Evaluation and treatment of iron deficiency anemia: a gastroenterological perspective

Diagnosis and management of anemia in pediatric inflammatory bowel diseases: Clinical practice guidelines on behalf of the SIGENP IBD Working group

Anemia is one of the most frequent extra-intestinal manifestations of inflammatory bowel disease. Insidious onset, variability of symptoms and lack of standardized screening practices may increase the risk of underestimating its burden in children with IBD. Despite its relevance and peculiarity in everyday clinical practice, this topic is only dealt with in a few documents specifically for the pediatric field. The aim of the current guidelines is therefore to provide pediatric gastroenterologists with a practical update to support the clinical and therapeutic management of children with IBD and anemia. A panel of 19 pediatric gastroenterologists and 1 pediatric hematologist with experience in the field of pediatric IBD was agreed by IBD Working group of the Italian Society of Gastroenterology, Hepatology and Nutrition (SIGENP) to produce the present article outlining practical clinical approaches to the pediatric patient with IBD and anemia. The levels of evidence and recommendations have been defined for each part of the statement according to the GRADE system.

Role of micronutrients in inflammatory bowel disease

Inflammatory bowel disease (IBD) is an autoimmune intestinal disease that includes ulcerative colitis, Crohn's disease, and indeterminate colitis. Patients with IBD are often at risk for malnutrition, including micronutrient deficiencies, due to dietary restrictions and poor intestinal absorption. Micronutrients, including vitamins and minerals, play an important role in the human body's metabolism and maintenance of tissue functions. This article reviews the role of micronutrients in IBD. Micronutrients can affect the occurrence and progression of IBD by regulating immunity, intestinal flora, oxidative stress, intestinal barrier function, and other aspects. Monitoring and timely supplementation of micronutrients are important to delay progression and improve clinical symptoms in IBD patients.

Nutrition, Nutritional Status, Micronutrients Deficiency, and Disease Course of Inflammatory Bowel Disease

During the disease course, most Inflammatory Bowel Disease patients present a condition of malnutrition, undernutrition, or even overnutrition. These conditions are mainly due to suboptimal nutritional intake, alterations in nutrient requirements and metabolism, malabsorption, and excessive gastrointestinal losses. A suboptimal nutritional status and low micronutrient serum levels can have a negative impact on both induction and maintenance of remission and on the quality of life of Inflammatory Bowel Disease patients. We performed a systematic review including all the studies evaluating the connection between nutrition, nutrition status (including undernutrition and overnutrition), micronutrient deficiency, and both disease course and therapeutic response in Inflammatory Bowel Disease patients. This systematic review was performed using PubMed/MEDLINE and Scopus. Four main clinical settings concerning the effect of nutrition on disease course in adult Inflammatory Bowel Disease patients were analyzed (induction of remission, maintenance of remission, risk of surgery, post-operative recurrence, and surgery-related complications). Four authors independently reviewed abstracts and manuscripts for eligibility. 6077 articles were found; 762 duplicated studies were removed. Out of 412 full texts analyzed, 227 were included in the review. The evidence summarized in this review showed that many nutritional aspects could be potential targets to induce a better control of symptoms, a deeper remission, and overall improve the quality of life of Inflammatory Bowel Disease patients.

Modelling the episodes of care for iron deficiency anemia patients in a secondary-care center using continuous-time multistate Markov chain

BACKGROUND

Despite the high prevalence of gastro-intestinal (GI) cancer in iron deficiency anemia (IDA), some IDA patients do not complete all the necessary GI investigations at the initial referral. As a result, existing cancers are diagnosed at a later referral with worse prognosis. The potential to detect GI cancer early depends on minimizing the delay time spent between the two consecutive referrals, where a patient did not complete investigations at the first referral, but at the second is diagnosed with positive GI cancer. This retrospective longitudinal study aims to highlight the proper methods to model these referrals.

METHODS

Using anonymized data of 168 episodes of care for IDA patients at an IDA clinic in a secondary care setting, continuous-time multi-state Markov chain is employed to determine the transition rates among three observed states for IDA patients at the IDA clinic, "incomplete investigations," "negative GI cancer," and "positive GI cancer" and to estimate the delay time.

RESULTS

Once in the state of incomplete investigations, an estimated mean delay time of 3.1 years (95% CI: 1.2, 5) is spent before being diagnosed with positive GI cancer. The probability that a "positive GI diagnosis" is next after the state of "incomplete investigation" is 17%, compared with 11% when it is followed in the state of negative GI cancer. Defining the survival as the event of not being in the state of "positive GI cancer," the survival rate of IDA patients with negative GI cancer is always higher than those with incomplete investigations. Finally, being diagnosed with positive GI cancer is always preceded by the prediction of being considered "very high risk" at the earlier visit.

CONCLUSION

A baseline model was proposed to represent episodes of care for IDA patients at a secondary care center. Preliminary results highlight the importance of completing the GI investigations, especially in IDA patients, who are at high risk of GI cancer and fit to go through the investigations.

Anemia as a Problem: GEH Approach

BACKGROUND

Anemia is present in almost 5% of adults worldwide and accompanies clinical findings in many diseases. Diseases of the gastrointestinal (GI) tract and liver are a common cause of anemia, so patients with anemia are often referred to a gastroenterologist.

SUMMARY

Anemia could be caused by various factors such as chronic bleeding, malabsorption, or chronic inflammation. In clinical practice, iron deficiency anemia and the combined forms of anemia due to different pathophysiological mechanisms are most common. Esophagogastroduodenoscopy, colonoscopy, and the small intestine examinations in specific situations play a crucial role in diagnosing anemia. In anemic, GI asymptomatic patients, there are recommendations for bidirectional endoscopy. Although GI malignancies are the most common cause of chronic bleeding, all conditions leading to blood loss, malabsorption, and chronic inflammation should be considered. From a gastroenterologist's perspective, the clinical spectrum of anemia is vast because many different digestive tract diseases lead to bleeding. Key Messages: The gastroenterological approach in solving anemia's problem requires an optimal strategy, consideration of the accompanying clinical signs, and the fastest possible diagnosis. Although patients with symptoms of anemia are often referred to gastroenterologists, the diagnostic approach requires further improvement in everyday clinical practice.

Broad external validation of a multivariable risk prediction model for gastrointestinal malignancy in iron deficiency anaemia

BACKGROUND

Using two large datasets from Dorset, we previously reported an internally validated multivariable risk model for predicting the risk of GI malignancy in IDA-the IDIOM score. The aim of this retrospective observational study was to validate the IDIOM model using two independent external datasets.

METHODS

The external validation datasets were collected, in a secondary care setting, by different investigators from cohorts in Oxford and Sheffield derived under different circumstances, comprising 1117 and 474 patients with confirmed IDA respectively. The data were anonymised prior to analysis. The predictive performance of the original model was evaluated by estimating measures of calibration, discrimination and clinical utility using the validation datasets.

RESULTS

The discrimination of the original model using the external validation data was 70% (95% CI 65, 75) for the Oxford dataset and 70% (95% CI 61, 79) for the Sheffield dataset. The analysis of mean, weak, flexible and across the risk groups' calibration showed no tendency for under or over-estimated risks in the combined validation data. Decision curve analysis demonstrated the clinical value of the IDIOM model with a net benefit that is higher than 'investigate all' and 'investigate no-one' strategies up to a threshold of 18% in the combined validation data, using a risk cut-off of around 1.2% to categorise patients into the very low risk group showed that none of the patients stratified in this risk group proved to have GI cancer on investigation in the validation datasets.

