Anemia as a risk factor for cardiovascular disease

Artificial intelligence in chronic kidney diseases: methodology and potential applications

Chronic kidney disease (CKD) represents a significant global health challenge, characterized by kidney damage and decreased function. Its prevalence has steadily increased, necessitating a comprehensive understanding of its epidemiology, risk factors, and management strategies. While traditional prognostic markers such as estimated glomerular filtration rate (eGFR) and albuminuria provide valuable insights, they may not fully capture the complexity of CKD progression and associated cardiovascular (CV) risks.This paper reviews the current state of renal and CV risk prediction in CKD, highlighting the limitations of traditional models and the potential for integrating artificial intelligence (AI) techniques. AI, particularly machine learning (ML) and deep learning (DL), offers a promising avenue for enhancing risk prediction by analyzing vast and diverse patient data, including genetic markers, biomarkers, and imaging. By identifying intricate patterns and relationships within datasets, AI algorithms can generate more comprehensive risk profiles, enabling personalized and nuanced risk assessments.Despite its potential, the integration of AI into clinical practice faces challenges such as the opacity of some algorithms and concerns regarding data quality, privacy, and bias. Efforts towards explainable AI (XAI) and rigorous data governance are essential to ensure transparency, interpretability, and trustworthiness in AI-driven predictions.

Electrocardiogram Features in Non-Cardiac Diseases: From Mechanisms to Practical Aspects

Despite the noteworthy advancements and the introduction of new technologies in diagnostic tools for cardiovascular disorders, the electrocardiogram (ECG) remains a reliable, easily accessible, and affordable tool to use. In addition to its crucial role in cardiac emergencies, ECG can be considered a very useful ancillary tool for the diagnosis of many non-cardiac diseases as well. In this narrative review, we aimed to explore the potential contributions of ECG for the diagnosis of non-cardiac diseases such as stroke, migraine, pancreatitis, Kounis syndrome, hypothermia, esophageal disorders, pulmonary embolism, pulmonary diseases, electrolyte disturbances, anemia, coronavirus disease 2019, different intoxications and pregnancy.

Mechanisms and Cardiorenal Complications of Chronic Anemia in People with HIV

Chronic anemia is more prevalent in people living with HIV (PLWH) compared to the general population. The mechanisms that drive chronic anemia in HIV are multifaceted and include functional impairment of hematopoietic stem cells, dysregulation of erythropoietin production, and persistent immune activation. Chronic inflammation from HIV infection adversely affects erythropoiesis, erythrocyte lifespan, and erythropoietin response, leading to a heightened risk of co-infections such as tuberculosis, persistent severe anemia, and increased mortality. Additionally, chronic anemia exacerbates the progression of HIV-associated nephrotoxicity and contributes to cardiovascular risk through immune activation and inflammation. This review highlights the cardinal role of chronic inflammation as a link connecting persistent anemia and cardiovascular complications in PLWH, emphasizing the need for a universal understanding of these interconnected pathways for targeted interventions.

The importance of intensive follow-up and achieving optimal chronic antithrombotic treatment in hospitalized medical patients with anemia: A prospective cohort study

BACKGROUND

Anemia is a global health concern, particularly among the elderly on chronic antithrombotic treatment. Close monitoring of hemoglobin (Hb) levels and achievement of an optimized treatment significantly enhance patients' quality of life. This study aimed to examine the impact of antithrombotic treatment on Hb levels and readmissions in hospitalized patients with anemia.

METHODS

This is a prospective cohort study of patients admitted to the Department of Internal Medicine of the University Hospital of Heraklion, Greece, from November 2021 to October 2022 with the diagnosis of anemia while receiving antithrombotic treatment. Data regarding demographics, past medical history, and laboratory and endoscopy findings were recorded. For those receiving inappropriate therapy according to international guidelines, antithrombotic treatment was optimized. Subsequent follow-ups occurred at one and six months post-discharge. Six- and twelve-month anemia-caused readmissions, as well as annual mortality, were evaluated.

RESULTS

In total, 104 patients were assessed. Among them, 34.6% were on antiplatelets, 56.7% were on anticoagulants, and 8.7% were on combination treatment. The mean age was 80 ± 8.2 years, and 54.8% were males. On admission, mean Hb levels were 6.86 ± 1.23 g/dL, while 56 (53.8%) patients had severe anemia. Gastroscopy and colonoscopy were performed in 75.0% and 41.4% of patients, respectively, confirming gastrointestinal bleeding in most of the cases. Treatment optimization was carried out for 56 patients. Follow-up revealed elevated Hb levels after one and six months post-discharge, while anemia-related readmissions stayed below 10%.

CONCLUSIONS

Most hospitalized anemic patients on antithrombotic treatment had endoscopic findings favoring gastrointestinal bleeding. Half received inappropriate antithrombotic therapy. Treatment optimization and regular follow-up improved Hb levels and reduced readmissions.

Long-Term Exposure to Ambient PM2.5 and Hospitalizations for Myocardial Infarction Among US Residents: A Difference-in-Differences Analysis

Background Air pollution has been recognized as an untraditional risk factor for myocardial infarction (MI). However, the MI risk attributable to long-term exposure to fine particulate matter ≤2.5 μm in aerodynamic diameter (PM2.5) is unclear, especially in younger populations, and few studies have represented the general population or had power to examine comorbidities. Methods and Results We applied the difference-in-differences approach to estimate the relationship between annual PM2.5 exposure and hospitalizations for MI among US residents and further identified potential susceptible subpopulations. All hospital admissions for MI in 10 US states over the period 2002 to 2016 were obtained from the Healthcare Cost and Utilization Project State Inpatient Database. In total, 1 914 684 MI hospital admissions from 8106 zip codes were included in this study. We observed a 1.35% (95% CI, 1.11-1.59) increase in MI hospitalization rate for 1-μg/m3 increase in annual PM2.5 exposure. The estimate was robust to adjustment for surface pressure, relative humidity, and copollutants. In the population exposed to ≤12 μg/m3, there was a larger increment of 2.17% (95% CI, 1.79-2.56) in hospitalization rate associated with 1-μg/m3 increase in PM2.5. Young people (0-34 years of age) and elderly people (≥75 years of age) were the 2 most susceptible age groups. Residents living in more densely populated or poorer areas and individuals with comorbidities were observed to be at a greater risk. Conclusions This study indicates long-term residential exposure to PM2.5 could increase risk of MI among the general US population, people with comorbidities, and poorer individuals. The association persists below current standards.

Sex-specific improvement in cardiac phenotype in older females combining blood withdrawal and exercise training

This study determined whether an intervention combining hematological and exercise stimuli may overcome the prevailing limitations to improve the cardiac phenotype and orthostatic tolerance (OT) of females with advanced age. Healthy females (n = 15) and males (n = 14) matched by age (63.7 ± 7.0 vs. 63.6 ± 8.7 yr) and moderate physical activity were recruited. OT, transthoracic echocardiography, and central hemodynamics were assessed during incremental lower body negative pressure (LBNP) levels (up to -50 mmHg) for 1 h or until presyncope, prior to and after an intervention comprising standard (10%) blood withdrawal and an 8-wk exercise training program designed to maximize central hemodynamic adaptations. OT time was lower in females compared with males (48.1 ± 10.6 vs. 57.0 ± 4.8 min, P = 0.008) before the intervention. Improved OT time (+11%) in females (48.1 ± 10.6 vs. 53.5 ± 6.1 min, P = 0.021) but not in males (57.0 ± 4.8 vs. 56.7 ± 5.6 min, P = 0.868) was found following the intervention, resulting in similar OT time between females and males (P = 0.156). The intervention induced improvements in left ventricular (LV) diastolic function (+13% for myocardial e') along with increased LV mass (+13%) in females (P ≤ 0.039) but not in males (P ≥ 0.257). During the initial LBNP stages (0 to -20 mmHg), LV stroke volume and cardiac output were exclusively increased in females after the intervention (P ≤ 0.034). In conclusion, the cardiac phenotype of females with advanced age can be structurally and functionally modified in parallel to improved OT via short-term hematological and central hemodynamic stimuli.NEW & NOTEWORTHY Based on previous studies, main features of the cardiac phenotype in females with advanced age are generally unresponsive to lifestyle interventions. The present findings reveals that the cardiac phenotype of middle-age and older females is amenable to large modification in a short-term period when hematological stimuli are combined with those induced by exercise training. The same intervention only induced minor adaptations in males matched by age and potential confounding factors.

