British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults

Prevalence of iron deficiency in acute and chronic heart failure according to different clinical definitions

AIMS

Iron is essential to maintain cellular energy metabolism in the myocardium. Impaired cellular iron availability negatively affects myocardial physiology and can aggravate heart failure (HF). Iron deficiency (ID) is frequently found in patients with acute and chronic HF (AHF, CHF) and associated with clinical outcome. The aim of this analysis was to assess the true ID prevalence in HF patients on the basis of different ID definitions.

METHODS

We performed a retrospective analysis of 329 AHF and 613 CHF patients, recruited between 02/2021 and 05/2022 at the Innsbruck Medical University (47%/32% female, median age 81/64 years). ID was defined according to a general definition, gastroenterology and cardiology guidelines as ferritin <30 or <45 ng/mL or <100/ng/mL (absolute ID), ferritin 30-100 or 45-150 or 100-299 ng/mL plus TSAT <20% (combined ID), and ferritin >100 or >150 or ≥300 ng/mL plus TSAT <20% (functional ID).

RESULTS

ID prevalence was significantly higher in AHF compared with CHF patients: general definition (74.8% vs. 32.6%, P < 0.001), gastroenterology guidelines (75.7% vs. 34.7%, P < 0.001), cardiology guidelines (79.9% vs. 47.3%, P < 0.001). We found distinctive differences in prevalence of ID types between the three definitions. Absolute ID prevalence was highest when applying cardiology compared with gastroenterology guidelines and general definition (AHF: 44.7% vs. 20.4% vs. 7.0%; CHF: 34.1% vs. 13.4% vs. 7.2%), while frequency of combined ID was almost equally distributed. Functional ID prevalence was highest when applying general definition compared with gastroenterology and cardiology guidelines (AHF: 34.7% vs. 23.4% vs. 11.6%; CHF: 13.1% vs. 9.0% vs. 3.4%). Out of 494 patients classified as having absolute or combined ID according to the cardiology guidelines, only 252 patients received the same classification while 107 and 135 patients were classified having no and functional ID when applying the general definition.

CONCLUSIONS

We show that ID prevalence is higher in AHF versus CHF patients in a continuous cohort of HF patients managed at the same institution over the same period of time. There were distinctive differences in detection of ID and the type of ID when applying several recommended definitions thus affecting sensitivity and specificity for absolute and functional ID detection. This may result in exclusion of patients, which may benefit from iron supplementation and inclusion of those who may not respond or even anticipate site effects. Our study calls for the urgent need of prospective trials for redefinition of ID and identification of biomarkers associated with therapeutic response to optimize patient outcomes.

Efficacy and tolerability of valproate versus topiramate in migraine prevention, a randomized controlled multi-center trial

Although topiramate and valproate are antiseizure medications that have many contraindications and could produce many side effects, they are still used as migraine preventive therapy in middle- and low-income countries. Several trials compared valproate versus topiramate in patients with migraine showed inconclusive results. We aimed to evaluate the tolerability and efficacy of valproate compared to topiramate in migraineurs from the Middle East and North Africa. Our single-blinded, multi-centre, randomized controlled trial had two parallel groups: the (A) group, which included 300 patients who received valproate, and the (B) group, which included 300 patients who received topiramate. In our trial, 574 patients completed the 3-month follow-up period. Topiramate achieved a greater reduction in migraine attack severity on VAS and HIT-6 than valproate to a degree that was statistically significant. 129 (43 %) patients in valproate group and 66 (22 %) in topiramate group had any adverse effects (HR 3.11; 95 % CI 1.08-6.13; P = 0.05), of which 23 patients (7.7 %) in valproate group and twelve patients (4 %) in the topiramate group stopped treatment prematurely due to intolerable adverse effects (HR 2.47; 95 % CI 1.04-5.88; P = 0.04). We concluded that, in adult patients with migraine, the regular use of topiramate 50 mg Bid for three months yielded significantly higher reductions in migraine attack severity and HIT6 score compared to using valproate 500 mg Bid; valproate led to a significantly higher percentage of patients who prematurely stopped treatment due to intolerable adverse effects. Trial registration: ClinicalTrials.gov, (NCT06248931)- 08 February 2024.

Management of iron deficiency in children, adults, and pregnant individuals: evidence-based and expert consensus recommendations

Iron deficiency is the most common micronutrient deficiency worldwide. Oral iron is often recommended as first-line treatment, but there is no consensus on the optimal formulation, dosing strategy, or which patients should be treated preferentially with intravenous iron. To address these challenges, the Iron Consortium at Oregon Health & Science University (OHSU) convened an international panel of 26 experts in haematology, primary care, paediatrics, obstetrics, gastroenterology, cancer, and patient advocacy among its members. This panel was supplemented by insights from a four-person patient focus group to develop current recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel developed clinically relevant questions in five priority topic areas, a systematic literature search was performed, and studies meeting a priori criteria were included to generate evidence tables for recommendation development. Evidence-based and expert opinion-based recommendations were made through a structured anonymous consensus voting process at an in-person meeting in Portland, OR, USA, hosted by OHSU on Feb 16-17, 2024. The expert panel made seven evidence-based recommendations for three demographic groups with iron deficiency: non-pregnant adults, pregnant individuals, and infants, children, and adolescents. Expert opinions supported the recommendations on 21 aspects of care for which there is insufficient evidence. This Review provides evidence-based recommendations and expert consensus on the diagnosis, treatment, and management of iron deficiency, detailing best practices for oral and intravenous iron repletion across diverse patient populations.

Real-world evaluation of an intravenous iron service for the treatment of iron deficiency with or without anemia

Intravenous (IV) iron is a guideline-recommended treatment for iron deficiency when oral iron is contraindicated, ineffective, or not tolerated, or when rapid iron delivery is necessary. However, evidence suggests that some patients receive less IV iron than needed. This retrospective audit assessed the effectiveness and safety of ferric derisomaltose (FDI), a high-dose IV iron, in 2,468 patients. Efficacy outcomes assessed at 4-12 weeks post-infusion included changes in hemoglobin (Hb) and ferritin, proportion of courses (a course was defined as the treatment episode required to administer one total dose) after which patients were non-anemic (Hb ≥ 130 g/L [men] or ≥ 120 g/L [women]), and response rate (proportion of courses after which patients were non-anemic or Hb increased by ≥ 20 g/L). Safety was assessed through adverse events. Across 2,775 FDI courses, the mean dose was 1,244 mg, but mean estimated iron need was 1,580 mg. At follow-up, mean Hb had increased by 20.9 g/L and mean ferritin by 188.8 µg/L. Patients were non-anemic after 33.4% (n = 494/1,478) of courses and responded after 65.1% (n = 962/1,478) of courses. One patient (n = 1/2,468; 0.04%) had a serious allergic reaction. Patients remained anemic after > 65% of courses, demonstrating the need to optimize dosing based on iron need.

Cost-effectiveness of ferric citrate hydrate in patients with iron deficiency anemia

We investigated the cost-effectiveness of treating iron deficiency anemia (IDA) with ferric citrate hydrate (FC) in Japan. We employed four treatment strategies: switching from sodium ferrous citrate (SF) to FC at (1) 500 mg (approximately 120 mg of iron) per day or (2) 1000 mg (approximately 240 mg of iron) per day in patients with SF-induced nausea/vomiting, or starting treatment with FC at (3) 500 mg/day or (4) 1000 mg/day. We evaluated the cost-effectiveness of these strategies compared with SF 100 mg (100 mg of iron) per day. Incremental effects over 26 weeks relative to SF 100 mg were 0.0052 quality-adjusted life years (QALYs) for (1) and (2), and 0.0044 QALYs for (3) and (4). From the payer's perspective, incremental cost-effectiveness ratios (ICERs: JPY/QALY) against SF 100 mg were: (1) 1,107,780, (2) 2,257,477, (3) 5,588,430, and (4) 11,544,816. All four FC strategies were dominant (less costly and more effective) from a limited societal perspective. Treatment with FC for IDA was cost-effective (ICER ≤ JPY 5,000,000/QALY) when switching strategies from the payer perspective, and cost-saving (all FC strategies) from limited societal perspectives. Individual patients' characteristics and cost-effectiveness should be considered in treatment selection.

