Low Hemoglobin Concentration Research Articles

Association between immunity and viral shedding duration in non-severe SARS-CoV-2 Omicron variant-infected patients.

Coronavirus disease 2019 (COVID-19) is a respiratory-related disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). More than 200 countries worldwide are affected by this disease. The Omicron variant of SARS-CoV-2 is the major epidemic variant worldwide and is characterized by higher infectivity. However, the immunity and risk factors for prolonged viral elimination in patients with non-severe SARS-CoV-2 Omicron variant infections are unclear. Therefore, this study aimed to examine the relationship between immunity and duration of viral elimination in non-severe SARS-CoV-2 Omicron variant-infected patients in Shanghai. In total, 108 non-severe SARS-CoV-2 Omicron variant-infected patients from Shanghai New International Expo Center Fangcang Shelter Hospital were recruited in this study. They were further allocated to the early elimination (EE) and prolonged elimination (PE) groups according to SARS-CoV-2 nucleic acid positivity duration. Compared to patients with EE, those with PE had increased serum concentrations of interleukin (IL)-5, IL-6, and IL-8; higher neutrophil count and neutrophil-to-lymphocyte ratio (NLR); lower lymphocyte, eosinophil, and red blood cell counts; and lower concentrations of hemoglobin and albumin (ALB). In lymphocyte subpopulation analysis, lower numbers of CD3+ T cells, CD4+ T cells, CD8+ T cells, and NK cells and a higher CD4/CD8 ratio were observed in patients with PE. In addition, correlation analysis results revealed that cycle threshold values of SARS-CoV-2 Omicron variant ORF1ab and N were negatively correlated with IL-6 and IL-8 levels and positively correlated with eosinophil count in patients with COVID-19. Finally, multivariate regression analysis showed that ALB, CD4/CD8 ratio, NLR, and eosinophil count were predictors of the SARS-CoV-2 Omicron variant elimination. In this study, we identified that the ALB, CD4/CD8 ratio, NLR, and eosinophil count were risk factors for prolonged viral elimination in non-severe SARS-CoV-2 Omicron variant-infected patients. These factors might be efficient indicators in the diagnosis, evaluation, and prognosis monitoring of the disease.

574 DOUBLE VASCULAR COMPLICATION IN THE SITE OF PUNCTURE AFTER TAVI: A CASE REPORT

Abstract Hemorrhages represent one of the most frequent complications during TAVI. Their rapid recognition and a prompt treatment are necessary to avoid hemorrhagic shock, which can lead the patient to death in a short time. We report the case of a 79-year-old woman affected by severe and symptomatic aortic stenosis, who underwent TAVI in our Cath-lab. Through a right femoral echo-guided arterial access, implantation of a 26 mm self-expandable aortic bio-prosthesis and hemostasis in the site of puncture with 18F Manta vascular closure device were performed. At the end of the procedure, through radial artery, a femoral angiography was performed, showing an important leak of contrast medium upper the site of puncture, without any change in arterial pressure or heart rate. After echo-guided cannulation of left femoral artery with 8F sheath, implantation of endoprosthesis in the site of hemorrhage and hemostasis of left femoral artery with 8F AngioSeal VIP vascular closure device were performed. In cardiac intensive care unit (CICU) low dosage of vasoactive agents and blood were administered, guaranteeing a good arterial pressure. Computed tomography (CT) was performed after two days and confirmed the presence of a retroperitoneal hematoma, without active bleeding. After six days, the patient left CICU and was admitted to the cardiological ward, starting a gradual mobilization. However, after 48 hours she reported abdominal pain and became rapidly hypotensive, tachycardic and asthenic, requiring readmission in CICU. Serum exams showed low hemoglobin concentration, an abdominal CT was perfomed, showing an active bleeding from left femoral artery and a homolateral retroperitoneal hematoma. The patient was rapidly lead in the cath lab. Angiography confirmed the hemorrage and an endoprosthesis was successfully implanted in the left femoral artery. Blood and vasoactive agents were administered with a progressive improvement in hemodynamic and clinical conditions of the patients. Post-operative course was complicated by fever and empiric antiobiotic therapy was administered until blood culture revealed no bacterial growth. A third CT showed the stability of the hematomas and the absence of active bleeding, allowing hospital discharge of the patient. Vascular complications are frequent and sneaky during TAVI procedures. A prompt treatment is of paramount importance to prevent hemorrhagic shock. TAVI operators should have experience in the field of peripheral intervention for the management of vascular complications.

Maternal hemoglobin and risk of low birth weight: A hospital-based cross-sectional study in Nepal

BackgroundMaternal hemoglobin during pregnancy is an important predictor of neonatal outcomes such as birth weight. The newborn weight of an infant is considered a crucial factor for morbidity and mortality. This study aimed to assess the association between maternal hemoglobin concentration and newborn weight at term pregnancy. MethodsA hospital-based cross-sectional study was conducted at Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal from 14th April 2018 to 13th April 2019. Term singleton pregnant women who were admitted for delivery in the labor room of TUTH were included in this study. Maternal characteristics such as age, parity, birth space, ethnicity, education level, dietary habit, body mass index (BMI), and hemoglobin level were recorded. The newborn weight was taken immediately after delivery. The main outcome of this study was the birth weight. The association between hemoglobin level and newborn weight was analyzed using bivariate and multivariable logistic regression analysis. ResultsOf 2,418 term pregnant women, the prevalence of low hemoglobin and high hemoglobin levels were 24% (95% CI: 22–25.4), and 17% (95% CI: 15.7–18.7), respectively. The prevalence of low birth weight (LBW) was 12.9% (95% CI: 11.7–14.4). Multivariable logistic regression analysis showed that those mothers who had low hemoglobin concentration (adjusted Odds Ratio/aOR = 3.77, 95% CI: 2.84–5.01), and high hemoglobin concentration (aOR = 3.07, 95% CI: 2.23–4.24) had higher odds of having LBW compared to mothers having normal hemoglobin level. Mothers with both young age pregnancy (aged 16–20 years) and older pregnancy (aged ≥31 years) (aOR = 1.60, 95% CI: 1.01–2.52) and (aOR = 1.60, 95% CI: 1.06–2.41), respectively had higher odds of LBW compared to mothers aged 21–25 years. Those mothers who attended a primary level of education had higher odds of (aOR = 1.93, 95% CI: 1.05–3.55) LBW compared to those mothers with a higher level of education. Moreover, mothers who belonged to Janajati ethnic group (aOR = 0.47, 95% CI: 0.34–0.65) compared to the Brahmin/Chhetri ethnic group, and mothers with a birth space of more than three years (aOR = 0.63, 95% CI: 0.41–0.97) compared to those who had less than three years of birth spacing and mothers who were overweight/obese (aOR = 0.74, 95% CI: 0.55–0.99) compared to normal nutritional status had lower odds of having LBW. ConclusionsOur study concludes that both low and high hemoglobin had an increased risk of having low birth weight. Policies and programs can benefit by adopting the findings of this study. More empirical research is critical to understanding the impact of hemoglobin levels on birth weight.

