Red cell distribution width is an independent predictor of mortality in hip fracture

Prediction of Osteoporotic Hip Fracture Outcome: Comparative Accuracy of 27 Immune-Inflammatory-Metabolic Markers and Related Conceptual Issues

Objectives: This study, based on the concept of immuno-inflammatory-metabolic (IIM) dysregulation, investigated and compared the prognostic impact of 27 indices at admission for prediction of postoperative myocardial injury (PMI) and/or hospital death in hip fracture (HF) patients. Methods: In consecutive HF patient (n = 1273, mean age 82.9 ± 8.7 years, 73.5% females) demographics, medical history, laboratory parameters, and outcomes were recorded prospectively. Multiple logistic regression and receiver-operating characteristic analyses (the area under the curve, AUC) were used to establish the predictive role for each biomarker. Results: Among 27 IIM biomarkers, 10 indices were significantly associated with development of PMI and 16 were indicative of a fatal outcome; in the subset of patients aged >80 years with ischaemic heart disease (IHD, the highest risk group: 90.2% of all deaths), the corresponding figures were 26 and 20. In the latter group, the five strongest preoperative predictors for PMI were anaemia (AUC 0.7879), monocyte/eosinophil ratio > 13.0 (AUC 0.7814), neutrophil/lymphocyte ratio > 7.5 (AUC 0.7784), eosinophil count < 1.1 × 109/L (AUC 0.7780), and neutrophil/albumin × 10 > 2.4 (AUC 0.7732); additionally, sensitivity was 83.1-75.4% and specificity was 82.1-75.0%. The highest predictors of in-hospital death were platelet/lymphocyte ratio > 280.0 (AUC 0.8390), lymphocyte/monocyte ratio < 1.1 (AUC 0.8375), albumin < 33 g/L (AUC 0.7889), red cell distribution width > 14.5% (AUC 0.7739), and anaemia (AUC 0.7604), sensitivity 88.2% and above, and specificity 85.1-79.3%. Internal validation confirmed the predictive value of the models. Conclusions: Comparison of 27 IIM indices in HF patients identified several simple, widely available, and inexpensive parameters highly predictive for PMI and/or in-hospital death. The applicability of IIM biomarkers to diagnose and predict risks for chronic diseases, including OP/OF, in the preclinical stages is discussed.

A prediction model of elderly hip fracture mortality including preoperative red cell distribution width constructed based on the random survival forest (RSF) and Cox risk ratio regression

An independent correlation between pre-RDW and 1-year mortality after surgery in elderly hip fracture can be used to predict mortality in elderly hip fracture patients and has predictive significance in anemia patients. With further research, a treatment algorithm can be developed to potentially identify patients at high risk of preoperative mortality.

INTRODUCTION

Red blood cell distribution width (RDW) is an independent predictor of various disease states in elderly individuals, but its association with the prognosis of elderly hip fracture patients is controversial. This study aimed to evaluate the prognostic value of RDW in such patients, construct a prediction model containing RDW using random survival forest (RSF) and Cox regression analysis, and compare RDW in patients with and without anemia.

METHODS

We retrospectively analyzed the data of elderly patients who underwent hip fracture surgery, selected the best variables using RSF, stratified the independent variables by Cox regression analysis, constructed a 1-year mortality prediction model of elderly hip fracture with RDW, and conducted internal validation and external validation.

RESULTS

Two thousand one hundred six patients were included in this study. The RSF algorithm selects 12 important influencing factors, and Cox regression analysis showed that eight variables including preoperative RDW (pre-RDW) were independent risk factors for death within 1-year after hip fracture surgery in elderly patients. Stratified analysis showed that pre-RDW was still independently associated with 1-year mortality in the non-anemia group and not in the anemia group. The nomogram prediction model had high differentiation and fit, and the prediction model constructed by the total cohort of patients was also used for validation of patients in the anemia patients and obtained good clinical benefits.

CONCLUSION

An independent correlation between pre-RDW and 1-year mortality after surgery in elderly hip fracture can be used to predict mortality in elderly hip fracture patients and has predictive significance in anemia patients.

Red blood cell distribution width and Charlson comorbidity index help to identify frail polytraumatized patients : Experiences from a level I trauma center

INTRODUCTION

Little is known about the potential impact of the red blood cell distribution width (RDW) and pre-existing comorbidities on the late-phase survival of polytraumatized patients.

METHODS

A total of 173 polytraumatized patients were included retrospectively in this cohort study in a level I trauma center from January 2012 to December 2015. The Charlson comorbidity index (CCI) scores and RDW values were evaluated.

RESULTS

Out of all polytraumatized patients (n = 173), 72.8% (n = 126) were male, the mean ISS was 31.7 points (range 17-75) and the mean age was 45.1 years (range 18-93 years). Significantly higher RDW values (13.90 vs. 13.37; p = 0.006) and higher CCI scores (3.38 vs. 0.49; p < 0.001) were seen in elderly polytraumatized patients (age > 55 years). RDW values > 13.75% (p = 0.033) and CCI scores > 2 points (p = 0.001) were found to have a significant influence on the late-phase survival of polytraumatized patients. Age > 55 years (p = 0.009, HR 0.312; 95% confidence interval (CI) 0.130-0.749) and the presence of severe traumatic brain injury (TBI) (p = 0.007; HR 0.185; 95% CI 0.054-0.635) remained as independent prognostic factors on the late-phase survival after multivariate analysis.

CONCLUSION

Even younger elderly polytraumatized patients (> 55 years of age) showed significant higher RDW values and higher CCI scores. In addition to the presence of severe TBI and age > 55 years, RDW value > 13.75% on admission and CCI score > 2 might help to identify the "younger" frail polytraumatized patient at risk.

Predictors of one-year mortality following hip fracture surgery in elderly

Background

Understanding mortality risk factors is critical to reducing mortality among elderly hip fracture patients. To investigate the effects of admission and post-operative levels of distribution width of red blood cells (RDW), albumin, and RDW/albumin (RA) ratio on predicting 1-year mortality following hip fracture surgery.

Methods

A retrospective study was conducted on 275 elderly patients who underwent hip fracture surgery in a tertiary hospital between January 2018 and January 2022. Deaths within one year of hip fracture were defined as the deceased group. The survivors were defined as those who survived for at least one year. The relationship between admission and post-operative levels of RDW, albumin, RA, and mortality within one year after hip surgery was assessed statistically, including binary logistic regression analysis. The study also assessed other factors related to mortality.

Results

One-year mortality was 34.7%. There was a 3.03-year (95% CI [1.32-4.75]) difference between the deceased (79.55 ± 8.36 years) and survivors (82.58 ± 7.41 years) (p < 0.001). In the deceased group, the mean hemoglobin (HGB) values at admission (p = 0.022) and post-operative (p = 0.04) were significantly lower. RDW values at admission (p = 0.001) and post-op (p = 0.001) were significantly lower in the survivor group. The mean albumin values at admission (p < 0.001) and post-operative (p < 0.001) in the survivor group were significantly higher than in the deceased group. A significant difference was found between the survivor group and the deceased group in terms of mean RA ratio at admission and post-operative (p < 0.001). Based on binary logistic regression analysis, presence of chronic obstructive pulmonary disease (COPD) (OR 3.73, 95% CI [1.8-7.76]), RDW (OR 1.78, 95% CI [1.48-2.14]), and albumin (OR 0.81, 95% CI [0.75-0.87]), values at admission were found to be independent predictors of 1-year mortality in elderly patients with hip fracture.

