Association of Anemia with Rehabilitation Outcome for Subacute Geriatric Rehabilitation Patients in a Secondary Hospital in Malaysia

Objective: To evaluate the effect of Anemia on Rehabilitation Outcome for Geriatric Subjects in Taiping Hospital Subacute Geriatric Rehabilitation Ward.Methodology: This was a retrospective study, with 126 subjects to compare the change in modified Barthel Index score of anemic and non anemic subjects.Results: 44% of subjects were anemic and the Mean corpuscular hemoglobin and Mean corpuscular volume for anemic subjects were 85.4pg and 29.8fL. Among anemic subjects 45.5% were Malay, 38.2% were Chinese, 14.5% were Indian and 1% were others. The Median(IQR) Modified Barthel Index (MBI) on admission for anemic subjects and non anemic subjects were insignificantly difference which were 47 (29, 63) and 36 (21, 59) respectively, (p=0.059). The median(IQR) of MBI improvement for non anemic subjects was found to be significantly higher than anemic subjects which were 14 (5, 26) and 8 (1, 18) (p=0.021). Subject with hemoglobin (hb) ≥ 9g/dL were significantly associated with MBI improvement of more than 20, p=0.014. Multiple linear regression revealed a significant linear relationship between age and MBI score improvement (p=0.010). Subjects 10 years younger showed a 3.55 score improvement in MBI.Conclusion: The study suggested that non-anemic subjects showed significant MBI improvement. Our study also suggested judicious transfusion practices to maintain a hemoglobin threshold of 9 g/dL might be able to improve subject’s functional outcome. These results should encourage further research with a larger elderly subject population to provide insights and awareness for the need to correct anemia in rehabilitation subjects.

Lower versus higher hemoglobin threshold for transfusion in ARDS patients with and without ECMO

Background Efficacy and safety of different hemoglobin thresholds for transfusion of red blood cells (RBCs) in adults with an acute respiratory distress syndrome (ARDS) are unknown. We therefore assessed the effect of two transfusion thresholds on short-term outcome in patients with ARDS. Methods Patients who received transfusions of RBCs were identified from a cohort of 1044 ARDS patients. After propensity score matching, patients transfused at a hemoglobin concentration of 8 g/dl or less (lower-threshold) were compared to patients transfused at a hemoglobin concentration of 10 g/dl or less (higher-threshold). The primary endpoint was 28-day mortality. Secondary endpoints included ECMO-free, ventilator-free, sedation-free, and organ dysfunction-free composites. Measurements and main results One hundred ninety-two patients were eligible for analysis of the matched cohort. Patients in the lower-threshold group had similar baseline characteristics and hemoglobin levels at ARDS onset but received fewer RBC units and had lower hemoglobin levels compared with the higher-threshold group during the course on the ICU (9.1 [IQR, 8.7–9.7] vs. 10.4 [10–11] g/dl, P < 0.001). There was no difference in 28-day mortality between the lower-threshold group compared with the higher-threshold group (hazard ratio, 0.94 [95%-CI, 0.59–1.48], P = 0.78). Within 28 days, 36.5% (95%-CI, 27.0–46.9) of the patients in the lower-threshold group compared with 39.5% (29.9–50.1) of the patients in the higher-threshold group had died. While there were no differences in ECMO-free, sedation-free, and organ dysfunction-free composites, the chance for successful weaning from mechanical ventilation within 28 days after ARDS onset was lower in the lower-threshold group (subdistribution hazard ratio, 0.36 [95%-CI, 0.15–0.86], P = 0.02). Conclusions Transfusion at a hemoglobin concentration of 8 g/dl, as compared with a hemoglobin concentration of 10 g/dl, was not associated with an increase in 28-day mortality in adults with ARDS. However, a transfusion at a hemoglobin concentration of 8 g/dl was associated with a lower chance for successful weaning from the ventilator during the first 28 days after ARDS onset. Trial Registration: ClinicalTrials.gov NCT03871166.

The Prevalence and Management of Secondary Erythrocytosis in Transgender Individuals Undergoing Masculinizing Therapy