Boosting nutritional value: the role of iron fortification in meat and meat products

Iron deficiency is a widespread nutritional problem affecting millions of people globally, leading to various health issues including anemia. Iron fortification of meat and meat products has emerged as an effective strategy to combat this issue. This review explores the process and benefits of iron fortification, focusing on the types of iron compounds suitable for fortification, such as ferrous sulfate and ferric pyrophosphate, their bioavailability, and their impact on the sensory and nutritional qualities of meat products. Technological challenges and solutions, including encapsulation, chelation, and microencapsulation techniques, have been examined to minimize their negative impacts on sensory qualities. This review also discusses the regulatory framework governing iron fortification and consumer acceptance. Analytical methods for determining iron content, such as spectrophotometric and colorimetric detection, are discussed. Although iron-fortified meat products offer health benefits, sensory aspects and consumer acceptance are important considerations. This review provides a comprehensive understanding of the role and significance of iron fortification in meat products as a public health intervention to address iron deficiency.

Iron deficiency anaemia in a stable chronic intestinal failure cohort: Prevalence, associations and outcomes

BACKGROUND & AIMS

Current estimates of the prevalence of iron deficiency anaemia (IDA) in patients with chronic intestinal failure (CIF) exceed those seen in general population, however, the studies to-date are limited. The aim of this study was to determine the point prevalence of IDA in a large cohort of stable home parenteral nutrition (HPN) dependent adults managed by a specialist Intestinal Failure Unit.

METHODS

This was a retrospective cohort study of HPN-dependent adults managed by a national UK IF Reference Centre between 01/01/2019 and 31/12/2019. Patients with IDA were followed up until death or the end of the follow-up on 01/05/2024.

RESULTS

241 patients were included in the analysis. 27/241 (11.2 %) were diagnosed with IDA. Previous hypoferritinaemia, previous IDA and not receiving the recommended amount of iron via parenteral nutrition as per ESPEN guidelines were associated with higher likelihood of IDA diagnosis. Only 2/27 patients with IDA at inclusion fulfilled IDA criteria by the end of the follow up. Long-term outcomes in the patient cohort with IDA were good with no patients displaying evidence of malignancy until the end of the study period.

CONCLUSION

Our study shows that while IDA is common in patients with CIF, its clinical implications may differ from those in the general non-IF population. Further larger collaborative multi-centre research is necessary to confirm these findings with a view to develop evidence-based guidelines for the investigation of IDA in CIF.

Prevalence and patterns of testing for anaemia in primary care in England: a cohort study using an electronic health records database

BACKGROUND

Despite epidemiological data on anaemia being available on a global scale, the prevalence of anaemia in the UK is not well described.

AIM

To describe anaemia prevalence and testing patterns for haemoglobin and other blood parameters.

DESIGN AND SETTING

This study was a descriptive population-based cohort study using data drawn from the Clinical Practice Research Datalink Aurum database in 2019.

METHOD

Demographic data were extracted for each person who was registered at their current practice during 2019, including linked data on Index of Multiple Deprivation. Anaemia prevalence in 2019 was calculated based on World Health Organization-specified age and gender thresholds for haemoglobin. Anaemia was classified based on mean corpuscular volume and ferritin. People with anaemia were followed up for up to 1 year to investigate longitudinal testing patterns for haemoglobin.

RESULTS

The cohort contained 14 million people. Anaemia prevalence in England in 2019 was 4.1% (583 847/14 207 841) (5.1% [363 438/7 121 614] females and 3.1% [220 409/7 086 227] males). Prevalence was higher in people aged >65 years, people of Black and Asian ethnicities, and people living in areas with higher social deprivation. Only half of people with anaemia and a mean corpuscular volume of ≤100 fL had an accompanying ferritin value recorded. About half of people with anaemia had a follow-up haemoglobin test within 1 year, most of which still indicated anaemia.

CONCLUSION

Anaemia is prevalent in the UK with large disparities between levels of demographic variables. Investigation and follow-up of anaemia is suboptimal in many patients. Health interventions aimed at improving anaemia investigation and treatment are needed, particularly in the most at-risk groups.

Intravenous iron in chronic kidney disease without anaemia but iron deficiency: A scoping review

Iron deficiency (ID) is a prevalent complication of chronic kidney disease (CKD), often managed reactively when associated with anaemia. This scoping review evaluates the evidence supporting intravenous (IV) iron therapy in non-anaemic individuals with CKD and ID, focusing on safety, efficacy, and emerging therapeutic implications. Current diagnostic markers, including serum ferritin, transferrin saturation, and reticulocyte haemoglobin content, are reviewed alongside their limitations in the context of inflammation and variability. The pathophysiology of ID in CKD is explored, highlighting the roles of hepcidin, hypoxia-inducible factor pathways, and uraemic toxins. Comparative studies reveal that IV iron offers a more rapid correction of iron stores, improved compliance, and fewer gastrointestinal side effects compared to oral iron. Evidence from trials such as "iron and heart" and "iron and muscle" suggests potential benefits of IV iron on functional capacity and fatigue, though findings were statistically non-significant. Insights from heart failure trials support the safety and efficacy of IV iron in improving quality of life and reducing hospitalizations, with newer formulations like ferric derisomaltose demonstrating favourable safety profiles. This review underscores the need for standardized screening protocols for ID in CKD, even in the absence of anaemia, to facilitate earlier intervention. Future research should prioritise robust outcome measures, larger sample sizes, and person-specific treatment strategies to optimise dosing and administration frequency. Tailored approaches to IV iron therapy have the potential to significantly improve functional outcomes, quality of life, and long-term health in people with CKD.

Understanding and managing iron deficiency anaemia

Iron deficiency anaemia develops when there is not enough iron in the body to sustain normal red blood cell production. It is a major cause of morbidity worldwide and is linked to a range of comorbid conditions, including gastrointestinal cancer. In the UK, iron deficiency anaemia is the most common cause of anaemia identified in primary care and is estimated to affect 3% of men and 8% of women. Nurses can support the management of iron deficiency anaemia by identifying possible causes, ordering blood tests, advising on diet and iron supplementation, and referring patients for additional investigations as required. This article provides an overview of the pathophysiology, identification and diagnosis of iron deficiency anaemia, describes sources of dietary iron and factors influencing dietary iron absorption, and discusses patient management.

Diagnostic yield of upper gastrointestinal tract endoscopy and colonoscopy in patients with iron deficiency anaemia while on direct oral anticoagulants

BACKGROUND

Iron deficiency anaemia (IDA) related to occult gastrointestinal tract (GIT) blood loss is associated with high rates of GIT malignancies. Major society guidelines recommend bidirectional endoscopic evaluation for all men and post-menopausal women with newly diagnosed, unexplained IDA. However, in patients prescribed direct oral anticoagulants (DOACs), the endoscopic yield, specifically the rate of high-risk findings, including colorectal cancers (CRCs) and advanced adenomas (AAs), is unknown.

AIM

Our aim is to determine the endoscopic yield, specifically the prevalence of these high-risk findings in patients presenting with new-onset unexplained IDA while on a DOAC.

METHODS

This is a single-centre, retrospective analysis performed at a tertiary hospital in Australia. Between January 2015 and July 2019, 178 consecutive patients underwent endoscopic evaluation for IDA while prescribed a DOAC. Patient demographics, laboratory data, medications and endoscopic findings were summarised and compared by diagnostic yield. Associations were explored using logistic regression analysis.

RESULTS

CRCs were present in 2/178 (1.1% (95% confidence interval (CI): 0.1-4.0)) patients. AAs were found in 35/178 (19.6% (95% CI: 14.1-26.3)) patients. The most common AAs were tubular adenomas (45.7%), tubulovillous (31.4%) and sessile serrated adenomas (14.2%). Older age (P = 0.013) and lower ferritin levels (P = 0.009) were associated with the presence of high-risk findings.

