Epidemiology of iron deficiency anaemia in four European countries: a population-based study in primary care

Iron Deficiency: Global Trends and Projections from 1990 to 2050

BACKGROUND

Iron deficiency (ID) remains the leading cause of anemia, affects a vast number of persons globally, and continues to be a significant global health burden. Comprehending the patterns of ID burden is essential for developing targeted public health policies.

METHODS

Using data from the Global Burden of Disease (GBD) 2021 study for the years 1990-2021, the XGBoost model was constructed to predict prevalence and disability-adjusted life years (DALYs) for the period 2022-2050, based on key demographic variables. Shapley Additive exPlanations (SHAP) values were applied to interpret the contributions of each variable to the model's predictions. Additionally, the Age-Period-Cohort (APC) model was used to evaluate the effects of age, period, and birth cohort on both prevalence and DALYs. The relationship between the Socio-Demographic Index (SDI) and ID's age-standardized prevalence rate (ASPR) as well as the age-standardized DALYs rate (ASDR) was also analyzed to assess the influence of socioeconomic development on disease burden.

RESULTS

The global prevalent cases of ID grew from 984.61 million in 1990 to 1270.64 million in 2021 and are projected to reach 1439.99 million by 2050. Similarly, global DALYs from ID increased from 28.41 million in 1990 to 32.32 million in 2021, with a projected rise to 36.13 million by 2050. The ASPR declined from 18,204/100,000 in 1990 to 16,433/100,000 in 2021, with an estimated annual percentage change (EAPC) of -0.36% over this period. It is expected to decrease further to 15,922 by 2050, with an EAPC of -0.09% between 2021 and 2050. The ASDR was 518/100,000 in 1990 and 424/100,000 in 2021, with an EAPC of -0.68% from 1990 to 2021. It is expected to remain relatively stable at 419/100,000 by 2050, with an EAPC of -0.02% between 2021 and 2050. In 2021, the highest ASPRs were recorded in Senegal (34,421/100,000), Mali (34,233/100,000), and Pakistan (33,942/100,000). By 2050, Mali (35,070/100,000), Senegal (34,132/100,000), and Zambia (33,149/100,000) are projected to lead. For ASDR, Yemen (1405/100,000), Mozambique (1149/100,000), and Mali (1093/100,000) had the highest rates in 2021. By 2050, Yemen (1388/100,000), Mali (1181/100,000), and Mozambique (1177/100,000) are expected to remain the highest. SHAP values demonstrated that gender was the leading predictor of ID, with age and year showing negative contributions. Females aged 10 to 60 consistently showed higher prevalence and DALYs rates compared to males, with the under-5 age group having the highest rates for both. Additionally, men aged 80 and above exhibited a rapid increase in prevalence. Furthermore, the ASPR and ASDR were significantly higher in regions with a lower SDI, highlighting the greater burden of ID in less developed regions.

CONCLUSIONS

ID remains a significant global health concern, with its burden projected to persist through 2050, particularly in lower-SDI regions. Despite declines in ASPR and ASDR, total cases and DALYs are expected to rise. SHAP analysis revealed that gender had the greatest influence on the model's predictions, while both age and year showed overall negative contributions to ID risk. Children under 5, women under 60, and elderly men aged 80+ were the most vulnerable groups. These findings underscore the need for targeted interventions, such as improved nutrition, early screening, and addressing socioeconomic drivers through iron supplementation programs in low-SDI regions.

Iron deficiency in athletes: Prevalence and impact on VO2 peak

BACKGROUND

Iron is an important micronutrient in pathways of energy production, adequate nutrient intake and its balance is essential for optimal athletic performance. However, large studies elucidating the impact of iron deficiency on athletes' performance are sparse.

METHODS

Competitive athletes of any age who presented for preparticipation screening 04/2020-10/2021 were included in this study and stratified for iron deficiency (defined as ferritin level <20 µg/l with and without mild anemia [hemoglobin levels ≥11 g/dl]). Athletes with and without iron deficiency were compared and the impact of iron deficiency on athletic performance was investigated.

RESULTS

Overall, 1190 athletes (mean age 21.9 ± 11.6 years; 34.2% females) were included in this study. Among these, 19.7% had iron deficiency. Patients with iron deficiency were younger (18.1 ± 8.4 vs. 22.8 ± 12.1 years, P < 0.001), more often females (64.5% vs. 26.8%, P < 0.001), had lower VO2 peak value (43.4 [38.5/47.5] vs. 45.6 [39.1/50.6]ml/min/kg, P = 0.022) and lower proportion of athletes reaching VO2 peak of >50 ml/min/kg (8.5% vs. 16.1%, P = 0.003). Female sex (OR 4.35 [95% CI 3.13-5.88], P > 0.001) was independently associated with increased risk for iron deficiency. In contrast, the risk for iron deficiency decreased by every life year (OR 0.97 [95% CI 0.95-0.99], P = 0.003). Iron deficiency was independently associated with reduced VO2 peak (OR 0.94 [0.91-0.97], P < 0.001) and lower probability to reach VO2 peak >50 ml/min/kg (OR 0.42 [95% CI 0.25-0.69], P = 0.001).

CONCLUSIONS

Iron deficiency is common in athletes (predominantly in female and in young athletes). Iron deficiency was independently associated with reduced VO2 peak during exercise testing and lower probability to reach a VO2 peak >50 ml/min/kg.

Impact of weekly iron-folic acid supplementation on nutritional status and parasitic reinfection among school-age children and adolescents in Sub-Saharan Africa: a systematic review and meta-analysis

Background

Two significant etiological factors contributing to iron deficiency anemia, and undernutrition posing substantial public health challenges in Sub-Saharan Africa, are soil-transmitted helminths and malaria. This study carried out the effect of weekly iron-folic acid supplementation (WIFAS) on the nutrition and general health of school-age children and adolescents in Sub-Saharan Africa, a systematic review and meta-analysis have been conducted.

Methods

To find pertinent publications for this study, a thorough search was carried out on May 20, 2023, across five databases: Pubmed (MEDLINE), Web of Science, Scopus, Cochrane Library, and Google Scholar. In addition, a search was conducted on August 23, 2023, to capture any new records. The inclusion criteria for the studies were based on school-age children and adolescent populations, randomized controlled trials, and investigations into the effects of WIFAS. The outcomes of interest were measured through anthropometric changes, malaria, and helminthic reinfection.

Results

A systematic review of 11 articles revealed that WIFAS significantly decreased the risk of schistosomiasis reinfection by 21% among adolescents (risk ratio = 0.79, 95%CI: 0.66, 0.97; heterogeneity I 2 = 0.00%, P = 0.02). However, no significant impact was observed on the risk of malaria reinfection (risk ratio = 1.02, 95%CI: 0.92, 1.13; heterogeneity I 2 = 0.00%, P = 0.67) or A. Lumbricoides reinfection (risk ratio = 0.95, 95%CI: 0.75, 1.19; heterogeneity I 2 = 0.00%, P = 0.65). Moreover, the analysis demonstrated that there is no significant effect of iron-folic acid supplementation in measured height and height for age Z-score (HAZ) of the school-age children (Hedge's g -0.05, 95%CI: -0.3, 0.2; test for heterogeneity I 2 = 0.00%, P = 0.7) and (Hedge's g 0.12, 95%CI: -0.13, 0.37; test for heterogeneity I 2 = 0.00%, P = 0.36) respectively.

Conclusion

The effectiveness of WIFAS in reducing the risk of schistosomiasis reinfection in adolescents has been demonstrated to be greater than that of a placebo or no intervention. Additionally, the narrative synthesis of iron-folic acid supplementation has emerged as a potential public health intervention for promoting weight change. However, there was no significant association between WIFAS and Ascariasis, trichuriasis, and hookworm. Moreover, the certainty of the evidence for the effects of WIFAS on height and malaria is low and therefore inconclusive. Whereas, the certainty of the evidence for the effectiveness of WIFAS on Schistosomiasis is moderate. Even though the mechanisms need further research WIFAS may be implemented as part of a comprehensive public health strategy to address schistosomiasis in adolescents.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023397898, PROSPERO (CRD42023397898).

