Iron deficiency anaemia: a review of diagnosis, investigation and management

Iron deficiency anemia and its association with cognitive function among adolescents in the Ashanti Region - Ghana

BACKGROUND

Iron deficiency anemia (IDA) remains a global health concern, and has been associated with cognitive decline. However, very few studies have explored the association between IDA and cognitive function among Ghanaians. We assessed the association between IDA and cognitive function among adolescents in the Ashanti region, Ghana.

METHODS

This cross-sectional study involved 250 adolescents from Kumasi, Ghana. Sociodemographic and dietary data were obtained using a well-structured questionnaire. Blood samples were drawn for estimation of ferritin and complete blood count. The Test of Non-verbal Intelligence (TONI-4) was used to assess cognitive function. Binary logistic regression was used to determine the predictors of cognitive function.

RESULTS

The prevalence of IDA was 30.4%, which was higher among adolescents with poor cognitive performance test scores (CPTS) (71%). Being female [aOR = 0.32, 95% CI (0.10-0.99), p = 0.0480)], father having junior high education [aOR = 0.08, 95% CI (0.02-0.45), p = 0.0040)], being in a category B school [aOR = 0.26, 95% CI (0.09-0.81), p = 0.0200)] and C [aOR = 0.08, 95% CI (0.02-0.40), p = 0.0020)] and non-fruit consumption [aOR = 0.18, 95% CI (0.06-0.52), p = 0.0010)], were significantly associated with lower likelihood of having very good cognitive function. Moreover, ferritin (r = 0.451, p < 0.001) and hemoglobin (r = 0.402, p < 0.001) demonstrated a moderate positive correlation with CPTS.

CONCLUSION

The prevalence of IDA is high in our study population and was linked with poor cognitive function. Adolescents with IDA had low cognitive performance test scores. High levels of hemoglobin and ferritin showed a moderate correlation with higher cognitive performance. These findings suggest that adolescents' cognitive function may be moderately influenced by IDA, highlighting the potential impact of iron status on cognitive outcomes.

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

Background

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

Methods

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

Results

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

Conclusions

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

The impact of crohn's disease on patients undergoing total knee arthroplasty

BACKGROUND

The knee joint remains the most affected joint in extra-intestinal manifestations of Crohn's disease (CD). Given the increasing prevalence of CD and overall demand for total knee arthroplasty (TKA), it is likely that an increasing number of patients with CD will require TKA. The purpose of this study was to assess the inpatient postoperative complication in patients with CD undergoing TKA.

MATERIALS AND METHODS

We queried the Nationwide Inpatient Sample (NIS) database between the years of 2016 to 2019, including a total of 558,371 patients who underwent primary TKA. Among these, 1461 were in the CD group and 556,910 were in the non-CD group (controls). Data pertaining to demographics, length of stay (LOS), total healthcare cost, mortality, and in-hospital complications (blood loss anemia, blood transfusion, periprosthetic infection, periprosthetic dislocation, periprosthetic mechanical complication, acute renal failure, myocardial infarction, pneumonia, pulmonary embolism, deep vein thrombosis, superficial/deep surgical site infection, and wound dehiscence) were compared between the two groups.

RESULTS

Patients diagnosed with CD had higher postoperative complications such as blood loss anemia (OR: 1.22, 95% CI: 1.07-1.39, p = 0.004), periprosthetic infection (OR: 1.80, 95% CI: 1.23-2.63, p = 0.006), and the need for blood transfusion (OR: 1.447, 95% CI: 1.01-2.06, p = 0.044) in comparison to the control group. In-hospital mortality and acute renal failure were similar in both groups. The CD group had a significantly prolonged LOS (2.54 vs. 2.35 days, p < 0.001). No statistically significant difference was noted concerning in-hospital charges between the two groups.

CONCLUSIONS

CD patients undergoing TKA experienced increased LOS and postoperative complications. However, these complications were minor and did not affect total hospital cost. Further prospective cohort studies could build upon the findings described to continue to maximize outcomes in CD patients undergoing TKA, which might extend to other cohorts.

Defining ferritin clinical decision limits to improve diagnosis and treatment of iron deficiency: A modified Delphi study

BACKGROUND

Iron deficiency is highly prevalent worldwide and is an issue of health inequity. Despite its high prevalence, uncertainty on the clinical applicability and evidence-base of iron-related lab test cut-offs remains. In particular, current ferritin decision limits for the diagnosis of iron deficiency may not be clinically appropriate nor scientifically grounded.

METHODS

A modified Delphi study was conducted with various clinical experts who manage iron deficiency across Canada. Statements about ferritin decision limits were generated by a steering committee, then distributed to the expert panel to vote on agreement with the aim of achieving consensus and acquiring feedback on the presented statements. Consensus was reached after two rounds, which was defined as 70% of experts rating their agreement for a statement as 5 or higher on a Likert scale from 1 to 7.

RESULTS

Twenty-six clinical experts across 10 different specialties took part in the study. Consensus was achieved on 28 ferritin decision limit statements in various populations (including patients with multiple comorbid conditions, pediatric patients, and pregnant patients). For example, there was consensus that a ferritin <30 μg/L rules in iron deficiency in all adult patients (age ≥ 18 years) and warrants iron replacement therapy.

CONCLUSION

Consensus statements generated through this study corresponded with current evidence-based literature and guidelines. These statements provide clarity to facilitate clinical decisions around the appropriate detection and management of iron deficiency.

Modelling the episodes of care for iron deficiency anemia patients in a secondary-care center using continuous-time multistate Markov chain

BACKGROUND

Despite the high prevalence of gastro-intestinal (GI) cancer in iron deficiency anemia (IDA), some IDA patients do not complete all the necessary GI investigations at the initial referral. As a result, existing cancers are diagnosed at a later referral with worse prognosis. The potential to detect GI cancer early depends on minimizing the delay time spent between the two consecutive referrals, where a patient did not complete investigations at the first referral, but at the second is diagnosed with positive GI cancer. This retrospective longitudinal study aims to highlight the proper methods to model these referrals.

METHODS

Using anonymized data of 168 episodes of care for IDA patients at an IDA clinic in a secondary care setting, continuous-time multi-state Markov chain is employed to determine the transition rates among three observed states for IDA patients at the IDA clinic, "incomplete investigations," "negative GI cancer," and "positive GI cancer" and to estimate the delay time.

RESULTS

Once in the state of incomplete investigations, an estimated mean delay time of 3.1 years (95% CI: 1.2, 5) is spent before being diagnosed with positive GI cancer. The probability that a "positive GI diagnosis" is next after the state of "incomplete investigation" is 17%, compared with 11% when it is followed in the state of negative GI cancer. Defining the survival as the event of not being in the state of "positive GI cancer," the survival rate of IDA patients with negative GI cancer is always higher than those with incomplete investigations. Finally, being diagnosed with positive GI cancer is always preceded by the prediction of being considered "very high risk" at the earlier visit.

CONCLUSION

A baseline model was proposed to represent episodes of care for IDA patients at a secondary care center. Preliminary results highlight the importance of completing the GI investigations, especially in IDA patients, who are at high risk of GI cancer and fit to go through the investigations.

Broad external validation of a multivariable risk prediction model for gastrointestinal malignancy in iron deficiency anaemia

BACKGROUND

Using two large datasets from Dorset, we previously reported an internally validated multivariable risk model for predicting the risk of GI malignancy in IDA-the IDIOM score. The aim of this retrospective observational study was to validate the IDIOM model using two independent external datasets.

METHODS

The external validation datasets were collected, in a secondary care setting, by different investigators from cohorts in Oxford and Sheffield derived under different circumstances, comprising 1117 and 474 patients with confirmed IDA respectively. The data were anonymised prior to analysis. The predictive performance of the original model was evaluated by estimating measures of calibration, discrimination and clinical utility using the validation datasets.

