A prospective randomized, controlled trial of intravenous versus oral iron for moderate iron deficiency anaemia of pregnancy

BACKGROUND

Iron deficiency anaemia is the most common deficiency disorder in the world, affecting more than one billion people, with pregnant women at particular risk.

OBJECTIVES AND DESIGN

We conducted a single site, prospective, nonblinded randomized-controlled trial to compare the efficacy, safety, tolerability and compliance of standard oral daily iron versus intravenous iron.

SUBJECTS

We prospectively screened 2654 pregnant women between March 2007 and January 2009 with a full blood count and iron studies, of which 461 (18%) had moderate IDA. Two hundred women matched for haemoglobin concentration and serum ferritin level were recruited.

INTERVENTIONS

Patients were randomized to daily oral ferrous sulphate 250 mg (elemental iron 80 mg) with or without a single intravenous iron polymaltose infusion.

RESULTS

Prior to delivery, the intravenous plus oral iron arm was superior to the oral iron only arm as measured by the increase in haemoglobin level (mean of 19.5 g/L vs. 12 g/L; P < 0.001); the increase in mean serum ferritin level (222 microg/L vs. 18 ug/L; P < 0.001); and the percentage of mothers with ferritin levels below 30 microg/L (4.5% vs. 79%; P < 0.001). A single dose of intravenous iron polymaltose was well tolerated without significant side effects.

CONCLUSIONS

Our data indicate that intravenous iron polymaltose is safe and leads to improved efficacy and iron stores compared to oral iron alone in pregnancy-related IDA.

Hypotensive resuscitation

Hypotensive resuscitation in the trauma setting can be defined as deliberately allowing blood pressure to remain below normal until any active bleeding has been controlled. The dangers of aggressive fluid resuscitation in trauma were recognised as long ago as the First World War, in the intervening time, aggressive fluid resuscitation has become a mainstay of trauma management. More recently this trend of aggressive fluid resuscitation for trauma management seems to be reversing. Aggressive fluid resuscitation in trauma is based on animal studies from the 1950s and 1960s. These studies used models of controlled haemorrhage rather than uncontrolled haemorrhage. More recent studies using models of uncontrolled haemorrhage suggest an improved outcome with hypotensive resuscitation. Should there be a potential for uncontrolled haemorrhage a permissive hypotensive resuscitation strategy should be pursued until the haemorrhage has been controlled, but in certain types of trauma including blunt trauma and brain trauma the data is unclear as to the best fluid resuscitation strategy.

High output cardiac failure in a parturient with hereditary haemorrhagic telangiectasia

Hereditary haemorrhagic telangiectasia is a genetic condition which results in arteriovenous malformations involving the skin, mucous membranes, lung, brain, gastrointestinal tract, liver and spinal canal. The shunting of blood through arteriovenous malformations, especially in the liver,; leads to maldistribution of cardiac output. In order to supply blood to vital organs, cardiac output is increased through vasodilation, elevated stroke volume and elevated heart rate. Pregnancy can worsen the effects of the arteriovenous malformations. We present the peripartum management of a woman with hereditary haemorrhagic telangiectasia predominantly involving the liver that resulted in high output cardiac failure during two consecutive pregnancies.

Pandemic (H1N1) 2009 influenza

The clinical picture in severe cases of pandemic (H1N1) 2009 influenza is markedly different from the disease pattern seen during epidemics of seasonal influenza, in that many of those affected were previously healthy young people. Current predictions estimate that, during a pandemic wave, 12-30% of the population will develop clinical influenza (compared with 5-15% for seasonal influenza) with 4% of those patients requiring hospital admissions and one in five requiring critical care. This review covers the background, clinical presentation, diagnosis, and treatment. The role of immunization and antiviral drugs is discussed. Experience from the first wave of pandemic (H1N1) 2009 influenza suggests that a number of infected patients become critically ill and require intensive care admission. These patients rapidly develop severe progressive respiratory failure which is often associated with failure of other organs, or marked worsening of underlying airways disease. The critical care management of these patients and the implications for resources is reviewed. Guidance from a range of bodies has been produced in a relatively short period of time in response to pandemic (H1N1) 2009 influenza. Disease severity has the potential to change, especially if there is virus mutation. Clinicians must be prepared for the unexpected and continue to share their experiences to maximize patient outcomes.

