Correct assessment of iron depletion and iron deficiency anemia

Malnutrition in Orthopaedic Sports Medicine: A Review of the Current Literature

CONTEXT

Malnutrition is well-studied in various aspects of the orthopaedic literature, most commonly in relation to arthroplasty, spine surgery, and trauma. However, the management of nutritional deficiencies is commonly overlooked among orthopaedic sports medicine providers. The purpose of this article is to analyze the available sports medicine literature to review the associations between malnutrition and the management of orthopaedic sports medicine patients from a treatment and performance standpoint.

EVIDENCE ACQUISITION

PubMed was searched for relevant articles published from 1979 to 2019.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Few studies exist on the implications of macronutrient deficiencies specific to orthopaedic sports medicine procedures. Interestingly, micronutrient disorders-namely, hypovitaminosis D and iron deficiency-have been well studied and may lead to worse postoperative outcomes, injury rates, and athletic performance. Nutritional supplementation to correct such deficiencies has been shown to mitigate these effects, though further study is required.

CONCLUSION

Nutritional deficiencies are highly prevalent in orthopaedic sports medicine patients, and practitioners should be aware of their potential effects on treatment and performance outcomes. Management of such deficiencies and their effect on surgical patients remain an area of potential future research. Future studies are warranted in order to explore the potential therapeutic role of nutritional supplementation to prevent complications after common orthopaedic sports medicine procedures, improve athletic performance, and reduce injury rates.

Relative hypochromia and mortality in acute heart failure

BACKGROUND

Relative hypochromia of erythrocytes defined as a reduced mean corpuscular hemoglobin concentration (MCHC) is a surrogate of iron deficiency. We aimed to evaluate the prevalence and prognostic impact of relative hypochromia in acute heart failure (AHF).

METHODS

We prospectively characterized 1574 patients presenting with an adjudicated diagnosis of AHF to the emergency department. Relative hypochromia was defined as a MCHC ≤330 g/l and determined at presentation. The presence of AHF was adjudicated by two independent cardiologists. All-cause mortality and AHF-rehospitalization were the primary prognostic end-points.

RESULTS

Overall, 455 (29%) AHF patients had relative hypochromia. Patients with relative hypochromia had higher hemodynamic cardiac stress as quantified by NT-proBNP concentrations (p < 0.001), more extensive cardiomyocyte injury as quantified by high-sensitive cardiac troponin T (hs-cTnT) concentrations (p < 0.001), and lower estimated glomerular filtration rate (eGFR; p < 0.001) as compared to AHF patients without hypochromia. Cumulative incidences for all-cause mortality and AHF-rehospitalization at 720-days were 50% and 55% in patients with relative hypochromia as compared to 33% and 39% in patients without hypochromia, respectively (both p < 0.0001). The association between relative hypochromia and increased mortality (HR 1.7, 95% CI 1.4-2-0) persisted after adjusting for anemia (HR 1.5, 95% CI 1.3-1.8), and after adjusting for hemodynamic cardiac stress (HR 1.46, 95% CI 1.21-1.76) and eGFR (HR 1.5, 95% CI 1.3-1.8, p < 0.001).

CONCLUSIONS

Relative hypochromia is common and a strong and independent predictor of increased mortality in AHF. Given the direct link to diagnostic (endoscopy) and therapeutic interventions to treat functional iron deficiency, relative hypochromia deserves increased attention as an inexpensive and universally available biomarker.

Auditory brainstem response in full-term neonates born to mothers with iron deficiency anemia: relation to disease severity

Background: Iron is crucial for fetal brain development; however, there are insufficient data regarding the effects of maternal iron deficiency anemia (IDA) on auditory neural maturation.Aim: We evaluated the effect of maternal IDA on auditory brainstem response (ABR) in full-term neonates.Methods: Out of 223 pregnant women, 50 were diagnosed as having IDA and 50 healthy mothers were enrolled as controls. ABR test was done for the studied neonates within 48 hours after birth and at 3 months.Results: We found that hemoglobin and iron profile were lower in neonates born to anemic mothers compared with controls. Of 100 neonates screened for ABR, 25 failed the test (all of them were born to anemic mothers). The majority of neonates who failed the screening ABR test (88%) had latent iron deficiency (cord blood ferritin 11-75 µg/L). After 3 months, 85 neonates underwent diagnostic ABR test which revealed significantly prolonged interpeak latencies I-III, III-V, and I-V among neonates born to IDA mothers compared with the control group. Within the IDA group, all interpeak latencies were more prolonged in neonates with latent iron deficiency and in those born to mothers with serum ferritin <15 µg/L. Logistic regression analysis showed that maternal hemoglobin and mean corpuscular volume could predict neonatal ABR results.Conclusions: IDA during late pregnancy adversely affects cord blood iron and hearing status. ABR results are closely related to the severity of maternal and neonatal iron status. Antenatal screening of pregnant mothers is needed to improve fetal iron status and prevent abnormal auditory maturation.

