1
|
Zhang Q, Zhou B, Li X, Cong H. In-hospital changes in the red blood cell distribution width and mortality in critically ill patients with heart failure. ESC Heart Fail 2023; 10:3287-3298. [PMID: 37671738 PMCID: PMC10682898 DOI: 10.1002/ehf2.14513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 06/11/2023] [Accepted: 08/18/2023] [Indexed: 09/07/2023] Open
Abstract
AIMS A high red blood cell distribution width (RDW) at admission or discharge is associated with a worse prognosis in hospitalized patients with heart failure (HF), and the prognostic value of the in-hospital change in RDW (∆RDW) remains debatable. METHODS AND RESULTS We included 5514 patients with critical illness and HF from the MIMIC-IV database. The ΔRDW was calculated by the RDW at discharge minus that at admission. Clinical outcomes included all-cause mortality at 90 day, 180 day, and 1 year after discharge. The median age of the patients was 73.91 years, and 46.37% were women. Kaplan-Meier curve and Cox regression analyses were used to examine the association between the ΔRDW and all-cause mortality at different time points. A multivariable Cox proportional hazard model showed that the ΔRDW (per 1% increase) was independently associated with all-cause mortality at 90 day, 180 day, and 1 year after adjusting for confounding factors (hazard ratio [HR] = 1.17, 95% confidence interval [CI] = 1.13-1.21, P < 0.001; HR = 1.17, 95% CI = 1.14-1.20, P < 0.001; and HR = 1.18, 95% CI = 1.15-1.20, P < 0.001, respectively). Restricted cubic splines showed a non-linear relationship between the ΔRDW and the risk of clinical outcomes. High ΔRDW was associated with a high risk of mortality at different time points. A subgroup analysis showed that this positive association remained consistent in pre-specified subgroups. CONCLUSIONS Our study suggests that an increased RDW during hospitalization is independently associated with short- or long-term all-cause mortality in critical-ill patients with HF.
Collapse
Affiliation(s)
- Qi Zhang
- Department of CardiologyTianjin Chest HospitalTianjinChina
| | - Bingyang Zhou
- Department of CardiologyTianjin Chest HospitalTianjinChina
| | - Ximing Li
- Department of CardiologyTianjin Chest HospitalTianjinChina
- Tianjin Medical UniversityTianjinChina
- Tianjin UniversityTianjinChina
| | - Hongliang Cong
- Department of CardiologyTianjin Chest HospitalTianjinChina
- Tianjin Medical UniversityTianjinChina
- Tianjin UniversityTianjinChina
| |
Collapse
|
2
|
Hong WS, Rudas A, Bell EJ, Chiang JN. Association of red blood cell distribution width with hospital admission and in-hospital mortality across all-cause adult emergency department visits. JAMIA Open 2023; 6:ooad053. [PMID: 37501917 PMCID: PMC10368803 DOI: 10.1093/jamiaopen/ooad053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/07/2023] [Accepted: 07/12/2023] [Indexed: 07/29/2023] Open
Abstract
Objectives To test the association between the initial red blood cell distribution width (RDW) value in the emergency department (ED) and hospital admission and, among those admitted, in-hospital mortality. Materials and Methods We perform a retrospective analysis of 210 930 adult ED visits with complete blood count results from March 2013 to February 2022. Primary outcomes were hospital admission and in-hospital mortality. Variables for each visit included demographics, comorbidities, vital signs, basic metabolic panel, complete blood count, and final diagnosis. The association of each outcome with the initial RDW value was calculated across 3 age groups (<45, 45-65, and >65) as well as across 374 diagnosis categories. Logistic regression (LR) and XGBoost models using all variables excluding final diagnoses were built to test whether RDW was a highly weighted and informative predictor for each outcome. Finally, simplified models using only age, sex, and vital signs were built to test whether RDW had additive predictive value. Results Compared to that of discharged visits (mean [SD]: 13.8 [2.03]), RDW was significantly elevated in visits that resulted in admission (15.1 [2.72]) and, among admissions, those resulting in intensive care unit stay (15.3 [2.88]) and/or death (16.8 [3.25]). This relationship held across age groups as well as across various diagnosis categories. An RDW >16 achieved 90% specificity for hospital admission, while an RDW >18.5 achieved 90% specificity for in-hospital mortality. LR achieved a test area under the curve (AUC) of 0.77 (95% confidence interval [CI] 0.77-0.78) for hospital admission and 0.85 (95% CI 0.81-0.88) for in-hospital mortality, while XGBoost achieved a test AUC of 0.90 (95% CI 0.89-0.90) for hospital admission and 0.96 (95% CI 0.94-0.97) for in-hospital mortality. RDW had high scaled weights and information gain for both outcomes and had additive value in simplified models predicting hospital admission. Discussion Elevated RDW, previously associated with mortality in myocardial infarction, pulmonary embolism, heart failure, sepsis, and COVID-19, is associated with hospital admission and in-hospital mortality across all-cause adult ED visits. Used alone, elevated RDW may be a specific, but not sensitive, test for both outcomes, with multivariate LR and XGBoost models showing significantly improved test characteristics. Conclusions RDW, a component of the complete blood count panel routinely ordered as the initial workup for the undifferentiated patient, may be a generalizable biomarker for acuity in the ED.
Collapse
Affiliation(s)
- Woo Suk Hong
- Department of Emergency Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Akos Rudas
- Department of Computational Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Elijah J Bell
- Department of Emergency Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Jeffrey N Chiang
- Corresponding Author: Jeffrey N. Chiang, PhD, Department of Computational Medicine, University of California Los Angeles David Geffen School of Medicine, 621 Charles E Young Dr S, Room 5217 Life Sciences Bldg., Los Angeles, CA 90095, USA;
| |
Collapse
|
3
|
Cheyne H, Gandomi A, Hosseini Vajargah S, Catterson VM, Mackoy T, McCullagh L, Musso G, Hajizadeh N. Drivers of mortality in COVID ARDS depend on patient sub-type. Comput Biol Med 2023; 166:107483. [PMID: 37748219 DOI: 10.1016/j.compbiomed.2023.107483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/28/2023] [Accepted: 09/15/2023] [Indexed: 09/27/2023]
Abstract
The most common cause of death in people with COVID-19 is Acute Respiratory Distress Syndrome (ARDS). Prior studies have demonstrated that ARDS is a heterogeneous syndrome and have identified ARDS sub-types (phenoclusters). However, non-COVID-19 ARDS phenoclusters do not clearly apply to COVID-19 ARDS patients. In this retrospective cohort study, we implemented an iterative approach, combining supervised and unsupervised machine learning methodologies, to identify clinically relevant COVID-19 ARDS phenoclusters, as well as characteristics that are predictive of the outcome for each phenocluster. To this end, we applied a supervised model to identify risk factors for hospital mortality for each phenocluster and compared these between phenoclusters and the entire cohort. We trained the models using a comprehensive, preprocessed dataset of 2,864 hospitalized COVID-19 ARDS patients. Our research demonstrates that the risk factors predicting mortality in the overall cohort of COVID-19 ARDS may not necessarily apply to specific phenoclusters. Additionally, some risk factors increase the risk of hospital mortality in some phenoclusters but decrease mortality in others. These phenocluster-specific risk factors would not have been observed with a single predictive model. Heterogeneity in phenoclusters of COVID-19 ARDS as well as the drivers of mortality may partially explain challenges in finding effective treatments for all patients with ARDS.
