Lower Hemoglobin Values Research Articles

Ventricular assist devices as bridge to heart transplantation: minimally invasive approach with axial pumps vs sternotomy approach with centrifugal pumps: short term results

Abstract Introduction Microaxial flow ventricular assist devices (VADs) with hybrid approach could provide an advantage over centrifugal flow VADs with surgical implantation via median sternotomy as bridge to heart transplantation. Purpose We aimed to compare short-term results in intensive cardiac care unit between both groups. Methods Single-center retrospective registry comparing patients supported with microaxial flow VADs with hybrid approach (Impella 5.0 or 5.5) and surgical centrifugal flow VADs (biventricular or left univentricular CentriMag) as bridge to heart transplantation. Results Including 12 patients (January 2020-March 2022), 7 patients in hybrid approach group (2 patients with Impella 5.0-16,7% and 5 patients with Impella 5.5-41,7%) and 5 pacientes in sternotomy approach group (33.3% biventricular support and 8.3% left ventricular support). In first 48 hours after VAD implantation, worsening of renal function was greater in sternotomy approach group (Cr 2.23±0.88, 1.07±0.58;p=0.021) and there was a trend toward lower hemoglobin values (7.72±0.19, 8.9±1.35;p =0.059), with no differences in other analyzed variables (Table). A trend toward earlier respiratory weaning was observed in hybrid approach group (median 12 vs 48 hours,p=0.067). Sternotomy approach group required more frequent use of continuous renal replacement therapy (60% vs 0%,p=0.045). There were statistically non-significant differences in need for blood products or surgical reinterventions, although percentage of red blood cells transfused in first 48 hours after VAD implantation were lower in hybrid approach group than sternotomy approach group (median 4 (1.5-8) versus 8(2.5-13.5) in sternotomy approach group, p=0.309). The most common complication in sternotomy approach group was tamponade (80%- 4 patients versus 0 patients in hybrid approach) and in hybrid approach group access-related infections (28.57%, 2 patients). Ten patients received a transplant, one died for non-cardiovascular cause, and another underwent the implantation of long term VAD as bridge to transplantation. There were no differences in time from assistance implantation to heart transplantation. The most common complication after heart transplantation was primary graft failure in both groups (40%,2 patients) with no differences in mortality. Conclusions Microxial flow VADs with hybrid approach provide adequate support, with less need for continuous renal replacement therapy and shorter duration of mechanical ventilation after VAD implantation to admission in intensive cardiac care unit, a trend towards lower rates of reintervention due to bleeding was observed. The advantages of minimally invasive approach could increase its use as bridge to heart transplantation compared to VADs with sternotomy approach although small sample size may negatively influence the failure to reach statistical significance, and more studies are necessary to validate our preliminary experience.Variables analyzed 48 hours of admission

Correlation between staging classification of aortic stenosis based on the extent of cardiac damage and platelet indices

BackgroundPlatelets play a key role in the natural history of aortic stenosis (AS) and after transcatheter aortic valve implantation (TAVI). An echo-based staging system stratifies patients with severe AS into 5 groups according to the associated cardiac damage phenotype. We aimed to correlate these AS stages with platelet indices in post-TAVI patients.MethodsPatients with severe AS who underwent TAVI and were admitted to intensive cardiac care unit (ICCU) were prospectively identified and divided into 5 groups according to extra-valvular cardiac damage [no extravalvular cardiac damage (Stage 0), left ventricular damage (Stage 1), left atrial or mitral valve damage (Stage 2), pulmonary vasculature or tricuspid valve damage (Stage 3), or right ventricular damage (Stage 4)]. Baseline characteristics and complete blood count including mean platelet volume (MPV) and immature platelet fraction (IPF) were collected within 2 h after the procedure and analyzed in relation to aortic stenosis staging.ResultsA total of 220 patients were included. The mean age was 81 years old and 112 (50.9%) were female. Two (1%) patients were classified in stage 0; 34 (15%) in stage 1; 48 (22%) in stage 2; 49 (22%) in stage 3 and 87 (40%) in stage 4. Higher mean MPV values were correlated with higher AS staging (10.8 fL, 11 fL, 11.3 fL and 10.8 fL in stages 1, 2, 3 and 4, respectively, P = 0.02) as well as lower hemoglobin values (12 mg/dl, 11.6 mg/dl, 11 mg/dl and 11.3 mg/dl in stages 1, 2, 3 and 4, respectively P = 0.04). Mean IPF values were 5.3%, 5.58%, 5.57% and 4.83% in stage 1, 2, 3 and 4, respectively (P = 0.4). In a multivariate logistic regression model only MPV (OR = 2.6, P = 0.03) and body mass index (BMI) (OR = 1.17, P = 0.004) were correlated with higher staging (0–3) of AS.ConclusionsAlthough IPF and MPV levels increased in stages 0–3, there was a decrease in indices in stage 4, (probably due to bone marrow dysfunction) in this end-stage population. Higher levels of MPV and lower levels of hemoglobin were independently correlated with higher stages (0–3) of AS.

