Iron deficiency anaemia revisited

What We Are Missing: Using Machine Learning Models to Predict Vitamin C Deficiency in Patients with Metabolic and Bariatric Surgery

PURPOSE

Vitamin C (VC) is implicated in many physiological pathways. Vitamin C deficiency (VCD) can compromise the health of patients with metabolic and bariatric surgery (patients). As symptoms of VCD are elusive and data on VCD in patients is scarce, we aim to characterize patients with measured VC levels, investigate the association of VCD with other lab abnormalities, and create predictive models of VCD using machine learning (ML).

METHODS

A retrospective chart review of patients seen from 2017 to 2021 at a tertiary care center in Northeastern USA was conducted. A 1:4 case mix of patients with VC measured to a random sample of patients without VC measured was created for comparative purposes. ML models (BayesNet and random forest) were used to create predictive models and estimate the prevalence of VCD patients.

RESULTS

Of 5946 patients reviewed, 187 (3.1%) had VC measures, and 73 (39%) of these patients had VC<23 μmol/L(VCD. When comparing patients with VCD to patients without VCD, the ML algorithms identified a higher risk of VCD in patients deficient in vitamin B1, D, calcium, potassium, iron, and blood indices. ML models reached 70% accuracy. Applied to the testing sample, a "true" VCD prevalence of ~20% was predicted, among whom ~33% had scurvy levels (VC<11 μmol/L).

CONCLUSION

Our models suggest a much higher level of patients have VCD than is reflected in the literature. This indicates a high proportion of patients remain potentially undiagnosed for VCD and are thus at risk for postoperative morbidity and mortality.

Defective iron homeostasis and hematological abnormalities in Niemann-Pick disease type C1

Background: Niemann-Pick disease type C1 (NPC1) is a neurodegenerative lysosomal storage disorder characterized by the accumulation of multiple lipids in the late endosome/lysosomal system and reduced acidic store calcium. The lysosomal system regulates key aspects of iron homeostasis, which prompted us to investigate whether there are hematological abnormalities and iron metabolism defects in NPC1. Methods: Iron-related hematological parameters, systemic and tissue metal ion and relevant hormonal and proteins levels, expression of specific pro-inflammatory mediators and erythrophagocytosis were evaluated in an authentic mouse model and in a large cohort of NPC patients. Results: Significant changes in mean corpuscular volume and corpuscular hemoglobin were detected in Npc1 -/- mice from an early age. Hematocrit, red cell distribution width and hemoglobin changes were observed in late-stage disease animals. Systemic iron deficiency, increased circulating hepcidin, decreased ferritin and abnormal pro-inflammatory cytokine levels were also found. Furthermore, there is evidence of defective erythrophagocytosis in Npc1 -/- mice and in an in vitro NPC1 cellular model. Comparable hematological changes, including low normal serum iron and transferrin saturation and low cerebrospinal fluid ferritin were confirmed in NPC1 patients. Conclusions: These data suggest loss of iron homeostasis and hematological abnormalities in NPC1 may contribute to the pathophysiology of this disease.

Role of single-dose intravenous iron therapy for the treatment of anaemia after orthopaedic trauma: protocol for a pilot randomised controlled trial

INTRODUCTION

Orthopaedic trauma and fracture care commonly cause perioperative anaemia and associated functional iron deficiency due to a systemic inflammatory state. Modern, strict transfusion thresholds leave many patients anaemic; managing this perioperative anaemia is an opportunity to impact outcomes in orthopaedic trauma surgery. The primary outcome of this pilot study is feasibility for a large randomised controlled trial (RCT) to evaluate intravenous iron therapy (IVIT) to improve patient well-being following orthopaedic injury. Measurements will include rate of participant enrolment, screening failure, follow-up, missing data, adverse events and protocol deviation.

METHODS AND ANALYSIS

This single-centre, pilot, double-blind RCT investigates the use of IVIT for acute blood loss anaemia in traumatically injured orthopaedic patients. Patients are randomised to receive either a single dose infusion of low-molecular weight iron dextran (1000 mg) or placebo (normal saline) postoperatively during their hospital stay for trauma management. Eligible subjects include adult patients admitted for lower extremity or pelvis operative fracture care with a haemoglobin of 7-11 g/dL within 7 days postoperatively during inpatient care. Exclusion criteria include history of intolerance to intravenous iron supplementation, active haemorrhage requiring ongoing blood product resuscitation, multiple planned procedures, pre-existing haematologic disorders or chronic inflammatory states, iron overload on screening or vulnerable populations. We follow patients for 3 months to measure the effect of iron supplementation on clinical outcomes (resolution of anaemia and functional iron deficiency), patient-reported outcomes (fatigue, physical function, depression and quality of life) and translational measures of immune cell function.

ETHICS AND DISSEMINATION

This study has ethics approval (Oregon Health & Science University Institutional Review Board, STUDY00022441). We will disseminate the findings through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT05292001; ClinicalTrials.gov.

Prevalence and Risk Factors of Anaemia among Orang Asli Children in Malaysia: A Scoping Review

BACKGROUND

Anaemia continues to be a global public health burden affecting all age groups, particularly children. Indigenous people, including the Orang Asli (OA) population in Malaysia, are at risk of anaemia due to the vast disparities in social determinants of health in their population compared to the non-indigenous population.

OBJECTIVES

This review aimed to identify the prevalence and risk factors of anaemia among OA children in Malaysia and analyse the knowledge gaps.

METHODS

A systematic search was conducted in PubMed, Cochrane Library, Scopus and Google Scholar databases. This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines.

RESULTS

This review identified six studies involving the participation of OA children from eight subtribes residing in Peninsular Malaysia. The overall prevalence of anaemia among OA children ranged from 21.6 to 80.0%, with iron deficiency anaemia prevalence at 34.0%. The risk factors of anaemia among OA children reported from one study in this review were being younger than ten years old children (AOR 2.11 (95% CI 1.23, 3.63)) and moderate to heavy Ascaris infections (AOR 2.05 (95% CI 1.12, 3.76)). There was no data from OA children from certain age groups and subtribes. Additionally, there is a paucity of data on risk factors for anaemia among OA children from the currently available evidence.

CONCLUSION

The prevalence of anaemia among OA children poses a moderate to severe public health concern. Therefore, more comprehensive studies in the future are needed to address the gaps identified in this review, primarily regarding anaemia risk factors. This data would encourage policymakers in devising effective national prevention strategies to improve morbidity and mortality among OA children in the future.

Predictors of Incidence and Remission of Anemia among Never-Married Adolescents Aged 10-19 Years: A Population-Based Prospective Longitudinal Study in India

Background

Dynamics of the anemia burden among Indian adolescents are poorly understood because of a lack of population-based longitudinal data.

Objectives

To examine the burden of anemia among never-married adolescents aged 10-19 y from the states of Bihar and Uttar Pradesh, India, and a wide range of predictors of its incidence and remission.

Methods

A sample of 3279 adolescents (male: 1787 and female: 1492) aged 10-19 y were included from baseline (2015-2016) and follow-up (2018-2019) surveys of the UDAYA (Understanding the Lives of Adolescents and Young Adults) project in India. In 2018-2019, all new cases of anemia were considered as incidence, whereas a return to the nonanemic status from being anemic in 2015-2016 was considered remission. Univariate and multivariable modified Poisson regression models with robust error variance were deployed to attain the study objective.

Results

The crude prevalence of anemia among males decreased from 33.9% (95% CI: 30.7%-37.3%) in 2015-2016 to 31.6% (95% CI: 28.6%-34.7%) in 2018-2019 but increased among females from 57.7% (95% CI: 53.5%-61.7%) in 2015-2016 to 63.8% (95% CI: 59.9%-67.5%) in 2018-2019. Anemia incidence was estimated to be 33.7% (95% CI: 30.3%-37.2%), whereas nearly 38.5% (95% CI: 35.1%-42.1%) of adolescents experienced remission of anemia. Older adolescents (aged 15-19 y) were less likely to experience anemia incidence. Consumption of eggs daily or weekly was negatively associated with anemia incidence compared with occasional or never consumption. Females had a higher risk of experiencing an incidence of anemia and decreased risk of experiencing anemia remission. The likelihood of adolescents experiencing anemia increased with an increased patient health questionnaire score. Household size was also associated with an increased risk of anemia incidence.

Conclusions

Interventions that are sensitive to socio-demographic factors and encouraging access to mental health services and nutritious food consumption could be helpful in further anemia mitigation.