CONCLUSION

This external validation exercise has shown promising results for the IDIOM model in predicting the risk of underlying GI malignancy in independent IDA datasets collected in different clinical settings.

Safety, Tolerability, and Pharmacokinetics of Oral Ferric Maltol in Children With Iron Deficiency: Phase 1 Study

Iron deficiency is common in children and can have negative effects on behavior and function. Standard oral ferrous iron replacement is poorly absorbed and can cause treatment-limiting gastrointestinal adverse events (AEs). Ferric maltol is formulated to improve gastrointestinal absorption and tolerability versus oral ferrous compounds. In adult phase 3 trials, it increased hemoglobin and iron stores versus placebo, with a gastrointestinal AE profile similar to placebo. Here, we assess different doses of ferric maltol in children with iron deficiency.

Methods

This phase 1 trial involved children of age 10 to 17 years with ferritin <30 µg/L (or <50 µg/L with transferrin saturation [TSAT] <20%). Children were randomized 1:1:1 to oral ferric maltol 7.8 mg, 16.6 mg, or 30 mg twice daily for 9 days and once on day 10. The primary outcomes were iron uptake measures (serum iron and TSAT) and population pharmacokinetic analyses.

Results

The trial included 37 children (mean age 14.0 years; baseline mean ± standard deviation ferritin 16.3 ± 8.02 µg/L). Ferric maltol increased iron uptake nondose-proportionally: serum iron and TSAT plateaued between the 2 higher doses on day 1 and were comparable across all doses on day 10. Twenty children (54%) experienced AEs (all mild/moderate, gastrointestinal 32%), with similar frequencies in each group.

Conclusions

All 3 ferric maltol doses increased iron uptake in children with iron deficiency, even over the short study duration, and were well tolerated. Nondose-dependent changes in serum iron and TSAT indicate physiologic regulation of iron uptake to meet the body's needs.

Iron Deficiency and the Small bowel​

PURPOSE OF REVIEW

This article reviews iron deficiency anemia (IDA) and suspected small bowel bleeding (SSBB) from initial consultation through laboratory evaluation, endoscopic evaluation, and therapeutic options.

RECENT FINDINGS

Recent guidelines on management of SSBB, IDA, video capsule endoscopy (VCE), and device-assisted enteroscopy (DAE) are reviewed. The advantages and limitations of VCE, DAE, and imaging are discussed. Medical treatment for refractory small bowel bleeding is discussed. Evaluation of IDA starts with a detailed history and physical exam. Additional lab work can establish the diagnosis of IDA and evaluate for associated conditions. If initial endoscopic tests are unrevealing, SSBB should be ruled out. Further investigation can be performed using video capsule endoscopy (VCE), device-assisted enteroscopy (DAE), and imaging. The mainstay of medical treatment of IDA secondary to SSBB is iron supplementation. Additional treatment is tailored to the pathology and may include medical, endoscopic and surgical options.

Oral Ferric Maltol for the Treatment of Iron-Deficiency Anemia in Patients With CKD: A Randomized Trial and Open-Label Extension

RATIONALE & OBJECTIVE

Iron-deficiency anemia is common in patients with chronic kidney disease (CKD) not requiring kidney replacement therapy (KRT). We evaluated effects of oral iron replacement therapy with ferric maltol in these patients.

STUDY DESIGN

Phase 3, double-blind, randomized, placebo-controlled trial (AEGIS-CKD) and open-label extension.

SETTING & PARTICIPANTS

Adults with stage 3 or 4 CKD and iron-deficiency anemia at 30 US centers.

INTERVENTION

Oral ferric maltol at 30mg or placebo twice daily for 16 weeks (2:1 randomization) followed by ferric maltol at 30mg twice daily for up to 36 weeks (all patients).

OUTCOME

Change from baseline in hemoglobin (primary end point at week 16), ferritin, transferrin saturation, and serum iron; safety.

RESULTS

167 patients were randomized (ferric maltol, n=111; placebo, n=56). At week 16, hemoglobin had increased significantly with ferric maltol versus placebo (least-squares mean difference: 0.5±0.2 [SE] g/dL; 95% CI, 0.1-0.9; P=0.01). Ferritin, transferrin saturation, and serum iron increased with ferric maltol but declined with placebo (all P<0.05). Hemoglobin levels were sustained up to week 52 in patients continuing ferric maltol and increased in patients switching from placebo to ferric maltol. The most frequent adverse events were gastrointestinal (randomized phase: 41% vs 30% [ferric maltol vs placebo]; open-label phase: 56% vs 46%, respectively). Adverse events led to treatment withdrawal in 7 patients (6%) receiving ferric maltol and 5 patients (9%) receiving placebo during double-blind treatment, and 11 patients (9%) during the open-label extension.

LIMITATIONS

Heterogeneity in baseline ferritin levels; high proportion of female participants; single-arm open-label extension.

CONCLUSIONS

Ferric maltol was associated with statistically significant (week 16) and sustained (up to week 52) increases in hemoglobin and iron indices in patients with CKD and iron deficiency, and was well tolerated during treatment for up to 52 weeks.

FUNDING

Funded by Shield Therapeutics (UK) Ltd.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov with study number NCT02968368.

Leptin and Obesity: Role and Clinical Implication

The peptide hormone leptin regulates food intake, body mass, and reproductive function and plays a role in fetal growth, proinflammatory immune responses, angiogenesis and lipolysis. Leptin is a product of the obese (ob) gene and, following synthesis and secretion from fat cells in white adipose tissue, binds to and activates its cognate receptor, the leptin receptor (LEP-R). LEP-R distribution facilitates leptin's pleiotropic effects, playing a crucial role in regulating body mass via a negative feedback mechanism between adipose tissue and the hypothalamus. Leptin resistance is characterized by reduced satiety, over-consumption of nutrients, and increased total body mass. Often this leads to obesity, which reduces the effectiveness of using exogenous leptin as a therapeutic agent. Thus, combining leptin therapies with leptin sensitizers may help overcome such resistance and, consequently, obesity. This review examines recent data obtained from human and animal studies related to leptin, its role in obesity, and its usefulness in obesity treatment.

Gastrointestinal Endoscopic Outcome in Late Adolescent Women With Iron-Deficiency Anemia in Basrah-Iraq: A Multicenter Study

Background

Iron deficiency anemia (IDA) in late adolescent women has multiple pathophysiologies. Silent blood loss, celiac disease (CD), malignancies, and other gastrointestinal (GI) lesions receive much attention during IDA management. There is no consensus about endoscopic screening. Our study evaluates factors affecting GI endoscopic diagnosis for the etiology of IDA in late adolescent women.

Materials and Methods

We conducted an observational, multicenter retrospective analysis of 192 adolescent women with IDA admitted for GI endoscopic diagnosis from 2006 to 2016. Baseline measurements included hemoglobin, serum ferritin, mean corpuscular volume, serum iron, total iron-binding capacity, and transferrin saturation. We collected demographic characteristics, duration of hospital stay, the degree of severity of anemia, and endoscopic findings.