Associations between nutritional and immune status and clinicopathologic factors in patients with tuberculosis: A comprehensive analysis.

This study was designed to assess and analyze nutritional status (NS) and immune status in patients with tuberculosis. A retrospective analysis was conducted on 93 TB patients hospitalized in the tuberculosis ward of the West China Hospital of Sichuan University. Subgroup comparisons were made according to age (<65 years and ≥65 years), nutritional risk score 2002 (NRS 2002 <3 and ≥3), tuberculosis location [pulmonary tuberculosis and extrapulmonary tuberculosis (including pulmonary tuberculosis complicated with extrapulmonary tuberculosis)], and prognostic nutrition index (PNI) (<45 vs ≥45). Significantly increased weight loss was associated with extrapulmonary tuberculosis (P =0.0010). Serum albumin (P =0.0214), total lymphocyte count (P = 0.0009) and PNI (P = 0.0033) were significantly decreased in older patients. Neutrophils/lymphocytes (NLR) (P =0.0002), monocytes/lymphocytes (MLR) (P < 0.0001), and platelets/lymphocytes (PLR) (P =0.0107) were higher. According to NRS 2002, higher nutritional risk was associated with lower body weight and body mass index (BMI) (P < 0.0001), higher weight loss (P = 0.0012), longer duration of hospitalization (P =0.0100), lower serum albumin level and hemoglobin concentration (P <0.01), lower creatinine level, and lower PNI (P < 0.01). 0.0001), lower total lymphocyte count (P = 0.0004), higher neutrophil and monocyte counts (P <0.05), and higher NLR (P = 0.0002), MLR (P = 0.0006), and PLR (P = 0.0156). Lower PNI was associated with lower body weight (P = 0.0001) and BMI (P =0.0074), lower total protein, albumin, and hemoglobin concentrations (P < 0.0001), and lower total lymphocyte count (P < 0.0001) and creatinine levels (P = 0.0336), higher age (P =0.0002) and NRS 2002 score, P < 0.0001), longer hos-pital stay (P = 0.0003), higher neutrophil count (P = 0.0042), and NLR, MLR, and PLR (P <0.0001) were significantly correlated. In multivariate logistic regression analysis, weight loss (OR: 0.209, 95% CI: 0.060-0.722; p =0.013) was significantly associated with higher nutritional risk (NRS 2002≥3). In multiple linear regression analysis, the NRS 2002 score was higher (B=2.018; p =0.023), and extrapulmonary tuberculosis (B=-6.205; p =0.007) was linked with a longer duration of hos-pitalization. Older tuberculosis patients are at nutritional risk, and older patients (≥65 years old) need to pay attention to nutritional monitoring and intervention. Older TB patients and those at risk of malnutrition have increased immune ratio and impaired immune function. Management of TB patients using basic diagnostic tools to assess nutritional and immune status and calculate PNI and immunological indexes (NLR, MLR, PLR) to improve treatment outcomes.

Predictors and Clinical Complications Associated with Antiphospholipid Antibodies in Sickle Cell Disease

Introduction. The antiphospholipid syndrome is characterized by the presence of anti-phospholipid autoantibodies (aPL) leading to a hypercoagulable state as well as an arterial, venous, and microcirculatory vasculopathy. Under several physiological and pathological situations, including the sickling of red blood cells (RBC), negatively charged phospholipids translocate from the inner to the outer surface of cell membranes leading to the potential generation of the antigenic target of aPL. We tested the following two-part hypothesis: 1) repeated exposure of the immune system of patients with sickle cell disease (SCD) to the antigenic target of aPL leads to an increased formation of aPL; and 2) the presence of aPL is associated with pregnancy and SCD-related complications. Methods. We conducted a cross-sectional study in 63 adults with SCD who had aPL testing performed during a hospital admission between August 1999 & June 2017. We compared individual aPL levels with categorical and linear variables using the Kruskal-Wallis test and linear regression analysis, respectively. The anticardiolipin (aCL) IgG and lupus anticoagulant (LA) levels were log-transformed for these analyses. An abnormal aPL was defined as any of the following: IgM or IgG anti-b2GPI >20 IU/mL, IgM or IgG aCL > 20 IU/mL, LA > 10 seconds. Clinical complications were compared by abnormal aPL status using the chi-square test. Results. The median age of the SCD cohort was 32 years (IQR, 21 - 39 years), 49 (78%) were female, 62 (98%) were African American, 5 (8%) had a diagnosis of systemic lupus erythematosus (SLE), 43 (68%) were Hgb SS genotype, 17 (27%) were on hydroxyurea, and 16 (25%) were on chronic anticoagulation therapy. SCD patients with SLE had higher median aCL IgM (6 vs. 1 IU/mL, respectively; P=0.02) and anti-b2GPI IgG (3.5 vs. 0 IU/mL, respectively; P=0.008) levels compared to those without SLE, while lower hemoglobin concentrations were associated with higher aCL IgG levels (β -0.12; P=0.07) and longer LA times (β -0.18; P=0.02). Fifteen of 63 (24%) patients with SCD had an abnormal aPL. Patients with an abnormal aPL had a lower hemoglobin concentration (Figure 1A), a higher white blood cell (WBC; 13.5 vs. 11.8 x109/L, respectively; P=0.06) count, and a lower platelet (268 vs. 340 x109/L, respectively; P=0.05) count at the time of hospitalization compared to those with a normal aPL. A lower hemoglobin concentration (odds ratio [OR], 1.9; P=0.008), a higher WBC count (OR 1.2; P=0.03), and a lower platelet count (10 platelets/µL increment: OR 1.05, P=0.06) were independently associated with the presence of an abnormal aPL by logistic regression analysis, adjusting for age, sex, and prior SLE diagnosis. Consistent with the second part of our hypothesis, several adverse outcomes trended higher in SCD patients with an abnormal aPL. An abnormal aPL was more prevalent among women with ≥ 3 miscarriages, preterm deliveries, or pre-eclampsia as well as during a hospitalization complicated by acute chest syndrome or multiorgan failure (Figure 1B). Conclusions. These data support the hypothesis that patients with SCD have a high predilection to form aPL, and that the presence of an abnormal aPL is associated with pregnancy complications and the severity of acute SCD-related complications during hospitalization. Our study is limited by its small number of patients. Further larger studies are needed to assess the mechanisms of aPL generation as well as to determine the prevalence and associated risk of abnormal aPL status in patients with SCD. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Molecular Profiles and Clinical Features of Myeloproliferative Neoplasms Unclassifiable (MPN-U) with and without JAK2/CALR/MPL Mutations

