Unexplained Anemia Research Articles

856 Malignant Melanoma of the Small Bowel Causing Multiple Simultaneous Intussusceptions; a Rare Presentation

Abstract Background The rare occurrence of primary melanoma in the small bowel, particularly leading to simultaneous multiple intussusceptions, presents intricate challenges in diagnosis and management. We detail a case of a male in his late 50s with multiple intussusceptions secondary to melanoma deposits in the proximal small bowel. Case presentation 55-year-old patient presented with severe abdominal pain for 3 weeks, dark stools, unexplained anaemia, and unintentional weight loss. Imaging revealed small bowel obstruction due to intussusception caused by a polypoidal point, prompting surgical intervention. The initial laparotomy led to resecting a segment of the small bowel with the polyp, histopathology revealed malignant melanoma. Post-operatively the patient showed improvement but faced recurrent intussusceptions. Tertiary centre/multi-disciplinary team advise was sought and A PET-CT scan was done that identified 3 hotspots (likely polyps) in the proximal small bowel. Patient underwent a repeat laparotomy where 3 polyps were noted causing simultaneous intussusceptions and 68cm of proximal small bowel was resected with ileo-ileal anastomosis performed. Discussion This unique case highlights the rarity of simultaneous multiple intussusceptions due to small bowel melanoma deposits and emphasises the role of surgical intervention. While recognising the benefit of polyp resection during the initial surgery, the case suggests the importance of proactive management and multi-disciplinary approaches for optimal outcomes in such complex scenarios. Key takeaways include maintaining a high index of suspicion for malignancy in unusual presentations, advocating for timely expert consultation, emphasizing small bowel resection for intussusceptions, and considering resecting all identified polyps to prevent complications and improve patient outcomes.

Quality and Diagnostic Characterization of Bone Marrow Biopsies at Kamuzu Central Hospital, Malawi: A Retrospective Study

PURPOSE Diagnosis and management of many hematologic diseases depends on BM evaluation though data on diseases diagnosed and quality of bone marrow biopsies from Malawi is limited. METHODS We conducted a retrospective study of bone marrow biopsies taken for routine care from 2013-2023 at Kamuzu Central Hospital in Lilongwe, Malawi. We queried the laboratory database for patients age ≥18 with a pathology sample for “bone marrow biopsy” with location “iliac crest.” Patient characteristics were limited to those available from the pathology request request forms for each case including: age, sex, HIV status, details on history and laboratory findings. Diagnoses were made by routine care and recorded in the laboratory information system database (LIS), completed by the provider during the biopsy. Descriptive statistics were conducted in R. RESULTS 498 participants were identified; 273(55%) were male with median age of 41 (range 18-82). 305(61%) were HIV negative, 131(26%) HIV positive, and 62(12%) HIV unknown. Specimens collected and analyzed were either trephine and aspirates or both. Of the 498, 283(57%) were trephines, 88(18%) were aspirates and 127(25%) were both trephine and aspirate. Quality of biopsies was excellent, as only 29(6%) were sub-optimal or un-interpretable. Biopsy indications included unexplained anemia 40(8%), cancer staging 29(6%), pancytopenia 8(2%), lymphadenopathy 8(2%), and splenomegaly 5(1%). Indication was not given for 377(76%). The most common diagnosis was benign or reactive bone marrow (i.e., non-malignant) 275(60%). Other diagnoses included ALL 27(6%), AML 19(4%), Benign lesions-NOS 18(4%), DLBCL 16(4%), Aplastic anemias 11(2%), CLL 10(2%), Multiple myeloma 10(2%), MDS 8(2%), CML 8(2%), Carcinomas 8(2%), Hodgkin lymphoma 5(1%), HIV-infection 4(0.9%) among others. CONCLUSION Quality of bone marrow biopsies done under routine care is good in Malawi. However, the most common diagnosis in this population was a reactive bone marrow, for which the underlying cause was not evident to the treating provider. Therefore, further research is needed on the causes of cytopenia in this population.

Clinical Spectrum of Celiac Disease among Adult Population: Experience from Largest Tertiary Care Hospital in Karachi, Pakistan.

