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American Journal of Hematology Jul 2024Primum non nocere! Can iron deficiency, an abnormality that causes anemia, benefit people with sickle cell disease (SCD) who already have an anemia? The published... (Review)
Review
Primum non nocere! Can iron deficiency, an abnormality that causes anemia, benefit people with sickle cell disease (SCD) who already have an anemia? The published literature we review appears to answer this question in the affirmative: basic science considerations, animal model experiments, and noncontrolled clinical observations all suggest a therapeutic potential of iron restriction in SCD. This is because SCD's clinical manifestations are ultimately attributable to the polymerization of hemoglobin S (HbS), a process strongly influenced by intracellular HbS concentration. Even small decrements in HbS concentration greatly reduce polymerization, and iron deficiency lowers erythrocyte hemoglobin concentration. Thus, iron deficiency could improve SCD by changing its clinical features to those of a more benign anemia (i.e., a condition with fewer or no vaso-occlusive events). We propose that well-designed clinical studies be implemented to definitively determine whether iron restriction is a safe and effective option in SCD. These investigations are particularly timely now that pharmacologic agents are being developed, which may directly reduce red cell hemoglobin concentrations without the need for phlebotomies to deplete total body iron.
Topics: Anemia, Sickle Cell; Humans; Animals; Iron; Hemoglobin, Sickle; Anemia, Iron-Deficiency; Erythrocytes
PubMed: 38400590
DOI: 10.1002/ajh.27267 -
Journal of Viral Hepatitis May 2024Widespread screening for hepatitis C virus (HCV) is necessary for Canada to meet its HCV elimination goals by 2030. People who currently or previously injected drugs are...
Widespread screening for hepatitis C virus (HCV) is necessary for Canada to meet its HCV elimination goals by 2030. People who currently or previously injected drugs are at high risk for HCV. Opioid agonist therapy (OAT, such as methadone and buprenorphine) has been shown to help stabilize the lives of people who are opioid-dependent. The distribution of OAT in North America typically requires daily, weekly, or monthly clinic visits and presents an opportunity for engagement, screening and treatment for those at high-risk of HCV. In this study, HCV screening was conducted by staff at OAT clinics in Ontario from 2016 to 2020 and those with chronic infections were treated on-site with direct-acting antivirals. Point-of-care or dried blood spot (DBS) testing was used for antibodies, DBS or serum for HCV RNA and serum for HCV RNA at SVR12 (sustained virological response). Clinics screened 1954 people (mean age 40 years ±12, 63% male). Forty-five percent were antibody positive, of whom 64% were HCV RNA+. Eighty percent of those RNA+ set an appointment in which 99% attended. Ninety-six percent started treatment with 87% completing treatment. Sixty-eight percent of people who completed treatment submitted a sample for SVR12 testing of which 97% achieved a virological cure. Results suggest that HCV screening and treatment at OAT clinics is feasible, effective and warrants expansion. Data suggest strong treatment adherence due to high rates of SVR12 comparable with other OAT-based HCV treatment programs. The lack of SVR12 sampling could be addressed by either on-site phlebotomy or incentivizing SVR12 sampling.
Topics: Humans; Male; Adult; Female; Hepacivirus; Analgesics, Opioid; Antiviral Agents; Ontario; Prevalence; Hepatitis C, Chronic; Hepatitis C; RNA; Substance Abuse, Intravenous
PubMed: 38385850
DOI: 10.1111/jvh.13931 -
Transfusion Mar 2024Adult extracorporeal membrane oxygenation (ECMO) patients are at high risk for allogeneic blood transfusion. Few studies have characterized iatrogenic blood loss from...
BACKGROUND
Adult extracorporeal membrane oxygenation (ECMO) patients are at high risk for allogeneic blood transfusion. Few studies have characterized iatrogenic blood loss from phlebotomy in adult ECMO patients. We hypothesized that iatrogenic phlebotomy would be a significant source of blood loss during ECMO.
METHODS
Adults who had their entire ECMO run at our medical center between 2020 and 2022 were included. Average daily phlebotomy volume and total phlebotomy volume during ECMO were estimated based on the total number of laboratory tests that were processed. In addition, the crude and adjusted association between total phlebotomy volume during ECMO and RBC transfusion during ECMO was evaluated using linear regression and Loess curve analysis.
