Red cell distribution width improves the simplified acute physiology score for risk prediction in unselected critically ill patients

Association between red blood cell distribution width and 30-day mortality in critically ill septic patients: a propensity score-matched study

BACKGROUND

Sepsis is the leading cause of death worldwide, and a number of biomarkers have been developed for early mortality risk stratification. Red blood cell distribution width (RDW) is a routinely available hematological data and has been found to be associated with mortality in a number of diseases; therefore, we aim to address the association between RDW and mortality in critically ill patients with sepsis.

METHODS

We analyzed data of critically ill adult patients with sepsis on the TriNetX platform, excluding those with hematologic malignancies, thalassemia, and iron deficiency anemia. Propensity score-matching (PSM) (1:1) was used to mitigate confounding effects, and hazard ratio (HR) with 95% confidence (CI) was calculated to determine the association between RDW and 30-day mortality. We further conducted sensitivity analyses through using distinct cut-points of RDW and severities of sepsis.

RESULTS

A total of 256,387 critically ill septic patients were included in the analysis, and 40.0% of them had RDW equal to or higher than 16%. After PSM, we found that high RDW was associated with an increased 30-day mortality rate (HR: 1.887, 95% CI 1.847-1.928). The associations were consistent using distinct cut-points of RDW, with the strength of association using cut-points of 12%, 14%, 16%, 18% and 20% were 2.098, 2.204, 1.887, 1.809 and 1.932, respectively. Furthermore, we found consistent associations among critically ill septic patients with distinct severities, with the association among those with shock, receiving mechanical ventilation, bacteremia and requirement of hemodialysis being 1.731, 1.735, 2.380 and 1.979, respectively.

CONCLUSION

We found that RDW was associated with 30-day mortality in critically ill septic patients, underscoring the potential as a prognostic marker in sepsis. More studies are needed to explore the underlying mechanisms.

Prognosis impact of multiple novel lymphocyte-based inflammatory indices in patients with initially diagnosed coronary artery disease

BACKGROUND

This study aimed to evaluate six novel lymphocyte-based inflammatory markers (neutrophil-lymphocyte ratio, monocyte-lymphocyte ratio, platelet-lymphocyte ratio [PLR], systemic immune inflammation index [SII], systemic inflammatory response index, and systemic immune inflammation response index [SIIRI]) in patients with newly diagnosed coronary artery disease [CAD].

METHODS

A total of 959 patients newly diagnosed with CAD and underwent diagnostic coronary angiography were enrolled in this study and followed for major adverse cardiovascular events (MACEs), including cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke. The best cutoff value was used to compare the six indicators. Cox risk regression analysis evaluated the relationship between novel lymphocyte-based inflammatory markers and MACEs in newly diagnosed CAD patients.

RESULTS

During a mean follow-up period of 33.3 ± 9.9 months, 229 (23.9%) MACEs were identified. Multivariate Cox regression analysis showed that only SIIRI (hazard ratio [HR]: 5.853; 95% confidence interval [CI]: 4.092-8.371; p < .001) and PLR (HR: 1.725; 95% CI: 1.214-2.452; p = .002) were independent predictors of MACEs. Nevertheless, following the adjustment for covariates, only the SIIRI was found to be a significant predictor MACEs and its corresponding specific endpoint occurrences. The predictive ability of the model was improved when six different inflammatory markers were added to the basic model established by traditional risk factors, namely, the C-index increased, and the SIIRI increased most significantly (AUC: 0.778; 95% CI: 0.743-0.812; p < .001). However, among the six novel inflammatory markers, only SIIRI had improved net reclassification improvement (NRI) and integrated discrimination improvement (IDI) (NRI: 0.187; 95% CI: 0.115-0.259, p < .001. IDI: 0.135; 95% CI: 0.111-0.159, p < .001), which was superior to the basic model established by traditional risk factors.

CONCLUSIONS

SIIRI is independent predictor of MACEs in newly diagnosed CAD patients. SIIRI was superior to other measures in predicting MACEs. The combination of SIIRI and traditional risk factors can more accurately predict MACEs.

Red blood cell distribution width predicts mortality of adult patients receiving veno-arterial extracorporeal membrane oxygenation

BACKGROUND

Red blood cell distribution width (RDW) is a numerical measure of the variation in the size of circulating red blood cells. Recently, there is increasing interest in the role of RDW as a biomarker for inflammatory states and as a prognostication tool for a wide range of clinical manifestations. The predictive power of RDW on mortality among patients receiving mechanical circulatory support remains largely unknown.

METHODS

A retrospective analysis of 281 VA-ECMO patients at a tertiary referral academic hospital from 2009 to 2019 was performed. RDW was dichotomized with RDW-Low <14.5% and RDW-High ≥14.5%. The primary outcome was all-cause mortality at 30 days and 1 year. Cox proportional hazards models were used to examine the association between RDW and the clinical outcomes after adjusting for additional confounders.

RESULTS

281 patients were included in the analysis. There were 121 patients (43%) in the RDW-Low group and 160 patients (57%) in the RDW-High group. Survival to ECMO decannulation [RDW-H: 58% versus RDW-L: 67%, p = 0.07] were similar between the two groups. Patients in RDW-H group had higher 30-days mortality (RDW-H: 67.5% vs RDW-L: 39.7%, p < 0.001) and 1 year mortality (RDW-H: 79.4% vs RDW-L: 52.9%, p < 0.001) compared to patients in the RDW-L group. After adjusting for confounders, Cox proportional hazards model demonstrated that patients with high RDW had increased odds of mortality at 30 days (hazard ratio 1.9, 95% CI 1.2-3.0, p < 0.01) and 1 year (hazard ratio 1.9, 95% CI 1.3-2.8, p < 0.01) compared to patients with low RDW.

CONCLUSIONS

Among patients receiving mechanical circulatory support with VA-ECMO, a higher RDW was independently associated with increased 30-days and 1-year mortality. RDW may serve as a simple biomarker that can be quickly obtained to help provide risk stratification and predict survival for patients receiving VA-ECMO.

Association between Red Cell Distribution Width and Outcomes of Nonagenarians Admitted to the Intensive Care Unit-A Retrospective Cohort Study

The red cell distribution width (RDW) measures the heterogeneity of the erythrocyte volume. Different clinical conditions are associated with increased RDW, and high levels (>14.5%) have been described as a predictive marker for unfavorable outcomes and mortality in critically ill patients. However, there is a lack of data on very elderly critically ill patients. Therefore, we aimed to investigate the association of RDW with outcomes in critically ill patients ≥ 90 years. A retrospective analysis was conducted for all consecutive critically ill patients ≥ 90 years who were admitted to the Department of Intensive Care Medicine of the Medical University Centre Hamburg-Eppendorf (Hamburg, Germany) with available RDW on admission. Clinical course and laboratory were analyzed for all patients with eligible RDW. High RDW was defined as (>14.5%). We clinically assessed factors associated with mortality. Univariable and multivariable Cox regression analysis was performed to determine the prognostic impact of RDW on 28-day mortality. During a 12-year period, we identified 863 critically ill patients ≥ 90 years old with valid RDW values and complete clinical data. In total, 32% (n = 275) died within 28 days, and 68% (n = 579) survived for 28 days. Median RDW levels on ICU admission were significantly higher in non-survivors compared with survivors (15.6% vs. 14.8%, p < 0.001). Overall, 38% (n = 327) had low, and 62% (n = 536) had high RDW. The proportion of high RDW (>14.5%) was significantly higher in non-survivors (73% vs. 57%, p < 0.001). Patients with low RDW presented with a lower Charlson Comorbidity Index (p = 0.014), and their severity of illness on admission was lower (SAPS II: 35 vs. 38 points, p < 0.001). In total, 32% (n = 104) in the low and 35% (n = 190) in the high RDW group were mechanically ventilated (p = 0.273). The use of vasopressors (35% vs. 49%, p < 0.001) and renal replacement therapy (1% vs. 5%, p = 0.007) was significantly higher in the high RDW group. Cox regression analysis demonstrated that high RDW was significantly associated with 28-day mortality [crude HR 1.768, 95% CI (1.355-2.305); p < 0.001]. This association remained significant after adjusting for multiple confounders [adjusted HR 1.372, 95% CI (1.045-1.802); p = 0.023]. High RDW was significantly associated with mortality in critically ill patients ≥ 90 years. RDW is a useful simple parameter for risk stratification and may aid guidance for the therapy in very elderly critically ill patients.

Predictive Modeling Using Artificial Intelligence and Machine Learning Algorithms on Electronic Health Record Data: Advantages and Challenges

The rapid adoption of electronic health record (EHR) systems in US hospitals from 2008 to 2014 produced novel data elements for analysis. Concurrent innovations in computing architecture and machine learning (ML) algorithms have made rapid consumption of health data feasible and a powerful engine for clinical innovation. In critical care research, the net convergence of these trends has resulted in an exponential increase in outcome prediction research. In the following article, we explore the history of outcome prediction in the intensive care unit (ICU), the growing use of EHR data, and the rise of artificial intelligence and ML (AI) in critical care.