Platelet-hemoglobin ratio predicts amputation in patients with below-knee peripheral arterial disease

BACKGROUND

Peripheral arterial disease (PAD) causes significant morbidity today. Atherosclerosis is evident in the pathophysiological process in most patients, so PAD has similar risk factors as coronary artery disease. Platelet-Hemoglobin ratio (PHR) has been proven to predict mortality in atherosclerotic heart disease. We aimed to determine the relationship between PHR and below-knee amputation.

METHODS

The study is a single-center retrospective study. Platelet count/hemoglobin amount formula was used for PHR. Only PAD patients with below-knee critical extremity ischemia and unsuitable for revascularization were included in the study.

RESULTS

235 patients were included in the study retrospectively. The mean age was 65.7 ± 9.9 years and 175(74.5%) of them were male. In the amputated group, white blood cell, neutrophil, platelet, creatinine, glucose, and PHR were higher (p = .031, p = .045, p = .011, p = .048 p = .018, p = .004, respectively). Only hemoglobin values were lower (p = .003). Multivariable regression analysis showed; age, albumin and PHR were determined as independent risk factors for amputation (Age; OR (95%CI): (1.094(1.040-1.152), p = .001) (Albumin; OR (95% CI): 1.950(1.623-1.799), p = .001) (PHR; OR (95% CI): 1.872(1.246-2.812), p = .003). Receiver operating characteristics analysis performed to determine the optimal cut-off value of PHR for amputation, the optimal value was found 2.08 (65.8% sensitivity, 67.5% specificity, p < .001).

CONCLUSIONS

PHR was a good predictor for BKA. Using the PHR, it may be possible to identify high-risk patients for amputation.

Marked improvements in cardiac function in postmenopausal women exposed to blood withdrawal plus endurance training

The cardiac phenotype of a substantial fraction of the population, i.e., mature women, is mainly unresponsive to endurance training (ET), the most effective intervention to improve cardiorespiratory fitness. This study assessed whether a novel intervention comprising additional haemodynamic stimuli may overcome the generalized limitations to modify the cardiac phenotype of middle-aged and older women. Fifteen healthy postmenopausal women (52-75 yr) were recruited. Transthoracic echocardiography and central haemodynamics were assessed during incremental cycle ergometry (i) in baseline conditions, (ii) after standard (10%) blood withdrawal and (iii) subsequent 8-week ET. Main outcomes such as left ventricular (LV) function and structure and blood volume (BV) were determined. Phlebotomy induced a 0.5 ± 0.1 l reduction of BV, which was re-established after ET. Decrements in LV end-systolic volume (-27%) and increments in LV ejection fraction (+8%) during exercise as well as improved E/A ratio were detected after ET compared with baseline. In parallel, ET induced a 10% increment in LV mass without a concomitant increase in LV size. In conclusion, postmenopausal women exhibit large improvements in cardiac systolic and diastolic functions along with LV concentric remodelling in response to the sequenced combination of blood withdrawal and ET.

Does Iron Deficiency Affect the Heart in Children?

INTRODUCTION

It is well known that serum iron parameters are closely related to cardiovascular health. Iron deficiency may lead to significant cardiac problems, such as atrioventricular conduction abnormalities, and systolic and/or diastolic dysfunction. Studies related to the effect of iron deficiency on cardiac functions are limited in children. Therefore, the aim of this study was to evaluate the effect of low iron stores on cardiac repolarization parameters which are used to predict arrhythmia and cardiac functions.

MATERIALS AND METHODS

Onehundred thirty-five children 2 to 18 years of age without structural heart disease who were referred to the Pediatric Cardiology Department for various reasons such as chest pain, heart murmur, or evaluation before sports participation were evaluated prospectively. The cases were separated into 3 groups according to ferritin levels (group 1: ferritin <15 ng/mL [n=48], group 2: ferritin 15 to 25 ng/mL [n=51], and group 3: ferritin >25 ng/mL [n=36]). Evaluations were made with detailed 12-lead surface electrocardiography (ECG) and transthoracic echocardiogram. Cardiac repolarization parameters were measured from surface ECG and systolic functions, left ventricular wall diameters were evaluated from transthoracic echocardiogram.

RESULTS

Eighty-four (62.2%) girls and 51 (37.8%) boys are included in the study. The average age of the groups was similar. In children with low ferritin levels (group 1); Pw, Pw max, and Pw dis; QT, QTc, and QTc dis; Tp-Te, Tp-Te dis, Tp-Te/QT, and Tp-Te/QTc were significantly longer compared with the group 3 (P<0.05). There was a negative correlation between ferritin level and Pw, P max, and Pw dis; QT, QT dis, QTc, and QTc dis; Tp-Te, Tp-Te dis, Tp-Te/QT, and Tp-Te/QTc (P<0.05). No correlation was found between ferritin level and Pw min. There was no difference between the groups in respect of ejection phase indices, heart wall measurements, and end-diastolic diameter measurements.

CONCLUSION

Iron deficiency may be related to the tendency of arrhythmias in children without structural heart disease. Therefore, careful evaluation of ECG parameters of healthy children with low iron stores, and follow up with intermittent monitoring is highly important.

Response Assessment to Erythropoietin-Zeta (Epo-Alpha Biosimilar) Therapy in Low-Risk Myelodysplastic Syndromes

Background. This prospective observational study aimed to verify the efficacy of erythropoietin zeta in the treatment of patients with low-risk myelodysplastic syndrome. Methods. Patients with low/int-1 IPSS risk and serum erythropoietin level below 500 U/L were enrolled. Treatment consisted of erythropoietin zeta 40,000 U subcutaneously once a week. The primary endpoint was the erythroid response. According to Simon’s two-stage statistical design, 36 patients were recruited. The median age was 75 years (range 56–83 years), male/female ratio was 1.1/1, median baseline serum erythropoietin was 57.9 U/L (range 9.4–475 U/L). 53% of patients had low-risk disease, while the remaining had Int-1 risk. Results. After 8 weeks, a significant response (rise in Hb levels of at least 1.5 g/dL) was achieved in 18 patients (50%) out of 36. However, 17 patients did not improve; 8/17 patients pursued the 40,000 U weekly schedule of erythropoietin zeta, and 4/8 (50%) of them reached the erythroid response after 16 weeks. Nine patients underwent dosage doubling (40,000 U twice per week), and 5/9 (55%) of them achieved the erythroid response. Conclusion. Compared with data from the literature, this prospective study revealed that EPO-zeta is a safe and effective therapeutic option in low-risk MDS patients.

Platelet-to-hemoglobin ratio as a valuable predictor of long-term all-cause mortality in coronary artery disease patients with congestive heart failure

BACKGROUND

The platelet-to-hemoglobin ratio (PHR) has emerged as a prognostic biomarker in coronary artery disease (CAD) patients after PCI but not clear in CAD complicated with congestive heart failure (CHF). Hence, we aimed to assess the association between PHR and long-term all-cause mortality among CAD patients with CHF.

METHODS

Based on the registry at Guangdong Provincial People's Hospital in China, we analyzed data of 2599 hospitalized patients who underwent coronary angiography (CAG) and were diagnosed with CAD complicated by CHF from January 2007 to December 2018. Low PHR was defined as ˂ 1.69 (group 1) and high PHR as ≥ 1.69 (group 2). Prognosis analysis was performed using Kaplan-Meier method. To assess the association between PHR and long-term all-cause mortality, a Cox-regression model was fitted.

RESULTS

During a median follow-up of 5.2 (3.1-7.8) years, a total of 985 (37.9%) patients died. On the Kaplan-Meier analysis, patients in high PHR group had a worse prognosis than those in low PHR group (log-rank, p = 0.0011). After adjustment for confounders, high PHR was correlated with an increased risk of long-term all-cause mortality in CAD patients complicated with CHF. (adjusted hazard ratio [aHR], 1.31; 95% confidence interval [CI], 1.13-1.52, p < 0.0001).

CONCLUSION

Elevated PHR is correlated with an increased risk of long-term all-cause mortality in CAD patients with CHF. These results indicate that PHR may be a useful prognostic biomarker for this population. Meanwhile, it is necessary to take effective preventive measures to regulate both hemoglobin levels and platelet counts in this population.

