Anemia: Evaluation and Diagnostic Tests

Clinical characteristic of isolated thrombocytopenia in patients with bone marrow failure-related germline variants: a retrospective study from a single centre

BACKGROUND

Immune thrombocytopenia (ITP) comprises the majority of thrombocytopenia. Some patients respond poorly to first-line ITP therapy or develop pancytopenia years later. Recent studies link heterozygous germline variants in acquired aplastic anemia (AA), yet their role in isolated thrombocytopenia carrying bone marrow failure-related germline variants (ITGV-BMFs) remains unclear. While whole-exome sequencing (WES) detects these variants, its cost limits routine use. This study compares prognosis and clinical features of isolated thrombocytopenia in patients with ITGV-BMFsand those with classic ITP.

METHODS

The clinical data of patients diagnosed with ITGV-BMFs were retrospectively analyzed and compared with those of patients with classic ITP from August 2018 to February 2024. The baseline characteristics, genomic systematically background, previous treatment response as well as their follow-up outcomes were compared.

RESULTS

Patients with ITGV-BMFs demonstrated earlier onset age (p < 0.001), lower bleeding scores and CD34%, along with elevated mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and reticulocyte (RET) counts (p < 0.001). Multivariate logistic regression analysis showed that the patients with ITGV-BMFs may possess distinct characteristics, including an earlier age at onset (p = 0.014) and lower bleeding score (p = 0.048). Notably, MCV and RET showed promising performance in receiver operating characteristic (ROC) curve analysis. During the follow-up period, 57.69% (15/26) ITGV-BMFs patients were further confirmed as aplastic anemia (AA, n = 13) or myelodysplastic syndrome (MDS, n = 2), with a median progression-free survival (PFS) of 7.25 years (p < 0.0001).

CONCLUSION

ITGV-BMFs may be diagnosed early using elevated MCV and reticulocyte counts, a diagnostic approach that may lead to earlier intervention and improved prognosis.

Rising trends on folic acid test requests in a middle-income large academic hospital: A low-value care target for improvement

OBJECTIVES

To evaluate the trends in serum folate test ordering and their abnormal results.

METHODS

The authors retrieved data from an anonymized laboratory database from a single, large, academic hospital from Brazil. The authors retrieved serum folate test results, the number of repetitions and other laboratory measurements obtained in the same time window, ordering setting and clinic. The authors then evaluated the trends in test ordering, and prevalence of low (< 3 ng/dL) results, and assessed targets for improvement in test ordering.

RESULTS

From January 1st, 2018, to December 31st, 2022, 181,379 folate tests were ordered from 82,052 patients, with 0.7 % of low results, rising from 33,988 in 2018 to 44,187 in 2022. The outpatient setting was the most frequent (89.5 %). The clinics that most frequently ordered folate tests were Gastroenterology (33 %) and Nephrology (9.8 %). Most patients had more than one test ordered (74.8 %). The 135,787 re-tests were performed in 36,300 patients. Many exams were repeated within three (22,570) or six months (46,881). Only 24,243 repetitions were made more than a year after the prior exam.

CONCLUSIONS

Folate test ordering is an increasing trend in this large academic hospital, suggestive of non-clinical guided test ordering and low-value testing.

Status and factors related to hemoglobin concentration of people with vs. without disability-using nationwide claims check-up database

Background

Blood hemoglobin level is a key indicator of organ function and health status throughout the life course. As hemoglobin-related health problems are gaining attention, many studies on factors related to hemoglobin concentration are being conducted, yet few researches have been conducted targeting persons with disabilities. Furthermore, researches that consider the association between blood hemoglobin and the regional level health welfare resources are rare. This study aimed to explore the factors related to blood hemoglobin concentration among people with and without disability, and to contribute to the development of future nutritional policies and projects for persons with disabilities.

Methods

A health insurance claims database with check-ups provided by the National Health Insurance Services (NHIS) was used. One-to-three propensity score matching was conducted between participants with and without disabilities. In addition to the individual clinical and health behavioral aspects based on the claims data, regional-level data of healthcare and social welfare resources was also collected, and multi-level analysis was conducted to identify factors associated with low blood hemoglobin level.

Results

A total of 1,697 participants with disability and 5,091 without disabilities were yielded. Disability was significantly associated with lower hemoglobin level, even after propensity score matching. Sex, BMI, health behaviors, and clinical indicators were significantly associated with the blood hemoglobin level. Furthermore, region-level welfare budget was a significant factor among persons with disability.

Conclusion

Our findings confirmed the significant association between disability and lower hemoglobin level. Regional health and welfare resources, as well as individual characteristics should be considered in implementation of further nutrition and health policies for persons with disabilities. Further studies are needed to understand of health outcomes of low hemoglobin level.

Cytopenias in Autoimmune Liver Diseases-A Review

Autoimmune liver diseases (AiLDs), including autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC), are immune-mediated conditions associated with significant hepatic and systemic manifestations. Among these, cytopenias-defined as reductions in blood cell counts affecting single or multiple lineages-represent a clinically important, though often under-recognized, complication. Cytopenias in AiLDs arise from diverse mechanisms, including immune-mediated destruction, hypersplenism due to portal hypertension, bone marrow suppression, and nutritional deficiencies. These abnormalities can exacerbate bleeding, infections, or fatigue, complicating the disease course and impacting therapeutic strategies. Immune-mediated cytopenias, such as autoimmune hemolytic anemia (AIHA), immune thrombocytopenic purpura (ITP), and autoimmune neutropenia (AIN), are more frequently associated with AIH, whereas cytopenias in PBC and PSC are largely attributed to hypersplenism. Diagnostic evaluation involves a systematic approach combining clinical history, laboratory testing (e.g., complete blood counts, Coombs tests, and nutritional assessments), imaging studies, and bone marrow evaluation in complex cases. Treatment strategies aim to address the underlying cause of cytopenias, including immunosuppressive therapy for autoimmune mechanisms, beta-blockers or splenectomy for hypersplenism, and supplementation for nutritional deficiencies. Challenges include distinguishing between immune- and hypersplenism-related cytopenias, managing drug-induced cytopenias, and optimizing care in transplant candidates. The recently recognized IgG4-related disease, often mimicking cholestatic AiLDs, adds another layer of complexity, given its association with autoimmune cytopenias and hypersplenism. This review aims to act as a guide for the clinician dealing with patients with AiLDs with respect to the occurrence of cytopenias, with a specific focus on pathophysiology and management of these cytopenias. Furthermore, there need to be enhanced multidisciplinary discussions about those patients between the hematologists and hepatologists, with a maintenance of a high index of suspicion for the rarer causes of cytopenias in AiLDs on the part of the treating physician, and there is a need for further studies to elucidate the mechanisms behind the occurrence of cytopenias in AiLDs.

A Risk Warning Model for Anemia Based on Facial Visible Light Reflectance Spectroscopy: Cross-Sectional Study

Background

Anemia is a global public health issue causing symptoms such as fatigue, weakness, and cognitive decline. Furthermore, anemia is associated with various diseases and increases the risk of postoperative complications and mortality. Frequent invasive blood tests for diagnosis also pose additional discomfort and risks to patients.

Objective

This study aims to assess the facial spectral characteristics of patients with anemia and to develop a predictive model for anemia risk using machine learning approaches.

Methods

Between August 2022 and September 2023, we collected facial image data from 78 anemic patients who met the inclusion criteria from the Hematology Department of Shanghai Hospital of Traditional Chinese Medicine. Between March 2023 and September 2023, we collected data from 78 healthy adult participants from Shanghai Jiading Community Health Center and Shanghai Gaohang Community Health Center. A comprehensive statistical analysis was performed to evaluate differences in spectral characteristics between the anemic patients and healthy controls. Then, we used 10 different machine learning algorithms to create a predictive model for anemia. The least absolute shrinkage and selection operator was used to analyze the predictors. We integrated multiple machine learning classification models to identify the optimal model and developed Shapley additive explanations (SHAP) for personalized risk assessment.

Results

The study identified significant differences in facial spectral features between anemic patients and healthy controls. The support vector machine classifier outperformed other classification models, achieving an accuracy of 0.875 (95% CI 0.825-0.925) for distinguishing between the anemia and healthy control groups. In the SHAP interpretation of the model, forehead-570 nm, right cheek-520 nm, right zygomatic-570 nm, jaw-570 nm, and left cheek-610 nm were the features with the highest contributions.

Conclusions

Facial spectral data demonstrated clinical significance in anemia diagnosis, and the early warning model for anemia risk constructed based on spectral information demonstrated a high accuracy rate.

High hemoglobin-to-red cell distribution width ratio reduces adverse events in patients with pacemaker implantation

BACKGROUND

The prognostic significance of the hemoglobin-to-red blood cell distribution width (Hb/RDW) ratio in patients undergoing pacemaker implantation (PMI) remains uncertain. Our study aimed to explore the prospective relationship between the Hb/RDW ratio and the risk of major cardiovascular events (MCEs) in Chinese patients with PMI.