Introduction: Myeloproliferative neoplasms (MPNs) are clonal hematopoietic neoplasms and include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF), etc., each with specific diagnostic criteria. Patients who display features compatible with MPN but do not meet the diagnostic criteria for a specific entity are commonly assigned a diagnosis of MPN, unclassifiable (MPN-U). JAK2, CALR, and MPL are well-known driver mutations in PV, ET, and PMF. With the advancement and application of next-generation sequencing (NGS), the molecular profiles of the above 3 well-defined MPNs have been extensively studied. However, the molecular profile of MPN-U remains ill-defined. In this study, we aimed to describe the clinical and molecular features of MPN-U in our institution and then compare these features between patients with and without JAK2, CALR, or MPL mutations to better understand the clinicopathologic characteristics and prognosis of MPN-U. Method: The patients with a diagnosis of MPN-U and available NGS test results at our cancer center were identified and divided into two groups: cohort A) MPN-U with mutations in JAK2, CALR, or MPL, and cohort B) triple-negative. The patients' survival data, clinical parameters, bone marrow findings, and cytogenetics were collected for comparison. Baseline characteristics and somatic mutation distributions were compared using the chi-square test (categorical variables) and Wilcoxon rank sum test (continuous variables). Overall survival (OS) was calculated using the Kaplan-Meier method and compared using the log-rank test. A Cox proportional-hazards model was used to evaluate the association between OS and clinical factors. Results: Out of 8285 patients in our institutional clinical molecular database which houses NGS, we identified and confirmed MPN-U diagnosis in 53 patients. Among this group, 39 patients harbored JAK2 (n=36), CALR (n=1), MPL (n=1), or JAK2 and CALR co-mutations (n=1) and were assigned to cohort A. The remaining 14 patients were triple-negative and assigned to cohort B. The triple-negative patients in cohort B had higher median WBC count (18.5 x 10 9/L vs 9.98 x 10 9/L, p=0.04) and bone marrow cellularity (81% vs 64%, p=0.02) (Table 1). The mutational profile of cohort B was enriched for CUX1, ETV6, NRAS, SETBP1, and SRSF2 mutations. ASXL1 and SETBP1 were the most frequently mutated genes in the triple-negative group, and were often co-mutated with ETV6, NRAS, and/or SRSF2 (Figure 1). TET2 mutations appeared more common in cohort A, but this finding was not statistically significant. There were no significant differences in the other parameters, including gender, bone marrow blast percentage, karyotype, hemoglobin concentration, platelet count, and bone marrow fibrosis. Kaplan-Meier analysis demonstrated that the median OS time in cohorts A and B was not reached, and survival differences were not statistically significant (p-value 0.23). We used a Cox proportional-hazards model to evaluate the association between OS and clinical factors. Via backward elimination, we uncovered that high WBC count and low hemoglobin concentration were significantly associated with worse outcome (hazard ratios of 1.04 and 1.33, respectively, and p-values of 0.007 and 0.01). Conclusion: In our small cohort, the patients with MPN-U who were triple-negative for JAK2,CALR, and MPL mutations had more frequent CUX1, ETV6, NRAS, SETBP1, and SRSF2 mutations. ASXL1 and SETBP1 were the most frequently mutated genes in the triple-negative group, and were often co-mutated with ETV6, NRAS, and/or SRSF2. In addition, triple-negative patients had higher WBC counts and higher bone marrow cellularity. A Cox proportional-hazards model identified high WBC count and low hemoglobin concentration as being significantly associated with a worse outcome. Kaplan-Meier analysis did not reveal a difference in OS between triple-negative and JAK2, CALR, or MPL mutated MPN-U. A larger cohort is needed to evaluate the survival outcome of these two distinct groups. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Effect of Delayed Cell Infusion in Patients with Large B-Cell Lymphoma Treated with CAR T-Cell Therapy

