Association of anemia with health-related quality of life and survival: a large population-based cohort study

Association between exposure to smoke from cooking fuels and anaemia among women of reproductive age in Ghana

In low- and middle-income countries, indoor air pollution (IAP) is a serious public health concern, especially for women and children who cook with solid fuels. IAP exposure has been linked to a number of medical conditions, including pneumonia, ischemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lung cancer, and anaemia. Around 500 million women of reproductive age (WRA) suffer from anaemia globally, with an estimated 190 million cases in sub-Saharan Africa (SSA). This study, which is based on prior research, investigates the relationship between IAP exposure and anaemia among WRA in Ghana. A diverse sample of 2,406 WRA living in Ghana were interviewed, of which 58.06% were anaemic and used high-pollutant fuels for cooking. Age, place of residence, region, education level, religion, ethnicity, wealth index, type of drinking water, type of toilet facility, and type of cooking fuels were all found to be significantly linked with anaemic state by bivariate analysis. Type of cooking fuels utilized, age, region of residence, and the type of residence were shown to be significant predictors of anaemia status using sequential binary logit regression models. The results emphasise the critical need for efforts to promote the usage of clean cooking fuel in an attempt to lower anaemia prevalence in Ghana. To reduce dependency on solid fuels for cooking, initiatives should promote the use of cleaner cooking fuels and enhance the socioeconomic status of households. These interventions could have significant public health effects by reducing the burden of anaemia and improving maternal and child health outcomes due to the prevalence of anaemia among WRA. Overall, this study sheds light on the relationship between IAP exposure and anaemia in Ghana and highlights the demand for focused public health initiatives to address this serious health problem.

Association of anemia with all-cause mortality in Chinese centenarians: a prospective cohort study

OBJECTIVES

This study aimed to examine the relationship between anemia and all-cause mortality in Chinese centenarians.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

We included 1002 Chinese centenarians from the China Hainan Centenarian Cohort Study (CHCCS) MEASUREMENTS: Standard procedures were followed to perform blood analysis, home interviews, and physical examinations. Anemia was defined as a hemoglobin level of less than 130 g/L for men and less than 120 g/L for women.

RESULTS

During the 9-year follow-up period, a total of 929 (92.7%) deaths were identified. Cox proportional hazards regression models revealed that anemia (hazard ratio [HR] 1.289, 95% confidence interval [CI]: 1.117-1.489) was significantly associated with all-cause mortality. There was an apparent dose-response relationship between anemia and all-cause mortality. Centenarians with severe anemia had approximately 1.6 times higher likelihood of all-cause mortality than those without anemia (HR 1.662; 95% CI: 1.154-2.394).

CONCLUSION

Anemia is associated with an increased risk of all-cause mortality in Chinese centenarians. Further research will be needed to collect more comprehensive data on the etiology of anemia and causes of death in centenarians.

Elevated neutrophil-to-hemoglobin ratio as an indicator of poor survival in hepatitis B virus-related decompensated cirrhosis

Aim: Our goal was to explore the prognostic value of the neutrophil-to-hemoglobin ratio (NHR) in HBV-related decompensated cirrhosis (HBV-DC) patients. Methods: 172 HBV-DC patients were enrolled. Multivariate analyses were used to identify risk factors influencing 30-day mortality. Results: The 30-day mortality was 12.8% (22/172). nonsurvivors exhibited a higher NHR than survivors. On multivariate analysis, NHR and model for end-stage liver disease (MELD) score were the only independent predictors of mortality. Notably, the predictive capabilities of NHR were found to be comparable to those of the MELD score. Conclusion: High NHR was associated with poor prognosis in HBV-DC patients, and NHR can serve as an effective and readily available indicator for the prediction of mortality in these patients.

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

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

IL-6 inhibitors and JAK inhibitors as favourable treatment options for patients with anaemia and rheumatoid arthritis: ANSWER cohort study

OBJECTIVES

Anaemia, a common comorbidity of RA, is related to high disease activity and poor prognosis. It is unknown which biologic/targeted synthetic (b/ts)-DMARDs are optimal for patients with anaemia and RA in regulating anaemia and controlling disease activity.

METHODS

We investigated the change in haemoglobin (Hb) levels, drug retention rates and disease activities after the administration of b/ts-DMARDs with different modes of action [TNF inhibitors (TNFis), immunoglobulin fused with cytotoxic T-lymphocyte antigen (CTLA-4-Ig), IL-6 receptor inhibitors (IL-6Ris) and Janus kinase inhibitors (JAKis)] in patients with RA stratified by baseline Hb levels using the multicentre observational registry for patients with RA in Japan (ANSWER cohort).

RESULTS

A total of 2093 patients with RA were classified into three groups based on tertiles of the baseline Hb levels (Hblow, anaemic; Hbint, intermediate; Hbhigh, non-anaemic). IL-6Ri increased Hb levels in all groups (the mean change at 12 months in Hblow was +1.5 g/dl, Hbint +0.7 g/dl and Hbhigh +0.1 g/dl). JAKis increased the Hb level in patients with anaemia and RA and retained or decreased the Hb level in non-anaemic patients (the mean change at 12 months in Hblow was +0.6 g/dl, Hbint 0 g/dl and Hbhigh -0.3 g/dl). In patients with anaemia and RA, overall adjusted 3-year drug retention rates were higher in JAKi followed by IL-6Ri, CTLA4-Ig and TNFi (78.6%, 67.9%, 61.8% and 50.8%, respectively). Change of disease activity at 12 months was not different among different b/ts-DMARDs treatments.

CONCLUSION

IL-6Ri and JAKi can effectively treat patients with anaemia and RA in a real-world setting.

How I treat anemia in older adults

ABSTRACT

With the global growing older adult population, clinicians face the common, yet complex challenge of how to evaluate and manage anemia in this population. Older age predisposes to common causes of anemia such as nutritional deficiencies, inflammatory disorders, chronic kidney disease, and hematologic malignancies. Failure to diagnose and appropriately manage anemia may result in decreased quality of life, impaired cognition, impaired mobility, and increased mortality. Anemia diagnosis in older adults presents a diagnostic conundrum because anemia may have a single cause, may be multifactorial, or may have no apparent cause even after an extensive evaluation. We believe a systematic approach to diagnosis ensures appropriate testing and avoids the pitfall of undertreatment and overtreatment. In this article we present our recommended approach through common scenarios for the management of anemia in the older adult.

Determinants and spatial factors of anemia in women of reproductive age in Democratic Republic of Congo (drc): a Bayesian multilevel ordinal logistic regression model approach

BACKGROUND

As a global public health problem, anemia affects more than 400 million women of reproductive age worldwide, mostly in Africa and India. In the DRC, the prevalence of anemia has decreased slightly from 52.9% in 2007, to 46.4% in 2012 and 42.4% in 2019. However, there is considerable regional variation in its distribution. The aim of this study is to determine the factors contributing to anemia in women of reproductive age and to explore its spatial distribution in the DRC.

METHODS

Based on the Bayesian Multilevel Spatial Ordinal Logistic Regression Model, we used the 2013 Democratic Republic of Congo Demographic and Health Survey (DHS-DRC II) data to investigate individual and environmental characteristics contributing to the development of anemia in women of reproductive age and the mapping of anemia in terms of residual spatial effects.

RESULTS

Age, pregnancy status, body mass index, education level, current breastfeeding, current marital status, contraceptive and insecticide-treated net use, source of drinking water supply and toilet/latrine use including the province of residence were the factors contributing to anemia in women of reproductive age in DRC. With Global Moran's I = -0.00279, p-value ≥ 0.05, the spatial distribution of anemia in women of reproductive age in DRC results from random spatial processes. Thus, the observed spatial pattern is completely random.

CONCLUSION

The Bayesian Multilevel Spatial Ordinal Logistic Regression statistical model is able to adjust for risk and spatial factors of anemia in women of reproductive age in DRC highlighting the combined role of individual and environmental factors in the development of anemia in DRC.

