Purpose
Anaemia is a common complication of cancer causing symptoms including fatigue. It is also associated with shorter survival. Cancer causes systemic inflammation which interrupts iron ...metabolism leading to a functional iron deficiency (FID). There are few data on prevalence or aetiology of anaemia in those with advanced cancer. We aimed to establish the prevalence of anaemia and estimate extent of FID anaemia in patients with advanced cancer.
Methods
All patients with advanced cancer referred to two UK specialist palliative care services over 1 year were identified. Demographic and clinical data were linked with routinely collected haematological and biochemical profiles. We assessed the numbers of patients with abnormal values for haemoglobin, % hypochromic red cells (>5% indicates iron-restricted erythropoiesis) and CRP (>10 indicates systemic inflammation). We judged that FID anaemia was likely when patients had all three abnormalities and ferritin 30–800 ng/ml.
Results
Out of 2416 patients, 1797 had a cancer diagnosis and laboratory data available. Mean haemoglobin was 116 g/l. Sixty-three percent of patients were anaemic, mild 25%, moderate 35% and severe 3%. Women had significantly higher mean haemoglobin than men, and there was wide variation in anaemia prevalence across tumour sites. Thirty-nine percent of patients who had all four parameters checked met our criteria for FID anaemia. There were significant relationships between haemoglobin, % hypochromic red cells and CRP (
p
= 0.0001).
Conclusions
Anaemia was common in this population, and we estimate this was caused by FID in 66% of anaemic patients. Further research is needed to validate our diagnostic criteria before this approach can be used in clinical practice.
Worldwide, over 1.6 billion people are anaemic. The prevalence of anaemia and contribution of iron deficiency to this burden is heterogeneous between different populations. Iron deficiency anaemia ...(IDA) is associated with impaired development in children, adverse effects on cognitive and physical performance in adults, and poorer maternal and infant outcomes in pregnancy. Causes of anaemia other than iron deficiency are important in developed countries and where malaria, thalassaemia or haemoglobinopathy are prevalent. Haemoglobin is the most commonly used screening test for iron deficiency, but may have inadequate sensitivity and specificity to determine iron status in many settings. Screening for anaemia during pregnancy is widely recommended. In children, studies evaluating screening programs have found problems with implementation, acceptability and follow-up of testing, and most international authorities do not support this practice. Nevertheless, certain groups with a particularly high pre-test probability of IDA may benefit from testing following clinical evaluation. Further research is required to define the role of screening and improve available tests for IDA in both developed and developing settings. In this review, the rationale, evidence, experience and expert guidelines regarding screening for IDA, especially among pregnant and paediatric populations, will be evaluated.
Iron and Cognitive Development Larson, Leila M.; Phiri, Kamija S.; Pasricha, Sant-Rayn
Annals of nutrition and metabolism,
01/2017, Letnik:
71, Številka:
3
Journal Article
Recenzirano
Odprti dostop
The theoretical irreversible damage that iron deficiency and iron deficiency anemia can exert on child development makes a compelling argument for action to alleviate the burden. However, a critical ...analysis of evidence from iron interventions in early life is necessary to determine whether and how iron interventions improve cognitive outcomes. Key iron interventions used in clinical and public health practice include oral iron supplementation and, in young children, iron-containing multiple micronutrient powders. This article examines the evidence to answer 4 main questions. (1) Does antenatal iron supplementation influence long-term child cognitive development? (2) Does oral iron supplementation in preschool children improve short-term cognitive development? (3) Does oral iron supplementation in older children improve cognitive development? And (4), can provision of iron harm cognitive development? Early trials indicated benefit from parenteral iron in young children regardless of anemia status. There also appears to be evidence for benefit using oral iron treatment on cognitive performance in anemic primary school children. However, antenatal and early childhood oral iron intervention studies show inconsistent effects on early and long-term childhood cognitive outcomes. These data suggest either that (a) effects from oral iron on cognitive development in young children are small or nonexistent or that (b) heterogeneity between trials and the low quality of many studies make assessment of effect difficult. Importantly, few large, placebo-controlled trials in under-2-year-old children in low-income settings assessing effects of iron interventions on cognition have been performed; high-quality, placebo-controlled, adequately powered trials of universal iron interventions on cognitive performance in young children are urgently needed to justify policies of universal iron intervention in this group.
Evidence regarding the utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the assessment of isolated mediastinal lymphadenopathy (IMLN) is evolving. Its ...diagnostic accuracy in the evaluation of suspected lymphoma remains uncertain.
We reviewed a prospectively recorded database of consecutive patients with suspected lymphoma who underwent EBUS-TBNA to evaluate IMLN. Patients in whom EBUS-TBNA was nondiagnostic subsequently underwent surgical biopsy or a minimum of 6 months radiologic surveillance.