Collapse
Affiliation(s)
| | - Amir Gandomi
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA; Frank G. Zarb School of Business, Hofstra University, Hempstead, NY, USA
| | | | | | | | | | | | - Negin Hajizadeh
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA.
| |
Collapse
|
4
|
Urben T, Amacher SA, Becker C, Gross S, Arpagaus A, Tisljar K, Sutter R, Pargger H, Marsch S, Hunziker S. Red blood cell distribution width for the prediction of outcomes after cardiac arrest. Sci Rep 2023; 13:15081. [PMID: 37700019 PMCID: PMC10497505 DOI: 10.1038/s41598-023-41984-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/04/2023] [Indexed: 09/14/2023] Open
Abstract
The red blood cell distribution width (RDW) is a routinely available blood marker that measures the variation of the size/volume of red blood cells. The aim of our study was to investigate the prognostic value of RDW in cardiac arrest patients and to assess whether RDW improves the prognostic value of three cardiac arrest-specific risk scores. Consecutive adult cardiac arrest patients admitted to the ICU of a Swiss university hospital were included. The primary outcome was poor neurological outcome at hospital discharge assessed by Cerebral Performance Category. Of 702 patients admitted to the ICU after cardiac arrest, 400 patients (57.0%) survived, of which 323 (80.8%) had a good neurological outcome. Higher mean RDW values showed an independent association with poor neurological outcomes at hospital discharge (adjusted OR 1.27, 95% CI 1.14 to 1.41; p < 0.001). Adding the maximum RDW value to the OHCA- CAHP- and PROLOGUE cardiac arrest scores improved prognostic performance. Within this cohort of cardiac arrest patients, RDW was an independent outcome predictor and slightly improved three cardiac arrest-specific risk scores. RDW may therefore support clinical decision-making.
Collapse
Affiliation(s)
- Tabita Urben
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
| | - Simon A Amacher
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Christoph Becker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - Sebastian Gross
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
| | - Armon Arpagaus
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
| | - Kai Tisljar
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Raoul Sutter
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Hans Pargger
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Stephan Marsch
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Sabina Hunziker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland.
- Medical Faculty, University of Basel, Basel, Switzerland.
| |
Collapse
|
5
|
Peng S, Li W, Ke W. Association between red blood cell distribution width and all-cause mortality in unselected critically ill patients: Analysis of the MIMIC-III database. Front Med (Lausanne) 2023; 10:1152058. [PMID: 37064043 PMCID: PMC10098131 DOI: 10.3389/fmed.2023.1152058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 03/08/2023] [Indexed: 03/31/2023] Open
Abstract
BackgroundAlthough red cell distribution width (RDW) is widely observed in clinical practice, only a few studies have looked at all-cause mortality in unselected critically ill patients, and there are even fewer studies on long-term mortality. The goal of our study was to explore the prediction and inference of mortality in unselected critically ill patients by assessing RDW levels.MethodsWe obtained demographic information, laboratory results, prevalence data, and vital signs from the unselected critically ill patients using the publicly available MIMIC-III database. We then used this information to analyze the association between baseline RDW levels and unselected critically ill patients using Cox proportional risk analysis, smoothed curve fitting, subgroup analysis, and Kaplan–Meier survival curves for short, intermediate, and long-term all-cause mortality in unselected critically ill patients.ResultsA total of 26,818 patients were included in our study for the final data analysis after screening in accordance with acceptable conditions. Our study investigated the relationship between RDW levels and all-cause mortality in a non-selected population by a smoothed curve fit plots and COX proportional risk regression models integrating cubic spline functions reported results about a non-linear relationship. In the fully adjusted model, we found that RDW values were positively associated with 30-day, 90-day, 365-day, and 4-year all-cause mortality in 26,818 non-selected adult patients with HRs of 1.10 95%CIs (1.08, 1.12); 1.11 95%CIs (1.10, 1.13); 1.13 95%CIs (1.12, 1.14); 1.13 95%CIs (1.12, 1.14).ConclusionIn unselected critically ill patients, RDW levels were positively associated with all-cause mortality, with elevated RDW levels increasing all-cause mortality.
Collapse
Affiliation(s)
- Shixuan Peng
- Department of Oncology, Graduate Collaborative Training Base of The First People’s Hospital of Xiangtan City, Hengyang Medical School, University of South China, Hengyang, Hunan, China
| | - Wenxuan Li
- Department of Anesthesiology, The First People’s Hospital of Yueyang, Yueyang, Hunan, China
| | - Weiqi Ke
- Department of Anesthesiology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
- *Correspondence: Weiqi Ke,
| |
Collapse
|
6
|
Zhao L, Zhang Y, Lin P, Li W, Huang X, Li H, Xia M, Chen X, Zhu X, Tang X. Postoperative red blood cell distribution width predicts functional outcome in aneurysmal subarachnoid hemorrhage after surgical clipping: A single-center retrospective study. Front Neurol 2022; 13:1036433. [PMID: 36619907 PMCID: PMC9817139 DOI: 10.3389/fneur.2022.1036433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022] Open
Abstract
Objective Red blood cell (RBC) parameters are associated with outcomes following aneurysmal subarachnoid hemorrhage (aSAH), but their predictive value remains uncertain. This study aimed to detect the association between RBC parameters and functional outcome in aSAH patients undergoing surgical clipping. Methods This retrospective observational study included aSAH patients who underwent surgical clipping at Affiliated Hospital of North Sichuan Medical College between August 2016 and September 2019. The functional outcome following aSAH was assessed by modified Rankin Scale (mRS), and mRS 3-6 was defined as poor functional outcome. Results Out of 187 aSAH patients included (62% female, 51-66 years old), 73 patients had poor functional outcome. Multivariate logistic regression of admission parameters showed that World Federation of Neurosurgical Societies (WFNS) grade (odds ratio [95% CI]: 1.322 [1.023-1.707], p = 0.033) and white blood cell (WBC) (odds ratio [95% CI]: 1.136 [1.044-1.236], p = 0.003) were independently associated with poor functional outcome. In postoperative parameters, RBC distribution width (RDW) (odds ratio [95% CI]: 1.411 [1.095-1.818], p = 0.008), mean platelet volume (MPV, odds ratio [95% CI]: 1.253 [1.012-1.552], p = 0.039) and admission WFNS grade (odds ratio [95% CI]: 1.439 [1.119-1.850], p = 0.005) were independently associated with poor functional outcome. The predictive model including WFNS grade, admission WBC, and postoperative RDW and MPV had significantly higher predictive power compared to WFNS grade alone (0.787 [0.722-0.852] vs. 0.707 [0.630-0.784], p = 0.024). The combination of WFNS grade and WBC on admission showed the highest positive predictive value (75.5%) and postoperative RDW and MPV combined with admission WFNS grade and WBC showed the highest negative predictive value (83.7%). Conclusion Postoperative RDW is independently associated with poor functional outcome in aSAH patients undergoing surgical clipping. A combined model containing postoperative RDW may help predict good outcome in patients with aSAH after timely aneurysm clipping.