CONCLUSION

In patients presenting with new-onset, unexplained IDA while on a DOAC, the prevalence of CRCs is lower than previously reported in studies involving populations not prescribed DOACs. Conversely, there is a higher incidence of AAs, including high-risk histological features, such as tubulovillous adenomas and sessile serrated polyps.

The Diagnostic Yield of Video Capsule Endoscopy for Uncomplicated Asymptomatic Iron Deficiency Anemia With Negative Bidirectional Endoscopy in a Large Military Gastroenterology Program

BACKGROUND

 Iron-deficiency anemia (IDA) often results from gastrointestinal (GI) bleeding. Video capsule endoscopy (VCE) is increasingly used to investigate suspected small bowel bleeding, particularly when bidirectional endoscopy is nondiagnostic. However, the diagnostic yield of VCE in asymptomatic patients with IDA and negative bidirectional endoscopy is not well-established, leading to variability in clinical guidelines.

METHODS

We conducted a retrospective review of patients at Brooke Army Medical Center who underwent VCE from January 2019 to April 2023 following negative bidirectional endoscopy for IDA, defined as ferritin <45 ng/mL. We analyzed demographic data, VCE findings, and outcomes, including need for further intervention, persistence of IDA, and hospitalizations. We also assessed the impact of referral delays on outcomes.

RESULTS

Out of 238 patients, 75 met the inclusion criteria. VCE revealed abnormal findings in 36% of cases, with 8% having actionable findings necessitating repeat endoscopy. The most common abnormality was small bowel angiodysplasias. No small bowel malignancies were detected. Patients aged over 65 had a higher rate of abnormal findings and actionable lesions. Delays in subspecialty evaluation (>180 days) did not significantly affect patient outcomes.

CONCLUSION

In asymptomatic IDA patients with negative bidirectional endoscopy, VCE demonstrates a 36% diagnostic yield, primarily identifying small bowel angiodysplasias, with limited impact on detecting malignancies. This study highlights the importance of individualizing VCE use to each patient, and suggests that delays in referral do not adversely affect outcomes. Further prospective studies are needed to refine diagnostic guidelines and enhance cost-effectiveness.

Iron in Chronic Kidney Disease and End-Stage Kidney Disease-Current Trends and Future Direction

Anaemia is a frequent and serious complication in chronic kidney disease (CKD), affecting both non-dialysis-dependent (NDD) and dialysis-dependent (DD) patients. While erythropoietin (EPO) deficiency is the primary cause, iron deficiency (ID) also plays a crucial role. ID in CKD can be classified as either absolute, resulting from blood loss, or functional, driven by inflammation and elevated hepcidin levels, which trap iron in macrophages and hepatocytes, preventing its use in erythropoiesis. Elevated hepcidin also reduces dietary iron absorption in the gut, making oral iron supplements ineffective, particularly in advanced CKD. This review summarises the available intravenous (IV) iron formulations, discusses diagnostic definitions and treatment thresholds for ID in NDD and DD CKD, and explores potential future therapeutic directions.

MultiThal-classifier, a machine learning-based multi-class model for thalassemia diagnosis and classification

BACKGROUND

The differential diagnosis between iron deficiency anemia (IDA) and thalassemia trait (TT) remains a significant clinical challenge. This study aimed to develop a machine learning-based multi-class model to differentiate among Microcytic-TT(TT with low mean corpuscular volume), Normocytic-TT (TT with normal mean corpuscular volume), IDA, and healthy individuals.

METHODS

A comprehensive dataset comprising 1,819 individuals was analyzed using six distinct machine learning algorithms. The eXtreme Gradient Boosting (XGBoost) algorithm was ultimately selected to construct the MultiThal-Classifier (M-THAL) model. SMOTENC (Synthetic Minority Over-sampling Technique for Nominal and Continuous features) was employed to address data imbalance. Model performance was evaluated using various metrics, and SHAP values were applied to interpret the model's predictions.Additionally, external validation was conducted to assess the model's robustness and generalizability.

RESULTS

After performing 1000 bootstrap resamples of the test set, the average performance metrics of M-THAL and the 95 % confidence interval(CI) were as follows, sensitivity 90.27 % (95 % CI: 84.88-95.26), specificity 97.87 % (95% CI: 97.10-98.55), PPV 93.42 % (95 % CI: 89.34-96.48), NPV 97.82% (95 % CI: 97.00-98.53), F1-score 91.50 % (95% CI: 87.29-95.34), Youden's index 88.15 % (95 % CI: 82.33-93.70), accuracy 97.06 % (95% CI: 96.06-97.99), and AUC 94.07 % (95 % CI: 91.17-96.84).Feature importance analysis identified mean corpuscular volume(MCV), mean corpuscular hemoglobin(MCH), red cell distribution width - standard deviation(RDW-SD), and hemoglobin (HGB) were identified as the most important features. External validation confirmed the model's robustness and generalizability.

CONCLUSION

The M-THAL effectively distinguishes Normocytic-TT, Microcytic-TT, IDA, and healthy individuals using hematological parameters, offers a rapid and cost-effective screening tool that can be readily implemented in diverse healthcare settings.

The experiences of ferric carboxymaltose desensitization and provocation

Background

To present the characteristics of drug hypersensitivity reactions (DHR) among iron preparations and to describe the outcomes of rapid drug desensitization (RDD) and drug provocation tests (DPT) of ferric carboxymaltose (FCM).

Methods

The retrospective descriptive study comprised patients with hypersensitivy to iron supplements. Low-risk according to the index reaction with iron, 10 patients underwent a 4-step DPT with FCM; an 11-step RDD protocol was administered to 21 patients not classified as low-risk. RDD success was evaluated for each cycle separately, defining successful completion as the implementation of all steps in both RDD and DPT protocols without subsequent early and/or late reactions.

Results

Among the 21 patients (mean age: 41.73 ± 10.98 years, all female) hypersensitive to iron underwent FCM RDD, 20 patients (95.2%) successfully completed FCM treatment with RDD. RDD failed in only 1 patient (4.8%). The total number of desensitization cycles was 29, of which 28 (96.5%) were successful. Urticaria was the most common breakthrough hypersensitivity reaction and observed in 7 (33.3%) patients. Ten patients received FCM with DPT. The iron replacement therapy for these 10 patients was successfully completed. Urticaria developed in 2 patients after the completion of DPT.

Conclusions

RDD is a dependable procedure facilitating the efficient delivery and completion of FCM treatments in patients with iron hypersensitivity. Additionally, FCM can be applied with DPT in low-risk patients.

Interpretation of ferritin concentrations in the dermatology clinic

Ferritin measurement is a common laboratory test in dermatology. Ferritin is a marker of iron storage in the human body but can also be -elevated in inflammatory states. Therefore, changes in ferritin are nonspecific, and correlation of specific clinical findings and risk factors with ferritin concentration and other biomarkers, e.g. iron studies or C-reactive protein tests, is recommended. This article discusses iron metabolism and the indications for ferritin measurement in dermatology and how to interpret the laboratory results.

Management of post-operative anaemia in patients undergoing surgery for colorectal cancer: a qualitative focus group-based study

BACKGROUND

Optimal management of anaemia following surgery for colorectal cancer remains unclear. Peri-operative anaemia is common in patients undergoing resectional surgery for colorectal cancer. A significant amount of research has been conducted into the management of pre-operative anaemia; however, little work has investigated post-operative anaemia. We intended to investigate the facilitators of and barriers against the standardised correction of post-operative anaemia. These can aid in identifying optimum treatment for patients following surgery for colorectal cancer.

METHODS

Four focus groups were held with 29 participants from a multidisciplinary panel of healthcare professionals from two different NHS hospital sites in the UK. The discussions were audio recorded and underwent professional transcription. Transcripts were checked against recordings before undergoing thematic analysis using a realist approach.