Low Serum Alanine Aminotransferase Blood Activity Is Associated with Shortened Survival of Renal Cell Cancer Patients and Survivors: Retrospective Analysis of 1830 Patients

Background: Sarcopenia is characterized by a loss of muscle mass and function and is often associated with frailty, a syndrome linked to physical disability and shortened survival in various patient populations, including cancer patients. Low serum alanine aminotransferase (ALT) values, serving as a biomarker for sarcopenia, were previously associated with frailty and shortened survival in several cancers. In the current study, we aimed to test the association between low ALT and shorter survival in renal cell carcinoma (RCC) patients and survivors. Methods: This was a retrospective analysis of RCC patients and survivors, both in- and outpatients. We defined patients with sarcopenia as those presenting with ALT < 17 IU/L. Results: We identified records of 3012 RCC patients. The cohort included 1830 patients (mean age 65.6 ± 13.3 years, 68% were men) of whom only 179 underwent surgical treatment. Out of the eligible cohort, 811 patients (44.3%) had ALT < 17 IU/L, with a mean ALT value of patients within the low-ALT group of 11.79 IU/L, while the mean value in the higher ALT level group was 24.44 IU/L (p < 0.001). Patients in the low-ALT group were older (67.9 vs. 63.7 years; p < 0.001) and had lower BMIs (26.6 vs. 28; p < 0.001). In addition, patients with low ALT had lower hemoglobin values (12.14 vs. 12.91 g/dL; p < 0.001), higher serum creatinine (1.49 vs. 1.14; p < 0.001) and higher platelet to lymphocyte ratios (178 vs. 156; p < 0.001). In a univariate analysis, low ALT levels were associated with a 72% increase in mortality (95% CI 1.46–2.02, p < 0.001). In a multivariate model controlled for age, gender, hemoglobin, platelets, LDH, neutrophil to lymphocyte ratios and platelet to lymphocyte ratios, low ALT levels were still associated with a 27% increase in mortality (HR = 1.27, 95% CI 1.08–1.51; p = 0.005). Conclusion. Low ALT values, associated with sarcopenia and frailty, are also associated with shortened survival in RCC patients, and survivors and could potentially be applied for optimizing individual treatment decisions.

Clusters of patients with non-ST-segment elevation acute coronary syndrome depending on the laboratory data

Aim. To identify clusters of patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) depending on the laboratory data, including platelet function tests.Material and methods. The study included 109 patients hospitalized in the cardiology department with NSTE-ACS. All patients underwent a standard examination, including a complete blood count. In addition, the platelet function was assessed using impedance aggregometry with various inducers (adenosine diphosphate (5 and 10 μmol/L), collagen (2 μmol/L)). We assessed the P-selectin expression level using flow cytometry. Patients were followed up for 6 months. As a statistical method, we performed сluster analysis by K-means algorithm.Results. We registered 18 adverse outcomes (myocardial infarction, unstable angina) during 6-month follow-up. Cluster analysis revealed 3 clusters. The first cluster included 39 (36%) patients with higher monocyte values and lower hemoglobin values, probably indicating chronic inflammation and a tendency towards anemia. The second cluster included 13 older patients (12%) with high comorbidity and high platelet function. Both the first and second clusters recorded 23% adverse outcomes. Third cluster, on the contrary, included mostly younger patients with fewer comorbidities, which had more favorable course of ACS (no signs of platelet hyperaggregation, chronic inflammation and anemia). This cluster included more than half (n=57, 52%) of all patients; adverse outcomes at 6 months in these patients developed 2-fold less frequently than in the other clusters (11% vs 23%).Conclusion. Among patients with NSTE-ACS, groups differing in laboratory parameters were identified, based on which clusters were formed using the k-means method. Clusters with high levels of platelet functional activity, monocyte count and low hemoglobin values included older patients with severe comorbidity and showed a tendency towards more frequent adverse outcomes of the disease.

The Importance of Cell Saver Usage in Complex Endovascular Repair of Thoraco-Abdominal Aortic Aneurysms

The use of the cell saver is well-established in open aneurysm repair; however, its role in endovascular repair is yet to be determined. The aim of this study was to analyze the effects of cell saver usage in patients undergoing complex endovascular procedures. Single-center retrospective cohort study, including consecutive patients undergoing fenestrated and/or branched repair for the treatment of thoracoabdominal and complex abdominal aortic aneurysms (CAAAs) between January 2019 and December 2022. The cell saver was a standard part of the intraoperative setup of these procedures, and its use was readily available. The primary endpoint was the percentage of patients, in which autologous blood collected was transfused (cell saver blood transfusion [CSBT]), alongside the useable amount obtained. Secondary endpoints included mean blood loss, postoperative hemoglobin levels, and 30-day mortality. A total of 170 patients (77.1% male, mean age 71.2±9.2years) were included, with a median blood loss of 700mL (interquartile range [IQR] 400-1,200mL). A total of 96 patients received some kind of blood transfusion (BT) (56.5%): 35 patients were (20.6%) allogenic BT, 31 patients were (18.2%) CSBT only, and 30 patients were (17.6%) a combination of both. In total, 61 patients (35.9% or 63.5% of all patients requiring BTs) received CSBT, with a median useable blood volume of 282mL (IQR, 194.5-508 mL). Thirty-day mortality was similar in both groups. Although the CSBT group had lower intraoperative hemoglobin values (9.25±1.55 vs. 10.36±1.88mg/dL; P<0.001), both groups presented similar postoperative hemoglobin (Hb) levels. Blood loss during complex endovascular repair is not insignificant. In this cohort, over 50% of included patients required some kind of BT, 32.3% of which received exclusively CSBT, while 31.3% had supplementary CSBT alongside allogenic BT. This data showcases its potential role in these repairs, paving the way for its standardization in the intraoperative setup of these complex procedures.

