Nonanemic Patients Research Articles

May C-peptide index be a new marker to predict proteinuria in anemic patients with type 2 diabetes mellitus?

C-peptide is a reliable marker of beta cell reserve and is associated with diabetic complications. Furthermore, HbA1c level is associated with micro- and macro-vascular complications in diabetic patients. HbA1c measurement of diabetic patients with anemia may be misleading because HbA1c is calculated in percent by taking reference to hemoglobin measurements. We hypothesized that there may be a relationship between C-peptide index (CPI) and proteinuria in anemic patients with type 2 diabetes mellitus (T2DM). Therefore, the aim of the present study was to investigate the association between C-peptide levels and CPI in anemic patients with T2DM and proteinuria. The patients over 18 years of age with T2DM whose C-peptide levels were analyzed in Endocrinology and Internal medicine clinics between 2014 and 2018 with normal kidney functions (GFR>60 ml/min) and who do not use any insulin secretagogue oral antidiabetic agent (i.e. sulfonylurea) were enrolled into the study. Hemoglobin levels were present in 342 patients with T2DM. Among these 342 cases, 258 (75.4%) were non-anemic whereas 84 (24.6%) were anemic. The median DM duration of the anemic group was statistically significantly higher in T2DM (p=0.003). There was no statistically significant difference found in proteinuria prevalence between non-anemic and anemic patient groups (p=0.690 and p=0.748, respectively). Anemic T2DM cases were corrected according to the age, gender, and duration of DM. C-peptide and CPI levels were not statistically significant to predict proteinuria (p=0.449 and p=0.465, respectively). The present study sheds light to the association between C-peptide, CPI, and anemic diabetic nephropathy in T2DM patients and indicates that further prospective studies are needed to clarify this issue.

Perioperative Complications Associated with Severity of Anemia in Geriatric Patients Undergoing Spinal Procedures

To investigate preoperative baseline anemia, stratified by severity as a function of hematocrit level, as a risk factor for perioperative complications in geriatric patients undergoing spinal procedures. Previous literature has examined the impact of anemia on risk for complications and adverse outcomes in patients undergoing elective spinal procedures. However, there is a paucity of literature analyzing the impact of anemia in the geriatric population, specifically. The American College of Surgeons-National Surgical Quality Improvement Database was used to identify patients older than 65 years who had undergone elective spinal procedures and were subsequently stratified into 3 separate cohorts based on hematocrit levels: severe/moderate (hematocrit level <30%), mild (30%-37%), and no anemia (>38%). These patient samples were then analyzed using multivariate analyses to assess severity of anemia as a risk factor for complications in elderly patients undergoing spinal procedures. When anemia classes were analyzed as separate independent risk factors for complications, mild anemia (class II) was a significant risk factor for the same complications as moderate/severe anemia (class III/IV), with the exception of 2 complications, compared with nonanemic patients. Mild anemia was independently associated with wound dehiscence (odds ratio, 1.521; 95% confidence interval, 1.126-2.054; P= 0.006), whereas moderate/severe anemia did not show an increased risk for wound dehiscence. However, moderate/severe anemia independently increased the risk for deep venous thromboembolism (odds ratio, 1.437; 95% confidence interval, 1.028-2.011; P= 0.034), compared with mild anemia. Both categories of anemia independently increased the risk for additional complications such as deep incisional surgical site infection, organ/space surgical site infection, pneumonia, unplanned intubation, ventilator dependence, progressive renal insufficiency, acute renal failure, urinary tract infections, cardiac arrest, myocardial infarctions, blood transfusions, systemic sepsis, reoperation, extended length of stay of ≥5 days, unplanned readmission, and mortality. This study indicated that patients with preoperative baseline anemia were at risk for requiring transfusions, renal failure, and infectious complications. Physicians should be cognizant of anemia as a risk factor affecting numerous perioperative complications and adverse outcomes to work toward improving health-related quality of life.

Association of ferritin levels with depression, anxiety, sleep quality, and physical functioning in patients with fibromyalgia syndrome: a cross-sectional study

AimTo determine the frequency of ferritin deficiency in individuals with fibromyalgia syndrome (FMS) and to evaluate the association of ferritin level with depression, anxiety, sleep quality, and physical functioning.MethodsThis cross-sectional study, conducted from 2016 to 2017, compared the frequency of ferritin deficiency between 100 non-anemic fibromyalgia patients and 100 non-anemic individuals without FMS. Serum ferritin level of <30 ng/mL indicated iron deficiency. FMS patients filled out demographic questionnaire, Fibromyalgia Impact Questionnaire, Beck Anxiety Inventory, Beck Depression Inventory, and Pittsburg Sleep Quality Index.ResultsMedian serum ferritin level was 20.95 ng/mL. A total of 64% of patients and 42% of controls had iron deficiency. Beck Anxiety Inventory, Beck Depression Inventory, and Pittsburgh Sleep Quality Index scores were not associated with ferritin levels. FMS patients with poor sleep quality had significantly higher Beck Depression Inventory, Beck Anxiety Inventory, and Fibromyalgia Impact Questionnaire scores (P < 0.05). In individuals with poor sleep quality, lower ferritin levels also correlated with higher Beck Depression Inventory scores (r = -0.277, P < 0.05). Sleep quality was not significantly associated with age, body mass index, duration of diagnosis, and serum ferritin levels.ConclusionsPatients with fibromyalgia syndrome have a rather high prevalence of non-anemic iron deficiency. No associations were found between serum ferritin level and anxiety, depression, sleep quality, and physical functioning.ClinicalTrials.gov identifier: NCT03825393.

