A Novel Discriminating Tool for Microcytic Anemia in Childhood

Accurate and timely interpretation of microcytic anemia can be diagnostically challenging in the primary care setting. We sought to develop a novel model for distinguishing iron-deficiency anemia from thalassemia trait in the modern pediatric population. Demographic history and red blood cell indices were retrospectively characterized for 76 children referred to our pediatric hematology clinic for evaluation of microcytic anemia. Statistically significant variables were sequentially added into a logistic regression model to develop the final model. The final discriminating model incorporates red cell distribution width, mean corpuscular hemoglobin concentration, and red blood cell values. Favorable predictive performance is seen in the initial (sensitivity 89.2%, specificity 92.3%) and external validation cohort (sensitivity 84.4%, specificity 88.9%). This novel tool may aid in determining the cause of hypochromic, microcytic anemia in the primary care setting. Finally, the study cohort reflects an underrepresented group in the development of screening tools, and thus offers generalizability.

Clinical effectiveness of ferric carboxymaltose (iv) versus iron sucrose (iv) in treatment of iron deficiency anaemia in pregnancy: A systematic review and meta-analysis

BACKGROUND OBJECTIVES

Iron deficiency anaemia (IDA) during pregnancy is treated with oral and parenteral iron. The objective of this review was to compare the clinical effectiveness, safety, pregnancy and neonatal outcomes of intravenous (iv) ferric carboxymaltose (FCM) and iv iron sucrose (IS) in treating IDA in pregnancy.

METHODS

The Department of Health Research funded this study. PubMed, Cochrane Library, EMBASE and Scopus were searched to include studies published till November 2022. The protocol was registered in PROSPERO (CRD42022306092). Pregnant women (15-49 yr) in second and third trimesters, diagnosed with moderate-to-severe iron deficiency anaemia, treated with either of the drugs were included. The included studies were critically assessed using appropriate tools. We conducted a qualitative synthesis of the studies and meta-analysis for improvement in haematological parameters and incidence of adverse events.

RESULTS

A total of 18 studies were included. The risk of bias was low to moderate. A rise in haemoglobin up to four weeks was higher with FCM than IS by 0.57 (0.24, 0.9) g/dl. Intravenous FCM is associated with fewer adverse events than IS [pooled odds ratio: 0.5 (0.32, 0.79)]. The included studies had limited evidence on pregnancy and neonatal outcomes after iv iron treatment.

INTERPRETATION CONCLUSIONS

Intravenous FCM is effective and safer than intravenous IS in terms of haematological parameters, in treating IDA in pregnancy. Further research is required on the effects of iv FCM and iv IS on the pregnancy and neonatal outcomes when used for treating IDA in pregnancy.

Neonatal outcomes from a randomized controlled trial of maternal treatment of iron deficiency anemia with intravenous ferumoxytol vs oral ferrous sulfate

BACKGROUND

Anemia in pregnancy is common worldwide and has known maternal risks. The relationship between the types of treatment offered for maternal anemia and the effects on the fetus and newborn are largely uninvestigated.

OBJECTIVE

This study aimed to investigate whether maternal treatment with intravenous ferumoxytol compared to oral ferrous sulfate results in an increase in neonatal hematologic and iron indices. These analyses were planned secondary outcomes and post hoc analysis from the trial with a primary outcome of change in maternal hemoglobin.

STUDY DESIGN

A randomized controlled trial including 124 participants with anemia by World Health Organization criteria was performed in which participants were allocated in a 1:1 ratio to either 2 infusions of 510 mg of intravenous ferumoxytol or 325 mg oral ferrous sulfate twice daily. Fetal monitoring was performed during each intravenous iron infusion. Standard univariable statistical techniques were used to compare groups and to investigate associations between maternal and neonatal hemoglobin and iron indices.

RESULTS

Cord blood hematological parameters were equivalent between groups. Hemoglobin was 15.7 g/dL vs 15.4 g/dL (P=.6) and hematocrit was 50.5% and 49.2% (P=.4) in those randomized to intravenous ferumoxytol and oral ferrous sulfate, respectively. Iron studies revealed higher cord blood ferritin concentrations in infants of participants treated with intravenous ferumoxytol (294 vs 186, P=.005). There were equivalent iron (158 vs 146, P=.4), transferrin (186 vs 196, P=.4) and total iron binding capacity (246 vs 244, P=1) in neonates of participants receiving intravenous vs oral treatment. There were no effects of the infusions observed on cardiotocography. Gestational age at birth was equivalent between groups. We noted a larger birthweight in neonates of participants treated with intravenous ferumoxytol (3215 g vs 3033 g, P=.09), which was not statistically significant. Post hoc analyses revealed a statistically significant correlation between neonatal ferritin and maternal hemoglobin (P=.006) and neonatal ferritin and maternal ferritin (P=.017) at admission for delivery.

CONCLUSION

Neonates of participants who received intravenous ferumoxytol were born with higher ferritin concentrations in cord blood, at the same gestation with the same birthweight. Participants with higher hemoglobin and ferritin indices delivered infants with higher ferritin concentrations in cord blood.

Intravenous infusions of ferumoxytol compared to oral ferrous sulfate for the treatment of anemia in pregnancy: a randomized controlled trial

BACKGROUND

Iron-deficiency anemia in pregnancy is highly prevalent and presents significant risk to patients. Initial treatment is often with oral medication. We hypothesized that intravenous ferumoxytol would result in superior treatment of anemia as compared to oral ferrous sulfate.

OBJECTIVE

This study aimed to investigate whether 2 infusions of intravenous ferumoxytol are superior to the use of twice-daily oral ferrous sulfate for the treatment of iron-deficiency anemia in pregnancy.

STUDY DESIGN

A randomized controlled trial was performed in which participants with anemic (hemoglobin <11 g/dL and hematocrit <33%) were allocated to receive either 2 infusions of 510 mg of intravenous ferumoxytol approximately 7 days apart, or 325 mg oral ferrous sulfate twice daily from enrollment to the end of their pregnancy. Participants were randomized in a 1:1 ratio to each treatment. Our primary outcome was the change in maternal hemoglobin. Secondary outcomes included maternal iron indices, maternal safety, and maternal tolerability.

RESULTS

There were 124 participants (N=62 per group). In the intravenous iron group, the mean change in hemoglobin was 1.86 g/dL (95% confidence interval, 1.57 g/dL-2.14 g/dL) and in the oral group was 0.79 g/dL (95% confidence interval, 0.42 g/dL-1.17 g/dL) (P<.0001). The median change in ferritin between groups was 64.5 (range, 31-364) vs 8 (range, -436 to +167) (P=.0001). The median change in iron between groups was also statistically significant with 47.5 ug/dL (range, -133 ug/dL to +664 ug/dL) in the intravenous group vs 8.5 ug/dL (range, -313 ug/dL to +437 ug/dL) in the oral iron group (P=.001).

CONCLUSION

Intravenous ferumoxytol was well tolerated, and it was associated with statistically significant increases in maternal hemoglobin, hematocrit, iron, and ferritin compared to oral ferrous sulfate.

An Audit of Iron Deficiency in Hospitalised Heart Failure Patients: A Commonly Neglected Comorbidity

Introduction Iron deficiency (ID) is a common comorbidity in patients with heart failure (HF) and can significantly impact morbidity and mortality, regardless of the presence of anaemia. Aim This audit aimed to assess the current practice in diagnosing and assessing iron deficiency (ID) in hospitalised patients with heart failure and reduced ejection fraction (HFrEF). The primary goal was to determine the prevalence of ID in HF patients and the frequency of iron testing in those patients. Additionally, the secondary aims included evaluating the presence of anaemia, the length of hospital stay, and the adequacy of appropriate management for iron deficiency in this patient population. Methods A retrospective audit was conducted, reviewing data from patients admitted to St. Vincent University Hospital over a period of 4 months. Results Out of the 111 patients audited, only 74% (82) had their iron status checked, and among those tested, 63% (52) met the criteria for iron deficiency according to the European Society of Cardiology (ESC). Additionally, 54% (28) of iron-deficient patients were also anaemic. Iron replacement was administered to 34 out of the 52 patients diagnosed with iron deficiency, accounting for 65% of the identified cases. The average duration of hospital stay for patients with iron deficiency was 13.8 days, while those without iron deficiency had a shorter mean length of stay of 11.2 days. However, it is important to note that the presence of co-morbidities and other confounding factors might have influenced these results. Conclusion Despite guideline recommendations, iron deficiency remains under-recognised and undertreated in clinical practice among heart failure patients. There is a crucial need for increased awareness, education, and practical guidance to improve the screening, diagnosis, and management of iron deficiency in hospitalised heart failure patients.