RESULTS

The discrimination of the original model using the external validation data was 70% (95% CI 65, 75) for the Oxford dataset and 70% (95% CI 61, 79) for the Sheffield dataset. The analysis of mean, weak, flexible and across the risk groups' calibration showed no tendency for under or over-estimated risks in the combined validation data. Decision curve analysis demonstrated the clinical value of the IDIOM model with a net benefit that is higher than 'investigate all' and 'investigate no-one' strategies up to a threshold of 18% in the combined validation data, using a risk cut-off of around 1.2% to categorise patients into the very low risk group showed that none of the patients stratified in this risk group proved to have GI cancer on investigation in the validation datasets.

CONCLUSION

This external validation exercise has shown promising results for the IDIOM model in predicting the risk of underlying GI malignancy in independent IDA datasets collected in different clinical settings.

Anemia in Crohn's Disease-The Unseen Face of Inflammatory Bowel Disease

Background and Objectives: Anemia is the most frequent complication of inflammatory bowel diseases. Clinically, anemia can affect important quality-of-life (QoL) components, such as exercise capacity, cognitive function, and the ability to carry out social activities. The disease activity has a significant impact on QoL, mainly due to clinical manifestations, which are more severe during the periods of disease activity. Our aim was to estimate the impact of anemia on QoL in patients with Crohn's disease. Material and Methods. We made a prospective study on 134 patients with Crohn's disease (CD) in a Romanian tertiary center. The CD diagnosis was established by colonoscopy and histopathological examination. In particular cases, additional examinations were required (small bowel capsule endoscopy, computed tomography enterography, and magnetic resonance enterography). Anemia was defined according to the World Health Organization's definition, the activity of the disease was assessed by Crohn's disease activity index (CDAI) score, and the QoL was evaluated by Inflammatory Bowel Disease Questionnaire 32 (IBDQ 32). Results: 44.8% patient had anemia, statistically related to the activity of the disease and corticoids use. We found a strong association between QoL and disease activity on all four sub-scores: patients with more severe activity had a significantly lower IBDQ (260.38 ± 116.96 vs. 163.85 ± 87.20, p = 0.001) and the presence of anemia (127.03 vs. 148.38, p = 0.001). In multiple regression analyses, both disease activity and anemia had an impact on the QoL. Conclusions: Anemia has high prevalence in the CD in northeastern region of Romania. Anemia was more common in female patients, in patients undergoing corticosteroid treatment, and in those with active disease. Both anemia and disease activity had a strong negative and independent impact on QoL.

Gastrointestinal Endoscopic Outcome in Late Adolescent Women With Iron-Deficiency Anemia in Basrah-Iraq: A Multicenter Study

Background

Iron deficiency anemia (IDA) in late adolescent women has multiple pathophysiologies. Silent blood loss, celiac disease (CD), malignancies, and other gastrointestinal (GI) lesions receive much attention during IDA management. There is no consensus about endoscopic screening. Our study evaluates factors affecting GI endoscopic diagnosis for the etiology of IDA in late adolescent women.

Materials and Methods

We conducted an observational, multicenter retrospective analysis of 192 adolescent women with IDA admitted for GI endoscopic diagnosis from 2006 to 2016. Baseline measurements included hemoglobin, serum ferritin, mean corpuscular volume, serum iron, total iron-binding capacity, and transferrin saturation. We collected demographic characteristics, duration of hospital stay, the degree of severity of anemia, and endoscopic findings.

Results

The mean age was 19±1 years (range 17 to 21 years), with mildly to moderately severe IDA. Patients received esophagogastroduodenoscopy (EGD, n=178) or colonoscopy (n=14). The mean hospital stay was 2.0±1.0 days. We found negative endoscopies (n=74), CD (n=85), gastric ulcer (n=19), malignancy (n=2), inflammatory bowel disease (n=1), and other nonsignificant endoscopic findings (n=11). We found no correlation between the duration of the hospital stay with the severity of IDA, no significant association between GI symptoms of the patients with endoscopic findings, and a significant but weak association between GI symptoms and serum ferritin.

Conclusions

In late adolescent women with IDA who have significant GI endoscopic lesions, the GI symptoms are of limited value in guiding the endoscopic diagnostic approach for evaluation of IDA.

Optical density based quantification of total haemoglobin concentrations with spectroscopic optical coherence tomography

Spectroscopic optical coherence tomography (sOCT) has emerged as a new possibility for non-invasive quantification of total haemoglobin concentrations [tHb]. Recently, we demonstrated that [tHb] measured in ex-vivo human whole-blood with a conventional sOCT system achieves a precision of 9.10 g/dL with a bias of 1.50 g/dL. This precision improved by acquiring data with a combination of focus tracking and zero-delay acquisition (FZA) that compensated for experimental limitations, increasing to 3.80 g/dL with a bias of 1.50 g/dL. Nevertheless, sOCT precision should improve at least to \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\sim 2$$\end{document}∼2 g/dL to be clinically relevant. Therefore, sOCT-based [tHb] determinations require the development of new analysis methods that reduce the variability of [tHb] estimations. In this work, we aim to increase sOCT precision by retrieving the [tHb] content from a numerical optimisation of the optical density (OD), while considering the blood absorption flattening effect. The OD-based approach simplifies previous two-step Lambert–Beer fitting approaches to a single step, thereby reducing errors during the fitting procedure. We validated our model with ex-vivo [tHb] measurements on flowing whole-blood samples in the clinical range (7–23 g/dL). Our results show that, with the new model, conventional sOCT can determine [tHb] with a precision of 3.09 g/dL and a bias of 0.86 g/dL compared to a commercial blood analyser. We present further precision improvement by combining the OD methodology with FZA, leading to a precision of 2.08 g/dL with a bias of 0.46 g/dL.

Do Gastrointestinal Symptoms Affect the Endoscopic Outcome in Anemic Premenopausal Women Due to Iron Deficiency: A Multicenter Study From Basrah-Iraq

BACKGROUND AND OBJECTIVES

The most common cause for iron deficiency anemia (IDA) in women before menopause is menstrual blood loss. The persistence of digestive symptoms despite iron supplementation is the only indication for gastrointestinal (GI) endoscopy in premenopausal women (PW) with IDA. We evaluated how the GI symptomatology manifestation affects the GI endoscopy diagnostic outcome in this cohort.

MATERIALS AND METHODS

This is an observational, multicenter retrospective evaluation of 245 PW admitted for GI endoscopic diagnosis for the etiology of IDA from 2006 to 2016. Baseline measurements included hemoglobin, iron status tests, and red blood corpuscle morphological evaluation. We evaluated the relationships of different endoscopic findings to the severity of IDA, different demographic characteristics, and hospitalization duration.

RESULTS

The mean age was 40±7 years. The duration of hospitalization was neither associated with age nor the IDA severity. The IDA was mild to moderate. More than 53% (n=131) had either a negative study or nonspecific inflammatory changes. Around 16% (n=39) had GI malignancies. There was a significant association between initial GI symptoms with endoscopic GI finding and GI malignancy diagnosis in particular. The relationship loses its power during further assessment by general univariate analysis.

CONCLUSION

A considerable percentage of anemic PW due to iron deficiency has an endoscopically-diagnosed pathology for IDA determined during GI endoscopy. The GI symptoms' phenotypes were unrelated to the endoscopically-diagnosed GI lesion location, even if they were malignant. Therefore, the determination of IDA severity must be thoroughly and individually determined.

