Fournier's Gangrene: clinical case review and analysis of risk factors for mortality.

BACKGROUND: Fournier's Gangrene is a severe surgical infectious disease, and various risk factors can increase its mortality rate. The purpose of this study is to retrospectively analyze the clinical characteristics and laboratory data of Fournier's Gangrene patients, followed by an analysis of mortality-related risk factors. This study has no secondary objectives. METHODS: This study included 46 hospitalized patients diagnosed with Fournier's Gangrene at Suzhou Traditional Chinese Medicine Hospital from December 2013 to March 2024. Clinical data for all patients were extracted from the electronic medical records system. The collected data included gender, age, duration of illness, length of hospital stay, sites of infection involvement, comorbidities, white blood cell count, hematocrit, albumin, blood glucose, creatinine, serum sodium, serum potassium upon admission, microbial culture results, and patient outcomes (survival/death). The Simplified Fournier Gangrene Severe Index (SFGSI) was used to score all patients. Patients were categorized into survival and death groups based on clinical outcomes. Differences between categorical variables were compared using the χ² test or Fisher's exact test. Differences between numerical variables were compared using Student's t-test or the Mann-Whitney U test. Binary logistic regression was employed to analyze the risk factors for mortality in Fournier's Gangrene. RESULTS: Among the 46 Fournier's Gangrene patients, 39 were male (84.8%) and 7 were female (15.2%). The age ranged from 17 to 86 years, with a median age of 61 years. Fourteen cases (30.4%) were confined to the perianal area, 26 cases (56.5%) had fascial necrosis involving the perianal, perineal, and genital regions, while 6 cases (13.0%) extended to the abdominal wall. At a 3-month postoperative follow-up, 43 patients (93.5%) survived, while 3 patients (6.5%) died shortly after admission due to severe illness. Based on the outcome, patients were divided into survival and death groups with 43 and 3 cases, respectively. Significant differences were observed between the two groups in terms of age (P<0.05), extension to the abdominal wall (P<0.01), hematocrit (P<0.01), albumin (P<0.01), SFGSI (P<0.01), and SFGSI>2 (P<0.01). Binary logistic regression analysis indicated that decreased hematocrit was an independent risk factor for mortality in Fournier's Gangrene patients. CONCLUSION: This study provides a detailed analysis of the clinical characteristics and risk factors for mortality in Fournier's Gangrene patients. The primary outcome of this study is that a decreased hematocrit is an independent risk factor for predicting mortality in FG patients. These findings offer valuable prognostic insights for clinicians, underscoring the importance of early identification and correction of reduced hematocrit to improve patient outcomes and survival rates.

Investigating the Impact of Cold Agglutinins on Red Blood Cell Parameters in a Trauma Patient.

Cold agglutinins are autoantibodies that can cause primary hemolytic anemia and RBC agglutination syndrome. Secondary agglutination of RBCs may be found in hypothermia, as well as in cancers, infections, and traumatic injuries. This report presents the case of a 37-year-old man who suffered multiple injuries in a motorcycle accident. On admission, the patient's laboratory tests showed a high concentration of cold agglutinins associated with low RBC count, hemoglobin, and hematocrit, and elevated mean corpuscular hemoglobin and mean corpuscular volume. Intravenous immunoglobulin treatment was effective at reversing the abnormal blood parameters to normal. Unlike acute blood loss, which typically manifests with normal hemoglobin and hematocrit levels initially due to proportional loss of plasma and red cells, the presence of cold agglutinins can lead to abnormal agglutination and sequestration of RBCs, with low hemoglobin and hematocrit. The findings of this case report highlight the importance of recognizing cold agglutinins in trauma patients to avoid misdiagnosis and misinterpretation of laboratory results.

Predictive factors of hemoglobin drop after robot-assisted radical prostatectomy: a single center prospective study.