Reducing the risk: the use of placebo respiratory equipment in clinical practice

Placebo respiratory devices, such as inhalers, large volume spacers and peak flow meters provide reli able methods of teaching patients effective drug able methods of teaching patients effective drug delivery techniques and monitoring compliance and treatment progress. Concern has been raised that using such demonstration devices on more than one person may expose patients to the risk of cross-infection with pathogenic organisms. The lack of regulation and guidance on the use and decontamination of placebo devices prompted us to complete a risk assessment, examining the likelihood and consequence of acquisition of pathogens and resultant illness in our respiratory patient group.

Biomimetic polymers in pharmaceutical and biomedical sciences

This review describes recent developments in the emerging field of biomimetic polymeric biomaterials, which signal to cells via biologically active entities. The described biological effects are, in contrast to many other known interactions, receptor mediated and therefore very specific for certain cell types. As an introduction into this field, first some biological principles are illustrated such as cell attachment, cytokine signaling and endocytosis, which are some of the mechanisms used to control cells with biomimetic polymers. The next topics are then the basic design rules for the creation of biomimetic materials. Here, the major emphasis is on polymers that are assembled in separate building blocks, meaning that the biologically active entity is attached to the polymer in a separate chemical reaction. In that respect, first individual chemical standard reactions that may be used for this step are briefly reviewed. In the following chapter, the emphasis is on polymer types that have been used for the development of several biomimetic materials. There is, thereby, a delineation made between materials that are processed to devices exceeding cellular dimensions and materials predominantly used for the assembly of nanostructures. Finally, we give a few current examples for applications in which biomimetic polymers have been applied to achieve a better biomaterial performance.

Sources of support for older people after discharge from hospital: 10 years on

AIMS OF THE STUDY

The aim of this research was to find out who supports older people at home after discharge from hospital and if sources of support have changed between the 1980s and the 1990s.

BACKGROUND

More and more older people are being discharged from hospital earlier and this creates additional pressures on families, community health and social services and the independent care sector. The research was concerned with how sources of support may have changed in a 10-year period.

METHODS

A comparison is made of two separate nonrandom samples, taken 10 years apart, of older people following discharge from hospital. Interviews were conducted in participants' homes to establish levels of dependence and the source of support given in response to the need for help with personal and domestic activities of daily living.

RESULTS

Although limited by the use of relatively small, nonrandom samples, the research found that proportions needing help with domestic activities were higher than those needing help with personal activities of daily living. Although dependence for help with bathing had declined between the 1980s and 1990s, help was still needed with bathing and dressing. Unmet need for help with bathing remained a problem in the 1990s. A growing role for home helps was identified, especially in personal care (bathing and dressing), where support from district nurses had declined. By the 1990s, home helps were doing less cooking and housework, including heavy laundry. Relatives were doing more of most domestic activities except shopping, which was being carried out by home helps.

CONCLUSIONS

The paper concludes by arguing that hospitals should consider if pressures to discharge older people more quickly might hinder the discharge planning process and communication between hospital and community sectors.

A recessive variant of the Romano-Ward long-QT syndrome?

BACKGROUND

The congenital long-QT syndrome (LQTS) is a genetically heterogeneous disease characterized by prolonged ventricular repolarization and life-threatening arrhythmias. Mutations of the KVLQT1 gene, a cardiac potassium channel, generate two allelic diseases: the Romano-Ward syndrome, inherited as a dominant trait, and the Jervell and Lange-Nielsen syndrome, inherited as an autosomal recessive trait.

METHODS AND RESULTS

A consanguineous family with the clinical phenotype of LQTS was screened for mutations in the KVLQT1 gene. Complementary RNAs for injection into Xenopus oocytes were prepared, and currents were recorded with the double microelectrode technique. A homozygous missense mutation, leading to an alanine-to-threonine substitution at the beginning of the pore domain of the KVLQT1 channel, was found in the proband, a 9-year-old boy with normal hearing, a prolonged QT interval, and syncopal episodes during physical exercise. The parents of the proband were heterozygous for the mutation and had a normal QT interval. The functional evaluation of the mutant channel activity showed reduction in total current, a hyperpolarizing shift in activation, and a faster activation rate consistent with a mild mutation likely to require homozygosity to manifest the phenotype.