Comparative Evaluation of Intestinal Absorption and Functional Value of Iron Dietary Supplements and Drug with Different Delivery Systems

Iron is a fundament micronutrient, whose homeostasis is strictly regulated. Iron deficiency anemia is among the most widespread nutritional deficiencies and its therapy, based on dietary supplement and drugs, may lead to severe side effects. With the aim of improving iron bioavailability while reducing iron oral therapy side effects, novel dietary supplements based on innovative technologies-microencapsulation, liposomes, sucrosomes-have been produced and marketed. In the present work, six iron dietary supplements for different therapeutic targets were compared in terms of bioaccessibility, bioavailability, and safety by using an integrated in vitro approach. For general-purpose iron supplements, ME + VitC (microencapsulated) showed a fast, burst intestinal iron absorption kinetic, which maintained iron bioavailability and ferritin expression constant over time. SS + VitC (sucrosomes), on the other side, showed a slower, time-dependent iron absorption and ferritin expression trend. ME + Folate (microencapsulated) showed a behavior similar to that of ME + VitC, albeit with a lower bioavailability. Among pediatric iron supplements, a time-dependent bioavailability increase was observed for LS (liposome), while PIC (polydextrose-iron complex) bioavailability is severely limited by its poor bioaccessibility. Finally, except for SS + VitC, no adverse effects on intestinal mucosa vitality and barrier integrity were observed. Considering obtained results and the different therapeutic targets, microencapsulation-based formulations are endowed with better performance compared to the other formulations. Furthermore, performances of microencapsulated products were obtained with a lower iron daily dose, limiting the potential onset of side effects.

Iron: Key player in cancer and cell cycle?

BACKGROUND

Iron is an essential element for growth and metabolic activities of all living organisms but remains in its oxyhydroxide ferric ion form in the surrounding. Unavailability of iron in soluble ferrous form led to development of specific pathways and machinery in different organisms to make it available for use and maintain its homeostasis. Iron homeostasis is essential as under different circumstances iron in excess as well as deprivation leads to different pathological conditions in human.

OBJECTIVE

This review highlights the current findings related to iron excess as well as deprivation with regards to cellular proliferation.

CONCLUSIONS

Iron excess is extensively associated with different types of cancers viz. colorectal cancer, breast cancer etc. by producing an oxidative stressed condition and alteration of immune system. Ironically its deprivation also results in anaemic conditions and leads to cell cycle arrest at different phases with mechanism yet to be explored. Iron deprivation arrests cell cycle at G1/S and in some cases at G2/M checkpoints resulting in growth arrest. However, in some cases iron overload arrests cell cycle at G1 phase by blocking certain signalling pathways. Certain natural and synthetic iron chelators are being explored from few decades to combat diseases caused by alteration in iron homeostasis.

Refinement and validation of the IDIOM score for predicting the risk of gastrointestinal cancer in iron deficiency anaemia

OBJECTIVE

To refine and validate a model for predicting the risk of gastrointestinal (GI) cancer in iron deficiency anaemia (IDA) and to develop an app to facilitate use in clinical practice.

DESIGN

Three elements: (1) analysis of a dataset of 2390 cases of IDA to validate the predictive value of age, sex, blood haemoglobin concentration (Hb), mean cell volume (MCV) and iron studies on the probability of underlying GI cancer; (2) a pilot study of the benefit of adding faecal immunochemical testing (FIT) into the model; and (3) development of an app based on the model.

RESULTS

Age, sex and Hb were all strong, independent predictors of the risk of GI cancer, with ORs (95% CI) of 1.05 per year (1.03 to 1.07, p<0.00001), 2.86 for men (2.03 to 4.06, p<0.00001) and 1.03 for each g/L reduction in Hb (1.01 to 1.04, p<0.0001) respectively. An association with MCV was also revealed, with an OR of 1.03 for each fl reduction (1.01 to 1.05, p<0.02). The model was confirmed to be robust by an internal validation exercise. In the pilot study of high-risk cases, FIT was also predictive of GI cancer (OR 6.6, 95% CI 1.6 to 51.8), but the sensitivity was low at 23.5% (95% CI 6.8% to 49.9%). An app based on the model was developed.

CONCLUSION

This predictive model may help rationalise the use of investigational resources in IDA, by fast-tracking high-risk cases and, with appropriate safeguards, avoiding invasive investigation altogether in those at ultra-low predicted risk.

Non-steroidal anti-inflammatory drug (NSAID) therapy in patients with hypertension, cardiovascular, renal or gastrointestinal comorbidities: joint APAGE/APLAR/APSDE/APSH/APSN/PoA recommendations

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly prescribed medications, but they are associated with a number of serious adverse effects, including hypertension, cardiovascular disease, kidney injury and GI complications.

OBJECTIVE

To develop a set of multidisciplinary recommendations for the safe prescription of NSAIDs.

METHODS

Randomised control trials and observational studies published before January 2018 were reviewed, with 329 papers included for the synthesis of evidence-based recommendations.

RESULTS

Whenever possible, a NSAID should be avoided in patients with treatment-resistant hypertension, high risk of cardiovascular disease and severe chronic kidney disease (CKD). Before treatment with a NSAID is started, blood pressure should be measured, unrecognised CKD should be screened in high risk cases, and unexplained iron-deficiency anaemia should be investigated. For patients with high cardiovascular risk, and if NSAID treatment cannot be avoided, naproxen or celecoxib are preferred. For patients with a moderate risk of peptic ulcer disease, monotherapy with a non-selective NSAID plus a proton pump inhibitor (PPI), or a selective cyclo-oxygenase-2 (COX-2) inhibitor should be used; for those with a high risk of peptic ulcer disease, a selective COX-2 inhibitor plus PPI are needed. For patients with pre-existing hypertension receiving renin-angiotensin system blockers, empirical addition (or increase in the dose) of an antihypertensive agent of a different class should be considered. Blood pressure and renal function should be monitored in most cases.

CONCLUSION

NSAIDs are a valuable armamentarium in clinical medicine, but appropriate recognition of high-risk cases, selection of a specific agent, choice of ulcer prophylaxis and monitoring after therapy are necessary to minimise the risk of adverse events.

The Efficacy of Ferumoxytol for Iron Deficiency Anemia: A Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

This systematic review and meta-analysis aims to explore the influence of ferumoxytol versus placebo on iron deficiency anemia.

METHODS

We search for randomized controlled trials (RCTs) assessing the effect of ferumoxytol on iron deficiency anemia on PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases. This meta-analysis is performed using the random-effects model.

RESULTS

Four RCTs are included in the meta-analysis. Compared with the control group for iron deficiency anemia, intravenous ferumoxytol can significantly improve the proportion of patients with a ≥20 g/L hemoglobin (Hb) increase (RR = 18.43; 95% CI = 7.29-46.57; p < 0.00001), the proportion of patients with an Hb level ≥120 g/L (RR = 18.55; 95% CI = 8.66-39.72; p < 0.00001), transferrin saturation (mean difference = 11.08; 95% CI = 9.86-12.31; p < 0.00001) and FACIT-fatigue score (mean difference = 4.60; 95% CI = 3.21-6.00; p < 0.00001), but has no remarkable influence on adverse events (RR = 1.33; 95% CI = 0.84-2.10; p = 0.22), serious adverse events (RR = 1.22; 95% CI = 0.74-2.02; p = 0.44), and death (RR = 0.32; 95% CI = 0.05-1.95; p = 0.22).

CONCLUSIONS

Intravenous ferumoxytol can provide the important benefits for iron deficiency anemia.