Introduction: Lymphodepleting chemotherapy (LDC) is essential for optimal efficacy of chimeric antigen receptor (CAR) T-cell therapy and functions through multiple mechanisms, including elimination of sinks for homeostatic cytokines, such as interleukin [IL]-7 and IL-15. In clinical trials, LDC is typically given on the fifth through third day before cell infusion. However, in real-world practice, cell infusion may be delayed for multiple reasons, including clinical and logistical complications. It remains unclear whether delaying cell infusion impacts clinical outcomes and whether LDC should be repeated if cell infusion is delayed. Methods: We performed a retrospective cohort analysis of all patients with relapsed or refractory large B-cell lymphoma who received LDC with fludarabine and cyclophosphamide followed by standard of care axicabtagene ciloleucel (axi-cel) at the University of Texas MD Anderson Cancer Center between 1/2018 and 12/2021. For multivariate analyses, only factors significantly associated in univariate analysis were included. Results: Of 240 patients treated with axi-cel, 40 (16.7%) received delayed cell infusion with a median delay of 2 days (range 1-14 days). Reasons for delay included infections in 34 (85%) patients, disease-related procedures in 3 (7.5%) patients and logistical complications in 3 (7.5%) patients. On univariate analysis, baseline characteristics associated with infusion delay were extra-nodal sites > 1 (p = 0.034), high number of prior therapies (p = 0.015), low absolute monocyte count (p = 0.003), low hemoglobin concentration (p < 0.001), low platelet count (p = 0.009), high C-reactive protein (CRP; p < 0.001), high ferritin (p = 0.01) and high lactate dehydrogenase (LDH; p = 0.016) levels at the time of LDC initiation. On multivariate analysis, the association was maintained only for elevated CRP (odds ratio 1.009; 95% confidence interval [CI] 1.002-1.017; p = 0.009). When compared to patients who received cell infusion on-time, patients with delayed infusion had similar rates of cytokine release syndrome (CRS) of any grade (90% vs. 93.5%; p = 0.496), grade 3-4 CRS (12.5% vs. 8.0%; p = 0.542), immune effector cell-associated neurotoxicity syndrome (ICANS) of any grade (65% vs. 64.5%; p = 0.952) and grade 3-4 ICANS (42.5% vs. 39.5%; p = 0.860), but exhibited a trend towards increased rate of grade 3-4 cytopenias at day 30 (74.3% vs. 58.0%; p = 0.09). Patients with delayed infusion had a significantly lower day 30 overall response rate (59.0% vs. 79.4%; p = 0.008) but similar complete response rate (43.6% vs. 54.3%; p = 0.293) to those with on-time infusion. After a median follow-up of 25.7 months (95% CI 22.6-28.8 months), patients with delayed infusion had significantly shorter median progression-free survival (PFS; 3.5 vs. 8.2 months; p = 0.002) and overall survival (OS; 7.8 vs. 26.4 months; p = 0.046) compared to those with on-time infusion. An association between extent of delay and survival was observed, with significantly shorter median PFS in patients who had delay of 2-5 days (1.8 vs. 8.2 months; p = 0.002) and >5 days (4.6 vs. 8.2 months; p = 0.040) but no significant difference in median PFS for patients with a delay of 1 day (5.4 vs. 8.2 months; p = 0.240) compared to those with on-time infusion (Figure). The association between delayed infusion and shorter PFS was maintained on multivariate analysis including age, International Prognostic Index score, LDH and CRP (hazard ratio 1.567; 95% CI 1.045-2.351; p = 0.03). When compared to patients with on-time infusion, patients with delayed infusion had lower serum IL-15 concentration (17.0 vs. 26.3 pg/mL) at time of cell infusion but comparable IL-7 concentration (16.4 vs 15.7 pg/mL). Conclusions: In real-world practice, cell infusion is delayed in more than 15% of patients, mostly due to infectious complications. In this single-center retrospective analysis, cell infusion delay was associated with higher rates of prolonged severe cytopenia and worse clinical outcomes, particularly if delay was longer than 1 day. Larger cohorts are needed to further characterize the impact of delayed cell infusion on treatment efficacy and determine whether biologically rational treatments directed at improving CAR T-cell function in these patients would be beneficial. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Infectious Complications and Their Relationship with Mortality in Patients Newly Diagnosed with Multiple Myeloma

INTRODUCTION. Early mortality after diagnosis of Multiple Myeloma (MM) is common and frequently associated with infections. A Danish study reported a mortality of 22% among the first 180 days with infections being responsible for 50.9% of deaths. Treatment for MM has been related with infections in some studies, but this data is not consistent. Infections typically occur during the first months after MM diagnosis and initiation of treatment. In Latin America there is a lack of information about infections in patients diagnosed with MM, with only one study reporting a prevalence of 35.9% within the first 6 months, and most of them, 67.3%, during the first 3 months. To describe infections and to evaluate potential risk factors associated with them could help to improve the care of patients with MM. METHODS We conducted a retrospective cohort from a tertiary referral center in Mexico City. We included patients diagnosed with MM according to the International Myeloma Working Group criteria, between January 2017 and December 2020. Baseline clinical characteristics, disease parameters and infections at or after the MM diagnosis were collected, as well as the etiologic agents and their outcomes. The primary outcome was to describe the infectious complications of patients with MM in the first 6 months after diagnosis. The secondary outcome was to identify risk factors for early mortality defined as death during the first 6 months after diagnosis. Baseline characteristics and infections were described using mean and standard deviation or median and interquartile ranges. For the secondary outcome, patients were analysed in two groups depending in the presence of infections or not. Comparisons between groups were made by chi square, Fisher's exact test, t-tests, and rank-sum test; multivariate analysis by means of a logistic regression was performed. Two-sided p-values of <0.05 were considered statistically significant. All analysis were performed using STATA version 15.1. RESULTS Eighty-two patients were diagnosed and included in the study in the specific period. Median age was 66.5 and 56% were male. Median follow-up time was 28.6 months; 49/82 (60%) developed > 1 infections, of which 33/49 (67%) were in the first 4 months after MM diagnosis and 16/33 patients (48%) experienced two or more episodes. Distribution of infections was as follows: lower respiratory tract (45%), urinary tract (24%), gastrointestinal tract (9%) and primary bacteriemia (6%). Bacteria were the most common etiologic agents. There were 3 cases of Clostridium difficile infection documented during the second and third episodes of infection. The mortality associated with this infection was very high (66%). High plasma cell infiltration in bone marrow aspirate (p=0.03), increased kappa free light chain concentration (p=0.02), lower hemoglobin concentration (p=0.003), decreased serum albumin (p=0.004) and high serum globulin concentration (p=0.04) were associated with infection. Alkylating agents were the only treatment associated with increased risk of infection (p=0.05). Overall mortality during the first 6 months was 11%. There was a significantly higher cumulative risk (46.4%) of early death in patients who developed infections, compared to those who did not. CONCLUSIONS. Sixty percent newly diagnosed MM developed infections during the first 6 months after diagnosis. The most common affected sites were lower respiratory tract, urinary tract, gastrointestinal tract and primary bacteriemia. Sixty-seven percent of the infectious episodes were developed among the first four months after the diagnosis. The most common etiologic agents were bacteria. There were two episodes of infections caused by candida SPP and three caused by influenza virus. Gram-negative bacteria were the most common bacteria isolated during the second and third episodes, with 3 cases of Clostridium difficile infection. Infections were responsible of 46.4% more early deaths in newly diagnosed MM patients compared to those that did not have infections. High tumor burden characteristics were associated with greater risk of infections. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Association of Community-Level Socioeconomic Distress with Nutritional Status in People with Sickle Cell Anemia