Robotic surgery provides precise control, allowing for optimal dissection and cutting of tissues while minimizing bleeding. However, a significant drop in hemoglobin (Hb) after robot-assisted radical prostatectomy (RARP) is often recorded. The current study aimed to examine the postoperative Hb drop and its predictive factors in prostate cancer (PCa) patients who underwent RARP. From our tertiary care center's prospectively maintained database, all PCa patients who underwent RARP from January 2022 to January 2023 were identified. For each patient, baseline, anesthesiologic, and surgical characteristics, as well as blood samples before and after surgery, were collected. Multivariable linear and logistic regression models were fitted to investigate potential predictive factors of linear Hb drop or Hb drop ≥ 2 g/dl between preoperative and postoperative day (POD) one, after RARP. Overall, 110 RARP patients were enrolled. Considering the Hb, the median preoperative and POD1 values were 14.6 and 12.7 g/dl respectively (∆ = 1.9, p < 0.001); between POD2 and POD3, no statistically significant difference was recorded (12.4 vs 12.5 g/dl, ∆ = 0.1, p = 0.1). After multivariable analyses, age, BMI, prostate volume, nerve-sparing approach, anesthesia time, intraoperative fluids, intraoperative blood loss, and intraoperative diuresis did not show a statistically significant predictive value (all p > 0.05). The current prospective study showed a statistically significant Hb drop until POD1. After that, a quick stabilization of the Hb value was recorded. This reduction was not correlated with pre- and intraoperative variables. These observations might play an important role in postoperative inpatient RARP management, in both large and low-volume centers.

Preoperative Autologous Blood Donation for Rh-Negative Pregnant Women Undergoing Cesarean Sections.

Background: Cesarean sections (C-section) often require blood transfusions in cases of severe bleeding, particularly challenging in Rh-negative pregnancies due to the scarcity of Rh-negative donors, with only approximately 0.3% of the population in Thailand. Autologous blood donation, where individuals donate their own blood before surgery, offers a promising solution. Our study focused on preparing preoperative autologous blood donations (PAD) for Rh-negative pregnancies. Methods: We conducted blood screening on 7,182 pregnancies at Takuapa Hospital from October 2013 to September 2018, identifying 21 Rh-negative pregnant women. We established criteria based on hemoglobin (Hb) levels, which are crucial for autologous blood preparation (Hb at 11.0 g/dL, and hematocrit (Hct) above 33%). Blood samples were collected twice during pregnancy, at 36 and 37 weeks, with the second collection 1 week before the C-section. Pregnancies testing positive for infectious markers were excluded following standard blood donation guidelines. Twelve pregnant women testing negative for infectious markers were enrolled. Results: The demographic data showed 12 subjects aged 17 to 41 years, with an average of 27.83. Initial blood tests indicated Hb and Hct levels of 12.5 g/dL, and 36.4%, slightly decreasing to 12.2 g/dL and 35.8% in the second collection. On the day of the cesarean, levels further declined to 11.6 g/dL and 34.4%, respectively, within normal ranges. At discharge, the Hct measured 34.8%. Maternal and infant health post-C-section were good, with baby weights ranging from 2,640 to 4,080 g. None of the 12 cases required autologous blood transfusion, validating the safety of standard autologous blood preparation practices. Conclusions: This study highlights the safety of autologous blood donation for pregnant women with rare blood types, which was achieved through effective planning and collaboration among hospital departments. These findings can serve as a model for other hospitals and significantly reduce the burden of searching for Rh-negative donors.

Preoperative anemia is a risk factor for worse 30-day outcomes in both open and endovascular repair of non-ruptured infrarenal abdominal aortic aneurysm.