Survival After Wait-and-See Approach in Older Patients With Unexplained Iron Deficiency Anemia in Primary Care: A Practice Evaluation

OBJECTIVES

Guidelines recommend upper and lower gastrointestinal endoscopic evaluation for patients without a clear physiological explanation for iron deficiency anemia (IDA). However, the consequences of watchful waiting in older patients with unexplained IDA in general practice are unknown. The aim of this study was to investigate characteristics and survival of patients with an unexplained IDA in general practice who refrain from medical specialist evaluation.

DESIGN

Historical prospective study.

SETTING AND PARTICIPANTS

Patients aged ≥70 years with IDA coded in their medical records were selected from the Dutch Academic General Practitioner Development Network (AHON) database.

METHODS

Based on their medical records, patients with an unexplained IDA were classified as (1) referred for medical specialist evaluation, or (2) no or noninvasive evaluation in general practice.

RESULTS

Compared to patients who were referred for medical specialist evaluation (n = 235, 47.8%), patients who had no or noninvasive evaluation (n = 257; 52.5%) were older (median respectively 79 vs 82 years old, P < .01) and more likely to have congestive heart failure (respectively 17.4% and 26.1%, P = .02) and dementia (respectively 2.6% and 8.9%, P < .01). Two-year survival was significantly higher in patients who were referred for medical specialist evaluation compared to patients who had no or noninvasive evaluation (respectively, 83.9% and 75.5%, P = .02).

CONCLUSIONS AND IMPLICATIONS

Although mortality was significantly higher in the older and more comorbid patients who had no or noninvasive evaluation in general practice, survival was still high in this patient group. Therefore, non-guideline adherence and a wait-and-see approach could be discussed in a shared-decision-making consultation.

ESPEN practical short micronutrient guideline

BACKGROUND

Trace elements and vitamins, named together micronutrients (MNs), are essential for human metabolism. The importance of MNs in common pathologies is recognized by recent research, with deficiencies significantly impacting the outcome.

OBJECTIVE

This short version of the guideline aims to provide practical recommendations for clinical practice.

METHODS

An extensive search of the literature was conducted in the databases Medline, PubMed, Cochrane, Google Scholar, and CINAHL for the initial guideline. The search focused on physiological data, historical evidence (for papers published before PubMed release in 1996), and observational and/or randomized trials. For each MN, the main functions, optimal analytical methods, impact of inflammation, potential toxicity, and provision during enteral or parenteral nutrition were addressed. The SOP wording was applied for strength of recommendations.

RESULTS

The limited number of interventional trials prevented meta-analysis and led to a low level of evidence for most recommendations. The recommendations underwent a consensus process, which resulted in a percentage of agreement (%): strong consensus required of >90 % of votes. Altogether the guideline proposes 3 general recommendations and specific recommendations for the 26 MNs. Monitoring and management strategies are proposed.

CONCLUSION

This short version of the MN guideline should facilitate handling of the MNs in at-risk diseases, whilst offering practical advice on MN provision and monitoring during nutritional support.

Sex differences in patterns of referral and resource utilization in the cardiology clinic: an outpatient analysis

Aims

Women may have different management patterns than men in specialised care. Our aim was to assess potential sex differences in referral, management and outcomes of patients attending outpatient cardiac consultations.

Methods and results

Retrospective observational analysis of patients ≥18 years referred for the first time from primary care to a tertiary hospital cardiology clinic in 2017-2018, comparing reasons for referral, decisions and post-visit outcomes by sex.A total of 5,974 patients, 2,452 (41.0%) men aged 59.2 ± 18.6 years and 3,522 (59.0%) women aged 64.5 ± 17.9 years (P < 0.001) were referred for a first cardiology consultation. The age-related referral rates were higher in women. The most common reasons for consultation were palpitations in women (n = 676; 19.2%) and ECG abnormalities in men (n = 570; 23.2%). Delays to cardiology visits and additional tests were similar. During 24 months of follow-up, women had fewer cardiology hospitalisations (204; 5.8% vs. 229; 9.3%; P = 0.003) and lower mortality (65; 1.8% vs. 66; 2.7%; P = 0.028), but those aged <65 years had more emergency department visits (756; 48.5% vs. 560; 39.9%, P < 0.001) than men.

Conclusion

There are substantial sex differences in primary care cardiology referral patterns, including causes, rates, decisions and outcomes, which are only partially explained by age differences. Further research is needed to understand the reasons for these differences.

Machine Learning Prediction of Iron Deficiency Anemia in Chinese Premenopausal Women 12 Months after Sleeve Gastrectomy

Premenopausal women, who account for more than half of patients for bariatric surgery, are at higher risk of developing postoperative iron deficiency anemia (IDA) than postmenopausal women and men. We aimed at establishing a machine learning model to evaluate the risk of newly onset IDA in premenopausal women 12 months after sleeve gastrectomy (SG). Premenopausal women with complete clinical records and undergoing SG were enrolled in this retrospective study. Newly onset IDA after surgery, the main outcome, was defined according to the age- and gender-specific World Health Organization criteria. A linear support vector machine model was developed to predict the risk of IDA after SG with the top five important features identified during feature selection. Four hundred and seven subjects aged 31.0 (Interquartile range (IQR): 26.0-36.0) years with a median follow-up period of 12 (IQR 7-13) months were analyzed. They were divided into a training set and a validation set with 285 and 122 individuals, respectively. Preoperative ferritin, age, hemoglobin, creatinine, and fasting C-peptide were included. The model showed moderate discrimination in both sets (area under curve 0.858 and 0.799, respectively, p < 0.001). The calibration curve indicated acceptable consistency between observed and predicted results in both sets. Moreover, decision curve analysis showed substantial clinical benefits of the model in both sets. Our machine learning model could accurately predict newly onset IDA in Chinese premenopausal women with obesity 12 months after SG. External validation was required before the model was used in clinical practice.

Vegetables with Enhanced Iron Bioavailability-German Consumers' Perceptions of a New Approach to Improve Dietary Iron Supply

Iron deficiency is still widespread as a major health problem even in countries with adequate food supply. It mainly affects women but also vegans, vegetarians, and athletes and can lead to various clinical pictures. Biofortification of vitamin C-rich vegetables with iron may be one new approach to face this nutritional challenge. However, so far, little is known about the consumer acceptance of iron-biofortified vegetables, particularly in developed countries. To address this issue, a quantitative survey of 1000 consumers in Germany was conducted. The results showed that depending on the type of vegetable, between 54% and 79% of the respondents were interested in iron-biofortified vegetables. Regression analysis showed a relationship between product acceptance, gender, and area of residence. In addition, relationships were found between consumer preferences for enjoyment, sustainability, and naturalness. Compared to functional food and dietary supplements, 77% of respondents would prefer fresh iron-rich vegetables to improve their iron intake. For a market launch, those iron-rich vegetables appear especially promising, which can additionally be advertised with claims for being rich in vitamin C and cultivated in an environmentally friendly way. Consumers were willing to pay EUR 0.10 to EUR 0.20 more for the iron-biofortified vegetables.

Assessment of Serum Electrolytes and Glycated Hemoglobin Level in Non-diabetic Iron-Deficient Anaemic Patients

INTRODUCTION

The WHO has recognised iron deficiency anaemia (IDA) as the most common nutritional deficiency in the world, with 30% of the population being affected by this condition. The patient's glycemic status during the past three months is shown by the glycated haemoglobin A1C (HbA1c) test. According to several studies, iron deficiency can increase HbA1C levels without affecting blood sugar levels. HbA1C levels of ≥ 6.5% have been approved by the American Diabetes Association (ADA) as a diagnostic indicator for diabetes mellitus (DM). An imbalance in serum electrolyte levels and anaemia have been linked by several studies.  Aim: To analyze the effect of iron deficiency anaemia on HbA1c levels and serum electrolytes in an adult non-diabetic population.

METHODS

This was a descriptive cross-sectional study conducted in Shri BM Patil Medical College, Hospital and Research Centre, Vijayapura, Karnataka, India from January 2021 to June 2022. A total of 65 moderate to severe normoglycemic iron deficiency anemia patients between 18 to 75 years were enrolled in the study after fulfilling inclusion and exclusion criteria. A detailed history, clinical and biochemical examination was performed including HbA1c levels. The results were pooled and statistical analyses were performed using Statistical Package for Social Sciences (SPSS) version 20 (IBM Corp., Armonk, NY, USA).

