Underlying Cause Of Anaemia Research Articles

Automated tools for identifying the causes of anaemia in general practices are particularly advantageous for patients who do not fit the typical profile.

The Dutch guideline algorithm for the analysis of anaemia in patients of general practitioners (GPs) was programmed in a Clinical Decision Support system (CDS-anaemia) to support the process of diagnosing the cause of anaemia in the laboratory. This research aims to assess the supplementary benefit provided by the automated algorithm in various demographic categories, including different sexes, age groups and severities of anaemia, in comparison to the manual diagnostic approach employed by GPs. This was a retrospective cohort study of 5399 primary care patients where the cause of anaemia was diagnosed by GPs with or without the aid of CDS-anaemia within the age groups 18-44, 45-64, 65-79 and 80 and older. Anaemia was defined according to the Dutch College of General Practitioners (DCGP) guideline. Causes of anaemia were based on the DCGP guidelines with the corresponding blood tests. By calculation of rate ratios and percentage differences of the determined cause of anaemia we evaluated the effect of the diagnostic algorithm. The percentage patients in which an underlying cause of anaemia was found increased 34 and 46 percentage points in males and females, respectively, when GPs were supported by CDS-anaemia compared to GPs who were not supported by CDS-anaemia. The highest increase in percentage points when CDS-anaemia was used, was found in younger- and middle-aged males and mild or moderate anaemia.

Preventing overuse of laboratory diagnostics: a case study into diagnosing anaemia in Dutch general practice

BackgroundMore information is often thought to improve medical decision-making, which may lead to test overuse. This study assesses which out of 15 laboratory tests contribute to diagnosing the underlying cause of anaemia by general practitioners (GPs) and determines a potentially more efficient subset of tests for setting the correct diagnosis.MethodsLogistic regression was performed to determine the impact of individual tests on the (correct) diagnosis. The statistically optimal test subset for diagnosing a (correct) underlying cause of anaemia by GPs was determined using data from a previous survey including cases of real-world anaemia patients.ResultsOnly 9 (60%) of the laboratory tests, and patient age, contributed significantly to the GPs’ ability to diagnose an underlying cause of anaemia (CRP, ESR, ferritin, folic acid, haemoglobin, leukocytes, eGFR/MDRD, reticulocytes and serum iron). Diagnosing the correct underlying cause may require just five (33%) tests (CRP, ferritin, folic acid, MCV and transferrin), and patient age.ConclusionsIn diagnosing the underlying cause of anaemia a subset of five tests has most added value. The real-world impact of using only this subset should be further investigated. As illustrated in this case study, a statistical approach to assessing the added value of tests may reduce test overuse.

PSY37 MORE INFORMATION WORSE DECISIONS? EVALUATING POTENTIAL OVERUSE OF LABORATORY DIAGNOSTICS IN DIAGNOSING ANAEMIA

Objectives: More information is often thought to improve medical decision making, which may lead to overuse of relatively cheap tests. For diagnosing the underlying cause of aneamia in general practice, up to 14 different laboratory tests may be ordered by general practitioners (GPs), according to the Dutch guideline. This study assessed which of these 14 tests actually contribute to diagnosing an underlying cause of anaemia, and which subset of tests is optimal for establishing a correct diagnosis. Methods: Data from a previous questionnaire presenting GPs (n=139) with three varying real-world anaemia cases, and all 14 corresponding test results, was used. GPs selected the expected underlying cause (anaemia of chronic disease, iron deficiency anaemia, renal anaemia, 'unknown or other'). The correct underlying cause was established by an expert panel (i.e. GP, internist, clinical chemist). In this study, multinomial regression was used to determine the value of each test for establishing a particular underlying cause. Logistic regression was used to determine the value of each test for establishing the correct underlying cause. Stepwise backward selection using the Akaike Information Criterion was applied to determine the optimal subset of tests. Results: Only 9 (60%) of the laboratory tests, and patient age, contributed to diagnosing an underlying cause of anaemia (CRP, ESR, ferritin, folic acid, haemoglobin, leukocytes, MDRD, reticulocytes and serum iron). Diagnosing the correct underlying cause required just five (33%) tests (CRP, ferritin, folic acid, MCV and transferrin), and patient age. Conclusions: Of the full set of 14 laboratory tests recommended by the Dutch guideline, only a subset enhances the ability of the GP to diagnose an underlying cause of anaemia, from a statistical perspective. A subset of five tests has most added value. Extending this set with more tests may lead to lead to a decrease rather than increase in correct diagnoses.