Anemia, iron, and HIV: decoding the interconnected pathways: A review

This review delves into the intricate relationship between anemia, iron metabolism, and human immunodeficiency virus (HIV), aiming to unravel the interconnected pathways that contribute to the complex interplay between these 3 entities. A systematic exploration of relevant literature was conducted, encompassing studies examining the association between anemia, iron status, and HIV infection. Both clinical and preclinical investigations were analyzed to elucidate the underlying mechanisms linking these components. Chronic inflammation, a hallmark of HIV infection, disrupts iron homeostasis, impacting erythropoiesis and contributing to anemia. Direct viral effects on bone marrow function further compound red blood cell deficiencies. Antiretroviral therapy, while essential for managing HIV, introduces potential complications, including medication-induced anemia. Dysregulation of iron levels in different tissues adds complexity to the intricate network of interactions. Effective management of anemia in HIV necessitates a multifaceted approach. Optimization of antiretroviral therapy, treatment of opportunistic infections, and targeted nutritional interventions, including iron supplementation, are integral components. However, challenges persist in understanding the specific molecular mechanisms governing these interconnected pathways. Decoding the interconnected pathways of anemia, iron metabolism, and HIV is imperative for enhancing the holistic care of individuals with HIV/AIDS. A nuanced understanding of these relationships will inform the development of more precise interventions, optimizing the management of anemia in this population. Future research endeavors should focus on elucidating the intricate molecular mechanisms, paving the way for innovative therapeutic strategies in the context of HIV-associated anemia.

Association between suicide attempts and anemia in late-life depression inpatients

BACKGROUND

Anemia is strongly associated with late-life depression (LLD), however, few studies have investigated the relationship between anemia and suicide attempts in LLD patients. It is still challenging to predict suicide risk in patients with depression. Therefore, there is growing interest in potential biomarkers of depressive disorders and suicidal behavior, which may play a significant role in the early diagnosis and treatment of depression. This study aimed to compare serum ferritin, folate, vitamin B12, and erythrocyte parameter levels in patients with LLD with those in healthy older adults, and the relationship between serum ferritin, folate, vitamin B12, and suicide attempts in patients.

METHODS

Serum ferritin, folate, vitamin B12, and erythrocyte parameter levels were measured in 66 hospitalized LLD patients (30 without suicide attempt, 36 with suicide attempt) and 47 healthy individuals. All participants were surveyed for basic conditions and suicide attempts, and depression was assessed in LLD patients.

RESULTS

Serum ferritin, folate, vitamin B12, red blood cell count, hemoglobin, hematocrit, mean platelet volume and plateletcrit levels were significantly lower in LLD patients compared with healthy older adults (P < 0.05). Further analysis of the relationship between serum ferritin, folate, and vitamin B12 levels and LLD patients' suicide attempts and showed a significant negative association between serum folate and vitamin B12 and suicide attempts (P < 0.05).

CONCLUSIONS

Serum ferritin, folate, vitamin B12, red blood cell count, hemoglobin, hematocrit, mean platelet volume and plateletcrit levels were significantly lower in LLD patients than in healthy older adults. In addition, reduced serum folate and vitamin B12 levels in patients may have some effect on suicide attempts. More mechanistic studies are needed to further explain this association.

The value of genetic data from 665,460 individuals in managing iron deficiency anaemia and suitability to donate blood

BACKGROUND AND OBJECTIVES

Although the genetic determinants of haemoglobin and ferritin have been widely studied, those of the clinically and globally relevant iron deficiency anaemia (IDA) and deferral due to hypohaemoglobinemia (Hb-deferral) are unclear. In this investigation, we aimed to quantify the value of genetic information in predicting IDA and Hb-deferral.

MATERIALS AND METHODS

We analysed genetic data from up to 665,460 participants of the FinnGen, Blood Service Biobank and UK Biobank, and used INTERVAL (N = 39,979) for validation. We performed genome-wide association studies (GWASs) of IDA and Hb-deferral and utilized publicly available genetic associations to compute polygenic scores for IDA, ferritin and Hb. We fitted models to estimate the effect sizes of these polygenic risk scores (PRSs) on IDA and Hb-deferral risk while accounting for the individual's age, sex, weight, height, smoking status and blood donation history.

RESULTS

Significant variants in GWASs of IDA and Hb-deferral appear to be a small subset of variants associated with ferritin and Hb. Effect sizes of genetic predictors of IDA and Hb-deferral are similar to those of age and weight which are typically used in blood donor management. A total genetic score for Hb-deferral was estimated for each individual. The odds ratio estimate between first decile against that at ninth decile of total genetic score distribution ranged from 1.4 to 2.2.

CONCLUSION

The value of genetic data in predicting IDA or suitability to donate blood appears to be on a practically useful level.

Hypothyroidism, comorbidity and health-related quality of life: a population-based study

Hypothyroidism is associated with a decreased health-related quality of life (HRQoL). We hypothesized that individuals with hypothyroidism (defined as use of thyroid hormone (TH)) and especially those having an impaired HRQoL are characterized by a high prevalence of comorbid disorders and that the impact of hypothyroidism and comorbidity on HRQoL is synergistic. Presence of comorbidity was based on data obtained using structured questionnaires, physical examination, biochemical measurements and verified medication use. Single morbidities were clustered into 14 different disease domains. HRQoL was measured using the RAND-36. Logistic regression analyses were used to determine the effect of TH use on the odds of having an affected disease domain and a lower score than an age- and sex-specific reference value for HRQoL. TH was used by 4537/14,7201 participants of the population-based Lifelines cohort with a mean (± s.d.) age of 51.0 ± 12.8 years (88% females). Eighty-five percent of the TH users had ≥1 affected disease domain in contrast to 71% of nonusers. TH use was associated with a higher odds of 13 out of 14 affected disease domains independent of age and sex. In a multivariable model, TH use was associated with a decreased HRQoL across six out of eight dimensions. No significant interactions between TH use and affected disease domains were observed. TH users with an impaired HRQoL had significantly more comorbidity than those not having an impaired HRQoL. In this large, population-based study, we demonstrated that TH users had more comorbidity than individuals not using TH. The coexistence of other chronic medical conditions in subjects with TH use led to further lowering of HRQoL in an additive manner.

Association between depression, anemia and physical activity using isotemporal substitution analysis

BACKGROUND

Depression is a leading cause of disability and mortality, with estimated number of deaths exceeding 2.2 million worldwide. We examined depression in relation to anemia and physical activity, both of which have an impact on depression mechanisms.

METHODS

This cross-sectional study used data from the Korean National Health and Nutrition Examination Survey, including 18,622 participants. Depression was measured by The Patient Health Questionnaire-9, and physical activity was assessed by the Global Physical Activity Questionnaire. Anemia was defined by World Health Organization criteria for blood hemoglobin levels. Isotemporal substitution model for physical activity was used to assess the effect of replacing sedentary behavior to each intensity level of physical activity. Logistic regression was applied to estimate the association on depression.

RESULTS

Replacing sedentary behavior with moderate or vigorous physical activity was associated with a lower risk of depression in the anemic (OR: 0.875, 95% CI: 0.782-0.978) and non-anemic groups (OR: 0.943, 95% CI: 0.919-0.967). Depression risk was significantly reduced by replacing walking with moderate to vigorous physical activity in both anemic (OR: 0.877, 95% CI: 0.784-0.982) and non-anemic groups (OR: 0.951, 95% CI: 0.927-0.976).

CONCLUSIONS

Moderate to vigorous physical activity had a protective association against depression in both anemic and non-anemic groups. Anemic patients are recommended to perform physical activity for any duration acceptable to them to prevent depression.

The effect of postoperative intravenous iron in anaemic, older cardiac surgery patients on disability-free survival (AGE ANEMIA study): study protocol for a multi-centre, double-blind, randomized, placebo-controlled trial

BACKGROUND

Postoperative anaemia is common in older cardiac surgery patients and often caused by iron deficiency. Anaemia may negatively affect recovery after cardiac surgery. This study aims to determine the efficacy of treatment of postoperative iron deficiency anaemia (IDA) with intravenous iron (IVI) on disability 90 days after cardiac surgery in older patients.