Quantifying the Effect of Anemia on Major Lower Limb Amputation

Introduction: Major Lower limb amputation (MLLA) for end stage vascular disease are unfortunately common. Approximately 4000 are performed each year within the UK. These patients have often suffered years of chronic disease and as such many are anaemic. A 2017 Delphi consensus identified that improving outcomes for amputees are included in the top ten research priorities in the UK. This tertiary center cohort study evaluates the impact of anaemia on the outcome of MLLA to help understand if there is a role in optimization of haemoglobin (Hb) to improve outcomes. Methods: A prospectively maintained database was reviewed. All MLLA between 2015 and 2018 were identified. Anaemia was defined as a pre-operative Hb of less than 120g/dL as per WHO guidance. In addition, a ROC analysis was performed to identify the most sensitive and specific 'critical Hb'. Groups were stratified accrodingly into non-anaemics, moderate anaemia (Hb of < 120-100) and severe anaemia (Hb < 100). Pre-, intra- and post-operative metrics were analyzed to understand if anaemia impacted on clinical outcome. Inter-group comparative statistics and regression analyses were performed. Results: 337 MLLA patients were included. 98 were not anaemic with an average Hb of 133(13.7) g/dL, 111 were mildly anaemic; Hb of 109(5.73) g/dL and 128 were severely anaemic with a mean Hb of 87.8(7.3) g/dL. Mean follow-up period was 22 months. Baseline comparisons were equivalent for age, gender, co-morbidity and medications, as were intra-operative blood loss for all groups. Length of stay was significantly longer with progressive anaemia with the non-anaemic group staying 26.7(25) days, for the moderate group 36.5(42) days and the severely anaemic group 36.6 (30) days (P=0.003). Overall anaemia was associated with a greater 22-month mortality (P=0.021), this was most significant in the severely anaemic group (P< 0.001). The non-anaemics had a probability of survival of 76% compared to the anaemic groups. Regression analysis also demonstrated that an incremental increase of Hb by 1g/dL leads to 2% increase in survival probability. The severely anaemic group fared worse for overall complications but there was no statistical difference in the specific wound complication or revision surgery rates in either anaemia group compared to the non-anaemics. Myocardial events were greatest in the mildly-anaemic group compared to the non-anaemic patients. ROC analysis revealed that 111g/dL to be the most sensitive and specific Hb level to predict, complications and long-term mortality. Conclusion: Pre-operative anaemia significantly increases the length of hospital stay following MLLA. It is also associated with higher long-term mortality and a lower Hb equates to a greater probability of death. Consequently, optimisation of baseline Hb may improve these outcomes in this high risk non-elective group of patients. More work is being undertaken to fully appreciate this relationship. Disclosure: Nothing to disclose

Cell Blood Count Alterations and Patterns of Anaemia in Autoimmune Atrophic Gastritis at Diagnosis: A Multicentre Study.

Background: Autoimmune atrophic gastritis (AAG) leads to iron and/or vitamin B12 malabsorption, with subsequent haematological alterations which could represent the sole clinical manifestation. We aimed to assess patterns of anaemia and micronutrient deficiencies in patients with AAG at the time of diagnosis. Methods: Observational, multicentre, cross-sectional study including consecutive adult patients diagnosed with AAG within the last ten years. Cell blood count, red cell distribution width, serum vitamin B12, and ferritin were collected. Multivariate analysis for predictive factors of anaemia was computed. Results: 654 AAG patients (mean age 59.2 ± 13.8 years, female (F): male (M) ratio = 2.3:1) were included. Anaemia was present in 316 patients (48.3%; mean age 60.1 ± 15.8 years, F:M ratio = 2.3:1). Pernicious anaemia (132/316 cases, 41.7%) was more common in males (27.1% versus 12.4%; p = 0.001) and in older patients (63.0 ± 14.6 versus 58.9 ± 14.9 years; p = 0.014), while iron deficiency anaemia (112/316 cases, 35.4%) was more common in females (16.9% versus 10.0%; p = 0.039) and in younger patients (56.8 ± 16.6 versus 60.2 ± 14.6 years; p = 0.043). The prevalence of iron deficiency was equally distributed between anaemic and non-anaemic patients (p = 0.9). Anisocytosis (odds ratio: 10.65, 95% confidence interval: 6.13–18.50, p < 0.0001) was independently associated with anaemia. Conclusions: Anaemia is a common manifestation in AAG patients, mostly due to micronutrient deficiencies. Scant haematologic alterations and micronutrient deficiencies may precede overt anaemia.

