Intravenous iron versus blood transfusion for postpartum anemia: a systematic review and meta-analysis

BACKGROUND

Intravenous iron (IV-iron) is used as an alternative to, or alongside, red blood cell transfusion (RBC-T) to treat more severe postpartum anemia (PPA), although optimal treatment options remain unclear. No previous systematic reviews have examined IV-iron and RBC-T, including patient-reported outcomes and hematological responses.

METHODS

A systematic review and meta-analysis of randomized trials comparing IV-iron and RBC-T with each other, oral iron, no treatment, and placebo for the treatment of PPA. Key inclusion criteria were PPA (hemoglobin < 12 g/dL) and IV-iron or RBC-T as interventions. Key exclusion criteria were antenatal IV-iron or RBC-T. Fatigue was the primary outcome. Secondary outcomes included hemoglobin and ferritin concentrations, and adverse events. From 27th August 2020 to 26th September 2022, databases, registries, and hand searches identified studies. A fixed-effect meta-analysis was undertaken using RevMan (5.4) software. The quality of the studies and the evidence was assessed using the Cochrane Risk of Bias table, and Grading of Recommendations, Assessment, Development, and Evaluation. This review is registered with the Prospective Register of Systematic Reviews (CRD42020201115).

RESULTS

Twenty studies and 4196 participants were included: 1834 assigned IV-iron, 1771 assigned oral iron, 330 assigned RBC-T, and 261 assigned non-intervention. Six studies reported the primary outcome of fatigue (1251 participants). Only studies of IV-iron vs. oral iron (15 studies) were available for meta-analysis. Of these, three reported on fatigue using different scales; two were available for meta-analysis. There was a significant reduction in fatigue with IV-iron compared to oral iron (standardized mean difference - 0.40, 95% confidence interval (CI) - 0.62, - 0.18, I2 = 0%). The direction of effect also favored IV-iron for hemoglobin (mean difference (MD) 0.54 g/dL, 95% confidence interval (CI) 0.47, 0.61, I2 = 91%), ferritin, (MD 58.07 mcg/L, 95% CI 55.74, 60.41, I2 = 99%), and total adverse events (risk-ratio 0.63, 95% CI 0.52, 0.77, I2 = 84%). The overall quality of the evidence was low-moderate.

DISCUSSION

For all outcomes, the evidence for RBC-T, compared to IV-iron, non-intervention, or dose effects of RBC-T is very limited. Further research is needed to determine whether RBC-T or IV-iron for the treatment of PPA is superior for fatigue and hematological outcomes.

Transobturator and retropubic tape procedures in stress urinary incontinence: a systematic review and meta-analysis of effectiveness and complications

BACKGROUND

Various types of suburethral tapes inserted via the transobturator route (tension-free vaginal tape obturator route [TVTO] and transobturator tape [TOT]) have been widely adopted for treatment of stress urinary incontinence (SUI) before proper evaluation of their effectiveness and complications.

OBJECTIVES

To assess the effectiveness and complications of TOTs as treatment of SUI by means of a systematic review.

SEARCH STRATEGY

MEDLINE, EMBASE, CINAHL, LILIACS (up to September 2006), CENTRAL (The Cochrane Library, Issue 3, 2006), MetaRegister of Controlled Trials, The National Library for Health, the National Research Register and Google Scholar were searched using various relevant search terms. The citation lists of review articles and included trials were searched, and contact with the corresponding author of each included trials was attempted.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared the effectiveness of TVTO or TOT with synthetic tension-free vaginal tape (TVT) by retropubic route (Gynecare; Ethicon Inc., NJ, USA) for the treatment of SUI in all languages were included.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data on participants' characteristics, study quality, population, intervention, cure and adverse effects independently. The data were analysed in the Review Manager 4.2.8 software.

MAIN RESULTS

There were five RCTs that compared TVTO with TVT and six RCTs that compared TOT with TVT. When compared by subjective cure, TVTO and TOT at 2-12 months were no better than TVT (OR 0.85; 95% CI 0.60-1.21). Adverse events such as bladder injuries (OR 0.12; 95% CI 0.05-0.33) and voiding difficulties (OR 0.55; 95% CI 0.31-0.98) were less common, whereas groin/thigh pain (OR 8.28; 95% CI 2.7-25.4), vaginal injuries or erosion of mesh (OR 1.96; 95% CI 0.87-4.39) were more common after tape insertion by the transobturator route.