METHODS

This is a randomized placebo-controlled double-blind multi-centre trial. In total, 310 patients aged ≥ 70 years with moderate IDA on postoperative day 1 (haemoglobin 85-110 g/L and ferritin concentration < 100 μg/L or iron saturation < 20%) after uncomplicated elective cardiac surgery (aortic valve repair or coronary artery bypass graft surgery) will be included. Patients will be randomly allocated to receive either IVI (ferric derisomaltose) or placebo (sodium chloride 0.9%) on postoperative day 1 in a 1:1 ratio, stratified by centre and type of cardiac surgery. The primary outcome is disability measured by the 12-item World Health Organization Disability Assessment score 2.0 after 90 days. Secondary outcome measures are the number of postoperative red blood cell (RBC) transfusions, change in reticulocyte haemoglobin content (pg) from randomization to hospital discharge, Hb levels at discharge, hospital complications, dyspnoea (assessed with the Rose Dyspnoea Scale) and health-related quality of life (HRQL) (assessed with The Older Persons and Informal Caregivers-Short Form (TOPICS-SF) questionnaire) after 90 days and days alive and out of hospital after 90 days. Lastly, the functional outcomes (e.g. steep ramp or 6-min walk test) and Hb level after 90 days will be assessed as an exploratory endpoint.

DISCUSSION

The results of this study will demonstrate whether early treatment of postoperative IDA with IVI improves disability at 90 days in older cardiac surgery patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04913649. Registered on June 4, 2021.

How I treat non-transfusion-dependent β-thalassemia

The intricate interplay of anemia and iron overload under the pathophysiological umbrella of ineffective erythropoiesis in non-transfusion-dependent β-thalassemia (NTDT) results in a complex variety of clinical phenotypes that are challenging to diagnose and manage. In this article, we use a clinical framework rooted in pathophysiology to present 4 common scenarios of patients with NTDT. Starting from practical considerations in the diagnosis of NTDT, we delineate our strategy for the longitudinal care of patients who exhibit different constellations of symptoms and complications. We highlight the use of transfusion therapy and novel agents, such as luspatercept, in the patient with anemia-related complications. We also describe our approach to chelation therapy in the patient with iron overload. Although tackling every specific complication of NTDT is beyond the scope of this article, we touch on the management of the various morbidities and multisystem manifestations of the disease.

MDS-Related Anemia Is Associated with Impaired Quality of Life but Improvement Is Not Always Achieved by Increased Hemoglobin Level

Quality of life is impaired in MDS, but the role of hemoglobin level is unclear. To study the Hb-QoL correlation at diagnosis and 1 year later, patients filled out the EQ-5D questionnaire, assessing their mobility, self care, daily activities, pain/discomfort, and anxiety/depression, using scores of 0 (normal), 1 (mild/moderate), or 2 (poor). They also evaluated their health using a visual analogue scale, scoring from 0 (poor) to 100 (excellent). The anemia subgroups were: none/normal (Hb ≥ 12.5 g/dL), mild (10 ≤ Hb < 12.5), moderate (9 ≤ Hb < 10), severe (8 ≤ Hb < 9), or very severe (Hb < 8). LR-MDS patients (n = 127) and inpatient controls (n = 141) participated. The anemic patients had a poor QoL and the MDS patients had a lower QoL with a lower Hb. The controls had no QoL difference among the various anemia subgroups. In addition, the MDS QoL sharply decreased with an Hb of < 9. The MDS patients showed a wide QoL variability, i.e., different QoL scores in the same Hb subgroup, suggesting that other factors affect QoL (e.g., age and comorbidities). After 1 year (n = 61), the QoL was still poor for most MDS patients (including 27 patients with an increased Hb). In summary: (1) a poor QoL in MDS-anemia is non-linear, suggesting other influencing factors on QoL. (2) The sharp QoL drop with Hb < 9 g/dL challenges the transfusion Hb threshold. (3) The QoL in anemic MDS patients might differ from that in non-MDS patients. (4) Raising Hb, while recommended, does not guarantee an improved QoL.

Prevalence of Anemia Among the Elderly in India: Evidence From a Systematic Review and Meta-Analysis of Cross-Sectional Studies

Anemia is a leading cause of increased morbidity and mortality among the elderly population. In spite of numerous interventions and strategies rolled out to tackle the growing burden of anemia, lesser importance is being given to this age group. There is a lack of data on the national level burden of anemia among elderly persons (≥ 60 years) in India. We aimed at estimating the prevalence of anemia among elderly persons (≥ 60 years) in India by conducting a systematic review and meta-analysis. We searched PubMed, Embase, Cochrane Library, Google Scholar, and IndMed, and included cross-sectional studies reporting data on the prevalence of anemia among elderly persons in India and used random effects model to estimate pooled point prevalence with 95% confidence interval (CI), To explore the heterogeneity further, we did sub-group analyses based on zonal divisions of India (region), rural or urban, study setting, method of hemoglobin estimation and sampling strategy. Out of 22 studies, one study was of high quality of bias, 11 of moderate, and 10 were of low quality of bias. The pooled estimate of anemia was 68.3% (95%CI: 60.7 to 75.9), I2 = 99.0%, and Q=2079.2 (p-value <0.001). The pooled prevalence of anemia among the elderly in India was found to be high and necessary actions need to be taken at the policy level to achieve "active and healthy ageing".

Prevalence and morphological subtype distributions of anaemia in a Chinese rural population: the Henan Rural Cohort study

OBJECTIVE

This study aimed to evaluate the recent prevalence and the distributions of morphological subtypes of anaemia in the rural population.

DESIGN

Anaemia was defined according to the WHO and the Chinese criteria, and the morphological subtypes of anaemia were classified based on the erythrocyte parameters. The age-standardised prevalence was calculated according to the data of the Population Census 2010 in China.

SETTING

A cross-sectional study in Henan Province.

PARTICIPANTS

33 585 subjects aged 18-79 years old.

RESULTS

The standardised prevalence of anaemia across the WHO and the Chinese definitions was 13·63 % and 5·45 %, respectively. Regardless of which criteria was used, the standardised prevalence of anaemia was higher among women than among men and that increased with age in men, while markedly decreased after menopause in women. There were shifts in morphological patterns of anaemia using the WHO and the Chinese criteria that the standardised prevalence of microcytic anaemia was 3·74 % and 2·97 %, normocytic anaemia was 9·20 % and 2·34 %, and macrocytic anaemia was 0·75 % and 0·14 %, respectively. Besides, there were differences in the influencing factors of anaemia according to different criteria or gender. However, age, education level and renal damage were consistently significantly associated with anaemia in all participants.

CONCLUSIONS

Anaemia may still be a serious health problem in rural China. It is necessary to reformulate prevention and management strategies to reduce the disease burden of anaemia.

The Role of Inflammation in Age-Associated Changes in Red Blood System

Aging-related anemia contributes to frailty syndrome, cognitive decline and early mortality. The study aim was to evaluate inflammaging in relation to anemia as a prognostic indicator in affected older patients. The participants (73.0 ± 7.2 years) were allocated into anemic (n = 47) and non-anemic (n = 66) groups. The hematological variables RBC, MCV, MCH, RDW, iron and ferritin were significantly lower, whereas erythropoietin EPO and transferrin Tf tended toward higher values in the anemic group. Approx. 26% of individuals demonstrated transferrin saturation TfS < 20%, which clearly indicates age-related iron deficiency. The cut-off values for pro-inflammatory cytokine IL-1β, TNFα and hepcidin were 5.3 ng/mL, 97.7 ng/mL and 9.4 ng/mL, respectively. High IL-1β negatively affected Hb concentration (r_s = -0.581, p < 0.0001). Relatively high odds ratios were observed for IL-1β (OR = 72.374, 95%Cl 19.688-354.366) and peripheral blood mononuclear cells CD34 (OR = 3.264, 95%Cl 1.263-8.747) and CD38 (OR = 4.398, 95%Cl 1.701-11.906), which together indicates a higher probability of developing anemia. The results endorse the interplay between inflammatory status and iron metabolism and demonstrated a high usefulness of IL-1β in identification of the underlying causes of anemia, while CD34 and CD38 appeared useful in compensatory response assessment and, in the longer term, as part of a comprehensive approach to anemia monitoring in older adults.

The changing prevalence of anemia and risk factors in people with HIV in North America who have initiated ART, 2007-2017

OBJECTIVE

To characterize the prevalence of anemia and risk factors between 2007 and 2017 for moderate/severe anemia among people with HIV (PWH) in North America who have initiated antiretroviral therapy (ART).

DESIGN

Observational study of participants in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD).

