Toby Richards

Background: Most studies evaluate perioperative hemoglobin at a single time point despite substantial changes across the perioperative period. We examined whether perioperative hemoglobin trajectory and perioperative hemoglobin decrease were associated with postoperative outcomes after major abdominal surgery. Methods: We performed a secondary analysis of the international POSTVenTT cohort, a prospective multicentre observational study of adults undergoing major abdominal surgery. Hemoglobin trajectory was defined according to anemia status preoperatively and at hospital discharge. Perioperative hemoglobin decrease was defined as the difference between preoperative and discharge hemoglobin concentration. Mixed‐effects logistic regression models adjusted for predefined clinical covariates and center clustering were used to evaluate associations with postoperative complications, postoperative transfusion, and 30‐day readmission. Results: Among 5302 patients, 3735 had both preoperative and discharge hemoglobin measurements and were included in trajectory analyses. Compared with patients without perioperative anemia, persistent anemia was associated with the higher odds of postoperative complications, postoperative transfusion, and 30‐day readmission, whereas new postoperative anemia showed similar but smaller associations. Greater perioperative hemoglobin decrease was associated with higher odds of postoperative complications. For each 10 g/L decrease, the odds of any postoperative complication increased by 35% (OR 1.35, 95% CI 1.26–1.45) and major complication by 49% (OR 1.49, 1.35–1.64). Associations persisted after accounting for transfusion exposure and baseline hemoglobin. Conclusions: Perioperative hemoglobin trajectory and perioperative hemoglobin decrease were associated with postoperative complications and 30‐day readmission after major abdominal surgery. Greater hemoglobin decrease remained associated with adverse outcomes after accounting for transfusion exposure and baseline hemoglobin. Trial Registration: The POSTVenTT study was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12621001517864; 8 November 2021). The trial protocol was approved by the South Metropolitan Health Service (Western Australia) Health Research Ethics Committee (EC00265), the Western Australia Research Governance System (RCG 4477), with local ethics and governance confirmed at each site before patient recruitment

Background/Objectives: Iron deficiency has been suggested as a potential mechanism for attention-deficit hyperactivity disorder (ADHD) development due to involvement in neurotransmitter synthesis and transporter expression. As iron deficiency is particularly common in women of reproductive age, often due to heavy menstrual bleeding (HMB), we aimed to explore the relationship between iron deficiency, HMB and ADHD in women. Methods: We screened women (18–49 years) at university and local sporting events in Western Australia. To screen for ADHD, section A of the Adult ADHD Self-Report Scale-V1.1 (ASRS-V1.1) and the Adult Concentration Inventory were used to assess cognitive disengagement syndrome (CDS) symptoms. Risk factors for iron deficiency, such as HMB, commonly reported symptoms and a fingerpick haemoglobin concentration (Hb) (Hemocue Hb801) were recorded. Results: Of the 405 completed questionnaires, the mean age was 24.8 ± 10.1 years, the mean Hb was 136.8 ± 12.4 g/L and 6.4% of women were anaemic. Symptoms suggestive of ADHD were reported by 174/405 (43%) women, and 128/405 (32%) women reported HMB. There was a greater prevalence of HMB reported in those experiencing symptoms suggestive of ADHD (39% vs. 26%, p = 0.01). Symptoms of fatigue, dizziness, brain fog, anxiety, heart palpitations, headaches, restless legs and depression were more common in patients with symptoms suggestive of ADHD (p ≤ 0.01) and HMB (p < 0.05). Anaemia status did not influence ADHD status (p = 0.87) nor CDS scores (15.7 ± 7.0 vs. 13.8 ± 6.1, p = 0.17). Conclusions: There is an apparent relationship between those with symptoms reported in ADHD, HMB and iron deficiency. Further exploration is required to determine whether there is a causative relationship.

Beth Maclean, Mubashshira Tahsin Ahmed, Jayne Lim, Toby Richards; The duration of iron deficiency burden, Blood Advances, , bloodadvances.2024014579, https Beth Maclean, Mubashshira Tahsin Ahmed, Jayne Lim, Toby Richards; The duration of iron deficiency burden, Blood Advances, , bloodadvances.2024014579, https