Hemoglobin Optimization Prior to Cardiac Surgery Results in Improved Patient Outcomes

Background: Anemia has an estimated prevalence of 5.6% in the overall United States population. In patients undergoing cardiac surgery, as many as 16-54% of patients are estimated to have anemia. Common causes of anemia in the perioperative setting include iatrogenic anemia due to blood draws and lab tests, iron deficiency anemia, and anemia of chronic disease. Studies show that patients with pre-operative anemia undergoing coronary artery bypass surgery have increased lengths of stay in the hospital and higher 30-day mortality rates post-operatively compared to non-anemic patients. The use of transfusions to address blood loss anemia is quite common, as approximately 50% of all patients undergoing cardiac surgery receive blood. In addition to common risks associated with transfusions, studies also note that in cardiac surgery patients, there is an increased risk of infection associated with receiving blood products. To address the issue of pre-operative anemia, we developed an Anemia Clinic to help optimize patients scheduled to undergo non-emergent cardiac surgery. Patients meet with a multidisciplinary team and interventions including lifestyle modifications, erythropoietin-stimulating agents, and intravenous iron are utilized to help patients reach target hemoglobin values, per surgeon preference. The length of treatment through the Clinic is individualized for each patient based on the risk-benefit analysis of delaying surgery and the amount of time available between evaluation by the clinic and the anticipated date of the procedure. To date, 21 patients have been evaluated in the clinic and have successfully undergone cardiac surgery. Methods: Patients included in our study were those who were assessed through the Anemia Clinic following referral from their cardiac surgeons. Baseline characteristics, including lifestyle choices, tobacco use, exercise routines, and pre-operative complete blood count, basic metabolic panel, iron studies, and when possible, erythropoietin levels, were obtained. Patients then were evaluated by a multidisciplinary team comprised of physicians, nurses, social workers, and dietitians. Those who do not accept blood products also met with Transfuse-Free Medicine Care Coordinators. Prior to surgery, we measured hemoglobin values. Following surgery, we assessed two primary endpoints, namely post-operative transfusion rates and 30-day readmission rates. Results: In total, 21 patients have been evaluated in our Anemia Clinic. We report that 6 patients received post-operative blood transfusions (28.6%). Furthermore, we report zero 30-day readmissions. Other data are presented in Table 1. Conclusion: Through the use of a multifaceted approach, hemoglobin optimization prior to cardiac surgery results in improved outcomes. Blood transfusions were required in only 28.6% of patients, compared to national averages of approximately 50%. Furthermore, we report zero hospital readmissions in 30 days, as compared to state-average readmission rates following cardiac surgery of 11.7%. Overall, our approach to hemoglobin optimization appears to improve outcomes for patients undergoing cardiac surgery. Disclosures No relevant conflicts of interest to declare.

Associations between tryptophan and iron metabolism observed in individuals with and without iron deficiency

Current literature proposes associations between tryptophan metabolism and anaemia. However, study cohorts are rather small and final conclusions are still lacking. Here, we evaluated potential associations of tryptophan, kynurenine, and kynurenic acid with indicators of iron metabolism (i.e., mean corpuscular volume, mean corpuscular haemoglobin, ferritin, transferrin saturation, serum iron, transferrin, soluble transferrin receptor, reticulocyte haemoglobin) and haemoglobin in 430 individuals grouped by the presence or absence of iron deficiency or anaemia. Indicators of tryptophan metabolism were positively correlated with haemoglobin and markers of iron metabolism (p-values: <0.001–0.038; r-values: 0.100–0.305). The strongest correlation was observed between tryptophan and haemoglobin (p < 0.001, r = 0.305). The cubic regression model yielded the highest R-square values between haemoglobin and tryptophan markers. Overall, 115 patients with iron deficiency showed lower tryptophan and kynurenic acid concentrations compared to 315 individuals without iron deficiency. Six patients with anaemia of chronic disease were observed with the lowest serum tryptophan levels and the highest kynurenine/tryptophan ratio compared to 11 individuals with iron deficiency anaemia and 413 non-anaemic patients. This study showed little/moderate associations between haemoglobin, biomarkers of iron metabolism and tryptophan markers. Further studies are needed to get better insight in the causality of these findings.

3331Impact of baseline hemoglobin level and white blood cell count in real-world patients undergoing contemporary percutaneous coronary intervention: insights from the GLOBAL LEADER study