BACKGROUND: Anemia is a highly prevalent condition potentially linked to chronic inflammation. Preoperative anemia is an independent risk factor across many surgical fields. However, the relationship between anemia and abdominal aortic aneurysm (AAA) repair outcomes remains unclear. This study aimed to examine the effects of preoperative anemia on 30-day outcomes of non-ruptured infrarenal AAA repair. METHODS: Patients who underwent open surgical repair (OSR) and endovascular aneurysm repair (EVAR) for infrarenal AAA were identified in National Surgical Quality Improvement Program (NSQIP) targeted databases from 2012 to 2021. Anemia was defined as preoperative hematocrit less than 39% in males and 36% in females. Multivariable logistic regression was used to compare 30-day perioperative outcomes between anemic and non-anemic patients, adjusting for demographics, comorbidities, indications, aneurysm extents, operation time, and surgical approaches. RESULTS: There were 408 (22.13%) anemic and 1436 (77.88%) non-anemic patients who underwent OSR for non-ruptured AAA, while 3586 (25.20%) patients with and 10,644 (74.80%) without anemia underwent EVAR. In both OSR and EVAR, anemic patients had higher risks of bleeding requiring transfusion (OSR, aOR = 2.446, p < .01; EVAR, aOR = 3.691, p < .01), discharge not to home (OSR, aOR = 1.385, p = .04; EVAR, aOR = 1.27, p < .01), and 30-day readmission (OSR, aOR = 1.99, p < .01; EVAR, aOR = 1.367, p < .01). Also, anemic patients undergoing OSR had higher pulmonary events (aOR = 2.192, p < .01), sepsis (aOR = 2.352, p < .01), and venous thromboembolism (aOR = 2.913, p = .01), while in EVAR, anemic patients had higher mortality (aOR = 1.646, p = .01), cardiac complications (aOR = 1.39, p = .04), renal dysfunction (aOR = 1.658, p = .02), and unplanned reoperation (aOR = 1.322, p = .01). Moreover, in both OSR and EVAR, anemic patients had longer hospital length of stay (p < .01). CONCLUSION: In OSR and EVAR, preoperative anemia was independently associated with worse 30-day outcomes. Preoperative anemia could be a useful marker for risk stratification for patients undergoing infrarenal AAA repair.

Polycythemia Vera Presenting As Acute Non-hemorrhagic Infarction and Chronic Bleed: Deception Between the Lines.

Patients with polycythemia vera (PV) develop various complications due to hyper-viscous blood, causing events such as ischemic stroke. There are other associated complications due to the dysfunction of platelet activity, causing hemorrhages. In our unusual case, we present a patient who came to the OPD complaining of slurring speech. An MRI was done and was suggestive of acute lacunar infarcts with changes in chronic bleed. CBC and hematocrit were consistent for PV, with the genetic marker JAK2 being positive.

Effect of testosterone formulations on hematocrit in transgender individuals: A systematic review.

BACKGROUND: Approximately, 11% of trans men experience erythrocytosis diagnosis due to testosterone administration during the first year of the gender-affirming hormone treatment (GAHT). OBJECTIVES: To identify and compare the effect of different testosterone formulations on hematocrit (Hct) and diagnose erythrocytosis in trans men. MATERIALS AND METHODS: This systematic review was based on PRISMA guidelines. We performed an electronic search of PubMed, Embase, and Web of Science in January 2024. The Newcastle-Ottawa scale was used to evaluate the quality of evidence in the observational studies. RESULTS: Of the 152 records retrieved, 18 met the eligibility criteria. Studies observed an increase of up to 5% in Hct in trans men using injectable testosterone undecanoate (TU), and up to 6.9% in trans men using intermediate injectable testosterone esters (TE). Trans men using TE experience a larger increase in serum Hct levels compared to those receiving TU. Erythrocytosis prevalence varies according to the cutoff used (50%, 52%, and 54%). Erythrocytosis was also associated with tobacco use, age at initiation of hormone therapy, body mass index (BMI), and pulmonary conditions. Studies that evaluated the effect of testosterone formulation on erythrocytosis diagnosis present conflicting result. Trans men have a hazard ratio of 7.4 (95% CI: 4.1, 13.4) of developing erythrocytosis compared to cisgender men, using a 52% hematocrit cutoff. CONCLUSION: All testosterone formulations result in an increase in Hct, irrespective of dose, formulation, and administration method. Smoking, higher age at initiation of the testosterone therapy, higher BMI, and a predisposing medical history are associated with this increase in Hct. The difference in effect of TE and TU on Hct is conflicting, although it is important to point out that these data come from observational studies, retrospective, and with a small-sample size.

Contemporary Challenges in Polycythemia Vera Management From the Perspective of Patients and Physicians.