RESULTS
A total of 161 patients who underwent 162 ECMO runs were included. Of the 162 ECMO runs, 88 (54.3%) were veno-arterial and 74 (45.7%) were veno-venous ECMO. Median duration of ECMO was 5 days [25th, 75th percentile = 2, 11]. Median daily phlebotomy volume was 130 mLs [25th, 75th percentile = 94, 170] and median total phlebotomy volume during ECMO was 579 mLs [25th, 75th percentile = 238, 1314]. There was a significant crude and adjusted association between total phlebotomy volume and RBC transfusion during ECMO (beta coefficient = 0.0023 and 0.0024 respectively, both p < .001) based on linear regression analysis.
DISCUSSION
Phlebotomy for laboratory testing is a significant source of blood loss during ECMO in adults. Comprehensive patient blood management for adult ECMO patients should include strategies to reduce laboratory testing and/or phlebotomy volume during ECMO.
Topics: Adult; Humans; Phlebotomy; Extracorporeal Membrane Oxygenation; Retrospective Studies; Blood Transfusion; Hemorrhage; Stroke; Iatrogenic Disease
PubMed: 38385665
DOI: 10.1111/trf.17729 -
The New England Journal of Medicine Feb 2024Polycythemia vera is a chronic myeloproliferative neoplasm characterized by erythrocytosis. Rusfertide, an injectable peptide mimetic of the master iron regulatory... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Polycythemia vera is a chronic myeloproliferative neoplasm characterized by erythrocytosis. Rusfertide, an injectable peptide mimetic of the master iron regulatory hormone hepcidin, restricts the availability of iron for erythropoiesis. The safety and efficacy of rusfertide in patients with phlebotomy-dependent polycythemia vera are unknown.
METHODS
In part 1 of the international, phase 2 REVIVE trial, we enrolled patients in a 28-week dose-finding assessment of rusfertide. Part 2 was a double-blind, randomized withdrawal period in which we assigned patients, in a 1:1 ratio, to receive rusfertide or placebo for 12 weeks. The primary efficacy end point was a response, defined by hematocrit control, absence of phlebotomy, and completion of the trial regimen during part 2. Patient-reported outcomes were assessed by means of the modified Myeloproliferative Neoplasm Symptom Assessment Form (MPN-SAF) patient diary (scores range from 0 to 10, with higher scores indicating greater severity of symptoms).
RESULTS
Seventy patients were enrolled in part 1 of the trial, and 59 were assigned to receive rusfertide (30 patients) or placebo (29 patients) in part 2. The estimated mean (±SD) number of phlebotomies per year was 8.7±2.9 during the 28 weeks before the first dose of rusfertide and 0.6±1.0 during part 1 (estimated difference, 8.1 phlebotomies per year). The mean maximum hematocrit was 44.5±2.2% during part 1 as compared with 50.0±5.8% during the 28 weeks before the first dose of rusfertide. During part 2, a response was observed in 60% of the patients who received rusfertide as compared with 17% of those who received placebo (P = 0.002). Between baseline and the end of part 1, rusfertide treatment was associated with a decrease in individual symptom scores on the MPN-SAF in patients with moderate or severe symptoms at baseline. During parts 1 and 2, grade 3 adverse events occurred in 13% of the patients, and none of the patients had a grade 4 or 5 event. Injection-site reactions of grade 1 or 2 in severity were common.
CONCLUSIONS
In patients with polycythemia vera, rusfertide treatment was associated with a mean hematocrit of less than 45% during the 28-week dose-finding period, and the percentage of patients with a response during the 12-week randomized withdrawal period was greater with rusfertide than with placebo. (Funded by Protagonist Therapeutics; REVIVE ClinicalTrials.gov number, NCT04057040.).
Topics: Humans; Hematocrit; Hepcidins; Iron; Polycythemia; Polycythemia Vera; Peptides; Injections; Double-Blind Method; Hematologic Agents
PubMed: 38381675
DOI: 10.1056/NEJMoa2308809 -
Transfusion Mar 2024Subcutaneous emphysema is a condition where air becomes trapped under the skin, typically resulting from surgery or skin trauma. It is mostly localized and its...