METHODS

We estimated the annual prevalence between 1 January 2007 and 31 December 2017 of mild (11.0-12.9 g/dl men, 11.0-11.9 g/dl women), moderate (8.0-10.9 g/dl regardless of sex) and severe (<8.0 g/dl regardless of sex) anemia. Poisson regression models with robust variance and general estimating equations estimated crude and adjusted prevalence ratios (aPR) with 95% confidence intervals ([-]) comparing risk factors for moderate/severe vs. no/mild anemia between 2007 and 2017.

RESULTS

Among 73 898 PWH we observed 366 755 hemoglobin measurements following ART initiation, 37 301 (50%) had one or more measures of anemia during follow-up (mild = 17 743 [24%]; moderate = 13 383[18%]; severe = 6175 [8%]). Moderate/severe anemia was more prevalent among women, non-Hispanic Black and Hispanic PWH (vs. non-Hispanic white), those with underweight body mass index (<18.5 kg/m2) and with comorbidities and coinfections. Older age had increased prevalence of moderate/severe anemia among males and decreased prevalence among females. Prevalence of moderate/severe anemia was greater among those with lower CD4+ cell count (≤200 cells/μl) [aPR = 2.11 (2.06-2.17)] unsuppressed HIV viral load (>200 copies/ml) [aPR = 1.26 (1.23-1.29)] and within the first 6 months of ART initiation (vs. >1 year of ART) [aPR = 1.66 (1.61-1.72)].

CONCLUSION

The prevalence of anemia among PWH is reduced after ART initiation but remains high. Risk factors differ by sex and include comorbidities and HIV disease severity. The persistent, substantial prevalence of anemia among PWH merits further investigation, targeted screening, and clinical interventions.

Association of Anemia with Clinical Symptoms Commonly Attributed to Anemia-Analysis of Two Population-Based Cohorts

BACKGROUND

Fatigue, dyspnea, and lack of energy and concentration are commonly interpreted as indicative of symptomatic anemia and may thus play a role in diagnostic and therapeutic decisions.

OBJECTIVE

To investigate the association between symptoms commonly attributed to anemia and the actual presence of anemia.

METHODS

Data from two independent cohorts of the Study of Health in Pomerania (SHIP) were analyzed. Interview data, laboratory data, and physical examination were individually linked with claims data from the Association of Statutory Health Insurance Physicians. A complete case analysis using logistic regression models was performed to evaluate the association of anemia with symptoms commonly attributed to anemia. The models were adjusted for confounders such as depression, medication, insomnia, and other medical conditions.

RESULTS

A total of 5979 participants (53% female, median age 55) were included in the analysis. Of those, 30% reported fatigue, 16% reported lack of energy, 16% reported lack of concentration, and 29% reported dyspnea and/or weakness. Anemia was prevalent in about 6% (379). The symptoms were more prevalent in participants with anemia. However, participants with anemia were older and had a poorer health status. There was no association in multivariate logistic regression models between the symptoms fatigue, lack of concentration, dyspnea, and/or weakness and anemia. Anemia was associated (OR: 1.45; 95% CI: 1.13-1.86) with lack of energy in the multivariate analysis. Other factors such as depression, insomnia, and medication were more strongly associated with the symptoms.

CONCLUSION

The clinical symptoms commonly attributed to anemia are unspecific and highly prevalent both in non-anemic and anemic persons. Even in the presence of anemia, other diagnoses should be considered as causes such as depression, heart failure, asthma, and COPD, which are more closely associated with the symptoms. Further diagnostic research is warranted to explore the association of symptoms in different subgroups and settings in order to help clinical decision making.

Association of lifestyle behaviors with health-related quality of life among patients with hematologic diseases

PURPOSE

Health-related quality of life (HRQoL) is a multi-dimensional construct used to assess the impact of health status on quality of life, and it is known to be affected by lifestyle behaviors. This study focused on multiple lifestyle behaviors among patients with hematologic diseases, including physical activity, dietary intake, sleep quality, occupational exposure, alcohol consumption and smoking. The main objective was to investigate the association of both individual and clustering of health behaviors with HRQoL among the population with hematologic diseases based on a comprehensive lifestyle survey.

METHODS

A total of 539 patients with hematologic diseases aged over 18 years were enrolled in this cross-sectional study. Latent class analysis was used to identify homogeneous, mutually exclusive lifestyle classes, and multinomial logistic regression was then performed to explore the association of lifestyle classes membership with HRQoL. Meanwhile, multiple linear regression and quantile regression were used to identify the relationship between individual lifestyle behaviors and HRQoL.

RESULTS

A three-class model was selected based on conceptual interpretation and model fit. We found no association between multiple lifestyle behaviors and HRQoL in the 3-class model, either in the whole patients or in subgroups stratified by hematological malignancies. Further research on each lifestyle found that physical activity, dietary intake, occupational exposure, alcohol consumption or smoking were independent of HRQoL. Sleep quality was positively associated with HRQoL.

CONCLUSION

Our findings suggested that clustering of lifestyle behaviors may not be an indicator to reflect the health quality of patients with hematologic diseases. Sleep represents a viable intervention target that can confer health benefits on the hematologic patients.

Increased Risk of Anemia in Patients with Asthma

Purpose

Asthma can cause a systemic inflammatory response, and anemia of chronic disease (ACD) is known to be caused by other disorders with a chronic inflammatory state. However, it is unclear whether the incidence of anemia is increased in patients with asthma. The objective of this study was to compare the incidence of anemia in patients with asthma and healthy adults.

Patients and Methods

This retrospective cohort study included patients newly diagnosed with asthma at Seoul National University Hospital from 2010 to 2017. Patients with comorbidities before the first visit (index date) that may increase anemia risk were excluded. Cox regression models adjusting for patient age, sex, and obesity were used to compare anemia hazard ratios (HRs) between asthma patients (n=1354) and healthy adults (n=1731).

Results

This study included 3085 patients. During 5-y follow-up, anemia occurred in 203 (15.0%) patients with asthma and 79 (4.6%) healthy adults. Compared with healthy adults, the HR for anemia after adjusting for age, sex, and obesity was 4.06 (95% CI: 2.70-6.09) in patients with asthma. In patients aged 18-64.9 y, the adjusted HR of anemia was 3.27 (95% CI: 2.12-5.04) in patients with asthma, compared to healthy patients. In patients >65 y, this adjusted HR was 5.56 (95% CI: 1.31-23.67).

Conclusion

The risk of anemia was increased in patients with asthma after adjusting for sex, age, and obesity and excluding comorbidities that can cause anemia. These results suggest the need for regular monitoring for anemia in patients with asthma.

Hemoglobin modulation affects physiology and patient reported outcomes in anemic and non-anemic subjects: An umbrella review

Background: An abnormal hemoglobin concentration has a substantial effect on a person's quality of life and physiology. Lack of tools that effectively evaluate hemoglobin-related outcomes leads to uncertainty regarding optimal hemoglobin levels, transfusion thresholds and treatment targets. We therefore aim to summarize reviews that assess the effects of hemoglobin modulation on the human physiology at various baseline hemoglobin levels, and identify gaps in existing evidence. Methods: We conducted an umbrella review of systematic reviews. PubMed, MEDLINE (OVID), Embase, Web of Science, Cochrane Library and Emcare were searched from inception to the 15th of April 2022 for studies that reported on physiological and patient reported outcomes following a hemoglobin change. Results: Thirty-three reviews were included of which 7 were scored as of high quality and 24 of critically low quality using the AMSTAR-2 tool. The reported data generally show that an increase in hemoglobin leads to improvement of patient reported and physical outcomes in anaemic and non-anaemic subjects. At lower hemoglobin levels, the effect of a hemoglobin modulation on quality of life measures appears more pronounced. Conclusion: This overview has revealed many knowledge gaps due to a lack of high-quality evidence. For chronic kidney disease patients, a clinically relevant benefit of increasing the hemoglobin levels up until 12 g/dL was found. However, a personalized approach remains necessary due to the many patient-specific factors that affect outcomes. We strongly encourage future trials to incorporate physiological outcomes as objective parameters together with subjective, but still very important, patient reported outcome measures.