An observational and Mendelian randomisation study on iron status and sepsis

Iron deficiency is associated with a substantial burden of morbidity. However, supplementation of iron has been linked to increased rates of serious infection in randomised trials of children in sub-Saharan Africa. Randomised trials in other settings have been inconclusive and it is unknown if changes in levels of iron biomarkers are linked to sepsis in these other settings. We used genetic variants associated with levels of iron biomarkers as instrumental variables in a Mendelian randomisation (MR) analysis to test the hypothesis that increasing levels of iron biomarkers increase the risk of sepsis. In observational and MR analyses we found that increases in iron biomarkers increase the odds of sepsis. In stratified analyses, we show that this risk may be larger in those with iron deficiency and/or anaemia. Taken together, results here suggest a required caution in supplementation of iron and underline the role of iron homeostasis in severe infection.

Causes of Moderate and Severe Anaemia in a High-HIV and TB-Prevalent Adult Population in the Eastern Cape Province, South Africa

BACKGROUND

Anaemia affects one in four adults in South Africa, with a higher prevalence in persons with HIV and tuberculosis. The aim of this study is to characterise the causes of anaemia in primary care and a district hospital setting.

METHODS

A cross-sectional study design investigated a purposive sample of adult males and non-pregnant females at two community health centres and a hospital casualty and outpatients. Fingerpick blood haemoglobin was measured with HemoCueHb201+. Those with moderate and severe anaemia underwent clinical examination and laboratory tests.

RESULTS

Of 1327 patients screened, median age was 48 years, and 63.5% were female. Of 471 (35.5%) with moderate and severe anaemia on HemoCue, 55.2% had HIV, 16.6% tuberculosis, 5.9% chronic kidney disease, 2.6% cancer, and 1.3% heart failure. Laboratory testing confirmed 227 (48.2%) with moderate and 111 (23.6%) with severe anaemia, of whom 72.3% had anaemia of inflammation, 26.5% iron-deficiency anaemia, 6.1% folate deficiency, and 2.5% vitamin B12 deficiency. Overall, 57.5% had two or more causes of anaemia. Multivariate modelling showed that patients with severe anaemia were three times more likely to have tuberculosis (OR = 3.1, 95% CI = 1.5-6.5; p-value = 0.002). Microcytosis was present in 40.5% with iron deficiency, macrocytosis in 22.2% with folate deficiency, and 33.3% with vitamin B12 deficiency. The sensitivities of the reticulocyte haemoglobin content and % hypochromic red blood cells in diagnosing iron deficiency were 34.7% and 29.7%, respectively.

CONCLUSIONS

HIV, iron deficiency, and tuberculosis were the most prevalent causes of moderate and severe anaemia. The majority had multiple causes. Iron, folate, and vitamin B12 deficiencies should be identified by biochemical testing rather than by red cell volume.

Shooting shadows: India's struggle to reduce the burden of anaemia

Despite several efforts by the Government of India, the national burden of anaemia remains high and its growing prevalence (between 2015-2016 and 2019-2021) is concerning to India's public health system. This article reviews existing food-based and clinical strategies to mitigate the anaemia burden and why they are premature and insufficient. In a context where multiple anaemia control programmes are in play, this article proposes a threefold strategy for consideration. First, except the Comprehensive National Nutrition Survey, 2016-2018, which measured Hb concentration among children and adolescents aged 1-19 years using venous blood samples, all national surveys use capillary blood samples to determine Hb levels, which could be erroneous. The Indian government should prioritise conducting a nationwide survey for estimating the burden of anaemia and its clinical determinants for all age groups using venous blood samples. Second, without deciding the appropriate dose of Fe needed for an individual, food fortification programmes that are often compounded with layering of other micronutrients could be harmful and further research on this issue is needed. Same is true for the pharmacological intervention of Fe tablet or syrup supplementation programmes, which is given to individuals without assessing its need. In addition, there is a dire need for robust research to understand both the long-term benefit and side effects of Fe supplementation programmes. Third and final, the WHO is in process of reviewing the Hb threshold for defining anaemia, therefore the introduction of new anaemia control programmes should be restrained.

Vitamin E protective effects on genomic and cellular damage caused by paediatric preventive supplementation for anaemia: an experimental model

Iron deficiency is the leading cause of anaemia. In Argentina, the prevalence of anaemia and iron deficiency is very high; for that reason, the Argentine Society of Pediatrics recommends daily ferrous sulphate supplementation as a preventive treatment strategy. Alternatively, weekly ferrous sulphate supplementation has also been shown to be effective for anaemia prevention. Excess iron could be related to oxidative stress, which may in turn cause cytomolecular damage. Both can be prevented with vitamin E supplementation. We evaluated the effect of both daily and weekly ferrous sulphate supplementation combined with two doses of vitamin E on cell viability, oxidative stress and cytomolecular damage in peripheral blood cultured in vitro. The experimental design included the following groups: untreated negative control, two vitamin E controls (8·3 and 16·6 µg/ml), weekly ferrous sulphate supplementation (0·55 mg/ml) with each vitamin E dose, daily ferrous sulphate supplementation (0·14 mg/ml) with each vitamin E dose and a positive control. Daily ferrous sulphate supplementation decreased cell viability and increased the levels of reactive oxygen species, lipid peroxidation and cytomolecular damage (P < 0·5) compared with the weekly supplementation, probably due to the excess iron observed in the former. Vitamin E seemed to reduce ferrous sulphate-induced oxidative stress and genomic damage.

How can pharmacists contribute to anaemia management? A review of literature and exploratory study on pharmacists' role in anaemia

Background

Iron deficiency anaemia (IDA) is the leading cause of anaemia globally, most frequently found in children and pregnant women. With their increasing role in the healthcare system, pharmacists may contribute to the management of anaemia. Through the International Pharmaceutical Federation (FIP) Multinational Needs Assessment Programme, the FIP explored the contribution of pharmacists in anaemia, specifically IDA, focusing on five countries: India, Indonesia, Malaysia, Philippines and Singapore.

Objective

To explore information on pharmacists' roles in a variety of settings related to 1) IDA management; 2) education and training needed to support the roles; and 3) barriers and enablers to expanding or developing the roles.

Methods

This study involved a literature review and a focus group discussion with twelve participants selected purposively and nominated by national professional leadership bodies across five countries. A literature search was conducted using PubMed Database. A focus group discussion explored pharmacists' roles, education and training needs, as well as barriers and enablers to support their roles in anaemia management, specifically in IDA. A codebook thematic analysis approach was conducted according to the study objectives.

Results

Sixteen articles were included in the analysis. The pharmacists' roles in anaemia identified from literature ranged from patient management and monitoring, collaboration with other healthcare professionals and involvement in guideline development, in which the roles vary according to the workplace. Twelve participants attended the focus group discussion. Participants highlighted pharmacists' roles in screening and detection, medication therapeutic management, patient counselling and patient monitoring. Participants emphasised a need for guidelines or toolkits with subsequent training or workshops to support their competency development in anaemia. Monitoring the success of pharmacist delivered anaemia programmes was recommended to support advocating for active pharmacist roles.

Conclusion

Pharmacists have a growing opportunity to contribute to achieving the global targets on anaemia through their involvement in screening and managing anaemia and increasing anaemia awareness among the patients and community.

Incidence of iron deficiency Anaemia during pregnancy in Far North Queensland

INTRODUCTION

The WHO estimates the incidence of iron deficiency anaemia in Australia is 25%. However there is considerable variation during pregnancy and in regional areas.

OBJECTIVE

The aim of this investigation is to quantify the incidence of iron deficiency anaemia during pregnancy within Far North Queensland.

DESIGN

This is a single-centre retrospective cohort study. Cairns Hospital is the main referral centre for complex maternity care in Far North Queensland with an estimated population of 280-000, which includes many people from rural and remote communities and a high proportion who identify as Aboriginal or Torres Strait Islander. This study included all births at the Cairns Hospital in 2018, a total of 2190 deliveries.

FINDINGS

The study randomly sampled 551 mothers from the cohort, and the incidence of iron deficiency anaemia was 34.9%. 48.7% of women who identified as Aboriginal or Torres Strait Islander within the region were anaemic. This was significantly higher than an incidence of 28.9% for the rest of the population. Other risk factors include booking appointment after 28-weeks, Asian ethnicity and age less than 25-years. A BMI greater than 35 was protective DISCUSSION: This study will inform antenatal care providers within the region and improve obstetric outcomes by increasing awareness. Identifying risk factors will also facilitate prompt treatment and improve maternity care for vulnerable patient groups. On a broader level, the study provides new data to inform population health estimates both nationally and internationally.

CONCLUSION

The incidence of iron deficiency anaemia during pregnancy in Far North Queensland is significantly higher than previous estimates.

Assessment of the effect of iron-rich humic substances on hematological parameters in the model of acute posthemorrhagic and iron deficiency anemia

Aim. To assess the effect of iron-rich humic substances on hematological parameters in acute post-hemorrhagic and iron deficiency anemia.