Conclusion

Based on this study, presence of COPD, higher RDW, and lower albumin levels at admission were independent predictors of 1-year mortality following hip fracture surgery in the elderly.

The Association Between Red Cell Distribution Width (RDW) and All-Cause Mortality in Elderly Patients with Hip Fractures: A Retrospective Cohort Study

Background

Red cell distribution width (RDW) may be related to the prognosis of hip fractures. The purpose of this study was to evaluate the association between (RDW) and all-cause mortality in elderly hip fractures.

Materials and Methods

Elderly patients aged ≥65 years who had a hip fracture were screened between January 1, 2015, and September 30, 2019. The age, gender of patients and other demographics, as well as history of allergy, injury mechanism, underlying illnesses at the time of admission, fracture classification, time from admission to operation, RDW, operation time, blood loss, infusion, transfusion, treatment strategy, and length in hospital stay and follow-up and other clinical characteristics were collected. Linear and nonlinear multivariate Cox regression models were used to identify the association between RDW and mortality in these patients. Analyses were performed using EmpowerStats and the R software.

Results

A total of 2587 patients were included in this retrospective cohort study. The mean follow-up period was 38.92 months. A total of 873 (33.75%) patients died due to all-cause mortality. The RDW was linearly associated with mortality in elderly patients with hip fractures. Linear multivariate Cox regression models showed that RDW was associated with mortality (hazard ratio [HR]=1.03, 95% confidence interval [CI]:1.02-1.05, P < 0.0001) after adjusting for confounding factors. The mortality risk increased by 3% when RDW increased by 1 fL.

Conclusion

RDW is associated with mortality in elderly patients with hip fractures, and RDW could be considered a predictor of mortality risk.

Registration

ChiCTR2200057323.

A machine learning-based prediction model for in-hospital mortality among critically ill patients with hip fracture: An internal and external validated study

INTRODUCTION

Few studies have investigated the in-hospital mortality among critically ill patients with hip fracture. This study aimed to develop and validate a model to estimate the risk of in-hospital mortality among critically ill patients with hip fracture.

METHODS

For this study, data from the Medical Information Mart for Intensive Care III (MIMIC-III) Database and electronic Intensive Care Unit (eICU) Collaborative Research Database were evaluated. Enrolled patients (n=391) in the MIMIC-III database were divided into a training (2/3, n=260) and a validation (1/3, n=131) group at random. Using machine learning algorithms such as random forest, gradient boosting machine, decision tree, and eXGBoosting machine approach, the training group was utilized to train and optimize models. The validation group was used to internally validate models and the optimal model could be obtained in terms of discrimination (area under the receiver operating characteristic curve, AUROC) and calibration (calibration curve). External validation was done in the eICU Collaborative Research Database (n=165). To encourage practical use of the model, a web-based calculator was developed according to the eXGBoosting machine approach.

RESULTS

The in-hospital death rate was 13.81% (54/391) in the MIMIC-III database and 10.91% (18/165) in the eICU Collaborative Research Database. Age, gender, anemia, mechanical ventilation, cardiac arrest, and chronic airway obstruction were the six model parameters which were identified using the Least Absolute Shrinkage and Selection Operator (LASSO) method combined with 10-fold cross-validation. The model established using the eXGBoosting machine approach showed the highest area under curve (AUC) value (0.797, 95% CI: 0.696-0.898) and the best calibrating ability, with a calibration slope of 0.999 and intercept of -0.019. External validation also revealed favorable discrimination (AUC: 0.715, 95% CI: 0.566-0.864; accuracy: 0.788) and calibration (calibration slope: 0.805) in the eICU Collaborative Research Database. The web-based calculator could be available at https://doctorwangsj-webcalculator-main-yw69yd.streamlitapp.com/.

CONCLUSION

The model has the potential to be a pragmatic risk prediction tool that is able to identify hip fracture patients who are at a high risk of in-hospital mortality in ICU settings, guide patient risk counseling, and simplify prognosis bench-marking by controlling for baseline risk.

Elevated Red Blood Cell Distribution Width Is Associated with Poor Prognosis in Fractured Patients Admitted to Intensive Care Units

OBJECTIVES

Red blood cell distribution width (RDW) with prognosis in various infectious diseases. For fractured patients admitted to the intensive care units (ICU), an accurate and fast appraisal is essential. To investigate the association between RDW and prognosis in fractured patients admitted to the ICU utilizing the MIMIC-III database.

METHODS

A retrospective cohort from the MIMIC III database from 2001 and 2012 was constructed. RDW and other information were collected with in-hospital mortality as the primary outcome and 90-day mortality and hospital and intensive care unit (ICU) length of stay (LOS) as secondary outcomes. Univariate and multivariate logistic regression models with propensity score inverse probability of treatment weighting (IPTW) were used to investigate the prognostic value of RDW. A nomogram was built with significant prognostic factors to predict in-hospital mortality, and the performance of the nomogram was evaluated and compared with other severity assessment scores. Subgroup analysis was also conducted.

RESULTS

A total of 2721 fracture patients admitted to the ICU were identified. After IPTW, the group with higher RDW was significantly associated with elevated in-hospital mortality (odds ratio [OR]: 1.68, 95% confidence interval [CI]: 1.19-2.37), 90-day mortality (OR: 1.39, 95% CI: 1.04-1.86), prolonged hospital LOS (OR: 1.25, 95% CI: 1.03-1.50), and ICU LOS significantly (OR: 1.26, 95% CI: 1.05-1.53) in the multivariate logistics model. The nomogram showed optimal discriminative ability and predictive accuracy with an area under the receiver operating characteristic curve of 0.77.

CONCLUSION

RDW independently predicted in-hospital mortality, 90-day mortality, and hospital and ICU LOS in fractured patients admitted to ICU. The nomogram including RDW could also be a promising tool with potential clinical benefits.

Succinate dehydrogenase inversely regulates red cell distribution width and healthy lifespan in chronically hypoxic mice

Increased red cell distribution width (RDW), which measures erythrocyte volume (MCV) variability (anisocytosis), has been linked to early mortality in many diseases and in older adults through unknown mechanisms. Hypoxic stress has been proposed as a potential mechanism. However, experimental models to investigate the link between increased RDW and reduced survival are lacking. Here, we show that lifelong hypobaric hypoxia (~10% O2) increases erythrocyte numbers, hemoglobin and RDW, while reducing longevity in male mice. Compound heterozygous knockout (chKO) mutations in succinate dehydrogenase (Sdh; mitochondrial complex II) genes Sdhb, Sdhc and Sdhd reduce Sdh subunit protein levels, RDW, and increase healthy lifespan compared to wild-type (WT) mice in chronic hypoxia. RDW-SD, a direct measure of MCV variability, and the standard deviation of MCV (1SD-RDW) show the most statistically significant reductions in Sdh hKO mice. Tissue metabolomic profiling of 147 common metabolites shows the largest increase in succinate with elevated succinate to fumarate and succinate to oxoglutarate (2-ketoglutarate) ratios in Sdh hKO mice. These results demonstrate that mitochondrial complex II level is an underlying determinant of both RDW and healthy lifespan in hypoxia, and suggest that therapeutic targeting of Sdh might reduce high RDW-associated clinical mortality in hypoxic diseases.

Higher red cell distribution width and poorer hospitalization-related outcomes in elderly patients

BACKGROUND

Red cell distribution width (RDW), an index for variation of red blood cell (RBC) size, has been proposed as a potential marker for poorer outcomes in several aging-related diseases and conditions. We tested whether greater variability of RBC size, presented as a higher RDW value, predicts poor prognoses among hospitalized patients over 60 years old.