Although polycythemia vera (PV) is a chronic and incurable disease, effective management can allow most patients to maintain functional lives with near-normal life expectancy. However, there remain several inter-related factors that contribute to many ongoing challenges associated with the management of PV, which this review aims to explore. First, as a disease hallmarked by constitutive activation of the JAK/STAT pathway, PV is often accompanied by inflammatory symptoms that negatively impact quality of life. Next, patients often require recurrent therapeutic phlebotomies to maintain their hematocrit below the 45% threshold that has been associated with a decreased risk of thrombotic events. The need to closely monitor hematocrit and perform conditional therapeutic phlebotomies ties patients to the healthcare system, thereby limiting their autonomy. Furthermore, many patients describe therapeutic phlebotomies as burdensome and the procedure is often poorly tolerated, further contributing to quality-of-life decline. Phlebotomy needs can be reduced by utilizing cytoreductive therapy; however, standard first-line cytoreductive options (i.e., hydroxyurea and interferon) have not been shown to significantly improve symptom burden. Collectively, current PV management, while reducing thrombotic risk, often has a negative impact on patient quality of life. As researchers continue to advance towards the goal of developing a disease-modifying therapy for patients with PV, pursuit of nearer-term opportunities to shift the current treatment paradigm towards improving symptoms without compromising quality of life is also warranted, for example, by reducing or eliminating the frequent use of phlebotomy.

Association of iron supplementation, HFE and AMPD1 polymorphisms and biochemical iron metabolism parameters in the performance of a men's World Tour cycling team: A pilot study.

BACKGROUND: Nutritional strategies with iron supplementation have been shown to be effective in preventing the decline of blood biochemical parameters and sports performance. The aim of the study was to describe biochemical iron metabolism parameters in association with iron supplementation and HFE and AMPD1 polymorphisms in a Union Cycliste Internationale (UCI) World Tour cycling team to evaluate performance during a whole season METHODS: Twenty-eight professional men cyclists took part in this longitudinal observational pilot study. AMPD1 c.34 C>T (rs17602729) and HFE c.187 C>G (rs1799945) polymorphisms were genotyped using Single Nucleotide Primer Extension (SNPE). All the professional cyclists took oral iron supplementation throughout the season. Four complete blood analyses were carried out corresponding to UCI controls in January (1st), April (2nd), June (3rd) and October (4th). Data on participation in three-week Grand Tours, kms of competition and wins were analyzed. RESULTS: In performance, especially in wins, there was a significant effect in HFE on biochemical hemoglobin (F = 4.255; p = 0.021) and biochemical hematocrit (F = 5.335; p = 0.009) and a hematocrit biochemical × genotype interaction (F = 3.418; p = 0.041), with higher values in professional cyclist with GC genotype. In AMPD1 there were significant effects in the biochemical iron x genotype interaction in three-week Grand Tours (F = 3.874; p = 0.029) and wins (F = 3.930; p = 0.028) CONCLUSIONS: Blood biochemical iron metabolism parameters could be related to performance in the season due to increasing hemoglobin and hematocrit concentration under iron supplementation, associated with winning in the professional cyclists with GC genotype of the HFE polymorphism.

Efficacy of essential oil from ginger (Zingiber officinale) for anesthesia and transport sedation of pacu (Piaractus mesopotamicus).

This study evaluated the anesthetic and sedative effects of the essential oil of Zingiber officinale (EOZO) on juvenile pacu (Piaractus mesopotamicus). Experiment 1 evaluated concentrations of 0, 50, 100, 200 and 400 mg L-1 EOZO for times of induction and recovery from anesthesia. Furthermore, hematological responses and residual components of EOZO in plasma were determined immediately after anesthesia. Experiment 2 evaluated the effect of 0, 10, 20 and 30 mg L-1 EOZO on water quality, blood variables and residual components of EOZO in plasma and tissues (muscle and liver) immediately after 2 h of transport. Survival was 100%. The three main compounds of EOZO [zingiberene (32.27%), ß-sesquiphellandrene (18.42%) and ß-bisabolene (13.93%)] were observed in animal plasma and tissues (muscle and liver) after anesthesia and transport, demonstrating a direct linear effect among the evaluated concentrations. The concentration of 200 mg L-1 EOZO promoted surgical anesthesia of pacu and prevented an increase in monocyte and neutrophil levels, yet did not alter other hematological parameters. The use of 30 mg L-1 EOZO has a sedative effect on juvenile pacu, thereby reducing oxygen consumption during transport. Furthermore, the use of 30 mg L-1 EOZO in transport water prevented an increase in hemoglobin and hematocrit, with minimal influences on other blood variables.