Celiac disease (CD) is a systemic autoimmune enteropathy triggered by dietary gluten in genetically susceptible individuals. Celiac disease affects 0.6-1.0% of the population worldwide. The prevalence of CD in Pakistan is yet unknown due to under diagnosis and lack of awareness. To determine a vast variety of presenting features in subtypes of CD to overcome the burden of disease. This was a prospective, comparative, cross-sectional study conducted at Gastroenterology department of Jinnah Postgraduate Medical Center, Karachi from December 2022 till June 2023. This study included all adult patients ≥18 years diagnosed with CD on the basis of clinical presentation, positive IgA and IgG anti-transglutaminase antibodies (value >12 IU/mL detected by ELISA followed by small intestinal biopsy classified as per Marsh criteria. The data obtained were analyzed on the statistical software SPSS version 23. Descriptive statistics were obtained by frequencies and percentages. About 142 patients were enrolled in the study, 103 (91.5%) had classical CD (CCD) whereas 36 (25%) had non-classical (NCCD). About 89 (62.7%) were females and 53 (37.3%) were males. The mean age was found to be 23 ± 6 years. Nutritional deficiencies including anemia, B12, folate, osteopenia and low body mass index (BMI) <18 was found more in CCD group as compared with NCCD group with significant p-values. Titers of anti-TTG between CCD and NCCD were not statistically significant. Hypothyroidism and PCOS were the most common associated conditions observed in adult CD patients. In conclusion, CD in adults and has diverse presentations. Adults with unexplained extra-intestinal symptoms like anemia and bone pain should be investigated for CD. Butt N, Shahid B, Butt S, et al. Clinical Spectrum of Celiac Disease among Adult Population: Experience from Largest Tertiary Care Hospital in Karachi, Pakistan. Euroasian J Hepato-Gastroenterol 2024;14(1):24-29.

Intestinal T-cell lymphomas NOS presenting as a polypoidal lesion: A case report

Rationale:Intestinal T-cell lymphomas are exceedingly rare diseases. Intestinal T-cell lymphoma NOS, as a “wastebasket” category, is difficult to diagnosis. Endoscopy can identify abnormal mucosa in most patients at a reasonably early stage. Therefore, it is crucial to increase the understanding of endoscopists in terms of the endoscopic characteristics of ITCL.Patient concerns:A 74‐year‐old male alone with wasting as the major complaint, had multiple polypoid lesions in the large intestine. The patient then had endoscopic care.Diagnoses:Only 1 polypoid lesion on white-light endoscopy in the sigmoid colon was pathologically diagnosed as intestinal T-cell lymphomas, not otherwise specified (ITCL-NOS).Interventions:The patient underwent intensity-reduced CHOP therapy.Outcomes:The patient is still with controlled disease but developed chemotherapy-related side effects.Lessons:In the individual with unexplained anemia and waste, endoscopy should not be delayed. For each of polypoid lesion on white-light endoscopy, the endoscopist need to remain cautious, because every lesion in the same patient can exhibit the independence of histopathological features. Meanwhile, we suggest that endoscopists should routinely observe the terminal ileum, even take biopsy samples if necessary.

Autoimmune Hemolytic Anemia Associated with Mature Ovarian Cystic Teratoma Containing Monoclonal Immunoglobulin G: A Case Report and Review of Literature

Background. Autoimmune hemolytic anemia (AIHA) associated with solid tumors such as mature cystic teratomas is rare and poorly understood. Here, we report a successfully treated case of secondary AIHA in a mature cystic teratoma containing antibodies against red blood cells. Case description. A 22-year-old woman was referred to our hospital with progressive anemia. Laboratory findings revealed hemolysis with a positive direct and indirect antiglobulin test. Imaging studies identified a left ovarian mass, suspected to be a mature cystic teratoma, which was later confirmed by histopathology after laparoscopic oophorocystectomy. The patient was treated with prednisolone, resulting in improved anemia. To examine the relationship between the tumor and AIHA, an indirect antiglobulin test was performed on the tumor contents. Stronger aggregations were observed at any concentration diluted by 10 times from 10 to 10,000 times of the tumor contents compared to the patient’s serum. Additionally, immunofixation electrophoresis of the tumor contents revealed the presence of monoclonal immunoglobulin G-κ. Conclusion. The presence of monoclonal IgG-κ in the tumor suggests intratumoral antibody production as a possible mechanism. Further research is necessary to elucidate the pathogenic relationship between such tumors and AIHA. The report also highlights the importance of considering secondary AIHA in patients with unexplained anemia and solid tumors.