METHODS

We retrospectively collected data from older hospitalized patients aged ≥60 years between January 2013 to December 2017 at Sutter Health, a large integrated health system in Northern California. The RDW was measured during hospital admission and categorized with 1% intervals (≤13.9, 14.0-14.9, 15.0-15.9, 16.0-16.9, 17.0-17.9 and ≥18.0%). The primary outcome was the rate of in-hospital mortality and secondary outcomes included 30-day re-admission rate and length of hospital stay (in days).

RESULTS

A total of 167,292 admissions from 94,617 patients were included. The overall in-hospital mortality rate was 6.3%. As the RDW value increased, the rate of in-hospital mortality gradually increased from 2.7% for the lowest RDW category to 12.2% in the highest category (p-trend <0.001). The overall 30-day re-admission rate after discharge was 12.5% and the rate of 30-day re-admission also increased with increasing RDW categories (7.4% in the lowest group vs. 15.8% in the highest group, p-trend <0.001). Patients with the highest RDW values at admission stayed 1.5-2.0 times longer in the hospital than patients with lower RDW values who were admitted for the same causes.

CONCLUSIONS

Greater variability of RBC size is significantly associated with worse prognosis in hospitalized elderly patients, indicating higher mortality, greater risk of early re-admission, and longer hospital stay days. Risk stratification strategies for hospitalized elderly should include RDW value.

Does Red Cell Distribution Width Predict Hip Fracture Mortality Among the Arab Population? A Single-Center Retrospective Cohort Study

BACKGROUND

Hip fractures impose significant morbidity and mortality. Red cell distribution width (RDW) appears to be an emerging tool in predicting mortality following hip fractures. Several factors can influence the RDW value including genetic factors and ethnicity. The purpose of the study was to assess the relation between RDW level at admission and hip fracture mortality within 6 months among Arab/Middle East populations.

METHODS

We conducted a single-center retrospective cohort study including 549 patients (274 female and 275 male) diagnosed with a hip fracture undergoing surgery from February 2016 to December 2019. All included patients shared the same country of origin which is Arab Middle East country. Statistical analysis, including binary regression, was performed to assess the relationship between RDW and mortality within 6 months of admission. Other predictors of mortality following hip fracture surgery were also assessed.

RESULTS

The mean age was 76.42 (±9.19) years. Seventy (12.8%) of participants died within 6 months. No statistically significant association (P=0.053) between RDW level at admission and mortality within 6 months of surgery was found. Binary regression demonstrated that the only independent predictors of mortality were age (P= 0.003, odds ratio 1.048 with 95% CI 1.016 to 1.080) and male gender (P= 0.021, odds ratio 1.872 with 95% CI 1.100 to 3.185).

CONCLUSION

Although the previous studies reported that RDW is one of the predictors of mortality in hip fracture patients, our study found no relation in the Arab population. This finding may confirm the influence of genetic factors and ethnicity on RDW value. We recommend further large-scale multicenter studies to solidly establish the relationship between RDW and hip fracture mortality among the Arab/Middle East population.

Pretreatment red blood cell distribution width as an efficient predictor of survival in older patients undergoing hip fracture surgery

PURPOSE

We aimed to determine whether pretreatment red blood cell distribution width (RDW) is an efficient predictor of 30-day mortality in older patients undergoing hip fracture surgery.

METHODS

In this prospective cohort study, 203 patients with hip fractures were eligible and followed up for at least 30 days. All the patients underwent medical examinations. RDW was measured using an automated hematology analyzer. To evaluate the prognostic significance of RDW, Cox proportional hazard model and Kaplan-Meier analyses were performed.

RESULTS

Of the 203 patients (114 men, 89 women), 28 (13.79%) died within 30 days. The mean RDW was significantly higher in the deceased group than in the survival group (14.54% ± 1.09% vs 13.26% ± 0.57%; P < .001). Multivariate Cox regression analysis showed that elevated RDW (hazard ratio = 2.73, 95% confidence interval = 2.06-3.62, P < .001) was the key predictor of 30-day mortality in older patients undergoing hip fracture surgery. Survival analysis showed that patients with a high RDW had a significantly higher 30-day mortality rate (log-rank test, P < .05). Similar results were observed in the male and female subgroups.

CONCLUSION

RDW might be an effective predictor of 30-day mortality in older patients undergoing hip fracture surgery.

Red Cell Distribution Width: Commonly Performed Test Predicts Mortality in Primary Total Joint Arthroplasty

INTRODUCTION

Mortality after total joint arthroplasty (TJA) has been thoroughly explored. Short and long-term mortality appear to be correlated with patient comorbidities. Red Cell Distribution Width (RDW) is a commonly performed test that reflects the variation in red blood cell size. This study investigated the utility of RDW, when combined with comorbidity indices, in predicting mortality after TJA.

METHODS

Using a single institutional database, 30,437 primary TJA were identified. Patient demographics (age, gender, body mass index (BMI), pre-operative hemoglobin, RDW, and Charlson Comorbidity Index(CCI)) were queried. The primary outcome was 1-year mortality after TJA. Anemia was defined as hemoglobin <12g/dL for women and <13 g/dL for men. The normal range for RDW is 11.5-14.5%. A preliminary analysis assessed the bivariate association between demographics, preoperative anemia, RDW, CCI, and all-cause mortality within 1-year after TJA. A multivariate regression model was conducted to determine independent predictors of 1-year mortality. Finally, ROC curves were used to compare AUC of RDW, CCI and the combination of both in predicting 1-year mortality.

RESULTS

The mean RDW was 13.6% ± 1.2. Eighteen percent of patients had pre-operative anemia. The mean CCI was 0.4 ± 0.9. RDW, anemia, CCI, and age were significantly associated with a higher incidence of 1-year mortality. RDW, CCI, age, and male sex were found to be independent risk factors for 1-year mortality. RDW (AUC = 0.68) was a better predictor of mortality compared to CCI (AUC = 0.66). The combination of RDW and CCI (AUC = 0.76) predicted 1-year mortality more accurately than CCI or RDW alone.

CONCLUSION

RDW appears to be a useful parameter that, when combined with CCI, can predict the risk for 1-year mortality after TJA.

A novel machine-learning algorithm for predicting mortality risk after hip fracture surgery

INTRODUCTION

Although several risk stratification models have been developed to predict hip fracture mortality, efforts are still being placed in this area. Our aim is to (1) construct a risk prediction model for long-term mortality after hip fracture utilizing the RSF method and (2) to evaluate the changing effects over time of individual pre- and post-treatment variables on predicting mortality.

METHODS

1330 hip fracture surgical patients were included. Forty-five admission and in-hospital variables were analyzed as potential predictors of all-cause mortality. A random survival forest (RSF) algorithm was applied in predictors identification. Cox regression models were then constructed. Sensitivity analyses and internal validation were performed to assess the performance of each model. C statistics were calculated and model calibrations were further assessed.

RESULTS

Our machine-learning RSF algorithm achieved a c statistic of 0.83 for 30-day prediction and 0.75 for 1-year mortality. Additionally, a COX model was also constructed by using the variables selected by RSF, c statistics were shown as 0.75 and 0.72 when applying in 2-year and 4-year mortality prediction. The presence of post-operative complications remained as the strongest risk factor for both short- and long-term mortality. Variables including fracture location, high serum creatinine, age, hypertension, anemia, ASA, hypoproteinemia, abnormal BUN, and RDW became more important as the length of follow-up increased.