Hematocrit control and thrombotic risk in patients with polycythemia vera treated with ruxolitinib in clinical practice.

Polycythemia vera (PV) is a myeloproliferative neoplasm characterized by unregulated red blood cell production resulting in elevated hemoglobin and/or hematocrit levels. Patients often have symptoms such as fatigue, pruritus, and painful splenomegaly, but are also at risk of thrombosis, both venous and arterial. Ruxolitinib, a selective Janus kinase inhibitor, is approved by the US Food and Drug Administration as second-line cytoreductive treatment after intolerance or inadequate response to hydroxyurea. Although ruxolitinib has been widely used in this setting, limited data exist in the literature on ruxolitinib treatment patterns and outcomes among patients with PV in routine clinical practice. We report a retrospective, observational, cohort study of patients treated for PV with ruxolitinib across three US centers (academic and regional practice) from December 2014-December 2019. The study included 69 patients, with a median follow-up duration of 3.7 years (95% CI, 2.9-4.4). Our data demonstrate very high rates of hematocrit control (88% of patients by three months and 89% by six months); few patients required dose adjustments or suspension. No arterial thromboses were observed; however, the follow-up duration does not allow for the generation of meaningful conclusions from this. Three patients had thrombotic events; one was in the setting of a second malignancy, one post-operative, and a third related to prolonged immobility. We also found that 28% of patients initiated ruxolitinib as a result of poorly controlled platelet counts, second only to hydroxyurea intolerance (46%) as a reason to start therapy. In clinical practice, ruxolitinib continues to be effective in controlling hematocrit levels after three and six months of treatment in patients and is associated with low thrombotic risk.

Predictors of Progression in a Series of 81 Adult Patients Surgically Managed for an Intracranial Hemangioblastoma: Implications for the Postoperative Follow-Up.

The aim was to identify predictors of progression in a series of patients managed for an intracranial hemangioblastoma, in order to guide the postoperative follow-up modalities. The characteristics of 81 patients managed for an intracranial hemangioblastoma between January 2000 and October 2022 were retrospectively analyzed. The mean age at diagnosis was of 48 ± 16 years. Eleven (14%) patients had von Hippel-Lindau disease. The most frequent tumor location was the cerebellar hemispheres (n = 51, 65%) and 11 (14%) patients had multicentric hemangioblastomas. A gross total resection was achieved in 75 (93%) patients. Eighteen (22%) patients had a local progression, with a median progression-free survival of 56 months 95% CI [1;240]. Eleven (14%) patients had a distant progression (new hemangioblastoma and/or growth of an already known hemangioblastoma). Local progression was more frequent in younger patients (39 ± 14 years vs. 51 ± 16 years; p = 0.005), and those with von Hippel-Lindau disease (n = 8, 44% vs. n = 3, 5%, p < 0.0001), multiple cerebral locations (n = 3, 17% vs. n = 2, 3%, p = 0.02), and partial tumoral resection (n = 4, 18% vs. n = 1, 2%, p = 0.0006). Therefore, it is advisable to propose a postoperative follow-up for at least 10 years, and longer if at least one predictor of progression is present.

Increased risk of erythrocytosis in men with type 2 diabetes treated with combined sodium-glucose cotransporter-2 inhibitor and testosterone replacement therapy.