RESULTS

Four themes were identified. The key barriers to standardised post-operative anaemia correction were a lack of protocoled guidelines or a defined pathway, insufficient education and training, and systemic barriers, such as financial drivers and drug availability. The key facilitator identified was collaboration and communication.

DISCUSSION

This study has identified several key barriers and thresholds which can be used in future studies to improve the standardised management of post-operative anaemia.

Evaluation of a new soluble transferrin receptor assay and comparison to three measurement procedures

BACKGROUND

Soluble transferrin receptor (sTfR) is a useful marker in the differentiation of anemia. Clinical utility is limited by lack of standardization between measurement procedures and interpretative recommendations. Our objective was to evaluate the analytical performance of a research sTfR immunoturbidimetric assay (Alinity c, Abbott Diagnostics) and compare it to three established measurement procedures.

METHODS

Assay imprecision was assessed with 7 panels across the analytical measuring interval. 159 patient samples were measured across four instrument systems (Alinity c [Abbott Diagnostics], Tina-quant c502 [Roche Diagnostics], Quantex Biokit [Werfen], and ACCESS [Beckman Coulter]). Ferritin was also measured to calculate an sTfR/Log Ferritin ratio. Sera from 100 reference individuals were assayed for sTfR and ferritin (Alinity) for reference interval (RI) verification (sTfR) or establishment (sTfR index).

RESULTS

Assay imprecision met defined goals. Method comparison between Alinity c and ACCESS sTfR assays showed good agreement (slope: 1.06, intercept: -0.12, r: 0.989). Comparisons across other assays demonstrated significant proportional bias with slopes ranging from 0.44 (Tina-quant c502, mean bias: -2.52 mg/L) to 1.24 (Quantex Biokit, mean bias: 0.60 mg/L). A proportional bias was observed between other instruments. While the sTfR RI was verified on the Alinity assay, agreement in interpretation (within vs outside RI) between Alinity and other platforms ranged from 74.2 to 80.5 %.

CONCLUSION

We report the first characterization of the performance of a research sTfR immunoturbidimetric assay (Alinity c, Abbott Diagnostics). Our findings emphasize the lack of harmonization between measurement procedures and result interpretation for sTfR and sTfR index, necessitating standardization efforts and clinical studies.

Myocardial iron intake following intravenous iron therapy with ferric carboxymaltose is sustained at 1 year despite recurrence of iron deficiency

In clinical practice, intravenous (IV) iron therapy is used for the correction of iron deficiency. Patients with chronic causes of iron deficiency, for example, women with abnormal uterine bleeding, patients with inflammatory bowel disease often require repeated dosing with IV iron therapy. After a single standard dose of IV iron therapy (1000 mg) with ferric carboxymaltose, there is a rapid intake of iron into the myocardium, resulting in a sustained increase in myocardial iron content. The increase in myocardial iron content is independent of changes in plasma ferritin levels, and the recurrence of iron deficiency is not accompanied by a normalisation of myocardial iron. The most important implication is that repeated dosing with IV iron (ferric carboxymaltose) can result in cumulative build-up of iron in the myocardium.

Korean Practice Guidelines for Gastric Cancer 2024: An Evidence-based, Multidisciplinary Approach (Update of 2022 Guideline)

Gastric cancer is one of the most common cancers in both Korea and worldwide. Since 2004, the Korean Practice Guidelines for Gastric Cancer have been regularly updated, with the 4th edition published in 2022. The 4th edition was the result of a collaborative work by an interdisciplinary team, including experts in gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology, and guideline development methodology. The current guideline is the 5th version, an updated version of the 4th edition. In this guideline, 6 key questions (KQs) were updated or proposed after a collaborative review by the working group, and 7 statements were developed, or revised, or discussed based on a systematic review using the MEDLINE, Embase, Cochrane Library, and KoreaMed database. Over the past 2 years, there have been significant changes in systemic treatment, leading to major updates and revisions focused on this area. Additionally, minor modifications have been made in other sections, incorporating recent research findings. The level of evidence and grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation system. Key factors for recommendation included the level of evidence, benefit, harm, and clinical applicability. The working group reviewed and discussed the recommendations to reach a consensus. The structure of this guideline remains similar to the 2022 version. Earlier sections cover general considerations, such as screening, diagnosis, and staging of endoscopy, pathology, radiology, and nuclear medicine. In the latter sections, statements are provided for each KQ based on clinical evidence, with flowcharts supporting these statements through meta-analysis and references. This multidisciplinary, evidence-based gastric cancer guideline aims to support clinicians in providing optimal care for gastric cancer patients.

Targeting ferroptosis in the neurovascular unit: A promising approach for treating diabetic cognitive impairment

The cognitive decline associated with chronic metabolic disease diabetes has garnered extensive scrutiny, yet its pathogenesis remains incompletely understood, and the advancement of targeted therapeutics has posed a persistent challenge. Ferroptosis, a novel form of cell death characterized by intracellular lipid peroxidation and iron overload, has recently emerged as a significant factor. Numerous contemporary studies have corroborated that ferroptosis within the neurovascular unit is intimately associated with the onset of diabetes-induced cognitive impairment. Numerous contemporary studies have corroborated that ferroptosis within the neurovascular unit is intimately associated with the onset of diabetic cognitive impairment (DCI). This article initially conducts a profound analysis of the mechanism of ferroptosis, followed by a detailed elucidation of the specific manifestations of neurovascular unit ferroptosis in the context of diabetic cognitive function impairment. Furthermore, an exhaustive review of pertinent literature from April 2020 to March 2024 has been undertaken, resulting in the selection of 31 documents of significant reference value. These documents encompass studies on 11 distinct drugs, all of which are centered around investigating methods to inhibit the ferroptosis pathway as a potential treatment for DCI. Simultaneously, we conducted a review of 12 supplementary literary sources that presented 10 pharmacological agents with anti-ferroptosis properties in other neurodegenerative disorders. This article critically examines the potential influence of neurovascular unit ferroptosis on the progression of cognitive impairment in diabetes, from the three aforementioned perspectives, and organizes the existing and potential therapeutic drugs. It is our aspiration that this article will serve as a theoretical foundation for scholars in related disciplines when conceptualizing, investigating, and developing novel clinical drugs for DCI.

Correlation between triglyceride-glucose index and atrial fibrillation in acute coronary syndrome patients: a retrospective cohort study and the establishment of a LASSO-Logistic regression model

BACKGROUND

Insulin resistance (IR) is an independent predictor of atrial fibrillation (AF), but the specific utility of the triglyceride-glucose (TyG) index as a predictive marker for the incidence of AF in the acute coronary syndrome (ACS) population has not yet been explored.

OBJECTIVE

To explore the correlation between TyG index and the risk of AF in ACS patients and to establish a predictive model.

METHODS

A retrospective study was conducted on 613 ACS patients admitted to the Department of Cardiovascular Medicine at the First Teaching Hospital of Tianjin University of Traditional Chinese Medicine from January 2022 to September 2024. Patients were divided into four groups based on quartiles of TyG index. Patients were further divided into two groups based on the occurrence of AF: the AF group and the non-AF group. Patient information was collected through the hospital's HIS system. Variable selection was completed using LASSO regression algorithms. Multivariate logistic bidirectional stepwise regression analysis was used to explore the correlation between the TyG index and the risk of AF in ACS patients and to construct a regression model. Three different models were constructed by adjusting for confounding factors and restricted cubic spline plots were drawn to validate the significance of the TyG index combined with AF further. The predictive value of the LASSO-multivariate logistic bidirectional stepwise regression model and the TyG index alone for predicting AF in ACS patients was analyzed using the receiver operating characteristic curve.