RESULTS

We found elevated HbA1c levels (5.67±1.1%) in non-diabetic iron-deficient anaemia individuals, and elevation was more in women of reproductive age group (30.8%). There was a statistically significant Spearman negative correlation between hemoglobin and HbA1C levels. Also, 16 patients had hyponatremia with a mean haemoglobin (Hb) of 4.8 g/dL and one patient had hyperkalemia with a mean Hb of 3.2 g/dL which was statistically non-significant.

CONCLUSION

In this study haemoglobin and HbA1c had a statistically significant positive correlation with serum sodium and a negative correlation with serum potassium in moderate to severely iron-deficient anaemic patients, especially females of the reproductive age group.

An active new formulation of iron carried by aspartyl casein for iron-deficiency anemia: results of the ACCESS trial

Oral iron supplementation is the cornerstone for the management of iron-deficiency anemia. A new oral formulation of iron conjugated with N-aspartyl-casein (Fe-ASP) (Omalin®, Uni-Pharma) is studied in the ACCESS double-blind, double-dummy randomized clinical trial; 60 patients were randomized to 12-week oral treatment twice every day either with oral ferrous sulfate (FeSO₄) delivering 47 mg elementary iron or oral Fe-ASP delivering 40 mg elementary iron. Participants had hemoglobin less than 10 g/dl, decreased red blood cell (RBC) count, and ferritin lower than 30 ng/ml; patients with a medical history of malignancy were excluded. The primary endpoint was the increase of Hb in the first 4 weeks of treatment, and the study was powered for non-inferiority. A new score of global improvement was introduced where all participants were given one point for any at least 10% increase of Hb, RBC, and reticulocytes. At week 4, the mean (SE) change of Hb was 0.76 g/dl in the FeSO₄ group and 0.83 g/dl in the Fe-ASP group (p: 0.876). The odds for worse allocation of the global score were 0.35 in the Fe-ASP group compared to the FeSO₄ group. Patients in the Fe-ASP group experienced a significant decrease in the number of IDA-related physical signs by week 4. No differences were found between the two groups in any of the patient-reported outcomes of fatigue and of gastrointestinal adverse events either at week 4 or at week 12. ACCESS is the most recent clinical trial showing the non-inferiority of Fe-ASP to FeSO₄ for the primary endpoint of the Hb change.

The Effects of Iron Deficiency on the Gut Microbiota in Women of Childbearing Age

Iron deficiency anemia (IDA) is the most prevalent and common nutritional deficiency worldwide and is a global health problem with significant risk, particularly among women of reproductive age. Oral iron supplementation is the most widely used and cost-effective treatment for iron deficiency and IDA. However, there are limitations regarding side effects such as enteritis, treatment compliance, and bioavailability. Intestinal microbiome characteristic research has been recently conducted to overcome these issues, but more is needed. Against this background, a metagenomics study on the 16S gene in the feces of young women vulnerable to IDA was conducted. As a result of analyzing 16 normal subjects and 15 IDA patients, significant differences in bacterial community distribution were identified. In particular, a significant decrease in Faecalibacterium was characteristic in IDA patients compared with normal subjects. Furthermore, in the case of patients who recovered from IDA following iron supplementation treatment, it was confirmed that Faecalibacterium significantly recovered to normal levels. However, no significance in beta diversity was seen compared with before treatment. There were also no differences in the beta diversity results between the recovered and normal subjects. Therefore, intestinal dysbiosis during the disease state was considered to be restored as IDA improved. Although the results were derived from a limited number of subjects and additional research is needed, the results of this study are expected to be the basis for developing treatment and prevention strategies based on host-microbiome crosstalk in IDA.

Dietary Iron Intake and Biomarkers of Iron Status in Slovenian Population: Results of SI.Menu/Nutrihealth Study

Inadequate iron intake and iron deficiency are recognised as a public health problem in the population at large, and particularly in specific subpopulations. Dietary iron intake was analysed using data of the national Slovenian food consumption study, SI.Menu (n = 1248 subjects; 10−74 years), while iron status was evaluated with laboratory analyses of blood haemoglobin, serum ferritin, and iron concentration in samples, collected in the Nutrihealth study (n = 280, adults). The estimated daily usual population-weighted mean iron intakes ranged from 16.0 mg in adults and the elderly to 16.7 in adolescents, and were lower in females for all three age groups. The main dietary iron sources in all the age groups were bread and bakery products, meat (products), fruit, and vegetables. The highest prevalence of haemoglobin anaemia was observed in females aged 51−64 years (6.7%). Critically depleted iron stores (ferritin concentration < 15 µg/L) were particularly found in premenopausal females (10.1%). Factors influencing low haemoglobin, ferritin, and iron intake were also investigated. We observed significant correlations between iron status with meat and fish intake, and with iron intake from meat and fish, but not with total iron intake. We can conclude that particularly premenopausal females are the most fragile population in terms of inadequate iron intake and iron deficiency, which should be considered in future research and public health strategies.

Lifestyle and dietary factors, iron status and one-carbon metabolism polymorphisms in a sample of Italian women and men attending a Transfusion Medicine Unit: a cross-sectional study

Iron (Fe) status among healthy male and female blood donors, aged 18–65 years, is estimated. General characteristics and lifestyle factors, dietary habits and major one-carbon metabolism-related polymorphisms were also investigated. An explorative cross-sectional study design was used to examine a sample of blood donors attending the Transfusion Medicine Unit of the Verona University Hospital, Italy. From April 2016 to May 2018, 499 subjects were enrolled (255 men, 244 women, 155 of whom of childbearing age). Major clinical characteristics including lifestyle, dietary habits and Fe status were analysed. The MTHFR 677C > T, cSHMT 1420C > T, DHFR 19bp ins/del and RFC1 80G > A polymorphisms were also assayed. Mean plasma concentrations of Fe and ferritin were 16·6 µmol/l (95 % CI 16·0, 17·2) and 33·8 µg/l (95 % CI 31·5, 36·2), respectively. Adequate plasma Fe concentrations (> 10·74 µmol/l) were detected in 84·3 % and adequate ferritin concentrations (20–200 µg/l) was found in 72·5 % of the whole cohort. Among the folate-related polymorphisms analysed, carriers of the DHFR 19bp del/del mutant allele showed lower ferritin concentration when compared with DHFR 19bp ins/del genotypes. In a sample of Italian healthy blood donors, adequate plasma concentrations of Fe and ferritin were reached in a large proportion of subjects. The relationship of Fe status with lifestyle factors and folate-related polymorphisms requires more investigation to clarify further gene–nutrient interactions between folate and Fe metabolism.

Cognitive control inhibition networks in adulthood are impaired by early iron deficiency in infancy

Iron deficiency, a common form of micronutrient deficiency, primarily affects children and women. The principal cause of iron deficiency is undernutrition in low-income countries and malnutrition in middle to upper income regions. Iron is a key element for myelin production, neuronal metabolism, and dopamine functions. Iron deficiency in early life can alter brain development and exert long-lasting effects. Control inhibition is an executive function that involves several brain regions, including the prefrontal cortex and caudate and sub-thalamic nuclei. Dopamine is the prevalent neurotransmitter underlying cognitive inhibition. We followed cohort study participants who had iron deficiency anemia in infancy as well non-anemic controls. At 22 years of age, the participants were subjected to functional magnetic resonance imaging (fMRI) to evaluate the correlation between functional connectivity and performance on an inhibitory cognitive task (Go/No-Go). We hypothesized that former iron deficient anemic (FIDA) participants demonstrate less strength in functional connectivity compared with controls (C). There were not significant group differences in the behavioral results in terms of accuracy and response time. A continuous covariate interaction analysis of functional connectivity and the Go/No-Go scores demonstrated significant differences between the FIDA and C groups. The FIDA participants demonstrated less strength in connectivity in brain regions related to control inhibition, including the medial temporal lobe, impairment in the integration of the default mode network (indicating decreased attention and alertness), and an increase in connectivity in posterior brain areas, all of which suggest slower circuitry maturation. The results support the hypothesis that FIDA young adults show differences in the connectivity of networks related to executive functions. These differences could increase their vulnerability to develop cognitive dysfunctions or mental disorders in adulthood.

ESPEN micronutrient guideline

BACKGROUND

Trace elements and vitamins, named together micronutrients (MNs), are essential for human metabolism. Recent research has shown the importance of MNs in common pathologies, with significant deficiencies impacting the outcome.