Materials and methods. Materials for the study were samples of iron-rich active pharmaceutical ingredients based on humic substances (Fe(III) hydroxide complexes with humic substances and polymaltose): HA-Fe3+, HA-PMFe3+, FA-Fe3+, and FA-PM-Fe3+. The anti-anemic activity of the substances was studied on 53 female Wistar rats of the conventional rat line in the model of acute posthemorrhagic and iron deficiency anemia. Anti-anemic activity was assessed by the hemoglobin level, erythrocyte count, hematocrit, and serum iron level.

Results. The studied substances HA-Fe3+ and FA-Fe3+ are the most effective in correcting the consequences of both experimental acute posthemorrhagic anemia and iron deficiency anemia. Their effect is comparable to that of the positive control drug Ferrum Lek.

Conclusion. Fe(III) hydroxide complexes stabilized by humic and fulvic acids exhibit anti-anemic activity.

Role of Iron Deficiency in Heart Failure-Clinical and Treatment Approach: An Overview

BACKGROUND

The association of chronic heart failure (CHF) and iron deficiency (ID) with or without anemia is frequently encountered in current medical practice and has a negative prognostic impact, worsening patients' exercise capacity and increasing hospitalization costs. Moreover, anemia is common in patients with chronic kidney disease (CKD) and CHF, an association known as cardio-renal anemia syndrome (CRAS) possessing a significantly increased risk of death.

AIM

This review aims to provide an illustrative survey on the impact of ID in CHF patients-based on physiopathological traits, clinical features, and the correlation between functional and absolute ID with CHF-and the benefit of iron supplementation in CHF.

METHOD

We selected the most recent publications with important scientific content covering the association of CHF and ID with or without anemia.

DISCUSSIONS

An intricate physiopathological interplay is described in these patients-decrease in erythropoietin levels, activation of the renin-angiotensin-aldosterone system, systemic inflammation, and increases in hepcidin levels. These mechanisms amplify anemia, CHF, and CKD severity and worsen patients' outcomes.

CONCLUSIONS

Anemia is frequently encountered in CHF and represents a negative prognostic factor. Data from randomized controlled trials have underlined the administration of intravenous iron therapy (ferric carboxymaltose) as the only viable treatment option, with beneficial effects on quality of life and exercise capacity in patients with ID and systolic heart failure.

How to diagnose iron deficiency in chronic disease: A review of current methods and potential marker for the outcome

Iron deficiency (ID) is the most common nutritional disorder worldwide. It is often observed in patients with chronic diseases, such as heart failure (HF), chronic kidney disease (CKD), inflammatory bowel disease (IBD) and cancer. ID is associated with poor clinical outcome, including poor performance, reduced quality of life, as well as increased hospitalization and mortality. The aim of this review is to provide an overview about the role of ID in chronic diseases (HF, CKD, IBD, cancer) regarding their current definitions and clinical relevance; diagnostic accuracy of iron parameters in chronic inflammatory conditions and its potential as prognostic markers. Due to different definitions and guideline recommendations of ID, various laboratory parameters for ID diagnostic exist and there is no general consensus about the definition of ID and its treatment. Still, a general trend can be observed across all investigated indications of this review (HF, CKD, IBD, cancer) that serum ferritin and transferrin saturation (TSAT) are the two parameters mentioned most often and emphasized in all guidelines to define ID and guide treatment. The most commonly used threshold values for the diagnosis of ID are TSAT of < 20% and serum ferritin of < 100-300 µg/L. Noteworthy, both TSAT and particularly ferritin are frequently applied, but both may vary due to inflammatory conditions. Studies showed that TSAT is less affected by inflammatory processes and may therefore be more accurate and reliable than serum ferritin, particularly in conditions with elevated inflammatory state. A low iron status and particularly a low TSAT value was associated with a poor outcome in all investigated indications, with the strongest evidence in HF patients. Routine surveillance of iron status in these groups of patients with chronic conditions is advisable to detect ID early. Depending on the inflammatory state, TSAT < 20% may be the more accurate diagnostic marker of ID than ferritin. Moreover, TSAT may also be the more reliable estimate for the prognosis, particularly in HF.

Preparation, characterization, antioxidant and antianemia activities of Poria cocos polysaccharide iron (III) complex

As a new natural antioxidant with high safety and non-toxic side effects, polysaccharide can also be used as a critical macromolecular carrier to form a stable iron complex with Fe³⁺. Our previous study has extracted and purified the homogeneous polysaccharide (PCP1C) from Poria cocos. In this study, the PCP1C-iron (III) complex was synthesized by co-thermal synthesis with PCP1C and ferric trichloride. The chelating capacity, iron releasing capacity, and qualitative identification of complex were evaluated. The complex was characterized by scanning electron microscope-energy dispersive spectrometer (SEM-EDS) analysis, particle size distribution, and fourier transform infrared (FTIR) spectroscopy. The antioxidant and iron supplement effects of the complex were also studied in vitro and in the iron deficiency anemia (IDA) rat model. The results showed that the iron content in the PCP1C-iron (III) complex was 28.14% with no free iron, and the iron release rate was 95.3%. The structure analysis showed that the iron core of the PCP1C-iron (III) complex existed in the form of β-FeOOH and the surface of the complex become smooth and particle size increased, which indicated the high iron content of polysaccharide iron and slow release. Furthermore, we found that the PCP1C iron (III) complex had positive scavenging effect on DPPH, ABTS, MDA, and hydroxyl radical in vitro study and significantly increased the levels of red blood cell (RBC), Hemoglobin (Hb), and red blood cell specific volume (HCT) in IDA rat model. Therefore, our results suggested that the PCP1C-iron (III) complex is expected to develop into a new comprehensive iron supplement and antioxidant.

Prevalence, Pathogenesis and Management of Anemia in Inflammatory Bowel Disease: An IG-IBD Multicenter, Prospective, and Observational Study

BACKGROUND

Anemia is a common extraintestinal manifestation of inflammatory bowel disease (IBD), with a 6% to 74% prevalence and a negative impact on patient survival and quality of life, although the prevalence is apparently declining due to improved disease treatment. We aimed to investigate the prevalence, pathogenesis, and clinical correlates of anemia in Italian patients with IBD.

METHODS

A multicenter, prospective, observational study, involving 28 Italian gastroenterology centers, was conducted to investigate the epidemiology and consequences of IBD-associated anemia. Clinical and laboratory data of anemic patients were obtained at study enrolment.

RESULTS

Anemia was diagnosed in 737 of 5416 adult IBD outpatients (prevalence 13.6%); females were more commonly affected than males (odds ratio, 1.5; 95% confidence interval [CI], 1.2-1.7) and had more severe anemia. In the majority of cases, anemia was due to iron deficiency (62.5% of cases; 95% CI, 58.3%-66.6%), either isolated or in association with inflammation and/or vitamin deficiencies; anemia of inflammation accounted for only 8.3% of cases. More severe anemia was associated with increasing fatigue and worse quality of life. Only 68.9% of anemic patients with iron deficiency (95% CI, 63.4%-73.8%) and 34.6% of those with vitamin deficiencies (95% CI, 26.2%-44.2%) were properly treated with supplementation therapy.

CONCLUSIONS

In Italy, the prevalence of IBD-associated anemia is lower than previously reported. Anemia of IBD is most commonly due to iron deficiency and contributes to fatigue and poor quality of life, but remains untreated in a large proportion of patients with iron and/or vitamin deficiencies. This study is registered at clinicaltrials.gov as NCT02872376.

Defining ferritin clinical decision limits to improve diagnosis and treatment of iron deficiency: A modified Delphi study

BACKGROUND

Iron deficiency is highly prevalent worldwide and is an issue of health inequity. Despite its high prevalence, uncertainty on the clinical applicability and evidence-base of iron-related lab test cut-offs remains. In particular, current ferritin decision limits for the diagnosis of iron deficiency may not be clinically appropriate nor scientifically grounded.

METHODS

A modified Delphi study was conducted with various clinical experts who manage iron deficiency across Canada. Statements about ferritin decision limits were generated by a steering committee, then distributed to the expert panel to vote on agreement with the aim of achieving consensus and acquiring feedback on the presented statements. Consensus was reached after two rounds, which was defined as 70% of experts rating their agreement for a statement as 5 or higher on a Likert scale from 1 to 7.

RESULTS

Twenty-six clinical experts across 10 different specialties took part in the study. Consensus was achieved on 28 ferritin decision limit statements in various populations (including patients with multiple comorbid conditions, pediatric patients, and pregnant patients). For example, there was consensus that a ferritin <30 μg/L rules in iron deficiency in all adult patients (age ≥ 18 years) and warrants iron replacement therapy.