#1274 Post kidney transplant parvovirus disease presenting as refractory anemia—case series of 21 patients

Abstract Background and Aims Kidney transplant recipients (KTRs) are susceptible to a wide range of infections, one of which includes Parvovirus B19 (PVB19). It usually presents in the first year after transplant, with anemia and causes increased morbidity and risk of graft dysfunction. Method Charts of patients undergoing kidney transplant between May 2013 and March 2022 were reviewed. 21 patients had PVB19. Their clinical presentation, laboratory parameters and outcome was studied. The diagnosis of PVB19 was established by PVB19 polymerase chain reaction (PCR) and by bone marrow examination(BME) in 6 patients. Results Prevalence of PVB19 disease was 1.9% (21/1164) with a median time to onset was 39 days post-transplantation. Clinical presentation included fever, generalized weakness, dyspnea, and myalgia in 47%, 76%, 23%, and 33% of patients respectively. Anemia, leukopenia, and thrombocytopenia were present in 100%, 14%, and 9.5% of patients respectively. Graft dysfunction was observed in 61.9% (13/21) patients. 20/21 (95%) patients had a positive PVB19 PCR and one patient had a typical viral inclusion on BME. Immunosuppression especially antiproliferative was reduced in all patients. 8 patients received IVIG, 8 received packed cell blood transfusion and 7 received Erythropoietin therapy. All patients recovered with median time to normalization of hemoglobin was 30 days. One patient had graft loss secondary to non-responsive graft rejection. Conclusion PVB19 is a rare but clinically significant cause of refractory anemia during the early post-transplantation. Any kidney transplant patient in first 4 months who has unexplained normocytic normochromic refractory anemia with or without graft dysfunction should be screened for PVB19 by DNA PCR or BME to rule out PVB19 infection. The use of PCR for diagnosis and reduction in immunosuppressants particularly antiproliferative drugs is the mainstay of treatment.

Severe Unexplained Iron Deficiency Anemia in Children: High Yield of Upper Gastrointestinal Endoscopy Regardless of Gastrointestinal Symptoms.

In this retrospective study spanning 2016 to 2022, we aimed to evaluate the diagnostic utility of upper gastrointestinal endoscopy (UGE) in children under 18 years presenting with severe unexplained iron deficiency anemia (IDA), defined as microcytic anemia of hemoglobin ≤7g/dL with low ferritin levels. Of 106 children hospitalized for severe anemia, 29 had unexplained IDA (mean hemoglobin level of 6.2 [3.2 to 6.9] gr/dL), and 25 of them underwent UGE. The mean age was 10.7 ± 3.9 years, with 76% being female. Ten children (40%) had gastrointestinal (GI) symptoms at presentation. The cause of IDA was found in 18 (72%) of 25 children who underwent UGE, of whom 12 were without GI symptoms. Gastric nodularity, erosions, or polyps were observed in 68%, and gastritis was evident in 72% based on histopathology. Helicobacter pylori was found in 50% of those with gastritis. Follow-up showed normalized hemoglobin levels in 92% of cases, with only 2 children requiring repeat iron therapy. Our findings underscore the importance of incorporating UGE into the diagnostic investigation of severe unexplained IDA in children, irrespective of the presence of GI symptoms.

Anemia and Its Connections to Inflammation in Older Adults: A Review.

Anemia is a common hematological disorder that affects 12% of the community-dwelling population, 40% of hospitalized patients, and 47% of nursing home residents. Our understanding of the impact of inflammation on iron metabolism and erythropoiesis is still lacking. In older adults, anemia can be divided into nutritional deficiency anemia, bleeding anemia, and unexplained anemia. The last type of anemia might be caused by reduced erythropoietin (EPO) activity, progressive EPO resistance of bone marrow erythroid progenitors, and the chronic subclinical pro-inflammatory state. Overall, one-third of older patients with anemia demonstrate a nutritional deficiency, one-third have a chronic subclinical pro-inflammatory state and chronic kidney disease, and one-third suffer from anemia of unknown etiology. Understanding anemia's pathophysiology in people aged 65 and over is crucial because it contributes to frailty, falls, cognitive decline, decreased functional ability, and higher mortality risk. Inflammation produces adverse effects on the cells of the hematological system. These effects include iron deficiency (hypoferremia), reduced EPO production, and the elevated phagocytosis of erythrocytes by hepatic and splenic macrophages. Additionally, inflammation causes enhanced eryptosis due to oxidative stress in the circulation. Identifying mechanisms behind age-related inflammation is essential for a better understanding and preventing anemia in older adults.