PURPOSE: In clinical trials, sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and testosterone replacement therapy (TRT) were shown to stimulate red blood cell production. Little is known if combination therapy poses risk of erythrocytosis in real world clinical practice. METHODS: This was a retrospective nationwide cohort study of US Veterans with type 2 diabetes (T2D) and baseline hematocrit between 38 and 50% who were prescribed SGLT-2i and/or TRT between 3/2013 and 10/2022 and had adequate adherence based on the proportion of days covered > 80%. Patients were divided into 3 groups: SGLT-2i only, TRT only, or combination therapy. Odds Ratio (OR) of new erythrocytosis defined as hematocrit level > 54% within 365 days of therapy initiation was calculated by logistic regression model adjusted for baseline hematocrit, age, BMI, obstructive sleep apnea, diuretic use, and smoking status. RESULTS: Of the entire cohort of 53,971 people with T2D, total of 756 (1.4%) patients developed erythrocytosis. In unadjusted analyses, the OR of new onset erythrocytosis was higher in the combined SGLT-2i and TRT group compared with the SGLT-2i or TRT group alone (4.99, 95% CI (3.10-7.71) and 2.91, 95% CI (1.87-4.31), respectively). In the models adjusted for baseline characteristics, patients on combination therapy had significantly higher odds of erythrocytosis compared to those on SGLT-2i (OR 3.80, 95% CI (2.27-6.11)) or TRT alone (OR 2.49, 95% CI (1.51-3.59)). Testosterone delivery route (topical vs injectable) did not modify increased odds of erythrocytosis. CONCLUSIONS: For the first time, we demonstrated that in large cohort of patients combined therapy with SGLT-2i and TRT is associated with increased erythrocytosis risk compared with either treatment alone. Given rising prevalence of SGLT-2i use, providers should consider periodic hematocrit assessment in persons receiving both SGLT-2i and TRT.

A Comparison of the Clinical Outcomes of Minimum and Maximum Hematocrit Levels During Cardiopulmonary Bypass (CPB) in Low-risk Patients Undergoing Coronary Artery Bypass Graft Surgery (CABG): A Cross-sectional Study.

Background: This study investigated the clinical outcomes at the minimum and maximum levels of hematocrit (HCT) during cardiopulmonary bypass (CPB) in low-risk patients undergoing coronary artery bypass graft (CABG) surgery. Materials and Methods: In this cross-sectional study, 85 patients who underwent CABG with an ejection fraction of greater than 35% were selected. Based on the HCT range during CPB, patients were divided into two groups: minimum HCT: HCT = 16-18% and maximum HCT: HCT = 25-27%. Then the operation outcomes, amount of drainage, and transfusion were recorded and compared between these groups. Results: In the middle tube 8 h after surgery and left tube 24 h after surgery, the amount of drainage in the minimum HCT group with mean of 71.00 ± 130.9 and 60.65 ± 71.23, respectively, was significantly lower than the maximum HCT group with mean of 101.5 ± 246.50 and 123.76 ± 93.17, respectively (P value < 0.05). The incidence of cognitive disorders in the maximum HCT group was significantly higher than in the minimum HCT group (11.1% vs. 0%, P value = 0.041). Also, the mean transfusion of packed red blood cell (PRBC) and fresh frozen plasm (FFP) during CPB in the maximum HCT group, with mean of 346.7 ± 86.22 and 396.1 ± 21.05, respectively, were significantly higher than the minimum HCT group with mean of 178.8 ± 80.91 and 136.8 ± 46.77, respectively (P value < 0.05). After CPB, there was no significant difference in transfusion products (P value > 0.05). Conclusion: According to the results of this study, patients undergoing CABG surgery with maximum HCT level versus minimum HCT level during CPB, need more packed cells and fresh frozen plasma products transfusion, which will be associated with the complication of cognitive impairment.

Impacts of temperature and turbidity on the gill physiology of darter species.

Fish gills are complex organs that have direct contact with the environment and perform numerous functions including gas exchange and ion regulation. Determining if gill morphometry can change under different environmental conditions to maintain and/or improve gas exchange and ion regulation is important for understanding if gill plasticity can improve survival with increasing environmental change. We assessed gill morphology (gas exchange and ion regulation metrics), hematocrit and gill Na+/K+ ATPase activity of wild-captured blackside darter (Percina maculata), greenside darter (Etheostoma blennioides), and johnny darter (Etheostoma nigrum) at two temperatures (10 and 25 °C) and turbidity levels (8 and 94 NTU). Samples were collected August and October 2020 in the Grand River to assess temperature differences, and August 2020 in the Thames River to assess turbidity differences. Significant effects of temperature and/or turbidity only impacted ionocyte number, lamellae width, and hematocrit. An increase in temperature decreased ionocyte number while an increase in turbidity increased lamellae width. Hematocrit had a species-specific response for both temperature and turbidity. Findings suggest that the three darter species have limited plasticity in gill morphology, with no observed compensatory changes in hematocrit or Na+/K+ ATPase activity to maintain homeostasis under the different environmental conditions.