CONCLUSION

Consensus statements generated through this study corresponded with current evidence-based literature and guidelines. These statements provide clarity to facilitate clinical decisions around the appropriate detection and management of iron deficiency.

Intravenous Iron Therapy for Children With Iron Deficiency Anemia

Iron deficiency anemia in children is a public health problem. Although oral iron treatment is the first choice, common side effects and compliance problems can cause the treatment to be interrupted. This study retrospectively evaluated children treated with intravenous (IV) iron sucrose or ferric carboxymaltose (FCM) and compared the treatment processes and efficacy. The demographic characteristics and treatment details of the 44 children with iron deficiency anemia were retrospectively evaluated. Iron sucrose was administered to 25 patients and FCM was administered to 19 patients. The IV iron infusion was applied to 64% of the patients because of unresponsiveness to oral treatment, 25% of the patients because of compliance problems, and 11% of the patients because of severe anemia. IV iron therapy increased hemoglobin, mean corpuscular volume, mean corpuscular hemoglobin, red-cell distribution width, and serum ferritin levels and decreased platelet count. The mean number of infusions per patient in the FCM group was lower, and the total treatment time was shorter. In conclusion, IV iron sucrose or FCM can be used in children with nonadherence to oral therapy and severe anemia in addition to specific indications.

Association between iron deficiency and hospitalization rate in community-dwelling older adults: A 3-year prospective observational study of DO-HEALTH

BACKGROUND

Iron deficiency (ID) is associated with negative health outcomes in older adults. However, data on the impact of ID on the number of hospitalizations and length of hospital stay (LOS) is lacking.

OBJECTIVE

To explore the associations between baseline ID and the number of hospitalizations and between baseline ID and at least one LOS ≥5 days in community-dwelling older adults.

METHODS

This is a secondary observational analysis of a randomized controlled trial including 2157 community-dwelling adults aged ≥70 years without major diseases at baseline. The main exposure was defined as ID (soluble transferrin receptor [sTfR] concentrations >28.1 nmol/L) at baseline. The primary outcome was the number of hospitalizations over a 3-year follow-up. The secondary outcome was having at least one LOS ≥5 days over the study period among individuals with one or more hospitalizations. Interaction between ID and anemia (hemoglobin <130 g/L for men and <120 g/L for women) was also investigated.

RESULTS

Baseline sTfR concentration was determined in 2141 participants (median age 74.0 years). At 3 year, 1497 hospitalizations were reported with an incidence rate of hospitalization of 0.26 per person-year (95% CI: 0.24, 0.28). Overall, baseline ID was associated with a 24% increased incidence rate of hospitalization (incidence rate ratio: 1.24; 95% CI: 1.05, 1.45) over 3 years. This association was independent of anemia status at baseline since the interaction between ID and anemia at baseline was not significant. Moreover, ID was not significantly associated with having a LOS ≥5 days (OR: 1.40; 95% CI: 1.00, 1.97) among participants with at least one hospitalization over 3 years.

CONCLUSIONS

ID is associated with increased hospitalization rate and not associated with LOS ≥5 days among generally healthy older adults. Efforts to minimize ID in older adults may improve overall health and optimize healthcare costs.

Haem Iron Intake Is Associated with Increased Major Adverse Cardiovascular Events, All-Cause Mortality, Congestive Cardiac Failure, and Coronary Revascularisation in Older Men: The Concord Health and Ageing in Men Project

BACKGROUND

Nutritional intake can influence major adverse cardiovascular events (MACE). Dietary iron is found in two forms: haem-iron (HI) only found in animal sources and non-haem iron (NHI) present mostly in plant sources.

OBJECTIVE

We evaluated the associations between dietary iron intakes with MACE and iron status biomarkers.

DESIGN

Prospective cohort study.

SETTING

The Concord Health and Ageing in Men Project, Sydney, Australia.

PARTICIPANTS

539 community-dwelling older Australian men aged 75 years and older.

METHODS

Men underwent nutritional assessment using a validated diet history questionnaire. Entries were converted to food groups and nutrients. The dietary calculation was used to derive HI and NHI intakes from total iron intakes. Analyses of iron intakes with iron status biomarkers were conducted using linear regression, and with MACE and individual endpoints were conducted using Cox regression. Five-point MACE comprised of all-cause mortality, myocardial infarction (MI), congestive cardiac failure (CCF), coronary revascularisation, and/or ischaemic stroke. Four-point MACE included the four endpoints of MI, CCF, coronary revascularisation, and/or ischaemic stroke, and excluded all-cause mortality.

RESULTS

At a median of 5.3 (4.6 - 6.3) years follow-up, the incidences were: 31.2% (n = 168) five-point MACE, 17.8% (n = 96) four-point MACE excluding all-cause mortality, 20.1% (n = 111) all-cause mortality, 11.3% (n = 61) CCF, and 3.1% (n = 15) coronary revascularisation. In adjusted analyses, higher HI intake (per 1mg increment) was associated with increased five-point MACE (HR: 1.45 [95% CI: 1.16, 1.80, P = .001]), four-point MACE excluding all-cause mortality (HR: 1.64 [95% CI: 1.26, 2.15, P <.001]), all-cause mortality (HR: 1.51 [95% CI: 1.15, 1.99, P = .003]), CCF (HR: 2.08 [95% CI: 1.45, 2.98, P <.001]), and coronary revascularisation (HR: 1.89 [95% CI: 1.15, 3.10, P = .012]). Compared with the bottom tertile of NHI intake, the middle tertile of NHI intake was associated with reduced risk of all-cause mortality (HR: 0.56 [95% CI: 0.33, 0.96, P = .035]). Total iron intake was not associated with MACE and individual endpoints. Dietary iron intakes were not associated with serum iron and haemoglobin.

CONCLUSION

Higher haem iron intake was independently associated with increased risks of five-point MACE, four-point MACE excluding all-cause mortality, all-cause mortality, CCF, and coronary revascularisation in older men over 5 years.

Comparative analysis of oral and intravenous iron therapy in rat models of inflammatory anemia and iron deficiency

Anemia is a major health issue and associated with increased morbidity. Iron deficiency anemia (IDA) is the most prevalent, followed by anemia of chronic disease (ACD). IDA and ACD often co-exist, challenging diagnosis and treatment. While iron supplementation is the first-line therapy for IDA, its optimal route of administration and the efficacy of different repletion strategies in ACD are elusive. Female Lewis rats were injected with group A streptococcal peptidoglycan-polysaccharide (PG-APS) to induce inflammatory arthritis with associated ACD and/or repeatedly phlebotomized and fed with a low iron diet to induce IDA, or a combination thereof (ACD/IDA). Iron was either supplemented by daily oral gavage of ferric maltol or by weekly intravenous (i.v.) injection of ferric carboxymaltose for up to 4 weeks. While both strategies reversed IDA, they remained ineffective to improve hemoglobin (Hb) levels in ACD, although oral iron showed slight amelioration of various erythropoiesis-associated parameters. In contrast, both iron treatments significantly increased Hb in ACD/IDA. In ACD and ACD/IDA animals, i.v. iron administration resulted in iron trapping in liver and splenic macrophages, induction of ferritin expression and increased circulating levels of the iron hormone hepcidin and the inflammatory cytokine interleukin-6, while oral iron supplementation reduced interleukin-6 levels. Thus, oral and i.v. iron resulted in divergent effects on systemic and tissue iron homeostasis and inflammation. Our results indicate that both iron supplements improve Hb in ACD/IDA, but are ineffective in ACD with pronounced inflammation, and that under the latter condition, i.v. iron is trapped in macrophages and may enhance inflammation.

Knowledge and practices on childhood anaemia, thalassaemia and iron deficiency among mothers of children aged between 6 and 59 months in a suburban area of Sri Lanka

BACKGROUND

Childhood anaemia is one of the most common public health problems worldwide. Here, we aim to describe the knowledge and practices on childhood anaemia, thalassaemia and iron deficiency among mothers of children aged between 6 and 59 months in a suburban district of Sri Lanka.

METHODS

We performed a cross-sectional survey in the Gampaha District of Sri Lanka from December 2020 to February 2021. One well-baby clinic each from four Medical Officer of Health areas in the district was selected using stratified random sampling. Mothers of all children aged between 6 and 59 months attending well-baby clinics were recruited until the sample size was achieved. Data were collected using a self-administered questionnaire and analysed using logistic regression.

RESULTS

A total of 392 mothers were recruited; 53% of their children were males. Only 33% of mothers had an accurate understanding of anaemia, while 71% and 28%, respectively, could name at least one symptom and two causes of anaemia; 12% could not name a single food rich in iron. Only 13% of mothers knew that thalassaemia is a cause of anaemia, and 14% had been screened for thalassaemia. Logistic regression analysis that examined for factors associated with higher knowledge of anaemia revealed that an accurate understanding of anaemia was associated with maternal age over 30 years (p < 0.05) and maternal education level beyond grade ten (p < 0.001). In contrast, higher knowledge of symptoms of anaemia was associated with maternal employment (p < 0.01).