Red blood cell distribution width for the prediction of outcomes after cardiac arrest

The red blood cell distribution width (RDW) is a routinely available blood marker that measures the variation of the size/volume of red blood cells. The aim of our study was to investigate the prognostic value of RDW in cardiac arrest patients and to assess whether RDW improves the prognostic value of three cardiac arrest-specific risk scores. Consecutive adult cardiac arrest patients admitted to the ICU of a Swiss university hospital were included. The primary outcome was poor neurological outcome at hospital discharge assessed by Cerebral Performance Category. Of 702 patients admitted to the ICU after cardiac arrest, 400 patients (57.0%) survived, of which 323 (80.8%) had a good neurological outcome. Higher mean RDW values showed an independent association with poor neurological outcomes at hospital discharge (adjusted OR 1.27, 95% CI 1.14 to 1.41; p < 0.001). Adding the maximum RDW value to the OHCA- CAHP- and PROLOGUE cardiac arrest scores improved prognostic performance. Within this cohort of cardiac arrest patients, RDW was an independent outcome predictor and slightly improved three cardiac arrest-specific risk scores. RDW may therefore support clinical decision-making.

Prognostic Role of Red Cell Distribution Width (RDW) in Patients with Diffuse Large B-cell Lymphoma

INTRODUCTION

Several A number of prognostic blood markers related tofor Diffuse Large B-Cell Lymphoma (DLBCL) have been identified, most of which are costly and not easily availableaccessible. Although the relationship between the prognostic role of RDW and some cancers has been well established, the role it   of RDW plays in DLBCL patients is unclear still questionable and requires more investigations.

METHODS

All patients diagnosed with DLBCL who had referred to Imam Reza Hospital, during  were included in this retrospective cohort study. Based onRegarding their RDW, the subjects were divided into two groups of normal (RDW ≤14.6%) and elevated RDW (RDW > 14.6%) RDW, and the outcomes were investigated.

RESULTS

One hundred fifty patients with DLBCL were included in this study. The results showed a significant relationship between the RDW values of the DLBCL patients and stage frequency distribution, relapse, mortality, and complete remission (P value<0.05). It was also found out that elevated RDW > 14.6% was associated with the risk of relapse (OR=2.50, P value<0.05), mortality (OR=3.59, P value<0.01), and lack of complete remission (OR=0.115, P value< 0.01). The results of the survival analysis indicated that the subjects with higher RDWs had a lower median survival rate than those with low RDWs. In addition, the mortality risk for the individuals with RDW > 14.6% was 2.44 times that of those with RDW≤14.6% (HR=2.44, P value<0.05).

CONCLUSION

The results of this study well indicated that as an independent prognostic factor, RDW was associated with the stage of DLBCL patients, failure to achieve complete remission, disease relapse, and patient mortality. However, further studies are would be needed to realize determine the role of RDW in DLBCL patients.

A new hematologic predictor of major adverse events after cardiac surgery: red cell distribution width to lymphocyte ratio

BACKGROUND

The perioperative risk factors that cause severe morbidity and prolongation of postoperative hospital stay after cardiac surgery should be determined. Various scores have been used to predict morbidity and mortality. Preoperative blood counts are considered potential biomarkers of inflammation and oxidative stress. Inflammatory and immune imbalances may have a significant impact on postoperative adverse events. The present study aimed to investigate the association and potential predictive properties of red cell distribution width/ lymphocyte ratio (RLR) for major adverse events in adult patients who underwent coronary surgery with cardiopulmonary bypass.

METHODS

After approval from the ethics committee, pre- and post-operative data of 700 patients were obtained from the electronic database of the hospital, intra- and post-operative anesthesia, and intensive care unit follow-up charts. We performed a stepwise multiple logistic regression analysis to investigate the association of RLR with major adverse events in adult patients who underwent coronary surgery with cardiopulmonary bypass.

RESULTS

Among 700 patients, 47 (6.7%) had major adverse events after surgery. Multivariate logistic regression analysis showed that age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.03-1.12; P < 0.001), mean platelet volume (OR, 1.49; 95% CI, 1.07-2.06; P = 0.017), and RLR (OR, 1.21; 95% CI, 1.02-1.43; P = 0.026) were significantly associated with major adverse events.

CONCLUSIONS

RLR indicates the balance between inflammatory and immune responses. Therefore, it can be used to predict adverse events following coronary surgery.

Association between red blood cell distribution width and all-cause mortality in unselected critically ill patients: Analysis of the MIMIC-III database

Background

Although red cell distribution width (RDW) is widely observed in clinical practice, only a few studies have looked at all-cause mortality in unselected critically ill patients, and there are even fewer studies on long-term mortality. The goal of our study was to explore the prediction and inference of mortality in unselected critically ill patients by assessing RDW levels.

Methods

We obtained demographic information, laboratory results, prevalence data, and vital signs from the unselected critically ill patients using the publicly available MIMIC-III database. We then used this information to analyze the association between baseline RDW levels and unselected critically ill patients using Cox proportional risk analysis, smoothed curve fitting, subgroup analysis, and Kaplan–Meier survival curves for short, intermediate, and long-term all-cause mortality in unselected critically ill patients.

Results

A total of 26,818 patients were included in our study for the final data analysis after screening in accordance with acceptable conditions. Our study investigated the relationship between RDW levels and all-cause mortality in a non-selected population by a smoothed curve fit plots and COX proportional risk regression models integrating cubic spline functions reported results about a non-linear relationship. In the fully adjusted model, we found that RDW values were positively associated with 30-day, 90-day, 365-day, and 4-year all-cause mortality in 26,818 non-selected adult patients with HRs of 1.10 95%CIs (1.08, 1.12); 1.11 95%CIs (1.10, 1.13); 1.13 95%CIs (1.12, 1.14); 1.13 95%CIs (1.12, 1.14).

Conclusion

In unselected critically ill patients, RDW levels were positively associated with all-cause mortality, with elevated RDW levels increasing all-cause mortality.

Comparison of Serum Selenium, Homocysteine, Zinc, and Vitamin D Levels in Febrile Children with and without Febrile Seizures: A Prospective Single-Center Study

OBJECTIVE

Febrile seizure is a complication that makes physicians and families uneasy when detected in children with a high fevers. This study aimed to compare children with febrile seizures and children without seizures in blood selenium, zinc, homocysteine, vitamin D, vitamin B12, and magnesium levels.

MATERIALS AND METHODS

The study group included sixty-one children between the ages of 1-5 who came to the pediatric emergency department with febrile seizure. The control group had 61 children with fever without seizure, who were compatible with the study group in age, sex, and elapsed time since the onset of fever. Blood samples were taken from the patients during their admission. Selenium, zinc, vitamin D, homocysteine, vitamin B12, and magnesium levels were measured, and the data of the two groups were compared. Additionally, patients in the study group had two subgroups, simple and complex febrile seizures, and their parameters were compared.

RESULTS

Selenium, zinc, vitamin D, and vitamin B12 levels were significantly lower in the study group than in the control group (p < 0.001), and there was no significant difference in homocysteine (p = 0.990) and magnesium levels (p = 0.787) between the two groups. Moreover, no significant difference was found between those with simple and complex febrile seizures in selenium, vitamin D, homocysteine, vitamin B12, and magnesium levels.

CONCLUSIONS

Elevated levels of selenium, zinc, vitamin D, and vitamin B12 in the blood of children with fevers help to prevent febrile seizures.

Effect of Red Cell Distribution Width on the Prognosis of Patients with Traumatic Brain Injury: A Retrospective Cohort Study

BACKGROUND

The link between red cell distribution width (RDW) and prognosis of traumatic brain injury (TBI) is controversial. Whether RDW can increase the prognostic value of established predictors remains unknown. This study aimed to provide supportive evidence for the prognostic value of RDW.

METHODS

Clinical data of 1488 patients with TBI were extracted from the Multiparameter Intelligent Monitoring in Intensive Care III database and classified into 2 groups: 1) one with RDW <14.5% (n = 1061) and 2) the other with RDW ≥14.5% (n = 427). Multivariable logistic regression models were used to estimate the relationship between RDW and outcomes. Stratified analyses and interactions were also performed. We compared the area under the receiver operating characteristic curve of the International Mission for Prognoses and Clinical Trial Design in TBI (IMPACT) core and extended models with and without RDW.

RESULTS

After adjusting for confounding factors, RDW was an independent risk consideration for TBI prognoses; the odds ratios were 1.62 (95% confidence interval (CI): 1.05, 2.50) and 1.89 (95% CI: 1.35, 2.64) for hospital mortality and 6-month mortality, respectively. This association was crucial for patients with a Glasgow Coma Score of 3-12 (odds ratio, 2.79; 95% CI: 1.33, 5.87). For 6-month mortality, when RDW was added to the core and extended IMPACT models, the area under the receiver operating characteristic curve increased from 0.833 to 0.851 (P = 0.001) and from 0.842 to 0.855 (P = 0.002), respectively.