Ninety-eight patients underwent EBUS-TBNA for evaluation of IMLN. Clinicoradiologic features suggested sarcoidosis as the likely diagnosis in 43 patients. In the remaining 55 patients, EBUS-TBNA achieved definitive diagnosis in 42 patients (76%; 95% confidence interval CI 55–90). Lymphoma was ultimately diagnosed in 21 of 55 patients (38%). EBUS-TBNA demonstrated lymphoma in 16 (76%) patients; however, four patients required further surgical biopsy to completely characterize lymphoma subtypes. Surgical biopsy was required to diagnose specific lymphoma subtypes not readily amenable to diagnosis with low volume specimens. Sensitivity and specificity for definitive diagnosis of lymphoma were 57% (95% CI 37–76) and 100% (95% CI 91–100), respectively.
Although the diagnostic accuracy of EBUS-TBNA for lymphoma is lower than that for the lung cancer staging, the procedure is an appropriate investigative technique for the patients with IMLN because of the low incidence of lymphoma in this population, and the significant proportion of such patients (76%) in whom surgical biopsy is obviated.
Iron deficiency and anemia have been associated with poor cognition in children, yet the effects of iron supplementation on neurocognition remain unclear.
We aimed to examine the effects of ...supplementation with iron on neural indices of habituation using auditory event-related brain potentials (ERPs).
This substudy was nested within a 3-arm, double-blind, double-dummy, individual randomized trial in Bangladesh, in which 3300 8-mo-old children were randomly selected to receive 3 mo of daily iron syrup (12.5 mg iron), multiple micronutrient powders (MNPs) (including 12.5 mg iron), or placebo. Children were assessed after 3 mo of intervention (mo 3) and 9 mo thereafter (mo 12). The neurocognitive substudy comprised a randomly selected subset of children from the main trial. Brain activity elicited during an auditory roving oddball task was recorded using electroencephalography to provide an index of habituation. The differential response to a novel (deviant) compared with a repeated (standard) sound was examined. The primary outcome was the amplitude of the mismatch response (deviant minusstandard tone waveforms) at mo 3. Secondary outcomes included the deviant and standard tone-evoked amplitudes, N2 amplitude differences, and differences in mean amplitudes evoked by deviant tones presented in the second compared with first half of the oddball sequence at mo 3 and 12.
Data were analyzed from 329 children at month 3 and 363 at mo 12. Analyses indicated no treatment effects of iron interventions compared with placebo on the amplitude of the mismatch response (iron syrup compared with placebo: mean difference (MD) = 0.07μV 95% CI: −1.22, 1.37; MNPs compared with placebo: MD = 0.58μV 95% CI: −0.74, 1.90) nor any secondary ERP outcomes at mo 3 or 12, despite improvements in hemoglobin and ferritin concentrations from iron syrup and MNPs in this nested substudy.
In Bangladeshi children with >40% anemia prevalence, iron or MNP interventions alone are insufficient to improve neural indices of habituation.
This trial was registered at the Australian New Zealand Clinical Trials Registry as ACTRN12617000660381.
Currently used indicators of iron status have limitations. Hepcidin, a key regulator of iron metabolism, is reduced in iron deficiency. We sought to determine the properties of hepcidin as a ...diagnostic test of iron deficiency.
Sera from female, non-anemic, whole blood donors were analyzed for hepcidin (enzyme-linked immunosorbent assay), ferritin, soluble transferrin receptor and C-reactive protein. Iron deficiency was defined as (i) serum ferritin less than 15 ng/mL or (ii) soluble transferrin receptor /log(ferritin) index greater than 3.2 if the C-reactive protein concentration was less than 10 mg/L, or greater than 2.2 if the C-reactive protein concentration was greater than 10 mg/L). Receiver operating characteristic curves were plotted to determine the overall utility and identify optimal cut-points of hepcidin as a test of iron deficiency.
In 261 blood donors the prevalence of iron deficiency defined by ferritin concentration was 59/261 22.6% (17.5, 27.7), whereas defined by soluble transferrin receptor/log(ferritin) index it was 53/261 20.4% (15.4, 25.2). The 95% reference range of hepcidin concentration in the iron-replete population was 8.2-199.7 ng/mL. The area under the receiver operating characteristic curve for hepcidin compared with ferritin concentration less than 15 ng/mL was 0.87 (0.82, 0.92), while that compared with the soluble transferrin receptor /log(ferritin) index was 0.89 (95% CI 0.84, 0.93). For a diagnosis of iron deficiency defined by the soluble transferrin receptor/log(ferritin) index, hepcidin less than 8 ng/mL had a sensitivity of 41.5% and a specificity of 97.6%, while hepcidin less than 18 ng/mL had a sensitivity of 79.2% and a specificity of 85.6%.