Efficacy and Cardiovascular Safety of Roxadustat in Dialysis-Dependent Chronic Kidney Disease: Pooled Analysis of Four Phase 3 Studies

INTRODUCTION

This integrated phase 3 analysis examined efficacy and cardiovascular safety for roxadustat vs erythropoiesis-stimulating agents (ESAs) in dialysis-dependent patients.

METHODS

Efficacy and safety results from four phase 3, randomized, open-label studies comparing roxadustat to ESAs (PYRENEES, SIERRAS, HIMALAYAS, ROCKIES) in dialysis-dependent patients with anemia of chronic kidney disease (CKD) were evaluated by study, pooled population and in two subgroups: incident dialysis and stable dialysis. The primary efficacy endpoint per study was hemoglobin change from baseline (CFB) to weeks 28-36 using least-squares mean difference (LSMD) without rescue therapy. Pooled safety endpoints included time to major adverse cardiovascular event (MACE; myocardial infarction, stroke, and all-cause mortality [ACM]) and MACE+ (MACE plus congestive heart failure or unstable angina requiring hospitalization), ACM, and treatment-emergent adverse events (TEAEs). MACE and MACE+ were evaluated for non-inferiority at 1.8 and 1.3 margins using hazard ratios (HRs) and 95% confidence intervals (CIs). TEAEs were descriptively summarized.

RESULTS

In total, 4714 patients were randomized (2354 roxadustat; 2360 ESA). Hemoglobin CFB to weeks 28-36 achieved non-inferiority for roxadustat vs ESA in each study. Roxadustat was non-inferior to ESA for risks for MACE and MACE+ in the entire cohort (MACE: HR 1.09, 95% CI 0.95-1.26; MACE+ : HR 0.98, 95% CI 0.86-1.11) and similar to the incident dialysis and stable dialysis subgroups; ACM results were consistent with MACE and MACE+ (HR 1.13, 95% CI 0.95-1.34). TEAEs were generally comparable between groups.

CONCLUSION

Roxadustat improved hemoglobin similarly to ESA while demonstrating comparable cardiovascular and overall safety profiles in a wide spectrum of dialysis-dependent patients with anemia of CKD. Roxadustat represents an oral alternative to ESAs for achieving a target hemoglobin for anemia of CKD in dialysis-dependent patients.

Anemia of Chronic Disease in Patients With Cardiovascular Disease

Objective: Anemia is often found in patients with coronary artery disease (CAD) or acute coronary syndrome (ACS) and related to disease severity. Our study investigated the relationship between anemia, iron homeostasis and inflammation in CAD and examined their influence on the outcome of patients. Patients and Methods: Markers of immune activation (neopterin, interleukin [IL]-12, IL-6, high sensitive C-reactive protein (hsCRP), fibrinogen, serum amyloid A [SAA]) and iron metabolism (ferritin, transferrin saturation, hemoglobin) were determined in 2,082 patients (68.7 % men, median age 63 years) from the Ludwigshafen Risk and cardiovascular Health (LURIC) cohort. Patients were followed-up for a median of 9.81 years. Results: 960 patients (46.1 %) presented with chronic CAD, 645 patients (31.0 %) had an ACS, and 477 patients (22.9 %) presented with no CAD in coronary angiography (CAG). Anemia (n = 357, 17.1 %) was associated with disease severity (reflected by more progressed stenosis in CAG, CCS, and NYHA classes, and a lower LV-EF), a higher cardio-cerebrovascular event rate and higher levels of inflammatory markers. Interestingly, anemia was only predictive for an adverse outcome in patients with elevated inflammatory markers. Accordingly, anemia of chronic disease (ACD) was associated with a higher cardio-cerebrovascular event-rate in the subsequent 2 years as compared to patients with other types of anemia or without anemia (14.3 vs. 6.1 vs. 4.0%, p < 0.001). Conclusions: This study confirms that anemia and immune activation are strongly related to cardiovascular disease progression and an adverse outcome. Our data suggest that the association of anemia with disease severity and outcome might mainly be due to underlying inflammation.

History of anemia and long-term mortality due to infection: a cohort study with 12 years follow-up in South Korea

BACKGROUND

Anemia, which is a condition with reduced healthy red blood cells, is reported to be closely related to the development of infectious diseases. We aimed to investigate the association between history of anemia and 12-year mortality rate due to infections, and compare it with that among non-anemic individuals.

METHODS

Data from the National Health Insurance Service Health Screening Cohort were used in this population-based cohort study. Adults who underwent standardized medical examination between and 2002-2003 were included, and the mortality rate due to infection between 2004 and 2015 was analyzed. Individuals were considered to have a history of anemia if the serum hemoglobin level in 2002-2003 was < 12 g/dL for women and < 13 g/dL for men. The severity of anemia at that time was categorized as mild (12 g/dL > hemoglobin ≥11 g/dL in women and 13 g/dL > hemoglobin ≥11 g/dL in men), moderate (hemoglobin 8-10.9 g/dL), or severe (hemoglobin < 8 g/dL). Propensity score (PS) matching and Cox regression analysis were used as statistical methods.

RESULTS

Overall, 512,905 individuals were included in this study. The mean age of the participants was 54.5 years old (range: 40-98), and 49,042 (9.6%) individuals were classified in the anemic group, which comprised of 36,383 (7.1%), 11,787 (2.3%), and 872 (0.2%) participants in the mild, moderate, and severe sub-groups, respectively. After PS matching, 49,039 individuals in each group were included in the analysis. The risk of mortality due to infection in the anemic group was 1.77-fold higher (hazard ratio [HR]: 1.77, 95% confidence interval [CI]: 1.52-2.60; P < 0.001) than that in the non-anemic group. In the subgroup analysis, the mild and moderate anemia groups had 1.38-fold (HR: 1.38, 95% CI: 1.23 to 1.55; P < 0.001) and 2.02-fold (HR: 2.02, 95% CI: 1.62 to 2.50; P < 0.001) risk of mortality due to infection compared to that of the non-anemic group, respectively. The severe anemia group did not have a significantly different risk of mortality due to infection (P = 0.448).

CONCLUSIONS

History of anemia was associated with increased mortality rate due to infection at 12-year follow-up.

Coronary microvascular dysfunction is associated with degree of anaemia in end-stage renal disease

BACKGROUND

Coronary microvascular dysfunction (CMD) is common in end-stage renal disease (ESRD) and is an adverse prognostic marker. Coronary flow velocity reserve (CFVR) is a measure of coronary microvascular function and can be assessed using Doppler echocardiography. Reduced CFVR in ESRD has been attributed to factors such as diabetes, hypertension and left ventricular hypertrophy. The contributory role of other mediators important in the development of cardiovascular disease in ESRD has not been studied. The aim of this study was to examine the prevalence of CMD in a cohort of kidney transplant candidates and to look for associations of CMD with markers of anaemia, bone mineral metabolism and chronic inflammation.

METHODS

Twenty-two kidney transplant candidates with ESRD were studied with myocardial contrast echocardiography, Doppler CFVR assessment and serum multiplex immunoassay analysis. Individuals with diabetes, uncontrolled hypertension or ischaemic heart disease were excluded.

RESULTS

7/22 subjects had CMD (defined as CFVR < 2). Demographic, laboratory and echocardiographic parameters and serum biomarkers were similar between subjects with and without CMD. Subjects with CMD had significantly lower haemoglobin than subjects without CMD (102 g/L ± 12 vs. 117 g/L ± 11, p = 0.008). There was a positive correlation between haemoglobin and CFVR (r = 0.7, p = 0.001). Similar results were seen for haematocrit. In regression analyses, haemoglobin was an independent predictor of CFVR (β = 0.041 95% confidence interval 0.012-0.071, p = 0.009) and of CFVR < 2 (odds ratio 0.85 95% confidence interval 0.74-0.98, p = 0.022).

CONCLUSIONS

Among kidney transplant candidates with ESRD, there is a high prevalence of CMD, despite the absence of traditional risk factors. Anaemia may be a potential driver of microvascular dysfunction in this population and requires further investigation.

Comparison of Effects of a Thrombin-Based Hemostatic Agent and Topical Tranexamic Acid on Blood Loss in Patients with Preexisting Thromboembolic Risk Undergoing a Minimally Invasive Total Knee Arthroplasty. A Prospective Randomized Controlled Trial

Background

The efficacy of a thrombin-based hemostatic agent (Floseal®) on reducing postoperative blood loss after total knee arthroplasty (TKA) was still unclear. The aim of our study was to conduct a prospective randomized controlled study to compare the blood conservation effects of Floseal® and topical TXA in patients with preexisting thromboembolic risk undergoing primary minimally invasive TKA.