CONCLUSIONS

Elevated RDW is an independent risk consideration for hospital and 6-month mortality rates. When RDW was added to the IMPACT core and extended models, it improved its predictive ability for 6-month mortality in patients with TBI.

Prognostic value of red cell distribution width and mean corpuscular volume on mortality in hemodialysis patients

BACKGROUND

Anemia is a common consequence of chronic kidney disease (CKD). Red cell distribution width (RDW) and mean corpuscular volume (MCV) are principally used for differential diagnosis of anemia. Limited evidence is available for its prognostic value for mortality in hemodialysis (HD) patients. We aimed to definite the relationship between RDW and MCV and mortality in HD patients.

METHOD

This cohort study examined all-cause and cardiovascular (CV) mortality with 181 maintenance HD patients from February 2015. Patients were divided into four groups according to the median of RDW and MCV. Pearson analysis was conducted to determine the related factors of RDW and MCV. The independent association of RDW and MCV with mortality was examined with Kaplan-Meier curve and Cox regression analysis.

RESULTS

This study included 181 HD patients for a median follow-up of 71 months. We found RDW was positively related to neutrophil count, C-reaction protein, and ferritin, while negatively related to hemoglobin, albumin, and creatinine. Only neutrophil count and ferritin were significantly related to MCV in this study. In the multivariate Cox regression analysis, the high RDW group was associated with higher risk of all-cause mortality (odds ratio, 3.787; 95% confidence interval, 1.037 to 13.834; p = 0.044). The relationship between RDW and MCV and CV mortality was not significant.

CONCLUSIONS

RDW could emerge as an additive risk factor for all-cause mortality in maintenance HD patients, independent of other factors. An absolute value of MCV to predict mortality and the underlying pathophysiologic mechanisms should be confirmed in the future.

Haematological parameters predicting cardiac involvement in children with COVID-19 infection

AIM

Haematological parameters obtained from the full blood count, such as neutrophil-to-lymphocyte ratio (NLR), are cost-effective tests which have been shown to be predictive of the prognosis of many diseases. We aimed to evaluate certain haematological parameters and cardiac biomarkers to test whether they could predict cardiac involvement by COVID-19 infection.

METHODS

This retrospective study included patients aged 1 month to 18 years having a positive COVID-19 PCR test but no comorbidity, who were admitted to the paediatric emergency department between 15 March 2020 and 1 February 2021.

RESULTS

There were 292 COVID-19 PCR-positive patients, 12 MIS-C patients and 70 healthy controls. A receiver operator characteristic curve analysis was performed to predict MIS-C in patients with COVID-19 infection. An NLR value of ≥5.03 could predict MIS-C with a sensitivity of 66.7% and a specificity of 91.6%; a proBNP value of ≥329.5 ng/L with a sensitivity of 91.7% and a specificity of 95.6%; a CKMB value of ≥2.95 μg/L with a sensitivity of 100% and a specificity of 77.7%; and a troponin-I value of ≥0.03 μg/L with a sensitivity of 75% and a specificity of 99.2%. A logistic regression analysis showed that an NLR value of ≥5.03 increased the risk of MIS-C 19.3 fold; a proBNP value of ≥329.5 ng/L increased the risk 238 fold; and a troponin-I value of ≥0.03 μg/L increased the risk 60 fold.

CONCLUSIONS

At the time of admission, parameters such as proBNP, troponin-I and NLR can predict the development of MIS-C in COVID-19 patients with high sensitivity and specificity.

Acute Myocardial Infarction (AMI) as the Effect Modifiers to Modify the Association Between Red Blood Cell Distribution Width (RDW) and Mortality in Critically Ill Patients With Stroke

Background and Objectives

Few studies have evaluated the impact of red blood cell distribution width (RDW) on prognosis for critically ill patients with acute stroke according to recent studies. The aim of this study was to investigate the association between RDW and mortality in these patients.

Methods

Clinical data were extracted from the eICU Collaborative Research Database (eICU-CRD) and analyzed. The exposure of interest was RDW measured at admission. The primary outcome was in-hospital mortality. Binary logistic regression models and interaction testing were performed to examine the RDW-mortality relationship and effect modification by acute myocardial infarction and hypertension (HP).

Results

Data from 10,022 patients were analyzed. In binary logistic regression analysis, after adjusting for potential confounders, RDW was found to be independently associated with in-hospital mortality {odds ratio (OR) 1.07, [95% confidence interval (CI) 1.03 to 1.11]; p = 0.001}. Higher RDW linked to an increase in mortality (OR, 1.07; 95% CI, 1.03 to 1.11; P for trend < 0.0001). Subgroup analysis showed that, in patients combined with AMI and without HP (both P-interaction <0.05), the correlation between RDW and in-hospital mortality is stronger (AMI group: OR, 1.30; 95% CI, 1.07 to 1.58, not the AMI group: OR, 1.06; 95% CI, 1.02, 1.10; the HP group: OR,.98; 95% CI,.91 to 1.07, not the HP group: OR, 1.09; 95% CI, 1.05 to 1.14).

Conclusions

A higher baseline RDW is independently correlated with prognosis in critically ill patients with acute stroke, and the correlation can be modified by AMI and HP duration.

Domain Adaptation Using Convolutional Autoencoder and Gradient Boosting for Adverse Events Prediction in the Intensive Care Unit

More than 5 million patients have admitted annually to intensive care units (ICUs) in the United States. The leading causes of mortality are cardiovascular failures, multi-organ failures, and sepsis. Data-driven techniques have been used in the analysis of patient data to predict adverse events, such as ICU mortality and ICU readmission. These models often make use of temporal or static features from a single ICU database to make predictions on subsequent adverse events. To explore the potential of domain adaptation, we propose a method of data analysis using gradient boosting and convolutional autoencoder (CAE) to predict significant adverse events in the ICU, such as ICU mortality and ICU readmission. We demonstrate our results from a retrospective data analysis using patient records from a publicly available database called Multi-parameter Intelligent Monitoring in Intensive Care-II (MIMIC-II) and a local database from Children's Healthcare of Atlanta (CHOA). We demonstrate that after adopting novel data imputation on patient ICU data, gradient boosting is effective in both the mortality prediction task and the ICU readmission prediction task. In addition, we use gradient boosting to identify top-ranking temporal and non-temporal features in both prediction tasks. We discuss the relationship between these features and the specific prediction task. Lastly, we indicate that CAE might not be effective in feature extraction on one dataset, but domain adaptation with CAE feature extraction across two datasets shows promising results.

Red cell distribution width, illness severity, and all-cause mortality in dogs admitted to the ICU

OBJECTIVE

To determine whether red cell distribution width (RDW) can predict illness severity and mortality risk in a heterogenous population of dogs admitted to the ICU.

DESIGN

Prospective observational study.

SETTING

Large, urban, private teaching hospital.

ANIMALS

One hundred eleven dogs consecutively admitted to the ICU between September 2017 and December 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Abbreviated Acute Patient Physiologic and Laboratory Evaluation (APPLE_fast ) score and RDW were measured within 6 h of ICU admission. This study did not demonstrate a significant difference in illness severity across patients stratified by RDW. There was no difference in RDW between survivors and nonsurvivors at hospital discharge or at 30 days.

CONCLUSIONS

In this study population, RDW did not correspond with illness severity as measured by APPLE_fast . Moreover, RDW did not predict in-hospital or 30-day mortality.

Retrospective evaluation of red blood cell distribution width as a prognostic factor in critically ill dogs (December 2016 to April 2017): 127 cas

OBJECTIVE

To evaluate the association between RBC distribution width (RDW) and in-hospital mortality, length of hospitalization, and leukocyte count in critically ill dogs.

DESIGN

Retrospective study.

SETTING

University teaching hospital.

ANIMALS

One hundred and twenty-seven dogs admitted to the ICU from December 2016 to April 2017. Patients were included if they had a CBC performed within the first 24 h of admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The overall in-hospital mortality rate was 29% (37/127), and median length of hospital stay was 3 days (interquartile range [IQR], 5). The median RDW value was 13.8% (IQR, 1.6%; reference interval, 11.9%-14.5 %). The canine Acute Patient Physiologic and Laboratory Evaluation (APPLE) fast score was calculated in 81 of 127 (64%) patients; the median score was 24/50 (IQR, 9). There was no significant correlation between RDW and APPLE fast score (P = 0.163). Subgroup analysis was performed according to the following diagnostic categories: abdominal (36%; 46/127), hematological (13%; 16/127), respiratory (13%; 16/127), neurological (12%; 15/127), cardiovascular (11%; 14/127), integument (3%; 4/127), trauma (3%; 4/127), musculoskeletal (2%; 3/127), and others (7%; 9/127). Increased RDW was not associated with in-hospital mortality overall (P = 0.381) or in any individual subgroup analysis. No association was found between length of hospitalization and RDW values in either survivors (P = 0.548) or nonsurvivors (P = 0.083). The correlation between RDW and leukocyte count was nonsignificant (P = 0.12).