Collapse
Affiliation(s)
- Long Zhao
- Department of Neurosurgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China,School of Clinical Medicine, North Sichuan Medical College, Nanchong, China,Neurosurgical Research Center, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Yi Zhang
- School of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Ping Lin
- School of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Weida Li
- School of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Xingyuan Huang
- School of Psychiatry, North Sichuan Medical College, Nanchong, China
| | - Hangyang Li
- School of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Mingkai Xia
- School of Medical Imaging, North Sichuan Medical College, Nanchong, China
| | - Xinlong Chen
- School of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Xi Zhu
- Outpatient Department, Affiliated Hospital of North Sichuan Medical College, Nanchong, China,*Correspondence: Xi Zhu ✉
| | - Xiaoping Tang
- Department of Neurosurgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China,Neurosurgical Research Center, Affiliated Hospital of North Sichuan Medical College, Nanchong, China,Xiaoping Tang ✉
| |
Collapse
|
7
|
Valko L, Baglyas S, Podmaniczky E, Prohaszka Z, Gal J, Lorx A. Exploring red cell distribution width as a biomarker for treatment efficacy in home mechanical ventilation. BMC Pulm Med 2022; 22:115. [PMID: 35354396 DOI: 10.1186/s12890-022-01916-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 03/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With the growing practice of home mechanical ventilation, there is a need to identify biological markers for adequate follow-up. Red cell distribution width (RDW) is a promising candidate because it is convenient, objective and may reflect treatment effect over a long period of time. The aim of this study was to explore the possible role of RDW as a marker for home mechanical ventilation in real-life, unselected chronic respiratory patient populations. METHODS First, we identified characteristic RDW values for mixed case, unselected chronic respiratory failure and home mechanical ventilated patients through retrospective review within our institutional database. Next, we conducted a prospective observational study to identify RDW changes during the first six months of optimized home mechanical ventilation treatment. Adult patients starting home mechanical ventilation were included. Factors affecting RDW change during the first 6 months of treatment were analysed. RESULTS RDW was elevated in both chronic respiratory failure and home mechanical ventilation patients compared to healthy individuals in the retrospective review. In the prospective study of 70 patients, we found that 55.4% of patients starting home mechanical ventilation have abnormal RDW values which are reduced from 14.7 (IQR = 13.2-16.2)% to 13.5 (IQR = 13.1-14.6)% during the first 6 months of HMV treatment (p < 0.001). RDW improvement correlates with improvement in self-reported health-related quality of life and sleepiness scale scores, as well as physical functional status during the same time frame. RDW proved to be a comparable marker to other parameters traditionally used to evaluate treatment efficacy. CONCLUSIONS RDW is elevated in chronic respiratory failure patients and is significantly reduced in the first six months of optimized home mechanical ventilation. Although further research is needed to verify if RDW change reflects outcome and how comorbidities influence RDW values, our results suggest that RDW is a promising marker of home mechanical ventilation efficacy. Trial registration This study was approved by and registered at the ethics committee of Semmelweis University (TUKEB 250/2017 and TUKEB 250-1/2017, 20th of December 2017 and 1st of October 2019).
Collapse
|
8
|
Seo YJ, Yu J, Park JY, Lee N, Lee J, Park JH, Kim HY, Kong YG, Kim YK. Red cell distribution width/albumin ratio and 90-day mortality after burn surgery. Burns Trauma 2022; 10:tkab050. [PMID: 35097135 PMCID: PMC8793164 DOI: 10.1093/burnst/tkab050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 11/03/2021] [Indexed: 01/13/2023]
Abstract
Background Red cell distribution width (RDW) and serum albumin concentration are associated with postoperative outcomes. However, the usefulness of the RDW/albumin ratio in burn surgery remains unclear. Therefore, we evaluated the association between RDW/albumin ratio and 90-day mortality after burn surgery. Methods Between 2013 and 2020, a retrospective review of patients in a burn intensive care unit (ICU) was performed. Receiver operating characteristic curve, multivariate Cox logistic regression, multivariate logistic regression and Kaplan–Meier analyses were conducted to evaluate the association between RDW/albumin ratio and 90-day mortality after burn surgery. Additionally, prolonged ICU stay rate (>60 days) and ICU stay were assessed. Results Ninety-day mortality was 22.5% (210/934) in burn patients. Risk factors for 90-day mortality were RDW/albumin ratio at postoperative day 1, age, American Society of Anesthesiologists physical status, diabetes mellitus, inhalation injury, total body surface area burned, hypotensive event and red blood cell transfusion volume. The area under the curve of the RDW/albumin ratio at postoperative day 1 to predict 90-day mortality, after adjusting for age and total body surface area burned, was 0.875 (cut-off value, 6.8). The 90-day mortality was significantly higher in patients with RDW/albumin ratio >6.8 than in those with RDW/albumin ratio ≤6.8 (49.2% vs 12.3%, p < 0.001). Prolonged ICU stay rate and ICU stay were significantly higher and longer in patients with RDW/albumin ratio >6.8 than in those with RDW/albumin ratio ≤6.8 (34.5% vs 26.5%; 21 [11–38] vs 18 [7–32] days). Conclusion RDW/albumin ratio >6.8 on postoperative day 1 was associated with higher 90-day mortality, higher prolonged ICU stay rate and longer ICU stay after burn surgery.
Collapse
Affiliation(s)
- Young Joo Seo
- Department of Anesthesiology and Pain Medicine, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07247, Republic of Korea
| | - Jihion Yu
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Jun-Young Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Narea Lee
- Department of Anesthesiology and Pain Medicine, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07247, Republic of Korea
| | - Jiwoong Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Ji Hyun Park
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul 04564, Republic of Korea
| | - Hee Yeong Kim
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul 04564, Republic of Korea
| | - Yu-Gyeong Kong
- Department of Anesthesiology and Pain Medicine, CHA Gangnam Medical Center, CHA University School of Medicine, Seoul 06135, Republic of Korea
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| |
Collapse
|
9
|
Oh SH, Do HJ, Park JS, Cho JY, Park CH. Can red cell distribution width in very low birth weight infants predict bronchopulmonary dysplasia? Medicine (Baltimore) 2022; 101:e28640. [PMID: 35060550 PMCID: PMC8772710 DOI: 10.1097/md.0000000000028640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/30/2021] [Indexed: 01/05/2023] Open
Abstract
Red cell distribution width (RDW) is a useful marker for assessing the severity and prognosis of various diseases in adults. However, whether it is applicable to children, especially in newborns, has not been determined.This study aimed to investigate the RDW values of preterm infants and evaluate whether RDW values in the early days of life can predict bronchopulmonary dysplasia (BPD) development.One hundred and eight infants born at <30 weeks of gestation with a birth weight of <1500 g participated in this retrospective study. RDW values measured at birth, 7 days (D7), and 28 days (D28) after birth were reviewed. The changes in RDW values in the first month of life were analyzed, and we evaluated the relationship between RDW and BPD.The mean RDW values at birth, D7, D28 and the change from birth to D7 were 16.2 ± 0.1%, 17.5 ± 0.2%, 17.6 ± 0.2% and 1.3 ± 1.8%, respectively. RDW at birth was lower in the infants born at <28 weeks' gestational age than in those born at ≥28 weeks' gestational age (15.7 ± 0.3 vs 16.4 ± 0.2, P = .024). RDW values of both groups increased during the first week after birth and did not differ significantly at D7. The levels remained similar at 1 month of age. RDW at birth, D7, and D28 and the changes in RDW from birth to D7 were not correlated with the development of BPD independent of its severity.The usefulness of RDW as a predictor of BPD development remains questionable and requires further study.