CONCLUSIONS

The knowledge of anaemia and awareness of thalassaemia among mothers was poor. Very few mothers were aware of iron-rich food and feed it to their children. Despite being located in a thalassaemia-endemic region, very few knew that thalassaemia is a cause of anaemia and have got themselves screened for thalassaemia.

Improved Diagnosis of Iron Deficiency Anemia in the Critically Ill via Fluorescence Flowcytometric Hemoglobin Biomarkers

BACKGROUND

Iron deficiency anemia (IDA) is common in critically ill patients treated in the intensive care unit (ICU), and it can lead to severe consequences. Precise and immediate diagnostics are not available, but they are inevitably needed to administer adequate therapy. Serological parameters such as serum ferritin and transferrin saturation (TSAT) are heavily influenced by simultaneous inflammation reactions, resulting in the need for more suitable parameters. Reticulocyte biomarkers such as reticulocyte hemoglobin content (RET-He) and Delta-hemoglobin equivalent (Delta-He) determined by fluorescence flowcytometry are more specific for the diagnosis of IDA-based anemia and should be investigated for this purpose.

METHODS

In a prospective cohort single-center study, serum ferritin and transferrin saturation (TSAT) were collected and compared to RET-He and Delta-He by performing a receiver operating curve (ROC) analysis. The sensitivity and specificity of a single variable or the combination of two variables, as well as cutoff values, for the diagnosis of IDA were calculated. A group comparison for IDA patients without IDA was performed for a control group.

RESULTS

A total of 314 patients were enrolled from an interdisciplinary ICU. RET-He (area under the curve (AUC) 0.847) and Delta-He (AUC 0.807) did indicate iron-deficient anemia that was more specific and sensitive in comparison to serum ferritin (AUC 0.678) and TSAT (AUC 0.754). The detection of functional iron deficiency (FID) occurred in 28.3% of cases with anemia.

CONCLUSIONS

Determination of RET-He and Delta-He allows for the increased precision and sensitivity of iron-deficient anemia in the ICU.

The Role of Iron and Cobalt in Gynecological Diseases

Iron and cobalt are micronutrients that play an important role in the regulation of cellular processes, being part of the centre of catalases, peroxidases, cytochromes and metalloproteins such as hemoglobin and myoglobin (Fe). Cobalt primarily functions as a component of hydroxycobalamin, which is essential for regulating red blood cell production. Maintaining normal levels of cobalt and iron in the human body is important, as a deficiency can lead to anaemia. These elements are also involved in reactions during which oxidative stress occurs and are therefore considered to be a cause of tumor formation. This paper will discuss aspects of the influence of cobalt and iron on mechanisms that may contribute to the growth of gynecological tumors, as well as other obstetric-gynecological disease entities, by altering the conditions of the microenvironment. In addition, the following review also highlights the role of cobalt and iron in the treatment of gynecological tumors.

Effect of hemoglobin extracted from Tegillarca granosa on iron deficiency anemia in mice

Iron deficiency anemia (IDA) is the most common nutritional deficiency in the world. This study was aimed to evaluate the therapeutic effects of hemoglobin from Tegillarca granosa (T. granosa) on IDA in mice. Mice were randomly divided into five groups: a normal control group, an anemia model group, a positive (FeSO₄) control group, a low-dose and high-dose hemoglobin groups. After 4-week iron supplements administration, it was observed that hemoglobin at 2.0 mg iron/kg body weight had better restorative effective on IDA mice than that of FeSO₄ with regard to routine blood parameters and serum biochemical indicators. Meanwhile, the IDA-caused alterations of organ coefficients and liver morphology were ameliorated in mice after hemoglobin supplementation in a dose-dependent manner. Further correlation analysis of indicators showed that serum ferritin (iron storage protein) and soluble transferrin receptor (cellular iron uptake membrane glycoprotein) were susceptible to iron deficiency, indicating possibledisorder of iron metabolism caused by IDA. And levels of serum ferritin and soluble transferrin receptor were restored after administration of hemoglobin. These findings confirmed the safety and effectiveness of T. granosa derived hemoglobin in alleviating IDA in mice, suggesting its great potential as an alternative for iron supplementation.

Significance of low ferritin without anaemia in screen-detected, adult coeliac disease patients

BACKGROUND

Low ferritin without anaemia has been linked to adverse health effects.

OBJECTIVES

To investigate the prevalence and clinical significance of low ferritin in screen-detected coeliac disease.

METHODS

Seventy-six screen-detected coeliac disease patients were enrolled in the prospective collection of comprehensive clinical, laboratory and histological data at diagnosis and after 1-2 years on a gluten-free diet (GFD). All variables were compared between patients with different ferritin levels.

RESULTS

At coeliac disease diagnosis, six patients had anaemia. Of the 70 nonanaemic patients, ferritin levels were <15 μg/L in 21%, 15-29 μg/L in 19%, 30-99 μg/L in 36% and ≥100 μg/L in 24%. Those with lower ferritin were more often females, had lower body mass index, haemoglobin and villous height-crypt depth ratio and also had higher intra-epithelial lymphocyte CD3+ levels in duodenal biopsies. The groups did not differ in neurological or gastrointestinal symptoms, health-related quality of life, bone mineral density, liver values, vitamin, albumin or coeliac autoantibody levels or the prevalence of comorbidities. Median ferritin levels increased from 41.5 μg/L to 86.0 μg/L on GFD (p < 0.001). Ferritin remained <30 μg/L in 21% of patients but was not associated with dietary compliance, nor was any correlation between changes in ferritin and quality of life, gastrointestinal symptoms, autoantibody levels or degree of histological damage detected.

CONCLUSION

Decreased ferritin is a frequent finding in screen-detected coeliac disease and may not be fully restored on a GFD. However, low ferritin levels are not associated with more severe symptoms or poorer quality of life.

The Contribution of Hydrophobic Interactions to Conformational Changes of Inward/Outward Transmembrane Transport Proteins

Proteins transporting ions or other molecules across the membrane, whose proper concentration is required to maintain homeostasis, perform very sophisticated biological functions. The symport and antiport active transport can be performed only by the structures specially prepared for this purpose. In the present work, such structures in both In and Out conformations have been analyzed with respect to the hydrophobicity distribution using the FOD-M model. This allowed for identifying the role of individual protein chain fragments in the stabilization of the specific cell membrane environment as well as the contribution of hydrophobic interactions to the conformational changes between In/Out conformations.

The basics of blood and associated disorders

The blood and its components are involved in a wide range of processes to support life, including fighting infection and providing the body's tissues with oxygen and nutrients. If any stage in the development of blood cells is disrupted, for example by genetic abnormalities or a lack of nutrients, disease may result. This article provides an overview of some of the blood's key components, blood cells and their formation and functions, blood groups and some of the problems that can arise from malfunctions. A case study on haemophilia A as a blood disorder is presented to consolidate knowledge.

Association of Zinc with Anemia

Zinc is an essential trace element, and anemia is the most common blood disorder. The association of zinc with anemia may be divided into three major forms: (1) zinc deficiency contributing to anemia, (2) excess intake of zinc leading to anemia, and (3) anemia leading to abnormal blood-zinc levels in the body. In most cases, zinc deficiency coexists with iron deficiency, especially in pregnant women and preschool-age children. To a lesser extent, zinc deficiency may cooperate with other factors to lead to anemia. It seems that zinc deficiency alone does not result in anemia and that it may need to cooperate with other factors to lead to anemia. Excess intake of zinc is rare. However, excess intake of zinc interferes with the uptake of copper and results in copper deficiency that leads to anemia. Animal model studies indicate that in anemia, zinc is redistributed from plasma and bones to the bone marrow to produce new red blood cells. Inadequate zinc status (zinc deficiency or excess) could have effects on anemia; at the same time, anemia could render abnormal zinc status in the body. In handling anemia, zinc status needs to be observed carefully, and supplementation with zinc may have preventive and curative effects.