OBJECTIVE

This guideline aims to provide information for daily clinical nutrition practice regarding assessment of MN status, monitoring, and prescription. It proposes a consensus terminology, since many words are used imprecisely, resulting in confusion. This is particularly true for the words "deficiency", "repletion", "complement", and "supplement".

METHODS

The expert group attempted to apply the 2015 standard operating procedures (SOP) for ESPEN which focuses on disease. However, this approach could not be applied due to the multiple diseases requiring clinical nutrition resulting in one text for each MN, rather than for diseases. An extensive search of the literature was conducted in the databases Medline, PubMed, Cochrane, Google Scholar, and CINAHL. The search focused on physiological data, historical evidence (published before PubMed release in 1996), and observational and/or randomized trials. For each MN, the main functions, optimal analytical methods, impact of inflammation, potential toxicity, and provision during enteral or parenteral nutrition were addressed. The SOP wording was applied for strength of recommendations.

RESULTS

There was a limited number of interventional trials, preventing meta-analysis and leading to a low level of evidence. The recommendations underwent a consensus process, which resulted in a percentage of agreement (%): strong consensus required of >90% of votes. Altogether the guideline proposes sets of recommendations for 26 MNs, resulting in 170 single recommendations. Critical MNs were identified with deficiencies being present in numerous acute and chronic diseases. Monitoring and management strategies are proposed.

CONCLUSION

This guideline should enable addressing suboptimal and deficient status of a bundle of MNs in at-risk diseases. In particular, it offers practical advice on MN provision and monitoring during nutritional support.

Daily versus every other day oral iron supplementation in patients with iron deficiency anemia (DEODO): study protocol for a phase 3 multicentered, pragmatic, open-label, pilot randomized controlled trial

BACKGROUND

Iron deficiency anemia (IDA) accounts for the majority of anemia cases across the globe and can lead to impairments in both physical and cognitive functioning. Oral iron supplementation is the first line of treatment to improve the hemoglobin level for IDA patients. However, gaps still exist in understanding the appropriate dosing regimen of oral iron. The current trial proposes to evaluate the feasibility of performing this study to examine the effectiveness and side-effect profile of oral iron once daily versus every other day.

METHODS

In this open-label, pilot, feasibility, randomized controlled trial, 52 outpatients over 16 years of age with IDA (defined as hemoglobin < 12.0 g/dL in females and < 13.0 g/dL in males and ferritin < 30 mcg/L) will be enrolled across two large academic hospitals. Participants are randomized in a 1:1 ratio to receive 300 mg oral ferrous sulfate (60 mg of elemental iron) either every day or every other day for 12 weeks. Participants are excluded if they are as follows: (1) pregnant and/or currently breastfeeding, (2) have a disease history that would impair response to oral iron (e.g., thalassemia, celiac disease), (3) intolerant and/or have an allergy to oral iron or vitamin C, (4) on new anticoagulants in the past 6 months, (5) received IV iron therapy in the past 12 weeks, (6) have surgery, chemotherapy, or blood donation planned in upcoming 12 weeks, (7) a creatinine clearance < 30 mL/min, or (8) hemoglobin less than 8.0 g/dL with active bleeding. The primary outcome is feasibility to enroll 52 participants in this trial over a 2-year period to determine the effectiveness of daily versus every other day oral iron supplementation on hemoglobin at 12 weeks post-initiation and side-effect profile.

DISCUSSION

The results of this trial will provide additional evidence for an appropriate dosing schedule for treating patients with IDA with oral iron supplementation. Additional knowledge will be gained on how the dosing regimen of oral iron impacts quality of life and hemoglobin repletion in IDA patients. If this trial is deemed feasible, it will inform the development and implementation of a larger multicenter definitive trial.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03725384 . Registered 31 October 2018.

Wen Dan Tang: A Potential Jing Fang Decoction for Headache Disorders?

BACKGROUND

Chinese herbal medicine is considered relatively safe, inexpensive, and easily accessible. Wen Dan Tang (WDT), a Jing Fang ancient classical Chinese herbal formula with a broad indication profile has been used for several centuries in China to treat various illnesses.

QUESTION

Are there evidence-based clinical trials that show that WDT has a significant impact on the treatment of various diseases, especially in patients with migraine and tension-type headaches (TTH)?

METHODS

This study is based on an online database search using PubMed, Medline, Cochrane Library, AcuTrials, Embase, Semantic Scholar, Jstor, internet research, and review of ancient and modern Chinese medical textbooks regarding WDT and its compounds.

RESULTS

There were no studies on WDT in migraine and TTH; therefore, this work gathers and describes data for every single compound in the formula.

CONCLUSION

This study suggests that the bioactive compounds found in WDT composition show potential in treating patients with neurological, psychiatric disorders, cardiovascular diseases, metabolic syndrome, and digestive disorders. Some coherence between WDT in headache reduction and improvements in the quality of life in patients with migraines and TTH could be evaluated, showing positive results of WDT in these patients.

Assessing the use of antibiotics and the burden of varicella in Belgium using a retrospective GP database analysis

Background

Varicella is a highly contagious infection that typically occurs in childhood. While most cases have a generally benign outcome, infection results in a considerable healthcare burden and serious complications may occur.

Objectives

The objective of this study was to characterize the burden of varicella in a real-world primary care setting in Belgium, including the rate of varicella-related complications, medication management and general practitioner (GP) visits.

Methods

The study was a retrospective observational study using data from a longitudinal patient database in a primary care setting in Belgium. Patients with a GP visit and a varicella diagnosis between January 2016 and June 2019 were eligible and data one month prior and three months after the diagnosis were included. Outcomes included varicella-related complications, antibiotic use, antiviral use, and GP follow-up visits. Antibiotic use could be specified by class of antibiotic and linked to a diagnosis. Complications were identified based on concomitant diagnosis with varicella during the study period.

Results

3,847 patients with diagnosis of varicella were included, with a mean age of 8.4 years and a comparable distribution of gender. 12.6% of patients with varicella had a concomitant diagnosis of a varicella-related complication. During the follow-up period, 27.3% of patients with varicella were prescribed antibiotics, either systemic (19.8%) and/or topical (10.3%). The highest rate of antibiotic prescriptions was observed in patients with complications (63.5%) and in patients younger than 1 year (41.8%). Nevertheless, 5.3% of the patients were prescribed antibiotics without a concomitant diagnosis of another infection. The most commonly prescribed systemic antibiotics were amoxicillin alone or combined with beta-lactamase inhibitor, and thiamphenicol. Fusidic acid and tobramycin were the most prescribed topical antibiotics. Antivirals were prescribed for 2.7% of the study population. 4.7% of the patients needed a follow-up visit with their GP.

Conclusions

This study reports a substantial burden of varicella in a primary care setting in Belgium, with high rates of complications and antibiotic use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06848-4.

Evaluation of Serum Electrolyte Levels in Patients With Anemia

INTRODUCTION

Anemia is one of the most prevalent diseases globally. Various diseases have linked anemia with electrolyte disturbance. However, the local data are limited. In this study, we will determine the prevalence of electrolyte imbalance in anemic patients.

METHODS

This case-control study was conducted in a tertiary care hospital from January 2021 to July 2021. A total of 500 anemic patients were enrolled in the study after informed consent. Another 500 non-anemic patients were enrolled as the control group. Blood was taken from both groups and send for assessment of electrolytes.

RESULTS

Sodium levels were significantly lower in anemic patients compared to non-anemic patients (131.42 ± 0.82 meq/L vs. 135.57 ± 0.42 meq/L; p-value: <0.0001). Potassium levels were significantly higher in anemic patients compared to non-anemic participants (4.37 ± 0.12 meq/L vs. 4.09 ± 0.11 meq/L; p-value: <0.0001). Chloride levels were significantly higher in participants with anemia compared to non-anemic participants (103.92 ± 0.46 meq/L vs. 100.99 ± 0.41 meq/L).

CONCLUSION

Our study indicates that sodium levels and potassium levels are impacted in patients with anemia compared to patients without anemia. Close monitoring of serum electrolytes is suggested in patients with anemia to avoid complications and life-threatening conditions.

An Italian individual-level data study investigating on the association between air pollution exposure and Covid-19 severity in primary-care setting

BACKGROUND

Several studies have been focusing on the potential role of atmospheric pollutants in the diffusion and impact on health of Covid-19. This study's objective was to estimate the association between ≤10 μm diameter particulate matter (PM10) exposure and the likelihood of experiencing pneumonia due to Covid-19 using individual-level data in Italy.