Abstract Introduction The impact of hemoglobin (Hb) level and white blood cell count (WBC) on the outcomes in all-comers PCI patients is unknown. Purpose We sought to assess the association between baseline Hb level, WBC count on 2-year outcomes after PCI in all-comers patients in the GLOBAL LEADERS study. We compared the outcomes between anemic and non-anemic patients according to WHO definition. Methods GLOBAL LEADERS study assessed the efficacy and safety of two antiplatelet strategies in 15,991 patients undergoing PCI. The primary endpoint was all-cause mortality or new Q wave myocardial infarction (MI) at 2 years. Secondary safety endpoint was BARC 3 or 5 bleeding at 2 years. The association between WBC count, Hb level and outcomes at 2 years were assessed in the multivariable Cox model adjusted for age, diabetes, ejection fraction and renal impairment. For Hb level, patients were categorized according to the WHO definition of anemia (Hb &lt;12 g/dL in women, Hb &lt;13 g/dL in men). Results Of 15991 patients randomized in the GLOBAL LEADER study, baseline WBC count and Hb levels were available in 14960 (93.7%) patients and 15215 (95.3%) patients, respectively. Hb level had an inverse association with adverse events after PCI. In the multivariable Cox model, Hb level was an independent predictor for ischemic and bleeding outcomes at 2 years while the WBC count was not (see table). Compared with non-anemic patients, anemic patients had significantly higher risk of primary endpoint (adjusted HR 2.07, 95% CI 1.72–2.49), BARC 3 or 5 bleeding (adjusted HR 1.49 95% CI 1.14–1.96), all-cause mortality (adjusted HR 2.33, 95% CI 1.89–2.86), any MI (adjusted HR 1.41, 95% CI 1.11–1.80), and any revascularization (adjusted HR 1.20, 95% CI 1.03–1.39). Hb level, WBC count and 2-year outcomes Outcomes at 2 years Hemoglobin level (mg/dL) WBC count (109/L) HR (95% CI) P value HR (95% CI) P value All-cause mortality or new Q wave MI 0.87 (0.82–0.91) &lt;0.0001 1.00 (0.999–1.002) 0.33 All-cause mortality 0.82 (0.78–0.87) &lt;0.0001 1.00 (0.999–1.002) 0.37 Any myocardial infarction 0.93 (0.87–0.99) 0.0165 1.00 (0.996–1.001) 0.23 Any revascularization 0.96 (0.93–1.00) 0.0302 1.00 (1.00–1.001) 0.25 BARC 3 or 5 bleeding 0.85 (0.79–0.91) &lt;0.0001 1.00 (0.997–1.002) 0.76 Conclusion In the all-comers patients undergoing PCI, the baseline Hb level was significantly associated with the ischemic and bleeding outcomes at 2 years whereas baseline WBC count was not. Baseline WBC count may not be useful as a prognostic factor after PCI.

Iron and stable ischemic heart disease - lessons from heart failure

Iron is an essential element for cardiomyocyte viability and contractility. Systemic iron deficiency, even without anemia, is reflected by iron deficiency in cardiomyocytes. As in other cells, there is here a complex, local and autonomous regulation of iron metabolism, based on two molecular systems: the hepcidin/ferroportin/transferrin receptor-1 axis; and the iron regulatory proteins-1,2 system. These molecular pathways allow cardiomyocytes to react to changes in serum iron availability. In mice, dietary manipulations of serum iron availability or cardio-specific deletions and mutations of regulatory genes for intracellular iron metabolism have clarified some aspects of the causal relationship between cardiomyocyte iron deficiency and the development of severe heart failure, prevented by intravenous iron treatment even without the occurrence of iron deficiency (sideropenic) anemia. The deleterious effects of iron deficiency and hypoxia on gene expression of the main regulators of intracellular iron and oxygen metabolism and on cardiac function are very similar in heart failure and in chronic stable ischemic heart disease, and conjure towards cardiomyocyte injury. We here hypothesize that in non-anemic patients with stable ischemic heart disease a chronic or acute serum iron deficiency can amplify the chronic activation of the cardiomyocyte hypoxia-inducible factor-1α. As a consequence, cardiac adaptative responses to chronic hypoxia/ischemia are significantly impaired, and cardiac dysfunction exacerbated. We hypothesize that, in such patients, iron replacement through forced iron supplementation may replete cardiomyocyte iron deficiency and improve ischemic heart disease. This hypothesis requires further experimental studies, but also, and already now, specific clinical trials.