Methods

Our power analysis of this study was based upon the following description, to obtain a statistical power of 0.90 and an alpha error of 0.05, 30 patients were required in each group. Therefore, we enrolled a total of 103 patients with at least one of the risk factors for thromboembolism who underwent unilateral primary minimally invasive TKA, and the participants were randomly divided into the topical TXA group (n = 34), receiving intra-articular injection of 3 g of TXA in 100 mL saline after TKA, the topical Floseal® group (n = 34), receiving 10 mL of Floseal® intra-articularily during surgery, and the placebo group (n = 35), receiving an intra-articular saline injection only. The total blood loss (TBL) and hemoglobin (Hb) drop were compared among the 3 groups.

Results

The TXA group had a lower TBL of 645 mL (227 to 1090) in comparison with 1145 mL (535 to 1942) in the Floseal® group and 1103 mL (424 to 1711) in the placebo (p < 0.001, respectively). The TBL was similar between the Floseal® group and the placebo group (p = 0.819). No patients in any group had symptoms of venous thromboemblism.

Conclusion

Our prospective randomized controlled study showed that intra-articular application of TXA was superior to hemostatic matrix (Floseal®) in terms of blood conservation in patients with preexisting thromboembolic risk undergoing minimally invasive TKA. This trial is registered with Clinicaltrials.gov (NCT02865174) on 08/09/2016.

Occult Blood in Feces Is Associated With an Increased Risk of Ischemic Stroke and Myocardial Infarction: A Nationwide Population Study

Background

Although occult hemoglobin in feces is universally valued as a screening tool for colorectal cancer (CRC), only few studies investigated the clinical meaning of fecal immunochemical test (FIT) in other diseases. We evaluated the clinical utility of FIT in patients with cardiovascular diseases (namely, ischemic stroke and myocardial infarction [MI]).

Methods and Results

Using the National Health Insurance database, participants (aged >50 years) with CRC screening records from 2009 to 2012 were screened and followed up. Subjects with a history of cardiovascular diseases and CRC were excluded. Ischemic stroke, MI, and other comorbidities were defined by International Classification of Diseases, Tenth Revision (ICD‐10), codes. Age, sex, smoking, alcohol consumption, regular exercise, diabetes mellitus, hypertension, dyslipidemia, and body mass index were adjusted in a multivariate analysis. A total of 6 277 446 subjects were eligible for analysis. During the mean 6.79 years of follow‐up, 168 570 participants developed ischemic stroke, 105 983 developed MI, and 11 253 deaths were observed. A multivariate‐adjusted model revealed that the risk of ischemic stroke was higher in the FIT‐positive population (adjusted hazard ratio [HR], 1.09; 95% CI, 1.07–1.11). Similarly, FIT‐positive subjects were at an increased risk of MI (adjusted HR, 1.09; 95% CI, 1.06–1.12). Moreover, increased all‐cause mortality was observed in the FIT‐positive population (adjusted HR, 1.15; 95% CI, 1.07–1.23). The increased risk remained consistent in the stratified analysis on anemia and CRC status.

Conclusions

Positive FIT findings were associated with ischemic stroke, MI, and mortality. Occult blood in feces may offer more clinical information than its well‐known conventional role in CRC screening.

Managing preoperative anemia: Evolving concepts and strategies for improving patient outcomes

Anemia is the most common hematological disease, and is defined by the World Health Organization as a condition in which the number of red blood cells and consequently oxygen-carrying capacity is insufficient to meet the physiological needs of the body. Anemia can occur throughout the perioperative period and has important clinical consequences. Preoperative anemia is usually regarded as no more than a surrogate marker of a patient's physical status, and it is not always adequately addressed before surgery. Postoperative anemia is a common event and occurs in 80-90% of patients who have undergone major surgery. This manuscript discusses the detection and management of preoperative anemia, the three pillars of patient blood management, perioperative anemia management, and risk stratification for anemia in the surgical setting.

Predicting ischaemic events using platelet reactivity in patients receiving clopidogrel: Indirect meta-comparison among VerifyNow, light transmission aggregometry and thromboelastography

The present study compared performances of the three major methods used for assessing platelet reactivity (PR)-VerifyNow, light transmission aggregometry (LTA) and thromboelastography (TEG)-to predict ischaemic events in patients receiving clopidogrel. PubMed, EMBASE and the Cochrane Library were searched from their inception to April 2019 for prospective studies that examined PR using VerifyNow, LTA or TEG and the incidence of ischaemic events. The investigated diagnostic indices include sensitivity, specificity, positive (PLR) and negative likelihood ratio (NLR), diagnostic odds ratio and area under the receiver operating characteristic curves (AUC) of VerifyNow, LTA and TEG, respectively. A total of 26 prospective studies involving 22 185 patients were included in the analysis. The pooled AUC was 0.71 (95% CI: 0.67-0.75) for VerifyNow, 0.60 (95% CI: 0.55-0.64) for LTA and 0.81 (95% CI: 0.77-0.84) for TEG. Results of indirect comparisons indicated the AUC of VerifyNow was higher than that of LTA (1.18, 95% CI: 1.08-1.30) and lower than that of TEG (0.88, 95% CI: 0.82-0.94). TEG outperformed the other two methods for assessing PR in all predictive measures, including sensitivity, specificity, PLR and NLR. Despite a lack of studies that directly compared the three methods, our findings suggest that TEG should be recommended.

Impact of Hemoglobin Levels and Their Dynamic Changes on the Risk of Atrial Fibrillation: A Nationwide Population-Based Study

Anemia is a risk factor for cardiovascular disease, but its impact on new-onset atrial fibrillation (AF) is unclear. In this study, we investigated the effect of hemoglobin (Hb) levels and their changes on the risk of AF development in the general population of Korea. We retrospectively analyzed a cohort from the Korean National Health Insurance Service database and identified 9,686,314 subjects (49.8% male) without a history of AF, aged ≥40 years, and with Hb levels available for both first (2009-2010) and second (2011-2012) health checkups. These subjects were followed up until 2017 to determine AF development. The presence of anemia (Hb level <13 g/dL in men and <12 g/dL in women) was a significant risk factor for AF development. However, Hb levels showed a U-shaped association with incident AF after adjustment for cardiovascular risk factors. AF incidence was lowest at Hb levels of 14-14.9 g/dL in men and 12-12.9 g/dL in women. Among individuals with Hb levels within normal ranges (13-15.9 g/dL in men and 12-14.9 g/dL in women), both decrease and increase in Hb levels at the second measurement outside the normal ranges showed an elevation of AF risk by 11% and 21% for men and 3% and 36% for women, respectively, compared with those who maintained normal Hb levels. In conclusion, low or high Hb levels are associated with an increased risk of incident AF. This study suggests that maintaining Hb levels within the normal ranges confers a low risk of AF development.

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

Background

Anemia 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.

Methods

This 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.

Results

A 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.

Conclusions

Anemia 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.

Sickle cell disease: Clinical presentation and management of a global health challenge

Sickle cell disease is an autosomal recessive, multisystem disorder, characterised by chronic haemolytic anaemia, painful episodes of vaso-occlusion, progressive organ failure and a reduced life expectancy. Sickle cell disease is the most common monogenetic disease, with millions affected worldwide. In well-resourced countries, comprehensive care programs have increased life expectancy of sickle cell disease patients, with almost all infants surviving into adulthood. Therapeutic options for sickle cell disease patients are however, still scarce. Predictors of sickle cell disease severity and a better understanding of pathophysiology and (epi)genetic modifiers are warranted and could lead to more precise management and treatment. This review provides an extensive summary of the pathophysiology and management of sickle cell disease and encompasses the characteristics, complications and current and future treatment options of the disease.