Introduction: Sickle cell anemia (SCA) is characterized by a myriad of acute and chronic complications. These complications negatively impact the ability to achieve educational and occupational goals making this group a particularly vulnerable population to socioeconomic challenges (PMID 30540112). Furthermore, most patients with SCA in the U.S. are Black and are disproportionately affected by socioeconomic inequity due to the historical effects of systemic racism (PMCID: PMC4817358). In the general population, indices of socioeconomic distress are associated with poor nutrition (PMID 25573510). Patients with SCA also experience a high frequency of food insecurity (PMID 34811867). The association of community-level socioeconomic distress with nutritional status in people with SCA is unknown. Methods: We conducted a cross-sectional study to describe the burden of community-level socioeconomic distress and its impact on nutritional status in an SCA cohort (n=332) treated at an urban academic institution. The distressed community index (DCI), a composite of socioeconomic indicators (including no high school diploma, housing vacancy rate, adults not working, poverty rate, median income ratio, and changes in employment and establishments) that estimate the economic well-being of a community, was determined for each individual patient's residential address using 2014-2018 U.S. Census Bureau's American Community Survey and the Business Patterns database. DCI score ranges from 0-100 with a higher score indicating a more distressed community. The association of DCI with measures of nutritional status (serum albumin, body mass index [BMI], vitamin D 25-OH) and hemoglobin concentration were determined using linear regression. The analyses were adjusted for age, sex, and hydroxyurea use. The beta coefficients provided are based on increments of 10 for DCI. Median and interquartile ranges (IQR) are provided. Results: The median age of the cohort was 31 years (IQR, 24-41 years), 55% were female, 53% were on hydroxyurea therapy, and the median BMI was 23 kg/m2 (IQR, 21-26 kg/m2). The median DCI in this cohort was 87 (IQR, 61-96) with 61% of SCA patients living in a distressed tier (DCI≥ 80) and only 5% living in a prosperous tier (DCI< 20). A higher DCI, reflecting an increase in socioeconomic distress, was associated with a trend for a lower odds ratio (OR) of being on hydroxyurea therapy (OR 0.93; 95% CI 0.86-1.0). An increasing DCI was significantly associated with lower serum albumin (β= -0.02; P=0.016), BMI (β= -0.01; P=0.045), and vitamin D 25-OH levels (β= -0.7; P=0.001), adjusting for age, sex, and hydroxyurea use (Figure). Furthermore, SCA patients living in a more distressed community had a trend for lower hemoglobin concentrations (β= -0.05; P=0.077) with similar adjustments. Discussion: In conclusion, we demonstrate that a high proportion of patients with SCA treated at an urban academic institution live in distressed socioeconomic communities. Higher distressed community indices are associated with lower utilization of hydroxyurea and lower measures of nutritional status. Future studies investigating the effects of socioeconomic distress on access to outpatient care and healthy foods may guide public health strategies to improve health disparities in the SCA population. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Associated Effect of SLC40A1 and TMPRSS6 Polymorphisms on Iron Overload.

Mutations in the ferroportin (FPN) gene SLC40A1 alter iron recycling and cause disturbances in iron homeostasis. The variants of TMPRSS6 contribute to the development of iron deficiencies. In this study, we determined the role of FPN and TMPRSS6 gene polymorphisms in the modulation of iron homeostasis based on biochemical parameters. PCR analysis and sequencing were performed to determine the single nucleotide polymorphisms (SNPs) SLC40A1 c.44–24G>C (rs1439816), SLC40A1 c.663T>C (rs2304704), and TMPRSS6 c.2207T>C (rs855791). Hemoglobin concentration and iron status were determined by standard procedures. We studied 79 iron-loaded individuals for SLC40A1 polymorphisms. Interestingly, 35/79 individuals with SLC40A1 SNPs also carried a TMPRSS6 c.2207T>C polymorphism. The biochemical values of the iron overloaded individuals were compared to those of the individuals carrying TMPRSS6 SNPs and the healthy individuals (wild-type group). The ferritin concentration, transferrin saturation % (TS%), and hemoglobin concentration were significantly higher in the participants with FPN SNPs than in the other three groups. The ferritin concentration and TS% were higher in participants with both SLC40A1 and TMPRSS6 SNPs than in the TMPRSS6 and wild-type groups, while hemoglobin concentration was significantly higher than that in the TMPRSS6 SNP group only. The participants with TMPRSS6 SNPs had significantly lower ferritin concentration, TS%, and hemoglobin concentration than all the other groups. SLC40A1 and TMPRSS6 SNPs might act in the opposite direction, preventing the development of severe iron overload, and the modulation of the iron status by TMPRSS6 SNPs might provide protection.

Clinical characteristics and risk factors of in-hospital gastrointestinal bleeding in patients with acute myocardial infarction.