ANEMIA AS A PROGNOSTIC FACTOR IN PATIENTS WITH SEVERE SEPSIS AND SEPTIC SHOCK

SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: Sepsis which is a leading cause of admission to the intensive care unit is associated with high mortality, morbidity, and hospital costs. Likewise, anemia also a common condition in critically ill patients is also associated with worse outcomes. consequently, we aim to study the role of anemia with regards to the outcomes of patients diagnosed with sepsis. METHODS: We utilized the National Inpatient Sample (NIS) database to identify all patient with diagnoses of severe sepsis and septic shock (using ICD-10-CM Diagnosis Code J44.1) who were admitted to hospital over the period from 01/01/2015 to 01/01/2016. Patients with a diagnosis of (ICD-10-CM Diagnosis Code D64.9) were further identified within each hospitalization. The comparison group will be severe sepsis/septic shock patients with normal hemoglobin (hemoglobin >12). Multivariable logistic regression models were used to evaluate the association of anemia and 28 days mortality, length of stay in hospital and cost. RESULTS: In 2016, there were an estimated 4,985 hospitalizations with a primary discharge diagnoses of severe sepsis or septic shock (95% CI: 4,533 to 5,417), of which an estimated 526 (10.5%) hospitalizations had a secondary anemia diagnosis. The overall mortality rate was estimated to be 14.8% (95% CI: 12.6% to 17.2%), and although the mortality rate was lower in sepsis hospitalizations with a secondary anemia diagnosis compared to hospitalizations without anemia (10.5% vs. 15.3%,), this difference was not statistically significant (p = .204). The median overall hospital length of stay was 5.0 days (95% CI: 4.8 days to 5.3 days), with hospitalizations with a secondary anemia diagnosis having 44.7% longer stays compared to hospitalizations without an anemia diagnosis (95% CI: 24.6% to 68.1%; 7.0 days vs. 4.9 days, p < .001). Finally, median overall hospital cost was $12,679 (95% CI: $11,949 to $13,453), with hospitalizations with a secondary anemia diagnosis having 61.2% higher cost compared to hospitalizations without an anemia diagnosis (95% CI: 59.3% to 63.1%; $10,394 vs. $6,448, p < .001). Of course, this result was expected given that the anemia group had a longer length of stay. CONCLUSIONS: Severe sepsis patients with anemia had a higher length of stay and cost as compared to non-anemic patients. The in-hospital mortality difference, however, was not statistically significant. Septic patients who were anemic had worse outcomes and may require blood transfusion at a lower threshold as they can be considered as a high-risk sub-group. This study aimed to bring attention to the anemia as a prognostic factor, further studies need to be conducted to identify the exact type of the anemia and hemoglobin level associated with the poor outcomes. CLINICAL IMPLICATIONS: The purpose of identifying such a relation is so that it may be used to define a new threshold for transfusing patients with a diagnosis of sepsis in future studies. DISCLOSURES: No relevant relationships by Sara Albagoush, source=Web Response No relevant relationships by Faysal Alghoula, source=Web Response No relevant relationships by Haitam Buaisha, source=Web Response No relevant relationships by Maryam Gbadamosi-Akindele, source=Web Response No relevant relationships by Adam Highley, source=Web Response No relevant relationships by Ryan Walters, source=Web Response

Preoperative Anaemia in Primary Hip and Knee Arthroplasty.

Approximately one in three patients has untreated preoperative anaemia, which in turn is associated with an increased need for transfusion of allogenic red blood cell concentrates (RBC) and complications in the context of a surgical intervention. Here, the prevalence of preoperative and postoperative anaemia as well as their effects on transfusion rate, hospital length of stay and hospital mortality in primary hip and knee arthroplasty has been analysed. From January 2012 to September 2018, 378,069 adult inpatients from 13 German hospitals were analysed on the basis of an anonymized registry. Of these, n = 10,017 patients had a hip and knee joint primary arthroplasty. The primary endpoint was the incidence of preoperative anaemia, which was analysed by the first available preoperative haemoglobin value according to the WHO definition. Secondary endpoints included in-hospital length of stay, number of patients with red blood cell concentrate transfusion, incidence of hospital-acquired anaemia, number of deceased patients, and postoperative complications. The preoperative anaemia rate was 14.8% for elective knee joint arthroplasty, 22.9% for elective hip joint arthroplasty and 45.0% for duo-prosthesis implantation. Preoperative anaemia led to a significantly higher transfusion rate (knee: 8.3 vs. 1.8%; hip: 34.5 vs. 8.1%; duo-prosthesis: 42.3 vs. 17.4%), an increased red blood cell concentrate consumption (knee: 256 ± 107 vs. 29 ± 5 RBC/1000 patients; hip: 929 ± 60 vs. 190 ± 16 RBC/1000 patients; duo-prosthesis: 1411 ± 98 vs. 453 ± 42 RBC/1000 patients). Pre-operative anaemia was associated with prolonged hospital stay (12.0 [10.0; 17.0] d vs. 11.0 [9.0; 13.0] d; p < 0.001) and increased mortality (5.5% [4.6 - 6.5%] vs. 0.9% [0.7 - 1.2%]; Fisher p < 0.001) compared to non-anaemic patients. In patients aged 80 years and older, the incidence of preoperative anaemia and thus the transfusion rate was almost twice as high as in patients under 80 years of age. Preoperative anaemia is common in knee and hip primary arthroplasty and was associated with a relevant increase in red blood cell concentrate consumption. In the context of patient blood management, a relevant potential arises, especially in elective orthopaedic surgery, to better prepare elective patients, to avoid unnecessary transfusions and thus to conserve the valuable resource blood.

Can red blood cell distribution width predict long-term cardiovascular event after off-pump coronary artery bypass? A retrospective study.