Modulatory effects of melatonin and vitamin C on oxidative stress-mediated haemolytic anaemia and associated cardiovascular dysfunctions in rats

Background Phenylhydrazine (PHE) in experimental animal models has been widely reported to cause haemolytic anaemia, via the induction of oxidative stress and thus causing deleterious cardiovascular complications. Hence, this study was designed to evaluate the possible modulatory role of melatonin (MLT) or vitamin C when co-administered with PHE. Methods Anaemia was established with PHE administration. MLT or vitamin C was co-administered with PHE. Haematological parameters, markers of oxidative stress, enzymic and non-enzymic antioxidants, blood pressure and electrocardiograms were assessed. Results PHE administration led to a significant (p<0.05) increase in malondialdehyde (MDA), and hydrogen peroxide (H2O2) generated in cardiac, renal and red blood cell (RBC) lysates. PHE also significantly reduced the activity of glutathione peroxidase (GPx), superoxide dismutase (SOD) and reduced glutathione (GSH) contents, respectively. The RBC counts, haemoglobin (Hb) concentration and packed cell volume (PCV) were also significantly reduced following the administration of PHE. Furthermore, the systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial blood pressure (MABP) increased significantly in rats administered PHE alone. Similarly, PHE administration led to a significant drop in heart rate but prolonged QRS, QT and QTc interval. Pathology of the heart and kidney was also observed in PHE treated group. However, treatment with MLT and vitamin C improved enzymic and non-enzymic antioxidant system together with the restoration of SBP, DBP and MABP to near normal. The architectural anarchy observed in the heart and kidney of PHE administered rats was reversed to some extent. Conclusions Hence, MLT and vitamin C could be employed as therapeutic targets in various cardiovascular diseases and its complications.

Modest and Severe Maternal Iron Deficiency in Pregnancy are Associated with Fetal Anaemia and Organ-Specific Hypoxia in Rats

Prenatal iron-deficiency (ID) is known to alter fetal developmental trajectories, which predisposes the offspring to chronic disease in later life, although the underlying mechanisms remain unclear. Here, we sought to determine whether varying degrees of maternal anaemia could induce organ-specific patterns of hypoxia in the fetuses. Pregnant female Sprague Dawley rats were fed iron-restricted or iron-replete diets to induce a state of moderate (M-ID) or severe ID (S-ID) alongside respective controls. Ultrasound biomicroscopy was performed on gestational day (GD)20 to assess uterine and umbilical artery blood flow patterns. On GD21, tissues were collected and assessed for hypoxia using pimonidazole staining. Compared to controls, maternal haemoglobin (Hb) in M- and S-ID were reduced 17% (P < 0.01) and 48% (P < 0.001), corresponding to 39% (P < 0.001) and 65% (P < 0.001) decreases in fetal Hb. Prenatal ID caused asymmetric fetal growth restriction, which was most pronounced in S-ID. In both severities of ID, umbilical artery resistive index was increased (P < 0.01), while pulsatility index only increased in S-ID (P < 0.05). In both M-and S-ID, fetal kidneys and livers showed evidence of hypoxia (P < 0.01 vs. controls), whereas fetal brains and placentae remained normoxic. These findings indicate prenatal ID causes organ-specific fetal hypoxia, even in the absence of severe maternal anaemia.

Impact of renal transplantation on cardiac morphological and functional characteristics in children and adults

AIM

To compare the effects of renal transplantation on cardiac functions in children and adults.

METHODS

One hundred and ten patients attending the nephrology outpatient clinic were enrolled in this study and were divided into six groups. The first two groups consisted each of 30 renal transplant patients who had a successful renal transplantation more than six months, but less than one year. Group I were less than 18 years and group II were more than 18 years. The third and fourth groups, each were 20 chronic renal failure patients on regular hemodialysis. Again, group III were less than 18 years and group IV were more than 18 years. Group V and VI (The control Groups) consisted each of 5 subjects below and above 18 years of age, respectively with normal kidney functions. All patients were subjected to history and examination. The kidney functions and the hemoglobin were analyzed. After obtaining informed consent, echocardiography was done to all patients.

RESULTS

There was a statistically significant improvement (P < 0.0001) in all cardiac parameters. A regression in left ventricular end diastolic volume (LVED) both in children (4.7 ± 0.8 to 4.2 ± 0.5) and in adults (5.9 ± 0.7 to 4.9 ± 0.6) were found. There was a regression in left ventricular end systolic volume (LVES) both in children (3.1 ± 0.6 to 2.4 ± 0.4) and in adults (4.1 ± 0.9 to 3.1 ± 0.5). Fractional shortening improves both in children (32.6 ± 5.3 to 41.7 ± 7.6) and in adults (29.0 ± 6.6 to 36.5 ± 4.1). The improvement in ejection fraction (EF) was higher in children (59.7 ± 7.0 to 71.9 ± 6.1) than in adults (52.0 ± 12.5 to 64.8 ± 5.9). However, this degree of improvement (in children: 12.2 ± 5.1) did not show statistical difference (P-value 0.8), when compared to adults (12.7 ± 9.8).

CONCLUSION

After renal transplantation cardiac functions and morphology (EF/LVED/LVES) do improve markedly and rapidly in both children and adults.

The effect of hematocrit and hemoglobin on the risk of ischemic heart disease: A Mendelian randomization study

Hematocrit and hemoglobin affect viscosity, and have been considered as risk factors for ischemic heart disease (IHD), although observations are inconsistent; randomized controlled trials targeting hematocrit or hemoglobin have not been definitive. To clarify their role, the risk of IHD was assessed according to genetically determined hematocrit and hemoglobin. We applied single nucleotide polymorphisms (SNPs) strongly determining hematocrit and hemoglobin, from a genome wide association study, to a large case (64,746) control (130,681) study of coronary artery disease, CARDIoGRAMplusC4D, to obtain unconfounded estimates using instrumental variable analysis by combining the Wald estimators for each SNP taking into account any correlation between SNPs using weighted generalized linear regression. Hematocrit was positively associated with IHD, odds ratio (OR) 1.07 per %, 95% confidence interval (CI) 1.03 to 1.11, before and after excluding SNPs from gene regions directly functionally relevant to IHD. However, hematocrit was not associated with IHD (OR 0.99, 0.94 to 1.04) after also excluding SNPs associated with lipids at genome wide significance. Hemoglobin was not associated with IHD (OR 1.06 per g/dL, 0.97 to 1.15) which was similar (OR 1.02, 0.94 to 1.11) after excluding SNPs from gene regions directly functionally relevant to IHD. Hemoglobin was negatively associated with IHD after also excluding SNPs associated with lipids at genome wide significance (OR 0.86, 0.78 to 0.94). In conclusion, hematocrit shares genetic determinants with IHD, but whether the genes contribute to IHD via hematocrit or other mechanisms is not entirely clear. Higher Hemoglobin is unlikely to cause IHD.

Impact of Anemia on Platelet Reactivity and Ischemic and Bleeding Risk: From the Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents Study

Anemic patients remain at increased risk of ischemic and bleeding events. Whether the effects of hemoglobin levels on thrombotic and bleeding risk are independent of platelet reactivity on clopidogrel, however, remains unknown. Patients from the Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents study were categorized by the presence of anemia at baseline, defined according the World Health Organization criteria. Platelet reactivity was measured with VerifyNow assay; high platelet reactivity (HPR) on clopidogrel was defined as platelet reactive units value >208. Of 8,413 patients included in the study cohort, 1,816 (21.6%) had anemia. HPR was more prevalent in patients with anemia (58.3% vs 38.4%; p <0.001), an association that persisted after multivariate adjustment (adjusted odds ratio: 2.04; 95% confidence interval [CI]: 1.82 to 2.29; p <0.0001). Patients with anemia had higher 2-year rates of major adverse cardiac events (9.5% vs 5.6%; p <0.0001), major bleeding (11.8% vs 7.7%; p <0.0001), and all-cause mortality (4.0% vs 1.4%; p <0.0001); however, after adjustment for baseline clinical confounders, including HPR, anemia was no longer significantly associated with major adverse cardiac events but was still independently associated with all-cause mortality (adjusted HR 1.61, 95% CI 1.23 to 2.12; p <0.0001) and major bleeding (adjusted HR 1.42, 95% CI 1.20 to 1.68; p <0.0001). The effect of HPR on clinical outcomes was uniform according to anemia status, without evidence of interaction. In conclusion, anemia independently correlated with HPR. After percutaneous coronary intervention with drug-eluting stents, anemia at baseline was significantly associated with higher 2-year hemorrhagic and mortality risk; conversely, its association with ischemic risk was attenuated after multivariate adjustment, including HPR.