CONCLUSIONS

These findings provide the first evidence for a recessive form of the Romano-Ward long-QT syndrome and indicate that homozygous mutations on KVLQT1 do not invariably produce the Jervell and Lange-Nielsen syndrome. The implications of this observation prompt a reconsideration of the penetrance of different mutations responsible for LQTS and suggest that mild mutations in LQTS genes may be present among the general population and may predispose to drug-induced ventricular arrhythmias.

A mechanism for the proarrhythmic effects of cisapride (Propulsid): high affinity blockade of the human cardiac potassium channel HERG

Cisapride (Propulsid) is a gastrointestinal prokinetic agent commonly used to treat nocturnal heartburn as well as a variety of other gastrointestinal disorders. The use of cisapride has been associated with acquired long QT syndrome and ventricular arrhythmias such as torsades de pointes which produces sudden cardiac death. These cardiotoxic effects can be due to blockade of one or more types of K+ channel currents in the human heart. For this reason we compared the effects of cisapride on two cloned human cardiac K+ channels, Kv1.5 and the human ether-a-go-go-related gene (HERG) stably transfected into mammalian cells. Using patch clamp electrophysiology, we found that cisapride was a potent inhibitor of HERG displaying an IC50 value of 44.5 nmol/l when tail currents at -40 mV were measured following a 2 s test depolarization to +20 mV. When HERG currents were measured at the end of prolonged (20 s) depolarizing steps to +20 mV, the apparent affinity of cisapride was increased and measured 6.70 nmol/l. The main effect of cisapride was to enhance the rate of HERG current decay thereby reducing current at the end of the voltage clamp pulse. Furthermore, the potency of cisapride for the HERG channel was similar to that observed for the class III antiarrhythmic agent dofetilide (IC50 = 15.3 nmol/l) and the nonsedating antihistamine terfenadine (IC50 = 56.0 nmol/l). In contrast to its effects on HERG, cisapride inhibited Kv1.5 channel currents weakly displaying an IC50 value of 21.2 micromol/l. It is concluded that cisapride displays specific, high affinity block of the human cardiac K+ channel HERG. It is likely that this interaction underlies the proarrhythmic effects of the drug observed under certain clinical settings.

Pharyngeal perforation: an easily missed finding following intra-oral injury

A 2-year-old child presented with pharyngeal perforation following a peroral injury with a toothbrush. Direct force applied to an object such as a toothbrush in the mouth may cause either superficial or penetrating injury within the oropharynx. A high index of suspicion is sometimes necessary to identify a pharyngeal perforation and if this is diagnosed we would advocate admission to hospital, restriction of oral intake, intravenous fluids and antibiotics, with close observation to ensure that healing occurs without development of further complications.

Effects of passive and active smoking on induction of anaesthesia

It is said that cigarette smokers suffer stormy induction of anaesthesia; although plausible, this is unsubstantiated. We have studied the incidence of adverse events during induction, together with peripheral oxygen saturation (SpO2), in active and passive smokers, and in non-smokers. During induction, both active and passive smokers had a higher incidence of adverse events than non-smokers (P < 0.01 and P < 0.05, respectively). Irrespective of smoking status, those suffering adverse events had greater concentrations of carboxyhaemoglobin and suffered more oxygen desaturation than those not suffering such events. Although we were unable to demonstrate a direct link between smoking status and oxygen desaturation during induction, our study gives a firmer basis for exhorting patients not only to stop smoking before anaesthesia but also to avoid passive smoking.

Dimensional accuracy and stability of acrylic resin denture bases

Proponents of injection molding systems have claimed a number of benefits over conventional press-pack dough molding systems. The aim of this study was to evaluate a recently developed injection (dry heat) procedure of processing compared with press-pack dough molding utilizing three curing cycles. The dimensional accuracy and stability of acrylic resin bases produced by the two molding procedures were compared. Dimensional changes were assessed over a period of 4 months using an optical comparator. The results demonstrate that baseplates produced by the injection molding procedure exhibit less shrinkage than those produced by the conventional press-pack procedures.

Yeast mutants conferring resistance to toxic effects of cloned human insulin-like growth factor I

The production of extracellular human insulin-like growth factor I (IGF-I) in yeast is deleterious to the growth of the host organism. Mutants resistant to the toxic effects of IGF-I production were isolated. A subset of these mutants produced levels of IGF-I greater than the parent strain and were due to chromosomal recessive mutations at a single locus, hpx1. The overproduction of IGF-I was independent of the original promoter and vector expression system. The mutant strains also displayed enhanced extracellular production of other heterologous proteins.