CONCLUSIONS

In this study, admission RDW was not associated with in-hospital mortality or length of hospitalization in critically ill dogs. The correlation between RDW and leukocyte count was nonsignificant.

A Prognostic Model Incorporating Red Cell Distribution Width to Platelet Ratio for Patients with Traumatic Brain Injury

BACKGROUND

As an inflammation-based marker, red cell distribution width to platelet ratio (RPR) has been verified to be associated with disease severity and outcome in many clinical settings. We designed this study to evaluate the prognostic value of RPR in patients with traumatic brain injury (TBI).

METHODS

A total of 420 patients admitted with TBI were included in this study. Laboratory and clinical data were collected from an electronic medical record system. Univariate and multivariate logistic regression analyses were sequentially performed to discover risk factors of in-hospital mortality. Receiver operating characteristic (ROC) curves were drawn to confirm the predictive value of different markers including RPR in training set and testing set.

RESULTS

Non-survivors had higher level of RPR than survivors (P<0.001). Logistic regression analysis showed that RPR was significantly associated with mortality even after adjusting for confounding factors (P<0.001). The area under the ROC curve (AUC) value of Glasgow Coma Scale (GCS) for predicting mortality was 0.761 and 0775 in training set and testing set, respectively. And the constructed predictive model incorporating RPR had the highest AUC value of 0.858 and 0.884 in training set and testing set.

CONCLUSION

RPR is significantly associated with mortality in TBI patients. Utilizing RPR to construct a predictive model is valuable to evaluate prognosis of TBI patients.

The Role of Red Blood Cell Distribution Width in the Severity and Prognosis of Community-Acquired Pneumonia

Objectives

The objective of this study is to unravel the correlation between RDW and the severity and prognosis of CAP, as well as exploring RDW with the inflammatory markers white blood cells (WBC), C-reactive protein (CRP), and procalcitonin (PCT).

Methods

According to the data characteristics, appropriate statistical methods were selected to analyze the relationship between RDW and the severity and prognosis of CAP patients and to determine whether RDW is associated with the inflammatory markers WBC, CRP, and PCT.

Results

The results show that with the increase of PSI and CURB-65 values, the proportion of patients with RDW ≥ 12.987% is significantly higher than that of RDW < 12.987% (P < 0.01). When RDW is combined with PSI or CURB-65 to predict the 90-day mortality of CAP patients, the area under the receiver operating characteristic (ROC) curve increased prominently, and if RDW, PSI, and CURB-65 are combined, the area under the ROC curve is maximized.

Conclusions

Our findings suggest that the higher RDW value is associated with short-term adverse outcomes in CAP patients. We also find that when RDW, PSI, and CURB-65 are combined, the best performance is achieved to predict CAP 90-day mortality risk.

Red blood cell distribution width predicts in-hospital mortality in patients with a primary diagnosis of seizures in the ICU: a retrospective database study

Purpose

The aim of this study was to determine the predictive value of red blood cell distribution width (RDW) in patients with a primary diagnosis of seizures admitted to the intensive care unit (ICU) in terms of in-hospital mortality.

Methods

This was a retrospective study of the eICU Collaborative Research Database of adult patients (aged 18–88 years) with a primary diagnosis of seizures in 2014 and 2015. The prognostic value of RDW was investigated using a receiver operating characteristic (ROC) curve, multiple logistic regression model, and net reclassification index (NRI).

Results

We identified 1568 patients who met the inclusion criteria. High RDW was significantly correlated with in-hospital mortality after adjusting for potential confounders with an odds ratio (OR) of 3.513 (95% confidence interval [CI]:1.699–7.266). The area under the ROC curve of RDW for in-hospital mortality was 0.7225. Compared with the prediction of in-hospital mortality using APACHE IV score alone, the continuous NRI with the RDW variable was 0.3507 (95%CI: 0.0584–0.6431, p < 0.05). The length of stay in the ICU of patients with an RDW >14.65% was significantly increased compared to those with normal RDW (log-rank test, p < 0.0001).

Conclusion

RDW width can be useful for prediction of in-hospital mortality in patients with seizures admitted to the ICU, and it provides additional prognostic value beyond the APACHE IV score alone.

Complete hemogram: simple and cost-effective in staging and predicting outcome in acute pancreatitis

BACKGROUND

An important goal in management of acute pancreatitis (AP) is early prediction and recognition of disease severity. Various predictive scoring systems are in clinical use with their own limitations and there is always a quest for simple, practical, quantifiable, dynamic and readily available markers for predicting disease severity and outcome. Complete hemogram is routinely ordered in all patients with AP. In recent years red cell distribution width (RDW), neutrophil-lymphocyte ratio (NLR), lymphocyte-monocyte ratio (LMR) and platelet lymphocyte ratio (PLR) have been found to be independent predictors of prognosis in various benign and malignant conditions. This prospective study evaluated complete hemogram based markers in AP.

MATERIAL AND METHODS

Complete hemogram analysis was done and NLR, LMR, PLR values were calculated. Development of organ failure, the need for intensive care unit (ICU) admission and interventions, development of complications (local/systemic) and 100-day mortality were assessed.

RESULTS

In this study 160 subjects of AP were included. Complete hemogram analysis was performed within 24 h after admission. C‑reactive protein, RDW, NLR, PLR and bedside index of severity in acute pancreatitis (BISAP) values were higher in severe AP than moderate AP group than mild AP group, while LMR values were decreased in the corresponding severe, moderate and mild AP groups (p < 0.001). The NLR performed best for prediction of ICU admission, organ failure, interventions and mortality with area under receiver operating curve (AUROC) were 0.943, 0.940, 0.902 and 0.910, respectively.

CONCLUSION

Hemogram based markers are simple, objective, dynamic and readily available. They can be considered in addition to conventional multifactorial scoring systems for prediction of outcome and prognosis of AP.

Anemia in patients with Covid-19: pathogenesis and clinical significance

COVID-19 patients typically present with lower airway disease, although involvement of other organ systems is usually the rule. Hematological manifestations such as thrombocytopenia and reduced lymphocyte and eosinophil numbers are highly prevalent in COVID-19 and have prognostic significance. Few data, however, are available about the prevalence and significance of anemia in COVID-19. In an observational study, we investigated the prevalence, pathogenesis and clinical significance of anemia among 206 patients with COVID-19 at the time of their hospitalization in an Internal Medicine unit. The prevalence of anemia was 61% in COVID-19, compared with 45% in a control group of 71 patients with clinical and laboratory findings suggestive of COVID-19, but nasopharyngeal swab tests negative for SARS-CoV-2 RNA (p = 0.022). Mortality was higher in SARS-CoV-2 positive patients. In COVID-19, females had lower hemoglobin concentration than males and a higher prevalence of moderate/severe anemia (25% versus 13%, p = 0.032). In most cases, anemia was mild and due to inflammation, sometimes associated with iron and/or vitamin deficiencies. Determinants of hemoglobin concentration included: erythrocyte sedimentation rate, serum cholinesterase, ferritin and protein concentrations and number of chronic diseases affecting each patient. Hemoglobin concentration was not related to overall survival that was, on the contrary, influenced by red blood cell distribution width, age, lactate dehydrogenase and the ratio of arterial partial oxygen pressure to inspired oxygen fraction. In conclusion, our results highlight anemia as a common manifestation in COVID-19. Although anemia does not directly influence mortality, it usually affects elderly, frail patients and can negatively influence their quality of life.

Initial red cell distribution width as a predictor of poor neurological outcomes in out-of-hospital cardiac arrest survivors in a prospective, multicenter observational study (the KoCARC study)

This study aimed to investigate whether the initial red cell distribution width (RDW) at the emergency department (ED) is associated with poor neurological outcomes in out-of-hospital cardiac arrest (OHCA) survivors. We performed a prospective observational analysis of patients admitted to the ED between October 2015 and June 2018 from the Korean Cardiac Arrest Research Consortium registry. We included OHCA patients who visited the ED and achieved return of spontaneous circulation. Initial RDW values were measured at the time of the ED visit. The primary outcome was a poor neurological (Cerebral Performance Category, or CPC) score of 3–5. A total of 1008 patients were ultimately included in this study, of whom 712 (70.6%) had poor CPC scores with unfavorable outcomes. Higher RDW quartiles (RDW 13.6–14.9%, RDW ≥ 15.0%), older age, female sex, nonshockable initial rhythm at the scene, unwitnessed cardiac arrest, bystander cardiopulmonary resuscitation (CPR), medical history, low white blood cell counts and high glucose levels were associated with poor neurological outcomes in univariate analysis. In multivariate analysis, the highest RDW quartile was independently associated with poor neurological outcomes (odds ratio 2.04; 95% confidence interval 1.12–3.69; p = 0.019) at hospital discharge after adjusting for other confounding factors. Other independent factors including age, initial rhythm, bystander CPR and high glucose were also associated with poor neurological outcomes. These results show that an initial RDW in the highest quartile as of the ED visit is associated with poor neurological outcomes at hospital discharge among OHCA survivors.