Diagnostic Workup of Microcytic Anemia: An Evaluation of Underuse or Misuse of Laboratory Testing in a Hospital Setting Using the AlinIQ System

CONTEXT.—

Underuse of laboratory testing has been previously investigated in preselected populations, such as documented malpractice claims. However, these numbers might not reflect real-life situations.

OBJECTIVE.—

To evaluate the underuse and misuse of laboratory follow-up testing in a real-life hospital patient population with microcytic anemia, using laboratory results ordered during routine patient care.

DESIGN.—

From all patients in whom a microcytic anemia was detected during routine diagnostics in 2018, all available laboratory data were collected and screened for appropriateness of diagnostic workup of iron deficiency and thalassemia. Subgroup analysis was performed for patient groups with mean corpuscular volume values 75 to 79 μm3 (group 1), 65 to 74 μm3 (group 2), and <65 μm3 (group 3).

RESULTS.—

A total of 2244 patients with microcytic anemia were identified. Follow-up testing for iron deficiency was not performed in 761 cases (34%). For inconclusive ferritin levels due to elevated C-reactive protein results (n = 336), reticulocyte hemoglobin content or soluble transferrin receptor levels were missing in 86 cases (26%). In patients with suspected thalassemia (n = 127), follow-up testing for hemoglobin variants was not performed in 70 cases (55%). Subgroup analysis showed that the frequency of underuse of iron status as well as thalassemia/hemoglobinopathy testing decreased from group 1 to group 3. When considering relevant preexisting anemia diagnoses, laboratory tests were underused in 904 cases (40.3%).

CONCLUSIONS.—

Because 40% (n = 904) of the patients with microcytic anemia were potentially not followed up correctly, laboratory specialists are advised to act by implementing demand management strategies in collaboration with clinicians to overcome underuse of laboratory tests and to improve patient safety.

The role of iron in chronic inflammatory diseases: from mechanisms to treatment options in anemia of inflammation

Anemia of inflammation (AI) is a highly prevalent comorbidity in patients affected by chronic inflammatory disorders, such as chronic kidney disease, inflammatory bowel disease, or cancer, that negatively affect disease outcome and quality of life. The pathophysiology of AI is multifactorial, with inflammatory hypoferremia and iron-restricted erythropoiesis playing a major role in the context of disease-specific factors. Here, we review the recent progress in our understanding of the molecular mechanisms contributing to iron dysregulation in AI, the impact of hypoferremia and anemia on the course of the underlying disease, and (novel) therapeutic strategies applied to treat AI.

Relative Handgrip Strength Mediates the Relationship between Hemoglobin and Health-Related Quality of Life in Older Korean Adults

Background: Little is known regarding how anemia and handgrip strength influence the health-related quality of life (HRQoL) of older populations. This population-based study aimed to examine whether handgrip strength mediates the association between anemia and HRQoL in a representative sample of 6892 Korean adults aged ≥ 65 years (3753 females). Methods: HRQoL was assessed with the EuroQol-5 dimension. Anemia was defined according to World Health Organization (WHO) criteria, and handgrip strength was measured with a digital hand dynamometer. Results: Individuals with anemia were at increased risk for a lower HRQoL (odds ratio, OR = 1.285, p = 0.002) even after adjustment for age, sex, body mass index, income, marital status, education, physical activity, and multimorbidity compared with individuals without anemia (OR = 1). Individuals with weak handgrip strength were also at increased risk for a lower HRQoL (OR = 1.429, p < 0.001) even after adjustment for all the covariates compared with individuals with normal handgrip strength (OR = 1). Mediation analysis with a bootstrapping procedure showed that relative handgrip strength mediated the relationship between hemoglobin and HRQoL (95% confidence interval, CI 0.0192 to 0.0289) even after adjustment for all covariates, with 42.0% of the total effect of hemoglobin on HRQoL explained. Conclusions: The current findings suggest that the impact of anemia on HRQoL is partially mediated by weak handgrip strength, implying the clinical importance of having or maintaining adequate hemoglobin and handgrip strength via healthy lifestyle choices to maintain a high HRQoL later in life.

Comparison between thoracic low-dose computed tomography and conventional-dose computed tomography in evaluating anemia: A preliminary study in a Chinese screening cohort

Purpose

To investigate and evaluate the value of thoracic low dose computed tomography (LDCT) scan in the diagnosis of anemia.

Materials and methods

661 patients who received thoracic computed tomography (CT) examination and underwent a peripheral blood examination were retrospectively included. 341 patients underwent conventional dose CT (CDCT), and 320 patients underwent LDCT. Regions of interest (ROI) were placed on the left ventricular cavity (LV), descending aorta (DAo), and interventricular septum (IVS). The corresponding CT attenuation was measured, and the CT attenuation difference between LV and IVS (IVS-LV) and between DAo and IVS (IVS-DAo) was calculated, respectively. One-way analysis of variance (ANOVA) and linear regression were performed to analyze the relationship between these indicators and Hb levels. The receiver operating characteristic (ROC) curve was used to evaluate prediction performance.

Results

Both attenuation on LDCT and CDCT showed significant differences between the healthy group and the anemic group (P &lt; 0.05). In the LDCT group, the LV and DAo were more relevant with the hemoglobin (Hb) level (correlation coefficient 0.618 and 0.602) than other indicators, with AUCs of 0.815 (95% CI: 0.763–0.868) and 0.803 (95% CI: 0.747–0.859), respectively. The linear regression formulas for Hb level with the LV and DAo were 19.14 + 0.15 × HU [95% CI: (16.52, 21.75) + (0.12, 0.17) × HU] and 19.46 + 0.16 × HU [95% CI: (16.55, 22.36) + (0.13, 0.18) × HU], respectively. Youden’s index indicated that 37.5 HU and 38.5 HU were the best thresholds to diagnose anemia for LV and DAo, respectively. In the CDCT group, the LV and IVS-LV got obviously higher correlation coefficients (0.813 and 0.812), with AUCs of 0.831 (95% CI: 0.786–0.877) and 0.851 (95% CI: 0.808–0.894), respectively. The optimal thresholds for LV and IVS-LV were 40.5 HU and 9.5 HU, respectively.

Conclusion

In LDCT examinations, an approximation of Hb level and detecting of anemia can be conducted based on simple attenuation measurements.

Predicting readmission due to severe hyperglycemia after a hyperglycemic crisis episode

AIM

This study aimed to investigate the readmission pattern and risk factors for patients who experienced a hyperglycemic crisis.

METHODS

Patients admitted to MacKay Memorial Hospital for diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS) between January 2016 and April 2019 were studied. The timing of the first readmission for hyperglycemia and other causes was recorded. Kaplan-Meier analysis was used to compare patients with hyperglycemia and all-cause readmissions. Cox regression was used to identify independent predictors for hyperglycemia and all-cause readmission post-discharge.

RESULTS

The study cohort included 410 patients, and 15.3 % and 46.3 % of them had hyperglycemia and all-cause readmissions, respectively. The DKA and HHS group showed a similar incidence for hyperglycemia, with the latter group showing a higher incidence of all-cause readmissions. The significant predictors of hyperglycemia readmissions included young age, smoking, hypoglycemia, higher effective osmolality, and hyperthyroidism in the DKA group and higher glycated hemoglobin level in the HHS group.

CONCLUSIONS

Patients who experienced DKA and HHS had similar hyperglycemia readmission rates; however, predictors in the DKA group were not applicable to the HHS group. Designing different strategies for different types of hyperglycemic crisis is necessary for preventing readmission.

