Hospital-Acquired Anaemia Secondary to Phlebotomy in Elderly Patients

Introduction: Anaemia contributes to increased morbidity and mortality in hospitalised patients, yet unnecessary blood tests from inpatients may actually induce a “hospital acquired anaemia” (HAA). This study examines the incidence of phlebotomy-induced anaemia during a hospital admission. Methods: Patients admitted to the Royal Bournemouth Hospital between 2009 and 2011 for a period of more than two weeks were identified. Those with normal haemoglobins on admission (Hb > 130 g/dL in men;Hb > 120 g/dL in women) were selected to be included in the study. One hundred and sixty two patients were randomly selected from this group and their admission and discharge haemoglobin was recorded, and the change in Hb was calculated. The number of blood tests taken during admission was calculated from each patient from which volume of blood lost was determined. Age, sex and co-morbidities, bleeding complications and blood transfusions were noted. T-test for unequal variance was used for analysis. Results: Of the 162 patients, 69 (42.5%) developed a HAA (defined as haemoglobin drop from normal to <110 g/dL). The average number of blood tests taken in the anaemia group was 37, compared to only 23 in the “no-anaemia” group. i.e. 132 mls in the anaemia group vs. only 80.2 mls in no-anaemia group. Further analysis of the anaemia group revealed that 40 patients developed a “mild anaemia” (defined as drop in Hb from normal to <110 g/dL) and 29 developed a moderate/severe anaemia (drop from a normal Hb at admission to <100 g/dL). Significantly higher volume of blood was withdrawn from this moderate/severe anaemia group compared to those that developed a mild anaemia 177.9 mls vs. 121.34 mls (p-Value 0.007, F = 0.001) 95% CI 2.08 to 9.22. Conclusion: This study suggests that patients admitted for inpatient stays of more than two weeks may be at high risk of HAA as a consequence of diagnostic blood loss. This anaemia in turn may have detrimental consequences, especially in patients with pre-existing cardio-respiratory disease. There needs to be increased awareness of the risk posed to patients as a result of diagnostic phlebotomy and further studies are required to study its impact on LOS, morbidity and mortality outcomes.

Persian medicine non-pharmacological therapies for headache：phlebotomy and wet cupping

OBJECTIVE: To describe the common causes of headache as well as the different methods of Phlebotomy(Fasd) and wet Cupping(Hijamat) based on Persian Medicine.METHODS: In this study, we searched Google Scholar, Science Direct, Pub Med and Scopus to get any in vitro or clinical evidence of the efficacy and possible mechanisms of phlebotomy or wet cupping on different types of headaches. Also different types of headaches, according to PM, under the title of "Sodaa"; extracted from famous Persian medical text books with key words including "Sodaa","Bayze" and "Shaqiqe".RESULTS: According to PM, diseases(dystemperament) are created by abnormal alteration in temperament. Temperament is a monolithic quality yielded by interaction between opposing qualities of four elements that are coldness, hotness, dryness and wetness. Headaches are caused by dystemperament(sue-Mizaj) in brain or in total body that are divided into simple and corporal. Common forms of the latter type are Vaporal and Migrant headache(Bokhari and Rihi). Each of these headaches is treated either through phlebotomy or wet cupping.CONCLUSION: In Persian Medicine, Fasd and Hijamat are easy and economical methods for treatment of headache with reasonable results. By describing the precise areas and indications of phlebotomy and wet cupping, this study provides the first step for future clinical trials in this field.

Iron Depletion Improves Glycemic Control in Poorly Controlled Type 2 Diabetic Patients with Iron Overload and Negative Main HFE-Gene Mutations