Effects of Iron Salts on Demineralization and Discoloration of Primary Incisor Enamel Subjected to Artificial Cariogenic Challenge versus Saline Immersion

AIM

This study aimed to assess the effects of iron salts on the demineralization and discoloration of primary incisor enamel subjected to artificial cariogenic challenge (ACC) versus saline immersion.

METHODOLOGY

In this in vitro experimental study, 90 primary incisors were evaluated in 10 groups (n = 9). Five groups were subjected to ACC, and the other five were immersed in saline. Ferrous sulfate, ferrous fumarate, ferrous ammonium citrate, and ferrous gluconate were added to both saline and cariogenic solutions. The solutions were refreshed every 48 h. After 14 days, the teeth were removed from the media and their demineralization was inspected via scanning electron microscopy (SEM). Energy-dispersive X-ray spectroscopy (EDX) was also performed. The color of the specimens was measured at baseline and after the intervention using the Vita Shade Guide.

RESULTS

Data were analyzed by the Kruskal-Wallis test, one-way ANOVA, and Tukey's test. The color change of specimens subjected to ACC was greater than the color change of those in saline (p = 0.083). The teeth subjected to ACC showed greater iron uptake than did those in saline (p = 0.023). SEM assessment revealed a regular pattern of enamel prisms, with some broken prisms and superficial cracks in the teeth immersed in saline. The teeth subjected to ACC showed numerous fractures and cracks, which were greater in the ferrous sulfate group.

CONCLUSIONS

Immersion in ACC increased the structural porosities and led to greater iron uptake and, consequently, higher discoloration. The maximum structural changes and subsequent staining were noted in the ferrous sulfate group, followed by ferrous ammonium citrate, ferrous fumarate, and ferrous gluconate.

Screening of Iron Deficiency Anemia in Children Using Mentzer Index in Pakistan: A Cross Sectional Study

The objective of the study was to determine the diagnostic accuracy of Mentzer Index in children with hypochromic microcytic anemia by taking serum ferritin levels as a gold standard. This cross-sectional study was conducted in the Department of Pediatric Medicine, Liaquat National Hospital Karachi, from 1st January to 30th June 2022. Children age 1 to 5 years and both genders were included in this study. Children who have had a history of blood transfusion in the past 3 months or Thalassemia or blood disorders, chronic liver disease or kidney diseases, and children with malignancy and congenital abnormalities were excluded. Eligible children were enrolled after taking written informed consent. Complete blood count (CBC) and serum ferritin were sent to the laboratory. Sensitivity, specificity, diagnostic accuracy, and likelihood ratio were calculated taking serum ferritin levels as a gold standard. A total of 347 subjects were enrolled. The median age was 26 (IQR-18) months and 42.9% were males. The most common symptom was fatigue 40.9%. The sensitivity of the Mentzer index was 80.7% while the specificity was 77.7%. Similarly, the positive predictive value (PPV) was 56.8% while the negative predictive value (NPV) was 91.6%. Finally, the accuracy of the Mentzer index in determining iron deficiency anemia was 78.4%. Diagnostic accuracy was 78.4% and the likelihood ratio was 3.6. Mentzer index is a valuable tool in the early detection of IDA in children. It has got high sensitivity, specificity diagnostic accuracy, and likelihood ratio.

Study of Relationship Between Iron Deficiency and Thyroid Function in Pregnant Females

BACKGROUND

Iron is essential for the normal functioning of thyroid peroxidase and iron deficiency is very commonly encountered during pregnancy. Thyroid disorders and iron deficiency are associated with obstetrical and fetal complications. The aim of the study was to find out the relationship between iron deficiency and thyroid function in pregnant females during first trimester.

METHODOLOGY

 The present cross-sectional observational study was conducted among first trimester pregnant females at the Department of Medicine, Obstetrics and Gynecology, and Biochemistry at Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi. Hundred pregnant women were included in this study. On the basis of serum ferritin value, the study population was divided into two groups namely iron deficient and non-iron deficient. Serum thyroid-stimulating hormone (TSH), FT4, and anti-thyroid peroxidase (TPO) values were then compared between the two groups.

RESULTS

In the present study, 68% of the females were iron deficient. In the Iron deficient group, serum TSH and anti-TPO levels were significantly higher as compared to that in the non-iron deficient group (35.29% vs. 6.25% and 22.06% vs. 3.13%; p=0.001 and 0.018, respectively). A positive correlation was obtained between FT4 and ferritin with correlation coefficient of 0.907 and p-value of 0.0001. Serum TSH levels and serum anti-TPO levels were inversely correlated with ferritin. Univariate logistic regression analysis revealed that iron deficiency was associated with an increased risk of subclinical hypothyroidism with odds ratio (OR) 8.182 (95% CI: 1.798-37.234, p=0.007) and raised anti-TPO with OR 8.77 (95% CI: 1.105-69.681; p=0.040).

CONCLUSIONS

Iron deficiency is frequent during the first trimester of pregnancy and is associated with an increased risk of subclinical hypothyroidism and thyroid autoimmunity.

New Insights into Iron Deficiency Anemia in Children: A Practical Review

Iron deficiency anemia (IDA) is the most frequent hematological disorder in children, with an incidence in industrialized countries of 20.1% between 0 and 4 years of age and 5.9% between 5 and 14 years (39 and 48.1% in developing countries). Although IDA has been recognized for a long time, there are still uncovered issues and room for improving the management of this condition. New frontiers regarding its diagnosis and therapeutic options emerge every day; recently, innovative formulations of iron have been launched, both for oral and parenteral administration, with the aim of offering treatment schedules with higher efficacy and lower toxicity. As a matter of fact, glycinate and liposomal preparations, while maintaining a satisfying efficacy profile, have significantly fewer side effects, in comparison to the traditional elemental iron salts; parenteral iron, usually considered a second-choice therapy reserved to selected cases, may evolve further, as a consequence of the production of molecules with an interesting clinical profile such as ferrocarboxymaltose, which is already available for adolescents aged >14 years. The present article reports the clinically relevant latest insights regarding IDA in children and offers a practical guide to help pediatricians, particularly to choose the most appropriate prevention and therapy strategies.

Iron-deficiency anaemia in childhood: a risk factor for severe venous thrombosis?

Iron deficiency anaemia is a common disorder in the paediatric age-group. The association between iron deficiency and venous thrombosis in children without an underlying illness is rare. Two cases are described. A 17-year-old girl had been taking oestrogen-progestogen therapy for contraception for about 2 years and developed a lower-limb deep vein thrombosis associated with pulmonary embolism. A 3-year-old girl was admitted to the paediatric emergency department with pallor, weakness and vomiting, and a cerebral CT showed a recent cerebral venous thrombosis. Both cases had severe iron-deficiency anaemia which increases a thrombotic tendency and could be a further crucial trigger of venous thrombosis in patients at low risk; therefore, in cases of unexplained thrombosis, it must always be considered to be a risk factor.Abbreviations APCR: activated protein C resistance; CMV: cytomegalovirus; CT: computerised tomography; CVST: cerebral venous sinus thrombosis; CVT: cerebral venous thrombosis; DVT: deep vein thrombosis; DOACs: direct oral anticoagulants; EBV: Epstein-Barr virus; ID: iron deficiency; IDA: iron deficiency anaemia; LMWH: low molecular weight heparin; PE: pulmonary embolism; RDW: red blood cell distribution width; VT: venous thrombosis.