BackgroundGastrointestinal bleeding (GIB) is one of the most serious complications of acute myocardial infarction (AMI) and is correlated with poor outcomes.ObjectiveTo evaluate the prevalence, risk factors and in-hospital mortality of GIB in patients with AMI.MethodsThis observational case-control study retrospectively enrolled consecutive patients with AMI from the Department of Cardiovascular Medicine and Cardiovascular Surgery of the First Affiliated Hospital of Xi'an Jiaotong University from January 2015 to December 2020. GIB after AMI was identified by International Classification of Diseases (ICD) codes from inpatient medical settings and validated by medical record review. AMI patients without GIB were accordingly classified as the control group. Propensity score matching (PSM) was used to match with the GIB group and the control group. All anonymized clinical data were provided by the Biobank of the First Affiliated Hospital of Xi'an Jiaotong University.ResultsA total of 5,868 AMI patients were enrolled, 0.87% (51/5,868) of whom developed GIB after AMI. On the univariate analysis, history of diabetes, chronic kidney disease, Killip IV, a lower hemoglobin concentration, a higher serum level of creatinine, blood urea nitrogen and D-dimer were closely associated with the risk of GIB (P < 0.05). On the multivariable analysis, a lower hemoglobin concentration (OR: 0.93, 95% CI: 0.89–0.96, P < 0.001) was independently associated with the risk of GIB. Patients with GIB had a much higher in-hospital mortality rate than those without GIB (14.3 vs. 2.1%, P = 0.047). In-hospital mortality among patients with GIB after AMI appeared to be associated with a decreased hemoglobin concentration (OR: 0.93, 95% CI: 0.86–0.99, P = 0.045) and Killip IV (OR: 51.59, 95% CI: 2.65–1,005.30, P = 0.009).ConclusionThe history of diabetes, poor renal function and heart failure were associated with the high risk of GIB in patients experiencing AMI. The in-hospital mortality in patients with AMI complicating GIB was higher than that in patients without GIB and was associated with a decreased hemoglobin concentration and high Killip classification.

Association between anaemia and hospital readmissions in patients undergoing major surgery requiring postoperative intensive care.

Anaemia is a common sequela of surgery, although its relationship with patient recovery is unclear. The goal of this investigation was to assess the associations between haemoglobin concentrations at the time of hospital discharge following major surgery and early post-hospitalisation outcomes, with a primary outcome of 30 day unanticipated hospital readmissions. This investigation includes data from two independent population-based observational cohorts of adult surgical patients (aged ≥ 18 years) requiring postoperative intensive care unit admission between 1 January 2010 and 31 December 2019 in hospitals in Olmsted County, Minnesota, and between 1 July 2010 and 30 June 2017 in the Kaiser Permanente Northern California integrated healthcare system, California. Cox proportional hazards models assessed the associations between discharge haemoglobin concentrations (per 10 g.l-1 ) and outcomes, with prespecified multivariable adjustment. A total of 3260 patients were included from Olmsted County hospitals and 29,452 from Kaiser Permanente Northern California. In adjusted analyses, each 10 g.l-1 decrease in haemoglobin at hospital discharge was associated with a 9% (hazard ratio 1.09, 95%CI 1.02-1.18; p = 0.014) and 8% increase (hazard ratio 1.08, 95%CI 1.06-1.11; p < 0.001) in the hazard for readmission within 30 days in Olmsted County and Kaiser Permanente Northern California, respectively. In a sensitivity analysis exploring relationships across varying levels of pre-operative anaemia severity, these associations remained consistent, with lower discharge haemoglobin concentrations associated with higher readmissions irrespective of pre-operative anaemia severity. Anaemia at hospital discharge in surgical patients requiring postoperative intensive care is associated with increased rates of hospital readmission in two large independent cohorts. Future studies are necessary to evaluate strategies to prevent and/or treat anaemia in these patients for the improvement of post-hospitalisation outcomes.

The Limits of Acute Anemia.

For many years, physicians’ approach to the transfusion of allogeneic red blood cells (RBC) was not individualized. It was accepted that a hemoglobin concentration (Hb) of less than 10 g/dL was a general transfusion threshold and the majority of patients were transfused immediately. In recent years, there has been increasing evidence that even significantly lower hemoglobin concentrations can be survived in the short term without sequelae. This somehow contradicts the observation that moderate or mild anemia is associated with relevant long-term morbidity and mortality. To resolve this apparent contradiction, it must be recognized that we have to avoid acute anemia or treat it by alternative methods. The aim of this article is to describe the physiological limits of acute anemia, match these considerations with clinical realities, and then present “patient blood management” (PBM) as the therapeutic concept that can prevent both anemia and unnecessary transfusion of RBC concentrates in a clinical context, especially in Intensive Care Units (ICU). This treatment concept may prove to be the key to high-quality patient care in the ICU setting in the future.

Clinical and Pathological Features of Chinese Patients with Type 2 Diabetes, Biopsy-Proven Diabetic Kidney Disease, and Rapid eGFR Decline.

ObjectiveThe rate of kidney function decline in patients with diabetic kidney disease (DKD) is known to differ. This study analyzed the clinicopathologic features and related risk factors affecting long-term renal survival in Chinese type 2 diabetic patients with rapid estimated glomerular filtration rate (eGFR) decline.MethodsIn this retrospective descriptive study, 191 DKD patients were first classified as rapid eGFR decliners and slow eGFR decliners on the basis of the median eGFR slope value (−8.0 mL/min/1.73 m2/year). In total, 96 patients with rapid eGFR decline were included in the analyses and subsequently allocated to end-stage renal disease (ESRD) and non-ESRD groups. Baseline clinicopathological data of rapid eGFR decliners were collected. Cox proportional hazard analysis was performed to calculate the hazard ratios (HRs) for progression to ESRD.ResultsDuring a median follow-up of 25 months, 52 (54.2%) rapid eGFR decliners progressed to ESRD. These 52 rapid eGFR decliners had poorer renal function, lower hemoglobin and albumin concentrations, higher total cholesterol and baseline proteinuria levels, and more severe interstitial inflammation than those who did not progress to ESRD. After adjustment for age, gender, baseline eGFR, proteinuria, hemoglobin level, serum albumin concentration, and histopathologic parameters, multivariate Cox proportional hazard analysis revealed that eGFR (HR 0.973, 95% CI 0.956–0.989) and proteinuria (HR 1.125, 95% CI 1.030–1.228) were associated with the increased risk of progression to ESRD.ConclusionHigher proteinuria and lower eGFR were independent risk factors for renal progression in Chinese patients with type 2 diabetes and rapid eGFR decline.

Haematological and Chosen Biochemical Parameter Assessment of the Antioxidant System in Red Deer (Cervus Elaphus) Blood in Early and Late Pregnancy.