Collapse
Affiliation(s)
- Seong Hee Oh
- Department of Pediatrics, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneung, South Korea
| | - Hyun-Jeong Do
- Department of Pediatrics, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneung, South Korea
| | - Ji Sook Park
- Department of Pediatrics, College of Medicine, Gyeongsang National University, Gyeongsang National University Hospital, Jinju, South Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, South Korea
| | - Jae Young Cho
- Department of Pediatrics, College of Medicine, Gyeongsang National University, Gyeongsang National University Hospital, Jinju, South Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, South Korea
| | - Chan-Hoo Park
- Institute of Health Sciences, Gyeongsang National University, Jinju, South Korea
- Department of Pediatrics, College of Medicine, Gyeongsang National University, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| |
Collapse
|
10
|
Wang J, Xiao Q, Li Y. ΔRDW: A Novel Indicator with Predictive Value for the Diagnosis and Treatment of Multiple Diseases. Int J Gen Med 2021; 14:8667-8675. [PMID: 34849010 PMCID: PMC8627260 DOI: 10.2147/ijgm.s339945] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/28/2021] [Indexed: 12/22/2022] Open
Abstract
Elevated red blood cell distribution width (RDW) is a powerful predictor of poor prognosis in a variety of diseases, but a single measurement of RDW cannot reflect the dynamic change of diseases. ΔRDW, as a risk stratification tool, can be used to record changes in RDW before and after treatment; also, it allows investigators to name the unit change of RDW in the studied population. So far, there have been few relevant studies on the predictive value of ΔRDW for different diseases; this article aims to review the studies and summaries of the current understandings on the correlation between ΔRDW and disease outcomes.
Collapse
Affiliation(s)
- Jingsheng Wang
- Department of Cardiology, the Second Affiliated Hospital, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian, People's Republic of China
| | - Qiang Xiao
- Department of Cardiology, the Second Affiliated Hospital, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian, People's Republic of China
| | - Yuanmin Li
- Department of Cardiology, the Second Affiliated Hospital, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian, People's Republic of China
| |
Collapse
|
11
|
Abstract
Context Red blood cell distribution width (RDW) has been used to predict mortality during infection and inflammatory diseases. It also been purported to be predictive of mortality following traumatic injury. Objective To identify the role of RDW in predicting mortality in trauma patients. We also sought to identify the role of RDW in predicting the development of sepsis in trauma patients. Methods A retrospective observational study was performed of the medical records for all adult trauma patients admitted to Loyola University Medical Center from 2007 to 2014. Patients admitted for fewer than four days were excluded. Admission, peak, and change from admission to peak (Δ) RDW were recorded to determine the relationship with in-hospital mortality. Patient age, development of sepsis during the hospitalization, admission to the intensive care unit (ICU), and discharge disposition were also examined. Results A total of 9,845 patients were admitted to the trauma service between 2007 and 2014, and a total of 2,512 (25.5%) patients fit the inclusion criteria and had both admission and peak values available. One-hundred twenty (4.6%) died while in the hospital. RDW values for all patients were (mean [standard deviation, SD]): admission 14.09 (1.88), peak 15.09 (2.34), and Δ RDW 1.00 (1.44). Admission, peak, and Δ RDW were not significant predictors of mortality (all p>0.50; hazard ratio [HR], 1.01-1.03). However, trauma patients who eventually developed sepsis had significantly higher RDW values (admission RDW: 14.27 (2.02) sepsis vs. 13.98 (1.73) no sepsis, p<0.001; peak RDW: 15.95 (2.55) vs. 14.51 (1.97), p<0.001; Δ RDW: 1.68 (1.77) vs. 0.53 (0.91), p<0.001). Conclusion Admission, peak, and Δ RDW were not associated with in-hospital mortality in adult trauma patients with a length of stay (LOS) ≥four days. However, the development of sepsis in trauma patients is closely linked to increased RDW values and in-hospital mortality.
Collapse
Affiliation(s)
- McKenzie Brown
- Department of Surgery and Public Health Sciences , Loyola University Medical Center , Maywood , IL , USA
| | - Sean Nassoiy
- Department of Surgery and Public Health Sciences , Loyola University Medical Center , Maywood , IL , USA
| | - Timothy Plackett
- Department of Surgery and Public Health Sciences , Loyola University Medical Center , Maywood , IL , USA.,759th Forward Surgical Team , BLDG A-6631 Gorham Street , 28310-0001 Fort Bragg , NC , USA
| | - Fred Luchette
- Department of Surgery and Public Health Sciences , Loyola University Medical Center , Maywood , IL , USA.,Department of Surgery , Edward Hines Jr. Veterans Administration Hospital , Hines , IL , USA
| | - Joseph Posluszny
- Department of Surgery and Public Health Sciences , Loyola University Medical Center , Maywood , IL , USA
| |
Collapse
|
12
|
Su YC, Wen SC, Li CC, Su HC, Ke HL, Li WM, Lee HY, Li CY, Yang SF, Tu HP, Wu WJ, Yeh HC. Low Hemoglobin-to-Red Cell Distribution Width Ratio Is Associated with Disease Progression and Poor Prognosis in Upper Tract Urothelial Carcinoma. Biomedicines 2021; 9:672. [PMID: 34208273 DOI: 10.3390/biomedicines9060672] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/02/2021] [Accepted: 06/09/2021] [Indexed: 11/17/2022] Open
Abstract
The importance of blood cell markers in patients with malignant tumors has been studied, but there are few studies on the prognostic value of hemoglobin-to-red cell distribution width ratio (HRR) in cancer. This is the first study to investigate the effect of preoperative HRR on patients with upper tract urothelial carcinoma (UTUC). Our retrospective cohort study included 730 UTUC patients who underwent nephroureterectomy from 2000 to 2019. Clinicopathological parameters were compared according to HRR levels, and the relationship between blood cell markers (HRR, white blood cell [WBC] count, platelet count) and prognosis was evaluated using Kaplan-Meier method and Cox regression model. We found that patients with HRR ≤ 1.05 tended to have worse renal function, higher pathological stages, and more high-grade tumors. In univariate analysis, HRR ≤ 1.05, WBC > 8.65 × 103 cells/μL and platelets >309 × 103 cells/μL were associated with poor progression-free survival (PFS), cancer-specific survival (CSS), and overall survival (OS). Multivariate analysis demonstrated that HRR ≤ 1.05 and WBC > 8.65 × 103 cells/μL were independent prognostic factors for predicting deterioration of PFS, CSS, and OS. In conclusion, HRR and WBC are easy to obtain in clinical practice and are useful indicators to provide prognostic information before surgery for UTUC.