Iron overload increases the risk of diabetes via mechanisms of abnormal glucose metabolism: insulin deficiency, insulin resistance, and/or hepatic dysfunction. Iron reduction upregulates glucose uptake and improves hepatocytes insulin receptor activity. This study was conducted to examine the effects of iron depletion—via controlled phlebotomy—on the hypoglycemic treatment in poorly controlled type 2 diabetes mellitus (T2DM) patients with non-genetic iron overload. Forty three patients with poorly controlled T2DM and iron overload were divided into 2 groups: iron depletion group and control group. Regular phlebotomy was performed for iron depletion group on monthly basis until serum ferritin reached 20 μg/L or less. Both groups were examined and compared for blood pressure, serum ferritin, lipid profile, HFE-gene, HbA1c, HOMA-IR and number of medicines used for diabetic control. The results had revealed that group differences of HbA1c (-2.64, 95% CI -3.23 to 2.04, p < 0.001) and HOMA-IR (-0.68, 95% CI -0.98 to -0.37, p < 0.001) showed significant decreases in iron depletion group at end of study. Significant decrease in the numbers of hypoglycemic medicines in iron depletion group was shown at end of study (p < 0.001);66.7% of iron depletion group patients were receiving 1 or 2 medicines at end of studyversus none of the control group. Diastolic blood pressure (DBP), triglycerides and LDL-C decreased significantly while HDL-C levels showed significant rise after iron depletion. It can be concluded from the present study that iron depletion therapy is beneficial for improving the efficiency of glycemic control, DBP, and dyslipidemia in poorly controlled type 2 diabetics with iron over load.

Categorization and Frequency of Indications for Packed Cell Transfusion in the Preterm Newborn during the Initial Hospital Stay at a Tertiary Care Hospital: A Cross-Sectional Study

Introduction: Packed cell transfusion is a lifesaving procedure in premature babies as they have more complications as compared to babies who are born at term. Complications related to prematurity increase as gestational age decreases and anemia is one of the complications of prematurity which needs packed cell transfusions. To date, when to transfuse preterm babies and what would be the threshold for hemoglobin and hematocrit is still a point of argument as well as liberal versus restrictive transfusion protocols have been developed but what should be followed still needs more data. In our study, we have observed frequencies of different indications of packed cell transfusion in the neonatal intensive care unit of a tertiary care hospital. This endeavor will help in the establishment of guidelines regarding transfusion and the threshold on which any intervention should be done also it would be a step towards the identification of preventable causes that lead to transfusion and transfusion-related risks and hazards. Objective: To determine the indication of packed cell transfusion and their frequencies in preterm neonates. Study Design: This was a cross-sectional study. Setting: The study was carried out in the neonatal intensive care unit (NICU). Study Duration: The duration of the study was 1 year. Material and Methods: A total of 246 preterm neonates admitted to Aga Khan University Hospital (AKUH) neonatal intensive care unit in the tenure of 1 year, fulfilling the inclusion criteria and requiring packed cell transfusion were included. After the approval from ethical review committee, charts were reviewed for gestational age, birth weight, mode of delivery (normal vaginal or Cesarean-section) were recorded. Indications of packed cell transfusion (intraventricular hemorrhage, infection or sepsis, anemia of prematurity, phlebotomy losses, increase oxygen requirement, hematological causes, other causes of hemorrhage and other causes) were observed and recorded. Pre-transfusion hemoglobin levels (g/dL) and hematocrit levels were also recorded. Other information like number and volume of transfusion and day of life on which transfusion was administered was also documented. Results: A total of 246 critically ill children were enrolled in this study. Of the total, 52.8% were baby boys and 47.2% were baby girls. 57% of babies were born via cesarean section and 43% were born via vaginal delivery. Out of total preterm newborns admitted in NICU, 22.8% were extremely preterm, 35.4% were very preterm and 41.9% were late preterm. Mean gestational age was observed to be 31 (±4) weeks and the mean birth weight of newborns was 1500 (±600) grams. Indications of packed cell transfusion observed in our study are intraventricular hemorrhage 10%, 26% sepsis/infection, 4% hematological disorders, 12.8% anemia of prematurity, 25.2% was related to increase in oxygen requirement, 13% other hematological causes and 9.3% other causes. Conclusion: An increase in oxygen requirement and anemia of prematurity were the indications that were observed in the extremely preterm and very preterm groups. Sepsis and increase oxygen requirement are some of the major causes of transfusions observed in the late preterm group. Preventable indications can be one of the areas that can be worked on and will reduce the need for transfusion in preterm babies with subsequent prevention of transfusion-associated risks.