A 42-year-old woman with abnormal uterine bleeding—leiomyoma (AUB-L) reporting a hemoglobin of 1.6 g/dL: a case report

BackgroundAbnormal uterine bleeding, formerly known as menometrorrhagia, is estimated to occur in up to one-third of women, commonly at menarche or perimenopause. Among many other causes, abnormal uterine bleeding is known to be caused by leiomyomas, and is itself a leading cause of severe iron deficiency and iron deficiency anemia in women. Rarely, abnormal uterine bleeding can lead to critically low hemoglobin values of less than 2 g/dL. We report here a case of a woman with abnormal uterine bleeding caused by leiomyomas presenting with severely low hemoglobin.Case presentationWe report the case of a 42-year-old Asian American woman who presented to the emergency department with chronic abnormal uterine bleeding and symptoms of anemia, including multiple syncopal episodes and abnormally pale skin but otherwise alert and oriented. Laboratory tests found a record-low hemoglobin of 1.6 g/dL and hematocrit of 6%. Transabdominal pelvic ultrasound revealed a lower uterine segment/cervical fibroid measuring 7.5 × 5 × 7.8 cm (length × depth × width). Patient was diagnosed with abnormal uterine bleeding–leiomyoma and received five units of packed red blood cells, one unit of fresh frozen plasma, Venofer infusions, tranexamic acid, and medroxyprogesterone. She was discharged from the hospital after 4 days.ConclusionTo date, only a handful of cases have been reported of female patient survival following severely low hemoglobin caused by abnormal uterine bleeding. This case adds to this literature, highlighting the remarkable degree of compensation that can lead to an alert, ambulatory, and oriented patient with abnormal uterine bleeding caused by leiomyoma.

Performance Analysis of the Ensemble Model in Anaemia Detection from Unmodified Smartphone-Captured Conjunctiva Images

Anaemia is a blood-related disorder that is sometimes a harbinger of a much more severe condition like cancer. WHO recommends context-specific diagnosing methods for anaemia in the case of in-feasibility of traditional diagnosing methods, including a haemoglobin colour scale method that is based on the colour of the blood. In this manifesto, we take it one step further and diagnose anaemia using images of lower palpebral conjunctiva captured in consumer-grade cameras. Data that include lower palpebral conjunctiva images, basic details, and haemoglobin values are collected from participants. Pixel parameters of collected conjunctiva images are extracted in various colour spaces and used as input features. An ensemble learning model was developed with K-Nearest Neighbour (KNN), Random Forest and Decision Tree algorithms which showed better classification performance in classifying anaemic and non-anaemic samples. This Ensemble Model-Based Anaemia Classifier (EMBAC) performed well with both training and test sets and produced 90.91% sensitivity, 89.06% specificity, 89.69% accuracy, and area under the Receiver Operating Characteristics(ROC) curve of 0.90 for the unseen test data. EMBAC also outperformed the conventional ensemble algorithms in terms of sensitivity and accuracy. EMBAC will classify the samples more correctly irrespective of the image acquisition device under any lighting conditions without any additional hardware. This research work attempts to lay the foundation for a smartphone application to detect anaemia in real-life conditions which will enable access to a mobile healthcare instrument to diagnose anaemia for the proletariat.

Hypogonadism in men with inflammatory joint diseases: Frequency and clinical characteristics

To study the frequency of hypogonadism (HG) in men with rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA) and to evaluate the impact of HG on the course of RA and and concomitant diseases. A single-stage continuous study included 170 men with RA, 57 men with AS and 85 men with PsA, who were hospitalized at the Nasonova Research Institute of Rheumatology. Patients were assessed for total testosterone (ТS) levels and subsequently divided into subgroups with normal (>12 nmol/l) and reduced levels. An intergroup comparison was carried out on the main indicators used in clinical rheumatological practice to assess the stage, activity and other medical and demographic characteristics of rheumatic disease, as well as on concomitant conditions. The second stage of the study involved a pairwise intergroup comparison among patients with HG with RA, AS and PsA. The incidence of ТS deficiency among patients with RA was 24.1%, among patients with AS - 17.5%, and with PsA - 31.8%. In patients with RA, HG was associated with a significantly higher mean body mass index, higher fasting blood glucose and uric acid, higher erythrocyte sedimentation rate and anemia. Patients with AS with HG had significantly lower hemoglobin levels and more frequent anemia, as well as higher levels of C-reactive protein and erythrocyte sedimentation rate. In PsA, older age was observed in the androgen deficiency group, as well as higher body mass index and fasting glucose levels; obesity was more common. An intergroup comparison of quantitative and qualitative indicators between patients with androgen deficiency in all three rheumatic diseases (RDs) did not reveal significant differences in the average concentrations of ТS, luteinizing hormone, sex hormone binding globulin, experience of RD, laboratory markers of inflammatory activity, as well as glucose and uric acid. A similar incidence of diabetes mellitus, obesity and anemia was noted for all three nosologies. ТS levels and the presence of HG were not associated with the stage and activity of RD, but ТS deficiency was accompanied by higher laboratory indicators of inflammatory activity, lower hemoglobin values, and metabolic disorders. Patients with HG, regardless of nosology, had similar levels of sex hormones and indicators reflecting RD and concomitant conditions.