Curcumin induces mild anemia in a DSS-induced colitis mouse model maintained on an iron-sufficient diet

Anemia is frequently encountered in patients with inflammatory bowel disease (IBD), decreasing the quality of life and significantly worsening the prognosis of the disease. The pathogenesis of anemia in IBD is multifactorial and results mainly from intestinal blood loss in inflamed mucosa and impaired dietary iron absorption. Multiple studies have proposed the use of the polyphenolic compound curcumin to counteract IBD pathogenesis since it has significant preventive and therapeutic properties as an anti-inflammatory agent and very low toxicity, even at high dosages. However, curcumin has been shown to possess properties consistent with those of an iron-chelator, such as the ability to modulate proteins of iron metabolism and decrease spleen and liver iron content. Thus, this property may further contribute to the development and severity of anemia of inflammation and iron deficiency in IBD. Herein, we evaluate the effects of curcumin on systemic iron balance in the dextran sodium sulfate (DSS) model of colitis in C57Bl/6 and BALB/c mouse strains that were fed an iron-sufficient diet. In these conditions, curcumin supplementation caused mild anemia, lowered iron stores, worsened colitis and significantly decreased overall survival, independent of the mouse strain. These findings suggest that curcumin usage as an anti-inflammatory supplement should be accompanied by monitoring of erythroid parameters to avoid exacerbation of iron deficiency anemia in IBD.

Diagnosis of chronic anaemia in gastrointestinal disorders: A guideline by the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) and the Italian Society of Paediatric Gastroenterology Hepatology and Nutrition (SIGENP)

Anaemia is a common pathologic condition, present in almost 5% of the adult population. Iron deficiency is the most common cause; other mechanisms can be involved, making anaemia a multi-factorial disorder in most cases. Anaemia being a frequent manifestation in the diseases of the gastrointestinal tract, patients are often referred to gastroenterologists. Furthermore, upper and lower endoscopy and enteroscopy are pivotal to the diagnostic roadmap of anaemia. In spite of its relevance in the daily clinical practice, there is a limited number of gastroenterological guidelines dedicated to the diagnosis of anaemia. For this reason, the Italian Association of Hospital Gastroenterologists and Endoscopists and the Italian Society of Paediatric Gastroenterology, Hepatology and Nutrition commissioned a panel of experts to prepare a specific guideline on anaemia and its diagnostic roadmap in the gastroenterological scenario. The panel also discussed about the potential involvement of gastroenterologists and endoscopists in the management of patients with anaemia, with particular attention to the correct use of investigations. The panel paid particular attention to practical issues with the aim to support gastroenterologists in their clinical practice when dealing with patients with anaemia.

Ferric Gluconate Complex in Elderly Hospital Inpatients without Terminal Kidney Failure

BACKGROUND

Anemia is a common health issue for elderly patients. For patients with iron deficiency who cannot tolerate iron supplementation by the oral route, the parenteral route may be used. Options for parenteral iron supplementation include ferric gluconate complex (FGC).

OBJECTIVES

To evaluate the safety of FGC in elderly patients without terminal kidney failure and to assess its efficacy in treating iron-deficiency anemia.

METHODS

An observational chart review was conducted at a tertiary care university health centre. Patients included in the study were 65 years of age or older, had received at least 1 dose of FGC between January 1, 2014, and December 31, 2015, and had a hemoglobin count of less than 130 g/L (men) or less than 120 g/L (women) at baseline. For each patient, the observation period began when the first dose of FGC was administered and ended 60 days after the last dose. The main safety outcome (occurrence of any adverse reaction) was evaluated for every patient, with the efficacy analysis being limited to patients with a diagnosis of iron-deficiency anemia.

RESULTS

A total of 144 patients were included in the study, of whom 76 had iron-deficiency anemia. No serious, life-threatening adverse reactions were reported. The most commonly reported adverse reactions were nausea and vomiting. The mean increase in hemoglobin count was 13.5 g/L, a statistically significant change from baseline.

CONCLUSIONS

These results show that FGC is safe for use in elderly patients, with very few mild adverse reactions. Use of FGC led to increased hemoglobin count within 60 days. Of the 3 options for parenteral iron supplementation available in Canada, iron sucrose has not been studied in elderly patients, and iron dextran has a higher incidence of anaphylaxis, whereas FGC appears to be a safe alternative for patients with intolerance to oral iron.

The difference in endoscopic yield in patients with either iron-deficiency anemia or anemia with normal ferritin

OBJECTIVE

Current guidelines recommend a gastroduodenoscopy (GDS) and colonoscopy in patients with iron-deficiency anemia (IDA). However, in daily practice, patients with nonferriprive anemia are also referred for endoscopy. The aim of this study is to compare the diagnostic yield of colonoscopy and GDS in patients with IDA and non-IDA.

PATIENTS AND METHODS

A retrospective single-center cohort study was carried out from January 2013 till February 2016 that included 917 patients with anemia. We compared the endoscopic yield in patients with IDA versus patients with anemia otherwise. Multivariate regression analyses were carried out to identify predictive factors for the diagnostic yield of GDS and colonoscopy.

RESULTS

The yield of both GDS (25%) and colonoscopy (30%) was comparable in IDA and non-IDA patients. However, in patients without known gastrointestinal medical history and without concomitant indications for endoscopy (N=373), the diagnostic yield of GDS was three times higher in IDA patients compared with non-IDA patients (P<0.01). The diagnostic yield for colonoscopy was not significantly different between the two groups. Age and sex were recurrent predictive variables in the outcome of both GDS and colonoscopies.

CONCLUSION

We recommend IDA as well as non-IDA as indications for GDS and colonoscopy. Only in patients without gastrointestinal history or localizing complaints a significant difference in the diagnostic yield is found between IDA and non-IDA patients. In this group, upper endoscopy can be omitted in non-IDA patients as they were three times less likely to have a bleeding source found on GDS compared with IDA patients.

Assessing the cost-effectiveness of a routine versus an extensive laboratory work-up in the diagnosis of anaemia in Dutch general practice

Background Establishing the underlying cause of anaemia in general practice is a diagnostic challenge. Currently, general practitioners individually determine which laboratory tests to request (routine work-up) in order to diagnose the underlying cause. However, an extensive work-up (consisting of 14 tests) increases the proportion of patients correctly diagnosed. This study investigates the cost-effectiveness of this extensive work-up. Methods A decision-analytic model was developed, incorporating all societal costs from the moment a patient presents to a general practitioner with symptoms suggestive of anaemia (aged ≥ 50 years), until the patient was (correctly) diagnosed and treated in primary care, or referred to (and diagnosed in) secondary care. Model inputs were derived from an online survey among general practitioners, expert estimates and published data. The primary outcome measure was expressed as incremental cost per additional patient diagnosed with the correct underlying cause of anaemia in either work-up. Results The probability of general practitioners diagnosing the correct underlying cause increased from 49.6% (95% CI: 44.8% to 54.5%) in the routine work-up to 56.0% (95% CI: 51.2% to 60.8%) in the extensive work-up (i.e. +6.4% [95% CI: -0.6% to 13.1%]). Costs are expected to increase slightly from €842/patient (95% CI: €704 to €994) to €845/patient (95% CI: €711 to €994), i.e. +€3/patient (95% CI: €-35 to €40) in the extensive work-up, indicating incremental costs of €43 per additional patient correctly diagnosed. Conclusions The extensive laboratory work-up is more effective for diagnosing the underlying cause of anaemia by general practitioners, at a minimal increase in costs. As accompanying benefits in terms of quality of life and reduced productivity losses could not be captured in this analysis, the extensive work-up is likely cost-effective.

A Novel Model for Predicting Incident Moderate to Severe Anemia and Iron Deficiency in Patients with Newly Diagnosed Ulcerative Colitis

BACKGROUND

Anemia and iron deficiency are common complications of ulcerative colitis (UC). We aimed to develop and internally validate a prediction model for the incidence of moderate to severe anemia and iron deficiency anemia (IDA) in newly diagnosed patients with UC.