Collapse
|
13
|
Go H, Ohto H, Nollet KE, Sato K, Ichikawa H, Kume Y, Kanai Y, Maeda H, Kashiwabara N, Ogasawara K, Sato M, Hashimoto K, Hosoya M. Red cell distribution width as a predictor for bronchopulmonary dysplasia in premature infants. Sci Rep 2021; 11:7221. [PMID: 33790386 PMCID: PMC8012706 DOI: 10.1038/s41598-021-86752-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/19/2021] [Indexed: 01/21/2023] Open
Abstract
Bronchopulmonary dysplasia (BPD) is the most common morbidity complicating preterm birth. Red blood cell distribution width (RDW), a measure of the variation of red blood cell size, could reflect oxidative stress and chronic inflammation in many diseases such as cardiovascular, pulmonary, and other diseases. The objectives of the present study were to evaluate perinatal factors affecting RDW and to validate whether RDW could be a potential biomarker for BPD. A total of 176 preterm infants born at < 30 weeks were included in this study. They were categorized into BPD (n = 85) and non-BPD (n = 91) infants. RDW at birth and 14 days and 28 days of life (DOL 14, DOL 28) were measured. Clinical data were obtained from all subjects at Fukushima Medical University (Fukushima, Japan). The mean RDW at birth, DOL 14 and DOL 28 were 16.1%, 18.6%, 20.1%, respectively. Small for gestational age (SGA), chorioamnionitis (CAM), hypertensive disorders of pregnancy (HDP), gestational age and birth weight were significantly associated with RDW at birth. SGA, BPD and red blood cell (RBC) transfusion before DOL 14 were associated with RDW at DOL 14. BPD and RBC transfusion before DOL 14 were associated with RDW at DOL 28. Compared with non-BPD infants, mean RDW at DOL 14 (21.1% vs. 17.6%, P < 0.001) and DOL 28 (22.2% vs. 18.2%, P < 0.001) were significantly higher in BPD infants. Multivariate analysis revealed that RDW at DOL 28 was significantly higher in BPD infants (P = 0.001, odds ratio 1.63; 95% CI 1.22–2.19). Receiver operating characteristic analysis for RDW at DOL 28 in infants with and without BPD yielded an area under the curve of 0.87 (95% CI 0.78–0.91, P < 0.001). RDW at DOL 28 with mild BPD (18.1% vs. 21.3%, P < 0.001), moderate BPD (18.1% vs. 21.2%, P < 0.001), and severe BPD (18.1% vs. 24.0%, P < 0.001) were significantly higher than those with non-BPD, respectively. Furthermore, there are significant differences of RDW at DOL 28 among mild, moderate, and severe BPD. In summary, we conclude that RDW at DOL 28 could serve as a biomarker for predicting BPD and its severity. The mechanism by which RDW at DOL 28 is associated with the pathogenesis of BPD needs further elucidation.
Collapse
Affiliation(s)
- Hayato Go
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan.
| | | | - Kenneth E Nollet
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kenichi Sato
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| | - Hirotaka Ichikawa
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| | - Yohei Kume
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| | - Yuji Kanai
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| | - Hajime Maeda
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| | - Nozomi Kashiwabara
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| | - Kei Ogasawara
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| | - Maki Sato
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| | - Koichi Hashimoto
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| | - Mitsuaki Hosoya
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| |
Collapse
|
14
|
Fan YW, Liu D, Chen JM, Li WJ, Gao CJ. Fluctuation in red cell distribution width predicts disseminated intravascular coagulation morbidity and mortality in sepsis: a retrospective single-center study. Minerva Anestesiol 2021; 87:52-64. [PMID: 33538418 DOI: 10.23736/s0375-9393.20.14420-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Red cell distribution width (RDW) values increase in many diseases and conditions, including sepsis. However, the relationship between RDW fluctuation and prognosis in patients with sepsis or the likely morbidity associated with sepsis-induced disseminated intravascular coagulation (DIC) has not been previously investigated. This study examined the association between dynamic changes to RDW and DIC occurrence in sepsis, as well as the prognostic significance of changes to RDW during hospital stay in patients with sepsis. METHODS We collected baseline emergency department admissions' data. All RDW values recorded during hospitalization of patients with sepsis were combined to calculate RDW standard deviation (RDW-SD) and the increase rate of RDW; we also collected data on coagulation indicators. The endpoints were 28-day mortality and sepsis-related DIC morbidity. RESULTS Of 232 patients included in our analysis, 66 were diagnosed with DIC (28.4%), and 86 (37.1%) died within 28 days. The RDW-SD and the increase rate of RDW were independent risk factors for 28-day mortality and sepsis-associated DIC morbidity, respectively. The DIC occurrence and mortality rate increased continually with an increasing rate of RDW of at least 6%. CONCLUSIONS The RDW-SD and RDW increase rate shown in the study as the indicators of RDW fluctuation can help predict sepsis-related DIC morbidity and prognosis in patients with sepsis.
Collapse
Affiliation(s)
- Yi W Fan
- Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dan Liu
- Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jia M Chen
- Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wen J Li
- Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Cheng J Gao
- Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China -
| |
Collapse
|
15
|
Lorente L, Martín MM, Argueso M, Solé-Violán J, Perez A, Marcos Y Ramos JA, Ramos-Gómez L, López S, Franco A, González-Rivero AF, Martín M, Gonzalez V, Alcoba-Flórez J, Rodriguez MÁ, Riaño-Ruiz M, Guillermo O Campo J, González L, Cantera T, Ortiz-López R, Ojeda N, Rodríguez-Pérez A, Domínguez C, Jiménez A. Association between red blood cell distribution width and mortality of COVID-19 patients. Anaesth Crit Care Pain Med 2021; 40:100777. [PMID: 33171297 PMCID: PMC7648194 DOI: 10.1016/j.accpm.2020.10.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 06/23/2020] [Accepted: 10/02/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE We have previously reported an association between high red blood cell distribution width (RDW) and mortality in septic and brain infarction patients. However, no association between RDW and mortality in coronavirus disease 2019 (COVID-19) patients has been reported so far; thus, the objective of this study was to determine if that association exists. METHODS Prospective and observational study carried out in 8 Intensive Care Units from 6 hospitals of Canary Islands (Spain) including COVID-19 patients. We recorded RDW at ICU admission and 30-day survival. RESULTS We found that patients who did not survive (n=25) compared to surviving patients (n=118) were older (p=0.004), showed higher RDW (p=0.001), urea (p<0.001), APACHE-II (p<0.001) and SOFA (p<0.001), and lower platelet count (p=0.007) and pH (p=0.008). Multiple binomial logistic regression analysis showed that RDW was associated with 30-day mortality after controlling for: SOFA and age (OR=1.659; 95% CI=1.130-2.434; p=0.01); APACHE-II and platelet count (OR=2.062; 95% CI=1.359-3.129; p=0.001); and pH and urea (OR=1.797; 95% CI=1.250-2.582; p=0.002). The area under the curve (AUC) of RDW for mortality prediction was of 71% (95% CI=63-78%; p<0.001). We did not find significant differences in the predictive capacity between RDW and SOFA (p=0.66) or between RDW and APACHE-II (p=0.12). CONCLUSIONS Our study provides new information regarding the ability to predict mortality in patients with COVID-19. There is an association between high RDW and mortality. RDW has a good performance to predict 30-day mortality, similar to other severity scores (such as APACHE II and SOFA) but easier and faster to obtain.