Increased hemoglobin concentration and related factors in maintenance hemodialysis patients in Anhui, China

To investigate the hemoglobin (Hb) concentration and related factors among maintenance hemodialysis (MHD) patients in Anhui province in 2020, so as to compare with the results in 2014. The cases of 3025 MHD patients were investigated in 27 hemodialysis centers of Anhui province from January 2020 to December 2020. The data of age, sex, primary disease, dialysis age, dialysis mode, drug use and laboratory tests were collected and analyzed. Compared with the survey in 2014, the average Hb level of MHD patients in Anhui province was increased (107.41 ± 20.40 g/L vs 100.2 ± 28.1 g/L), the anemia prevalence was decreased (65.9% vs 82.4%), and the percentage of patients with standard Hb level was increased significantly (47.1% vs 32.9%). Compared with low-Hb patients (Hb < 110 g/L), patients with Hb ≥ 110 g/L had lower age, higher proportion of males, longer dialysis age, higher levels of serum Alb, creatinine, total cholesterol, triglyceride, low density lipoprotein, calcium, phosphorus, magnesium, and lower high-density lipoprotein (P < .05). The multivariate logistic regression analysis results showed that male, longer duration of dialysis therapy, treatment with iron, higher triglyceride and albumin were protective factors of anemia, but older age was independent risk factors. The anemia treatment in MHD patients in Anhui province was significantly improved. Male, long dialysis age, use of iron, high serum albumin and triglyceride levels may be protective factors for Hb reaching standard level, and old age may be an independent risk factor.

Prevalence of anaemia in adults with chronic kidney disease in a representative sample of the United States population: analysis of the 1999-2018 National Health and Nutrition Examination Survey

Background

Population-based estimates of anaemia prevalence in patients with chronic kidney disease (CKD) vary, and data on the prevalence of severe anaemia of CKD are limited. This study examined the prevalence of anaemia and anaemia eligible for erythropoiesis-stimulating agent (ESA) treatment in patients with CKD in the USA.

Methods

National Health and Nutrition Examination Survey (NHANES) data from 1999-2000 to 2017-18 were used to determine the prevalence of diagnosed anaemia (haemoglobin <12 g/dL in women; <13 g/dL in men) and anaemia eligible for ESA treatment (haemoglobin <10 g/dL) in survey participants aged ≥18 years with stage 3-5 non-dialysis-dependent CKD (estimated glomerular filtration rate <60 mL/min/1.73 m²). The study objectives were to (i) obtain a more recent estimate of anaemia prevalence in patients with non-dialysis-dependent CKD and (ii) examine the characteristics of individuals with CKD and haemoglobin <10 g/dL.

Results

Of 51 163 eligible NHANES participants, 2926 (5.7%) with stage 3-5 CKD were included. In all participants, the weighted prevalences of anaemia and haemoglobin <10 g/dL were 25.3% and 1.9%, respectively. Mean haemoglobin levels decreased numerically between 1999 and 2012 and remained stable thereafter. The prevalence of anaemia and haemoglobin <10 g/dL increased with advancing CKD stage. The odds of haemoglobin <10 g/dL were significantly higher in stage ≥3B versus 3A and in non-Hispanic Blacks versus other races.

Conclusions

In our analysis, approximately 25% of individuals with stage 3-5 CKD in the USA had anaemia and approximately 2% had anaemia eligible for ESA treatment.

Intravenous ferric carboxymaltose for the management of iron deficiency and iron deficiency anaemia in children and adolescents: a review

Iron deficiency is the primary cause of anaemia worldwide and is particularly common among children and adolescents. Intravenous (IV) iron therapy is recommended for paediatric patients with certain comorbidities or if oral iron treatment has been unsuccessful. IV ferric carboxymaltose (FCM) has recently been approved by the US Food and Drug Administration for use in children aged > 1 year. This narrative review provides an overview of the available publications on the efficacy and safety of IV FCM in children and adolescents. A literature search using PubMed and Embase yielded 153 publications; 33 contained clinical data or reports on clinical experience relating to IV FCM in subjects < 18 years of age and were included in the review. No prospective, randomised controlled studies on the topic were found. Most publications were retrospective studies or case reports and included patients with various underlying conditions or patients with inflammatory bowel disease. Efficacy data were included in 27/33 publications and improvements in anaemia, and/or iron status parameters were reported in 26 of them. Safety data were included in 25/33 publications and were in line with the adverse events described in the prescribing information.

CONCLUSION

The available publications indicate that IV FCM, a nanomedicine with a unique and distinctive therapeutic profile, is an effective and generally well-tolerated treatment for iron deficiency or iron deficiency anaemia in children and adolescents. Despite the wealth of retrospective evidence, prospective, randomised controlled trials in the paediatric setting are still necessary.

WHAT IS KNOWN

• Iron deficiency and iron deficiency anaemia are usually managed using oral iron therapy, but intravenous iron therapy is recommended for certain paediatric patients. • Intravenous ferric carboxymaltose (FCM) has recently been approved in the US for use in children aged > 1 year.

WHAT IS NEW

• Despite evidence that FCM is effective and generally well tolerated in children and adolescents, so far, only retrospective studies, non-randomised uncontrolled prospective studies, or case reports have been published in full. • There is a strong need for prospective, randomised controlled trials on FCM in the paediatric setting.

Defective iron homeostasis and hematological abnormalities in Niemann-Pick disease type C1

Background: Niemann-Pick disease type C1 (NPC1) is a neurodegenerative lysosomal storage disorder characterized by the accumulation of multiple lipids in the late endosome/lysosomal system and reduced acidic store calcium. The lysosomal system regulates key aspects of iron homeostasis, which prompted us to investigate whether there are hematological abnormalities and iron metabolism defects in NPC1. Methods: Iron-related hematological parameters, systemic and tissue metal ion and relevant hormonal and proteins levels, expression of specific pro-inflammatory mediators and erythrophagocytosis were evaluated in an authentic mouse model and in a large cohort of NPC patients. Results: Significant changes in mean corpuscular volume and corpuscular hemoglobin were detected in Npc1 -/- mice from an early age. Hematocrit, red cell distribution width and hemoglobin changes were observed in late-stage disease animals. Systemic iron deficiency, increased circulating hepcidin, decreased ferritin and abnormal pro-inflammatory cytokine levels were also found. Furthermore, there is evidence of defective erythrophagocytosis in Npc1 -/- mice and in an in vitro NPC1 cellular model. Comparable hematological changes, including low normal serum iron and transferrin saturation and low cerebrospinal fluid ferritin were confirmed in NPC1 patients. Conclusions: These data suggest loss of iron homeostasis and hematological abnormalities in NPC1 may contribute to the pathophysiology of this disease.

Iron deficiency and soil-transmitted helminth infection: classic and neglected connections

Beyond participating in the oxygen transport by red blood cells, iron is an essential micronutrient and contributes to different physiological pathways and processes, such as cell proliferation, DNA repair, and other homeostatic functions. Iron deficiency affects millions of people, especially children and pregnant women. The consequences of iron deficiency are diverse, including inadequate child development, impaired cognition, and reduced productivity. Several factors contribute to iron deficiency, such as iron-poor diet, genetic factors, and infection with soil-transmitted helminths (STHs), especially roundworms (Ascaris lumbricoides), hookworms (Necator americanus and Ancylostoma duodenale), and whipworms (Trichuris trichiura). This review updates and summarizes the role of STHs as drivers of iron deficiency. Also, the poorly explored connections between STH infection, geophagia (a pica manifestation), immune response, and iron deficiency are discussed, highlighting how iron deficiency may act as a risk factor for infections by STHs, in addition to being a consequence of intestinal parasitic infections. Finally, strategies for control and management of iron deficiency and STH infection are described.

Overexpression of Nicotianamine Synthase (AtNAS1) Increases Iron Accumulation in the Tuber of Potato

Iron (Fe) deficiency is a global health problem, especially in underdeveloped countries. Biofortification with genetic engineering methods has been used to improve Fe nutrition in a number of crops. Various steps, e.g., uptake, distribution, and storage, involved in Fe homeostasis have been manipulated to increase the Fe concentration in the edible portions of plants. Nicotianamine (NA) is an important metal ion chelator in plants. It promotes the mobility of Fe and decreases cellular Fe toxicity. Increasing the Fe content in crops by promoting NA synthesis could help decrease human diseases associated with Fe deficiency. In the present study, Arabidopsis thaliana nicotianamine synthase 1 (AtNAS1) was overexpressed in potato (Solanum tuberosum, St) under the control of the cauliflower mosaic virus 35S promoter. Transgenic plants had a significantly increased amount of Fe in tubers (52.7 µg/g dry weight, 2.4-fold the amount in wild-type tubers), while no differences in plant phenotype or yield were detected between transgenic and wild-type plants. The expression of genes involved in root mineral uptake and homeostasis, such as StYSL1, StIRT1, StFRO1, and StNAS, was also altered in the roots and leaves of the transgenic plants. Our results demonstrate that the manipulation of Fe chelation is a useful strategy for Fe nutrition improvement, and the increased Fe accumulation in tubers of transgenic potato plants is most likely caused by the increased movement of Fe from the leaf to the tuber.