Results

The mean age was 19±1 years (range 17 to 21 years), with mildly to moderately severe IDA. Patients received esophagogastroduodenoscopy (EGD, n=178) or colonoscopy (n=14). The mean hospital stay was 2.0±1.0 days. We found negative endoscopies (n=74), CD (n=85), gastric ulcer (n=19), malignancy (n=2), inflammatory bowel disease (n=1), and other nonsignificant endoscopic findings (n=11). We found no correlation between the duration of the hospital stay with the severity of IDA, no significant association between GI symptoms of the patients with endoscopic findings, and a significant but weak association between GI symptoms and serum ferritin.

Conclusions

In late adolescent women with IDA who have significant GI endoscopic lesions, the GI symptoms are of limited value in guiding the endoscopic diagnostic approach for evaluation of IDA.

Do Gastrointestinal Symptoms Affect the Endoscopic Outcome in Anemic Premenopausal Women Due to Iron Deficiency: A Multicenter Study From Basrah-Iraq

BACKGROUND AND OBJECTIVES

The most common cause for iron deficiency anemia (IDA) in women before menopause is menstrual blood loss. The persistence of digestive symptoms despite iron supplementation is the only indication for gastrointestinal (GI) endoscopy in premenopausal women (PW) with IDA. We evaluated how the GI symptomatology manifestation affects the GI endoscopy diagnostic outcome in this cohort.

MATERIALS AND METHODS

This is an observational, multicenter retrospective evaluation of 245 PW admitted for GI endoscopic diagnosis for the etiology of IDA from 2006 to 2016. Baseline measurements included hemoglobin, iron status tests, and red blood corpuscle morphological evaluation. We evaluated the relationships of different endoscopic findings to the severity of IDA, different demographic characteristics, and hospitalization duration.

RESULTS

The mean age was 40±7 years. The duration of hospitalization was neither associated with age nor the IDA severity. The IDA was mild to moderate. More than 53% (n=131) had either a negative study or nonspecific inflammatory changes. Around 16% (n=39) had GI malignancies. There was a significant association between initial GI symptoms with endoscopic GI finding and GI malignancy diagnosis in particular. The relationship loses its power during further assessment by general univariate analysis.

CONCLUSION

A considerable percentage of anemic PW due to iron deficiency has an endoscopically-diagnosed pathology for IDA determined during GI endoscopy. The GI symptoms' phenotypes were unrelated to the endoscopically-diagnosed GI lesion location, even if they were malignant. Therefore, the determination of IDA severity must be thoroughly and individually determined.

Low isolated ferritin levels without anemia: is gastrointestinal tract endoscopy sufficient to explain the cause?

AIM

The present study assesses the diagnostic significance of low ferritin levels in gastrointestinal diseases by evaluating the endoscopic findings of patients with low ferritin levels without anemia.

METHOD

The study included patients aged 0-18 years who underwent an upper and lower gastrointestinal system endoscopy in the Pediatric Gastroenterology Department of our hospital. The patients were divided into three groups based on hemoglobin, and ferritin levels at the time of initial presentation and endoscopic and histopathological findings were recorded retrospectively.

RESULTS

In the present study, 2391 pediatric patients were reviewed, among which 29% (n = 699) had anemia, 23% (n = 549) had low ferritin levels without anemia, and 48% (n = 1143) did not have anemia. The most common symptoms were abdominal pain, dyspepsia, and growth retardation. When the endoscopy findings were compared with those of patients with non-anemic group, Helicobacter pylori gastritis (24%/17.6%) and celiac disease (6%/2.2%) were more common in low ferritin levels without anemia, which indicated a statistically significant difference (p = 0.000/p = 0.04).

CONCLUSIONS

Helicobacter pylori gastritis and celiac disease were more commonly observed in association with low ferritin levels. Low ferritin levels without anemia can be an early and silent sign of celiac disease.

Immunometabolism, Micronutrients, and Bariatric Surgery: The Use of Transcriptomics and Microbiota-Targeted Therapies

BACKGROUND

Obesity is associated with the gut microbiota and decreased micronutrient status. Bariatric surgery is a recommended therapy for obesity. It can positively affect the composition of the gut bacteria but also disrupt absorption of nutrients. Low levels of micronutrients can affect metabolic processes, like glycolysis, TCA cycle, and oxidative phosphorylation, that are associated with the immune system also known as immunometabolism.

METHODS

MEDLINE, PUBMED, and Google Scholar were searched. Articles involving gut microbiome, micronutrient deficiency, gut-targeted therapies, transcriptome analysis, micronutrient supplementation, and bariatric surgery were included.

RESULTS

Studies show that micronutrients play a pivotal role in the intestinal immune system and regulating immunometabolism. Research demonstrates that gut-targeting therapies may improve the microbiome health for bariatric surgery populations. There is limited research that examines the role of micronutrients in modulating the gut microbiota among the bariatric surgery population.

CONCLUSIONS

Investigations are needed to understand the influence that micronutrient deficiencies have on the gut, particularly immunometabolism. Nutritional transcriptomics shows great potential in providing this type of analysis to develop gut-modulating therapies as well as more personalized nutrition recommendations for bariatric surgery patients.

Ascorbate and Tumor Cell Iron Metabolism: The Evolving Story and Its Link to Pathology

Significance: Vitamin C or ascorbate (Asc) is a water-soluble vitamin and an antioxidant that is involved in many crucial biological functions. Asc's ability to reduce metals makes it an essential enzyme cofactor. Recent Advances: The ability of Asc to act as a reductant also plays an important part in its overall role in iron metabolism, where Asc induces both nontransferrin-bound iron and transferrin-bound iron uptake at physiological concentrations (∼50 μM). Moreover, Asc has emerged to play an important role in multiple diseases and its effects at pharmacological doses could be important for their treatment. Critical Issues: Asc's role as a regulator of cellular iron metabolism, along with its cytotoxic effects and different roles at pharmacological concentrations, makes it a candidate as an anticancer agent. Ever since the controversy regarding the studies from the Mayo Clinic was finally explained, there has been a renewed interest in using Asc as a therapeutic approach toward cancer due to its minimal side effects. Numerous studies have been able to demonstrate the anticancer activity of Asc through selective oxidative stress toward cancer cells via H₂O₂ generation at pharmacological concentrations. Studies have demonstrated that Asc's cytotoxic mechanism at concentrations (>1 mM) has been associated with decreased cellular iron uptake. Future Directions: Recent studies have also suggested other mechanisms, such as Asc's effects on autophagy, polyamine metabolism, and the cell cycle. Clearly, more has yet to be discovered about Asc's mechanism of action to facilitate safe and effective treatment options for cancer and other diseases.

The dedicated iron deficiency anaemia clinic: a 15-year experience

OBJECTIVE

To report our cumulative experience from a dedicated iron deficiency anaemia (IDA) clinic over the last 15 years-with particular emphasis on referral rate, uptake of investigation, impact on endoscopy services, diagnostic yield of gastrointestinal (GI) investigation and the issue of recurrent IDA.

METHOD

A series of analyses of a register of 2808 referrals to the Poole IDA clinic between 2004 and 2018.