#2595 Evolution of hemoglobin and serum uric acid levels after SGLT2i initiation in patients with and without diabetic nephropathy

Abstract Background and Aims Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are glucose-lowering drugs that inhibit glucose reabsorption in the proximal tubule, enhancing urinary glucose excretion. SGLT2i exhibit significant cardio- and renoprotective effects due to their capacity to increase diuresis and weight loss and reduce intraglomerular and blood pressure. Moreover, recent studies have described the potential of SGLT2i to improve additional cardiovascular risk factors, such as anemia or hyperuricemia. In this study, we aimed to describe the evolution of hemoglobin (Hb) and serum uric acid (SUA) levels in CKD patients with and without diabetic nephropathy before and after the initiation of SGLT2i therapy. Method CKD patients with and without diabetic nephropathy that were followed in the outpatient clinic of a tertiary referral academic hospital during January 2020 to September 2023 and that started SGLT2i therapy during that period were randomly recruited in the study. Patient characteristics, CKD staging, and levels of Hb and SUA before and after SGLT2i initiation were compared between groups. Hb and SUA levels were averaged considering all available laboratory controls during the last 12 months before treatment initiation and any available controls after treatment start. Results Demographic and clinical characteristics of enrolled patients are summarized in Fig. 1. Subjects with diabetic nephropathy were significantly older, more commonly hypertensive, presented worse kidney function, had received SGLT2i for a lengthier time and had lower hemoglobin values. We observed no change in hemoglobin levels after the initiation of SGLT2i in our sample, independently of diabetic nephropathy status or CKD stage (Fig. 2A, C). In contrast, SUA levels decreased significantly both in patients with and without diabetic nephropathy (Fig. 2B). This effect was observed across all the spectrum of CKD in our sample (Fig. 2D). Conclusion In our sample, SGLT2i initiation was associated with a significant decrease in SUA levels, both in patients with and without diabetic nephropathy and independently of CKD stage, which may help to explain its cardio- and nephroprotective effects. No change in Hb levels was observed, possibly due to a low prevalence of anaemia in our sample.

Single Versus 3-incision Triple Pelvic Osteotomy: Comparison of Clinical and Radiologic Results.

Triple pelvic osteotomy (TPO) is indicated when the anatomic and functional realignment of the hip joint is needed. Although the traditional approach for TPO involves a separate incision for ischial cut, there has been a trend for single-incision TPO in recent years. This study aims to compare the clinical and radiologic results of 2 different approaches. Forty-two hips of 39 patients treated using TPO with a minimum of 24 months of follow-up were included in our cohort. Demographics, perioperative, and radiologic parameters were evaluated. Harris Hip Score and International Hip Outcome Tool were used for clinical evaluation. A single anterolateral incision approach was used in 18 hips (17 patients), whereas a 3-incision approach was used in 24 hips (22 patients). The mean follow-up was 4.7 years in the 3-incision group and 3.8 years in the single-incision group ( P =0.43), with mean surgery age at 8.7 years (range, 5.4 to 12) for single-incision and 9.7 years (range, 7.7 to 11.7) for 3e-incision ( P =0.22). There were no significant differences observed between the 2 groups concerning radiographic measurements, complications, and functional scores. The mean surgical time was 118.6 minutes in the single-incision group and 97.9 minutes in 3-incision group ( P =0.036). Mean intraoperative blood loss was 181.7ml in the single-incision group and 243.4ml in 3-incision group ( P =0.028). Three-incision group demonstrated significantly higher intraoperative blood loss, leading to lower hemoglobin values ( P =0.042). The single-incision TPO demonstrated similar outcomes compared with the traditional 3-incision approach in terms of radiologic correction and functional improvement. The single-incision technique exhibited advantages such as reduced intraoperative blood loss and potential benefit of decreased pain due to fewer scars. However, it required a longer surgical time compared with the 3-incision approach. Surgeons should consider patient-specific factors and their expertise when selecting the most appropriate approach for each case. Level III-retrospective comparative series.

Predictive Factors for Major Complications and Urological Cancer Diagnosis in Older Adults (≥80 Years) Admitted to the Emergency Department for Hematuria.