METHODS

A total of 595 patients with permanent PMI were enrolled. Patients were divided into the high-Hb/RDW (≥ 9.1 g/L per percent) and the low-Hb/RDW (< 9.1 g/L per percent) groups according to the levels of the Hb/RDW ratio using the receiver operating characteristic curve. The primary outcome was the composite MCEs including heart failure hospitalization, myocardial infarction, stroke, and all-cause death, presented as hazard ratios (HR) with 95% confidence intervals (CI) estimated by the Cox Proportional Hazards models, propensity score (PS) adjusted, and inverse probability weighting (IPW) analyses, respectively.

RESULTS

During the median 2-year follow-up period, 95 (16%) MCEs were identified among the 595 patients with PMI Patients with a high Hb/RDW ratio exhibited a lower risk of MCEs compared to those with a low Hb/RDW ratio (adjusted HR: 0.456; 95% CI: 0.376-0.848). In additional analyses with different statistical models, the multivariate-adjusted HR was 0.592 (95% CI: 0.380-0.920) for the PS-adjusted analysis and 0.444 (95% CI: 0.271-0.729) for the IPW, respectively. There were no interactions between subgroups and Hb/RDW in our analysis.

CONCLUSION

High levels of the Hb/RDW ratio were linked to a lower risk of composite MCEs. The Hb/RDW ratio was a better predictor of MCEs than Hb or RDW alone.

Impact of Occupational Cement Dust Exposure on Hematological Health Parameters: A Cross-Sectional Study

Introduction Contact with the dust of cement consisting of toxic components brings about inflammatory damage (often irreversible) to the body of a human being. The circulatory system exhibits sensitivity to inflammatory changes in the body, and one of the earliest changes may be observed in the blood parameters like mean corpuscular hemoglobin (MCH) and mean corpuscular hemoglobin concentration (MCHC). MCHC and MCH are possibly easily accessible and affordable parameters that can detect harmful changes in the body before any irreversible damage occurs. Objectives This research aimed to seek the changes in MCHC and MCH upon occupational contact with the toxic dust of cement. Methods The execution of this research was done in the Department of Physiology, Dhaka Medical College, Bangladesh, and a cement plant in Munshiganj, Bangladesh. This research was carried out between September 2017 and August 2018. Individuals (20 to 50 years old, 92 male adults) participated and were grouped into the group with occupational cement dust impact (46 subjects) and the group without occupational dust of cement impact (46 subjects). Data was collected in a pre-designed questionnaire. An independent sample t-test was conducted to analyze statistical and demographic data like body mass index and blood pressure. A multivariate regression model was applied to note the impact of cement dust on the group working in this dusty environment. Again, a multivariate regression model was employed to observe whether the duration of exposure to this dust affected MCHC and MCH. The significance level was demarcated at p < 0.05 Stata-15 (StataCorp LLC, College Station, TX, US) for statistical analysis, and GraphPad Prism v8.3.2 (Insight Venture Management, LLC, New York, NY, US) was employed to present the data graphically when required. Results There was a reduction in MCHC by 0.58 g/dL and MCH levels by 0.68 pg in the cement dust-exposed subjects when compared to controls, but not significant (95% CI: -0.93, 2.10; p  = 0.448 and 95% CI: -0.37, 1.73; p = 0.203, respectively). However, MCHC was reduced significantly by 0.51 g/dL (p = 0.011) with the duration of exposure to the dust. Conclusion The study showed that MCHC was significantly reduced with the duration of exposure to cement dust in cement plant workers. Such alterations may hamper heme synthesis, hemolysis, and inflammatory changes in the body.

Establishment of a Diamond-Blackfan anemia like model in zebrafish

BACKGROUND

Anemia is defined as a lack of erythrocytes, low hemoglobin levels, or abnormal erythrocyte morphology. Diamond-Blackfan anemia (DBA) is a rare and severe congenital hypoplastic anemia that occurs due to the dominant inheritance of a ribosomal protein gene mutation. Even rarer is a case described as Diamond-Blackfan anemia like (DBAL), which occurs due to a loss-of-function EPO mutation recessive inheritance. The effective cures for DBAL are bone marrow transfusion and treatment with erythropoiesis-stimulating agents (ESAs). To effectively manage the condition, construction of DBAL models to identify new medical methods or screen drugs are necessary.

RESULTS

Here, an epoa-deficient mutant zebrafish called epoaszy8 was generated to model DBAL. The epoa-deficiency in zebrafish caused developmental defects in erythroid cells, leading to severe congenital anemia. Using the DBAL model, we validated a loss-of-function EPO mutation using an in vivo functional analysis and explored the ability of ESAs to alleviate congenital anemia.

CONCLUSIONS

Together, our study demonstrated that epoa deficiency in zebrafish leads to a phenotype resembling DBAL. The DBAL zebrafish model was found to be beneficial for the in vivo assessment of patient-derived EPO variants with unclear implications and for devising potential therapeutic approaches for DBAL.

Red cell size factor is a sensitive index in the early diagnosis of nondigestive tract cancer-related anemia: An observational study

Cancer-related anemia (CRA) is a common comorbidity in cancer patients, and it can lead to a worse prognosis. The aim of this cross-sectional study is to investigate the clinical value of the red cell size factor (Rsf) in the early diagnosis of nondigestive tract CRA. A total of 231 patients with nondigestive tract solid cancer were included, and they were divided into anemic and nonanemic subjects according to the hemoglobin (Hb) levels. A BC-7500 blood analyzer was used to detect the indices of red blood cell and reticulocyte, and the mean corpuscular volume (MCV), mean reticulocyte volume (MRV), reticulocyte hemoglobin (RHE) content, and reticulocyte production index were observed. Subsequently, the Rsf was calculated. Receiver operating characteristic curve analysis was used to evaluate the identifying power of Rsf for anemia diagnosed by the combination of RHE and reticulocyte production index. The adjusted-multivariate analysis and quartiles were used to assess the relation of reduced Rsf level with the risk and incidence of anemia diagnosed by combining the MCV, MCH, and mean corpuscular hemoglobin concentration (MCHC), respectively. Rsf levels showed no statistical differences between anemia and nonanemia subjects grouped by Hb (P > .05). Rsf has a high correlation with the RHE level (R > 0.900, P < .001), or MCV, mean corpuscular hemoglobin (MCH), and MCHC in anemia patients (r: 0.435-0.802, P < .001). Receiver operating characteristic curves showed that Rsf had the highest overall area under curve of 0.886 (95% confidence interval: 0.845-0.927) in identifying anemia of cancer patients (P < .001). When the optimal cutoff values of Rsf were set at 97.05 fl in males and 94.95 fl in females, the sensitivity and specificity were 0.94 and 0.76, and 0.98 and 0.75, respectively. Being treated as a categorical variable, Rsf had a highest odds ratio value of 30.626 (12.552-74.726; P < .001) for the risk of anemia. The increment of Rsf quartiles was highly associated with the decreased incidence of overall anemia (P trend < 0.001). The study suggests that decreased Rsf level is a potentially powerful predictor of overt anemia in nondigestive tract cancer, and it can be used as a convenient, practical, cost-free, and sensitive index in early diagnosis of nondigestive tract CRA.

Machine learning-assisted rapid determination for traditional Chinese Medicine Constitution

The aim of this study was to develop a machine learning-assisted rapid determination methodology for traditional Chinese Medicine Constitution. Based on the Constitution in Chinese Medicine Questionnaire (CCMQ), the most applied diagnostic instrument for assessing individuals' constitutions, we employed automated supervised machine learning algorithms (i.e., Tree-based Pipeline Optimization Tool; TPOT) on all the possible item combinations for each subscale and an unsupervised machine learning algorithm (i.e., variable clustering; varclus) on the whole scale to select items that can best predict body constitution (BC) classifications or BC scores. By utilizing subsets of items selected based on TPOT and corresponding machine learning algorithms, the accuracies of BC classifications prediction ranged from 0.819 to 0.936, with the root mean square errors of BC scores prediction stabilizing between 6.241 and 9.877. Overall, the results suggested that the automated machine learning algorithms performed better than the varclus algorithm for item selection. Additionally, based on an automated machine learning item selection procedure, we provided the top three ranked item combinations with each possible subscale length, along with their corresponding algorithms for predicting BC classification and severity. This approach could accommodate the needs of different practitioners in traditional Chinese medicine for rapid constitution determination.

An Introduction to the Complete Blood Count for Clinical Chemists: Red Blood Cells

BACKGROUND

The most frequently ordered laboratory test worldwide is the complete blood count (CBC).

CONTENT

In this primer, the red blood cell test components of the CBC are introduced, followed by a discussion of the laboratory evaluation of anemia and polycythemia.

SUMMARY

As clinical chemists are increasingly tasked to direct laboratories outside of the traditional clinical chemistry sections such as hematology, expertise must be developed. This review article is a dedication to that effort.

Exploring the influence of anemia and inflammation indices on colorectal cancer: analysis of the national health and nutrition examination survey From 2011 to 2018

Purpose

Patients with colorectal cancer (CRC) frequently present with anemia and signs of infection. However, the relationships between these factors remain unclear. This study investigated the potential association between anemia, inflammatory indices, and CRC.

Methods

We analyzed data from the 2011-2018 National Health and Nutrition Examination Survey to investigate links between anemia, inflammation, and CRC. Inflammatory indices, including the neutrophil-percentage-to-albumin ratio, neutrophil-to-lymphocyte ratio, and eosinophil-to-lymphocyte ratio, were analyzed. Following rigorous inclusion criteria, 14,114 participants were included. Statistical methods such as logistic regression and subgroup analyses were employed. Moreover, survival analysis was performed.