RESULTS

The study population of 2808 had a sex ratio of 1.9 (female/male ratio) and a median age of 72 years (IQR: 60-79). A rising referral rate over the study period appears to be plateauing at around 2 cases per 1000 population per annum. On the basis of a snapshot audit, investigation of IDA may now account for over 20% of all diagnostic endoscopies.Overall, 86% of cases underwent examination of the upper and lower GI tract. Significant GI pathology was identified in 27% of the investigated cohort. Adenocarcinoma of the upper or lower GI tract was found in 8.3%, the majority in the right colon. The prevalence of recurrent IDA was estimated at 12.4%, and the results of investigation of this subgroup are reported.

CONCLUSION

Unexplained IDA is common, particularly in those over 60 years, and may be the first indication of underlying GI malignancy in over 8% of cases. Unresolved challenges include accommodating the resulting endoscopy workload, establishing a risk/benefit ratio for investigating those with major comorbidities and the management of recurrent IDA.

Study to evaluate the etiology of iron deficiency anemia at a teaching hospital in northeastern part of India

Introduction

The causes of iron deficiency may be either due to excessive loss or, less frequently, decrease absorption. Data related to etiology are not available from this part of the country.

Objective

A study to evaluate the etiology of iron-deficiency anemia at a teaching hospital in the northeastern part of India.

Materials and Methods

In this cross-sectional study, cases of iron-deficiency anemia were selected from the OPD and indoor, after taking proper written consent. Iron-deficiency anemia was diagnosed by sending the complete hematological investigations. Other specific investigations including imaging were done in selected patients as per indications.

Results

A total of 102 patients of iron-deficiency anemia were included in the study. The age of the selected population was between 18 and 80 years. 37.3% were male and 62.7% were female patients. Upper gastrointestinal endoscopy was done in 56, out of these, 9.7% had antral gastritis and 2.9% had a duodenal ulcer. Lower gastrointestinal endoscopy was done in 30 patients and out of these seven patients had hemorrhoids, one patient had multiple ulcers in the colon, one had ulcers in the sigmoid colon, and one had ulceroproliferative mass in the transverse colon. Biopsy through the upper gastrointestinal endoscopy showed chronic duodenitis in three patients (2.9%), carcinoma stomach in one (0.98%), and periampullary carcinoma in one (0.98%). Biopsy after lower gastrointestinal endoscopy showed one case each of carcinoma colon, ulcerative colitis, nonspecific colitis, and nonspecific enteritis.

Conclusion

Diagnosis of iron-deficiency anemia is not sufficient without the diagnosis of underlying etiology. Special concern will be taken to gastrointestinal malignancies like colorectal cancers in which iron-deficiency anemia may be the only manifestation and diagnosis that can be missed if we do not investigate properly.

Iron pill induced gastritis causing severe anemia

Iron supplementation is ubiquitously prescribed and considered a benign means of therapy. However, side effects such as iron pill gastritis can be life threatening prompting discontinuation. We describe a case of a 71-year-old man who presents with severe iron deficiency anemia on oral iron therapy. Esophagogastroduodenoscopy revealed mucosal injury in the fundus, including erythema and ulceration. Biopsy of the area was significant for pill debris. After switching to intravenous iron supplementation, his gastric mucosa healed and anemia improved. This case demonstrates the rare life-threatening side effect of iron pills causing corrosive mucosal damage and significant anemia from gastrointestinal bleeding.

Refinement and validation of the IDIOM score for predicting the risk of gastrointestinal cancer in iron deficiency anaemia

OBJECTIVE

To refine and validate a model for predicting the risk of gastrointestinal (GI) cancer in iron deficiency anaemia (IDA) and to develop an app to facilitate use in clinical practice.

DESIGN

Three elements: (1) analysis of a dataset of 2390 cases of IDA to validate the predictive value of age, sex, blood haemoglobin concentration (Hb), mean cell volume (MCV) and iron studies on the probability of underlying GI cancer; (2) a pilot study of the benefit of adding faecal immunochemical testing (FIT) into the model; and (3) development of an app based on the model.

RESULTS

Age, sex and Hb were all strong, independent predictors of the risk of GI cancer, with ORs (95% CI) of 1.05 per year (1.03 to 1.07, p<0.00001), 2.86 for men (2.03 to 4.06, p<0.00001) and 1.03 for each g/L reduction in Hb (1.01 to 1.04, p<0.0001) respectively. An association with MCV was also revealed, with an OR of 1.03 for each fl reduction (1.01 to 1.05, p<0.02). The model was confirmed to be robust by an internal validation exercise. In the pilot study of high-risk cases, FIT was also predictive of GI cancer (OR 6.6, 95% CI 1.6 to 51.8), but the sensitivity was low at 23.5% (95% CI 6.8% to 49.9%). An app based on the model was developed.

CONCLUSION

This predictive model may help rationalise the use of investigational resources in IDA, by fast-tracking high-risk cases and, with appropriate safeguards, avoiding invasive investigation altogether in those at ultra-low predicted risk.

Nano-scientific Application of Atomic Force Microscopy in Pathology: from Molecules to Tissues

The advantages of atomic force microscopy (AFM) in biological research are its high imaging resolution, sensitivity, and ability to operate in physiological conditions. Over the past decades, rigorous studies have been performed to determine the potential applications of AFM techniques in disease diagnosis and prognosis. Many pathological conditions are accompanied by alterations in the morphology, adhesion properties, mechanical compliances, and molecular composition of cells and tissues. The accurate determination of such alterations can be utilized as a diagnostic and prognostic marker. Alteration in cell morphology represents changes in cell structure and membrane proteins induced by pathologic progression of diseases. Mechanical compliances are also modulated by the active rearrangements of cytoskeleton or extracellular matrix triggered by disease pathogenesis. In addition, adhesion is a critical step in the progression of many diseases including infectious and neurodegenerative diseases. Recent advances in AFM techniques have demonstrated their ability to obtain molecular composition as well as topographic information. The quantitative characterization of molecular alteration in biological specimens in terms of disease progression provides a new avenue to understand the underlying mechanisms of disease onset and progression. In this review, we have highlighted the application of diverse AFM techniques in pathological investigations.

Plummer-Vinson syndrome: improving outcomes with a multidisciplinary approach

Plummer-Vinson syndrome is a rare condition associated with dysphagia, iron deficiency, and esophageal webs. Data regarding this condition is limited to mostly case reports and a few small cohort studies. Although most cases have a benign and indolent course, the risk of malignancy warrants long-term surveillance. A multidisciplinary approach among healthcare providers is of the utmost importance in the management of this condition.

Gut Microbiota and Iron: The Crucial Actors in Health and Disease

Iron (Fe) is a highly ample metal on planet earth (~35% of the Earth’s mass) and is particularly essential for most life forms, including from bacteria to mammals. Nonetheless, iron deficiency is highly prevalent in developing countries, and oral administration of this metal is so far the most effective treatment for human beings. Notably, the excessive amount of unabsorbed iron leave unappreciated side effects at the highly interactive host–microbe interface of the human gastrointestinal tract. Recent advances in elucidating the molecular basis of interactions between iron and gut microbiota shed new light(s) on the health and pathogenesis of intestinal inflammatory diseases. We here aim to present the dynamic modulation of intestinal microbiota by iron availability, and conversely, the influence on dietary iron absorption in the gut. The central part of this review is intended to summarize our current understanding about the effects of luminal iron on host–microbe interactions in the context of human health and disease.