Background: Gross Hematuria is a relevant cause of admission to the emergency department in the general population and particularly in older adults (≥80 years). This specific urological symptom is often underestimated and usually associated with benign conditions such as urinary infections or poor hydration. Nevertheless, hematuria could lead to severe acute complications or be the first symptom of urological cancers. Methods: We retrospectively analyzed clinical data from 1169 patients aged ≥80 years consecutively admitted to the emergency department for hematuria. The primary endpoint of the study was to identify risk factors for major complications, and the secondary endpoint was to analyze risk factors for urological cancer diagnosis. The median age was 85 years (IQR 82-88 years), and 908 (77%) were males. Among them, 449 (38.4%) had a past medical history of urological neoplasm (kidney, ureter, bladder, prostate, or urethral cancer). Results: Overall, 87 patients (7.4%) had major complications (patient death, septic shock, and admission to the intensive care unit). Worse vital signs at admission, fever, and confusion (p < 0.001, OR 18.0 IC 95% [5.5-58.7]; p = 0.015, OR 2.0 IC 95% [1.1-3.5]; p = <0.001, OR 4.2 IC 95% [1.9-3.5], respectively), as well as lower hemoglobin values and higher Charlson comorbidity index (p < 0.001, OR 0.8 IC 95% [0.7-0.9]), p = 0.002, OR = 1.2 [1.1-1.3]) were independent predictive factors for major complications. The multivariate analysis identified as risk factors for diagnosis of urological cancer older age, male sex and higher comorbidity (OR 1.05 IC95% [1-1.09]; OR 2.19 IC95% [1.42-3.39] and OR 1.11 IC95% [1.2-1.2], respectively); interestingly the presence of indwelling vesical catheter (IVC) (OR 0.44 IC95% [0.24-0.82]) resulted as an independent factor for absence of urological cancers. Conclusions: Hematuria is a frequent symptom in older adults admitted to the emergency department. While this is often associated with benign conditions, there are some risk factors for major complications and for urological cancer that must be taken into account to identify the patients who need further evaluation or prompt hospital admission.

Does frailty have an influence on MINOCA?

Abstract Funding Acknowledgements None. Introduction Frailty is a condition that is associated with aging, the presence of comorbidities and disability. The occurrence of frailty may aggravate the course of illnesses, including myocardial infarction (MI), with significant higher rates of complications and mortality in frail patients. Purpose We aim to build and validate for our population a frailty índex (FI) using the information present in the National Registry of Acute Coronary Syndromes (ACS). This will later be used to characterize the sample and evaluate the impact of frailty in patients with acute myocardial infarction with non-obstructive coronary arteries (MINOCA), in terms of management, complications, in-hospital mortality and 1-year mortality in a real-world scenario. Methods Multicenter retrospective study, based on the National Registry of ACS, from 1/10/2010-24/10/2022. Only patients hospitalized with a diagnosis of MINOCA (coronary stenosis &amp;lt;50%) were included. FI was created including 22 variables identified from baseline characteristics (Table 1). The FI was calculated, ranging between 0-1. Patients were then divided into two groups: Group A - non-frail (FI ≤0.25) – and Group B – frail (FI&amp;gt;0.25). Kaplan-Meier test was performed to establish the survival rates, CV readmissions (R) and R for other causes, at one year. Results A total of 1358 patients were analyzed, 1195 in group A (88.0%) and 163 in group B (12.0%). Mean age was 63.9±13.9 years and 62.8% of the patients were male in group A, while in group B mean age was 68.0±10.8 and 72.4% were men. Group B had more cardiovascular risk factors, such as hypertension (94.5% vs 63.2% p&amp;lt;0.001), diabetes (55.2% vs 22.6% p&amp;lt;0.001), dyslipidemia (52.2% vs 89.0% p&amp;lt;0.001). Patients in group B also had more previous history of heart failure (27.6% vs 4.9% p&amp;lt;0.001), stroke (15.3% vs 3.9% p&amp;lt;0.001) and chronic kidney disease (17.8% vs 1.5% p&amp;lt;0.001). On admission, group B presented: higher heart rate (HR) (15.7% with HR ≥100bpm vs 9.0%; p=0.008), more atrial fibrillation (14.7% vs 6.7%, p&amp;lt;0.001); lower blood pressure (BP) (5.1% with BP &amp;lt;90mmHg vs 1.0%; p&amp;lt;0.001), and higher Killip-Kimball (KK) classification (24.1% in KK class &amp;gt;I vs 8.3%; p&amp;lt;0.001). During hospitalization, group B presented higher maximum creatinine values (2.0±2.2mg/dL vs 1.2±0.9 mg/2mg/dL, p&amp;lt;0.001) and lower hemoglobin values (11.9±2.2 vs 12.9±1.7g/dL, p&amp;lt;0.001). There were no differences between the two groups in terms of complications during hospitalization, intrahospital mortality or regarding lenght of hospital stay or mortality rates, R for CV causes and R for other causes at one-year follow-up, with a Kaplan-Meier test of p=0.186 (Figure 1A), p=0.789 (Figure 1B) and p=0.118 (Figure 1C), respectively. Conclusions As expected, frail patients have more comorbidities than non-frail patients. However, this does not translate into differences in terms of patients’ treatment, number of complications, intrahospital mortality, or 1-year follow up. Figures 1A, 1B and 1C