The effect of red blood cell distribution width (RDW) on long-term major cardiac and cardiovascular event (MACCE) in patients with off-pump coronary artery bypass (OPCAB) has not been adequately studied. We investigated the relationship between RDW and the risk of MACCE in patients who underwent OPCAB. We retrospectively analyzed the data of 440 consecutive, nonanemic patients (362 males; 82.27% and mean age 60.8 ± 8.9 years) who underwent OPCAB between October 2009 and September 2012 in Fuwai Hospital. Long-term follow-up was obtained through phone calls, hospital records, and clinic visits. MACCE (death, ST elevated infarction, repeat coronary revascularization, stroke) was determined. Over a median of 7.0-year follow-up, 80 incident MACCE events were identified. The RDW levels on admission were significantly higher in MACCE group than non-MACCE group (13.1 ± 0.7 vs 12.8 ± 0.7; P = .005). Using the Cox proportional hazards models, we found that per 1% increment of RDW, the incident of MACCE was increased in different models (hazard ratio [HR] was 1.520, 1.532, and 1.795, respectively; P = .002, .004, and .002). The receiver-operating characteristic analysis revealed an RDW cut-off value of 13% predicting MACCE. Therefore, patients were grouped on this cut-off value. The Kaplan-Meier plot revealed significantly lower event-free survival in the higher RDW group (P = .0158). Compared with subjects in the RDW <13% in full model, subjects in the RDW ≥13% had an HR of 1.829 (95% confidence interval, 1.103-3.032; P = .019). An RDW level greater than 13% in hospital admission is independently associated with an increased incidence of long-term MACCE after OPCAB.

Assessment of T helper 17-associated cytokines in thromboangiitis obliterans.

BackgroundThe management of thromboangiitis obliterans (TAO) remains a medical challenge because of its unknown etiology. It is also not known whether it is a systemic or localized disease or a type of autoimmune vasculitis.MethodsIn this study, we evaluated the serum level of IL-17 and IL-23 which increase in both systemic inflammation and autoimmunity, in 60 TAO patients and 30 age- and smoking habit-matched controls. Also, IL-22, which has reported high level during infection but not in autoimmunity, was evaluated.ResultsThe serum levels of IL-17, IL-22 and IL-23 were significantly higher in the TAO patients in comparison with the controls (P<0.001). Notably, the serum levels of IL-17, IL-22 and IL-23 were highest in the patients with the chief complaint of chronic ulcer and lowest in the patients with gangrene (P<0.05). Also, the serum level of IL-22 was significantly higher in the anemic patients in comparison with the non-anemic patients (P=0.03).ConclusionOwing to our findings, TAO appears more likely to be a systemic disorder rather than a localized vasculopathy. Therefore, treatment protocols based on systemic treatment of TAO patients may be more helpful than localized treatment, such as bypass surgery and endovascular procedures. Also, according to our findings regarding the high level of IL-22, the trigger of TAO development may be an infectious pathogen. However, additional research is highly recommended to investigate whether TAO is an infectious disease or an infectious-induced autoimmunity.

Anemia in patients with Takayasu arteritis: prevalence, clinical features, and treatment.

BackgroundAnemia is a common comorbidity of patients with Takayasu arteritis (TA). This study evaluated the prevalence, clinical characteristics, and treatment in Chinese TA patients with anemia.MethodsThis retrospective study included 533 consecutive patients hospitalized for TA from January 2009 to April 2018. Anemia was diagnosed on the basis of hemoglobin level, according to World Health Organization criteria.ResultsA total of 194 patients (36.4%) were diagnosed with anemia. Most had mild anemia (177, 91.2%). Female patients were predominant (92.8% of anemic patients). Normocytic anemia (62.9%) was the most common pattern. Anemic patients were more likely than non-anemic patients to have dizziness (29.4% vs. 21.2%), low body mass index (22.0 ± 3.6 vs. 22.9 ± 3.4 kg/m2), and active disease stage (64.9% vs. 50.1%); pulmonary involvement (12.4% vs. 26.8%), pulmonary hypertension (12.9% vs. 20.1%) and pulmonary hypertensive-target drugs (2.8% vs. 11.6%) were less common among anemic than non-anemic patients (all P < 0.05). Larger left ventricular end-diastolic diameter and lower left ventricular ejection fraction were observed in anemic patients. Over a median follow-up of four months, the increase of hemoglobin in anemic patients was associated with the use of iron supplementation.ConclusionsAnemia is a very common concurrent condition in TA, especially in young, female patients. Patients with anemia are more likely to be in the active disease stage. Iron supplementation helps increase hemoglobin.

Relation of Preprocedural Hemoglobin Level to Outcomes After Percutaneous Coronary Intervention

Adverse effects have been reported in patients with preprocedural anemia after percutaneous coronary intervention (PCI), but data regarding the relation between elevated hemoglobin (Hb) level and post-PCI prognosis remain limited. This study assessed the impact of elevated Hb on major adverse cardiac and cerebrovascular event (MACCE) at 12 months, a composite of all-cause mortality, nonfatal myocardial infarction, and ischemic stroke after PCI. We pooled patient-level data from four Korean multicenter drug-eluting stent registries from 2010 to 2016. In total, 5,107 patients were divided into 5 categories according to the baseline Hb level (<10, 10 to 12.9, 13 to 14.9, 15 to 16.9 and ≥17 g/dl). Patients with higher Hb levels were significantly younger, predominantly male, current smokers with higher body mass index, and more frequent dyslipidemia. Hypertension, diabetes, chronic kidney disease, and cerebrovascular accident were more prevalent in lower Hb groups. Categorically, a U-shaped curvilinear relation was observed between baseline Hb and clinical outcomes showing significantly higher MACCE rate in <10g/dl (hazard ratio [HR], 4.62 [2.81 to 7.68]) and ≥17 g/dl (HR, 4.06 [1.57 to 10.5]) groups compared with the reference group (13 to 14.9 g/dl), especially in men. In nonanemic patients (Hb ≥13 g/dl), adjusted HRs of MACCE, mortality, and stroke were significantly higher in ≥17 g/dl group than in the reference group. Furthermore, ≥17 g/dl was an independent predictor for MACCE and all-cause mortality after PCI. In conclusion, not only low Hb but also elevated Hb of ≥17 g/dl was significantly associated with higher MACCE rates and all-cause mortality after PCI. An appropriate treatment strategy for patients with high Hb level should be identified through future studies.