AUTHOR'S CONCLUSIONS

The evidence for short-term superiority of effectiveness of TOTs is currently limited. Bladder injuries and voiding difficulties are lower, but the risk of vaginal erosions and groin pain is higher with TVTO/TOT. Methodologically sound and sufficiently powered RCTs with long-term follow up are needed, and the results of continuing trials are awaited.

Haem disorder in two myoglobins: comparison of reorientation rate

The globins from sperm whale and from Aplysia limacina myoglobins were reconstituted by addition of stoichiometric ferric protohaem and the Soret c.d. was followed as a function of time. For both reconstituted proteins, the Soret c.d. changes with time, reflecting haem reorientation inside its pocket, as previously described [Aojula, Wilson & Drake (1986) Biochem. J. 237, 613-616] for sperm whale myoglobin. The time course of the c.d. transition is found to be approx. 10 times faster in Aplysia than in sperm whale myoglobin, a result which is in agreement with the known structural and physicochemical properties of the two myoglobins; furthermore, these results confirm that c.d. and n.m.r. data on haem orientation in haemoproteins reflect the same molecular phenomenon.

Solvolysis of sulphonyl halides. VIII. Reaction of methane and ethane sulphony1 chlorides with methanol, ethanol, and mixed solvent systems

At room temperature methanesulphonyl chloride reacts more rapidly than ethanesulphonyl chloride in solvolysis by ethanol. Their rates of reaction with methanol are approximately equal while ethanesulphonyl chloride is the more reactive in hydrolysis. The enthalpies and entropies of activation have been determined for the solvolysis of ethanesulphonyl chloride in mixtures of ethanol with benzene, carbon tetrachloride, or 2,2,4-trimethylpentane. A comparison of the excess enthalpies and entropies of mixing in the formation of these solvents with the corresponding parameters for reaction shows that the effects on reaction rate are not due merely to the modification of the initial state of the system. The effect of the polar aprotic solvent nitrobenzene on the rate of reaction with methanol is attributed to an increase in the nucleophilic tendency of the methanol rather than to solvation of the reactive centre in the transition state.

Solvolysis of Sulphonyl Halides. IV. The Hydrolysis of Some Substituted Aliphatic Sulphonyl Chlorides and of Ethanesulphonyl Bromide in Aqueous Dioxan

The effects of substitution in the alkyl group of an alkanesulphonyl chloride, on the rate of hydrolysis, vary with the solvent composition. The relative rates can be explained in terms of the theory of Grunwald and Winstein that there is a continuous range of transition complexes, with " bond making " between the water molecule and the sulphur atom controlling the rate in the less aqueous media, while the stretching and charging of the sulphur to chlorine bond controls the rate in solvents of higher water content. The inhibition of the simple SN2 reaction, which gives rise to a maximum rate constant as the composition of the solvent approaches pure water, resembles that noted with methane- and ethanesulphonyl chlorides.�The hydrolysis of ethanesulphonyl bromide, at 25 �C, proceeds at three to eight times the rate for the corresponding sulphonyl chloride in solvents varying in composition from 0.99 to 0.2 mole fraction of water with dioxan. Over most of the solvent range both the entropy and enthalpy of activation are favourable to a higher rate of solvolysis for the sulphonyl bromide.

Solvolysis of Sulphonyl Halides. III. The Hydrolysis of Methane- and Ethanesulphonyl Chlorides in Aqueous Dioxan and Aqueous Acetone

The hydrolyses of methane- and ethanesulphonyl chlorides in aqueous acetone and aqueous dioxan, in the range 0.2-1.0 mole fraction of water, follow an SN2 mechanism. The first-order rate constants at low temperature go through a maximum as the composition of the solvent approaches pure water and there is a marked retardation at other temperatures. There is strong evidence that the nature of the transition complex is changing as the solvent composition is changed. The data arising from the use of an extended range of solvent composition have invalidated earlier discussions of the nature of this reaction.