Mortality and its associated factors in transfused patients at a tertiary hospital in Uganda

Blood transfusion is life-saving but sometimes also associated with morbidity and mortality. There is limited data on mortality in patients transfused with whole blood in sub-Saharan Africa. We described the 30-day all-cause mortality and its associated factors in patients transfused with whole blood to inform appropriate clinical intervention and research priorities to mitigate potential risks. A retrospective study was performed on purposively sampled patients transfused with whole blood at the Uganda Cancer Institute (UCI) and Mulago hospital in the year 2018. Two thousand twelve patients with a median (IQR) age of 39 (28–54) years were enrolled over a four month period. There were 1,107 (55%) females. Isolated HIV related anaemia (228, 11.3%), gynaecological cancers (208, 10.3%), unexplained anaemia (186, 9.2%), gastrointestinal cancers (148, 7.4%), and kidney disease (141, 7.0%) were the commonest diagnoses. Most patients were transfused with only one unit of blood (n = 1232, 61.2%). The 30 day all-cause mortality rate was 25.2%. Factors associated with mortality were isolated HIV related anaemia (HR 3.2, 95% CI, 2.3–4.4), liver disease (HR 3.0, 95% CI, 2.0–4.5), kidney disease (HR 2.2, 95% CI, 1.5–3.3; p<0.01), cardiovascular disease (HR 2.9, 95% CI, 1.6–5.4; p<0.01), respiratory disease (HR 3.0, 95% CI 1.8–4.9; p<0.01), diabetes mellitus (HR 4.1, 95% CI, 2.3–7.4; p<0.01) and sepsis (HR 6.2, 95% CI 3.7–10.4; p<0.01). Transfusion with additional blood was associated with survival (HR 0.8, 95% CI 0.7–0.9, p<0.01). In conclusion, the 30-day all-cause mortality was higher than in the general inpatients. Factors associated with mortality were isolated HIV related anaemia, kidney disease, liver disease, respiratory disease, cardiovascular disease, diabetes mellitus and sepsis. Transfusion with additional blood was associated with survival. These findings require further prospective evaluation.

Health-related quality of life after restrictive versus liberal RBC transfusion for cardiac surgery: Sub-study from a randomized clinical trial

BACKGROUND

Transfusion Requirements in Cardiac Surgery III (TRICS III), a multi-center randomized controlled trial, demonstrated clinical non-inferiority for restrictive versus liberal RBC transfusion for patients undergoing cardiac surgery. However, it is uncertain if transfusion strategy affects long-term health-related quality of life (HRQOL).

STUDY DESIGN AND METHODS

In this planned sub-study of Australian patients in TRICS III, we sought to determine the non-inferiority of restrictive versus liberal transfusion strategy on long-term HRQOL and to describe clinical outcomes 24 months postoperatively. The restrictive strategy involved transfusing RBCs when hemoglobin was <7.5 g/dl; the transfusion triggers in the liberal group were: <9.5 g/L intraoperatively, <9.5 g/L in intensive care, or <8.5 g/dl on the ward. HRQOL assessments were performed using the 36-item short form survey version 2 (SF-36v2). Primary outcome was non-inferiority of summary measures of SF-36v2 at 12 months, (non-inferiority margin: -0.25 effect size; restrictive minus liberal scores). Secondary outcomes included non-inferiority of HRQOL at 18 and 24 months.

RESULTS

Six hundred seventeen Australian patients received allocated randomization; HRQOL data were available for 208/311 in restrictive and 217/306 in liberal group. After multiple imputation, non-inferiority of restrictive transfusion at 12 months was not demonstrated for HRQOL, and the estimates were directionally in favor of liberal transfusion. Non-inferiority also could not be concluded at 18 and 24 months. Sensitivity analyses supported these results. There were no differences in quality-adjusted life years or composite clinical outcomes up to 24 months after surgery.

DISCUSSION

The non-inferiority of a restrictive compared to a liberal transfusion strategy was not established for long-term HRQOL in this dataset.

Lower socioeconomic status strengthens the effect of cooking fuel use on anemia risk and anemia-related parameters: Findings from the Henan Rural Cohort

The established evidence of cooking fuel use and socioeconomic status related to anemia is limited in low- and middle-income countries. The current study aims to examine the independent and combined effects of cooking fuel use and socioeconomic status on anemia risk as well as anemia-related parameters in rural China. A total of 21,050 participants were included from the baseline of the Henan Rural Cohort. Anemia was determined according to the World Health Organization criteria. Data on cooking fuel use (electricity, gas and solid fuel) and socioeconomic status (education and income levels) were collected using a standardized questionnaire by face-to-face interview. Logistic and linear regression models were applied to evaluate the effects of cooking fuel use or socioeconomic indicators on anemia risk, hemoglobin (HGB), red blood count (RBC), and hematocrit (HCT) levels. Using gas or solid fuel for cooking was positively associated with prevalent anemia risk and negatively related to HGB, RBC, and HCT levels compared to using electricity. Significant independent associations were also found between socioeconomic status (education and income levels) and prevalent anemia risk as well as these anemia-related parameters. In general, with decreased socioeconomic status, associations of using gas or solid fuel for cooking with advanced anemia risk as well as lower anemia-related parameters were increased. Furthermore, participants using gas or solid fuel for cooking and with lower education or income level were related to increased high anemia risk as well as low HGB, RBC and HCT levels, compared to those using electricity for cooking and with high education or income level (P <0.05 for all). The finding suggested that lower socioeconomic status strengthens the adverse effect of cooking fuel use on the higher anemia risk and lower HGB, RBC, and HCT levels in rural China.

Prevalence and Associated Factors of Anemia among Breast Cancer Patients Undergoing Chemotherapy: A Prospective Study

Purpose

The purpose of this study was to ascertain the prevalence and factors associated with anemia (hemoglobin [Hb] 12 g/dL) in breast cancer patients undergoing chemotherapy.

Materials and Methods

We conducted a prospective longitudinal study to collect demographic and clinical data on adult breast cancer patients with or without anemia who were admitted to HKL, UMMC, and NCI. The incidence of anemia was determined by detecting whether or not anemia developed during the course of chemotherapy. Mild, moderate, or severe anemia was defined. A chi-squared and logistic regression model were used to assess the effect of demographic and clinical factors on the incidence of anemia and multiple logistic regression analysis was used to evaluate the associations of potential risk factors with the presence of CRA.

Results

The study enrolled a total of 292 breast cancer patients. Anemia occurred at a rate of 41.1% (n = 120). Our findings indicated that clinical factors such as the number of chemotherapy regimens, dose reduction, and type of chemotherapy, for example, docetaxel, as well as demographic covariates such as age and BMI, all contribute to the incidence of anemia in cancer patients.

Conclusions

According to this study, the prevalence of anemia in breast cancer patients is high. Patients' age, BMI, number of chemotherapy regimens, and docetaxel were risk factors; thus, protocols are needed to identify subgroups of breast cancer likely to benefit from novel management strategies.

Unexplained anemia of aging: Etiology, health consequences, and diagnostic criteria

BACKGROUND

Up to 15% of people aged 60 and over are anemic, and the prevalence of anemia increases with age. In older men and women, anemia is associated with increases in the risk of death and all-cause hospitalization, poor functional capacity, quality of life, and depression.

METHODS AND RESULTS

We reviewed the literature describing anemia in aging populations, focusing on the specific diagnostic criteria of anemia and potential causes in older men and women. Even after extensive etiologic workup that involves careful medical history, physical examination, laboratory measurements, and additional studies such as bone marrow biopsy, anemia of aging is unexplained in up to 40% of older patients with anemia. As a result, treatment options remain limited.

CONCLUSIONS

The prevalence of unexplained anemia of aging (UAA; also called unexplained anemia of the elderly, UAE), its deleterious impacts on health, physical function, and quality of life, and the lack of effective treatment or therapy guidelines represent a compelling unmet clinical need. In this review and consensus document, we discuss the scope of the problem, possible causes of UAA, diagnostic criteria, and potential treatment options. Because even mild anemia is strongly linked to poor clinical outcomes, it should receive clinical attention rather than simply being considered a normal part of aging.

Hematopoiesis, Inflammation and Aging-The Biological Background and Clinical Impact of Anemia and Increased C-Reactive Protein Levels on Elderly Individuals

Anemia and systemic signs of inflammation are common in elderly individuals and are associated with decreased survival. The common biological context for these two states is then the hallmarks of aging, i.e., genomic instability, telomere shortening, epigenetic alterations, loss of proteostasis, deregulated nutrient sensing, mitochondrial dysfunction, cellular senescence, stem cell exhaustion and altered intercellular communication. Such aging-associated alterations of hematopoietic stem cells are probably caused by complex mechanisms and depend on both the aging of hematopoietic (stem) cells and on the supporting stromal cells. The function of inflammatory or immunocompetent cells is also altered by aging. The intracellular signaling initiated by soluble proinflammatory mediators (e.g., IL1, IL6 and TNFα) is altered during aging and contributes to the development of both the inhibition of erythropoiesis with anemia as well as to the development of the acute-phase reaction as a systemic sign of inflammation with increased CRP levels. Both anemia and increased CRP levels are associated with decreased overall survival and increased cardiovascular mortality. The handling of elderly patients with inflammation and/or anemia should in our opinion be individualized; all of them should have a limited evaluation with regard to the cause of the abnormalities, but the extent of additional and especially invasive diagnostic evaluation should be based on an overall clinical evaluation and the possible therapeutic consequences.