METHODS

Information on Covid-19 patients was retrieved from the Italian IQVIA® Longitudinal Patient Database (LPD), a computerized network of general practitioners (GPs) including anonymous data on patients' consultations and treatments. All patients with a Covid-19 diagnosis during March 18th, 2020 - June 30th, 2020 were included in the study. The date of first Covid-19 registration was the starting point of the 3-month follow-up (Index Date). Patients were classified based on Covid-19-related pneumonia registrations on the Index date and/or during follow-up presence/absence. Each patient was assigned individual exposure by calculating average PM10 during the 30-day period preceding the Index Date, and according to GP's office province. A multiple generalized linear mixed model, mixed-effects logistic regression, was used to assess the association between PM10 exposure tertiles and the likelihood of experiencing pneumonia.

RESULTS

Among 6483 Covid-19 patients included, 1079 (16.6%) had a diagnosis of pneumonia. Pneumonia patients were older, more frequently men, more health-impaired, and had a higher individual-level exposure to PM10 during the month preceding Covid-19 diagnosis. The mixed-effects model showed that patients whose PM10 exposure level fell in the second tertile had a 30% higher likelihood of having pneumonia than that of first tertile patients, and the risk for those who were in the third tertile was almost doubled.

CONCLUSION

The consistent findings toward a positive association between PM10 levels and the likelihood of experiencing pneumonia due to Covid-19 make the implementation of new strategies to reduce air pollution more and more urgent.

Iron Deficiency - Not Only a Premenopausal Topic After Bariatric Surgery?

Purpose

In our centre, specialized high dose multivitamin supplementation designed to meet the needs of patients after gastric bypass surgery is routinely recommended in the early postoperative period. The aim of the present study was to analyse whether iron supplementation prescribed in clinical practice is sufficient in both sexes and whether multivitamin supplementation standardized for women might potentially lead to iron overload in men.

Materials/Methods

This was a retrospective study covering the period up to 36 months after bariatric surgery. Three groups were compared (men, premenopausal and postmenopausal women). The iron status was evaluated employing serum ferritin concentrations.

Results

A total of 283 patients who had at least one follow-up visit between January 2015 and April 2018 at a specialized academic outpatient centre were included (71 men, 130 premenopausal women, 82 postmenopausal women). Thirty-six months after surgery, 33.3%, 68.4% and 54.5% of the men, pre- and postmenopausal women, respectively, were iron deficient. The preoperative prevalence of excess ferritin levels was 13.7% in premenopausal, 3.0% in postmenopausal women, 5.7% in men and declined in the following months.

Conclusion

Iron deficiency is very common after gastric bypass surgery, and even high dosages of multivitamin and mineral supplements might not be sufficient to prevent the development of iron deficiency. Men, pre- and postmenopausal women differ in their prevalence of iron deficiency which demands adapted iron dosage regimens based on the sex and the age. Iron overload is rare in all observed groups and highest in premenopausal women.

Graphical abstract

Iron deficiency anemia in males: a dosing dilemma?

Introduction: Iron deficiency anemia is a major problem worldwide treated by replenishment of iron stores. The treatment is complicated by differing pharmacodynamics of administrative routes, equations with design effects, ongoing losses, additional daily requirement, plateauing of markers required for iron absorption, food-drug interactions, gender, and age. Accounting for these factors in one dosing regimen becomes difficult, specifically in males. This review aimed at analyzing multiple dosages of iron supplements in different studies and determining if there are factors that could individualize treatment in male patients. Methods: A scoping review was performed using PubMed, Google Scholar, and ClinicalTrials.gov. We reviewed literature from 1980 to 2020. The keywords used in the review were 'iron deficiency', 'dosage', 'males', and 'standardized'. Results and conclusions: The review included 1507 male participants from 9 major studies (4 clinical trials, 1 systematic review, 2 prospective and 2 descriptive studies). In the case of males, differences in lean body weight, and factors affecting absorption of iron also need to be considered. In order to thoroughly explore the issues in treatment of iron deficiency anemia, randomized controlled trials are required to investigate the frequency of dosing, impact of vitamin C and proper counselling, and weight changes in male participants.

Predictors of iron-deficiency anemia in primary care older adults: a real-world European multi-country longitudinal study

BACKGROUND

Iron deficiency is a major cause of anemia in older people. Increasing the knowledge on the predictors of iron-deficiency anemia (IDA) may facilitate its timely diagnosis.

AIM

To investigate the predictors of IDA in older people in four European countries.

DESIGN AND SETTING

Retrospective longitudinal study. Primary care patients aged 65 or older (N = 24,051) in four European countries.

METHODS

IDA predictors were estimated using multivariate Cox regression based on information gathered from national primary care databases: Italy (years 2002-2013), Belgium, Germany and Spain (years 2007-2012). Adjusted hazard ratios (aHR) with 95% confidence intervals (CIs) were estimated.

RESULTS

In Spain and Belgium, men were at greater risk of IDA than women, while they had a lower risk in Italy. Weakness, irritability, alopecia and xerostomia were signs and symptoms significantly associated with IDA. Concurrent diseases, potential causes of anemia, positively associated with IDA were small bowel polyposis, stomach cancer, obesity, gastritis and peptic ulcer, esophagitis, Crohn's disease, celiac disease, lymphangiectasis, gastrectomy or gastric atrophy, gut resection or bypass, and cardiac prosthetic valve. Aspirin users had a 12-35% higher hazard of IDA than non-users. Similarly, corticosteroids and anti-acids were positively associated with IDA. A higher level of comorbidity was associated with an increased hazard of IDA in all countries.

CONCLUSIONS

Specific signs and symptoms, chronic conditions, a greater comorbidity burden, and specific pharmacological treatments registered in primary care databases represent relevant predictors and correlates of incident IDA in older people in Europe. General practitioners might employ this information to obtain early diagnosis of IDA in community-dwelling older adults.

Screening for Anemia and Iron Deficiency in the Adult Portuguese Population

Anemia and iron deficiency (ID) can impair quality of life and socioeconomic development. We evaluated the prevalence of anemia and ID in the adult Portuguese population in real-life contexts by gender, age, and pregnancy status. We performed a cross-sectional screening in adult individuals in mainland Portugal from 2013 to 2017. Participants completed a survey about demographics and signs or symptoms compatible with anemia, and ID and hemoglobin and ferritin concentrations were determined by point-of-care tests. We estimated and compared prevalence ratios (PR) of anemia and ID using Poisson regression with robust variance and the Wald chi-square test. We collected data from 11,030 individuals (26% men, 64% nonpregnant women, and 10% pregnant women). We found anemia in 51.8% (95% CI 50.1–53.4%) of nonpregnant women in fertile age, 46.6% (95% CI 44.7–48.6%) of nonpregnant women >51 years, 38.2% (95% CI 35.4–41.1%) of pregnant women, and 33.3% (95% CI 31.6–35.1%) of men. The prevalence of ID was 72.9% (95% CI 71.4–74.4%) in nonpregnant women in fertile age, 50.5% (95% CI 48.5–52.4%) in nonpregnant women >51 years, 94.8% (95% CI 93.3–96.0%) in pregnant women, and 28.9% (95% CI 27.3–30.6%) in men. We found significant associations between the prevalence of anemia or ID and nonpregnant women (PR: 1.50, 95% CI 1.42–1.59 or PR: 2.21, 95% CI 2.09–2.35, respectively), manifestation of signs or symptoms (PR: 1.19, 95% CI 1.53–1.23 or PR: 1.22, 95% CI 1.18–1.26), pregnant women (PR: 0.74, 95% CI 0.68–0.80 or PR: 1.30, 95% CI 1.27–1.33), and nonpregnant women ≤51 years (PR: 1.11, 95% CI 1.06–1.17 or PR: 1.42, 95% CI 1.36–1.48). In conclusion, anemia and ID represent moderate to severe public health problems, particularly among women in fertile age and in 3rd trimester, of pregnancy emphasizing the need to raise the public and health professionals' awareness of these problems and their prevention, diagnosis, and treatment.