Trends in ferritin measurements in children and adolescents: A Finnish 9-year observational study

AIM

A lack of stored iron, indicated by low serum ferritin, has been associated with various clinical symptoms. There are no longitudinal data on the frequency of ferritin measurements in children and adolescents.

METHODS

A total of 2834 children aged <18 years with serum ferritin and other anaemia-related blood parameters taken during an outpatient visit between 2012 and 2019 were investigated. Patients with acute infections were excluded. Nationwide temporal and regional variations and correlations with public information searches through Google were analysed.

RESULTS

A significant increase in the frequency of ferritin measurements was seen starting in 2018, with a 47-fold rise in 2019 compared to 2012. A simultaneous escalation in Google Search activity was seen. Deficiency of stored iron was relatively common: 21.6% of children with normal haemoglobin and 14.9% of non-anaemic children with normal red cell indices exhibited ferritin levels below 15 μg/L.

CONCLUSION

Ferritin measurement has increased greatly among children and adolescents. Our results suggest that public interest and popular trends can significantly influence health care practices. This calls for further investigation into the causes and consequences of such a phenomenon. Prospective randomised intervention studies are needed to evaluate the utility of iron supplementation in patients with low iron storage levels.

Iron metabolism and iron deficiency anemia in women

Iron deficiency (ID) and iron deficiency anemia (IDA) are highly prevalent among women across their reproductive age. An iron-deficient state has been associated with and causes a number of adverse health consequences, affecting all aspects of the physical and emotional well-being of women. Heavy menstrual bleeding, pregnancy, and the postpartum period are the major causes of ID and IDA. However, despite the high prevalence and the impact on quality of life, ID and IDA among women in their reproductive age is still underdiagnosed and undertreated. In this chapter we summarized the iron metabolism and the diagnosis and treatment of ID and IDA in women.

Effectiveness of prophylactic iron supplementation in the reduction of recurrence of febrile seizures in children: A prospective study with comparison with historical controls

Objectives

The primary objective of the study was to compare the number of patients with febrile seizure recurrence within 1 year of presenting to our institute, among patients who received and didn't receive oral iron supplementation.

Materials and Methods

This prospective intervention study with historical controls was conducted to compare the number of patients with febrile seizure recurrence within 1 year, among patients who received and did not receive oral iron supplementation. The intervention group additionally received prophylactic iron supplementation of 20 mg biweekly for 1 year.

Results

A total of 53 patients each were enrolled in both the groups, with comparable baseline characteristics. Although there was a trend toward a lower rate of recurrence of febrile seizures in the interventional group, as compared to the control group, it did not reach the point of statistical significance (P = 0.35). Both in the worst-case scenario and best-case scenario, there was a trend toward less risk of recurrence of febrile seizure in the intervention group, but it did not reach the point of statistical significance (P = 0.43 and 0.52). For the original scenario, worst-case scenario, and best-case scenario, the absolute risk reduction was 6.5%, 7%, and 6%, respectively, with corresponding number needed to treat (NNT) being 15, 14, and 16, respectively. The trend for absolute risk reduction was more pronounced in those with complex febrile seizures with an NNT of 6.5, but it still did not reach the point of statistical significance (P = 0.16). Moderate/severe IDA was also found to be an independent risk factor for recurrence of febrile seizure in the intervention group (P = 0.03).

Conclusion

Oral serum iron supplementation does not significantly reduce the recurrence rate of febrile seizures in children aged 6-60 months. However, there is a trend toward reduction in the frequency of recurrence of febrile seizures, which is more pronounced in the subset with complex febrile seizures.

Polyphenol-Rich Ginger (Zingiber officinale) for Iron Deficiency Anaemia and Other Clinical Entities Associated with Altered Iron Metabolism

Ginger (Zingiber officinale) is rich in natural polyphenols and may potentially complement oral iron therapy in treating and preventing iron deficiency anaemia (IDA). This narrative review explores the benefits of ginger for IDA and other clinical entities associated with altered iron metabolism. Through in vivo, in vitro, and limited human studies, ginger supplementation was shown to enhance iron absorption and thus increase oral iron therapy's efficacy. It also reduces oxidative stress and inflammation and thus protects against excess free iron. Ginger's bioactive polyphenols are prebiotics to the gut microbiota, promoting gut health and reducing the unwanted side effects of iron tablets. Moreover, ginger polyphenols can enhance the effectiveness of erythropoiesis. In the case of iron overload due to comorbidities from chronic inflammatory disorders, ginger can potentially reverse the adverse impacts and restore iron balance. Ginger can also be used to synthesise nanoparticles sustainably to develop newer and more effective oral iron products and functional ingredients for IDA treatment and prevention. Further research is still needed to explore the applications of ginger polyphenols in iron balance and anaemic conditions. Specifically, long-term, well-designed, controlled trials are required to validate the effectiveness of ginger as an adjuvant treatment for IDA.

Phenotypic characterization and multiple resistance analysis in an experimentally selected albendazole-resistant hookworm isolate

For some nematodes, alterations that leads to a resistance genotype may be accompanied by other modifications, causing changes in the biology of the parasite, although the exact mechanisms of this relationship are still not very clear. These alterations can have deleterious effects on their survival or even potentiate their pathogenicity. In this study a phenotypic characterization was carried out to compare two Ancylostoma ceylanicum isolates, a wild type one, kept in the laboratory and an albendazole selected resistant isolate (AceyBZR2). Differences in some analyzed parameters, between the two strains, were registered, as patency period, number and size of the recovered worms, including differences in the body structures. The AceyBZR2 isolate showed to be less adapted to the host, leading to a smaller number of recovered worms. However, no difference on the female egg content was observed between the two isolates. Concerning blood evaluation, no differences were found between the wild type and AceyBZR2 isolates, related to hemoglobin and hematocrit levels. However, animals in the group infected with the wild type isolate had lower serum iron concentrations than animals in the AceyBZR2 group. The possibility that the AceyBZR2 isolate might be resistant to other drugs was evaluated and it was demonstrated that it does not present cross-resistance to ivermectin and nitazoxanide. However, when animals infected with the AceyBZR2 were treated with another drug from the benzimidazoles group (mebendazole), the cross-resistance effect was observed. Morphometric analyses were performed comparing female and male adult worms from the two isolates. The results presented here allow a better understanding of the parasite-host relationship and may constitute a useful basis for establishing future control strategies for soil-transmitted helminths.

Investigation of optimum hemoglobin levels in older patients with chronic kidney disease

AIM

The aim of the present study is to determine target hemoglobin (Hgb) values ​​in older females and males with chronic kidney disease (CKD) according to best performance in mood, gait and balance, muscle strength and activities of daily living, which are important parameters of geriatric assessment.

METHOD

Patients' age, gender, education level, and comorbidities were recorded. All the participants underwent comprehensive geriatric assessment (CGA) including Basic and Instrumental Activities of Daily Living for functional evaluation, Tinetti Performance-Oriented Assessment of Mobility and Timed Up and Go Test for fall risk, and hand grip strength for muscle strength. Hgb levels and kidney functions were analyzed on the same day as CGA measurements. Receiver Operating Characteristic (ROC) analysis was used to detect the optimum level of Hgb according to the best performance of CGA parameters.

RESULTS

622 elderly CKD patients (69.3% female, 55.7% with anemia) were included. After adjustment for confounders, those with anemia had dynapenia (OR 1.60), high risk of falls (OR 1.60), and decreased functional capacity (OR 1.83) among females and those with anemia had dynapenia (OR 4.31), a high risk of falling (OR 2.42) and decreased functional capacity (OR 2.94) among males. The optimum value of Hgb level is 11.8-12.1 in females and 12.6-12.8 in males according to ROC analysis.

CONCLUSION

Anemia is associated with dynapenia, high risk of falls, and decreased functional capacity in older CKD patients regardless of genericity. To prevent these negative outcomes, Hgb should be kept in the range of 11.8-12.1 in older females with CKD and 12.6-12.8 in older males with CKD.

Effects and Safety of Oral Iron for Heart Failure with Iron Deficiency: A Systematic Review and Meta-Analysis with Trial Sequential Analysis

Background

Oral iron supplement is commonly prescribed to heart failure patients with iron deficiency. However, the effects of oral iron for heart failure remain controversial. This study included randomized controlled trials (RCTs) for meta-analysis to evaluate the effects of oral iron for heart failure patients.

Methods

Nine databases (The Cochrane Library, Embase, PubMed, CINAHL, Web of science, CNKI, SinoMed, VIP, and Wanfang) were searched for RCTs of oral iron for heart failure from inception to October 2021. The effects were assessed with a meta-analysis using Revman 5.3 software. The trial sequential analysis was performed by TSA 0.9.5.10 beta software. The risk of bias of trials was evaluated via Risk of Bias tool. The evidence quality was assessed through GRADE tool.