Prognostic implications of relative hypochromia in ambulatory patients with chronic systolic heart failure

Iron insufficiency has been associated with heart failure, but the impact of a reduction of hemoglobin content in the erythrocytes as estimated by mean corpuscular hemoglobin concentration (MCHC) to myocardial structure, performance, and long-term clinical outcomes has not been well-established. The authors examined hematologic data and long-term outcomes of 197 ambulatory patients with chronic systolic and symptomatic heart failure who underwent comprehensive echocardiographic evaluation. The authors observed that relative hypochromia (defined as low MCHC) was associated with higher natriuretic peptide levels (NT-proBNP, r =-0.40, P<.0001) and lower estimated glomerular filtration rate (eGFR; r = 0.45, P <. 0001) and correlated modestly with indices of left and right ventricular diastolic dysfunction (all P<.05), but were not related to left ventricular ejection fraction (LVEF, r=0.17, P=.079). After 5 years of follow-up, lower MCHC levels were associated with higher risk of death, transplant, or heart failure hospitalization after adjusting for age, LVEF, eGFR, and New York Heart Association class (hazard ratio, 1.34; 95% confidence interval, 1.04-1.72; P=.025), particularly in those with above-median hemoglobin (>13.8 g/dL; hazard ratio, 2.02; 95% confidence interval, 1.44-2.81, P<.0001). Taken together, the observations imply that physicians should take notice of the presence of relative hypochromia particularly in the absence of anemia in the setting of chronic systolic heart failure.

Identifying a window of vulnerability during fetal development in a maternal iron restriction model

It is well acknowledged from observations in humans that iron deficiency during pregnancy can be associated with a number of developmental problems in the newborn and developing child. Due to the obvious limitations of human studies, the stage during gestation at which maternal iron deficiency causes an apparent impairment in the offspring remains elusive. In order to begin to understand the time window(s) during pregnancy that is/are especially susceptible to suboptimal iron levels, which may result in negative effects on the development of the fetus, we developed a rat model in which we were able to manipulate and monitor the dietary iron intake during specific stages of pregnancy and analyzed the developing fetuses. We established four different dietary-feeding protocols that were designed to render the fetuses iron deficient at different gestational stages. Based on a functional analysis that employed Auditory Brainstem Response measurements, we found that maternal iron restriction initiated prior to conception and during the first trimester were associated with profound changes in the developing fetus compared to iron restriction initiated later in pregnancy. We also showed that the presence of iron deficiency anemia, low body weight, and changes in core body temperature were not defining factors in the establishment of neural impairment in the rodent offspring.Our data may have significant relevance for understanding the impact of suboptimal iron levels during pregnancy not only on the mother but also on the developing fetus and hence might lead to a more informed timing of iron supplementation during pregnancy.

Commentary: Iron deficiency and hair loss: problems with measurement of iron

Iron is involved in many critical physiologic processes within the hair follicle, suggesting that iron deficiency could disrupt hair synthesis. However, studies of iron as a cause of hair loss have produced conflicting results. Some of the discrepancies may relate to limitations of assays for iron deficiency. This commentary discusses the sensitivity and specificity of available tests for iron deficiency and presents practical guidelines for testing and supplementation.