Risks of preoperative anemia in women undergoing elective hysterectomy and myomectomy

Hysterectomy is one of the most common surgeries performed worldwide. Identification of modifiable risk factors for complications or readmissions could lead to targeted interventions to improve patient care and reduce health care costs. Preoperative anemia has been identified as a risk factor for adverse postoperative outcomes following noncardiac surgery. However, studies have not focused on young and healthy surgical populations, such as women undergoing gynecologic surgery for benign indications. The purpose of this study was to evaluate whether preoperative anemia in women undergoing elective hysterectomy or myomectomy for benign indications was associated with increased 30 day postoperative morbidity and mortality. In this retrospective, population-based cohort study, we followed up adult women (≥18 years of age) who underwent elective hysterectomy or myomectomy (laparoscopic/laparotomy) between the years 2013 and 2015 for benign indications in Ontario, Canada. We used linked administrative data from a government-administered, single-payer provincial health care system using Canadian Classification of Health Interventions intervention codes, International Classification of Diseases, 10th revision, diagnostic codes, physician billing codes, and laboratory data from both community and hospital laboratories across the province. Our exposure of interest was preoperative anemia, defined as a hemoglobin value <12 g/dL on the complete blood count measured closest to the date of surgery. Our primary outcome was the composite of 30 day postoperative morbidity and mortality. Secondary outcomes were 5 individual components of the primary outcome: death, transfusion, surgical site infection, venothromboembolism, and return to the hospital within 30 days. To adjust for confounding, we generated a propensity score using a multiple logistic regression model in which the presence of anemia was regressed on all baseline characteristics. We matched anemic to nonanemic patients on the logit of the propensity score. Using an unadjusted log-binomial model estimated using generalized estimating equations to account for the matched pairs, we calculated the relative risk, 95% confidence intervals, and P values to evaluate the effect of anemia on outcomes. Of the 16,218 women in the cohort, 3664 (22.6%) had anemia. After propensity matching, standardized differences in all baseline characteristics (n= 3261 per group) were <0.10. In the matched cohort, the primary outcome (death, complications, or readmission) occurred in 41.2% of anemic patients and 36.2% of nonanemic patients (relative risk, 1.14, 95% confidence interval, 1.07-1.21, P < .0001; absolute risk reduction, 5.03%, 95% confidence interval, 2.70-7.36; (number needed to harm= 20). The risk of transfusion was significantly higher in anemic patients (relative risk, 3.25, 95% confidence interval, 2.67-3.95, P < .0001; absolute risk reduction, 8.34%, 95% confidence interval, 7.06-9.63; number needed to harm= 12). There was no difference in other secondary outcomes. In a subgroup analysis (women >55 years vs ≤55, n= 736), older women were at increased risk of the primary outcome (relative risk, 1.40, 95% confidence interval, 1.12-1.76, P= .004), transfusion (relative risk, 4.20, 95% confidence interval, 1.65-10.72, P= .003), surgical site infection (relative risk, 1.35, 95% confidence interval, 1.01-1.81, P= .04), and return to the hospital (relative risk, 2.36, 95% confidence interval, 1.54-3.62, P < .0001). Preoperative anemia in women undergoing elective hysterectomy/myomectomy was common and is an independent risk factor for 30 day postoperative adverse outcomes, especially in older women.

Prevalence of preoperative anemia in pediatric surgical patients and its impact on perioperative blood transfusion

Aim: To determine the prevalence of preoperative anemia in children presenting for surgery at our institution and to establish whether preoperative anemia increased the likelihood of perioperative transfusion. Methods: A retrospective review of all noncardiac surgical patients over a 2-week period. Data were collected for demographics, type of surgery, hemoglobin concentration within 28 days of surgery, severity of anemia and whether a blood transfusion was administered within 28 days of surgery. Results: 723 patients underwent non-cardiac surgery during the study period, of which 334 had a preoperative hemoglobin measurement, 116 of those were anemic. Blood transfusion was administered in 19.9% of all anemic patients, compared to 5.4% of non-anemic patients (odd ratio [OR] 4.383; 95% confidence interval [CI], 2.10–9.53; p less than 0.0001). In anemic children over six months of age, 75.3% were of moderate severity, 22.6% were mild, and 2.1% severe, with transfusion rates being similar 23.6, 15.1, and 33.0%, respectively. The prevalence of anemia increased with ASA severity with blood transfusion occurring more often in anemic than non-anemic patients in all ASA grades. Anemic patients who underwent intermediate or major procedures were significantly more likely to be transfused than their non-anemic counterparts, with no significant difference seen for minor procedures. Conclusion: Preoperative anemia is common in children presenting for surgery at our institution and in the majority of cases, this is of moderate severity. Preoperative anemia is associated with an increased likelihood of perioperative blood transfusion compared to patients with hemoglobin concentrations within the normal range.