Results

Four studies including 582 patients with heart failure and iron deficiency were enrolled. The results indicated that oral iron treatment could improve left ventricular ejection fraction (LVEF, MD = 1.52%, 95% CI: 0.69 to 2.36, P = 0.0003) and serum ferritin (MD = 1.64, 95% CI: 0.26 to 3.02, P = 0.02). However, there was no between-group difference in the 6-minute walk distances (6MWT), N terminal pro B type natriuretic peptide (NT-proBNP) or hemoglobin level when compared with control group. Subgroup analyses revealed that the effects of oral iron on 6 MWT and serum ferritin could not be affected by duration and frequency of oral iron uptakes. In trial sequential analysis of LVEF and serum ferritin, the Z-curves crossed the traditional boundary and trail sequential monitoring boundary but did not reach the required information size.

Conclusion

This analysis showed that oral iron could improve cardiac function measured by LVEF, and iron stores measured serum ferritin, but lack of effect on exercise capacity measured by 6 MWT, and iron stores measured by hemoglobin. Given the overall poor methodological quality and evidence quality, these findings should be treated cautiously.

Perioperative Quality Initiative and Enhanced Recovery After Surgery-Cardiac Society Consensus Statement on the Management of Preoperative Anemia and Iron Deficiency in Adult Cardiac Surgery Patients

Preoperative anemia is common in patients presenting for cardiac surgery, with a prevalence of approximately 1 in 4, and has been associated with worse outcomes including increased risk of blood transfusion, kidney injury, stroke, infection, and death. Iron deficiency, a major cause of anemia, has also been shown to have an association with worse outcomes in patients undergoing cardiac surgery, even in the absence of anemia. Although recent guidelines have supported diagnosing and treating anemia and iron deficiency before elective surgery, details on when and how to screen and treat remain unclear. The Eighth Perioperative Quality Initiative (POQI 8) consensus conference, in conjunction with the Enhanced Recovery after Surgery-Cardiac Surgery Society, brought together an international, multidisciplinary team of experts to review and evaluate the literature on screening, diagnosing, and managing preoperative anemia and iron deficiency in patients undergoing cardiac surgery, and to provide evidence-based recommendations in accordance with Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria for evaluating biomedical literature.

Use of blood and its components in the treatment of anaemia in children

Blood transfusion is a well-established treatment for anaemia. Herein, blood and its components are transfused to replenish circulating blood volume, maintain the oxygen capacity of the blood and normalise the function of the coagulation system. Anaemia treatment by blood transfusions is a great challenge, especially with reference to paediatric patients. Blood is irreplaceable in a life-threatening situation, but it has its own side effects, just like all applied pharmacological products. Hence, it is extremely important to carefully select donors and utilise blood components according to the patient’s individual needs. Children represent a group that requires specific criteria to be met, mainly because of the fact that their physiological and haematological systems differ from those of adults. The most common types of anaemia seen in children are deficiency anaemias such as iron-deficiency anaemia, while less common are vitamin B12 deficiency anaemia or folate deficiency anaemia. Secondary anaemia is also relatively frequent in chronic diseases, among others, immunological or infectious, as well as renal, liver, endocrine and neoplastic diseases. Anaemia due to blood loss is also included in this group. Furthermore, some anaemias, such as aplastic anaemia (due to impaired erythrocyte production) and haemolytic anaemia (due to excessive destruction of red blood cells) may be congenital or acquired. Before deciding to implement blood therapy, the patient’s clinical condition or the different haematological, biochemical and immunological parameters at different stages of life should be considered. Since each transfusion may result in a variety of post-transfusion reactions, immunisation or transmission of infectious diseases, the decision to transfuse blood or blood components should be taken only when the patient cannot be treated effectively by any other means and the expected benefits of the transfusion outweigh the risks associated with possible complications. Considering the recipients’ low blood volume, low metabolic efficiency, higher haematocrit levels than in adults and immature immune system, products for these patients should be prepared in a special way. These components must ensure minimal risk of metabolic and haemostatic disorders. The collection of these products, as well as their preparation, storage and transfusion, should be carried out in accordance with current legislation.

The Dark Side of Iron: The Relationship between Iron, Inflammation and Gut Microbiota in Selected Diseases Associated with Iron Deficiency Anaemia—A Narrative Review

Iron is an indispensable nutrient for life. A lack of it leads to iron deficiency anaemia (IDA), which currently affects about 1.2 billion people worldwide. The primary means of IDA treatment is oral or parenteral iron supplementation. This can be burdened with numerous side effects such as oxidative stress, systemic and local-intestinal inflammation, dysbiosis, carcinogenic processes and gastrointestinal adverse events. Therefore, this review aimed to provide insight into the physiological mechanisms of iron management and investigate the state of knowledge of the relationship between iron supplementation, inflammatory status and changes in gut microbiota milieu in diseases typically complicated with IDA and considered as having an inflammatory background such as in inflammatory bowel disease, colorectal cancer or obesity. Understanding the precise mechanisms critical to iron metabolism and the awareness of serious adverse effects associated with iron supplementation may lead to the provision of better IDA treatment. Well-planned research, specific to each patient category and disease, is needed to find measures and methods to optimise iron treatment and reduce adverse effects.

Identification of Serum Ferritin-Specific Nanobodies and Development towards a Diagnostic Immunoassay

Serum ferritin (SF) is an iron-rich protein tightly connected with iron homeostasis, and the variations are frequently observed in diseased states, including iron-deficiency anemia, inflammation, liver disease, and tumors, which renders SF level an indicator of potential malignancies in clinical practice. Nanobodies (Nbs) have been widely explored and developed into theranostic reagents. Surprisingly, no reports stated the identification of anti-SF Nbs, nor the potential of such Nbs as a diagnostic tool. In this study, we generated SF-specific Nbs and provided novel clinical diagnostic approaches to develop an immunoassay. An immune library was constructed after immunizing an alpaca with SF, and five Nbs specifically targeting human SF were retrieved. The obtained Nbs exhibited robust properties including high stability, affinity, and specificity. Then, an ELISA-based test using a heterologous Nb-pair was developed. The calibration curve demonstrated a linear range of SF between 9.0 to 1100 ng/mL, and a limit of detection (LOD) of 1.01 ng/mL. The detecting recovery and coefficient variation (CV) were determined by spiking different concentrations of SF into the serum sample, to verify the successful application of our selected Nbs for SF monitoring. In general, this study generated SF-specific Nbs and demonstrated their potential as diagnostic immunoassay tools.

The multi-faced role of FUNDC1 in mitochondrial events and human diseases

Mitophagy plays a vital role in the selective elimination of dysfunctional and unwanted mitochondria. As a receptor of mitophagy, FUN14 domain containing 1 (FUNDC1) is attracting considerably critical attention. FUNDC1 is involved in the mitochondria fission, the clearance of unfolded protein, iron metabolism in mitochondria, and the crosstalk between mitochondria and endoplasmic reticulum besides mitophagy. Studies have demonstrated that FUNDC1 is associated with the progression of ischemic disease, cancer, and metabolic disease. In this review, we systematically examine the recent advancements in FUNDC1 and the implications of this protein in health and disease.

Influence of an energy deficient and low carbohydrate acute dietary manipulation on iron regulation in young females

Hepcidin is a liver-derived hormone that regulates iron metabolism. Recent studies suggest that an energy-deficient diet or low carbohydrate (CHO) availability may increase hepcidin in the absence of inflammation. The purpose of the present study was to examine the impact of either an energy-deficient diet or an ED diet with low CHO intake during three consecutive days on hepcidin responses, hematological variables, and energy metabolism in young Japanese women. Twenty-two young females were divided into two different groups, either an energy-deficient with low CHO intake group (ED + LCHO; 2.0 ± 0.3 g/kg/day CHO, 39%CHO, 1123 kcal/day) or an energy deficient with moderate CHO intake group (ED; 3.4 ± 0.3 g/kg/day CHO, 63%CHO, 1162 kcal/day). During the three consecutive days of the dietary intervention program, participants consumed only the prescribed diet and maintained their habitual physical activity levels. Body composition, substrate oxidation, iron metabolism, and inflammation were evaluated pre- and post-intervention. Serum iron and ferritin levels were significantly elevated following the intervention (p < 0.001, p = 0.003, respectively). Plasma interleukin-6 (IL-6) levels did not change following the intervention. Serum hepcidin levels significantly increased after the intervention (p = 0.002). Relative change in hepcidin levels was significantly higher in the ED + LCHO (264.3 ± 87.2%) than in the ED group (68.9 ± 22.1%, p = 0.048). Three consecutive days of an energy-deficient diet increased fasting hepcidin levels. Moreover, elevated hepcidin levels were further augmented when an energy-deficient diet was combined with a lower CHO intake.