Evaluation of the usefulness of red blood cell distribution width in critically ill pediatric patients

Red blood cell distribution width (RDW) is a component of routine complete blood count, which reflects variability in the size of circulating erythrocytes. Recently, there have been many reports about RDW as a strong prognostic marker in various disease conditions in the adult population. However, only a few studies have been performed in children. This study aimed to investigate the association between RDW and pediatric intensive care unit (PICU) mortality in critically ill children. This study includes 960 patients admitted to the PICU from November 2012 to May 2018. We evaluated the associations between RDW and clinical parameters including PICU mortality outcomes. The median age of the study population was 15.5 (interquartile range, 4.8-54.5) months. The mean RDW was 15.6% ± 3.3%. The overall PICU mortality was 8.8%. As we categorized patients into 3 groups with respect to RDW values (Group 1: ≤14.5%; Group 2: 14.5%-16.5%; and Group 3: >16.5%) and compared clinical parameters, the higher RDW groups (Groups 2 and 3) showed more use of vasoactive-inotropic drugs, mechanical ventilator support, higher severity scores, including pediatric risk of mortality III, pediatric sequential organ failure assessment, pediatric logistic organ dysfunction-2 (PELOD-2), and pediatric multiple organ dysfunction syndrome scores, and higher PICU mortality than the lower RDW group (Group 1) (P < .05). Based on multivariate logistic regression analysis adjusted for age and sex, higher RDW value (≥14.5%) was an independent risk factor of PICU mortality. Moreover, adding RDW improved the performance of the PELOD-2 score in predicting PICU mortality (category-free net reclassification index 0.357, 95% confidence interval 0.153-0.562, P = .001). In conclusion, higher RDW value was significantly associated with worse clinical parameters including PICU mortality. RDW was an independent risk factor of PICU mortality and the addition of RDW significantly improved the performance of PELOD-2 score in predicting PICU mortality. Thus, RDW could be a promising prognostic factor with advantages of simple and easy measurement in critically ill pediatric patients.

The predictive value of RDW in AKI and mortality in patients with traumatic brain injury

Background

Red blood cell distribution width (RDW) has been validated valuable in predicting outcome and acute kidney injury (AKI) in several clinical settings. The aim of this study was to explore whether RDW is associated with outcome and AKI in patients with traumatic brain injury (TBI).

Methods

Patients admitted to our hospital for TBI from January 2015 to August 2018 were included in this study. Multivariate logistic regression analysis was performed to identify risk factors of AKI and outcome in patients with TBI. The value of RDW in predicting AKI and outcome was evaluated by receiver operating characteristic (ROC) curve.

Results

Three hundred and eighteen patients were included in this study. The median of RDW was 14.25%. We divided subjects into two groups based on the median and compared difference of variables between two groups. The incidence of AKI and mortality was higher in high RDW (RDW > 14.25) group (31.45% vs 9.43%, P < .001; 69.81% vs 29.56%, P < .001). Spearman's method showed RDW was moderately associated with 90‐day Glasgow Outcome Scale (GOS) (P < .001). In multivariate logistic regression analysis, RDW, lymphocyte, chlorine, and serum creatinine were risk factors of AKI. And Glasgow Coma Scale (GCS), glucose, chlorine, AKI, and RDW were risk factors of mortality. The area under the ROC curve (AUC) of RDW for predicting AKI and mortality was 0.724 (0.662‐0.786) and 0.754 (0.701‐0.807), respectively. Patients with higher RDW were likely to have shorter median survival time (58 vs 70, P < .001).

Conclusions

Red blood cell distribution width is an independent risk factor of AKI and mortality in patients with TBI.

Erythrocyte transfusion limits the role of elevated red cell distribution width on predicting cardiac surgery associated acute kidney injury

BACKGROUND

Acute kidney injury (AKI) is one of the more serious complications after cardiac surgery. Elevated red cell distribution width (RDW) was reported as a predictor for cardiac surgery associated acute kidney injury (CSAKI). However, the increment of RDW by erythrocyte transfusion makes its prognostic role doubtful. The aim of this study is to elucidate the impact of erythrocyte transfusion on the prognostic role of elevated RDW for predicting CSAKI.

METHODS

A total of 3207 eligible patients who underwent cardiac surgery during 2016-2017 were enrolled. Changes of RDW was defined as the difference between preoperative RDW and RDW measured 24 h after cardiac surgery. The primary outcome was CSAKI which was defined by the Kidney Disease: Improving Global Outcomes Definition and Staging (KDIGO) criteria. Univariate and multivariate analysis were performed to identify predictors for CSAKI.

RESULTS

The incidence of CSAKI was 38.07% and the mortality was 1.18%. CSAKI patients had higher elevated RDW than those without CSAKI (0.65% vs. 0.39%, p < 0.001). Multivariate regression showed that male, age, New York Heat Association classification 3-4, elevated RDW, estimated glomerular filtration rate < 60 mL/min/1.73 m2, cardiopulmonary bypass time > 120 min and erythrocyte transfusion were associated with CSAKI. Subgroup analysis showed elevated RDW was an independent predictor for CSAKI in the non-transfused subset (adjusted odds ratio: 1.616, p < 0.001) whereas no significant association between elevated RDW and CSAKI was found in the transfused patients (odds ratio: 1.040, p = 0.497).

CONCLUSIONS

Elevated RDW is one of the independent predictors of CSAKI in the absence of erythrocyte transfusion, which limits the prognostic role of the former on predicting CSAKI.

Mortality prediction models in the adult critically ill: A scoping review

BACKGROUND

Mortality prediction models are applied in the intensive care unit (ICU) to stratify patients into different risk categories and to facilitate benchmarking. To ensure that the correct prediction models are applied for these purposes, the best performing models must be identified. As a first step, we aimed to establish a systematic review of mortality prediction models in critically ill patients.

METHODS

Mortality prediction models were searched in four databases using the following criteria: developed for use in adult ICU patients in high-income countries, with mortality as primary or secondary outcome. Characteristics and performance measures of the models were summarized. Performance was presented in terms of discrimination, calibration and overall performance measures presented in the original publication.

RESULTS

In total, 43 mortality prediction models were included in the final analysis. In all, 15 models were only internally validated (35%), 13 externally (30%) and 10 (23%) were both internally and externally validated by the original researchers. Discrimination was assessed in 42 models (98%). Commonly used calibration measures were the Hosmer-Lemeshow test (60%) and the calibration plot (28%). Calibration was not assessed in 11 models (26%). Overall performance was assessed in the Brier score (19%) and the Nagelkerke's R² (4.7%).

CONCLUSIONS

Mortality prediction models have varying methodology, and validation and performance of individual models differ. External validation by the original researchers is often lacking and head-to-head comparisons are urgently needed to identify the best performing mortality prediction models for guiding clinical care and research in different settings and populations.

Red blood cell distribution width is associated with mortality after acute ischemic stroke: a cohort study and systematic review

Background

Whether red blood cell distribution width (RDW) is associated with the prognosis of acute ischemic stroke is inconclusive according to recent studies. We performed a cohort study and meta-analysis to explore the association between RDW and functional outcome.

Methods

Patients with ischemic stroke admitted to the Department of Neurology within 24 hours of stroke onset between January 1, 2015 to December 31, 2018 were enrolled. Blood was sampled within 24 hours after admission. We searched PubMed, Embase, Web of Science databases up to Nov 2019 to identify studies investigating the association between RDW values and prognosis following stroke. Outcomes included 3-month death and poor functional outcome [defined by modified Rankin Scale (mRS) score ≥3].

Results

We included 1,558 patients in cohort study. RDW was independently associated with 3-month death [odds ratio (OR), 1.19; 95% confidence interval (CI), 1.03, 1.37], but not associated with 3-month poor outcome (OR 1.05, 95% CI, 0.95, 1.16), after adjustment for confounders. A dose-dependent relationship between RDW levels and 3-month death was revealed in the restricted cubic spline plot. Seven observational studies with 4,407 patients were identified for systematic review. When combining our study and previous studies, the association was significant for RDW predicting death (5 studies with 3,366 patients, OR 1.25, 95% CI, 1.15, 1.35), as well as for poor outcome (4 studies with 3,483 patients, OR 1.23, 95% CI, 1.05, 1.44).