Diagnosis of Anaemia in Patients Presenting to the General Practitioner: Causes and Survival

Introduction: Anaemia is a common finding in the elderly population and for many years it was assumed to be a normal consequence of aging. Recently, anaemia has been shown to be associated with increased mortality and morbidity and decreased quality of life.The prevalence of anaemia increases with age, starting with a prevalence of 4.4% in men and 6.8% in women in the age group 50-64 years and rising to a prevalence of 26.1% in men and 20.1% in women in the age group 85 years and older. Despite this high prevalence and the significance of anaemia, information on the causes of anaemia in general practice is limited. A large prospective cohort study with general practice patients newly diagnosed with anaemia was set up to increase knowledge regarding the causes of anaemia and improve quality of care for anaemia patients.Methods: Between the 1st of February 2007 and the 1st of February 2013 patients presenting to one of the 63 participating general practitioners with a newly diagnosed anaemia (i.e. no anaemia in the preceding two years) were included in the study, resulting in a population-based registry. Anaemia was defined as haemoglobin level below 13.7 g/dL (men) and below 12.1 g/dL (women). Men were included from age 18 and women were included when 50 years or older to prevent an overabundance of iron deficiency due to hypermenorrhea as a cause of the anaemia. The follow-up period ended on the 1st of September 2013.A wide range of parameters was analysed for each patient to aid diagnosis. Two experts independently reviewed the laboratory results of all patients and established the underlying cause of anaemia. In case of discordance, the experts deliberated until a consensus was reached. The survival in months after entry into the study was determined per gender and per class of anaemia (microcytic, normocytic or macrocytic).Results: A total number of 2738 patients were included in the study, 1463 men (average age at entry 66.8 years) and 1275 women (average age at entry 75.1 years). Of these 2738 patients, 242 presented with two or more causes for their anaemia. Anaemia of chronic disease was established in 910 patients (30.3%), haemoglobinopathy in 23 patients (0.8%), renal anaemia in 342 patients (11.4%), haemolysis in 18 patients (0.6%) and possible bone marrow disease in 117 patients (3.9%). Iron deficiency was established in 563 patients (18.7%), vitamin B12 deficiency in 123 patients (4.1%) and folic acid deficiency in 24 patients (0.8%). Other causes were established in 117 patients (3.9%). If no cause could be established it was classified as unknown, which was found in 768 patients (25.6%). The distribution of these causes in the microcytic, normocytic and macrocytic cohort is presented in Table 1.Overall survival of the cohort was 66.2 months (95% CI 65.2-67.3) after entry into the study. Men demonstrated an overall survival of 66.5 months (95% CI 65.1-67.9) and women a survival of 65.2 months (95% CI 63.6-66.7) (p = 0.637). The survival of patients with microcytic, normocytic and macrocytic anaemia was 65.5 (95% CI 62.6-68.4), 66.9 (95% CI 65.7-68.0) and 57.9 (95% CI 53.4-62.5) months respectively. The survival of both microcytic and normocytic patients was significantly longer than the survival of patients with a macrocytic anaemia (p = 0.005 and p < 0.001 respectively). Analysis of the different causes and their influence on survival will be presented.Conclusion: An extensive cohort of 2738 general practice patients newly diagnosed with anaemia was set up, resulting in a detailed study of the prevalence of a broad range of causes of anaemia and of the factors influencing survival of this group of patients.Table 1Distribution of causes in the microcytic, normocytic and macrocytic cohortsCauseMicrocytic anaemiaNormocytic anaemiaMacrocytic anaemiaTotalAnaemia of chronic disease30 (9.0%)839 (33.9%)41 (20.7%)910 (30.3%)Haemoglobinopathy22 (6.6%)1 (0.0%)0 (0.0%)23 (0.8%)Haemolysis1 (0.3%)10 (0.4%)7 (3.5%)18 (0.6%)Possible bone marrow disease9 (2.7%)90 (3.6%)18 (9.1%)117 (3.9%)Iron deficiency215 (64.8%)344 (13.9%)4 (2.0%)563 (18.7%)Vitamin B12 deficiency11 (3.3%)85 (3.4%)27 (13.6%)123 (4.1%)Folic acid deficiency3 (0.9%)11 (0.4%)10 (5.1%)24 (0.8%)Renal anaemia14 (4.2%)298 (12.0%)30 (15.2%)342 (11.4%)Other6 (1.8%)79 (3.2%)32 (16.2%)117 (3.9%)Unknown21 (6.3%)718 (29.0%)29 (14.6%)768 (25.6%)Total332 (100%)2475 (100%)198 (100%)3005 (100%) DisclosuresSonneveld:Celgene: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Onyx: Honoraria, Research Funding; Millenium: Honoraria, Research Funding.

Intravenous immune globulin therapy for Stevens-Johnson syndrome/toxic epidermal necrolysis complicated by hemolysis leading to pigment nephropathy and hemodialysis

Intravenous immune globulin (IVIG) is generally thought to be of relatively low risk for adverse events and some experts consider this to be the best treatment for Stevens-Johnson syndrome/toxic epidermal necrolysis. We evaluated the underlying cause of anemia and renal failure in 2 consecutive patients being treated with IVIG for Stevens-Johnson syndrome/toxic epidermal necrolysis. This is a retrospective chart review. We present 2 patients with Stevens-Johnson syndrome/toxic epidermal necrolysis and severe hemolysis requiring blood transfusion who subsequently developed pigment nephropathy necessitating hemodialysis after treatment with IVIG. Both patients had antibodies to their ABO blood type detected in the eluate from their red blood cell membrane. This is a retrospective review with only 2 cases. We propose that IVIG-associated hemolysis is an adverse reaction that may not be as rare as once thought, presenting as a mild decrease in hemoglobin and hematocrit. Antibodies to blood type A and B are given as part of pooled immune globulin and are considered to be the cause of hemolysis. More severe anemia requiring transfusion is less common, and the breakdown products produced by hemolysis can lead to pigment nephropathy and renal failure. We present methods by which this severe complication can be anticipated and managed more effectively.