Results

Among the 14,114 participants, 0.6% had CRC and 11.0% were diagnosed with anemia. Anemia and inflammatory indices were associated with CRC, suggesting an increased risk (OR range: 2.03-2.50, P<0.05). Patients with CRC had lower red blood cell counts, reduced hemoglobin levels, and higher inflammatory indices. This is accompanied by an increase in the inflammatory indices, which is also a risk factor for CRC (OR range: 1.12-7.00, P<0.05). Survival analyses indicated that anemia was associated with lower survival rates, impacting all-cause, cancer, and CRC mortality.

Conclusion

Our results indicate that anemia and inflammatory indices are correlated with CRC. Patients with CRC tend to exhibit increased inflammatory indices and decreased red blood cell count and albumin levels, potentially impacting survival.

Comparison of venous and pooled capillary hemoglobin levels for the detection of anemia among adolescent girls

Introduction

Blood source is a known preanalytical factor affecting hemoglobin (Hb) concentrations, and there is evidence that capillary and venous blood may yield disparate Hb levels and anemia prevalence. However, data from adolescents are scarce.

Objective

To compare Hb and anemia prevalence measured by venous and individual pooled capillary blood among a sample of girls aged 10-19 years from 232 schools in four regions of Ghana in 2022.

Methods

Among girls who had venous blood draws, a random subsample was selected for capillary blood. Hb was measured using HemoCue® Hb-301. We used Lin's concordance correlation coefficient (CCC) to quantify the strength of the bivariate relationship between venous and capillary Hb and a paired t-test for difference in means. We used McNemar's test for discordance in anemia cases by blood source and weighted Kappa to quantify agreement by anemia severity. A multivariate generalized estimating equation was used to quantify adjusted population anemia prevalence and assess the association between blood source and predicted anemia risk.

Results

We found strong concordance between Hb measures (CCC = 0.86). The difference between mean venous Hb (12.8 g/dL, ± 1.1) and capillary Hb (12.9 g/dL, ± 1.2) was not significant (p = 0.26). Crude anemia prevalence by venous and capillary blood was 20.6% and 19.5%, respectively. Adjusted population anemia prevalence was 23.5% for venous blood and 22.5% for capillary (p = 0.45). Blood source was not associated with predicted anemia risk (risk ratio: 0.99, 95% CI: 0.96, 1.02). Discordance in anemia cases by blood source was not significant (McNemar p = 0.46). Weighted Kappa demonstrated moderate agreement by severity (ĸ = 0.67). Among those with anemia by either blood source (n = 111), 59% were identified by both sources.

Conclusion

In Ghanaian adolescent girls, there was no difference in mean Hb, anemia prevalence, or predicted anemia risk by blood source. However, only 59% of girls with anemia by either blood source were identified as having anemia by both sources. These findings suggest that pooled capillary blood may be useful for estimating Hb and anemia at the population level, but that caution is needed when interpreting individual-level data.

Dietary factors associated with anaemia among pregnant women attending antenatal care clinics in Sekota town, Northern Ethiopia: a facility-based cross-sectional study

Background

Anaemia is a major public health problem during pregnancy, especially in developing countries such as Ethiopia. Poor diet patterns are common contributors to anaemia. This study assessed the dietary factors associated with anaemia among pregnant women attending antenatal care clinics in Sekota town, Northern Ethiopia.

Methods

A facility-based cross-sectional study was conducted from June to August 2021 among 367 pregnant women who were selected using systematic random sampling techniques. A structured questionnaire was used to collect sociodemographic, obstetric and dietary data. The nutritional status of pregnant women was assessed using a mid-upper arm circumference measuring tape, and haemoglobin levels were tested using the haematocrit centrifugation technique. The data were analysed using SPSS V.21. Bivariate and multivariate logistic regression analyses were performed to assess dietary factors associated with anaemia and p<0.05 was used to declare statistical significance.

Results

Dietary pattern predictors such as meal frequency (adjusted OR (AOR)=0.27, 95% CI: 0.12, 0.59), meat consumption frequency (AOR=4.05, 95% CI: 2.46, 33.65), fruit and vegetable consumption frequency (AOR=2.88, 95% CI: 2.08, 26.81), Dietary Diversity Score (AOR=12.81, 95% CI: 3.93, 41.75), food aversion (AOR=0.12, 95% CI: 0.03, 0.47) and undernutrition (AOR=0.22, 95% CI: 0.07, 0.64) were significantly associated with anaemia.

Conclusion

Predictors of dietary pattern, such as meal frequency, Dietary Diversity Score, food aversion, meat consumption frequency, fruit and vegetable consumption frequency, and undernutrition were significantly associated with anaemia among pregnant women in the study area. Therefore, healthcare providers, policymakers, researchers and other stakeholders should pay special attention to maternal dietary patterns to address the identified factors. Programmes should be developed and implemented to improve optimal dietary patterns and proper nutrition during pregnancy to overcome anaemia and other pregnancy complications.

A novel discriminant algorithm for differential diagnosis of mild to moderate thalassemia and iron deficiency anemia

BACKGROUND

Mild to moderate thalassemia trait (TT) and iron deficiency anemia (IDA) are the most common conditions of microcytic hypochromic anemia (MHA) and they exhibit highly similar clinical and laboratory features. It is sometimes difficult to make a differential diagnosis between TT and IDA in clinical practice. Therefore, a simple, effective, and reliable index is needed to discriminate between TT and IDA.

METHODS

Data of 598 patients (320 for TT and 278 for IDA) were enrolled and randomly assigned to training set (278 of 598, 70%) and validation set (320 of 598, 30%). Stepwise discriminant analysis was used to define the best diagnostic formula for the discrimination between TT and IDA in training set. The accuracy and diagnostic performance of formula was tested and verified by receiver operating characteristic (ROC) analysis in validation set and its diagnostic performance was compared with other published indices.

RESULTS

A novel formula, Thalassemia and IDA Discrimination Index (TIDI) = -13.932 + 0.434 × RBC + 0.033 × Hb + 0.025 ×MCHC + 53.593 × RET%, was developed to discriminate TT from IDA. TIDI showed a high discrimination performance in ROC analysis, with the Area Under the Curve (AUC) = 0.936, Youden' s index = 78.7%, sensitivity = 89.5%, specificity = 89.2%, respectively. Furthermore, the formula index also obtained a good classification performance in distinguishing 5 common genotypes of TT from IDA (AUC from 0.854-0.987).

CONCLUSION

The new, simple algorithm can be used as an effective and robust tool for the differential diagnosis of mild to moderate TT and IDA in Guangxi region, China.

The mean reticulocyte volume is a valuable index in early diagnosis of cancer-related anemia

Background

Cancer-related anemia (CRA) is a functional iron deficient anemia, and the early diagnosis will improve the prognosis of the patients. This prospective study aimed to investigate the utility of mean reticulocyte volume (MRV) in the early diagnosis of CRA.

Methods

A total of 284 first-diagnosed cancer patients were enrolled, and the subjects were assigned anemia and non-anemia groups by hemoglobin (Hb) concentrations. The mature RBC and reticulocyte indices were detected with BC-7500 blood analyzer, and the MRV, reticulocyte hemoglobin (RHE) content, and reticulocyte production index (RPI) were obtained. ROC curves were constructed in identifying anemia diagnosed by the combination of RHE and RPI. An adjusted multivariate analyse and quartiles were used to assess the associations of MRV with early CRA diagnosed by combining RBC indices (MCV, MCH and MCHC), respectively.

Results

No statistical differences were observed in MCV, RHE and MRV levels between anemia and non-anemia subjects (p > 0.05). MRV exhibited a complete or high correlation with the RHE levels (r = 1.000, p < 0.001), or MCV, MCH, and MCHC in anemia patients (R: 0.575-0.820, p < 0.001). ROC curves analyse indicated a highest area under curve of 0.829 (95% CI [0.762-0.895]) and 0.884 (95% CI [0.831-0.936]) for MRV in identifying anemia in male and female patients, respectively (p < 0.001). When the optimal cutoff values of MRV were set at 100.95 fl in males and 98.35 fl in females, the sensitivity and specificity were 1.00 and 0.68, and 1.00 and 0.73, respectively. The regression analyse showed that, when being as a categorical variable, MRV showed an odds ratio of 19.111 (95% CI [6.985-52.288]; p < 0.001) for the incidence of CRA. The incidence of overall anemia demonstrated a more significant decrease trend along with the increase of MRV quartiles (p-trend < 0.001).

Conclusion

This study revealed that the MRV can be used as a convenient and sensitive index in early diagnosis of cancer-related anemia, and decreased MRV level may be the powerful predictor of overt anemia in cancer patients.

Algorithm of differential diagnosis of anemia involving laboratory medicine specialists to advance diagnostic excellence

OBJECTIVES

Anemia is a severe global public health issue. Testing practices for anemia suggest overuse of screening laboratory tests and misinterpretation of studies even in "easy-to-diagnose" underlying causes, leading to late diagnoses and missed treatment opportunities. We aimed to develop a complete and efficient algorithm for clinical pathologists and laboratory medicine physicians for the differential diagnosis of anemia.