Transferrin Saturation: A Body Iron Biomarker

Iron is an essential element for several metabolic pathways and physiological processes. The maintenance of iron homeostasis within the human body requires a dynamic and highly sophisticated interplay of several proteins, as states of iron deficiency or excess are both potentially deleterious to health. Among these is plasma transferrin, which is central to iron metabolism not only through iron transport between body tissues in a soluble nontoxic form but also through its protective scavenger role in sequestering free toxic iron. The transferrin saturation (TSAT), an index that takes into account both plasma iron and its main transport protein, is considered an important biochemical marker of body iron status. Its increasing use in many health systems is due to the increased availability of measurement methods, such as calorimetry, turbidimetry, nephelometry, and immunochemistry to estimate its value. However, despite its frequent use in clinical practice to detect states of iron deficiency or iron overload, careful attention should be paid to the inherent limitations of the test especially in certain settings such as inflammation in order to avoid misinterpretation and erroneous conclusions. Beyond its usual clinical use, an emerging body of evidence has linked TSAT levels to major clinical outcomes such as cardiovascular mortality. This has the potential to extend the utility of TSAT index to risk stratification and prognostication. However, most of the current evidence is mainly driven by observational studies where the risk of residual confounding cannot be fully eliminated. Indeed, future efforts are required to fully explore this capability in well-designed clinical trials or prospective large-scale cohorts.

Maternal Myocardial Performance in Second Trimester of Pregnancy With Iron Deficiency Anaemia

INTRODUCTION

Anaemia affects various organs in body including the heart. In anaemia, oxygen carrying capacity of blood decreases. Iron depletion and the amount of stored iron are reduced in iron deficiency anaemia which limits red cell production. However, the studies which show the effect of anaemia on myocardial function during pregnancy are few in India.

AIM

To study the effect of iron deficiency anaemia on myocardial function by ECG during second trimester of pregnancy and to compare ECG changes with normal pregnant women in second trimester.

MATERIALS AND METHODS

The study was conducted at antenatal OPD between Oct 2014 to Jul 2015. Hundred pregnant women were selected and divided into 2 groups. A total of 50 normal pregnant women (control group) in 2(nd) trimester (10-14 weeks of gestation) were compared with equal number of pregnant women with anaemia (study group) in 2(nd) trimester, aged between 20-30 years. Electrocardiogram was recorded using Philips twelve channel ECG machine model TC20 in both control and study groups to evaluate myocardial performance. Haematological parameters were analysed by SYSMEX auto analyser. Analysis of Variance (One way ANOVA) was used for comparison between study and control groups and the data was analysed by t-tests.

RESULTS

In our study a significant decrease in QRS duration and increase in QTc were observed in study group (p<0.05). T-wave abnormalities like flat and negative T-waves in lead II, III, avF, V2 - V4 were more frequent (p<0.05). 90% of subjects in study group had tachycardia and ECG abnormalities. There was a negative correlation between Hb level, serum ferritin and tachycardia, ECG abnormalities.

CONCLUSION

Pregnancy with Iron deficiency anaemia brings about various changes in ECG, suggesting that anaemia and volume overload in pregnancy is a risk factor that may lead to cardiac hypertrophy.

Current practices in coronary artery disease evaluation of renal transplant candidates prior to renal transplantation

Cardiovascular disease is the leading cause of morbidity and mortality in renal transplant recipients and candidates awaiting transplant. Pre-transplant coronary artery disease evaluation can aid in determining transplant candidacy, identifying patients who may benefit from pre-operative cardiac intervention, and implementing measures to reduce perioperative and post-transplant cardiovascular events. However, the choice of investigations and approach in evaluation has yet to be well defined. This article aims to review the evidence for the use of non-invasive investigations and coronary angiography in prognostication, as well as the evidence for revascularization in reducing future cardiac events. The article will also summarize international recommendations and describe the local practice in coronary artery disease evaluation prior to transplant.

Comparison of a restrictive versus liberal red cell transfusion policy for patients with myelodysplasia, aplastic anaemia, and other congenital bone marrow failure disorders

BACKGROUND

Bone marrow failure disorders include a heterogenous group of disorders, of which myelodysplastic syndrome (MDS), forms the largest subgroup. MDS is predominantly a disease of the elderly, with many elderly people managed conservatively with regular allogeneic red blood cell (RBC) transfusions to treat their anaemia. However, RBC transfusions are not without risk. Despite regular transfusions playing a central role in treating such patients, the optimal RBC transfusion strategy (restrictive versus liberal) is currently unclear.

OBJECTIVES

To assess the efficacy and safety of a restrictive versus liberal red blood cell transfusion strategy for patients with myelodysplasia, acquired aplastic anaemia, and other inherited bone marrow failure disorders.

SEARCH METHODS

We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 4), Ovid MEDLINE (from 1946), Ovid EMBASE (from 1974), EBSCO CINAHL (from 1937), the Transfusion Evidence Library (from 1980) and ongoing trial databases to 26th May 2015.

SELECTION CRITERIA

RCTs including patients with long-term bone marrow failure disorders that require allogeneic blood transfusion, who are not being actively treated with a haematopoietic stem cell transplant, or intensive chemotherapy.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane review methodology. One author initially screened all references, and excluded any that were clearly irrelevant or duplicates. Two authors then independently screened all abstracts of articles, identified by the review search strategy, for relevancy. Two authors independently assessed the full text of all potentially relevant articles for eligibility, completed the data extraction and assessed the studies for risk of bias using The Cochrane Collaboration's 'Risk of bias' tool.

MAIN RESULTS

We included one trial (13 participants) and identified three ongoing trials that assess RBC transfusion strategies in people with MDS.The quality of the evidence was very low across different outcomes according to GRADE methodology.The one included study randomised participants to a restrictive [haemoglobin (Hb) transfusion trigger < 72 g/L, 8 participants] or liberal [Hb trigger < 96 g/L, 5 participants] transfusion policy. There was insufficient evidence to determine a difference in all-cause mortality (1 RCT; 13 participants; RR 0.13, 95% CI 0.01 to 2.32; very low quality evidence). There was insufficient evidence to determine a difference in the number of red blood cell transfusions (1 RCT; 13 participants; 1.8 units per patient per month in the liberal group, compared to 0.8 in the restrictive arm, no standard deviation was reported; very low quality evidence). There were no anaemia-related complications reported (cardiac failure) and no reported effect on activity levels (no statistics provided). The study did not report: mortality due to bleeding/infection/transfusion reactions or iron overload, quality of life, frequency and length of hospital admissions, serious infections (requiring admission to hospital), or serious bleeding (e.g. WHO/CTCAE grade 3 (or equivalent) or above).

AUTHORS' CONCLUSIONS

This review indicates that there is currently a lack of evidence for the recommendation of a particular transfusion strategy for bone marrow failure patients undergoing supportive treatment only. The one RCT included in this review was only published as an abstract and contained only 13 participants. Further randomised trials with robust methodology are required to develop the optimal transfusion strategy for such patients, particularly as the incidence of the main group of bone marrow failure disorders, MDS, rises with an ageing population.

Comparison of a restrictive versus liberal red cell transfusion policy for patients with myelodysplasia, aplastic anaemia, and other congenital bone marrow failure disorders

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the efficacy and safety of a restrictive versus liberal red cell transfusion strategy for patients with long-term bone marrow failure. These include myelodysplasia, acquired aplastic anaemia, and other inherited bone marrow failure disorders.

Correlation Between Haemoglobin Level and Electrocardiographic (ECG) Findings in Anaemia: A Cross-Sectional Study

BACKGROUND

Anaemia affects the body by decreased oxygen (O2) carrying capacity of the blood. There is growing evidence that anaemia contributes to cardiac disease and death. It causes O2 supply - demand myocardial mismatch causing myocardial ischemia. There is diversity of opinion available in literature on reports of electrocardiographic (ECG) changes in anaemia.

AIM

To study the ECG changes in anemic population and to correlate ECG changes seen with increasing severity of anaemia.

MATERIALS AND METHODS

In hundred anemic adults, haemoglobin level and resting ECG were recorded. They were grouped according to haemoglobin level. ECG findings and varying severity of haemoglobin (Hb) level of each group were correlated using Pearson 's co-relation co-efficient and association was calculated using Chi-square test.

RESULTS

ECG changes in patients with Hb level of 0-5gm% showed ST segment depression in 50-75%, T wave changes in 29-50% and Left Ventricular Hypertrophy (LVH) in 25-30% of patients. Less percentage of patients with 5-7gm% Hb showed such changes, and patients with 7-8gm% Hb, showed no changes. As the Hb level decreased there was more percentage of patients having tachycardia and ECG changes. There was a strong negative correlation between Hb level and tachycardia and ECG changes.