METHODS

Multivariable logistic regression was performed among a nationwide cohort of patients who were newly diagnosed with UC in the VA health-care system. Model development was performed in a random two-third of the total cohort and then validated in the remaining one-third of the cohort. As candidate predictors, we examined routinely available data at the time of UC diagnosis including demographics, medications, laboratory results, and endoscopy findings.

RESULTS

A total of 789 patients met the inclusion criteria. For the outcome of moderate to severe anemia, age, albumin level and mild anemia at UC diagnosis were predictors selected for the model. The AUC for this model was 0.69 (95% CI 0.64-0.74). For the outcome of moderate to severe anemia with evidence of iron deficiency, the predictors included African-American ethnicity, mild anemia, age, and albumin level at UC diagnosis. The AUC was 0.76, (95% CI 0.69-0.82). Calibration was consistently good in all models (Hosmer-Lemeshow goodness of fit p > 0.05). The models performed similarly in the internal validation cohort.

CONCLUSIONS

We developed and internally validated a prognostic model for predicting the risk of moderate to severe anemia and IDA among newly diagnosed patients with UC. This will help identify patients at high risk of these complications, who could benefit from surveillance and preventive measures.

A comprehensive evaluation of the gastrointestinal tract in iron-deficiency anemia with predefined hemoglobin below 9mg/dL: A prospective cohort study

BACKGROUND

Anemia is defined as hemoglobin below the cutoff of normal in studies examining the gastrointestinal (GI) tract in iron-deficiency anemia (IDA). Although the risk of GI cancer (GIC) increases as hemoglobin decreases, guidelines do not usually recommend hemoglobin thresholds for IDA investigation.

METHODS

To elucidate whether underlying GI disorders explain the different hemoglobin values and clinical outcomes observed initially in IDA patients referred for GI workup, we prospectively investigated the diagnostic yield of a thorough GI examination in consecutive IDA adults with predefined hemoglobin <9g/dL and no extraintestinal bleeding.

RESULTS

4552 patients were enrolled over 10 years. 96% of 4038 GI lesions were consistent with occult bleeding disorders and 4% with non-bleeding disorders. Predominant bleeding disorders included upper GI ulcerative/erosive lesions (51%), GIC (15%), and angiodysplasias (12%). Diffuse angiodysplasias (45% of angiodysplasias) and GIC showed the lowest hemoglobin values (6.3 [1.5] and 6.4 [1.3]g/dL, respectively). While the spread (diffuse vs. localized) and number (<3 vs. ≥3) of angiodysplasias correlated with the degree of anemia, hemoglobin values were lower in GIC with vs. without ulcerated/friable lesions (6.0 [1.1] vs. 7.0 [1.2]g/dL, P<0.001).

CONCLUSION

Not only GIC but also diffuse angiodysplasias caused the most severe anemia in IDA with predefined hemoglobin values <9g/dL.

Comparison of the Effects of Iron Oxide, as a New Form of Iron Supplement, and Ferrous Sulfate on the Blood Levels of Iron and Total Iron-Binding Globulin in the Rabbit

Iron oxide is an important biological agent that has a key role in medical processes; however, the mechanism whereby it provides iron for human and animal cells and its biological uses remains unclear. We aimed to evaluate the effects of oral iron oxide on serum iron status and compare the results with those of iron sulfate as a reference salt. Fifteen adult rabbits were divided into 3 groups of 5 each: control group, iron sulfate group, and iron oxide group. The groups received doses of 3.3, 10, and 33 mg/kg in 3 experiments. Venous blood samples were obtained just before the oral administration of iron sulfate and iron oxide (3.3 mg/kg). More blood samples were taken 3 times at the time points of 1, 6, and 12 hours after the administration of the solutions. Serum was separated for the measurement of iron (Fe) and total iron-binding globulin (TIBG) with routine methods. One week later, the same experiment was repeated with 10 mg/kg of iron sulfate and iron oxide; and 1 week later after the second experiment, again the same experiment was repeated with 33 mg/kg of iron sulfate and iron oxide. The results showed that 33 mg/kg of iron sulfate 1 hour after treatment caused a significant difference in the Fe and TIBG levels between all the groups (P=0.014 for Fe and P=0.027 for TIBG). Our data showed that the absorption of iron oxide was similar to that of ferrous sulfate and in high doses was as useful as iron supplement.

Anemia and Iron Deficiency in Children With Potential Celiac Disease

OBJECTIVES

Active screening for celiac disease frequently detects seropositive children with normal villous morphology (potential celiac disease). It remains unclear whether these subjects should be treated. We here investigated the prevalence of anemia and iron deficiency in children with potential and mucosal atrophy celiac disease.

METHODS

The prospective study involved 19 children with potential disease, 67 with partial or subtotal villous atrophy (P/SVA), and 16 with total villous atrophy (TVA). Twenty-three healthy children comprised the control group. The groups were compared for various clinical, histological, and laboratory parameters and hepcidin.

RESULTS

The prevalence of abnormal parameters was as follows (controls, potential celiac disease, P/SVA, and TVA, respectively): anemia 0%, 15%, 22%, and 63%; low iron 5%, 0%, 14%, and 50%; increased transferrin receptor 1 5%, 16%, 20%, and 47%; low ferritin 0%, 21%, 35%, and 87%; and low transferrin saturation 10%, 11%, 41%, and 71%. One subject had low folate and none had low vitamin B12. The median values for hemoglobin, total iron, ferritin, and transferrin saturation were significantly lower and transferrin receptor 1 values higher in TVA group compared with other groups. After a median of 7 months on a gluten-free diet hemoglobin, total iron, ferritin, and albumin in children with P/SVA exceeded the baseline values in the potential celiac disease group.

CONCLUSIONS

The development of anemia and iron deficiency in celiac disease is a continuum and may already be present in children with normal villous morphology, advocating an early diagnosis and possible dietary treatment of these patients.

Genetic factors associated with iron storage in Australian blood donors

BACKGROUND

Blood donors are at risk of developing iron deficiency and/or iron deficiency anaemia. This may affect their health and affect their eligibility to give subsequent donations. Investigating genetic factors that may predispose donors to high or low iron stores is of interest; this may assist with providing optimal management strategies for maintaining donor health. This study aimed to investigate whether the presence of selected single nucleotide polymorphisms (SNPs) affecting parameters of iron status were associated with ferritin levels in Australian donors.

MATERIALS AND METHODS

Samples (n=800) were collected from non-first-time blood donors in Queensland. Plasma ferritin levels were quantified and the genotypes for ten SNPs, identified by a review of relevant literature, were determined for each sample. Associations between SNPs and ferritin levels were investigated.

RESULTS

Three SNPs were associated with ferritin levels. In male donors, high ferritin levels were associated with the variant allele (G) of the SNP rs3923809 in the BTBD9 gene. An association with ferritin levels was also identified with the SNP rs235756 in the BMP2 gene in males. The SNP rs4820268 in the TMPRSS6 gene was associated with ferritin levels in females, with donors with the AG genotype being three times more likely to have low ferritin levels.

DISCUSSION

Variants in the genes TMPRSS, BTBD9 and BMP2 were associated with ferritin levels in Australian blood donors. These findings provide support that genetic testing may be useful for the generation of predictive algorithms that may allow for management strategies to be tailor-made for individual donors.

Factors Predicting Testing and Treatment of Iron Deficiency in a Nationwide Cohort of Anemic UC Patients

BACKGROUND

Iron deficiency anemia (IDA) is an often unrecognized and undertreated complication of ulcerative colitis (UC). We conducted the first nationwide study in the United States to evaluate the prevalence of testing for iron deficiency (ID) in anemic UC patients and determine the frequency of treatment with iron supplementation in patients with IDA.