METHODS

Comprehensive literature search encompassing original articles, studies, reviews, gold standard books, and other evidence.

RESULTS

We created a complex algorithm, primarily for clinical pathology/laboratory use, that explores all major and several rare causes of anemia in an efficient and evidence-based manner. The algorithm includes gold-standard diagnostic laboratory tests available in most clinical laboratories and indices that can be easily calculated to provide an evidence-based differential diagnosis of anemia.

CONCLUSIONS

The diagnostic strategy combines previously available diagnostic tests and protocols in an efficient order. Clinical pathologists following the algorithm can independently provide valuable diagnostic support for healthcare providers. Clinical pathologists providing complete differential diagnostic services with the proposed algorithm may create an opportunity for an advanced diagnostic service that supports diagnostic excellence and helps patients receive a timely diagnosis and early treatment opportunities.

Prediction of plasma volume and total hemoglobin mass with machine learning

Hemoglobin concentration ([Hb]) is used for the clinical diagnosis of anemia, and in sports as a marker of blood doping. [Hb] is however subject to significant variations mainly due to shifts in plasma volume (PV). This study proposes a newly developed model able to accurately predict total hemoglobin mass (Hbmass) and PV from a single complete blood count (CBC) and anthropometric variables in healthy subject. Seven hundred and sixty-nine CBC coupled to measures of Hbmass and PV using a CO-rebreathing method were used with a machine learning tool to calculate an estimation model. The predictive model resulted in a root mean square error of 33.2 g and 35.6 g for Hbmass, and 179 mL and 244 mL for PV, in women and men, respectively. Measured and predicted data were significantly correlated (p < 0.001) with a coefficient of determination (R2 ) ranging from 0.76 to 0.90 for Hbmass and PV, in both women and men. The Bland-Altman bias was on average 0.23 for Hbmass and 4.15 for PV. We herewith present a model with a robust prediction potential for Hbmass and PV. Such model would be relevant in providing complementary data in contexts such as the epidemiology of anemia or the individual monitoring of [Hb] in anti-doping.

Clinical Guidance on the Monitoring and Management of Trastuzumab Deruxtecan (T-DXd)-Related Adverse Events: Insights from an Asia-Pacific Multidisciplinary Panel

Trastuzumab deruxtecan (T-DXd)-an antibody-drug conjugate targeting the human epidermal growth factor receptor 2 (HER2)-improved outcomes of patients with HER2-positive and HER2-low metastatic breast cancer. Guidance on monitoring and managing T-DXd-related adverse events (AEs) is an emerging unmet need as translating clinical trial experience into real-world practice may be difficult due to practical and cultural considerations and differences in health care infrastructure. Thus, 13 experts including oncologists, pulmonologists and a radiologist from the Asia-Pacific region gathered to provide recommendations for T-DXd-related AE monitoring and management by using the latest evidence from the DESTINY-Breast trials, our own clinical trial experience and loco-regional health care considerations. While subgroup analysis of Asian (excluding Japanese) versus overall population in the DESTINY-Breast03 uncovered no major differences in the AE profile, we concluded that proactive monitoring and management are essential in maximising the benefits with T-DXd. As interstitial lung disease (ILD)/pneumonitis is a serious AE, patients should undergo regular computed tomography scans, but the frequency may have to account for the median time of ILD/pneumonitis onset and access. Trastuzumab deruxtecan appears to be a highly emetic regimen, and prophylaxis with serotonin receptor antagonists and dexamethasone (with or without neurokinin-1 receptor antagonist) should be considered. Health care professionals should be vigilant for treatable causes of fatigue, and patients should be encouraged to use support groups and practice low-intensity exercises. To increase treatment acceptance, patients should be made aware of alopecia risk prior to starting T-DXd. Detailed monitoring and management recommendations for T-DXd-related AEs are discussed further.

Driving license regranting: Hair EtG, serum CDT, and the role of sociodemographic and medicolegal variables

Driving under the influence (DUI) of alcohol is a road safety problem. Driving license regranting is based on the evaluation of medicolegal and toxicological variables that may include serum carbohydrate-deficient transferrin (CDT) and hair ethyl glucuronide (hEtG). The aim of the study was to compare the diagnostic performance of CDT and hEtG in a population of DUI offenders. Other factors potentially associated with heavy alcohol use were explored. The population included DUI offenders examined during the period of January 1, 2019, through June 30, 2022. Sociodemographic, medicolegal, and toxicological variables were collected. CDT in serum and EtG in head hair were determined in all subjects. Excessive alcohol intake (hEtG ≥30 pg/mg) was considered cause for unfitness to drive. Cohen's kappa coefficient was calculated. Descriptive analyses were performed using chi-square and Mann-Whitney tests. Variables significantly different between the groups were included in a multivariate binary logistic regression model. The sample encompassed 838 subjects (case group: 179, comparison group: 689). CDT exhibited poor agreement (κ = 0.053) with hEtG as the reference test. Lower education, age at DUI, heavy smoking, and GGT levels associated with heavy alcohol consumption differentiated the two groups. For DUI offenders, the use of CDT to assess heavy alcohol consumption is limited, possibly due to the time-window assessed, the time required for normalization, and the different amount of ethanol needed to reach higher CDT levels, in comparison to hEtG; thus, hEtG assessment is strongly recommended for this population. Heavy smoking, GGT, education, and age could be related to heavy alcohol consumption and higher risk of DUI.

Anemia in patients with hidradenitis suppurativa : A systematic review with meta-analysis

IMPORTANCE

Hidradenitis suppurativa (HS) is associated with a number of physical and psychological comorbidities. Studies have suggested an association between HS and anemia; however, this association is not widely understood and may result in delayed diagnosis and treatment and possible increase in morbidity and mortality.

OBJECTIVE

To systematically review and perform a meta-analysis regarding the association between HS and anemia, and to characterize the subtypes of anemia associated with HS.

DATA SOURCES

A search of the EMBASE, Medline, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials databases from the time of database inception to September 25, 2022, yielded 313 unique articles.

STUDY SELECTION

All observational studies and randomized controlled trials published in English that examined the odds ratio (OR) of anemia in patients with HS were screened by 2 independent reviewers. Case reports were excluded. Among 313 unique articles, 7 were deemed eligible.

DATA EXTRACTION AND SYNTHESIS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines facilitated data extraction. The Newcastle-Ottawa Scale (NOS) was used to analyze risk of bias of included studies. In addition to OR and 95% confidence intervals, relevant data on patient demographics and anemia subtypes were also extracted.

MAIN OUTCOMES AND MEASURES

The primary outcome was the OR of anemia in HS patients. This study also attempted to characterize anemia subtypes associated with HS.

RESULTS

In total, 2 case-control and 5 cross-sectional studies featured a total of 11,693 patients. Among the studies, 4 of 7 demonstrated a statistically significant positive association between anemia and HS (ORs, 2.20 [1.42-3.41], 2.33 [1.99-2.73], 1.87 [1.02-3.44], and 1.50 [1.43-1.57]), with macrocytic and microcytic subtypes being most common. After adjusting for publication bias, meta-analysis with random effects revealed HS to be associated with increased odds of anemia compared to non-HS groups (OR 1.59 [1.19, 2.11]).

CONCLUSIONS AND RELEVANCE

There is a statistically significant positive association between HS and anemia, particularly for the aforementioned subtypes. Patients with HS should be screened for anemia. In case of lower hemoglobin concentration, the anemia of HS patients should be subdivided according to mean corpuscular volume of the red blood cells and further investigated depending on subtype.

The Clinical Usefulness of Mean Corpuscular Hemoglobin Concentration in Patients with Pneumoconiosis

Aim

We investigated the clinical usefulness of mean corpuscular hemoglobin concentration (MCHC) in patients with pneumoconiosis.

Methods

We retrospectively investigated the medical records from 52 patients with pneumoconiosis, and erythrocyte parameters were analyzed in pneumoconiosis patients with different stages.

Results

Here, we found that the values of MCHC were significantly lower in III stage pneumoconiosis than those with I/II stage (p = 0.024), and there was no significantly difference in MCHC between smoking pneumoconiosis patients and non-smoking pneumoconiosis patients. A negatively correlation between MCHC and disease stage was observed in patients with pneumoconiosis (r = -0.298, p = 0.032). In multiple linear regression analysis, the MCHC was found to be independently associated with advanced pneumoconiosis in patients with pneumoconiosis (p=0.011). The results of logistic regression analysis indicated that decreased MCHC was an independent risk factor of advanced pneumoconiosis in patients with pneumoconiosis (OR: 0.936, CI95%: 0.877-0.999, p = 0.046). Receiver operating characteristic curve analysis showed that the optimal cutoff value of MCHC was 330 g/L to identify advanced pneumoconiosis with the area under the curve of 0.694 (CI95%:0.550-0.839, p = 0.018).

Conclusion

The decreased MCHC is associated with advanced pneumoconiosis, and MCHC may be used as a monitoring marker for follow-up of pneumoconiosis patients.

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.