Timing of Red Blood Cell Transfusions and Occurrence of Necrotizing Enterocolitis

Observational studies often report that anemia and red blood cell (RBC) transfusions are associated with a higher risk of necrotizing enterocolitis (NEC) among extremely low-birthweight (ELBW) infants. To evaluate whether there is a temporal association between 72-hour hazard periods of exposure to RBC transfusions and NEC among ELBW infants randomized to either higher or lower hemoglobin transfusion thresholds. This post hoc secondary analysis of 1690 ELBW infants who survived to postnatal day 10 enrolled in the Transfusion of Prematures (TOP) randomized multicenter trial between December 1, 2012, and April 12, 2017, was performed between June 2021 and July 2023. First, the distribution of RBC transfusions and the occurrence of NEC up to postnatal day 60 were examined. Second, 72-hour posttransfusion periods were categorized as hazard periods and the pretransfusion periods of variable duration as control periods. Then, the risk of NEC in posttransfusion hazard periods was compared with that in pretransfusion control periods, stratifying the risk based on randomization group (higher or lower hemoglobin transfusion threshold group). The primary outcome was incidence of NEC stage 2 or 3. Secondary outcomes included the incidence rates of NEC within five 10-day intervals, taking into account the number of days at risk. Of 1824 ELBW infants randomized during the TOP trial, 1690 were included in the present analysis (mean [SD] gestational age, 26.0 [1.5] weeks; 899 infants [53.2%] were female). After categorizing 4947 hazard periods and 5813 control periods, we identified 133 NEC cases. Fifty-nine of these cases (44.4%) occurred during hazard periods. Baseline and clinical characteristics of infants with NEC during hazard periods did not differ from those of infants with NEC during control periods. The risk of NEC was 11.9 per 1000 posttransfusion hazard periods and 12.7 per 1000 control periods (adjusted risk ratio, 0.95; 95% CI, 0.68-1.32; P = .74). This risk did not differ significantly between randomization groups, but the incidence rate of NEC per 1000 days peaked between postnatal days 20 and 29 in the lower hemoglobin transfusion threshold group. The findings of this post hoc analysis suggest that, among ELBW infants with the hemoglobin ranges occurring in the TOP trial, exposure to RBC transfusions was not temporally associated with a higher risk of NEC during 72-hour posttransfusion hazard periods. Given that the incidence rate of NEC peaked between postnatal days 20 and 29 among infants with lower hemoglobin values, a more in-depth examination of this at-risk period using larger data sets is warranted. ClinicalTrials.gov Identifier: NCT01702805.

Assessment of rehabilitation practices during hematopoietic stem cell transplantation in the United States: a survey.

Rehabilitation therapy is important to treat physical and functional impairments that may occur in individuals receiving physically taxing, yet potentially curative hematopoietic stem cell transplants (HSCT). However, there is scarce data on how rehabilitation is delivered during HSCT in real-life setting. Our objective is to assess the rehabilitation practices for adult patients hospitalized for HSCT in the United States. A 48-question online survey with cancer centers with the top 10% HSCT volumes (per American registries). We obtained data on patient characteristics, rehabilitation therapy details (timing, indication, administering providers), physical function objective and subjective outcome measures, and therapy activity precautions. Fourteen (out of 21) institutions were included. Rehabilitation therapy referrals occurred at admission for all patients at 35.7% of the centers for: functional decline (92.9%), fall risk (71.4%), and discharge planning (71.4%). Participating institutions had physical therapists (92.9%), occupational therapists (85.7%), speech language pathologists (64.3%) and therapy aides (35.7%) in their rehabilitation team. Approximately 71% of centers used objective functional measures including sit-to-stand tests (50.0%), balance measures (42.9%), and six-minute walk/gait speed (both 35.7%). Monitoring of blood counts to determine therapy modalities frequently occurred and therapies held for low platelet or hemoglobin values; but absolute neutrophil values were not a barrier to participate in resistance or aerobic therapies (42.9%). Rehabilitation practices during HSCT varied among the largest volume cancer centers in the United States, but most centers provided skilled therapy, utilized objective, clinician and patient reported outcomes, and monitored blood counts for safety of therapy administration.