CONCLUSION

The RSF machine-learning algorithm represents a novel approach to identify important risk factors and a risk stratification models for patients undergoing hip fracture surgery is built through this approach to identify those at high risk of long-term mortality.

Red Cell Distribution Width as a Novel Predictor of Mortality and Complications After Primary Shoulder Arthroplasty

INTRODUCTION

Variability in red blood cell volume can occur in disease states and is quantified using a simple equation, yielding the relative distribution of width (RDW). Recent literature has correlated RDW with outcomes in many cardiac disease states, hip fractures, and even revision hip arthroplasty. The association with outcomes in total shoulder arthroplasty (TSA) is yet to be delineated. The purpose of this study was to investigate the possible relationship between preoperative RDW levels and mortality and other adverse outcomes after primary TSA.

METHODS

Patients who underwent primary TSA and had RDW values on record were identified in a national database. Patients were then grouped by RDW, and the incidence of complications was calculated for each group, including mortality within 1 year, periprosthetic infection within 1 year, acute venous thromboembolism within 30 days, and readmission to a hospital within 30 days. A threshold value of RDW for increased complications was established using receiver operator characteristic (ROC) curves.

RESULTS

Five thousand two hundred forty-five patients who underwent TSA with a recorded RDW were included in the study. An RDW cutoff of 16% was found to be significantly associated with mortality at 1 year (P < 0.0001), readmission (P < 0.0001), and infection (P = 0.013) on ROC analysis. When controlling for demographic and comorbidity values, a high RDW was markedly associated with a higher mortality rate (odds ratio 2.0, 95% confidence interval 18 to 2.2) and readmission rate (odds ratio 1.5, 95% confidence interval 1.3 to 1.8). A high RDW was not markedly associated with increased infection or venous thromboembolism rate in the multivariate analysis.

DISCUSSION

Increasing preoperative RDW is associated with increasing complication rates after TSA. This value can be used as an indirect, real-time preoperative predictor of adverse outcomes and most importantly one-year mortality and hospital readmission.

LEVEL OF EVIDENCE

III retrospective cohort study.

Red Cell Distribution Width Is a Risk Factor for Hip Fracture in Elderly Men Without Anemia

Red cell distribution width (RDW), routinely assessed as a component of a complete blood count (CBC), quantifies the variation in the size of red blood cells. It increases with age, and increased RDW predicts many aging-related diseases and mortality. However, whether it also predicts hip fracture is unknown. We prospectively evaluated the association between RDW and hip fracture using data from the Osteoporotic Fracture in Men (MrOS) study. RDW was measured in 3635 men (aged 71 to 99 years) along with bone mineral density (BMD) in MrOS. RDW ranged from 11.3% to 32.9% (median 14.0%; interquartile range 13.5% to 14.8%) and was categorized into four groups (≤13.0%, 13.1% to 14.0%, 14.1% to 15.0%, ≥15.1%). Study participants with a hemoglobin level <13.0 g/dL were classified as having anemia. During an average 8.1 years, 164 men suffered hip fractures. The risks of hip fractures increased with increase of RDW category. Furthermore, there was a significant interaction between anemia and RDW: An association between RDW and hip fractures was only observed in participants without anemia. In those without anemia, the relative hazard of hip fractures increased with increases in RDW category: Men in the highest RDW category had a 2.8 times higher risk of hip fractures than men in the lowest group (95% confidence interval 1.1 to 7.1). The risks of all-clinical fractures were also increased along with higher RDW values. Additionally, RDW was significantly associated with the risk of having a fall but not with femoral neck or total hip BMD. In conclusion, RDW and anemia defined by hemoglobin are widely available routine laboratory measurements that together could indicate increased risk of hip fracture, reflecting the neuromuscular effects of aging rather than lower hip BMD. © 2020 American Society for Bone and Mineral Research.

Mortality After Traumatic Brain Injury in Elderly Patients: A New Scoring System

BACKGROUND

Traumatic brain injury (TBI) remains a life-threatening condition characterized by growing incidence worldwide, particularly in the aging population, in which the primary goal of treatment appears to be avoidance of chronic institutionalization.

METHODS

To identify independent predictors of 30-day mortality or vegetative state in a geriatric population and calculate an intuitive scoring system, we screened 480 patients after TBI treated at a single department of neurosurgery over a 2-year period. We analyzed data of 214 consecutive patients aged ≥65 years, including demographics, medical history, cause and time of injury, neurologic state, radiologic reports, and laboratory results. A predictive model was developed using logistic regression modeling with a backward stepwise feature selection.

RESULTS

The median Glasgow Coma Scale (GCS) score on admission was 14 (interquartile range, 12-15), whereas the 30-day mortality or vegetative state rate amounted to 23.4%. Starting with 20 predefined features, the final prediction model highlighted the importance of GCS motor score (odds ratio [OR], 0.17; 95% confidence interval [CI], 0.09-0.32); presence of comorbid cardiac, pulmonary, or renal dysfunction or malignancy (OR, 2.86; 9 5% CI, 1.08-7.61); platelets ≤100 × 10⁹ cells/L (OR, 13.60; 95% CI, 3.33-55.49); and red blood cell distribution width coefficient of variation ≥14.5% (OR, 2.91; 95% CI, 1.09-7.78). The discovered coefficients were used for nomogram development. It was further simplified to facilitate clinical use. The proposed scoring system, Elderly Traumatic Brain Injury Score (eTBI Score), yielded similar performance metrics.

CONCLUSIONS

The eTBI Score is the first scoring system designed specifically for older adults. It could constitute a framework for clinical decision-making and serve as an outcome predictor. Its capability to stratify risk provides reliable criteria for assessing efficacy of TBI management.

Elevated Red Blood Cell Distribution Width Is Associated with Morphometric Vertebral Fracture in Community-Dwelling Older Adults, Independent of Anemia, Inflammation, and Nutritional Status: The Korean Urban Rural Elderly (KURE) Study

Elevated red blood cell distribution width (RDW), a simple measure of red blood cell size heterogeneity, has been associated with increased mortality and morbidity in the elderly population, which might reflect systemic inflammation and malnutrition. However, whether elevated RDW is associated with prevalent morphometric vertebral fracture (VF) in older adults has not been investigated. We examined 2127 individuals (mean age 71.7 years; women 66%) from a community-based cohort. VF was defined as ≥ 25% reduction in vertebral column height using the Genant semiquantitative method. Multiple VF was defined as the presence of VF at two or more sites. The prevalence of any VF and multiple VF was 14% and 4%, respectively, increasing from the lowest to the highest RDW tertiles (12-18% and 3-6%, p for trend < 0.05 for all). RDW was positively associated with age, body mass index (BMI), malnutrition, and high-sensitivity C-reactive protein (hsCRP), whereas it was negatively associated with albumin, hemoglobin, and ferritin levels. Elevated RDW was associated with any VF [adjusted odds ratio (aOR) 1.26; p = 0.008] and multiple VF (aOR 1.36; p = 0.010) after adjustment for covariates, including age, sex, BMI, hsCRP, malnutrition, self-reported previous fracture, falls, osteoporosis, and hemoglobin and ferritin levels. The association between elevated RDW and VF remained robust in subgroups with (aOR 1.39; p = 0.048) or without anemia (aOR 1.26; p = 0.030). Elevated RDW was associated with prevalent morphometric VF in community-dwelling elderly individuals, independent of anemia, inflammation, and nutritional status.