METHODS

Nationwide cohort of patients with newly diagnosed UC in the Veterans Affairs health care system was identified. Primary outcome was to evaluate if anemic UC patients were tested for ID and subsequently treated with iron replacement therapy if IDA is confirmed. Candidate parameters included factors that can impact testing and treatment of anemia including patients' demographics, severity of anemia, and endoscopic findings.

RESULTS

Of 836 newly diagnosed patients with UC, 585 patients (70%) developed anemia over the course of median 8 years of follow-up. Of 585 patients, 401 patients (68.6%) had iron study evaluation. Two hundred fifty-one patients (62.6%) were diagnosed with IDA, and among them, 191 patients (76.1%) were treated with oral iron therapy. None of the patient received intravenous iron therapy. In multivariate analysis, patients with mild/moderate anemia and patients from Midwest and South region were independent predictors of iron study evaluation in patients with anemia.

CONCLUSIONS

More than a third of anemic UC patients were not tested for ID. Once tested, almost a quarter of the patients with IDA were not treated with iron replacement therapy. Testing for ID and subsequent treatment with iron replacement therapy should be considered among the quality process indicators in UC.

Efficacy and Safety of Ferric Carboxymaltose and Other Formulations in Iron-Deficient Patients: A Systematic Review and Network Meta-analysis of Randomised Controlled Trials

Background

Iron deficiency is very common in a number of medical conditions. Ferric carboxymaltose is a new stable iron preparation that can be administered in single infusions over short periods of time. The aim of this study was to conduct a systematic review of randomised controlled trials (RCTs) regarding the efficacy and safety of the novel complex compared with other iron formulations. In addition, the feasibility of a network meta-analysis for indirect comparisons was investigated.

Methods

A systematic literature review was performed for published RCTs on the use of ferric carboxymaltose in iron deficiency between July and October 2014. Indirect comparisons were also addressed using terms referring to competing iron formulations. We further supported the qualitative results of the systematic review by a network meta-analysis that allows pooling the evidence around different intervention outcomes in the absence of trials involving a direct comparison.

Results

The initial search yielded 1027 citations, which was decreased to 21 studies eligible for inclusion in the review. Studies were heterogeneous in the number of patients randomised, iron deficiency-related conditions addressed, trial inclusion criteria, time horizon, treatment dosage and outcomes assessed. Six studies with the same time horizon (i.e. 6 weeks) were included in the network meta-analysis. Considering the differences between final and initial outcome values for each iron formulation, the mean difference of these differences (delta) was estimated for each couple of treatments involving ferric carboxymaltose. Significant improvements in serum ferritin (µg/l) were obtained with ferric carboxymaltose compared to oral iron (delta 172.8; 95 % CI 66.7–234.4) and in haemoglobin (g/dl) with respect to ferric gluconate (delta 0.6; 95 % CI 0.2–0.9), oral iron (delta 0.8; 95 % CI 0.6–0.9) and placebo (delta 2.1; 95 % CI 1.2–3.0).

Conclusions

All currently available intravenous iron preparations appear to be safe and effective, but ferric carboxymaltose seems to provide a better and quicker correction of haemoglobin and serum ferritin levels in iron-deficient patients.

Ferumoxytol versus iron sucrose treatment: a post-hoc analysis of randomized controlled trials in patients with varying renal function and iron deficiency anemia

Background

Iron deficiency anemia is highly prevalent in patients with chronic kidney disease and is often treated with intravenous iron. There are few trials directly comparing the safety and efficacy of different intravenous iron products.

Methods

This post-hoc analysis pooled data from 767 patients enrolled in two randomized, controlled, open-label trials of similar design comparing the treatment of iron deficiency anemia with ferumoxytol and iron sucrose across patients with all stages of renal function. One trial was conducted in adults with CKD either on or not on dialysis and the second in adults with IDA of any underlying cause and a history of unsatisfactory oral iron therapy or in whom oral iron could not be used who had normal to no worse than moderately impaired renal function. Patients were categorized by chronic kidney disease stage (i.e., estimated glomerular filtration rate), and the primary efficacy endpoint was the mean change in hemoglobin from Baseline to Week 5.

Results

The overall incidence of adverse events was numerically lower in ferumoxytol-treated patients compared to those treated with iron sucrose (42.4 vs. 50.2 %, respectively); the incidence of treatment-related adverse events was generally similar between the two treatment groups (13.6 vs. 16.0 %, respectively). Adverse events of Special Interest (i.e., hypotension, hypersensitivity) occurred at lower rates in those treated with ferumoxytol compared to those treated with iron sucrose (2.5 vs. 5.3 %, respectively). Overall, mean hemoglobin increased in both treatment groups, regardless of degree of renal insufficiency, although greater increases were seen among those with less severe kidney damage. Mean increases in hemoglobin from Baseline to Week 5 were significantly greater with ferumoxytol than with iron sucrose treatment in the subgroup with an estimated glomerular filtration rate ≥90 mL/min (Least Squares mean difference = 0.53 g/dL; p < 0.001). There were no other consistent, significant differences in hemoglobin levels between treatment groups for the other chronic kidney disease categories except for isolated instances favoring ferumoxytol.

Conclusions

The efficacy and safety of ferumoxytol is at least comparable to iron sucrose in patients with varying degrees of renal function.

Trial registration

(CKD-201; ClinicalTrials.gov identifier: NCT01052779; registered 15 January, 2010), (IDA-302; ClinicalTrials.gov identifier: NCT01114204; registered 29 April, 2010).

Electronic supplementary material

The online version of this article (doi:10.1186/s12878-016-0060-x) contains supplementary material, which is available to authorized users.

Ferumoxytol versus placebo in iron deficiency anemia: efficacy, safety, and quality of life in patients with gastrointestinal disorders

Introduction

Iron deficiency anemia (IDA) is common in patients with gastrointestinal (GI) disorders and can adversely affect quality of life. Oral iron is poorly tolerated in many patients with GI disorders. Ferumoxytol is approved for the intravenous treatment of IDA in patients with chronic kidney disease. This study aimed to evaluate the efficacy and safety of ferumoxytol in patients with IDA and concomitant GI disorders.

Patients and methods

This analysis included 231 patients with IDA and GI disorders from a Phase III, randomized, double-blind, placebo-controlled trial evaluating ferumoxytol (510 mg ×2) versus placebo in patients who had failed or were intolerant of oral iron therapy. The primary study end point was the proportion of patients achieving a ≥20 g/L increase in hemoglobin (Hgb) from baseline to Week 5. Other end points included mean change in Hgb, proportion of patients achieving Hgb ≥120 g/L, mean change in transferrin saturation, and patient-reported outcomes (PROs).

Results

Significantly more patients with IDA receiving ferumoxytol achieved a ≥20 g/L increase in Hgb versus placebo (82.1% vs 1.7%, respectively; P<0.001). Mean increase in Hgb (28.0 g/L vs −1.0 g/L, respectively; P<0.001) significantly favored ferumoxytol treatment. Ferumoxytol-treated patients demonstrated significantly greater improvements than placebo-treated patients relative to their very poor baseline PRO scores posttreatment, including improvements in the Functional Assessment of Chronic Illness Therapy–Fatigue questionnaire and various domains of the 36-Item Short-Form Health Survey. Ferumoxytol-treated patients had a low rate of adverse events.

Conclusion

In this study, ferumoxytol was shown to be an efficacious and generally well-tolerated treatment option for patients with IDA and underlying GI disorders who were unable to use or had a history of unsatisfactory oral iron therapy.

