Sex differences in fatigue and symptoms of anemia in relation to hemoglobin level in hospitalized patients

The hemoglobin threshold for transfusion of red cells in patients with acute gastrointestinal bleeding is controversial. We compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy. We enrolled 921 patients with severe acute upper gastrointestinal bleeding and randomly assigned 461 of them to a restrictive strategy (transfusion when the hemoglobin level fell below 7 g per deciliter) and 460 to a liberal strategy (transfusion when the hemoglobin fell below 9 g per deciliter). Randomization was stratified according to the presence or absence of liver cirrhosis. A total of 225 patients assigned to the restrictive strategy (51%), as compared with 61 assigned to the liberal strategy (14%), did not receive transfusions (P<0.001) [corrected].The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group (P=0.01), and adverse events occurred in 40% as compared with 48% (P=0.02). The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (hazard ratio, 0.70; 95% CI, 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child-Pugh class A or B disease (hazard ratio, 0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child-Pugh class C disease (hazard ratio, 1.04; 95% CI, 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy (P=0.03) but not in those assigned to the restrictive strategy. As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding. (Funded by Fundació Investigació Sant Pau; ClinicalTrials.gov number, NCT00414713.).

The diagnosis of anemia is an important aspect of the practice of hematology. The first step is to decide whether the patient is, in fact, anemic. Unless earlier blood counts are available, and they often are not, the physician must make his or her decision on the basis of the population distribution of hemoglobin values. How likely is it that the patient's hemoglobin value lies below the normal distribution; that is, "the lower limit"?

Anemia is common in cancer and has been associated with fatigue and reduced health-related quality of life (HRQOL). We report the association between hemoglobin and fatigue and the impact of reducing fatigue on several domains of HRQOL. These analyses were based on five randomized trials. Patients completed the Functional Assessment of Cancer Therapy (FACT) Anemia scales and numeric rating scales of Energy, Activity and Overall Health at baseline and after the 12-week treatment period. t-tests and linear regression models were used to evaluate associations. Analyses were stratified into three groups: solid tumor chemotherapy patients, lymphoproliferative malignancy chemotherapy patients and non-chemotherapy patients. Adjusted mean differences (95% CI) in FACT Fatigue change scores between hemoglobin responders (> or =2 g/dl increase) and non-responders were 3.0 (1.2, 4.7), 2.8 (0.6, 5.0) and 5.8 (2.2, 9.5) among the solid tumor, lymphoproliferative malignancy and non-chemotherapy groups, respectively. Significantly greater improvements (P or =3 points). After controlling for other factors, patients whose fatigue improved reported substantially greater improvements in energy, ability to perform usual activities and overall health (P <0.0001). Across five trials of cancer patients on and off chemotherapy, hemoglobin response was associated with meaningful improvements in fatigue, which, in turn, was associated with improved physical, functional, emotional and overall well-being.