Optimisation of a serum albumin removal protocol for use in a proteomic study to identify the protein biomarkers for silent gastric ulceration in horses

Silent gastric ulceration occurs without evidence of clinical signs and is common in horses. There is currently no a simple and effective method to diagnose this disease. Proteomics can be used to identify serum biomarkers, but the most abundant serum protein, albumin, could conceal candidate biomarkers. Therefore, it is recommended to remove albumin before a proteomic study; however, there is no specific albumin depletion kit or standard protocol available for horse samples. The objectives of this study were to optimise a protocol to remove equine serum albumin and to use albumin-depleted serum to identify the protein biomarkers for silent gastric ulceration. Gastroscopy was used to identify gastric ulceration, and serum was obtained from horses with either a healthy gastric mucosa or gastric ulceration. Serum albumin was removed using the trichloroacetic acid (TCA) protein precipitation method, and this protocol was optimised by varying the concentration of TCA, type of organic solvents, ratio of serum to protein precipitation solution, and incubation times. Electrophoresis and image analysis were used to compare the amounts of albumin, immunoglobulins G (IgG), and protein degradation before and after TCA precipitation. The best protocol was chosen to remove albumin for a proteomic study (electrophoresis and mass spectrometry). The results revealed that protocol 2 (ratio of serum to solution 1:5, 10% TCA in acetone, and 90 min incubation) was the most efficient protocol to remove albumin (98%) and IgG heavy (80%) and light (98%) chains without degrading other proteins. After electrophoresis and mass spectrometry analysis, KRT1, KRT6A and KRT18 were identified as potential markers for silent gastric ulceration.

The difference in endoscopic yield in patients with either iron-deficiency anemia or anemia with normal ferritin

OBJECTIVE

Current guidelines recommend a gastroduodenoscopy (GDS) and colonoscopy in patients with iron-deficiency anemia (IDA). However, in daily practice, patients with nonferriprive anemia are also referred for endoscopy. The aim of this study is to compare the diagnostic yield of colonoscopy and GDS in patients with IDA and non-IDA.

PATIENTS AND METHODS

A retrospective single-center cohort study was carried out from January 2013 till February 2016 that included 917 patients with anemia. We compared the endoscopic yield in patients with IDA versus patients with anemia otherwise. Multivariate regression analyses were carried out to identify predictive factors for the diagnostic yield of GDS and colonoscopy.

RESULTS

The yield of both GDS (25%) and colonoscopy (30%) was comparable in IDA and non-IDA patients. However, in patients without known gastrointestinal medical history and without concomitant indications for endoscopy (N=373), the diagnostic yield of GDS was three times higher in IDA patients compared with non-IDA patients (P<0.01). The diagnostic yield for colonoscopy was not significantly different between the two groups. Age and sex were recurrent predictive variables in the outcome of both GDS and colonoscopies.

CONCLUSION

We recommend IDA as well as non-IDA as indications for GDS and colonoscopy. Only in patients without gastrointestinal history or localizing complaints a significant difference in the diagnostic yield is found between IDA and non-IDA patients. In this group, upper endoscopy can be omitted in non-IDA patients as they were three times less likely to have a bleeding source found on GDS compared with IDA patients.

Practical gastrointestinal investigation of iron deficiency anaemia

About 10% of oesophagogastroduodenoscopies (OGDs) and colonoscopies are done for investigation of iron deficiency anemia (IDA) . Much of the existing guidance on investigation of IDA predates CRC screening, which has driven significant improvements in colonoscopy quality and completion rates, as well as a reduction in Helicobacter pylori prevalence and increase in PPI usage, and therefore probably needs re-consideration. New investigations, e.g. CT colonography, enteroscopy and capsule endoscopy have also been introduced. Areas covered: This review updates the approach to practical investigation of IDA. Medline was searched using the terms iron deficiency AND anemia AND/OR gastroscopy, colonoscopy, capsule and enteroscopy, together with review of recent relevant published abstracts on the topic. Expert commentary: Gastrointestinal pathology is now a more common cause of IDA than upper GI causes, reflecting better colonoscopy accuracy and completion rates as well as changing disease patterns, and carcinomas are more likely cause IDA than benign adenomas. Increasing use of antiplatelet and anticoagulants is driving greater presentation of IDA. Capsule endoscopy, enteroscopy and CT colonography are increasingly used. Fecal occult blood testing may be a useful simple screening method in the frail, as a negative test can avoid the need for invasive tests.

Effectiveness and safety of ferric carboxymaltose compared to iron sucrose in women with iron deficiency anemia: phase IV clinical trials

BACKGROUND

Iron deficiency anemia (IDA) is a significant problem worldwide particularly in women. The aim of the study was to evaluate the effectiveness and safety of intravenous ferric carboxymaltose (FCM) in comparison to iron sucrose (IS) in women with IDA.

METHOD

Two hundred patients at Department of Obstetrics and Gynaecology, Sher-i-Kashmir Institute of Medical Sciences Medical College and Hospital, Jammu & Kashmir, India identified with IDA were enrolled for the study. Intravenous FCM and IS were both given as per the protocol. Change in the laboratory parameters such as hemoglobin (Hb), mean corpuscular value, and serum ferritin levels at two weeks and four weeks interval after the treatment was recorded.

RESULT

A significant increase in the mean Hb was observed from 7.76 ± 0.709 to 13.25 ± 0.606 in patients treated with FCM and 7.64 ± 0.710 to 11.59 ± 0.733 g/dL (P < 0.001) in patients treated with IS after four weeks of therapy. The rise in mean corpuscular volume was from 66.82 ± 5.24 to 86.76 ± 3.765 and 68.05 ± 5.56 to 93.80 ± 3.80 and rise in serum ferritin levels were from 8.32 ± 1.787 to 38.94 ± 6.095 μg/L and 8.16 ± 1.540 to 27 ± 8.175 μg/L in patients treated with FCM and IS respectively after four weeks of therapy. No serious adverse effects were reported.

CONCLUSION

Parenteral therapy is effective in IDA, but FCM elevates hemoglobin level and restored iron stores faster than IS with minimum adverse drug reactions.

TRIAL REGISTRATION NUMBER

ISRCTN14484575 Dated: 15-12-2017 retrospectively registered. https://doi.org/10.1186/ISRCTN14484575.

Effect of Helicobacter pylori eradication on elder cases: Observational study in community-based medicine

AIM

To examine the effect of Helicobacter pylori (H. pylori) eradication therapy on the extra-gastrointestinal factors in elderly patients by a before-after observational study in community medicine.

METHODS

Medical records (1 May 2013-31 January 2014) of 130 patients who underwent H. pylori eradication therapy with 2-year after-eradication observation in our institute were reviewed. Data on sex; age; body weight; body mass index (BMI); mean corpuscular volume (MCV); total protein; low-density lipoprotein cholesterol, triglyceride, haemoglobin A1c and haemoglobin levels and gastric hyperplastic polyps (GHPs) at eradication was extracted. Two-year after-eradication change in data was analysed by paired-sample t-test; relationship between GHPs and subclinical iron deficiency anaemia (IDA) improvement was evaluated.

RESULTS

The mean patient age (median, interquartile range) at eradication was 69.6 (71.5, 64-77) years. Paired-sample t-tests showed that body weight, BMI and MCV increased by 0.52 kg (P = 0.018), 0.25 kg/m² (P = 0.006) and 0.83 fL (P < 0.001), respectively. The nonparametric Mann-Whitney test showed no significant difference in the change rate of MCV after eradication between the groups with and without GHPs (P = 0.892).