Red Cell Distribution Width: An Unacknowledged Predictor of Mortality and Adverse Outcomes Following Revision Arthroplasty

BACKGROUND

Revision total joint arthroplasties (TJAs) have been empirically associated with significant postoperative morbidity and mortality. Red blood cell distribution width (RDW), a frequently measured hematological parameter, has been shown to predict mortality in hip fracture patients. However, its utility in risk-stratifying patients before revision TJA remains unknown. The aim of this study was to investigate the possible relationship between preoperative RDW levels and outcome of revision arthroplasty in terms of mortality, adverse outcomes, and length of hospital stay.

METHODS

A single-institution retrospective study was conducted on 4633 patients who underwent revision TJA (3289 hips and 1344 knees) between 2000 and September 2016. Of those, 656 (14.1%) surgeries were performed due to periprosthetic joint infection, and 3977 (85.9%) were aseptic revisions. The association between preoperative RDW and various outcomes, including 1-year mortality, in-hospital medical complications, length of hospital stay, and 90-day all-cause readmission, was examined.

RESULTS

The average age of patients in the cohort was 65.4 ± 12.9 years. The average Charlson comorbidity index was 0.6 (standard deviation = 1.0), with 691 patients (14.9%) having 2 or more comorbidities. Mean preoperative RDW level was 14.4% (standard deviation = 1.8). After adjusting for covariates, higher RDW levels were statistically significantly associated with mortality (adjusted odds ratio [OR], 1.25; 95% confidence interval [CI], 1.13-1.39; P < .001), any in-hospital medical complications (adjusted OR, 1.12; 95% CI, 1.07-1.18; P < .001), and readmission (adjusted OR, 1.07; 95% CI, 1.02-1.13; P < .001).

CONCLUSION

Higher levels of preoperative RDW appeared to be associated with less optimal outcomes after revision TJA. Adult reconstruction orthopedic surgeons should be aware of this predictive factor and exercise caution with TJA revision patients with high values of preoperative RDW. RDW could be included in the routine perioperative workup and used to counsel patients on their postoperative risk.

Validity of Nottingham Hip Fracture Score in Different Health Systems and a New Modified Version Validated to the Greek Population

Background

The Nottingham Hip Fracture Score (NHFS) is validated as a predictive mortality tool in patients with hip fracture. However, it has not been modified or validated widely other than in the UK NHS health systems.

Material/Methods

We assessed the predictive capability of the NHFS for 30-day mortality after surgery for hip fracture in the Greek population and then compared the original model to a modified one. We applied the NHFS to the Greek population and created a modified model of the NHFS by including the New Mobility Score (NMS) (Parker and Palmer, 1993) to the evaluated parameters and excluding the parameter of institution.

We ran a prospective study over a period of 3 years in our institution, collecting full data from 349 patients. All data were analyzed using SPSS, version 20.

Results

From all 349 patients, with a mean age of 80.82 years, only 85 (24.4%) were men. All patients were followed up for at least 30 days and the NHFS and modified NHFS prediction were compared with the mortality rate of patients. The area under the ROC curve for both models suggested acceptable accuracy (original NHFS 0.83, modified NHFS 0.84). Calibration was acceptable for both models (Hosmer-Lemeshow p=0.31 and 0.11, respectively).

Conclusions

Both the original and the modified NHFS were significant predictors of 30-day mortality. A higher-power study might be able to show superiority of the modified one for the Greek population in the future.

Hip fracture patients who experience a greater fluctuation in RDW during hospital course are at heightened risk for all-cause mortality: a prospective study with 2-year follow-up

This study aims to detect whether there remains valuable prognostic information in fluctuation of red cell distribution width (RDW) in hip fracture patients. Results show that this readily available parameter may provide a more effective strategy for assessment of mortality risk, therefore providing a reference for clinical planning and decision-making.

INTRODUCTION

Prognostic values have been found in the fluctuation of some hematologic parameters. The red cell distribution width (RDW) routinely reported with all complete blood cell counts (CBC) has proven to be associated with poor outcomes in various diseases. However, whether the fluctuation in RDW is predictive of long-term mortality in hip fracture patients treated with surgery remains unknown.

METHODS

One thousand three hundred thirty hip fracture patients who underwent surgery from January 1, 2000 to November 18, 2012 were recruited in this prospective cohort study. Fluctuation in the RDW between admission and discharge was measured, and a Kaplan-Meier (KM) analysis and multivariable Cox regression model were applied to evaluate the relationship between this fluctuation and mortality. Risk factors for a larger fluctuation were detected by using Logistic regression analyses.

RESULTS

In addition to the admission RDW, a high RDW level at the time of discharge was also associated with an increased risk of death, while no significant difference was found in the postoperative RDW. Fluctuation in the RDW between admission and discharge was an independent risk predictor for 2-year mortality (HR 1.45 95%CI 1.06-2.00, p = 0.022). Factors affecting the change in the RDW between admission and discharge included both the demographic characteristics of the patients and clinical interventions.

CONCLUSION

Hip fracture patients who experience a greater fluctuation in RDW during the hospital course are at a heightened risk for 2-year all-cause mortality.

Combination of measures of handgrip strength and red cell distribution width can predict in-hospital complications better than the ASA grade after hip fracture surgery in the elderly

BACKGROUND

Early detection of a high-risk patient following hip fracture surgery is of paramount clinical importance. American Society of Anesthesiologists (ASA) grading is an easy and efficient index in predicting a worse outcome. The red cell distribution width (RDW) and handgrip strength, are gaining interest as a prediction tool as well. Accordingly, the objective of this study was to investigate the potential association between ASA, RDW and grip strength and detect the effects of combining RDW and grip strength for predicting early complication after hip fracture surgery in the elderly.

METHODS

Eighty-three consecutive patients operated with hip fracture surgeries were identified retrospectively. Age, gender, diagnosis, RDW, handgrip strength and ASA grade were recorded. Admission to the intensive care unit (ICU), length of ICU stay, transfer to other departments, in-hospital death, and readmission were investigated as early complications. Logistic regression analysis was applied to evaluate the estimates in predicting complications, and receiver operating characteristics curves were constructed to compare the estimates and decide which method is more accurate.

RESULTS

After the surgery, 52% of the patients were admitted to the ICU. From the analyses, RDW and grip strength had no significant relation with each other. However, the ICU stay was correlated with RDW and grip strength but not for the ASA grade. A higher ASA grade and grip strength could independently predict ICU admission. The combination of RDW with grip strength outweighed the ASA grade in predictive ability.

CONCLUSIONS

The current study indicated that combining RDW and grip strength measures can be efficient and clinically relevant in predicting early postoperative complications after fragility hip fracture in the elderly. Due to the objectivity and availability of those two approaches, patient care, and functional outcomes are expected to be improved by adopting these measures in the clinical setting.

Red blood cell distribution width in patients with limb, chest and head trauma

INTRODUCTION

This study investigated the values of red blood cell distribution width (RDW), an emerging and independent predictor of morbidity and mortality, in patients with limb, chest and head trauma.

MATERIAL AND METHODS

The study sample consisted of all patients who attended the emergency department (ED) of the University Hospital of Parma for limb, chest and head traumas requiring admission to hospital wards during the year 2014. The controls consisted of outpatients living in the same geographical area and undergoing routine laboratory testing for health check-up.

RESULTS

The final study sample consisted of 290 patients with limb (n = 97), chest (n = 49) or head (n = 144) trauma and 967 outpatients. Significantly increased RDW values at admission were observed in all trauma patients compared with controls. Although the frequency of increased RDW (> 14.6%) was higher in all trauma patients than in controls, a subanalysis revealed that increased RDW values were significantly more frequent in patients with head trauma than in controls, but not in those with limb or chest trauma. In multivariate analysis, a significant association was found between head trauma and hemoglobin (p < 0.001) or RDW (p = 0.005). Head trauma patients had a ~3-fold higher likelihood of increased RDW values than controls. The negative and positive predictive values of increased RDW for predicting the presence of head trauma were 0.90 (95% CI: 0.88-0.92) and 0.24 (95% CI: 0.19-0.30).