Questions and answers on iron deficiency treatment selection and the use of intravenous iron in routine clinical practice

Iron deficiency is a common cause of morbidity and can arise as a consequence or complication from many diseases. The use of intravenous iron has increased significantly in the last decade, but concerns remain about indications and administration. Modern intravenous iron preparations can facilitate rapid iron repletion in one or two doses, both for absolute iron deficiency and, in the presence of inflammation, functional iron deficiency, where oral iron therapy is ineffective or has not worked. A multidisciplinary team of experts experienced in iron deficiency undertook a consensus review to support healthcare professionals with practical advice on managing iron deficiency in gastrointestinal, renal and cardiac disease, as well as; pregnancy, heavy menstrual bleeding, and surgery. We explain how intravenous iron may work where oral iron has not. We provide context on how and when intravenous iron should be administered, and informed opinion on potential benefits balanced with potential side-effects. We propose how intravenous iron side-effects can be anticipated in terms of what they may be and when they may occur. The aim of this consensus is to provide a practical basis for educating and preparing staff and patients on when and how iron infusions can be administered safely and efficiently. Key messages Iron deficiency treatment selection is driven by several factors, including the presence of inflammation, the time available for iron replenishment, and the anticipated risk of side-effects or intolerance. Intravenous iron preparations are indicated for the treatment of iron deficiency when oral preparations are ineffective or cannot be used, and therefore have applicability in a wide range of clinical contexts, including chronic inflammatory conditions, perioperative settings, and disorders associated with chronic blood loss. Adverse events occurring with intravenous iron can be anticipated according to when they typically occur, which provides a basis for educating and preparing staff and patients on how iron infusions can be administered safely and efficiently.

Examining prescribing practices with respect to oral iron supplementation for post-partum anemia: a retrospective review

PURPOSE

Treatment for post-partum anemia frequently entails oral iron supplementation, but questions remain regarding optimal dosing, frequency, and efficacy. The objective of this study was to describe oral iron prescribing practices in post-partum women delivered via Cesarean section, and identify factors associated with iron supplementation.

METHODS

A retrospective review of Cesarean section deliveries at a single tertiary center between May 2019 and April 2020 was undertaken. Patient demographics, hematological indices, indication for Cesarean section and discharge prescriptions were collected. Univariate and multivariable analyses were performed to identify factors associated with oral iron prescription at discharge.

RESULTS

During the study period, 1470 women were eligible for inclusion. The mean age at delivery was 34.4 ± 4.9 years and mean gestational age was 37.2 ± 3.6 weeks. Most pregnancies (92%) were singleton. Ninety-six total patients (6.5%) received intravenous iron post-partum. Fourteen percent of women (210/1470) received prescriptions for oral iron at discharge, most commonly ferrous fumarate (61.9%, 130/210). The most common dose provided was 300 mg (145/210). Ante-partum ferritin was available for most patients (64.3%, 945/1470), but only for 17 post-partum patients (1.2%). Factors significantly associated with oral iron prescription were earlier gestational age at birth (aOR 0.93, 95% CI 0.89-0.97), history of complications during pregnancy or labor (aOR 1.92, 95% CI 1.26-2.98), higher blood loss (aOR 2.66, 95% CI 1.36-5.44), post-partum anemia (aOR 6.28, 95%-CI 4.41-8.96), blood transfusion (aOR 5.43, 95%-CI 1.81-18.19) and antenatal iron supplementation (aOR 5.70, 95%-CI 4.02-8.17).

CONCLUSIONS

In summary, a relatively small proportion of women following Cesarean section were prescribed oral iron at discharge. We identified several factors associated with post-partum iron supplementation. This information will inform future prospective studies investigating the efficacy of iron supplementation in the treatment of post-partum anemia.

Iron-Deficiency Anemia in an Elderly Caucasian Female: An Unusual Colonoscopic Finding

Iron-deficiency anemia (IDA) is common in the elderly population. It is usually the result of chronic gastrointestinal diseases which could lead to iron losses, malabsorption, or both. IDA is most often the result of chronic gastrointestinal blood loss caused by esophagitis, gastritis, ulcer, colon cancer, pre-malignant polyps, or angiodysplasia. We are presenting a unique case that describes the unusual finding of intestinal helminthiasis in an elderly patient during endoscopic evaluation for IDA. It also touches on the risk factors, clinical manifestations, diagnosis, and treatment of enterobiasis.

Visits to general practitioners after iron-related deferrals from blood donation in middle-aged and older Australian blood donors

BACKGROUND

Australian Red Cross Lifeblood (Lifeblood) advises donors to visit their general practitioner (GP) for medical follow-up if they are deferred from donating due to having a lower than acceptable level of hemoglobin (Hb) and/or serum ferritin (iron-related deferrals).

METHODS

We used the Sax Institute's 45 and Up Study data linked to Lifeblood's donor datasets and other health administrative datasets. We examined the rate of visits to a GP after iron-related deferral from donation, and investigated whether an early visit to a GP (within 30 days following the deferral) had an impact on return to make successful donation within 12, 18, and 24 months compared to a delayed or no GP visit.

RESULTS

A total of 1928 donors underwent iron-related deferral. The rate of visits to a GP in the first month after deferral was double the rate observed a month prior. However, only 52.4% of those deferred visited a GP early with slightly more than half of those receiving an iron-monitoring test. Return to donate over the 24 months was lower in donors visiting their GP early (adjusted Hazard Ratio [aHR] 0.86, 95% CI 0.77-0.97). Early GP visitors were likely to have a relatively poorer health than the delayed or no GP visit group.

CONCLUSIONS

Only half of the donors with an iron-related deferral followed advice from Lifeblood and visited their GP within 30 days of deferral, and these donors have a significantly reduced likelihood of future successful blood donation which may be due to their relatively poorer health status.

The dynamic effects of preoperative intravenous iron in anaemic patients undergoing surgery for colorectal cancer

AIM

The aim of this study was to describe the dynamic changes in blood work following individual adjusted dosage of intravenously administered iron(III) isomaltoside in a 4-week period prior to surgery in patients with colorectal cancer.

METHODS

This was a single-centre, observational cohort study with prospectively collected data, including patients with colorectal cancer receiving preoperative treatment with iron(III) isomaltoside. Blood samples were taken at baseline, 1 week, 2 weeks and 4 weeks after initial treatment. Sixty-two patients were included in the study.

RESULTS

Sixty-two patients were included for final analysis. The mean increase in haemoglobin was 0.77 g/dl (95% CI 0.52-1.03 g/dl, P < 0.0001) at week 1, 1.5 g/dl (95% CI 1.21-1.80 g/dl, P < 0.0001) at week 2 and 2.13 g/dl (95% CI 1.71-2.55 g/dl, P < 0.0001) at week 4. Patients with severe anaemia (<9.02 g/dl) showed the largest increase in haemoglobin during the treatment course (2.92 g/dl, 95% CI 2.27-3.58 g/dl, P < 0.0001). Patients with mild anaemia (>10.31 g/dl) did not show a significant increase (0.66 g/dl, 95% CI -0.29-1.61 g/dl, P = 0.17). The mean of transferrin saturation after 4 weeks was 8% (95% CI 6%-10%, P < 0.0001).

CONCLUSIONS

After intravenously administered iron, patients with severe anaemia had the most substantial increase in haemoglobin, and the increase was largest after 4 weeks. Patients with mild anaemia did not have an increase in haemoglobin during the treatment course. The vast majority of patients still had iron deficiency at surgery 4 weeks after the initial treatment.

Nitric Oxide Prevents Fe Deficiency-Induced Photosynthetic Disturbance, and Oxidative Stress in Alfalfa by Regulating Fe Acquisition and Antioxidant Defense

Iron (Fe) deficiency impairs photosynthetic efficiency, plant growth and biomass yield. This study aimed to reveal the role of nitric oxide (NO) in restoring Fe-homeostasis and oxidative status in Fe-deficient alfalfa. In alfalfa, a shortage of Fe negatively affected the efficiency of root andshoot length, leaf greenness, maximum quantum yield PSII (Fv/Fm), Fe, S, and Zn accumulation, as well as an increase in H₂O₂ accumulation. In contrast, in the presence of sodium nitroprusside (SNP), a NO donor, these negative effects of Fe deficiency were largely reversed. In response to the SNP, the expression of Fe transporters (IRT1, NRAMP1) and S transporter (SULTR1;2) genes increased in alfalfa. Additionally, the detection of NO generation using fluorescence microscope revealed that SNP treatment increased the level of NO signal, indicating that NO may act as regulatory signal in response to SNP in plants. Interestingly, the increase of antioxidant genes and their related enzymes (Fe-SOD, APX) in response to SNP treatment suggests that Fe-SOD and APX are key contributors to reducing ROS (H₂O₂) accumulation and oxidative stress in alfalfa. Furthermore, the elevation of Ascorbate-glutathione (AsA-GSH) pathway-related genes (GR and MDAR) Fe-deficiency with SNP implies that the presence of NO relates to enhanced antioxidant defense against Fe-deficiency stress.