Conclusions

RDW was an independent predictor of 3-month functional outcome, and a trend of dose-dependent relationship between RDW and 3-month death was detected.

A Predictive Model for Acute Respiratory Distress Syndrome Mortality Using Red Cell Distribution Width

Methods

This observational retrospective cohort study includes 318 ARDS patients extracted from an ICU database between the years of 2001 and 2008. Clinical factors including age, gender, comorbidity score, Sequential Organ Failure Assessment (SOFA) score, and PaO₂/FiO₂ ratio were chosen for the base model to predict ICU mortality. The RDW value at the time of ARDS diagnosis was added to the base model to determine if it improved its predictive ability.

Results

318 subjects were included; 113 (36%) died in the ICU. AUC for the base model without RDW was 0.76, and 0.78 following the addition of RDW [p=0.048]. The NRI was 0.46 (p=0.001), indicating that, in 46% of patients, the predictive probability of the model was improved by the inclusion of RDW.

Conclusions

Adding RDW at time of ARDS diagnosis improved discrimination in a model using 4 clinical factors to predict ICU mortality.

The Relationship Between Hematological Parameters and Mortality in Cardiovascular Patients With Postcardiac Arrest Syndrome

Background: Post-cardiac arrest syndrome is the insufficiency of cardiac and cerebral functions caused by ischemia after sudden cardiac arrest. We aimed to determine the hematological parameters associated with mortality in the intensive care follow-up of patients with post-cardiac arrest syndrome.

Methods: The hematological parameters of 285 cardiovascular patients who were admitted to the emergency department of Harran University Medical Faculty between 2013 and 2018 and followed up in the intensive care unit with post-cardiac arrest syndrome were examined. A total of 85 patients were included in the study. These parameters were recorded as the time of arrival to the emergency department (0 hour) and hematological parameters at the 24^th and 48^th hours of intensive care follow-up.

Results: In the mortality group, albumin (P:0.030), hemoglobin (Hg) (P: 0.049), and hematocrit (HCT) (P: 0.020) values ​​in the blood parameters, at the time of admission to the emergency department, were significantly lower than those in the survival group. Red blood cell distribution width (RDW) (P: 0.009) and urea (P <0.001) values ​​at the time of arrival were higher than the survival group. In the 24^th and 48^th hours, mean hemoglobin (MCHC) (P <0.05) values ​​were lower and RDW (P <0.05) values ​​were higher in the mortality group compared to the survival group.

Conclusions: In this retrospective validation, low albumin, Hg, HCT, MCHC, and high RDW and urea levels may increase mortality in cardiovascular patients who develop post-cardiac arrest syndrome within the first 48 hours. Correcting these values ​​early may reduce mortality.

Red blood cell distribution width provides additional prognostic value beyond severity scores in adult critical illness

BACKGROUND

The prognostic value of red blood cell distribution width (RDW) in critical illness remains controversial. The aim of this study was to investigate the prognostic value of on-admission RDW for in-hospital and 4-year mortality in adults with critical illness.

METHODS

This is a retrospective cohort study from the Medical Information Mart for Intensive Care III (MIMIC III) database (version 1.4). Patients admitted to the intensive care unit (ICU) for the first time were included. Their on-admission RDW and severity scores were extracted with the Structured Query Language (SQL). The patients were categorized into a training set and a validation set. The relation of RDW to in-hospital and 4-year all-cause mortality was analyzed using receiver operating characteristic (ROC) curve, Kaplan-Meier curve, Cox model, net reclassification index (NRI), integrated discriminatory index (IDI) and nomogram.

RESULTS

A total of 36,532 patients (21,090 in training and 15,442 in validation set) were included in this study. Increased RDW was significantly associated with higher in-hospital and 4-year mortality. The prognostic value of RDW for 4-year mortality was independent of conventional severity scores. Using conventional severity scores as covariates the continuous NRI and IDI of RDW for in-hospital mortality were around 0.3-0.5 and 0.01-0.03, respectively. For 4-year mortality the NRI was around 0.2-0.3 and IDIs was around 0.03-0.08.

CONCLUSIONS

Admission RDW predicts both in-hospital and 4-year mortality in adult patients with critical illness admitted in the ICU, and can provide additional prognostic values beyond conventional clinical severity scores.

The potential value of red blood cell distribution width in patients with invasive hydatidiform mole

Background

Red blood cell distribution width (RDW) has attracted increasing attention in cancer. The aim of this study was to assess the changes of RDW in patients with invasive hydatidiform mole and analyze the relationship between RDW and invasive hydatidiform mole.

Methods

A retrospective analysis was performed on 102 patients diagnosed as invasive hydatidiform mole in the First Affiliated Hospital of Guangxi Medical University from January 2009 to March 2018. A total of 120 healthy subjects were used as a control group. The Mann‐Whitney U test was used for comparison between the invasive hydatidiform mole and control groups. Comparison of RDW with other blood parameters was performed using Spearman's. The area under the ROC curve (AUC) and 95% confidence interval (95% CI) were also determined.

Results

The RDW, platelet‐lymphocyte ratio (PLR), neutrophil‐lymphocyte ratio (NLR), and absolute lymphocyte count were significantly elevated in the invasive hydatidiform mole group compared with control group. The hemoglobin (Hb) concentration, mean red blood cell volume (MCV) and platelet count (PLT) were significantly lower in invasive hydatidiform mole group than control group. Grade III and above invasive hydatidiform mole patients had higher levels of RDW than grade I and II patients. Correlation analysis showed that RDW was negatively correlated with Hb, MCV, NLR, and neutrophil count, but positively correlated with PDW and different stages of invasive hydatidiform mole. The ROC curve showed that the AUC of the RDW was 0.660 (95% CI 0.581‐0.740; P < 0.01).

Conclusion

This study reveals the potential value of RDW in invasive hydatidiform mole.

Usefulness of RBC distribution width and C-reactive protein to predict mortality in pediatric non-cardiac critical illness

INTRODUCTION

We aimed to assess the performance of red blood cell distribution width (RDW), C-reactive protein (CRP) or the combination of both to predict clinical outcomes in pediatric non-cardiovascular critical illness.

MATERIALS AND METHODS

We analyzed 404 pediatric non-cardiovascular critically ill patients admitted to pediatric intensive care unit (PICU). Potential predictors were identified using multivariable logistic regression. We also calculated the power of RDW and CRP additive to pediatric critical illness score (PCIS) to predict mortality with calculation of C-index value, integrated discrimination improvement (IDI) and net reclassification improvement (NRI) indices.

RESULTS

RDW and CRP independently predicted PICU mortality. The C-index value of PCIS with respect to prediction of PICU mortality was greater than that of RDW and CRP. The combination of RDW or CRP or both with PCIS did significantly increase C-index value for predicting mortality (all p < 0.01). Addition of RDW or CRP or their combination to PCIS provided IDI of 7%, 1.1% and 9.4% (p = 0.009, 0.01 and 0.003) and NRI of 15.9%, 13.1% and 19.6% (p = 0.002, 0.043 and 0.002), respectively.

CONCLUSIONS

In pediatric non-cardiovascular critically ill patients, RDW and CRP could serve as independent predictors of PICU mortality and addition of RDW or CRP or both to PCIS significantly improves the ability to predict PICU mortality.

A New Insight Into Missing Data in Intensive Care Unit Patient Profiles: Observational Study

Background

The data missing from patient profiles in intensive care units (ICUs) are substantial and unavoidable. However, this incompleteness is not always random or because of imperfections in the data collection process.

Objective

This study aimed to investigate the potential hidden information in data missing from electronic health records (EHRs) in an ICU and examine whether the presence or missingness of a variable itself can convey information about the patient health status.

Methods

Daily retrieval of laboratory test (LT) measurements from the Medical Information Mart for Intensive Care III database was set as our reference for defining complete patient profiles. Missingness indicators were introduced as a way of representing presence or absence of the LTs in a patient profile. Thereafter, various feature selection methods (filter and embedded feature selection methods) were used to examine the predictive power of missingness indicators. Finally, a set of well-known prediction models (logistic regression [LR], decision tree, and random forest) were used to evaluate whether the absence status itself of a variable recording can provide predictive power. We also examined the utility of missingness indicators in improving predictive performance when used with observed laboratory measurements as model input. The outcome of interest was in-hospital mortality and mortality at 30 days after ICU discharge.

Results

Regardless of mortality type or ICU day, more than 40% of the predictors selected by feature selection methods were missingness indicators. Notably, employing missingness indicators as the only predictors achieved reasonable mortality prediction on all days and for all mortality types (for instance, in 30-day mortality prediction with LR, we achieved area under the curve of the receiver operating characteristic [AUROC] of 0.6836±0.012). Including indicators with observed measurements in the prediction models also improved the AUROC; the maximum improvement was 0.0426. Indicators also improved the AUROC for Simplified Acute Physiology Score II model—a well-known ICU severity of illness score—confirming the additive information of the indicators (AUROC of 0.8045±0.0109 for 30-day mortality prediction for LR).