BACKGROUND
Subcutaneous emphysema is a condition where air becomes trapped under the skin, typically resulting from surgery or skin trauma. It is mostly localized and its occurrence in blood donors is exceedingly rare. Phlebotomy poses minimal risk of subcutaneous emphysema, but procedural errors may lead to such complications.
STUDY DESIGN AND METHOD
This is a case report of 29-year-old repeat blood donor who experienced subcutaneous emphysema following blood donation. The donor was vigorously squeezing sponge ball during donation resulting in displacement of the needle which required readjustment. Post-donation, the donor reported a crackling sensation and mild swelling near phlebotomy site. Non-contrast computed tomography (NCCT) scans confirmed subcutaneous emphysema, attributing its development to air trapping in subcutaneous plane due to ball valve mechanism.
RESULTS
Computed tomography (CT) imaging revealed subcutaneous emphysematous changes in the right cubital region and no evidence of hematoma. The swelling spontaneously subsided in 10-12 days without any intervention. The case underscores the importance of differentiating subcutaneous emphysema from common complications like hematoma.
DISCUSSION
Subcutaneous emphysema in blood donors is exceptionally rare but should be managed with clear communication. Donors should be reassured that the condition, although rare, is benign and self-resolving. Healthcare providers should be equipped to handle such rare complications, offering appropriate care and documenting incidents for future prevention.
Topics: Humans; Adult; Blood Donation; Subcutaneous Emphysema; Tomography, X-Ray Computed; Blood Donors; Hematoma
PubMed: 38380495
DOI: 10.1111/trf.17762 -
The American Journal of Case Reports Feb 2024BACKGROUND Hyperparathyroidism is a common issue in patients on long-term hemodialysis, necessitating parathyroidectomy with deep venipuncture. These patients frequently...
BACKGROUND Hyperparathyroidism is a common issue in patients on long-term hemodialysis, necessitating parathyroidectomy with deep venipuncture. These patients frequently exhibit a heightened incidence of vascular calcification, complicating deep venipuncture and increasing the risk of associated complications. Therefore, a crucial aspect of preoperative assessment in this population involves identifying vascular calcification, with a preference for ultrasound-guided intraplane puncture. Special care is required to prevent blood vessel injuries and postoperative complications such as deep vein thrombosis. CASE REPORT We present the case of a 66-year-old woman with secondary hyperparathyroidism who encountered challenges during an internal jugular vein puncture, leading to subsequent thrombosis. Initial attempts were hindered by calcification of the internal jugular vein's vascular wall, resulting in stratified damage to the vessel's wall. However, the ultrasound-guided in-plane puncture technique successfully allowed the insertion of a central venous catheter without further damage to the vascular wall. On the postoperative fourth day, thrombus formation was observed in the damaged vascular wall from the initial puncture. CONCLUSIONS The ultrasound-guided in-plane puncture technique is advantageous in overcoming the difficulties associated with puncturing through deep vein calcification in patients with secondary hyperparathyroidism. This technique also diminishes the likelihood of complications such as venous thrombosis.
Topics: Female; Humans; Aged; Catheterization, Central Venous; Phlebotomy; Jugular Veins; Thrombosis; Ultrasonography, Interventional; Hyperparathyroidism, Secondary; Vascular Calcification
PubMed: 38379277
DOI: 10.12659/AJCR.943270 -
Zhongguo Zhen Jiu = Chinese Acupuncture... Feb 2024To analyze the research hotspots, frontiers and trends of fire needle clinical randomized controlled trial (RCT) literature in the past 10 years by using bibliometrics... (Randomized Controlled Trial)
Randomized Controlled Trial
To analyze the research hotspots, frontiers and trends of fire needle clinical randomized controlled trial (RCT) literature in the past 10 years by using bibliometrics and knowledge mapping methods. Six Chinese and English databases including CNKI, Wanfang, VIP, SinoMed, PubMed and Web of Science ( WOS ) were searched for RCT research literature on fire needle. CiteSpace V6.1.R6 and VOSviewer V1.6.18 software were used to analyze the cooperation network, keyword co-occurrence, keyword clustering, keyword timeline, keyword emergence, etc., and to draw a visual knowledge map. A total of 1 973 Chinese articles and 3 English articles were included. The top three institutions that publish articles were Guangzhou University of CM, Heilongjiang University of CM and Beijing Hospital of TCM Affiliated to Capital Medical University. The fire needle was often combined with acupuncture, cupping and bloodletting therapy in the treatment of acne, vitiligo, lumbar disc herniation, herpes zoster, stroke sequelae, facial paralysis, knee osteoarthritis and so on. The research frontiers included the combined application of fire needle and other therapies, clinical mechanism research and efficacy evaluation index research. In the future, we should expand the dominant diseases, optimize the research design, strengthen the cooperation between the teams, and carry out high-level clinical research.