The effect of polycythemia vera on choroidal thickness and retrobulbar blood flow.

BACKGROUND: To evaluate the choroidal thickness and retrobulbar hemodynamic parameters in polycythemia vera (PV) patients in comparison with healthy individuals, and to investigate the relationship of these values with blood hematocrit levels. METHODS: This prospective study included the 35 eyes of 35 PV patients and the 30 eyes of 30 healthy individuals. Choroidal thickness was measured at the subfoveal area and at 500 µm intervals nasal and temporal to the fovea up to a distance of 1500 µm. Color Doppler ultrasonography (CDU) was used to evaluate the retrobulbar vessels. Complete blood count values were recorded. RESULTS: Choroidal thickness was found to be significantly lower in the PV group than in the control group at the subfoveal, nasal 500, and temporal 500 and 1000 µm measurement points (p = 0.01, p = 0.011, p = 0.04, p = 0.045, respectively). The central retinal artery (CRA) peak systolic velocity (PSV) and end diastolic velocity (EDV) values and the ophthalmic artery (OA) PSV value were significantly lower in the PV group than in the control group (p < 0.001, p < 0.001, p = 0.019, respectively). No significant difference was present between the groups in terms of CRA and OA resistive index (RI) and pulsatile index (PI) values (p = 0.388, p = 0.564, p = 0.897, p = 0.693, respectively). A negative correlation was found between the blood hematocrit levels and the subfoveal, nasal 500 µm, and temporal 500 µm choroidal thickness measurements and the CRA PSV and EDV and the OA PSV values. CONCLUSIONS: PV may cause microvascular changes and lead to ocular vascular complications by affecting the choroidal and retrobulbar blood flow.

Prediction of hematocrit decline and the impact of peri-operative fluid use in lumbar spinal fusion surgery.

PURPOSE: Peri-operative blood loss unaccounted for and post-operative hematocrit decline could have a significant impact on the outcome of elective spinal surgery patients. The study assesses the accuracy of predictive models of hematocrit decline and blood loss in spinal surgery and determines the impact of peri-operative fluid administration on hematocrit levels of patients undergoing first-time single level lumbar fusion surgery for degenerative spine disease and the trend thereof in the first 24 h post-operatively. METHODS: Clinical and biochemical parameters were prospectively collected in patients undergoing single level lumbar spinal surgery. Predictive models were applied to assess their accuracy in intra-operative blood loss and post-operative hematocrit decline. RESULTS: High correlation (0.98 Pearson correlation coefficient) occurred between calculated (predicted) and recorded hematocrit from hours 2 to 6 post-operatively. Predictive accuracy declined thereafter yet remained moderate. Patients received an average intra-operative fluid volume of 545.45 ml per hour (47% of estimated total blood volume). A significant hematocrit decline occurred post-induction (43.47-39.78%, p < 0.001) with total fluid volume received being the significant contributing variable (p < 0.001). Hypertensive patients were the only subgroup to drop below the safe hematocrit threshold of 30%. CONCLUSION: Iatrogenic hemodilution can accurately be predicted for the first six hours post-operatively, with high risk patients identifiable. Fluid therapy should be goal directed rather than generic, and good communication between the surgeon and anesthesiologist remains the cornerstone to manage physiological changes secondary to blood loss. Although helpful, predictive formulas are not universally applicable to all phenotypes.

Evaluation of Blood Loss in Third-Generation Internal Ultrasound-Assisted Liposuction.