Autophagy Mediates the Degradation of Plant ESCRT Component FREE1 in Response to Iron Deficiency

Multivesicular body (MVB)-mediated endosomal sorting and macroautophagy are the main pathways mediating the transport of cellular components to the vacuole and are essential for maintaining cellular homeostasis. The interplay of these two pathways remains poorly understood in plants. In this study, we show that FYVE DOMAIN PROTEIN REQUIRED FOR ENDOSOMAL SORTING 1 (FREE1), which was previously identified as a plant-specific component of the endosomal sorting complex required for transport (ESCRT), essential for MVB biogenesis and plant growth, can be transported to the vacuole for degradation in response to iron deficiency. The vacuolar transport of ubiquitinated FREE1 protein is mediated by the autophagy pathway. As a consequence, the autophagy deficient mutants, atg5-1 and atg7-2, accumulate more endogenous FREE1 protein and display hypersensitivity to iron deficiency. Furthermore, under iron-deficient growth condition autophagy related genes are upregulated to promote the autophagic degradation of FREE1, thereby possibly relieving the repressive effect of FREE1 on iron absorption. Collectively, our findings demonstrate a unique regulatory mode of protein turnover of the ESCRT machinery through the autophagy pathway to respond to iron deficiency in plants.

Potential of crocodile blood as a medication and dietary supplement: A systemic review

Crocodile blood has long been used as a traditional medicine in many Asian countries to treat diseases such as asthma, allergies, and many others. Yet, only recently has the safety and effectiveness of using crocodile blood as a medicine been examined using modern scientific methods; with both conserved and novel active components identified from crocodile blood. Further in vitro and in vivo investigations found that crocodile blood can have a wide range of beneficial effects, including antimicrobial, antiviral, anti-oxidative, anti-inflammatory, antitumour effects, anti-anaemia, and enhancement of wound healing. A systematic research of literature published in English-language journals up to April 2020 was conducted in PubMed, Google Scholar, and Web of Science. Based on the biological and chemical knowledge of crocodile immunity and crocodile blood, this article aims to: provide a critical review on the proposed properties of crocodile blood, identify the knowledge gap and offer some insights for future investigations regarding the use of crocodile blood as a medication or dietary supplement.

Maternal anemia and preterm birth among women living with HIV in the United States

BACKGROUND

Women living with HIV (WLHIV) have a higher prevalence of anemia than women without HIV, possibly related to the effects of HIV and antiretroviral medications.

OBJECTIVES

To estimate the prevalence of anemia in the third trimester of pregnancy and the effect of anemia on preterm births in WLHIV in the longitudinal, US-based Pediatric HIV/AIDS Cohort Study (PHACS).

METHODS

During the third trimester, we obtained up to three 24-hour dietary recalls to estimate daily intakes of nutrients and measured serum concentrations of iron, vitamin B6, vitamin B12, zinc, folate, ferritin, total iron-binding capacity (TIBC), and high sensitivity C-reactive protein. Third trimester anemia was defined as hemoglobin < 11 g/d and iron-deficiency anemia (IDA) was defined as low ferritin, high TIBC, and low transferrin saturation. A preterm birth was defined as birth at < 37 completed weeks of gestation, regardless of etiology. We fit separate modified Poisson regression models for each outcome (anemia, preterm birth) and each main exposure, adjusted for confounders, and report adjusted prevalence ratios (aPR) and 95% CIs.

RESULTS

Of the 267 WLHIV, 50% were anemic in the third trimester, of whom 43.5% (n = 57/131) had IDA. On average, women with anemia were younger, were more likely to be black, started antiretroviral medications in the second trimester, had a low CD4 count (<200 cells/mm3) early in pregnancy, and were less likely to meet recommended intakes for iron, B6, and folate. The prevalence of anemia was greater in WLHIV with a low CD4 count (aPR = 1.65; 95% CI: 1.20-2.27) and high HIV viral load (>10,000 copies/mL; aPR = 1.38; 95% CI: 1.02-1.87). In total, 16% of women delivered preterm. Anemia was associated with a 2-fold (aPR = 2.04; 95% CI: 1.12-3.71) higher prevalence of preterm births.

CONCLUSIONS

Anemia is common in pregnant WLHIV, highlighting the need to address the underlying factors and clinical outcomes of anemia in this population.

Iron Deficiency Anemia as a Rare Risk Factor for Recurrent Pulmonary Embolism and Deep Vein Thrombosis

Iron deficiency is a well-known cause of anemia. However, it is an under-recognized cause of venous thromboembolism (VTE). Iron deficiency predisposes to VTE mainly by inducing thrombocytosis, which can lead to a hypercoagulable state. Identifying iron deficiency as a possible cause of thromboembolic phenomena has clinical significance since this is a potentially avoidable risk factor. This case report serves as a reminder that iron deficiency is an important risk factor for VTE that should be considered in the evaluation of patients. This is particularly true in patients like ours who have recurrent venous thromboembolic disease.

Relationship between Down-Regulation of Copper-Related Genes and Decreased Ferroportin Protein Level in the Duodenum of Iron-Deficient Piglets

In mammals, 2 × 10¹² red blood cells (RBCs) are produced every day in the bone marrow to ensure a constant supply of iron to maintain effective erythropoiesis. Impaired iron absorption in the duodenum and inefficient iron reutilization from senescent RBCs by macrophages contribute to the development of anemia. Ferroportin (Fpn), the only known cellular iron exporter, as well as hephaestin (Heph) and ceruloplasmin, two copper-dependent ferroxidases involved in the above-mentioned processes, are key elements of the interaction between copper and iron metabolisms. Crosslinks between these metals have been known for many years, but metabolic effects of one on the other have not been elucidated to date. Neonatal iron deficiency anemia in piglets provides an interesting model for studying this interplay. In duodenal enterocytes of young anemic piglets, we identified iron deposits and demonstrated increased expression of ferritin with a concomitant decline in both Fpn and Heph expression. We postulated that the underlying mechanism involves changes in copper distribution within enterocytes as a result of decreased expression of the copper transporter—Atp7b. Obtained results strongly suggest that regulation of iron absorption within enterocytes is based on the interaction between proteins of copper and iron metabolisms and outcompetes systemic regulation.

Root Silicon Addition Induces Fe Deficiency in Cucumber Plants, but Facilitates Their Recovery After Fe Resupply. A Comparison With Si Foliar Sprays

Silicon has not been cataloged as an essential element for higher plants. However, it has shown beneficial effects on many crops, especially under abiotic and biotic stresses. Silicon fertilization was evaluated for the first time on plants exposed to fluctuations in an Fe regime (Fe sufficiency followed by Fe deficiency and, in turn, by Fe resupply). Root and foliar Si applications were compared using cucumber plants that were hydroponically grown in a growth chamber under different Fe nutritional statuses and Si applied either to the roots or to the shoots. The SPAD index, Fe, and Mn concentration, ROS, total phenolic compounds, MDA concentration, phytohormone balance, and cell cycle were determined. The results obtained showed that the addition of Si to the roots induced an Fe shortage in plants grown under optimal or deficient Fe nutritional conditions, but this was not observed when Si was applied to the leaves. Plant recovery following Fe resupply was more effective in the Si-treated plants than in the untreated plants. A relationship between the ROS concentration, hormonal balance, and cell cycle under different Fe regimes and in the presence or absence of Si was also studied. The contribution of Si to this signaling pathway appears to be related more to the induction of Fe deficiency, than to any direct biochemical or metabolic processes. However, these roles could not be completely ruled out because several hormone differences could only be explained by the addition of Si.