Mild anemia and 11- to 15-year mortality risk in young-old and old-old: Results from two population-based cohort studies

BACKGROUND

Mild anemia is a frequent although often overlooked finding in old age. Nevertheless, in recent years anemia has been linked to several adverse outcomes in the elderly population. Objective of the study was to investigate the association of mild anemia (hemoglobin concentrations: 10.0-11.9/12.9 g/dL in women/men) with all-cause mortality over 11-15 years and the effect of change in anemia status on mortality in young-old (65-84 years) and old-old (80+ years).

METHODS

The Health and Anemia and Monzino 80-plus are two door-to-door, prospective population-based studies that included residents aged 65-plus years in Biella municipality and 80-plus years in Varese province, Italy. No exclusion criteria were used.

RESULTS

Among 4,494 young-old and 1,842 old-old, mortality risk over 15/11 years was significantly higher in individuals with mild anemia compared with those without (young-old: fully-adjusted HR: 1.35, 95%CI, 1.15-1.58; old-old: fully-adjusted HR: 1.28, 95%CI, 1.14-1.44). Results were similar in the disease-free subpopulation (age, sex, education, smoking history, and alcohol consumption adjusted HR: 1.54, 95%CI, 1.02-2.34). Both age groups showed a dose-response relationship between anemia severity and mortality (P for trend <0.0001). Mortality risk was significantly associated with chronic disease and chronic kidney disease mild anemia in both age groups, and with vitamin B12/folate deficiency and unexplained mild anemia in young-old. In participants with two hemoglobin determinations, seven-year mortality risk was significantly higher in incident and persistent anemic cases compared to constant non-anemic individuals in both age groups. In participants without anemia at baseline also hemoglobin decline was significantly associated with an increased mortality risk over seven years in both young-old and old-old. Limited to the Monzino 80-plus study, the association remained significant also when the risk was further adjusted also for time-varying covariates and time-varying anemia status over time.

CONCLUSIONS

Findings from these two large prospective population-based studies consistently suggest an independent, long-term impact of mild anemia on survival at older ages.

Relationship Between Hemoglobin and Blood Pressure Levels in the Context of Chronic Morbidity Among Older Adults Residing in a Developing Country: A Community-Level Comparative Cross-Sectional Study

Objectives: The objective of this study is to assess the association between hemoglobin (Hb) and blood pressure (BP) levels among community-dwelling older adults.

Materials and Methods: This comparative cross-sectional study was conducted in April 2021 in West Bengal, India. Individuals who are receiving treatment for hypertension, or had a history of blood transfusion, or had a history of intake of iron and vitamins were excluded from the study. A total of 81 and 106 individuals were recruited in “Group 1” (no self-reported comorbidity) and “Group 2” (self-reported comorbidity present), respectively.

Results: The mean (SD) age of the participants (n = 187) was 67.4 (7.4) years; 54% (n = 101) were males; and 45.4% (n = 85) were obese. We found a significant association of Hb level with systolic blood pressure (SBP) (r = 0.22, p = 0.04) and mean arterial pressure (MAP) (r = 0.22, p = 0.04) in “Group 1”. The quantum of increases in SBP, diastolic blood pressure (DBP), pulse pressure (PP), and MAP with one gram/dl change in Hb level were 3.24 (95% CI: -0.75 to 7.24) mmHg, 1.17 (95% CI: -0.84 to 3.20) mmHg, 2.06 (95% CI: -0.67 to 4.81) mmHg, and 1.87 (95% CI: -0.65 to 4.39) mmHg, respectively, in “Group 1” after adjustment for age, gender, and body mass index. The findings were inconsistent in “Group 2”, and the changes in Hb level were 0.5 (95% CI: -3.77 to 2.77) mmHg, 0.92 (95% CI: -0.72 to 2.75) mmHg, -1.42 (95% CI: -4.09 to 1.24) mmHg, and 0.45 (95% CI: -1.05 to 2.40) mmHg, respectively.

Conclusion: Hb level has a positive correlation with SBP and MAP only in those without comorbidities.

Is Hemoglobin Concentration a Linear Predictor of Mortality in Older Adults From Chinese Longevity Regions?

Introduction: The association patterns of hemoglobin (HB) concentrations with mortality among the longevity older adults are unclear. We aimed to evaluate the relationship among older adults form Chinese longevity regions. Methods: We included 1,785 older adults aged ≥65 years (mean age, 86.7 years; 1,002 women, 783 men) from the community-based Chinese Longitudinal Healthy Longevity Survey. We estimated the hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality using multivariable Cox proportional hazards models and Cox models with restricted cubic spline. Results: In total, 999 deaths occurred during a median follow-up of 5.4 years from 2011 to 2017. Restricted cubic spline analysis found no non-linear association between HB concentrations and all-cause mortality after a full adjustment for covariates among the older adults form longevity regions (p > 0.05 for non-linearity). The risk for all-cause mortality was significantly higher in the groups with HB concentration of <11.0 g/dL (HR: 1.37, 95% CI: 1.10-1.70) and 11.0-12.0 g/dL (HR: 1.25, 95% CI: 1.01-1.54); the risk of all-cause mortality was significantly lower in the groups with HB concentration ≥14.0 g/dL (HR: 0.76, 95% CI: 0.60-0.97) compared with the reference group (13.0-13.9 g/dL). Conclusions: Among older adults form Chinese longevity regions, HB concentrations were found to be inversely and linearly associated with all-cause mortality. Further prospective intervention trials are needed to confirm whether higher HB concentrations had a lower risk of mortality in these older adults.

The genetic analysis of Chinese patients with clonal cytopenias using targeted next-generation sequencing

BACKGROUND

Clonal hematopoiesis (CH) can be found in various myeloid neoplasms (MN), such as myelodysplastic syndromes (MDS), myelodysplastic syndromes/myeloproliferative neoplasms (MDS/MPN), also in pre-MDS conditions.

METHODS

Cytogenetics is an independent prognostic factor in MDS, and fluorescence in-situ hybridization (FISH) can be used as an adjunct to karyotype analysis. In the past 5 years, only 35 of 100 newly diagnosed MDS and MDS/MPN patients were identified abnormalities, who underwent the FISH panel. In addition, we examined a cohort of 51 cytopenic patients suspected MDS or MDS/MPN with a 20-gene next generation sequencing (NGS), including 35 newly diagnosed MN patients and 16 clonal cytopenias of undetermined significance (CCUS) patients.

RESULTS

Compared with the CCUS group, the MN group had higher male ratio (22/13 vs 10/6), cytogenetics abnormalities rate (41.4% vs 21.4%) and frequency of a series of mutations, such as ASXL1 (28.6% vs 25%), U2AF1 (25.7% vs 25%), RUNX1 (20% vs 0.0%); also, higher adverse mutations proportion (75% vs 85.2%), and double or multiple mutations (54.3% vs 43.75%). There were 7 MN patients and 4 CCUS patients who experienced cardio-cerebrovascular embolism events demonstrated a significant difference between the two groups (25% vs 20%). Ten of the 11 patients had somatic mutations, half had DNA methylation, while the other half had RNA splicing. Additionally, six patients had disease transformation, and four patients had mutated U2AF1, including two CCUS cases and two MDS-EB cases. Following up to January 2021, there was no significant difference in over survival between the CCUS and MN groups.

CONCLUSION

NGS facilitates the diagnosis of unexplained cytopenias. The monitoring and management of CCUS is necessary, also cardio-cerebrovascular embolism events in patients with CH need attention in the clinical practice.

Impact of in-hospital intravenous iron supplementation on red blood cell transfusions: experience from an Internal Medicine Unit

BACKGROUND

Pharmacological treatment of iron deficiency anaemia can reduce red blood cell (RBC) transfusions. Intravenous iron provides a more effective and quicker correction of iron deficiency anaemia than oral iron, and third-generation high-dose intravenous iron formulations allow the complete correction of iron deficiency with just one or two drug infusions, thus facilitating iron supplementation therapy and reducing transfusion requirement.