The impact of perioperative risk factors on long-term survival after radical cystectomy: a prospective, high-volume cohort study

IntroductionRadical cystectomy (RC) is the gold standard for muscle-invasive bladder cancer. Nevertheless, RC is associated with substantial perioperative morbidity and mortality. We aimed to evaluate the role of important perioperative risk factors in predicting long-term survival after RC.MethodsAn analysis of the prospective cohort of patients undergoing open RC from 2004 to 2023 at our center was performed. Patients who died within one month after RC were excluded from the study. A univariate and multivariable Cox regression analysis was performed to assess the role of sex, age, urinary diversion, preoperative values of creatinine and hemoglobin, first-day postoperative values of CRP, leucocytes, and thrombocytes, perioperative Clavien-Dindo complications, perioperative chemotherapy, admission to the intensive or intermediate care unit, as well as type of histology, pathologic T-stage, positive lymph nodes, and positive surgical margins on predicting the long-term overall survival after RC. For all analyses hazard ratios (HRs) with the corresponding 95% confidence intervals (CIs) were estimated.ResultsA total of 1,750 patients with a median age of 70 years (IQR: 62–76) were included. Of them, 1,069 (61%) received ileal conduit and 650 (37%) neobladder. Overall, 1,016 (58%) perioperative complications occurred. At a median follow-up of 31 months (IQR: 12–71), 884 (51%) deaths were recorded. In the multivariable Cox regression analysis, increasing age (HR: 1.03, 95%CI: 1.02–1.04, p < 0.001), higher preoperative creatinine values (HR: 1.27, 95%CI: 1.12–1.44, p < 0.001), lower preoperative hemoglobin values (HR: 0.93, 95%CI: 0.89–0.97, p = 0.002), higher postoperative thrombocyte values (HR: 1.01, 95%CI: 1.01–1.02, p = 0.02), Clavien-Dindo 1–2 complications (HR: 1.26, 95%CI: 1.03–1.53, p = 0.02), Clavien-Dindo 3–4 complications (HR: 1.55, 95%CI: 1.22–1.96, p < 0.001), locally advanced bladder cancer (HR: 1.29, 95%CI: 1.06–1.55, p = 0.009), positive lymph nodes (HR: 1.74, 95%CI: 1.45–2.11, p < 0.001), and positive surgical margins (HR: 1.61, 95%CI: 1.29–2.01, p < 0.001) negatively affected long-term survival.ConclusionBeside increased age and worse oncological status, impaired renal function, lower preoperative hemoglobin values, higher postoperative thrombocyte values, and perioperative complications are independent risk factors for mortality in the long term in patients undergoing open RC.

Validation of ToucHb, a non-invasive haemoglobin estimation: Effective for normal ranges, needs improvement for anaemia detection.

Non-invasive methods for haemoglobin estimation hold enormous potential for early detection and treatment of anaemia, especially in limited resource settings. We sought to validate the diagnostic accuracy of ToucHb, a non-invasive haemoglobin estimation device available in the Indian market. We prospectively evaluated the diagnostic performance of the ToucHb device using the Automated complete blood count (CBC) method as the gold standard. Persons referred for haemoglobin estimation to the central laboratory of the government medical college hospital in Mysore, southern India were included in the study. Out Of 140 people approached, 127 gave consent; 65% (n = 82) were female with median age of 37 (IQR 28-45). ToucHB reported median haemoglobin value of 14 g/dL compared to 13.3 g/dL for CBC. Within 1 g/dL and 2 g/dL of CBC, 55.2% (70/127) and 74% (94/127) of ToucHb haemoglobin observations fell, respectively. The Bland-Altman plot showed a mean difference of 3 g/dL in haemoglobin between ToucHb and CBC among those with anaemia. The ToucHb device showed 22.2% sensitivity and 94.5% specificity for anaemia detection. In rural resource-limited settings, point of care non-invasive devices such as ToucHb can improve access and acceptance for anaemia screening. However, ToucHb has showed low sensitivity for anaemia detection and low accuracy at lower haemoglobin values. The utility of the instrument is especially limited in detecting anaemia, while it can estimate haemoglobin accurately among those with haemoglobin is in the normal range. Based on these findings, ToucHb and devices that work on the core technology deployed in ToucHb may be better suited to monitor known haemoglobin level rather than in anaemia screening or detection in primary/ secondary care and community settings.

The relationship between Mycoplasma and Kawasaki disease in pediatric patients: An updated systematic review and meta-analysis.

This study aimed to clarify the relationship between Mycoplasma pneumoniae (M. pneumoniae) and Kawasaki disease by conducting an updated systemic review and meta-analysis of published studies. Studies mentioning M. pneumoniae and Kawasaki disease before October 2022 were included in this meta-analysis. The pooled prevalence was calculated, and the log odds ratio in the random effects model was applied to estimate the pooled prevalence of M. pneumoniae infection in pediatric patients with Kawasaki disease. In addition, the clinical parameters, such as hemoglobin and erythrocyte sedimentation rate, were analyzed. Six studies with a total of 1,859 pediatric patients with Kawasaki disease were enrolled. The focused outcome was the pooled prevalence and clinical parameters. The pooled prevalence of M. pneumoniae infection was statistically significant in pediatric patients with Kawasaki disease. In addition, the values of hemoglobin and erythrocyte sedimentation rate were significantly different between M. pneumoniae-infected and non-M. pneumoniae-infected patients with Kawasaki disease. Other clinical parameters were not significantly different between M. pneumoniae-infected and non-M. pneumoniae-infected patients with Kawasaki disease. The results suggest that M. pneumoniae infection is significantly prevalent in pediatric patients with Kawasaki disease. The lower values of hemoglobin and erythrocyte sedimentation rate in M. pneumoniae-infected patients with Kawasaki disease might be needed to investigate further.