Ultrastructural analysis of nucleated erythrocyte in patients with autoimmune hemolytic anemia (AIHA)

Autoimmune hemolytic anemia (AIHA) is a group of diseases characterized by immune-mediated lysis of mature red blood cells (RBCs). It is mainly classified into primary and secondary types based on etiology and mechanisms underlying autoantibody production. AIHA is diagnosed using morphological observation of bone marrow smears under a light microscope and monospecific direct antiglobulin test to detect hemolysis. Here, we retrospectively studied ultrastructural abnormalities of nucleated erythroid cells in bone marrows from 10 patients with AIHA using transmission electron microscopy. Our results revealed severe damage and injury to nucleated erythroid cells, including morphological irregularity, pyknosis, karyolysis, expansion of perinuclear cisternae and cytoplasmic lysis. These results indicate that aberrant immunity attacks not only mature RBCs but also nucleated erythroid cells, and ineffective hematopoiesis is partly involved in the pathogenesis of AIHA.

Chronic Obstructive Pulmonary Disease and Its Effect on Red Blood Cell Indices

Chronic obstructive pulmonary disease (COPD) constitutes a set of heterogeneous symptoms affecting millions of people worldwide. The associated comorbidities developing in COPD involve dysregulation in physiological pathways resulting from systemic inflammation in respiratory airways. In addition to mentioning the pathophysiology, stages, and consequences of COPD, this paper also defines red blood cell (RBC) indices such as hemoglobin, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin concentration, red blood cell distribution width, and RBC count. It explains the role of RBC indices and RBC structural abnormalities with disease severity and exacerbations in COPD patients. Although many factors have been studied as a marker of morbidity and mortality for COPD patients, RBC indices have emerged as revolutionary evidence. Therefore, the effectiveness of evaluating RBC indices in COPD patients and their importance as a negative predictor of survival, mortality, and clinical outcomes have been debated through rigorous literature reviews. Furthermore, the prevalence, mechanisms of development, and prognosis of underlying anemia and polycythemia in COPD have also been evaluated, with anemia most significantly associated with COPD. Therefore, more studies should be conducted to address underlying anemia in COPD patients to lessen the severity and disease burden. Correcting the RBC indices in COPD patients remarkably impacts the quality of life and reduces in-patient admissions, healthcare resource utilization, and costs. Hence, it is noteworthy to understand the significance of considering RBC indices while dealing with COPD patients.

Kitchen ventilation attenuated the associations of solid fuel use and long duration for cooking with the increased prevalence of normocytic anemia

Evidence on the potential risk factors of normocytic anemia, the most prevalent morphology subtype of anemia, was scarce to date. The purpose of this study is to investigate the association of cooking fuel use or daily cooking duration with normocytic anemia and further explore the modification effect of mechanical ventilation. Participants totaling 29,448 from the Henan Rural Cohort were included in this study. Normocytic anemia was defined by hemoglobin (based on the World Health Organization criteria) and mean corpuscular volume. Cooking-related data was collected by questionnaire, and the average daily cooking duration was calculated by the weekly cooking frequency and the cooking duration of each meal. Logistic regression models were employed to derive the combined and independent associations of cooking fuel type and daily cooking duration with normocytic anemia and the modification effect of ventilation. Compared with people who never cooked, both clean fuel and solid fuel users were significantly associated with increased prevalent normocytic anemia [OR (95% CI) = 1.196 (1.014, 1.411) and 1.335 (1.105, 1.614), respectively], and the effect estimates on normocytic anemia risk were 1.260 (1.043, 1.523), 1.320 (1.104, 1.578), and 1.310 (1.081, 1.587) in participants who daily cooked < 1 h/day, 1-2 h/day, and ≥ 2 h/day, respectively. These relationships were attenuated in subjects with mechanical ventilation (All P < 0.05). Cooking with solid fuel or for a long duration are independently associated with prevalent normocytic anemia in rural population, and mechanical ventilation could attenuate these associations. Future efforts to reduce the burden of anemia could target the universal use of ventilation and solid fuel use or cooking duration reduction.Clinical trial registration: The Henan Rural Cohort Study has been registered at Chinese Clinical Trial Register (Registration number: ChiCTR-OOC-15006699). Date of registration: 06 July, 2015. http://www.chictr.org.cn/showproj.aspx?proj=11375.

Clinical utility of reticulocyte haemoglobin in the assessment of iron deficiency and iron deficiency anaemia in the paediatric population

AIM

Reticulocyte haemoglobin (Ret-He) is a useful marker in the assessment of iron stores in adult and paediatric patients. It is currently not utilised in Pathology Queensland. The objective of this study is to verify Ret-He in our Pathology Queensland laboratory and assess the clinical utility in the assessment of iron deficiency (ID) and iron deficiency anaemia (IDA) in paediatric patients.

METHODS

Samples from patients aged <18 years sent to the Pathology Queensland laboratory that had paired full blood count and iron studies were included in this study. A minimum of 120 samples were required for verification of testing requirements and a minimum of 30 samples per age range were required for confirmation of published age-related reference intervals.

RESULTS

Published Ret-He reference intervals were confirmed for stated age ranges in normal (non-ID) patients. Ret-He below the reference range for age demonstrated a good correlation with ID and IDA.

CONCLUSIONS

Ret-He is a useful marker in the assessment of ID and IDA in a paediatric population. It is not affected by acute or chronic inflammation. Ret-He is sensitive and specific (86% and 92%) for the diagnosis of ID.

Comparison of the red blood cell indices based on accuracy, sensitivity, and specificity to predict one-year mortality in heart failure patients

BACKGROUND

Various investigations have specified the role of each RBC indices separately [including hemoglobin (Hb), hematocrit (HCT), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), and red blood cell distribution width (RDW)] to predict the prognosis of acute heart failure (AHF) patients. However, in the current study, these variables were compared based on accuracy, sensitivity, and specificity to determine the best prognostic factor.

METHODS

Of 734 heart failure patients referred to the emergency department, 400 cases were enrolled based on the inclusion and exclusion criteria. Data of them were documented, and patients were followed for one year. Eventually, the association of clinical variables and RBC indices with one-year mortality was explored.

RESULTS

The study included 226 (56%) men and 174 (44%) women with a median age of 66 years. Body Mass Index (HR 1.098, p = 0.016), Hb (HR 0.728, p = 0.024), HTC (HR 0.875, p = 0.066), MCHC (HR 0.795, p = 0.037), and RDW-CV (HR 1.174, p = 0.006) were confirmed as predictors of long-term mortality. Despite confirming the predictive role of these variables by ROC curves, their sensitivity and specificity were reported as follows: [72% and 50% for Hb], [75% and 52% for  HCT], [88% and 27% for MCHC], and [49% and 81% for RDW]. In addition, stratified groups of patients, based on normal cut-off values obtained from scientific literature, had significantly different survival in Kaplan-Meier analyses.

CONCLUSION

Whilst proving the predictive role of Hb,  HCT, MCHC, and RDW in AHF patients, the most sensitive measurement was MCHC and the most specific one was RDW; therefore, these variables should be considered for risk stratification purposes of AHF patients in daily clinical practice.

Prediction of anemia using facial images and deep learning technology in the emergency department

Background

According to the WHO, anemia is a highly prevalent disease, especially for patients in the emergency department. The pathophysiological mechanism by which anemia can affect facial characteristics, such as membrane pallor, has been proven to detect anemia with the help of deep learning technology. The quick prediction method for the patient in the emergency department is important to screen the anemic state and judge the necessity of blood transfusion treatment.

Method

We trained a deep learning system to predict anemia using videos of 316 patients. All the videos were taken with the same portable pad in the ambient environment of the emergency department. The video extraction and face recognition methods were used to highlight the facial area for analysis. Accuracy and area under the curve were used to assess the performance of the machine learning system at the image level and the patient level.

Results

Three tasks were applied for performance evaluation. The objective of Task 1 was to predict patients' anemic states [hemoglobin (Hb) <13 g/dl in men and Hb <12 g/dl in women]. The accuracy of the image level was 82.37%, the area under the curve (AUC) of the image level was 0.84, the accuracy of the patient level was 84.02%, the sensitivity of the patient level was 92.59%, and the specificity of the patient level was 69.23%. The objective of Task 2 was to predict mild anemia (Hb <9 g/dl). The accuracy of the image level was 68.37%, the AUC of the image level was 0.69, the accuracy of the patient level was 70.58%, the sensitivity was 73.52%, and the specificity was 67.64%. The aim of task 3 was to predict severe anemia (Hb <7 g/dl). The accuracy of the image level was 74.01%, the AUC of the image level was 0.82, the accuracy of the patient level was 68.42%, the sensitivity was 61.53%, and the specificity was 83.33%.

Conclusion

The machine learning system could quickly and accurately predict the anemia of patients in the emergency department and aid in the treatment decision for urgent blood transfusion. It offers great clinical value and practical significance in expediting diagnosis, improving medical resource allocation, and providing appropriate treatment in the future.