Collapse
Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, Ofra, s/n. La Laguna, 38320 Santa Cruz de Tenerife, Spain.
| | - María M Martín
- Intensive Care Unit, Hospital Universitario Nuestra Señora de Candelaria, Crta del Rosario s/n, Santa Cruz de Tenerife 38010, Spain
| | - Mónica Argueso
- Intensive Care Unit, Complejo Hospitalario Universitario Insular, Plaza Dr. Pasteur s/n, Las Palmas de Gran Canaria 35016, Spain
| | - Jordi Solé-Violán
- Intensive Care Unit, Hospital Universitario Dr. Negrín, Barranco de la Ballena s/n, Las Palmas de Gran Canaria 35010, Spain
| | - Alina Perez
- Internal Intensive Care Unit, Hospital Universitario de Canarias, Ofra, s/n, La Laguna, 38320 Santa Cruz de Tenerife, Spain
| | - José Alberto Marcos Y Ramos
- Intensive Care Unit, Hospital Doctor José Molina Orosa, Ctra. Arrecife-Tinajo, km 1.300, Arrecife, Lanzarote 35550, Spain
| | - Luis Ramos-Gómez
- Intensive Care Unit, Hospital General La Palma, Buenavista de Arriba s/n, Breña Alta, La Palma 38713, Spain
| | - Sergio López
- Department of Anaesthesiology, Hospital Universitario Dr. Negrín, Barranco de la Ballena s/n, Las Palmas de Gran Canaria 35010, Spain
| | - Andrés Franco
- Immunology Unit of Laboratory Department, Hospital Universitario de Canarias, Ofra, s/n. La Laguna, 38320 Santa Cruz de Tenerife, Spain
| | - Agustín F González-Rivero
- Laboratory Department, Hospital Universitario de Canarias, Ofra, s/n. La Laguna, 38320 Santa Cruz de Tenerife, Spain
| | - María Martín
- Intensive Care Unit, Hospital Universitario de Canarias, Ofra, s/n. La Laguna, 38320 Santa Cruz de Tenerife, Spain
| | - Verónica Gonzalez
- Intensive Care Unit, Hospital Universitario de Canarias, Ofra, s/n. La Laguna, 38320 Santa Cruz de Tenerife, Spain
| | - Julia Alcoba-Flórez
- Microbiology Unit of Laboratory Department, Hospital Universitario Nuestra Señora de Candelaria, Crta del Rosario s/n, Santa Cruz de Tenerife 38010, Spain
| | - Miguel Ángel Rodriguez
- Intensive Care Unit, Hospital Universitario Nuestra Señora de Candelaria, Crta del Rosario s/n, Santa Cruz de Tenerife 38010, Spain
| | - Marta Riaño-Ruiz
- Department of Biochemistry, Complejo Hospitalario Universitario Insular, Plaza Dr. Pasteur s/n, Las Palmas de Gran Canaria 35016, Spain
| | - Juan Guillermo O Campo
- Intensive Care Unit, Complejo Hospitalario Universitario Insular, Plaza Dr. Pasteur s/n, Las Palmas de Gran Canaria 35016, Spain
| | - Lourdes González
- Internal Intensive Care Unit, Hospital Universitario de Canarias, Ofra, s/n, La Laguna, 38320 Santa Cruz de Tenerife, Spain
| | - Tamara Cantera
- Intensive Care Unit, Hospital Doctor José Molina Orosa, Ctra. Arrecife-Tinajo, km 1.300, Arrecife, Lanzarote 35550, Spain
| | - Raquel Ortiz-López
- Intensive Care Unit, Hospital General La Palma, Buenavista de Arriba s/n, Breña Alta, La Palma 38713, Spain
| | - Nazario Ojeda
- Department of Anaesthesiology, Hospital Universitario Dr. Negrín, Barranco de la Ballena s/n, Las Palmas de Gran Canaria 35010, Spain
| | - Aurelio Rodríguez-Pérez
- Department of Anaesthesiology, Hospital Universitario Dr. Negrín, Barranco de la Ballena s/n, Las Palmas de Gran Canaria 35010, Spain
| | - Casimira Domínguez
- Laboratory Department, Hospital Universitario Dr. Negrín, Barranco de la Ballena s/n, Las Palmas de Gran Canaria 35010, Spain
| | - Alejandro Jiménez
- Research Unit, Hospital Universitario de Canarias, Ofra, s/n, La Laguna, 38320 Santa Cruz de Tenerife, Spain
| |
Collapse
|
16
|
Fogagnolo A, Taccone FS, Benetto G, Franchi F, Scolletta S, Cotoia A, Kozhevnikova I, Volta CA, Spadaro S. Platelet morphological indices on Intensive Care Unit admission predict mortality in septic but not in non-septic patients. Minerva Anestesiol 2020; 87:184-192. [PMID: 32959630 DOI: 10.23736/s0375-9393.20.14528-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Thrombocytopenia is associated with worse outcomes in critically ill patients. The clinical relevance of other platelets indices is less studied. We investigated the ability of the platelets distribution width (PDW) and the mean platelet volume (MPV) to predict mortality in critically ill patients. We hypothesized that the prognostic values of PDW and MPV could be different in septic and non-septic patients. METHODS We prospectively analyzed patients with an expected ICU length of stay ≥48 hours. Repeated measurements of PDW and MPV were considered (on ICU admission and up to day 5 thereafter). The primary outcome was to investigate the ability of PDW and MPV to predict 90-day mortality in septic and non-septic patients. RESULTS We included in the study 234 patients of which 31% patients were septic. 90-day mortality was 39% in septic and 27% non-septic patients. PDW and MPV values on admission were 12.5±2.5% and 10.7±1.1 fL, respectively. The AUROC of PDW values on admission to predict 90-day mortality in septic patients was 0.813, being higher than those in non-septic patients (0.550, P<0.001). Similarly, the AUROC for MPV in septic patients was higher than non-septic patients (0.55, P<0.001). The combined analysis of platelets morphological indices and lactate improved the predictive accuracy (PDW and lactate AUROC=0.870; MPV and lactate AUROC=0.867). CONCLUSIONS Platelet morphological indices are independent predictor of 90-day mortality in septic patients but not in non-septic patients. A combined analysis of platelets morphological indices and lactate in septic patients resulted in improved prediction of mortality.