Topics: Humans; Acupuncture Therapy; Herpes Zoster; Needles; Bloodletting; Bibliometrics
PubMed: 38373773
DOI: 10.13703/j.0255-2930.20230321-0004 -
Medicine Feb 2024As the second leading cause of death and disability worldwide, stroke is mainly caused by atherosclerosis and cardiac embolism, particularly in older individuals.... (Review)
Review
INTRODUCTION
As the second leading cause of death and disability worldwide, stroke is mainly caused by atherosclerosis and cardiac embolism, particularly in older individuals. Nevertheless, in young and otherwise healthy individuals, the causes of stroke can be more diverse and may include conditions such as patent foramen ovale, vasculitis, coagulopathies, genetic factors, or other undetermined causes. Although these other causes of stroke account for a relatively small proportion compared to ischemic stroke, they are becoming increasingly common in clinical practice and deserve attention. Here, we present a rare female patient with polycythemia vera (PV) who was admitted to the hospital as a stroke patient without any previous medical history.
PATIENT CONCERNS
A 40-year-old young woman felt sudden dizziness and slow response. After 4 days of being admitted, she developed blurry vision on the right.
DIAGNOSES
Cranial magnetic resonance imaging revealed aberrant signals in the left temporal and parietal lobe, as well as multiple small focal signal abnormalities were observed in the left frontal lobe. Magnetic resonance angiography revealed partial stenosis of the left internal carotid artery. The patient's blood routine examination revealed a significant elevation in complete blood counts, particularly the increase in red blood cells, as well as prolonged clotting time. An abdominal ultrasound and abdomen computed tomography showed splenomegaly. The outcome of the genetic testing was positive for the Janus kinase JAK2 exon V617F mutation (JAK2/V617F). The patient was diagnosed with PV-related stroke.
INTERVENTIONS
The patient was treated with phlebotomy, cytoreductive therapy, and low-dose aspirin antiplatelet therapy and was regularly followed up in hematology and neurology clinics after discharge.
OUTCOMES
The patient's red blood cell, leukocyte, and thrombocyte counts had fully normalized, with her hemoglobin level measuring at 146 g/L and hematocrit value at 43%. Furthermore, there had been a significant improvement in neurological symptoms.
LESSONS
PV, a rare hematological disorder, can present with ischemic stroke as the initial performance, and the diagnosis mainly relies on routine blood tests, bone marrow biopsies, and genetic test. Therefore, clinicians should pay attention to PV, a low-prevalence disease, when encountering stroke in youth.
Topics: Female; Humans; Young Adult; Aged; Adolescent; Adult; Male; Polycythemia Vera; Ischemic Stroke; Janus Kinase 2; Bone Marrow; Mutation
PubMed: 38363912
DOI: 10.1097/MD.0000000000036953 -
JMIR Diabetes Mar 2024Diabetes and hypertension are some of the most prevalent and costly chronic conditions in the United States. However, outcomes continue to lag behind targets, creating...
BACKGROUND
Diabetes and hypertension are some of the most prevalent and costly chronic conditions in the United States. However, outcomes continue to lag behind targets, creating further risk of long-term complications, morbidity, and mortality for people living with these conditions. Furthermore, racial and ethnic disparities in glycemic and hypertension control persist. Flexible telehealth programs leveraging asynchronous care allow for increased provider access and more convenient follow-up, ultimately improving critical health outcomes across demographic groups.