Summary: Background: Iron deficiency is present in up to 75% of patients presenting for colorectal cancer surgery. It is unclear whether iron deficiency without anaemia is associated with worse postoperative outcomes. We hypothesised that, in adults without anaemia undergoing surgery for colorectal cancer, iron deficiency would be associated with worse postoperative outcomes relative to an iron‐replete state. Methods: We performed a prospective, observational study, recruiting adults (aged ≥ 18 y) without anaemia who were undergoing surgery for colorectal cancer in 16 hospitals across Australia and Aotearoa/New Zealand. Anaemia was defined as a haemoglobin concentration < 130 g.l ^‐1 for men and < 120 g.l ^‐1 for women. Iron deficiency was defined primarily as transferrin saturation < 20%. The primary endpoint was days alive and at home on postoperative day 90. The primary endpoint analysis was adjusted for surgical risk based on recruiting institution; sex; Charlson comorbidity index; CR‐POSSUM score; surgical approach; and requirement for neoadjuvant therapy. Results: Of 420 patients, 170 were iron deficient and 250 were iron replete. The median (IQR [range]) days alive and at home in the iron‐deficient group was 84.0 (80.7–85.9 [0–88.2]) days and in the iron‐replete group was 83.1 (78.7–85.1 [0–88.9]) days. The unadjusted difference in medians between groups was 0.9 (95%CI 0–1.8, p = 0.047) days and the adjusted difference was 0.9 (95%CI 0–1.80, p = 0.042) days, favouring the iron‐deficient group. Conclusions: In adult patients without anaemia undergoing surgery for colorectal cancer, iron deficiency defined by transferrin saturation < 20% was not associated with worse patient outcomes and appeared to be associated with more days alive and at home on postoperative day 90.

Diabetic foot osteomyelitis (DFO) is a significant complication of diabetic foot disease, however diagnosis remains challenging and treatment success is difficult to ascertain. Literature in this space has utilized varying diagnostic criteria and ideal outcome measures for success is unclear. This scoping review assesses methods of diagnosis of DFO and definitions of treatment outcomes in literature assessing antibiotic therapy for treatment of DFO. There is a lack of consensus in design of diabetic foot trials, resulting in difficulty for clinicians to assess and manage serious conditions such as DFO. Cure of DFO is challenging to ascertain and treatment failure may be a better approach to assess outcomes in research assessing efficacy of antibiotic therapy. In the absence of gold standard diagnostic tools, practical approaches to outcome assessment may allow for greater clinical applicability of available data.

This updated British Society for Haematology guideline provides an up-to-date literature review and recommendations regarding the identification and management of preoperative anaemia. This includes guidance on thresholds for the diagnosis of anaemia and the diagnosis and management of iron deficiency in the preoperative context. Guidance on the appropriate use of erythropoiesis-stimulating agents and preoperative transfusion is also provided.

Summary: Background: Anaemia following major surgery may be associated with unplanned readmission to hospital. However, the severity‐response relationship between the degree of anaemia at discharge and the risk of unplanned readmission is poorly defined. We aimed to describe the severity‐response relationship between haemoglobin concentration at the time of discharge and the risk of unplanned readmission in a cohort of patients undergoing different types of major surgery. Methods: We performed a retrospective cohort study in a single tertiary health service, including all patients who underwent major surgery (orthopaedic, abdominal, cardiac or thoracic) between 1 May 2011 and 1 February 2022. The primary outcome was unplanned readmission to hospital in the 90 days following discharge after the index surgical procedure. These complex, non‐linear relationships were modelled with restricted cubic splines. Results: We identified 22,134 patients and included 14,635 in the primary analysis, of whom 1804 (12%) experienced at least one unplanned readmission. The odds of unplanned readmission rose when the discharge haemoglobin concentration was < 100 g.l ^‐1 (p < 0.001). On subgroup analysis, the haemoglobin threshold below which odds of readmission began to increase appeared to be higher in patients undergoing emergency surgery (110 g.l ^‐1 ; p < 0.001) compared with elective surgery. Declining discharge haemoglobin concentration was associated with increased odds ratios (95%CI) of unplanned readmission in patients undergoing orthopaedic (1.08 (1.01–1.15), p = 0.03), abdominal (1.13 (1.07–1.19), p < 0.001) and thoracic (1.12 (1.01–1.24), p = 0.03) procedures, but not cardiac surgery (1.09 (0.99–1.19), p = 0.07). Conclusions: Our findings suggest that a haemoglobin concentration < 100 g.l ^‐1 following elective procedures and < 110 g.l ^‐1 following emergency procedures, at the time of hospital discharge after major surgery, was associated with unplanned readmission. Future interventional trials that aim to treat postoperative anaemia and reduce unplanned readmission should include patients with discharge haemoglobin below these thresholds.