developing a statistically significant fall in ΔeGFR was 0.26 (95% confidence interval = 0.13 to 0.45). No differences were found in initial hemoglobin or cholesterol concentrations. Overall, the annualized rate of decrease in eGFR tended to be greater in those with the higher initial eGFR (P = 0.04), but correlation was poor (rho(2) = 0.04) and failed to achieve an a priori level of statistical significance. No statistically significant correlation was found between ΔeGFR and any other variable. Only those patients with polycystic kidney disease with a statistically significant annualized decrease in eGFR may need to be referred for hospital follow-up in the renal clinic. This simple selection would reduce referrals by 78%.

What are Predictors of Mortality in Patients with Pelvic Fractures?

Our knowledge of factors influencing mortality of patients with pelvic ring injuries and the impact of associated injuries is currently based on limited information. We identified the (1) causes and time of death, (2) demography, and (3) pattern and severity of injuries in patients with pelvic ring fractures who did not survive. We prospectively collected data on 5340 patients listed in the German Pelvic Trauma Registry between April 30, 2004 and July 29, 2011; 3034 of 5340 (57%) patients were female. Demographic data and parameters indicating the type and severity of injury were recorded for patients who died in hospital (nonsurvivors) and compared with data of patients who survived (survivors). The median followup was 13 days (range, 0-1117 days). A total of 238 (4%) patients died a median of 2 days after trauma. The main cause of death was massive bleeding (34%), predominantly from the pelvic region (62% of all patients who died because of massive bleeding). Fifty-six percent of nonsurvivors and 43% of survivors were male. Nonsurvivors were characterized by a higher incidence of complex pelvic injuries (32% versus 8%), less isolated pelvic ring fractures (13% versus 49%), lower initial blood hemoglobin concentration (6.7 ± 2.9 versus 9.8 ± 3.0 g/dL) and systolic arterial blood pressure (77 ± 27 versus 106 ± 24 mmHg), and higher injury severity score (ISS) (35 ± 16 versus 15 ± 12). Patients with pelvic fractures who did not survive were characterized by male gender, severe multiple trauma, and major hemorrhage. Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

An expected association between low haemoglobin and poor outcome in severe head injury and an insufficiently detailed multivariate analysis

I read with interest the paper by Sekhon and colleagues, ‘Association of hemoglobin concentration in critically ill patients with severe traumatic brain injury’ (July edition of Critical Care) [1]. Whilst the conclusion (‘mean 7-day haemoglobin concentration <90 g/L associated with increased hospital mortality in patients with severe traumatic brain injury’) is striking, it is plausible, if not likely, that both the haemoglobin defi cit and the observed mortality are dependent upon the severity of the initial injury, and therefore an association between these two might be expected. Given the lack of transfusion trigger and a target haemo globin concentration post-transfusion in this study, and a generous group upper limit of 90 g/L, would those patients with the lowest initial haemoglobin concen tration not be likely to stay below that threshold despite transfusion? Are not the most severe injuries also likely to be associated with a 7-day mean haemoglobin of less than 90 g/L? Injury severity was reportedly accounted for in the multivariate analysis, although the details of the model used were not given. What weighting was given to each variable, such as Glasgow Coma Scale, or CT appearance, and on what basis? Of note is the lack of information regarding other injuries, not just in the multivariate analysis but indeed the entire paper. Were only isolated head injuries considered or were polytrauma patients included in this study? To accept that more than an association exists between two variables - as implied - we must be satisfi ed of the validity of the multivariate analysis.

Dihydroartemisinin-piperaquine versus chloroquine to treat vivax malaria in Afghanistan: an open randomized, non-inferiority, trial.

BackgroundAfghanistan's national guidelines recommend chloroquine for the treatment of Plasmodium vivax infection, the parasite responsible for the majority of its malaria burden. Chloroquine resistance in P. vivax is emerging in Asia. Therapeutic responses across Afghanistan have not been evaluated in detail.MethodsBetween July 2007 and February 2009, an open-label, randomized controlled trial of chloroquine and dihydroartemisinin-piperaquine in patients aged three months and over with slide-confirmed P. vivax mono-infections was conducted. Consistent with current national guidelines, primaquine was not administered. Subjects were followed up daily during the acute phase of illness (days 0-3) and weekly until day 56. The primary endpoint was the overall cumulative parasitological failure rate at day 56 after the start of treatment, with the hypothesis being that dihydroartemisinin-piperaquine was non-inferior compared to chloroquine (Δ = 5% difference in proportion of failures).ResultsOf 2,182 individuals with positive blood films for P. vivax, 536 were enrolled in the trial. The day 28 cure rate was 100% in both treatment groups. Parasite clearance was more rapid with dihydroartemisinin-piperaquine than chloroquine. At day 56, there were more recurrent infections in the chloroquine arm (8.9%, 95% CI 6.0-13.1%) than the dihydroartemisinin-piperaquine arm (2.8%, 95% CI 1.4-5.8%), a difference in cumulative recurrence rate of 6.1% (2-sided 90%CI +2.6 to +9.7%). The log-rank test comparing the survival curves confirmed the superiority of dihydroartemisinin-piperaquine over chloroquine (p = 0.003). Multivariate analysis showed that a lower initial haemoglobin concentration was also independently associated with recurrence. Both regimens were well tolerated and no serious adverse events were reported.ConclusionsChloroquine remains an efficacious treatment for the treatment of vivax malaria in Afghanistan. In a setting where radical therapy cannot be administered, dihydroartemisinin-piperaquine provides additional benefit in terms of post-treatment prophylaxis, reducing the incidence of recurrence from 4-8 weeks after treatment.Trial RegistrationThe trial was registered at ClinicalTrials.gov under identifier NCT00682578.