CONCLUSION

Diagnosing anaemia in critical care can be supported by ECG changes like ST depression, T wave changes, with/without associated QRS abnormalities to avoid misdiagnosis and also as dramatic clinical and ECG recovery can be achieved with anaemia correction.

The role of oxidative stress in alterations of hematological parameters and inflammatory markers induced by early hypercholesterolemia

AIMS

The investigation of the effects of a high cholesterol diet (HD) for a short-time period on hematological parameters and the potential role of oxidative stress and inflammation markers.

MAIN METHODS

Rabbits were fed either a control diet or a diet containing 1% cholesterol (HD) for 5-6 weeks. The plasma lipid levels, C reactive protein (CRP), total red blood cells (RBC), total white blood cells (WBC), platelet count, packed cell volume (PCV) and leukocyte formula were determined. Oxidative stress was evaluated by the thiobarbituric acid reactive substances (TBARS), total glutathione and GSH serum level measurements. The osmotic fragility and the membrane fluidity of erythrocytes were determined. The levels of total cholesterol and TBARS were also measured in the erythrocyte membrane suspension.

KEY FINDINGS

A decrease in the RBC and PCV was observed in rabbits fed on HD. The membrane rigidity and osmotic fragility were increased, and the morphological changes caused by the HD and TBARS levels in the erythrocyte membrane may account for this phenomenon. The inflammatory markers as the CRP levels, the platelet count, the WBC and the neutrophils were increased. The TBARS and GSH levels in the serum were increased and decreased, respectively.

SIGNIFICANCE

This study shows that feeding rabbits an HD for a short time induces hematological alterations, disturbances in the oxidant-antioxidant balance and an increase of inflammatory markers. These findings support the importance of the early correction or prevention of high cholesterol levels to disrupt the process leading to the development of cardiovascular diseases.

Evidence for a novel mechanism independent of myocardial iron in β-thalassemia cardiac pathogenesis

Human β-thalassemia major is one of the most prevalent genetic diseases characterized by decrease/absence of β-globin chain production with reduction of erythrocyte number. The main cause of death of treated β-thalassemia major patients with chronic blood transfusion is early cardiac complications that have been attributed to secondary iron overload despite optimal chelation. Herein, we investigated pathophysiological mechanisms of cardiovascular dysfunction in a severe murine model of β-thalassemia from 6 to 15-months of age in the absence of confounding effects related to transfusion. Our longitudinal echocardiography analysis showed that β-thalassemic mice first display a significant increase of cardiac output in response to limited oxygen-carrying erythrocytes that progressed rapidly to left ventricular hypertrophy and structural remodeling. Following this compensated hypertrophy, β-thalassemic mice developed age-dependent deterioration of left ventricular contractility and dysfunction that led toward decompensated heart failure. Consistently, murine β-thalassemic hearts histopathology revealed cardiac remodeling with increased interstitial fibrosis but virtual absence of myocardial iron deposits. Importantly, development of thalassemic cardiac hypertrophy and dysfunction independently of iron overload has uncoupled these cardiopathogenic processes. Altogether our study on β-thalassemia major hemoglobinopathy points to two successive phases resulting from severe chronic anemia and from secondarily induced mechanisms as pathophysiologic contributors to thalassemic cardiopathy.

Anaemia, haemoglobin level and cause-specific mortality in people with and without diabetes

BACKGROUND

Both anaemia and cardiovascular disease (CVD) are common in people with diabetes. While individually both characteristics are known to raise mortality risk, their combined influence has yet to be quantified. In this pooling project, we examined the combined impact of baseline haemoglobin levels and existing CVD on all-cause and CVD mortality in people with diabetes. We draw comparison of these effects with those apparent in diabetes-free individuals.

METHODS/PRINCIPAL FINDINGS

A combined analyses of 7 UK population-based cohorts resulted in 26,480 study members. There were 946 participants with physician-diagnosed diabetes, 2227 with anaemia [haemoglobin<13 g/dl (men) or <12 (women)], 2592 with existing CVD (stroke, ischaemic heart disease), and 21,396 with none of the conditions. Across diabetes and anaemia subgroups, and using diabetes-free, non-anaemic participants as the referent group, the adjusted hazard ratios (HR) were 1.46 (95% CI: 1.30-1.63) for anaemia, 1.67 (1.45-1.92) for diabetes, and 2.10 (1.55-2.85) for diabetes and anaemia combined. Across combined diabetes, anaemia and CVD subgroups, and compared with non-anaemic, diabetes-free and CVD-free participants, HR (95% CI) for all-cause mortality were 1.49 (1.32-1.69) anaemia, 1.60 (1.46-1.76) for existing CVD, and 1.66 (1.39-1.97) for diabetes alone. Equivalents were 2.13 (1.48-3.07) for anaemia and diabetes, 2.68 (2.14-3.36) for diabetes and existing CVD, and 3.25 (1.88-5.62) for the three combined. Patterns were similar for CVD mortality.

CONCLUSIONS/SIGNIFICANCE

Individually, anaemia and CVD confer similar mortality risks in people with diabetes, and are excessively fatal in combination. Screening for anaemia would identify vulnerable diabetic patients whose outcomes can potentially be improved.

The prevalence of hearing impairment and associated risk factors: the Beaver Dam Offspring Study

OBJECTIVE

To estimate the prevalence of hearing impairment (HI) and evaluate the cross-sectional associations of environmental and cardiovascular disease risk factors and HI in middle-aged adults.

DESIGN

Data were collected as part of the Beaver Dam Offspring Study, an epidemiological cohort study of aging. Hearing impairment was defined as a pure-tone average (0.5, 1.0, 2.0, and 4.0 kHz) greater than 25 db hearing level in either ear. Word recognition in competing message (WRCM) was measured using the Northwestern University No. 6 word list. Questionnaire information about behaviors, environmental factors, and medical history was also collected.

PARTICIPANTS

The participants (N = 3285) were offspring of participants of the population-based Epidemiology of Hearing Loss Study and ranged in age from 21 to 84 years (mean age, 49 years).

RESULTS

The prevalence of HI was 14.1%, and the mean (SD) WRCM score was 64% (15%). In a multivariate model, after age, sex, education, and occupational noise were controlled for, a history of ear surgery (odds ratio [OR], 4.11; 95% confidence interval [CI], 2.37-7.15), a larger central retinal venular equivalent (OR, 1.77; 95% CI, 1.20-2.60 [fourth quartile vs first quartile]), and a higher hematocrit percentage (OR, 0.77; 95% CI, 0.63-0.95 [per 5%]) were independently associated with HI. Factors associated with lower WRCM scores were similar but also included mean intima-media thickness (mean difference, -0.63%; 95% CI, -1.06% to -0.19%; P = .005 [per 0.1 mm]) and statin use (mean difference, -2.09%; 95% CI, -3.58% to -0.60%; P = .005).

CONCLUSIONS

Hearing impairment is a common condition in middle-aged adults. Cardiovascular disease risk factors may be important correlates of age-related auditory dysfunction.

Hemoglobin concentration in men with type 2 diabetes mellitus

Anemia is a common but often overlooked complication of diabetes. We investigated the relationship between hemoglobin concentration and various factors as well as markers of subclinical atherosclerosis in men with type 2 diabetes mellitus. Hemoglobin concentration was measured in 319 men with type 2 diabetes mellitus. We evaluated the relationship between hemoglobin concentration and various factors including age, body mass index, and glycemic control, as well as between hemoglobin concentration and pulse wave velocity or ankle-brachial index (n = 209) and between hemoglobin concentration and carotid intima-media thickness or plaque score (n = 125). Mean hemoglobin concentration was 14.2 +/- 0.80 g/dL. Body mass index (r = 0.340, P < .0001) and estimated glomerular filtration rate (r = 0.219, P = .0011) were positively associated with hemoglobin concentration, whereas age (r = -0.388, P < .0001), glycated albumin (r = -0.148, P = .0121), serum creatinine concentration (r = -0.206, P = .0019), and log (urinary albumin excretion) (r = -0.188, P = .0010) were negatively associated with hemoglobin concentration. Multiple regression analysis identified age (beta = -0.222, P = .0019), body mass index (beta = 0.145, P = .0432), systolic blood pressure (beta = 0.214, P = .0015), total cholesterol concentration (beta = 0.170, P = .0077), and serum creatinine concentration (beta = -0.181, P = .0045) as independent determinants of hemoglobin concentration. No significant association was observed between hemoglobin concentration and serum erythropoietin concentration (r = -0.079, P = .2980). Negative correlations were found between hemoglobin concentration and pulse wave velocity (r = -0.289, P < .0001) and between hemoglobin concentration and plaque score (r = -0.275, P = .0024). In conclusion, hemoglobin concentration was associated with various factors; and decreased hemoglobin concentration was associated with subclinical markers of atherosclerosis in men with type 2 diabetes mellitus.