Effects of Iron Supplementation With and Without Docosahexaenoic Acid on the Cardiovascular Disease Risk Based on Paraoxonase-1, hs-CRP, and ApoB/ApoA-I Ratio in Women with Iron Deficiency Anemia

Numerous studies have demonstrated that tissue deposition of iron following prolonged high dose of oral supplementation for treatment of iron deficiency anemia (IDA) leads to body iron overload and oxidative stress, which starts the process of atherosclerosis. This study aimed to determine the effect of iron supplementation in combination with docosahexaenoic acid (DHA) on the cardiovascular disease risk based on paraoxonase-1 (PON-1), high-sensitivity C-reactive protein (hs-CRP), and ApoB/ApoA-I ratio in women with IDA. In this randomized controlled trial, 76 women with IDA, aged 15-45 years, were included. The patients were randomly assigned to receive 500 mg of DHA supplement or placebo with an iron tablet, once daily for 12 weeks. The participants were assessed by measurement of the serum iron, ferritin, PON-1, hs-CRP levels, and the ApoB/ApoA-I ratio at the beginning and end of study. Serum hs-CRP decreased in the DHA-supplemented group (p = 0.036), and ApoA-I decreased in the placebo group (p = 0.013). No significant difference was detected for the serum PON-1 concentration and the ApoB/ApoA-I ratio in two groups. Iron supplementation combined with DHA may have favorable effects on serum hs-CRP in women with IDA.

Role of nutrition on anemia in elderly

Anemia in elderly population have a great incidence and is related to increased mortality risk. The incidence of nutrition in anemia is about one third of the total. Caloric and protein restriction, iron, vitamin B₁₂, folic deficiency are the causes of nutritional anemia. Protein and energy malnutrition stimulate an increased cytokines production with induction of inflammation, immunodeficiency and anemia. Anorexia and obesity can be associated with anemia due to increased cytokines and hepdicin serum level. Macrophages activity is inhibited and a decrease in red blood cells (RBC), hemoglobin (Hb) concentration due to ineffective erythropoiesis is observed. An adequate energy and protein diet is necessary to reduce inflammation and increase iron absorption. A minimum of 1700 kcal/day and 1.7 gr/kg/day of protein intake are necessary to maintain anabolism in chronic patients to prevent and treat anemia. Iron supplementation by intravenous injection is safe and effective to correct severe iron deficiency. The supplementation of vitamins and oligomineral are useful to reduce oxidative stress and improve RBC longevity. Anemia in elderly could be prevented by an adequate nutrition, a simple and not expensive intervention, and associated to physical exercise reduce the incidence of mortality rate.

An unusual autopsy case of lethal hypothermia exacerbated by body lice-induced severe anemia

Pediculus humanus humanus (known as body lice) are commonly found in the folds of clothes, and can cause skin disorders when they feed on human blood, resulting in an itching sensation. Body lice are known as vectors of infectious diseases, including typhus, recurrent fever, and trench fever. An infestation with blood-sucking body lice induces severe cutaneous pruritus, and this skin disorder is known as "vagabond's disease." A body lice infestation is sometimes complicated with iron deficiency anemia. In the present case, a man in his late 70s died of lethal hypothermia in the outdoors during the winter season. The case history and autopsy findings revealed that the cause of the lethal hypothermia was iron deficiency anemia, which was associated with a prolonged infestation of blood-sucking body lice. Also, he had vagabond's disease because the skin on his body was abnormal and highly pigmented. This is an unusual autopsy case since the body lice contributed to the cause of the death.

[Diagnostic yield of video capsule endoscopy in premenopausal women with iron-deficiency anemia]

Clinical practice guidelines recommend video capsule endoscopy (VCE) studies in patients with iron-deficiency anemia (IDA) after conventional upper and lower endoscopies but there is a need for studies demonstrating the diagnostic yield, clinical impact, and cost in some patient subgroups.

OBJECTIVES

1.To determine the diagnostic yield of VCE in premenopausal women with IDA compared with that in men and postmenopausal women. 2. To identify the presence of VCE predictors in premenopausal women. 3. To estimate the cost-clinical impact relationship associated with VCE in this indication.

MATERIAL AND METHOD

We retrospectively analyzed 408 patients who underwent VCE. Patients with IDA were enrolled (premenopausal, postmenopausal women, and men), with previous normal work-up by conventional endoscopies.

RESULTS

A total of 249 patients were enrolled: 131 women (52.6%), of which 51 were premenopausal and 80 were post-menopausal, and 118 men. The mean age was 60.7±16 years. The diagnostic yield of VCE for the diagnosis of IDA was 44.6% (95% CI 39.9 - 50.8). Diagnostic yield was 50.8% vs 38.9% in men vs women (p=0.05) and was 55% vs 13.7% in postmenopausal vs premenopausal women (p<0.001). No predictors of small bowel lesions were found in premenopausal women. The most common findings in the postmenopausal group were angioectasias (70.5%) and erosions (57.1%) in the premenopausal group. The cost in premenopausal women was 44.727€ and 86.3% of the procedures had no clinical impact.

CONCLUSIONS

The diagnostic yield of VCE is low in the etiological study of IDA in premenopausal women and there is no cost-effectiveness in relation to clinical impact. No predictors of small bowel lesions were found in this group.

Anemia in inflammatory bowel disease outpatients: prevalence, risk factors, and etiology

Anemia is common in inflammatory bowel disease (IBD). However, epidemiological studies of nonwestern IBD populations are limited and may be confounded by demographic, socioeconomic, and disease-related influences. This study evaluated the prevalence, risk factors, and etiology of anemia in Brazilian outpatients with IBD.

METHODS

In this cross-sectional study, 100 Crohn's disease (CD) patients and 100 ulcerative colitis (UC) subjects were assessed. Anemia workup included complete blood count, ferritin, transferrin saturation, serum levels of folic acid and vitamin B12, and C-reactive protein (CRP) concentration.

RESULTS

The overall prevalence of anemia in IBD was 21%. There was no significant difference in the prevalence of anemia between CD subjects (24%) and UC (18%). Moderate disease activity (OR: 3.48, 95% CI, 1.95-9.64, P = 0.002) and elevated CRP levels (OR: 1.8, 95% CI, 1.04-3.11, P = 0.02) were independently associated with anemia. The most common etiologies of anemia found in both groups were iron deficiency anemia (IDA; 10% on CD and 6% on UC) followed by the anemia of chronic disease (ACD; 6% for both groups).

CONCLUSIONS

In Brazilian IBD outpatients, anemia is highly concurrent condition. Disease moderate activity as well as increased CRP was strongly associated with comorbid anemia. IDA and/or ACD were the most common etiologies.

Iron therapy in anaemic adults without chronic kidney disease

BACKGROUND

Anaemia affects about a quarter of the world's population. An estimated 50% of anaemic people have anaemia due to iron deficiency.

OBJECTIVES

To assess the safety and efficacy of iron therapies for the treatment of adults with anaemia who are not pregnant or lactating and do not have chronic kidney disease.

SEARCH METHODS

We ran the search on 11 July 2013. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE (Ovid SP), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus (EBSCO Host), the Institute for Scientific Information Web of Science (ISI WOS) Scientific Citation Index (SCI)-EXPANDED (1970) and Conference Proceedings Citation Index (CPCI)-Science (1990) and Clinicaltrials.gov; we also screened reference lists. An updated search was run on 24 November 2014 but the results have not yet been incorporated into the review.

SELECTION CRITERIA

Two review authors independently selected references for further assessment by going through all titles and abstracts. Further selection was based on review of full-text articles for selected references.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted study data. We calculated the risk ratio (RR) with 95% confidence interval (CI) for binary outcomes and the mean difference (MD) or the standardised mean difference (SMD) with 95% CI for continuous outcomes. We performed meta-analysis when possible, when I(2) was less than or equal to 80% using a fixed-effect or random-effects model, using Review Manager software. The range of point estimates for individual studies is presented when I(2) > 80%.