Background:Gender-affirming hormone therapy is integral to the care of transgender individuals, but the hematologic complications of this therapy are not entirely understood. While secondary erythrocytosis is a widely recognized complication of testosterone administration, the exact prevalence of erythrocytosis in patients receiving exogenous testosterone for gender transition and the optimal management of this condition remain unclear. We performed a retrospective analysis of transgender individuals undergoing masculinizing therapy with testosterone at our institution to assess the prevalence of secondary erythrocytosis and review the management techniques utilized. Methods:We performed a retrospective observational study of transgender individuals over the age of 18 years undergoing masculinizing therapy with exogenous testosterone between June 30, 2019 and June 30, 2020 at Oregon Health & Science University Hospital in Portland, Oregon. We collected data on average pre-testosterone hemoglobin and hematocrit values, formulation of testosterone and route of administration, peak hemoglobin and hematocrit values after the initiation of endocrine therapy, management of secondary erythrocytosis, and thrombotic events in those with secondary erythrocytosis. Descriptive statistics were employed to determine the prevalence of erythrocytosis using the reference ranges for cisgender males and to quantify average increase in hemoglobin and hematocrit levels from pre-therapy levels. Seaborn and Matplotlib libraries in Python were used for data visualization and pandas library in Python was used for statistical analysis. Results:A total of 234 individuals were included in this study with a mean age of 29 years. Testosterone cypionate was the most commonly administered formulation at 77.8% of cases, followed by transdermal testosterone formulations 14.5%, testosterone enanthate 4.2%, and combination transdermal testosterone plus cypionate 2.1%. Intramuscular injection was the most common route of administration at 65.4% followed by subcutaneous injection 15.8% and transdermal gel 12% and patch 2.1%. The mean pre-testosterone hemoglobin was 13.5 g/dL and hematocrit was 40.3%. After initiation of hormone therapy, the mean hemoglobin peak was 15.7 g/dL and hematocrit peak was 47.2% (Figures 1 and 2). It took an average of 21 months after initiation of therapy to reach peak hemoglobin and hematocrit levels. 23.5% of patients met the definition of erythrocytosis using our institutional cisgender male reference range for hematocrit above 50%, and 8.5% exceeded a hemoglobin threshold of 17.5 g/dL. Only one thrombotic event, a superficial venous thrombosis, occurred in those with secondary erythrocytosis. Dose reduction of testosterone was performed for 14.5% of patients who developed erythrocytosis, and no other management strategies, including therapeutic phlebotomy, were documented. 88.9% of patients with erythrocytosis had received testosterone cypionate, with other formulations infrequently associated with polycythemia-range hematocrit levels. Discussion:Our analysis of transgender individuals undergoing masculinizing therapy with testosterone revealed an average increase in hemoglobin of 2.2 g/dL and in hematocrit of 6.9% after the onset of endocrine therapy. In total, 23.5% of patients met the threshold for secondary erythrocytosis using the hematocrit reference range for cisgender men after initiation of testosterone while only 8.5% met the hemoglobin threshold of 17.5 g/dL. The clinical consequences of this hematologic shift are unclear, with only one patient documented as developing a superficial venous thrombosis, and no occurrences of deep venous thrombosis, pulmonary embolism, or other thrombotic events. It also remains uncertain if utilizing the reference range for cisgender men is an appropriate method of predicting thrombotic risk in this population. The sole management strategy recorded was testosterone dose reduction as no patients had documentation of any therapeutic phlebotomy to lower their hematocrit levels. Of note, some providers recommended that their patients with erythrocytosis donate blood, which was not able to be documented in the medical record. Further studies are required to better define the clinical sequelae of erythrocytosis in this patient population and to determine optimal management of this condition. Figure Disclosures Shatzel: Aronora, Inc.:Consultancy.

Patient Blood Management Program Improves Blood Use and Clinical Outcomes in Orthopedic Surgery

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Although randomized trials show that patients do well when given less blood, there remains a persistent impression that orthopedic surgery patients require a higher hemoglobin transfusion threshold than other patient populations (8 g/dl vs. 7 g/dl). The authors tested the hypothesis in orthopedic patients that implementation of a patient blood management program encouraging a hemoglobin threshold less than 7 g/dl results in decreased blood use with no change in clinical outcomes. Methods After launching a multifaceted patient blood management program, the authors retrospectively evaluated all adult orthopedic patients, comparing transfusion practices and clinical outcomes in the pre- and post-blood management cohorts. Risk adjustment accounted for age, sex, surgical procedure, and case mix index. Results After patient blood management implementation, the mean hemoglobin threshold decreased from 7.8 ± 1.0 g/dl to 6.8 ± 1.0 g/dl (P &lt; 0.0001). Erythrocyte use decreased by 32.5% (from 338 to 228 erythrocyte units per 1,000 patients; P = 0.0007). Clinical outcomes improved, with decreased morbidity (from 1.3% to 0.54%; P = 0.01), composite morbidity or mortality (from 1.5% to 0.75%; P = 0.035), and 30-day readmissions (from 9.0% to 5.8%; P = 0.0002). Improved outcomes were primarily recognized in patients 65 yr of age and older. After risk adjustment, patient blood management was independently associated with decreased composite morbidity or mortality (odds ratio, 0.44; 95% CI, 0.22 to 0.86; P = 0.016). Conclusions In a retrospective study, patient blood management was associated with reduced blood use with similar or improved clinical outcomes in orthopedic surgery. A hemoglobin threshold of 7 g/dl appears to be safe for many orthopedic patients.