Impact of transcription factors KLF1 and GATA1 on red blood cell antigen expression: a review.

KLF transcription factor 1 (KLF1) and GATA binding protein 1 (GATA1) are transcription factors (TFs) that initiate and regulate transcription of the genes involved in erythropoiesis. These TFs possess DNA-binding domains that recognize specific nucleotide sequences in genes, to which they bind and regulate transcription. Variants in the genes that encode either KLF1 or GATA1 can result in a range of hematologic phenotypes-from benign to severe forms of thrombocytopenia and anemia; they can also weaken the expression of blood group antigens. The Lutheran (LU) blood group system is susceptible to TF gene variations, particularly KLF1 variants. Individuals heterozygous for KLF1 gene variants show reduced Lutheran antigens on red blood cells that are not usually detected by routine hemagglutination methods. This reduced antigen expression is referred to as the In(Lu) phenotype. For accurate blood typing, it is important to distinguish between the In(Lu) phenotype, which has very weak antigen expression, and the true Lunull phenotype, which has no antigen expression. The International Society of Blood Transfusion blood group allele database registers KLF1 and GATA1 variants associated with modified Lutheran expression. Here, we review KLF1 and recent novel gene variants defined through investigating blood group phenotype and genotype discrepancies or, for one report, investigating cases with unexplained chronic anemia. In addition, we include a review of the GATA1 TF, including a case report describing the second GATA1 variant associated with a serologic Lu(a-b-) phenotype. Finally, we review both past and recent reports on variations in the DNA sequence motifs on the blood group genes that disrupt the binding of the GATA1 TF and either remove or reduce erythroid antigen expression. This review highlights the diversity and complexity of the transcription process itself and the need to consider these factors as an added component for accurate blood group phenotyping.

P259 Clinical characteristics and long-term disease course in patients with Crohn’s disease diagnosed by video capsule endoscopy; A retrospective multicentre matched case-control study

Abstract Background Video capsule endoscopy (VCE) is a non-invasive and accurate diagnostic modality that allows for direct visualization of the small intestinal mucosa in Crohn’s disease (CD). In rare cases, lesions not detected by other diagnostic modalities in patients suspected to have CD are solely identified through VCE. We aim to evaluate the clinical characteristics and long-term outcomes of these rare cases. Methods A retrospective multicentre matched case-control analysis was conducted in patients with CD across three hospitals in Korea, from January 2007 to April 2023. To perform a matched case-control study, we defined cases (VCE group) as patients with normal findings at colonoscopy and cross-sectional imaging, ultimately diagnosed with CD by VCE; the controls were patients with CD diagnosed with specific findings at endoscopy or cross-sectional imaging (non-VCE group). Controls were matched to cases with a ratio of 3:1 for sex, calendar year of diagnosis, and age at diagnosis. Clinical characteristics and outcomes between the two groups were compared. Results Of the 3,137 patients diagnosed with CD during the study period, 24 were diagnosed solely by VCE. When compared to 72 matched patients with CD, the mean duration from symptom onset to diagnosis did not significantly differ (27.2 months [SD 10.2] vs. 25.3 months [SD 8.9], p=0.394). There was a significant difference in the proportion of Montreal behaviour (p&amp;lt;0.001). In the VCE group, non-stricturing and non-penetrating (B1) type and stricturing (B2) type accounted for 91.7 and 8.3%, respectively. However, there was no significant difference in the perianal fistula modifier (25% vs. 33.3%, p=0.446). Within the VCE group, 45.8% underwent the examination due to abdominal pain with diarrhoea, followed by 25.0% with perianal disease, and 20.8% with unexplained iron deficiency anaemia. Regarding capsule findings, the ileum was mostly involved (87.5%), while the jejunum and duodenum were affected in 70.8 and 16.7% of cases, respectively. Fifteen patients had two or three segments affected. The Median Lewis score was 838 [IQR 393–1803]. Concerning the cumulative incidence of clinical outcomes over 10 years, complicated behaviour, need for biologics, and CD-related hospitalization and surgery were all significantly lower in the VCE group than in the non-VCE group (p&amp;lt;0.005). Conclusion Patients diagnosed with CD solely by VCE are rare. In this study, they exhibited different clinical characteristics and a more favourable long-term disease course compared to the general population of patients with CD. This included a lower incidence of complicated behaviour, reduced need for biologics, and CD-related hospitalization and surgery.