Trends and Between-Physician Variation in Laboratory Testing: A Retrospective Longitudinal Study in General Practice

Laboratory tests are frequently ordered by general practitioners (GPs), but little is known about time trends and between-GP variation of their use. In this retrospective longitudinal study, we analyzed over six million consultations by Swiss GPs during the decade 2009–2018. For 15 commonly used test types, we defined specific laboratory testing rates (sLTR) as the percentage of consultations involving corresponding laboratory testing requests. Patient age- and sex-adjusted time trends of sLTR were modeled with mixed-effect logistic regression accounting for clustering of patients within GPs. We quantified between-GP variation by means of intraclass correlation coefficients (ICC). Nine out of the 15 laboratory test types considered showed significant temporal increases, most eminently vitamin D (ten-year odds ratio (OR) 1.88, 95% confidence interval (CI) 1.71–2.06) and glycated hemoglobin (ten-year OR 1.87, 95% CI 1.82–1.92). Test types both subject to substantial increase and high between-GP variation of sLTR were vitamin D (ICC 0.075), glycated hemoglobin (ICC 0.101), C-reactive protein (ICC 0.202), and vitamin B12 (ICC 0.166). Increasing testing frequencies and large between-GP variation of specific test type use pointed at inconsistencies of medical practice and potential overuse.

Office-based approach to urinary tract infections in 50 000 patients: results from the REWIND study

OBJECTIVES

The REWIND study sought to describe the real-world clinical and prescribing practices for the management of urinary tract infection (UTI) in Italy, Belgium, Russia and Brazil in order to compare current practices with international, European and national guidelines.

METHODS

An integrated mixed-methods approach was adopted that used information from primary care electronic medical records in longitudinal patient databases available in Italy and Belgium, and surveys of physicians in Russia (general practitioners) and Brazil (gynaecologists).

RESULTS

In total, 49 548 female patients were included in the study. Antibiotics were the most common management option for UTI in Italy (71.1%, n=27 600), Belgium (92.4%, n=7703), Russia (81.9%, n=1231) and Brazil (82.4%, n=740). Fosfomycin trometamol was the first-choice antibiotic for the treatment of UTI in all countries. Ciprofloxacin was also commonly prescribed in Italy (24.6%, n=6796), Belgium (17.8%, n=1373), Russia (14.9%, n=184) and Brazil (9.6%, n=71), while prescription of nitrofurantoin was common in Belgium (24.5%, n=1890) alone.

CONCLUSIONS

Despite differences in study designs and data sources, fosfomycin trometamol was found to be the most commonly prescribed treatment for UTI in all participating countries. In Belgium, real-world prescribing practices for UTI adhered more closely to European guidelines than national guidelines. Although not recommended in international and European guidelines for lower UTI management, the use of fluoroquinolones was still widespread.

What drives inhaler prescription for asthma patients? Results from a real-life retrospective analysis

BACKGROUND

The choice of inhaler device for asthma patients depends upon multiple attributes. We investigated factors that may drive general practitioners (GPs) and respiratory specialists in the prescription of inhaler devices for asthma patients who initiated inhalation therapy.

METHODS

We retrospectively analysed prescriptions by GPs and respiratory specialists to asthma patients commencing inhaled corticosteroid/long-acting β2-agonist combination therapy available as both pressurised metered-dose inhalers (pMDIs) and dry powder inhalers (DPIs). Patient characteristics were compared by device and multivariate analysis was used to model the likelihood of receiving a pMDI as opposed to a DPI in order to identify drivers for prescription. A sample of the respiratory specialists completed an ad-hoc survey of their perceived success in achieving asthma control in their patients and barriers to attaining full control.

RESULTS

Prescription of a particular inhaler device was unrelated to the characteristics of the patients. Multivariate analysis revealed that the main driver for the choice of inhaler device was the medication (Odds Ratio and 95% Confidence Interval, respectively for GPs and specialists: 0.19 [0.16-0.23]; 0.17 [0.08-0.37]). Specialists perceived asthma as being inadequately controlled in 41% of their patients, and considered patients' difficulties in using DPIs and pMDIs as instrumental in this, citing a need for a novel, more effective inhaler technology.

CONCLUSION

Physicians choose inhaler devices according to the prescribed drugs and not to the characteristics of the individual patient. This may reflect a lack of confidence in existing inhaler devices and underlines the need for technologies, which are more reliable and easier to use by patients.

Anaemia, iron deficiency, iron-deficiency anaemia and their associations with obesity among schoolchildren in Guangzhou, China

OBJECTIVE

The association of Fe metabolism with obesity in children remains unclear. The present study aimed to assess the status of Fe metabolism parameters, the prevalence of anaemia, Fe deficiency (ID) and Fe-deficiency anaemia (IDA), and the associations of these variables with obesity in Chinese schoolchildren.

DESIGN

A cross-sectional study conducted in 5295 schoolchildren aged 7-11 years in Guangzhou, China, 2014-2015. Full data of anthropometric and Fe metabolic parameters were collected to assess obesity, anaemia, ID and IDA. Logistic regression models were established to determine the possible associations of anaemia, ID and IDA with obesity. Two-tailed P values of <0·05 was considered statistically significant.

SETTING

Guangzhou City, China.

PARTICIPANTS

Schoolchildren aged 7-11 years (n 5295).

RESULTS

In this sample, mean Hb concentration was 128·1 g/l and the prevalence of anaemia, ID and IDA was 6·6, 6·2 and 0·6 %, respectively. Of the participants, 14·0 % were overweight and 8·8 % were obese. Importantly, obesity was associated with lower anaemia risk (adjusted OR = 0·553; 95 % CI 0·316, 0·968) but higher ID risk (adjusted OR = 1·808; 95 % CI 1·146, 2·853) after adjustment for confounders. No significant relationship was found between obesity and IDA.

CONCLUSIONS

Our results confirmed that anaemia and ID remain public health concerns among schoolchildren in Guangzhou, while IDA is remarkably less prevalent. Furthermore, obesity was associated with lower anaemia risk, but higher ID risk. More efforts should be made to prevent the onset of ID and obesity in the same individual, thus improving the health and fitness of children.

Sleep and motor sequence learning consolidation in former iron deficient anemic adolescents

BACKGROUND

Iron deficiency is the most prevalent micronutrient deficiency worldwide. There is evidence that iron deficiency produces alterations in the developing brain, eventually leading to long-lasting effects on various cognitive functions.

METHODS

Here, we investigated motor learning and its consolidation after sleep in adolescents who sustained iron deficiency anemia (IDA) in infancy, compared to healthy controls, in the context of a long-term follow-up Chilean research project. Fifty-three adolescents who formerly had iron deficiency anemia as infants and 40 control adolescents practiced a sequential motor finger tapping task, before and after a night of sleep. Performance was measured at the end of learning, 30 min later (boost effect), and the next morning.

RESULTS

Revealed slower learning in subjects with infant iron deficiency anemia than control subjects, followed by a proportionally similar performance boost at 30 min. Performance remained stable overnight in healthy controls but further improved in infant IDA adolescents, suggesting a beneficial effect of post-training sleep on the consolidation of incompletely learned motor skills. In particular, overnight gains in performance were observed in female, but not male infant iron deficiency anemic subjects, suggesting a gender effect.

CONCLUSIONS

Our results indicate long-lasting motor learning deficits in infant IDA adolescents and provide support to the hypothesis that post-training sleep might, to some extent, compensate for hampered motor learning during wakefulness.

Computed and Subjective Blue Scleral Color Analysis as a Diagnostic Tool for Iron Deficiency: A Pilot Study

Iron deficiency (ID) is the most common nutritional deficiency. ID diagnosis requires ferritin measurement because clinical findings are poor and nonspecific. We studied the diagnostic value of blue sclera, which was scarcely reported as a specific and sensitive sign of ID. We enrolled 74 patients suspected of having ID. Pictures of their eyes were taken using a smartphone under similar daylight conditions. Three independent physicians graded the scleral color, and a computer analysis yielded the blue percentile of the sclera image. Final analysis included 67 patients (mean age 59.9 ± 20.1 years). Fifty-one had ID. Subjective blue scleral color was associated with ID for physician 1 (64.5% vs. 86.1%, p = 0.03). Sensitivity was 60.8% (CI95: 46.1%; 74.2%), specificity 68.8% (CI95: 41.3%; 89%), and positive predictive value 86.1% (CI95: 70.5%; 95.3%). A marginal difference was observed for other physicians (p = 0.05). Computer analysis showed higher blue in the ID group (p = 0.04). The area under the receiver operating characteristic (ROC) curve was 0.7 (0.54; 0.85). Sensitivity was 78.4% (CI95: 63.7%; 88.7%), specificity was 50% (CI95: 24.7%; 75.3%). Assessment of blue sclera was not influenced by iris color, sex, or anemia. We showed that blue sclera has good positive predictive value for ID diagnosis, and computer analysis was correlated to clinical assessment. Improvement of this innovative, non-invasive method could provide an easy handling and inexpensive diagnosis tool for ID.