A Scoping Review of the Risk Factors Associated with Anaemia among Children Under Five Years in Sub-Saharan African Countries

Background/Purpose: Globally, anaemia is a severe public health condition affecting over 24% of the world’s population. Children under five years old and pregnant women are the most vulnerable to this disease. This scoping review aimed to evaluate studies that used classical statistical regression methods on nationally representative health survey data to identify the individual socioeconomic, demographic and contextual risk factors associated with developing anaemia among children under five years of age in sub-Saharan Africa (SSA). Methods/Design: The reporting pattern followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. The following databases were searched: MEDLINE, EMBASE (OVID platform), Web of Science, PUBMED, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Scopus, Cochrane library, African Journal of online (AJOL), Google Scholar and Measure DHS. Results: The review identified 20 relevant studies and the risk factors for anaemia were classified as child-related, parental/household-related and community- or area-related factors. The risk factors for anaemia identified included age, birth order, sex, comorbidities (such as fever, diarrhoea and acute respiratory infection), malnutrition or stunting, maternal education, maternal age, mother’s anaemia status, household wealth and place of residence. Conclusion: The outcome of this review is of significant value for health policy and planners to enable them to make informed decision that will correct any imbalances in anaemia across socioeconomic, demographic and contextual characteristics, with the view of making efficient distributions of health interventions.

Unraveling the Mysteries of Restless Leg Syndrome

Restless leg syndrome (RLS) or Willis-Ekbom disease (WED) is an under-diagnosed, chronic, and progressive primary sensory-motor disorder. It is characterized by an uncontrollable urge to move the legs due to uncomfortable and sometimes painful sensations, with a diurnal variation. RLS can lead to severe sleep disturbances, a usual cause of consultation. The pathophysiology is known partially, and it is believed that there is an association between the different variants of genetic mutations combined with dopaminergic and brain iron dysregulation, which plays an important role. The data used for this study were extracted from the articles found in the PubMed database that discuss different gene variants, pathophysiology, and various methods of treatment. They also highlight the role of iron in the pathogenesis of RLS as it is required for the synthesis of tyrosine hydroxylase, which is the rate-limiting step for dopamine synthesis. This review article provides a clinically useful overview of RLS in terms of pathophysiological findings, its genetic associations, and therapeutic options by using the currently available literature. Because RLS presents with vague symptoms and shares similarities with many other diseases, it might be overlooked by many physicians resulting in underdiagnosis and under-treatment. While these discoveries provide a breakthrough in understanding the details of RLS, further studies are recommended as these studies are limited to animal models and provide a limited representation of the general population.

Annual Prevalence, Health Expenditures, and Co-Morbidities Trend of Iron Deficiency Anemia in Korea: National Health Insurance Service Data from 2002 to 2013

Despite improvements in nutritional status, iron deficiency anemia (IDA) remains a debilitating nutritional problem worldwide. We estimate annual IDA prevalence rates by sex and age and the trends therein in Korea. We also calculate the health expenditures of IDA and its co-morbidities by analyzing claims data in the National Health Information Database from 2002 to 2013. All analyses were performed based on diagnosis codes of IDA (D50, D50.0, D50.8, and D50.9) regardless of whether IDA was the principal or a coexisting disease. Trends in IDA prevalence rates were evaluated by calculating annual percent changes (APCs) in prevalence. The health expenditures of IDA were calculated based on the direct medical costs (outpatient and hospitalization costs, pharmaceutical costs) and direct non-medical costs (travel costs). The overall IDA prevalence in both sexes increased approximately 2.3-fold from 2002 to 2013; the APC was +7.6%. In females, the prevalence of IDA was highest in aged 30–39 and 40–49 years. The APC was highest in those aged <10 years (+18.2%), followed by those aged ≥80 (+14.7%) and 70–79 (+9.8%) years. In males, the prevalence rates were highest in aged <10 years, followed by those aged ≥60 years. The APC was highest in those aged <10 years (+19.1%), followed by those aged ≥80 years (+10.5%). The total health expenditures increased 2.8-fold during 12 years. Diseases of the respiratory or gastrointestinal tract were the most prevalent co-morbidities in both males and females. The annual prevalence of IDA continues to rise in association with adverse health expenditures and co-morbidities in spite of improvements in nutritional status. Most importantly, infants and young children, the elderly, and females aged 30–49 years are at highest risk of IDA. A national, prospective, and well-organized effort to improve iron status and to manage IDA is required.

Role of RDW in mathematical formulas aiding the differential diagnosis of microcytic anemia

Many mathematical formulas containing simple red blood cell parameters have been proposed for differentiating between iron deficiency and thalassemia in patients with microcytic anemia. Approximately half of these formulas do include red cell distribution width (RDW), along with other red cell parameters. In the present study we investigated the role of RDW, expressed in relative or in absolute units in relation with the formulas' discriminant performance. We used a database containing over 2200 subjects with microcytic anemia, for whom a final diagnosis (iron-deficiency anemia, thalassemia, both or other) was available. Performance of the discriminant formulas was assessed by Receiver Operator Curve analysis. Substitution of relative by absolute RDW resulted in statistically significant performance increase (area under the ROC curve) in 16 out of 23 formulas, predominantly due to increased specificity. Relevant performance deterioration was seen in only three formulas that had low initial performance already with the original relative RDW. For optimal differential diagnostic performance, an RDW-based formula for distinguishing thalassemia from iron-deficiency anemia in microcytic anemia should contain 'absolute' instead of relative RDW.

The Impact of Iron Supplementation for Treating Anemia in Patients with Chronic Kidney Disease: Results from Pairwise and Network Meta-Analyses of Randomized Controlled Trials

After relative erythropoietin deficiency, iron deficiency is the second most important contributing factor for anemia in chronic kidney disease (CKD) patients. Iron supplementation is a crucial part of the treatment of anemia in CKD patients, and intravenous (IV) iron supplementation is considered to be superior to per os (PO) iron supplementation. The differences between the available formulations are poorly characterized. This report presents results from pairwise and network meta-analyses carried out after a comprehensive search in sources of published and unpublished studies, according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) recommendations (International prospective register of systematic reviews PROSPERO reference ID: CRD42020148155). Meta-analytic calculations were performed for the outcome of non-response to iron supplementation (i.e., hemoglobin (Hgb) increase of <0.5–1.0 g/dL, or initiation/intensification of erythropoiesis-stimulating agent (ESA) therapy, or increase/change of iron supplement, or requirements of blood transfusion). A total of 34 randomized controlled trials (RCT) were identified, providing numerical data for analyses covering 93.7% (n = 10.097) of the total study population. At the network level, iron supplementation seems to have a more protective effect against the outcome of non-response before the start of dialysis than once dialysis is initiated, and some preparations seem to be more potent (e.g., ferumoxytol, ferric carboxymaltose), compared to the rest of iron supplements assessed (surface under the cumulative ranking area (SUCRA) > 0.8). This study provides parameters for adequately following-up patients requiring iron supplementation, by presenting the most performing preparations, and, indirectly, by making it possible to identify good responders among all patients treated with these medicines.

The Effect of Lactobacillus plantarum 299v on Iron Status and Physical Performance in Female Iron-Deficient Athletes: A Randomized Controlled Trial

Iron is an essential micronutrient for oxygen transport and mitochondrial metabolism and is critical for physical performance. Compromised iron stores are more commonly found among athletes, and females are especially at risk. Iron deficiency is generally treated using oral iron supplements. However, only a small proportion of ingested iron is absorbed, necessitating higher intakes, which may result in adverse side effects, reduced compliance, and inefficient repletion of iron stores. The probiotic strain Lactobacillus plantarum 299v (Lp299v) significantly increases intestinal iron absorption in meal studies. The present study was conducted to explore the effects of 20 mg of iron with or without Lp299v on iron status, mood state, and physical performance. Fifty-three healthy non-anemic female athletes with low iron stores (ferritin < 30 μg/L) were randomized, and 39 completed the study. Intake of Lp299v with iron for four weeks increased ferritin levels more than iron alone (13.6 vs. 8.2 µg/L), but the difference between the groups was not significant (p = 0.056). The mean reticulocyte hemoglobin content increased after intake of Lp299v compared to control (1.5 vs. 0.82 pg) after 12 weeks, but the difference between the group was not significant (p = 0.083). The Profile of Mood States (POMS) questionnaire showed increased vigor with Lp299v vs. iron alone after 12 weeks (3.5 vs. 0.1, p = 0.015). No conclusive effects on physical performance were observed. In conclusion, Lp299v, together with 20 mg of iron, could result in a more substantial and rapid improvement in iron status and improved vigor compared to 20 mg of iron alone. A larger clinical trial is needed to further explore these findings as well as the impact of Lp299v on physical performance.