Collapse
Affiliation(s)
- Alberto Fogagnolo
- Unit of Anesthesia and Intensive Care, Department of Morphology, Surgery and Experimental Medicine, Sant'Anna University Hospital, University of Ferrara, Ferrara, Italy -
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Giulia Benetto
- Unit of Anesthesia and Intensive Care, Department of Morphology, Surgery and Experimental Medicine, Sant'Anna University Hospital, University of Ferrara, Ferrara, Italy
| | - Federico Franchi
- Department of Anesthesia and Intensive Care, University of Siena, Siena, Italy
| | - Sabino Scolletta
- Department of Anesthesia and Intensive Care, University of Siena, Siena, Italy
| | - Antonella Cotoia
- Department of Anesthesiology and Intensive Care, University of Foggia, Foggia, Italy
| | - Iryna Kozhevnikova
- Unit of Anesthesia and Intensive Care, Department of Morphology, Surgery and Experimental Medicine, Sant'Anna University Hospital, University of Ferrara, Ferrara, Italy
| | - Carlo A Volta
- Unit of Anesthesia and Intensive Care, Department of Morphology, Surgery and Experimental Medicine, Sant'Anna University Hospital, University of Ferrara, Ferrara, Italy
| | - Savino Spadaro
- Unit of Anesthesia and Intensive Care, Department of Morphology, Surgery and Experimental Medicine, Sant'Anna University Hospital, University of Ferrara, Ferrara, Italy
| |
Collapse
|
17
|
Ghimire R, Shakya YM, Shrestha TM, Neupane RP. The utility of red cell distribution width to predict mortality of septic patients in a tertiary hospital of Nepal. BMC Emerg Med 2020; 20:43. [PMID: 32456665 PMCID: PMC7249690 DOI: 10.1186/s12873-020-00337-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 05/14/2020] [Indexed: 12/27/2022] Open
Abstract
Background Sepsis is a common problem encountered in the emergency room which needs to be intervened early. Predicting prognosis is always a difficult task in busy emergency rooms using present scores, which has several variables to calculate. Red cell distribution width (RDW) is an easy, cheap, and efficacious score to predict the severity and mortality of patients with sepsis. Methods This prospective analytical study was conducted in the emergency room of Tribhuvan University Teaching Hospital among the patients age ≥ 16 years and with a clinical diagnosis of sepsis using qSOFA score. 148 patients were analyzed in the study by using a non-probability purposive sampling method. Results RDW has fair efficacy to predict the mortality in sepsis (Area under the Curve of 0.734; 95% C. I = 0.649–0.818; p-value = 0.000) as APACHE II (AUC of 0.728; 95% C. I = 0.637 to 0.819; p-value = 0.000) or SOFA (AUC of 0.680, 95% C. I = 0.591–0.770; p-value = 0.001). Youden Index was maximum (37%) at RDW value 14.75, which has a sensitivity of 83% (positive likelihood ratio = 1.81) and specificity of 54% (negative likelihood ratio = 0.32). Out of 44 patients with septic shock 16 died (36.4%) and among 104 patients without septic shock, 24 died (22.9%) which had the odds ratio of 0.713 (p = 0.555, 95% C. I = 0.231–2.194). Overall mortality was 27.02% (n = 40). RDW group analysis showed no mortality in RDW < 13.1 group, 3.6% mortality in 13.1 to 14 RDW group, 22.0% mortality in 14 to > 15.6 RDW group and 45.9% mortality in > 15.6 RDW group. Significant mortality difference was seen in 14 to > 15.6 and > 15.6 RDW subgroups with a p-value of 0.003 and 0.008 respectively. Conclusion Area under the curve value for RDW is fair enough to predict the mortality of patients with sepsis in the emergency room. It can be integrated with other severity scores (APACHE II or SOFA score) for better prediction of prognosis of septic patients.
Collapse
Affiliation(s)
- Rajan Ghimire
- Department of General Practice and Emergency Medicine, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.
| | - Yogendra Man Shakya
- Department of General Practice and Emergency Medicine, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Tirtha Man Shrestha
- Department of General Practice and Emergency Medicine, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Ram Prasad Neupane
- Department of General Practice and Emergency Medicine, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| |
Collapse
|
18
|
Jiang W, Zou Z, Zhao S, Fang Y, Xu J, Wang Y, Shen B, Luo Z, Wang C, Ding X, Teng J. Erythrocyte transfusion limits the role of elevated red cell distribution width on predicting cardiac surgery associated acute kidney injury. Cardiol J 2020; 28:255-261. [PMID: 32419126 DOI: 10.5603/cj.a2020.0070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 04/16/2020] [Accepted: 04/21/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is one of the more serious complications after cardiac surgery. Elevated red cell distribution width (RDW) was reported as a predictor for cardiac surgery associated acute kidney injury (CSAKI). However, the increment of RDW by erythrocyte transfusion makes its prognostic role doubtful. The aim of this study is to elucidate the impact of erythrocyte transfusion on the prognostic role of elevated RDW for predicting CSAKI. METHODS A total of 3207 eligible patients who underwent cardiac surgery during 2016-2017 were enrolled. Changes of RDW was defined as the difference between preoperative RDW and RDW measured 24 h after cardiac surgery. The primary outcome was CSAKI which was defined by the Kidney Disease: Improving Global Outcomes Definition and Staging (KDIGO) criteria. Univariate and multivariate analysis were performed to identify predictors for CSAKI. RESULTS The incidence of CSAKI was 38.07% and the mortality was 1.18%. CSAKI patients had higher elevated RDW than those without CSAKI (0.65% vs. 0.39%, p < 0.001). Multivariate regression showed that male, age, New York Heat Association classification 3-4, elevated RDW, estimated glomerular filtration rate < 60 mL/min/1.73 m2, cardiopulmonary bypass time > 120 min and erythrocyte transfusion were associated with CSAKI. Subgroup analysis showed elevated RDW was an independent predictor for CSAKI in the non-transfused subset (adjusted odds ratio: 1.616, p < 0.001) whereas no significant association between elevated RDW and CSAKI was found in the transfused patients (odds ratio: 1.040, p = 0.497). CONCLUSIONS Elevated RDW is one of the independent predictors of CSAKI in the absence of erythrocyte transfusion, which limits the prognostic role of the former on predicting CSAKI.
Collapse
Affiliation(s)
- Wuhua Jiang
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China, No 180 Fenglin Road, Shanghai 200032, China, 200032 Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China
| | - Zhouping Zou
- Department of Nephrology, Xuhui Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shuan Zhao
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China, No 180 Fenglin Road, Shanghai 200032, China, 200032 Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China
| | - Yi Fang
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China, No 180 Fenglin Road, Shanghai 200032, China, 200032 Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China
| | - Jiarui Xu
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China, No 180 Fenglin Road, Shanghai 200032, China, 200032 Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China
| | - Yimei Wang
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China, No 180 Fenglin Road, Shanghai 200032, China, 200032 Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China
| | - Bo Shen
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China, No 180 Fenglin Road, Shanghai 200032, China, 200032 Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China
| | - Zhe Luo
- Department of Intensive Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chunsheng Wang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoqiang Ding
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China, No 180 Fenglin Road, Shanghai 200032, China, 200032 Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Department of Nephrology, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
| | - Jie Teng
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China, No 180 Fenglin Road, Shanghai 200032, China, 200032 Shanghai, China. .,Shanghai Medical Center of Kidney, Shanghai, China. .,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China. .,Department of Nephrology, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China.