CONCLUSIONS

The results of this study highlight that RDW is increased in patients admitted to the ED with head trauma.

Both initial red cell distribution width (RDW) and change in RDW during heart failure hospitalization are associated with length of hospital stay and 30-day outcomes

INTRODUCTION

We examined the predictive ability of red cell distribution width (RDW) and the change in RDW during hospitalization (ΔRDW) for length of stay (LOS) and 30-day outcomes after heart failure (HF) inpatient stay.

METHODS

Electronic query of Intermountain Healthcare medical records identified patients (N = 6414) with a primary diagnosis of HF who were discharged between 2004 and 2013, had RDW measured within 24 h after admission, and had RDW tested at least once more during the same hospitalization. ΔRDW was defined as the last RDW within 24 h prior to discharge minus the first RDW.

RESULTS

Median LOS by initial RDW quartiles was Q1: 3.0, Q2: 3.1, Q3: 3.7, and Q4: 4.0 days (P-trend<0.001), and by ΔRDW quartiles was Q1: 4.1, Q2: 3.4, Q3: 3.6, and Q4: 4.7 days (P-trend<0.001). Both initial RDW (16.8 ± 2.8% vs. 16.3 ± 2.7%, P < 0.001) and ΔRDW (0.21 ± 1.09% vs. 0.14 ± 1.04%, P = 0.039) predicted 30-day readmission vs. no readmit. For 30-day decedents vs. survivors, initial RDW was 17.3 ± 3.0% vs. 16.3 ± 2.6% (P < 0.001), while ΔRDW was +0.20 ± 1.14% vs. +0.14 ± 1.04% (P = 0.15).

CONCLUSIONS

Greater initial RDW and ΔRDW during HF hospitalization were associated with 30-day mortality, longer LOS, and 30-day all-cause readmission, suggesting both ΔRDW and initial RDW may aid in personalizing prognosis and treatment.

Prognostic Value of Red Blood Cell Distribution Width in Non-Cardiovascular Critically or Acutely Patients: A Systematic Review

BACKGROUND

RDW (red cell distribution width) has been reported to been associated with the prognosis of patients with cardiovascular diseases. However, RDW is often overlooked by clinicians in treating patients with non-cardiovascular diseases, especially in an emergency. The objective of this systematic review is to explore the prognostic value of RDW in non-cardiovascular emergencies.

METHODS

PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were systematically searched from their inception to December 31, 2015. We included studies examining the relationship between RDW and mortality rate by adjusting important covariables in non-cardiovascular emergencies. All included studies were divided into three groups. Group A: general critically ill patients; Group B: patients with infectious disease; Group C: other conditions. We extracted each study' characteristics, outcomes, covariables, and other items independently.

RESULTS

A total of 32 studies were eligible for inclusion in our meta-analysis. Six studies belonged to Group A, 9 studies belonged to Group B and 17 studies belonged to Group C. Among these included studies, RDW was assessed as a continuous variable (per 1% increase) in 16 studies, as a binary variable in 8 studies, and as a categorical variable in 8 studies. In addition, AUCs (area under the receiver operating characteristic curve) of RDW for predicting mortality were reported in 25 studies. All studies were published between 2011-2015. The qualities of included 32 studies were moderate or high.

CONCLUSION

The present systematic review indicates that the increased RDW is significantly associated with a higher mortality rate in an non-cardiovascular emergency. The low cost and readily accessible of this laboratory variable may strengthen its usefulness in daily practice in the future.

Prognostic Value of Red Blood Cell Distribution Width in Non-Cardiovascular Critically or Acutely Patients: A Systematic Review

Background

RDW (red cell distribution width) has been reported to been associated with the prognosis of patients with cardiovascular diseases. However, RDW is often overlooked by clinicians in treating patients with non-cardiovascular diseases, especially in an emergency. The objective of this systematic review is to explore the prognostic value of RDW in non-cardiovascular emergencies.

Methods

PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were systematically searched from their inception to December 31, 2015. We included studies examining the relationship between RDW and mortality rate by adjusting important covariables in non-cardiovascular emergencies. All included studies were divided into three groups. Group A: general critically ill patients; Group B: patients with infectious disease; Group C: other conditions. We extracted each study’ characteristics, outcomes, covariables, and other items independently.

Results

A total of 32 studies were eligible for inclusion in our meta-analysis. Six studies belonged to Group A, 9 studies belonged to Group B and 17 studies belonged to Group C. Among these included studies, RDW was assessed as a continuous variable (per 1% increase) in 16 studies, as a binary variable in 8 studies, and as a categorical variable in 8 studies. In addition, AUCs (area under the receiver operating characteristic curve) of RDW for predicting mortality were reported in 25 studies. All studies were published between 2011–2015. The qualities of included 32 studies were moderate or high.

Conclusion

The present systematic review indicates that the increased RDW is significantly associated with a higher mortality rate in an non-cardiovascular emergency. The low cost and readily accessible of this laboratory variable may strengthen its usefulness in daily practice in the future.

Multiplicative interaction between mean corpuscular volume and red cell distribution width with target organ damage in hypertensive patients

BACKGROUND

Accumulating evidence suggests that increased red cell distribution width (RDW) and mean corpuscular volume (MCV) were both poor prognostic factors for patients with cardiovascular diseases. Recently, the multiplicative interaction between RDW and MCV has been observed for predicting mortality in elderly patients without anemia; however, the relationship between the product of RDW-MCV and hypertension-induced target organ damage (TOD) has not been evaluated.

METHODS

We performed a cross-sectional study in 1115 hypertensive patients. RDW and MCV were determined using automated hematology analyzers. Prevalence of TOD was evaluated by estimated glomerular filtration rate, carotid intima-media thickness, and left ventricular mass index.

RESULTS

The prevalence of TOD was observed to be increased with the RDW or product of RDW-MCV quartiles. Moreover, RDW, MCV and product of RDW-MCV were significantly higher in patients with TOD compared to those without TOD. According to two logistic regression models, the associations of RDW and MCV with TOD were lost after adjustment for other factors. However, product of RDW-MCV remains an independent predictor of TOD, with per 0.4 fL increase in the product of RDW-MCV associated with a 16% increased risk of TOD (P=.012).

CONCLUSIONS

The inclusion of MCV by calculating the product of RDW-MCV appears to enhance the association of RDW with TOD.

The Penrod score: a prognostic instrument to balance an increasing geriatric fracture caseload with diminishing health care resources?

INTRODUCTION

Geriatric hip fracture patients are a highly heterogeneous collective, what distinctly aggravates the best possible treatment. Consequently, it is becoming more important to identify selection criteria that can distinguish those patients who can benefit the most from treatment in a geriatric fracture center. In our pilot study, we assessed the 2007 published Penrod score for its utility as a useful selection tool by prospectively comparing our own patient's outcome with the Penrod study.

METHODS

77 patients treated for geriatric hip fracture were preoperatively classified according to the Penrod score. Patients were divided into three clusters by age (1: <75 years, 2: 75-84 years, 3: ≥85 years). Clusters 2 and 3 were then classified according to their ability to perform activities of daily living (ADL's) and cognitive status (presence or absence of dementia). In 51 out of these 77 patients, the ability to perform ADLs could be assessed 6 months postoperatively and was compared with the Penrod scores.