A novel model forecasting perioperative red blood cell transfusion

We aimed to establish a predictive model assessing perioperative blood transfusion risk using a nomogram. Clinical data for 97,443 surgery patients were abstracted from the DATADRYAD website; approximately 75% of these patients were enrolled in the derivation cohort, while approximately 25% were enrolled in the validation cohort. Multivariate logical regression was used to identify predictive factors for transfusion. Receiver operating characteristic (ROC) curves, calibration plots, and decision curves were used to assess the model performance. In total, 5888 patients received > 1 unit of red blood cells; the total transfusion rate was 6.04%. Eight variables including age, race, American Society of Anesthesiologists' Physical Status Classification (ASA-PS), grade of kidney disease, type of anaesthesia, priority of surgery, surgery risk, and an 18-level variable were included. The nomogram achieved good concordance indices of 0.870 and 0.865 in the derivation and validation cohorts, respectively. The Youden index identified an optimal cut-off predicted probability of 0.163 with a sensitivity of 0.821 and a specificity of 0.744. Decision curve (DCA) showed patients had a standardized net benefit in the range of a 5–60% likelihood of transfusion risk. In conclusion, a nomogram model was established to be used for risk stratification of patients undergoing surgery at risk for blood transfusion. The URLs of web calculators for our model are as follows: http://www.empowerstats.net/pmodel/?m=11633_transfusionpreiction.

Survival Prediction in Patients with Hypertensive Chronic Kidney Disease in Intensive Care Unit: A Retrospective Analysis Based on the MIMIC-III Database

Objective

Disease prediction is crucial to treatment success. The aim of this study was to accurately and explicably predict, based on the first laboratory measurements, medications, and demographic information, the risk of death in patients with hypertensive chronic kidney disease within 1 and 3 years after admission to the Intensive Care Unit (ICU).

Methods

Patients with hypertensive chronic kidney disease who had been registered in the Medical Information Mart for Intensive Care (MIMIC-III) database of critical care medicine were set as the subject of study, which was randomly divided into a training set and a validation set in a ratio of 7 : 3. Univariate Cox regression analysis and stepwise Cox regression analysis were applied in the training set to identify the predictive factors of prognosis of patients with hypertensive chronic kidney disease in ICU, and the predictive nomogram based on Cox regression model was constructed. We internally validated the model in the training set and externally validated that in the validation model. The efficacy was assessed primarily through area under the receiver operating characteristic (ROC) curve, clinical decision curves, and calibration curves.

Results

A total of 1762 patients with hypertensive chronic kidney disease were finally included. During the 3-year follow-up, 667 patients (37.85%) died, with a median follow-up time of 220 days (1-1090). The data set were randomly divided into a training set (n = 1231) and a validation set (n = 531). It was identified in the training set that insurance, albumin, alkaline phosphatase, the mean corpuscular hemoglobin concentration, mean corpuscular volume, history of coronary angiogram, hyperlipemia, medication of digoxin, acute renal failure, and history of renal surgery were the most relevant features. Taking 1 year and 3 years as the cut-off points, the AUC of participants were 0.736 and 0.744, respectively, in the internal validation and were 0.775 and 0.769, respectively, in the external validation, suggesting that the model is of favorable predictive efficacy.

Conclusion

We trained and validated a model using data from a large multicenter cohort, which has considerable predictive performance on an individual scale and could be used to improve treatment strategies.

Impact of Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitor on Heart Failure with Preserved Ejection Fraction

Hypoxia-inducible factor prolyl hydroxylase (HIF-PH) inhibitor is a recently introduced oral medication to treat renal anemia, but its clinical implication in patients with heart failure, particularly heart failure with preserved ejection fraction (HFpEF), remains unknown. We had a 91-year-old woman with HFpEF who was admitted to our institute to treat her worsening heart failure. She initiated HIF-PH inhibitor daprodustat to treat her renal anemia (hemoglobin 8.8 g/dL and estimated glomerular filtration ratio 15.6 mL/min/1.73 m²). Following a 6-month treatment with daprodustat, hemoglobin increased up to 10.4 g/dL, left ventricular mass index decreased from 107 g/m² to 88 g/m², and plasma B-type natriuretic peptide decreased from 276 pg/mL to 122 pg/mL, despite doses of other medications remaining unchanged. HIF-PH inhibitors might be a promising tool to ameliorate renal anemia and facilitate cardiac reverse remodeling in patients with HFpEF.

The accuracy of mean corpuscular volume guided anaemia classification in primary care

BACKGROUND

Anemia can be categorized into micro-, normo- or macrocytic anemia based on the mean corpuscular volume (MCV). This categorization might help to define the etiology of anemia.

METHODS

The cohort consisted of patients newly diagnosed with anaemia in primary care. Seven aetiologies of anaemia were defined, based on an extensive laboratory protocol. Two assumptions were tested: (i) MCV <80 fl (microcytic) excludes vitamin B12 deficiency, folic acid deficiency, suspected haemolysis and suspected bone marrow disease as anaemia aetiology. (ii) MCV >100 fl (macrocytic) excludes iron deficiency anaemia, anaemia of chronic disease and renal anaemia as anaemia aetiology.

RESULTS

Data of 4129 patients were analysed. One anaemia aetiology could be assigned to 2422 (59%) patients, more than one anaemia aetiology to 888 (22%) patients and uncertainty regarding the aetiology remained in 819 (20%) patients. MCV values were within the normal range in 3505 patients (85%). In 59 of 365 microcytic patients (16%), the anaemia aetiology was not in accordance with the first assumption. In 233 of 259 macrocytic patients (90%), the anaemia aetiology was not in accordance with the second assumption.

CONCLUSIONS

Anaemia aetiologies might be ruled out incorrectly if MCV guided classification is used as a first step in the diagnostic work-up of anaemia. We recommend using a broader set of laboratory tests, independent of MCV.

Correlation Analysis between Hemoglobin and C-Reactive Protein in Patients Admitted to an Emergency Unit

Anemia and inflammation are common clinical conditions in emergency departments. This study explored a cohort of patients admitted to the emergency department with a particular interest in determining the frequency of anemia and inflammation and the association between hemoglobin (Hb) and C-reactive protein (CRP) concentrations. The study included 125 patients categorized according to their demographic (gender and age) and clinical condition (Hb and CRP concentrations, pathological background, and diagnostic). We found that anemia and inflammation were simultaneously present in 36.0% of the cohort, reaching 67.0% in patients that were subsequently hospitalized. The Hb level was significantly lower in patients with elevated concentration of CRP when compared to individuals with normal CRP levels (11.58 ± 2.23 vs. 13.25 ± 1.80, p = 0.001); furthermore, we found a significantly negative correlation between Hb concentration and the CRP level (rs = −0.42, p < 0.001). The linear regression model applied to the cohort showed that CRP levels explain 15% of Hb variations. The sensitivity of the CRP/Hb ratio (cut-off = 1.32) as a predictor of hospitalization was 80.0%, with a specificity of 68.4% for all patients. These findings confirmed the prevalence of anemia and inflammation and identified a moderate but significant association between Hb and serum CRP in a heterogeneous group of patients admitted to the emergency department.

Red cell distribution width: A new parameter for predicting the risk of exacerbation in COPD patients

BACKGROUND

Red cell distribution width (RDW) is a numerical measurement of the size variability of erythrocytes and is routinely reported as a component of complete blood count in the differential diagnosis of anemia. In recent years, researchers have reported high mortality and poor prognosis associated with higher RDW in populations with cardiovascular disease, cancer, pneumonia, and chronic obstructive pulmonary disease (COPD). The aim of the study is to evaluate the role of RDW in predicting the risk of COPD exacerbations and the impact of symptoms.

METHODS

We designed an observational retrospective study based on patients hospitalized for acute exacerbation of COPD, between January 2015 and December 2018.

RESULTS

We included 169 patients, 120 at GOLD four stage. RDW was significantly higher in COPD patients vs controls (P = .014). We found a positive correlation with c-reactive protein (r  = 0.375, P < .01), COPD assessment test (CAT) Score (R2 = 0.658, sy.x = 2.226; P < .01), number of exacerbations (R2=0.289; sy.x = 0.86; P = .002), and GOLD score (r = 0.30; P = .05). In ROC curve analysis, the area under the curve of RDW for the identification of frequent exacerbator was 1.0 (95% confidence interval, 1.0-1.0; P < .0001).

CONCLUSION

Our data show that elevated RDW may be a useful tool in predicting the risk of exacerbation in COPD patients and may be a good indicator of the impact of symptoms.

Extremely Old Patients Hospitalized in Internal Medicine: What about Their Anemia?

In western countries, about half of the hospitalized patients are anemic. Generally, these patients are old, often with multiple diseases, and anemia worsens the prognosis, finally increasing the risk of death. We describe a monocentric observational study that evaluates 249 consecutive adult patients (160 women and 89 men) with anemia admitted in the internal medicine department over five months. They represent 71.5% of all patients admitted in the study period. Demographic, historical, and clinical data, laboratory tests, duration of hospitalization, readmission at 30 days, and death were recorded. Patients were stratified by age (75-84=old, >85 years=oldest-old), anemia severity, and etiology of anemia. Anemia was found in 67.5% of old and in 77.2% of oldest-old patients. In 37% of old and 32% of oldest-old patients, anemia was mild, in 43% old and 59% of oldest-old moderate and in 20% old and 9% of oldest-old severe in agreement with WHO criteria. Moderate anemia was significantly more common in the oldest-old (p=0.01). The causes of anemia were iron deficiency in 10.6% of patients, other deficiencies in 2.8%, chronic diseases in 38.2%, hematologic neoplasms in 6.1%, multifactorial in 24.1%, and undetermined in 19.9%. The oldest-old have a higher frequency of multifactorial anemia (p=0.04), while hematologic neoplasms were more common in old patients (p=0.03). Most patients with undetermined anemia had mild/moderate forms. An anti-anemic treatment, mainly blood transfusion, was adopted in 100% of oldest-old patients and in 60% of old (p= 0.04). Anemia (and/or its treatment) was reported in the discharge letter in 19% of old and in 28.2% of oldestold patients. From a general point of view, physicians seem to disregard anemia in the context of more important pathologic conditions. In oldest-old patients, multifactorial anemia seems to be considered only "one more cause of disability." When borderline anemia occurs, even if it can represent a relevant adverse condition in frailty, it is poorly considered.