Ultrasound as First Line Step in Anaemia Diagnostics

This review covers the role of ultrasonography as an essential non-invasive diagnostic approach when facing patients with anaemia, a common clinical problem. Abdomen ultrasound is well recognised as a first-line examination in the setting of blood loss, both acute and chronic. Less is clear about the additional opportunities, given by ultrasound in anaemia, due to the many other possible causes. Here we provide information on the utility of ultrasound in different contexts and a practical guide for clinicians facing anaemic patients.

Iron Deficiency in Acute Decompensated Heart Failure

The aim of this study was to characterize iron deficiency (ID) in acutely decompensated heart failure (ADHF) and identify whether ID is associated with dyspnea class, length of stay (LOS), biomarker levels, and echocardiographic indices of diastolic function in patients with reduced ejection fraction (HFrEF) and with preserved ejection fraction (HFpEF). Consecutive patients admitted with ADHF at a single tertiary center were included. Demographic information, pathology investigations, and metrics regarding hospital stay and readmission were recorded. Patients were classified as having 'absolute' ID if they had a ferritin level <100 ng/mL; or 'functional' ID if they had a ferritin 100-200 ng/mL and a transferrin saturation <20%. Of 503 patients that were recruited, 270 (55%) had HFpEF, 160 (33%) had HFREF, and 57 (12%) had heart failure with mid-range ejection fraction. ID was present in 54% of patients with HFrEF and 56% of patients with HFpEF. In the HFpEF group, ID was associated with a LOS of 11 ± 7.7 vs. 9 ± 6 days in iron replete patients, p = 0.036, and remained an independent predictor of increased LOS in a multivariate linear regression incorporating comorbidities, age, and ID status. This study corroborates a high prevalence of ID in both HFrEF and HFpEF, and further shows that in patients with HFpEF there is a prolongation of LOS not seen in HFrEF which may indicate a more prominent role for ID in HFpEF.

Real-world insights on the management of migraine patients: an Italian nationwide study

Objectives: Understanding migraine management using data from a sample of patients representative of the Italian general adult population.Methods: Retrospective analysis on IQVIA Italian Longitudinal Patient Database. Two cohorts were created. (a) The triptan user cohort included patients with triptan prescriptions between November 2015 and October 2016. Migraine days were estimated counting triptan and indometacin/caffeine/prochlorperazine (ICP) pills prescribed during the 6 months following first triptan prescription. Patients were categorized as having episodic (EM) or chronic (CM) migraine based on the number of migraine days following International Classification of Headache Disorders criteria. (b) The migraine preventive treatment (MPT) user cohort included patients with MPT prescriptions during the period June 2016-May 2017. MPTs considered included beta-blockers, calcium-channel blockers, antiepileptics, antidepressants and antiserotoninergics. Migraine days experienced by MPTs users were estimated counting triptan and ICP pills prescribed during the 6 months following the most recent MPT prescription, while the number of MPT switches was estimated based on MPT prescriptions during the previous two years.Results: There were 9461 patients with triptan prescriptions to treat migraine acute attacks, which accounted yearly for 0.8% of general adult population. CM patients accounted for 3% of triptan users. There were 2004 patients prescribed with MPTs, which accounted for 0.16% of general adult population. Overall, among MPT users, 291 (15%) were still experiencing at least four migraine days/month, with this proportion increasing with the increase in the number of MPT switches.Conclusions: Results from this study suggest an unmet need in the management of migraine: too many patients did not receive MPTs, with this potentially due to several reasons requiring further investigations. Furthermore, even among patients receiving MPTs, disease control level with now available drugs seems to be sub-optimal.

Gender differences in determinants of iron-deficiency anemia: a population-based study conducted in four European countries

Iron-deficiency anemia (IDA) was the main condition contributing to higher rates of years lived with disabilities in women in 2016. To date, few studies have investigated gender differences in determinants of IDA in Europe. The aim of the present study was to evaluate the determinants of IDA among females and males in four European countries. IDA determinants were estimated using multivariable Cox regression based on information gathered from national primary care databases, namely Italy (for years 2002-2013), Belgium, Germany, and Spain (for years 2007-2012). Adjusted hazard ratios (aHR) with 95% confidence intervals (CIs) were estimated. Age was significantly associated with IDA in females of childbearing age in all four countries, as well as pregnancy, for which the aHR ranged from 1.20 (95% CI 1.15-1.25) in Italy to 1.88 (95% CI 1.53-2.31) in Germany. In males, the aHR increased with age starting from the 65-69 age group. Menometrorrhagia was associated with IDA in Germany (aHR 2.71, 95% CI 1.96-3.73), Italy (aHR 1.80, 95% CI 1.60-2.03), and Spain (aHR 1.52, 95% CI 1.31-1.76). A greater risk for women with alopecia was also observed. Weakness and headache indicated a higher risk in both men and women. Patients with diseases characterized by blood loss or gastrointestinal malabsorption were also at significantly increased risk. Physicians should encourage women of childbearing age to adhere to dietary recommendations regarding iron intake and regularly prescribe screening of iron status. Upper and lower gastrointestinal investigations should be recommended for patients with a confirmed diagnosis of IDA.

The usefulness of reticulocyte haemoglobin content, serum transferrin receptor and the sTfR-ferritin index to identify iron deficiency in healthy children aged 1-16 years

This cross-sectional study, conducted on a population-based representative sample, evaluates the usefulness of reticulocyte haemoglobin content (CHr), serum transferrin receptor (sTfR) and sTfR/log ferritin (sTfR-F index) to recognise iron deficiency (ID) without anaemia, provides specific cut-off points for age and gender, and proposes a new definition of ID. A total of 1239 healthy children and adolescents aged 1-16 years were included. Complete blood count, iron biomarkers, erythropoietin, C-reactive protein, CHr, sTfR, and sTfR-F index were determined. ROC curves were obtained and sensitivity, specificity, predictive values, likelihood ratios, and accuracy for each specific cut-off points were calculated. Seventy-three had ID without anaemia. Area under the curve for sTfR-F index, sTfR and CHr were 0.97 (CI95% 0.95-0.99), 0.87 (CI95% 0.82-0.92) and 0.68 (CI95% 0.61-0.74), respectively. The following cut-off points defined ID: sTfR-F Index > 1.5 (1-5 years and 12-16 years boys) and > 1.4 (6-11 years and 12-16 years girls); sTfR (mg/L) > 1.9 (1-5 years), > 1.8 (6-11 years), > 1.75 (12-16 years girls) and > 1.95 (12-16 years boys); and CHr (pg) < 27 (1-5 years) and < 28.5 (6-16 years).Conclusions: CHr, sTfR and the sTfR-F index are useful parameters to discriminate ID without anaemia in children and adolescents, and specific cut-off values have been established. The combination of these new markers offers an alternative definition of ID with suitable discriminatory power. What is Known: • In adults, reticulocyte haemoglobin content (CHr), serum transferrin receptor (sTfR) and sTfR/log ferritin index (sTfR-F index) have been evaluated and recognised as reliable indicators of iron deficiency (ID). • Clinical manifestations of ID may be present in stages prior to anaemia, and the diagnosis of ID without anaemia continues to pose problems. What is New: • CHr, sTfR and the sTfR-F index are useful parameters in diagnosis of ID in childhood and adolescence when anaemia is not present. • We propose a new strategy for the diagnosis of ID in childhood and adolescence, based on the combination of these measures, which offer greater discriminatory power than the classical parameters.

Effect of iron-folic acid supplementation on change of hemoglobin among visceral Leishmaniasis patients in northwest Ethiopia: a retrospective follow up study

Background

An individual with visceral Leishmaniasis (VL) commonly present with anemia and one of the VL treatment center in northwest Ethiopia has been recommended iron-folic acid supplementation to these patients. But there is no documented evidence whether iron-folic acid supplementation improves the hematological profile of patients. Therefore, the study aimed to assess change in hemoglobin (Hb) and its determinant factors among VL patients with and without iron-folic acid supplementation in northwest Ethiopia.