BACKGROUND: In large-volume liposuction procedures, one of the most important limitations of total lipoaspirate volume is blood loss. In this study, we aimed to determine the amount of blood loss in individuals who underwent a third-generation internal ultrasound-assisted liposuction (UAL). METHODS: Eleven female and eleven male participants with a mean age of 35.31 (range 20-47) were included in this prospective study. The third-generation internal UAL was performed on multiple anatomical regions using the VASER® Internal Ultrasound Device (Sound Surgical Technologies; Louisville, CO). The demographic characteristics of the participants, the amount of aspirate collected, and hemoglobin (Hgb) and hematocrit (Htc) values before and after the third-generation internal UAL were evaluated. RESULTS: The mean third-generation internal UAL time was 74.81 ± 17.95 minutes, and the mean aspiration amount was 5,122.27 ± 1,597.43 ml. The aspirated amount was 6.64% ± 2.20 of body weight. The mean Hgb value was 13.87 ± 1.99 before the third-generation internal UAL and 11.26 ± 2.16 (g/dL) after the third-generation internal UAL (z = 4.108, p < 0.001). The mean reduction in Hgb levels with the third-generation internal UAL was 2.61 ± 1.73 and 0.53 ± 0.36 per liter of aspirate taken. The mean Htc value after the third-generation internal UAL was 33.91 ± 6.03 and was significantly lower than the mean Htc value before the third-generation internal UAL, 41.39 ± 5.13 (z = -3.946, p < 0.001). The mean reduction in Htc with the third-generation internal UAL was 7.48 ± 5.42, and the Htc value decreased by 1.50 ± 1.13 per liter of aspirate ingested. The amount of aspirated supernatant was responsible for 44.4% of the change in Hgb and 30.9% of the change in Htc after the third-generation internal UAL. CONCLUSION: Knowing the reduction rates in Hgb and Htc with the third-generation internal UAL is useful to plan the amount of aspirate to be taken, the amount of blood loss that may occur with the third-generation internal UAL, and the postoperative care of the patients. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Ruxolitinib in patients with polycythemia vera resistant and/or intolerant to hydroxyurea: European observational study.

BACKGROUND: Hydroxyurea (HU) is a commonly used first-line treatment in patients with polycythemia vera (PV). However, approximately 15%-24% of PV patients report intolerance and resistance to HU. METHODS: This phase IV, European, real-world, observational study assessed the efficacy and safety of ruxolitinib in PV patients who were resistant and/or intolerant to HU, with a 24-month follow-up. The primary objective was to describe the profile and disease burden of PV patients. RESULTS: In the 350 enrolled patients, 70% were >60 years old. Most patients (59.4%) had received ≥1 phlebotomy in the 12 months prior to the first dose of ruxolitinib. Overall, 68.2% of patients achieved hematocrit control with 92.3% patients having hematocrit <45% and 35.4% achieved hematologic remission at month 24. 85.1% of patients had no phlebotomies during the study. Treatment-related adverse events were reported in 54.3% of patients and the most common event was anemia (22.6%). Of the 10 reported deaths, two were suspected to be study drug-related. CONCLUSION: This study demonstrates that ruxolitinib treatment in PV maintains durable hematocrit control with a decrease in the number of phlebotomies in the majority of patients and was generally well tolerated.

Masked anemia and hematocrit elevation under sodium glucose transporter inhibitors: findings from a large real-world study.

AIMS: Sodium glucose transporter inhibitors (SGLT2i) therapy is associated with an increase in hematocrit as a class effect. There is a lack of information regarding the clinical magnitude and significance of hematocrit elevation, especially cardiovascular outcomes in patients with polycythemia and possible masking of lower hemoglobin levels as a sign of potential severe disease. METHODS: A retrospective study utilizing large community healthcare provider electronic database. Hematocrit levels and variables with potential effect on hematocrit change were compared before and during SGLT2i treatment in adults with type 2 diabetes mellitus. RESULTS: Study population included 9646 patients treated with Dapagliflozin or Empagliflozin between 01.2015 and 06.2019. Hematocrit levels were significantly higher after treatment initiation (2.1%), with higher median elevation among male vs female (2.3% vs. 1.8%). Anemia prevalence was significantly lower under treatment (20% vs. 31.6%). In multivariable model, gender, smoking status, SGLT2i type, pretreatment hematocrit, diabetes duration, body mass index and estimated glomerular filtration rate change significantly effected hematocrit change. CONCLUSIONS: In the current study SGLT2i treatment was associated with significant hematocrit elevation, polycythemia and lower anemia prevalence. Further studies are needed to determine the clinical significance and approach to patients with pretreatment or on treatment polycythemia and the approach to patients with lower-normal hemoglobin levels under SGLT2i treatment.