Vitamin A deficiency regulates the expression of ferritin in young male Wistar rats

ABSTRACT Objective Iron deficiency and vitamin A deficiency are two of the main micronutrient deficiencies. Both micronutrients are essential for human life and children's development. This study aimed to investigate the effects of vitamin A deficiency on ferritin and transferrin receptors' expression and its relationship with iron deficiency. Methods Five diets with different vitamin A-to-iron ratios were given to thirty five 21-day-old male Wistar rats (separated in groups of seven animals each). The animals received the diet for six weeks before being euthanized. Serum iron and retinol levels were measured as biochemical parameters. Their duodenums, spleens, and livers were analyzed for the expression of ferritin and transferrin receptors by Western Blotting. Results Regarding biochemical parameters, the results show that when both vitamin A and iron are insufficient, the serum iron content (74.74µg/dL) is significantly lower than the control group (255.86µg/dL). The results also show that vitamin A deficiency does not influence the expression of the transferrin receptor, but only of the ferritin one. Conclusion Vitamin A deficiency regulates the expression of ferritin in young male Wistar rats.

Bed bugs are associated with anemia

INTRODUCTION

Bed bugs are hematophagous insects that can be problematic in some urban emergency departments. The objective was to determine if red blood cell (RBC) and coagulation indices of bed bug-infested emergency department (ED) patients differed from those of noninfested control patients.

METHODS

A chart review from a single health system was performed for ED patients between February 1, 2011, and February 1, 2017. Bed bug-infested patients were matched to noninfested control patients on the basis of age, sex, and the presenting ED. Variables were analyzed with the t-test and Pearson χ² test and were modeled with multivariable logistic regression.

RESULTS

The study had 332 bed bug-infested patients and 4952 controls. Infested patients had lower hemoglobin (11.7 g/dL vs 12.8 g/dL), hematocrit (35.0% vs 37.9%), RBC counts (4.1 × 10⁹/L vs 4.4 × 10⁹/L), mean corpuscular volume (86.0 vs 87.5 fL/cell), and mean corpuscular hemoglobin concentrations (33.2 vs 33.7 g/dL) and higher RBC distribution width-coefficient of variation (RDW-CV) (15.2% vs 14.2%) than noninfested patients (all P ≤ .003). Infested patients were more likely to be anemic (59.5% vs 36.9%) and to have severe anemia (4.4% vs 0.7%) (P < .001 for both). Blood transfusions were more common in those with bed bugs (5.1%) than those without bed bugs (2.3%) (P < .001).

CONCLUSION

Bed bug infestated patients in the ED are associated with anemia.

Screening of repeated dose toxicity data in safety evaluation reports of cosmetic ingredients issued by the Scientific Committee on Consumer Safety between 2009 and 2019

A focal point in the safety evaluation of cosmetic ingredients includes oral repeated dose toxicity testing, which is intended to address the most complex human endpoints. Seven years after the full implementation of the animal testing ban for cosmetic ingredients in the EU, there are still no alternative methods available capable of fully replacing oral repeated dose toxicity testing. Until this issue is resolved, the development of new cosmetic ingredients remains seriously hampered. The present paper describes a thorough screening of the oral repeated dose toxicity data included in safety evaluation reports of cosmetic ingredients addressed in the Annexes of the Cosmetics Regulation (EC) No 1223/2009, issued by the Scientific Committee on Consumer Safety between 2009 and 2019. The liver and the haematological system were identified as the potentially most frequently affected organs upon oral administration of cosmetic ingredients to animals. Evaluation of altered biochemical, morphological, and histopathological parameters related to hepatotoxicity indicated that the most recurrent events are liver weight changes, elevated liver enzymes, and alterations in serum cholesterol and bilirubin levels. Combined listing of affected parameters associated with steatosis and cholestasis indicated the possible occurrence of cholestasis, provoked by a limited number of cosmetic ingredients. The most frequently affected parameters related to the haematological system were indicative of anaemia. An in-depth analysis allowed characterisation of both regenerative and non-regenerative anaemia, pointing to direct and indirect haematotoxicity, respectively. The results presented in this study call for prioritisation of research targeted towards the development of new approach methodologies fit for animal-free repeated dose toxicity evaluation of cosmetic ingredients.

Prognostic Value of Admission Mean Corpuscular Volume for Major Adverse Cardiovascular Events following Stent Implantation in Nondiabetic and Diabetic Patients with Acute Coronary Syndrome

Background

One of the key concerns of the clinician is to identify and manage risk factors for major adverse cardiovascular events (MACEs) in nondiabetic and diabetic patients with acute coronary syndrome (ACS) undergoing stent implantation. Mean corpuscular volume (MCV) is a marker of erythrocyte size and activity and is associated with prognosis of cardiovascular disease. However, the role of admission MCV in predicting MACEs following stent implantation in diabetes mellitus (DM), non-DM, or whole patients with ACS remains largely unknown.

Methods and Results

A total of 437 ACS patients undergoing stent implantation, including 294 non-DM (59.08 ± 10.24 years) and 143 DM (63.02 ± 9.92 years), were analyzed. Admission MCV was higher in non-DM than DM patients. During a median of 31.93 months follow-up, Kaplan-Meier curve demonstrated that higher admission MCV level was significantly associated with increased MACEs in whole and non-DM, but not in DM patients. In Cox regression analysis, the highest MCV tertile was associated with higher MACEs in whole ([HR] 1.870, 95% CI 1.113-3.144, P = 0.018), especially those non-DM ([HR] 2.089, 95% CI 1.077-4.501, P = 0.029) patients after adjustment of several cardiovascular risk factors. MCV did not predict MACEs in DM patients. During landmark analysis, admission MCV showed better predictive value for MACEs in the first 32 months of follow-up than in the subsequent period. Finally, the receiver operating characteristic (ROC) curve was conducted to confirmed the value of admission MCV within 32 months.

Conclusion

In patients with ACS, elevated admission MCV is an important and independent predictor for MACEs following stent implantation, especially amongst those without DM even after adjusting for lifestyle and clinical risk factors. However, as the follow-up period increased, the admission MCV lost its ability to predict MACEs.

Vitamin A does not influence mRNA expression of hormone hepcidin but other biomarkers of iron homeostasis in young male Wistar rats

The effects of an adequate supply of vitamin A and iron, in comparison with diets low or absent in vitamin A and low in iron, on the mRNA expression of some biomarkers of iron homeostasis as hepcidin (Hamp), transferrin receptor-1 (Tfrc), iron regulatory protein-2 (Ireb2) and ferritin (Fth1) in rats were investigated. 35 male Wistar rats were randomly divided into 5 dietary groups: control, sufficient in iron and insufficient in vitamin A (FesvAi), sufficient in iron and depleted in vitamin A (FesvAd), insufficient in iron and sufficient in vitamin A (FeivAs) and insufficient in both iron and vitamin A (FeivAi). After 6 weeks rats showed no significant effects of variations in vitamin A on the expression of Hamp relative to the control group (FesvAi: 1.37-fold; FesvAd: 1.22-fold); however, iron deficiency showed significant reduction on it relative to the control group (FeivAs: 71.4-fold, P = 0.0004; FeivAi: 16.1-fold, P = 0.0008). Vitamin A deficiency (FesvAd) affects expression of Fth1 independent of low dietary iron in spleen (0.29-fold, P = 0.002) and duodenum (5.15-fold, P = 0.02). Variations of dietary iron and vitamin A showed significant effects relative to the control group for expression of Tfrc in spleen (FesvAd: 0.18-fold, P = 0.01; FeivAs: 0.24-fold, P < 0.0001; FeivAi: 0.42-fold, P = 0.014), Ireb2 in spleen (FeivAs: 3.7-fold, P < 0.0001; FeivAi: 2.9-fold, P < 0.0001) and Ireb2 in duodenum (FeivAs: 2.68-fold, P = 0.012; FeivAi: 2.60-fold, P = 0.014). These results show that vitamin A and iron must be supplied together to regulate some of the main biomarkers of iron metabolism as a strategy to reduce prevalence of iron deficiency anemia.

Classic and emergent indicators for the assessment of human iron status

Iron deficiency is the leading cause of anemia, a significant global public health problem. Different methods exist for assessing iron nutritional status, including laboratory tests that focus on storage, transportation, and iron functional compartment parameters. Classical markers such as bone marrow, serum iron, ferritin, hemoglobin, erythrocyte parameters, transferrin, transferrin receptors, and zinc protoporphyrin are discussed in this review. Additional parameters calculated from these indicators, including transferrin saturation, ferritin index and Thomas plot, and some emergent parameters such as hepcidin, erythroferrone, and low hemoglobin density are also discussed. There is no a single indicator for assessing iron nutritional status. Therefore, the use of more than one indicator may be the best practice to obtain the correct diagnosis, also considering the influence of inflammation/infection on many of these indicators. The constant validation of the current parameters, the improvement of assessment methods, and the identification of new indicators will be the key to refine the assessment of iron nutritional status and the right choice of treatment for its improvement.