Methods

A retrospective cohort study was conducted from January 2015 to December 2016. Data were entered into Epi-Data version 3.1 and transferred to Statistical Package for Social Science (SPSS) version 20 for analysis. Independent sample T-test and linear regression were used to compare the change in Hb and identify factors associated with a change in Hb, respectively. A 95% confidence level and p-values less than 0.05 were used determine statistically significant.

Results

From a total of 602 VL patients, 299 (49.7%) were from University of Gondar hospital. The mean (±SD) change of Hb from baseline to end of treatment was 0.99(±1.64) and 1.61(±1.88) g/dl with and without iron-folate supplementation, respectively, with mean difference 0.62, 95% CI (0.34, 0.90) and a p-value of < 0.0001. In multiple linear regressions, combination therapy of sodium stibogluconate-paramomycin (SSG-PM) was positively associated with a change of Hb (β [SE, p]: 0.710/0.15, < 0.0001). Whereas age (- 0.030/0.009, 0.001), nasal bleeding (- 0.261/0.123, 0.035), baseline white blood cell (- 0.139/0.044, 0.002) and hemoglobin (- 0.513/0.031, < 0.0001), end of treatment spleen size (- 0.059/0.015, < 0.0001) and iron-folic acid supplementation (- 0.574/0.163, < 0.0001) were negatively associated with change of Hb.

Conclusion

Iron-folic acid supplementation had a negative effect on the change of Hb. A combination therapy of SSG-PM, age, nasal bleeding, baseline white blood cells and Hb, and iron-folic acid supplementation were the determinants of change of Hb. Therefore, avoiding iron-folic acid supplementation and strengthening VL treatment with a combination of SSG-PM and, and early identification of complications is recommended for a better outcome.

Impact of Inflammation on Ferritin, Hepcidin and the Management of Iron Deficiency Anemia in Chronic Kidney Disease

Iron deficiency anemia (IDA) is a major problem in chronic kidney disease (CKD), causing increased mortality. Ferritin stores iron, representing iron status. Hepcidin binds to ferroportin, thereby inhibiting iron absorption/efflux. Inflammation in CKD increases ferritin and hepcidin independent of iron status, which reduce iron availability. While intravenous iron therapy (IIT) is superior to oral iron therapy (OIT) in CKD patients with inflammation, OIT is as effective as IIT in those without. Inflammation reduces predictive values of ferritin and hepcidin for iron status and responsiveness to iron therapy. Upper limit of ferritin to predict iron overload is higher in CKD patients with inflammation than in those without. However, magnetic resonance imaging studies show lower cutoff levels of serum ferritin to predict iron overload in dialysis patients with apparent inflammation than upper limit of ferritin proposed by international guidelines. Compared to CKD patients with inflammation, optimal ferritin levels for IDA are lower in those without, requiring reduced iron dose and leading to decreased mortality. The management of IDA should differ between CKD patients with and without inflammation and include minimization of inflammation. Further studies are needed to determine the impact of inflammation on ferritin, hepcidin and therapeutic strategy for IDA in CKD.

Effects of iron and vitamin B12 deficiencies on peripheral blood colony-forming unit capacity

Iron and vitamin B12 deficiencies are two of the most common diseases in the childhood group. Deficiencies of iron and vitamin B12 affect many systems in the body. In this study, to discover the effects of iron and vitamin B12 deficiencies on the hematopoietic stem cells, we studied CFU assay from peripheral blood. One hundred and two children were included in our study and were evaluated in five categories: iron deficiency, iron deficiency anemia, vitamin B12 deficiency, iron and vitamin B12 deficiency, and controls. As a result of statistical analysis, no significant difference was detected between five groups in terms of CFU assays. The results of our study suggest that, in emergent situations, stem cell samples can be collected before treatment with B12 or iron which are common deficiencies in donors of hematopoietic stem cell transplantation. We conclude that we could reach more accurate results by designing a study which contains more patients and includes in vivo results.

Characteristics, resource utilization and safety profile of patients prescribed with neuropathic pain treatments: a real-world evidence study on general practices in Europe - the role of the lidocaine 5% medicated plaster

OBJECTIVES

To identify characteristics, resource utilization, and safety profile of patients prescribed with lidocaine 5% medicated plaster, pregabalin, gabapentin, amitriptyline and duloxetine when experiencing pain in the real-world setting of general practitioners (GPs) in Europe.

METHODS

Retrospective analysis on real world data from IMS Health Longitudinal Patient Database. Patients with at least one prescription of the drugs of interest during 2014 were selected and those with a non-neuropathic pain-related diagnosis were excluded. Patients' demographic and clinical characteristics, resource utilization data and adverse drug reactions (ADRs) as described in the leaflet were extracted. The association between treatments and ADR occurrence was evaluated applying multivariate logistic models.

RESULTS

A total of 70,515 patients were selected from Italy, Germany, the UK, Spain and Belgium. Lidocaine 5% medicated plaster patients were the oldest in Italy, the UK and Spain and the most health impaired in Italy, Spain and Belgium. No relevant differences in the number of co-prescriptions, specialist visits, examinations and hospitalizations were found. Significantly less lidocaine 5% plasters patients experienced ADRs, with odds ratios in favor of lidocaine 5% medicated plasters ranging from 3.41 (p = .036) to 52.33 (p < .001).

CONCLUSIONS

Evidence from daily clinical practice in GP settings agrees with the findings from more controlled clinical-trial settings, with lidocaine 5% medicated plaster patients showing a better safety profile, but also a comparable level of resource utilization. A possible re-evaluation of the scientific value coming from this retrospective study in building up a diagnostic as well as a therapeutic algorithm is suggested.

Clinical management of iron deficiency anemia in adults: Systemic review on advances in diagnosis and treatment

Global burden disease studies point out that one of the top cause-specific anemias is iron deficiency (ID). Recent advances in knowledge of iron homeostasis have shown that fragile patients are a new target population in which the correction of ID might impact their morbidity, mortality and quality of life. We did a systematic review using specific search strategy, carried out the review of PubMed database, Cochrane Database of systemic reviews and international guidelines on diagnosis and clinical management of ID from 2010 to 2016. The International guidelines were limited to those with peer-review process and published in journal present in citation index database. The eligible studies show that serum ferritin and transferrin saturation are the key tests in early decision-making process to identify iron deficiency anemia (IDA). The clinician has to carefully consider fragile and high-risk subset of patients such as elders or individuals with chronic diseases (i.e chronic kidney disease, inflammatory bowel disease, chronic heart failure). Treatment is based on iron supplementation. Infusion route should be preferentially considered in frail patients especially in the view of new iron available formulations. The available evidences indicate that (i) recurrent IDA should always be investigated, considering uncommon causes; (ii) IDA might worse the performance and the clinical outcome of fragile and high-risk patients and require an intensive treatment.

Forty to fifty-five-year-old women and iron deficiency: clinical considerations and quality of life

Between the age of 40 and 55 years, women experience important changes in their lives. This period, which corresponds to the perimenopause for most women, is associated with the risk of iron deficiency anemia (IDA). The clinical presentation of anemia can be misleading, and the underlying cause, particularly bleeding, is frequently treated without concomitant iron prescription. Iron deficiency (ID) remains a social and economic burden in European countries. Underdiagnosed and undertreated, this problem has a strong negative impact on women's quality of life. The risk factors for ID are well known. The physician's role is essential in recognizing the symptoms, identifying the risk factors, detecting IDA by testing hemoglobin, and evaluating the degree of ID by measuring serum ferritin (SF). Iron therapy treats the anemia and restores iron stores, thus decreasing symptoms such as fatigue and restoring quality of life. Among the available forms of iron, evidence is in favor of ferrous sulfate in a slow release formulation, which is well-tolerated and results in good adherence, a key factor for efficacious supplementation.

Unusual Anemias

Many processes lead to anemia. This review covers anemias that are less commonly encountered in the United States. These anemias include hemoglobin defects like thalassemia, bone marrow failure syndromes like aplastic anemia and pure red cell aplasia, and hemolytic processes such as paroxysmal nocturnal hemoglobinuria. The pathogenesis, diagnostic workup, and treatment of these rare anemias are reviewed.

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.