Bone marrow metastasis in nonhematological malignancies: A study from tertiary care center.

Metastatic cancer presents a treatment challenge to clinicians, particularly for patients with bone marrow infiltration. For tumor staging, therapy selection, and prognosis risk stratification, the status of the bone marrow should be known for the presence or absence of metastasis. The study aimed to evaluate the hematological findings and comprehensive analysis of bone marrow in cases of nonhematological malignancies with bone marrow metastasis. This retrospective study comprised a record retrieval of the departmental archives for the past 6 years. A total of 331 patients with nonhematological malignancies were found, of whom 31.42% (104/331) showed bone marrow metastasis. An integrated clinical approach with bone marrow examination findings and immunohistochemistry whenever necessary was used to achieve a definitive diagnosis of bone marrow metastasis. Among the study population, 31.42% (104/331) of patients had nonhematological malignancies that metastasized to the bone marrow. Most of the patients with bone marrow metastasis had anemia, which was found in 77.88% (81/104) of the cases. Leukoerythroblastic reaction was noted in 31.73% (33/104) of the cases, and thrombocytopenia was found in 25% (26/104) of the cases. The most common malignancy with bone marrow metastasis in adults was prostatic adenocarcinoma (28.1%) (9/32) and in pediatric cases, neuroblastoma (53.9%) (52/98). It is essential to diagnose nonhematological malignancies that have metastasized to the bone marrow since this necessitates tumor staging, therapy selection, and prognosis risk stratification. To conclude, not a single hematological parameter is predictive of bone marrow metastasis; however, unexplained anemia, a leukoerythroblastic blood picture, and thrombocytopenia in peripheral blood should raise suspicion for bone marrow metastasis in cases of nonhematological malignancies.

375 Elevated middle cerebral artery peak systolic velocity (MCA PSV) in fetuses with unexplained anemia

375 Elevated middle cerebral artery peak systolic velocity (MCA PSV) in fetuses with unexplained anemia

Thrombocytopenia and Hyperhaemolysis Section in a Patient with Non Sickle Cell Familial Anaemia: A Case Report

Hyperhaemolysis syndrome, often associated with sickle cell disease, can also occur in non sickle cell conditions following viral infections and autoimmune disorders. This case report presents a rare instance of hyperhaemolysis in the context of familial anaemia. A 41-year-old female with a history of unexplained anaemia presented with four episodes of haematemesis, abdominal pain, and headache. She had received a blood transfusion a month prior. Upon admission, she was diagnosed with pancytopenia and hypovolemic shock and was treated with packed cell volume transfusions. The patient had a significant family history of anaemia in her sisters, who also required intermittent blood transfusions. Following admission, she developed thrombocytopenia, a drop in Haemoglobin (Hb), petechiae, and subdural haemorrhage. Further investigations confirmed hyperhaemolysis syndrome. Treatment included blood transfusions, random donor platelet transfusions, and corticosteroids. The patient was discharged on prednisolone and cyclosporine. Over six months, her condition improved significantly, with no further bleeding episodes and stable Hb levels. Diagnosing hyperhaemolysis syndrome is challenging and requires a high index of suspicion. This case underscores the importance of considering hyperhaemolysis in patients with familial anaemia and unexplained haemolytic episodes. Early recognition and appropriate management are crucial for favourable outcomes.

Transfusion- Associated Graft vs Host Disease in a Post-Coronary Artery Bypass Graft Patient