Microcytic anemia in children: parallel screening for iron deficiency and thalassemia provides a useful opportunity for thalassemia prevention in low- and middle-income countries

Microcytic anemia in children is commonly attributed to iron deficiency without attempting to find the cause. Inadequate investigations to exclude hemoglobinopathies lead to missed opportunities for identification of thalassemia carriers. Here we aim to describe the relative contribution of iron deficiency and thalassemia to microcytic anemia in children. This hospital-based prospective study was conducted at the Colombo North Teaching Hospital, Ragama, Sri Lanka. All newly diagnosed patients with microcytic anemia were recruited and data were collected using an interviewer-administered questionnaire. Full blood count, blood film, serum ferritin, c-reactive protein, quantification of hemoglobin sub-types and α-globin genotype were performed using 4 ml of venous blood. A total of 104 children (Male- 60.5%) were recruited. Iron deficiency was the cause for anemia in 49% whilst 16% and 10% had α- and β-thalassemia trait respectively. Seven (6.7%) children had co-existing iron deficiency and thalassemia trait while two coinherited α- and β-thalassemia trait. Children with β-thalassemia trait had significantly higher red cell count and lower mean corpuscular volume compared to children with iron deficiency. However, none of the red cell parameters were significantly different between children with α-thalassemia trait and iron deficiency. Iron deficiency contributes only to half of children with microcytic anemia; one-fourth had thalassemia trait. Co-existence of iron deficiency and thalassemia trait or co-inheritance of α- and β-thalassemia trait were found in 9%. Parallel investigation of children with microcytic anemia to diagnose iron deficiency and thalassemia provides an opportunity to identify thalassemia carriers which is beneficial for thalassemia prevention.

Nano-scientific Application of Atomic Force Microscopy in Pathology: from Molecules to Tissues

The advantages of atomic force microscopy (AFM) in biological research are its high imaging resolution, sensitivity, and ability to operate in physiological conditions. Over the past decades, rigorous studies have been performed to determine the potential applications of AFM techniques in disease diagnosis and prognosis. Many pathological conditions are accompanied by alterations in the morphology, adhesion properties, mechanical compliances, and molecular composition of cells and tissues. The accurate determination of such alterations can be utilized as a diagnostic and prognostic marker. Alteration in cell morphology represents changes in cell structure and membrane proteins induced by pathologic progression of diseases. Mechanical compliances are also modulated by the active rearrangements of cytoskeleton or extracellular matrix triggered by disease pathogenesis. In addition, adhesion is a critical step in the progression of many diseases including infectious and neurodegenerative diseases. Recent advances in AFM techniques have demonstrated their ability to obtain molecular composition as well as topographic information. The quantitative characterization of molecular alteration in biological specimens in terms of disease progression provides a new avenue to understand the underlying mechanisms of disease onset and progression. In this review, we have highlighted the application of diverse AFM techniques in pathological investigations.

Anemia Screening in Naval Aviation: Is Hemoglobin a Better Indicator Than Hematocrit as the Primary Index?

INTRODUCTION

Because of the rigorous mental and physical health requirements for Naval Aviation, all applicants and designated personnel must meet physical standards, including initial and periodic screening for anemia. Most standards, including for accession to the U.S. Navy, use hemoglobin as the standard marker to screen for anemia. Moreover, previous literature generally supports the assertion that hemoglobin is more reliable and accurate than hematocrit. However, the U.S. Navy Aeromedical Reference and Waiver Guide uses a hematocrit standard for anemia screening. The purpose of this study was to determine whether hemoglobin or hematocrit correlates better with clinical anemia and evaluate which index is a more accurate indicator for anemia screening in Naval Aviation personnel.

MATERIALS AND METHODS

This is a retrospective cross-sectional study of Naval Aviation applicants (N = 95) who were evaluated by the Human Performance and Aeromedical Qualifications department at Naval Aerospace Medical Institute Clinic in Pensacola, Florida, from January 1, 2015 to September 30, 2018. Data were collected from electronic medical records in a de-identified manner that included demographics, class designations, labs results, diagnoses, and final disposition. Logistic regression was used to analyze whether hemoglobin (using the U.S. Navy standard of 13.5 g/dL for men and 12.0 g/dL for women) or hematocrit (using the Naval Aviation standard of 40% for men and 37% for women) predicted the diagnosis of anemia for subjects having at least one lab sample (1-sample) and for those having three samples (3-samples). Sensitivity and specificity values were calculated for hemoglobin and hematocrit as tools to predict a diagnosis of anemia using the same standards in the 1-sample and 3-sample groups.

RESULTS

Data were collected for 95 subjects, 53 of whom had three sets of paired hemoglobin/hematocrit values. Using logistic regression, hemoglobin was found to be a statistically significant predictor of anemia for both the 1-sample group (odds ratio 3.4, confidence interval [1.130-10.196], P < 0.05) and the 3-sample group (odds ratio 10.5, confidence interval [1.776-62.580], P < 0.01). Hematocrit was not a significant predictor in either group. Hemoglobin was 80% sensitive and 52.3% specific for a diagnosis of anemia in the 1-sample group and 91.3% sensitive and 50.0% specific in the 3-samples group. Hematocrit was 86.7% sensitive and 35.4% specific for a diagnosis of anemia in the 1-sample group and 91.3% sensitive and 23.3% specific in the 3-samples group.

CONCLUSIONS

This study found that hemoglobin correlates better with the diagnosis of anemia than hematocrit. When three samples are analyzed, hemoglobin is equally sensitive and more specific than hematocrit. Based on these results and the U.S. Navy accession standards using hemoglobin as the standard index for anemia, the U.S. Navy Aeromedical Reference and Waiver Guide should consider using hemoglobin instead of hematocrit to screen for anemia. Future research should focus on prospective research to determine whether hemoglobin or hematocrit is a better indicator of anemia in screening military personnel.

New Insights and Methods in the Approach to Thalassemia Major: The Lesson From the Case of Adrenal Insufficiency

Background: Thalassemia Major (TM) is a complex pathology that needs a highly skilled approach. Endocrine comorbidities are nowadays the most important complications, including hypogonadism, hypothyroidism, diabetes mellitus, and bone diseases. Recent works stated that there could be a relevant prevalence of adrenal insufficiency (AI) present in TM, and this fact may become crucial, especially in case of major stressful events.

Aim: Test the reliability of the standard test to diagnose AI in a group of TM and correlate it with clinical, hematological, and radiological data.

Methods: We evaluated endocrine damages and the efficacy of iron chelation therapy in 102 patients affected by TM. AI was assessed by tetracosactide (Synacthen) 1 mcg iv (low-dose test, LDT) stimulation test. Patients with a subnormal response (peak cortisol < 500 nmol/L) were followed up to 5 years to check the symptoms and signs of AI.

Results: We found AI in 13.7% of the population studied. We did not find any correlation between AI and all data evaluated. Only female gender seems to be a protective factor. A follow up of the patients affected by AI showed no signs of adrenal crisis, in spite of no replacement therapy.

Conclusions: Our study shows a relevant prevalence of AI in TM, especially in males. The absence of an adrenal crisis, in spite of no replacement therapy, during the long-term follow up, seems to underline that current methods to evaluate AI, in TM, should consider a different and specific diagnostic test or different cut off for diagnosis.

Mean Corpuscular Volume Predicts In-Stent Restenosis Risk for Stable Coronary Artery Disease Patients Receiving Elective Percutaneous Coronary Intervention

Background

The purpose of this study was to analyze predictive performance of MCV in midterm ischemic events among SCAD patients undergoing elective PCI.

Material/Methods

We retrospectively included 226 consecutive patients with SCAD who received elective PCI. The patients were grouped based on MCV quartile values. The prognostic significance of MCV was assessed using univariate and multivariate Cox proportional hazard regression analyses.

Results

According to MCV quartile points (87.5 fL, 89.7 fL, and 92.4 fL, respectively), the included patients were divided into 4 groups, with an average follow-up of 34.2 months. There were 28 (48.3%) patients with stent thrombosis in the 1^st quartile, 24 (29.1%) in the 2^nd quartile, 18 (31.6%) in the 3^rd quartile, and 15 (27.8%) in the 4^th quartile (log-rank test, P=0.027). Multivariate analysis confirmed that MCV 1^st quartile (HRadj=2.047, 95% CI 1.041–4.026; P=0.038), ALT (HRadj=1.013, 95% CI 1.004–1.023; P=0.004) and number of PCI vessels (HRadj=1.198 95% CI 1.013–1.415; P=0.034) were risk factors for ischemic events. The restenosis rate in patients belonging to the MCV 1^st quartile was 2 times higher than that in MCV 2^nd, 3^rd, and 4^th quartile groups (P=0.007).

Conclusions

MCV value may be independently correlated with restenosis in SCAD patients undergoing PCI. Low MCV predicts high risk of in-stent restenosis.