The impact of two radical sternectomy surgical techniques on the outcome of deep sternal wound infections

BackgroundDeep sternal wound infection (DSWI) is a rare, yet devastating complication after cardiac surgery. While the surgical treatment always implies the soft tissue and bone debridement, there is little data about this procedure. The aim of our study was to evaluate the impact of the radical sternectomy on the outcome in patients with DSWI and to identify the risk factors which could influence the result. The surgical techniques of piecemeal sternectomy and the newly developed en bloc sternectomy were also evaluated.MethodsThe study was developed as a retrospective cohort study. 86 patients with DSWI who received a radical sternal resection at our institution between March 2018 and December 2021 were included.ResultsThe average age of the cohort was 67.3 ± 7.4 years, and 23.3% of patients were female. The average length of stay trended shorter after en bloc sternectomy (median 26 days) compared to piecemeal sternectomy (37 days). There were no significant differences between the piecemeal and en bloc sternal resection techniques. Anticoagulant and antiplatelet drugs had no significant influence on bleeding and transfusion rates. Obese patients showed an increased risk for postoperative bleeding requiring reintervention. Transfusion of packed red blood cells was significantly associated with lower hemoglobin values before surgery and ASA Class 4 compared to ASA Class 3. The in-hospital mortality was 9.3%, with female sex and reintervention for bleeding as significant risk factors. Nine patients developed an infection relapse as a chronic fistula at the level of clavicula or ribs, with ASA Class 4 as a risk factor.ConclusionRadical sternectomy is a safe procedure to treat DSWI with compromised sternal bone. Both piecemeal and en bloc techniques ensure reliable results, while complications and mortality appear to be patient-related.

Management of acute diverticulitis in Stage 0-IIb: indications and risk factors for failure of conservative treatment in a series of 187 patients

Left-sided acute diverticulitis in WSES Stage 0-IIb preferentially undergoes conservative management. However, there is limited understanding of the risk factors for failure of this approach. The aim of this study was to investigate the factors associated with the decision to perform conservative treatment as well as the predictors of its failure. We included patients with a diagnosis of WSES diverticulitis CT-driven classification Stage 0-IIb treated in the Emergency Surgery Unit of the Agostino Gemelli University Hospital Foundation between 2014 and 2020. The endpoints were the comparison between the characteristics and clinical outcomes of acute diverticulitis patients undergoing conservative versus operative treatment. We also identified predictors of conservative treatment failure. A set of multivariable backward logistic analyses were conducted for this purpose. The study included 187 patients. The choice for operative versus conservative treatment was associated with clinical presentation, older age, higher WSES grade, and previous conservative treatment. There were 21% who failed conservative treatment. Of those, major morbidity and mortality rates were 17.9% and 7.1%, respectively. A previously failed conservative treatment as well as a greater WSES grade and a lower hemoglobin value were significantly associated with failure of conservative treatment. WSES classification and hemoglobin value at admission were the best predictors of failure of conservative treatment. Patients failing conservative treatment had non-negligible morbidity and mortality. These results promote the consideration of a combined approach including baseline patients’ characteristics, radiologic features, and laboratory biomarkers to predict conservative treatment failure and therefore optimize treatment of acute diverticulitis.

Endovascular Repair of Ruptured Aortic Aneurysm: A Single-Center Experience.

Aortic rupture is a rare and catastrophic emergency. Prompt diagnosis and treatment are the primary determinants of mortality. During follow-up, the majority of patients who have been effectively treated die from hypovolemic shock and multiorgan failure. This article describes the clinical and procedural details of sixteen patients with ruptured aortic aneurysms treated endovascularly. In addition, it discusses the main factors contributing to the mortality of these patients. Patients who underwent endovascular treatment for acute aortic rupture at our center from October 2016 to March 2023 were included in this retrospective study. A total of 16 patients underwent endovascular aneurysm repair (EVAR) or thoracic endovascular aneurysm repair (TEVAR) for acute aortic rupture. The patients' mean age was 73.06 years (range: 52-92), and 15 of them were male. The ruptures occurred in the abdominal aortic aneurysm in ten patients, in thoracic aortic aneurysm in three patients, in the isolated iliac artery aneurysm in two patients, and there was one case of non-aneurysmal aortic rupture. In our series, patients who presented with an impending, self-limited rupture and stable hemodynamic status had good prognostic outcomes. However, eight patients died due to multiorgan failure, hemorrhagic shock, disseminated intravascular coagulopathy, renal failure, or abdominal compartment syndrome. These patients generally had poor admission vital signs and low hemoglobin values. The most critical determinants for the success of the procedure are promptly stopping the bleeding, avoiding general anesthesia, and opting for blood product replacement instead of fluid replacement. Each patient with ruptured aortic aneurysm should be managed according to the patient's hemodynamics at presentation, the size of the aneurysm, the suitability for percutaneous procedure, logistical factors, and the operator-center's experience.