The aim of this study was to investigate changes in haematological parameters and the antioxidant system in the early and late pregnancy of red deer (Cervus elaphus). Blood samples were collected from 30 red deer females 50 days after impregnation and 40 days before calving. Complete blood counts and stained blood smears were assessed. Paraoxonase 1 (PON1), superoxide dismutase (SOD), catalase (CAT), glutathione reductase (GR) activities, glutathione disulphide (GSSG), total glutathione, total bilirubin, total protein, albumin, uric acid, malondialdehyde (MDA), beta-hydroxybutyrate (BHB), low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides, cholesterol levels and total antioxidant status (TAS) were measured. The haematological characteristics of blood collected in the third trimester showed higher haemoglobin levels, haematocrit, mean corpuscular volume (P < 0.05) and a lower mean cell haemoglobin concentration (P < 0.05) in comparison to samples collected on the 50th day after mating. Activity of CAT and MDA, LDL, and triglyceride levels were lower while GR, GSSG, total glutathione, total protein and BHB levels were increased in blood samples drawn in the third trimester compared with the first trimester blood samples. There were no changes in SOD, PON1 activities, TAS, bilirubin, albumin, HDL, cholesterol or uric acid concentrations. Red deer's compensatory mechanisms facilitate its optimal adaptation to seasonal changes evidenced by mild pronounced haematological disturbances and an effective antioxidant system during pregnancy.

Haptoglobin 1 allele predicts higher serum haptoglobin concentration and lower multiorgan failure risk in sickle cell disease

AbstractHaptoglobin (HP) is an acute-phase protein and the main scavenger of cell-free hemoglobin. When HP is depleted, as observed in hemolytic conditions such as sickle cell disease (SCD), cell-free hemoglobin can lead to acute organ damage. The impact of the HP 1-1, 2-1, and 2-2 isoforms on HP and cell-free hemoglobin concentrations and SCD-related complications is unclear. In a longitudinal cohort of patients with SCD, the HP 1 allele was associated with higher HP and lower cell-free hemoglobin concentrations at a routine clinic visit as well as during hospitalization for a vaso-occlusive episode or acute chest syndrome. With a median follow-up of 6.8 years, acute chest syndrome occurred in 42% (n = 163) and multiorgan failure in 14% (n = 53) of 391 patients with SCD with a minimum follow-up of 6 months. The HP 1 allele was independently associated with lower risk of developing multiorgan failure during acute chest syndrome (additive model hazard ratio, 0.5; P < .001). Future studies assessing the regulation of HP concentrations and ability to bind cell-free hemoglobin according to the HP genotype may help to identify patients with SCD at high risk for multiorgan failure and to guide interventions, such as rapid initiation of exchange transfusion or HP replacement therapy.

A Contemporary Analysis of Phlebotomy and Iatrogenic Anemia Development Throughout Hospitalization in Critically Ill Adults.

Anemia is common in critically ill patients and may be exacerbated through phlebotomy-associated iatrogenic blood loss. Differences in phlebotomy practice across patient demographic characteristics, clinical features, and practice environments are unclear. This investigation provides a comprehensive description of contemporary phlebotomy practices for critically ill adults. This is an observational cohort study of adults ≥18 years of age requiring intensive care unit (ICU) admission between January 1, 2019, and December 31, 2019, at a large academic medical center. Descriptive statistics were utilized to summarize all phlebotomy episodes throughout hospitalization, with each phlebotomy episode defined by unique peripheral venous, central venous, or arterial accesses for laboratory draws, exclusive of finger sticks. Secondarily, financial costs of phlebotomy and the relationships between phlebotomy practices, hemoglobin concentrations, and red blood cell (RBC) transfusions were evaluated. A total of 6194 patients were included: 59% were men with a median (interquartile range) age of 66 (54-76) years and median ICU and hospital durations of 2.1 (1.4-3.9) and 7.1 (4.3-11.8) days, respectively. The median number of unique laboratory draws was 41 (18-88) throughout hospitalization, with a median volume of 232 (121-442) mL, corresponding to 5.2 (2.6-8.8) draws and 29 (19-43) mL per day. Waste (ie, discard) volume was responsible for 10.8% of total phlebotomy volume. Surgical patients had a higher number of phlebotomy episodes and greater total phlebotomy volumes compared to nonsurgical patients. Phlebotomy practices differed across ICU types, with the greatest frequency of laboratory draws in the cardiac surgical ICU and the greatest daily phlebotomy volume in the medical ICU. Across hospitalization, ICU environments had the greatest frequency and volumes of laboratory draws, with the least intensive phlebotomy practice observed in the general hospital wards. Patients in the highest quartile of cumulative blood drawn experienced the longest hospitalizations, lowest nadir hemoglobin concentrations, and greatest RBC transfusion utilization. Differences in phlebotomy practice were limited across patient age, gender, and race. Hemoglobin concentrations declined during hospitalization, congruent with intensity of phlebotomy practice. Each 100 mL of phlebotomy volume during hospitalization was associated with a 1.15 (95% confidence interval [CI], 1.14-1.17; P < .001) multiplicative increase in RBC units transfused in adjusted analyses. Estimated annual phlebotomy costs exceeded $15 million (approximately $2500 per patient admission). Phlebotomy continues to be a major source of blood loss in hospitalized patients with critical illness, and more intensive phlebotomy practices are associated with lower hemoglobin concentrations and greater transfusion utilization.