Conclusions

Our study demonstrated that the presence or absence of LT measurements is informative and can be considered a potential predictor of in-hospital and 30-day mortality. The comparative analysis of prediction models also showed statistically significant prediction improvement when indicators were included. Moreover, missing data might reflect the opinions of examining clinicians. Therefore, the absence of measurements can be informative in ICUs and has predictive power beyond the measured data themselves. This initial case study shows promise for more in-depth analysis of missing data and its informativeness in ICUs. Future studies are needed to generalize these results.

High red blood cell distribution width as a marker of hospital mortality after ICU discharge: a cohort study

Background

High red blood cell distribution width (RDW) is associated with worse outcome in diverse scenarios, including in critical illness. The Sabadell score (SS) predicts in-hospital survival after ICU discharge. We aimed to determine RDW’s association with survival after ICU discharge and whether RDW can improve the accuracy of the SS.

Design

Retrospective cohort study. Setting: general ICU at a university hospital.

Patients

We included all patients discharged to wards from January 2010 to October 2016.

Methods

We analyzed associations between RDW and variables recorded on admission (age, comorbidities, severity score), during the ICU stay (treatments, complications, length of stay (LOS)), and at ICU discharge (SS). The primary outcome was hospital mortality. Statistical analysis included multivariable logistic regression and receiver operating characteristic curve (ROC) analyses.

Results

We discharged 3366 patients to wards; median ward LOS was 7 [4–13] days; ward mortality was 5.2%. Mean RDW at ICU discharge was 15.4 ± 2.5%. Ward mortality was higher at each quartile of RDW (0.7%, 2.9%, 7.5%, 10.3%; area under ROC 0.81). A logistic regression model with Sabadell score obtained an excellent accuracy for ward mortality (area under ROC 0.863), and the addition of RDW slightly improved accuracy (AUROC 0.890, p < 0.05). Recursive partitioning demonstrated higher mortality in patients with high RDW at each SS level (1.6% vs. 0.3% in SS0, 9.7% vs. 1.1% in SS1, 21.9% vs. 9.7% in SS2), but not in SS3.

Conclusion

High RDW is a marker of severity at ICU discharge and improves the accuracy of Sabadell score in predicting ward mortality except in the more extreme SS3.

Red cell distribution width as a predictor of multiple organ dysfunction syndrome in patients undergoing heart valve surgery

The aim of the study was to evaluate the prognostic value of red cell distribution width (RDW) for multiple organ dysfunction syndrome (MODS) in the early postoperative period in patients undergoing valve replacement or repair surgery. A prospective study was conducted on a group of 713 patients with haemodynamically significant valvular heart disease who underwent elective valvular surgery. The primary end-point at the 30-day follow-up was postoperative MODS. The secondary end-point was death from all causes in patients with MODS. The postoperative MODS occurred in 72 patients. At multivariate analysis: RDW (OR 1.267; 95% CI 1.113-1.441; P=0.0003), creatinine (OR 1.007; 95% CI 1.001-1.013; P=0.02) and age (OR 1.047; 95% CI 1.019-1.077; P=0.001) remained independent predictors of the primary end-point. Receiver operator characteristics analysis determined a cut-off value of RDW for the prediction of the occurrence of the perioperative MODS at 14.3%. RDW (OR 1.448; 95% CI 1.057-1.984; P=0.02) and age (OR 1.057; 95% CI 1.007-1.117; P=0.04) were associated with an increased risk of death in patients with perioperative MODS. Elevated RDW is associated with a higher risk of MODS and death in patients with MODS following heart valve surgery.

Role of elevated red cell distribution width on acute kidney injury patients after cardiac surgery

Background

The aim of the study was to explore associations between elevated red cell distribution width (RDW) and acute kidney injury (AKI) in patients undergoing cardiac surgery (CS-AKI).

Methods

Preoperative, intraoperative and postoperative data of 10,274 patients undergoing cardiac surgery, including demographic data, were prospectively collected from January 2009 to December 2014. Propensity score matching was used on the basis of clinical characteristics and preoperative variables. An elevated RDW was defined as the difference between RDW 24 h after cardiac surgery and the latest RDW before cardiac surgery.

Results

A total of 10,274 patients were included in the unmatched cohort, and 3146 patients in the propensity-matched cohort. In the unmatched cohort, the overall CS-AKI incidence was 32.8% (n = 3365) with a hospital mortality of 5.5% (n = 185). In the propensity-matched cohort, the elevated RDW in AKI patients was higher than in patients without AKI (0.3% (0.0%, 0.7%) vs 0.5% (0.1, 1.1%), P <  0.001) and the elevated RDW incidences were 0.4% (0.1%, 0.9%), 0.6% (0.2%, 1.1%) and 1.1% (0.3%, 2.1%) in stage 1, 2 and 3 AKI patients (P <  0.001). Among propensity-matched patients with CS-AKI, the level of elevated RDW in non-survivors was higher than in survivors [1.2% (0.5%, 2.3%) vs 0.5% (0.1%, 1.0%), P <  0.001] and a 0.1% increase in elevated RDW was associated with a 0.24% higher risk of within-hospital mortality in patients with CS-AKI. Estimating the receiver-operating characteristic (ROC) area under the curve (AUC) showed that an elevated RDW had moderate discriminative power for AKI development (AUC = 0.605, 95% CI, 0.586–0.625; P <  0.001) and hospital mortality (AUC = 0.716, 95% CI, 0.640–0.764; P <  0.001) in the propensity-matched cohort.

Conclusions

An elevated RDW might be an independent prognostic factor for the severity and poor prognosis of CS-AKI.

The prognostic value of interaction between mean corpuscular volume and red cell distribution width in mortality in chronic kidney disease

Recently, both red cell distribution width (RDW) and mean corpuscular volume (MCV) have been associated with unfavorable outcomes in several medical conditions. Therefore, we conducted this retrospective study of 1075 patients with stage 3-5 chronic kidney disease to investigate whether interactions between RDW and MCV influence the risk of mortality. These patients were divided into four groups: group A (n = 415), RDW ≤ 14.9% and MCV ≤ 91.6 fL; group B (n = 232), RDW > 14.9% and MCV ≤ 91.6 fL; group C (n = 307), RDW ≤ 14.9% and MCV > 91.6 fL; and group D (n = 121), RDW > 14.9% and MCV > 91.6 fL. The adjusted hazard ratio (HR) of all-cause mortality for group B versus group A was 1.44 (95% confidence interval [CI], 1.14-2.12, p = 0.02), group C versus group A 2.14 (95% CI, 1.31-3.48, p = 0.002), and group D versus group A 5.06 (95% CI, 3.06-8.37, p < 0.001). There was a multiplicative interaction between MCV and RDW in predicting patient mortality. The use of RDW in conjunction with MCV may improve healthcare by identifying those at an increased risk for mortality compared with the use of either RDW or MCV alone.

Red Cell Distribution Width Predicts 90 Day Mortality in Continuous-Flow Left Ventricular Assist Device Patients

Red cell distribution width (RDW) measures the variance in size of circulating red blood cells and is a strong independent predictor of morbidity and mortality in cardiovascular disease and heart failure. Predictive power of RDW on mortality after continuous-flow left ventricular assist device (CF-LVAD) implantation remains largely unknown. Four hundred nine patients who underwent CF-LVAD implantation between April 2004 and December 2015 were retrospectively analyzed. The primary outcome of interest was 90 day mortality after CF-LVAD implantation. Median RDW before CF-LVAD implantation was 15.8%. Patients with elevated RDW (>15.8%) at baseline had significantly lower hemoglobin (10.6 ± 1.8 vs. 11.9 ± 2.1 mg/dl; p < 0.001), lower mean corpuscular volume (84.9 ± 7.7. vs. 88.7 ± 5.9; p < 0.001), higher blood urea nitrogen (BUN; 36.3 ± 21.8 vs. 30.1 ± 17.1; p < 0.001), lower albumin (3.4 ± 0.6 vs. 3.7 ± 0.5; p < 0.001), and higher total bilirubin levels (1.67 ± 2.21 vs. 1.29 ± 0.96). Red cell distribution width was independently predictive of 90 day mortality (odds ratio [OR], 1.16 for 1% increase; CI, 1.04-1.31; p = 0.010). Discriminatory power of RDW alone was comparable to model of end-stage liver disease excluding international normalized ratio (MELD-Xi) and HeartMate II risk scores. Mechanical unloading with CF-LVAD was associated with a reduction in RDW levels. These findings suggest that RDW, a simple and inexpensive test available through routine complete blood count, can be successfully used for mortality risk assessment in CF-LVAD candidates.

Elevated red blood cell distribution width at ICU discharge is associated with readmission to the intensive care unit

BACKGROUND

Red blood cell distribution width (RDW) is a predictor of mortality in critically ill patients. Our objective was to investigate the association between the RDW at ICU discharge and the risk of ICU readmission or unexpected death in the ward.