MATERIAL AND METHODS

In an observational, retrospective study we compared RBC transfusion requirement during hospitalisation and within 3 months of hospital discharge in 88 patients with iron deficiency anaemia treated with high-dose ferric carboxymaltose and in 85 patients treated with ferric gluconate while hospitalised in the Internal Medicine unit of our Institution.

RESULTS

Ferric carboxymaltose reduced the number of RBC units given to each transfused patient during hospitalisation (1.81±0.84 vs 2.39±1.49, p=0.011). At hospital discharge, fewer ferric carboxymaltose patients were prescribed home therapy with iron. No differences between treatment groups were observed in the proportion of patients or the number of RBC units transfused within 3 months of discharge. At one month from discharge, however, only 2 ferric carboxymaltose patients had been transfused compared with 7 ferric gluconate patients (p=0.078). Patients transfused post-discharge were more likely to have an underlying malignancy and/or higher serum creatinine concentrations.

DISCUSSION

Treatment with ferric carboxymaltose reduced the number of RBC units per transfused patient. Larger studies are required to define risk factors associated with post-discharge transfusion requirement and to establish if home therapy with iron will reduce subsequent transfusions in patients treated with ferric carboxymaltose.

Etiology of Anemia in Older Mexican Adults: The Role of Hepcidin, Vitamin A and Vitamin D

Anemia in older adults is a growing public health issue in Mexico; however, its etiology remains largely unknown. Vitamin A deficiency (VAD) and vitamin D deficiency (VDD) have been implicated in the development of anemia, though by different mechanisms. The aim of this study is to analyze the etiology of anemia and anemia-related factors in older Mexican adults. This is a cross-sectional study of 803 older adults from the southern region of Mexico in 2015. The anemia etiologies analyzed were chronic kidney disease (CKD), nutritional deficiencies (ND), anemia of inflammation (AI), anemia of multiple causes (AMC) and unexplained anemia (UEA). VAD was considered to be s-retinol ≤ 20 μg/dL, and VDD if 25(OH)D < 50 nmol/L. IL-6 and hepcidin were also measured. Multinomial regression models were generated and adjusted for confounders. Anemia was present in 35.7% of OA, independent of sex. UEA, CKD, AI and ND were confirmed in 45%, 29.3%, 14.6% and 7% of older adults with anemia, respectively. Hepcidin and log IL-6 were associated with AI (p < 0.05) and CKD (p < 0.001). VAD was associated with AI (p < 0.001), and VDD with ND and AMC (p < 0.05). Log-IL6 was associated with UEA (p < 0.001). In conclusion, anemia in older adults has an inflammatory component. VAD was associated to AI and VDD with ND and AMC.

Early detection of anaemia in primary care with haemoglobinometry: ANHEMOG clinical trial protocol

Abstract

Background

Detecting, treating and monitoring anaemia has a functional, social and economic impact on patients’ quality of life and the health system, since inadequate monitoring can lead to more accident & emergency visits and hospitalizations. The aim of this study is to evaluate the impact in the patient clinical outcomes of using haemoglobinometry to early detect anaemia in patients with chronic anaemia in primary care.

Methods

Randomized controlled trial Capillary haemoglobin will be measured using a haemoglobinometer on a monthly basis in the intervention group. In the control group, the protocol currently in force at the primary care centre will be followed and venous haemoglobin will be measured. Any cases of anaemia detected in either group will be referred to the transfusion circuit of the reference hospital.

Discusion

The results will shed light on the impact of the intervention on the volume of hospitalizations and accident & emergency (A&E) visits due to anaemia, as well as patients’ quality of life. Chronic and repeated bouts of anaemia are detected late, thus leading to decompensation in chronic diseases and, in turn, more A&E visits and hospitalizations. The intervention should improve these outcomes since treatment could be performed without delay. Improving response times would decrease decompensation in chronic diseases, as well as A&E visits and hospitalizations, and improve quality of life. The primary care nurse case manager will perform the intervention, which should improve existing fragmentation between different care levels.

Trial registration

NCT04757909. Registered 17 February 2021. Retrospectively registered.

Cost-Effectiveness of Ferrous Fumarate-Folic Acid and Ferrous Gluconate-Multivitamins in a High Prevalence Area of Iron Deficiency Anemia in Indonesia

BACKGROUND

Up to now, the combinations of ferrous fumarate-folic acid (FF-FA) and ferrous gluconate-multivitamins (FG-MV) have been implemented by the local government in the province of Papua. Nevertheless, there is no a specific economic evaluation that has been applied to investigate the cost-effectiveness of FF-FA and FG-MV.

OBJECTIVE

This study aimed to investigate the cost-effectiveness of FF-FA and FG-MV to be implemented in Teluk Bintuni, as one of the districts with the highest prevalence of iron deficiency anemia in Papua by taking the healthcare perspective into account.

METHODS

A prospective observational study was applied by considering two groups of women (15-49 years old) with iron deficiency anemia who received FF-FA and FG-MV from September to November 2018. Applying a purposive sampling method, respondents were selected from 875 targeted women in six sub-districts, who met inclusion criteria. To estimate the total cost, we applied a healthcare perspective that considered direct medical cost only (eg, the procurement cost of iron tablets, cost of Hb test, and cost of healthcare visit). To estimate the effectiveness of intervention, we applied two major parameters, such as Hb level and utility score in quality-adjusted life year (QALY). The cost-effectiveness values were evaluated by using the criteria on the cost-effectiveness of healthcare intervention according to the threshold of gross domestic product (GDP) per capita (cost per QALY gained).

RESULTS

From 875 targeted women in six sub-districts who met inclusion criteria, we found approximately 222 women with moderate-severe iron deficiency anemia and 110 women with complete data in the group of FF-FA (n=69) and FG-MV (n-41). The results showed that there were significant differences (p-value <0.05) on the number of respondents, age, oral iron cost, total healthcare cost and utility score in both intervention groups. Comparing the use of FG-MV with FF-FA, we estimated the incremental cost-effectiveness ratios (ICERs) would be $255.77 per controlled patient, $142.09 per patient with Hb increment >2.00 g/dL, $79.93 per patient with Hb increment >1.00 g/dL, and $11.59 per QALY gained.

CONCLUSION

The ICER was estimated to be $11.59 per QALY gained, which was highly cost-effective, according to GDP-based cost-effectiveness threshold. In addition, the utility score of women with iron deficiency anemia was considered to be the most influential factor impacting the cost-effectiveness value.

The anemia-independent impact of myelodysplastic syndromes on health-related quality of life

Myelodysplastic syndromes (MDS) are in the majority of cases characterized by anemia. Both anemia and MDS per se may directly contribute to impairments in health-related quality of life (HRQoL). In this study, we aimed to investigate the anemia-independent impact of MDS on HRQoL. We evaluated participants (≥ 50 years) from the large population-based Lifelines cohort (N = 44,694, mean age 59.0 ± 7.4 years, 43.6% male) and the European MDS Registry (EUMDS) (N = 1538, mean age 73.4 ± 9.0 years, 63.0% male), which comprises a cohort of lower-risk MDS patients. To enable comparison concerning HRQoL, SF-36 scores measured in Lifelines were converted to EQ-5D-3L index (range 0–1) and dimension scores. Lower-risk MDS patients had significantly lower HRQoL than those from the Lifelines cohort, as illustrated in both the index score and in the five different dimensions. Multivariable linear regression analysis demonstrated that MDS had an adjusted total impact on the EQ-5D index score (B =  − 0.12, p < 0.001) and an anemia-independent “direct” impact (B =  − 0.10, p < 0.001). Multivariable logistic regression analysis revealed an anemia-independent impact of MDS in the dimension mobility, self-care, usual activities, and anxiety/depression (all except pain/discomfort). This study demonstrates that the major part of the negative impact of lower-risk MDS on HRQoL is not mediated via anemia. Thus, the therapeutic focus should include treatment strategies directed at underlying pathogenic mechanisms to improve HRQoL, rather than aiming predominantly at increasing hemoglobin levels.