CONCLUSION

H. pylori eradication therapy prevented weight loss and subclinical IDA in elderly individuals. GHPs were not associated with subclinical IDA.

Open questions and misconceptions in the diagnosis and management of anemia in patients with gastrointestinal bleeding

Despite high prevalence of iron deficiency anemia (IDA) in patients with acute or chronic gastrointestinal bleeding (GIB), IDA and iron deficiency (ID) are frequently untreated. Reasons may be misconceptions about the impact and diagnosis of IDA and the efficacy of new treatments. Addressing these misconceptions, this article summarizes current evidence for better understanding and management of GIB-associated IDA. Despite only few controlled studies evaluated the efficacy of iron treatment in patients with GIB, there is consistent evidence suggesting that: (a) IDA should be diligently investigated, (b) effective treatment of ID/IDA improves outcomes such as health-related quality of life and can avoid severe cardiovascular consequences, and (c) intravenous iron should be considered as well-tolerated treatment in this setting. Overall, the misconceptions and practices outlined in this article should be replaced with strategies that are more in line with current guidelines and best practice in GIB and other underlying conditions of ID/IDA.

Randomized Open-Label Phase 1 Study of the Pharmacokinetics of Ferric Maltol in Inflammatory Bowel Disease Patients with Iron Deficiency

BACKGROUND

Iron deficiency anemia (IDA) is a common complication of inflammatory bowel disease (IBD). Oral ferric maltol improves and normalizes hemoglobin (Hb) in patients with IBD.

AIM

This open-label, randomized Phase 1 study evaluated the pharmacokinetics of ferric maltol and its effect on iron indices in IBD patients with iron deficiency (with or without anemia).

METHODS

Iron deficient adult IBD patients received ferric maltol 30, 60, or 90 mg twice daily during an 8-day period. Pharmacokinetics and iron uptake were assessed on days 1 and 8.

RESULTS

Twenty-four patients were included: 13 with Crohn's disease and 11 with ulcerative colitis (mean age 39 years; 67 % female, mean Hb 13.0 g/dL; mean reticulocyte Hb content (CHr) 31.9 pg; mean ferritin 13.9 µg/L). Plasma maltol and maltol glucuronide increased rapidly at all doses, reaching maximum plasma concentration (C _max) 1.0-1.5 h post-dose and declining to baseline after 3-6 h. Maltol and maltol glucuronide exposure (area under the concentration-time curve; AUC) appeared dose proportional with twice-daily dosing, with higher exposure to maltol glucuronide vs. maltol. Mean day 8/day 1 ratios for C _max and AUC_0-t indicated no accumulation after 7 days of twice-daily dosing. Serum iron and transferrin saturation (TSAT) increased with all doses (maximum values at 1.5-3.0 h post-dose). Serum ferritin and CHr increased by day 8, with greater improvements with 60 and 90 mg twice-daily doses than with 30 mg twice-daily doses.

CONCLUSIONS

The key constituents of ferric maltol showed predictable pharmacokinetics, with no accumulation over 7 days and increased iron uptake and storage over time at 30-90 mg twice-daily doses.

Work related musculoskeletal disorders among adolescent girls and young women employees of textile industries in Tamil Nadu, India - a comparative study

Musculoskeletal disorders are common in those employed in the textile industry. The aim of the study is to assess musculoskeletal disorders among adolescent girls who are current employees of textile industries in comparison with the adolescent girls and young women who are past employees of textile industries and adolescent girls who have never been employed in the textile industry. Methodology This is a cross-sectional study. A total of 321 subjects, 107 in each study group were sampled. Standardized nordic questionnaires (SNQ) was used to assess musculoskeletal symptoms. Results More than half of the current employees (67.28%) and past employees (67.28%) reported musculoskeletal pain. Among the never been employed, 18.69% reported musculoskeletal pain. Neck and shoulder were the most common sites of musculoskeletal pain among the current employees (49.5% and 50.5%, respectively) and the past employees (45.8% and 49.5%, respectively). In the regression model, having ever been diagnosed for anemia (AOR 6.57, 95% CI 1.4 to 30.76), working for more than 48 h in a week (AOR 3.37, 95% CI 1.53 to 7.41) and the presence of depression (AOR 6.6, 95% CI 1.48 to 29.36) were significantly associated with the presence of musculoskeletal pain in the study participants. Conclusion Musculoskeletal disorders are a major occupational health problem among the adolescent and young women employees of textile industries. Working hours should be fixed at 48 h per week and anemia and depression should be treated to avert the work related musculoskeletal disorders in the study population.

Oral iron supplementation: Potential implications for the gut microbiome and metabolome in patients with CKD

Patients with chronic kidney disease (CKD) and loss of kidney function are at increased risk for morbidity and mortality. The risks of CKD are attributed to "uremia," an increased concentration of uremic retention solutes (toxins) in the plasma. Recently, a colo-renal axis became clearly apparent and uremia has been associated with an altered gut microbiome composition and metabolism. There is a high prevalence of anemia in patients with CKD, for which patients are often treated with oral or intravenous iron. Recent in vivo and in vitro studies have reported adverse effects of oral iron supplementation on the gut microbiota composition, gut metabolome, and intestinal health, which in turn may result in an increased production of uremic toxins. It may also affect circulating levels of other microbe-derived molecules, that can act as mediators of immune regulation. Changes in body iron levels have also been reported to exert subtle effects on host immune function by modulating immune cell proliferation and differentiation, and by directly regulating cytokine formation and antimicrobial immune effector mechanisms. Based on the foregoing it is conceivable that oral iron supplementation in iron deficient predialysis CKD patients adversely changes gut microbiota composition, the gut and systemic metabolome, and host immunity and infection. Future studies are needed to confirm these hypotheses and to assess whether, compared to IV iron supplementation, oral iron supplementation negatively impacts on morbidity of CKD, and whether these adverse effects depend on the iron bioavailability of the iron formulation to the microbiota.

Iron Deficiency Anemia

Iron deficiency is one of the most common causes of anemia. The 2 main etiologies of iron deficiency are blood loss due to menstrual periods and blood loss due to gastrointestinal bleeding. Beyond anemia, lack of iron has protean manifestations, including fatigue, hair loss, and restless legs. The most efficient test for the diagnosis of iron deficiency is the serum ferritin. Iron replacement can be done orally, or in patients in whom oral iron is not effective or contraindicated, with intravenous iron.

Haemoglobin responses to transfusion in severe iron deficiency anaemia: potential impact of gastrointestinal disorders

BACKGROUND AND OBJECTIVES

Red blood cell (RBC) transfusion may be justified in iron deficiency anaemia (IDA) when an increase in oxygen delivery is needed, as sometimes occurs in subjects with haemoglobin <8·0 mg/dL, serious comorbidities or at risk of cardiovascular instability. Earlier investigations showed that some patients with severe IDA requiring transfusion had lower than expected post-transfusion haemoglobin levels with poorer clinical outcomes than other patients. After hypothesizing that haemoglobin responses to transfusion were different and that the underlying gastrointestinal (GI) disorders causing IDA could be a confounder explaining this association, these responses were analysed in a prospective cohort of IDA adults referred for outpatient GI investigation.