METHODS

A secondary analysis of prospectively collected data study was conducted including patients discharged alive from the ICU to the ward. The target variable was the RDW collected at ICU discharge. Elevated RDW was defined as an RDW > 16%. Outcomes of interest included readmission to the ICU, unexpected death in the ward and in-hospital death. Variables with a p-value <0.1 in the univariate analysis or with biological plausibility for the occurrence of the outcome were included in the Cox proportional hazards model for adjustment.

RESULTS

We included 813 patients. A total of 138 readmissions to the ICU and 44 unexpected deaths in the ward occurred. Elevated RDW at ICU discharge was independently associated with readmission to the ICU or unexpected death in the ward after multivariable adjustment (HR: 1.901; 95% CI 1.357-2.662). Other variables associated with this outcome included age, tracheostomy and mean corpuscular volume (MCV) at ICU discharge. Similar results were obtained after the exclusion of unexpected deaths in the ward (HR 1.940; CI 1.312-2.871) and for in-hospital deaths (HR 1.716; 95% CI 1.141-2.580).

CONCLUSIONS

Elevated RDW at ICU discharge is independently associated with ICU readmission and in-hospital death.

Red cell distribution width is a prognostic marker of perioperative stroke in patients undergoing cardiac valve surgery

OBJECTIVES

Numerous studies have shown that elevated red cell distribution width (RDW) is associated with poor outcomes in patients with cardiovascular diseases such as coronary artery disease, peripheral artery disease or stroke. The usefulness of the RDW as a predictor of perioperative stroke in patients with valve disease undergoing valve surgery is currently unknown. The aim of the study was to evaluate the prognostic value of RDW for stroke in the early postoperative period in patients undergoing valve replacement or repair surgery.

METHODS

A prospective study was conducted on a group of 500 consecutive patients with haemodynamically significant valvular heart disease who underwent elective valvular surgery. Preoperative complete blood count, data on risk factors, the course of operations and the postoperative period were assessed. The primary end-point at the 30-day follow-up was perioperative stroke or transient ischaemic attack. The secondary end-point was death from all causes in patients with perioperative stroke. Univariate analysis, followed by multivariate regression analysis, was performed.

RESULTS

The perioperative stroke occurred in 14 patients. At multivariate analysis: RDW [odds ratio (OR) 1.640, 95% confidence interval (CI) 1.132-2.377; P = 0.009] and haemoglobin (OR 0.655, 95% CI 0.447-0.961; P = 0.03) remained independent predictors of the primary end-point. Receiver operator characteristics analysis determined a cut-off value of RDW for the prediction of the occurrence of the perioperative stroke/transient ischaemic attack at 14.1%. Creatinine (OR 1.015, 95% CI 1.004-1.026; P = 0.0079) and RDW (OR 1.493, 95% CI 1.171-1.815; P = 0.04) were associated with an increased risk of death in patients with perioperative stroke.

CONCLUSIONS

Elevated RDW is associated with a higher risk of perioperative stroke/transient ischaemic attack and death in patients with perioperative stroke.

Single and combined use of red cell distribution width, mean platelet volume, and cancer antigen 125 for differential diagnosis of ovarian cancer and benign ovarian tumors

BACKGROUND

Cancer is widely believed to result from chronic inflammation, and red cell distribution width (RDW) and mean platelet volume (MPV) are considered as inflammatory markers for cancer. We investigated the values of RDW, MPV, and cancer antigen 125 (CA125), alone or in combination, for distinguishing between ovarian cancer and benign ovarian tumors.

METHODS

The study included 326 patients with ovarian cancer, 290 patients with benign ovarian tumors, and 162 control subjects. Hematologic tests were performed at initial diagnosis.

RESULTS

RDW was increased and MPV was decreased in the ovarian cancer group compared with the control and benign ovarian tumor groups. RDW was positively correlated and MPV was negatively correlated with cancer stage. Area under the curve (AUC) analysis for ovarian cancer versus benign ovarian tumors revealed that the specificity and sensitivity were increased for the combination of MPV and CA125 compared with either marker alone, and the specificity was increased for the combination of RDW and CA125, compared with either alone. The AUCs for RDW plus CA125 and MPV plus CA125 were significantly larger than for any of the markers alone.

CONCLUSIONS

In conclusion, combinations of the markers RDW, MPV, and CA125 may improve the differential diagnosis of ovarian cancer and benign ovarian tumors.

Biological pathways underlying the association of red cell distribution width and adverse clinical outcome: Results of a prospective cohort study

Background

Red cell distribution width (RDW) predicts disease outcome in several patient populations, but its prognostic value in addition to other disease parameters in unselected medical inpatients remains unclear. Our aim was to investigate the association of admission RDW levels and mortality adjusted for several disease pathways in unselected medical patients from a previous multicenter study.

Methods

We included consecutive adult, medical patients at the time point of hospital admission through the emergency department into this observational, cohort study. The primary endpoint was mortality at 30-day. To study association of admission RDW and outcomes, we calculated regression analysis with step-wise inclusion of clinical and laboratory parameters from different biological pathways.

Results

The 30-day mortality of the 4273 included patients was 5.6% and increased from 1.4% to 14.3% from the lowest to the highest RDW quartile. There was a strong association of RDW and mortality in unadjusted analysis (OR 1.32; 95%CI 1.27–1.39, p<0.001). RDW was strongly correlated with different pathways including inflammation (coefficient of determination (R²) 0.30; p<0.001), nutrition (R² 0.20; p<0.001) and blood diseases (R² 0.30; p<0.001 The association was eliminated after including different biological pathways into the models with the fully adjusted regression model showing an OR of 1.02 (95%CI 0.93–1.12; p = 0.664) for the association of RDW and mortality. Similar effects were found for other outcomes including intensive care unit admission and hospital readmission.

Conclusion

Our data suggests that RDW is a strong surrogate marker of mortality in unselected medical inpatients with most of the prognostic information being explained by other disease factors. The strong correlation of RDW and different biological pathways such as chronic inflammation, malnutrition and blood disease suggest that RDW may be viewed as an unspecific and general “chronic disease prognostic marker”.

Novel Mortality Markers for Critically Ill Patients

AIM

Inflammatory markers, such as the neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR), derived from a complete blood count have recently attracted attention as potential markers of morbidity and mortality in various diseases. The aim of the present study was to assess the usefulness of the NLR and PLR as markers of hospital stay and mortality of patients in intensive care units (ICUs).

METHODS

Patients treated in the ICU of our institution between October 2016 and August 2017 were enrolled in the study. After obtaining approval from the institutional committee, patient data were sourced from the institution's computerized database and retrospectively analyzed. The patients were assigned to 2 groups according to the outcomes: survivors and deceased.

RESULTS

The NLR of survivors and deceased patients was 2.06 (1.18-21.68) and 10.42 (2.85-48.2), respectively. The NLR was significantly elevated in deceased patients as compared with that of survivors (P < .001). Similarly, the median PLR of patients in the deceased group (268.9 [150-3000]) was significantly higher than that of patients in the survivor group (55.7 [11.8-152.5]). The difference in the PLR between groups was significant (P < .001).

CONCLUSION

Both the NLR and PLR, as well as C-reactive protein, predicted mortality in this critically ill population. The PLR and NLR are easy-to-measure, inexpensive markers. Physicians should be aware of elevations in PLR and NLR in patient care in ICUs.

Evaluation of Early Prognostic Factors of Mortality in Patients with Acute Pancreatitis: A Retrospective Study

Early and accurate assessment of severity in acute pancreatitis (AP) is of great importance to provide effective disease management and prevent mortality. In this study, we aim to evaluate early indicators that predict the mortality of AP. We retrospectively analyzed 24-hour clinical characteristics and laboratory data in 166 AP patients recruited between January 2014 and November 2015 in Baotou Central Hospital. In total, 18 patients did not survive the disease. Multivariate logistic regression showed that red cell distribution (RDW) (OR = 2.965, P = 0.001) and creatinine (OR = 1.025, P = 0.005) were early independent risk factors of AP mortality while albumin (OR = 0.920, P = 0.032) levels reduced AP mortality. The corresponding optimal cut-off values were 14.45, 125.5, and 34.95, respectively. The positive predictive values of the AP mortality were 80.1%, 54.5%, and 69.5%. In combined measurement, the area under the curve of RDW, creatinine, and albumin was 0.964 (95% CI: 0.924 to 1.000, P < 0.001). RDW ≥ 14.45%, creatinine ≥ 125.5 μmol/l, and albumin ≤ 34.95 g/l indicated a good predictive value for mortality in AP patients with a sensitivity of 100% and specificity of 64.2%. RDW, creatinine, and albumin may serve as early indicators for AP mortality which warrants further clinical investigation.