RESULTS

The LASSO-multivariate logistic bidirectional stepwise regression algorithm showed that coronary heart disease (CHD), valvular heart disease (VHD), TyG, age (AGE), and diastolic blood pressure (DBP) were risk factors for AF in ACS. The restricted cubic spline model demonstrated a significant linear relationship between a higher TyG index and an increased risk of AF in the ACS patient population. The area under the curve (AUC) for predicting AF in ACS patients using the TyG index and the LASSO-multivariate logistic bidirectional stepwise regression model was 0.65(95%CI = 0.58 ~ 0.73) and 0.71(95%CI = 0.65 ~ 0.77) respectively. Additionally, the correlation between the TyG index and AF was consistent across different subgroups.

CONCLUSION

In ACS patients, the TyG index is a stable and independent predictor of AF, with specific clinical value in identifying the occurrence of AF in this population.

The influence of celiac disease on fertility and pregnancy: an Italian survey

BACKGROUND

Celiac disease (CD) is an inflammatory enteropathy that has been associated to obstetric and gynecological disorders. However, it is still not adequately tested by gynecologists due to the misconception that it is solely a gastrointestinal disease. This underestimation requires the development of targeted interventions.

PURPOSE

This study aims to evaluate the association between CD and obstetric/gynecological complications, highlight the importance of informing patients about CD manifestations, and assess the patient satisfaction with the information provided by healthcare professionals on the disease.

METHODS

A digital survey was administered to celiac women via the Italian Celiac Association's website.

RESULTS

We analyzed 493 questionnaires. Obstetric and gynecological disorders led to the diagnosis of CD in 11.7% of interviewed. The study revealed that untreated CD patients are more predisposed to miscarriages (41.8% vs 34% before/after diagnosis, respectively, p = 0.111), anemia in pregnancy (71.4% vs 40.4% before/after diagnosis, respectively, p < 0.001) and the risk of low birth weight (newborns weighing < 1500 g were 4.0% before and 1.1% after the gluten-free diet, p = 0.028). Women with CD, both before and after gluten-free diet, had higher infertility rates (about 19%) than the general population. Additionally, 73% of interviewees were dissatisfied with the information they received from health professionals about the reproductive implications of CD.

CONCLUSION

Our research contributes to a deeper understanding of the intersection between CD and reproductive outcomes, highlighting the main obstetric and gynecological problems related to it. It emphasizes the importance of patient's perspective and the need for greater awareness about celiac disease from healthcare workers.

Extraintestinal complications of celiac disease: treatment considerations

INTRODUCTION

Celiac disease (CD) is an autoimmune enteropathy characterized by atrophy of the intestinal mucosa triggered by the ingestion of gluten in individuals with a genetic predisposition. CD manifests with heterogeneous array of symptoms, including a wide range of intestinal and extraintestinal symptoms and manifestations (EIMs). The mechanisms involved in the pathogenesis of EIMs in CD are not only related to intestinal mucosal damage and associated malabsorption but also to systemic inflammation. To date, the only effective treatment for CD is a lifelong gluten-free diet (GFD). Proper adherence to the GFD leads in most cases to a gradual resolution of intestinal atrophy and results in an improvement of the clinical manifestations associated with intestinal damage.

AREAS COVERED

This review, based on a Pubmed literature search, describes the extraintestinal complications associated with CD, emphasizing strategies for therapeutic management and responsiveness to the GFD.

EXPERT OPINION

CD is associated with different EIMs which can affect different organs. The main clinical interest is if these complications respond to the GFD, which occur at variable rate and not for all disorders associated with CD. Therefore, often complementary additional therapies are needed to achieve optimal symptoms resolution.

Mistakes in the management of iron deficiency anaemia: a narrative review

INTRODUCTION

Anaemia occurs due to an imbalance between erythrocyte production and loss. This imbalance can be due to ineffective erythropoiesis, blood loss or haemolysis. Whilst there are many causes for anaemia, iron deficiency anaemia (IDA) remains the predominant cause worldwide.

AREAS COVERED

There have been many updated guidelines on the management of IDA in the past few years. As the reasons for IDA are many, evaluation requires thorough analysis and focused investigations. As an asymptomatic disease in the early stages, IDA can lead to many mistakes in its management. This review highlights potential mistakes in assessing and managing IDA and recommendations to avoid them.

CONCLUSION

The effective management of IDA necessitates a comprehensive and multidisciplinary approach. By recognising and addressing the common mistakes highlighted in this narrative review, healthcare professionals can improve patient outcomes, minimise complications, and enhance the overall quality of care.

Unraveling the Mysteries of Autoimmune Gastritis

Autoimmune gastritis is an immune-mediated disease characterized by the destruction of parietal cells and atrophy of the oxyntic mucosa due to anti-parietal cell antibodies. It may lead to serious conditions including iron/vitamin B12 and micronutrient deficiencies, neurological disorders, and gastric malignancies. The exact mechanism of this disease is not exactly understood; however, dysregulated immunological mechanisms appear to be major contributors. Patients with this disease are often asymptomatic but may present with gastrointestinal symptoms and/or iron/vitamin B12 deficiencies. Although important serological markers are available and despite advanced endoscopic techniques, the definitive diagnosis relies on histopathological examination of gastric corporal biopsy specimens. Autoimmune gastritis is closely related with increased risk of gastric neuroendocrine tumors and gastric adenocarcinoma. Patients with autoimmune gastritis do not benefit from specific treatments, thus, management is directed to restore micronutrient deficiencies and to prevent occurrence of neoplastic transformation with appropriate endoscopic surveillance.

Rebamipide Prevents the Hemoglobin Drop Related to Mucosal-Damaging Agents at a Level Comparable to Proton Pump Inhibitors

Background/Aims

: The effect of proton pump inhibitors (PPIs) on the lower gastrointestinal (GI) tract is uncertain, with potential to worsen damage. This study aimed to find the best method for protecting the entire GI tract from mucosal damage.

Methods

: A retrospective cohort study at Samsung Medical Center (2002-2019) included 195,817 patients prescribed GI mucosa-damaging agents. The primary goal was to assess the effectiveness of GI protective agents in preventing significant hemoglobin drops (>2 g/dL), indicating overall GI mucosal damage. Self-controlled case series and landmark analysis were used to address biases in real-world data.

Results

: The incidence rate ratios for rebamipide, PPI, and histamine-2 receptor antagonist (H2RA) were 0.34, 0.33, and 0.52, respectively. Rebamipide showed a significantly lower incidence rate than H2RA and was comparable to PPIs. Landmark analysis revealed significant reductions in hemoglobin drop risk with rebamipide and H2RA, but not with PPI.

Conclusions

: Rebamipide, like PPIs, was highly effective in preventing blood hemoglobin level decreases, as shown in real-world data. Rebamipide could be a comprehensive strategy for protecting the entire GI tract, especially when considering PPIs' potential side effects on the lower GI tract.

Current iron therapy in the light of regulation, intestinal microbiome, and toxicity: are we prescribing too much iron?

Iron deficiency is a widespread global health concern with varying prevalence rates across different regions. In developing countries, scarcity of food and chronic infections contribute to iron deficiency, while in industrialized nations, reduced food intake and dietary preferences affect iron status. Other causes that can lead to iron deficiency are conditions and diseases that result in reduced intestinal iron absorption and blood loss. In addition, iron absorption and its bioavailability are influenced by the composition of the diet. Individuals with increased iron needs, including infants, adolescents, and athletes, are particularly vulnerable to deficiency. Severe iron deficiency can lead to anemia with performance intolerance or shortness of breath. In addition, even without anemia, iron deficiency leads to mental and physical fatigue, which points to the fundamental biological importance of iron, especially in mitochondrial function and the respiratory chain. Standard oral iron supplementation often results in gastrointestinal side effects and poor compliance. Low-dose iron therapy seems to be a valid and reasonable therapeutic option due to reduced hepatic hepcidin formation, facilitating efficient iron resorption, replenishment of iron storage, and causing significantly fewer side effects. Elevated iron levels influence gut microbiota composition, favoring pathogenic bacteria and potentially disrupting metabolic and immune functions. Protective bacteria, such as bifidobacteria and lactobacilli, are particularly susceptible to increased iron levels. Dysbiosis resulting from iron supplementation may contribute to gastrointestinal disorders, inflammatory bowel disease, and metabolic disturbances. Furthermore, gut microbiota alterations have been linked to mental health issues. Future iron therapy should consider low-dose supplementation to mitigate adverse effects and the impact on the gut microbiome. A comprehensive understanding of the interplay between iron intake, gut microbiota, and human health is crucial for optimizing therapeutic approaches and minimizing potential risks associated with iron supplementation.