Drug safety profile of darbepoetin alfa for anemia of chronic kidney disease

Anemia of chronic kidney disease due to deficiency of erythropoietin is common and has clinical consequences. Erythropoiesis stimulating agents including darbepoetin alfa (DA) are effective in correcting anemia. DA is generally well tolerated and has side effect profile similar to recombinant human erythropoietin. It has a long half-life permitting infrequent dosing. DA has been tested extensively in preclinical and clinical studies and significant experience has accumulated in clinical practice. Global safety profile of DA must consider recent data indicating worse survival, poor cardiovascular outcomes and thrombotic risks of targeting near normal hemoglobin levels and administering high doses of erythropoiesis stimulating agents. Strategies to achieve and maintain a reasonable, individualized target hemoglobin level with minimal variations in hemoglobin level are needed.

Noninvasive Optical, Electrical, and Acoustic Methods of Total Hemoglobin Determination

Background: Anemia is an underdiagnosed, significant public health concern afflicting &gt;2 billion people worldwide. The detrimental effects of tissue oxygen deficiency on the cardiovascular system and concurrent appearance of anemia with numerous high-risk disorders highlight the importance of clinical screening. Currently there is no universally accepted, clinically applicable, noninvasive hemoglobin/hematocrit screening tool. The need for such a device has prompted an investigation into a breadth of techniques.

Methods: A synopsis of the literature and current directions of research in noninvasive total hemoglobin measurement was collected. Contributions highlighted in this review are limited to those studies conducted with a clinical aspect, and most include in vivo patient studies.

Results: The review of potential techniques presented here includes optoacoustic spectroscopy, spectrophotometric imaging, diffuse reflectance spectroscopy, transcutaneous illumination, electrical admittance plethysmography, and photoplethysmography. The technological performance, relative benefits of each approach, potential instrumentation design considerations, and future directions are discussed in each subcategory.

Conclusions: Many techniques reviewed here have shown excellent accuracy, sensitivity, and specificity in measuring hemoglobin/hematocrit, thus in the near future a new clinically viable tool for noninvasive hemoglobin/hematocrit monitoring will likely be widely used for patient care. Limiting factors in clinical adoption will likely involve technology integration into the current standard of care in each field routinely dealing with anemia.

Cardiovascular disease in children with chronic renal failure

Cardiovascular disease (CVD), including atherosclerosis, hypertension, myocardial infarction, and cerebrovascular accidents, constitutes an important cause of morbidity and mortality in adults with chronic kidney disease (CKD). However, evidence has been accumulating over the past several years that children and young adults with CKD also experience significant cardiovascular complications. Studies in the United States and Europe have shown that CVD is a leading cause of death in young adults diagnosed with CKD in childhood. Risk factors include hypertension, dyslipidemia, anemia, and abnormal calcium-phosphorus metabolism, all of which are present in many children with CKD. Although improved control of uremia and treatment of traditional and nontraditional cardiovascular risk factors have proved to be beneficial in adults with CKD, no such data exist for children. The NIH is currently conducting a large-scale, prospective observational study of children with CKD that should help to elucidate the role of CVD in the progression of CKD in children and what interventions might reduce the risk of cardiovascular complications in these young patients.

Anemia and cardiovascular disease in diabetic nephropathy

Cardiovascular disease (CVD) is the major cause of morbidity and mortality in people with diabetes and in those with chronic kidney disease (CKD). Diabetes, occurring in epidemic proportions in the United States and worldwide, is also the leading cause of CKD and kidney failure. Identification of modifiable risk factors for CVD in patients with diabetes and CKD is thus of paramount importance. Anemia is increasingly recognized as a potential CVD risk factor in patients with diabetic nephropathy, in whom it is generally more severe and occurs at an earlier stage of CKD. In this review, we discuss the epidemiologic evidence, pathophysiologic mechanisms, and the current research findings, highlighting the role of anemia as a potential modifiable risk factor for CVD in patients with diabetic nephropathy, a particularly vulnerable population for CVD.

Mild renal insufficiency is associated with reduced coronary flow in patients with non-obstructive coronary artery disease

Patients with chronic kidney disease (CKD) have increased risk for cardiovascular events. However, the association between these pathophysiological processes is unclear. Therefore, this study was designed to determine the association between early CKD and coronary microvascular disease in patients with normal or mildly diseased coronary arteries. A total of 605 patients with normal or mildly diseased coronary arteries based on angiography underwent coronary flow reserve (CFR) evaluation using intracoronary adenosine. Patients were divided based on glomerular filtration rate (GFR). CKD was defined as calculated GFR<60 ml/min/1.73 m(2). Patients with normal GFR (> or =60 ml/min/1.73 m(2), n=481) had higher CFR compared to those with CKD (n=124, CFR=3.0+/-0.8 vs 2.6+/-0.6, P<0.001, respectively). Patients with abnormal GFR were more likely to be older and of female gender, with greater prevalence of hypertension. Multiple logistic regression analysis adjusted for the aforementioned risk factors further supported the observed relationship. The current study shows that reduced renal function is associated with attenuated coronary vasodilator capacity in patients without obstructive coronary artery disease. The correlation between low GFR and reduced CFR may suggest parallel alterations in the renal and coronary microcirculation at the early stage of disease. Impairment in both microcirculatory beds may reflect an unmeasured risk factor induced by blunted renal function and add a burden to the increased propensity for cardiovascular events in CKD.

Diffuse reflectance spectra of the palpebral conjunctiva and its utility as a noninvasive indicator of total hemoglobin

The palpebral conjunctiva is an attractive location to qualitatively examine for the presence of anemia; however, this method of diagnosis has not been shown to be accurate. A spectroscopic examination of the palpebral conjunctiva enables the use of a quantitative parameter as a basis for diagnoses. Visible range diffuse reflectance spectra from the palpebral conjunctiva are examined from 30 patients and hemoglobin levels are extracted from these signatures using both a partial least-squares (PLS) multivariate regression model and a discrete spectral region model. Hemoglobin concentration derived from both these models is compared to an in vitro measurement of hemoglobin. Root mean squared errors of cross validation for the two analytical methods are 0.67 g/dL and 1.07 g/dL, respectively. Conjunctival reflectance spectra coupled with a PLS analysis achieve an enhanced specificity and sensitivity for anemia diagnoses over reported observational studies using the palpebral conjunctiva and achieve improved accuracy to other reported methods of noninvasive hemoglobin measurement.

Enhanced programmed cell death of iron-deficient erythrocytes

Exposure of erythrocytes to osmotic shock, oxidative stress, and energy depletion activates Cl--sensitive and Ca2+-permeable cation channels. Subsequent Ca2+ entry triggers eryptosis, characterized by erythrocyte shrinkage, membrane blebbing, and phosphatidylserine exposure all features typical for apoptotic death of nucleated cells. Erythrocytes exposing phosphatidylserine are recognized, bound, engulfed, and degraded by macrophages. Eryptosis thus fosters clearance of affected erythrocytes from circulating blood. Iron deficiency leads to anemia, in part by decreasing erythrocyte life span. In this study, phosphatidylserine exposure, cell size, and cytosolic Ca2+ were measured by FACS analysis of annexin-V binding, forward scatter, and Fluo-3 fluorescence, respectively. Erythrocytes from mice on control diet were compared with erythrocytes from mice exposed 10 weeks to iron-deficient diet. Iron deficiency significantly (P<0.001) enhanced erythrocyte annexin-V binding (from 2.4 to 3.7%), decreased forward scatter (from 544 to 393), and increased cytosolic Ca2+ concentration. 45Ca2+ flux measurements and patch clamp experiments revealed enhanced Ca2+ uptake (by 2.3-fold) and cation channel activity. The half-life of fluorescence-labeled, iron-deficient, or Ca2+-loaded erythrocytes was significantly reduced compared with control erythrocytes. Thus, the experiments reveal a novel mechanism triggered by iron deficiency, which presumably contributes to accelerated clearance of erythrocytes in iron deficiency anemia.