Preoperative Anemia and Outcomes in Cardiovascular Surgery: Systematic Review and Meta-Analysis

Preoperative anemia is common in patients scheduled for cardiac surgery. However, its effect on postoperative outcomes remains controversial. This meta-analysis aimed to clarify the impact of anemia on outcomes after cardiac surgery. A literature search was conducted on MEDLINE, Embase, Cochrane, and Web of Science databases. The primary outcome was 30-day postoperative or in-hospital mortality. Secondary outcomes included acute kidney injury, stroke, blood transfusion, and infection. A meta-analytic model was used to determine the differences in the above postoperative outcomes between anemic and nonanemic patients. Of 1103 studies screened, 22 met the inclusion criteria. Of 114,277 patients, 23,624 (20.6%) were anemic. Anemia was associated with increased mortality (odds ratio [OR], 2.74; 95% confidence interval [CI], 2.32-3.24; I2= 69.6%; P < .001), acute kidney injury (OR, 3.13; 95% CI, 2.37-4.12; I2= 71.1%; P < .001), stroke (OR, 1.46; 95% CI, 1.24-1.72; I2= 21.6%; P < .001), and infection (OR, 2.65; 95% CI, 1.98-3.55; I2= 46.7%; P < .001). More anemic patients were transfused than nonanemic patients (33.3% vs 11.9%, respectively). No statistically significant association was found between mortality and blood transfusion (OR, 1.35; 95% CI, 0.92-1.98; I2= 83.7%; P= .12), but we were not able to compare mortality with or without transfusion in those who were or were not anemic. Preoperative anemia is associated with adverse outcomes after cardiac surgery. These findings support the addition of preoperative anemia to future risk prediction models and as a target for risk modification.

Effect of anaemia on the diagnosis of rheumatic heart disease using World Heart Federation criteria

There is overlap between pathological mitral regurgitation seen in borderline rheumatic heart disease using World Heart Federation echocardiography criteria and physiologic regurgitation found in normal children. One possible contributing factor is higher rates of anaemia in endemic countries. To investigate the contribution of anaemia as a potential confounder in the diagnosis of rheumatic heart disease detected in echocardiographic screening. A novel Server 2012 data warehouse tool was used to incorporate haematology and echocardiography databases. The study included a convenience sample of patients from 5 to 18 years old without structural or functional heart disease that had a haemoglobin value within 1 month prior to an echocardiogram. Echocardiogram images were reviewed to determine presence or absence of World Heart Federation criteria for rheumatic heart disease. The rate of rheumatic heart disease among anaemic and non-anaemic children according to gender- and age-based norms groups was compared. Of the 935 patients who met the study inclusion criteria, 406 were classified as anaemic. There was no difference in the rate of echocardiograms meeting criteria for borderline rheumatic heart disease in anaemic (2.0%, 95% CI 0.6-3.3%) and non-anaemic children (1.3%, 95% CI 0.3-2.3%). However, there was a statistically significant increase in rates of mitral regurgitation of unclear significance among anaemic versus non-anaemic patients (8.6 versus 3.6%; p = 0.0012). Anaemia does not increase the likelihood of meeting echocardiographic criteria for borderline rheumatic heart disease. Future studies should evaluate for the correlation between anaemia and mitral regurgitation in endemic settings.

Association Between Anemia and Blood Transfusion With Long-term Mortality After Cardiac Surgery

Preoperative anemia and red blood cell (RBC) transfusion are both associated with in-hospital mortality after cardiac surgery. The aim of this study was to investigate the interactions between preoperative anemia and RBC transfusion and their effect on the long-term survival of patients undergoing cardiac surgery. Between 2005 and 2012, 1170 patients with anemia who underwent elective or urgent cardiac surgery were included. A matched group of 1170 nonanemic patients was used as a control group. A binary logistic regression model was used. The median follow-up period was 64 months (range, 0-127). Anemic patients had higher mortality (45%, n= 526) than nonanemic patients (32%, n= 374; P< .001). Preoperative anemia was independently associated with long-term mortality (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.46-2.1; P < .001), with both moderate (OR, 2.27; 95% CI, 1.72-2.99; P < .001) and mild anemia (OR, 1.39; 95% CI, 1.13-1.71; P= .002) contributing significantly. RBC transfusion was not associated with long-term mortality (OR, 1.07; 95% CI, 0.88-1.31; P=.49). There was no interaction between preoperative anemia and RBC transfusion (P= .947). Long-term mortality is significantly high in patients who are anemic, regardless of their transfusion status. Preoperative anemia is a strong, independent predictor of mortality and therefore should be managed before cardiac surgery.