TA-GVHD is a rare, usually fatal complication of transfusion of blood and blood products containing viable T lymphocytes. Very rarely it may arise in an immunocompetent individual. There is an increased risk of TA-GVHD following bypass grafting and other surgical procedures where blood transfusion are required. Here we present a case of a 57 old patient who received 5 units of whole blood from his close relatives perioperatively and manifested unexplained anaemia, fever, skin rash which later became desquamating &amp; cheilitis on his 19th POD. His CBC report suggested pancytopenia indicating bone marrow failure. Skin biopsy confirmed the diagnosis as chronic TA-GVHD, lichenoid type. His liver function deteriorated and he died subsequently on his 32nd POD. TA-GVHD develops when immunocompetent T lymphocytes of transfused blood able to engraft in the recipient’s lymphoid tissues that fail to reject them. Those lymphocytes mediate immune response causing damage and dysfunction of the skin &amp; other organs. Our patient showed all features of TA-GVHD that was complicated by sepsis and multiorgan failure despite aggressive management. Pathologists, surgeons, physicians and transfusion centers must be aware of this sinister complication of perioperative blood transfusion in any surgery, including CABG. Though fatal in &gt;90% cases, it can be prevented by using irradiated blood. Patient parties must also be discouraged to donate blood to avoid this grave outcome.

Limitations in the management of colorectal cancer in sub-Saharan Africa

Colorectal cancer (CRC) was regarded as a rare disease in native West Africans. It is now accepted as an established disease with a rising incidence. The CRC is now known to be a complex tumour with different aetiopathological pathways. With all cancers early detection is important if one aims to cure the patient. A summary of the clinical features include: Unexplained ill-health and anaemia in patients with cancer of the caecum and ascending colon; palpable abdominal mass for colon cancer; rectal bleeding and tenesmus for carcinoma of the rectum; palpable mass on digital rectal examination in at least 75% of cases. The current complete management of this disease involves extirpative surgery and adjuvant treatment with a combination of cytotoxic chemotherapy and tailored therapy. This presentation will look at ways in which seamless management of CRC in this environment is hampered. The ‘PATIENT’ factor: Ignorance (which leads to unfavourable health-seeking behaviour) Poverty (goes for all developing countries) Gullibility (under which falls religion and alternative treatment) Cultural taboos (which lead to refusal of colostomy-based treatments) Aversion of the sequelae of rectal cancer treatment especially in males where up to 30% of patients are under the age of 40 years. Late presentation (effect of 1–5) The ‘COUNTRY’ factor: Politics: inadequate budget for health Workers not enough; current brain drain of doctors, major cancer centres are stretched. Infra-structure: There is a glaring lack of any population screening programme, a lack of public enlightenment messages for awareness and only two government centres have functioning radiotherapy machines. Staplers and cytotoxic drugs have to be imported, thus are expensive and out of reach of the common man. The ‘GENETICS’ factor: The biology of CRC in the native African is different from that of Caucasians and more aggressive. Carcinomatosis peritonei is frequent. There’s also the emergence of unusual metastases to the lungs and spine, bypassing the liver. A summary of the findings by Nigerian researchers on the molecular biology of native Nigerian CRC showed MSI (Not otherwise stated) occurred in 23–53% of Nigerian CRC, MSI-H seen in 28.1–43%. KRAS in 21% while BRAF was seen in 4.5%. The significance of these results may mean that we might not be administering the right combination chemotherapy in over 50% of our patients. Some studies have shown that patients with MSI-H CRC appear to have ineffectual or even detrimental responses to 5FU-based adjuvant chemotherapy. We all know that 5FU is the cornerstone of most of the combination chemotherapy we administer to patients (FOLFOX, FOLFIRI, CapeOX, XelOX). In addition, the 2012 study on BRAF and KRAS in Nigerians by Abdulkareem et al. also suggests that Nigerian patients may benefit more from anti-EGFR therapy (Cetuximab, Panitumumab) than Caucasians. However, cost implications will make prescribing these drugs a mere academic exercise in most Nigerian patients.

Survival After Wait-and-See Approach in Older Patients With Unexplained Iron Deficiency Anemia in Primary Care: A Practice Evaluation

ObjectivesGuidelines recommend upper and lower gastrointestinal endoscopic evaluation for patients without a clear physiological explanation for iron deficiency anemia (IDA). However, the consequences of watchful waiting in older patients with unexplained IDA in general practice are unknown. The aim of this study was to investigate characteristics and survival of patients with an unexplained IDA in general practice who refrain from medical specialist evaluation. DesignHistorical prospective study. Setting and ParticipantsPatients aged ≥70 years with IDA coded in their medical records were selected from the Dutch Academic General Practitioner Development Network (AHON) database. MethodsBased on their medical records, patients with an unexplained IDA were classified as (1) referred for medical specialist evaluation, or (2) no or noninvasive evaluation in general practice. ResultsCompared to patients who were referred for medical specialist evaluation (n = 235, 47.8%), patients who had no or noninvasive evaluation (n = 257; 52.5%) were older (median respectively 79 vs 82 years old, P < .01) and more likely to have congestive heart failure (respectively 17.4% and 26.1%, P = .02) and dementia (respectively 2.6% and 8.9%, P < .01). Two-year survival was significantly higher in patients who were referred for medical specialist evaluation compared to patients who had no or noninvasive evaluation (respectively, 83.9% and 75.5%, P = .02). Conclusions and ImplicationsAlthough mortality was significantly higher in the older and more comorbid patients who had no or noninvasive evaluation in general practice, survival was still high in this patient group. Therefore, non–guideline adherence and a wait-and-see approach could be discussed in a shared–decision-making consultation.