| |
Collapse
|
19
|
Fogagnolo A, Taccone FS, Vincent JL, Benetto G, Cavalcante E, Marangoni E, Ragazzi R, Creteur J, Volta CA, Spadaro S. Using arterial-venous oxygen difference to guide red blood cell transfusion strategy. Crit Care 2020; 24:160. [PMID: 32312299 PMCID: PMC7171832 DOI: 10.1186/s13054-020-2827-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 03/06/2020] [Indexed: 01/28/2023]
Abstract
Background Guidelines recommend a restrictive red blood cell transfusion strategy based on hemoglobin (Hb) concentrations in critically ill patients. We hypothesized that the arterial-venous oxygen difference (A-V O2diff), a surrogate for the oxygen delivery to consumption ratio, could provide a more personalized approach to identify patients who may benefit from transfusion. Methods A prospective observational study including 177 non-bleeding adult patients with a Hb concentration of 7.0–10.0 g/dL within 72 h after ICU admission. The A-V O2diff, central venous oxygen saturation (ScvO2), and oxygen extraction ratio (O2ER) were noted when a patient’s Hb was first within this range. Transfusion decisions were made by the treating physician according to institutional policy. We used the median A-V O2diff value in the study cohort (3.7 mL) to classify the transfusion strategy in each patient as “appropriate” (patient transfused when the A-V O2diff > 3.7 mL or not transfused when the A-V O2diff ≤ 3.7 mL) or “inappropriate” (patient transfused when the A-V O2diff ≤ 3.7 mL or not transfused when the A-V O2diff > 3.7 mL). The primary outcome was 90-day mortality. Results Patients managed with an “appropriate” strategy had lower mortality rates (23/96 [24%] vs. 36/81 [44%]; p = 0.004), and an “appropriate” strategy was independently associated with reduced mortality (hazard ratio [HR] 0.51 [95% CI 0.30–0.89], p = 0.01). There was a trend to less acute kidney injury with the “appropriate” than with the “inappropriate” strategy (13% vs. 26%, p = 0.06), and the Sequential Organ Failure Assessment (SOFA) score decreased more rapidly (p = 0.01). The A-V O2diff, but not the ScvO2, predicted 90-day mortality in transfused (AUROC = 0.656) and non-transfused (AUROC = 0.630) patients with moderate accuracy. Using the ROC curve analysis, the best A-V O2diff cutoffs for predicting mortality were 3.6 mL in transfused and 3.5 mL in non-transfused patients. Conclusions In anemic, non-bleeding critically ill patients, transfusion may be associated with lower 90-day mortality and morbidity in patients with higher A-V O2diff. Trial registration ClinicalTrials.gov, NCT03767127. Retrospectively registered on 6 December 2018.
Collapse
Affiliation(s)
- Alberto Fogagnolo
- Department of Morphology, Surgery and Experimental Medicine, Section of Anaesthesia and Intensive Care, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, 8, Aldo Moro, 44121, Ferrara, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Giulia Benetto
- Department of Morphology, Surgery and Experimental Medicine, Section of Anaesthesia and Intensive Care, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, 8, Aldo Moro, 44121, Ferrara, Italy
| | - Elaine Cavalcante
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Elisabetta Marangoni
- Department of Morphology, Surgery and Experimental Medicine, Section of Anaesthesia and Intensive Care, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, 8, Aldo Moro, 44121, Ferrara, Italy
| | - Riccardo Ragazzi
- Department of Morphology, Surgery and Experimental Medicine, Section of Anaesthesia and Intensive Care, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, 8, Aldo Moro, 44121, Ferrara, Italy
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Carlo Alberto Volta
- Department of Morphology, Surgery and Experimental Medicine, Section of Anaesthesia and Intensive Care, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, 8, Aldo Moro, 44121, Ferrara, Italy
| | - Savino Spadaro
- Department of Morphology, Surgery and Experimental Medicine, Section of Anaesthesia and Intensive Care, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, 8, Aldo Moro, 44121, Ferrara, Italy.
| |
Collapse
|
20
|
Fogagnolo A, Spadaro S, Taccone FS, Ragazzi R, Romanello A, Fanni A, Marangoni E, Franchi F, Scolletta S, Volta CA. The prognostic role of red blood cell distribution width in transfused and non-transfused critically ill patients. Minerva Anestesiol 2019; 85:1159-1167. [DOI: 10.23736/s0375-9393.19.13522-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
21
|
Fogagnolo A, Taccone FS, Campo G, Montanari G, Capatti B, Ferraro G, Erriquez A, Ragazzi R, Creteur J, Volta CA, Spadaro S. Impaired platelet reactivity in patients with septic shock: a proof-of-concept study. Platelets 2019; 31:652-660. [DOI: 10.1080/09537104.2019.1663807] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Alberto Fogagnolo
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant’ Anna, University of Ferrara, Ferrara, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliera Universitaria di Ferrara, Cona (FE), Italy and Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
| | - Giacomo Montanari
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant’ Anna, University of Ferrara, Ferrara, Italy
| | - Beatrice Capatti
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant’ Anna, University of Ferrara, Ferrara, Italy
| | - Gioconda Ferraro
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant’ Anna, University of Ferrara, Ferrara, Italy
| | - Andrea Erriquez
- Cardiovascular Institute, Azienda Ospedaliera Universitaria di Ferrara, Cona (FE), Italy and Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
| | - Riccardo Ragazzi
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant’ Anna, University of Ferrara, Ferrara, Italy
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Carlo Alberto Volta
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant’ Anna, University of Ferrara, Ferrara, Italy
| | - Savino Spadaro
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant’ Anna, University of Ferrara, Ferrara, Italy
| |
Collapse
|
22
|
Liu J, Chen S, Ye X. The effect of red blood cell transfusion on plasma hepcidin and growth differentiation factor 15 in gastric cancer patients: a prospective study. Ann Transl Med 2019; 7:466. [PMID: 31700902 DOI: 10.21037/atm.2019.08.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background Hepcidin and growth differentiation factor 15 (GDF-15) have been reported to be highly expressed in various cancers. Serum hepcidin and GDF-15 levels were demonstrated to be potential prognostic markers in cancers. This study aims to evaluate the effect of red blood cell (RBC) transfusion on plasma hepcidin and GDF-15 in gastric cancer patients. Methods In this prospective study, 40 patients with gastric cancer were eligible for this study. Peripheral blood samples were obtained before and within 24 h after RBC transfusion. A routine blood test was performed before transfusion and within 24 h post-transfusion. Plasma hepcidin, GDF-15, interleukin 6 (IL-6) and erythropoietin were determined by ELISA. Results In patients with metastasis, plasma hepcidin (P=0.02), and GDF-15 (P=0.01) levels were higher than without metastasis. Plasma hepcidin was increased after RBC transfusion (P=0.001), while plasma erythropoietin was decreased after transfusion (P=0.03). However, RBC transfusion did not affect plasma GDF-15 (P=0.32) and IL-6 (P=0.12). The effect of RBC transfusion on variables did not differ between metastatic and non-metastatic patients. The mean percentage change of hepcidin in transfusion volume 4 unit (U) was more than 2 U. Conclusions RBC transfusion could increase plasma hepcidin and have no effect on plasma GDF-15 in gastric patients.
Collapse
Affiliation(s)
- Jingfu Liu
- Department of Blood Transfusion, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou 350014, China
| | - Shan Chen
- Department of Blood Transfusion, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou 350014, China
| | - Xianren Ye
- Department of Blood Transfusion, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou 350014, China.,Fujian Provincial Key Laboratory of Tumor Biotherapy, Fuzhou 350014, China
| |
Collapse
|
23
|
Affiliation(s)
- Elio Antonucci
- Intermediate Care Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy -
| | - Manuela Giovini
- Intermediate Care Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
| |
Collapse
|