MAIN RESULTS

We included in this systematic review 4745 participants who were randomly assigned in 21 trials. Trials were conducted in a wide variety of clinical settings. Most trials included participants with mild to moderate anaemia and excluded participants who were allergic to iron therapy. All trials were at high risk of bias for one or more domains. We compared both oral iron and parenteral iron versus inactive controls and compared different iron preparations.The comparison between oral iron and inactive control revealed no evidence of clinical benefit in terms of mortality (RR 1.05, 95% CI 0.68 to 1.61; four studies, N = 659; very low-quality evidence). The point estimate of the mean difference in haemoglobin levels in individual studies ranged from 0.3 to 3.1 g/dL higher in the oral iron group than in the inactive control group. The proportion of participants who required blood transfusion was lower with oral iron than with inactive control (RR 0.74, 95% CI 0.55 to 0.99; three studies, N = 546; very low-quality evidence). Evidence was inadequate for determination of the effect of parenteral iron on mortality versus oral iron (RR 1.49, 95% CI 0.56 to 3.94; 10 studies, N = 2141; very low-quality evidence) or inactive control (RR 1.04, 95% CI 0.63 to 1.69; six studies, N = 1009; very low-quality evidence). Haemoglobin levels were higher with parenteral iron than with oral iron (MD -0.50 g/dL, 95% CI -0.73 to -0.27; six studies, N = 769; very low-quality evidence). The point estimate of the mean difference in haemoglobin levels in individual studies ranged between 0.3 and 3.0 g/dL higher in the parenteral iron group than in the inactive control group. Differences in the proportion of participants requiring blood transfusion between parenteral iron and oral iron groups (RR 0.61, 95% CI 0.24 to 1.58; two studies, N = 371; very low-quality evidence) or between parenteral iron groups and inactive controls (RR 0.84, 95% CI 0.66 to 1.06; eight studies, N = 1315; very low-quality evidence) were imprecise. Average blood volume transfused was less in the parenteral iron group than in the oral iron group (MD -0.54 units, 95% CI -0.96 to -0.12; very low-quality evidence) based on one study involving 44 people. Differences between therapies in quality of life or in the proportion of participants with serious adverse events were imprecise (very low-quality evidence). No trials reported severe allergic reactions due to parenteral iron, suggesting that these are rare. Adverse effects related to oral iron treatment included nausea, diarrhoea and constipation; most were mild.Comparisons of one iron preparation over another for mortality, haemoglobin or serious adverse events were imprecise. No information was available on quality of life. Thus, little evidence was found to support the use of one preparation or regimen over another.Subgroup analyses did not reveal consistent results; therefore we were unable to determine whether iron is useful in specific clinical situations, or whether iron therapy might be useful for people who are receiving erythropoietin.

AUTHORS' CONCLUSIONS

• Very low-quality evidence suggests that oral iron might decrease the proportion of people who require blood transfusion, and no evidence indicates that it decreases mortality. Oral iron might be useful in adults who can tolerate the adverse events, which are usually mild.• Very low-quality evidence suggests that intravenous iron results in a modest increase in haemoglobin levels compared with oral iron or inactive control without clinical benefit.• No evidence can be found to show any advantage of one iron preparation or regimen over another.• Additional randomised controlled trials with low risk of bias and powered to measure clinically useful outcomes such as mortality, quality of life and blood transfusion requirements are needed.

Effects of different doses and duration of iron supplementation on curing iron deficiency anemia: an experimental study

Many controversies persist with respect to the dosage and therapeutic duration concerning iron deficiency anemia (IDA) treatment. To identify the most suitable cure, this study evaluated the effect of iron supplementation with different doses and for different time periods in rats with iron deficiency anemia. The rats were randomly divided into five groups [normal control (NC), low- iron diet control (LC), normal doses of iron group (NI), middle dose of iron group (MI), and high dose of iron group (HI)]. Each group was subdivided into two subgroups (2 and 4 weeks). The rats were maintained on low-iron diets and treated with oral iron dextran at different dosages. Finally, we investigated red blood cell parameters, iron absorption and metabolism, oxidative stress, and the antioxidant capacity. Our study indicated that through the administration of normal dose iron by gavage to IDA rats, the levels of the red blood cell parameters can be restored in only 2 weeks. In the HI group, iron absorption and transferrin receptor expressions were markedly reduced after 2 weeks. However, the iron content, ferritin and hepcidin expressions were notably increased, and the changes were more apparent after 4 weeks. With increasing doses of iron supplementation and durations of treatment, the liver malondialdehyde (MDA) content in the LC, MI, and HI groups was markedly increased, whereas the superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) activities were obviously reduced. This study demonstrated that the dose of iron treatment for IDA should be controlled in a safe range, and a reasonable duration is also critical for IDA therapeutics.

Cerebral venous sinus thrombosis and venous hemorrhagic infarction in a young woman

Cerebral venous sinus thrombosis (CVST) is an uncommon cause of cerebral infarction, compared to arterial diseases. It is often unrecognized at initial presentation due to the diversity of causes and clinical manifestations. A 29-year-old female patient complained of severe headache and presented at the emergency room with altered consciousness. Brain computed tomography and brain magnetic resonance image revealed the left sigmoid sinus thrombosis with venous hemorrhagic infarction (VHI) in the left temporal lobe. The patient had no past medical and family history of bleeding diathesis. The laboratory finding at the admission showed severe iron-deficiency anemia (IDA), and protein C and S activities were decreased. After the neurosurgery, iron replacement, and neurorehabilitation, the patient had a good recovery. There has been no known recurrence. We report our therapeutic intervention on a very rare case of CVST and VHI, with IDA as a probable cause of cerebral thrombosis.

Clinical risk factors for underlying gastrointestinal malignancy in iron deficiency anaemia: the IDIOM study

OBJECTIVE

Ten percent of adults presenting with iron deficiency anaemia (IDA) have underlying cancer. This analysis - the Iron Deficiency as an Indicator Of Malignancy (IDIOM) study - was undertaken to assess whether five simple clinical parameters can usefully predict the likelihood of gastrointestinal (GI) malignancy on subsequent investigation of patients with IDA.

DESIGN

Retrospective observational study, with multivariable analysis of the predictive value of sex, age, haemoglobin concentration (Hb), mean red cell volume (MCV) and iron studies for the risk of underlying GI malignancy.

SETTING

District General Hospital IDA clinic.

PATIENTS

720 adults with confirmed IDA.

RESULTS

Sex, age and Hb were strongly associated with the risk of GI malignancy-the parsimonious model including only these variables yielded ORs of 4.0 (95% CI 2.3 to 7.0) for males compared with females; 3.3 (95% CI 1.7 to 6.4) for age >70 years compared with ≤70 years; and 5.3 (95% CI 2.4 to 11.7) for a Hb of ≤91.4 g/L compared with ≥111.5 g/L. Combining these risk factors identified a subgroup (12% of the study population) at particularly low risk (<2% likelihood), and a second subgroup (16% of the study population) at especially high risk (>20% likelihood) of underlying GI malignancy.

CONCLUSIONS

Three simple and objective clinical parameters can be combined to provide a clinically useful cancer risk stratification model for subjects with IDA. This may assist with patient counselling and the prioritisation of investigational resources.

The development of a nurse-led iron deficiency anaemia service in a district general hospital

OBJECTIVE

To improve the quality of care provided to patients with iron deficiency anaemia (IDA).

DESIGN

Service development.

SETTING

District General Hospital.

PATIENTS

Adults with IDA.

MAIN OUTCOME MEASURES

Descriptive report of the practicalities and benefits of establishing an IDA clinic.

CONCLUSIONS

The IDA clinic is a novel service development which enhances the management of patients with this common condition, by facilitating prompt confirmation of the diagnosis, replacement therapy and investigation for serious underlying pathology, in particular gastrointestinal malignancy.