Iron status of adolescent girls from two boarding schools in southern Benin

Iron deficiency (ID) is the most prevalent micronutrient deficiency in the world, particularly in developing countries. Blood samples and a qualitative FFQ on Fe- and vitamin C-rich foods were obtained in 180 adolescent girls aged 12 to 17 years living in two boarding schools from south Benin. ID, defined as serum ferritin either <20μg/l or 20–50μg/l, plus two of the following parameters: serum Fe<11μmol/l, total iron-binding capacity>73μmol/l or transferrin saturation<20%, was found in 32% of subjects. Anaemia (Hb<120g/l) was found in 51% of adolescents, while 24% suffered from iron-deficiency anaemia (IDA) (ID and Hb<20g/l). After adjusting for confounding factors (age, mother's and father's occupation, household size) in a logistic regression equation, subjects having a low meat consumption (beef, mutton, pork) (<4 times/week) were more than twice as likely to suffer from ID (OR=2·43; 95% CI 1·72, 3·35;P=0·04). Adolescents consuming less fruits (<4 times/week) also had a higher likelihood of suffering from ID (OR=1·53; 95% CI 1·31, 2·80;P=0·03). Finally, subjects whose meat consumption was low were twice as likely to suffer from IDA (OR=2·24; 95% CI 1·01, 4·96;P=0·04). The prevalence of ID represents an important health problem in these Beninese adolescent girls. A higher consumption of Fe-rich foods and of promoters of Fe absorption (meat factor and vitamin C) is recommended to prevent ID deficiency in these subjects.

A framework to analyse gender bias in epidemiological research

The design and analysis of research may cause systematic gender dependent errors to be produced in results because of gender insensitivity or androcentrism. Gender bias in research could be defined as a systematically erroneous gender dependent approach related to social construct, which incorrectly regards women and men as similar/different. Most gender bias can be found in the context of discovery (development of hypotheses), but it has also been found in the context of justification (methodological process), which must be improved. In fact, one of the main effects of gender bias in research is partial or incorrect knowledge in the results, which are systematically different from the real values. This paper discusses some forms of conceptual and methodological bias that may affect women's health. It proposes a framework to analyse gender bias in the design and analysis of research carried out on women's and men's health problems, and on specific women's health issues. Using examples, the framework aims to show the different theoretical perspectives in a social or clinical research context where forms of selection, measurement and confounding bias are produced as a result of gender insensitivity. Finally, this paper underlines the importance of re-examining results so that they may be reinterpreted to produce new gender based knowledge.

Intestinal parasitic infections in adolescent girls from two boarding schools in southern Benin

Intestinal parasitic infections (IPI), especially helminths, represent a major public health problem that increase iron deficiency anaemia in developing countries. This study investigated the prevalence, risk factors and nutritional consequences of IPIs in 180 adolescent girls aged 12-17 years living in two boarding schools in southern Benin. Data were collected using a structured questionnaire and laboratory analysis of blood and faecal samples. The relationships between socioeconomic indicators, IPIs and iron status were analysed using logistic regression analysis. Fifty percent of the subjects were infected with at least one IPI: 2% with helminths, 41% with protozoa and 7% with two or more intestinal parasites. Adolescent girls from a large family and those whose mothers were manual workers showed a higher risk of intestinal parasitism (odds ratio (OR)=3.5, 95% CI 2.5-5.2 (P=0.02) and OR=2.4, 95% CI 2.0-3.0 (P=0.03), respectively). Likewise, drinking untreated water was also a high risk factor for infection (OR=2.3, 95% CI 1.5-2.4; P=0.03). No significant association was observed between IPIs and iron deficiency or iron deficiency anaemia, which can be explained by the low wormload observed. These findings reinforce the need to involve mothers in health initiatives to control intestinal parasitism in Benin.

Impact of long-term oral iron supplementation in breast-fed infants

OBJECTIVE

To weigh benefits of oral iron supplements on infant's growth against its potential hazards.

METHODS

248 exclusively breast-fed infants aged 4-6 months were consecutively enrolled and divided into treatment group given iron containing multivitamin (TG = 198) and control group (placebo, PG = 50) given the same multivitamin but without is subdivided according to clinical assessment into group A (well nourished) and group B (malnourished); both were further stratified according to basal blood iron status. Assessment was done after 6 and 12 months with concurrent collection of morbidity parameters (diarrhea and fever). Data were normalized and analyzed using SPSS and Eurogrowth softwares.

RESULTS

After 6 months treatment, weight and length gain was better in TG compared to placebo especially evident in anemic malnourished infants (P 0.05). Morbidity risk was linked to immunologic background of infant; odds ratio for diarrhea and fever was higher in malnourished compared to well nourished (P 0.05) or iron therapy (P for well-nourished non-anemic treatment vs PG > 0.05).

CONCLUSION

Oral iron supplementation resulted in better effects on growth velocity of breast fed infants especially those who were initially malnourished and anemic or at least iron depleted, with less marked morbidity than in iron replete infants.