Simplified diagnostic algorithm for classification of preoperative anaemia based on complete blood count and its application in elective gastrointestinal surgery

Introduction Anaemia is associated with increased morbidity, mortality, length of stay, requirement for blood transfusion. Early differential diagnosis of anaemia may expedite treatment and outcome in the perioperative setting. The aim of our study was to create simplified diagnostic algorithm for classification of anaemia based on complete blood count and test its applicability in elective gastrointestinal surgical population. Material and methods Selected red blood cell (RBC) parameters derived from CBC test performed by the Central Laboratory of the University Clinical Centre of Medical University of Silesia, Katowice, Poland were reviewed retrospectively for the group of 442 consecutive patients scheduled for elective, high-risk (according to) GI surgery between January 2016 and August 2018. Based on pathophysiologic data we created a simplified diagnostic algorithm for classification of preoperative anaemia and applied it to the study population. Results Using the cut-off value of 130 g L-1 for both sexes, anaemia was diagnosed in 166 patients (37.5%). As many as 29 (17.5%) anaemic patients had aetiology of anaemia accurately established by using our simplified diagnostic algorithm - either iron or vitamin B12/folate deficiency. Discussion Preoperative anaemia is common in elective gastrointestinal surgery. Simplified diagnostic algorithm based solely on complete blood count parameters might be helpful in the preliminary identification of patients with iron and vitamin B12/folic acid deficiencies so haematinic supplementation can be started early.

Cost-effectiveness analysis of ferric carboxymaltose in pre-operative haemoglobin optimisation in patients undergoing primary knee arthroplasty

BACKGROUND

An analytic-decision model was built to estimate the cost-effectiveness of using ferric carboxymaltose for pre-operative haemoglobin optimisation in patients with iron deficiency anaemia undergoing primary knee arthroplasty.

MATERIALS AND METHODS

We simulated 20,000 patients who were randomly assigned to the haemoglobin optimisation arm or the non-optimisation control arm in a strict 1:1 ratio. The main outcomes were cost per patient transfusion avoided and red blood cell units spared. The analyses were performed from the hospital perspective with length of stay as the time horizon.

RESULTS

In the reference case scenario, pre-operative haemoglobin optimisation led to fewer patients being exposed to allogeneic red blood cell transfusion (2,212 vs 6,595 out of 10,000 patients) and a relevant decrease in the number of red blood cell units transfused (4.342 vs 13.336). The costs of avoiding one patient transfusion and sparing one red blood cell unit were € 831 and € 405, respectively. Increased costs in the optimisation arm were mostly associated with the outpatient day hospital visit (54%) and ferric carboxymaltose treatment (40%).

DISCUSSION

In primary knee arthroplasty, pre-operative haemoglobin optimisation with intravenous ferric carboxymaltose is less expensive than other reported patient blood management modalities and must be considered in patients with iron deficiency anaemia.

Nitric oxide regulates lateral root formation through modulation of ACC oxidase activity in sunflower seedlings under salt stress

Nitric oxide (NO) is established as a modulator of various developmental processes in plants through its interaction with multiple enzymatic and non-enzymatic biomolecules. Lateral root (LR) induction and extension in sunflower (Helianthus annuus L.) has been observed to be governed by a probable crosstalk between NO and ethylene biosynthesizing enzyme-ACC oxidase. NaCl (120 mM) stress not only lowers LR induction but also reduces their extension growth. Quenching of endogenous NO by raising seedlings in presence of 40 µM hemoglobin in the growth medium does not affect LR induction but lowers their extension growth. NaCl stress and NO depletion have additive effects on the enhancement of ACC oxidase activity, leading to enhanced ethylene biosynthesis. Role of NO has been further confirmed by raising sunflower seedlings in the presence of 20-60 µM of two NO donors, sodium nitroprusside (SNP) and diethylenetriamine NONOate (DETA). LR extension growth was higher with DETA than SNP as NO donor at 40 µM. Iron-deficiency also promoted LR proliferation. It also significantly lowered ACC oxidase activity in the seedling roots in response to salt stress. Based on the present findings it is proposed that salt stress-mediated LR proliferation is regulated by NO through its binding with ACC oxidase (an iron-containing enzyme). This results in the formation of a stable ternary complex (ACC-ACC oxidase-NO) which leads to the reduction in ethylene biosynthesis. Lesser availability of ethylene consequently brings about enhanced LR formation.

In rats gestational iron deficiency does not change body fat or hepatic mitochondria in the aged offspring

Mitochondrial dysfunction and resulting changes in adiposity have been observed in the offspring of animals fed a high fat (HF) diet. As iron is an important component of the mitochondria, we have studied the offspring of female rats fed complete (Con) or iron-deficient (FeD) rations for the duration of gestation to test for similar effects. The FeD offspring were ~12% smaller at weaning and remained so because of a persistent reduction in lean tissue mass. The offspring were fed a complete (stock) diet until 52 weeks of age after which some animals from each litter were fed a HF diet for a further 12 weeks. The HF diet increased body fat when compared with animals fed the stock diet, however, prenatal iron deficiency did not change the ratio of fat:lean in either the stock or HF diet groups. The HF diet caused triglyceride to accumulate in the liver, however, there was no effect of prenatal iron deficiency. The activity of the mitochondrial electron transport complexes was similar in all groups including those challenged with a HF diet. HF feeding increased the number of copies of mitochondrial DNA and the prevalence of the D-loop mutation, however, neither parameter was affected by prenatal iron deficiency. This study shows that the effects of prenatal iron deficiency differ from other models in that there is no persistent effect on hepatic mitochondria in aged animals exposed to an increased metabolic load.

Phase III randomized trial comparing intravenous to oral iron in patients with cancer-related iron deficiency anemia not on erythropoiesis stimulating agents

AIM

We aimed to find the optimal route of iron supplementation in patients with malignancy and iron deficiency (true or functional) anemia not receiving erythropoiesis stimulating agents (ESA).

METHODS

Adult patients with malignancy requiring chemotherapy, hemoglobin (Hb) <12 g/dL and serum ferritin <100 mcg/mL, transferrin saturation <20% or hypochromic red blood cells >10% were randomized to intravenous (IV) iron sucrose or oral ferrous sulfate. The primary endpoint was change in Hb from baseline to 6 weeks. Secondary endpoints included blood transfusion, quality of life (QoL), toxicity, response and overall survival.

RESULTS

A total of 192 patients were enrolled over 5 years: 98 on IV arm and 94 on oral arm. Median age was 51 years; over 95% patients had solid tumors. The mean absolute increase in Hb at 6 weeks was 0.11 g/dL (standard deviation [SD]: 1.48) in IV arm and -0.16 g/dL (SD: 1.36) in oral arm, P = 0.23. Twenty-three percent patients on IV iron and 18% patients on oral iron had a rise in Hb of ≥1 g/dL at 6 weeks, P = 0.45. Thirteen patients (13.3%) on the IV iron arm and 14 patients (14.9%) on the oral arm required blood transfusion, P = 1.0. Gastrointestinal toxicity (any grade) developed in 41% patients on IV iron and 44% patients on oral iron, P = 1.0. 5 patients on IV iron and none on oral iron had hypersensitivity, P = 0.06. QoL was not significantly different between the two arms.

CONCLUSION

IV iron was not superior to oral iron in patients with malignancy on chemotherapy and iron deficiency anemia.

Comparison of the Efficacies of Parenteral Iron Sucrose and Oral Iron Sulfate for Anemic Patients with Inflammatory Bowel Disease in Korea

BACKGROUND/AIMS

The optimal route for iron administration in anemic patients with inflammatory bowel disease (IBD) has not been determined. The aim of this study was to compare the efficacies of parenteral and oral iron therapy in IBD patients in Korea.

METHODS

A retrospective multicenter study was performed. Patients who had been administered parenteral iron were matched to the controls with oral iron at a 1:1 ratio according to age, sex, and type of IBD.