Serum hepcidin concentration may be a useful indicator of deficient iron stores. Further studies are required to evaluate the role of hepcidin in the diagnosis of iron deficiency in other groups of patients.
Polycythemia vera is a Philadelphia negative myeloproliferative neoplasm characterized by erythrocytosis in which the major cause of morbidity and mortality is thrombosis. Aspirin and hematocrit ...reduction by venesection or cytoreductive therapy are at the cornerstone of management. First line cytoreductive therapy in high-risk patients is hydroxyurea; however, its use is associated with toxicities and resistance in a significant proportion of patients. In a disease with a long overall survival with appropriate treatment, it is imperative that other treatment options do not accelerate the risk of progression to acute leukemia. The following review will appraise the evidence of interferon, ruxolitinib, and other agents in management of hydroxyurea resistant or intolerant polycythemia vera.
Universal provision of iron supplements or iron-containing multiple micronutrient powders (MNPs) is widely used to prevent anemia in young children in low- and middle-income countries. The BRISC ...(Benefits and Risks of Iron Interventions in Children) trial compared iron supplements and MNPs with placebo in children <2 y old in rural Bangladesh.
We aimed to assess the cost-effectiveness of iron supplements or iron-containing MNPs among young children in rural Bangladesh.
We did a cost-effectiveness analysis of MNPs and iron supplements using the BRISC trial outcomes and resource use data, and programmatic data from the literature. Health care costs were assessed from a health system perspective. We calculated incremental cost-effectiveness ratios (ICERs) in terms of US$ per disability-adjusted life-year (DALY) averted. To explore uncertainty, we constructed cost-effectiveness acceptability curves using bootstrapped data over a range of cost-effectiveness thresholds. One- and 2-way sensitivity analyses tested the impact of varying key parameter values on our results.
Provision of MNPs was estimated to avert 0.0031 (95% CI: 0.0022, 0.0041) DALYs/child, whereas iron supplements averted 0.0039 (95% CI: 0.0030, 0.0048) DALYs/child, over 1 y compared with no intervention. Incremental mean costs were $0.75 (95% CI: 0.73, 0.77) for MNPs compared with no intervention and $0.64 ($0.62, $0.67) for iron supplements compared with no intervention. Iron supplementation dominated MNPs because it was cheaper and averted more DALYs. Iron supplementation had an ICER of $1645 ($1333, $2153) per DALY averted compared with no intervention, and had a 0% probability of being the optimal strategy at cost-effectiveness thresholds of $200 (reflecting health opportunity costs in Bangladesh) and $985 half of gross domestic product (GDP) per capita per DALY averted. Scenario and sensitivity analyses supported the base case findings.
These findings do not support universal iron supplementation or micronutrient powders as a cost-effective intervention for young children in rural Bangladesh. This trial was registered at anzctr.org.au as ACTRN1261700066038 and trialsearch.who.int as U1111-1196-1125.
IntroductionAnaemia in pregnancy remains a critical global health problem, affecting 46% of pregnant women in Africa and 49% in Asia. Oral iron therapy requires extended adherence to achieve ...correction of anaemia and replenishment of iron stores. Ferric carboxymaltose (FCM) is a recently established intravenous iron formulation associated with substantial advantages in safety, speed of delivery and total dose deliverable in a single infusion. We aim to determine whether FCM given once during the second trimester of pregnancy compared with standard oral iron distributed through routine antenatal services is effective and safe for treatment of moderate to severe maternal anaemia in sub-Saharan Africa.Methods and analysisThe randomized controlled trial of the effect of intravenous iron on anaemia in Malawian pregnant women (REVAMP) is a two-arm confirmatory individually randomised trial set in Blantyre and Zomba districts in Malawi. The trial will randomise 862 women in the second trimester of pregnancy with a capillary haemoglobin concentration below 100.0 g/L. The study comprises two arms: (a) intravenous FCM (20 mg/kg up to 1000 mg) given once at randomisation, and (b) standard of care oral iron (65 mg elemental iron two times per day) for 90 days (or the duration of pregnancy, whichever is shorter) provided according to local healthcare practices. Both arms receive sulfadoxine-pyrimethamine as intermittent preventive treatment in pregnancy. The primary outcome is the prevalence of anaemia (Hb <110.0 g/L) at 36 weeks’ gestation. Secondary outcomes include birth weight, gestation duration and safety outcomes, including clinical malaria, serious perinatal events and postpartum haematologic and health-related outcomes in the mother and child.Ethics and disseminationEthical approval was granted by the Research Ethics Committee (COMREC P.02/18/2357) in Malawi and the Human Research Ethics Committee (WEHI: 18/02), Melbourne, Australia. The protocol is registered with the Australian and New Zealand Clinical Trials Registry. The results will be shared with the local community that enabled the research, and also to the international fora.Trial registration numberACTRN12618001268235; Pre-results.
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