Absolute and functional iron deficiency: Biomarkers, impact on immune system, and therapy

Iron is essential for numerous physiological processes and its deficiency often leads to anemia. Iron deficiency (ID) is a global problem, primarily affecting reproductive-age women and children, especially in developing countries. Diagnosis uses classical biomarkers like ferritin or transferrin saturation. Recent advancements include using soluble transferrin receptor (sTfR) or hepcidin for improved detection and classification of absolute and functional iron deficiencies, though mostly used in research. ID without anemia may present symptoms like asthenia and fatigue, even without relevant clinical consequences. ID impacts not only red-blood cells but also immune system cells, highlighting its importance in global health and immune-related comorbidities. Managing ID, requires addressing its cause and selecting appropriate iron supplementation. Various improved oral and intravenous products are available, but further research is needed to refine treatment strategies. This review updates on absolute and functional iron deficiencies, their relationships with the immune system and advancements in diagnosis and therapies.

Gastrointestinal pathology in patients presenting with iron deficiency anaemia: A single-centre cross-sectional study

Background

About a third of the world's population is estimated to suffer from anaemia, and iron deficiency is expected to account for about half of all anaemia cases. This study was designed to get an estimate of the proportion of patients with iron deficiency anaemia (IDA) who have a significant gastrointestinal (GI) pathology, in particular a GI malignancy, and to identify any risk factors or predictors for the same.

Methods

This cross-sectional study was conducted at a hospital in Eastern India. The study population comprised males above the age of 18 and postmenopausal females with IDA, excluding those haemodynamically unstable or with chronic diseases. Data collection included a detailed history, sociodemographic details, dietary habits, GI symptoms, and severity of anaemia. Faecal occult blood tests (OBTs) were conducted, and patients were referred for upper and lower GI endoscopy with biopsies.

Results

Out of the 257 patients, 50.97% (n = 131) had a significant GI pathology, and 25.68% (n = 66) had a GI malignancy. Male gender (AOR: 5.203, 95% CI: 1.725-15.698) and a positive stool OBT (AOR: 6.516, 95% CI: 2.255-18.828) were found to be independent risk factors for any GI pathology. Age 40 years or above (AOR: 11.376, 95% CI: 1.199-107.946), loss of appetite (AOR: 15.548, 95% CI: 1.416-170.735), pain abdomen (AOR: 5.566, 95% CI: 1.149-26.953), dysphagia (AOR: 7.945, 95% CI: 1.036-60.915), family history of malignancy (AOR: 46.726, 95% CI: 4.076-535.645), and positive OBT (AOR: 22.430, 95% CI: 3.933-127.915) were found to be independent risk factors of GI malignancy.

Conclusions

This study shows that a large proportion of adult males and postmenopausal females presenting with IDA in India have significant GI pathology. Furthermore, a significant proportion of them have GI malignancies. Thus, bidirectional endoscopy should be considered for these patients. Male patients, age >40, those with history of loss of appetite or weight, pain abdomen or dysphagia, positive family history, and positive OBT should be prioritised for the investigation.

Prevalence of Malnutrition and Micronutrient Deficiencies in Older Adults with Ulcerative Colitis

BACKGROUND AND AIMS

The nutritional status and consequences of malnutrition among older adults with ulcerative colitis (UC) are not known.

METHODS

We conducted a retrospective study of patients 65 years ≥ with Ulcerative colitis (UC). Malnutrition was defined using the European Society for Clinical Nutrition and Metabolism (ESPEN) definition. Eight micronutrients and nutrition-related outcomes were measured. The Saskatchewan Inflammatory Bowel Disease-Nutrition Risk Tool was utilized to identify patients at risk for malnutrition. Data were summarized using descriptive statistics. Characteristics of patients with and without malnutrition were compared using Chi-Square test or Fisher's exact tests (analysis of variance for age).

RESULTS

Two-hundred and ninety patients with a mean age of 73.4 years were included. 54% of patients had moderate-to-severe UC, with 52% receiving advanced therapy. Fifty-one patients (18%) met criteria for malnutrition, 17% were moderate-high risk for malnutrition, and 87% were low risk. Two-hundred and twenty patients (76%) had at least one micronutrient deficiency: 38% vitamin D, 43% iron, and 11% B12. Half of patients had osteoporosis or osteopenia (49%), however, only 39% of high-risk patients had undergone a DEXA scan.

CONCLUSIONS

The majority of patients were not found to have malnutrition, however, the prevalence of micronutrient deficiencies among older adults with UC was high. This population is at particularly high risk for bone-related disease, yet a significant proportion of patients are not undergoing guideline-directed bone density testing. These findings illustrate the need for regular screening for malnutrition, micronutrient deficiency, and bone-related disease in older adults with UC.

Gastric Carcinomas and Point-of-Care Ultrasound (POCUS): A Report of Two Cases

Stomach cancer remains a significant cause of mortality, as most patients are diagnosed at advanced stages. The primary method for diagnosis is endoscopy, along with tissue acquisition, supplemented by endoscopic ultrasound or computed tomography for disease staging. While point-of-care ultrasound (POCUS) is now firmly integrated into clinical practice, it is still not widely utilized. POCUS can be performed at the initial point of contact and provides instant information that can influence investigation strategies. We report two cases of gastric antral carcinoma detected by POCUS, which led to targeted investigations. Both patients underwent expedited upper gastrointestinal endoscopies that confirmed distal gastric carcinoma. These cases highlight the important role of POCUS in triaging patients for timely and appropriate targeted organ investigations.

Diagnostic Yield of Small Bowel Videocapsule Endoscopy in Patients with Iron Deficiency Anemia. A Systematic Review and meta-analysis

BACKGROUND AND AIM

Gastrointestinal (GI) bleeding or malabsorption represents the most frequent aetiologies of iron deficiency anemia (IDA). The cause of IDA remains undetermined in ~10% to 20% of patients undergoing upper and lower GI endoscopies. In this scenario, a small bowel examination with videocapsule endoscopy (VCE) is recommended. We performed a systematic review with meta-analysis to evaluate the diagnostic yield of VCE in patients with IDA without overt bleeding, assessing the prevalence of either any lesion or lesions at high potential of bleeding.

MATERIALS AND METHODS

A computerized literature search was performed using relevant keywords to identify all the pertinent articles published until March 2023.

RESULTS

Twelve studies with a total of 1703 IDA patients (Males: 47%; age range: 19-92 y) were included in this systematic review. The diagnostic yield of VCE for overall lesions in the small bowel was 61% (95% CI=44-77; 95 CI=97.2-98.1; I2 =97.7%). When analyzing only small bowel lesions likely responsible of IDA, the diagnostic yield was 40% (95% CI=27-53; 95% CI=95.3-97; I2 =96.3%).

CONCLUSION

VCE plays a relevant role in the diagnostic work-up of patients with IDA without overt bleeding with a satisfactory diagnostic yield.

Association between Adiposity and Iron Status in Women of Reproductive Age: Data from the UK National Diet and Nutrition Survey (NDNS) 2008-2019

BACKGROUND

Overweight/obesity and iron deficiency (ID) are highly prevalent in women of reproductive age (WRA), impacting on women's health. Obesity is a risk factor for nutritional deficiencies but its association with ID is unclear.

OBJECTIVES

To determine the association between adiposity and markers of iron status and ID prevalence in WRA.

METHODS

This cross-sectional study analyzed the National Diet and Nutrition Survey (2008-2019) data, focusing on women aged 18-49 y with body mass index (BMI) ≥18.5 kg/m2. Prevalence of anemia, iron deficiency anemia (IDA), and ID were analyzed. Ferritin was adjusted for C-reactive protein. Iron status was assessed across high and low BMI, waist circumference (WC), waist-to-height ratio (WHtR), and waist-to-hip ratio (WHR). χ2, linear and logistic regressions were performed adjusting for covariates.