RESULTS

58 % of cluster 1 patients were able to perform 4 ADLs independently 6 months postoperatively (52.9 % Penrod study). In clusters 2A and 3A, 48 and 50 %, respectively, were able to perform 4 ADLs independently, compared with 40.6 and 31.5 % (Penrod collective). 22 % of our patients in 2B performed all ADLs independently (3.6 % Penrod) and 25 % in cluster 3B (9.4 % Penrod).

CONCLUSION

Our preliminary results support the prognostic value of the Penrod score in the treatment of geriatric hip fracture patients. With the help of the Penrod score, it may be possible to identify patients, who are expected to significantly profit from an intensified treatment in a geriatric fracture center (clusters 2B, 3A, and 3B). By utilizing this score, improved outcomes and simultaneously a more effective utilization of valuable health care resources could be achieved.

Elevated Red Cell Distribution Width Is Associated With Decreased Ventilator-Free Days in Critically Ill Patients

INTRODUCTION

Elevated red cell distribution width (RDW) is associated with mortality in a variety of respiratory conditions. Recent data also suggest that RDW is associated with mortality in intensive care unit (ICU) patients. Although respiratory failure is common in the ICU, the relationship between RDW and pulmonary outcomes in the ICU has not been previously explored. Therefore, our goal was to investigate the association of admission RDW with 30-day ventilator-free days (VFDs) in ICU patients.

METHODS

We performed a retrospective analysis from an ongoing prospective, observational study. Patients were recruited from medical and surgical ICUs of a large teaching hospital in Boston, Massachusetts. The RDW was assessed within 1 hour of ICU admission. Poisson regression analysis was used to investigate the association of RDW (normal: 11.5%-14.5% vs elevated: >14.5%) with 30-day VFD, while controlling for age, sex, race, body mass index, Nutrition Risk in the Critically Ill score, the presence of chronic lung disease, Pao₂/Fio₂ ratio, and admission levels of hemoglobin, mean corpuscular volume, phosphate, albumin, C-reactive protein, and creatinine.

RESULTS

A total of 637 patients comprised the analytic cohort. Mean RDW was 15 (standard deviation 4%), with 53% of patients in the normal range and 47% with elevated levels. Median VFD was 16 (interquartile range: 6-25) days. Poisson regression analysis demonstrated that ICU patients with elevated admission RDW were likely to have 32% lower 30-day VFDs compared to their counterparts with RDW in the normal range (incidence rate ratio: 0.68; 95% confidence interval: 0.55-0.83: P < .001).

CONCLUSIONS

We observed an inverse association of RDW and 30-day VFD, despite controlling for demographics, nutritional factors, and severity of illness. This supports the need for future studies to validate our findings, understand the physiologic processes that lead to elevated RDW in patients with respiratory failure, and determine whether changes in RDW may be used to support clinical decision-making.

Combination of red cell distribution width and American Society of Anesthesiologists score for hip fracture mortality prediction

The prognostic value of red cell distribution width (RDW) and a combination of RDW and the American Society of Anesthesiologists (ASA) score for long-term hip fracture mortality remains unknown. Our data showed that both RDW and ASA were independent risk predictors. A combination of these two parameters may provide a more powerful strategy for the prediction of hip fracture mortality.

INTRODUCTION

Red cell distribution width (RDW) has recently been suggested as an independent predictor of prognosis in a variety of disorders. The American Society of Anesthesiologists (ASA) system has been widely used to stratify patients for outcome evaluations. However, the prognostic value of RDW and a combination of RDW and the ASA score for long-term hip fracture mortality has yet to be studied.

METHODS

This prospective cohort study included 1402 subjects from 2000 to 2011 with a follow-up study over a 2 year period. Cox proportional hazards models with a bootstrap validation were used to evaluate associations of RDW, ASA, and a combination of both with long-term mortality. The global fit and the area under the receiver operating characteristic (ROC) curve (AUC) for model discrimination were further analyzed.

RESULTS

Both RDW and ASA exhibited as independent risk predictors of 2-year mortality. The population with elevation of either RDW or ASA increased the risk of mortality (bootstrap validated hazard ratio (HR) 1.971 95 % confidence interval (CI) [1.336-3.005] p < 0.01) while those with an increase in both assessments (bootstrap validated HR 2.667 95 % CI [1.526-4.515] p < 0.01) were at the highest risk for mortality. The addition of the combination of ASA and RDW improved the discrimination power of risk prediction models (AUC increased from 0.700 to 0.723, p < 0.05).

CONCLUSION

Both RDW and ASA exhibited as independent risk predictors of 2-year hip fracture mortality. The combination of these two readily available parameters may provide a more powerful and effective strategy for the assessment of all-cause mortality in hip fracture patients.

Red Cell Distribution Width as an Independent Predictor of Long-Term Mortality in Hip Fracture Patients: A Prospective Cohort Study

Red blood cell distribution width (RDW) has been found to be a significant prognostic factor of mortality in many cardiovascular diseases. However, a link between RDW at admission with long-term mortality in the hip fracture population has not been well established. Therefore, we sought to evaluate the long-term prognostic value of RDW in a well-defined hip fracture cohort, and to compare the effect of RDW in patients with and without anemia. A prospective cohort study was performed on 1479 hip fracture patients admitted at the General Hospital of Chinese PLA between January 2000 and October 2011 with a follow-up study over a 2-year period. A total of 1479 patients were used for the evaluation of 2-year all-cause mortality, while 804 patients with more than 4 years of follow-up were extracted for further evaluation of 4-year all-cause mortality. Cox proportional regression was used to evaluate the association between admission RDW and long-term mortality, adjusting for potential confounding variables. Higher RDW values were strongly associated with increased all-cause mortality. After adjusting for age, mean corpuscular volume, admission hemoglobin, comorbidities, and complications, RDW had a significant independent association with both 2-year mortality with a hazard ratio (HR) of 1.183 (95% confidence interval [CI], 1.017 to 1.376) and 4-year mortality with an HR of 1.244 (95% CI, 1.052 to 1.471). In stratified analysis, the effect of RDW was even more pronounced, with 2-year mortality HR of 1.341 (95% CI, 1.095 to 1.643) and 4-year mortality HR of 1.345 (95% CI, 1.071 to 1.688) in non-anemic patients. In non-anemic patients, elevated RDW values are significantly associated with increased odds of all-cause mortality, implying that RDW may be a possible laboratory biomarker for risk stratification in non-anemic hip fracture patients. Further studies are needed to confirm the current finding in different and larger hip fracture cohorts.

Hematological Parameters Improve Prediction of Mortality and Secondary Adverse Events in Coronary Angiography Patients: A Longitudinal Cohort Study

Prediction of primary cardiovascular events has been thoroughly investigated since the landmark Framingham risk score was introduced. However, prediction of secondary events after initial events of coronary artery disease (CAD) poses a new challenge. In a cohort of coronary angiography patients (n = 1760), we examined readily available hematological parameters from the UPOD (Utrecht Patient Oriented Database) and their addition to prediction of secondary cardiovascular events. Backward stepwise multivariable Cox regression analysis was used to test their ability to predict death and major adverse cardiovascular events (MACE). Continuous net reclassification improvement (cNRI) and integrated discrimination improvement (IDI) measures were calculated for the hematological parameters on top of traditional risk factors to assess prediction improvement. Panels of 3 to 8 hematological parameters significantly improved prediction of death and adverse events. The IDIs ranged from 0.02 to 0.07 (all P < 0.001) among outcome measures and the cNRIs from 0.11 to 0.40 (P < 0.001 in 5 of 6 outcome measures). In the hematological panels red cell distribution width (RDW) appeared most often. The multivariable adjusted hazard ratio of RDW per 1 standard deviation (SD) increase for MACE was 1.19 [1.08-1.32], P < 0.001. Routinely measured hematological parameters significantly improved prediction of mortality and adverse events in coronary angiography patients. Accurately indicating high-risk patients is of paramount importance in clinical decision-making.