Case Report on Feline Polycythemia Vera

Polycythemia vera has been reported as a known condition in cats as early as 1966. This condition manifests as an increased mass in red blood cells and elevated hematocrit and is defined as an idiopathic chronic myeloproliferative disorder. The patient described in this paper presented with hyperemic gums and pinna and an acute onset of progressive ataxia and lethargy. Several possible underlying primary conditions such as cardiac disease and renal malignancy were excluded by running basic blood work and radiographic imaging. Initial blood work revealed a significantly elevated packed cell volume (88%). After diagnosis, treatment with phlebotomy and chemotherapy lead to a reduction in hematocrit and elimination of neurologic signs. This case study represents the diagnosis and successful management of this disease in a private practice setting. Polycythemia vera is relatively uncommon in dogs and cats, but should still be considered in cases of neurologic disorders, especially with the presence of bright red ears, paws, or gums.

Compound Heterozygous C282Y/H63D Mutation in Hemochromatosis: A Case Report

Hereditary hemochromatosis is a condition characterized by iron overload, which is both treatable and preventable. It’s mainly related to hepcidin deficiency related to mutations in genes involved in hepcidin regulation. Iron overload increases the risk of disease such as liver cirrhosis, heart disease and diabetes. Two HFE genotypes have been commonly described in cases of iron overload, C282Y homozygosity and C282Y/H63D compound heterozygoty. The diagnosis of this rare disease now can be explored by biological and imaging tools. We report a case of compound heterozygous C282Y/H63D discovered by family screening for elevated serum ferritin.

Blood-Letting Therapy for Hypertension: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective:To evaluate the efficacy and safety of blood-letting therapy(BLT)in treatment of hypertension.Methods:A comprehensive electronic and manual bibliographic searches were performed in Cochrane Central Register of Controlled Trials,Excerpt Medica Database(EMBASE),PubMed,China National Knowledge Infrastructure,Chinese Scientific Journal Database,Chinese Biomedical Literature Database,and Wanfang Database to identify randomized controlled trials(RCTs)in which hypertensive patients were treated with BLT or BLT plus antihypertensive drugs(BPAD)against placebo,no treatment or antihypertensive drugs.The Cochrane Risk Assessment Tool was used to assess the methodological quality of trials.The Review Manager 5.3 software was used for meta-analysis.Results:A total of 7 RCTs with 637 hypertensive patients from 1989 to 2017 were identified.Compared with antihypertensive drugs,blood pressure was significantly reduced by BLT(RR=1.21,95%CI:1.01 to 1.44,P=0.03;heterogeneity:P=0.06,I^2=60%)and BPAD(RR=1.25,95%CI,1.02 to 1.53,P=0.03;heterogeneity:P=0.01,I^2=71%).Moreover,a significant improvement in Chinese medicine syndrome by BLT(RR=1.32;95%CI:1.14 to 1.53,P=0.0002;heterogeneity:P=0.53,I^2=0%)and BPAD(RR=1.47;95%CI:1.06 to 2.04,P=0.02;heterogeneity:P=0.13,I^2=56%)was identified.The reported adverse effects were well tolerated.Conclusions:Although some positive findings were identified,no definite conclusions regarding the efficacy and safety of BLT as complementary and alternative approach for treatment of hypertension could be drew due to the generally poor methodological design,significant heterogeneity,and insufficient clinical data.Further rigorously designed trials are warranted to confirm the results.

Iron metabolism in non-alcoholic fatty liver disease: A promising therapeutic target

Non-alcoholic fatty liver disease(NAFLD)has become the most common cause of chronic liver disease worldwide,and is closely associated with the increased risk of the prevalence of obesity and diabetes.NAFLD begins with the presence of>5%excessive lipid accumulation in the liver,and potentially de-velops into non-alcoholic steatohepatitis,fibrosis,cirrhosis and hepatocellular carcinoma.Therefore,insight into the pathogenesis of NAFLD is of key importance to its effective treatment.Iron is an essential element in the life of all mammalian organisms.However,the free iron deposition is positively associated with histological severity in NAFLD patients due to the production of reactive oxygen species via the Fenton reaction.Recently,several iron metabolism-targeted therapies,such as phlebotomy,iron chela-tors,nanotherapeutics.and ferroptosis,have shown their potential as a therapeutic option in the treatment of NAFLD and as a clinical strategy to intervene in the progression of NAFLD.Herein,we review the recent overall evidence on iron metabolism and provide the mechanism of hepatic iron overload-induced liver pathologies and the recent advances in iron metabolism-targeted therapeutics in the treatment of NAFLD.