A Descriptive Analysis of Patients with ABCG8 Mutation and Anemia. a Meta-Analysis and Systematic Review of an Uncommon Cause of Unexplained Anemia

A Descriptive Analysis of Patients with ABCG8 Mutation and Anemia. a Meta-Analysis and Systematic Review of an Uncommon Cause of Unexplained Anemia

Do We Still Need to Perform Bone Marrow Examination in All Subjects Suspected of MDS? Evaluation and Validation of Non-Invasive (Web-Based) Algorithm

Do We Still Need to Perform Bone Marrow Examination in All Subjects Suspected of MDS? Evaluation and Validation of Non-Invasive (Web-Based) Algorithm

Anaemia and its causes at the Brazilian Longitudinal Study of Adult Health: a cross-sectional analysis of baseline data.

Most anaemia studies focus on children and women of childbearing age. We assessed the frequency and main aetiologies of anaemia according to sociodemographic characteristics at the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), a cohort of middle-aged adults. The primary analyses included 15,051 participants aged 35-74 years with a valid blood cell count. We built logistic models to analyse the association between socioeconomic characteristics and anaemia diagnosis. We also described the main aetiologies in a subset (n = 209) of participants with anaemia. Anaemia was present in 3.0% (95% confidence interval [95%CI]: 2.6-3.4%) of men and 7.4% (95%CI: 6.9-8.0%) of women. The frequency of anaemia diagnosis was higher in women in all subgroups except for the oldest age stratum (65-74 years). The frequency of anaemia was particularly high in Blacks (6.0% and 15.5% in men and women, respectively). The most common causes of anaemia were iron deficiency (in women), chronic kidney disease, and chronic inflammation (in men). The frequency of unexplained anaemia was respectively 33.3% and 34.2% for men and women, and this condition was more frequent among participants of Black or Mixed races. Anaemia was associated with age, female sex, Black race, and low socioeconomic status. Unexplained anaemia was common and more frequent in individuals of Black and Mixed races. ELSA-Brasil follow-up data may provide further insight into the relevance of unexplained anaemia in this setting.

Bilateral adrenal hemorrhage: learning notes from clinical practice and literature review.

Adrenal hemorrhage is a rare, but important, diagnosis to recognize, in particular when there is involvement of both adrenal glands. Bilateral adrenal hemorrhage can in fact lead to adrenal insufficiency, with dramatic consequences if not promptly recognized and treated. It is normally caused by systemic conditions that lead to the vasoconstriction and thrombosis of the adrenal vein. Oftentimes, the clinical diagnosis of this condition can be very challenging, as its signs and symptoms are generalized and nonspecific (abdominal pain, nausea, and fatigue). Here, we present the cases of two patients admitted to the Emergency Department in 2016 and 2022 with acute abdominal pain, having recently undergone surgery and subsequently prescribed low-molecular-weight heparin. In both cases, laboratory results revealed neutrophilic leukocytosis and an unexplained anemia. Due to the persistence of abdominal pain despite medication, a CT scan was performed, showing an enlargement of both adrenal glands suggestive of bilateral adrenal hemorrhage. Adrenal function was tested that correlated with a diagnosis of adrenal insufficiency, and both patients were promptly treated with parenteral hydrocortisone as a result. On 5 years' follow-up from the acute event, the second patient's adrenal function had returned to normal, and he has not needed further adrenal replacement therapy; the first patient however demonstrated persistence of adrenal failure requiring replacement therapy. In this paper, through our experience and a literature analysis, we will aim to outline some clues to identify patients at potential risk of bilateral adrenal hemorrhage.