RESULTS

Patients that received parenteral iron exhibited increases in hemoglobin levels of ≥20% from the baseline at lower doses and in shorter durations (p=0.034 and p=0.046, respectively). In the multivariate analysis, parenteral iron therapy appeared to be more efficient than oral iron therapy, but this difference was not statistically significant (hazard ratio [HR], 1.552; 95% confidence interval [CI], 0.844 to 2.851; p=0.157). Patients with ulcerative colitis responded better to iron therapy than those with Crohn's disease (HR, 3.415; 95% CI, 1.808 to 6.450; p<0.001). Patients with an initial hemoglobin level of 10 g/dL or higher responded poorly to iron therapy (HR, 0.345; 95% CI, 0.177 to 0.671; p=0.002).

CONCLUSIONS

Parenteral iron therapy appears to be more efficient than oral iron therapy. Physicians should focus on the iron deficiency of IBD patients and consider parenteral iron supplements in appropriate patient groups.

A Survey of Iron Supplementation Consumption and its Related Factors in High School Students in Southeast Iran, 2015

BACKGROUND

This study aimed to estimate the prevalence of iron supplement consumption and its associated factors among high school students in Iran.

METHODS

A mixed-methods (quantitative-qualitative) study was conducted in Zahedan, southeast Iran, in 2015. The sample comprised 400 high school students from different areas of Zahedan who were randomly selected. A standard questionnaire and semi-structured interview were used to collect data in the quantitative and qualitative phases, respectively. The data were analysed using SPSS software with one-way ANOVA and Pearson's chi square. Additionally, content analysis was used for the qualitative analysis.

RESULTS

In total, 38.2% of the students had not consumed iron supplements in the past 16 weeks, and students in third grade had the highest non-consumption rate (P=0.006). There was a significant positive relationship between iron tablet consumption and grade point average in the last year (P = 0.003). Digestive problems, influence of family and friends, students' reluctance, and poor environmental situations were the most important factors related to students' refusal to take tablets.

CONCLUSIONS

Most students did not take or irregularly consumed iron supplements. Based on the digestive problems of the students, improving the taste and quality of iron tablets is recommended.

Response of Iron Deficiency Anemia to Intravenous Iron Sucrose in Pediatric Inflammatory Bowel Disease

OBJECTIVES

The objective of this retrospective study was to evaluate the safety and efficacy of intravenous iron sucrose (IS) in iron deficient children with inflammatory bowel disease (IBD) in remission.

METHODS

Electronic medical records at a university based pediatric children's hospital were searched for patients in age range 0 to 18 years with diagnosis of IBD and treatment with IS over a 1-year period. Response to IS treatment was assessed by posttreatment changes in ferritin, hemoglobin (Hb), and mean corpuscular volume (MCV). Patients with recorded symptoms of active disease were excluded from analysis of treatment response.

RESULTS

Twelve patients were identified by the search criteria, 10 with Crohn's disease (CD), 2 with ulcerative colitis (UC). Data represent 8 patients in remission, 7 with CD and 1 with UC, who received a total of 34 IS infusions. Iron sucrose was administered in cycles of 2 infusions, 2.5 to 3.5 mg/kg/dose (maximum 200 mg), 1 week apart. Mean ferritin increased from 21.4 ± 9.2 to 52.9 ± 10.1 ng/mL (p = 0.0005), Hb from 10.9 ± 0.4 to 11.3 ± 0.3 g/dL (p = 0.02), and MCV from 76.9 ± 2 to 79.4 ± 2 fl (p = 0.006). Iron sucrose treatment normalized ferritin in 6 of 7, Hb in 2 of 8, and MCV in 2 of 5 patients with low pretreatment levels. No adverse effects were recorded.

CONCLUSIONS

Two IS infusions of 2.5 to 3.5 mg/kg/dose (maximum 200 mg), given 1 week apart normalized ferritin levels in most pediatric IBD patients in remission without adverse effects. Further studies are needed to determine optimal dosing schedules.

Ferric carboxymaltose in patients with iron-deficiency anemia and impaired renal function: the REPAIR-IDA trial

BACKGROUND

Iron-deficiency anemia in non-dialysis-dependent chronic kidney disease (NDD-CKD) frequently requires parenteral iron replacement, but existing therapies often require multiple administrations. We evaluated the efficacy and cardiovascular safety of ferric carboxymaltose (FCM), a non-dextran parenteral iron permitting large single-dose infusions, versus iron sucrose in patients with iron-deficiency anemia and NDD-CKD.

METHODS

A total of 2584 participants were randomized to two doses of FCM 750 mg in one week, or iron sucrose 200 mg administered in up to five infusions in 14 days. The primary efficacy endpoint was the mean change to highest hemoglobin from baseline to Day 56. The primary composite safety endpoint included all-cause mortality, nonfatal myocardial infarction, nonfatal stroke, unstable angina, congestive heart failure, arrhythmias and hyper- and hypotensive events.

RESULTS

The mean hemoglobin increase was 1.13 g/dL in the FCM group and 0.92 g/dL in the iron sucrose group (95% CI, 0.13-0.28). Similar results were observed across all subgroups, except Stage 2 CKD. More subjects in the FCM group achieved a hemoglobin increase of ≥ 1.0 g/dL between baseline and Day 56 (48.6 versus 41.0%; 95% CI, 3.6-11.6%). There was no significant difference between FCM and iron sucrose recipients with respect to the primary composite safety endpoint, including the major adverse cardiac events of death, myocardial infarction, or stroke. A significant difference in the number of protocol-defined, predominantly transient hypertensive episodes was observed in the FCM group.

CONCLUSIONS

Two 750-mg infusions of FCM are a safe and effective alternative to multiple lower dose iron sucrose infusions in NDD-CKD patients with iron-deficiency anemia.

Association of anaemia in primary care patients with chronic kidney disease: cross sectional study of quality improvement in chronic kidney disease (QICKD) trial data

BACKGROUND

Anaemia is a known risk factor for cardiovascular disease and treating anaemia in chronic kidney disease (CKD) may improve outcomes. However, little is known about the scope to improve primary care management of anaemia in CKD.

METHODS

An observational study (N = 1,099,292) with a nationally representative sample using anonymised routine primary care data from 127 Quality Improvement in CKD trial practices (ISRCTN5631023731). We explored variables associated with anaemia in CKD: eGFR, haemoglobin (Hb), mean corpuscular volume (MCV), iron status, cardiovascular comorbidities, and use of therapy which associated with gastrointestinal bleeding, oral iron and deprivation score. We developed a linear regression model to identify variables amenable to improved primary care management.

RESULTS

The prevalence of Stage 3-5 CKD was 6.76%. Hb was lower in CKD (13.2 g/dl) than without (13.7 g/dl). 22.2% of people with CKD had World Health Organization defined anaemia; 8.6% had Hb ≤ 11 g/dl; 3% Hb ≤ 10 g/dl; and 1% Hb ≤ 9 g/dl. Normocytic anaemia was present in 80.5% with Hb ≤ 11; 72.7% with Hb ≤ 10 g/dl; and 67.6% with Hb ≤ 9 g/dl; microcytic anaemia in 13.4% with Hb ≤ 11 g/dl; 20.8% with Hb ≤ 10 g/dl; and 24.9% where Hb ≤ 9 g/dl. 82.7% of people with microcytic and 58.8% with normocytic anaemia (Hb ≤ 11 g/dl) had a low ferritin (<100 ug/mL). Hypertension (67.2% vs. 54%) and diabetes (30.7% vs. 15.4%) were more prevalent in CKD and anaemia; 61% had been prescribed aspirin; 73% non-steroidal anti-inflammatory drugs (NSAIDs); 14.1% warfarin 12.4% clopidogrel; and 53.1% aspirin and NSAID. 56.3% of people with CKD and anaemia had been prescribed oral iron. The main limitations of the study are that routine data are inevitably incomplete and definitions of anaemia have not been standardised.

CONCLUSIONS

Medication review is needed in people with CKD and anaemia prior to considering erythropoietin or parenteral iron. Iron stores may be depleted in over >60% of people with normocytic anaemia. Prescribing oral iron has not corrected anaemia.

Accuracy of erythrogram and serum ferritin for the maternal anemia diagnosis (AMA): a phase 3 diagnostic study on prediction of the therapeutic responsiveness to oral iron in pregnancy

BACKGROUND

Pregnancy anemia remains as a public health problem, since the official reports in the 70's. To guide the treatment of iron-deficiency anemia in pregnancy, the haemoglobin concentration is the most used test in spite of its low accuracy, and serum ferritin is the most reliable test, although its cutoff point remains an issue.