MATERIALS AND METHODS

Transfused patients with proven IDA, baseline haemoglobin at referral <9·0 g/dL and no extraintestinal bleeding were eligible. To assess a homogeneous population, only GI disorders known to cause occult bleeding were considered. Haemoglobin increments per 100 mL of RBCs were investigated.

RESULTS

In total, 2818 patients were enrolled over 10·5 years. On multivariable regression, diffuse angiodysplasias and GI cancer independently predicted for reduced increments in post-transfusion haemoglobin [adjusted regression coefficients: -0·082 (95% confidence interval, -0·093 to -0·072) and -0·073 (95% confidence interval, -0·081 to -0·066), respectively, P < 0·001 in both]. Haemoglobin responses in the remaining bleeding disorders were adequate and agreed with the principle that one RBC unit increases the haemoglobin an average of 1 g/dL.

CONCLUSION

The potential differential impact of GI disorders on changes in haemoglobin levels after RBC transfusion could be useful for transfusing physicians, especially for diagnostic purposes.

Effect of Ayurveda Medications (Kasīsa Bhasma and Dhātrī Avaleha) on Iron Deficiency Anaemia: A Randomized Controlled Study

Background:

This paper explores the role that Ayurveda can play in the management of Iron Deficiency Anaemia, a major nutritional deficiency disorder affecting people across the globe.

Methodology:

Forty (40) patients suffering from Iron deficiency anaemia as per WHO guidelines, between the age group of 20 to 60 yrs of either sex participated in the study. Study was a randomized, controlled, open label clinical study. Patients were randomly divided into two groups: Group D (n = 20) received Dhārī avaleha 10 g twice a day after food. Group K (n = 20) received capsules Kasīsa bhasma 125 mg thrice a day. Both interventions were administered for 30 days and the subjects were followed up for next 30 days with placebo capsules to assess the sustainability of the effects. Assessments were done at baseline, 30^th and 60^th days. Primary outcome measure was hemoglobin estimation (Hb) and secondary outcome measures were the other hematological parameters such as Red blood cell (RBC) indices, total RBC count, Packed Cell volume (PCV) and Peripheral Blood smear study.

Results:

Both interventions produced significant improvements (P < 0.001). Kasīsa bhasma was better compared to dhātrī avaleha in terms of primary (P < 0.0001) and secondary outcomes. Comparison of outcomes from base line – 30^th day, base line – 60^th day and 30^th – 60^th day showed significant (P < 0.0001) improvement in both the groups in parameters such as haemoglobin, MCV and MCH. Hence improvements sustained during placebo intervened sustainability period also.

Conclusions:

Study effectively shows that Kasīsa bhasma is better then Dhātrī avaleha. Improvements by both interventions were sustained even during the sustainability period.

Utilization of fecal occult blood test in the acute hospital setting and its impact on clinical management and outcomes

Background:

Despite lack of evidence supporting the use of fecal occult blood test (FOBT) in the acute hospital setting, FOBT is commonly used in the inpatient setting for reasons other than colorectal cancer (CRC) screening.

Aims:

To evaluate practice trends in utilizing FOBT on inpatients and its impact on affecting clinical management and outcomes.

Materials and Methods:

A cross-sectional study of consecutive adult patients undergoing FOBT from January 1, 2011 to December 31, 2011 during an acute medical admission at a large urban safety net hospital was performed. Indications for FOBT, and the impact of FOBT results on endoscopic procedures performed and clinical outcomes were assessed. The number of inpatient endoscopic procedures before and after discontinuing inpatient FOBT was also assessed.

Results:

A total of 207 inpatient FOBTs were performed in 2011. The most common reason cited for FOBT was anemia (36%, n = 74) followed by gastrointestinal (GI) bleeding (27%, n = 55). Interestingly, 23% (n = 47) of the patients undergoing inpatient FOBT had overt GI bleeding. As expected, patients with positive FOBT were significantly more likely to undergo endoscopic examinations (P < 0.01). After discontinuing the availability of inpatient FOBT, patients were less likely to undergo endoscopic examinations [odds ratio (OR) 0.80, 95% confidence interval (CI) 0.75-0.85].

Conclusion:

Inappropriate utilization of FOBT in the inpatient setting is common, even when the indication does not support its use. Setting limitations on inpatient FOBT may reduce the inappropriate utilization of inpatient FOBT. Quality improvement initiatives are needed to educate clinicians on the appropriate use of FOBT, which is primarily for average risk CRC screening.

Iron deficient erythropoiesis might play key role in development of anemia in cancer patients

Introduction

Multifactorial pathogenesis is involved in anemia of cancer patients and defining the causes of anemia is not always simple.

Methods

The incidence of anemia among 4 major cancers (gastric, colorectal, lung cancer and hepatocellular carcinoma), and biochemical features of anemia using ferritin, CRP, hepcidin and soluble transferrin receptor (sTfR) were assessed. Anemia was defined either by hemoglobin (Hb) ≤11 g/dL or a drop of Hb 2 g/dL or more during anticancer treatment.

Results

Among the 345 patients including 152 lung cancer, 101 gastric cancer, 69 colorectal cancer and 23 hepatocellular carcinoma, 49 patients (14.2%) had anemia at their initial diagnosis of cancer. During treatment, 129 (37.4%) experienced anemia, and 34 (26.4%) were treated mostly by transfusion. Biochemical feature of anemia was examined with 39 patients' samples. When comparing to the reference value from general population, cancer patients showed numerically higher ferritin, sTfR, CRP and hepcidin level. Among the cancer patients, anemic patients had significantly higher ferritin (p = 0.050) and sTfR (p = 0.009) level compared to non-anemic patients.

Conclusion

Anemia is a common issue in cancer patients and is largely undertreated with sub-optimal diagnoses of cause. The rates of anemia increase significantly during anti-cancer treatment and appear to be largely associated with iron deficiency.

Anemia and iron deficiency in gastrointestinal and liver conditions

Iron deficiency anemia (IDA) is associated with a number of pathological gastrointestinal conditions other than inflammatory bowel disease, and also with liver disorders. Different factors such as chronic bleeding, malabsorption and inflammation may contribute to IDA. Although patients with symptoms of anemia are frequently referred to gastroenterologists, the approach to diagnosis and selection of treatment as well as follow-up measures is not standardized and suboptimal. Iron deficiency, even without anemia, can substantially impact physical and cognitive function and reduce quality of life. Therefore, regular iron status assessment and awareness of the clinical consequences of impaired iron status are critical. While the range of options for treatment of IDA is increasing due to the availability of effective and well-tolerated parenteral iron preparations, a comprehensive overview of IDA and its therapy in patients with gastrointestinal conditions is currently lacking. Furthermore, definitions and assessment of iron status lack harmonization and there is a paucity of expert guidelines on this topic. This review summarizes current thinking concerning IDA as a common co-morbidity in specific gastrointestinal and liver disorders, and thus encourages a more unified treatment approach to anemia and iron deficiency, while offering gastroenterologists guidance on treatment options for IDA in everyday clinical practice.