RESULTS

Among 1098 WRA, 496 normal weight and 602 overweight/obesity, prevalence rates were: anemia 9.2% and IDA 6.8%. Anemia was more prevalent in those with higher WHtR and WHR (11.9% compared with 5.9% and 16.7% compared with 6.5%, both P < 0.001). WRA with increased WC, WHtR, and WHR had higher IDA prevalence than those with lower adiposity (8.5% compared with 4.3%, P = 0.005; 9.4% compared with 3.3%, P < 0.001; 12.1% compared with 4.9%, P < 0.001). ID prevalence was 49.7% (ferritin cutoff 30 μg/L) and 19.6% (ferritin cutoff 15 μg/L), showing similar rates across adiposity groups. ID prevalence defined by soluble transferrin receptor (sTfR) was higher in women with increased WHR (P = 0.001). Higher WHR predicted ID categorized by sTfR (adjusted odds ratio [aOR]: 2.104, P = 0.004), and WHtR and WHR predicted anemia and IDA (anemia: WHtR aOR: 2.006, P = 0.036; WHR aOR: 4.489, P < 0.001 and IDA: WHtR aOR: 2.942, P = 0.012; WHR aOR: 4.142, P < 0.001).

CONCLUSIONS

At least 1 in 5 WRA in the UK are iron deficient, highlighting the need to revise current policies. Greater central adiposity was strongly associated with impaired iron status and the development of anemia, IDA, and ID.

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.

Randomized Controlled Trial of Intravenous Ferric Carboxymaltose vs Oral Iron to Treat Iron Deficiency Anemia After Variceal Bleed in Patients With Cirrhosis

INTRODUCTION

Limited evidence exists on the optimal strategy to correct iron deficiency anemia after variceal bleeding (VB) in cirrhosis. This trial compared the efficacy and safety of intravenous ferric carboxymaltose (IV-FCM) with those of oral iron therapy in this cohort.

METHODS

In this open-label, single-center, randomized controlled trial, eligible patients with hemoglobin <10 g/dL and iron deficiency (ferritin <100 ng/mL) after VB received either IV-FCM (1,500-2,000 mg) divided into 2 doses (n = 48) or oral carbonyl iron (100 mg elemental iron/day) (n = 44) for 3 months. The primary outcome was change in hemoglobin at 3 months. Secondary outcomes included improvement in anemia (last hemoglobin >12 g/dL), normalization of iron stores (ferritin >100 ng/mL), liver-related adverse events, adverse drug reactions, and changes in quality of life (CLDQOL questionnaire).

RESULTS

Baseline characteristics, including median Child-Turcotte-Pugh score 7 (interquartile range [IQR] 6-9), Model for End-Stage Liver Disease score 12 (IQR 10-17), blood hemoglobin (8.25 ± 1.06 g/dL), and ferritin (30.00 ng/mL [15.00-66.50]), were comparable in both arms. The median increase in hemoglobin at 3 months in the IV and oral arms was 3.65 g/dL (IQR 2.55-5.25) and 1.10 g/dL (IQR 0.05-2.90 g/dL) ( P < 0.001), respectively. Iron stores normalized in 84.6% and 21% of the IV and oral arms, respectively ( P < 0.001). Anemia improved in 50% and 21.9% in the IV and oral arms, respectively ( P < 0.009). Patients in the IV arm showed a significant improvement in all domains of CLDQOL. Liver-related adverse events were comparable in both arms. Transient mild/moderate hypophosphatemia developed in 43% of patients receiving IV-FCM.

DISCUSSION

Intravenous iron replacement is efficacious and safe to treat iron deficiency anemia after VB in patients with cirrhosis.

Gastrointestinal Angiodysplasia Resolution After Transcatheter Aortic Valve Implantation

Importance

Heyde syndrome is the cooccurrence of aortic stenosis and gastrointestinal bleeding secondary to vascular lesions, including angiodysplasias. Several studies have demonstrated cessation of gastrointestinal bleeding after transcatheter aortic valve implantation (TAVI), but the etiology and effects on vascular lesions are largely unknown.

Objective

To examine the associations of TAVI with gastrointestinal vascular lesions and identify factors associated with recovery among patients with iron deficiency anemia and severe aortic stenosis.

Design, Setting, and Participants

In this prospective, single-center cohort study, patients with iron deficiency anemia on the TAVI waiting list from September 2020 to February 2022 were assessed by capsule endoscopy. Those with vascular lesions were reassessed 6 months after TAVI. Endoscopic images were anonymized and evaluated by 2 independent researchers. Data were analyzed from September 2022 to August 2024.

Exposure

TAVI.

Main Outcomes and Measures

The primary outcome was the mean difference in the number of vascular lesions before vs after TAVI.

Results

A total of 24 patients (mean [SD] age, 77.4 [7.1] years; 18 [75.0%] male) underwent capsule endoscopy, and vascular lesions were present in 18 patients (75.0%). TAVI was performed in 15 of 18 patients with vascular lesions, of whom 11 agreed to a second capsule endoscopy. The mean (SD) number of vascular lesions across the gastrointestinal tract decreased from 6.4 (5.6) lesions before TAVI to 2.0 (2.1) lesions 6 months after TAVI (P = .04). The number of vascular lesions decreased in 9 of 11 patients (81.8%), including 6 patients (54.5%) who no longer had typical angiodysplasias. Resolution of angiodysplasias was less frequent in patients who had multiple valvular heart disease before TAVI (0 of 3 patients) vs those without multiple valvular heart disease (6 of 8 patients [75.0%]) and in patients with significant paravalvular leakage after TAVI (2 of 5 patients [40.0%]) vs those without significant leakage (4 of 6 patients [66.7%]).

Conclusions and Relevance

In this cohort study of 24 patients with iron deficiency anemia and severe aortic stenosis, angiodysplasias were present in 75.0% of patients. TAVI was associated with reduced size and number of angiodysplasias in these patients. These findings suggest that TAVI not only improves aortic stenosis but may also reduce gastrointestinal bleeding by resolving vascular lesions, offering a dual benefit for patients with Heyde syndrome.

Optimising the Diagnosis of Adult Coeliac Disease: Current Evidence and Future Directions

Coeliac disease is a common autoimmune disorder that affects nearly 1% of the general population. Current diagnostic strategies involve active case finding, serological tests, and endoscopy with biopsies. However, many patients with coeliac disease remain undiagnosed due to a wide gap between clinical guidelines and real-world practice in the diagnosis of adult coeliac disease. This highlights the need for increased education, training, and targeted quality-improvement interventions to optimise the diagnosis of coeliac disease.

Severe iron-deficiency anemia after short-term moderate consumption of green tea in woman: A rare case report

While the mechanisms by which tea consumption hinders iron absorption are well understood, tea-related anemia usually stems from prolonged and excessive intake, which obstructs iron absorption and depletes the body's iron reserves. Consequently, it is uncommon for hemoglobin levels to plummet by 6.9 g/dl solely due to moderate tea consumption over a span of three months. We present a case of severe iron-deficiency anemia in a woman following short-term, moderate green tea consumption. After modifying her tea intake regimen, there was no recurrence of anemia. Clinicians should be mindful that even moderate tea consumption can precipitate severe iron-deficiency anemia in individuals particularly vulnerable to its effects on iron absorption.

Updated adult ferritin reference intervals based on a large, healthy UK sample, measured on Roche Cobas series analysers

BACKGROUND

There is a lack of standardization of reference intervals (RIs) for ferritin across laboratories, particularly for postmenopausal women. Depending on the RI used, there can be more than a 4-fold difference in the upper limit of normal between laboratories, resulting in potential misinterpretation.