Health Assessment in Adolescents Transitioning from High School to University Based on Their Hematological Parameters

Background: The transition from high school to university can impair the adaptive potential of adolescents. Objective: To assess the level of adaptation of freshmen to higher education environment based on their blood parameters. Materials and methods: Blood samples were collected from healthy 17-year-old adolescents (n = 50) on the first week at university and then two and six weeks after. The general blood test was accompanied by measurements of protein and protein fractions, immunoglobulins A, M and G, cortisol and testosterone levels. Nonspecific adaptive reactions of the body were assessed by the lymphocyte count. Results: The level of cortisol in the blood was higher or equal to the upper limit of the normal range in 50.0 to 70.0 % of the adolescents at different stages of observation. At the beginning of the study, the lymphocyte count indicated stress in 10.0 % of the students, and 1.5 months after, it demonstrated overactivation of the immune response already in 35.0 % of the freshmen. The levels of albumins and α1-globulins increased while α2 -, β-, and γ-globulins decreased; serum immunoglobulins M increased and immunoglobulins A were below the normal range, indicating impairment of humoral immunity. The compensatory response was manifested by an increased mean corpuscular volume, a decreased amount of hemoglobin in erythrocyte, a low hemoglobin concentration in the cell volume, and a decreased mean platelet volume. High albumin levels in conjunction with changes in red blood demonstrated an electrolyte imbalance, while decreased testosterone levels against the increased cortisol ones showed the prevalence of catabolic processes in the body. Conclusion: Hematological parameters provide objective information about the health status of first-year university students. They are related to previous competitive selection that included evaluation of medical contraindications and physical fitness, examination stress, and adaptation to novel learning conditions, and require timely correction.

Dietary Diversity, Body Mass Index and Haemoglobin Concentration of Health Students in a Public University in Ghana

Background: Tertiary students are known to have poor dietary habits and at risk of iron deficiency anaemia. The aim of this study was to assess the dietary diversity of Allied Health students and determine its relationship with haemoglobin (Hb) concentration and body mass index (BMI). Methods: A cross-sectional descriptive study was carried out among 96 health students in the University of Ghana. A stratified systematic sampling technique was used to select the participants and a structured questionnaire used to obtain demographic and socioeconomic information. Weight and height were measured, and BMI determined. Dietary diversity (DD) was assessed using the WHO/FAO guidelines. Haemoglobin concentration was measured using a portable hemocue 301 + analyser. Linear regression was used to determine the relationship between the DDS and Hb concentration, and BMI of the students. Level of significance was set at p &lt; 0.05. Results: Mean age and BMI of the students were 21.8±1.7 years and 22.7±4.3kg/m 2 respectively. The mean DDS and Hb concentration were 4.68±1.40 and 12.6±1.3g/dl respectively. More than half (58%) of the students had moderate DD. Approximately forty percent (40.6%) of the students were anaemic. There was a strong positive correlation between BMI and DDS (r= +0.810, p= 0.434). Conclusion: These findings suggest a high prevalence of anaemia among the students, with half of them having a moderate DDS. There is a need for regular screening to identify and treat students with low haemoglobin concentrations. Although not significant there was a positive correlation between Hb concentration, BMI and Dietary Diversity score. Keywords : dietary diversity, haemoglobin concentration, body mass index DOI: 10.7176/JBAH/12-16-01 Publication date: August 31 st 2022

Diagnostic value of triglyceride and cystatin C ratio in diabetic kidney disease: a retrospective and prospective cohort study based on renal biopsy

BackgroundCurrently, there is a lack of clinical indicators that can accurately distinguish diabetic kidney disease (DKD) from non-diabetic kidney disease (NDKD) in type 2 diabetes. The purpose of this study was to investigate the diagnostic value of triglyceride and cystatin C (TG/ Cys-C) ratio in DKD. Nowadays, there are few studies on the differential diagnosis of TG/ Cys-C ratio between DKD and NDKD.MethodsThe clinical data of patients with type 2 diabetes complicated with proteinuria who underwent renal biopsy from January 2013 to September 2019 in 2 hospitals in Xuzhou were retrospectively collected. According to the pathological classification of kidney, 25 patients in group DKD and 34 patients in non-diabetic kidney disease (NDKD) group were divided into two groups. The admission information and blood biochemical indexes of all patients with renal biopsy were collected, and the TG / Cys-C ratio was calculated. Logistic regression analysis was used to analyze the related factors of DKD in patients with type 2 diabetes and proteinuria. Receiver operating characteristic (ROC) curve was used to evaluate the diagnostic value of TG/Cys-C ratio for DKD in patients with type 2 diabetes and proteinuria. Another 37 patients with type 2 diabetes complicated by proteinuria who were treated in the Department of Nephrology, four hospitals in Xuzhou from October 2019 to October 2021 were selected as the research objects. The TG/Cys-C value cut-off value selected in the retrospective study was selected as the boundary point and divided into two groups according to the values of greater than or equal to the tangent point and less than the tangential point. Serum triglyceride and cystatin C levels were measured and TG / Cys-C ratio was calculated. All patients underwent ultrasound-guided fine-needle renal biopsy. The positive rates of DKD diagnosis in the two groups were compared to verify the predictive value of TG / Cys-C ratio in the diagnosis of DKD.ResultsRetrospective study showed that compared with group NDKD, the DKD group had higher systolic blood pressure, higher cystatin C and creatinine, more diabetic retinopathy, longer duration of diabetes, lower hemoglobin concentration, lower glomerular filtration rate, lower cholesterol, lower triglyceride and lower TG/ Cys-C ratio (P < 0.05).Multivariate Logistic regression analysis showed that TG/Cys-C ratio (OR = 0.429, P = 0.009) was a protective factor for DKD in patients with type 2 diabetes and proteinuria. Diabetic retinopathy (OR = 7.054, P = 0.021) and systolic blood pressure (OR = 1.041, P = 0.047) were independent risk factors for DKD in patients with type 2 diabetes complicated with proteinuria. ROC curve showed that the area under the curve predicted by TG/Cys-C ratio for the diagnosis of DKD was 0.816, the sensitivity was 84%, and the specificity was 67.6%. The tangent value of TG / Cys-C ratio is 2.43. Prospective studies showed that in 37 patients with type 2 diabetes and proteinuria, 29 patients had a TG/Cys-C ratio of less than 2.43. The TG/Cys-C ratio of 8 patients was more than 2.43. Ultrasound guided fine needle aspiration biopsy revealed that 22 of the 29 patients had pathological diagnosis of DKD, sensitivity 91.67%, specificity 46.15%, positive predictive value 75.80%, and negative predictive value 75%.ConclusionIn type 2 diabetic patients with proteinuria, the ratio of TG/Cys-C has certain predictive value for the diagnosis of DKD.