Association of the dispersion in red blood cell volume with mortality

BACKGROUND

The red cell distribution width (RDW) predicts mortality among many populations. RDW is calculated as the standard deviation (SD) of the red blood cell (RBC) volume divided by mean corpuscular volume (MCV). Because higher MCV also predicts mortality, we hypothesized that the RDW numerator (one SD of RBC volume or 1SD-RDW) predicts mortality more strongly than the RDW.

MATERIAL AND METHODS

Adult subjects hospitalized during a contemporary clinical era (10/2005-1/2014, N = 135,963) and a historical era (1/1999-9/2005, N = 119,530) were studied. The RDW was obtained from the complete blood count (CBC), while 1SD-RDW was calculated (RDW multiplied by MCV and divided by 100).

RESULTS

In univariable Cox regression (2005-2014 cohort), 1SD-RDW (quintile 5 vs. 1: hazard ratio [HR] = 8.38, 95% confidence interval [CI] = 7.94, 8.85; P < 0.001) was a superior predictor of mortality compared to RDW (quintile 5 vs. 1: HR = 4.78, CI = 4.57, 5.00; P < 0.001). This superiority remained after adjustment for age, sex, basic metabolic profile components and other CBC factors excluding MCV (1SD-RDW: HR = 2.41, CI = 2.28, 2.55; RDW: HR = 2.01, CI = 1.92, 2.11). Further adjustment for MCV strengthened the RDW association (HR = 2.14, CI = 2.04, 2.24; P < 0.001), becoming indistinct from 1SD-RDW (HR = 2.20, CI = 2.08, 2.33; P < 0.001). Findings were similar for the 1999-2005 cohort.

CONCLUSIONS

The 1SD-RDW predicted mortality more strongly than RDW, suggesting that 1SD-RDW is superior to RDW as an individual risk predictor. Further, these results indicate that the dispersion of RBC volume and its mean are independent risk markers. Further research is required to understand the clinical value and mechanistic basis of these associations.

Continuous intravenous infusion of ATP in humans yields large expansions of erythrocyte ATP pools but extracellular ATP pools are elevated only at the start followed by rapid declines

The pharmacokinetics of adenosine 5'-triphosphate (ATP) was investigated in a clinical trial that included 15 patients with advanced malignancies (solid tumors). ATP was administered by continuous intravenous infusions of 8 h once weekly for 8 weeks. Three values of blood ATP levels were determined. These were total blood (erythrocyte) and blood plasma (extracellular) ATP pools along with the initial rate of release of ATP into the blood plasma. We found that values related to erythrocyte ATP pools showed great variability (diversity) among individuals (standard deviation of about 30-40% of mean at baseline). It was discovered that erythrocyte baseline ATP pool sizes are unique to each individual and that they fall within a narrow range in each individual. At the end of an 8 h continuous intravenous infusion of ATP, intracellular erythrocyte ATP pools were increased in the range of 40-60% and extracellular ATP declined from elevated levels achieved at the beginning and middle of the infusion, to baseline levels. The ability of erythrocytes to sequester exogenously administered ATP to this degree, after its initial conversion to adenosine in the blood plasma is unexpected, considering that some of the adenosine is likely to have been degraded by in vivo catabolic activities or taken up by organs. The data suggest that administration of ATP by short-term intravenous infusions, of up to 4 h, may be a favorable way for elevating extracellular ATP pools. A large fraction of the total exogenously administered ATP is sequestered into the intracellular compartments of the erythrocytes after an 8 h intravenous infusion. Erythrocytes loaded with ATP are known to release their ATP pools by the application of previously established agents or conditions applied locally or globally to circulating erythrocytes. Rapid degradation of intravenously administered ATP to adenosine and subsequent accumulation of ATP inside erythrocytes indicate the existence of very effective mechanisms for uptake of adenosine from blood plasma. These in vivo studies offer an understanding as to how both adenosine and ATP can act as purinergic transmission signals. ATP levels in blood are always accompanied by adenosine formed by catabolism of ATP. The continuous uptake of adenosine enables both to act in transmission of sometimes opposite functions.

Red blood cell distribution width: A simple parameter with multiple clinical applications

The red blood cell distribution width (RDW) is a simple and inexpensive parameter, which reflects the degree of heterogeneity of erythrocyte volume (conventionally known as anisocytosis), and is traditionally used in laboratory hematology for differential diagnosis of anemias. Nonetheless, recent evidence attests that anisocytosis is commonplace in human disorders such as cardiovascular disease, venous thromboembolism, cancer, diabetes, community-acquired pneumonia, chronic obstructive pulmonary disease, liver and kidney failure, as well as in other acute or chronic conditions. Despite some demographic and analytical issues related to the routine assessment that may impair its clinical usefulness, an increased RDW has a high negative predictive value for diagnosing a variety of disorders, but also conveys important information for short- and long-term prognosis. Even more importantly, the value of RDW is now being regarded as a strong and independent risk factor for death in the general population. Although it has not been definitely established whether an increased value of RDW is a risk factor or should only be considered an epiphenomenon of an underlying biological and metabolic imbalance, it seems reasonable to suggest that the assessment of this parameter should be broadened far beyond the differential diagnosis of anemias. An increased RDW mirrors a profound deregulation of erythrocyte homeostasis involving both impaired erythropoiesis and abnormal red blood cell survival, which may be attributed to a variety of underlying metabolic abnormalities such as shortening of telomere length, oxidative stress, inflammation, poor nutritional status, dyslipidemia, hypertension, erythrocyte fragmentation and alteration of erythropoietin function. As such, the aim of this article is to provide general information about RDW and its routine assessment, to review the most relevant implications in health and disease and give some insights about its potential clinical applications.

[Red cell distribution width and mortality following hospital discharge in patients over 70 years of age]

BACKGROUND AND OBJECTIVE

To examine whether red cell distribution width (RDW) performs as a mortality predictor after hospital discharge in patients over 70 years of age and if its prognostic power is superior to other laboratory parameters.

PATIENTS AND METHODS

Longitudinal and prospective study of 426 patients admitted to the Internal Medicine Department who survived hospitalization. Sociodemographic and comorbidity factors, functional and cognitive status as well as disease parameters causing admission (diagnosis, analytical parameters, length of stay) were collected. Patients were followed for one year by telephone interview and data were collected regarding vital status and, if appropriate, death date. RDW effect on mortality was assessed using logistic regression and prognostic capability by the area under the ROC curve.

RESULTS

Each percentage point rise in RDW was associated with increased mortality at one year with an odds ratio of 1.19 (95% confidence interval [95% CI] 1.08 to 1.31). Mortality in each tertile of RDW was 15.6% in the lowest, 21.5% in the middle and 30.5% in the highest. A clinical model supplemented with RDW improved mortality predictive ability assessed by ROC curve. Net reclassification improvement of the prediction rule was 1.71% (95% CI 0.07 to 3.35) p=0.04.

CONCLUSION

This study provides new evidence of the RDW association with mortality in a cohort of elderly patients who survived hospitalization. RDW was the only laboratory parameter that improved the one-year prognostic mortality ability.