Burden of Iron Deficiency Anemia in a Bariatric Surgery Population in the United States

BACKGROUND

Obesity is a serious condition affecting more than 35% of adults in the United States. In obese individuals for whom other weight control methods have been ineffective, bariatric surgery is a safe and effective method of weight control. An estimated 150,000 to 160,000 bariatric surgeries are performed in the United States yearly. Iron deficiency anemia is common in patients after bariatric surgery, with incidence rates up to 49%, and may be due to malabsorption of nutrients. 

OBJECTIVES

To (a) compare the medical resource utilization (MRU)- both medical care and treatment resources-and associated costs in a sample of commercially insured adult bariatric surgery patients with and without iron deficiency anemia (IDA), and (b) describe anti-anemia treatment patterns in those bariatric surgery patients diagnosed with IDA.

METHODS

Using Truven Health MarketScan claims data, bariatric surgery patients were identified by the ICD-9-CM and CPT procedure codes for bariatric surgery and classified by surgery and IDA diagnosis within 2 years of initial surgery. Intravenous (IV) iron treatment was determined by HCPCS codes, prescription oral iron by NDC numbers, and blood transfusions by CPT and ICD-9-CM codes. Clinical, MRU, and economic outcomes for all-cause health services were compared between IDA and non-IDA patients. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression, controlling for demographic and clinical characteristics on outcomes of complications and hospitalization.

RESULTS

Of the 24,344 bariatric surgery patients analyzed, 11.6% received an IDA diagnosis 2 years after surgery (average days to diagnosis = 279). Most IDA patients (78.5%) received a test for iron in the post-index period; only 9.1% received IV iron treatment, with iron dextran (3.8%) and iron sucrose (3.4%) being the most common (average days to IV iron treatment = 403 days). Prescription oral iron was found in 4.9% of all IDA patients (average days to oral iron treatment = 476.7). Approximately 9% of IDA patients received a blood transfusion (average days to transfusion = 304.8). For the total sample, the average age was 46 years with a higher percentage of females (83.9% IDA; 78.7% non-IDA). Most clinical characteristics were similar among patients with and without IDA, except heart disease (1.3% IDA vs. 0.8% non-IDA; P = 0.005) and gallbladder disease (0.0% IDA vs. 0.2% non-IDA; P = 0.037). More IDA patients had complications after surgery (40.4% vs. 27.7%; P  less than  0.001), such as nonabsorption (22.4% vs. 16.5%; P  less than  0.001); digestive (15.6% vs. 10.2%; P  less than  0.001); and gastrojejunal ulcer (7.6% vs. 2.0%; P  less than  0.001). Multivariate results showed that IDA patients were more likely to have a bariatric surgery complication over non-IDA patients (OR = 1.367, 95% CI = 1.257-1.487; P  less than  0.05). Adjusted results showed IDA patients more than twice as likely to be hospitalized (OR = 2.567, 95% CI = 2.363-2.790; P  less than  0.05). Total costs were twice as much in the IDA group compared with the non-IDA group ($37,882 vs. $19,253; P  less than  0.001). 

CONCLUSIONS

Bariatric surgery patients who develop IDA may be subject to higher complication rates, MRU, and direct medical costs. Although most bariatric surgery patients who develop IDA are tested for iron, most are not treated with IV iron or oral iron and do not receive blood transfusions. Further research is needed to determine if IDA is a result of bariatric surgery complications or a predictor of increased MRU and costs.

Serum Hepcidin and Iron Absorption in Paediatric Inflammatory Bowel Disease

BACKGROUND AND AIMS

We sought to correlate hepcidin levels in inflammatory bowel disease [IBD] children with disease activity, inflammatory markers, and iron load test [ILT] and to compare IBD patients with coeliac and healthy patients.

METHODS

Between December 2012 and June 2013, 145 subjects [50 IBD patients, 45 coeliac patients and 50 healthy controls] were included in the study. All patients underwent the following examinations: blood count, iron status, erythropoiesis parameters, serum hepcidin, C-reactive protein [CRP], and erythrocyte sedimentation rate [ESR]. In order to evaluate the efficacy of iron absorption, ILT was performed in IBD patients. Disease activity indexes and IBD duration, localisation, and therapy were also evaluated, and a faecal sample for calprotectin collected.

RESULTS

Serum hepcidin was significantly higher in IBD patients with active disease compared with both coeliac and healthy patients [p = 0.005, p = 0.003 respectively]. In a multivariate logistic regression model, having a Paediatric Crohn's Disease Activity Index [PCDAI] / Paediatric Ulcerative Colitis Activity Index [PUCAI] ≥ 30 resulted in the only variable independently associated with a positive serum hepcidin (odds ratio [OR] = 6.87; 95% confidence interval [CI] 1.4-33, p = 0.01]]. Patients with iron malabsorption [IM] showed higher values of ESR, CRP, and hepcidin [p = 0.02, p = 0.001, and p = 0.06, respectively]. Eight out of 12 [66.7%] children with IM showed an active disease compared with 6/31 [19.3%] children with normal ILT [p = 0.01]. Hepcidin levels correlated negatively with ILT [r = -0.451, p = 0.002], and positively with ferritin and CRP [r = 0.442, p = 0.0001; r = 0.243, p = 0.009, respectively]

CONCLUSIONS

Our study demonstrates that serum hepcidin is increased in IBD children with active disease and it is responsible for IM.

Antioxidant and haematological biomarkers in different groups of horses supplemented with polyunsaturated oil and vitamin E

Oxidative stress has been correlated with pathologies that impair the performance of athlete horses. The aim of this study was to assess the effects of supplementation with a mixture of polyunsaturated oil and vitamin E on the antioxidant and haematological biomarkers of horses. Horses under maintenance care (n = 6) and horses in training (n = 10) received 100 and 300 ml of the oil mixture respectively. Supplementation was provided for a period of 8 weeks, together with isocaloric inclusion. Blood samples were collected at three time periods (pretest, after 4 weeks and after 8 weeks) to analyse the following: the red blood cell count (RBCc); haemoglobin (Hb); haematocrit (HT); leucocytes; lymphocytes; platelets; the mean corpuscular volume (MCV); the mean corpuscular haemoglobin concentration (MCHC); the standard deviation of the red blood cell distribution width (RDW-SD); the coefficient of variation of the red blood cell distribution width (RDW-CV); glutathione peroxidase (GPx); superoxide dismutase (SOD); uric acid (UrAc); total plasma proteins (TPP); and creatine kinase (CK). After the 8 weeks of supplementation, animals under maintenance care exhibited significant increases in SOD, UrAc, the white blood cell count (WBCc), the RDW-SD and the RDW-CV (p < 0.05). The animals in training exhibited increases in GPx, SOD and UrAc (p < 0.05). In conclusion, supplementation with polyunsaturated oil and vitamin E increases blood antioxidants among animals under maintenance and in training, with different trends, while contributing to the fight against oxidative stress in each group analysed.

Evaluation of Anemia

Anemia is a common problem in primary care. Classification based on mean cell volume narrows the differential diagnosis and directs testing. A marked macrocytosis is characteristic of vitamin B12 and folate deficiencies, certain medications, and primary bone marrow disorders. The three most common causes of microcytic anemia are iron deficiency, thalassemia trait, and anemia of inflammation. Additional laboratory testing is required for diagnosis. Determination of the rate of development of anemia and examination of a blood smear may provide diagnostic clues to guide more specialized testing. Diagnosis of iron, vitamin B12, or folate deficiency mandates determination of the underlying cause.