OBJECTIVE
We aim to evaluate the 12-month clinical outcomes of participants in the 9amHealth web-based clinic for diabetes and hypertension. We hypothesized that participation in the 9amHealth program would be associated with significant improvements in glycemic and blood pressure (BP) control across a diverse group of individuals.
METHODS
We enrolled 95 patients in a completely web-based care clinic for diabetes and hypertension who received nutrition counseling, health coaching, and asynchronous physician consultations for medication prescribing. Patients received standard or cellular-connected glucose meters and BP cuffs in order to share data. Laboratory tests were completed either with at-home phlebotomy draws or a self-administered test kit. Patients' first and last hemoglobin A (HbA) and BP results over the 12-month period were compared, and analyses were repeated across race and ethnicity groups.
RESULTS
Among all 95 patients, the average HbA decreased by -1.0 (from 8.2% to 7.2%; P<.001) over 12 months of program participation. In those with a baseline HbA >8%, the average HbA decreased by -2.1 (from 10.2% to 8.1%; P<.001), and in those with a baseline HbA >9%, the average HbA decreased by -2.8 (from 11% to 8.2%; P<.001). Among participants who identified as a race or ethnicity other than White, the HbA decreased by -1.2 (from 8.6% to 7.4%, P=.001). Further examination of subgroups confirmed HbA lowering within each race or ethnicity group. In the overall population, the average systolic BP decreased by 17.7 mm Hg (P=.006) and the average diastolic BP decreased by 14.3 mm Hg (P=.002). Among participants self-identifying as a race or ethnicity other than White, the results similarly showed a decrease in BP (average reduction in systolic BP of 10 mm Hg and in diastolic BP of 9 mm Hg).
CONCLUSIONS
A fully web-based model leveraging all-asynchronous physician review and prescribing, combined with synchronous and asynchronous coaching and nutrition support, was associated with clinically meaningful improvement in HbA and BP control over a 12-month period among a diverse group of individuals. Further studies should prospectively evaluate the effectiveness of such models among larger populations, assess the longer-term sustainability of these outcomes, and explore financial models to make these types of programs broadly accessible.
PubMed: 38363585
DOI: 10.2196/53835 -
Journal of Hospital Medicine Apr 2024Phlebotomy for hospitalized children has consequences (e.g., pain, iatrogenic anemia), and unnecessary testing is a modifiable source of waste in healthcare. Days...
BACKGROUND
Phlebotomy for hospitalized children has consequences (e.g., pain, iatrogenic anemia), and unnecessary testing is a modifiable source of waste in healthcare. Days without blood draws or phlebotomy-free days (PFDs) has the potential to serve as a hospital quality measure.
OBJECTIVE
To describe: (1) the frequency of PFDs in children hospitalized with common infections and (2) the association of PFDs with clinical outcomes.
DESIGN, SETTINGS AND PARTICIPANTS
We performed a cross-sectional study of children hospitalized 2018-2019 with common infections at 38 hospitals using the Pediatric Health Information System database. We included infectious All Patients Refined Diagnosis Related Groups with a median length of stay (LOS) >2 days. We excluded patients with medical complexity, interhospital transfers, those receiving intensive care, and in-hospital mortality.
MAIN OUTCOME AND MEASURES
We defined PFDs as hospital days (midnight to midnight) without laboratory blood testing and measured the proportion of PFDs divided by total hospital LOS (PFD ratio) for each condition and hospital. Higher PFD ratios signify more days without phlebotomy. Hospitals were grouped into low, moderate, and high average PFD ratios. Adjusted outcomes (LOS, costs, and readmissions) were compared across groups.
RESULTS
We identified 126,135 encounters. Bronchiolitis (0.78) and pneumonia (0.54) had the highest PFD ratios (most PFDs), while osteoarticular infections (0.28) and gastroenteritis (0.30) had the lowest PFD ratios. There were no differences in adjusted clinical outcomes across PFD ratio groups. Among children hospitalized with common infections, PFD ratios varied across conditions and hospitals, with no association with outcomes. Our data suggest overuse of phlebotomy and opportunities to improve the care of hospitalized children.
Topics: Humans; Child; Phlebotomy; Cross-Sectional Studies; Length of Stay; Pneumonia; Hospitals
PubMed: 38348499
DOI: 10.1002/jhm.13282