METHODS/DESIGN

The aim of this protocol is to verify the accuracy of erythrocyte indices and serum ferritin (studied tests) for the diagnosis of functional iron-deficiency in pregnancy using the iron-therapy responsiveness as the gold-standard. This is an ongoing phase III accuracy study initiated in August 2011 and to be concluded in April 2013. The subjects are anemic pregnant women (haemoglobin concentration < 11.0 g/dL) attended at a low-risk prenatal care center in the Northeast of Brazil. The sample size (n 278) was calculated to estimate sensitivity of 90% and 80% of specificity with relative error of 10% and power of 95%. This study has a prospective design with a before-after intervention of 80 mg of daily oral iron during 90 days and will be analyzed as a delayed-type cross-sectional study. Women at the second trimester of pregnancy are being evaluated with clinical and laboratorial examinations at the enrollment and monthly. The 'responsiveness to therapeutic test with oral iron' (gold-standard) was defined to an increase of at least 0.55 Z-score in haemoglobin after 4 weeks of treatment and a total dose of 1200 mg of iron. At the study conclusion, sensitivities, specificities, predictive values, likelihood ratios and areas under the ROC (Receiver Operating Characteristic) curves of serum ferritin and erythrocyte indices (red blood cell count, haematocrit, haemoglobin concentration, mean corpuscular volume, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration, red blood cell distribution width, reticulocyte count) will be tested. The compliance and adverse effects are considered confounding variables, since they are the main obstacles for the iron-therapy responsiveness.

DISCUSSION

This study protocol shows a new approach on iron-deficiency anemia in pregnancy from a functional point of view that could bring some insights about the diagnostic misclassifications arising from the dynamic physiologic changes during the gestational cycle.

TRIAL REGISTRATION

WHO International Clinical Trials Registry Platform U1111-1123-2605.

Anaemia investigation in practice: inappropriate, cost inefficient with a risk of missing gastrointestinal cancer. Can we improve?

Iron-deficiency anaemia (IDA) is often inappropriately investigated. This study aimed to improve referrals, estimate cost implications and determine effectiveness of referral criteria for diagnosing cancer. Patients referred for investigation of anaemia were studied. IDA was defined as haemoglobin < 12.5 g/dl (M) and < 11.5 g/dl (F), with ferritin <15 ng/l (if normal erythrocyte sedimentation rate) or mean corpuscular volume <76 fl. After referral form redesign/trust education, data were recollected. Sixty-six of 118 referred patients had non-IDA with annual cost of inappropriate referrals pounds 176,840. The haematology database identified 37 patients (30 F) with uninvestigated IDA (lost revenue pounds 120,254). After changes, 43/103 referred patients had non-IDA (p < 0.05), with an annual saving of pounds 72,600. Fourteen of 112 patients with IDA had cancer versus 4/109 non-IDA (p < 0.025), overall prevalence 8.1%. Many referrals for anaemia investigation are inappropriate and a 35% reduction was achieved. The sensitivity and negative predictive value of the referral criteria for diagnosing gastrointestinal cancer were 77.8% and 96.3% respectively.

Exochelin production in Mycobacterium neoaurum

Mycobacterium neoaurum is a soil saprophyte and obligate aerobic bacterium. This group of mycobacterium is relatively fast-growing. They form colonies on nutrient agar at 37ºC within 3 – 4 days. In natural soil habitats, bioavailability of iron is limited. To facilitate iron uptake, most mycobacteria produce siderophores. One example is exochelin, which is extracellular and water-soluble. In this report, the production of exochelin in M. neoaurum was induced in iron-deficiency, but repressed under ironsufficiency growth conditions. It is however not induced under zinc-deficiency growth conditions. The growth of this mycobacterium was correlated with exochelin secretion under iron-deficiency culture conditions. When M. neoaurum was grown in defined medium containing 0.04 μg Fe(III)/mL (final concentration), the production of exochelin reached a maximum and the corresponding cell growth was comparable to that under iron-sufficiency conditions. In this study, exochelin was purified from spent supernatant of M. neoaurum by semi-preparative chromatography. When saturated ferric chloride solution was added into the purified exochelin, a ferri-exochelin complex was formed. It is proposed that iron uptake in M. neoaurum is exochelin-mediated.

Dietary intake and anthropometric status differ for anaemic and non-anaemic rural South African infants aged 6-12 months

The study was undertaken to determine anthropometric measurements, sociodemographic data, and dietary intake of 238 anaemic and 241 non-anaemic rural South African infants aged 6-12 months. Logistic regression with anaemia as a dependent variable showed an odds ratio (OR) of 1.89 (95% confidence interval [CI] 1.01-3.52) for low birth-weight, 2.04 (CI 1.29-3.22) for maternal age 20 years or younger, 2.21 (CI 1.29-3.76) for consumption of tea, and 0.40 (CI 0.26-0.63) for formula feeding. The anaemic infants, aged 6- < 9 months, had a lower average weight gain per month than the non-anaemic infants (727 g vs 772 g; p = 0.040, analysis of variance). Logistic regression with underweight as a dependent variable showed an OR of 3.55 (CI 1.26-10.01) for anaemia, and with stunting as a dependent variable, the OR was 2.71 (CI 1.46-5.02). Low birth-weight, a young mother aged 20 years or younger, and consumption of tea were identified as risk factors for anaemia, while formula feeding was shown to have a protective effect. The anaemic infants were more likely to show growth faltering.

Cocaine, anemia, and neurodevelopmental outcomes in children: a longitudinal study

This longitudinal study investigated the rates of iron-deficiency (ID) and iron-deficiency anemia (IDA) among prenatally cocaine-exposed and nonexposed two- and four-year-old children and assessed their relationships to neurodevelopmental outcomes. The sample consisted of 143 two-year-old (70 exposed and 73 nonexposed) and 274 four-year-old (139 exposed and 135 nonexposed) low socioeconomic status children recruited from an ongoing longitudinal study. Hematological assessments included hemoglobin, serum ferritin, mean corpuscular volume, transferrin saturation, and blood lead levels. The neurodevelopmental outcomes consisted of the Bayley Mental (MDI) and Motor (PDI) Development indices at two years, and the Wechsler Preschool and Primary Scales of Intelligence (WPPSI) and the Peabody Developmental Motor Scales (PDMS) at four years. The rate of IDA in four-year-old children was significantly greater among the cocaine-exposed compared to the nonexposed group (p =.026), while the rates at two years were not significant. Exposure to IDA at two years was associated with a significant decrease in concurrent motor scores (p =.011) after adjustment for relevant covariates. Peak exposure to IDA, defined as being anemic at 2 and/or 4 years of age, was associated with a significant (p <.05) decrease in Full Scale IQ after adjustment. Cocaine exposure was not a significant predictor of Full Scale IQ with the inclusion of peak IDA and lead in the model. These findings indicate the need for greater pediatric surveillance of IDA and lead in cocaine-exposed infants, in order to reduce long-term neuropsychological deficits.

Iron-deficiency specifically limits nodule development in peanut inoculated with Bradyrhizobium sp

Severely iron-deficient peanuts (Arachis hypogaaea L.) grown on calcareous soils in central Thailand failed to nodulate until given foliar iron applications. Glasshouse experiments were conducted on two cultivars (Tainan 9 and Robut 33-1) to identify which stage of the nodule symbiosis was most sensitive to iron-deficiency. Iron-deficiency did not limit growth of soil or rhizosphere populations of peanut liradyrhizobium. Similar numbers of root nodule initials formed in the roots of both control and iron-sprayed plants, showing that iron-deficiency did not directly affect root infection and nodule initiation. Plants sprayed with iron produced greater numbers of excisable nodules and carried a greater nodule mass than untreated plants. Five days after iron application, nodules on sprayed plants of CV. Tainan 9 contained 200-fold higher bacteroid numbers per unit weight and 14-fold higher concentrations of leghaemoglobain. The onset of nitrogenase activity was also delayed by iron deficiency in both cultivars. Tainan 9 appeared more sensitive to iron-deficiency than Robut 33-1 in terms of nodule mass produced, but both cultivars showed the same effect of iron-deficiency on nitrogenase activity per plant. It is concluded that the failure of the infecting rhizobia to obtain adequate amounts of iron from the plant results in arrested nodule development and a failure of nitrogen fixation.