METHODS

This retrospective study used a large dataset of blood test results from 25,425 healthy participants aged 18 to 97 over a 7-year period. Exclusion criteria were used to screen out individuals with conditions known to affect iron metabolism or raise ferritin as part of the acute phase response. Distributions were assessed using density and Q-Q plots, and age-banded cut-offs were determined. The non-parametric method was used to establish RIs for sex and age bands.

RESULTS

For females, 4 age bands were established (18-39, 40-49, 50-59 and 60+). For males, 2 bands were identified (18-39 and 40+). Performance against a validation dataset, followed by an expansive validation against an inclusive dataset, demonstrated the robustness of the derived RIs.

CONCLUSION

This study addresses the inconsistency in serum ferritin RIs by presenting intervals based on demographic parameters. This approach can potentially enhance the accuracy of interpreting serum ferritin levels, assisting clinicians in identifying patients requiring further evaluation.

Oral iron supplementation: new formulations, old questions

Iron-deficiency anemia and pre-anemic iron deficiency are the most frequent pathologies. The first line of treatment involves oral iron supplementation. The simplest, least expensive, and most commonly prescribed drug is ferrous sulfate, while other ferrous salts and ferric complexes with polysaccharides or succinylated milk proteins are also widely used. In recent years, novel iron formulations have been developed, such as the lipophilic iron donor ferric maltol, or nanoparticle encapsulated sucrosomial® iron. Oral iron supplementation is usually efficacious in correcting iron-deficiency anemia and replenishing iron stores but causes gastrointestinal side effects that reduce compliance. When oral iron supplementation is contraindicated, intravenous iron therapy can rapidly achieve therapeutic targets without gastrointestinal complications. Herein, we critically review literature on relative efficacy and tolerability of currently available oral iron supplements, and summarize recent data on optimal dosage and frequency.

Faecal immunochemical tests can improve colonoscopy triage in patients with iron deficiency: A systematic review and meta-analysis

BACKGROUND

Use of the faecal immunochemical test (FIT) to triage patients with iron deficiency (ID) for colonoscopy due to suspected colorectal cancer (CRC) may improve distribution of colonoscopic resources. We reviewed the diagnostic performance of FIT for detecting advanced colorectal neoplasia, including CRC and advanced pre-cancerous neoplasia (APCN), in patients with ID, with or without anaemia.

METHODS

We performed a systematic review of three databases for studies comprising of patients with ID, with or without anaemia, completing a quantitative FIT within six months prior to colonoscopy, where test performance was compared against the reference standard colonoscopy. Random effects meta-analyses determined the diagnostic performance of FIT for advanced colorectal neoplasia.

RESULTS

Nine studies were included on a total of n=1761 patients with ID, reporting FIT positivity thresholds between 4-150 µg haemoglobin/g faeces. Only one study included a non-anaemic ID (NAID) cohort. FIT detected CRC and APCN in ID patients with 90.7 % and 49.3 % sensitivity, and 81.0 % and 82.4 % specificity, respectively. FIT was 88.0 % sensitive and 83.4 % specific for CRC in patients with ID anaemia at a FIT positivity threshold of 10 µg haemoglobin/g faeces.

CONCLUSIONS

FIT shows high sensitivity for advanced colorectal neoplasia and may be used to triage those with ID anaemia where colonoscopic resources are limited, enabling those at higher risk of CRC to be prioritised for colonoscopy. There is a need for further research investigating the diagnostic performance of FIT in NAID patients.

Non-specific presentation of metastatic small bowel adenocarcinoma with diagnostic challenges

Diagnosing small bowel adenocarcinomas presents challenges due to non-specific symptoms, rarity and gastroscopy and colonoscopy's limited small intestine access, highlighting targeted diagnostic procedures' necessity. We present a late-diagnosed metastatic small bowel adenocarcinoma case in a man in his 80s who had asymptomatic mild iron-deficiency anaemia 1 year before diagnosis, with no active bleeding found on endoscopies. He experienced a single rectal bleeding episode 9 months prediagnosis, with subsequent severe iron-deficiency anaemia and no clear gastrointestinal source identified on gastroscopy. For 2 months, he had intermittent postprandial diarrhoea without abdominal pain, infectious or inflammatory causes. He experienced significant weight loss over 3 months prediagnosis. Subsequent gastroscopy indicated duodenal-gastric food retropulsion, suggesting a downstream blockage. Magnetic resonance enterography showed proximal jejunum thickening. Push enteroscopy confirmed jejunum adenocarcinoma. CT scans detected liver and peritoneal metastases. After one chemotherapy cycle, his condition worsened, leading to his passing 2 months post diagnosis.

Common Non-Rheumatic Medical Conditions Mimicking Fibromyalgia: A Simple Framework for Differential Diagnosis

Fibromyalgia (FM) is a chronic non-inflammatory disorder mainly characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and a constellation of other symptoms. For this reason, delineating a clear distinction between pure FM and FM-like picture attributable to other common diseases can be extremely challenging. Physicians must identify the most significant confounders in individual patients and implement an appropriate diagnostic workflow, carefully choosing a minimal (but sufficient) set of tests to be used for identifying the most plausible diseases in the specific case. This article discusses prevalent non-rheumatological conditions commonly observed in the general population that can manifest with clinical features similar to primary FM. Given their frequent inclusion in the differential diagnosis of FM patients, the focus will be on elucidating the distinctive clinical characteristics of each condition. Additionally, the most cost-effective and efficient diagnostic methodologies for accurately discerning these conditions will be examined.

Iron Deficiency and Sleep/Wake Behaviors: A Scoping Review of Clinical Practice Guidelines-How to Overcome the Current Conundrum?

Current evidence suggests that iron deficiency (ID) plays a key role in the pathogenesis of conditions presenting with restlessness such as attention deficit hyperactivity disorder (ADHD) and restless legs syndrome (RLS). In clinical practice, ID and iron supplementation are not routinely considered in the diagnostic work-up and/or as a treatment option in such conditions. Therefore, we conducted a scoping literature review of ID guidelines. Of the 58 guidelines included, only 9 included RLS, and 3 included ADHD. Ferritin was the most frequently cited biomarker, though cutoff values varied between guidelines and depending on additional factors such as age, sex, and comorbidities. Recommendations surrounding measurable iron biomarkers and cutoff values varied between guidelines; moreover, despite capturing the role of inflammation as a concept, most guidelines often did not include recommendations for how to assess this. This lack of harmonization on the interpretation of iron and inflammation biomarkers raises questions about the applicability of current guidelines in clinical practice. Further, the majority of ID guidelines in this review did not include the ID-associated disorders, ADHD and RLS. As ID can be associated with altered movement patterns, a novel consensus is needed for investigating and interpreting iron status in the context of different clinical phenotypes.

Pathophysiology and management of iron deficiency anaemia in pregnancy: a review

According to World Health Organization (WHO), iron deficiency anaemia (IDA) is considered the most prevalent nutritional deficiency worldwide, affecting approximately 30% of the global population. While gastrointestinal bleeding and menstruation in women are the primary causes of IDA, insufficient dietary iron intake and reduced iron absorption contribute to the condition. The aim of IDA treatment is to restore iron stores and normalise haemoglobin levels in affected patients. Iron plays a critical role in various cellular mechanisms, including oxygen delivery, electron transport, and enzymatic activity. During pregnancy, the mother's blood volume increases, and the growing foetus requires a significant increase in iron. Iron deficiency during pregnancy is associated with adverse outcomes such as maternal illness, low birth weight, preterm birth, and intrauterine growth restriction. Iron supplementation is commonly used to treat IDA; however, not all patients benefit from this therapy due to factors such as low compliance and ineffectiveness. In the past, IV iron therapy was underutilised due to its unfavourable and occasionally unsafe side effects. Nevertheless, the development of new type II and III iron complexes has improved compliance, tolerability, efficacy, and safety profiles. This article aims to provide an updated overview of the diagnosis and management of IDA during pregnancy. It will discuss the advantages and limitations of oral versus intravenous iron and the pathophysiology, diagnosis, treatment, and overall management of IDA in pregnancy.